Communicable Diseases, Table of Contents
CHAPTER XXI
NEUROCIRCULATORY ASTHENIA
Shortness of breath and cardiac palpitation, tachycardia,pain in the region of the heart, and unstable neurovascular reflexes constitutea syndrome to which various names have been given. The term "neurocirculatoryasthenia" was accepted for it by the Surgeon General in 1918.1There can be little doubt but that the symptomology is best described under thisname. MacFarlane2 proposed the name "Neurocirculatorymyasthenia," which possesses all the disadvantages of the official termwithout being so inclusively correct. While the "effort syndrome"described by Lewis3 may conform to the type ofthe syndrome recognized by British observers, it falls far short of describingthe form chiefly seen by us, in which the condition was usually well establishedbefore any unusual military effort had been demanded. The still moreunsatisfactory term of "disordered action of the heart," brieflyknown, after the British manner, as "D. A. H.," long held its own inthe British service, but it is extremely inadequate in every respect.
The term "irritable heart," originally proposed byDa Costa,4 is perhaps the best ofthe shorter names applied to the condition. This, however, definitely suggeststhat the disorder is essentially a cardiac one, which it certainly is not, andthe further modification of this term, "the irritable heart of thesoldier," is even less desirable, since the condition occurs alike in civiland military life, except that the complex becomes most apparent and perhapsmost disabling under military requirements.
Many other terms, variously applied to the condition, the"nervous heart," the "hyperthyroid heart," "shell-shockheart," and the like, are most unsatisfactory, in so far as defining thecondition is concerned. Unfortunately, before and during the World War thecondition was reported under all sorts of headings, depending very largely onthe degree of misunderstanding of the condition which existed in the mind of theauthor. This so confused the classification of the subject that it is quiteimpossible to judge adequately as to the rate of occurrence of the syndrome,since so much depends on the classification adopted by each particular writer.Even after the term "neurocirculatory asthenia" had been officiallyadopted by the Surgeon General incorrect recognition made it impossible to forma correct appraisal of the universal occurrence of the condition. Theunfortunate failure of most authors of textbooks on medicine to recognize thecondition at all resulted in a very inadequate appreciation, in both civil andmilitary practice, of the importance of the syndrome.
PRE-WAR OCCURRENCE
Most of the early references to the condition now known asneurocirculatory asthenia are to be found in American literature, especially inthat based on experiences during the Civil War. Thus, in the official MedicalDepartment history of that conflict one finds the following important statementunder the initial heading of "Functional disturbances":5"Among the affections of the
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heart a functional disturbance known by the name of irritableheart or cardiac muscular exhaustion was the most notable production of thewar." Da Costa studied a series of 300 cases of this disease in hishospital at Turners Lane, Philadelphia, whither cases of this condition werereferred for his observation.4 Smiley foundthat cases of this type which he studied at Hilton Head, S. C., occurred chieflyin every young man of feeble constitution, probably taxed beyond their strength.6,7McKelway6 said of the condition as itappeared during the Battle of Williamsburg: "Disease of the heart appearsto have been developed in several cases from overexertion preceding the battleand excitement and effort during its continuance." The text of the history5goes on with the statement that "Overaction of the heart during anengagement was due perhaps as much to nervous excitement and anticipation ofdanger as to overexertion."
Hunt is quoted as saying concerning the name "irritableheart"7: "The term is a misnomer;yet, as I have already shown, it was employed in 1,200 certificates ofdisability. In all cases the objectionable phrase described a heart far toorapid in its action, the pulse ranging from 120 to 150, frequently attended bydyspnoa, vertigo, or syncope, but revealing no abnormal sounds either onpercussion or auscultation. The convenience of this collocation of words wasperhaps the strongest reason for its employment. It saved an extended historicalnotice of each case upon the limited space of the certificate of disability. Inreality these were cases of disturbance of the function of the heart dependentupon causes foreign to the organ itself."
A full recognition of the condition as distinct from that ofdilatation of the heart is shown also in the reference to the work of Surg. M.K. Taylor, United States Volunteers, who made a special study of dilatation ofthe heart, incident to military service, in the hospitals at Keokuk, Iowa.7,8
Nothing better has ever been written concerning the subjectthan the contributions by Da Costa,4 Hartshorne,5,9 and of Still?,10 all names since famousin American medicine. None of the studies originating from the World War haveadded materially to the clinical description furnished by them. Only the advanceof medical science as a whole has contributed viewpoints essentially improvingor modifying the understanding of the condition as expressed by these observers.The heart sounds and murmurs which occur in this syndrome have never been soaccurately or graphically described as by Da Costa, so that nothing further needbe said of them. The essentials of successful treatment are also outlined inthis remarkable contribution as definitely as in any of the more recent studiesof the syndrome.
Furbinger11 mentions theoccurrence of a similar condition in the German Army in the campaigns of1870-71, and Wilson12 calls attention to thefact that in 1864 the British Government appointed a committee to investigatethe subject, and particularly the relationship which the equipment of thesoldier might bear to its occurrence. This last subject had been alreadycarefully considered by the medical officers of our own Army in the War of theRebellion. White13 goes so far as to state thatthe condition was old as the study of medicine, and that it was described byHippocrates, Galen, and other ancient masters.
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OCCURRENCE IN THE WORLD WAR
The great importance of the subject as it appeared among ourrecruits was very early apparent, as indicated by the numerous communicationsand articles which immediately began to appear from almost all mobilizationcenters. It is very regrettable that professional unfamiliarity with our ownmilitary medical history led to so much loss of time and effort before anadequate understanding of the subject was reached by the average medicalofficer.
During the entire period of the World War, neurocirculatoryasthenia was one of the most frequent causes of rejection and of disability. Thedegree to which this was true can not be appreciated adequately from statisticscollected by the Surgeon General's Office, due largely to the diversity ofdiagnosis of the condition in the early stages of mobilization, noted above, andthe lack of proper classification. Even after the disease was fairly wellrecognized by medical officers, it was so infrequently grouped under the singleterm, neurocirculatory asthenia, until well into 1918, that the availablestatistics for the Army as a whole give but a very meager picture of the problemduring mobilization.
Musser,14 after astudy of 424 cases of tachycardia from the 38th Division, classified thesecases, etiologically, as myocardial, 69 cases; hyperthyroid, 9 cases; neurotic,180 cases; nervous (emotional), 28 cases, and toxic, 36 cases. This probablygives a fair estimate of the relative occurrence in most divisions in which thecondition was carefully studied by competent medical officers. No valuableestimate of occurrence in draft boards and mobilization recruiting stations isavailable. It was certainly very great.
AGE
The syndrome is notably one of youth and early adult life. Itsappearance has been noted in children, usually in the offspring of nervouslydefective parents,15 but it is mostnotable in about the years of military service. Ceconi16found in the Italian troops that most cases occurred between 19 and 25, a fewwere observed over 25, but none over 30. This corresponds pretty closely withthe writer's observations, except that in groups of older soldiers, for thegreater part officers of the various corps, frequent cases were found over 30years of age. In civil life it occurs in much older persons, though still mostprevalent and disabling in the late teens and early twenties. This fact admitsof the simple explanation that in civil life by the time individuals reach 30years of age they have either succumbed to some disease condition, to whichthese persons are particularly prone, such as the infections, or they haveadjusted their conditions of life to their physical capabilities to such adegree that they are able to carry on fairly effectually. Under such favorableconditions many cases go on to substantial cure, and even when submitted finallyto the rigors of military life, as was the case with many reserve officers andvolunteers, they were then able to hold the symptomatic picture in abeyance.
