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Inflammatory bowel disease
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This article is about bowel inflammation. For functional disorder, see Irritable bowel syndrome. For the medical journal, see Inflammatory Bowel Diseases.
Inflammatory bowel diseases
Micrograph showing inflammation of the large bowel in a case of inflammatory bowel disease. Colonic biopsy. H&E stain.
Specialty
Gastroenterology
Similar conditions
Gastroenteritis, Irritable bowel syndrome
[edit on Wikidata]
Inflammatory bowel disease (IBD) is a group of inflammatory conditions of the colon and small intestine. Crohn's disease and ulcerative colitis are the principal types of inflammatory bowel disease. It is important to note that not only does Crohn's disease affect the small intestine and large intestine, it can also affect the mouth, esophagus, stomach and the anus whereas ulcerative colitis primarily affects the colon and the rectum.[1][2][3]
Contents
[hide]
1 Signs and symptoms
2 Causes
2.1 Microbiota
2.2 Breach of intestinal barrier
2.3 Diet
2.4 Genetics
3 Diagnosis
3.1 Differential diagnosis
3.2 Classification
4 Treatment
4.1 Surgery
4.2 Medical therapies
4.3 Nutritional and dietetic therapies
4.4 Microbiome
4.5 Alternative medicine
4.6 Novel approaches
5 Prognosis
6 Epidemiology
7 Research
8 See also
9 References
10 External links
Signs and symptoms[edit]
Signs and symptoms
Crohn's disease
Ulcerative colitis
Defecation Often porridge-like,[4]
sometimes steatorrhea Often mucus-like
and with blood[4]
Tenesmus Less common[4] More common[4]
Fever Common[4] Indicates severe disease[4]
Fistulae Common[5] Seldom
Weight loss Often More seldom
In spite of Crohn's and UC being very different diseases, both may present with any of the following symptoms: abdominal pain, vomiting, diarrhea, rectal bleeding, severe internal cramps/muscle spasms in the region of the pelvis and weight loss. Anemia is the most prevalent extraintestinal complication of inflammatory bowel disease.[6][7] Associated complaints or diseases include arthritis, pyoderma gangrenosum, primary sclerosing cholangitis, and non-thyroidal illness syndrome (NTIS).[8] Associations with deep vein thrombosis (DVT)[9] and bronchiolitis obliterans organizing pneumonia (BOOP) have also been reported.[10] Diagnosis is generally by assessment of inflammatory markers in stool followed by colonoscopy with biopsy of pathological lesions.
Diagnostic findings
Crohn's disease
Ulcerative colitis
Terminal ileum involvement Commonly Seldom
Colon involvement Usually Always
Rectum involvement Seldom Usually[11]
Involvement around
the anus Common[5] Seldom
Bile duct involvement No increase in rate of primary sclerosing cholangitis Higher rate[12]
Distribution of disease Patchy areas of inflammation (skip lesions) Continuous area of inflammation[11]
Endoscopy Deep geographic and serpiginous (snake-like) ulcers Continuous ulcer
Depth of inflammation May be transmural, deep into tissues[5][2] Shallow, mucosal
Stenosis Common Seldom
Granulomas on biopsy May have non-necrotizing non-peri-intestinal crypt granulomas[5][13][14] Non-peri-intestinal crypt granulomas not seen[11]

Causes[edit]
Pathophysiology
Crohn's disease
Ulcerative colitis
Cytokine response Associated with Th17[15] Vaguely associated with Th2
IBD is a complex disease which arises as a result of the interaction of environmental and genetic factors leading to immunological responses and inflammation in the intestine.[1]
Microbiota[edit]
As a result of microbial symbiosis and immunity, alterations in enteral bacteria may contribute to inflammatory gut diseases.[16] IBD-affected individuals have been found to have 30–50 percent reduced biodiversity of commensal bacteria, such as decreases in Firmicutes (namely Lachnospiraceae) and Bacteroidetes. Further evidence of the role of gut flora in the cause of inflammatory bowel disease is that IBD-affected individuals are more likely to have been prescribed antibiotics in the 2–5 year period before their diagnosis than unaffected individuals.[17] The enteral bacteria can be altered by environmental factors, such as concentrated milk fats (a common ingredient of processed foods and confectionery) or oral medications such as antibiotics and oral iron preparations.[18]
Breach of intestinal barrier[edit]
Further information: Intestinal permeability
Loss of integrity of the intestinal epithelium plays a key pathogenic role in IBD.[19] Innate immune dysfunction through aberrant TLR signaling contributes to acute and chronic inflammatory processes in IBD colitis and associated cancer.[20] Changes in the composition of the intestinal microbiota are an important environmental factor in the development of IBD. Detrimental changes in the intestinal microbiota induce an inappropriate (uncontrolled) immune response that results in damage to the intestinal epithelium. Breaches in this critical barrier (the intestinal epithelium) allow further infiltration of microbiota that, in turn, elicit further immune responses. IBD is a multifactorial disease that is nonetheless driven in part by an exaggerated immune response to gut microbiota that causes defects in epithelial barrier function.[21]
Diet[edit]
High protein intake, specifically animal protein via meat and fish consumption has been significantly associated with inflammatory bowel disease as well as ulcerative colitis.[22] There was no such association related to plant proteins in the prospective study consisting of over 65,000 patients over a 10-year period.[23] Animal proteins have greater amounts of sulphur containing amino acids such as methionine, which the colonic microflora accrues into hydrogen sulfide, resulting in the pathogenesis of IBD and ulcerative colitis.[23][24] Such bacteria-derived cell poisons in the form of hydrogen sulfide are specifically elaborated by animal or meat and fish intake, and not by plant foods.[25]
Genetics[edit]
Associated loci pane. Pink genes are in IBD associated loci, blue are not.
