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Chapter XVII

Contents

CHAPTER XVII

Peripheral Vascular Disorders

Fiorindo A. Simeone, M.D., and Robert W. Hopkins, M.D.

Peripheral vascular disorders encountered in World War II have been described in considerable detail in earlier volumes of the official history of the U.S. Army Medical Department in World War II.1 Trauma encountered in epidemic proportions during wartime provides a wealth of experience not found in civilian medicine, and accordingly, vascular abnormalities occurring subsequent to injury have provided most of the data for these volumes.

Work in the forward areas of theaters of operations provided an invaluable experience with early wounds of blood vessels and with such conditions as cold injury. From this experience, a number of earlier erroneous impressions were corrected, improved methods of prophylaxis and management of these injuries were suggested, and newer forms of therapy were evaluated. In the Zone of Interior, vascular centers were established to provide competent specialized care for large numbers of patients with vascular injuries and diseases. These centers provided not only facilities and personnel for optimum treatment, but also an unparalleled opportunity for study of the problems the patients presented. Significant improvements in the late management of arterial injuries and cryopathies resulted from work at these centers. Ideas and techniques were explored which forced the remarkable later advances in cardiovascular surgery.

Vascular disorders not directly the result of military action were observed in induction centers, in military medical units, and in the specialized vascular centers. These observations have provided data on the incidence and logistic significance of vascular disease in men of military age and on the effects of the military environment on men with these diseases. Insofar as the cases are documented by their military medical records, they constitute a group from which rosters can be developed for long-term followup studies. Such investigations can greatly benefit both military and civilian medicine and surgery.

1(1) Medical Department, United States Army. Surgery in World War II. Vascular Surgery. Washington: U.S. Government Printing Office, 1955. (2) Medical Department, United States Army. Cold Injury, Ground Type. Washington: U.S. Government Printing Office, 1958.


458

CENTERS FOR VASCULAR INJURY AND DISEASE

Experience with casualties returned to the Zone of Interior during the first year of the war suggested the need for specialized care of patients with certain injuries and diseases. However, the rapid increase in numbers of military hospitals precluded the assignment of adequate numbers of highly trained medical personnel to them. Nor could specialized equipment be made available to all general hospitals. Accordingly, specialized hospitals were designated for the treatment of such conditions by authority of War Department Memorandum No. W40-14-43, dated 28 May 1943.

Centers for the treatment of vascular disturbances first were established under this memorandum, in May 1943, in West Virginia at Ashford General Hospital and in California at Letterman General Hospital. In June 1944, a third center was established in the Middle West at Percy Jones General Hospital. Because of changing demands upon the facilities and of increased requirements for space, the center in California initially established at Letterman in San Francisco was transferred, in December 1943, to Torney General Hospital in Palm Springs, Calif., and from there, in June 1944, to DeWitt General Hospital in Auburn, Calif. The Middle West center was transferred in September 1944, shortly after its establishment (June 1944), from Percy Jones in Battle Creek, Mich., to Mayo General Hospital in Galesburg, Ill. Ashford General Hospital in White Sulphur Springs, W. Va., remained a center for vascular diseases throughout the war (May 1943-June 1946).

Referrals to the vascular centers, in accordance with the memorandum of 28 May 1943, included patients with the following disorders: "Major vascular injuries and their sequelae such as arteriovenous fistulae, aneurysms, and peripheral vascular disturbances such as chronic vasospastic conditions, those resulting from frostbite, immersion foot, and other conditions producing peripheral circulatory deficiency states; but not including minor disturbances such as varicose veins."

The advisability of providing centers for the study of vascular diseases not resulting from trauma was taken under consideration by the Office of The Surgeon General, in December 1943, and although the incidence of nontraumatic vascular diseases was not sufficient to warrant special centers, the advantages of the centers for study as well as for therapy provided strong argument in their favor. Therefore, centers for nontraumatic vascular diseases were established in association with the existing vascular centers, in August 1944. I

n accordance with War Department Circular No. 347, dated 25 August 1944, the designation of patients to be referred to the vascular centers was modified to include the following: "Patients with peripheral vascular disturbances, such as chronic vasospastic conditions, Raynaud's phenomenon, thromboangiitis obliterans, and the sequelae of trenchfoot, immersion foot, and frostbite; patients with peripheral vascular


459

injuries and their sequelae, such as arteriovenous fistulae and aneurysms. Does not include minor disturbances such as varicose veins."

At Mayo General Hospital, separate but closely cooperating medical and surgical sections were established with the activation of the vascular center on 15 September 1944. A similar organization was created in the vascular center at DeWitt General Hospital, in May 1945. At Ashford General Hospital, internists were assigned to the vascular service in the surgical section. The number of beds available at the three vascular centers varied during the hostilities, reaching a peak of 1,900 during the early months of 1945. In addition to providing an optimum in specialized care for these patients, the centers provided a unique opportunity for the study of patients with the vascular conditions cited in the directives of 1943 and 1944. The Annual Report of Ashford General Hospital for the year 1944, noting the 400 beds for vascular patients in use in the hospital and the 183 patients who had been operated upon for arterial aneurysm and for arteriovenous fistula, observed: "This is unquestionably the largest number of patients with these conditions treated in any clinic in a similar period of time and the largest number of aneurysms and arteriovenous fistulas treated by operation in one institution throughout any period of time." Publications from this experience and similar experiences in the other centers comprise an invaluable contribution not only to military surgery and the surgery of trauma, but to civilian medicine as well.

Clinical observations of the patients in the vascular centers provided much valuable information concerning the clinical course and management of vascular injuries, late sequelae of cold injury, and other vascular disturbances. The desirability of obtaining detailed physiologic studies on patients in the vascular centers was well recognized by the medical personnel in charge. Difficulties and delays were encountered in procurement of proper equipment, however, and when these did become available, adequate numbers of trained personnel were no longer available to carry out the studies.2 The numbers of physiologic studies of the circulation made in these patients were, therefore, regrettably few.