Every practitioner who has carefully studied the condition incivil life recognizes that it is quite as frequent here as in the Army, thoughless apparent, usually because of the greater possibilities of adaptationpermissible under civil as compared with military conditions. This observationwas emphasized
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by Neuhoff.17 Schlesinger,18on the other hand, from his experience in a cardiac hospital near thefront, believed that he could show a lower occurrence of real cardiac disease inthe Army and a proportionately higher appearance of the nervous forms. Fullyone-fourth of this class of cases, however, had suffered from the conditionprior to mobilization. The writer's own experience led him to feel that theoccurrence in the Army was precisely similar to that in civil life except thatthe rigors and restrictions of military life often caused the syndrome to becomeapparent, where it might have remained in abeyance under civil conditions.
SEX
As a military disease the complex is naturally seen mostly amongmen. This is due to the fact that women in the military personnel are sorelatively few in number, and, to some degree, because certain of the dominanttraits of the complex, while always noteworthy in men, would hardly be remarkedin women, in whom one accepts certain emotional instabilities as normal femininereactions. In nurses and other groups of women engaged in the more stressfultheaters of warfare, as in mobile operating units, evacuation hospitals, shockand operating teams, and the like, the occurrence of the complex appeared to beabout the same as in men. In civil life the writer's observations have led himto feel that sex in itself plays no real r?le in the determination ofoccurrence especially when women are subjected to the same rigors of lifedemanded of men, which in all instances cause the disease to become mostapparent.
RACE
As observed at Camp Upton, N. Y., during the mobilization of the77th Division, there was a very definite racial influence apparent in theoccurrence of the disease. From a special study of this racial influence at CampUpton, it was found that the syndrome occurred far more frequently among theHebrews, notably among the Russian Jews, than among other races. Next inoccurrence came those of Italian birth or origin, then the Irish, the Americans,the English, Scotch, German, and, last of all in point of frequency ofoccurrence, the negro. In an entire brigade of negro troops mobilized at CampUpton and largely selected from the adjacent territory, but augmented by severalsmall contingents from the Southwest, but one case of clearly definedneurocirculatory asthenia presented itself at the base hospital during thewriter's service there. Cases were seen by him in the field hospitalsoperating with the 92d Division in France, but they were definitely less innumber than developed among usual white troops. The complex would then appear tobear a very definite relationship to the emotional status of the variouspeoples. Roughly speaking, one may say that the greater the emotional status ofa people, the higher will be found the occurrence of neurocirculatory asthenia.It has been said that it is also a disease of the intellectual as compared tothe physical types; and while to a certain extent study of large groups appearsto bear this out, it will be found much nearer the truth to make such adistinction on an emotional rather than an intellectual basis.
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HEREDITY
Hereditary influences are definitely traceable in mostinstances. Conner,19 in his analysisof cases rejected for cardiac defects, mentions the not well-recognized factthat constitutionally inferior recruits suffered mostly from this complex. Therelationship of this status to hereditary influences is fully established. Clercand Aim?20 21 emphasized constitutionalpredisposition. Oppenheimer and Rothschild22stated positively that there is a definite family history of factorspredisposing to the psychoneuroses in most cases. They particularly urged theimportance of a fundamental inferiority in the development of the complex. Robeyand Boaz23 were of like opinion. While theestablishment of this important fact was often very difficult in the stress ofmobilization and military activity, the writer has been amply able, from a studyof the condition in civil life, to completely establish heredity as a veryimportant determining factor. One or both parents show, usually, traits ofnervous or endocrine instability of one sort or another. They may be hysterical,hyperthyroids, neurasthenics, hypertensives, insane, or they may, like theiroffspring, show the manifestations of the complex itself. A definitely obvioushereditary influence of instability of some sort is almost always obtainable ofthe nervous, endocrine, or circulatory systems.
GEOGRAPHICAL DISTRIBUTION
Study of the statistics from the Surgeon General's Officethrows no apparent light on this question, but the syndrome appears to be morefrequent in urban as compared with rural populations, and of course the racialinfluences already mentioned play a r?le in the geographical distribution.
INFLUENCE OF OCCUPATION ON OCCURRENCE
One might not unhappily reverse this heading and state, better,the influence of this syndrome on the selection of occupation. Almost withoutnotable exception successful men suffering from neurocirculatory asthenia arefound in the ranks of mental in contradistinction to physical occupations.Marshall24 called attention to the fact thatnearly all cases had neglected athletic training and had followed sedentaryoccupations, as the writer believes through necessity rather than throughchoice. As a rule it will be found also that when persons suffering from thiscondition are engaged in laborious occupations they are failures to a greater orlesser degree. On the contrary, many of them stand very high in the professionsand in occupations in which dominant mental or emotional characteristics arequalifying rather than otherwise. This was particularly manifest in the NationalArmy draft. In divisions, for example, the percentage of cases found amongbandsmen was much higher than in the infantry or mounted forces. The same statuswas noted in most of the allied forces. Thus Thomas25reports as follows on 1,000 cases under his observation: "Light work, 25.6per cent; work in open air, 20 per cent; sedentary occupations, 17.8 per cent;heavy industrial work, 15.2 per cent; light industrial work, 12.5 per cent; Armyand marine, 5.5 per cent; undetermined, 2 per cent." In civil life the veryfrequent occurrence among successful musicians, artists, actors, writers, andsimilar classes is striking and to a very convincing
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degree emphasizes the association of the complex withemotional activity. For the most part those engaged in physical occupationsfound to be afflicted with the status were almost without exception inferior orineffective workmen. Where it was possible in the assignment of soldiers to takecognizance of these tendencies, often men entirely unable to undergo the stressof real military work were found to be very efficient as clerks, signal men,bandsmen, and the like. In all armies it was soon found that a large number ofsoldiers who were unable to carry on in line duties were most effectivelyemployed in positions in the rear, as in the Services of Supply. This selectivetendency has been manifest in sports. As a general rule, in both military andcivil classes, it is found that few of these individuals are found, as, forexample, in colleges, on football or baseball teams. On the contrary, as a classsubjects of this condition, through obligation or by selection, elect sportsdemanding more emotional and temperamental, rather than physical, prowess. Whileunable as a class to endure prolonged physical stress, some excellent tennisplayers, golfers, and the like must be included as belonging to thisclassification.
RELATION OF OCCURRENCE TO MALINGERING,"CONSCIENTIOUS," AND OTHER "OBJECTORS," AND TO COWARDICE
Neurocirulatory asthenia is manifestly a disease of theemotionally unstable. It is to be expected, therefore, that it would be foundassociated more, rather than less, frequently with mental and moral aberrations.To a certain degree this has been found to be the case. In the writer'sobservation it has shown little or no relation to malingering. Malingering is acondition certainly associated with definite tendencies, and it is no morefrequent among those suffering from this disease than in any other class, socialor physical. Conscientious objectors present a quite different question.Inasmuch as this class of genus hominis can be divided roughly into those moreor less mentally or morally defective and those of a criminal type, it will bethought natural that in the first classification more than an ordinarypercentage of endocrine aberrations will appear from the close association ofneurocirculatory asthenia to such disorders. Our observations at Camp Uptonamply substantiated this surmise in so far as those who based their lack ofwillingness for service on real religious belief or on emotionally basedtheories of other varieties. This was notably true of hyperthyroid types thatconstituted a high percentage of enthusiasts of all varieties. As to the morefrequent criminal type of "objector," no particular relationship tothe complex appears to exist. Evasion of service was naturally attempted by someindividuals suffering from neurocirculatory asthenia; but, in so far as thewriter's observation goes, fully two sufferers from this disorder wereattempting subterfuge to enter the service to one who was attempting to evadeit. While doubtless frequently of an emotionally unstable character, cowardicewas by no means notable among neurocirculatory asthenics, and decorations forparticularly courageous service were awarded in several instances in the writer'sobservation to outspoken examples of this disorder.
