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Chapter XVI

Contents

CHAPTER XVI

Heart Disease

Edward F. Bland, M.D.

During World War II, the fevers and fluxes of previous wars were largely replaced by the hazards of high altitudes and by the devastation of blasts and bombs-circumstances where physical fitness assumed special significance. It was, therefore, inevitable that the stability of the circulation, its diseases and its disorders, should have attracted particular attention and detailed study. The Army Medical Corps, superbly equipped and augmented manifold by experienced physicians and able investigators from civilian life, was presented with an unparalleled opportunity to study disease and to acquire new knowledge in far and unfamiliar areas of the world. It is with the activities and contributions of these men in the field of cardiovascular disease that this report is concerned.1 It is a record of achievement and progress which testifies to their devotion to duty and to the diligence with which they pursued their studies, at times under difficult and dangerous circumstances.

SELECTION FOR SERVICE

Following the passage of the Selective Training and Service Act of 1940, there immediately arose the problem of standards for the new recruits. With the world again at war and with the contemplated requirements of the service, defects and disorders of the cardiovascular system assumed an important role in the selection of men for the fighting forces. The existing standards for acceptability as outlined in the early mobilization regulations before 1940, seemed, in the opinion of the Medical Corps of the Army, to warrant revision, and those pertaining to the heart and circulation were referred to a special committee2 on cardiovascular diseases appointed in 1940 as a subcommittee of the National Research Council.

The range of normal, as always, posed a problem, especially in terms of acceptable blood pressure and pulse rates. It was at first suggested by

1This chapter on the heart has been prepared at the invitation of The Surgeon General, 10 years after the war. The lapse of a decade has been in some respects an advantage in providing a perspective of the contributions of the war years in terms of their later significance.-E. F. B.
2This committee consisted of Dr. Paul D. White (Boston, Mass.), chairman, and Drs. Edgar V. Allen (Rochester, Minn.), E. Cowles Andrus (Baltimore, Md.), Ashton Graybiel (Boston), Robert L. Levy (New York, N.Y.), and William D. Stroud (Philadelphia, Pa.). Later, in 1943, the services of some of the committee members were required in the Armed Forces, and other members were added. (Personal communication from Dr. Paul D. White.)


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this committee that the blood pressure should be determined in all cases, but it was soon recognized that great difficulties would arise in the case of healthy young candidates who under the excitement of the occasion might have temporary elevations above the normal standards. Therefore, the Army wisely decided not to follow this earlier suggestion, and a more practical compromise in dealing with this troublesome problem was provided by the recommendation that the blood pressure will be determined only in those cases in which it appears indicated. Likewise, considerable leeway was recommended in dealing with pulse rates, but special scrutiny was advised of those above 100 per minute after a reasonable rest and of those under 50 per minute.3 These important variants of uncertain significance were subjected later to careful study during the war.

The earlier observations of Lewis4 and his collaborators, in World War I, on the soldier's heart and the effort syndrome had emphasized the importance of determining the response of each recruit to effort rather than of relying on instrumental methods of examination. In this connection, it was also early recognized that routine electrocardiograms would be of little or no value from the military standpoint in demonstrating cardiac abnormalities not evident on physical examination,5 although some useful data in terms of the range of normal were later recorded in electrocardiograms on large numbers of airmen in the United States6 and in Canada.7

Thus, during the summer of 1940, the simplified and revised recommendations8 were completed and incorporated in MR (Mobilization Regulations) 1-9, War Department, "Standards of Physical Examination During Mobilization," 1 August 1940, and the buildup of the new army acquired momentum.

It soon became evident from the early tabulation available in 1942 that diseases and disorders of the cardiovascular system by these standards had rendered unacceptable for general military service an alarming proportion of the eligible population. A summary of a statistical survey carried out by Selective Service and appearing as Medical Statistics Bulletin No. 1 indicated that, of the first 2 million men examined up to 31 May 1941, examining boards disqualified for general military service approximately

3White, P. D.: The Soldier and His Heart. War Med. 1: 158-167, March 1941.
4(1) Lewis, Thomas: Report Upon Soldiers Returned as Cases of Disordered Action of the Heart (D.A.H.) or Valvular Disease of the Heart (V.D.H.). Medical Research Committee, National Research Council, Special Report No. 8. London: His Majesty's Stationery Office, 1917. (2) Lewis, Thomas: The Soldier's Heart and the Effort Syndrome, 2d edition. London: Shaw and Sons, Ltd., 1940.
5Wood, F. C., Wolferth, C. C., and Miller, T. G.: Electrocardiography in Military Medicine, With Special Reference to Its Lack of Value in the Study of Recruits. War Med. 1: 696-709, September 1941.
6Graybiel, A., McFarland, R. A., Gates, D. C., and Webster, F. A.: Analysis of the Electrocardiograms Obtained From 1,000 Young Healthy Aviators. Am. Heart J. 27: 524-549, April 1944.
7(1) Hall, G. E., Stewart, C. B., and Manning, G. W.: The Electrocardiographic Records of 2,000 RCAF Aircrew. Canad. M.A.J. 46: 226-230, March 1942. (2) Stewart, C. B., and Manning, G. W.: A Detailed Analysis of the Electrocardiograms of 500 RCAF Aircrew. Am. Heart J. 27: 502-523, April 1944. 
8The procedure for determining the blood pressure only in those cases in which it appears indicated was rescinded in MR 1-9, 15 March 1942, by requiring that blood pressure be routinely measured. This became standard requirement beginning with the March 1942 revision of MR 1-9.


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1 million (50 percent). Of these rejectees, 10 percent (96,000) had cardiovascular defects, a figure exceeded only by deficiencies of the teeth (188,000) and the eyes (123,000) and by illiteracy (100,000).9 A subsequent and somewhat more detailed report from the same source10 on the causes for disqualification for general service in 18- and 19-year-old registrants indicated that 23.8 percent of the white youths were so disqualified, whereas, of Negroes, twice as many (45.5 percent) were disqualified. Cardiovascular defects were in fourth place for the white group and in third place for the Negro group. Valvular disease and hypertension in particular were more prevalent among the Negroes. Experience with the older registrants showed a similar distribution.11

These rejection rates during the early phases of the war were disturbing and seemed excessive for the age period covered. Therefore, a conference was called in Washington, D.C., on 27 June 1942, for a discussion of the problem. In attendance were members of the Subcommittee on Cardiovascular Disease of the National Research Council (p. 419), as well as representatives of the Army, Navy, Public Health Service, Selective Service, Veterans' Administration, the National Research Council, and the Committee on Medical Research. As a result of this conference, a letter was sent to Maj. Gen. Lewis B. Hershey, Director, Selective Service System, proposing that in each of five cities special boards of experienced cardiologists reexamine 1,000 registrants rejected for cardiovascular reasons. The project was approved and thus was launched one of the most important and practical cardiovascular studies of the war years-a study which in turn led to further investigations of considerable significance. Boston, Mass., Chicago, Ill., New York, N.Y., Philadelphia, Pa., and San Francisco, Calif., were designated as the five centers; the objectives of the program were (1) to determine the problems in diagnosis that particularly concern the range of the normal cardiovascular system with respect to service, (2) to determine the possible salvage of men for the Army by reclassification as 1A, and (3) to compare the opinions of cardiovascular experts with those of the examiners of local boards and induction stations to determine the desirability of such reexaminations in this or other special medical fields throughout the coun-

9Rowntree, L. G.: Rehabilitation and Prehabilitation. J.A.M.A. 119: 1171-1175, 8 Aug. 1942.
10Rowntree, L. G., McGill, K. H., and Edwards, T. I.: Causes of Rejection and the Incidence of Defects Among 18 and 19 Year Old Selective Service Registrants. J.A.M.A. 123: 181-185, 25 Sept. 1943.
11In view of this high overall rejection rate, it is of interest to recall comparable data from World War I. An official report of the Cardiovascular Section of the Office of the Surgeon General, U.S. Army (Connor, L. A.: Report of Cardiovascular Section. In Medical Department of the United States Army in the World War. Washington: U.S. Government Printing Office, 1923, p. 377) indicated that in one million recruits 1.15 percent were rejected for cardiovascular reasons, whereas 0.88 percent with cardiac disorders were accepted for limited service only. The causes of disqualification of the 11,562 rejected were: Valvular disease, 49 percent; other organic diseases, 19 percent; and functional disorders, 23 percent. The belief was expressed that the number rejected for organic heart disease was too high, because of the tendency of the examiners to classify functional conditions, such as irritability of the heart, as instances of organic disease. In the German and British official reports covering World War I, there were no features worthy of special note in this connection (cited by Levy, R. L.: The Stimulus of War to Cardiology. Bull. New York Acad. Med. 22: 237, May 1946).


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try. The results of this study, published in 1943, by Levy, Stroud, and White12 are noteworthy. These are summarized as follows:

Of the total number of 4,994 rejectees examined, there were 863 (17.3 percent) resubmitted as 1A and 4,131 (82.7 percent) whose rejection as 4F was confirmed. It was suggested that the low salvage rate might have been due to the already free use of cardiovascular experts in these communities in connection with doubtful cases, but in any event the wisdom of extending these reexaminations for the sake of the salvage alone seemed questionable.

The chief cause for rejection was rheumatic heart disease, found in 2,476 (50 percent) of the total 4,994 men.

The second most common cause for final rejection was hypertension, found in 1,059 cases (21 percent).

Third in frequency was neurocirculatory asthenia (204 cases, 4 percent) and fourth was sinus tachycardia (189 cases, 3.8 percent). Congenital heart disease was found in 183 cases.

In conclusion, Levy and his associates pointed out that there remained eight problems of special interest as yet unsettled but concerning which tentative opinions were expressed, as follows:

1. The interpretation of apical systolic murmurs-may they, if very slight or even slight, in the absence of any other abnormal or doubtful finding be considered inadequate reason for rejection?

2. The upper limits of the normal blood pressure-may the systolic pressure in very nervous young men be set perhaps as high as 160 mm. of mercury or even a shade more, provided the diastolic pressure does not exceed 90 mm.?

3. The limits of the normal pulse rate at rest-may there not be a wider range, perhaps 40 to 120 per minute, than that given in the current criteria?

4. The heart size-especially in relation to body build.

5. The electrocardiogram of which the wide range of normal has not been explored adequately.

6. Neurocirculatory asthenia-difficult to diagnose in mild degree, but probably rejectable even when slight, unless there is an obvious correctable cause.

7. Recent rheumatic fever-a hazard even when the heart seems normal.

8. Exercise tests-the usefulness of which in cardiovascular examination for military service is open to question.

The ensuing 4 years provided ample opportunities to observe the effectiveness of the screening program, and reports from medical officers in the Zone of Interior and from those overseas are available in this connec-

12Levy, R. L., Stroud, W. D., and White, P. D.: Report of Reexamination of 4,994 Men Disqualified for General Military Service Because of the Diagnosis of Cardiovascular Defects. J.A.M.A. 123: 937-944, 11 Dec. 1943; 1029-1035, 18 Dec. 1943; Am. Heart J. 27: 435, 1944.


