CHAPTER XVII
Peripheral Vascular Disorders
Fiorindo A. Simeone, M.D., and Robert W. Hopkins, M.D.
Peripheral vascular disorders encountered in World War IIhave been described in considerable detail in earlier volumes of the officialhistory of the U.S. Army Medical Department in World War II.1Trauma encountered in epidemic proportions during wartime provides a wealth ofexperience not found in civilian medicine, and accordingly, vascularabnormalities occurring subsequent to injury have provided most of the data forthese volumes.
Work in the forward areas of theaters of operations providedan invaluable experience with early wounds of blood vessels and with suchconditions as cold injury. From this experience, a number of earlier erroneousimpressions were corrected, improved methods of prophylaxis and management ofthese injuries were suggested, and newer forms of therapy were evaluated. In theZone of Interior, vascular centers were established to provide competentspecialized care for large numbers of patients with vascular injuries anddiseases. These centers provided not only facilities and personnel for optimumtreatment, but also an unparalleled opportunity for study of the problems thepatients presented. Significant improvements in the late management of arterialinjuries and cryopathies resulted from work at these centers. Ideas andtechniques were explored which forced the remarkable later advances incardiovascular surgery.
Vascular disorders not directly the result of military actionwere observed in induction centers, in military medical units, and in thespecialized vascular centers. These observations have provided data on theincidence and logistic significance of vascular disease in men of military ageand on the effects of the military environment on men with these diseases.Insofar as the cases are documented by their military medical records, theyconstitute a group from which rosters can be developed for long-term followupstudies. Such investigations can greatly benefit both military and civilianmedicine and surgery.
1(1) Medical Department, United States Army. Surgery in World War II. Vascular Surgery. Washington: U.S. Government Printing Office, 1955. (2) Medical Department, United States Army. Cold Injury, Ground Type. Washington: U.S. Government Printing Office, 1958.
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CENTERS FOR VASCULAR INJURY AND DISEASE
Experience with casualties returned to the Zone of Interiorduring the first year of the war suggested the need for specialized care ofpatients with certain injuries and diseases. However, the rapid increase innumbers of military hospitals precluded the assignment of adequate numbers ofhighly trained medical personnel to them. Nor could specialized equipment bemade available to all general hospitals. Accordingly, specialized hospitals weredesignated for the treatment of such conditions by authority of War DepartmentMemorandum No. W40-14-43, dated 28 May 1943.
Centers for the treatment of vascular disturbances first wereestablished under this memorandum, in May 1943, in West Virginia at AshfordGeneral Hospital and in California at Letterman General Hospital. In June 1944,a third center was established in the Middle West at Percy Jones GeneralHospital. Because of changing demands upon the facilities and of increasedrequirements for space, the center in California initially established atLetterman in San Francisco was transferred, in December 1943, to Torney GeneralHospital in Palm Springs, Calif., and from there, in June 1944, to DeWittGeneral Hospital in Auburn, Calif. The Middle West center was transferred inSeptember 1944, shortly after its establishment (June 1944), from Percy Jones inBattle Creek, Mich., to Mayo General Hospital in Galesburg, Ill. Ashford GeneralHospital in White Sulphur Springs, W. Va., remained a center for vasculardiseases throughout the war (May 1943-June 1946).
Referrals to the vascular centers, in accordance with thememorandum of 28 May 1943, included patients with the following disorders:"Major vascular injuries and their sequelae such as arteriovenous fistulae,aneurysms, and peripheral vascular disturbances such as chronic vasospasticconditions, those resulting from frostbite, immersion foot, and other conditionsproducing peripheral circulatory deficiency states; but not including minordisturbances such as varicose veins."
The advisability of providing centers for the study ofvascular diseases not resulting from trauma was taken under consideration by theOffice of The Surgeon General, in December 1943, and although the incidence ofnontraumatic vascular diseases was not sufficient to warrant special centers,the advantages of the centers for study as well as for therapy provided strongargument in their favor. Therefore, centers for nontraumatic vascular diseaseswere established in association with the existing vascular centers, in August1944. I
n accordance with War Department Circular No. 347, dated 25 August 1944,the designation of patients to be referred to the vascular centers was modifiedto include the following: "Patients with peripheral vascular disturbances,such as chronic vasospastic conditions, Raynaud's phenomenon, thromboangiitisobliterans, and the sequelae of trenchfoot, immersion foot, and frostbite;patients with peripheral vascular
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injuries and their sequelae, such as arteriovenous fistulaeand aneurysms. Does not include minor disturbances such as varicose veins."
At Mayo General Hospital, separate but closely cooperatingmedical and surgical sections were established with the activation of thevascular center on 15 September 1944. A similar organization was created in thevascular center at DeWitt General Hospital, in May 1945. At Ashford GeneralHospital, internists were assigned to the vascular service in the surgicalsection. The number of beds available at the three vascular centers variedduring the hostilities, reaching a peak of 1,900 during the early months of1945. In addition to providing an optimum in specialized care for thesepatients, the centers provided a unique opportunity for the study of patientswith the vascular conditions cited in the directives of 1943 and 1944. TheAnnual Report of Ashford General Hospital for the year 1944, noting the 400 bedsfor vascular patients in use in the hospital and the 183 patients who had beenoperated upon for arterial aneurysm and for arteriovenous fistula, observed:"This is unquestionably the largest number of patients with theseconditions treated in any clinic in a similar period of time and the largestnumber of aneurysms and arteriovenous fistulas treated by operation in oneinstitution throughout any period of time." Publications from thisexperience and similar experiences in the other centers comprise an invaluablecontribution not only to military surgery and the surgery of trauma, but tocivilian medicine as well.
Clinical observations of the patients in the vascular centersprovided much valuable information concerning the clinical course and managementof vascular injuries, late sequelae of cold injury, and other vasculardisturbances. The desirability of obtaining detailed physiologic studies onpatients in the vascular centers was well recognized by the medical personnel incharge. Difficulties and delays were encountered in procurement of properequipment, however, and when these did become available, adequate numbers oftrained personnel were no longer available to carry out the studies.2The numbers of physiologic studies of the circulation made in thesepatients were, therefore, regrettably few.