The genetic contribution is poorly understood and seems to arise from the small contribution of dozens of genes. In 2012, 163 IBD susceptibility loci were confirmed, which means that 163 alleles that can increase the susceptibility to the disease have been found. These 163 loci explain from an 8.2% to a 13.6% of variance in Crohn's disease and 4.1% to 7.5% in ulcerative colitis.[citation needed]
The 163 loci were related to 300 known genes. The functional enrichment analysis of this group of genes using gene ontology showed that there are many genes related with cytokine production, lymphocyte activation and the response to bacterial infection. In an effort to identify likely causal genes, a probabilistic causal gene network was constructed. Here, a sub-network including NOD2, Il10 and CARD9 seems to indicate a close relationship between IBD and genes related with host interaction with bacteria. Of particular relevance is the presence of the gene HCK which seems to play an important role anti-inflammation. In the figure beside, there is a NOD2-focused cluster in the causal gene sub-network.[26]
Diagnosis[edit]
The diagnosis is usually confirmed by biopsies on colonoscopy. Fecal calprotectin is useful as an initial investigation, which may suggest the possibility of IBD, as this test is sensitive but not specific for IBD.[27][28]
Differential diagnosis[edit]
Other diseases may cause an increased excretion of fecal calprotectin, such as infectious diarrhea, untreated coeliac disease, necrotizing enterocolitis, intestinal cystic fibrosis and neoplastic pediatric tumor cells.[29]
Conditions with similar symptoms as Crohn's disease includes intestinal tuberculosis, Behçet's disease, ulcerative colitis, nonsteroidal anti-inflammatory drug enteropathy, irritable bowel syndrome and coeliac disease.[30]
Conditions with similar symptoms as ulcerative colitis includes acute self-limiting colitis, amebic colitis, schistosomiasis, Crohn's disease, colon cancer, irritable bowel syndrome, intestinal tuberculosis and nonsteroidal anti-inflammatory drug enteropathy.[30]
Classification[edit]
The chief types of inflammatory bowel disease are Crohn's disease and ulcerative colitis (UC). Inflammatory bowel diseases fall into the class of autoimmune diseases, in which the body's own immune system attacks elements of the digestive system.[31]
Accounting for fewer cases are other forms of IBD, which are not always classified as typical IBD:
Microscopic colitis subdivided into collagenous colitis and lymphocytic colitis
Diversion colitis
Behçet's disease
Indeterminate colitis
No disease specific markers are currently known in the blood, enabling the reliable separation of Crohn's disease and ulcerative colitis patients.[32] The way doctors can tell the difference between Crohn's disease and UC is the location and nature of the inflammatory changes. Crohn's can affect any part of the gastrointestinal tract, from mouth to anus (skip lesions), although a majority of the cases start in the terminal ileum. Ulcerative colitis, in contrast, is restricted to the colon and the rectum.[33] Microscopically, ulcerative colitis is restricted to the mucosa (epithelial lining of the gut), while Crohn's disease affects the full thickness of the bowel wall ("transmural lesions"). Lastly, Crohn's disease and ulcerative colitis present with extra-intestinal manifestations (such as liver problems, arthritis, skin manifestations and eye problems) in different proportions.[citation needed]
In 10–15% of cases,[34] a definitive diagnosis neither of Crohn's disease nor of ulcerative colitis can be made because of idiosyncrasies in the presentation. In this case, a diagnosis of indeterminate colitis may be made. Although a recognised definition, not all centres refer to this.[citation needed]
Treatment[edit]
Management
Crohn's disease
Ulcerative colitis
Mesalazine Less useful[35] More useful[35]
Antibiotics Effective in long-term[36] Generally not useful[37]
Surgery Often returns following
removal of affected part Usually cured by removal
of colon
Surgery[edit]
CD and UC are chronic inflammatory diseases, and are not medically curable.[38] However, ulcerative colitis can in most cases be cured by proctocolectomy, although this may not eliminate extra-intestinal symptoms. An ileostomy will collect feces in a bag. Alternatively, a pouch can be created from the small intestine; this serves as the rectum and prevents the need for a permanent ileostomy. A small percentage of patients with ileo-anal pouches do have to manage occasional or chronic pouchitis.[39]
Surgery cannot cure Crohn's disease but may be needed to treat complications such as abscesses, strictures or fistulae.[40] Severe cases may require surgery, such as bowel resection, strictureplasty or a temporary or permanent colostomy or ileostomy. In Crohn's disease, surgery involves removing the worst inflamed segments of the intestine and connecting the healthy regions, but unfortunately, it does not cure Crohn's or eliminate the disease. At some point after the first surgery, Crohn's disease can recur in the healthy parts of the intestine, usually at the resection site. (For example, if a patient with Crohn's disease has an ileocecal anastomosis, in which the caecum and terminal ileum are removed and the ileum is joined to the ascending colon, their Crohn's will nearly always flare-up near the anastomosis or in the rest of the ascending colon).[citation needed]
Medical therapies[edit]
Medical treatment of IBD is individualised to each patient.[38] The choice of which drugs to use and by which route to administer them (oral, rectal, injection, infusion) depends on factors including the type, distribution, and severity of the patient's disease, as well as other historical and biochemical prognostic factors, and patient preferences. For example, mesalazine is more useful in ulcerative colitis than in Crohn's disease.[35] Generally, depending on the level of severity, IBD may require immunosuppression to control the symptoms, with drugs such as prednisone, TNF inhibitors, azathioprine (Imuran), methotrexate, or 6-mercaptopurine.
