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Peripheral Vascular Disturbances--Vasospastic Disorders--
Raynaud's Syndrome and Raynaud-Like Disorders
Harris B. Shumacker, Jr., M. D. and David I. Abramson, M. D.
The vasospastic disorders are a group of peripheral disturbances in which the arterial circulation is impaired either intermittently and spasmodically or more or less continuously as a result of the tonic contractions of blood vessels. This group of diseases is differentiated from the obliterative arterial diseases by the general absence in the walls of the arteries of pathologic changes which would lead to narrowing or occlusion of the lumen. If, however, the vasospastic state is long continued, alterations of this kind may follow in certain of these conditions as, for example, Raynaud's syndrome, in which intimal thickening and thrombosis of the arteries may be observed late in the course of the disease. Furthermore, it is well known that vasospastic phenomena are frequently part of the clinical picture of obliterative vascular diseases.
Normally all components of the peripheral vascular system, including the main arteries and their branches, the arterioles, the capillaries, the arteriovenous anastomoses, and the veins, are under the control of the vasomotor center in the medulla which maintains its effect through innervation of these vessels by the sympathetic nerves. The vasomotor center and other portions of the sympathetic nervous system are influenced, in turn, by hormonal action, by various physiologic body functions, by the emotions, and by such external stimuli as warmth, cold, and noxious agents. All these factors play a part in regulating the caliber of the vessels. Normally the impulses traveling over sympathetic nerves are constrictor in action and maintain the blood vessels in a state of tonic contraction or tonus. Tonus is particularly evident in the arterioles and therefore plays a most important role in the regulation of blood flow and in the maintenance of peripheral resistance. The arteriovenous shunts, which are located chiefly in the digits and which are also richly innervated by sympathetic vasoconstrictor nerves, are important in the regulation of the temperature of the extremities, in the conservation and dissipation of body heat, and in the local vascular response to a cold environment. Tonus of blood vessels and variability in blood flow are much more evident in the
distal than in the proximal portions of the extremities or in the trunk. This phenomenon explains the predilection of the vasospastic disorders for the hands and feet.
The degree of tonus varies widely from individual to individual. Normally some persons tend to have low vascular tonus. Their hands and feet are warm and dry and maintain a relatively stabile temperature under different environmental and emotional conditions. Others have a high vasomotor tonus. Their hands and feet are cold and moist and cool rapidly upon exposure to cold; they may cool and sweat profusely under emotion.
It is sometimes difficult to differentiate between the normal subject with a high vascular tonus and the subject with a mild but true vasospastic disorder. For all practical purposes, the same findings and the same reactions to a cold environment and to emotion may be present in both. Persons with high vascular tonus obviously have more complaints in cold than in warm climates. Furthermore, in one person a state of high vascular tonus and a responsive vasomotor system may cause no distress or inconvenience while the same symptoms in another person may constitute an annoying and perhaps disabling affliction. Numerous factors are responsible for these variations including climate, occupation, and personality makeup. Hyperhidrosis may be of no consequence in certain occupations but may be incapacitating to a chemist, an engineer, or others who must work with delicate weight balances. It was frequently observed in the course of World War II that a tendency to high vascular tonus which had caused no apparent inconvenience in civilian life sometimes led to annoying symptoms under the stress of a military regimen.
RAYNAUD'S DISEASE WITH DIGITAL SYNCOPE
In 1862 Raynaud 1
described the syndrome which now bears his name and which may be
defined as a symmetrical vasospastic disorder characterized by phasic
color changes in the digits
which may lead to ulceration or gangrene in the absence of obliterative
changes in the larger
arteries. Since this syndrome was first described, a wide divergence of
opinion has arisen over
what really constitutes Raynaud's disease. Some have tended to group
loosely together a wide
variety of circulatory disorders in which the common factor is an
abnormal responsiveness to
cold. Others have attempted to limit the term Raynaud's disease to a
progressive disorder which
is not preceded by local injury or disease, which appears in early
adult life or early middle age,
which occurs chiefly in women, and which is characterized by
symmetrical digital syncope or cyanosis upon exposure to cold or upon
emotional excitation. Still others are of the
opinion that a triphasic color reaction is an essential component of
Raynaud's disease, the
reaction consisting of blanching during the attack followed first by
cyanosis, and then by rubor
prior to restitution of normal color during the recovery period.