Although the detailed organization of the vascular servicesin the several hospitals differed, the cooperation of the various disciplinesinvolved in the care of the patients in these services was an essential factorin the success of the centers. Internists and surgeons participated jointly inthe management of the vascular problems encountered. Collaboration of thedepartments of roentgenology supported the programs at all centers. Departmentsof physical therapy and reconditioning and departments of occupational therapywere invaluable for the long-term management of the patients with vasculardisease.
2(1) Annual Report, Mayo General Hospital, 1945. (2) See pp. 11-16 in publication cited in footnote 1 (1), p. 457.
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ACUTE VASCULAR INJURIES
The most significant progress in the surgery of wounds in theU.S. Army in World War II was made in the prevention and control of infection.The principles of adequate debridement of wounds with removal of devitalizedtissue and foreign debris followed by delay in closure of wounds became wellestablished. Improvement in the prevention and control of infection by theemployment of these advances in wound surgery and by the use of chemotherapeuticand antibiotic agents was reflected by the relative increase in the importanceof arterial occlusion as an indication for amputation. While figures indicatethat amputation was required for infection 5 times as often as for arterialinjury in the German Army and 16 times as often in the Russian Army, data fromAmerican battle casualties show arterial injury to be nearly twice as frequent areason for amputation as infection (table 80). Additional benefit from improvedcontrol of infection was observed in the decrease in secondary hemorrhage fromwounds. Freeman3 reported an incidence of 1percent of secondary hemorrhage among 2,168 patients with wounds of the neck andextremities treated at the 20th General Hospital in Assam, India. In World WarI, Waugh4 reported an incidence of 14 percent from wounds in whichlong bones were involved.
TABLE 80.-Indications for amputation among German, Russian, andAmerican casualties, in World War II
Amputation | Casualties | ||
German | Russian | American | |
Cause: |
|
|
|
| Extensive trauma................................................................percent | 64.3 | 16 | 68.6 |
| Clostridial myositis or other infection ............................percent | 29.7 | 79 | 11.9 |
| Arterial injury.......................................................................percent | 6 | 5 | 19.5 |
Number studies | 1,359 | --- | 3,177 |
NOTE.-Percentages are based on the total number of amputations studied.
Source: DeBakey, Michael E., and Simeone, Fiorindo A.: Acute Battle-Incurred Arterial Injuries. In Medical Department, United States Army. Surgery in World War II. Vascular Surgery. Washington: U.S. Government Printing Office, 1955, text pp. 66-67.
The nature and location of arterial wounds in relation to the incidence ofamputation were studied by DeBakey and Simeone.5 Amputation was
3Freeman, N. E.: Secondary Hemorrhage Arising From Gunshot Wounds of Peripheral Blood Vessels. Ann. Surg. 122: 631-640, October 1945.
4Waugh, W. G.: Secondary Hemorrhage. In Bailey, Hamilton (editor): Surgery of Modern Warfare. Baltimore: Williams & Wilkins Co., 1941, vol. 1, pp. 328-332.
5DeBakey, Michael E., and Simeone, Fiorindo A.: Acute Battle-Incurred Arterial Injuries. In Medical Department, United States Army. Surgery in World War II. Vascular Surgery. Washington: U.S. Government Printing Office, 1955, chart 12, p. 81.
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required in approximately 30 percent of cases in which simplelaceration of the artery occurred and in about 50 percent when the artery wastransected. Injury associated with arterial thrombosis carried a much poorerprognosis, with loss of limb occurring in 70 percent of these patients.
The incidence of amputation with wounds of specific arteries(table 81) was noted to be at variance with previous observations and reports.In general, wounds of the arteries in the lower extremity were more likely to befollowed by amputation than those in the upper extremity. The highest proportionof gangrene occurred following injury to the popliteal artery, a finding inmarked contrast to some earlier impressions.6 Injury to more than one majorartery in an extremity was also followed by decreased salvage of the limb.
TABLE 81.-Incidence of amputation following arterial injuries, U.S. Army casualties, World War II
Artery | Total injuries (number) | Amputations | |
Number | Percent | ||
Brachial | 601 | 159 | 26.5 |
Subclavian | 21 | 6 | 28.6 |
Radial and ulnar | 28 | 11 | 39.3 |
Axillary | 74 | 32 | 43.2 |
External iliac | 30 | 14 | 46.7 |
Common iliac | 13 | 7 | 53.8 |
Femoral | 517 | 275 | 53.2 |
Anterior and posterior tibial | 91 | 63 | 69.2 |
Popliteal | 502 | 364 | 72.5 |
All others | 594 | 64 | 10.8 |
| Total | 2,471 | 995 | 40.3 |
Source: DeBakey, Michael E., and Simeone, Fiorindo A.: Acute Battle-IncurredArterial Injuries. In Medical Department, United States Army. Surgery inWorld War II. Vascular Surgery. Washington: U.S. Government Printing Office,1955, modified table 3, p. 69.
While the usual treatment for arterial wounds was ligation of the artery, restoration of blood flow by suture of lacerations, anastomosis of the severed ends of vessels, or vein grafting was attempted in a few instances. Unfortunately, the military situation and other considerations usually precluded attempt to repair the artery. The timelag between injury and arrival at a field hospital in a sample of 104 first-priority patients in the Mediterranean theater averaged 12? hours, considerably over the maximum safe time for arterial repair. In addition, the time required for the meticulous surgery involved was rarely justified, nor were sufficient experi-
6National Research Council, Division of Medical Sciences: Burns, Shock, Wound Healing and Vascular Injuries. Prepared under the auspices of the Committee on Surgery of the Division of Medical Sciences of the National Research Council. Military Surgical Manuals, vol. 5. Philadelphia: W. B. Saunders Co., 1943.
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enced personnel available in most hospitals in the field.Results in cases where repair was attempted were not uniformly good, althoughspecific instances where salvage of a limb could be attributed to restoration ofarterial flow were observed. Satisfactory evaluation of the indications andoverall usefulness of methods for direct repair could not be made from thisseries.