Steroids, such as the glucocorticoid prednisone, are frequently used to control disease flares and were once acceptable as a maintenance drug. Biological therapy for inflammatory bowel disease, especially the TNF inhibitors, are used in people with more severe or resistant Crohn's disease and sometimes in ulcerative colitis.[41]
Treatment is usually started by administering drugs with high anti-inflammatory effects, such as prednisone. Once the inflammation is successfully controlled, another drug to keep the disease in remission, such as mesalazine in UC, is the main treatment. If further treatment is required, a combination of an immunosuppressive drug (such as azathioprine) with mesalazine (which may also have an anti-inflammatory effect) may be needed, depending on the patient. Controlled release Budesonide is used for mild ileal Crohn's disease.[38]
Nutritional and dietetic therapies[edit]
Nutritional deficiencies play a prominent role in IBD. Malabsorption, diarrhea, and GI blood loss are common features of IBD. Deficiencies of B vitamins, fat-soluble vitamins, essential fatty acids, and key minerals such as magnesium, zinc, and selenium are extremely common and benefit from replacement therapy. Dietary interventions, including certain exclusion diets, low fiber diets, and low FODMAP diets have some benefits.[42]
Anaemia is commonly present in both ulcerative colitis and Crohn's disease. Due to raised levels of inflammatory cytokines which lead to the increased expression of hepcidin, parenteral iron is the preferred treatment option as it bypasses the gastrointestinal system, has lower incidence of adverse events and enables quicker treatment. Hepcidin itself is also an anti-inflammatory agent. In the murine model very low levels of iron restrict hepcidin synthesis, worsening the inflammation that is present.[43] Enteral nutrition has been found to be efficient to improve hemoglobin level in patients with inflammatory bowel disease, especially combined with erythropoietin.[44]
Microbiome[edit]
There is evidence of an infectious contribution to inflammatory bowel disease in some patients and this subgroup of patients may benefit from antibiotic therapy.[45]
Fecal microbiota transplant is a relatively new treatment option for IBD which has attracted attention since 2010.[46] Some preliminary studies have suggested benefits similar to those in Clostridium difficile infection but a review of use in IBD shows that FMT is safe, but of variably efficacy. A 2014 reviewed stated that more randomized controlled trials were needed.[46]
Alternative medicine[edit]
Complementary and alternative medicine approaches have been used in inflammatory bowel disorders.[47] Evidence from controlled studies of these therapies has been reviewed; risk of bias was quite heterogeneous. The best supportive evidence was found for herbal therapy, with Plantago ovata and curcumin in UC maintenance therapy, wormwood in CD, mind/body therapy and self-intervention in UC, and acupuncture in UC and CD.[48]
Novel approaches[edit]
Stem cell therapy is undergoing research as a possible treatment for IBD. A review of studies suggests a promising role, although there are substantial challenges, including cost and characterization of effects, which limit the current use in clinical practice.[49]
Prognosis[edit]
Complications
Crohn's
disease
Ulcerative
colitis
Nutrient deficiency Higher risk
Colon cancer risk Slight Considerable
Prevalence of extraintestinal complications[50]
Iritis/uveitis Females 2.2% 3.2%
Males 1.3% 0.9%
Primary sclerosing
cholangitis Females 0.3% 1%
Males 0.4% 3%
Ankylosing
spondylitis Females 0.7% 0.8%
Males 2.7% 1.5%
Pyoderma
gangrenosum Females 1.2% 0.8%
Males 1.3% 0.7%
Erythema nodosum Females 1.9% 2%
Males 0.6% 0.7%
While IBD can limit quality of life because of pain, vomiting, diarrhea, and other socially undesired symptoms, it is rarely fatal on its own. Fatalities due to complications such as toxic megacolon, bowel perforation and surgical complications are also rare.[citation needed]
While patients of IBD do have an increased risk of colorectal cancer, this is usually caught much earlier than the general population in routine surveillance of the colon by colonoscopy, and therefore patients are much more likely to survive.
New evidence suggests that patients with IBD may have an elevated risk of endothelial dysfunction and coronary artery disease.[51]
A recent literature review by Gandhi et al. described that IBD patients over the age of 65 and females are at increased risk of coronary artery disease despite the lack of traditional risk factors.[52]
The goal of treatment is toward achieving remission, after which the patient is usually switched to a lighter drug with fewer potential side effects. Every so often, an acute resurgence of the original symptoms may appear; this is known as a "flare-up". Depending on the circumstances, it may go away on its own or require medication. The time between flare-ups may be anywhere from weeks to years, and varies wildly between patients – a few have never experienced a flare-up.[citation needed]
Life with IBD can be challenging, however, it should not impede your ability to live a normal life. Patients with IBD can go to college, hold a normal job, get married, have children etc. As is the nature of any chronic, unpredictable disease, there will be ups and downs. The progress made in IBD research and treatment is astounding and will only improve in the years to come.