Although the detailed organization of the vascular services in the several hospitals differed, the cooperation of the various disciplines involved in the care of the patients in these services was an essential factor in the success of the centers. Internists and surgeons participated jointly in the management of the vascular problems encountered. Collaboration of the departments of roentgenology supported the programs at all centers. Departments of physical therapy and reconditioning and departments of occupational therapy were invaluable for the long-term management of the patients with vascular disease.

2(1) Annual Report, Mayo General Hospital, 1945. (2) See pp. 11-16 in publication cited in footnote 1 (1), p. 457.


460

ACUTE VASCULAR INJURIES

The most significant progress in the surgery of wounds in the U.S. Army in World War II was made in the prevention and control of infection. The principles of adequate debridement of wounds with removal of devitalized tissue and foreign debris followed by delay in closure of wounds became well established. Improvement in the prevention and control of infection by the employment of these advances in wound surgery and by the use of chemotherapeutic and antibiotic agents was reflected by the relative increase in the importance of arterial occlusion as an indication for amputation. While figures indicate that amputation was required for infection 5 times as often as for arterial injury in the German Army and 16 times as often in the Russian Army, data from American battle casualties show arterial injury to be nearly twice as frequent a reason for amputation as infection (table 80). Additional benefit from improved control of infection was observed in the decrease in secondary hemorrhage from wounds. Freeman3 reported an incidence of 1 percent of secondary hemorrhage among 2,168 patients with wounds of the neck and extremities treated at the 20th General Hospital in Assam, India. In World War I, Waugh4 reported an incidence of 14 percent from wounds in which long bones were involved. 

TABLE 80.-Indications for amputation among German, Russian, and American casualties, in World War II

Amputation

Casualties

German

Russian

American

Cause:

 

 

 

    

Extensive trauma................................................................percent

64.3

16

68.6

    

Clostridial myositis or other infection ............................percent

29.7

79

11.9

   

Arterial injury.......................................................................percent

6

5

19.5

Number studies

1,359

---

3,177


NOTE.-Percentages are based on the total number of amputations studied.

Source: DeBakey, Michael E., and Simeone, Fiorindo A.: Acute Battle-Incurred Arterial Injuries. In Medical Department, United States Army. Surgery in World War II. Vascular Surgery. Washington: U.S. Government Printing Office, 1955, text pp. 66-67.

The nature and location of arterial wounds in relation to the incidence of amputation were studied by DeBakey and Simeone.5 Amputation was

3Freeman, N. E.: Secondary Hemorrhage Arising From Gunshot Wounds of Peripheral Blood Vessels. Ann. Surg. 122: 631-640, October 1945.
4Waugh, W. G.: Secondary Hemorrhage. In Bailey, Hamilton (editor): Surgery of Modern Warfare. Baltimore: Williams & Wilkins Co., 1941, vol. 1, pp. 328-332.
5DeBakey, Michael E., and Simeone, Fiorindo A.: Acute Battle-Incurred Arterial Injuries. In Medical Department, United States Army. Surgery in World War II. Vascular Surgery. Washington: U.S. Government Printing Office, 1955, chart 12, p. 81.


461

required in approximately 30 percent of cases in which simple laceration of the artery occurred and in about 50 percent when the artery was transected. Injury associated with arterial thrombosis carried a much poorer prognosis, with loss of limb occurring in 70 percent of these patients.

The incidence of amputation with wounds of specific arteries (table 81) was noted to be at variance with previous observations and reports. In general, wounds of the arteries in the lower extremity were more likely to be followed by amputation than those in the upper extremity. The highest proportion of gangrene occurred following injury to the popliteal artery, a finding in marked contrast to some earlier impressions.6 Injury to more than one major artery in an extremity was also followed by decreased salvage of the limb.

TABLE 81.-Incidence of amputation following arterial injuries, U.S. Army casualties, World War II

Artery

Total injuries (number)

Amputations

Number

Percent

Brachial

601

159

26.5

Subclavian

21

6

28.6

Radial and ulnar

28

11

39.3

Axillary

74

32

43.2

External iliac

30

14

46.7

Common iliac

13

7

53.8

Femoral

517

275

53.2

Anterior and posterior tibial

91

63

69.2

Popliteal

502

364

72.5

All others

594

64

10.8

Total

2,471

995

40.3


Source: DeBakey, Michael E., and Simeone, Fiorindo A.: Acute Battle-Incurred Arterial Injuries. In Medical Department, United States Army. Surgery in World War II. Vascular Surgery. Washington: U.S. Government Printing Office, 1955, modified table 3, p. 69.

While the usual treatment for arterial wounds was ligation of the artery, restoration of blood flow by suture of lacerations, anastomosis of the severed ends of vessels, or vein grafting was attempted in a few instances. Unfortunately, the military situation and other considerations usually precluded attempt to repair the artery. The timelag between injury and arrival at a field hospital in a sample of 104 first-priority patients in the Mediterranean theater averaged 12 hours, considerably over the maximum safe time for arterial repair. In addition, the time required for the meticulous surgery involved was rarely justified, nor were sufficient experi-

6National Research Council, Division of Medical Sciences: Burns, Shock, Wound Healing and Vascular Injuries. Prepared under the auspices of the Committee on Surgery of the Division of Medical Sciences of the National Research Council. Military Surgical Manuals, vol. 5. Philadelphia: W. B. Saunders Co., 1943.


462

enced personnel available in most hospitals in the field. Results in cases where repair was attempted were not uniformly good, although specific instances where salvage of a limb could be attributed to restoration of arterial flow were observed. Satisfactory evaluation of the indications and overall usefulness of methods for direct repair could not be made from this series.

