Date: 8/6/2008 12:00 AM
By SHARON COHEN
EDITOR’S NOTE — Roadside bomb blasts change everything for two soldiers and their families back home. Fourth of a seven-part series on the longest deployment of the Iraq war.
By SHARON COHEN
AP National Writer
In that dreadful December, every day brought bloodshed, every week hundreds of attacks on Americans and Iraqis.
Car bombings. Drive-by shootings. Kidnappings. Torture. Bullet-riddled bodies. Sectarian fighting. It was a horrible end to a horrible year in the Iraq war.
And for two young soldiers, December 2006 was the month that changed everything, forever.
The sky was clear on Dec. 2 when Sgt. John Kriesel’s armored Humvee rolled out to check a report of suspicious activity: people digging on a dirt road near Fallujah.
His Humvee was turning a corner when the left front tire ran over something. Riding shotgun in the vehicle, Kriesel heard a metallic plink — like a rock striking a 55-gallon drum.
Then: BOOOM!
The Humvee flew into the air, its doors blowing open, the gunner shooting out of the turret like a Roman candle before the vehicle crashed down on its side.
Kriesel’s helmet and glasses flew off as he was thrown to the ground. Rocks rained down in a concrete storm, and Kriesel heard the screeching of twisted metal, then moans, groans, screams.
Strangely, he was calm. He saw the underside of the Humvee; the axle was blown off.
Then he looked down.
His left leg was nearly severed, still tucked in his pants leg, hanging by a piece of skin. His left thigh was split open like a baked potato, with a bone jutting out and blood oozing.
His right leg, from about six inches below the knee, was badly mangled, as if it had gotten stuck in a wood chipper.
“I’m going to die,” he told himself. “This is how it ends.”
Sgt. Kriesel, the eternal optimist, had lost faith.
He tried to get up, but it was useless. The bones of his lower left arm were broken; the arm flapped like a door off its hinge. Kriesel, who had trained to be a paramedic, was clear-minded enough to brace his arm to his chest, hoping to avoid nerve damage.
His right biceps had burst; they were peppered with shrapnel. A bracelet in honor of a fallen soldier sliced his right wrist down to the bone.
Kriesel closed his eyes. He couldn’t bear to see more.
“Help me! I need help,” Kriesel cried.
“Stay still,” said Sgt. Adam Gallant, who had jumped out of the Bradley ahead of him and had run back. Gallant did a quick assessment. One soldier was dead, another trapped and likely gone. Two others were walking. Kriesel was top priority.
“Kries,” he said, “I’m not going to lie to you, man. Your legs are real bad.”
But he tried to comfort him, too.
“You’re going to be OK,” he said. “We’re going to take care of you.”
Gallant and another soldier wrapped tourniquets on Kriesel’s legs. They propped him up on stacked boxes of MREs so blood would flow to his organs. No one knew it then, but beneath his armor the force of the 200-pound bomb had ripped open his abdomen, and his intestines were exposed.
Kriesel closed his eyes. It was almost like the movies: His life really was flashing before his eyes. He thought of Little League back in Minnesota, his elementary school days…
Then he felt someone shaking his shoulder.
“Keep your eyes open,” he heard. He didn’t want to.
He thought of his wife, Katie.
His gunner sat by his side to keep him awake. But the blast had left him with a concussion, and he kept asking Kriesel the same questions:
What’s your wife’s name?
Your kids’ names?
What state do you live in?
Kriesel answered over and over, until he lost patience.
“Leave me alone!” he snapped. “Let me die.”
The soldiers needed to move Kriesel so they could tip the Humvee wreckage and remove another soldier trapped beneath it.
“I ain’t going to lie to you, buddy,” Gallant said. “This is really going to suck.”
“What could suck worse?” Kriesel said. “Just go! Let’s do it.”
As they picked him up, Kriesel’s nearly detached leg flopped onto his chest. He howled in pain. No one knew then that his pelvis was shattered.
He was getting cold. Again, he felt sure he was going to die.
“Tell Katie I love her,” he implored.
“Shut up, you’re going to tell her yourself,” Gallant said.
When a young medic arrived, he administered morphine, and Kriesel was loaded onto a chopper. The drug was kicking in. But he managed to give his Social Security number.
Then he closed his eyes again.
