History

Medical Science Publication No. 4, Volume 1

MONDAY MORNING SESSION
19 April 1954

MODERATOR
RUSSELL SCOTT, JR.,M. D.

SOME GENERAL CONSIDERATIONS OF HOMEOSTATICAND 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 civiliancatastrophes that individuals respond to similarly painful situations withunequal degrees of effectiveness. This matter of individual differenceshas been approached from a variety of points of view, i. e., hereditary-constitutionalfactors, environmental factors (such as the personal emotional developmentof the subject in terms of his relationships with significant other peoplein his past), cultural-familial patterns in which he grew up, motivationfor combat, etc. Among the environmental factors which seem to be of considerableimportance are those in existence shortly preceding wounding. Not onlyare these factors of considerable importance, but they seem to be factorswhich, if we knew enough, would permit of some control. That is, in practicalterms, research in this area may ultimately provide us with the knowledgenecessary to minimize wounding and to maximize the effective destructiveforce upon the enemy.

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

Many of you with battalion aid station experience during combat havenoticed that different men react differently to similar wounds. One sourceof evidence comes from observations of reactions to blast effects fromgrenades and mortar shells. One soldier will react so that he is diagnosedas having concussion of the brain, lung, stomach, or bowels. Another soldierexposed to the same blast will continue to go about his business with orwithout somatic complaints. If the trauma is equal or only approximatelyequal, the question arises, why does one man continue aggressive actionand 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.

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

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

2. Captain A. took over a problem company 6 month prior to injury andwas successful in making it a more effective unit. He was wounded by adirect hit on his command post. Two sergeants were killed. His right armand leg were fractured. After regaining consciousness he was quickly evacuated.He had a great sense of guilt about carelessness in placing his tent inan 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 eightbunkers had been overrun when he had called for artillery fire on position.He was wounded by a grenade, sustaining multiple fractures of the leftarm and leg. He continued to throw grenades until too weak, then assistedan old sergeant with a machine gun until reinforcements arrived, at whichpoint 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 defensivelythrough two ravines. A major, a stranger to the captain, ordered him tosplit his unit into two forces. The captain's force was quickly pinneddown in the valley. After 10 minutes of immobili-

zation he opened the turret, got out, picked up the wounded, and orderedhis riflemen out of ditches. He continued going up the valley standingup in the turret of his tank, so his men could see him. A mortar shellhit 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 questionwas to ask who else had been hurt. He then resumed radio command untilthe objective was reached, at which point he went into shock. There wasno sense of guilt about leaving his company. He volunteered the statementthat his anger at being ordered to split his unit against his own betterjudgment made him more reckless.

I have only hinted at the psychological factors which are obvious intheir presence and complex in their operation. That which I would liketo underline at this point, however, is the fact that these statementsindicate that there are probably physiological differences which are concomitantand concurrent with psychological differences.

Inasmuch as we have little direct evidence of the physiology involvedin these two different types of reaction to wounding, further explanationscan be sought by drawing upon available experimental data. Such experimentaldata include the work of Funkenstein, et al., at Harvard, on the"Experimental Evocation of Stress," in which experimental psychologicalstress is correlated with certain psysiological responses, as measuredby ballistocardiograph patterns, blood pressure and pulse rate. In their70 subjects, two major responses, analogous to the two major types of responsesto combat wounds, were noted: (1) those which were characterized by angerbeing directed outward, and (2) those characterized by anger directed inwardtoward the self. These two physiological patterns correspond to those whichcan be obtained by injections of norepinephrine and epinephrine respectively.

