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Chapter 1

Battle Casualties in Korea: Studies of the Surgical Research Team, Volume IV

Introduction

Major William H. Meroney, MC, USA

This volume contains selected reports of members of the Surgical Research Team, Army Medical Service Graduate School, who concerned themselves primarily with study and treatment of battle casualties with renal failure. Many of the reports are published or are in press in current civilian journals, but they are collected here to provide a one-volume reference and to give perspective to evolving concepts. Space did not permit inclusion of all reports nor all information in the original versions of those selected. Some reports have been deferred pending confirmation of clinical observations by repetition or by animal experimentation. However, a reference volume containing complete data-raw, uninterpreted-will soon be filed with the Army Medical Service Graduate School to provide final detail when needed.

Most of the observations reported were completed at the Renal Insufficiency Center (Fig. 1) in Wonju, Korea, at a time when the main line of resistance was about 75 miles northward. Some studies, by their very nature, involved the more forward installations; others required analyses so complex that the specimens were sent to Japan or the U. S. The personnel of the Research Team were few, but they were joined or supported by a huge team of Eighth Army officers and men deployed through all echelons. Not only Medical Service personnel, but engineers, pilots and others contributed by transporting patients, supplies and specimens and providing or maintaining equipment. Few of these individuals were familiar, initially, with the mission of the Surgical Research Team, and their cooperation did not come about automatically. Considerable effort by men of vision and energy produced the rather remarkable phenomenon of the safe delivery of a patient to Wonju immediately following cessation of his urine flow. No less remarkable was the facility which received this patient. Within minutes of the time the helicopter touched the ground by the door of the admitting office, the patient had been examined, an electrocardiogram had given a close estimate of the concentration of plasma potassium, blood had been drawn for chemical analyses, and a decision had been made whether immediate artificial kidney dialysis was indicated. There was no precedent for the existence in the battlefield of such instruments as the artificial kidney and the supporting laboratory and paraphernalia (Figs. 2 and 3).


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Numerous individuals contributed to this venture and their names are recorded elsewhere. It seems proper, however, to repeat here a few primarily responsible. Dr. F. A. Simeone, at the behest of Colonel William S. Stone, MC, conducted the original survey which revealed the problem of renal failure in battle casualties in Korea. Captain Lloyd H. Smith, MC, demonstrated the need for an artificial kidney and first established it in the combat zone. Captain Roy Mundy, MSC, established the laboratory without which the artificial kidney would have been inoperable. The parent unit to which the Renal Center was attached was the 11th Evacuation Hospital, commanded by Colonel Harold W. Glascock, MC, later by Colonel Fred W. Seymour, MC, both of whom deserve special mention for their support and kindness. The Renal Center functioned as a unit of the Surgical Research Team, which was commanded by Captain John M. Howard, MC, supervised by Colonel Richard P. Mason, MC, and directed by Colonel William S. Stone, MC.

At the advisory level, several civilian consultants visited Wonju and helped to steer the effort on a course productive of practical results. Dr. A. C. Corcoran and Dr. William A. Altemeier, in particular, will long be remembered for their sage observations and agreeable endurance.

Some reports in this volume present experiences of several individuals observing the same patients from different points of view; others present experiences with a different group of patients at a different time. The conclusions of the investigators, therefore, do not agree in every detail. It will be noted, however, that certain themes recur in one report after another. The agreement among independent investigators adds to the validity of the observations, but it uncovers one of the major shortcomings of the series of studies. The experiences of each participant were not adequately transmitted to his successors, and sometimes painful repetition could have been avoided. Even so, a new arrival in the theater gained considerable information from the incumbent and was able to continue some projects and expand some ideas already established. It is to prevent unnecessary repetition by future workers that this volume is presented at this time. Further seasoning might allow preparation of a more polished version, but during the delay world events might require that some version be available.

The reports are based upon studies of approximately 150 patients with acute oliguria and approximately 50 patients with conditions simulating renal insufficiency or with renal insufficiency without oliguria. The studies establish several points which have been debated or little appreciated in the literature. There is no question now of the efficacy of artificial kidney dialysis in saving the lives of


FIGURE 1. 11th Evacuation Hospital (semi-mobile) to which the Renal Insufficiency Center was attached.


FIGURE 2. Artificial kidney (Kolff type) in operation at the Renal Insufficiency Center.


FIGURE 3. Water for artificial kidney being heated in an airplane wing tank by gasoline field stove.