Although it has been recognized since Raynaud's original publication that the primary color change in the digits during the attack may be either pallor or cyanosis, and although the clinical course is identical regardless of the type of the color reaction, the data analyzed in this section of this chapter were obtained only from those patients in whom digital syncope occurred. This limitation is necessary because in 1 of the 3 vascular centers in the Zone of Interior a diagnosis of Raynaud's disease was made only in those patients in whom digital syncope was present during attacks.It was therefore impossible to determine from the data submitted by this center (Ashford General Hospital) which patients had true Raynaud's disease and which had acrocyanosis or some other vasospastic syndrome. A study of the data on Raynaud's disease as reported from the other vascular centers (Mayo General Hospital and DeWitt General Hospital) reveals that most patients affected with this difficulty had pallor during the attacks. For this reason exclusion of those patients in whom a cyanotic reaction was characteristic, actually omits from the analysis only a small proportion of the patients observed.
In view of the confusion which has arisen concerning the initial color changes in Raynaud's disease, and since the typical response to cold may occur in a variety of conditions, it, has been suggested that the term Raynaud's disease might logically be replaced by the term Raynaud's phenomenon or Raynaud's syndrome. The rationale of the suggestion has been generally granted but the change in nomenclature has not been generally adopted. If and when it is, the term Raynaud's disease could be reserved for those patients with the syndrome in whom no definite etiology can be discovered and in whom intermittent episodes of digital syncope or cyanosis have been present for a relatively long period of time (not less than 2 years) without the appearance of signs of occlusive arterial disease.
Patients with so-called Raynaud's disease have been grouped in several different categories:
1. Patients with hereditary cold fingers. This is a mild condition which occurs in young persons and is characterized by blanching, cyanosis, or numbness of a few fingers on exposure to cold. Some authorities consider it a mild form of Raynaud's disease. The difficulty is seldom progressive and may become less severe or may disappear altogether with the passage of time.
2. Patients with pneumatic hammer disease. This disease, which is manifested by attacks indistinguishable from those of Raynaud's disease, results from prolonged use of vibrating tools.
3. Patients with a previous experience of frostbite. It has been questioned whether this disorder or the type of vasospastic disorder known as pneumatic hammer disease should be segregated from Raynaud's disease of unknown etiology since they are otherwise similar.
4. Patients with scleroderma and sclerodactylia associated with Raynaud's phenomenon. Opinions differ as to whether these diseases deserve a separate classification since they may be considered as cutaneous alterations which are a part of advanced Raynaud's disease itself.
Patients with acrocyanosis must be distinguished from those with true Raynaud's syndrome. In the former condition the hands or feet generally tend to be cool, blue, and wet except in an environment which causes extreme vasodilatation. Patients with this condition also have periods of marked responsiveness to cold and often to emotional stimuli. At such times there is an increase in cyanosis and coldness, though the color changes are not limited to these episodes.
As has already been mentioned Raynaud's phenomenon occurs not infrequently in association with obliterative arterial disease and other conditions in which there is organic obstruction of the arterial blood flow such as thromboangiitis obliterans, arteriosclerosis, and arteritis of either specific or unknown etiology. It may also occur in association with a cervical rib, in the scalenus anticus syndrome, and in patients in whom the vessels have been compressed by crutches or by tumors. Before a diagnosis of Raynaud's syndrome is made, therefore, it is necessary to make certain that these and other organic obliterative or occlusive disorders and conditions are not present.
