SURGICAL RETROSPECTION
Vascular Surgery in World War II The Shift to Repairing Arteries Justin Barr, PhD, Kenneth J. Cherry, MD, FACS, and Norman M. Rich, MD, FACSy
Vascular surgery in World War II has long been defined by DeBakey and Simeone’s classic 1946 article describing arterial repair as exceedingly rare. They argued ligation was and should be the standard surgical response to arterial trauma in war. We returned to and analyzed the original records of World War II military medical units housed in the National Archives and other repositories in addition to consulting published accounts to determine the American practice of vascular surgery in World War II. This research demonstrates a clear shift from ligation to arterial repair occurring among American military surgeons in the last 6 months of the war in the European Theater of Operations. These conclusions not only highlight the role of war as a catalyst for surgical change but also point to the dangers of inaccurate history in stymieing such advances. Keywords: arterial repair, auxiliary surgical groups, combat surgery, vascular surgery, World War II
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n 1946, Michael DeBakey and Fiorindo Simeone published their now classic article ‘‘Battle Injuries of the Arteries in World War II’’ in Annals of Surgery (Fig. 1).1 Since accumulating almost 1000 citations in the literature, the monograph has come to define vascular surgery in the Second World War. The authors pessimistically concluded that repairing wounded arteries in World War II was both rare—occurring in only 81 of 2471 cases—and unlikely to become more common in future conflicts. Subsequent historians have accepted DeBakey and Simeone’s claims uncritically and continue to parrot their findings.2 Our article returns to the original records of military units in World War II housed at the National Archives and demonstrates that although DeBakey and Simeone’s data accurately portray circumstances through 1944, they do not account for a transition to arterial repair in the European Theater of Operations in the last 6 months of the war. These conclusions expose some of the pitfalls inherent in senior, stateside officers writing definitive military medical papers without actually caring for combat casualties. Our new interpretation demonstrates not only the ability of war to change surgery but also the dangers and implications of inaccurate historical analysis on future practice.
SETTING THE STAGE Vascular surgery existed in a larger medical context, one that during World War II created more favorable conditions for arterial repair to take place. Alexis Carrel and Charles Guthrie’s triangulation technique was well-known and well-published by 1939, if infrequently practiced. Jay McClean and others had discovered heparin, and Gordon Murray had convincingly demonstrated its potential to reduce thrombotic complications of arterial surgery.3 –5 From the University of Virginia, Charlottesville, VA; and yUniformed Services University of the Health Sciences, Bethesda, MD. Disclosure: Authors have no financial ties or conflicts of interest to disclose. Reprints: Justin Barr, PhD, University of Virginia, Charlottesville, VA 22908. E-mail: [email protected]. Copyright ß 2015 Wolters Kluwer Health, Inc. All rights reserved. ISSN: 0003-4932/14/26105-0821 DOI: 10.1097/SLA.0000000000001181
Annals of Surgery Volume 263, Number 3, March 2016
Arteriograms, first appearing in the 1920s, had proven their value in diagnosing pathologies.6 By 1944, penicillin had become widely available to military surgeons, saving life and limb by dramatically reducing infection.7 Early fighting in North Africa definitively proved the importance of whole-blood transfusion in the resuscitation of grievously wounded soldiers.8 In an effort largely championed by Edward Churchill, the Army began banking and transfusing whole blood by 1943. This therapy proved especially important in vascular cases, with their high risk of pre- and intraoperative blood loss.
PREWAR PLANS The delayed entry of the United States into World War II provided time to learn from the experience of other countries, create and distribute instructional materials, establish courses, and teach the proper management of vascular injuries to a cohort of newly drafted physicians largely unfamiliar with the pathology. In 1943, the National Research Council published a series of Military Surgical Manuals to educate civilian physicians on topics specific to combat medicine. The fifth volume in this series covered the vascular system.9 Authored by such luminaries as Arthur W. Allen, Geza de Taka´ts, Daniel C. Elkin, and Walter G. Maddock, the book promised an accurate, authoritative accounting of the subject. Other leaders in the field like Emile Holman published ‘‘how-to’’ articles in widely read journals like Surgery, Gynecology, and Obstetrics.10,11 Periodically throughout the war, the Army distributed circulars as a form of continuing medical education, providing further and updated instructions on optimal wound management.12– 15 These publications and classes repeatedly emphasized ligating vessels. Specifically, they insisted on dividing the artery and warned that ligation in continuity presented a serious risk of secondary hemorrhage. In keeping with doctrine established in the First World War, sources also advised ligating the concomitant vein.10,15 A surgeon might attempt surgical repair of an artery if the clinical and tactical situation allowed, but even for these rare scenarios, most publications proposed just the lateral suturing of arterial lacerations, and even that only tepidly.9,11,13,15 Holman, Elkin, and the others certainly recognized the possibility of amputation after tying off arteries. But on the basis of their prewar experience, they believed the risk of limb loss after ligation sufficiently low and the likelihood of devastating complications from repair so high that they actively discouraged Carrel-style procedures in favor of ligation. Specifically, they feared: (a) clot forming at the suture line and propagating proximally, occluding collaterals; (b) pseudoaneurysms developing at the suture line, necessitating higher ligation for treatment; or (c) the suture line blowing out and the patient exsanguinating. Repairs were so new, and so rarely practiced in the civilian world, that no one had disproven these theoretical— and expected—complications. Furthermore, the challenges of postoperative care in combat environments with rapidly moving front lines precluded careful observation and heightened the risk of devastating complications going untreated. As such, leading surgeons hedged toward the surgery they knew despite the risk of amputation rather than an experimental operation with the potential for disastrous and fatal sequelae. www.annalsofsurgery.com | 615
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FIGURE 1. Michael DeBakey receives the legion of merit from Surgeon General Norman Kirk in 1945 (photo courtesy of Baylor College of Medicine Archives).
THE PRACTICE OF VASCULAR SURGERY IN WORLD WAR II, 1942–1944 Injuries to the vasculature comprised 0.96% of all combat wounds in World War II according to DeBakey and Simeone and 1.7% according to the US Army Medical Statistics Division.1,16 Ligation followed by sympathectomy treated the vast majority of vascular wounds through December 1944. DeBakey and Simeone’s article describes this era well and noted 1639 ligations in 1774 vascular injuries (92%).1 Surgeons in the Third Army reported ligating 96% (362/346) of vascular wounds between August and November of 1944.17 Other published accounts reflect a similar reliance on ligation.18–20 Few arterial repairs took place: the Third Army repaired only 16 of 362 vascular injuries (4.4%), 10 of which failed and required amputation.17,21,22 DeBakey and Simone identified only 81 instances of repair in 2471 cases, or a 3.3% repair rate; only 3 were end-to-end anastomosis and none were venous autografts; the rest were lateral suture of minor wounds.1 Concomitant vein ligation and sympathectomy were common postoperative interventions intended to lower amputation rates. Popularized by George Makins in World War I, concomitant vein ligation theoretically improved tissue oxygenation by reducing the outflow of blood from a wounded extremity. It featured prominently in pre-World War II instructions for American surgeons, who practiced the technique extensively in the early years of the conflict.19,22– 24 However, by late 1944, data did not reveal any benefit to the procedure, and an Inter-Allied Conference in December formally recommended its discontinuance, though many surgeons continued the practice.25,26 Established in the 1930s, chemical and surgical sympathectomies promised to revolutionize vascular surgery by dilating arteries. The increased collateral flow would supplement or, in some cases, replace operations. Sympathectomies also received strong *Because neither the Surgeon General nor the Adjutant General mandated reporting of vascular injuries, data include solely what units voluntarily collected and are incomplete, although consistency across multiple sources connotes at least rough accuracy. These numbers only reflect wounds to vessels in the extremities. Patients rarely survived injuries to the vasculature in the abdomen and thorax, which often went unrecorded. When surgeons did document such wounds, they typically classified them in reference to the organ damaged (eg, damage to the splenic artery was categorized as a splenic injury).