At the hospital at the Al Taqaddum Air Base, six surgeons worked on Kriesel as a chaplain stood by in a corner. Once Kriesel was stabilized for transfer to another hospital in Iraq and then to Germany, the doctors placed him in a “hot pocket” — a heated nylon bag from which only a breathing tube was visible.
Some of those who saw him wheeled by felt sure he was dead.
A doctor tried to reassure them. His heart is still beating, he said. He’s still alive.
___
It was almost midnight in Minnesota, and Katie Kriesel was asleep when the phone rang.
“Katie, I need you to sit up,” her mother-in-law said.
John must be dead, she thought.
He wasn’t, but the news was grim: John had lost both his legs, one above the knee, the other below.
Katie Kriesel started crying. She called her mother, who lived about a mile away, but she was so choked up, her mother thought something had happened to the boys. She was getting dressed, she said; she’d be right over.
The commotion woke 4-year-old Broden, and Katie tried to calm him, stretching out in his bed, where he dozed off again but she simply watched the clock, hour by hour, waiting for morning and more news.
Over the next two days, Katie tried to maintain normal routines — even taking the boys for a breakfast with Santa — and struggled to keep her voice steady and her eyes dry.
As calmly as she could, she told her sons their dad was hurt and she had to go to Germany to help him.
What kind of hurt? they asked.
“Dad doesn’t have his legs anymore,” she said.
They looked puzzled.
Everything will be OK, she said. He’ll get a wheelchair.
Later as Katie read her sons a bedtime story, 5-year-old Elijah had a question.
“Are Dad’s legs going to grow back?” he asked.
“No, honey, they don’t grow back.”
“I just don’t want to talk about it anymore,” Elijah said.
___
That Sunday, Sgt. Travis Ostrom received a call at home.
Terrible news for the 1st Brigade Combat Team: Three casualties from an IED attack. John Kriesel was badly injured, and two other Minnesota National Guardsmen — Specs. Corey Rystad and Bryan McDonough — had been killed.
Rystad, just a few weeks shy of his 21st birthday, was an avid hunter and a natural athlete, a quiet guy who was always asking questions, always interested in learning how to be a better soldier. McDonough, 22, liked to crack jokes; everyone enjoyed being around him. But he had a serious side, too. In an online entry, he had written that he was proud to defend his country and there was “no other place I would rather be.”
Ostrom had to start coordinating the military aspects of two funerals.
It was the most unwelcome part of a job he never wanted.
Ostrom, who had served in Bosnia, Somalia and the Persian Gulf, had expected to be a platoon sergeant in Iraq, but he never got there. A knee injury at the worst possible time, during pre-deployment training in Mississippi, had sidelined him.
While his comrades fought, he was ass
igned to a lonely armory in Minnesota serving those on the home front.
He felt guilty, but plunged into the crucial job helping families with bills, cutting red tape — and, as now, making preparations for final goodbyes.
That December day, Ostrom quickly called other Bravo Company soldiers on home leave. That way, they’d hear the news from him first. Also, some would be among the dozens of soldiers he’d tap for the sad necessities at hand: to carry flags in honor guards, to drive dignitaries at the two funerals, and to serve as pallbearers.
He scheduled rehearsals at the armory, bringing in a borrowed casket. The soldiers practiced folding the flag, synchronizing the 21-gun salute.
The dutiful sergeant had the same message for all of them: You have just one chance to do it right.
___
“Did everybody make it out OK?”
It was John Kriesel’s first question when he woke up more than a week later at Walter Reed Army Medical Center. He had no memory of the nine or 10 surgeries he’d undergone, first in Iraq, then at Landstuhl Regional Medical Center in Germany.
The look on his wife Katie’s face gave him the answer even before she spoke. His two buddies had been killed.
Though Kriesel couldn’t recall some things, he knew he had lost his legs.
In fact, he had come close to dying: His back was broken, his stomach, arms and face were pocked with shrapnel. His left arm was broken and part of his colon had to be removed. His pelvis and spine had to be fused with screws and pins.
He’d hardly had a day without surgery.
But already, Kriesel looked better than when Katie had arrived in Germany. She had fallen to her knees when she first saw his swollen face and blood seeping from his wounds. She decided immediately to sleep by his side every night, convinced if he knew, he’d fight harder to survive.
Kriesel wanted to see their sons, and in time he was well enough. Katie already had conferred with a child psychologist about how to prepare them and to describe what they’d see. Elijah and Broden had never visited a hospital or been around anyone disabled.