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

I must at this point ask for forbearance from the physiologists amongyou for this presumptuous oversimplification of their specialty. However,I do so only to suggest the possibility of a method of closer collaborativeeffort between physiologist and psychiatrist. Specifically, it would appearon an a priori basis that the norepinephrine type of physiologicalresponse to stress, with its specific psychological component (outwarddirected anger), is a more effective pattern of behavior for combat purposesthan the epinephrine type of response. To this end it would appear profitableto explore the possibilities of delineating those psychological factorswhich can be manipulated to favor the norepinephrine type of psycho-physiologicalresponse to stress. It has been demonstrated that any given individualis capable of both types of physiological response, and it is to be notedthat immediate environmental factors influence the manner in which thesubject responds to the experimental stress. That is, when the interviewsin Captain Reiser's study were conducted by an educated, well-trained enlistedman, there was a freer expression of anger outward by the subjects. Theresponses obtained to similar interviews conducted by a captain in theMedical Corps contained very few outward expressions of anger, and correspondinglyfewer norepinephrine-like patterns were obtained with the physiologicalmeasurements. This is not evidence against the existence of individualtendencies to respond more often or more strongly in one direction or another.The multiplicity of psychological factors involved in even this simplifiedlaboratory situation indicates the need for further study to determinethe more crucial psychological factors.

There are few published reports of direct psychiatric observation ofsubjects at the moment of wounding. I know of none dealing specificallywith this problem of different types of reaction to acute injury, althoughI have by no means covered the extensive literature in this general area.We can, however, refer to some of the systematic observations upon convalescentcombat cases and see if these findings elucidate the retrospective reportsfrom the wounded about their reactions to being wounded. In February 1954,Noble, Roudebush and Price published in the American Journal of Psychiatrya report of their study of 53 amputees on the orthopedic wards of theU. 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 acutewounds are handled by the wounded pertains to the various defenses employedby the amputees to avoid anxieties over separation, loss of body parts,aggressive feelings and passivity. These defenses included denialof loss in a variety of ways, displacement of feelings from thegenital organs to the amputated extremity, projection of their own

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

Dr. David A. Hamburg, in his study of severely burned patients, hasemphasized the role of denial of injury in maintaining homeostatis.Dr. E. Weinstein has commented on the mechanisms of denial of injuryand projection of anxiety as means of maintaining a modicum of personalidentity in the face of severe brain damage. Is it possible that similarmechanisms are employed to handle anxieties inherent in the acute stageof wounding? If our retrospective reports bear any resemblance to thatwhich actually happened, it is clear that denial of injury is verycommon. It takes place in at least three ways, depending only in part uponthe severity and location of the trauma. Many tearing flesh and musclewounds, as well as fractures of arms, hands, ribs, face and skull, are"discovered" by the recipient only after there is a decreasein the intensity of the combat. The trauma was not admitted into awarenesswhile the awareness was focused elsewhere. Another way in which denialfunctions is to minimize the severity or to put off evaluating theseverity of a wound as long as aggressive action is necessary and to goon "as if I weren't hurt." A third way that has been reportedis to take what first aid measures are possible and then "forget aboutit until later." Mechanisms of projection are to be seen inthe 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 possiblerole in getting wounded, e. g., reckless, unnecessary exposure to fire.Identification with others in the combat unit seems to be a factorin maintaining homeostasis, e. g., Captain J. in example No. 4 above.

While these mental mechanisms are frequently elicited in interviewswith those who have continued aggressive action after being wounded, ourinterview data would suggest that there are at least two common denominatorsin this phenomenon. These seem to be: (1) a ragelike reaction directedtoward the enemy, and (2) the fact that the situation is appropriate forimmediate aggressive action against the enemy.

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

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

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

That with which I would like to conclude, however, is to underline thefact that given the wide range of individual precombat adaptations, thereis highly suggestive psychological and physiological evidence of the existenceof important factors in the immediate combat situation which affect theaggressive potential of the individual and, hence, of the unit. It is inthis 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 EmotionalProblems 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. Psychiatry16: 1-20, Feb. 1953.

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

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

5. Weinstein, Edwin A., and Kahn, Robert L.: PersonalityFactors 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, HarvardUniversity, and the Dept. of Biostatistics, Harvard School of Public Health.