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endorsement in prewar instructional literature. Most military surgeons opted for temporary—and often repeated—sympathetic blocks with novocaine rather than operative interruption. The practice was widespread. The 95th Evacuation Hospital reported performing sympathetic blocks in ‘‘nearly most every’’ case.20,27 In their 487 vascular cases, the Third Auxiliary Surgical Group applied sympathetic blocks after 94% of their ligations.28 In contrast to their recommendation for the cessation of vein ligation, the Inter-Allied Surgery Conference in 1944 called for ‘‘more general use. . .of sympathetic blocks in an attempt to improve collateral circulation.’’26 Data collected during and after the fighting raised questions regarding its actual efficacy in saving limbs, but it nonetheless remained common in all theatres through the end of the war.29 Despite concomitant vein ligation and sympathectomy, amputation rates after ligation remained high—much higher than anticipated. Table 1 shows the forecasted amputation rates by artery and the actual amputation rates documented in DeBakey and Simeone’s article. The actual incidence of amputation far exceeded the predicted incidence for every single artery, with the actual rate sometimes 5 times higher than the predicted one. In the 2471 vascular wounds DeBakey and Simeone cataloged, fully 40%—or 995 arms and legs—required amputation.1 Smaller, more precise studies confirm those numbers.30 And this already elevated amputation rate excluded primary amputations where surgeons did not even attempt to save the limb; one large series showed 60% of primary amputations resulted from devascularization.31 The dissonance between expectations and reality partly resulted from the attempted application of civilian experience to a military environment. The devastating wounds destroyed collateral vessels and the acute nature of the injuries precluded the development of new branches. Civilian techniques of ligation plus sympathectomy relied on robust collateral circulation to preserve the extremity and simply failed in wartime. The excessively high amputation rate after ligation led surgeons to change their practice and attempt to repair arteries in the final months of the conflict.
THE SHIFT TO ARTERIAL REPAIR, 1945 From December 1944 through the end of the war, American military surgeons, particularly in Europe, began repairing damaged TABLE 1. Disparity Between Expected and Actual Amputation Rates After Ligation
Artery Internal carotid Subclavian Axillary Brachial Common iliac External iliac Common femoral, above profunda Femoral, below profunda Popliteal Anterior tibial Posterior tibial
Predicted Amputation Rate9
Actual Amputation Rate1
30% 9% 9% 3% 50% 13% 21% 10% 0%y 3% 3%
30% 29% 43% 27% 53% 47% 81% 55% 73% 9% 14%
Predicted values come from the 1943 book published by the military entitled Burns, Shock, Wound Healing, and Vascular Injuries9; the actual amputation rates are taken 1. from DeBakey and Simeone’s 1946 article. ‘‘Amputation’’ for the carotid refers to severe and irreversible neurological damage. yThis number is so far-fetched that presumably it was a typo or oversight, although the manual spelled out ‘‘none’’ rather than using Arabic numerals, so the mistake was larger than just dropping a digit.
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arteries instead of just ligating them. They employed primary arteriorrhaphy, end-to-end anastomosis, venous grafts, and, rarely, artificial prostheses called Lord-Blakemore-Stefko tubes. DeBakey and Simone’s classic article, while admirably documenting the first years of the war, failed to capture this important change in practice.
Limitations of DeBakey and Simeone’s Article DeBakey and Simeone’s series of 2471 cases is the largest single collection of vascular injuries from World War II. It remains a highly accurate description of events through mid-1944. Writing toward the end of the war, the authors lacked any central repository from which to collect data. Still, they unfortunately never document the source for the 2471 cases in the title. Nor, with the exception of a single chart, does their article actually analyze all 2471 cases. Instead, most statistics, as well as a subsequent, more detailed publication, relied on roughly 1500 cases (or fewer) as a denominator.32 Archival research has produced a report Simeone authored entitled ‘‘Wounds of the Arteries of the Extremities’’ that documented more than 1400 cases and clearly formed the foundation of their subsequent Annals of Surgery article.33,34 Problematically for the larger study, Simeone drew on the records of only 4 hospitals, all of which predominately served in the North African and Mediterranean Theaters,y and he largely stopped collecting data in December 1944. Thus DeBakey and Simeone’s article relies on roughly 6 months of data from the Mediterranean and Europe to characterize the entire war—which lasted another 6 months. By extrapolating their findings and not going back to the original records for the remaining 6 months of fighting, they missed the important shift to repairing arteries.
A Change in Practice The tack toward arterial repair occurred for 3 main reasons. First, medical officers grew frustrated with consistently abysmal rates of amputation after ligation. ‘‘In spite of the well-known poor results reported following vascular suture and anastomosis,’’ reported one team in 1945, ‘‘we elected to try it in preference to the seemingly invariably disastrous ligation.’’35 The author had ligated 8 popliteal arteries in the Italian campaign—with 8 subsequent amputations. When his unit transferred to Europe, he repaired 3 damaged popliteal arteries, saving the leg in each case. Other surgeons reported similarly dismal experience with ligation and similarly positive results when attempting repairs.18–20 By 1945, surgeons well understood the consequences of ligation and were willing to attempt something new and experimental, doubting the outcomes could be worse. One Evacuation Hospital in Europe, for example, ‘‘distressed’’ over the high amputation rates after ligation, transitioned from tying off 100% of their damaged arteries in 1944 to repairing 14% in 1945, a percentage that jumps to 23% if you discount wounds to the tibial vessels that surgeons rarely repaired; either rate far exceeded the 3.3% that DeBakey and Simeone quoted.27 By 1945, Surgeons in Patton’s Third Army ‘‘were thoroughly indoctrinated with the importance of attempting repair of major vascular injuries.’’36 Second, surgeons had more experience by 1945. In a period of months in combat, they had treated more vascular trauma than their civilian practices would see over the course of decades. Not only did this volume highlight the failure of ligation, it also imbued doctors with greater confidence and skill. Operators were generally more adroit after months of caring for wounded soldiers, evident not just in the increased proportion of arterial repair but also in improvement in other areas of surgery, like thoracic cases where mortality dropped over the course of the war despite the increasing severity of wounds reaching the surgeon.37 See Fig. 2. y Those hospitals were 94th Evacuation Hospital, 8th Evacuation Hospital, 171st Evacuation Hospital, and statistics from the 7th Army (the latter only through December 1944).