POSTTRAUMATIC ARTERIAL ANEURYSMS AND
ARTERIOVENOUS FISTULAS
The policy of management of aneurysms and arteriovenousfistulas in the oversea areas was entirely conservative. Usually, these lesionsdid not become manifest for several weeks. When they were observed, delay waswarranted for several reasons: to allow complete disappearance of any initialinfection, to diminish the likelihood of secondary infection or secondaryhemorrhage, to allow collateral circulation to develop, and to allow theaneurysm in the rare instance to heal spontaneously.
At the vascular center at Mayo General Hospital,7 spontaneousthrombosis with apparent cure was observed in 10 of 119 traumatic arterialaneurysms. Flow apparently continued through the artery involved in five of thenine cases where the observation was recorded. At this center, also, spontaneousclosure of the fistula was observed in 8 of 245 arteriovenous fistulas. Three ofthese required operation for an associated saccular aneurysm. At operation,thrombosis of the vein in all three was observed as the mechanism ofobliteration of the fistula. Although of considerable interest, thesespontaneous "cures" did not appear with sufficient frequency toindicate per se a prolonged period of observation before institution of surgicaltherapy.
Circulatory Studies of Patients With Arteriovenous Fistulas
Data concerning circulatory dynamics in patients witharteriovenous fistulas studied at Ashford General Hospital are summarized intable 82.
The cardiac output was studied preoperatively andpostoperatively in 47 patients by means of a low frequency, critically dampedballistocardiograph.8 The accuracy of the method was checked againstcomparative studies by the direct Fick technique. None of the patients in thisgroup had evidence of frank heart failure.
7Shumacker, Harris B., Jr.: Arterial Aneurysms and Arteriovenous Fistulas: Spontaneous Cures. In Medical Department, United States Army. Surgery in World War II. Vascular Surgery. Washington: U.S. Government Printing Office, 1955, pp. 361-374.
8Starr, I., Rawson, A. J., Schroeder, H. A., and Joseph, N. R.: Studies on Estimation of Cardiac Output in Man, and of Abnormalities in Cardiac Function, From Heart's Recoil and Blood's Impacts; Ballistocardiogram. Am. J. Physiol. 127: 1-28, August 1939.
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Observations | Preoperative | Postoperative | |
Average duration of fistula | months | 6.7 | --- |
Heart rate | beats per minute | 73.2 | 71.1 |
Stroke volume | milliliter | 118.1 | 92.8 |
Cardiac index | liters per minute per square meter | 4.9 | 3.7 |
Change in transverse diameter of heart | centimeter | --- | .45 |
Change in whole blood volume | milliliter per square meter | --- | 229 |
Source: Elkin, Daniel C.: Arterial Aneurysms and Arteriovenous Fistulas:Circulatory Effects of Arteriovenous Fistulas. In MedicalDepartment, United States Army. Surgery in World War II. Vascular Surgery.Washington: U.S. Government Printing Office, 1955, pp. 181-205.
The preoperative resting cardiac output was found to range from 21 percentbelow to 127 percent above the postoperative (normal) value. A 25-percentvariation in cardiac output was considered within a normal range. Of the 47patients, 25 exceeded this range and were therefore considered to have had asignificantly elevated cardiac output before surgery. The decrease in cardiacoutput after surgery was attributed chiefly to a change in stroke volume ratherthan to heart rate. The basal heart rate preoperatively was above 85 in only 7of the 47 patients.
Studies were also carried out on 25 patients with temporary occlusion of thearteriovenous fistula effected by means of a pneumatic tourniquet. In 17 of the25 patients, a prompt decrease in heart rate, ranging from 4 to 32 beats perminute, was observed (Branham's (Nicholadoni's) sign). In 19 patients, the stroke volume decreased by more than 10 ml. with suddenocclusion of the fistula. A decrease of the cardiac index of 0.5 to 3.6 litersper square meter of body surface was observed in 22 of the 25 patients. In fivepatients, additional tests were carried out following the administration ofatropine. The pulse rate rose, and in some instances, the cardiac indexincreased.Occlusion of the fistula at this time was not followed by a change in pulse rategreater than 4 beats per minute, while the cardiac index declined in amountsranging from 1.0 to 2.2 liters per square meter.
Determinations of the plasma and whole blood volume were made using the bluedye T-1824 (Evans blue) in 41 patients at Ashford General Hospital.Measurements were made preoperatively and 10 or more days postoperatively inall patients. In 23 patients, the change in blood volume was less than 200 cc.per square meter, considered to be within the range of normal variation. In18, there was a postoperative decrease in blood volume, ranging from 200 to1,060 cc. per square meter of body surface. Preoperative and postoperativedeterminations of hematocrit varied only slightly, indicating that parallelchanges occurred in the volumes of plasma and of whole blood.
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Studies on the effects of arteriovenous fistulas on heartsize were carried out at the vascular centers. The data obtained at Mayo GeneralHospital9 include measurements of cardiac frontal area from teleroentgenogramsof 185 patients. The predicted and actual frontal areas of the cardiacsilhouette were calculated according to the method of Ungerleider and Gubner.10
Preoperative measurements were in excess of 105 percent ofpredicted values in 55 percent of 153 of the 185 patients and in excess of 125percent of predicted values in 12 percent. Postoperatively, no patient hadmeasurements in excess of 125 percent of the predicted values and 27 percentexceeded 105 percent of the predicted size. Although definite conclusions couldnot be drawn, fistulas of long duration appeared to be associated with a greaterincrease in heart size than were those of shorter duration. Patients with largerfistulas also tended to have larger cardiac silhouettes.
There were two instances of frank congestive failure in thisgroup. One of these with two arteriovenous fistulas had been in failure beforeresection of an external iliac fistula prior to his admission to a vascularcenter. The other was a patient with a Streptococcus viridans infectionof a femoral arteriovenous fistula. The case history of this patient, the fourthwith bacteremia of this origin to be reported, has been presented in detailelsewhere.11 This patient was relieved of all his symptoms following resection ofthe arteriovenous fistula.