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ETIOLOGY
After the economic and military features, the chief interestin the syndrome centers about the question as to its real nature and etiology.It is notable that very little interest has been excited up to date among purelycivil practitioners in regard to the syndrome. It has been rated and describedalmost exclusively as appearing under conditions of military activity. It isvery obvious that the condition appears as a dominant problem only underconditions of mobilization, or of great emotional stress. It seems fair, then,to assume primarily that emotional stress and excitement bear an important r?lein the evolution of the complex, notwithstanding its great civil occurrence.
One of the most striking features which was apparent to everystudent of this condition in the United States was the marked difference in theconditions under which these cases developed in the camps of mobilization inthis country, as compared to the published accounts of the conditions,particularly as they appeared in British literature. In so far as one may judgefrom the British accounts, cases of the syndrome appeared practically only, orcertainly most frequently, in men after the stress of battle experience. In thiscountry, in practically all of the mobilization camps, it was found as a veryfrequent condition in recruits who had had no real military experience whatever.They came to the camps with the complex well developed, and the war in itselfcould have had no possible bearing on the condition, unless it be through thehighly emotional tension which prevailed in our society at large during thosetimes.
Perhaps to a considerable degree this emotional tension was aresult of the excitement and emotional cataclysm which attended enrollment anddeparture from home to the training camps. Large numbers of these men were foundat the very first examination to be entirely unfitted for military service ofany kind, and were forthwith discharged or sent to the base hospitals fortreatment and observation. Clinically these cases, none the less, completelyresembled those which developed under the stress of service, except that theBritish reported almost unanimously that rest gave great relief in their caseswhich had developed under heavy service conditions, while in our cases little orno improvement took place under rest treatment in the mobilization areas.Observation later on of our cases which also broke under the stress of activewar operations proved abundantly that the British observations were entirelycorrect, but that these cases represented minor or undeveloped degrees whichbroke under military stress, while cases which manifested the disease before anyreal service had been performed, though essentially of the same variety,represented the most active, constant, and incurable phases of the condition.
A sharp distinction in degree must then be made between caseswhich appeared so numerously in our mobilization camps and those whichsubsequently appeared in men who had stood reasonably well the strain ofmobilization but who broke under battle stress. Between these two classes liesanother smaller group which broke under the weight of military training. Many ormost of these men were able to carry on in a very satisfactory manner iftransferred to less arduous duties, as to the band, to clerkships, or todomestic quartermaster duty. Some who had borne the stress of training poorly asenlisted men were able to get on very well as noncommissioned and commissionedofficers.
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It must not be supposed from this statement that thecondition was unfamiliar in the commissioned personnel. It is the writer'sobservation that it was relatively quite as frequent among officers as amongenlisted men, and the number who eventually broke was probably relatively aslarge, though perhaps not quite so manifest because of the class pride whichcaused the officer to fight off the tendencies perhaps with more determinationthan was exercised by the average enlisted man. During the period of collapsethere was no essential difference between the various types of the disease whereit developed as a result of battle service, or was manifest on enlistment. Theformer, however, offered a much better prognosis as to ultimate result. Some ofthe cases which developed under the sudden weight of training were able torecover and finally to return to satisfactory but more gradual training. Thiswas especially true of persons who had been taken suddenly from sedentarypursuits to be placed at once under the severe physical exactions of militarytraining.
Throughout it was noted that the emotional type of recruitwas that which suffered most acutely. Phlegmatic men were far less prone tobreak, and yet it must be conceded that it is from the former class that many ofthe best soldiers were developed. Somewhat similar epidemic forms of the complexbecome manifest, for example, in schools and colleges at the time ofexaminations and the like. The disease is definitely not a military one, then,but one which becomes only more numerically manifest during war, because of theselective character of military service and of the existing conditions which nowbecome necessarily more insistent than is the case under mere civil life.
Certain observers, among them Lewis,3 pointedattention to the probable r?le of the infections in the genesis of thecondition. It can not be disputed that infections which, among many otherfactors, lower the resistance of the body against any pathological process mayact as an exciting or precipitating factor, but it is extremely improbable thatthey have any direct etiological r?le in the development of the condition.Briscoe and Diamond26 conducted a series of experiments to determineif bacteriemia was present, but met with negative results. There is no definiteevidence in favor of this theory except the frequent associated occurrence ofthe infections with the disease. It is conceded, however, by most writers thatthe existence of the syndrome greatly lowers resistance against infections, andthe observation of the writer corroborates the almost universally conceded pointthat patients with this disease have a much lowered resistance against certainspecific infectious processes, as tuberculosis.
Musser14 pointed out that soldiers who had beengassed were particularly prone to develop neurocirculatory asthenia, and a greatmany other similar factors, undoubtedly also through lowering of generalresistance or through abnormal production of exhaustion, act similarly. Forcedmarches, heavy firing, and the general commotion and unrest of the front, aspointed out by Thomas,25 are also undoubted predisposing but notcausative factors. Attention has long been directed to the possibility ofpredisposition being excited by unaccustomed physical effort with the productionof severe degrees of exhaustion. During the Civil War and again in the WorldWar, attention was directed to the possibility of uncomfortable uniforms, tooheavy and improperly adjusted
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equipment, and the like, being factors in the induction ofthe syndrome, but again these must be considered as predisposing and notelementally etiological factors.
Tedeschi,27 among others, has drawn attention tothe well-accepted fact that digestive disturbances induced either byunaccustomed or improperly prepared food, might be a factor of inductive nature.Clerc and Aim? (P)21 mention the effects of the excessive use oftobacco and of alcohol in the production of the disease. Merkel28 evenstates that it was found more frequently among Bavarian than among Prussiantroops because of the larger amounts of beer consumed by the former. Ourobservations at Camp Upton showed that the syndrome occurred quite as frequentlyamong nonsmokers as among those who use tobacco. Marshall24 alsocoincides in this observation. It is, none the less, the impression of thewriter that the abuse of tobacco does exaggerate the symptom complex, notablythe tachycardia. Many observers, however, dissent on this point. Tea andcoffee, with even less basis, have been urged as important etiological factors.
A relationship between previous cardiac disease andneurocirculatory asthenia has been noted by some authors, but in mostinstances reference to previous cardiac disturbances rather than to definitecardiac lesions is cited. The relatively frequent occurrence of the syndrome inmyocarditis, myocardial degeneration, and adhesive pericarditis has been citedoccasionally, but the number of cases in which these anatomical lesions havebeen found associated with the complex is very small, as is well illustrated bythe exceedingly low death rate in the syndrome. Certainly most cases of definiteorganic disease of the heart had been eliminated in the selection of soldiers,and the association of the syndrome with the development of organic heartdisease is so relatively low as to be unimportant and to quite definitely serveto class this syndrome as no instance of cardiac disease. This point wasapparently definitely decided in the Civil War, but it is continually beingrevived. It must be admitted, however, that these cases have a lowered cardiacreserve, just as they have also a lowered muscular, nervous, mental, and generalphysical reserve.