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tion. An early survey of the fate of selectees previously passed by their local draft boards revealed, upon later examination at the induction station at Camp Shelby, Miss., an additional rejection rate of 25 percent of which cardiac defects accounted for 1.9 percent-an indication, it was thought, of the initial confusion and variance in interpretation of the regulations prescribed by the War Department.13 The remarkable success of the overall program is borne out, however, by subsequent experience. Reports from the station and general hospitals at Fort Devens, Mass., covering a 1- and 2-year period, respectively,14 indicated an expected high incidence of functional complaints relating to the heart and the circulation and a low incidence of organic disease, with a ratio of approximately 10:1.

A reexamination for aircrew training of 344,134 men previously passed by other Army medical facilities and already in the service sheds some further light on the incidence and nature of the more frequently missed cardiovascular defects (fig. 53).15 As a result of this second screening, an additional 2,033 (5.9 per 1,000) were disqualified for cardiovascular defects. The majority, however, were for defects of conduction and for disturbances in blood pressure and circulation of psychogenic origin-variants quite understandably overlooked or considered less significant for general service.

In the South Pacific Area, Sprague and McGinn16 undertook a similar study with reference to the cardiovascular system. During the 12 months from 1 July 1942 to 1 July 1943, there were 22,085 patients (Army, Navy, and Marine) admitted to two hospital facilities. In that year, 143 patients (0.65 percent) were found to be suffering from valvular disease, degenerative heart disease, or important functional disorders of the heart. During the same period, 36 patients with rheumatic fever (0.16 percent) were evacuated. Typical effort syndrome (neurocirculatory asthenia), although important, appeared to be less common than in World War I, owing in part to this syndrome being absorbed in neuropsychiatric diagnoses without as much emphasis as in the past on the circulatory system. Sprague and McGinn believed that the elimination of men with heart ailments was being satisfactorily accomplished in enlistment, recruiting, induction, and training areas in the United States.

In concluding this review of the standards employed in the selection of men for service in World War II and of the results in terms of later reports from the United States and overseas, it is with great admiration

13(1) Saslaw, M. S.: Medical Aspects of the Selective Service System. War Med. 1: 486-492, July 1941. (2) Saslaw, M. S., and Jundermann, C. S.: Medical Aspects of the Selective Service System; Follow-Up Study. War Med. 2: 99-101, January 1942.
14(1) Brown, M. G.: Cardiac Problems in a Station Hospital. Am. Heart J. 27: 565-567, April 1944. (2) Porter, R. R.: Cardiovascular Experiences in an Army General Hospital. Am. Heart J. 27: 559-564, April 1944.
15Leach, J. E.: Diseases and Defects in Aircrew Trainees. I. Cardiovascular System. War Med. 8: 1, 1945.
16Sprague, H. B., and McGinn, S.: Heart Diseases and Disorders as Causes for Evacuation From the South Pacific Combat Area. Am. Heart J. 27: 568-574, April 1944.


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that one contemplates the long hours, the inherent difficulties, and the extraordinary efforts of our medical colleagues, on the induction boards, who so conscientiously sought and succeeded in providing the Armed Forces with men remarkably free of defects of the heart and circulation.

FIGURE 53.-Distribution of defects of the cardiovascular system in aircrew trainees. 
(Leach, J. E.: War Med. 8: 1, 1945.)

INFECTIONS AND DEFICIENCIES

Rheumatic fever and infections likely to injure the heart17 received careful study during World War II. In most instances, the observations served to extend existing knowledge, but occasionally an unusual opportunity was presented to acquire new and detailed information, notably in tsutsugamushi fever (scrub typhus), where earlier studies had been scant and sketchy. The availability and full use of electrocardiograms and roentgenograms in the field and the expert processing and study of the specimens

17In this section, a discussion of these infections is restricted to those aspects of the various diseases as they relate to the cardiovascular system.


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in laboratories overseas with subsequent assembly and analysis in the United States provided reliable and revealing data of lasting importance.

Furthermore, the harassing experiences and consequent debilitation of U.S. personnel in the prison camps of the Far East and of the inmates of the concentration camps in Germany presented medical officers with a keener insight into the untoward effects of deficiency states upon the circulation.

Rheumatic Fever and Rheumatic Heart Disease

In the early months of the war, the assemblage of large groups of men from civilian life in the crowded buildings and barracks of the training centers provided a favorable medium for the spread of respiratory infections, which at times reached epidemic proportions. This led, inevitably, to the appearance of rheumatic fever cases in considerable number. Thus, early in the war, a situation was created which, fortunately, proved far less troublesome later in the field, where more rugged but less crowded conditions prevailed. This early experience served as the basis for a number of important bacteriological and epidemiological studies concerning the role of the streptococcus and for the testing of preventive programs of early detection, intelligent isolation, and mass protection with chemotherapy (sulfonamides) and later with antibiotics (penicillin). It even provided the basis for a new and less conservative approach to the management of rheumatic fever than had hitherto been recommended, of merit perhaps under such special circumstances, although generally not acceptable in the younger age groups where the heart is more susceptible.

An extensive study18 of the protective effects of daily sulfadiazine (1.0 gm.) in 250,000 trainees at a large base, between December 1943 and April 1944, indicated that sulfadiazine could (1) check a well-advanced streptococcal epidemic, (2) repel a streptococcal outbreak at its onset, and (3) protect 85 percent of susceptible recruits from implantation with bacterial respiratory pathogens. Untoward effects were minimal, with evanescent rashes in 0.5 percent and dangerous constitutional disturbances in only 0.01 percent. All these factors are of special significance in the prevention and control of rheumatic fever.

Likewise, the Army Air Forces inaugurated a broad program19 in the spring of 1943 at 40 of the larger hospitals, representing 25,000 beds and 800,000 troops. The posts chosen were in areas where the incidence of rheumatic fever was high and intermediate, as well as low. At some airbases, the rates of incidence for 1943 were in excess of 25 per 1,000 troops, and, during the peak of the rheumatic fever season, one

18Coburn, A. F.: The Prevention of Respiratory Tract Bacterial Infections by Sulfadiazine Prophylaxis in the United States Navy. J.A.M.A. 126: 88-92, 9 Sept. 1944.
19Holbrook, W. P.: The Army Air Forces Rheumatic Fever Control Program. J.A.M.A. 126: 84-85, 9 Sept. 1944.


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large post experienced rates in excess of 100 per 1,000 troops. It was concluded from this extensive study that acute rheumatic fever occurring in high incidence was invariably preceded by a high incidence of hemolytic streptococcal infection. A 50- to 75-percent reduction was accomplished by the use of sulfadiazine prophylaxis (1.0 gm. daily) under careful conditions on a significantly large troop population. No serious drug reactions occurred, and from these data it appeared that the reduction in rheumatic fever paralleled that in streptococcal respiratory diseases.

The thesis that early physical activity might be of value in the treatment of rheumatic fever was explored by the Army Air Forces at the Regional Station Hospital, Orlando, Fla.20 The patient's comfort was employed as the principal determining factor in prescribing strict bed rest or in permitting early ambulation. In this program, apparently, the incidence of anxiety neurosis was considerably lessened, and at the same time satisfactory clinical results were obtained in 200 patients.21

A survey of the overall problem of preexisting valvular disease and the prevalence of acute rheumatic fever in the U.S. Army overseas was made in the Mediterranean (formerly North African) theater from November 1942 to the end of hostilities in May 1945.22 These data were obtained largely from the 17 general hospitals in that theater and from those station hospitals functioning in a like capacity. Approximately 1,400 patients were hospitalized, of whom more than one-half had rheumatic fever and the remainder inactive, preexisting rheumatic valvular disease. In addition, a review of the records of 1,507 consecutive post mortem examinations at the 15th Medical General Laboratory and from the 2d and 4th Medical Laboratories disclosed only 13 instances of healed valvulitis (all unrelated to the cause of death) and 2 instances of active carditis-an overall incidence of 9.9 per 1,000. This extraordinary low post mortem incidence, in terms of civilian experience, was thought to be due to careful preinduction screening and to the prompt evacuation to the Zone of Interior of patients with valvular defects or rheumatic activity.

From this study, it was noted also that rheumatic fever and rheumatic heart disease accounted for 3.9 percent of the patients returned to the Zone of Interior from the medical services of the general hospitals and that, if those patients with preexisting (and detectable) heart disease and those who had had recognizable rheumatic fever within 1 year of entry into the

20Robertson, H. F., Schmidt, R. E., and Feiring, W.: The Therapeutic Value of Early Physical Activity in Rheumatic Fever: Preliminary Report. Am. J.M. Sc. 211: 67-73, January 1946.
21This interesting report is open to the general objection that such a program is contrary to the well-established precepts of the beneficial effects of rest in combating inflammation and more specifically that it lacks clinical and laboratory details, adequate control studies, and followup data. Furthermore, the material concerns acute rheumatic fever in previously healthy young adults, where the duration of the disease is apt to be shorter and injury to the heart less common than in younger age groups. Nevertheless, it was evident that such a program had merit under the special circumstances.-E. F. B.
22Bland, E. F.: Rheumatic Fever and Rheumatic Heart Disease in the North African and Mediterranean Theater of Operations, United States Army. Am. Heart J. 32: 545-559, November 1946.


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service had been excluded, the problem presented to the Army overseas would have been reduced by 37 percent. Nevertheless, a scrutiny of the details in individual cases also indicated that the measures then in force to exclude from oversea service individuals with chronic valvular disease and those especially susceptible to rheumatic fever had been, with occasional evident exceptions, highly effective. Contrary to the earlier experiences in the training centers, no frank epidemics were encountered, and no mass protection with chemotherapy was undertaken.

Somewhat at variance with the foregoing studies are two reports from the postwar era which are provocative in their implication in terms of future planning. They concern the fate of known rheumatic fever subjects, in military service during the war, from two well-known series with long-term followups.23 In both instances, the recurrence rate was actually less in the service groups than in their civilian counterparts; furthermore, those with rheumatic heart disease (usually of minor degree) tolerated strenuous activity in basic training and under combat conditions without difficulty or detriment, and some even received decorations for outstanding service. This documented experience may well require further consideration should the Nation again be faced with a serious manpower shortage in some future crisis.

Scrub Typhus (Tsutsugamushi Fever)

Involvement of the heart and failure of the circulation in the course of severe scrub typhus had been recognized but only briefly described before World War II.24 This acute and serious disease was widely encountered by the Army in the Southwest Pacific Area and in Burma, where over 5,000 cases were reported. Three major epidemics occurred in northern Burma and in Netherlands New Guinea in 1944, and, as a direct result of the Army experience, ecologic concepts of this rickettsial disease were changed (it was found that there were no typical scrub typhus areas), a wider geographic distribution of the disease became evident, the etiology was confirmed, vector species were proved, strains were isolated, a new complement fixation test was evolved, and the clinical pattern and pathological features became established.25 Among the extensive studies completed during the war were a number of important reports of cardiovascular significance.