Put one hand under your knee and one hand above the other knee, Katie told the boys. Now pretend there isn’t anything below that anymore. That, she said, is what Dad is like.
When the boys arrived in the lobby, they weren’t interested in hearing explanations about bandages, machines or wounds. Dad. Dad. Dad. They just want to see Dad.
As Elijah entered his father’s room, Kriesel covered his amputated legs with a blanket.
“You don’t have to cover up your ovals, Dad,” said the boy, describing the shape of his wounds. “I’m just glad you’re alive.”
___
That bitter December was winding down when Sgt. J.R. Salzman, just back from home leave, heard about Kriesel. His convoy commander happened to be Kriesel’s cousin.
On Dec. 19, Salzman was in the scout truck leading three other Humvees and a 20-vehicle fuel tanker convoy through northwest Baghdad to Tallil Air Base. He was talking with his driver, when there was an enormous blast.
He lost consciousness, then woke to the sound of his gunner screaming obscenities; hot shrapnel had spattered over his legs.
Salzman smelled something sickening, like burning wires, mixing with the smell of burning flesh.
Bleeding and trapped in the still-idling Humvee, he thought of his wife, Josie, whom he’d married just nine months before. He muttered her name.
He tried to grab the right door lever to get out. But he couldn’t.
He felt terrible burning and when he looked down, he realized why: His right hand and wrist were gone. About six inches above his wrist, he saw two bones sticking out from chewed-up flesh.
Salzman’s Humvee had been hit by an armor-piercing bomb called an EFP — an explosively formed penetrator — that was hidden in a pile of rocks on the right side of the road.
Despite excruciating pain, he kept his cool, checking quickly to see if his left hand was there. It was. But it was swelling in his glove, and he couldn’t move two fingers.
He continued the inventory of his body. He rotated his shoulders. He felt below his waist. Everything was there.
He shuffled his feet — and at that moment, he had an incongruous thought that carried him far away, if only for a split second: He could still log roll, something he’d loved since he was 5, something that had made him a champion.
Then his mind snapped back: He needed a tourniquet. He carried two but there was no way he could put one on. He tried to call for help, pressing a radio button with his left thumb, but the blast had fried the electronic equipment.
“Get the medic up here,” he ordered his driver and gunner, “… if I don’t get a tourniquet on, I’m going to bleed out.”
Salzman wondered if this was the end, then pushed that thought away.
“No. No. NO WAY am I dying here,” he said to himself. “Not here. Not now. Not today. Not in this country, I’m not dying.”
___
TO BE CONTINUED …
___
NOTE: The story of 1st Brigade Combat Team/34th Infantry Division of the Minnesota National Guard and its tour in Iraq was reconstructed from scores of interviews with more than 20 soldiers and members of their families. Most quotations are as remembered by the speakers. In addition, the series draws upon numerous official documents, including after-action reports; videos of news conferences; correspondence provided by the families (including e-mails and letters); television coverage of the unit’s return; personal journals and blog postings.
Copyright 2008 The Associated Press.
Hysteria or Conversion Diagnosis Focuses on Perceived Character Flaws, not Relevant Injury Factors
In understanding the stain that the “hysteria” diagnosis has left on our medical science, it is important to distinguish “hysteria” from PTSD. The modern term for hysteria (if there should even be a modern term for it) is “Conversion Disorder”. See DSM-IV 300.11. PTSD is an entirely different matter as it relates to the development of specific emotional problems, as a result of emotional trauma. In Conversion Disorder, the emotional issues of the patient (not traumatically induced symptoms) are converted into physical problems. In Myers’ case studies, he attributed the neurological symptoms of his soldiers to this type of “hysterical” conversion of emotional problems.
The DSM-IV criteria for Conversion Disorder, stresses the likelihood that the patient have a prior history of psychosis.
“A history of other unexplained somatic (especially conversion) or dissociative symptoms signifies a greater likelihood that an apparent conversion symptom is not due to a general medical condition, especially if criteria for Somatization Disorder have been met in the past.”
While such criteria were not formally laid out in his time, Myers seemed to sense the need to show that his soldiers were psychologically weak. With respect to Soldier #1, he said:
“Prior history. –He had been for two months in the Aisne district on the lines of communication, sleeping badly all that time owing to lumbar pains (and toothache during the first three weeks.) He had failed to pass a medical examination some time previously because of renal trouble (abnormal amount of albumin in water) until after a long period of treatment. He had had lumbar pains a few nights before coming to France.”