Many observers, among them the writer, have called attentionto the association of the disease with thyroid instability, or definitely withhyperthyroid activity. Certain cases are so dominated by the symptoms ofhyperthyroid activity that it is very easy to fall into the error, as the writeroriginally did, that hyperthyroidism is an etiologic necessity in the syndrome.Among those who have stressed this relation are Lian,29 Caro,30 Aschenheim,31 Ehret,32 and Sir James Barr.33 Thewriter believes that hyperthyroid activity is an essential part of the syndromein many instances, as is indicated by the very frequent occurrence ofhyperthyroid symptoms in the cases, but he no longer feels that thisrelationship is etiologic or universal. Sturgis, Wearn, and Tompkins,34reported an increased metabolic rate in many of these cases and stated that theGoetch reaction is presented by them with considerable frequency. Spiller,35appeared to feel that hyperthyroid activity, probably in association with otherendocrine disorders, plays an important r?le in the complex, perhaps throughfixation of blood salts, as proposed by Lewis and his coworkers.3,36,37
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The similarity of many of the manifestations of theconditions to some of the types of thymus disease has already been pointed outby the writer. Evidence of adrenal disturbances has been remarked by manyobservers. There can be no doubt but that profound instability andincoordination of action of the various endocrines is present in the disease.The preponderance of evidences of thyroid instability is the most striking ofall, but at present appears to be but a part, not the sole, etiological factorconcerned in the production of neurocirculatory asthenia.
Very closely allied to the last mentioned factors is thestriking relationship of the sufferers from this complex to early exhaustion,both physical and nervous, and particularly to a combination of these withemotional exhaustion. The close relationship of the whole to "shellshock" is another bit of evidence pointing in the same direction. His38pointed out its close similarity to the traumatic neuroses. Excitability of thesympathetic system, lowered threshold of sympathetic stimulation response(MacIlwain39), all closely allied to endocrine fault, have been citedas of primary bearing in the complex. Various theories relative to the fixationof the salts of the blood, notably of the calcium, have been propounded, butthese lack both adequate laboratory and clinical substantiation.
Undoubtedly the theory as to basic etiology which has beststood the test of study is that originally proposed by Oppenheimer andRothschild,22 who asserted that the complex is certainly not adisease entity. They found that in half the cases there was a family andprevious history of factors predisposing to the psychoneuroses, and in almost 70per cent of these there was a history of constitutional asthenia. They pointedout that normal individuals when they break down under the complex presentsymptoms chiefly of exhaustion; the relatively inferior individuals show bothexcitation and exhaustion. Oppenheimer and Rothschild then particularly stressedthe importance of a fundamental inferiority in which doubtless endocrineimballance or inadequacy play an important determining part.
Given this primary tendency, under emotional and physicalstrain such as is exacted particularly under battle stress, loss of sleep,responsibility, prolonged shell fire, and the numerous other similar conditionswhich the soldier must meet, individuals showing perhaps but minor inferiorityinitially, break and develop the complex. Other soldiers, who primarilyrepresent a greater grade of fundamental inferiority, especially in theirendocrine and general physical make up, fail under much less stress. If theirprimary defect be sufficiently marked, under stress well borne by the normalindividual, they fail and may present the characteristic clinical picture ofneurocirculatory asthenia.
Although the writer agrees in the main with the assumptionthat we are not dealing with a disease entity in neurocirculatory asthenia, itseems certain that we are concerned with a fairly well-defined and readilyrecognized clinical condition based, not on a definite pathology perhaps, but ona chemical fault or status founded on a congenital defect in pronounced casesand developed in less marked instances by exhaustive chemical conditions whichhave definitely to do with the endocrine system.
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THE PHYSICAL TYPE
The physical appearance of these men is quite characteristicin all fully developed instances, in most of which it is in itself conclusivelydiagnostic.
The syndrome occurs in two chief types of figure. In the onethe patient is tall and slender, very likely to be stooped somewhat in posture.The thorax is narrow, long, and rounded in cross section. Lumbar lordosis isfrequent. The pelvic girdle is notably narrow. The extremities are long andslender; usually the muscles are soft and flabby and very poorly defined inform. The extremities suggest the female rather than the typical male type.The hands and feet are long and slender. They are practically always cyanosed,cold, and sweating. The capillary return in the hands, feet, and face, notablyin the nose and ears, is delayed. As a rule the skin is thin and soft. There isusually very little hair on the body and it is likely to be notably soft,silken, and curly, and the distribution is more of the female than of theusual male type. The external genitals are usually small and poorly formed.
The other type, which is far less frequent, is of coarsebuild. The trunk may be flat and broad, almost thin. The skin is very coarseand rough, covered with scanty, bristlelike hairs, again more female than malein type of distribution. The deposit of fat in this type is occasionallylarge, and sometimes the head, hands, and feet suggest an early acromegalictype. The distribution of fat is commonly small but occasionally this type mayshow a considerable deposit of loose, flabby adipose. Hernia is very common inboth types. The thyroid gland is prominent in most cases and in some of eithertype a certain degree of exophthalmus is present. The facial expression isanxious and worried, but the lining of the face is not ordinarily deep or theattitude sinister.
PATHOLOGY
Little information is available on this phase of the subject.The disease is not in itself a fatal condition and, during the war, when deathin these subjects occurred from concurrent or complicating conditions, theresulting material was not such as to permit of conclusive deductions in regardto the basic state itself. Furthermore, the pathologists were occupied with morepressing problems, so that undoubtedly the subject did not receive the amount ofattention which it merits.
In so far as the writer has been able to find, nocharacteristic pathological lesions exist either generally or in any specialorgan in neurocirculatory asthenia. Note has already been made of the enlargedthyroid present in many instances, but histological examination in these caseshas shown only the changes of a parenchymatous hyperplasia. In no instance wasthe goiter of the cystic variety.
Post-mortem examination of the heart showed no typicalchanges, though in the ordinary case the heart as a whole appeared to behypoplastic rather than otherwise. Smith,40 after ateleoroentographic study of the heart, considered that in instances which hadpersisted for a long time, the heart was smaller than normal. The long, narrow,or "drop" heart was not the predominating form, in his experience, andthe small heart might vary in shape as much as in the normal. The smaller heartswere found in men whose musculature also
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was below the normal. The cases studied, which developed thecondition under service stress, showed silhouette measurements that were wellwithin the range for area and volume. Where a persistent tachycardia develops,myocardials changes must appear eventually, notably fibrosis, fatty andparenchymatous degeneration. Notwithstanding the dominance of nervous andcerebral signs and symptoms in the disease, no actual lesions in the organs ofthe central nervous system appear to have been described.
RELATION TO OTHER DISEASE PROCESSES
Men suffering from this complex showed, in practically allrespects, a lowered resistance against other disease processes, particularly theinfectious diseases. So definitely was this evident that many observersconsidered neurocirculatory asthenia as caused either by a general or specificinfection. The peculiar susceptibility of these men to the acute respiratoryinfections has been mentioned. This tendency appeared to exist particularly withregard to tuberculosis. There is a possibility of easy confusion of thecondition with tuberculosis because the physical characteristics of the twoconditions in some respects appear quite similar, but beyond this there is avery certain lack of resistance on the part of these men toward this infection.
They were also particularly prone to measles, scarlet fever,and mumps, unless protected by previous attacks, and it was notable in anyorganization that the first groups of men to succumb to these diseases werethose who had the stigmata of this basic condition. General infections, as ofwounds, also ran a more unfavorable course than should normally be the case. Thesame was true of surgical conditions. Wounded men of this type were found torecover less rapidly and they were also often prostrated by relatively minortraumatic conditions.
Japhs and Meakins41 made a study of cases ofirritable heart associated with amebic dysentery in troops returned from theBritish Mediterranean force. They found that treatment of the dysentery by saltsof emetin also considerably improved the symptoms of irritable heart.