POSTTRAUMATIC ARTERIAL ANEURYSMS AND 
ARTERIOVENOUS FISTULAS

The policy of management of aneurysms and arteriovenous fistulas in the oversea areas was entirely conservative. Usually, these lesions did not become manifest for several weeks. When they were observed, delay was warranted for several reasons: to allow complete disappearance of any initial infection, to diminish the likelihood of secondary infection or secondary hemorrhage, to allow collateral circulation to develop, and to allow the aneurysm in the rare instance to heal spontaneously.

At the vascular center at Mayo General Hospital,7 spontaneous thrombosis with apparent cure was observed in 10 of 119 traumatic arterial aneurysms. Flow apparently continued through the artery involved in five of the nine cases where the observation was recorded. At this center, also, spontaneous closure of the fistula was observed in 8 of 245 arteriovenous fistulas. Three of these required operation for an associated saccular aneurysm. At operation, thrombosis of the vein in all three was observed as the mechanism of obliteration of the fistula. Although of considerable interest, these spontaneous "cures" did not appear with sufficient frequency to indicate per se a prolonged period of observation before institution of surgical therapy.

Circulatory Studies of Patients With Arteriovenous Fistulas

Data concerning circulatory dynamics in patients with arteriovenous fistulas studied at Ashford General Hospital are summarized in table 82.

The cardiac output was studied preoperatively and postoperatively in 47 patients by means of a low frequency, critically damped ballistocardiograph.8 The accuracy of the method was checked against comparative studies by the direct Fick technique. None of the patients in this group had evidence of frank heart failure.

7Shumacker, Harris B., Jr.: Arterial Aneurysms and Arteriovenous Fistulas: Spontaneous Cures. In Medical Department, United States Army. Surgery in World War II. Vascular Surgery. Washington: U.S. Government Printing Office, 1955, pp. 361-374.
8Starr, I., Rawson, A. J., Schroeder, H. A., and Joseph, N. R.: Studies on Estimation of Cardiac Output in Man, and of Abnormalities in Cardiac Function, From Heart's Recoil and Blood's Impacts; Ballistocardiogram. Am. J. Physiol. 127: 1-28, August 1939.


463

TABLE 82.-Summary of preoperative and postoperative observations of 47 patients with arteriovenous fistulas

Observations

Preoperative

Postoperative

Average duration of fistula

months

6.7

---

Heart rate

beats per minute

73.2

71.1

Stroke volume

milliliter

118.1

92.8

Cardiac index

liters per minute per square meter

4.9

3.7

Change in transverse diameter of heart

centimeter

---

.45

Change in whole blood volume

milliliter per square meter

---

229


Source: Elkin, Daniel C.: Arterial Aneurysms and Arteriovenous Fistulas: Circulatory Effects of Arteriovenous Fistulas. In Medical Department, United States Army. Surgery in World War II. Vascular Surgery. Washington: U.S. Government Printing Office, 1955, pp. 181-205.

The preoperative resting cardiac output was found to range from 21 percent below to 127 percent above the postoperative (normal) value. A 25-percent variation in cardiac output was considered within a normal range. Of the 47 patients, 25 exceeded this range and were therefore considered to have had a significantly elevated cardiac output before surgery. The decrease in cardiac output after surgery was attributed chiefly to a change in stroke volume rather than to heart rate. The basal heart rate preoperatively was above 85 in only 7 of the 47 patients.

Studies were also carried out on 25 patients with temporary occlusion of the arteriovenous fistula effected by means of a pneumatic tourniquet. In 17 of the 25 patients, a prompt decrease in heart rate, ranging from 4 to 32 beats per minute, was observed (Branham's (Nicholadoni's) sign). In 19 patients, the stroke volume decreased by more than 10 ml. with sudden occlusion of the fistula. A decrease of the cardiac index of 0.5 to 3.6 liters per square meter of body surface was observed in 22 of the 25 patients. In five patients, additional tests were carried out following the administration of atropine. The pulse rate rose, and in some instances, the cardiac index increased. Occlusion of the fistula at this time was not followed by a change in pulse rate greater than 4 beats per minute, while the cardiac index declined in amounts ranging from 1.0 to 2.2 liters per square meter.

Determinations of the plasma and whole blood volume were made using the blue dye T-1824 (Evans blue) in 41 patients at Ashford General Hospital. Measurements were made preoperatively and 10 or more days postoperatively in all patients. In 23 patients, the change in blood volume was less than 200 cc. per square meter, considered to be within the range of normal variation. In 18, there was a postoperative decrease in blood volume, ranging from 200 to 1,060 cc. per square meter of body surface. Preoperative and postoperative determinations of hematocrit varied only slightly, indicating that parallel changes occurred in the volumes of plasma and of whole blood.


464

Studies on the effects of arteriovenous fistulas on heart size were carried out at the vascular centers. The data obtained at Mayo General Hospital9 include measurements of cardiac frontal area from teleroentgenograms of 185 patients. The predicted and actual frontal areas of the cardiac silhouette were calculated according to the method of Ungerleider and Gubner.10

Preoperative measurements were in excess of 105 percent of predicted values in 55 percent of 153 of the 185 patients and in excess of 125 percent of predicted values in 12 percent. Postoperatively, no patient had measurements in excess of 125 percent of the predicted values and 27 percent exceeded 105 percent of the predicted size. Although definite conclusions could not be drawn, fistulas of long duration appeared to be associated with a greater increase in heart size than were those of shorter duration. Patients with larger fistulas also tended to have larger cardiac silhouettes.

There were two instances of frank congestive failure in this group. One of these with two arteriovenous fistulas had been in failure before resection of an external iliac fistula prior to his admission to a vascular center. The other was a patient with a Streptococcus viridans infection of a femoral arteriovenous fistula. The case history of this patient, the fourth with bacteremia of this origin to be reported, has been presented in detail elsewhere.11 This patient was relieved of all his symptoms following resection of the arteriovenous fistula.