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Arterial Repair in World War II
Third, by 1945, the Allies were fighting a different war. The Battle of the Bulge was the last offensive gasp from the Wehrmacht, and its defeat meant final victory in Europe became a question no longer of ‘‘if’’ but ‘‘when.’’38 Both front and supply lines became more stable. A surfeit of supplies accumulated. Hospitals became fixed facilities that featured more advanced technology. Feelings of confidence and security among troops—medical and otherwise— grew, and conditions generally became more conducive to practicing advanced arterial repair procedures. The Auxiliary Surgical Groups exhibited the most pronounced shift toward arterial repair due to the quality of their personnel and their extensive experience. Created by DeBakey, the units typically recruited the best-trained operators, and their fire-brigade like utilization led to thousands of cases.39–42 In 1945, they put that skill and experience to use in repairing arteries. The Second Auxiliary Surgical Group collected meticulous statistics on its patients. Out of 220 vascular injuries they cataloged in detail, they repaired 20, or 9%—a rate 3 times higher than DeBakey (3%) recorded.41 The Third Auxiliary Surgical Group was even more ambitious. From D-Day to December of 1944, their groups repaired a trifling 15 arteries, but disgusted with high rate of amputation that followed ligation, Third Auxiliary Surgical Group surgeons repaired 107 of 487 (22%) of their vascular cases between December 1944 and the end of the war.28 These 107 repairs that the Third Auxiliary Surgical Group alone performed exceeded the total number (81) of repairs DeBakey and Simeone cited for the entire war, demonstrating the shift to arterial repair in 1945. These repairs primarily involved lateral arteriorrhaphy and end-to-end anastomosis, although a few surgeons performed venous autografts. The more complex the operation, the higher the rate of failure. A new technology, Lord-Blakemore-Stefko tubes promised to simplify reparative procedures. These Vitallium prostheses, lined by either fresh or freeze-dried vein, were to be inserted into gaps in arteries and secured by a simple loop suture rather than the technically difficult and time-consuming triangulation method.43 Foreshadowing the shunts modern surgeons have employed in Iraq and Afghanistan over the last decade, Lord-Blakemore-Stefko tubes temporarily ensured blood flow to distal limbs. Lord-BlakemoreStefko tubes were designed to maintain blood flow for 7 to 10 days, at which point surgeons hoped that collateral circulation would have sufficiently developed to supply the distal appendage. No one anticipated them maintaining permanent patency.44 Better in theory than in reality, only 17 tubes were definitely placed during World War II as surgeons eschewed what was a demanding, lengthy, and rarely successful operation.29 Lord-Blakemore-Stefko tubes represented a good idea but a poor practical solution and highlight the challenges of applying surgical innovations. Repairing arteries saved limbs. DeBakey and Simeone documented a 50% amputation rate after ligation but only 35% after a repair.1 The second Auxiliary Surgical Group’s careful records demonstrate even greater success: patients with ligated arteries suffered amputations 44% of the time whereas those with repaired vessels lost their limbs after only 25% of operations.45 Certainly, these numbers reflect a selection bias, with surgeons often choosing to repair less severe cases and ligate in more challenging circumstances, but the increased occurrence of arterial repair nonetheless allowed hundreds of Americans to return home with arms and legs intact.
VASCULAR SURGERY AT HOME This shift to arterial repair did not just take place on the battlefield. In the continental United States, the Surgeon General established specialty hospitals to provide definitive care for wounded soldiers. Three such institutions treated vascular patients. At DeWitt hospital, led by Norman Freeman, and especially at Mayo Hospital, www.annalsofsurgery.com | 617
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FIGURE 2. US Army doctors operating on a gunshot wound to the left thigh at the 48th Surgical Hospital in North Africa, April 4, 1943. US Signal Corps Photo MM-STEI-43-1151, located in NARA RG 111-SC. Figure is in the public domain.
FIGURE 3. Arteriogram of a repair of an AV fistula and pseudoaneurysm from Mayo Hospital, 1945 highlighting not only the new reparative operation (in this case an end-to-end anastomosis) but also the novel technology of arteriograms to diagnose the pathology and assess the postoperative results.47 Figure is in the public domain.
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Annals of Surgery Volume 263, Number 3, March 2016
led by Harry B Shumacker, Jr, an analogous transition to reparative operations for arteriovenous fistulae and pseudoaneurysms occurred. In 1944, surgeons ligated 94% of arteriovenous fistulae cases and either ligated or performed an obliterative Matas Operation on 99% of pseudoaneurysms.46 Although these procedures did not result in amputation, Freeman and Shumacker did notice they frequently led to severe cases of debilitating vascular insufficiency. By 1945, they too began repairing arteries through arteriorrhaphy, end-to-end anastomosis, and venous autografts. Freeman’s unit repaired 34% of their cases (23/67) between June and November of 1945. Shumacker was even more ambitious. Mayo Hospital repaired only 3% (4/138) of cases in late 1944 but 53% (30/57) thereafter (Fig. 3).47 As with acute injuries, chronic vascular pathologies also benefited tremendously from reparative operations, with few complications and no incidences of vascular insufficiency after successful repairs.
Arterial Repair in World War II
Institute, and American College of Surgeons helped them navigate through reams of old records. Librarians at Yale University and the University of Virginia graciously aided their search. John Harley Warner, Dale C. Smith, Daniel J. Kevles, and Frank M. Snowden’s edits and comments greatly strengthened the article. Finally, they also appreciate the helpful comments from the anonymous reviewers at Annals of Surgery. All citations to documents in the US Government’s National Archives and Records Administration (NARA) refer to the repository in College Park, MD, and are abbreviated as: NARA, record group/ stack area/compartment/row/shelf/box/folder. Documents in the United States Army Military History Institute at the United States Army Heritage and Education Center, Carlisle, Pennsylvania, are abbreviated as MHI Archives, followed by the collection name and box/folder numbers.
CONCLUSIONS
REFERENCES
By returning to the original military medical records in the National Archives, our article contradicts DeBakey and Simeone’s findings that arterial repair was rare throughout the entirety of World War II. Our analysis of the data illuminates how both combatant units and stateside surgeons began repairing an ever-increasing percentage of injured arteries in 1945. Although such operations never predominated, surgeons nevertheless demonstrated that these procedures were not only possible but also, in the hands of trained and experienced surgeons, had far superior outcomes than simple ligation. This transition to arterial repair highlights the ability of war to catalyze surgical change. The milieu of war provided the conditions necessary for surgeons to begin to adopt Carrel-style arterial repairs. The technique had existed for decades before World War II but remained rarely practiced, partly because extensive vascular trauma remained relatively infrequent in the civilian world, partly due to the perceived efficacy of ligation þ sympathectomy, and partly from the lack of training most pre-World War II surgeons received. By generating a vast number of patients, the Second World War created an environment conducive to addressing these challenges. First, doctors simply had more general operative experience, gaining confidence and learning new techniques. Second, they saw more vascular trauma in a few months than their civilian practice might admit in decades. This concentration of cases both at the front and at specialized hospitals back home allowed the marked deficiencies of ligation þ sympathectomy to become apparent. The relatively unsupervised and urgent nature of combat surgery encouraged innovation, allowing physicians to try new operations. Again, the unprecedented number and concentration of cases created definitive evidence of the feasibility and efficacy of arterial repair while simultaneously proving the infrequency of feared complications. Unfortunately, DeBakey and Simeone’s article came to define vascular surgery in World War II. Drastically understating and minimizing the actual incidence of arterial repair, the article pessimistically concluded that vessel ligation ought to remain the standard military practice for vascular trauma in any future war. Thus, when American surgeons deployed to Korea in 1950, they resumed ligating damaged arteries as their forbearers had done in 1944. Few clearer cases of inaccurate history propagating poor clinical practice exist in the literature. It took hundreds of additional amputations and a new generation of surgeons led by men like Carl Hughes and Frank Spencer to re-recognize the feasibility and superiority of repairing arteries in traumatic vascular injuries and applying the technique en masse to wounded soldiers and Marines in Korea.