There is also a lowered resistance to many general diseases,especially toward those of endocrine origin, as Grave's disease, myxedema,Addison's disease, and diabetes mellitus. In several cases under ourobservation definite acromegalic stigmata developed. Susceptibility to trenchfoot, trench fever, nephritis, and similar diseases was noted by variousobservers. The general statement may be made that men suffering from thiscondition have a lowered resistance toward practically all disease conditions.
After what has been said, it appears unnecessary to point outthat the physical endurance of these men is definitely subnormal, and no matterhow determined or how well trained men might be, many of them broke under thestress of military service. This was particularly notable in certain officers ofthe Regular Establishment who were in all respects normal and well-prepared men,but who, having this complex as a basic state, failed in endurance when put tothe severe test of military life as it existed in the war.
The frequency of fear complexes was notable and theexaggeration of emotional stimuli sometimes led men otherwise exceedingly wellfitted for
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military responsibility to become men of poor judgment, andwith low grade powers of analysis. Recalling the elementary unstable mental andemotional tendencies of this type of man, it is entirely to be expected thatthey would furnish a high percentage of the cases of so-called shell shock andof war neuroses of all kinds. Once ideas of this kind become impressed on asubject of this complex, they are eradicated with much greater difficulty thanwould be the case in normal men. This tendency was found of particular import inthe treatment of these cases in that if they had once been impressed with theidea that they were suffering from cardiac disease it was found extremelydifficult, even with highly intelligent men, to disabuse them of the idea. Theease with which men of this type might be persuaded to the adoption of anytheory of a serious condition was very striking as compared to the extremedifficulty with which any such phobia could be dislodged. Even courageous anddetermined men of this type of infirmity found themselves possessed often byperiods of fright altogether out of proportion to the normal reaction called forin any emergency.
LABORATORY FINDINGS
The urine.-No detailed studies of the urine areavailable; in the cases under observation at Camp Upton nothing in any waycharacteristic was found. From studies of the urine made at the HamsteadMilitary Hospital it was found that the urine was hyperacid, and showed excessof phosphates and calcium oxalates, as in other neuroses.
The blood -A deficiency in the buffer salts of theblood was advanced by Lewis and his coworkers as explanatory of thebreathlessness observed in many cases.36 This symptom, however, isunrelieved by the administration of the alkalies, and Adams and Sturgis42 founda normal or combining capacity of the blood in their cases, concluding that thedyspnea was of neurotic type.
In a small group of unselected cases Levy43 found that thered cell blood count was high. The average number of red cells was 5,837,000.One-third of the cases had a count of over 6,000,000, and more than one-half, acount of 5,900,000 or over. The hemoglobin percentage was for the most partbelow normal, the average reading being 93.4 per cent.
Leucocytosis of moderate degree, with usually more or lessrelative lymphocytosis, was found by Briscoe.44 Gay's findingswere similar, but he reported also a slight eosinophilia. Laubry and Esmein45reported a mononucleosis in 22 out of 30 persons suffering from thecardiac instability.
Blood pressure -The blood pressure in the cases studiedwas lower, as a rule, than in most normal groups. Some cases, particularly whenin a marked state of exhaustion, showed definite hypotension, but underemotional excitement the pressure varied much, but still well within normallimits.
Electrocardiography -An electrocardiographic study of12 cases was made by Peabody, Clough, Sturgis, Wearn, and Tompkins.46 Themost striking change reported was a slight decrease in the height of the T-wave.This was most marked in lead II. In individual cases other abnormalities werefound, but they have probably little general significance.
Gastric test meal - Musser14 found that subjects ofthis complex showed a very definite increase in the total gastric acidity and infree hydrochloric acid,
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as compared to normal controls. The figures, however, do notrepresent definitely pathological degrees of hyperacidity.
Aside from these relatively inconclusive studies, very littlehas as yet been done in the way of routine clinical laboratory work inconnection with the complex, and it would appear that little of value is likelyto result from this line of study.
SYMPTOMS AND SIGNS
CARDIAC DISTURBANCES
It is because of cardiac signs and symptoms that most casesappear for examination, and it is also because of these dominant manifestationsthat most cases become inadequate. Again, most of the suffering, in so far asactual physical distress is concerned, is due to cardiac disturbances, and muchof the mental agony and apprehension is likewise caused by heart signs andsymptoms.
Tachycardia is the most striking of the cardiac signs. It isalso one of the most constant marks of the disease. It is developed typicallyunder emotional stress, and while it may also appear in some instances underphysical stimulus, especially in the exhausted type of case, in many instancesit is diminished or slowed under mild physical exercise, such, for example, asthe usual tests for cardiac muscle reserve.
Sturgis, Wearn, and Tompkins,34 showed that incases of irritable heart, after the injection of atropin there was a shortpreliminary drop in the pulse rate, followed, as in normal men, by an increasein pulse rate which was proportionately somewhat greater in the cases ofneurocirculatory asthenia.
With the tachycardia in some cases, again particularly thoseof the exhausted type, arrythmia develops. As a rule, unless the case iscomplicated by some true anatomical cardiac lesion, this arrythmia is of thesinus variety, and it is in such instances probably unaccompanied by any realcardiac pathology, though in long-standing cases such may eventually develop.The subjective symptoms of cardiac disturbance, as a rule, are more dominantthan the demonstrable signs. In general these may be included under the signsand symptoms of cardiac palpitation as described in the textbooks. A sense ofdistress or pain in the region of the heart is commonly complained of.Suffocation or pressure symptoms are located in the precordium.
Shortness of breath is the commonest of symptoms, but no truedyspnea is present except in severe instances of exhaustion or where some truelesion is present. This will be readily detected by subjecting the patient totemperate, physical exercise, which, in uncomplicated cases, either slows therate or leaves it unchanged. On the other hand, emotional stress gives rise tomarked accentuation of these symptoms, especially of the dyspnea. Often aconsiderable degree of physical exercise may be tolerated without any distresswhatever. Occasionally the cardiac distress takes on the character of a sharpstabbing pain which may become so intense that the patient is forced to stop andto press firmly against the precordium with his hand.
In many instances a broad area of apical pulsation was noted,and in thin men one sometimes found also pulsations manifest in the intercostalspaces over the entire precordium. Schlesinger18 states that markedirri-
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tability of the pectoral muscles may be present. The soldieralmost without exception complained bitterly of a sense of his own heart action.He was often able to count the rate, and to note any irregularities ormodification of rhythm. Physical examination of the heart showed, as a rule,clear, sharp muscle tones, but in cases of great rapidity a blurringindistinctness of the tone was present. In instances in which great physicalexhaustion was also present the character of the muscle tone was so indistinctthat the diagnosis of a presumable myocardial degeneration seemed justified.
Various cardiac murmurs were often present, even in caseswhich subsequent study demonstrated to be free from either muscle or valvelesions. These murmurs were very inconstant in character, differing from momentto moment, modified after exercise, and oftentimes entirely removed by it,especially in numerous instances in which exercise steadied and slowed theaction. The most frequent murmur was heard at the apex, was systolic in time,and was not transmitted from the point of greatest intensity. Soft blowingsystolic murmurs at the second right interspace were common. Sometimes they weretransmitted up into the carotid on the right side and frequently they wereaudible across the manubrium sterni, and at times were heard with maximumintensity in the left second interspace. After a study of the murmurs in casesof irritable heart, King47 stated, correctly, that they have probablyonly accidental relationship to the basic condition. Exercise, as a rule,greatly modifies all these adventitious sounds, and often entirely obliteratesthem. Change of posture also usually effects some change or causesdisappearance. Of course many instances are associated with all manner ofcirculatory lesions of a true organic character. In such, of course, there arepresent diagnostic signs of a character which often greatly confuses therecognition of neurocirculatory asthenia. Molle48 called especialattention to the frequency with which venous femoral bruits are found in casesof the "soldiers' heart."
