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Monday Morning Session

Medical Science Publication No. 4, Volume 1

MONDAY MORNING SESSION
19 April 1954

MODERATOR
RUSSELL SCOTT, JR., M. D.


SOME GENERAL CONSIDERATIONS OF HOMEOSTATIC AND ADAPTIVE MECHANISMS TO STRESS IN EFFECT PRIOR TO WOUNDING*

STANLEY H. ELDRED, M. D.

It has been repeatedly noted in World War II, Korea, and in civilian catastrophes that individuals respond to similarly painful situations with unequal degrees of effectiveness. This matter of individual differences has been approached from a variety of points of view, i. e., hereditary-constitutional factors, environmental factors (such as the personal emotional development of the subject in terms of his relationships with significant other people in his past), cultural-familial patterns in which he grew up, motivation for combat, etc. Among the environmental factors which seem to be of considerable importance are those in existence shortly preceding wounding. Not only are these factors of considerable importance, but they seem to be factors which, if we knew enough, would permit of some control. That is, in practical terms, research in this area may ultimately provide us with the knowledge necessary to minimize wounding and to maximize the effective destructive force upon the enemy.

The purpose of this paper is not to present a major contribution to our knowledge, but rather to bring together several incomplete but nonetheless convincing observations about conditions existing prior to wounding, which seem to affect the manner in which the trauma is handled.

Many of you with battalion aid station experience during combat have noticed that different men react differently to similar wounds. One source of evidence comes from observations of reactions to blast effects from grenades and mortar shells. One soldier will react so that he is diagnosed as having concussion of the brain, lung, stomach, or bowels. Another soldier exposed to the same blast will continue to go about his business with or without somatic complaints. If the trauma is equal or only approximately equal, the question arises, why does one man continue aggressive action and the other become immobilized?


*Presented 19 April 1954, to the Course on Recent Advances in Medicine and Surgery, Army Medical Service Graduate School. Walter Reed Army Medical Center. Washington. D. C.


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This problem became of interest to the speaker about a year ago while conducting exploratory interviews with company commanders who had been wounded in Korea. With 26 of these officers the interviews provided some data about stresses extant prior to wounding and the individual's reaction to his wound. While not of statistical import, because of the absence of controls and because of the limited number of cases, we were, nonetheless, impressed by the fact that with five exceptions the behavioral response to ultimately incapacitating wounds fell about equally into two large categories, i. e., those who from the moment of impact were immobilized for further action, and those who continued effective aggressive action for a significant period of time after impact. In order that I might demonstrate the complexity of this problem, permit me to give some examples from these interviews.

1. Second Lieutenant R. took command of a company for a period of 2 days after it had been reduced, because of combat casualties, to 3 officers and 56 men. While under attack he received mortar wounds to left leg, ultimately resulting in amputation. Several days of sleeplessness, cold weather, and some 3,000 rounds of shells in previous 24 hours in the area preceded his injury. He regained consciousness a few minutes after injury, turned his command over to another officer, and was shortly thereafter sedated with morphine and evacuated. Careful psychiatric interviewing revealed no evidence of a feeling of guilt about leaving his unit. He was only grateful that he had been wounded rather than killed.

2. Captain A. took over a problem company 6 month prior to injury and was successful in making it a more effective unit. He was wounded by a direct hit on his command post. Two sergeants were killed. His right arm and leg were fractured. After regaining consciousness he was quickly evacuated. He had a great sense of guilt about carelessness in placing his tent in an exposed position, and felt responsible for the deaths of his sergeants.

3. Captain S. was one of six men remaining in an outpost. Six of eight bunkers had been overrun when he had called for artillery fire on position. He was wounded by a grenade, sustaining multiple fractures of the left arm and leg. He continued to throw grenades until too weak, then assisted an old sergeant with a machine gun until reinforcements arrived, at which point he went into deep shock. He remembers being very angry at being wounded.