The significance of the reference to the lumbar pains, seems to be the implication that the emotional stress of coming combat had brought them on.
With respect to Soldier #2:
“As to his past history, he came out to the war on August 13th, and was in the last two days’ retreat at Mons and after at La Bassee. Has slept very badly since the start, often when billeted taking large doses of whisky to procure sleep. Has led a ‘fast’ life and has had recent domestic worry.”
While he has no comment on the prior history of Soldier #3, he stresses the nervousness of the soldier in his narrative.
“A healthy looking man, well-nourished, but obviously in an extremely nervous condition. He complains that the slightest noise makes him start…. His hands became very tremulous and his forehead sweated profusely. He appeared as if about to faint, and says that he felt cold and dizzy, and experienced “round and round movements of the stomach…. He complains that he gets very excited when anyone addresses him.”The use of these implicit (without direct comment on their relevancy) comments by Myers is strongly reminiscent of the character assassination found in Defense neurological and neuropsychological opinions. No where does Myers say these symptoms are related to these character issues, just the “no comment seems necessary.”
While Myers wasn’t working with a formal diagnostic criteria for a “hysterical” diagnosis, the modern definition of Conversion Disorder does at a minimum require ruling out all medical explanations for the neurological symptoms.
“A diagnosis of Conversion Disorder should be made only after a thorough medical investigation has been performed to rule out an etiological neurological or general medical condition. Because a general medical etiology for many cases of apparent Conversion Disorder can take years to become evident, the diagnosis should be evaluated periodically.” DSM-IV, page 493.
Did Myers rule out all medical conditions for the neurological symptoms? Of course not. As discussed in the previous blogs, there are clear neurological, biomechanical and pathological explanations for the amnesia and the anosmia. Much is made by Myers of the partial visual complaints of these three soldiers. Yet other Cranial Nerve damage can account for many of these phenomenon, even without any damage to the eye, or the Optic Nerve. There are references to Soldier #3’s stomach complaints, but anyone acquainted with the vestibular system should recognize these symptoms as being explained by vertigo: “He appeared as if about to faint, and says that he felt cold and dizzy, and experienced “round and round movements of the stomach.” See http://vestibulardisorder.com Further, the reports of sweating and feeling like he is about to faint, is clearly explained by a condition called POTS (postural orthostatic tachycardia syndrome), which would also cause the vertigo. POTS, vertigo, cranial nerve damage – are all clear markers of traumatic brain injury.
The Character Assassination: Soldier #1 back pains prior to deployment; Soldier #2, heavy drinker with domestic problems. While there might be emotional explanations for increasing back pain under extreme stress, that isn’t the type of deep psychosis which would explain an extremely rare diagnosis of “hysteria.” As for his attacks on Soldier #2’s character, one must ask: How many soldiers are heavy drinkers? (Even our current Republican Nominee, John McCain has admitted to hell-raising during his 20’s.) What soldier doesn’t have some worry about his marriage, his family while deployed in a combat zone?
Sleep. Myers discusses sleep with each of his soldiers. But diagnosing hysteria versus organic injury to the brain and neurological system because of pre-morbid problems with sleep, makes as much sense as stating that these soldiers were carrying a gun at the time they were shelled. The soldier who sleeps well, like a soldier who doesn’t carry a gun, is not a oldier to fare well in combat. Combat requires hypervigilance. The soldier who sleeps soundly, especially in World War I, is the soldier who is in peril. One of the most cogent theories of PTSD is that it is a result not of the specific instances of emotional shock, but as a result of the constant need to be hyper-aware. It is the never sleeping well, the need to being always ready to reach for the gun, to leap for cover, that may be the hardest thing for the combat veteran to wind down from, post combat. It may be the inability to shut off the mechanism to never truly sleep, to dream, that causes the surrealistic elements of post combat stress.
Next: We will discuss the elements of PTSD, its roots in combat, and its questionable applicability to more routine civilian stressors. But before this commentary leaves Myers behind, I do want to stress one important point:
Myers was not wrong to factor in the terror at the time of the injury and the precedent emotional vulnerability of the patient. His mistake was to miss the clear organic evidence of brain trauma, brain damage. It may be the terror or the emotional makeup of these specific soldiers, made them more likely to be disabled by the blast injury that might not have disabled a stronger individual. But the diagnosis must begin with a full differential consideration of brain or neurological damage. Once brain damage has been identified, it is fully appropriate to incorporate the synergistic interplay of the vulnerability of each individual, the additive factors of the combat stress such individual was under, and the emotional impact of such injury, on that particular brain.