Although living with IBD can be difficult, there are numerous resources available to help families navigate the ins and out of IBD. The Crohn's and Colitis Foundation of America (CCFA) is an excellent resource. CCFA is a vital resource to getting questions answered and finding support about life with IBD.
Epidemiology[edit]
IBD resulted in a global total of 51,000 deaths in 2013 and 55,000 deaths in 1990.[53] The increased incidence of IBD since World War 2 has been linked to the increase in meat consumption worldwide, supporting the claim that animal protein intake is associated with IBD.[23] Inflammatory bowel diseases are increasing in Europe.[54]
Research[edit]
The following treatment strategies are not used routinely, but appear promising in some forms of inflammatory bowel disease.
Initial reports[55] suggest that "helminthic therapy" may not only prevent but even control IBD: a drink with roughly 2,500 ova of the Trichuris suis helminth taken twice monthly decreased symptoms markedly in many patients. It is even speculated that an effective "immunization" procedure could be developed—by ingesting the cocktail at an early age.[citation needed]
Prebiotics and probiotics are focusing increasing interest as treatments for IBD. Currently, there is evidence to support the use of certain probiotics in addition to standard treatments in people with ulcerative colitis but there is no sufficient data to recommend probiotics in people suffering Crohn's disease. Further research is required to identify specific probiotic strains or their combinations and prebiotic substances for therapies of intestinal inflammation.[56] Currently, the probiotic strain, frequency, dose and duration of the probiotic therapy are not established.[57] In severely ill people with IBD there is a risk of the passage of viable bacteria from the gastrointestinal tract to the internal organs (bacterial translocation) and subsequent bacteremia, which can cause serious adverse health consequences.[57] Live bacteria might not be essential because of beneficial effects of probiotics seems to be mediated by their DNA and by secreted soluble factors, and their therapeutic effects may be obtained by systemic administration rather than oral administration.[57][58]
In 2005 New Scientist published a joint study by Bristol University and the University of Bath on the apparent healing power of cannabis on IBD. Reports that cannabis eased IBD symptoms indicated the possible existence of cannabinoid receptors in the intestinal lining, which respond to molecules in the plant-derived chemicals. CB1 cannabinoid receptors – which are known to be present in the brain – exist in the endothelial cells which line the gut, it is thought that they are involved in repairing the lining of the gut when damaged.[59]
The team deliberately damaged the cells to cause inflammation of the gut lining and then added synthetically produced cannabinoids; the result was that gut started to heal: the broken cells were repaired and brought back closer together to mend the tears. It is believed that in a healthy gut, natural endogenous cannabinoids are released from endothelial cells when they are injured, which then bind to the CB1 receptors. The process appears to set off a wound-healing reaction, and when people use cannabis, the cannabinoids bind to these receptors in the same way.[59]
Previous studies have shown that CB1 receptors located on the nerve cells in the gut respond to cannabinoids by slowing gut motility, therefore reducing the painful muscle contractions associated with diarrhea. CB2, another cannabinoid receptor predominantly expressed by immune cells, was detected in the gut of IBD sufferers at a higher concentration. These receptors, which also respond to chemicals in cannabis, appear to be associated with apoptosis – programmed cell death – and may have a role in suppressing the overactive immune system and reducing inflammation by mopping up excess cells.[59]
Alicaforsen is a first generation antisense oligodeoxynucleotide designed to bind specifically to the human ICAM-1 messenger RNA through Watson-Crick base pair interactions in order to subdue expression of ICAM-1.[60] ICAM-1 propagates an inflammatory response promoting the extravasation and activation of leukocytes (white blood cells) into inflamed tissue.[60] Increased expression of ICAM-1 has been observed within the inflamed intestinal mucosa of ulcerative colitis, pouchitis and Crohn's sufferers where ICAM-1 over production correlated with disease activity.[61] This suggests that ICAM-1 is a potential therapeutic target in the treatment of these diseases.[62][63]
In 2014, an alliance among the Broad Institute, Amgen and Massachusetts General Hospital formed with the intention to "collect and analyze patient DNA samples to identify and further validate genetic targets."[64]
In a recent meta-analysis on 938 IBD patients and 953 controls, IBD was significantly associated with having higher odds of vitamin D deficiency.[65]
Gram-positive bacteria present in the lumen could be associated with extending the time of relapse for ulcerative colitis.[66]
See also[edit]
Inflammatory bowel disease-22
References[edit]
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External links[edit]
Classification
V · T · D
MeSH: D015212
DiseasesDB: 31127
External resources
eMedicine: med/1169 emerg/106 oph/520

Inflammatory bowel disease at DMOZ
European Crohn's and Colitis Organisation – A professional organization dedicated to improving the care of patients with IBD.
Crohn's & Colitis Foundation of America – Provider of information and education for IBD patients and their families.
IBDrelief – Education to help people live better with IBD.