4. Captain J., tank company commander, had to go from A to B defensively through two ravines. A major, a stranger to the captain, ordered him to split his unit into two forces. The captain's force was quickly pinned down in the valley. After 10 minutes of immobili-


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zation he opened the turret, got out, picked up the wounded, and ordered his riflemen out of ditches. He continued going up the valley standing up in the turret of his tank, so his men could see him. A mortar shell hit his tank, destroying both his hands and fracturing his face and arms. He was knocked unconscious by the blast, but upon coming to his first question was to ask who else had been hurt. He then resumed radio command until the objective was reached, at which point he went into shock. There was no sense of guilt about leaving his company. He volunteered the statement that his anger at being ordered to split his unit against his own better judgment made him more reckless.

I have only hinted at the psychological factors which are obvious in their presence and complex in their operation. That which I would like to underline at this point, however, is the fact that these statements indicate that there are probably physiological differences which are concomitant and concurrent with psychological differences.

Inasmuch as we have little direct evidence of the physiology involved in these two different types of reaction to wounding, further explanations can be sought by drawing upon available experimental data. Such experimental data include the work of Funkenstein, et al., at Harvard, on the "Experimental Evocation of Stress," in which experimental psychological stress is correlated with certain psysiological responses, as measured by ballistocardiograph patterns, blood pressure and pulse rate. In their 70 subjects, two major responses, analogous to the two major types of responses to combat wounds, were noted: (1) those which were characterized by anger being directed outward, and (2) those characterized by anger directed inward toward the self. These two physiological patterns correspond to those which can be obtained by injections of norepinephrine and epinephrine respectively.

Captain Morton F. Reiser, of the Neuropsychiatry Division of the Army Medical Service Graduate School, has recently contributed some significant measurements tending to refine and extend Dr. Funkenstein's thesis. Correlating simultaneous recordings of the ballistocardiograph, EKG, pulse rate and blood pressure with tape recordings of interviews with young healthy males, he has demonstrated an "epinephrine" physiological pattern (high cardiac output, rapid pulse rate, wide pulse pressure, and little change in mean blood pressure indicative of decreased peripheral resistance) in those subjects in whom anger was not expressed during the stressful interview. In those subjects expressing open anger, there was demonstrated a norepinephrine pattern of physiological response, namely, no change in cardiac output and pulse rate, and a rise in mean blood pressure, indicating a rise in peripheral resistance.


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I must at this point ask for forbearance from the physiologists among you for this presumptuous oversimplification of their specialty. However, I do so only to suggest the possibility of a method of closer collaborative effort between physiologist and psychiatrist. Specifically, it would appear on an a priori basis that the norepinephrine type of physiological response to stress, with its specific psychological component (outward directed anger), is a more effective pattern of behavior for combat purposes than the epinephrine type of response. To this end it would appear profitable to explore the possibilities of delineating those psychological factors which can be manipulated to favor the norepinephrine type of psycho-physiological response to stress. It has been demonstrated that any given individual is capable of both types of physiological response, and it is to be noted that immediate environmental factors influence the manner in which the subject responds to the experimental stress. That is, when the interviews in Captain Reiser's study were conducted by an educated, well-trained enlisted man, there was a freer expression of anger outward by the subjects. The responses obtained to similar interviews conducted by a captain in the Medical Corps contained very few outward expressions of anger, and correspondingly fewer norepinephrine-like patterns were obtained with the physiological measurements. This is not evidence against the existence of individual tendencies to respond more often or more strongly in one direction or another. The multiplicity of psychological factors involved in even this simplified laboratory situation indicates the need for further study to determine the more crucial psychological factors.

There are few published reports of direct psychiatric observation of subjects at the moment of wounding. I know of none dealing specifically with this problem of different types of reaction to acute injury, although I have by no means covered the extensive literature in this general area. We can, however, refer to some of the systematic observations upon convalescent combat cases and see if these findings elucidate the retrospective reports from the wounded about their reactions to being wounded. In February 1954, Noble, Roudebush and Price published in the American Journal of Psychiatry a report of their study of 53 amputees on the orthopedic wards of the U. S. Naval Hospital in Bethesda and of Walter Reed Army Medical Center. One aspect of their data which may be pertinent to the study of how acute wounds are handled by the wounded pertains to the various defenses employed by the amputees to avoid anxieties over separation, loss of body parts, aggressive feelings and passivity. These defenses included denial of loss in a variety of ways, displacement of feelings from the genital organs to the amputated extremity, projection of their own


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attitudes about amputation onto others, and identification with a significant other person who had a similar difficulty.