Myers may not have had all the tools of modern medicine available to him, but he did have the most important: history and examination. He took the history, seemingly quite accurately. He did the examination better than most modern doctor s (especially with respect to the Olfactory Nerve). Where he failed, and perhaps because of British unwillingness to believe the brain could be so easily damaged, was in not believing the realness of his own findings. His soldiers couldn’t smell. They couldn’t remember. They had neurological explanations for the vast majority of their symptoms. Combat emotional stress could certainly explain the rest. Brain injury, by any other name, will still disable.
The Character Assassination: Soldier #1 back pains prior to deployment; Soldier #2, heavy drinker with domestic problems. While there might be emotional explanations for increasing back pain under extreme stress, that isn’t the type of deep psychosis which would explain an extremely rare diagnosis of “hysteria.” As for his attacks on Soldier #2’s character, one must ask: How many soldiers are heavy drinkers? (Even our current Republican Nominee, John McCain has admitted to hell-raising during his 20’s.) What soldier doesn’t have some worry about his marriage, his family while deployed in a combat zone?
Sleep. Myers discusses sleep with each of his soldiers. But diagnosing hysteria versus organic injury to the brain and neurological system because of pre-morbid problems with sleep, makes as much sense as stating that these soldiers were carrying a gun at the time they were shelled. The soldier who sleeps well, like a soldier who doesn’t carry a gun, is not a oldier to fare well in combat. Combat requires hypervigilance. The soldier who sleeps soundly, especially in World War I, is the soldier who is in peril. One of the most cogent theories of PTSD is that it is a result not of the specific instances of emotional shock, but as a result of the constant need to be hyper-aware. It is the never sleeping well, the need to being always ready to reach for the gun, to leap for cover, that may be the hardest thing for the combat veteran to wind down from, post combat. It may be the inability to shut off the mechanism to never truly sleep, to dream, that causes the surrealistic elements of post combat stress.
Next: We will discuss the elements of PTSD, its roots in combat, and its questionable applicability to more routine civilian stressors. But before this commentary leaves Myers behind, I do want to stress one important point:
Myers was not wrong to factor in the terror at the time of the injury and the precedent emotional vulnerability of the patient. His mistake was to miss the clear organic evidence of brain trauma, brain damage. It may be the terror or the emotional makeup of these specific soldiers, made them more likely to be disabled by the blast injury that might not have disabled a stronger individual. But the diagnosis must begin with a full differential consideration of brain or neurological damage. Once brain damage has been identified, it is fully appropriate to incorporate the synergistic interplay of the vulnerability of each individual, the additive factors of the combat stress such individual was under, and the emotional impact of such injury, on that particular brain.
Myers may not have had all the tools of modern medicine available to him, but he did have the most important: history and examination. He took the history, seemingly quite accurately. He did the examination better than most modern doctor s (especially with respect to the Olfactory Nerve). Where he failed, and perhaps because of British unwillingness to believe the brain could be so easily damaged, was in not believing the realness of his own findings. His soldiers couldn’t smell. They couldn’t remember. They had neurological explanations for the vast majority of their symptoms. Combat emotional stress could certainly explain the rest. Brain injury, by any other name, will still disable.
Loss of Smell was a Missed Sign of Brain Injury in World War I Shell Shock
Previous blogs in this series have focused on the contrast between the quality of the meticulous description of history by Charles Myers’ in his seminal 1915 Lancet paper on “Shell Shock” and his clearly flawed comment that these case studies were explained by hysteria. See “A Contribution to the Study of Shell Shock” published in the British Medical Journal, the Lancet, on February 13, 1915.
Yesterday’s blog focused on how he documented, but didn’t find significant evidence of amnesia. This blog will focus on the loss of taste and smell.
As thoroughly as we have criticized Myers’ conclusions, we must applaud the thoroughness of his investigative skills. One of the great flaws of current neurological exams is the failure to test all cranial nerves. The words “Cranial Nerves II through XII are intact” are tantamount to misrepresentation by omission in brain injury diagnosis. What about Cranial Nerve I?
