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Fatigue and Metabolic Deficit, A Study of the Combat and Injured Soldier

Medical Science Publication No. 4, Volume 1

FATIGUE AND METABOLIC DEFICIT
A STUDY OF THE COMBAT AND INJURED SOLDIER*

JOHN M. HOWARD, M. D.

These observations were made on the Eastern Front in Korea during the first half of 1952 and to a lesser extent throughout the succeeding year. January 1952 was a time when the front lines had begun to stabilize. There was complete uncertainty among the troops as to the tactical moves to be made by our forces as well as the forces of the enemy. Fighting was beginning to be limited to probing actions, patrols, and exchange of mortar and heavy artillery fire. The front lines were strung out across a chain of mountain tops and men had, at this time, reasonable protection from the cold.

Under these conditions, fatigue was seldom due to physical hardships. Fatigue was due to continued emotional stress-and, I believe, in part to uncertainty. This is the fatigue which does not disappear with sleep, and which has a cumulative effect. Under the conditions of 1952 in Korea, the extreme form, combat fatigue, was seldom recognized.

The question arose: Does the stress of combat lead to adrenal cortical insufficiency? Our studies permit a generalization only to the conditions in Korea. The studies were made under conditions of chronic stress, and I use the term deliberately, for I believe that it is the method or weapon by which strong men are being broken in certain parts of the world today.

The studies, obviously, had to be made in the front lines. They represent what can be achieved for the mutual welfare of our troops when problems are explained and approached on a cooperative basis.

Our primary aim was to get complete 24-hour urine collections from troops under combat stress. With the cooperation of the Army surgeon, the corps and division surgeons and the Commanding General of the infantry division, our officers and men gained access to the front lines to live and to work with the combat troops. Volunteers, including the company officers, were obtained because of their respect for the cooperating battalion surgeons and their corpsmen.


*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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Cooperation seemed complete. The completeness of the urinary collections was roughly checked by comparing the volume and the specific gravity.

Aliquots of the collection of urine were preserved in toluene or by refrigeration and shipped to the Department of Biochemistry here at the Army Medical Service Graduate School for analysis of 17-ketosteroids and corticosteroid content. The methods of analysis have been previously described and consisted of modifications of the Zimmerman and formaldehydogenic methods.(1)

Noncombat soldiers served as controls. The excretion of steroids indicated normal function as indicated by examples in table 1.

Three groups of combat troops were studied. They represented different groups under somewhat varying tactical conditions between January and July 1952. An effort was made to obtain approximately 12 volunteers in each group and to study each man for three consecutive days.

The results of individual studies are demonstrated in figures 1 to 6.

Table 1. Excretion of Steroids

Subject

Day

Urine volume, cc.

17-ketosteroids
mg. per 24 hours

Corticosteroids
mg. per 24 hours

No. 1

1

750

15. 1

1. 4

No. 1

2

800

19. 0

0. 9

No. 1

3

740

16.6

2. 4

No. 2

1

700

10. 9

1. 6

No. 2

2

600

11. 1

1. 7

No. 2

3

600

10. 5

1. 5

Average of 4 subjects
(12 days -total)


----------------------------


749


13. 6


2. 0

Reported normal range

----------------------------

-------------------------------------

8. 0-22. 0

0. 6-2. 6

A correlation between the external environment and the steroid excretion is not always possible but table 2 indicates that the adrenal response was noted fairly uniformly throughout a group during the same period of time. These soldiers had all been under daily fire for 40 days. On the first day of the study, they were under an unusually heavy barrage. Of the 12 men studied that day, only 1 had a corticosteroid excretion which was normal. All the others were elevated. Four had an excretion increased to almost 400 percent of normal. The following day, the artillery and mortar fire tapered off and so did the adrenal response. The next 2 days were quiet so that on the fourth day, the steroid excretion had, without exception, subsided to normal.


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This trend is best demonstrated by the average values shown in table 3. The 17-ketosteroid excretion was normal throughout this period.

Three soldiers shared a bunker which was in the center of the activity (fig. 1). Their bunker was destroyed by mortar fire a few hours after the 24-hour period ended and one of the soldiers was killed. Each demonstrated an increase to 200 to 300 percent in corticosteroid excretion but each had a normal 17-ketosteroid excretion.

Figure 2 demonstrates the gradual decrease in adrenal activity as the stress decreased. The maximal corticosteroid excretion did not

FIGURE 1. Demonstrating the response of three men who shared the same bunker on the day it was destroyed by incoming mortar fire. These men had been on front line duty for 40 days.This represents the adrenal response to acute emotional stress after 40 days of exposure. The corticosteroid excretion is elevated to 200 to 300 percent of normal. The 17-ketosteroid excretion is normal.