1. DeBakey ME, Simeone F. Battle injuries of the arteries in World War II. Ann Surg. 1946;123:534–579. 2. Friedman SG. A History of Vascular Surgery. Mount Kisco, NY: Factura; 1989:183–185. 3. Marcum JA. The origins of the dispute over the discovery of heparin. J Hist Med Allied Sci. 2000;55:37–66. 4. Marcum JA. The development of heparin in Toronto. J Hist Med Allied Sci. 1997;52:310–337. 5. Murray DWG, Jacques LB, Perrett TS, et al. Heparin and vascular occlusion. Can Med Assoc J. 1936;35:621–622. 6. Kevles BH. Naked to the Bone: Medical Imaging in the Twentieth Century.. New Brunswick, NJ: Rutgers University Press; 1987, 103-104. 7. Bud R. Penicillin: Triumph and Tragedy. New York, NY: Oxford University Press; 2007. 8. Kendrick DB. Blood Program in World War II. Washington, DC: Office of the Surgeon General; 1964. 9. Burns, Shock, Wound Healing, and Vascular. In: Injuries. Philadelphia, PA: W. B. Saunders Company; 1943. 10. Holman E. War injuries to arteries and their treatment. Surg Gynecol Obstet. 1942;75:183–192. 11. de Taka´ts G. Vascular surgery in the war. War Med. 1943;3:291–296. 12. Circular Letter No. 5: Gas Gangrene; NATOUSA; August 5, 1943; NARA 112/390/17/8/1/4/17. 13. Medical Circular No. 4 Gas Gangrene; Office of the Surgeon, 5th Army; October 20, 1943; NARA 112/390/17/8/1/4/18. 14. Circular Letter No. 8: Notes on Care of Battle Casualties; HQ MTO Office of the Surgeon; March 1945; NARA 112/390/17/9/2/5/5. 15. Circular Letter No. 2: Surgery; HQ 7th Army; July 18, 1944; NARA 112/390/ 17/8/1/4/1/18. 16. Corrections; NARA; 112/390/16/11/6/481/1. 17. Odom CB. Vascular Injuries, Report to Anglo-American Consultants Conference; December 10, 1944; NARA 331/290/7/34/4/3/2. 18. Bradford BJ Jr, Moore MJ. Vascular injuries in war. Surg Gynecol Obstet. 1946;83:667–673. 19. Rose CA, Hess OW, Welch CS. Vascular injuries of the extremities in battle casualties. Ann Surg. 1946;123:161–179. 20. Smith MK. Arterial injuries. Ann Surg. 1947;126:866–872. 21. Province CM. I Was Patton’s Doctor: The Reminisces of Charles B. Odom, MD. St Louis, MO: CMP Productions; 2010. 22. Taylor GW. Report of the surgical section. In: Sauer PK. Historical Records and Annual Report, 95th Evacuation Hospital. 1944; NARA 331/290/8/25/1/31/25. 23. Schlicke CP. Arterial Injuries, 247th General Hospital; December 7, 1944; NARA 112/390/17/13/6/235/1. 24. Kirtley JA Jr. Arterial injuries in a theater of operations. Ann Surg. 1945;122: 222–234. 25. Anglo-American Consultants Conference; December 10, 1944; NARA 331/ 290/7/34/4/3/2. 26. Elkin DC. Vascular injuries of warfare. Ann Surg. 1944;120:284–306. 27. Snyder JM. Vascular wounds: report of a series of 108 cases encountered in a forward evacuation hospital. Surgery. 1947;21:77–85. 28. 3rd Auxiliary Surgery Group Annual Report, 1945; NARA 112/390/17/17/5/ 393/3.
ACKNOWLEDGMENTS The authors are grateful for the generous assistance of other scholars. Archivists in the National Archives, Military History ß
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29. Barr J. Surgical Repair of the Arteries in War and Peace [PhD dissertation]. New Haven, CT: Yale University; 2014. 30. Semi-Annual Report of the 9th Evacuation Hospital; January 1-June 30, 1945; NARA 112/390/17/25/6/400/4; 16-17. 31. Arterial Injuries in War Wounds From the 2nd Auxiliary Surgical Group; NARA 112/390/16/11/6/358/2. 32. DeBakey ME, Simeone F. Acute battle-incurred arterial injuries.. In: Elkin DC, DeBakey ME, eds. Vascular Surgery in World War II.. Washington, DC: Office of the Surgeon General; 1955:534–579. 33. Simeone F. Wounds of the arteries of the extremities; August 1945; NARA 112/390/16/11/6/359/3. 34. Page Proofs; NARA 112/390/16/11/6/482/2. 35. Imes PR. Suture of the popliteal artery: a report of three cases. Surgery. 1945;18:644–646. 36. Odom CB. Causes of amputations in battle casualties with emphasis on vascular injuries. Surgery. 1946;19:562–569. 37. Carter N, DeBakey ME. Special reports and statistical data. In: Heaton LD, ed. Thoracic Surgery: Volume II. Washington, DC: Office of the Surgeon General; 1965:529–533. 38. .Toland J. Battle: The Story of the Bulge.. New York, NY: Random House; 1958 39. Marble WS. Forward surgery and combat hospitals: the origins of MASH. J Hist Med Allied Sci. 2014;69:68–100.
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40. Brewer LA. The contributions of the Second Auxiliary Surgical Group to military surgery during World War II with special reference to thoracic surgery. Ann Surg. 1987;197:318–326. 41. Forward Surgery of the Severely Wounded: a History of the Activities of the 2nd Auxiliary Surgical Group, 1942-1945; NARA 112/390/16/11/6/358/1-3. 42. Graves CL. Front Line Surgeons: The History of the Third Auxiliary Surgical Group. San Diego, CA; 1950. 43. Blakemore AH, Lord JW Jr, Stefko PL. The severed primary artery in the war wounded: a nonsuture method of bridging arterial defects. Surgery. 1942;12:488–508. 44. Rasmussen TE, Clouse WD, Jenkins DH, et al. The use of temporary vascular shunts as a damage control adjunct in the management of wartime vascular injury. J Trauma. 2006;61:8–15. 45. Forward Surgery of the Severely Wounded, data compiled from 717-741. 46. Elkin DC, Shumacker HB Jr. Arterial aneurysms and arteriovenous fistulas— general considerations. In: Elkin DC, DeBakey ME, eds. Vascular Surgery in World War II. Washington, DC: Office of the Surgeon General; 1955:149– 180. 47. Freeman NE, Shumacker HB Jr. Arterial Aneurysms and Arteriovenous Fistulas: Maintenance of Arterial Continuity. In: Elkin DC, DeBakey ME, eds. Vascular Surgery in World War II. Washington, DC: Office of the Surgeon General; 1955:264–301.