23(1) Wilson, M. G., Payson, J. W., and Lubschez, R.: Experience of Rheumatic Patients Who Served in the Armed Forces, 1942-1946. Am. J. Pub. Health 38: 398-405, March 1948. (2) Bland, E. F., and Jones, J. D.: Rheumatic Fever and Rheumatic Heart Disease: A 20 Year Report on 1,000 Patients Followed Since Childhood. Circulation 4: 836-843, December 1951.
24(1) Lewthwaite, R.: Pathology of the Tropical Typhus (Rural Type) of the Federated Malay States. J. Path. & Bact. 42: 23-30, January 1936. (2) Kouwenaar, W.: Investigations on Rickettsial Diseases in Sumatra; Pathological Anatomy of Human Mite Fever. Geneesk. tijdschr. v. Nederl.-Indie 80: 1119-1140, 30 Apr. 1940.
25
Developments in Military Medicine. Bull. U.S. Army M. Dept. 7: 594, July 1947.


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Two early studies at the 1st Evacuation Hospital, New Guinea, based on 200 cases indicated a mortality of nearly 10 percent.26 As regards the cardiovascular system, it was found that a sustained pulse rate above 120 per minute was of grave significance and was frequently a precursor of myocardial failure. In the severely ill patients (20 percent of the series), abnormalities referable to the circulatory system were noted, as follows: Extrasystoles were numerous; a soft, blowing, apical systolic murmur was not uncommon; a pronounced accentuation of the pulmonary second sound was frequent; and cyanosis of the lips, mucous membranes, and nail beds was often present without dyspnea or clinical evidence of pulmonary congestion. In those with a fulminating form of the disease, one or more of the following were noted: Cyanosis, severe dyspnea, profound tachycardia, atrial fibrillation, gallop rhythm, pulsus alternans, cardiac dilatation with signs of congestive failure, harsh pulmonary systolic murmur, thrombophlebitis, and pulmonary emboli. Subsequent reports by others attested to the severity of the acute illness.27

Although Kouwenaar28 had earlier demonstrated that myocarditis may complicate scrub typhus and be a frequent cause of death, the pathological features of the disease were more definitely described than ever before by the reports from the 3d Medical Laboratory overseas.29 The study was based on an analysis of 55 fatal cases in American troops in New Guinea and adjacent islands. In these cases, the heart on inspection exhibited relatively mild changes and was usually of normal weight, but the myocardium at times appeared flabby and in a few instances contained minute, pale, brownish-gray areas of degeneration and, more rarely, small focal hemorrhages. No valvular involvement was demonstrated. Microscopically, however, the heart was involved more seriously than any other organ of the body, since the dominant lesion in all cases was an acute, nonsuppurative myocarditis, focal as well as diffuse, varying in severity, patchy in distribution, and usually most severe in the interventricular septum and the left ventricle. The most marked and constant finding was a perivascular infiltration of mononuclear cells, chiefly plasma cells with lesser numbers of large mononuclear cells, occasional lymphocytes, and sometimes large multi-nucleated cells with vesicular nuclei and basophilic cytoplasm (fig. 54). The more diffuse type of myocarditis was characterized by columns of mononuclear cells, chiefly plasma cells, lying in the connective tissue interstices between individual muscle fibers and in close relationship to capillaries (fig.

26Lipman, B. L., Byron, R. A., and Casey, A. V.: Clinical Survey of Scrub Typhus Fever. Bull. U.S. Army M. Dept. 72: 63-70, January 1944.
27(1) Logue, J. B.: Scrub Typhus: Report of Epidemic in the Southwest Pacific. U.S. Nav. M. Bull. 43: 645-649, October 1944. (2) Berry, M. G., Johnson, A. S., Jr., and Warshauer, S. E.: Tsutsugamushi Fever: Clinical Observations in One Hundred and Ninety-Five Cases. War Med. 7: 71-75, February 1945. (3) Likoff, W.: Changes in the Cardiovascular System in Scrub Typhus in Early Convalescence. Am. J.M. Sc. 211: 694-700, June 1946.
28See footnote 24 (2), p. 427.
29Settle, E. B., Pinkerton, H., and Corbett, A. J.: A Pathologic Study of Tsutsugamushi Disease (Scrub Typhus) With Notes on Clinicopathologic Correlation. J. Lab. & Clin. Med. 30: 639-661, August 1945.


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FIGURE 54.-Photomicrograph, tsutsugamushi disease. Perivascular mononuclear cell infiltration around a small damaged vessel in a fibrous septum in the myocardium. (Settle, E. B., Pinkerton, H., and Corbett, A. J.: J. Lab. & Clin. Med. 30: 639-661, August 1945.)

55). The capillary endothelium often showed swelling and proliferation. Areas of focal hemorrhage were not unusual where this inflammatory reaction was severe. Degenerative changes in the cardiac muscle fibers varied from cloudy swelling, loss of striation, and fatty degeneration, to actual necrosis.

In summarizing their clinical and pathological correlations, Settle and his coworkers concluded:

Circulatory failure, evidenced by increasing pulse rate and falling blood pressure, rapid shallow respirations, cyanosis, sweating, and cold clammy skin, generally appears in the second week. This syndrome, usually diagnosed clinically as peripheral vascular collapse, closely resembled that seen in surgical shock. Less frequently circulatory embarrassment occurs which is referable to acute myocarditis. * * * The myocarditis is difficult to evaluate as a cause of death. We do not believe it is of great importance when mild. In the more severe cases, however, with degenerative changes in the myocardial fibers, death may be due to myocardial failure.

Clinically, death was ascribed to circulatory failure in about one-third of the patients, to respiratory failure in about one-third, and to cerebral


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FIGURE 55.-Photomicrograph, diffuse myocarditis in tsutsugamushi disease. (Settle, E. B., Pinkerton, H., and Corbett, A. J.: J. Lab. & Clin. Med. 30: 639-661, August 1945.)

involvement and miscellaneous complications in the remaining third. Generalized acute vasculitis was a constant finding. Woodward and Bland30 have emphasized the importance of myocarditis as a cause of death in typhus fever, and their conclusions may apply equally to tsutsugamushi disease.

The cardiac status during convalescence was the object of a special investigation for evidence of residual injury at a general hospital in the Southwest Pacific Area from July 1942 through February 1944.31 Electrocardiograms on 118 patients were normal in 109; striking, though transient abnormalities were noted in 7; and minor changes in 2. From the available clinical and laboratory data, Levine concluded:

The evidence for persistent myocardial damage following tsutsugamushi fever is not convincing. In its effect on the heart, this disease is rather like diphtheria. If the patient survives the acute phase of the disease, his heart eventually shows complete return of function.

30Woodward, T. E., and Bland, E. F.: Clinical Observations in Typhus Fever; With Special Reference to the Cardiovascular System. J.A.M.A. 126: 287-293, 30 Sept. 1944.
31Levine, H. D.: Cardiac Complications of Tsutsugamushi Fever (Scrub Typhus); An Investigation of Their Persistency. War Med. 7: 76-81, February 1945.


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Other Infections

Typhus fever.-In spite of fears to the contrary, and the wide distribution of American troops in many areas where typhus fever was endemic, this disease was rare in U.S. personnel. Shortly after the landings in North Africa and because of the known prevalence of the disease in that area, a special project was organized in French Morocco under the auspices of the United States of America Typhus Commission with the aid of the 6th General Hospital and the cooperation of the municipal authorities in Casablanca. A ward in the local infectious disease hospital was made available for the study and treatment of the disease in the local population (Arab and European). Later, in 1944, certain phases of the study were extended to the epidemic among civilians in Naples, Italy. Inasmuch as previous descriptions of the disease had emphasized circulatory collapse and the possible usefulness of cardiotonic drugs, the cardiovascular system was the object of special consideration and study.32 From detailed observations on patients with severe epidemic typhus, it was concluded, as follows:

The altered physiological state, probably owing to widespread endothelial damage in severe cases, consists primarily of an inadequate circulating blood volume, hypoproteinemia (especially the albumin fraction), hypochloremia, hemodilution without blood destruction, or an azotemia.

The circulatory collapse frequently encountered under these conditions is primarily of peripheral origin.

General supportive measures to increase circulating blood volumes are not beneficial.

Cardiac drugs (digitalis and allied preparations) are probably of benefit only in exceptional cases with clear evidence of congestive heart failure. This was not encountered in the study.

Further investigation is needed to clarify: (1) The blood electrolytes and tissue analysis to determine the fate of chloride, (2) carbon dioxide combining power and the general alkali reserve picture, and (3) blood volume studies with the use of both whole blood and plasma in support of the reduced volume.

Diphtheria.-During World War II, diphtheria was an important epidemic disease among the civilian population of both Europe and Asia, and numerous cases occurred in the American, British, and German Armies. In 1943, an estimated one million cases occurred among civilians on the European Continent, excluding the U.S.S.R., with a probable fatality rate of at least 5 percent. In 1945, there were 2,079 reported cases with at least 53 deaths among U.S. troops in Europe.33 Myocarditis was a frequent complication; in an analysis of 100 fatal cases in U.S. Army hospitals from 1943 through 1947, abnormal electrocardiograms were reported in 90 per-

32See footnote 30, p. 430.
33Diphtheria in American Troops in Europe. Bull. U.S. Army M. Dept. 5: 504, 1946.


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cent.34 Cutaneous diphtheria also was encountered, in which a 5-percent incidence of myocarditis was reported in 141 cases in American soldiers from a general hospital in the India-Burma theater from July through December 1944. In an additional 5 percent, myocarditis could not be definitely excluded. The electrocardiograph proved to be more reliable than the clinical examination in detecting cardiac involvement.35 A report on wound diphtheria in the German Army indicated myocardial involvement (by electrocardiogram) in 20 percent.36

Malaria.-It is generally agreed that malaria is the most widespread and serious disease in the world, and heavy plasmodial infection (especially Plasmodium falciparum) can cause death from myocardial inflammation or capillary thrombosis. However, in Sprague's experience37 based on several thousand cases occurring in members of the Armed Forces, mostly in the Southwest Pacific Area, there was no instance of an acute cardiac death or of a proved chronic cardiac disease. Likewise, in another, detailed study of 50 cases, including roentgenograms and electrocardiograms, Tumulty and his associates38 could detect no cardiac injury. Merkel,39 however, reported two cases of death resembling coronary thrombosis where, at autopsy, there was noted widespread obstruction of the coronary vessels by the parasites of falciparum malaria.

Dengue.-A large number of cases of dengue occurred among the naval and marine personnel in the combat area of the Southwest Pacific during the summers of 1942 and 1943, and the studies reported by Hyman40 indicated certain cardiovascular manifestations of interest. The disease was characterized by a slow pulse rate, low blood pressure, leukopenia, high temperature, and slow recovery from extreme physical and mental depression. The slow pulse rate was found to be due to a simple sinus bradycardia. Disturbances of conduction were discovered by electrocardiographic examination; these consisted of a delay in the P-R interval (up to 0.34 seconds) and a widening of the QRS complexes in three cases up to 0.12, 0.14, and 0.16 seconds, respectively. There were a few minor changes in the T waves and the R-T segments of the electrocardiogram.