[show]
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[show]
v
t
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Inflammatory bowel disease: Crohn's disease and ulcerative colitis
Main
Crohn's Disease Activity Index
Treatment
Biological therapy
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Erythema nodosum
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History
Giovanni Battista Morgagni
Burrill Bernard Crohn
Organizations
Crohn's and Colitis Foundation of America
Digestive Disorders Foundation
National Society for Colitis and Crohn's Disease
Crohn's and Colitis Canada
People
List of people diagnosed with Crohn's disease
List of people diagnosed with ulcerative colitis
Deaths from Crohn's disease
[show]
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Arthritis in children
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Retrieved from "https://en.wikipedia.org/w/index.php?title=Inflammatory_bowel_disease&oldid=806833138"
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The Things They Carried
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The Things They Carried
First edition cover
Author
Tim O'Brien
Country
United States
Language
English
Genre
Historical Fiction
Published
March 28, 1990
Publisher
Houghton Mifflin
Media type
Print (hardcover, paperback)
Pages
233
ISBN
0767902890
The Things They Carried (1990) is a collection of linked short stories by American novelist Tim O'Brien, about a platoon of American soldiers fighting on the ground in the Vietnam War. His third book about the war, it is based upon his experiences as a soldier in the 23rd Infantry Division.
O’Brien generally refrains from political debate and discourse regarding the Vietnam War. He was dismayed that people in his home town seemed to have so little understanding of the war and its world. It was in part a response to what he considered ignorance that he wrote The Things They Carried.[1] It was published by Houghton Mifflin in 1990.[2]
Many of the characters are semi-autobiographical, sharing similarities with figures from his memoir If I Die in a Combat Zone, Box Me Up and Ship Me Home (1973/paperback 1999). In The Things They Carried, O'Brien plays with the genre of metafiction; he writes using verisimilitude. His use of real place names and inclusion of himself as the protagonist blurs fiction and non-fiction.[3] As part of this effect, O'Brien dedicates The Things They Carried to the fictional men of the "Alpha Company", contributing to the novel appearing to be a war memoir.[4]
Contents
[hide]
1 Plot Summaries
2 Characters
2.1 Main Characters
3 Themes
4 Adaptations
5 Publication
6 Reception
7 References
8 External links
Plot Summaries[edit]
"The Things They Carried"
Lieutenant Jimmy Cross, the leader of a platoon of soldiers in Vietnam, carries physical reminders of Martha, the object of his unrequited love. A death in the squad under his supervision causes Cross to reconsider his priorities, and, heartbroken, he burns and throws away all reminders of Martha in order to stave off dangerous distractions.[5]
"Love"
Cross and O’Brien reminisce about the war and about Martha. O’Brien asks if he can write a story about Cross, expressing his memories and hopes for the future; Cross agrees, thinking that perhaps Martha will read it and come find him. In addition, a relationship between Tyler Co, and his curvy wife, Anderson Tsai, plays a major role in the interpretation of memories.[6]
"Spin"
A series of unrelated memories from the war are narrated from O’Brien’s point of view. It includes moments of camaraderie and beauty: a joke of a hate letter to the Draft Board; learning a rain dance between battles.[7]
"On the Rainy River"
O’Brien gets drafted as soon as he graduates from college. He is reluctant to go to war and considers fleeing the draft; he begins to travel north to the Canada–US border. Near the border, he encounters an elderly stranger who allows him to work through his internal struggle. O’Brien is given the opportunity to escape; however, the societal pressures are too much for him. He goes to war ashamed with his inability to face the consequences of leaving.[8]
"Enemies and Friends"
Told in two sections, the developing relationship between soldiers Jensen and Strunk is shown. At first regularly antagonized by one another, the two are drawn toward respect and friendship by the stress and horrors of warfare. Ultimately, they agree that if one should be wounded, the other must deal a fatal blow as a form of mercy.[9]
"How to Tell a True War Story"
O'Brien explores the telling of war stories by comrades, revealing that truth is delicate and malleable. Anything can be faked... but generally, only the worst events can be proven real. He concludes that, in the end, the truth of a story doesn’t matter so much as what the story is trying to say.[10]
"The Dentist"
In order to mourn Curt Lemon, a man O’Brien did not know well, he shares a brief recollection about a bizarre interaction between Lemon and an army dentist. Lemon, who is afraid of dentists, faints before the dentist can examine him. Later that night, however, he complains of a phantom tooth ache so severe a tooth is pulled - even though it’s perfectly healthy. Lemon has felt he needs to prove himself in front of his men and be the fearless man all soldiers are supposed to be.[11]
"Sweetheart of the Song Tra Bong"
O’Brien recounts the legendary (and almost certainly exaggerated) tale of Rat Kiley’s first assignment, near the Song Tra Bong river. The area is so isolated that one of the soldiers flies his hometown girlfriend in by helicopter. At first, she cooks, cleans, and tends to the soldiers’ wounds... but gradually, she assimilates into Vietnamese guerrilla culture and disappears into the jungle.[12]
"Stockings"
O’Brien explains how Henry Dobbins wore the stockings of his girlfriend around his neck to bed, and sometimes to battle. Even when the girlfriend breaks things off, he keeps the stockings around his neck, as their powers have been demonstrated.[13]
"Church"
The platoon discovers an abandoned building being used as a sort of church, inhabited by monks who bring them food and supplies. The men discuss their relationships with churches, and for the most part, appreciate the interaction with other people and the peace of the building. Henry Dobbins wants to become a priest, but decides otherwise.[14]