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Vascular Surgery in World War II The Shift to Repairing Arteries Justin Barr, PhD, Kenneth J. Cherry, MD, FACS, and Norman M. Rich, MD, FACSy
Vascular surgery in World War II has long been defined by DeBakey and Simeone’s classic 1946 article describing arterial repair as exceedingly rare. They argued ligation was and should be the standard surgical response to arterial trauma in war. We returned to and analyzed the original records of World War II military medical units housed in the National Archives and other repositories in addition to consulting published accounts to determine the American practice of vascular surgery in World War II. This research demonstrates a clear shift from ligation to arterial repair occurring among American military surgeons in the last 6 months of the war in the European Theater of Operations. These conclusions not only highlight the role of war as a catalyst for surgical change but also point to the dangers of inaccurate history in stymieing such advances. Keywords: arterial repair, auxiliary surgical groups, combat surgery, vascular surgery, World War II
(Ann Surg 2016;263:615–620)
I
n 1946, Michael DeBakey and Fiorindo Simeone published their now classic article ‘‘Battle Injuries of the Arteries in World War II’’ in Annals of Surgery (Fig. 1).1 Since accumulating almost 1000 citations in the literature, the monograph has come to define vascular surgery in the Second World War. The authors pessimistically concluded that repairing wounded arteries in World War II was both rare—occurring in only 81 of 2471 cases—and unlikely to become more common in future conflicts. Subsequent historians have accepted DeBakey and Simeone’s claims uncritically and continue to parrot their findings.2 Our article returns to the original records of military units in World War II housed at the National Archives and demonstrates that although DeBakey and Simeone’s data accurately portray circumstances through 1944, they do not account for a transition to arterial repair in the European Theater of Operations in the last 6 months of the war. These conclusions expose some of the pitfalls inherent in senior, stateside officers writing definitive military medical papers without actually caring for combat casualties. Our new interpretation demonstrates not only the ability of war to change surgery but also the dangers and implications of inaccurate historical analysis on future practice.
SETTING THE STAGE Vascular surgery existed in a larger medical context, one that during World War II created more favorable conditions for arterial repair to take place. Alexis Carrel and Charles Guthrie’s triangulation technique was well-known and well-published by 1939, if infrequently practiced. Jay McClean and others had discovered heparin, and Gordon Murray had convincingly demonstrated its potential to reduce thrombotic complications of arterial surgery.3 –5 From the University of Virginia, Charlottesville, VA; and yUniformed Services University of the Health Sciences, Bethesda, MD. Disclosure: Authors have no financial ties or conflicts of interest to disclose. Reprints: Justin Barr, PhD, University of Virginia, Charlottesville, VA 22908. E-mail: [email protected]. Copyright ß 2015 Wolters Kluwer Health, Inc. All rights reserved. ISSN: 0003-4932/14/26105-0821 DOI: 10.1097/SLA.0000000000001181
Annals of Surgery Volume 263, Number 3, March 2016
Arteriograms, first appearing in the 1920s, had proven their value in diagnosing pathologies.6 By 1944, penicillin had become widely available to military surgeons, saving life and limb by dramatically reducing infection.7 Early fighting in North Africa definitively proved the importance of whole-blood transfusion in the resuscitation of grievously wounded soldiers.8 In an effort largely championed by Edward Churchill, the Army began banking and transfusing whole blood by 1943. This therapy proved especially important in vascular cases, with their high risk of pre- and intraoperative blood loss.
PREWAR PLANS The delayed entry of the United States into World War II provided time to learn from the experience of other countries, create and distribute instructional materials, establish courses, and teach the proper management of vascular injuries to a cohort of newly drafted physicians largely unfamiliar with the pathology. In 1943, the National Research Council published a series of Military Surgical Manuals to educate civilian physicians on topics specific to combat medicine. The fifth volume in this series covered the vascular system.9 Authored by such luminaries as Arthur W. Allen, Geza de Taka´ts, Daniel C. Elkin, and Walter G. Maddock, the book promised an accurate, authoritative accounting of the subject. Other leaders in the field like Emile Holman published ‘‘how-to’’ articles in widely read journals like Surgery, Gynecology, and Obstetrics.10,11 Periodically throughout the war, the Army distributed circulars as a form of continuing medical education, providing further and updated instructions on optimal wound management.12– 15 These publications and classes repeatedly emphasized ligating vessels. Specifically, they insisted on dividing the artery and warned that ligation in continuity presented a serious risk of secondary hemorrhage. In keeping with doctrine established in the First World War, sources also advised ligating the concomitant vein.10,15 A surgeon might attempt surgical repair of an artery if the clinical and tactical situation allowed, but even for these rare scenarios, most publications proposed just the lateral suturing of arterial lacerations, and even that only tepidly.9,11,13,15 Holman, Elkin, and the others certainly recognized the possibility of amputation after tying off arteries. But on the basis of their prewar experience, they believed the risk of limb loss after ligation sufficiently low and the likelihood of devastating complications from repair so high that they actively discouraged Carrel-style procedures in favor of ligation. Specifically, they feared: (a) clot forming at the suture line and propagating proximally, occluding collaterals; (b) pseudoaneurysms developing at the suture line, necessitating higher ligation for treatment; or (c) the suture line blowing out and the patient exsanguinating. Repairs were so new, and so rarely practiced in the civilian world, that no one had disproven these theoretical— and expected—complications. Furthermore, the challenges of postoperative care in combat environments with rapidly moving front lines precluded careful observation and heightened the risk of devastating complications going untreated. As such, leading surgeons hedged toward the surgery they knew despite the risk of amputation rather than an experimental operation with the potential for disastrous and fatal sequelae. www.annalsofsurgery.com | 615
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FIGURE 1. Michael DeBakey receives the legion of merit from Surgeon General Norman Kirk in 1945 (photo courtesy of Baylor College of Medicine Archives).
THE PRACTICE OF VASCULAR SURGERY IN WORLD WAR II, 1942–1944 Injuries to the vasculature comprised 0.96% of all combat wounds in World War II according to DeBakey and Simeone and 1.7% according to the US Army Medical Statistics Division.1,16 Ligation followed by sympathectomy treated the vast majority of vascular wounds through December 1944. DeBakey and Simeone’s article describes this era well and noted 1639 ligations in 1774 vascular injuries (92%).1 Surgeons in the Third Army reported ligating 96% (362/346) of vascular wounds between August and November of 1944.17 Other published accounts reflect a similar reliance on ligation.18–20 Few arterial repairs took place: the Third Army repaired only 16 of 362 vascular injuries (4.4%), 10 of which failed and required amputation.17,21,22 DeBakey and Simone identified only 81 instances of repair in 2471 cases, or a 3.3% repair rate; only 3 were end-to-end anastomosis and none were venous autografts; the rest were lateral suture of minor wounds.1 Concomitant vein ligation and sympathectomy were common postoperative interventions intended to lower amputation rates. Popularized by George Makins in World War I, concomitant vein ligation theoretically improved tissue oxygenation by reducing the outflow of blood from a wounded extremity. It featured prominently in pre-World War II instructions for American surgeons, who practiced the technique extensively in the early years of the conflict.19,22– 24 However, by late 1944, data did not reveal any benefit to the procedure, and an Inter-Allied Conference in December formally recommended its discontinuance, though many surgeons continued the practice.25,26 Established in the 1930s, chemical and surgical sympathectomies promised to revolutionize vascular surgery by dilating arteries. The increased collateral flow would supplement or, in some cases, replace operations. Sympathectomies also received strong *Because neither the Surgeon General nor the Adjutant General mandated reporting of vascular injuries, data include solely what units voluntarily collected and are incomplete, although consistency across multiple sources connotes at least rough accuracy. These numbers only reflect wounds to vessels in the extremities. Patients rarely survived injuries to the vasculature in the abdomen and thorax, which often went unrecorded. When surgeons did document such wounds, they typically classified them in reference to the organ damaged (eg, damage to the splenic artery was categorized as a splenic injury).