Irregularities of rhythm were chiefly due to extrasystoles, for the most part ventricular in origin. The heart sounds were of poor quality, and systolic murmurs of varying intensity and localization appeared in many cases

34Edwards, W. M.: Analysis of Fatal Cases of Diphtheria. U.S. Armed Forces M. J. 2: 217-227, February 1951.
35Kay, C. F., and Livingood, C. S.: Myocardial Complications of Cutaneous Diphtheria. Bull. U.S. Army M. Dept. 4: 462-464, October 1945.
36Moser, H.: Wound Diphtheria. Deutsche med. Wchnschr. 70: 5, 7 Jan. 1944.
37Sprague, H. B.: The Effects of Malaria on the Heart. Am. Heart J. 31: 426-430, April 1946.
38Tumulty, P. A., Nichols, E., Singewald, M. L., and Lidz, T.: An Investigation of the Effects of Recurrent Malaria: An Organic and Psychological Analysis of 50 Soldiers. Medicine 25: 17-75, February 1946.
39Merkel, W. C.: Plasmodium Falciparum Malaria; Coronary and Myocardial Lesions Observed at Autopsy in 2 Cases of Acute Fulminating P. Falciparum Infection. Arch. Path. 41: 290-298, March 1946.
40Hyman, A. S.: The Heart in Dengue; Some Observations Made Among Navy and Marine Combat Units in the South Pacific. War Med. 4: 497-501, November 1943.


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(these all disappeared after convalescence). Roentgenograms showed no cardiac dilatation. The blood pressure was consistently low in almost every case and remained low for some time after the attack. There were no striking changes in venous pressure.

It was suggested that the slow pulse and other cardiovascular signs were due to an excessive vagal or autonomic response to viral infection.

Infectious mononucleosis.-A study of an epidemic of infectious mononucleosis from the Station Hospital, Fort Bliss, Tex., based on 556 cases observed during 15 months included some unusual features.41 The finding of electrocardiographic changes in 23 percent of 223 patients in the series was surprising. There was little else to differentiate this group from those with normal electrocardiograms. No cardiac symptoms were encountered except for precordial pain in an occasional patient, and abnormal physical findings were scant and unimpressive. All patients recovered.

Amebiasis.-The cardiovascular effects of emetine administration for amebiasis were studied in the Panama Canal Zone42 and at the Schick General Hospital, Clinton, Iowa.43 In the latter series, cardiovascular manifestations were observed in 83 percent of 93 subjects, but in most instances they were mild and transient. A significant fall in blood pressure occurred in 36 percent, precordial pain in 36 percent, dyspnea (of doubtful origin) in 15 percent, and tachycardia (at rest) in 13 percent. No instance of heart failure or of residual myocardial injury was observed.

Schistosomiasis.-The effects on the electrocardiogram of antimony compounds (tartar emetic and Fuadin) used in the treatment of schistosomiasis were studied at the Harmon General Hospital, Longview, Tex.,44 and at the Moore General Hospital, Swannanoa, N. C.45 In the former series, variations from the control records were found in all patients receiving tartar emetic and from 57 up to 80 percent in those receiving Fuadin, depending on the dose. The findings in the two series were similar and were confined for the most part to alterations in the T waves. The commonest finding was a decrease in amplitude, but actually negative T waves appeared in from 6 to 10 percent following tartar emetic. The S-T segment and other portions of the record (including cycle length) showed no significant change. In no instance was there evidence of cardiac weakness or persistent injury.

41Wechsler, H. F., Rosenblum, A. H., and Sills, C. T.: Infectious Mononucleosis; A Report of an Epidemic in an Army Post. Ann. Int. Med. 25: 113, July 1946; 236, August 1946.
42Dack, S., and Moloshok, R. E.: Cardiac Manifestations of Toxic Action of Emetine Hydrochloride in Amebic Dysentery. Arch. Int. Med. 79: 228-238, February 1947.
43Klatskin, G., and Friedman, H.: Emetine Toxicity in Man. Ann. Int. Med. 28: 892-915, May 1948.
44Tarr, L.: The Effect of Antimony Compounds, Fuadin and Tartar Emetic, on the Electrocardiogram of Man. Ann. Int. Med. 27: 970-988, December 1947.
45Schroeder, E. F., Rose, F. A., and Most, H.: The Effect of Antimony on the Electrocardiogram. Am. J.M. Sc. 212: 697-706, December 1946.


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Beriberi and Deficiency States

Deterioration of the cardiovascular system and circulatory failure during prolonged starvation and deficiency states was the fate of large numbers of allied personnel in the prison camps of the Far East. A remarkable and distressing on-the-spot study of beriberi in a Japanese camp by a medical officer, himself a prisoner, was reported following his release in 1945.46 The observations were made over a period of 34 months on approximately 8,000 Americans from Bataan and Corregidor and extended from their surrender on 9 April 1942 to their release on 30 January 1945. As Hibbs modestly points out, the study was handicapped by meager laboratory facilities, a complete lack of cooperation by the Japanese officials, lack of supplies for records, inability to maintain followup reports, and the poor state of health of most of the medical officers involved. In spite of these almost insurmountable obstacles, important data were obtained, and the observations and conclusions are noteworthy. These are summarized as follows:

Beriberi was probably the most important vitamin deficiency disease encountered for several reasons: (1) Beriberi had the highest incidence-everyone in the camp having some form of beriberi at one time or another; (2) beriberi had the highest morbidity-the disease was chronic in nature, incapacitating a soldier for months; (3) beriberi had complications and sequelae which were considered to be permanently disabling; and (4) beriberi was directly responsible for more deaths than any other vitamin deficiency disease; it was observed with many novel features far removed from the textbook picture.

In conclusion, Hibbs states that (1) enlargement of the heart is not to be expected in the majority of cases of beriberi heart disease, (2) thiamine deficiency may be the cause of almost any type of cardiac arrhythmia, (3) both left and right ventricles are involved in congestive heart failure, (4) digitalis is without benefit in the treatment of beriberi heart failure, and (5) beriberi heart disease is an acute medical emergency which must be treated energetically to prevent secondary irreversible damage or death.

Further observations on the released soldiers after the active phases of their avitaminosis had been relieved were more encouraging than the preceding paragraph suggests, since there were relatively few residua of a serious nature.47 However, an occasional instance of otherwise unexplained cardiac enlargement and chronic congestive failure has been described as a probable aftermath of wartime beriberi.48

46Hibbs, R. E.: Beriberi in a Japanese Prison Camp. Ann. Int. Med. 25: 270-282, August 1946.
47Fischbach, W. M.: Cardiac and Electrocardiographic Observations on American Prisoners of War Repatriated From Japan. U.S. Nav. M. Bull. 48: 69-75, January-February 1948.
48Alleman, R. J., and Stollerman, G. H.: The Course of Beriberi Heart Disease in American Prisoners-of-War in Japan. Ann. Int. Med. 28: 949-962, May 1948.


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FIGURE 56.-Electrocardiogram in severe malnutrition, showing broad high T waves and a long Q-T interval. (Ellis, L. B.: Brit. Heart J. 8: 53-61, April 1946.)

The striking electrocardiographic abnormalities reported from Europe by Ellis49 on four freed prisoners of war suffering from severe and prolonged malnutrition are of interest in this connection. These abnormalities consisted of marked prolongation of the Q-T interval, unusually well marked but not persistent U waves, and, less constantly, depression of the S-T segment, alterations in T waves, and increase in the P-R and QRS intervals (fig. 56). Although the available data did not permit definite conclusions on the cause of these changes, they were thought to represent a composite picture of prolonged protein and carbohydrate starvation and electrolyte imbalance. There was no evidence in these patients of a significant degree of anoxia of cardiac muscle or of clinical avitaminosis. Vitamin deficiency, however, could not be entirely ruled out as an etiological factor in spite of the absence of clinical symptoms or signs. That the electrocardiograms returned to normal within 2 to 3 weeks after the institution

49Ellis, L. B.: Electrocardiographic Abnormalities in Severe Malnutrition. Brit. Heart J. 8: 53-61, April 1946.


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of an adequate regimen suggests that the changes were due to functional and not to structural causes.50

HYPERTENSION

The importance of hypertension in determining fitness for active military duty is indicated by the fact that in World War II one-fourth of those rejected for cardiovascular defects were disqualified for this reason (p. 422). As was stressed by Levy and his associates, the range of the normal, both systolic and diastolic, was not clearly defined, and critical levels above which it is unsafe or unwise to accept a candidate had not been established on a sound factual basis. Transient emotional elevations of blood pressure were recognized and properly discounted by the Army. The guiding principles employed were set forth in MR 1-9, 15 October 1942, as follows: "If the blood pressure appears to be abnormally high, it will be measured after the subject has rested in the recumbent position." A cause for rejection is: "Persistent blood pressure at rest above 150 mm. systolic or above 90 diastolic, unless in the opinion of the medical examiner the increased blood pressure is due to psychic reaction and not secondary to renal or other systemic disease."

The high rejection rate led to a series of conferences early in the war from which evolved a carefully planned program of study for the primary purpose of obtaining information useful to the Army, but there was also a desire to contribute to the general knowledge of the problems involved. This important project was conceived and organized in 1942, and the subsequent results were published between 1944 and 1947.51 Because of the significance of the data and of the circumstances involved, certain details of this project, as recorded by Hillman, Levy, Stroud, and White,52 warrant special recognition in this account of World War II events. These details are as follows:

At a meeting of the Subcommittee on Cardiovascular Diseases of the National Research Council, held in Washington in June 1942, * * * the advisability of modifying certain of the existing criteria of physical fitness was considered. The urgent need for

50In view of postwar recognition of the profound and similar effects on the electrocardiogram of severe alterations of potassium concentration in the blood, this seems, in retrospect, to be the most likely explanation.
51(1) Hillman, C. C., Levy, R. L., Stroud, W. D., and White, P. D.: Studies of Blood Pressures in Army Officers; Observations Based on Analysis of the Medical Records of 22,741 Officers of the United States Army. J.A.M.A. 125: 699-701, 8 July 1944. (2) Levy, R. L., Hillman, C. C., Stroud, W. D., and White, P. D.: Transient Hypertension: Its Significance in Terms of Later Development of Sustained Hypertension and Cardiovascular-Renal Diseases. J.A.M.A. 126: 829-833, 25 Nov. 1944. (3) Levy, R. L., White, P. D., Stroud, W. D., and Hillman, C. C.: Transient Hypertension; The Relative Prognostic Importance of Various Systolic and Diastolic Levels. J.A.M.A. 128: 1059-1061, 11 Aug. 1945. (4) Levy, R. L., White, P. D., Stroud, W. D., and Hillman, C. C.: Transient Tachycardia; Prognostic Significance Alone and in Association With Transient Hypertension. J.A.M.A. 129: 585-588, 27 Oct. 1945. (5) Levy, R. L., White, P. D., Stroud, W. D., and Hillman, C. C.: Overweight; Its Prognostic Significance in Relation to Hypertension and Cardiovascular-Renal Diseases. J.A.M.A. 131: 951-953, 20 July 1946. (6) Levy, R. L., White, P. D., Stroud, W. D., and Hillman, C. C.: Sustained Hypertension; Predisposing Factors and Causes of Disability and Death. J.A.M.A. 135: 77-80, 13 Sept. 1947.
52See footnote 51 (1).


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manpower made it imperative to recruit all eligibles who could serve with safety to themselves and with advantage to the armed forces. With respect to the upper limits of blood pressure, it was suggested by some that these might be raised, whereas others claimed that the existing levels were too high. As a result of the discussion, it became clear that a change in either direction was not justified on the basis of the evidence at hand; for there was no large series of observations carried out over long periods of time. To obtain the lacking information as quickly as possible seemed highly desirable.