Blood pressure was found to be an extremely variable sign.Some observers state that it is usually elevated, others that it is low. Thewriter's experience has been that while it may be either, largely depending onconcommitant or associated disease or temperamental conditions, in pure casesit is more commonly low, but under certain stimuli, particularly under mentalstress or emotional excitement, it may become markedly elevated. In practicallyall instances blood pressure shows more variation than is usual in normal cases.
ARTERIAL TENSION
Laubry and LeConte,49 from cases of cardiacinstability studied in Professor Vaquez's service, delineated three groupsaccording to their arterial pressure: (1) The unstable, which represents abouttwo-thirds of the patients examined. Their tension varied from one day toanother. (2) The stable types, which presented a distinct fixation of tension.The variations from day to day were slight. (3) A small number of cases hadabnormal arterial tension at first, but this usually became normal under theinfluence of rest and diet. They never found durable, permanent hypertension.Variation
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in pressure was not especially marked in those with greatcardiac instability or tachycardia. There was no relation between the degree oftachycardia and hypertension.
A striking sign occasionally present was the absence of adefinable lower limit of diastolic pressure so that a condition ofsphygmomanometry very similar to that seen in double aortic endocarditis wasmanifested. At times also a pulse very closely simulating that of the Corriganor water-hammer variety was present. The tremendous effect which psychic factorsproduced on blood pressure was notable in most instances. A soft, irregular, attimes a dicrotic, pulse may occur in any case and apparently without anyessential anatomical disease.
FLUOROSCOPIC FINDINGS
Fleuroscopy of the heart often discovers extremelyinteresting data in the study of the syndrome. Wide, active contractures of theauricles, plainly visible on the screen, are the most striking of thesefindings. Occasionally ventricular hypertrophy is present, occasionally a truedilatation. In the typical uncomplicated case the size of the heart is not as arule modified; more frequently than otherwise the heart, even in largeindividuals, is relatively small, long, and narrow, and often definitely of thehypoplastic type. As compared with the aortic arch, the heart often seemsnotably hypoplastic, for dilatation of the aorta seems to be present in aconsiderable number of cases. This anatomical finding, often not demonstrablepost mortem, may account to some degree for many of the adventitious sounds,notably those heard at the base of the heart.
NEUROVASCULAR DISTURBANCES
Important as are the cardiac manifestations in the study of the problem, they are of but little more dominant character than the study ofthe other circulatory disturbances usually shown in the syndrome. Throughout andmanifest in every certain instance of the syndrome is a very unstableneurovascular control. This is shown by marked dermographia, which is asstriking, varied in type, and constant as in any group of cases of certainhyperthyroidism or goiter. The hands and feet are cold, usually cyanosed, thoughthe cyanosis may at times be quickly followed, as in true Raynaud's disease,by a condition of waxlike ischemia. Cold sweat bathes the hands, feet, andfrequently the entire body. Even when the surface of the skin is cold it may becovered with large globules of sweat.
These manifestations were notably emphasized when the soldierwas under considerable excitement, as when undergoing an examination,considering discharge, or the like. Frequently the face was flushed, bright redin color, this being quickly succeeded by a wave of paleness associated withcold. Occasionally these dermal manifestations were accompanied by an intensebut usually very transitory pruritus, commonly most marked over the anterior andlateral thorax and over the face. Other cases were associated with the formationof large wheals where the pressure of the clothing was marked or when slightblows were inflicted. Heat or cold may precipitate these lesions.
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These striking evidences of neurovascular disturbance wereoften accompanied by certain nervous phenomena to be described elsewhere. Thisassociation seemed to indicate that probably similar vascular disturbancesappear also in the deep viscera, thus explaining a large group of central signsand symptoms. Physical factors rarely precipitated these symptoms, thoughoccasionally they would appear in their most exaggerated form after drill orotherwise when more or less physical exhaustion was also present. They werealways most evident when cardiac disturbances were most annoying. They showedthroughout a very definite association with emotional and nervous factors.
Very closely allied with these circulatory symptoms, andprobably dependent on precisely identical factors, were certain urinarysymptoms, such as are also commonly associated with such signs and symptomsappearing with like conditions in other diseases, as in various neuroses and inhyperthyroidism. The most striking of these was polyuria, which occurred duringor immediately after the most violent attacks of tachycardia or syncope, or wasassociated with the dermal manifestations. This hypersecretion was apparentlysimilar to that which appears in paroxysmal tachycardia. The urine so voided wascommonly light in color and in weight. Tenesmus might follow or precede thevoiding of the urine, which was ejected only with difficulty and with more orless pain, as though from contraction of the urethra. Small quantities onlymight be voided at a time, but the insistence of the desire was so imperativethat complete urethral control was not always present. A good many of thesecases showed enuresis nocturni.
ENDOCRINE SYMPTOMS
Endocrine symptoms and signs were dominant throughout allthese cases, and the natural inclination of an observer familiar with this typeof disease and not familiar with the syndrome itself was at once to class thesemen as of an endocrine dyscrasia, usually as instances of hyperthyroidism. Thewriter, early in his experience in the war, was also definitely of this belief,and reported his first group of cases under the heading, "Hyperthyroidismin the recruit."50 The same error was made by many other observers, amongwhom are Caro,30 Barr,33 and Stoney.51 While a closestudy of large groups of the syndrome, especially of the instances whichdeveloped in battle, is almost certain to eliminate this idea, in many respectsit is rather well founded and one may well read into the interpretation of thedisease many factors, signs, and symptoms definitely of an endocrine type. Forthe greater part these signs and symptoms may be best grouped under the headingof "Signs and symptoms of hyperthyroidism." In a considerable numberof cases more or less goiter was present. Aschenheim31 found it in50 per cent of his cases. This was particularly evident in the cases whichpresented the well-developed syndrome on their induction into service, but itwas much less definite in the instances which developed under the stress ofservice. Most cases will respond also to the so-called Goetsch test forhyperthyroidism. Peabody, Clough, Sturgis, Wearn, and Tompkins46 founda positive response in 60 per cent of their cases, doubtful or suggestive in 10per cent, and negative in 19 per cent. Notable also was the tremor of the hands;to a less frequent degree twitching of the face and tongue.
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Dermographia was marked, and to a very large degree themental attitude of these men was similar to that of those of mildhyperthyroidism. Again, there is a definite relationship to endocrine disordersin the heredity of the cases. Analysis of this element in the mobilization campat Upton showed a very certain factor of this nature.50 Carefulstudy of large groups of the cases will, however, quite definitely indicatethat though there are certain clear indications of endocrine defect or imbalancein neurocirculatory asthenia, it is not a pure thyroid problem.
SEX CHARACTERISTICS
Beginning, as this complex does, during the period of sexdevelopment, and extending, as it does, throughout the period of greatest sexualactivity, it is quite natural to expect that these cases as a class earlymanifest certain sexual aberrations which appear to bear some definiterelationship to the complex. A study concerning this phase of the subject wasmade by Goddard52 at Camp Upton, N. Y., during the mobilization ofthe 77th Division. He found that a considerable percentage of well-marked casesof this disease had little or no normal sex instinct. Many had had no sexexperience or desires, and a considerable number presented definite perversionor sex inversion. Most of them were rather indifferent to the normal sex call,and in most who were married sexual relations were apparently more based onsentiment and emotional proclivities than on a normal sex appetite. Developmentof the genitalia was found defective in a surprisingly large number of thesemen, and only a very few showed such dominant sex craving as is the rule amongordinary virile soldiers. A consideration of this phase of the question in civillife convinced the writer as to the accuracy of these studies. Observations of asimilar trend were recorded by Aschenheim.31
Observations by the writer and by others in civil practicesuggested that the capacity for fecundation is lower in those suffering fromthis tendency than among ordinary subjects. That this phase of the questionbears a definite relation to other evidences of endocrine aberration so verymanifest in this disease seems certain.