Well Myers, for all his failure to “get it”, tested Cranial Nerve I and tested it thoroughly. Cranial Nerve I is the olfactory nerve, the nerve which comprises most of the human sense of smell. If all neurologists would so diligently test Cranial Nerve I (and unlike Myers understand its significance) the quality of brain injury diagnosis would go up exponentially.
What is the relevance of the loss of smell to a diagnosis of brain injury? To fully appreciate this, it is necessary to understand the basic geography of the brain and the cranial nerves. The cranial nerves are generally the nerve groups which control the function of muscles, organs and feelings in the head (the cranium). For example, Cranial Nerve VII is needed to make a person smile. Cranial Nerve VIII is involved in balance and the vestibular system. Cranial Nerve I is the Olfactory Nerve, which is responsible for the sense of smell. For a full chart of the Cranial Nerves see: http://www.gwc.maricopa.edu/class/bio201/cn/cranial.htm
Unlike the other Cranial Nerves, which take a circuitous route into the brain through the brainstem, Cranial Nerve I goes directly from the nose into the brain. At the juncture between the Olfactory Nerve and the brain is something called the Olfactory Bulb. Immediately adjacent to the Olfactory bulb, on the surface of the brain, are some of the most sensitive and important functions of the lower frontal lobes. While losing the sense of smell does not mean that a person has brain damage, when the Olfactory Nerve is injured in a traumatic event, there is in most cases, correlative damage to the adjacent structures of the brain. That particular part of the brain is the orbital frontal lobe.
Thus, when Myers was meticulously documenting the loss of smell in his patients, he was not describing an anomaly, but very significant correlative damage to the part of the neurological system, immediately adjacent to some of the most sensitive and important parts of the brain. The predictive value of loss of smell to brain injury pathology is born out by substantial research that correlates disability to loss of smell. See Neuropsychological Significance of Anosmia following Traumatic Brain Injury
Journal of Head Trauma Rehabilitation. 14(6):581-587, December 1999.
Callahan, Charles D. PhD, ABPP; Hinkebein, Joseph PhD http://www.headtraumarehab.com/pt/re/jhtr/abstract.00001199-199912000-00006.htm;jsessionid=LNTQj0tnvkKKVQB1Z2yMGwZphHLhQh2Q21TSY4HLQnCw8pFLyTlS!435538499!181195629!8091!-1 and Varney NR, Pinkston JB, Wu JC. Quantitative PET findings in patients with posttraumatic anosmia. J Head Trauma Rehabil. 2001;16:253–259. Such correlation is stronger than almost any other marker of brain injury with the exception of amnesia.
The technical term for loss of smell is anosmia. As most neurologists do not test for loss of smell, it is often necessary to look for clues that anosmia occurred. The best clues to anosmia are typically changes in taste, eating habits and weight. Smell is a big part of how people taste, especially the subtle differences between foods. Post traumatic anosmia fundamentally changes how and what people taste. This can leave the marker of weight loss – or the more common – weight gain. Those with anosmia often increase the fat content and the spice content of their food, in order to have it taste more.
As discussed on our related blog, http://subtlebraininjury.blogspot.com King Henry the VIII’s remarkable gain in weight after his jousting injury (and significant loss of consciousness) is probably best explained by anosmia. His patterns of neurobehavioral changes after such injury clearly correlate to frontal lobe injury. See http://subtlebraininjury.blogspot.com/2008/06/henry-viii-and-brain-injury-behavior.html
While Myers’s case study does not include any longitudinal study of either change in weight or future employability of his subjects, research done long term with Vietnam vets, clearly documents those phenomenon. If an injured individual has a dramatic change in diet or weight post accident, brain injury must be considered to be part of the diagnostic differential.
Next Understanding the Biomechanics of War Time Brain Injuries
Lancet Case Study of Three World War I Soldiers with Shell Shock
As introduced in yesterday’s blog, Captain Charles Myers, a British Physician authored a significant case study of three wounded soldiers with shell shock in the Lancet, the publication of the British Medical Society. See C.S. Myers, “A Contribution to the Study of Shell Shock” The Lancet, on February 13, 1915 page 316-320.
Myers begins his discussion of the three cases by calling them “remarkably similar.” All three soldiers were
• Injured by a by shells bursting near them;
• Had sleep problems before their injuries,
• Had memory disturbances after their injuries;
• Had vision affected;
• Had disturbances of smell and taste.