The findings in these patients tended to confirm previousimpressions of abnormal circulatory dynamics drawn from relatively isolatedcases in civilian experience. The numbers of patients studied here, however,added a wealth of preoperative and postoperative data in patients in whom thefistulas were successfully closed by surgery.
Surgical Management of Aneurysms and Arteriovenous Fistulas
Two technical considerations may be noted here briefly in thelight of their influence on subsequent developments in vascular surgery. Thefirst is the improvement of techniques for surgical exposure of major vessels,especially in the mediastinum. Further use and extensions of these proceduresdeveloped for managing traumatic lesions have stimulated the remarkabledevelopments in the surgery of lesions of the great vessels. The second is thedevelopment of a policy favoring restoration of normal arterial and venous bloodflow instead of interruption of the affected vessels.
9Shumacker, Harris B., Jr.: Arterial Aneurysms and Arteriovenous Fistulas: Alterations in the Cardiac Size in Arteriovenous Fistulas. In Medical Department, United States Army. Surgery in World War II. Vascular Surgery. Washington: U.S. Government Printing Office, 1955, pp. 206-224.
10Ungerleider, H. E., and Gubner, R.: Evaluation of Heart Size Measurements. Am. Heart J. 24: 494-510, October 1942.
11Elkin, Daniel C., and Shumacker, Harris B., Jr.: Arterial Aneurysms and Arteriovenous Fistulas: General Considerations. In Medical Department, United States Army. Surgery in World War II. Vascular Surgery. Washington: U.S. Government Printing Office, 1955, pp. 165-173.
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Because of the presence of collateral circulation adequate tomaintain viability of a limb in the presence of aneurysms and arteriovenousfistulas, ligation was considered the safest procedure, and repair of the arterywas not commonly attempted until the last months of the war. It becameincreasingly evident, however, that although a viable limb was maintained, thefunction of the extremity was often seriously impaired.
During the latter part of the war, therefore, repair of theartery with preservation of its lumen became the rule in appropriate cases.12While only 4 reparative procedures had been performed in the first 138cases at Mayo General Hospital, 30 of the last 57 cases were handled in thismanner. Similarly, restoration was attempted for 23 of 67 patients operated uponat DeWitt General Hospital from June to November 1945. Of these 57 attempts atrepair, 46 (81 percent) were successful in preserving normal blood flow. Largelyas a result of these successes, surgeons were no longer content with theprevious goal of maintaining a viable limb. The importance and feasibility ofrestoring normal arterial flow and normal function of the limb becameestablished.
COLD INJURY
The ravages of cold injury in warfare have seldom beeneffectively anticipated. Serious consequences in terms of significant losses ofmilitary manpower and subsequent chronic disability to individual soldiers haveoccurred through the centuries of military operations forced upon commanders insevere cold and in wet terrain. Yet, in each war, the lesson has had to belearned anew. It is especially regrettable that these losses occur in spite ofthe fact that cold injury is a preventable disease. With proper indoctrinationof troops and adequate provision of proper footgear, the condition can virtuallybe eliminated.
The nature of the problem makes effective preventive measuresa responsibility of command rather than of the Medical Department. However, thisresponsibility historically has not been recognized by higher command and staffechelons until loss of combat manpower brought the problem acutely to theforeground.
In World War II, the first experience with cold injury amongAmerican troops occurred on the Aleutians. Here, a high incidence of injuryoccurred among men exposed to cold and wet with inadequate indoctrination andimproper clothing. In sharp contrast was the paucity of cold injury in a singleunit which had had earlier experience on maneuvers in cold weather.13
These lessons were not immediately transferred to theMediterranean theater, and the first winter of fighting under difficultcircumstances, that
12Freeman, Norman E., and Shumacker, Harris B., Jr.:Arterial Aneurysms and Arteriovenous Fistulas: Maintenance of ArterialContinuity. In Medical Department, United States Army. Surgery in WorldWar II. Vascular Surgery. Washington: U.S. Government Printing Office, 1955, pp.264-301.
13Orr, R. D.: Report on Attu Operations. May 11-June 16,1943, dated 30 July 1943.
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of 1943-44, saw a distressing number of casualties from cold injury.Preventive measures were instituted too late to be effective during this firstwinter, but their value was well demonstrated during the subsequent winter, 1944-45.
A consideration of vital statistics emphasizes the military significance ofthis preventable disease. The incidence of cold injury in World War II issummarized in table 83. A total of 7,514,000 man-days were lost during theperiod of 1942-45. This is equivalent to the loss of an entire division,15,000 strong, for 16 months. Disregarding the time factor and calculated on thebasis of loss of combat troops in the European theater alone in 1944-45, itcan be said that about 5 divisions (derived from approximately 70,000 cases)were lost to combat. However, since about 90 percent of all cold injurycasualties were riflemen and since some 4,000 riflemen were in each infantrydivision, the loss of effective fighting strength could be interpreted as morenearly 16 divisions than as 5 divisions. This loss of combat manpower was inaddition to the huge logistic cost in terms of transportation, hospitaloccupancy, and professional and nursing care.
The experience with cold injury in World War II provided a wealth of materialfrom which clinical and pathologic observations could be made.