It was known that, in the Office of the Surgeon General of the Army, there were filed abstracts of the medical records of some 23,000 officers, on which were noted the results of annual physical examinations made between January 1924 and December 1941. Appended to many of these were the detailed reports of special examining boards, submitted on the occasion of promotion or retirement or of examination incident to hospitalization. Often electrocardiograms and teleroentgenograms were made at such times, and other laboratory procedures were employed. In many cases the record began with the admission of the young man, as a cadet, to West Point. Annual examinations were discontinued in 1941 owing to the pressure of work essential to the war. No examinations were made after an officer had retired unless he applied for reinstatement for active duty. Samples of these records were inspected, and it was at once apparent that here was a valuable storehouse of material.

To supplement the histories in the Surgeon General's Office, Col. Albert G. Love, Medical Corps, United States Army, kindly offered to place at our disposal his notes on the medical records of 5,000 officers who were in the service on Jan. 1, 1901 and also those commissioned between that time and Dec. 31, 1916. These had been analyzed in collaboration with Professor Lowell J. Reed of the Johns Hopkins University, and the results published in 1931 and 1932 in a series of papers dealing with "Biometric Studies on U.S. Army Officers."

The availability of this material appeared to offer an unusual opportunity to study variations of blood pressure during the passage of a number of years and to relate them to various other factors. Of particular immediate importance was the significance of transient hypertension. Additional topics for consideration which at once came to mind were the later course of those who developed sustained hypertension, the relationship between body weight and hypertension, and the significance of tachycardia, both transient and sustained. These could all be correlated with disability retirement and mortality rates at various ages, with the causes of retirement and death and, in those who died, with the findings at necropsy.

*          *          *          *          *          *          *

On Sept. 12, 1942 a contract, recommended by the Committee on Medical Research, was made between the Office of Scientific Research and Development and Columbia University, providing funds for this study. Dr. Levy was appointed chairman of the project.

From this study and analysis of the long-term records of 22,741 officers of the U.S. Army, the following findings of significance were established:

1. Transient hypertension or transient tachycardia or overweight, each by itself, increased the probability of the later development of sustained hypertension and of retirement or death with cardiovascular-renal disease. The presence of two of these conditions was of greater importance, in these respects, than that of any one alone. The presence of all three was of major prognostic importance.

2. In the group in which sustained hypertension developed, the leading causes of retirement because of cardiovascular-renal diseases were hypertension itself, coronary heart disease, and cerebral arteriosclerosis, including


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hemorrhage and thrombosis. These three conditions together accounted for 84 percent of such retirements. Coronary heart disease and cerebral hemorrhage together were responsible for 66 percent of the deaths from cardiovascular-renal conditions during the period of observation.

It was suggested that, in revising standards for the selection of those physically qualified for military service, factors predisposing to the later development of sustained hypertension and cardiovascular-renal diseases should be taken into account. When making disposition of men in whom sustained hypertension develops while they are in service, consideration may well be given to the high incidence and disabling nature of the circulatory and renal complications associated with this condition. The extent to which the conclusions derived from these studies are applied can be varied according to the need for manpower.

Furthermore, it seems probable that the facts obtained from this analysis hold true also for the general male population of comparable physical fitness and similar age groups.

Thus ended a unique undertaking, based on the exigencies of the war and combining the accumulated experience of the Army and the resources of the Government with the services of an expert civilian committee.

CORONARY DISEASE

The stress and strain of the war upon carefully screened young men in service made it possible to study the potential effects of these factors upon latent and unsuspected coronary arteriosclerosis. Furthermore, the results of this study may be, in part, responsible for the existing suspicion that coronary disease is more prevalent in young men of this generation than in those of the past.

Relatively early in the war, an analysis was undertaken of the clinical and pathological features in 80 fatal cases in soldiers from 20 to 36 years of age. This material from the Army Medical Museum, Washington, D.C., revealed that coronary disease occurred in men of various racial and national origins without predilection for any particular stock.53 The most striking, and presumably predisposing, factor was overweight, present in 91 percent of the cases. Vigorous effort and the activities of early morning chores brought on the fatal attacks in over 50 percent of the cases. Sudden death or the onset of the fatal attack occurred during sleep in 10 percent. The basis of the occlusion in every case was arteriosclerosis, and a scar of previous infarction was found in 59 percent.

A subsequent and more extensive study of sudden and unexpected death in young soldiers, based on material received at the Army Institute of Pathology, Washington, D.C., during the 4 years between January 1942 and

53French, A. J., and Dock, W.: Fatal Coronary Arteriosclerosis in Young Soldiers. J.A.M.A. 124: 1233-1237, 29 Apr. 1944.


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January 1946, contributed further significant data.54 Among the 40,000 autopsy protocols, there were approximately 1,000 which concerned young and apparently healthy soldiers whose collapse and death were so sudden and unexpected that there was little or no opportunity to make an ante mortem diagnosis. The most frequent conditions responsible for death under these circumstances were heart disease, intracranial hemorrhage, and meningococcemia. Among these 1,000, there were approximately 350 sudden deaths from previously unrecognized heart disease; almost 300 were due to coronary arteriosclerosis. The following additional facts and opinions were derived from a detailed analysis of the data on 115 who died of coronary disease: There were 8 percent under 25 years of age, and 22 percent under 30. White and Negro soldiers were represented in proportion to their numbers in the Army. The body weights were significantly greater than those for healthy inductees; however, this was equally true of the weights in autopsy protocols of soldiers dead of accidental injuries. This important control observation was not considered in the earlier report by French and Dock (p. 438); its possible significance is weakened somewhat, as Moritz and Zamcheck noted, by the fact that the body weights were mostly estimates and hence cannot be used without reservation in appraising the relation of obesity to any given disease.

The frequency with which the onset of the fatal attack of coronary insufficiency occurred during a period of strenuous physical exertion supports the plausible opinion that violent exercise is probably dangerous for persons with severe coronary disease. Moritz and Zamcheck further suggest, however, that this information would be of little practical value to the Army in the prevention of such casualties, since none of these soldiers was suspected of underlying heart disease before death, and even in retrospect less than 25 percent of them had a history of symptoms that might have been of cardiac origin.

In addition to the two foregoing reports assembled during the war, a third and important study, based in part upon the material from the Armed Forces Institute of Pathology but expanded during the early postwar years to include further data from the Veterans' Administration, has been reported in papers by Yater and his associates.55 These reports dealt with initially nonfatal coronary disease in World War II soldiers. The earlier communications concerned the younger men, from 18 to 39 years of age, and the later study the age group over 40. The 1951 report included data

54Moritz, A. R., and Zamcheck, N.: Sudden and Unexpected Deaths of Young Soldiers; Diseases Responsible for Such Deaths During World War II. Arch. Path. 42: 459-494, November 1946.
55(1) Yater, W. M., Traum, A. H., Brown, W. G., Fitzgerald, R. P., Geisler, M. A., and Wilcox, B. B.: Coronary Disease in Men Eighteen to Thirty-Nine Years of Age: Report of Eight Hundred Sixty-Six Cases, Four Hundred Fifty With Necropsy Examinations. Am. Heart J. 36: 334-372, September 1948; 481-526, October 1948; 683-722, November 1948. (2) Yater, W. M., Welsh, P. P., Stapleton, J. F., and Clark, M. L.: Comparison of Clinical and Pathologic Aspects of Coronary Artery Disease in Men of Various Age Groups: Study of 950 Autopsied Cases From Armed Forces Institute of Pathology. Ann. Int. Med. 34: 352-392, February 1951.


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on 950 autopsied cases. This formidable undertaking was approached as follows:

During 1945-46, a study was made of 866 male patients, ages 18 through 39, for whom the principal diagnosis was coronary artery disease. These included 416 who had survived typical attacks of acute myocardial infarction and whose case histories were obtained from the Veterans' Administration and 450 who died while in the Army and whose autopsy protocols were in the files of the Armed Forces Institute of Pathology.

Following completion of the study of the younger age group, research was begun to determine what similarities or differences might exist in the clinical and pathological aspects of coronary artery disease in older men as compared to those under 40 years of age. For this purpose, selection was made of 500 additional autopsy records of men 40 years of age and over.

That the 635 fatalities from coronary artery disease among World War II soldiers in this series do not represent, either numerically or percentagewise, the total picture of its incidence among military personnel is shown by the fact that as of 30 June 1948, 6,075 World War II veterans were receiving service-connected disability pension awards principally because of coronary artery disease.

From these two related studies, it was found that Negroes comprised only 4 percent of the World War II soldiers in the series, although they constituted approximately 10 percent of the Army during that period.

No definite conclusions could be drawn as to the role of army life in precipitating fatal attacks; however, generally shorter length of service of these men as compared with the average in the World War II Army suggests that they were not in condition to withstand the stress of army life. In contrast to the findings of French and Dock (p. 438) and of Moritz and Zamcheck (p. 439), the etiological importance of obesity as a predisposing factor in coronary disease could not be definitely established in any age group, although a tendency to overweight appeared to accompany advancing age. The onset of the coronary attack occurred in a higher percentage of the younger men while they were engaged in strenuous activity and in a higher percentage of the older men while they were in bed. The data also suggested that coronary disease carried a more serious prognosis for men under 40 than for those of 40 and over.

The relation of unusual or extreme effort to acute myocardial infarction is of considerable practical as well as theoretical importance, since legal decisions and line-of-duty determinations are often vitally affected thereby. Blumgart56 cited some striking examples and summarized his Army experience in this connection. He discussed the clinical criteria which he considered necessary to establish this relation and the pathological mechanisms involved.

These extensive data acquired during the war have emphasized the mounting incidence of coronary disease in otherwise vigorous young men and have indicated the need for broader and more basic studies in its causes and its prevention. In conclusion, a final lesson of the war years

56Blumgart, H. L.: The Relation of Effort to Attacks of Acute Myocardial Infarction. J.A.M.A. 128: 775-778, 14 July 1945.


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should not pass unheeded: Industry, faced with a manpower shortage incident to the war, demonstrated that individuals with healed infarcts and those with lesser degrees of angina, although unsuited for the Armed Forces, are capable of pursuing useful and productive lives under proper training and supervision without added risk to themselves or to their fellow workers. Their zeal and energy more than compensate for their physical handicaps. It is unfortunate that with the passing of the emergency the rules and practices of peacetime economy often force such useful workers into the ranks of the unemployed. This practical demonstration as a corollary of the war presents a challenge to the medical profession and to the legislators in planning future programs for the welfare of the United States and its citizens.