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certain patients who would have died without it. Many died anyway, but in them dialysis was effective in controlling uremia and served to separate, for the first time, the manifestations of uremia from those of sepsis. When a seriously injured man is noted to be oliguric, there is a great temptation to attribute all features of his condition to uremia. Correction of the chemical abnormalities by dialysis is followed by striking, if temporary, amelioration of all signs and symptoms if uremia alone is responsible; those features which persist after effective dialysis are the result of some other disorder. This technic served to clarify some manifestations of generalized sepsis and aseptic necrosis. Patients with oliguria who have little devitalization of non-renal tissue, particularly muscle, experience no symptoms until the retention of urinary chemicals produces marked aberration of concentration of plasma chemicals, and several days pass before this occurs. Patients with nausea and vomiting, tremulousness, disorientation and convulsions during the first few days of oliguria do have azotemia, but correction of the azotemia by dialysis causes little if any clinical improvement. These patients have hypotension, or sepsis, or muscle necrosis, or central nervous system damage unrelated to uremia. Amputation, débridement or supportive measures correct the clinical features with correcting the chemical abnormalities. The chemical abnormalities progress at an astonishing rate, however, if the devitalized tissue is not removed. This requires that surgery be prompt and radical, and if it is incomplete, dialysis must be done early and frequently. This difference in degree of tissue destruction in war wounds and civilian injuries probably accounts for the difference in opinions regarding the necessity for dialysis.

Much has been written about the clinical syndrome of potassium intoxication. In Korea it was noted that plasma potassium could rise to 10 mEq./L. and produce no symptoms whatever. Symptoms and signs usually ascribed to excess potassium-tingling of extremities, reflex changes, respiratory distress, circumoral paresthesias and central nervous system signs-were associated with hypocalcemia and usually could be obliterated instantly by infusion of calcium. However, when hyperkalemia progressed to the degree that the electrocardiogram showed prolongation of the QRS complex, in the presence of a normal calcium concentration, the symptoms and signs returned. These observations are consonant with Ringer's classic descriptions of the behavior of potassium and calcium on isolated amphibian hearts. The mutual antagonism of these ions, which has received insufficient attention in this century, provides a life-saving tool for the treatment of potassium intoxication.

The water requirements during anuria received considerable attention in these patients. Although tools for definitive studies were not


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available, many careful clinical observations indicated that the usual rules of thumb are not reliable in this type of patient. Endogenous water production and insensible water loss have been studied carefully in normal persons, but the estimates so derived do not apply during excessive catabolism secondary to tissue damage with infection, hyperpnea secondary to acidosis, or dependence upon intravenous glucose for nutrition. These patients appeared to require little more than half of the 40 cc./hour usually suggested. This fact and some prevailing misconceptions of renal physiology allowed overhydration in some patients. Missionary efforts were reasonably successful in restraining those differently oriented from overhydrating patients to "flush out the kidneys" or "to rule out dehydration."

Most of the patients in this series had undergone long periods of hypotension, which presumably was the cause of the oliguria. Patients with comparable wounds and hypotension failed to develop oliguria, but defects of renal function were demonstrated in many of them. A few transfusion reactions were documented, but not all produced renal failure. There is a growing suspicion that pigments do not cause tubular necrosis, although the shock with which they may be associated can cause the lesion. Hemorrhagic fever and chemical agents accounted for a few cases in the series. Dehydration was not observed as a cause for oliguria. On the basis of the available data, shock remains the major cause of renal insufficiency in this series of cases.

The mechanism of renal function during oliguria was considered from several points of view, but no definite conclusions were reached. It was apparent, however, that published theories of function were incompatible with some of the observations. Data suggested that the kidney with tubular necrosis functioned as if it were qualitatively normal but quantitatively insufficient. The studies of wound healing and resistance to infection are difficult to assess. The predisposition of the uremic patient to complications is well recognized, but the particular defense systems studied do not appear abnormal. Also, some patients have been observed to heal one wound and not another. Relative starvation, vitamin imbalance, wasting of specific tissues, and associated infections are interwoven in such a way that their individual effects have not been distinguished. From the purely clinical point of view, failure of wound healing was associated with local infection, and weight loss beyond that expected from the caloric intake was associated with systemic infection. There were not enough control studies to establish whether renal insufficiency, per se, contributed significantly. Also, the dangers inherent in artificial kidney dialysis under field conditions were not fully assessed, but the dangers


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in withholding dialysis were well enough established to justify the procedure.

The net results of this experience are that a Renal Center in support of a field army in combat can be expected to save lives, to influence favorably the standards of medical and surgical care in other units, and to provide information from study of abnormalities in extreme degree which can be applied in the recognition and treatment of abnormalities of lesser degree. The optimal location of such a center will be governed by numerous factors in geography, tactics, weather and logistics which can be resolved into a single factor: evacuation time. The center may be located in any area otherwise suitable which can be reached by the casualty within 3 days, provided the recommended measures in medical management are employed. The mobility of a Renal Center is not yet established, but the practicality of a mobile, self-contained unit is under consideration.