One hundred eighty-four patients with Raynaud's disease with digital syncope were observed at the 3 vascular centers in the Zone of Interior during the course of World War 11.2 Ninety-seven patients were admitted to the Ashford General Hospital, 57 to the Mayo General Hospital, and 30 to the DeWitt General Hospital. Data were available for analysis on all such patients treated at the vascular centers of Mayo and DeWitt General Hospitals and on 40 of those handled at Ashford General Hospital, giving a grand total of 127 patients.
In all of these, digital syncope was observed by the attending medical officer, had been seen previously and described accurately in other medical installations, or had occurred so regularly and in so clear-cut a fashion that its presence could readily be established by interrogation of the patient.
2 In addition to the patients with clear-cut Raynaud's disease with digital syncope and those with related vasospastic disorders but without digital syncope who are discussed in this chapter as distinct groups, a large number of patients were observed at the vascular centers who presented ill-defined vasospastic conditions. These patients formed a heterogeneous group and detailed analysis of the cases would be without profit. In most instances evidences of increased vascular tone and sympathetic overactivity were present under ordinary circumstances. In some instances only 1 limb was involved, but in a few all 4 were affected.
It is likely that in some of these patients the difficulty represented little more than a normally high vasomotor tonus to which attention was directed either by the stress of Army life or by the motivation of possible release from the service because of these complaints. Both of these theories are strengthened by the numerous and varied symptoms presented by the patients which could not be adequately explained upon organic or physiologic grounds. Ed.
Of the 127 patients 5 were Negroes and 122, Caucasians. One hundred eleven (87.4 percent) were males; 16 were females. Among Army personnel the annual admission rate for Raynaud's syndrome during World War II was five times as great among females as among males; the annual admission rate for females was .10 per 1,000 mean strength and .02 per 1,000 males.
The age range in this series was from 21 to 51 years; the average age 31.4 years. In two-thirds of the patients the disorder was of 2 years duration or less; in the remainder it varied from 2 to 24 years.
In a few patients the first attack appeared during cool weather but in the great majority it occurred during cold weather. In 46 of the 97 patients concerning whom such data were available, the onset occurred in the United States. In 21 it began in England, and in 15 others in France, Germany, Belgium, or Holland. In the remaining 15 it was first observed in Alaska, Australia, Iceland, Iran, Italy, and North Africa. In only 5 of 57 patients from the Mayo General Hospital questioned on this point did the symptoms arise either during or immediately before conditions of combat.
Attacks were initiated in all instances by exposure to cold. The critical temperature, however, varied widely. Some patients experienced blanching of the fingers in slightly cool weather, but in most instances the phenomenon was observed only during severe cold. Only 14 of the 97 patients for whom such data were available gave a history of the precipitation of attacks by emotional excitement or stress and in 10 of the 14 some neuropsychiatric disorder or emotional instability was found. In 8 other patients who were found to have psychiatric disabilities emotion played no role in producing the color changes in the fingers.
Frostbite antedated the first appearance of the Raynaud phenomenon in 16 patients in most of whom the exact time relationship was not known. In 2 of 6 patients questioned on this point at Mayo General Hospital, frostbite preceded by a number of years the onset of Raynaud's phenomenon, while in the other 4 patients, attacks of digital syncope appeared immediately after frostbite had been sustained and became progressively more severe with the passage of time. Two of the 57 patients with Raynaud's syndrome at the Mayo General Hospital had used vibrating tools for some years prior to the onset of Raynaud's disorder.
Twenty of the 57 patients studied at the Mayo General Hospital showed all the features which have been regarded as classical in Raynaud's phenomenon. (Figs. 51A, B, C, and D.) The involved digits, immediately upon exposure to cold, would turn dead white and the patient would experience in them the sensation of intense coldness, numbness, and stiffness. A clear-cut line of demarcation was generally present between the portion of the digit showing
the pallor and that retaining normal color. After a variable interval following return to a warm environment, the digits would become 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 most patients complained of tingling, throbbing, and burning sensations or other paresthesias.