NEUROCIRCULATORY ASTHENIA

(Soldiers' Heart, Effort Syndrome, Shellshock, Anxiety Neurosis)

A wide variety of names had been used to identify the syndrome which, in 1918, The Surgeon General officially designated as "neurocirculatory asthenia," a term considered moderately descriptive and yet adequately noncommittal.57 In 1871, DaCosta,58 an army physician in the Civil War, proposed the term "irritable heart." Another early American description of the disorder was given by Beard,59 in 1880, using the terms "neurasthenia" and "nervous exhaustion." The name "anxiety neurosis" was substituted later for neurasthenia by Freud.60 In World War I, the terms "shellshock" and "effort syndrome" were employed, the latter chiefly by British investigators under Sir Thomas Lewis. A group of American workers61 in World War I devised the term "neurocirculatory asthenia," and this term was adopted for use in the American Army and was the title of the report by Brooks62 in the official Army history of World War I. Studies of civilians with the disorder were carried on between World Wars I and II by Craig

57This section on neurocirculatory asthenia has been prepared, at my request, by Dr. Mandel E. Cohen, Boston, Mass., whose long interest and extensive studies qualify him to speak with authority concerning this controversial but important symptom complex, especially troublesome during the stress of war.-E. F. B.
58DaCosta, J. M.: On Irritable Heart; A Clinical Study of a Form of Functional Cardiac Disorder and Its Consequences. Am. J.M. Sc. 61: 17, January 1871.
59Beard, G. B.: A Practical Treatise on Nervous Exhaustion (Neurasthenia): Its Symptoms, Nature, Sequences, Treatment. New York: William Wood and Co., 1880.
60Freud, S.: Ueber die Berechtigung von der Neurasthenia einen Bestimmten Symptomencomplex als "Angstneurose" abzutrenn. Neurol. Centralbl. 14: 50, 1895.
61(1) Oppenheimer, B. S., Levine, S. A., Morison, R. A., Rothschild, M. A., St. Lawrence, W., and Wilson, F. N. (cited by T. Lewis): Report on Neuro-Circulatory Asthenia and Its Management. Mil. Surg. 42: 409, April 1918. (2) Oppenheimer, B. S., Levine, S. A., Morison, R. A., Rothschild, M. A., St. Lawrence, W., and Wilson, F. N.: Illustrative Cases of Neurocirculatory Asthenia. Mil. Surg. 42: 711, 1918.
62Brooks, Harlow: Neurocirculatory Asthenia. In The Medical Department of the United States Army in the World War. Washington: U.S. Government Printing Office, 1928, vol. IX.


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and White.63 In World War II, British studies under Wood64 were reported as DaCosta's syndrome or effort syndrome. In the American Army, official terminology was shifted somewhat to fit certain etiological and psychological theories, and terms, such as "anxiety state," "somatization reactions," "psychogenic reactions," and "combat fatigue," were introduced. German Army terminology was even longer, such as "personalities with mixed psychic * * * constitutionally labile * * * organ systems." World War II investigations, however, were mainly reported under the term "neurocirculatory asthenia" (anxiety neurosis, neurasthenia, effort syndrome, nervous exhaustion) in an effort to reach physicians of various interests and specialties.

Research During and After World War II

Because of the importance of neurocirculatory asthenia in World War I, further organized research was conducted during and after World War II under the leadership of White and his associates, with Army support.65 The plan of study was based on applying the best quantitative techniques of the day to the problem of explaining the symptoms and the other phenomena of the disorder. For instance, because patients complained of troubles while working, studies in work physiology were done. Because of such symptoms as nervousness, psychological studies were done. Because patients said other members of the family had symptoms similar to theirs, genetic studies were done. This is, then, simply the method of scientific investigation in contrast to a method used so often in fields such as psychology, for instance, of applying the theories and conclusions of a special school or authority to a given problem.

Studies of breathing and dyspnea

Patients with neurocirculatory asthenia commonly complain of shortness of breath, of inability to draw a satisfactory breath, and of inability to do hard work because of breathlessness. Such patients sigh, have difficulty in wearing a gas mask, and find it extremely difficult to run while wearing the mask. They may complain of difficult breathing during swimming and of shortness of breath for as far back as they can remember.

63Craig, H. R., and White, P. D.: Etiology and Symptoms of Neurocirculatory Asthenia; Analysis of One Hundred Cases, With Comments on Prognosis and Treatment. Arch. Int. Med. 53: 633-648, May 1934.
64Wood, P.: DaCosta's Syndrome (or Effort Syndrome). Brit. M. J. 1: 767-772, 24 May 1941.
65(1) Cohen, M. E., White, P. D., and Johnson, R. E.: Neurocirculatory Asthenia, Anxiety Neurosis or the Effort Syndrome. Arch. Int. Med. 81: 260-281, March 1948. (2) Cohen, M. E., Johnson, R. E., Consolazio, F. C., and White, P. D.: Low Oxygen Consumption and Low Ventilatory Efficiency During Exhausting Work in Patients With Neurocirculatory Asthenia, Effort Syndrome, Anxiety Neurosis. J. Clin. Invest. 25: 920, 1946. (3) Cohen, M. E., Johnson, R. E., Chapman, W. P., Badal, D. W., Cobb, S., and White, P. D.: A Study of Neurocirculatory Asthenia, Anxiety Neurosis, Effort Syndrome. Final Report to the Committee of Medical Research, Office of Scientific Research and Development. Washington: National Research Council, 1946.


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Quantitative studies of respiration showed that, while resting and breathing oxygen, patients with neurocirculatory asthenia have more rapid respiratory rates and more shallow breathing than do healthy control subjects. The ventilation index was abnormally high in patients for four speeds of exercise; the more severe the exercise, the greater the discrepancy between patients and controls. This was due to a high ventilation factor and not to vital capacity. (The mean vital capacity for 54 healthy men was 2,387 cc. per square meter of body surface and for 73 patients with neurocirculatory asthenia, 2,362 cc.)

The ventilation index is usually an objective correlate of the subjective phenomenon of dyspnea. When the level of ventilation index was the same, more patients than healthy controls complained of dyspnea. Furthermore, the degree of dyspnea complained of was greater in patients than in healthy controls doing the same amount of exercise and with the same ventilation index.

Drury,66 in 1919, had demonstrated that intolerant hyperpnea developed in these patients at a lower level of concentration of inspired carbon dioxide than in control subjects. It was noted that patients complained of choking or smothering and had undergone anxiety attacks in crowded places, such as subways, bargain basements, and theaters. This suggested a study in which 43 patients and 27 control subjects first breathed oxygen for 12 minutes; then, a second test of 12 minutes of rebreathing was done in which carbon dioxide had accumulated to about 4 percent of inspired air. This showed that an increase of sighs to a mean of 7.5 per 12-minute period took place in patients as contrasted with 2.8 in comparable controls. It was concluded that intolerable hyperpnea, increased sighing, and symptoms of the disorder identical with anxiety attacks can be produced by rebreathing a mixture containing an excess of carbon dioxide. It was not clear, however, that a natural stimulus for the disorder was reproduced experimentally. Nor did this observation show whether the entire abnormal response was set off by carbon dioxide, by nonspecific discomfort (this seemed unlikely), or by the awareness of the sensation of disturbed breathing or by something else.

Cardiovascular studies

Cardiovascular studies showed only a few significant deviations from the normal. The pulse rate at rest, during exercise, and after exercise was higher than average by 8 to 10 beats per minute as compared with healthy controls. The size of the heart, as determined by measurements of the diameter and area of the heart in roentgenograms, was not significantly different in the two groups (50 subjects in each group). These findings did not confirm the conclusion of others that neurocirculatory asthenia is

66Drury, A. N.: The Percentage of Carbon Dioxide in the Alveolar Air, and the Tolerance to Accumulating Carbon Dioxide in Cases of So-Called "Irritable Heart of Soldiers." Heart 7: 165, April 1920.


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characterized by the presence of a small heart. The electrocardiogram, made with the patient at rest and after mild exercise (Master's tolerance test), was within normal limits.

Other normal findings were related to responses of the blood pressure and the pulse to changes of posture on a tilt table, resting venous pressure, blood volume, vital capacity, circulation time, and resting cardiac output as measured by the acetylene method of Grollman and compared with normal standards. Measurement of the cardiac output by the direct Fick method, employing catheterization of the right auricle of the heart, gave mean values that were within the limits of those reported for normal subjects with evidence of anxiety. Patients seemed tense and apprehensive during the procedure. Values obtained by the Grollman method were lower than those obtained by the direct Fick method.

Studies of muscular work

Studies of muscular work were of special interest because (1) patients say they cannot do hard work; (2) the symptoms of the illness have been compared with the feelings of hard work, this being the basis for the concept of the effort syndrome; and (3) patients with this disorder say that they are made worse by doing hard work.

White,67 in 1920, had described an abnormal performance of and response to a test which combined work, respiration, and discomfort (a 100-meter run, wearing a gas mask) as compared with control subjects. Hence, patients and controls were studied during and after muscular work in the laboratory. Moderate work consisted of walking on a treadmill, and hard work consisted of running on a treadmill, of stepping up and down on a 20-inch (50.8 cm.) step, and of stepping up and down with a pack on the back.

In the basal condition, the pulse and respiratory rates are slightly abnormal in neurocirculatory asthenia, but there was no difference between patients with neurocirculatory asthenia and controls in regard to oxygen consumption and the blood lactate concentration while resting. When one compares groups of subjects who work hardest and longest with those who work least (women, men in poor training, and patients with neurocirculatory asthenia), differences between the two groups become more apparent as the intensity and duration of the work tests are increased. In other words, the more the work is stepped up, the more clearly does a "poor work group" separate itself from a "good work group." When the subjects are at rest, the measurable differences appear consistently. During a hard-work test which all subjects perform for a comparable length of time at a fixed pace and grade, all the differences seen in walking are accentuated. In addition, oxygen consumption is lowest in groups who do not run well. When subjects run at a fixed pace until they reach their stopping point, those who run

67White, P. D.: Observations on Some Tests of Physical Fitness. Am. J.M. Sc. 159: 866, June 1920.


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longest have higher oxygen consumption, higher pulmonary ventilation, higher blood lactate levels, higher ventilatory efficiency, and lower pulse.

It was concluded that with either moderate or exhausting muscular work, during which patients and controls alike perform for the same duration and at the same rate, there are many measurable abnormalities in patients with neurocirculatory asthenia. The findings are consistent with the hypothesis that aerobic metabolism is abnormal in these patients. The high blood lactate concentration suggests reciprocal high oxygen debt. It cannot be stated whether these findings apply specifically to patients with neurocirculatory asthenia or whether they are the general signs of poor health, chronic illness, poor runners, or poor state of training.

The results of further studies showed that painful stimuli could produce abnormal responses, also responses at unusually low stimulus levels in some systems, in patients with neurocirculatory asthenia.68

It was concluded from the studies and the general experience in World War II that there are fairly definite quantitative abnormalities in neurocirculatory asthenia. The disorder has many recurring symptoms, is never monosymptomatic, and can be diagnosed on the basis of symptoms. The laboratory abnormalities furnish objective evidence related to patients' subjective complaints. It is also clear that several functions seem normal under basal conditions, but under stress, for instance, work or discomfort, measurable differences appear between patients and controls.

The question remains, once the diagnosis is made, what is the military future of the patient with neurocirculatory asthenia? It was believed that the automatic rejection or discharge of these patients may not be the right answer and that the favorable course of most of the patients in civilian life, and of some in army life, suggests that although neurocirculatory asthenia is a handicap and difficulty it is not necessarily a disabling disorder.

Finally, it should be pointed out that, as yet, the answers to many of the problems posed by neurocirculatory asthenia are unsettled and that more scientific investigation is needed.