Dr. David A. Hamburg, in his study of severely burned patients, has emphasized the role of denial of injury in maintaining homeostatis. Dr. E. Weinstein has commented on the mechanisms of denial of injury and projection of anxiety as means of maintaining a modicum of personal identity in the face of severe brain damage. Is it possible that similar mechanisms are employed to handle anxieties inherent in the acute stage of wounding? If our retrospective reports bear any resemblance to that which actually happened, it is clear that denial of injury is very common. It takes place in at least three ways, depending only in part upon the severity and location of the trauma. Many tearing flesh and muscle wounds, as well as fractures of arms, hands, ribs, face and skull, are "discovered" by the recipient only after there is a decrease in the intensity of the combat. The trauma was not admitted into awareness while the awareness was focused elsewhere. Another way in which denial functions is to minimize the severity or to put off evaluating the severity of a wound as long as aggressive action is necessary and to go on "as if I weren't hurt." A third way that has been reported is to take what first aid measures are possible and then "forget about it until later." Mechanisms of projection are to be seen in the rather primitive half-truth of blaming the enemy for one's injury. This is a lot easier to do than to objectively evaluate one's own possible role in getting wounded, e. g., reckless, unnecessary exposure to fire. Identification with others in the combat unit seems to be a factor in maintaining homeostasis, e. g., Captain J. in example No. 4 above.

While these mental mechanisms are frequently elicited in interviews with those who have continued aggressive action after being wounded, our interview data would suggest that there are at least two common denominators in this phenomenon. These seem to be: (1) a ragelike reaction directed toward the enemy, and (2) the fact that the situation is appropriate for immediate aggressive action against the enemy.

It is physiologically plausible, then, that these aforementioned psychological concomitants make it possible for some individuals to postpone or avoid the advent of traumatic shock. In those who have not demonstrated such post-traumatic aggressiveness, and in whom traumatic shock has set in rapidly, we have not obtained evidence in the interviews which suggests a rage reaction to being wounded. This would possibly be analogous to the epinephrine type of response with peripheral vasodilatation and decreased mean blood pressure.

To attempt to delineate those stresses in operation prior to wounding which tend to make for effective aggressive adaptations is beyond the


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scope of this paper. This could, as a matter of fact, be one of the goals of this symposium and of many symposiums to come.

That with which I would like to conclude, however, is to underline the fact that given the wide range of individual precombat adaptations, there is highly suggestive psychological and physiological evidence of the existence of important factors in the immediate combat situation which affect the aggressive potential of the individual and, hence, of the unit. It is in this area that further study is indicated.

References

1. Hamburg, David A., Artz, Curtis P., Reiss, Eric, Amspacher, William H., and Chambers, Rawley, E.: Clinical Importance of Emotional Problems in Care of Patients with Burns. New England J. Med. 248: 355-359, Feb. 1953.

2. Hamburg, David A., Hamburg, Betty A., and DeGoza, Sydney: Adaptive Problems and Mechanisms in Severely Burned Patients. Psychiatry 16: 1-20, Feb. 1953.

3. Hamburg, David A., Hamburg, Betty A., and DeGoza, Sydney: Adaptive Problems and Mechanisms in Severely Burned Patients. Digest of Neurol. and Psychiat., 215, May 1953 (abstract).

4. Reiser, Morton F., Reeves, Robert B., and Armington, John: The Ballistocardiograph in Psychophysiological Research. Circulation Res. 1: 469-470, Sept. 1953.

5. Weinstein, Edwin A., and Kahn, Robert L.: Personality Factors in Denial of Illness. A. M. A. Arch. Neurol. and Psychiat. 69: 355-367, Mar. 1953.

6. Weinstein, Edwin A., Alvord, E. C., Jr., and Rioch, David McK.: Disorders Associated with Disturbance of Brain Function. Ann. Am. Acad. Political and Soc. Science, 34-44, Mar. 1953.

7. Funkenstein, Daniel H., King, Stanley H., and Drolette, Margaret: The Experimental Evocation of Stress. Presented 18 March 1953, to the Symposium on Stress, AMSGS, WRAMC, Washington, D. C. From the Dept. of Psychiatry, Harvard Medical School, the Dept. of Social Relations, Harvard University, and the Dept. of Biostatistics, Harvard School of Public Health.