The triphasic color reaction was not present in the other 37 patients observed at Mayo General Hospital. In 16 patients cyanosis followed the pallor and was succeeded by a return to normal color, the phase of rubor being omitted. Eleven patients experienced rubor immediately after syncope, the phase of noticeable cyanosis being omitted. In the remaining 10 patients digital syncope was followed directly by return of normal color. In all instances, however, the initial response was either pallor or cyanosis, with pallor much more frequent. It was the general experience that digital syncope could be more regularly elicited by exposure to a cold environment or by taking a cold shower than by immersion of the limb in ice water.
The syncope affected varying numbers of digits and varying portions of digits. In some patients only the tips of the fingers or toes were affected. In others the changes occurred in the distal phalanx, the distal and middle phalanges, or the entire digit. In some patients only a single digit became blanched while in others all 5 were affected. In a number of patients blanching occurred initially in only 1 limb with involvement of the contralateral extremity occurring later. In a number of patients with symmetrical involvement the phenomenon was observed first in 1 or 2 digits in a single extremity and later it was noted to spread progressively to other portions of the hand or foot and eventually to the contralateral limb.
Of 47 patients about whom these data were recorded at the Mayo General Hospital, 27 had involvement of the second, third, fourth, and fifth digits of both hands or both feet, while some of this group also had involvement of the thumb and great toe. Unfortunately, recorded data were not always specific on the latter point. In 5 patients, 2 or 3 digits were symmetrically involved and in another the symmetrical response was observed in a single digit. Fourteen patients had asymmetrical distribution of the syncope; of this number, 8 exhibited syncope of 1 or several digits in only 1 limb.
The upper extremity was more commonly affected than the lower. In the aggregate of 127 patients analyzed, both hands were affected in 69 (54.3 percent), one hand or the other in 7 (5.5 percent), both hands and feet in 45 patients (35.4 percent), one hand and one or both feet in 3 patients (2.4 percent), both feet in 2 patients (1.6 percent), and 1 foot in 1 patient (0.8 percent).
Blanching and symptoms did not necessarily coincide. A number of patients had experienced numbness, coldness, stiffness, and paresthesias in the involved limbs and digits years before the onset of the attacks of digital syncope. In others, although the symptoms were usually worse on the side exhibiting pallor, exposure to cold frequently elicited similar complaints in
Figure 51. Typical digital syncope in patient with Raynaud's disease on exposure to cold. A. Dorsal surface of fingers. B. Palmar aspect. Marked loss of the subcutaneous pulp of the fingertips occurred in this patient within a few weeks after the onset of symptoms. C. Dorsal aspect of hands after bilateral sympathectomy. D. Appearance of fingers (palmar view) after bilateral sympathectomy. The subcutaneous pulp of the fingertips regained its normal appearance shortly after operation.
the contralateral limb in which color changes were not present. It was quite possible for these symptoms to be incapacitating in the absence of color changes. Two patients in whom sympathectomy was performed because of the frequent occurrence of blanching associated with symptoms in an upper extremity, expressed the desire after they were separated from the service to have the same procedure carried out on the other extremity in which syncope had never occurred but in which marked symptoms were being experienced.
In the interval between attacks many patients were completely asymptomatic and circulation was normal. About half of the patients seen at the Mayo General Hospital, however, had at all times some evidence of excessive sympathetic activity, manifested either as cool, moist, and slightly cyanotic hands and feet or in the form of coolness and excessive sweating. Still others, although their limbs were normal in warmth and color, experienced moderate hyperhidrosis. As a rule, symptoms experienced between acute attacks were mild.
Trophic changes occurred in 20 of the 127 patients (15.7 percent).In most instances they were slight and consisted of little more than slight distortion of the nails or slight thickening of the skin. In a few patients in this group, however, the skin covering the fingertips seemed actually to be separated from the deeper tissues. Pressure applied in this area produced a temporary dimpling; after release of pressure the skin ballooned out again. In 5 instances scleroderma or sclerodactylia was present. One patient (Fig. 52A) had small areas of bilateral gangrene of the fingertips.