[Preliminary data based on sample tabulations of individualmedical records]
Theater or area | Total | Trenchfoot | Frostbite | Immersion foot | Chilblains | Other effects |
All theaters and area | 90,535 | 64,590 | 19,559 | 1,451 | 971 | 3,964 |
| Continental United States | 5,203 | 315 | 4,342 | 36 | 335 | 175 |
| Total outside continental United States | 285,332 | 64,275 | 15,217 | 1,415 | 636 | 3,789 |
| Europe | 71,038 | 53,911 | 13,134 | 506 | 204 | 3,283 |
| Mediterranean3 | 11,192 | 9,778 | 765 | 322 | 272 | 55 |
| Middle East | 33 | 22 | 11 | --- | --- | --- |
| China-Burma-India | 35 | 7 | 12 | --- | 15 | 1 |
| Southwest Pacific | 578 | 351 | 10 | 214 | 3 | --- |
| Central and South Pacific | 139 | 26 | 36 | 68 | 1 | 8 |
| North America4 | 2,225 | 145 | 1,230 | 295 | 141 | 414 |
| Latin America | 28 | 25 | 1 | 1 | --- | 1 |
1Consists of both admissions for cold injury and cases in which admission was for other conditions but in which cold injuries appeared as secondary diagnoses. Data on secondary-diagnosis cases are not presently available for 1942 and 1943, and for these 2 years, only admissions have been included in this table. It should be noted that cold injury admissions in 1942 and 1943 constituted but a small proportion of the World War II admissions for cold injury. For 1942 and 1943, admissions may be considered an approximation of incidence. During 1944-45, in the total Army, the incidence of cold injury exceeded admissions by 11 percent.
2Includes 64 cases among admissions on board transports.
3Includes North Africa.
4Includes Alaska and Iceland.
Source: Medical Statistics Division, Office of The Surgeon General, Department of the Army.
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These are recorded in detail in the volume on cold injury14and will be summarized only briefly here.
Cold injury may be caused by exposure to dry cold or wet andcold in various combinations. Frostbite results from actual freezing of tissues.Wet and cold combine to cause injury in immersion foot with wetnesspredominating. In trenchfoot, wet and cold are relatively equal in importance asetiologic factors. Cold injury resulting from these factors may be consideredbasically the same pathologic process, with the extent and nature of the injurydependent upon the intensity and duration of the cold stimulus. In World War II,fought predominantly in temperate climates, trenchfoot was most common.
Other factors relating to the production of frostbite wereconsidered extensively. Most important were factors classified as socioeconomic.These included (1) the intensity of combat activity, (2) the availability ofproper clothing, especially footgear, (3) the attitude of those in command, (4)adequate training and discipline of troops in prevention of cold injury, (5)previous experience with cold weather, and (6) rotation of troops.
Although pathologic material in trenchfoot is generallylimited, Friedman's15 study of 14 specimens at various stages may beregarded as definitive. The histologic pattern was common to all cold injury.The essential early change was circulatory. There was marked engorgement of thevascular tree with extravasation of red blood cells. Agglutinative erythrocytic thrombi, poor in fibrin, of the type seen in stagnant blood, werecommonly observed. Endothelial damage was not striking in early stages. Later,arteritis obliterans of varying degrees was present in arteries and veins.
Changes in fatty tissue were profound. Early leukocyticinfiltration of the deeper subcutaneous tissues and proliferation of adventitialcells of prominent capillaries and smaller vessels in the interlobular fibroussepta were seen. Later, fat lobules were diffusely infiltrated with foam cellsladen with fat, and fibrous replacement of adipose tissue was notable. Muscletissues exhibited degeneration, necrosis, and inflammation but no atrophy inspecimens of early trenchfoot. Atrophy, however, was extensive in all specimensof late cases. In early specimens, nerves in the area of inflammation wereswollen and edematous, and degeneration of both axis cylinders and myelin waspresent. Damage was severe in areas of gangrene in late cases, anddemyelinization and perineural fibrosis were marked. Many small vessels inthe nerves were thickened, and lipoid phagocytosis was pronounced. Most of thechanges observed, whether superficial or deep, were regarded as secondaryto vascular occlusion. It was also thought that structures rich in lipoids,especially adipose tissue and myelinated nerve fibers, might sustain a directthermal effect from cold trauma.
14 See footnote 1 (2), p. 457.
15Friedman, N. B.: Pathology of' Trench Foot. Am. J. Path. 21: 387-433, May 1945.
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Clinical picture.-Three separate phases in the clinicalcourse of cold injury were described in World War II, as follows:
1. The preinflammatory stage, without blisters or gangrene.The skin was cold and might still be wet.
2. The inflammatory stage, characterized by vasodilatation,blisters with or without gangrene, and by edema and dryness of the skin. Theskin was hot to palpation, except in the gangrenous areas.
3. The postinflammatory stage, characterized by coldness,cyanosis with or without gangrene, and by hyperhidrosis.
The preinflammatory stage (the ischemic or prehyperemicstage) usually lasted only an hour or two beyond the period of exposure exceptin cases with intense vascular involvement. The vasodilatation of theinflammatory stage became apparent almost immediately after the patient wasremoved from the cold environment. In cases where this was mild or almostundetectable, prompt return to duty was possible. More frequently, thevasodilatation was obvious and lasted for a week or more. Small patchy areas ofecchymosis were present at pressure points, and areas of superficial thrombosiswere sometimes present. In severe cases, early blister formation was evident.Impending gangrene might be apparent, progressing to frank gangrene within 48hours.
Pain was a prominent symptom in trenchfoot in all stagesbeyond the preinflammatory. This was in contrast to frostbite where pain wassurprisingly absent. It persisted through the inflammatory, postinflammatory,and late stages, frequently lasting for months following evacuation to thecontinental United States. In specimens available for histologic study, it wasoften possible to relate pain to excessive perineural fibrosis.16 Late in thepostinflammatory stage of trenchfoot, the skin was delicate and waxy. Ambulationwas considerably delayed by the long period of time before callus formationdeveloped sufficiently to permit weight bearing. Claw foot and pes cavusdeformities sometimes developed. Gangrene in cold injury, short of frostbite,was relatively uncommon, appearing in less than 10 percent of cases. In manyinstances, gangrene was less extensive than it originally appeared to be. Deepgangrene requiring amputation of any extent was rare. These observationsindicated a conservative approach to excision of tissue, especially in the earlystages of the disease process.
Efforts to find specific therapeutic measures applicable tocold injury were unrewarding. Initial treatment during World War II consistedchiefly in the avoidance of further trauma. The patient was most comfortablewith the feet exposed at room temperature. No local applications appearedhelpful. Drugs were not effective. A trial of early sympathetic block proveddisappointing. Surgical treatment was limited to measures to maintaincleanliness, and with few exceptions, amputation of any sort was deferred
16White, J. C., and Warren, S.: Causes of Pain in Feet After Prolonged Immersion in Cold Water. War Med. 5: 6-15, January 1944.