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endorsement in prewar instructional literature. Most military surgeons opted for temporary—and often repeated—sympathetic blocks with novocaine rather than operative interruption. The practice was widespread. The 95th Evacuation Hospital reported performing sympathetic blocks in ‘‘nearly most every’’ case.20,27 In their 487 vascular cases, the Third Auxiliary Surgical Group applied sympathetic blocks after 94% of their ligations.28 In contrast to their recommendation for the cessation of vein ligation, the Inter-Allied Surgery Conference in 1944 called for ‘‘more general use. . .of sympathetic blocks in an attempt to improve collateral circulation.’’26 Data collected during and after the fighting raised questions regarding its actual efficacy in saving limbs, but it nonetheless remained common in all theatres through the end of the war.29 Despite concomitant vein ligation and sympathectomy, amputation rates after ligation remained high—much higher than anticipated. Table 1 shows the forecasted amputation rates by artery and the actual amputation rates documented in DeBakey and Simeone’s article. The actual incidence of amputation far exceeded the predicted incidence for every single artery, with the actual rate sometimes 5 times higher than the predicted one. In the 2471 vascular wounds DeBakey and Simeone cataloged, fully 40%—or 995 arms and legs—required amputation.1 Smaller, more precise studies confirm those numbers.30 And this already elevated amputation rate excluded primary amputations where surgeons did not even attempt to save the limb; one large series showed 60% of primary amputations resulted from devascularization.31 The dissonance between expectations and reality partly resulted from the attempted application of civilian experience to a military environment. The devastating wounds destroyed collateral vessels and the acute nature of the injuries precluded the development of new branches. Civilian techniques of ligation plus sympathectomy relied on robust collateral circulation to preserve the extremity and simply failed in wartime. The excessively high amputation rate after ligation led surgeons to change their practice and attempt to repair arteries in the final months of the conflict.
THE SHIFT TO ARTERIAL REPAIR, 1945 From December 1944 through the end of the war, American military surgeons, particularly in Europe, began repairing damaged TABLE 1. Disparity Between Expected and Actual Amputation Rates After Ligation
Artery Internal carotid Subclavian Axillary Brachial Common iliac External iliac Common femoral, above profunda Femoral, below profunda Popliteal Anterior tibial Posterior tibial
Predicted Amputation Rate9
Actual Amputation Rate1
30% 9% 9% 3% 50% 13% 21% 10% 0%y 3% 3%
30% 29% 43% 27% 53% 47% 81% 55% 73% 9% 14%
Predicted values come from the 1943 book published by the military entitled Burns, Shock, Wound Healing, and Vascular Injuries9; the actual amputation rates are taken 1. from DeBakey and Simeone’s 1946 article. ‘‘Amputation’’ for the carotid refers to severe and irreversible neurological damage. yThis number is so far-fetched that presumably it was a typo or oversight, although the manual spelled out ‘‘none’’ rather than using Arabic numerals, so the mistake was larger than just dropping a digit.
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Annals of Surgery Volume 263, Number 3, March 2016
arteries instead of just ligating them. They employed primary arteriorrhaphy, end-to-end anastomosis, venous grafts, and, rarely, artificial prostheses called Lord-Blakemore-Stefko tubes. DeBakey and Simone’s classic article, while admirably documenting the first years of the war, failed to capture this important change in practice.
Limitations of DeBakey and Simeone’s Article DeBakey and Simeone’s series of 2471 cases is the largest single collection of vascular injuries from World War II. It remains a highly accurate description of events through mid-1944. Writing toward the end of the war, the authors lacked any central repository from which to collect data. Still, they unfortunately never document the source for the 2471 cases in the title. Nor, with the exception of a single chart, does their article actually analyze all 2471 cases. Instead, most statistics, as well as a subsequent, more detailed publication, relied on roughly 1500 cases (or fewer) as a denominator.32 Archival research has produced a report Simeone authored entitled ‘‘Wounds of the Arteries of the Extremities’’ that documented more than 1400 cases and clearly formed the foundation of their subsequent Annals of Surgery article.33,34 Problematically for the larger study, Simeone drew on the records of only 4 hospitals, all of which predominately served in the North African and Mediterranean Theaters,y and he largely stopped collecting data in December 1944. Thus DeBakey and Simeone’s article relies on roughly 6 months of data from the Mediterranean and Europe to characterize the entire war—which lasted another 6 months. By extrapolating their findings and not going back to the original records for the remaining 6 months of fighting, they missed the important shift to repairing arteries.
A Change in Practice The tack toward arterial repair occurred for 3 main reasons. First, medical officers grew frustrated with consistently abysmal rates of amputation after ligation. ‘‘In spite of the well-known poor results reported following vascular suture and anastomosis,’’ reported one team in 1945, ‘‘we elected to try it in preference to the seemingly invariably disastrous ligation.’’35 The author had ligated 8 popliteal arteries in the Italian campaign—with 8 subsequent amputations. When his unit transferred to Europe, he repaired 3 damaged popliteal arteries, saving the leg in each case. Other surgeons reported similarly dismal experience with ligation and similarly positive results when attempting repairs.18–20 By 1945, surgeons well understood the consequences of ligation and were willing to attempt something new and experimental, doubting the outcomes could be worse. One Evacuation Hospital in Europe, for example, ‘‘distressed’’ over the high amputation rates after ligation, transitioned from tying off 100% of their damaged arteries in 1944 to repairing 14% in 1945, a percentage that jumps to 23% if you discount wounds to the tibial vessels that surgeons rarely repaired; either rate far exceeded the 3.3% that DeBakey and Simeone quoted.27 By 1945, Surgeons in Patton’s Third Army ‘‘were thoroughly indoctrinated with the importance of attempting repair of major vascular injuries.’’36 Second, surgeons had more experience by 1945. In a period of months in combat, they had treated more vascular trauma than their civilian practices would see over the course of decades. Not only did this volume highlight the failure of ligation, it also imbued doctors with greater confidence and skill. Operators were generally more adroit after months of caring for wounded soldiers, evident not just in the increased proportion of arterial repair but also in improvement in other areas of surgery, like thoracic cases where mortality dropped over the course of the war despite the increasing severity of wounds reaching the surgeon.37 See Fig. 2. y Those hospitals were 94th Evacuation Hospital, 8th Evacuation Hospital, 171st Evacuation Hospital, and statistics from the 7th Army (the latter only through December 1944).
