Posted on 17th June 2008 by Gordon Johnson in Brain Injury
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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.
Posted on 16th June 2008 by Gordon Johnson in Brain Injury
brain injury, brain injury attorney, head injury, head injury attorney, Iraq war brain injuries, world war I and Brain injury
Previous blogs in this series have focused on the contrast between the quality of the meticulous description of history and symptoms 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. Yesterday’s blog focused on how he documented, but didn’t find significant the loss of taste and smell. This blog will focus on the biomechanical clues to the proper diagnosis, found in Myers’ detailed descriptions.
According to Myers’ Soldier#1 was injured when he was surrounded by exploding shells, while he was caught in barbed wire. Soldier #2 was injured when the trench that he was taking cover in was imploded by an exploding shell and Patient #3 was injured when he was knocked 15 feet off a pile of bricks, by another shell. What could clearly have accounted for Myers’ misdiagnosis in these three cases studies was absence of evidence of a clear blow to the head from a shell in any of the above case studies. As is shown by other British research at the time, the head injury focus was with soldiers who suffered skull facture.
It is now a known medical fact, that a direct blow to the head is not necessary for the brain to be injured in a traumatic event. Known mechanisms of brain damage could have occurred to all three of these soldiers. Those mechanisms include blast phenomenon, indirect blows to the head from either falls or flying objects, and acceleration/deceleration injuries.
Blast Injury. When an explosion occurs, shock waves are generated that can penetrate the human body. Such shock waves can directly injure the brain and/or force the brain into the skull, injuring the brain as a result of such collision. For an illustration of the force of a blast, see the below picture of the displacement occurring to a battleship when its guns are firing. Blast injury can injure, not just at the receiving end of the blast, but also at the firing end. One historic perspective of military medicine is that sailors who fired guns below deck, would over time show evidence of shell shock and dementia. See http://www.research.va.gov/news/features/blasts.cfm for research as to the direct effect of blast force waves on the brain. All three of Myers’ soldiers could have been injured by shock waves directly from the blast.
Indirect Blows to the Head. The perfect example of an indirect blow to the head in Myers story is Soldier #3 who was knocked down from a height of 15 feet by the force of the blast. In the fall, such soldier clearly could have hit his head. Similarly, at the time that Soldier #2’s trench imploded on him, he could have been either knocked to the ground (striking his head) or some portion of the trench, or some object within it, could have hit him the head. While there is no direct details of a fall or a flying object in Soldier #1’s case study, such could also have occurred. A fall – especially one propelled by a blast – is one of the clearest understood mechanisms of injury. Not only is the force of the body being rapidly transferred to the head at the time of the fall, but the brain bounces inside the skull in reaction of the striking of the head.
In a slightly different mechanism, the force of a flying object is transferred to the brain, through the mechanism of a force wave, when the head is hit by an object. There is no way a rational analysis of what happened to these three soldiers could have ruled out a mechanism of injury from an indirect blow to the head. Clearly, Myers’ didn’t believe that any such blows to the head were sufficient to leave any substantial injury to the brain.
Acceleration/Deceleration Injury to the Brain. Without a doubt, all three of these soldiers head and necks were exposed to severe whiplash forces. Even without a blow to the head, such forces would be sufficient to injure the brain. Such injury can occur through at least two mechanisms: the collision between the brain and the skull or through the mechanism of diffuse axonal injury.
In a whiplash mechanism, especially one where a soldier is knocked down or falls, the brain and skull are accelerated at different speeds. When such occurs, there is a collision between the brain and the skull. See
In a diffuse axonal injury, it is not just that the brain is moving at relatively different speeds than the skull, but that different layers of the brain, are moving at different speeds from each other. This occurs because all human acceleration is angular, not linear. This means that rather than going in a straight line, the brain matter rotates on the radius of a circle. Layers of the brain have different densities and different distances from the fulcrum of the acceleration. This means that there is significant torque between these different parts of the brain.
Axons are long are microscopically thin connective portions of neurons, that span across these different layers of density and rotations. At the points of the greatest internal differential acceleration, forces can be sufficient to begin to stretch and tear the axons. For more information on Diffuse axonal injury, see http://subtlebraininjury.com/
One side note, in addition to these three potential mechanisms of injury, Soldier #2 could have suffered a hypoxic injury as a result of being buried in the trench. Hypoxia is when the brain or other organ, doesn’t get enough oxygen or blood flow to sustain itself. It is possible he did not receive enough oxygen during such period, resulting in brain damage.
It is odd that Myers would not have appreciated the potential for injury in the fall mechanism, especially with Soldier #3. But he can certainly not be criticized for his failure to recognize the potential for other injuries occurring without a direct impact to the head. Yet that flaw, whether excusable or not, makes his conclusion with respect to hysteria, completely dismissible. It is essential that current brain injury diagnosis exercise any lingering use of the hysterical or conversion diagnosis.
In our next part, we will look at the emotional issues that existed both before and after the injuries to these soldiers, and the role the wrong diagnosis, over emphasized the role of pre-injury emotional factors.
Next Hysteria or Conversion Diagnosis
Posted on 13th June 2008 by Gordon Johnson in Brain Injury
brain damage, brain injury, brain injury attorney, brain injury lawyer, head injury, Iraq war brain injuries, Shell Shock, world war I and Brain injury
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
Posted on 12th June 2008 by Gordon Johnson in Brain Injury
amnesia, brain injury, brain injury attorney, brain injury lawyer, Iraq war brain injuries, Post Traumatic Amnesia, Vietnam and Brain Injury, world war I and Brain injury
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
Posted on 11th June 2008 by Gordon Johnson in Brain Injury
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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:
“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.
Posted on 10th June 2008 by Gordon Johnson in Brain Injury
brain injury, coma, head injury, Iraq war brain injuries, Shell Shock, Vietnam and Brain Injury, world war I and Brain injury
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
Posted on 9th June 2008 by Gordon Johnson in Brain Injury
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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