The findings in these patients tended to confirm previous impressions of abnormal circulatory dynamics drawn from relatively isolated cases in civilian experience. The numbers of patients studied here, however, added a wealth of preoperative and postoperative data in patients in whom the fistulas were successfully closed by surgery.

Surgical Management of Aneurysms and Arteriovenous Fistulas

Two technical considerations may be noted here briefly in the light of their influence on subsequent developments in vascular surgery. The first is the improvement of techniques for surgical exposure of major vessels, especially in the mediastinum. Further use and extensions of these procedures developed for managing traumatic lesions have stimulated the remarkable developments in the surgery of lesions of the great vessels. The second is the development of a policy favoring restoration of normal arterial and venous blood flow instead of interruption of the affected vessels.

9Shumacker, Harris B., Jr.: Arterial Aneurysms and Arteriovenous Fistulas: Alterations in the Cardiac Size in Arteriovenous Fistulas. In Medical Department, United States Army. Surgery in World War II. Vascular Surgery. Washington: U.S. Government Printing Office, 1955, pp. 206-224.
10Ungerleider, H. E., and Gubner, R.: Evaluation of Heart Size Measurements. Am. Heart J. 24: 494-510, October 1942.
11Elkin, Daniel C., and Shumacker, Harris B., Jr.: Arterial Aneurysms and Arteriovenous Fistulas: General Considerations. In Medical Department, United States Army. Surgery in World War II. Vascular Surgery. Washington: U.S. Government Printing Office, 1955, pp. 165-173.


465

Because of the presence of collateral circulation adequate to maintain viability of a limb in the presence of aneurysms and arteriovenous fistulas, ligation was considered the safest procedure, and repair of the artery was not commonly attempted until the last months of the war. It became increasingly evident, however, that although a viable limb was maintained, the function of the extremity was often seriously impaired.

During the latter part of the war, therefore, repair of the artery with preservation of its lumen became the rule in appropriate cases.12 While only 4 reparative procedures had been performed in the first 138 cases at Mayo General Hospital, 30 of the last 57 cases were handled in this manner. Similarly, restoration was attempted for 23 of 67 patients operated upon at DeWitt General Hospital from June to November 1945. Of these 57 attempts at repair, 46 (81 percent) were successful in preserving normal blood flow. Largely as a result of these successes, surgeons were no longer content with the previous goal of maintaining a viable limb. The importance and feasibility of restoring normal arterial flow and normal function of the limb became established.

COLD INJURY

The ravages of cold injury in warfare have seldom been effectively anticipated. Serious consequences in terms of significant losses of military manpower and subsequent chronic disability to individual soldiers have occurred through the centuries of military operations forced upon commanders in severe cold and in wet terrain. Yet, in each war, the lesson has had to be learned anew. It is especially regrettable that these losses occur in spite of the fact that cold injury is a preventable disease. With proper indoctrination of troops and adequate provision of proper footgear, the condition can virtually be eliminated.

The nature of the problem makes effective preventive measures a responsibility of command rather than of the Medical Department. However, this responsibility historically has not been recognized by higher command and staff echelons until loss of combat manpower brought the problem acutely to the foreground.

In World War II, the first experience with cold injury among American troops occurred on the Aleutians. Here, a high incidence of injury occurred among men exposed to cold and wet with inadequate indoctrination and improper clothing. In sharp contrast was the paucity of cold injury in a single unit which had had earlier experience on maneuvers in cold weather.13 

These lessons were not immediately transferred to the Mediterranean theater, and the first winter of fighting under difficult circumstances, that

12Freeman, Norman E., and Shumacker, Harris B., Jr.: Arterial Aneurysms and Arteriovenous Fistulas: Maintenance of Arterial Continuity. In Medical Department, United States Army. Surgery in World War II. Vascular Surgery. Washington: U.S. Government Printing Office, 1955, pp. 264-301.
13Orr, R. D.: Report on Attu Operations. May 11-June 16, 1943, dated 30 July 1943.


466

of 1943-44, saw a distressing number of casualties from cold injury. Preventive measures were instituted too late to be effective during this first winter, but their value was well demonstrated during the subsequent winter, 1944-45.

A consideration of vital statistics emphasizes the military significance of this preventable disease. The incidence of cold injury in World War II is summarized in table 83. A total of 7,514,000 man-days were lost during the period of 1942-45. This is equivalent to the loss of an entire division, 15,000 strong, for 16 months. Disregarding the time factor and calculated on the basis of loss of combat troops in the European theater alone in 1944-45, it can be said that about 5 divisions (derived from approximately 70,000 cases) were lost to combat. However, since about 90 percent of all cold injury casualties were riflemen and since some 4,000 riflemen were in each infantry division, the loss of effective fighting strength could be interpreted as more nearly 16 divisions than as 5 divisions. This loss of combat manpower was in addition to the huge logistic cost in terms of transportation, hospital occupancy, and professional and nursing care.

The experience with cold injury in World War II provided a wealth of material from which clinical and pathologic observations could be made.