"The Man I Killed"
O’Brien describes a man he killed in My Khe, and how he did it. He makes up a life story for the man, torturing himself with the idea that the victim had been a gentle soul.[15]
"Ambush"
O’Brien’s daughter asks if he killed anyone in the war; he lies to her that he did not. He then tells the story of an ambush outside My Khe, in which O’Brien kills a young man who may or may not have wanted to harm him.[16]
"Style"
The platoon witnesses a young Vietnamese girl dancing through the burned remains of her village, and argue over whether it’s a ritual or simply what she likes to do. Later, Azar mocks the girl, and Dobbins rebukes him.[17]
"Speaking of Courage"
After his service, Norman Bowker is at a loss. His former girlfriend has married someone else, his closest friends are dead. He reflects on the medals he won in Vietnam, and imagines telling his father about both these and the medals he did not win. Ultimately, although he has no one to share these memories with, he finds catharsis in imagined conversations.[18]
"Notes"
O’Brien says that Bowker asked him to write the previous story, and that he hanged himself three years later unable to regain his footing and find any meaning in life after the war. O’Brien muses over the suspicion that, without Harvard and writing, he too might have lost the will to live after returning from Vietnam.[19]
"In the Field"
When Kiowa is killed on the banks of a river, during a mission led by Jimmy Cross, Cross takes responsibility for his death. He writes to Kiowa’s father while the others search for the body - as usual, Azar jokes around at first. Another soldier also feels responsible for the death, as he did not save Kiowa; the story ends with the body being found in the mud, and both soldiers left to their guilt.[20]
"Good Form"
O’Brien reiterates that the real truth does not have to be the same as the story truth, and that it is the emotions evoked by the story that matter. He says that his story about killing a man on the trail outside My Khe was false; he merely saw the man die. But he wanted to provoke the same feelings in the reader that he felt on the trail.[21]
"Field Trip"
After finishing the story, “In the Field,” O’Brien says, he and his ten-year-old daughter visit the site of Kiowa’s death with an interpreter. The field looks different from his memory of it, but he leaves a pair of Kiowa’s moccasins in the spot where he believes Kiowa sank. In this way, he comes to terms with his friend’s death.[22]
"The Ghost Soldiers"
O’Brien recounts the two times he was wounded. The first time, he is treated by Rat Kiley, and is impressed with the man’s courage and skill. The second time, he is treated by Kiley’s replacement, Bobby Jorgenson; Jorgenson is incompetent, and nearly kills O’Brien. Furious, O’Brien promises revenge, but can recruit only Azar. They scare Jorgenson by pretending to be enemy soldiers, but the soldier proves that he is not a coward, O’Brien lets go of his resentment.[23]
"Night Life"
O’Brien tells the second-hand account of Rat Kiley’s injury: warned of a possible attack, the platoon is on edge. Kiley reacts by distancing himself, the stress causing him first to be silent for days on end, and then to talk constantly. He has a breakdown from the pressure of being a medic, and shoots himself in the toe in order to get released from combat. No one questions his bravery.[24]
"The Lives of the Dead"
O’Brien remembers his very first encounter with a dead body, that of his childhood sweetheart Linda. Suffering from a brain tumor, Linda died at the age of nine and O’Brien was deeply affected by her funeral. In Vietnam, O’Brien explains, the soldiers keep the dead alive by telling stories about them; in this way, he keeps Linda alive by telling her story.[25]
Characters[edit]
Main Characters[edit]
Tim O'Brien
The narrator and protagonist. While modeled after the author and sharing the same name, O'Brien (within the book) is a fictional character. The author intentionally blurs this distinction.
Lt. Jimmy Cross
The platoon leader. He is obsessed with a young woman back home, Martha (who does not return his feelings). He later believes that his obsession led to the death of Ted Lavender.
Bob "Rat" Kiley
A young medic whose exaggerations are complemented by his occasional cruelty. Eventually, he sees too much gore and begins to break down, imagining "the bugs are out to get [him]."
Norman Bowker
A soldier who O'Brien says attempted to save Kiowa the night he died. When Kiowa slips into the "shitfield," Bowker repeatedly tries to save him but is unable to; as a result, he feels guilty for Kiowa's death after the war. His memories continue to haunt Norman at home as he realizes that the world has moved on from the war, and wants nothing to do with the "hell" in Vietnam. He is continually haunted by the fact that he could not save Kiowa from sinking under the "shitfield" on a rainy night. However, O'Brien admits eventually that Norman did not fail to save Kiowa, that was fictional. After the war he briefly assists O'Brien in writing a story about Vietnam, but he hangs himself with a jump rope in an Iowa YMCA facility, leaving no note and his family shocked.
Henry Dobbins
Machine gunner. A man who, despite having a rather large frame, is gentle and kind. He is very superstitious; as a result, he wears his girlfriend's pantyhose around his neck as a protective "charm," even after she dumps him. He briefly contemplates becoming a monk after the war due to their acts of charity.
Kiowa
A compassionate and talkative soldier; he demonstrates the importance of talking about one's problems and traumatic experiences. He is also a devout Baptist and a Native American that occasionally feels contempt and distrust towards white people. However, he appears to be Tim O'Brien's best friend in the company. Kiowa often helps other soldiers deal with their own actions, such as taking the lives of other human beings. He is eventually killed when camping out in the "shitfield."
Mitchell Sanders
He is the radiotelephone operator for the platoon. Like O'Brien, he is also a storyteller and is portrayed as a mentor.