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Arterial Repair in World War II
Third, by 1945, the Allies were fighting a different war. The Battle of the Bulge was the last offensive gasp from the Wehrmacht, and its defeat meant final victory in Europe became a question no longer of ‘‘if’’ but ‘‘when.’’38 Both front and supply lines became more stable. A surfeit of supplies accumulated. Hospitals became fixed facilities that featured more advanced technology. Feelings of confidence and security among troops—medical and otherwise— grew, and conditions generally became more conducive to practicing advanced arterial repair procedures. The Auxiliary Surgical Groups exhibited the most pronounced shift toward arterial repair due to the quality of their personnel and their extensive experience. Created by DeBakey, the units typically recruited the best-trained operators, and their fire-brigade like utilization led to thousands of cases.39–42 In 1945, they put that skill and experience to use in repairing arteries. The Second Auxiliary Surgical Group collected meticulous statistics on its patients. Out of 220 vascular injuries they cataloged in detail, they repaired 20, or 9%—a rate 3 times higher than DeBakey (3%) recorded.41 The Third Auxiliary Surgical Group was even more ambitious. From D-Day to December of 1944, their groups repaired a trifling 15 arteries, but disgusted with high rate of amputation that followed ligation, Third Auxiliary Surgical Group surgeons repaired 107 of 487 (22%) of their vascular cases between December 1944 and the end of the war.28 These 107 repairs that the Third Auxiliary Surgical Group alone performed exceeded the total number (81) of repairs DeBakey and Simeone cited for the entire war, demonstrating the shift to arterial repair in 1945. These repairs primarily involved lateral arteriorrhaphy and end-to-end anastomosis, although a few surgeons performed venous autografts. The more complex the operation, the higher the rate of failure. A new technology, Lord-Blakemore-Stefko tubes promised to simplify reparative procedures. These Vitallium prostheses, lined by either fresh or freeze-dried vein, were to be inserted into gaps in arteries and secured by a simple loop suture rather than the technically difficult and time-consuming triangulation method.43 Foreshadowing the shunts modern surgeons have employed in Iraq and Afghanistan over the last decade, Lord-Blakemore-Stefko tubes temporarily ensured blood flow to distal limbs. Lord-BlakemoreStefko tubes were designed to maintain blood flow for 7 to 10 days, at which point surgeons hoped that collateral circulation would have sufficiently developed to supply the distal appendage. No one anticipated them maintaining permanent patency.44 Better in theory than in reality, only 17 tubes were definitely placed during World War II as surgeons eschewed what was a demanding, lengthy, and rarely successful operation.29 Lord-Blakemore-Stefko tubes represented a good idea but a poor practical solution and highlight the challenges of applying surgical innovations. Repairing arteries saved limbs. DeBakey and Simeone documented a 50% amputation rate after ligation but only 35% after a repair.1 The second Auxiliary Surgical Group’s careful records demonstrate even greater success: patients with ligated arteries suffered amputations 44% of the time whereas those with repaired vessels lost their limbs after only 25% of operations.45 Certainly, these numbers reflect a selection bias, with surgeons often choosing to repair less severe cases and ligate in more challenging circumstances, but the increased occurrence of arterial repair nonetheless allowed hundreds of Americans to return home with arms and legs intact.
VASCULAR SURGERY AT HOME This shift to arterial repair did not just take place on the battlefield. In the continental United States, the Surgeon General established specialty hospitals to provide definitive care for wounded soldiers. Three such institutions treated vascular patients. At DeWitt hospital, led by Norman Freeman, and especially at Mayo Hospital, www.annalsofsurgery.com | 617
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FIGURE 2. US Army doctors operating on a gunshot wound to the left thigh at the 48th Surgical Hospital in North Africa, April 4, 1943. US Signal Corps Photo MM-STEI-43-1151, located in NARA RG 111-SC. Figure is in the public domain.
FIGURE 3. Arteriogram of a repair of an AV fistula and pseudoaneurysm from Mayo Hospital, 1945 highlighting not only the new reparative operation (in this case an end-to-end anastomosis) but also the novel technology of arteriograms to diagnose the pathology and assess the postoperative results.47 Figure is in the public domain.
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Annals of Surgery Volume 263, Number 3, March 2016
led by Harry B Shumacker, Jr, an analogous transition to reparative operations for arteriovenous fistulae and pseudoaneurysms occurred. In 1944, surgeons ligated 94% of arteriovenous fistulae cases and either ligated or performed an obliterative Matas Operation on 99% of pseudoaneurysms.46 Although these procedures did not result in amputation, Freeman and Shumacker did notice they frequently led to severe cases of debilitating vascular insufficiency. By 1945, they too began repairing arteries through arteriorrhaphy, end-to-end anastomosis, and venous autografts. Freeman’s unit repaired 34% of their cases (23/67) between June and November of 1945. Shumacker was even more ambitious. Mayo Hospital repaired only 3% (4/138) of cases in late 1944 but 53% (30/57) thereafter (Fig. 3).47 As with acute injuries, chronic vascular pathologies also benefited tremendously from reparative operations, with few complications and no incidences of vascular insufficiency after successful repairs.
Arterial Repair in World War II
Institute, and American College of Surgeons helped them navigate through reams of old records. Librarians at Yale University and the University of Virginia graciously aided their search. John Harley Warner, Dale C. Smith, Daniel J. Kevles, and Frank M. Snowden’s edits and comments greatly strengthened the article. Finally, they also appreciate the helpful comments from the anonymous reviewers at Annals of Surgery. All citations to documents in the US Government’s National Archives and Records Administration (NARA) refer to the repository in College Park, MD, and are abbreviated as: NARA, record group/ stack area/compartment/row/shelf/box/folder. Documents in the United States Army Military History Institute at the United States Army Heritage and Education Center, Carlisle, Pennsylvania, are abbreviated as MHI Archives, followed by the collection name and box/folder numbers.
CONCLUSIONS
REFERENCES
By returning to the original military medical records in the National Archives, our article contradicts DeBakey and Simeone’s findings that arterial repair was rare throughout the entirety of World War II. Our analysis of the data illuminates how both combatant units and stateside surgeons began repairing an ever-increasing percentage of injured arteries in 1945. Although such operations never predominated, surgeons nevertheless demonstrated that these procedures were not only possible but also, in the hands of trained and experienced surgeons, had far superior outcomes than simple ligation. This transition to arterial repair highlights the ability of war to catalyze surgical change. The milieu of war provided the conditions necessary for surgeons to begin to adopt Carrel-style arterial repairs. The technique had existed for decades before World War II but remained rarely practiced, partly because extensive vascular trauma remained relatively infrequent in the civilian world, partly due to the perceived efficacy of ligation þ sympathectomy, and partly from the lack of training most pre-World War II surgeons received. By generating a vast number of patients, the Second World War created an environment conducive to addressing these challenges. First, doctors simply had more general operative experience, gaining confidence and learning new techniques. Second, they saw more vascular trauma in a few months than their civilian practice might admit in decades. This concentration of cases both at the front and at specialized hospitals back home allowed the marked deficiencies of ligation þ sympathectomy to become apparent. The relatively unsupervised and urgent nature of combat surgery encouraged innovation, allowing physicians to try new operations. Again, the unprecedented number and concentration of cases created definitive evidence of the feasibility and efficacy of arterial repair while simultaneously proving the infrequency of feared complications. Unfortunately, DeBakey and Simeone’s article came to define vascular surgery in World War II. Drastically understating and minimizing the actual incidence of arterial repair, the article pessimistically concluded that vessel ligation ought to remain the standard military practice for vascular trauma in any future war. Thus, when American surgeons deployed to Korea in 1950, they resumed ligating damaged arteries as their forbearers had done in 1944. Few clearer cases of inaccurate history propagating poor clinical practice exist in the literature. It took hundreds of additional amputations and a new generation of surgeons led by men like Carl Hughes and Frank Spencer to re-recognize the feasibility and superiority of repairing arteries in traumatic vascular injuries and applying the technique en masse to wounded soldiers and Marines in Korea.