TABLE 83.-Incidence1 of cold injury in the U.S. Army (including the Army Air Forces), by specific diagnosis and theater, 1942-45

[Preliminary data based on sample tabulations of individual medical records]

Theater or area

Total 
cold injuries

Trenchfoot

Frostbite

Immersion foot 
(or hand)

Chilblains

Other effects 
of cold

All theaters and area

90,535

64,590

19,559

1,451

971

3,964

    

Continental United States

5,203

315

4,342

36

335

175

    

Total outside continental United States

285,332

64,275

15,217

1,415

636

3,789

         

Europe

71,038

53,911

13,134

506

204

3,283

         

Mediterranean3

11,192

9,778

765

322

272

55

         

Middle East 

33

22

11

---

---

---

         

China-Burma-India

35

7

12

---

15

1

         

Southwest Pacific

578

351

10

214

3

---

         

Central and South Pacific

139

26

36

68

1

8

         

North America4

2,225

145

1,230

295

141

414

         

Latin America

28

25

1

1

---

1


1Consists of both admissions for cold injury and cases in which admission was for other conditions but in which cold injuries appeared as secondary diagnoses. Data on secondary-diagnosis cases are not presently available for 1942 and 1943, and for these 2 years, only admissions have been included in this table. It should be noted that cold injury admissions in 1942 and 1943 constituted but a small proportion of the World War II admissions for cold injury. For 1942 and 1943, admissions may be considered an approximation of incidence. During 1944-45, in the total Army, the incidence of cold injury exceeded admissions by 11 percent.
2Includes 64 cases among admissions on board transports.
3Includes North Africa.
4Includes Alaska and Iceland.
Source: Medical Statistics Division, Office of The Surgeon General, Department of the Army.


467

These are recorded in detail in the volume on cold injury14 and will be summarized only briefly here.

Cold injury may be caused by exposure to dry cold or wet and cold in various combinations. Frostbite results from actual freezing of tissues. Wet and cold combine to cause injury in immersion foot with wetness predominating. In trenchfoot, wet and cold are relatively equal in importance as etiologic factors. Cold injury resulting from these factors may be considered basically the same pathologic process, with the extent and nature of the injury dependent upon the intensity and duration of the cold stimulus. In World War II, fought predominantly in temperate climates, trenchfoot was most common.

Other factors relating to the production of frostbite were considered extensively. Most important were factors classified as socioeconomic. These included (1) the intensity of combat activity, (2) the availability of proper clothing, especially footgear, (3) the attitude of those in command, (4) adequate training and discipline of troops in prevention of cold injury, (5) previous experience with cold weather, and (6) rotation of troops.

Although pathologic material in trenchfoot is generally limited, Friedman's15 study of 14 specimens at various stages may be regarded as definitive. The histologic pattern was common to all cold injury. The essential early change was circulatory. There was marked engorgement of the vascular tree with extravasation of red blood cells. Agglutinative erythrocytic thrombi, poor in fibrin, of the type seen in stagnant blood, were commonly observed. Endothelial damage was not striking in early stages. Later, arteritis obliterans of varying degrees was present in arteries and veins.

Changes in fatty tissue were profound. Early leukocytic infiltration of the deeper subcutaneous tissues and proliferation of adventitial cells of prominent capillaries and smaller vessels in the interlobular fibrous septa were seen. Later, fat lobules were diffusely infiltrated with foam cells laden with fat, and fibrous replacement of adipose tissue was notable. Muscle tissues exhibited degeneration, necrosis, and inflammation but no atrophy in specimens of early trenchfoot. Atrophy, however, was extensive in all specimens of late cases. In early specimens, nerves in the area of inflammation were swollen and edematous, and degeneration of both axis cylinders and myelin was present. Damage was severe in areas of gangrene in late cases, and demyelinization and perineural fibrosis were marked. Many small vessels in the nerves were thickened, and lipoid phagocytosis was pronounced. Most of the changes observed, whether superficial or deep, were regarded as secondary to vascular occlusion. It was also thought that structures rich in lipoids, especially adipose tissue and myelinated nerve fibers, might sustain a direct thermal effect from cold trauma.

14 See footnote 1 (2), p. 457.
15Friedman, N. B.: Pathology of' Trench Foot. Am. J. Path. 21: 387-433, May 1945.


468

Clinical picture.-Three separate phases in the clinical course of cold injury were described in World War II, as follows:

1. The preinflammatory stage, without blisters or gangrene. The skin was cold and might still be wet.

2. The inflammatory stage, characterized by vasodilatation, blisters with or without gangrene, and by edema and dryness of the skin. The skin was hot to palpation, except in the gangrenous areas.

3. The postinflammatory stage, characterized by coldness, cyanosis with or without gangrene, and by hyperhidrosis.

The preinflammatory stage (the ischemic or prehyperemic stage) usually lasted only an hour or two beyond the period of exposure except in cases with intense vascular involvement. The vasodilatation of the inflammatory stage became apparent almost immediately after the patient was removed from the cold environment. In cases where this was mild or almost undetectable, prompt return to duty was possible. More frequently, the vasodilatation was obvious and lasted for a week or more. Small patchy areas of ecchymosis were present at pressure points, and areas of superficial thrombosis were sometimes present. In severe cases, early blister formation was evident. Impending gangrene might be apparent, progressing to frank gangrene within 48 hours.

Pain was a prominent symptom in trenchfoot in all stages beyond the preinflammatory. This was in contrast to frostbite where pain was surprisingly absent. It persisted through the inflammatory, postinflammatory, and late stages, frequently lasting for months following evacuation to the continental United States. In specimens available for histologic study, it was often possible to relate pain to excessive perineural fibrosis.16 Late in the postinflammatory stage of trenchfoot, the skin was delicate and waxy. Ambulation was considerably delayed by the long period of time before callus formation developed sufficiently to permit weight bearing. Claw foot and pes cavus deformities sometimes developed. Gangrene in cold injury, short of frostbite, was relatively uncommon, appearing in less than 10 percent of cases. In many instances, gangrene was less extensive than it originally appeared to be. Deep gangrene requiring amputation of any extent was rare. These observations indicated a conservative approach to excision of tissue, especially in the early stages of the disease process.

Efforts to find specific therapeutic measures applicable to cold injury were unrewarding. Initial treatment during World War II consisted chiefly in the avoidance of further trauma. The patient was most comfortable with the feet exposed at room temperature. No local applications appeared helpful. Drugs were not effective. A trial of early sympathetic block proved disappointing. Surgical treatment was limited to measures to maintain cleanliness, and with few exceptions, amputation of any sort was deferred

16White, J. C., and Warren, S.: Causes of Pain in Feet After Prolonged Immersion in Cold Water. War Med. 5: 6-15, January 1944.