Ted Lavender
A grenadier. He dies from a gunshot wound to the back of the head. He is notorious for using tranquilizers to cope with the pain of war, and for carrying a (rather large—six to eight ounces) stash of "premium dope" with him. Cross blames himself for Lavender's death, as he was fantasizing about Martha when Lavender was shot.
Curt Lemon
A young man that frequently attempts to assume the role as a tough soldier. However, he is also good friend of Rat Kiley. Lemon dies after setting off a rigged artillery shell. In one of the book's more disturbing scenes, O'Brien and Dave Jensen help clear the trees of Curt's scattered remains, during which Jensen sings "Lemon Tree" (something that "wakes [Tim] up"). After Lemon dies, Kiley writes a long, eloquent letter to Lemon's sister, describing his friendship with Lemon and emphasizing how good a person Lemon was; Lemon's sister never responds, which crushes Kiley emotionally.
Azar
A young, rather unstable soldier who engages in needless and frequent acts of brutality; in one story, he blows up an orphan puppy that Ted Lavender had adopted by strapping it to a Claymore mine, then detonating it. He also aids Tim O'Brien in gaining revenge on Bobby Jorgenson, but mocks O'Brien when he's not willing to take the revenge further. At one point, Azar breaks down emotionally, revealing that his cruelty is merely a defense mechanism.
Dave Jensen and Lee Strunk
Minor soldiers who are the main characters of "Enemies" and "Friends." Jensen fights with Strunk over a stolen jackknife, but they became uneasy friends afterwards. They each sign a pact to kill the other if he is ever faced with a "wheelchair wound." After Strunk steps on a rigged mortar round and loses a leg, he begs Jensen not to kill him. Jensen obliges, but seems to have an enormous weight relieved when he learns "Strunk died somewhere over in Chu Lai." Jensen is sometimes mentioned singing "Lemon Tree" after Curt Lemon's abrupt death. Jensen also appears in "The Lives of the Dead", where he pressures O'Brien to shake hands with a dead Vietnamese.
Bobby Jorgenson
Rat Kiley's replacement, after Rat "put a round through his foot" due to breaking under pressure. Green and terrified, he is slow to aid O'Brien when he is shot in the behind; nearly killing O'Brien after failing to treat him for shock. Filled with rage after his recovery, O'Brien elicits help from Azar to conspire and punish Jorgenson with a night of terrifying pranks; afterward, however, O'Brien and Jorgenson become friends. Jorgenson may be a reference to a similarly-named character from The Caine Mutiny.
Themes[edit]
In the short story "Good Form," the narrator makes a distinction between "story truth" and "happening truth." O'Brien feels that the idea of creating a story that is technically false yet truthfully portrays war, as opposed to just stating the facts and creating no emotion in the reader, is the correct way to clear his conscience and tell the story of thousands of soldiers. Critics often cite this distinction when commenting on O'Brien's artistic aims in The Things They Carried and, in general, all of his fiction about Vietnam, claiming that O'Brien feels that the realities of the Vietnam War are best explored in fictional form rather than the presentation of precise facts. O'Brien's fluid and elliptical negotiation of truth in this context finds echoes in works labeled as 'non-fiction novels'. The fine line of what constitutes fiction versus non-fiction is blurred throughout the book, for though Tim O'Brien claims this book to be fiction, the author and the protagonist share the same name and same profession as writers. Additionally, the character Tim references writing the book Going After Cacciato which the author Tim had written and published previously. The theme of believing in the people around you and having reliable people with you comes from the time period being filled with people who are opposed to the action of war. This causes the people who are drafted into the mutual hate to band together to live.[26]
Adaptations[edit]
Film
The story "Sweetheart of the Song Tra Bong" was made into a film in 1998, titled A Soldier's Sweetheart starring Kiefer Sutherland.
Theatre
The legal rights to adapt the book into a play were awarded to James R. Stowell. The book was adapted into a play and it premiered at The History Theatre in Saint Paul, Minnesota, March 14, 2014. A second production was performed at The Lied Center, Lincoln Nebraska November 5, 2015. The stories "The Things They Carried," "On the Rainy River," "How to Tell a True War Story," "Sweetheart of the Song Tra Bong," "The Man I Killed," and "Lives of the Dead" were adapted for the theatre in March 2011 by the Eastern Washington University Theatre Department as part of the universities' Get Lit! Literary Festival in cooperation with the National Endowment for the Arts The Big Read 2011, of which The Things They Carried was the featured novel.[27] The same department remounted the production in December 2011 for inclusion as a Participating Entry in the Kennedy Center American College Theater Festival.[28] The production was selected as an alternate for KCACTF Region VII, as well as receiving other KCACTF honors for the production's director, actors, and production staff.[29]
Music
The band TV Girl features a song off their 2014 album 'French Exit' called 'Pantyhose'. The song alludes to the "Stockings" chapter from the book and references Henry Dobbins and his girlfriend's stockings, which he ties around his neck to keep him from harm. Lyrics such as,"And when the bullets came, he didn't duck; He wrapped her pantyhose around his neck; And he could feel their magic working; Keeping him from harm; Away to some place mystical and warm; His lucky charm" clearly references to Dobbins and his tactic that the scent of his girlfriend's stockings protect him and take him some place far from Vietnam.