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always coincide with the heaviest fire (fig. 3) but, if not, followed shortly thereafter. Adrenal cortical response continued for 24 hours after the shelling had subsided (fig. 4). The adrenal response to the stress of battle appears comparable to the response of major injuries as demonstrated by figure 5. There can be no doubt that these men were under stress and that their adrenal cortex remained responsive.

A total of 35 combat soldiers were studied by this method. The excretion of 17-ketosteroids was normal. The excretion of corticosteroids was normal or elevated. The increase in excretion could usually, but not always, be correlated with the day's activity. In no instance was evidence of adrenal insufficiency detected.

In a different phase of the study, an officer under long-standing nervous tension was found to be developing an anxiety state which was

FIGURE 2. Demonstrating a subsidence in the adrenal cortical response in this soldier in the face of continued danger.


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Table 2. Combat Stress*-Corticosteroid Excretion** by Combat Soldiers, Milligrams per 24 Hours

Date

Activity

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

11 May 1952

Heavy artillery fire

3.9

6.2

----

5.3

5.9

5.0

5.5

----

9.4

4.9

8.6

8.6

2.6

----

9.2

12 May 1952

Fewer incoming shells

6.3

2.1

4.4

6.2

----

----

3.1

4.5

4.3

----

----

----

1.0

1.6

----

13 May 1952

Rain-quiet

----

----

----

----

----

----

----

----

----

----

----

----

----

----

----

14 May 1952

Quiet day

2.0

2.1

1.0

1.5

----

----

2.0

2.1

1.1

1.2

----

1.0

1.0

1.1

----

*All men on front line for previous 40 days.
**Normal 0.6-2.6 mg. per day.


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becoming incapacitating. After 30 days of increasing tension, his corticosteroid excretion was found to be high (fig. 6). Adrenal insufficiency was not an associated factor.

The next step was to study the wounded man to determine if he could manifest the normal adrenal cortical response to physical injury. This was approached in two ways.

FIGURE 3. After 40 days of exposure, this officer responded to an increased hazard by an increase in excretion of corticosteroids. The 17-ketosteroid excretion remained normal.

First, 64 casualties were studied with eosinophile counts immediately after injury. Each demonstrated a typical adrenal cortical response as manifested by a marked depression in the concentration of circulating eosinophiles (1).


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An additional 20 casualties were selected for continued study during the day of injury and the succeeding 7 to 14 days thereafter (1).

TABLE 3. Combat Stress-All Men on Front Line 40 Days-A Study of 15 Soldiers

Date

Activity

Average corticosteroid excretion* milligrams per 24 hours

11 May 1952

Heavy artillery fire

6.3 mg.

12 May 1952

Fewer incoming shells

3.7 mg.

13 May 1952

Rain-quiet

-----

14 May 1952

Quiet day

1.5 mg.

*Normal range 0.6-2.6 mg.

FIGURE 4. Demonstrating a continued response for 24 hours after the shelling had subsided.


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FIGURE 5. The response to danger appears approximately equal to the response to major injury in these specific instances. Both subjects demonstrate fairly representative findings.

The following two patients are typical of the group.

Patient No. 6

Twenty-one-year-old American soldier, weight 175 pounds, blood type A, in Korea for 30 days and in combat 20 days. This soldier was wounded by multiple shell fragments at 0330 hours, 3 August 1952. Arriving at the battalion aid station 1 hour later, he was given 15 mg. of morphine, 600,000 units of penicillin, and 0.5 cc. of tetanus toxoid. On arrival at the hospital 5 hours after injury, his blood pressure was 148/78 and his pulse rate 104 per minute. He was pale and considered to be in incipient shock. After 1,500 cc. of blood in the preoperative ward, his pressure was 160/100. His wounds included a perforation


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of the right side of the chest, diaphragm, and liver. The wound of the right lobe of the liver would easily admit four fingers. In addition, he had multiple small penetrating wounds of three extremities.

FIGURE 6. This officer had not been under condition of combat nor actual personal danger. Nervous tension became as intense as in soldiers in the front lines. Adrenal function appears to be increased during a representative period of time and activity.