469

until the patient was evacuated to the Zone of Interior. In later stages, sympathectomy proved to be of some value in minimizing tissue loss and accelerating healing. When hyperhidrosis and maceration were prominent, sympathectomy was beneficial. It was of questionable value in limiting pain of weight bearing and in relieving the "burning" neuritic type of pain observed late in the disease.

The most significant advance in rehabilitation after cold injury was probably the demonstration of the value of early supervised exercise. The feet of patients from hospitals where this had been insisted upon were in much better condition, when the patient reached installations in the Zone of Interior, than were the feet of patients who did not participate in such early exercise. Radiographic evidence of osteoporosis of metatarsals and phalanges, often quite extensive, was maximal when early exercise had not been practiced. Weight bearing for these patients was often long delayed.

The importance of cold injury in terms of loss of manpower was also emphasized by the high recurrence rate among men returned to duty. Early estimates anticipated recurrences of about 15 percent. Experience with recurrences and recognition of the insidious and prolonged nature of the injury led the staffs of most hospitals in the Mediterranean theater to conclude that less than 10 percent of men who had suffered attacks of cold injury could be returned to combat duty.

THROMBOANGIITIS OBLITERANS

In World War II, 1,030 admissions of patients with a diagnosis of thromboangiitis obliterans were recorded, a rate of 4 per year per 100,000 average strength (table 84). Of these patients, 274 were admitted to the special vascular centers.17 According to a study of 152 male patients with thromboangiitis obliterans seen in the vascular centers, the majority (122 patients) were between the ages of 26 and 40. The race of 2 was not recorded, 7 were Negroes, and 143 were Caucasians of whom 32 were Jews. Among the 152 patients, intermittent claudication was the most common symptom and was present in 67 percent. Many complained of pain or numbness in the foot. Migratory phlebitis was present in one-third of the patients, and ulceration was present in 20 percent. Gangrene was unusual and was found in only 4.4 percent of the cases treated in the vascular centers.

In addition to a complete history and physical examination, special procedures were used to study the patients at the vascular centers where constant-temperature rooms were available. Using skin temperature as an index of blood flow, measurements were recorded before and after thermoregulatory vasodilatation and nerve block with procaine hydrochloride.

17Freeman, Norman E.: Peripheral Vascular Disturbances: Thromboangiitis Obliterans, Arteriosclerosis, and Arterial Thrombosis and Embolism. In Medical Department, United States Army. Surgery in World War II. Vascular Surgery. Washington: U.S. Government Printing Office, 1955, pp. 375-382.


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TABLE 84.-Morbidity data on selected vascular diseases, U.S. Army, 1942-45

[Preliminary data based on sample tabulations of individual medical records]

Cause of admission 

Admissions1

Noneffective rate2

Separations for disability3

Number

Rate4

Number

As a percent of admissions

Arteriosclerosis5

6,230

0.25

4.29

2,856

45.8

Thromboangiitis obliterans

1,030

.04

1.33

774

75.1

Raynaud's disease

650

.03

.49

297

45.7

Varicose veins

54,383

2.15

15.27

4,061

7.5

Thrombophlebitis

14,733

.58

6.24

3,001

20.4

Hemorrhoids

221,289

8.73

46.08

1,588

.7

Other vascular diseases

10,688

.42

6.32

4,008

37.5

Total

309,003

12.20

80.02

16,585

5.4


1The term "admissions" refers to cases newly admitted to medical treatment facilities for the indicated disease as the primary cause of admission.
2Expressed as average number noneffective daily per 100,000 average strength.
3This category refers to disability separations for any cause among admissions for the specified disease during 1942-45.
4Expressed as number of admissions per year per 1,000 average strength.
5Excludes arteriosclerosis of coronary artery, kidney, and eye.
Source: Medical Statistics Division, Office of The Surgeon General, Department of the Army.

Oscillometric measurements were also made. Arteriographic studies with Thorotrast in four patients with normal peripheral pulses demonstrated that circulation was maintained by means of collaterals. The diagnosis of thromboangiitis obliterans was substantiated by biopsy in four other patients.

Nonmedical therapy consisted chiefly of attempts to eliminate smoking. Only 4 of 274 patients with thromboangiitis obliterans at the vascular centers did not smoke. Nonsmoking wards with special privileges, group therapy, occupational therapy, and sedation appeared to help. Of 93 patients whose subsequent habits were known, 77 did not smoke. Only two of these had persistent symptoms. Of the 16 who continued to smoke, 8 were observed to have progression of vascular obliteration. Indifferent results were secured by use of conservative measures other than elimination of smoking. These included Buerger's exercises, intermittent venous occlusion, and intermittent suction and pressure (pavex boot).

Sympathectomy was performed for 75 extremities in 53 of the 152 patients from whom data were available. Results were felt to be good in all but three patients. Two of these came to major amputation. Minor amputations were required in 12 other patients.

In spite of the generally good results obtained in this group of patients, only 24 of 274 patients (9 percent) recovered sufficiently to continue in service, and most of these in a limited duty capacity. The overall statistics compiled by the Medical Statistics Division, Office of The Surgeon General,


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reveal that 75 percent of the men with a recorded diagnosis of thromboangiitis obliterans were separated from the service for disability.

It was noted that thromboangiitis was encountered in the early stages of the disease. This may relate to the fact that more advanced disease was detected in induction centers, as reported by Jahsman and coworkers,18 and, therefore, such men were not inducted into military service. It is also true that men living under stress of military life may have sought medical aid sooner than in civilian life. These men constitute a group from which long-term followup studies on the causative factors and the natural history of Buerger's disease can be done.

