Shell Shock to Traumatic Brain Injury: what’s changed in the last 100 years?

November 14th, 2018

Chrisanne Gordon, MD, Founder and Chair of Resurrecting Lives Foundation, and Brigadier General (Retired) Gerald Dieter Griffin, MD, PharmD, a member of the RLF Board of Advisers, presented “The Evolution of TBI Diagnosis, the Revolution of TBI Treatment” at the NATO Interallied Confederation of Medical Reserve Officers Summer Congress in August, 2018. This article is, in part, based on their presentation.

Sleeplessness. Blurry vision. Temporary loss of hearing, smell, and taste. Shivering. Loss of memory. These symptoms were exhibited by young men injured in blasts in 1914 and 1915, arising from “the effects of shell-shock,” according to Charles S. Myers, MD, Captain, Royal Army Medical Corps. Myers’ article, “A contribution to the study of shell shock,” published in the February 13, 1915 issue of The Lancet, was the first to use the term in the published medical literature.

On November 11, 2018, the world commemorates the Armistice that ended World War I, “the war to end all wars.” Over the last 100 years we have not, unfortunately, seen the end of war. We continue to see returning service members injured in horrific ways, not least of which is the often invisible wound of traumatic brain injury (TBI) or post-traumatic stress disorder (PTSD).

Injury and trauma from warfare have been documented since the early times of human history. But with the introduction of modern technological weapons during the first World War, the nature of that trauma has escalated, even while the science to diagnose those “invisible injuries” has continued to advance.

As noted by Dr. Gordon and BG (Ret.) Dr. Griffin, every conflict has its own injuries, illnesses, drugs, technologies, and reintegration policies. But survival wounds in the last century are clearly similar: “shell-shock” and traumatic war neurosis in World War I, battle fatigue in World War II, post-traumatic stress disorder in the Vietnam War, and traumatic brain injury in Operation Iraqi Freedom (OIF)/ Operation Enduring Freedom (OEF).

At the start of World War I, shelling and shrapnel brought a huge increase in head injuries to soldiers in the trenches. Said Britain’s The Illustrated War News on November 17, 1915, “Head-wounds have been more than usually numerous during the war, owing to the trench-fighting, and more than usually severe, owing to the extensive use of shrapnel. … Our Army has now followed the French by adopting steel helmets, calculated to stop shell-splinters and shrapnel. Even in cases of extreme risk, not only has death been avoided, but injuries have been confined to bruises or superficial wounds.”

This was an optimistic statement so early in the war. But officials were shocked and stymied by the head wounds. Initially thought to be physical injuries, or “commotional,” due to the commotion rocking the brain in the cranium, British soldiers who experienced these wounds received a uniform “wound stripe,” and eventually a war pension. But the symptoms – including trembling, headaches, tinnitus, confusion, dizziness, and sleep disturbances – started appearing in military members who were not directly in the line of the blasts. The diagnosis soon became a psychological one: neurasthenia, or a “nervous breakdown.” Removing the physical diagnosis in place of a psychological one meant the soldier received no “wound stripe,” no rehabilitation leave… and no war pension. The debate over whether “shell shock” was physical or psychological (or even both) continued for decades.

Therapy for those who survived head wounds ranged from rest, quiet, and nutrition, to the extremes of electro-therapy, and rehabilitation near the front, so that the recovering soldier could reacclimate to the environment of warfare.

Dr. Myers concluded that the symptoms he wrote about in the 1915 Lancet article cited above were likely due to hysteria. But soldiers who witnessed the damage of explosions knew that physical or psychological, the damage was real. Of the First Battle of Ypres, Lt. B. H. Waddy wrote in 1914, “My first bullets frightened me, while my first shells did not; but with the evidence now before my eyes that the latter possessed invisible powers of destruction as well as visible, there was born in me a fear, a hatred of shellfire stronger than any other I have ever experienced.” “B.H.Waddy: Survivor’s account of 2 battles,” by Waddy, Bentley Herbert. The Great War Archive, University of Oxford / Primary Contributor via First World War Poetry Digital Archive, accessed November 10, 2018, http://www.oucs.ox.ac.uk/ww1lit/gwa/document/8697.

Study of war trauma continued through the 20th century’s conflicts in World War II, the Korean War, and the Vietnam War. Psychological injuries, long-lasting post-concussive trauma, and PTSD have all gained the legitimacy of diagnosis; we continue to understand more and more about TBI.

Now, 100 years post-Armistice, over 3.7 million service personnel have been deployed to the war zone in Iraq and Afghanistan, many with multiple deployments. TBI has been estimated in nearly 20% of the veterans returning from Iraq and Afghanistan, and an estimated 30% have PTSD. And we now understand that most military-related TBI comes from blast exposure.

Due to the evolution of military technology, blasts and artillery cause exponentially more damage than in 1918. But also due to scientific advances and the evolution of scientific research, we can now identify changes in brain physiology at a cellular level; due to the evolution of newer diagnostic techniques, especially neuroradiology studies, we can now even look inside the brain.

Through the early 1970s, our diagnostic procedure for head wounds was largely the x-ray. Advances in computer science and medicine during the end of the 20th century brought us lightyears forward through various imaging techniques, including diffusion tensor imaging (DTI), which lets us see nerve tracts and the brain; neuroradiology now enables us to map the brain. RLF is proud to have supported the DTI research conducted under Michael L. Lipton, MD, PhD, at Albert Einstein College of Medicine, contributing to the body of evidence proving that blast waves themselves are a source of TBI in military personnel.

Today, devices the size of cell phones enable scans for TBI in combat, thus enabling treatment as quickly as possible. This evolution of diagnostics has given way to a revolution of treatment for brain specific injuries.

Biomarkers, or biological substances that can act as clues in the body, are being developed to detect the presence of TBI. Treatment in the immediate phase after TBI now provides damage control through procedures like immune therapy, temperature and volume therapies, and aggressive symptomatic care for the trauma of TBI. PTSD therapies include “exposure” therapy, or repeated exposure to the conditions of the event which caused the trauma to begin with – much like those WWI solders rehabilitating near the front – to cognitive therapy and psychopharmaceuticals. Mindfulness training, including meditation, is gaining ground as a positive and non-invasive means to recovery. Rehabilitation delivered through virtual reality, as the fledgling company Gray Matter Innovations focuses on, complements these approaches.

Progress in science and medicine since Armistice Day, 1918, has enabled a generation of brain-injured warriors to recover from an injury that only tens of years ago was thought not to be an injury at all. Still, not all those who suffer from TBI or PTSD have been diagnosed – the first step in recovery – and prompt diagnosis is best, since both TBI and PTSD are now wounds that can be healed.

RLF honors all military service members who put their lives on the line for our freedoms, and we advocate for continued advances in diagnosis and treatment for these invisible injuries – as well as for prevention of TBI with peace and understanding among all nations.