DIGESTIVE SYMPTOMS
Among the more prominent gastrointestinal aberrations whichappear in the course of the disease, undoubtedly the most frequent and annoyingis spontaneous attacks of diarrhea, which frequently mark the more violentattacks of the syndrome. These diarrheal attacks may be followed by shortperiods of constipation. Nearly all soldiers afflicted by the permanent form ofthis disease showed gaseous eructations to a greater or lesser degree. In mostcases this symptom was accompanied by more or less swallowing of air.Occasionally acid eructations took place as in ordinary gastric hyperacidity. Asa rule, cases which were investigated in this respect were found to show more orless gastric hyperacidity. Musser14 verified this finding by hiscareful study. Borborygmi and annoying gaseous distention of the gut, especiallyof the colon, was present in some cases. The use of alkalies or washing of thelower bowel with an enema commonly gave temporary relief from these symptoms.
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As a rule these men were poor and inadequate eaters, finickyand complaining about their diet. While most cases were in thin, rathermalnourished men, there was another type of persons, who though not usuallylarge eaters, were none the less obese. As a rule, sufferers from this complexwere tall rather than short, slim rather than stout, undernourished rather thanovernourished.
RESPIRATORY SYMPTOMS
Very few symptoms of the respiratory tract were manifestedexcept those of rapid and shallow respiration. That this had no organic basiswas readily shown, inasmuch as a little training served usually to causebreathing to become absolutely normal. The shortness of breath, dyspnea fromwhich all complained most piteously, was not a true dyspnea, and it was notaccentuated by reasonable exercise except, of course, in cases in which a realcardiac exhaustion or lesion had developed.
Adams and Sturgis42 made a study of the vital capacity ofthe lungs and of the combining capacity of the blood in cases of effortsyndrome. Their study, which was conducted on a group of 100 cases, tended toshow that the vital capacity of the lungs of these men was but little below whathas been accepted as normal, corroborating the well-established clinicalobservation that these patients do not suffer with a true dyspnea, but thattheir complaint of shortness of breath is founded on a neurosis and doubtlesssomewhat dependent on early muscle exhaustibility. Similarly, this wascorroborated by the findings of these investigators that the combining capacityof the blood is found to be well within normal limits. This apparently showsthat Lewis's theory of a decrease in the buffer salts in the blood as anexplanation of shortness of breath is not well founded.
Levine and Wilson,53 on the other hand, found thatthe average vital capacity of the lungs was slightly but definitely reduced inthe severer cases of "D. A. H." They believed that the discomfort which deepbreathing brings on in these persons was a factor. Exercise, they found,considerably reduced the vital capacity of the lungs, probably due, at least inpart, to fatigue.
Drury54 found that the percentage of carbon dioxide in thealveolar air, taken at rest, is within the lower limits of normality, or isdecreased in these cases. The reaction of the alveolar carbon dioxide pressureto exercise is similar to and of the same order as that found in the healthysubject. The time during which the breath could be held is much less than inhealthy subjects. The percentage of carbon dioxide in inspired air whichproduces intolerable hyperpnea is below normal, except in very mild cases.
A certain number of these men were held under the suspicionof being tuberculous. This diagnosis has usually been considered because of thegeneral build of the man, from his asthenic attitude and improper carriage, andfrom his easy exhaustability rather than because of suspicious pulmonary signs.Quite naturally low stamina, particularly against the infections, is clearly acomplication and not a part of the disease itself. These men appeared also to beparticularly susceptible to pulmonary infections of all sorts to bronchitis,pneumonia, and to the effects of the war gases.
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NERVOUS AND MENTAL SYMPTOMS
Nervous and mental symptoms are very important in thesyndrome. Few cases are free from this group of symptoms, which, to aconsiderable extent and in many instances, entirely dominated the case. Roughly,from a mental standpoint, one may group all the cases under two heads. Thelarger group is composed of men who are hypersensitive, neurotic, imaginative,often to the point of genius-all were unstable in a nervous way. Thesesoldiers are quick in perception, overly intelligent in many ways, but tooimaginative to permit them to become made over into stable line soldiers. Yetthese very characteristics made them often very desirable as bandsman, clerks,stenographers, and the like. Several officers of brilliant records weredefinitely of this classification, and there can be no question but that in somecircumstances the very defects which are part of this disorder becomeattractions increasing efficiency under special demands and circumstances.
The other group was composed of excessively dull individuals.Most of the individuals of this group were of the heavy, obese type, slow andweak in physical effort, and puerile and illogical mentally. Many were large,ill-shapen, and strongly suggested hypothyroid types, or pituitary individuals.The last material was valueless for any military purpose; they became so quickly exhausted that they were useless for labor purposes; they were notsufficiently intelligent for line duty, even had they had the physical or moralstamina demanded of the good soldier; they were not sufficiently teachable evento learn any less complex duty, and at the same time they possessed all thenervous instability of the first-mentioned group. They would become hystericalon the slightest provocation and were subject to attacks of melancholia anddepression which made them a nuisance in any position, a very positive detrimentto the whole Military Establishment. Associated with these characteristics andpresent in both groups was an intense sense of apprehension, a fear complexwhich in men of a higher type was controlled and often conquered by a sense ofduty, patriotism, and self-sacrifice, but which, in the lower classification,made these men of a particularly difficult type to adapt in the militaryorganization. Of this obese, pituitary-hypothyroid type was composed aconsiderable list of "conscientious objectors," their objection beingprimarily based on a fear complex, but in a so low-grade mentality that onecould not question their honesty. Of this type also were many of the so-called"religious" type of objectors.
Among the numerous nervous disturbances associated in thedisorder are various tics, tremors, twitchings of the face and extremities,strongly suggestive at times of chorea, and sometimes a disseminated sclerosisis closely simulated. Sbrocchi55 emphasized the importance of tremor of theeyelids when the eyes are closed, and directed attention to an attenuation ofthe conjunctival and pharyngeal reflexes. As a rule all the normal reflexes areincreased, the knee, ankle, wrist, and arm jerks are especially exaggerated, andthere is a hyperexcitability manifest in practically all reactions. The frequentassociation of hysteria in these individuals is very striking. Exaggeration is amental trait of these persons, so much so that little trust could be imposed onthem, notwithstanding the honesty of their desire.
Sleep, in sufferers from neurocirculatory asthenia, iscommonly fitful and insufficient. Many patients are haunted by dreams which moreor less visualize
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the worries and stresses of the day. Yet soldiers are morethan ordinarily dependent upon sleep and rest, and no doubt a considerablefactor contributing to the break of these men under battle condition is loss ofsufficient sleep.
Closely associated with the nervous manifestations of thedisease is a condition of asthenia, or early exhaustibility, which was evidentin every branch of activity, mental or physical. The researches of King,56 usingthe white vasomotor reaction of Ryan, indicate the rapid and profound exhaustionin the subjects of this disease. The fatigue, in his opinion, may thus bemeasured, and is of actual physical nature and not purely of psychic origin.These studies tend to corroborate the clinical observations concerning thedisease in the early studies of Da Costa. Few of these men would attemptanything in the nature of competition in physical sports; or if they did, theywould quickly develop inaccuracy in physical or mental judgment, breathlessness,pain in the heart, and great muscle uncontrol. The gait, as a rule, was weak andshuffling, like that of a person convalescent from some grave disease. Evenmental effort caused a degree of prostration altogether out of proportion, whilethe intense emotional episodes, such as anger, were followed by a very profoundreaction. In subjects who have broken under stress, and in a limited number ofspontaneous cases, exercise gradually introduced and intelligently supervisedgreatly increased endurance and strength. This effect was particularly manifestin some of the training battalions and was very evident to us in the basehospital at Camp Upton, where, for a short time, we were able to carry out testsof this character.