In an occasional patient trophic changes occurred very early in the disease, in 1 instance there was a well marked loss of subcutaneous pulp within a few weeks of the onset of symptoms. Livedo reticularis, which is actually not a trophic change, was observed in 2 of the 57 patients treated at the Mayo General Hospital (Figs. 53A and B).
Examination of the peripheral circulation in a warm environment consistently revealed no abnormalities in any of the patients in this group. Except for the occasional absence of the dorsalis pedis pulse on one or both sides, all the pulses in the extremities were readily palpable. No signs of arteriosclerosis were noted. Various simple procedures for the determination of the state of the circulation such as the plantar pallor test, the venous filling time, oscillometric recordings of arterial pulsations, and the production of local vasodilatation by means of body heat or paravertebral sympathetic block with procaine, all indicated that no organic vascular disease existed in these cases.
The majority of the patients in this series were separated from the service without active treatment. Prior to their separation their vascular status was discussed with them and they were advised to stop smoking, to attempt to control their emotions, if the emotional factor was believed to be important in precipitating the color changes, and to live in a warm environment if possible. If it was not, they were told to attempt to avoid exposure to cold and were given advice on how to dress during the winter. If the number or severity of the attacks was distressing or incapacitating, or if nutritional disturbances existed, sympathetic ganglionectomy was performed.
One hundred sympathectomies were performed upon 46 of the 127 patients. Spread of the denervation was as follows: In 5 patients all 4 extremities, in 4 patients 3 extremities, in 31 patients 2 extremities, and in 6 patients 1 extremity.
At Mayo General Hospital 21 sympathectomies were performed upon 9 patients. Since both of us were able to follow the patients closely during their period of hospitalization the results of the experience at Mayo are presented herewith
With one possible exception the immediate therapeutic effects were excellent in all patients (Figs. 51-53). In the single exception all 4 extremities were denervated in 4 stages. Although after each operation the patient felt sufficiently relieved to desire the next stage, at the completion of the procedure he was in doubt about the total benefit he had received. He no longer had attacks of digital syncope and had relatively stabile circulation in the extremities, but experienced tingling sensations in cold weather. He also suffered from annoying, and at times incapacitating, hyperhidrosis of the trunk in warm weather. Another patient who had had all 4 extremities denervated also suffered from excessive sweating of the trunk in hot weather or with exercise, but to him the relief of vasospasm far outweighed this annoyance.
All of the remaining patients had warm, dry, well-colored extremities which tended to cool slowly upon exposure to cold. They ceased to have attacks of syncope. Those who had lost pulp in the tips of the fingers had a striking
Figure 53. A. Marked livido reticularis of lower extremities in patient with Raynaud's syndrome. B. Appearance of feet following bilateral lumbar sympathectomy. Note improvement in livido reticularis.
restoration to normal following operation (Fig. 51B). The areas of gangrene present in a single patient healed promptly and the marked livedo reticularis noted in another patient (Fig. 53A) cleared to a considerable extent after operation (Fig. 53B).
OTHER VASOSPASTIC DISORDERS
In addition to the patients with Raynaud's disease observed at the vascular centers in the Zone of Interior, 135 other patients treated at these centers suffered from a vasospastic disorder characterized by abnormal responsiveness to cold but not by clear-cut digital syncope. The findings varied in respect to the type of reaction to cold, the severity of the symptoms, and the vasomotor tonus under ordinary environmental conditions. Some patients fell into the category of true acrocyanosis. A few presented a syndrome similar to Raynaud's disease except for the absence of digital syncope. Others had a history of attacks in which they thought blanching had occurred but the color change, judging from the patients' descriptions, was either not definite or took place infrequently.