And quite significantly to Myers, despite the proximity of the blasts, none had any significant disruption in hearing.
Soldier # 1:
Myers describes the first soldiers case as follows:
Soldier # 2:
“During the (retreat) from this trench at 1:30 p.m., they were “found” by the German artillery. Up to that time he had not been feeling afraid; he had rather ‘been enjoying it’ and was in the best of spirits until the shells burst about him… He was trying to creep under wire entanglements when two or three shells burst near him. As he was struggling to disentangle himself from the wire, three more shells burst behind and one in front of him. After the shells had burst he succeeded in getting back under the wire entanglements. … Immediately after the shell burst in front of him his sight became blurred. It hurt his eyes, and they burned when closed. At the same moment he was seized with the shivering, and the cold sweat broke out especially around the loins “like a punch on the head, without any pain of it’. The shell in front cut his haversack clean away, bruised his side, and apparently it burned his little finger. …
“When he got to treatment… he was crying the whole time and worrying as to whether he was going blind. … At the dressing table station he was crying and shivering; he was taken thence to a hospital by horse ambulance… He thinks he must have slept on the ambulance, as he remembers nothing. (Emphasis in original.)
Three months post injury ‘says he has lost the sense of taste and smell since the shell’s burst around him.’
Woke up last night and found himself crying: ‘not thinking of anything in particular’.
Past history: He had been for two months in the Aisne district on the lines of communication, sleeping badly all the time owing to lumbar pain… He had failed to pass a medical examination some time previously because of renal trouble.
Soldier # 2:
Myers says of the second soldiers combat experience:
“The patient says he was buried for 18 hours owing to a shell bursting and ‘blowing in’ the trench in which he lay.”
This soldier also has lost his sense of smell and much of his sense of taste. While some “memory” of the events around the time of his injury returned, comparison to his later description of events was not consistent with what other soldiers who survived the battle remembered. While Myers seemed troubled by the conflict in these stories, it can clearly be explained by the brain injury symptom of “confabulation”.Soldier # 3:
Myers detailed the history as follows:
The patient says was blown off a heap of bricks, 15 feet high, owing to a shell bursting close to him. Thinks he must have fallen into a pool of water, as he next remembers finding himself, about 3 p.m., the same afternoon in a cellar near a church with his clothes drenched. He does not know how he got there or how he left the cellar, but he remembers being in another hospital before he was admitted here.”
Myers details this soldier’s symptoms as follows:
“A healthy-looking man, well-nourished, but obviously in extreme nervous condition. He complains that the slightest noise makes him start. His legs feel weak and he has pain in the precordial region. His sight has been very much impaired since the shock. …
He has slept very little the last two nights. Hands tremulous. Knee jerks normal, but the first attempts to evoke them provoked a spasm of the calf muscles and a few general convulsive movements as the patient lay in bed. His hands became very tremulous and his forehead sweated profusely. He appeared as if about to faint and says that he felt cold and dizzy, and experienced round and round movements of the stomach. … The slightest touch on the legs provoked well-marked spasm of the quadriceps muscles of the same thigh. Extensor muscles of the toes appeared to be in a state of clonic contraction.
Left nostril fails to detect smell of ether, peppermint, eucalyptus, ammonia, carbolic acid, or iodine tincture, all of which are at once recognized when placed beneath the right nostril. No signs of nasal obstruction. Taste: Only tastes very strong solutions of sugar, salt and acid…”
Conclusions. Myers, after discussing the three histories, ends his paper with this comment:
Comment on these cases seems superfluous. They appear to constitute a definite class among others arising from the effects of shell-shock. The shells in question appear to have burst with considerable noise, scattering much dust, but this was not attended by the production of odor. It is therefore difficult to understand why hearing should be (practically) unaffected and the dissociated “complex” be confined to the senses of sight, smell and taste (and to memory). The relation of these cases to those of “hysteria” appears fairly certain.
Thus, at a critical juncture in military medicine, with all the observational facts recorded to shift the focus to brain injury, the theory of hysterical illness raises its specter. That pattern gets repeated and becomes the cornerstone of far too much bad diagnosis – even to this day – at least in forensic neurological practice.