A laparotomy was performed and the hepatic wound drained. The soft tissue wounds were débrided. Ether, oxygen, and nitrous oxide were given by inhalation. His operative course was smooth, his pressure ranging about 120/75, pulse 120. Another pint of blood was given during operation. Thoracentesis was repeatedly performed postoperatively until on the fifth day a tube drainage of the right side


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of the chest was performed. Blood loss was estimated at 500 cc. during operation. His subsequent course was smooth.

This soldier demonstrated the rise in corticosteroid excretion following injury. The response subsided but was detectable again on the seventh day (fig. 7) due, perhaps, to the earlier secondary trauma of intubation of the pleural cavity. This patient's sodium intake

FIGURE 7. Note the fall in eosinophile concentration in the blood and the increase in the urinary excretion of corticosteroids.


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was quite limited so that he was slow to develop a positive sodium balance (figs. 8, 9, and 10). The potassium diuresis was rather marked. He, therefore, demonstrated the manifestations of a rather typical adrenal cortical response to injury (fig. 11).

Patient No. 8

This soldier, 30 years of age, was wounded by mortar shell fragments at 1100 hours 20 September 1952. The injuries included traumatic amputation of both legs and both upper extremities at the forearm. He was seen shortly thereafter at the battalion aid station where he was given albumin 500 cc., morphine 30 mg., streptomycin 1.0 gram, and penicillin 600,000 units. He arrived at the hospital 2.5 hours after injury. At this time, his blood pressure could not be measured because of the limited areas exposed. His pulse rate was 102 per minute. He was pale, lethargic and dry. No peripheral vessels were visible.

Eighteen pints of blood were given intra-arterially. Meanwhile, hemostasis was obtained. The pulse averaged 130 to 140 beats per

FIGURE 8. Sodium intake was zero during the first 2 days so that he was slow to develop a positive sodium balance. Potassium diuresis was marked. Figure above column represents intake, figure in column represents output, and figure below column (and shaded area) represents balance (after Moore).


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CUMULATIVE SODIUM AND POTASSIUM BALANCE (Meq.)

FIGURE 9.

minute and was irregular. At 2000 hours, under pentothal, oxygen and ether anesthesia, four surgical teams reamputated all four extremities. The operation required only 20 minutes but was poorly tolerated. By the end of surgery the patient had received 23 pints of blood in addition to 5 units of albumin. The following day he received three more pints of blood. His subsequent convalescence was fairly slow but uneventful.

His wounds were dressed on the sixth postoperative day. No anesthesia was used at this time.

Figure 12 demonstrates the rise in corticosteroid excretion on the day after injury. This response slowly subsided but was again noted


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after the trauma of the secondary dressing on the sixth day. The 17-ketosteroid excretion remained essentially normal. Potassium diuresis and sodium and water retention (figs. 13, 14, 15, 16) were uniformly observed.

These patients were rather typical of the group. Again, each of the 20 patients demonstrated a normal response of the adrenal cortex following injury.

FIGURE 10. Note the evidence of sodium retention and potassium loss as indicated by the rapid decrease in the Na/K ratio.

Summary

A study of the combat casualty was made during the first half of 1952 on the Eastern Korean front. Adrenal cortical function appeared normal in the front line soldiers. After prolonged exposure to the stress of battle exposure, acute danger stimulated an adrenal response of the magnitude found after severe combat injury.

Following combat injury, each soldier studied demonstrated a response of the adrenal cortex.

Under the conditions of the study in Korea, therefore, adrenal insufficiency was not found to result from combat stress.


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Reference

1. Howard, J. M., Olney, J. M., Frawley, J. P., Peterson, R. E., Serfin, Guerra, and Dibrell, W.: Studies of Adrenal Function in the Combat and Wounded Soldier. Report to the Army Medical Service Graduate School, 1954.

DAILY WATER BALANCE (c.c.)
NO CORRECTION FOR INSENSIBLE LOSS

FIGURE 11. Demonstrating a positive water balance for at least the first few days.


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FIGURE 12. The corticosteroid excretion was elevated on the day after injury and thereafter gradually returned to normal. It again increased following secondary trauma on the sixth day. The 17-ketosteroid excretion (normal 8 to 22 mg.) remained essentially normal.


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FIGURE 13. Sodium retention was marked throughout the first 9 days. Potassium was lost for 2 days and then conserved. Figure above column represents intake, figure in column represents output, and figure below column (and shaded area) represents balance (after Moore).


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FIGURE 14. Demonstrating the continuing change.


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FIGURE 15. Potassium was excreted in larger amounts than sodium throughout the first week.


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FIGURE 16. Demonstrating water retention early.