68In a 20-year followup of 173 civilian patients with neurocirculatory asthenia, Wheeler and his associates (see Journal of American Medical Association, vol. 142, 25 Mar. 1950, pp. 878-889) showed the following:
1. Significant amounts of handicap and disability were present in 15 percent of the patients, the others reporting that the disorder and its symptoms produced little or no disability.
2. The number of children, divorces, marriages, employment problems, adequate income, and reasonably happy lives was not obviously different from that of the general population.
3. Hospitalizations, surgical operations, the development of other diseases, and mortality are not excessive in patients over 20 years when compared with the general population.
4. Although these patients showed "anxiety" as a characteristic phenomenon, they did not develop to any unusual extent diseases such as hypertension, peptic ulcer, asthma, diabetes, which some authors have speculated are caused by "anxiety."
5. A comparison of the condition of these 173 patients who received only a thorough examination and a simple explanation and reassurance compared favorably with the published therapeutic results after sanitarium psychotherapy, out-patient psychotherapy, Freudist psychoanalysis, sanitarium care, electroshock procedure and frontal lobotomy.
6. Veterans showed more disability as compared with others of the followup study.


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WOUNDS AND FOREIGN BODIES

In World War II, it was estimated that the heart and pericardium were injured in 3.3 percent of intrathoracic wounds in casualties arriving at the forward installation.69 Occasionally, the heart or lungs were involved secondarily by missiles migrating in the bloodstream from elsewhere in the thorax or the abdomen. Serious wounds were detected earlier and treated more effectively than ever before, and from this experience evolved new techniques and an attitude of confidence which have contributed significantly to the remarkable success of the operations for acquired valvular disease developed in the postwar decade. This important and inspiring facet in the progress of the war years is worthy of special consideration here.

In spite of the dramatic and often singular features incident to wounds of the heart and great vessels, it is well to remember, as pointed out by Barrett70 in his excellent review, that the unique cases recorded during each World War usually have had their counterparts in previous conflicts. This is well illustrated by three case histories from the early 19th century. The first describes an unusual foreign body (embolic) in the chamber of the right ventricle, reported first by Davis,71 in 1834, and commented upon later by Bland-Sutton,72 in 1919, as follows:

A boy, aged 10, made a gun of a telescopic toasting fork. To form the breach of the gun he drove a plug of wood three inches long into the hollow handle of the fork and made a touch-hole. When the gunpowder exploded the stick was forced into his chest between the third and fourth costal cartilages, to the right of the sternum. Immediately after the accident the boy walked a distance of 40 yards to his home. He survived the accident thirty-seven days. After death, a piece of wood 3 in. long and as thick as a cedar pencil was found in the right ventricle of the heart encrusted in a clot. Thomas Davis reported these facts in 1834; he found no wound in the pericardium or the heart, and expressed the opinion that the stick, after wounding the lung, had passed into the vena cava and was carried by the bloodstream into the right auricle and then into the right ventricle, where it was found. On reading this report for the first time, I was skeptical in regard to the emboli theory that Davis advanced to explain the presence of the stick in the ventricle, for at the date of the accident surgeons knew nothing of the transport of bloodclot either to or from the heart. It was at least a quarter of a century later that the word "embolus" was coined by Virchow, and the dangers underlying the movement of clot began to be understood.

The second case cited by Barrett dates from the Napoleonic Wars and demonstrates that a large object may enter the aorta near the heart without causing the patient to die of primary hemorrhage:

Mr. Beunton, Assistant Surgeon on board the hospital ship in the Mediterranean, says that a boat's crew, detached to cut-out a French vessel, met with such determined

69Samson, P. C.: Battle Wounds and Injuries of Heart and Pericardium; Experiences in Forward Hospitals. Ann. Surg. 127: 1127-1149, June 1948.
70Barrett, N. R.: Foreign Bodies in the Cardiovascular System. Brit. J. Surg. 37: 416-445, April 1950.
71Davis, T. D.: Cited by Bland-Sutton (see footnote 72) and Barrett (footnote 70). Trans. Prov. Med. Surg. Assoc. 2: 357, 1834.
72Bland-Sutton, J.: A Lecture on Missiles as Emboli. Lancet 1: 773, 10 May 1919.


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resistance that several were killed or wounded, and amongst the latter was a seaman who affirmed that a musket-ball, striking his oar, had run along it and entered his side; he bled a good deal and then, almost completing the third day from the injury, he died.

The post-mortem examination showed that the missile entered the body between the eighth and ninth ribs, it had wounded the diaphragm and passed into the pericardium, which was full of blood; a hole in the aorta had been made by the shot, and this had been closed up by a firm coagulum. Much blood had escaped into the chest and abdomen, not only from the vessels wounded in the course followed by the ball, but from the heart itself. The ball was found adhering to the inner side of the aorta, and there it is now. (The ball measured 1½ inches in diameter.)

A third case of historical interest mentioned by Bland-Sutton concerns a foreign body which entered the left side of the heart by penetrating a pulmonary vein:

At the storming of the Great Pagoda, Rangoon, 1852, a round leaden bullet entered the chest of a soldier between the third and fourth ribs near the anterior fold of the left axilla. Blood and air issued from the wound for several days, and the surrounding tissues became emphysematous. The man was attended in the field hospital by Dr. J. Fayrer (the late Sir Joseph Fayrer), the symptoms abated, and the patient came under the care of Dr. W. White. The soldier died 72 days after being wounded. An examination of the body revealed a pint of pus in the left pleural cavity and a piece of cloth from his jacket. The lung was solid. The track of the missile ran through the chest to the left pulmonary veins. The rifle ball lay in the left ventricle of the heart near its apex. There was no wound of the heart. It appeared from these facts that the ball perforated one of the left pulmonary veins, entered the left auricle, and finally passed into, and settled in, the left ventricle. The heart is preserved in the Museum of the Medical College, Calcutta.73

Others had recognized in the 19th century that patients could survive for years with foreign bodies (usually needles) in their hearts without apparent harm, and by 1900, although it was known that the heart could survive serious wounds and heal well, cases of weak scar with aneurysm formation had been recorded and the risks of sepsis appreciated. Suture of heart wounds was known to be possible and was accepted as indicated in certain emergencies.

The experience provided by World War I with heart wounds was extensive. Numerous operations for the removal of foreign bodies from in and around the heart were recorded between 1914 and 1918, for which the French surgeons deserve especial credit. Delorme,74 in 1917, reviewed 13 operations (Beaussenat (2), Beloit, Laurent, Bichat, Dujarrior (2), Chauvel, Hallopean, LeFort, Gaudier, Fredet, and Delbet), in France, of which the results were known with only 3 deaths. Of special interest were four operations for the removal of intraventricular (right) foreign bodies, all of which were successful. The following year, LeFort75 reported the first

73White, W.: Case of Lodgment of a Musket Ball in the Left Ventricle of the Heart. Indian Ann. M. Sc. 1: 294, 1853-54. Cited by Bland-Sutton (see footnote 72, p. 446) and by Barrett (see footnote 70, p. 446).
74Delorme, E.: Contribution à l'étude de la Chirurgie Cardiaque. Bull. Acad. de méd., Paris 78: 243, 18 Sept. 1917.
75LeFort, R.: Extraction d'un Eclat de Grenade de la Cavité du Ventricle Gauche; Guérison: Présentation du Malade. Bull. Acad. de méd., Paris 80: 147, 6 Aug. 1918.


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case in France of a fragment successfully removed from the left ventricular chamber. He also recorded a consecutive series of nine cardiotomies for the removal of foreign bodies with only one death.

Nonetheless, as Barrett (p. 446) points out, opinion was still divided at the start of World War II. An extensive survey by Decker,76 in 1939, indicated that the late mortality from foreign bodies in the heart was 20 percent and that the mortality from operations for their removal was no less, with the probability that many unsuccessful attempts had escaped publication and that therefore the risk was understated. Likewise, Turner77 at this time (1941) advised caution, with the admonition: "It would seem to be a good rule to leave the foreign body alone unless the heart continues to rebel against its presence."

On the other hand, after World War I, a considerable group of well-informed surgeons, including Leriche,78 Delorme (p. 447), Tuffier,79 and Sauerbruch,80 advocated the removal of all foreign bodies lodged in the heart. Sauerbruch recorded in 1941 a series of 105 patients from whose hearts foreign bodies had been taken to control late complications, with a mortality of 8 percent. Further, he concurred with Stephens (cited by Barrett), who stated that, although 95 percent of people who survive cardiac injuries and who have foreign bodies in their hearts are symptomless, only 13 percent continue to be well indefinitely.

Since these conflicting opinions were expressed by able observers, the experience gained in another war has added to our knowledge. It was the author's privilege during World War II to assemble and review on behalf of the Mediterranean theater surgeon (and his medical and surgical consultants81) the total experience with wounds and injuries of the heart in the North African, Sicilian, and Italian campaigns from November 1942 until the end of hostilities in May 1945.82 This material consisted of 94 cases (of which 15 were  personally observed) and included the cases recorded in the report of the 2d Auxiliary Surgical Group and additional cases encountered by others in the Mediterranean theater. The pertinent features of the total experience are as follows:

Wounds of the ventricular wall occurred in 53 cases; of the auricular wall, in 5; and of the pericardium alone, in 22. The remaining 14 patients presented a variety of conditions, including 3 with retained missiles for 9,

76Decker, H. R.: Foreign Bodies in the Heart and Pericardium-Should They Be Removed? J. Thoracic Surg. 9: 62-79, October 1939.
77Turner, G. G.: A Bullet in the Heart for Twenty-Three Years. Surgeon 9: 832-852, June 1941.
78Leriche, R.: Sur un Cas d'ablation de Corps Etranger du Coeur Suivie de Guérison. Rev. de chir., Paris 51: 274, 1916.
79Tuffier, T.: Surgery of the Heart. Cinquième Congress la Societe International de Chirurgie Rapports Proces-Verbaux et Discussions. Bruxelles: M. Hayez, 1921, pp. 5-75.
80Sauerbruch, F.: Steckgeschosse in Herz und Lunge. Deutsche Ztschr. f. Chir. 255: 152-170, 1941.
81Col. Perrin H. Long, MC, and Col. Edward D. Churchill, MC, respectively.
82Bland, E. F.: War Wounds of the Heart: A Report of 94 Cases With a Note on Foreign Body Emboli. [Unpublished data, The Surgeon General's Office, U.S. Army, 1945.]


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13, and 20 years, respectively, and 4 others in whom metallic shell fragments migrated in the bloodstream from distant wounds.

Cardiac tamponade occurred in 12 cases. It was relieved by early surgical intervention in 10 but was an unexpected post mortem finding in the remaining 2. In an additional eight patients, active hemorrhage of serious proportions was encountered at operation, but the escape of blood into the pleural cavity through the pericardial laceration prevented the development of tamponade.

Pericardial effusion of clinical significance occurred in seven cases. Its delayed appearance from 2 to 6 weeks after injury in one-fourth of those with retained foreign bodies was of special interest. Pneumopericardium was a complication in three, and in one additional patient purulent pericarditis was successfully relieved by surgical drainage.

Intracardiac mural thrombi were found post mortem in three cases, and thrombosis of an injured left coronary artery was noted in another fatal case. Peripheral emboli from the heart were not encountered.