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until the patient was evacuated to the Zone of Interior. Inlater stages, sympathectomy proved to be of some value in minimizing tissue lossand accelerating healing. When hyperhidrosis and maceration were prominent,sympathectomy was beneficial. It was of questionable value in limiting pain ofweight bearing and in relieving the "burning" neuritic type of painobserved late in the disease.
The most significant advance in rehabilitation after coldinjury was probably the demonstration of the value of early supervised exercise.The feet of patients from hospitals where this had been insisted upon were inmuch better condition, when the patient reached installations in the Zone ofInterior, than were the feet of patients who did not participate in such earlyexercise. Radiographic evidence of osteoporosis of metatarsals and phalanges,often quite extensive, was maximal when early exercise had not been practiced.Weight bearing for these patients was often long delayed.
The importance of cold injury in terms of loss of manpowerwas also emphasized by the high recurrence rate among men returned to duty.Early estimates anticipated recurrences of about 15 percent. Experience withrecurrences and recognition of the insidious and prolonged nature of the injuryled the staffs of most hospitals in the Mediterranean theater to conclude thatless than 10 percent of men who had suffered attacks of cold injury could bereturned to combat duty.
THROMBOANGIITIS OBLITERANS
In World War II, 1,030 admissions of patients with adiagnosis of thromboangiitis obliterans were recorded, a rate of 4 per year per100,000 average strength (table 84). Of these patients, 274 were admitted to thespecial vascular centers.17 According to a study of 152 male patientswith thromboangiitis obliterans seen in the vascular centers, the majority (122patients) were between the ages of 26 and 40. The race of 2 was not recorded, 7were Negroes, and 143 were Caucasians of whom 32 were Jews. Among the 152patients, intermittent claudication was the most common symptom and was presentin 67 percent. Many complained of pain or numbness in the foot. Migratoryphlebitis was present in one-third of the patients, and ulceration was presentin 20 percent. Gangrene was unusual and was found in only 4.4 percent of thecases treated in the vascular centers.
In addition to a complete history and physical examination,special procedures were used to study the patients at the vascular centers whereconstant-temperature rooms were available. Using skin temperature as an index ofblood flow, measurements were recorded before and after thermoregulatoryvasodilatation and nerve block with procaine hydrochloride.
17Freeman, Norman E.: Peripheral Vascular Disturbances:Thromboangiitis Obliterans, Arteriosclerosis, and Arterial Thrombosis and Embolism. In Medical Department, United States Army. Surgery in World War II. Vascular Surgery. Washington: U.S. Government Printing Office, 1955, pp. 375-382.
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TABLE 84.-Morbidity data on selected vasculardiseases, U.S. Army, 1942-45
[Preliminary data based on sample tabulations of individual medical records]
Cause of admission | Admissions1 | Noneffective rate2 | Separations for disability3 | ||
Number | Rate4 | Number | As a percent of admissions | ||
Arteriosclerosis5 | 6,230 | 0.25 | 4.29 | 2,856 | 45.8 |
Thromboangiitis obliterans | 1,030 | .04 | 1.33 | 774 | 75.1 |
Raynaud's disease | 650 | .03 | .49 | 297 | 45.7 |
Varicose veins | 54,383 | 2.15 | 15.27 | 4,061 | 7.5 |
Thrombophlebitis | 14,733 | .58 | 6.24 | 3,001 | 20.4 |
Hemorrhoids | 221,289 | 8.73 | 46.08 | 1,588 | .7 |
Other vascular diseases | 10,688 | .42 | 6.32 | 4,008 | 37.5 |
| Total | 309,003 | 12.20 | 80.02 | 16,585 | 5.4 |
1The term "admissions" refers to cases newly admitted tomedical treatment facilities for the indicated disease as the primary cause ofadmission.
2Expressed as average number noneffective daily per 100,000 average strength.
3This category refers to disability separations for any cause among admissions for the specified disease during 1942-45.
4Expressed as number of admissions per year per 1,000 average strength.
5Excludes arteriosclerosis of coronary artery, kidney, and eye.
Source: Medical Statistics Division, Office of The Surgeon General, Department of the Army.
Oscillometric measurements were also made. Arteriographicstudies with Thorotrast in four patients with normal peripheral pulsesdemonstrated that circulation was maintained by means of collaterals. Thediagnosis of thromboangiitis obliterans was substantiated by biopsy in fourother patients.
Nonmedical therapy consisted chiefly of attempts to eliminatesmoking. Only 4 of 274 patients with thromboangiitis obliterans at the vascularcenters did not smoke. Nonsmoking wards with special privileges, group therapy,occupational therapy, and sedation appeared to help. Of 93 patients whosesubsequent habits were known, 77 did not smoke. Only two of these had persistentsymptoms. Of the 16 who continued to smoke, 8 were observed to have progressionof vascular obliteration. Indifferent results were secured by use ofconservative measures other than elimination of smoking. These included Buerger'sexercises, intermittent venous occlusion, and intermittent suction and pressure(pavex boot).
Sympathectomy was performed for 75 extremities in 53 of the152 patients from whom data were available. Results were felt to be good in allbut three patients. Two of these came to major amputation. Minor amputationswere required in 12 other patients.
In spite of the generally good results obtained in this groupof patients, only 24 of 274 patients (9 percent) recovered sufficiently tocontinue in service, and most of these in a limited duty capacity. The overallstatistics compiled by the Medical Statistics Division, Office of The SurgeonGeneral,
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reveal that 75 percent of the men with a recorded diagnosisof thromboangiitis obliterans were separated from the service for disability.
It was noted that thromboangiitis was encountered in theearly stages of the disease. This may relate to the fact that more advanceddisease was detected in induction centers, as reported by Jahsman and coworkers,18 and, therefore, such men were not inducted into militaryservice.It is also true that men living under stress of military life may have soughtmedical aid sooner than in civilian life. These men constitute a group fromwhich long-term followup studies on the causative factors and the naturalhistory of Buerger's disease can be done.