One hundred seven of the 135 patients in this group were observed at the Ashford General Hospital, 22 at the Mayo General Hospital and 6 at the DeWitt General Hospital. Data for analysis were available in 55 cases. Fifty-two of the 55 patients were males and 3 females. Two were Negroes. The age range was from 19 to 45 years, the average about 30 years. In almost three-fourths of the patients the disorder was of 2 years duration or less. In the remaining patients it had been present for periods ranging from 2 to 38 years. In 10 of the 22 patients observed at the Mayo General Hospital the vasospastic difficulty began in the Zone of Interior. In 5 patients it began in England, and in 4 in France or North Africa.In the other 3 patients the place of onset was not recorded.
In 3 of the 55 patients there was a history of antecedent frostbite but in only 1 of these was information available concerning the exact interval between the thermal injury and the first note of an abnormal response to cold. This patient reported that a progressively severer sensitivity to cold had developed shortly after a mild frostbite which had been sustained 3 years earlier. Scleroderma had been present in both hands for about 9 months before he had entered the hospital. Two patients had used vibrating tools before the development of the disorder. Infected ulcers of the fingertips were present in I of these patients.
For most of the patients in this group no active treatment was instituted. According to the severity of their disorder they were returned to duty or sepa-
rated from service, with the advice to abstain from smoking and to avoid if possible exposure to cold. If the condition was advanced, a move to a warm climate was suggested.
Twelve sympathectomies were performed upon 6 patients. Spread of denervation was as follows: In 1 patient all 4 extremities, in 1 patient both upper extremities, in 2 patients both lower extremities, and in 2 patients 1 upper extremity.
Immediate results were good in all. The extremities became warm, dry, and well colored and were no longer abnormally sensitive to cold. There was dramatic improvement in the condition of the patient who had lost subcutaneous pulp from the fingertips, and in the patient with scleroderma there was lessening in the degree of involvement as well as relief of symptoms.
The term Raynaud's syndrome should be reserved for cases in which transient digital syncope or cyanosis occurs upon exposure to cold or upon emotional excitation. By commonly accepted definition those patients with cold sensitivity but without significant color changes upon exposure to cold should be considered to present not Raynaud's syndrome but rather Raynaud-like disorders. Those with persistent cyanosis and coldness who do not manifest transient alteration in color of the digits should be placed in the category ordinarily diagnosed as acrocyanosis.
One of the criteria generally accepted as necessary for the diagnosis of Raynaud's disease is bilateral and symmetrical involvement of the extremities. In approximately 6 percent of the patients with clear-cut digital syncope in this series, however, only one extremity was involved. The explanation may be that many of these patients, because they were in the service, were seen earlier than they would have been seen in civilian life, and it is possible that the earlier the patient is observed, the more frequently will the disease be noted in one limb alone.
In approximately two-thirds of the patients at Mayo General Hospital the classical triphasic color reaction was not present. This brings up the question of whether the triphasic color response is necessary for the diagnosis. It was the consensus at the vascular centers that the diagnosis of Raynaud's disease can reasonably be entertained in the presence of vascular attacks of digital syncope or cyanosis elicited by exposure to cold or emotion, whether or not the triphasic color reaction is observed, provided no etiologic factor can be established for the condition and if signs of obliterative vascular disease are absent. Furthermore, it does not appear to be necessary for either cyanosis or pallor to be replaced by rubor as a preliminary step to the return of normal color when the extremity is exposed to a warm environment. Although segregation of patients according to the presence or absence of digital syncope is a purely artificial classification, it has been employed in this analysis, as has been explained, because the
diagnosis of Raynaud's disease was made upon this basis at one of the centers. To be sure, the dead white character of the change is so striking that it affords one means of definitely differentiating patients with a true Raynaud's phenomenon from others with cold sensitivity alone. Furthermore, it was noted, in comparing the patients showing digital syncope with those falling into the same category but without this response, that the vasospastic difficulty was generally more severe in the former group. Nutritional disturbances were also more frequently present in this group, although in at least 2 cases typical trophic changes were also noted in the group of related cases without digital syncope.