1. DeBakey ME, Simeone F. Battle injuries of the arteries in World War II. Ann Surg. 1946;123:534–579. 2. Friedman SG. A History of Vascular Surgery. Mount Kisco, NY: Factura; 1989:183–185. 3. Marcum JA. The origins of the dispute over the discovery of heparin. J Hist Med Allied Sci. 2000;55:37–66. 4. Marcum JA. The development of heparin in Toronto. J Hist Med Allied Sci. 1997;52:310–337. 5. Murray DWG, Jacques LB, Perrett TS, et al. Heparin and vascular occlusion. Can Med Assoc J. 1936;35:621–622. 6. Kevles BH. Naked to the Bone: Medical Imaging in the Twentieth Century.. New Brunswick, NJ: Rutgers University Press; 1987, 103-104. 7. Bud R. Penicillin: Triumph and Tragedy. New York, NY: Oxford University Press; 2007. 8. Kendrick DB. Blood Program in World War II. Washington, DC: Office of the Surgeon General; 1964. 9. Burns, Shock, Wound Healing, and Vascular. In: Injuries. Philadelphia, PA: W. B. Saunders Company; 1943. 10. Holman E. War injuries to arteries and their treatment. Surg Gynecol Obstet. 1942;75:183–192. 11. de Taka´ts G. Vascular surgery in the war. War Med. 1943;3:291–296. 12. Circular Letter No. 5: Gas Gangrene; NATOUSA; August 5, 1943; NARA 112/390/17/8/1/4/17. 13. Medical Circular No. 4 Gas Gangrene; Office of the Surgeon, 5th Army; October 20, 1943; NARA 112/390/17/8/1/4/18. 14. Circular Letter No. 8: Notes on Care of Battle Casualties; HQ MTO Office of the Surgeon; March 1945; NARA 112/390/17/9/2/5/5. 15. Circular Letter No. 2: Surgery; HQ 7th Army; July 18, 1944; NARA 112/390/ 17/8/1/4/1/18. 16. Corrections; NARA; 112/390/16/11/6/481/1. 17. Odom CB. Vascular Injuries, Report to Anglo-American Consultants Conference; December 10, 1944; NARA 331/290/7/34/4/3/2. 18. Bradford BJ Jr, Moore MJ. Vascular injuries in war. Surg Gynecol Obstet. 1946;83:667–673. 19. Rose CA, Hess OW, Welch CS. Vascular injuries of the extremities in battle casualties. Ann Surg. 1946;123:161–179. 20. Smith MK. Arterial injuries. Ann Surg. 1947;126:866–872. 21. Province CM. I Was Patton’s Doctor: The Reminisces of Charles B. Odom, MD. St Louis, MO: CMP Productions; 2010. 22. Taylor GW. Report of the surgical section. In: Sauer PK. Historical Records and Annual Report, 95th Evacuation Hospital. 1944; NARA 331/290/8/25/1/31/25. 23. Schlicke CP. Arterial Injuries, 247th General Hospital; December 7, 1944; NARA 112/390/17/13/6/235/1. 24. Kirtley JA Jr. Arterial injuries in a theater of operations. Ann Surg. 1945;122: 222–234. 25. Anglo-American Consultants Conference; December 10, 1944; NARA 331/ 290/7/34/4/3/2. 26. Elkin DC. Vascular injuries of warfare. Ann Surg. 1944;120:284–306. 27. Snyder JM. Vascular wounds: report of a series of 108 cases encountered in a forward evacuation hospital. Surgery. 1947;21:77–85. 28. 3rd Auxiliary Surgery Group Annual Report, 1945; NARA 112/390/17/17/5/ 393/3.
ACKNOWLEDGMENTS The authors are grateful for the generous assistance of other scholars. Archivists in the National Archives, Military History ß
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29. Barr J. Surgical Repair of the Arteries in War and Peace [PhD dissertation]. New Haven, CT: Yale University; 2014. 30. Semi-Annual Report of the 9th Evacuation Hospital; January 1-June 30, 1945; NARA 112/390/17/25/6/400/4; 16-17. 31. Arterial Injuries in War Wounds From the 2nd Auxiliary Surgical Group; NARA 112/390/16/11/6/358/2. 32. DeBakey ME, Simeone F. Acute battle-incurred arterial injuries.. In: Elkin DC, DeBakey ME, eds. Vascular Surgery in World War II.. Washington, DC: Office of the Surgeon General; 1955:534–579. 33. Simeone F. Wounds of the arteries of the extremities; August 1945; NARA 112/390/16/11/6/359/3. 34. Page Proofs; NARA 112/390/16/11/6/482/2. 35. Imes PR. Suture of the popliteal artery: a report of three cases. Surgery. 1945;18:644–646. 36. Odom CB. Causes of amputations in battle casualties with emphasis on vascular injuries. Surgery. 1946;19:562–569. 37. Carter N, DeBakey ME. Special reports and statistical data. In: Heaton LD, ed. Thoracic Surgery: Volume II. Washington, DC: Office of the Surgeon General; 1965:529–533. 38. .Toland J. Battle: The Story of the Bulge.. New York, NY: Random House; 1958 39. Marble WS. Forward surgery and combat hospitals: the origins of MASH. J Hist Med Allied Sci. 2014;69:68–100.
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40. Brewer LA. The contributions of the Second Auxiliary Surgical Group to military surgery during World War II with special reference to thoracic surgery. Ann Surg. 1987;197:318–326. 41. Forward Surgery of the Severely Wounded: a History of the Activities of the 2nd Auxiliary Surgical Group, 1942-1945; NARA 112/390/16/11/6/358/1-3. 42. Graves CL. Front Line Surgeons: The History of the Third Auxiliary Surgical Group. San Diego, CA; 1950. 43. Blakemore AH, Lord JW Jr, Stefko PL. The severed primary artery in the war wounded: a nonsuture method of bridging arterial defects. Surgery. 1942;12:488–508. 44. Rasmussen TE, Clouse WD, Jenkins DH, et al. The use of temporary vascular shunts as a damage control adjunct in the management of wartime vascular injury. J Trauma. 2006;61:8–15. 45. Forward Surgery of the Severely Wounded, data compiled from 717-741. 46. Elkin DC, Shumacker HB Jr. Arterial aneurysms and arteriovenous fistulas— general considerations. In: Elkin DC, DeBakey ME, eds. Vascular Surgery in World War II. Washington, DC: Office of the Surgeon General; 1955:149– 180. 47. Freeman NE, Shumacker HB Jr. Arterial Aneurysms and Arteriovenous Fistulas: Maintenance of Arterial Continuity. In: Elkin DC, DeBakey ME, eds. Vascular Surgery in World War II. Washington, DC: Office of the Surgeon General; 1955:264–301.
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