ARTERIOSCLEROSIS OBLITERANS
Arteriosclerosis of peripheral vessels with symptoms ofarterial insufficiency was observed in 55 patients seen in the vascular centers.19The majority of patients in this group were from 40 to 55 years of age. Theyoungest was 30; only one was over 60. Intermittent claudication was present in27 of them. Twenty complained of pain and eleven of abnormal coldness in theextremities. Ten patients had cardiac disease, five hypertension, threediabetes, and one nephritis.
Special attention in diagnosis was paid to evidences ofcalcification on roentgenograms of the extremities. Calcification was observedin all patients studied at Ashford General Hospital and in two-thirds of thoseseen at the other vascular centers. Other studies in constant-temperature roomsincluded skin temperatures and oscillometry. Lumbar sympathectomy was performedon four of these patients with satisfactory results reported in all. One minoramputation was performed; no major amputation was done. With the exception offive patients who were returned to limited duty, all men in this group wereseparated from the service for disability.
An additional 10 men were studied at Ashford General Hospitalbecause of the incidental finding of calcification in peripheral blood vesselsnoted in films taken elsewhere for other purposes. No abnormality of thecirculation could be detected clinically or by study in the vascularlaboratory. None of the roentgenograms demonstrated spotty,mottled calcifications; all showed smooth, uniform shadows fading into normalvessels proximally and distally. These findings were consistent with earlierstudies20 revealing that men with the smooth type of calcification demonstratedby X-ray were relatively symptom free as compared with those with calcificationof the mottled type.
18Jahsman, W. E., Durham, R. H., and Dallis, N. P.:Recognition of Incipient Thromboangiitis Obliterans in Young Draftees. Ann. Int.Med. 18: 164-176, February 1943.
19See footnote 17 p. 469.
20Huyler, W. C.: Calcification in Arteries of Leg. Am. J. Roentgenol. 41: 784-788, May 1939.
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ARTERIAL EMBOLISM
Arterial embolism was relatively uncommon in the Army.Sixty-seven patients with this diagnosis were admitted to hospitals during thewar; of these, six went to the vascular centers. For only 3 patients are casehistories available, and the source of the embolus is not known for any of the67 patients. One underwent a successful popliteal embolectomy overseas. Twopatients required major amputation because of gangrene of the leg. Of the total67 patients, only 8 (12 percent) were separated from the service as a result ofthe arterial embolus.
RAYNAUD'S DISEASE
The war provided an unusual opportunity to observe themanifestations of Raynaud's disease, and this diagnosis was recorded for 650admissions during this time (table 84). Those admitted were predominantly men;however, in relation to the number of men and women in the Army, the admissionrate for women was about five times the rate for men. One hundred andeighty-four patients with Raynaud's disease with digital syncope were observedat the three vascular centers. Data were available for analysis of 127 of these.21At the centers, 111 were male and 16 female, ranging in age from 21 to 51 years.There was no evidence for occlusive vascular disease in any of these patients.
The digital syncope was observed in all patients included inthe series from the three vascular centers. Of 57 patients studied at MayoGeneral Hospital, 20 exhibited the classical triphasic color changescharacteristic of Raynaud's disease. The involved digits, immediately onexposure to cold, would turn "dead white," and the patient wouldexperience in them the sensation of intense coldness, numbness, and stiffness. Aclear-cut line of demarcation was generally present between the portion of thedigit showing the pallor and that portion retaining the normal color. After avariable interval following return to a warm environment, the digits wouldbecome cyanotic. Cyanosis was followed by a period of rubor which was succeeded,in turn, by return to normal color. During the late stages of the attack, mostpatients complained of tingling, throbbing, and burning sensations or otherparesthesias. In the remaining patients, the blanching occurred, but the phaseof rubor or cyanosis or both was not perceptible before the return to normalcolor.
About half the patients were asymptomatic in the interval between attacks. The remainder experienced varying degrees of hyperhidrosis, cool-
21Shumacker, Harris B., Jr., and Abramson, David I.: Peripheral Vascular Disturbances-Vasopastic Disorders-Raynaud's Syndrome and Raynaud-Like Disorders. In Medical Department, United States Army. Surgery in World War II. Vascular Surgery. Washington: U.S. Government Printing Office, 1955, pp. 383-394.
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ness, or mild cyanosis. Trophic changes, usuallyminimal, occurred in 20 of the 127 patients. In five instances, sclerodermaor sclerodactylia was present, and one patient had areas of gangrene of thefingertips in both hands. The majority of the patients seen in the vascularcenters were separated from the service without active treatment.Sympathectomy was performed for those with incapacitating or severesymptoms. Sympathectomy was usually bilateral, with three extremitiesdenervated in four patients and four extremities denervated in five. A total of100 sympathectomies were performed in 46 of the 127 patients. At Mayo GeneralHospital, 21 sympathectomies were performed on 9 patients and the immediateresults were considered excellent in all but 1, who had all 4 extremitiesdenervated in stages. In this patient, digital syncope was abolished, but sometingling sensations persisted in cold weather. He also complained of annoyinghyperhidrosis of the trunk. The fingertips of the one patient with gangrenehealed promptly following sympathectomy.
Other disorders involving the vasomotor system were seenat the vascular centers. Some presented the picture of acrocyanosis. Otherspresented a picture similar to that of Raynaud's disease with increasedsensitivity to cold but without digital syncope or with only a vague history ofblanching. These patients were treated according to the severity of symptoms.Some were separated from the service; others returned to duty. Sympathectomy wasperformed in 6 of the 55 patients from whom data were available. Immediateresults were good in all.
At the vascular centers, the presence of digital syncope wasused as a necessary criterion for the diagnosis of Raynaud's disease in thecases reported. Six percent of these patients were observed to have symptomsand digital syncope in one extremity only, instead of the bilateraldisturbances characteristic of Raynaud's disease. It may be that unilateralsymptoms were an early manifestation of Raynaud's disease in these individualsand that the men in the service sought medical aid sooner than they wouldhave in civilian life. Patients with digital syncope differed from the groupwithout digital syncope in that hands were involved alone or more severely thanwere the feet. About one-third of the patients without digital syncope hadinvolvement of the feet alone. Although the syndromes may in many instances bequite similar, the opinion was developed at the centers that the diagnosis ofRaynaud's disease should be reserved, at least for those patients in whompallor (or cyanosis) occurs on exposure to cold.