Myers’ choice of the word “hysteria”, is now replaced by the words “conversion disorder”. Myers might have been a pioneer – a leader in the field of military medicine in 1915 – yet his ignorance relative to what we know today about brain anatomy, is significant. The two most predictable markers of brain injury are loss of memory for events around the time of the injury (amnesia) and the loss of smell. He dismissed these findings. Further, he clearly lacked any basic understanding of the biomechanical forces which result in brain injury. While his ignorance is understandable, the ongoing use of these ridiculous psychiatric excuses for clear-cut neurological phenomenon, are not.
In the coming blogs, we will look at the clues to a proper diagnosis in these three cases histories: amnesia, loss of smell and the biomechanical and neuropathological explanations for brain injury.
World War I Literature Shows the Reluctance to Identify Brain Injury in Shell Shock Soldiers
I owe my perception of the World War I literature on Shell Shock to a good friend’s academic pursuit of such topic while at Yale. The below quotes are from a paper discussing the dichotic treatment of shell shock as an emotional/organic injury in the novel: Return of the Soldier, by Rebecca West. Quoting from Kara Harton’s paper:
Shell Shock in Rebecca West’s Return of the Soldier
Set in 1916 at the Baldry family estate outside London, Return of the Soldier is the fictional story of Chris Baldry, a veteran of The Great War, who is discharged from the military due to shell shock-induced amnesia. His only memories are expressed as flashbacks of his pre-war life.
The idea of shell shock is introduced in the novel before the main character actually appears. Kitty and Jenny are at Baldry Court, nostalgically reminiscing about the past, when Margaret arrives with news about Chris. She informs the women that Chris has experienced some sort of misfortune on the battlefield but is somewhat hesitant to reveal the details. When Kitty asks if he is wounded, Margaret responds with, “Yes . . . he’s wounded,” but soon corrects herself by explaining, “I don’t know how to put it, he’s not exactly wounded. A shell burst –.” “Concussion?” Kitty asks. Margaret clarifies that Chris has shell shock and is “not dangerously ill.” After her explanation, the women share an awkward silence; they are obviously uncomfortable, and it is clear that neither of them is certain of the implications of the news.
Just as the characters of Return of the Soldier are not quite sure how to classify this condition, most Europeans, including medical and psychological experts, were unsure of the exact cause and characteristics of shell shock. There was an extensive debate about whether the nature of the condition was physical or mental, and whether it could legitimately be classified as a “wound.” The inability to pinpoint Chris’s injury in the previous passage is an excellent illustration of this uncertainty. It is not a tangible injury, and no one can decide exactly how to refer to it. The women seem uncomfortable using the term “shell shock,” which shows their lack of familiarity and understanding of the condition.
In addition to providing an excellent illustration of the uncertainty with which people approached shell shock, Return of the Soldier also contains numerous examples of the way that this condition disrupted society during and after the War. After Chris’s return, Kitty wants their lives to return to normalcy because as members of the upper echelon of society, they both have important responsibilities and obligations to fulfill.
* * *
Jay Winter, a notable World War One historian, calls shell shock “a code to describe the shock of the war to the ruling elite, whose sons and apprentices, being groomed for war, were slaughtered in France and Flanders.” (Winter 10) In this war, unlike other wars, the higher a man’s socioeconomic status, the greater his chances of becoming a casualty. This fact was very real to the social elites, and the phenomenon of shell shock provided “a symbol . . . of the effect of the war on both their own social formation and British society as a whole, which many of them took to be interchangeable.” (10) Officers were expected to be shielded from the danger of emotional breakdown by their superior competence and judgment, their position of responsibility, and the need to set an example for their inferiors. The awareness that officers were more likely to become casualties (both due to shell shock and more conventional injuries) was an uncomfortable reality for society.
© Kara S. Harton, 2007 For the full paper, click here.
In following up on Kara Harton’s research, I found some of the published works of the British physician, Charles S. Myers. Tragically, Myers had immense difficulty overcoming his skepticism that an actual injury to the brain could have occurred without obvious head trauma, despite his focus on the “shell shock” events at the time of onset of the symptoms. While Myers did an excellent job in documenting diagnostic information from which a brain injury diagnosis could have been made, he sarcastically dismissed these cluster of symptoms as “hysterical” (psychiatric) in nature.
Tomorrow: A closer look at Myers’ 1915 seminal paper on “A Contribution to the Study of Shell Shock” published in the British medical journal, The Lancet, on February 13, 1915. Lancet Case Study of Three World War I Soldiers with Shell Shock