Date: 1/7/2009
By PAUL ELIAS
Associated Press Writer
SAN FRANCISCO (AP) — Six veterans who claim they were unwittingly exposed to dangerous chemicals and germs during government-sponsored Cold War experiments have sued the CIA, Department of Defense and other agencies.
The vets volunteered for military experiments they say were part of a program started in the 1950s to test nerve agents, biological weapons and mind-control techniques. They allege in their federal lawsuit filed Wednesday in San Francisco that they are in poor health today because of the experiments. They are demanding health care and a court ruling that the program was illegal.
The organization Vietnam Veterans of America is also part of the lawsuit, which seeks class action status on behalf of all participants who were allegedly exposed to unhealthful experiments without their knowledge.
Copyright 2009 The Associated Press.
Vietnam Remains Our Biggest Military Health Issue
As we shift our focus of this blog to the emotional side of the synergistic neuropsychiatric disability that faces combat vets, I want to put the context of current soldier suicides and PTSD into perspective. This series of blogs began with my reaction to this news:
“The Associated Press announced that active duty military suicides hit its highest level on record in 2007, 119 soldiers dead. See the AP story at: http://hosted.ap.org/dynamic/stories/M/MILITARY_SUICIDES?SITE=CADIU&SECTION;=HOME&TEMPLATE;=DEFAULT “
My first reaction to that number when I read it was that there was something wrong with the record books, because I had remembered reading a number of references over the years about suicide in Vietnam veterans with numbers as high as 250,000 people. Well, the reason 119 is a “record” is the Pentagon didn’t start recording soldier suicides until around 1980 and that number is for active duty soldiers and doesn’t include vets.
Still, the overwhelming question that seems to being missed in the political debate and news coverage of 2008 is what about the Vietnam vets? As tragic as the Iraq and Afghanistan Wars have been, their footprint of death, disability and psychosis has yet to reach 10% of the magnitude of that of Vietnam. While Vietnam is now more than 30 years in our rear view mirrors, the primary group of soldiers it affected are from 55 to 70 years old. That is a serious public and military health issue for at least another generation.
$500 million dollars for TBI research for blast injuries in the so-called War on Terror is great – but what about Vietnam? The discovery of brain injury and brain damage in Iraq by the politicos and news media is truly wonderful. But Iraq is not the first war with blast injuries, not the first war where our soldiers suffered brain injury, not the first war where the soldier who returned home is a brittle, vulnerable shadow of the vibrant young man who left.
John McCain makes great political hay out of his Vietnam heroism as a prisoner of war. But how can McCain make those claims without looking back and recognizing that the United States mental health obligations to its Vets reaches back to Vietnam, Korea and even World War II survivors?
The issue of the brain injury disability and mental health of older Vets has countless sub-issues, but the most important for this blog is that brain injury and brain damage were not even considered in what we today call mild to moderate brain injury during Vietnam. Prior to 1990, there was little belief in the medical community that a brain injury that involved less than a five minute loss of consciousness was significant. Now we recognize, and have highly sophisticated neuroimaging and neuropsychological methodologies to confirm, that brain damage can occur without a loss of consciousness.
We often hear that our modern medical interventions result in more people surviving brain injury, because soldiers who would have died in Iraq or Afghanistan are now saved because of the rapid evac and treatment. That is true, but what is implicitly missing in such a statement is the clear fact that almost no one with a mild to moderate brain injury would die from it, regardless of whether they got prompt treatment. The realities of combat in Vietnam, and all wars that preceded it, is that a soldier on the front lines who gets knocked out, dazed or confused – is not likely to die from such injuries, unless he is killed by his inability to respond to the immediacy of the combat demands at the time.
Thus, there are probably far more vets with mild brain injuries in the Vietnam era than in the current generation of soldier and vets, but there are no medical records to document that they suffered such injuries. A soldier with a short-term confusion in that combat was likely expected to shrug it off and go back to fighting. Making matters worse, the complete catastrophe that is the Vietnam military health records makes it almost a certainty that documentation of brain injury is just not there. Further, the brain damage suffered in Vietnam is considerably broader than just brain injury because of the prevalence of Cerebral Malaria, which may have caused brain damage to hundreds of thousands of U.S. soldiers in Vietnam. See http://www.va.gov/OCA/testimony/hvac/16JY98NV.asp
Without the documentation of brain damage, what came out of Vietnam were hundreds of thousands of soldiers with clear cut neuropsychiatric symptoms in search of a diagnosis. The result: PTSD. PTSD is a Vietnam era syndrome of severe emotional problems, that are tied to some type of extreme emotional stressor, such as combat. But as with most “syndromes” the purity of its diagnostic criteria is lacking. The resulting over inclusive use of it in differential diagnosis of any emotional or neuropsychiatric symptom is staggering. At its threshold criteria, it requires life-threatening terror.
See http://en.wikipedia.org/wiki/PTSD which states the threshold requirement that “the person experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others.” The second (A2) requires that “the person’s response involved intense fear, helplessness, or horror.”
This sounds like combat, it does not sound like a rear end automobile collision. While some automobile or other accidents involve prolonged moments of terror, most do not. They are over within a few moments of beginning. I have experienced both kinds but my memory of the truly terrorizing accidents (and yes, I did have that realization that my life was about to end both times) ended abruptly at the moment of collision. Relatively few people who suffer concussions have clear enough memory of the event to be exposed to a pure PTSD terror. What most relate is a moment of surprise that an accident is about to happen and then a gap in memory.