VENOUS DISEASE
Problems encountered with disorders of the venous systemwere similar to those in civilian life. Specific studies were not undertaken ofindividuals with varicose veins and thrombophlebitis, and as a rule, they werenot sent to the vascular centers. Of interest, however, are the effects of
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these diseases on the individual as a soldier and on military manpower, andthe effect of the military situation on the disease.
Statistics compiled by the Medical Statistics Division, Office of The SurgeonGeneral, show 54,383 admissions to medical treatment facilities for varicoseveins and 14,733 for thrombophlebitis, a combined incidence of 2.73 per 1,000average strength per year (table 84). With an average duration of stay of 26days for the former condition and 39 days for the latter, the loss in militarymanpower came to approximately 2 million man-days, equal to the loss of 5,500men for a year. Approximately three-fourths of the patients were admitted in thecontinental United States. Among the patients with a diagnosis ofthrombophlebitis, the secondary diagnoses were investigated in a sample of 1,597patients.22 A diagnosis of pulmonary embolus or pulmonary infarctionwas made in 36 (2.25 percent). The provisional mortality due to varicose veinswas 0.02 percent and that due to thrombophlebitis was 0.17 percent per year per100,000 average strength. Of men admitted for varicose veins, 92 percent werereturned to duty. Nearly all of the remainder, over 4,000 men, were separatedfrom the service for disability. Of men admitted for thrombophlebitis, 21percent were returned to civilian life.
Methods of management of patients with thrombophlebitis were similar to thoseused in civilian practice. Conservative measures included bed rest, elevation ofthe legs, and elastic support. Venous surgery consisted largely in ligation ofsuperficial or deep veins in the leg as appeared to be indicated.Anticoagulation with heparin or Dicumarol (bishydroxycoumarin) or both wasused. Statistical and followup data are not available for these patients.Sympathectomy was tried because of sweating, diminished peripheral circulation,cyanosis, and pain in seven of the patients referred to the vascular centers forlongstanding thrombophlebitis. Although sweating and vasoconstriction wererelieved and pain sometimes improved, the venous congestion and edema were nothelped and in some instances appeared to be worse following surgery. It wasbelieved, therefore, that sympathectomy was not of value in treatment of thelate residuals of thrombophlebitis.
HEMORRHOIDAL VARICES
Although not generally considered among the vascular diseases, hemorrhoidalvarices caused a rather significant loss in military manpower and so will bementioned briefly. There were over 220,000 admissions to medical treatmentfacilities for hemorrhoids (table 84) with an average duration of stay of 19days. The resulting loss in manpower was 4,265,000 man-days, equivalent to theloss of a hypothetical 15,000-man division for 9.5 months.
22Data compiled by the Medical Statistics Division, Office of The Surgeon General, Department of the Army.
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Data such as these indicate to some extent the significance of a seeminglyminor illness in the progress of the military effort. The importance ofmanaging such problems with minimal loss of duty time must repeatedly bestressed.
SUMMARY
The results of observations on certain aspects of peripheral vasculardisease and injury during World War II broadened our understanding of thenature and logistic or economic significance of vascular disorders and provideda stimulus for the remarkable subsequent advances in cardiovascular medicine andsurgery. The appalling loss of limbs after acute interruption of major arteries and the apparent impairment of function after arterial interruption foracute or chronic lesions stimulated interest in exploiting reconstructivevascular surgery as opposed to obliterative surgery in the management ofboth acute and chronic arterial lesions.
Much was learned about the mistakes which permitted the catastrophicincidence of cold injury in one theater of war after another;unfortunately, too little cognizance was taken of the experience gained inantecedent operations of other theaters in this war, as well as in previouswars. The recognition of the responsibility of command with regard to preventionof cold injury should prove of inestimable value for possible futureoperations in cold environments. The information collected has provided aclearer picture than heretofore of the natural history of cold injury andof the results of conservative management. This is of value not only for themilitary but also for the civilian surgeon who encounters this condition notinfrequently during the winters of temperate climates.
Although little that is new was discovered with regard to such civilianconditions as phasic vasospasm and cold sensitivities, thromboangiitisobliterans, and arteriosclerosis, some idea was gained of the prevalence ofthese conditions in a selected and fairly homogeneous group of subjects. Muchwas learned of the clinical characteristics of these vascular diseases in their early stages, andtheir significance as a drain on military resources is better known thanheretofore. But of greatest import andbroadest implication for medical science is the fact that records areavailable of groups of individuals with certain diseases of the peripheralcirculation and contain baseline data, disappointingly scant as they may be inmany instances, for future reference. From these groups, rosters can bedeveloped for followup studies.
A review of the available records with regard to peripheral vascular diseasehas emphasized the rather obvious fact that relatively little of value forsubsequent clinical studies can be achieved without effort. Records preparedwithout anticipation that they would be of special value for subsequentinvestigation of a particular condition have been of relatively little
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use. Perhaps the greatest single achievement in thisconnection was the establishment of vascular centers in the Zone of Interior.Had nontraumatic vascular disturbances been referred to these centers earlierthan the summer of 1944, unquestionably more would have been learned about thesediseases. The credit for the unequaled achievements in the physiologic studiesand in the surgical approach to chronic arterial and arteriovenous lesions mustgo to the establishment of these centers. One regrets that lack of equipment andof personnel made it impossible to take truly full advantage of theextraordinary opportunity for study of these vascular conditions.
Finally, it is well to emphasize here that the effortexpended in the centers and by individual investigators in the field bore fruitnot alone for this and subsequent military operations but for medical science asa whole. Indeed, the great potential of valuable information from clinicalresearch based upon data recorded during the war has barely been touched andremains a challenge for the future.