Publication[edit]
Before the book's publication in 1990, five of the stories: "The Things They Carried," "How to Tell a True War Story," "Sweetheart of the Song Tra Bong," "The Ghost Soldiers," and "The Lives of the Dead" had been published in Esquire.[30]
"Speaking of Courage" was originally published (in heavily modified form) as a chapter of O'Brien's earlier novel Going After Cacciato.
"The Things They Carried" was also included in the 1987 volume of The Best American Short Stories, edited by Ann Beattie[31] and the second edition of Literature: Approaches to Fiction, Poetry, and Drama by Robert DiYanni.
Reception[edit]
The Things They Carried has received critical acclaim and has been established as one of the preeminent pieces of Vietnam War literature.[32] It has sold over 2 million copies worldwide[33] and celebrated its 20th anniversary in 2010. It has received multiple awards such as France’s Prix du Meilleur Livre Etranger Award and the Chicago Tribune Heartland Prize, as well as being a finalist for the Pulitzer Prize and National Book Critics Circle Award.[34]
O’Brien has expressed surprise at how the book has become a staple in middle schools and high schools, stating that he "certainly hadn’t imagined fourteen year-old kids and eighteen year-olds and those even in their early twenties reading the book and bringing such fervor to it, which comes from their own lives, really. The book is applied to a bad childhood or a broken home, and these are the things they're carrying. And in a way, it's extremely flattering, and other times, it can be depressing."[35]
In 2014, the book was included in Amazon.com's list of 100 Books to Read in a Lifetime[36] and credited as the inspiration for a National Veterans Art Museum exhibit.[37]
References[edit]
Jump up ^ Herzog, Toby C., “Tim O’Brien,” New York: Twayne Publishers, 1997.
Jump up ^ Israel, Elfie (Dec 1997). "What Contemporary Authors Can Teach Us". The English Journal. 86 (8). JSTOR 821615.
Jump up ^ Smith, Jack (Jul 2010). "INTERVIEW". Writer. 123 (7): 16–47. Retrieved April 2, 2015.
Jump up ^ "Local Author Tim O'Brien Wins Lifetime Achievement Award". www.austinchronicle.com. Retrieved 2016-10-30.
Jump up ^ O'Brien 1990, p. 1.
Jump up ^ O'Brien 1990, p. 26.
Jump up ^ O'Brien 1990, p. 30.
Jump up ^ O'Brien 1990, p. 37.
Jump up ^ O'Brien 1990, p. 59.
Jump up ^ O'Brien 1990, p. 62.
Jump up ^ O'Brien 1990, p. 82.
Jump up ^ O'Brien 1990, p. 85.
Jump up ^ O'Brien 1990, p. 111.
Jump up ^ O'Brien 1990, p. 113.
Jump up ^ O'Brien 1990, p. 118.
Jump up ^ O'Brien 1990, p. 125.
Jump up ^ O'Brien 1990, p. 129.
Jump up ^ O'Brien 1990, p. 131.
Jump up ^ O'Brien 1990, p. 149.
Jump up ^ O'Brien 1990, p. 155.
Jump up ^ O'Brien 1990, p. 171.
Jump up ^ O'Brien 1990, p. 173.
Jump up ^ O'Brien 1990, p. 180.
Jump up ^ O'Brien 1990, p. 208.
Jump up ^ O'Brien 1990, p. 213.
Jump up ^ McCoy, Erin R. "Stalemate Or Cultural Crossroad?: Exploring U.S. "Systems" During The Vietnam War." Interdisciplinary Humanities 30.2 (2013):
Jump up ^ "GetLIT Festival Guide". Pagegangster.com. Retrieved 2012-05-01.
Jump up ^ "EWU | 2011-2012 Season Schedule". Ewu.edu. Retrieved 2012-05-01.
Jump up ^ Eastern 24/7. "Theatre Program Wins Awards at Kennedy Center Festival". Sites.ewu.edu. Retrieved 2012-05-01.
Jump up ^ Nagel, James (2001). The Contemporary American Short-story Cycle: The Ethnic Resonance of Genre. LSU Press. p. 286. ISBN 9780807129616. Retrieved 5 April 2015.
Jump up ^ Charters, Ann (2011). The Story and Its Writer. Boston: Bedford/St. Martins. p. 636.
Jump up ^ Hanna, Julia (Spring 2003). "The Things He Carries". Kennedy School Bulletin. Archived from the original on May 7, 2013.
Jump up ^ Kurutz, Steven, “A War Book’s Long Shelf Life,” Wall Street Journal, March 19, 2010.
Jump up ^ "The Things They Carried". Houghton Mifflin Harcourt. Houghton Mifflin Harcourt. Retrieved 7 April 2015.
Jump up ^ Conan, Neal (March 24, 2010). "The Things They Carried, 20 Years On". NPR.
Jump up ^ "100 Books To Read In A Lifetime". Amazon.com. Retrieved 2014-02-09.
Jump up ^ "Permanent Exhibit — The Things They Carried". National Veterans Art Museum. Archived from the original on 7 April 2015. Retrieved 7 April 2015.
External links[edit]
The Tim O'Brien page at Houghton Mifflin Harcourt
The Things They Carried
A Soldier's Sweetheart on IMDb
An Index to The Things They Carried
Retrieved from "https://en.wikipedia.org/w/index.php?title=The_Things_They_Carried&oldid=849029805"
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