In contrast – combat, rape, fires – involve prolonged exposure to truly terrorizing events. This is the type stressor that can actually make a hard wire change to the way the brain processes information. This is the type of stressor that can create haunting memories. This is the type of stressor that can create nightmares. Yet PTSD should never become a catchall for all emotional reactions to life changing events. The category for stressor has as its blue print combat. When there is no elongated exposure to terror, the focus should be on normal human emotional responses, not a psychiatric catchall.
Next Brain Injury is not New to Iraq
Amnesia was a Missed Marker of Brain Injury in World War I Shell Shock
In this series of blogs, we have been focusing on the synergistic interplay between the emotional problems related to combat stress and war-time brain injuries. The previous blog focused on Charles Myers’ 1915 case studies of three British soldiers injured in World War I, and what we believe to be his failure to properly factor in amnesia, loss of smell (and taste) and the neuropathological and biomechanical explanations for brain injury. See “A Contribution to the Study of Shell Shock” published in the British Medical Journal, The Lancet, on February 13, 1915. Today, we will focus on the specifics of amnesia, with the next blog relating to loss of smell and the next, the likely neuropathology of these three injuries.
Amnesia in Myers’ patients. Myers seemed completely ignorant about the nature of amnesia and its correlative symptom of confabulation. Each of his patients had hallmark examples of post-traumatic amnesia. Soldier #1’s recollection of the ambulance ride is a classic: “He thinks he must have slept on the ambulance, as he remembers nothing.” How telling that Myers initialized those words in the original, as if it was evidence for what he said needed no comment, the similarity to “hysteria?”
Soldier #2’s narrative begins with the statement: “Can remember nothing until he found himself in a dressing station at a barn lying on straw.” According to Myers’ narrative, the soldier’s description of how he got hurt is clearly contradicted by uninjured eye-witnesses.
Soldier #3’s bizarre theory that he must have been knocked into a lake is a pure example of confabulation. The soldier admitted it was something he deduced, not something he actually remembered. Myers states: “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.” What other explanation is there for such statement other than amnesia?
While 1915 is nearly 100 years ago, it still seems odd that a combat physician would not realize the significance of amnesia with respect to a diagnosis of injury to the brain. As I have often commented – there is a collective wisdom passed down through the ages with respect to the symptoms of brain injury. The most understood of those symptoms is amnesia. See my essay: The Boy who Could Not Remember, taken from an Alaskan Indian myth.
Yet, Myers ignored that wisdom and the evidence in his own detailed case notes. The result: the wrong diagnosis. Could it be that with the other innovations of modern warfare having their genesis in World War I, the horror of supplanting thousands of years of human experience with the arrogance of a “modern” diagnosis, also arose?
What has been the impact of Myers getting it wrong on Western medical thought? That is hard to measure. But his sarcastic reference to the obvious hysteria diagnosis was published in the leading medical journal of its time, The Lancet. Over the next 75 years, the culprit of a false diagnosis of “hysteria” seeps into almost all neurological diagnosis. Only by focusing on the clear cut neuropathological clues found in Myers’ detailed case studies, can this stain on neurological diagnosis be removed.
Tomorrow: This series will continue with a focus on the significance of loss of smell and taste to a modern diagnosis of brain injury. Loss of Smell was a Missed Sign of Brain Injury in World War I Shell Shock
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
Shell Shock – Then and Now – Eliminating the Stigma and Labels Key to Treatment
While this issue may in fact be prehistoric, the dilemma as to whether the radically different emotions and behaviors of the returning vet were the result of injury or psychic stress was an important theme of post World War I thought. World War I, like Vietnam, (and now our occupation of Iraq) was a war without decisive battles, where returning soldiers returned home with little thoughts of glory, and severe difficulty adapting to civilian life. As World War I and Vietnam were fought repeatedly over the same turf, there was little drama in the successes and failures in the field. There were no great battle movies like the Battle of the Bulge or Midway to come out of those conflicts. Instead, we got All Quiet on the Western Front, Apocalypse Now and The Deerhunter.
The literature of the time focused on the futility and horror of the conflict. It may be that such “treading water” kind of war results in either more psychic stress or more non-fatal closed head injury. It may be a combination of the two, but both wars resulted in a mushrooming of anti-war literature, focused on the ravages of such conflict on the minds of its veterans. In many ways, it is through listening to the voices of literature that so many diagnostic clues of what we would today diagnose as Post Concussion Syndrome, can be heard.
The literature after World War I as it pertained to “shell shock” reflected the struggle for society to accept that its brave soldiers could be “weak” enough to be haunted by the psychological horror of war. It is claimed that the British resisted such labels, instead looking for physical injuries which could explain the major change in the personality of its returning veterans.
“In order for the condition to seem more valid, the stigma of psychological disorder had to be surmounted – a significant obstacle to a society in which the mentally ill were considered outsiders. Therefore, it could not be attributed to fear or nervous breakdown due to the atrocities of war; medical experts had to assert that shell shock was caused by proximity to an exploding shell. “
See Kara S. Harton paper on The Return of the Soldier.
While French and German medical experts more easily accepted the psychological explanation, the British medical experts shifted the focus to the more tangible explanation that proximity to an exploding shell, explained the change. However, even the British fell far short of truly appreciating the brain injury that occurred as a result of those blast injuries. Tomorrow: A Closer Look at the British View of Combat Neuro-Trauma
Next World War I Literature Shows the Reluctance to Identify Brain Injury in Shell Shock Soldiers