ARTERIOSCLEROSIS OBLITERANS

Arteriosclerosis of peripheral vessels with symptoms of arterial insufficiency was observed in 55 patients seen in the vascular centers.19 The majority of patients in this group were from 40 to 55 years of age. The youngest was 30; only one was over 60. Intermittent claudication was present in 27 of them. Twenty complained of pain and eleven of abnormal coldness in the extremities. Ten patients had cardiac disease, five hypertension, three diabetes, and one nephritis.

Special attention in diagnosis was paid to evidences of calcification on roentgenograms of the extremities. Calcification was observed in all patients studied at Ashford General Hospital and in two-thirds of those seen at the other vascular centers. Other studies in constant-temperature rooms included skin temperatures and oscillometry. Lumbar sympathectomy was performed on four of these patients with satisfactory results reported in all. One minor amputation was performed; no major amputation was done. With the exception of five patients who were returned to limited duty, all men in this group were separated from the service for disability.

An additional 10 men were studied at Ashford General Hospital because of the incidental finding of calcification in peripheral blood vessels noted in films taken elsewhere for other purposes. No abnormality of the circulation could be detected clinically or by study in the vascular laboratory. None of the roentgenograms demonstrated spotty, mottled calcifications; all showed smooth, uniform shadows fading into normal vessels proximally and distally. These findings were consistent with earlier studies20 revealing that men with the smooth type of calcification demonstrated by X-ray were relatively symptom free as compared with those with calcification of the mottled type.

18Jahsman, W. E., Durham, R. H., and Dallis, N. P.: Recognition of Incipient Thromboangiitis Obliterans in Young Draftees. Ann. Int. Med. 18: 164-176, February 1943.
19See footnote 17 p. 469.
20Huyler, W. C.: Calcification in Arteries of Leg. Am. J. Roentgenol. 41: 784-788, May 1939.


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ARTERIAL EMBOLISM

Arterial embolism was relatively uncommon in the Army. Sixty-seven patients with this diagnosis were admitted to hospitals during the war; of these, six went to the vascular centers. For only 3 patients are case histories available, and the source of the embolus is not known for any of the 67 patients. One underwent a successful popliteal embolectomy overseas. Two patients required major amputation because of gangrene of the leg. Of the total 67 patients, only 8 (12 percent) were separated from the service as a result of the arterial embolus.

RAYNAUD'S DISEASE

The war provided an unusual opportunity to observe the manifestations of Raynaud's disease, and this diagnosis was recorded for 650 admissions during this time (table 84). Those admitted were predominantly men; however, in relation to the number of men and women in the Army, the admission rate for women was about five times the rate for men. One hundred and eighty-four patients with Raynaud's disease with digital syncope were observed at the three vascular centers. Data were available for analysis of 127 of these.21 At the centers, 111 were male and 16 female, ranging in age from 21 to 51 years. There was no evidence for occlusive vascular disease in any of these patients.

The digital syncope was observed in all patients included in the series from the three vascular centers. Of 57 patients studied at Mayo General Hospital, 20 exhibited the classical triphasic color changes characteristic of Raynaud's disease. The involved digits, immediately on exposure to cold, would turn "dead white," and the patient would experience in them the sensation of intense coldness, numbness, and stiffness. A clear-cut line of demarcation was generally present between the portion of the digit showing the pallor and that portion retaining the normal color. After a variable interval following return to a warm environment, the digits would become cyanotic. Cyanosis was followed by a period of rubor which was succeeded, in turn, by return to normal color. During the late stages of the attack, most patients complained of tingling, throbbing, and burning sensations or other paresthesias. In the remaining patients, the blanching occurred, but the phase of rubor or cyanosis or both was not perceptible before the return to normal color.

About half the patients were asymptomatic in the interval between attacks. The remainder experienced varying degrees of hyperhidrosis, cool-

21Shumacker, Harris B., Jr., and Abramson, David I.: Peripheral Vascular Disturbances-Vasopastic Disorders-Raynaud's Syndrome and Raynaud-Like Disorders. In Medical Department, United States Army. Surgery in World War II. Vascular Surgery. Washington: U.S. Government Printing Office, 1955, pp. 383-394.


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ness, or mild cyanosis. Trophic changes, usually minimal, occurred in 20 of the 127 patients. In five instances, scleroderma or sclerodactylia was present, and one patient had areas of gangrene of the fingertips in both hands. The majority of the patients seen in the vascular centers were separated from the service without active treatment. Sympathectomy was performed for those with incapacitating or severe symptoms. Sympathectomy was usually bilateral, with three extremities denervated in four patients and four extremities denervated in five. A total of 100 sympathectomies were performed in 46 of the 127 patients. At Mayo General Hospital, 21 sympathectomies were performed on 9 patients and the immediate results were considered excellent in all but 1, who had all 4 extremities denervated in stages. In this patient, digital syncope was abolished, but some tingling sensations persisted in cold weather. He also complained of annoying hyperhidrosis of the trunk. The fingertips of the one patient with gangrene healed promptly following sympathectomy.

Other disorders involving the vasomotor system were seen at the vascular centers. Some presented the picture of acrocyanosis. Others presented a picture similar to that of Raynaud's disease with increased sensitivity to cold but without digital syncope or with only a vague history of blanching. These patients were treated according to the severity of symptoms. Some were separated from the service; others returned to duty. Sympathectomy was performed in 6 of the 55 patients from whom data were available. Immediate results were good in all.

At the vascular centers, the presence of digital syncope was used as a necessary criterion for the diagnosis of Raynaud's disease in the cases reported. Six percent of these patients were observed to have symptoms and digital syncope in one extremity only, instead of the bilateral disturbances characteristic of Raynaud's disease. It may be that unilateral symptoms were an early manifestation of Raynaud's disease in these individuals and that the men in the service sought medical aid sooner than they would have in civilian life. Patients with digital syncope differed from the group without digital syncope in that hands were involved alone or more severely than were the feet. About one-third of the patients without digital syncope had involvement of the feet alone. Although the syndromes may in many instances be quite similar, the opinion was developed at the centers that the diagnosis of Raynaud's disease should be reserved, at least for those patients in whom pallor (or cyanosis) occurs on exposure to cold.