Another interesting point of differentiation is the observation that in patients with digital pallor the hands were frequently affected alone, or, if all four extremities were involved, more severely than the feet. In the other group without digital pallor, approximately a third of the patients showed changes in the feet alone. In this group the entire hand or foot was likely to be affected, while in patients with digital syncope the change in color was usually limited to the digits.
The present series confirms what is generally known concerning the treatment of Raynaud's phenomenon and similar syndromes. If the difficulty is severe, if nutritional disturbances are present, if the process cannot be controlled by suitable climatic conditions, sympathectomy offers the best means of relief. This analysis furnishes support for the general experience concerning the excellence of this procedure. If the severity of the symptoms does not make it imperative, sympathectomy of all four extremities is to be avoided because of the discomfort which may result in warm weather from hyperhidrosis of the trunk.
Examination of the available data from the Army vascular centers reveals that 87.4 percent of the 127 patients having Raynaud's disease with digital syncope, and 94.5 percent of the 55 patients with vasospastic disorders but without digital syncope, were men.Since all of the patients in the first group, and some in the second, were instances of true Raynaud's disease, this series presents further confirmation for the view that though this disorder occurs primarily in females, it affects males as well. The great predominance of males in this series, as compared to the 23 percent reported by Hines and Christensen 3 in a group of civilians, is readily explained by the overwhelmingly predominance of males in the Army. The analysis also confirms the view that Raynaud's disease and comparable conditions as they occurred in the Army were quite similar to the same disorders as they are observed in civilian life.
It has been the general impression that transient episodes of color changes in the digits of the male are usually secondary manifestations of occlusive arterial disease. This opinion is not supported by the observations in the vascular centers. Although some cases of obliterative arterial disease associ-
3 Hines, E. A., Jr., and Christensen, N. A.: Raynaud's disease among men. J.A.M.A. 129:1-4, 1 Sep 45.
ated with Raynaud's syndrome were seen, in none of the patients in this series was there evidence that this type of arterial disease existed or that it might subsequently appear. On the other hand, observations of these patients were limited to a period of months, and whether or not some will subsequently have demonstrative evidence of organic vascular disease and will no longer fall into the category of Raynaud's disease can be determined only by followup studies. It is important to emphasize, however, that nothing to suggest obliterative arterial disease was evident during the period of hospitalization.
The theory that the stress and strain of Army life may be a factor in the precipitation of peripheral vascular disorders is not supported by the findings in this series. In a considerable number of patients the attacks began in civilian life and in only a small percentage did the disorder arise under conditions of combat or just prior to such activity. Emotional stress and excitement initiated the color changes in 14 of 97 patients concerning whom these data were available, while emotional instability or other neuropsychiatric disorders were present in 18 cases.These proportions are somewhat similar to those of Hines and Christensen 4 who reported that in 9 of their 100 male civilian patients, attacks occurred with emotional excitation and that functional or neurotic disorders were present in 29 patients. Nevertheless, military life may have been a factor in some instances. Soldiers are exposed to cold weather to a far greater extent than they are in civilian life and such exposure might aggravate a vascular disorder already existent or bring into activity a latent disturbance.
In a number of patients with digital syncope studied at Mayo General Hospital the onset of attacks was antidated by frostbite. In 1 of the 22 cases of Raynaud-like syndrome without digital syncope observed at the same hospital, extremely severe vasospastic disease followed a service-incurred frostbite. The use of vibrating tools may possibly have been an etiologic factor in 2 of the 57 patients with digital syncope and in 2 of the 55 in the group who did not show this response, though in each of these instances the instruments were used in civil life many years before the onset of the attack.
In spite of the fact that Raynaud's disease and similar disorders seldom resulted directly from military service, ill-defined heterogeneous difficulties with associated vasospasm often followed, or were aggravated by, the stress of Army life or by the motivation to be separated from the service. Though many men with Raynaud's disease and similar disorders served well in the Armed Forces, it is believed that, in general, the Army policy of considering such persons as ineligible for induction or enlistment was well founded.
4 See footnote 3, p. 393.