Missiles were removed at operation from the myocardium in 11 patients, in 1 of whom it extended into the ventricular cavity, and from the pericardium in 3 others. All made good recoveries. In 18 cases, foreign bodies remained within the heart or pericardium and, in 2 additional cases, against the ascending aorta. The subsequent progress of these patients should be followed carefully in connection with the unsettled question of future hazards from retained missiles. The intravascular migration of metallic fragments was recorded in four cases.

The mortality figure of 24.4 percent for this series, as contrasted with 45.5 percent for 428 cases collected from the literature in 1934 by Ramsdell,83 is noteworthy. Probably three factors were chiefly responsible for this striking reduction: (1) Early administration of plasma and blood, (2) chemotherapy and antibiotics, and (3) expert surgical intervention close to the frontlines.

Complete perforation of the heart with survival is unusual. In the Mediterranean theater series, there were four cases with two survivors. In one of these (Samson's case),84 in addition to a diagram of the operative findings (fig. 57), electrocardiograms were available during the recovery phase and are reproduced here as a matter of interest (fig. 58).

The migration of metallic fragments in the bloodstream is a bizarre complication, not necessarily fatal. The fragments usually enter by way of the great veins in the thorax, by the hepatic veins from liver wounds, or through the inferior vena cava, pass with the bloodstream to the chambers of the right side of the heart and, occasionally, on into the pulmonary circulation to lodge finally in a major pulmonary artery. Thus, a foreign body

83Ramsdell, E. G.: Stab Wounds of the Heart. Ann. Surg. 99: 141-151, January 1934.
84Samson, P. C.: Two Unusual Cases of War Wounds of the Heart. Surgery 20: 373-381, July-September 1946.


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FIGURE 57.-Diagram of the operative findings in a patient with through-and-through perforation of the left ventricle. (Samson, P.C: Surgery 20: 373-381, July-September 1946.)

at the hilum of the lung is sometimes found at operation impacted in a pulmonary artery. Harken and Williams85 encountered this in patients in the European theater, and a striking example of a casualty of the Italian campaign (in the Mediterranean theater series) is recorded herewith:

On 12 April 1944, an infantryman of the 45th Infantry Division received multiple severe penetrating wounds of the right thorax, right leg, and both feet. Roentgenogram showed a large metallic body at the hilum of the left lung. On 28 April, after transfer to a general hospital, his condition seemed good except for moderate dyspnea. Further X-ray study confirmed the presence of the foreign body in the left lung (fig. 59). On 10 May (4 weeks after injury), dissection of the left hilar region by Maj. Thomas H. Burford, MC (2d Auxiliary Surgical Group), failed to reveal the foreign body, and the chest was closed. Recovery was uneventful. Postoperative roentgenograms revealed the foreign body now at the right hilum (fig. 60). On 9 July (3 months after injury), a right thoracotomy revealed the foreign body impacted in the right pulmonary artery. The circulation to the lung seemed entirely adequate, and a palpable thrill was felt over the artery for a short distance distal to the foreign body. A complete dissection of the hilar structure did not mobilize the artery sufficiently to permit an arteriotomy, since the involved segment was directly beneath the superior pulmonary vein anteriorly and rested upon the right

85Harken, D. E., and Williams, A. C.: Foreign Bodies In, and In Relation To, the Thoracic Blood Vessels and Heart; Migratory Foreign Bodies Within the Blood Vascular System. Am. J. Surg. 72: 80-90, July 1946.


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stem bronchus posteriorly. Furthermore, since there was no evidence of aneurysmal dilatation of the artery or of inadequacy of the pulmonary circulation, it was decided not to sacrifice the superior pulmonary vein. The chest was closed, and convalescence was uneventful except for a disproportionate degree of dyspnea for a few days after operation. On 16 August 1944, the patient was transferred to the Zone of Interior, ambulant and in good condition. A followup letter in October (6 months after the injury) reported no further studies or operative procedures and no symptoms other than dyspnea on fast walking.86

FIGURE 58.-Electrocardiograms during recovery from the through-and-through wounds of the left ventricle in Samson's case (fig. 57). (Bland, E. F.: Am. Heart J. 27: 588, 1944.)

It is of interest that, during a review of this unusual case shortly after the first thoracotomy, Col. Edward D. Churchill, MC, suggested that the fragment had originally entered the superior vena cava and passed through the right heart chambers to the left pulmonary artery and later, just before or during operation, shifted intravascularly to the right pulmonary artery. In any event, the absence of infarction and significant impairment of respiratory function is remarkable.

A curious and further variant from the usual migration of foreign bodies in the direction of blood flow is represented by the infrequent case where the metallic fragment arriving in the right auricle passes down the inferior vena cava against the stream to lodge in the cava or in one of its main branches, as observed by Cutler87 in World War I and by others88 in World War II.

In contrast to the Mediterranean theater data where the emphasis was upon the management of cardiac wounds in the forward installations and

86Burford, T. H.: Personal communication, 1945.
87Cutler, E. C.: Migration of Shell Fragment From Inferior Vena Cava to Right Pulmonary Artery. Mil. Surgeon 53: 264-267, September 1923.
88Davey, W. W., and Parker, G. E.: Surgical Pursuit and Removal of Metallic Foreign Body From Systemic Venous Circulation. Brit. J. Surg. 34: 392-395, April 1947.


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FIGURE 59.-Roentgenograms showing an embolic shell fragment in the left pulmonary artery.

early protective operations, the extensive experience of Harken and his collaborators89 at the base center in England has a more direct bearing on the problems of later definitive and often elective surgery, in particular with the much discussed issue of retained foreign bodies. Their three reports cover a series of 134 fragments removed from within or adjacent to the heart and great vessels. The following tabulation shows the distribution of the 134 missiles in relation to the pericardium, heart, and great vessels:

 

Number of fragments

Pericardial

26

Involving pericardium, but principally pulmonary

17

Intracardiac

13

On great vessels (and in walls)

35

Intravascular (three embolic)

7

On great vessels, but principally pulmonary

17

Mediastinal, but not directly on great vessels

19


Total

134


There were no deaths in the three cited reports.

In particular, the successful evacuation of 13 missiles from within the cardiac chambers without mishap represents a brilliant extension of the

89(1) See footnote 82, p. 448. (2) Harken, D. E.: Foreign Bodies In, and In Relation To, the Thoracic Blood Vessels and Heart. Techniques for Approaching and Removing Foreign Bodies From the Chambers of the Heart. Surg., Gynec. & Obst. 83: 117-125, July 1946. (3) Harken, D. E., and Zoll, P. M.: Foreign Bodies In, and In Relation To, the Thoracic Blood Vessels and Heart. Indications for the Removal of Intracardiac Foreign Bodies and the Behavior of the Heart During Manipulation. Am. Heart J. 32: 1-19, 1946.


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FIGURE 60.-Roentgenograms showing the foreign body illustrated in figure 59, now lodged in the right pulmonary artery.

earlier French experience in World War I. This, together with the equally favorable outcome in removing fragments from the heart wall, both in the European theater and in the Mediterranean theater series (11 cases) without a fatality, represents a real advance in heart surgery. It in turn strengthens the position of those who believe all foreign bodies had best be removed. In particular, Harken and his associates naturally and strongly recommend their removal, in order (1) to prevent embolus of the foreign body or associated thrombus, (2) to reduce the danger of bacterial endocarditis, (3) to prevent recurrent pericardial effusions, and (4) to diminish the incidence of myocardial damage. The additional factors of pain and cardiac neurosis are occasional indications.

It seems appropriate to end this discussion with the conclusions of Barrett (p. 446) who, after a thoughtful consideration of both sides of the issue, observed:

There are three clinical phases in the history of these patients in which a decision must be taken. In the emergency the concern is to save life and the presence of a foreign body in the heart is of secondary importance. During the period of convalescence and shortly after, the decision to operate depends upon the belief that late complications can be avoided, or that limitations of cardiac function can be ameliorated without exposing the patient to mortal hazard. Patients who have harboured a foreign body in the heart for years without apparent harm will not want it removed, but they may come to the surgeon when complications occur; some of these late complications can still be relieved by removal of the foreign body, but others are by now beyond surgical cure.

To the medically minded, and especially to those who have discovered by chance retained foreign bodies of many years' standing, the sentiments


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attributed to Frank Jeans but quoted in this connection by Turner (p. 448) still have some appeal: "A living problem is better than a dead certainty."

SUMMARY

In summarizing this survey of diseases and disorders of the heart in the Second World War, it seems appropriate to commend again the wisdom and foresight of those responsible for the special Subcommittee on Cardiovascular Diseases. The wise counsel and sustained activities of this group throughout the emergency not only contributed directly to the war effort but, also, in various subtle ways afforded encouragement and aid to many doctors in uniform in their pursuit of useful knowledge. This coordination of military personnel, civilian consultants, and Government resources was of great practical benefit and lasting importance, and the lessons learned may serve well another generation should the need arise.

The special attention given to the circulatory system in the selection for service provided an insight into the strength as well as the weakness of our eligible population and, though it proved to be disturbing in certain respects, stimulated the thoughtful planning of special studies in the fields of hypertension and of latent coronary disease. The spread of respiratory infections in training centers led to a number of important epidemiological studies and, in turn, to effective programs of control and prevention, not only of streptococcal diseases but of rheumatic fever as well.

That traditionally troublesome complex, neurocirculatory asthenia (including shellshock) at best poorly understood, was again the object of careful analysis. Its apparent diminished incidence, in comparison with previous conflicts, was perhaps the result both of its earlier detection and of a shift in emphasis to its manifestations on other systems. In the oversea theaters, especially in the Southwest Pacific, the opportunity to observe and to delineate more carefully than ever before the cardiac lesions of tsutsugamushi fever was a noteworthy event. Elsewhere, our surgical colleagues, with the support of modern anesthesia, antibiotics, and blood, pushed forward in brilliant fashion to remove missiles from within the heart and great vessels more effectively than ever before. There still remains, moreover, an equal opportunity and obligation in this connection for the Army Medical Corps and the Veterans' Administration to trace and record the ultimate fate of that considerable number of soldiers who were discharged from the service with retained missiles in the cardiovascular system.

It is unlikely in future crisis of comparable magnitude that the United States can afford to write off one-half or even one-quarter of its eligible manpower as unfit for service by the standards of World War II. It now seems certain that future circumstances will require either broader standards or new categories whereby those with minor defects may serve with recognition, if not in the lines at least on the production front.


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The preparation of this chapter on the heart has been a personal privilege. It is submitted as a token of gratitude to our patients of the war years-the men and women of the Armed Forces who in spite of illness and injury did all they could to help. For the members of the medical profession who shared a little in this great effort, the recollection of those eventful years has probably been dimmed by other interests and new responsibilities, but to them in quieter moments of reflection the words of that noble Irish churchman, Jeremy Taylor, written in equally turbulent times three centuries ago may have a special significance: "To preserve a man alive in the midst of chances and hostilities is as great a miracle as to create him."90

90Taylor, Jeremy (1613-67), cited by Hume, E. E.: Introduction to Military Medicine. Mil. Surgeon 102: 17-24, January 1948.

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