VENOUS DISEASE

Problems encountered with disorders of the venous system were similar to those in civilian life. Specific studies were not undertaken of individuals with varicose veins and thrombophlebitis, and as a rule, they were not sent to the vascular centers. Of interest, however, are the effects of


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these diseases on the individual as a soldier and on military manpower, and the effect of the military situation on the disease.

Statistics compiled by the Medical Statistics Division, Office of The Surgeon General, show 54,383 admissions to medical treatment facilities for varicose veins and 14,733 for thrombophlebitis, a combined incidence of 2.73 per 1,000 average strength per year (table 84). With an average duration of stay of 26 days for the former condition and 39 days for the latter, the loss in military manpower came to approximately 2 million man-days, equal to the loss of 5,500 men for a year. Approximately three-fourths of the patients were admitted in the continental United States. Among the patients with a diagnosis of thrombophlebitis, the secondary diagnoses were investigated in a sample of 1,597 patients.22 A diagnosis of pulmonary embolus or pulmonary infarction was made in 36 (2.25 percent). The provisional mortality due to varicose veins was 0.02 percent and that due to thrombophlebitis was 0.17 percent per year per 100,000 average strength. Of men admitted for varicose veins, 92 percent were returned to duty. Nearly all of the remainder, over 4,000 men, were separated from the service for disability. Of men admitted for thrombophlebitis, 21 percent were returned to civilian life.

Methods of management of patients with thrombophlebitis were similar to those used in civilian practice. Conservative measures included bed rest, elevation of the legs, and elastic support. Venous surgery consisted largely in ligation of superficial or deep veins in the leg as appeared to be indicated. Anticoagulation with heparin or Dicumarol (bishydroxycoumarin) or both was used. Statistical and followup data are not available for these patients. Sympathectomy was tried because of sweating, diminished peripheral circulation, cyanosis, and pain in seven of the patients referred to the vascular centers for longstanding thrombophlebitis. Although sweating and vasoconstriction were relieved and pain sometimes improved, the venous congestion and edema were not helped and in some instances appeared to be worse following surgery. It was believed, therefore, that sympathectomy was not of value in treatment of the late residuals of thrombophlebitis.

HEMORRHOIDAL VARICES

Although not generally considered among the vascular diseases, hemorrhoidal varices caused a rather significant loss in military manpower and so will be mentioned briefly. There were over 220,000 admissions to medical treatment facilities for hemorrhoids (table 84) with an average duration of stay of 19 days. The resulting loss in manpower was 4,265,000 man-days, equivalent to the loss of a hypothetical 15,000-man division for 9.5 months.

22Data compiled by the Medical Statistics Division, Office of The Surgeon General, Department of the Army.


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Data such as these indicate to some extent the significance of a seemingly minor illness in the progress of the military effort. The importance of managing such problems with minimal loss of duty time must repeatedly be stressed.

SUMMARY

The results of observations on certain aspects of peripheral vascular disease and injury during World War II broadened our understanding of the nature and logistic or economic significance of vascular disorders and provided a stimulus for the remarkable subsequent advances in cardiovascular medicine and surgery. The appalling loss of limbs after acute interruption of major arteries and the apparent impairment of function after arterial interruption for acute or chronic lesions stimulated interest in exploiting reconstructive vascular surgery as opposed to obliterative surgery in the management of both acute and chronic arterial lesions.

Much was learned about the mistakes which permitted the catastrophic incidence of cold injury in one theater of war after another; unfortunately, too little cognizance was taken of the experience gained in antecedent operations of other theaters in this war, as well as in previous wars. The recognition of the responsibility of command with regard to prevention of cold injury should prove of inestimable value for possible future operations in cold environments. The information collected has provided a clearer picture than heretofore of the natural history of cold injury and of the results of conservative management. This is of value not only for the military but also for the civilian surgeon who encounters this condition not infrequently during the winters of temperate climates.

Although little that is new was discovered with regard to such civilian conditions as phasic vasospasm and cold sensitivities, thromboangiitis obliterans, and arteriosclerosis, some idea was gained of the prevalence of these conditions in a selected and fairly homogeneous group of subjects. Much was learned of the clinical characteristics of these vascular diseases in their early stages, and their significance as a drain on military resources is better known than heretofore. But of greatest import and broadest implication for medical science is the fact that records are available of groups of individuals with certain diseases of the peripheral circulation and contain baseline data, disappointingly scant as they may be in many instances, for future reference. From these groups, rosters can be developed for followup studies.

A review of the available records with regard to peripheral vascular disease has emphasized the rather obvious fact that relatively little of value for subsequent clinical studies can be achieved without effort. Records prepared without anticipation that they would be of special value for subsequent investigation of a particular condition have been of relatively little


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use. Perhaps the greatest single achievement in this connection was the establishment of vascular centers in the Zone of Interior. Had nontraumatic vascular disturbances been referred to these centers earlier than the summer of 1944, unquestionably more would have been learned about these diseases. The credit for the unequaled achievements in the physiologic studies and in the surgical approach to chronic arterial and arteriovenous lesions must go to the establishment of these centers. One regrets that lack of equipment and of personnel made it impossible to take truly full advantage of the extraordinary opportunity for study of these vascular conditions.

Finally, it is well to emphasize here that the effort expended in the centers and by individual investigators in the field bore fruit not alone for this and subsequent military operations but for medical science as a whole. Indeed, the great potential of valuable information from clinical research based upon data recorded during the war has barely been touched and remains a challenge for the future.

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