Mabon57 made a study of early exhaustibility inneurocirculatory asthenia in a group of 50 well-established cases. Theindividuals were subjected to as severe work tests as they could be induced toundergo. Pulse and blood pressure studies were made. It was definitely shownthat the amount of work which they could do without exhaustion was much belowthe normal. The pulse and blood pressure studies did not, however, indicate anyabnormal myocardiac exhaustion. This study substantiates our clinical contentionthat the early exhaustibility of these cases is not dependent on cardiac defectsbut on general muscular and nervous deficiencies.
Laubry and Esmein58 often observed a tendencytoward hyperthermia in cardiac irritability. The tendency is not marked, andonly slight thermic shifts take place from time to time. It occurs mostly inpersons who have indulged in some kind of physical or mental activity justbefore the temperature is taken. An hour in bed causes it to disappear. Theywere unable to connect this phenomenon with any present or subsequent infection,or with tuberculosis. Aubertin59 reported similar observations.
An important picture, not of great military occurrence, butwhich appears quite frequently in neurocirculatory asthenia in civil practice,is seen in attacks of syncope in which consciousness is completely lost.24,60 These attacks simulate epilepsy quite closely and are very frequentlymistaken for it. Because of this confusion with epilepsy, very few individualswho suffer from this particular symptom are admitted to the military service.Either they are rejected because of the history of the attacks or, if attacksoccur in recruit barracks, the man is promptly rejected, usually under thediagnosis of epilepsy.
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DIAGNOSIS
Diagnosis depends chiefly on tachycardia, associated withpalpitation, heart consciousness, precordial distress, and the very unstableneurovascular reflexes. Sweating, cyanosed or ischemic extremities, all of whichdevelop under emotional rather than physical stimuli, are further diagnosticpoints of very similar origin. The presence of these conditions without adequatephysical explanation are most suggestive. Emotional and nervous instability,fear complexes, hysterical manifestations, tremors, and more or less vagotoniaare the chief nervous phenomena of diagnostic value. Some diagnostic assistancemay be afforded by the hereditary factors and some by the sexual inadequacieswhich are likely to be present. Some stress may be justly laid on the physicaltypes mentioned, on early exhaustion, and especially important diagnostically isan otherwise unexplained and always dominant asthenia.
The picture of hyperthyroidism may or may not be present. Itis usually demonstrable in the spontaneously developed instances, but oftenentirely absent in those which have developed under stress. It will be noted,thus, that the most striking diagnostic signs are apparent on inspection andfrom the history of the patient, developing, as it is almost certain to do, astory of various inadequacies.
Careful physical examination, showing, as it will in mostcases, largely negative findings, is very important, particularly since itsnegative character excludes the other conditions, tuberculosis, purehyperthyroidism, and diseases of an exhaustive character, such as gastric orduodenal ulcer or neoplasm, which are most likely to be confused with thesyndrome. In other words, diagnosis is by exclusion. Fleuroscopy has also beenfound to be a very helpful diagnostic method, not only because of itsvalue in excluding disease of an organic nature, but also because thehypoplastic and often drop type of heart is most readily demonstrated by thismethod.
Snap diagnosis is a very dangerous procedure in these cases,tempting as the method is in military practice. When the list of serious organicdisease conditions which may be readily confused with this syndrome isconsidered, the necessity of careful study is fully apparent. One must recallalso the frequency with which serious secondary conditions, especially theinfections develop in the course of the disturbance. From a militarystandpoint, however, diagnosis, in so far as value to the service is concerned,is far from difficult. Except for highly specialized types of service, and onlyin exceptional instances otherwise, these subjects are undesirable for militaryduty, and the best procedure is their early elimination.
PROGNOSIS
Prognosis, from the military standpoint, does not seem to bea matter of very great difficulty or importance. With few exceptions menaffected primarily by this syndrome are not suitable for line military duty.Depending on the type of the disease and on the degree, selected individuals,however, may be often most advantageously employed in the MilitaryEstablishment. Bandsmen of the better type are comprised in considerable part oftypes either with the syndrome fully developed or likely under the stress ofwar conditions
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to develop it. If they are not of such a degree as would belikely to fail and to become a charge on the Military Establishment, they maycontinue in this capacity with full degree of efficiency. They may also beemployed in clerical positions, as stenographers, in the rehabilitationactivities, and in very many office positions for which their previousoccupations may have particularly fitted them. They should always be excluded,however, with the greatest possible care from positions in which cool judgment,endurance, and powers of analysis are requisites.
In creative and imaginative channels their efforts arefrequently of extraordinary value. They are not, however, a dependable militarymaterial. To a certain degree the same general facts must pertain in civil life,but under ordinary civil conditions curative progress is largely possible,particularly if the man may be kept under proper mental and occupationalenvironment. The prognosis as a whole is far better in the acquired cases thanin those in which the condition has developed spontaneously or from certainhereditary traits.
Very much in prognosis depends on environment and on thecooperation of the patient. In instances which have developed as a result of warstress obviously rest is the chief essential, and the same is true when for anyreason the heart muscle has become seriously compromised. Obviously, then,prognosis may depend essentially on the possibility of securing rest. In thecongenital cases, or those which have broken under the stress of ordinary life,more depends on a suitable environment and on adjusted training. On thepossibilities of these hangs prognosis. Briefly, the military value of eitherclass is very limited and circumscribed. Their increased vulnerability to allthe infections and to shock of all kinds, and their natural limited duration ofefficiency and life, must be always considered.
TREATMENT
From a military standpoint the first step in the treatment ofthis condition is the elimination from line duty of all except the veryexceptional soldier, particularly officers whose experience or service hasjustified the hope that they may again be able to stand the full rigor ofmilitary duty. Even these men should be selected mostly for training purposes,rather than for actual line service. From the remaining group should then beselected men who, because of their special training or education, are peculiarlyqualified for some particular service with troops and who are not so severelyaffected as likely to become a charge on the service. Among such men may bementioned musicians, draftsmen, clerks, suitable for quartermaster or otherclerical positions, men trained in telegraphy, telephony, or other work of valueto the special corps, stenographers, typists, translators, and cooks. No men notspecially qualified should be selected for duty with troops. Next are to beselected men whose training especially fits them for duty with the services ofsupply, such as clerks, stenographers, architects, carpenters, plumbers, andsimilar craftsmen, printers, classification and quartermaster clerks,storekeepers, bookkeepers, chemists, artists, and any other whose specialservices might be found of particular value.
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Among neither of these groups should advanced cases of thesyndrome be permitted, for the stress in any of these positions might at anytime become so great as to cause a break, and so possibly incommode necessaryroutine. All other recruits showing this complex should be promptly dischargedjust so soon as a tentatively correct diagnosis has been arrived at.
Where line soldiers have broken down with the condition underservice stress, after adequate treatment in base institutions they should bereclassified and assigned to base or other similar duties. The experience inpractically all armies has shown the inadvisability of returning these men tocombatant organizations, and for the greater part discharge and return tocivilian activities is the better in so far as the Army is concerned.
When for political or other reasons, initial cases of thesyndrome are required to be held in the Army, recognizing that this is from astandpoint of military efficiency an expensive, unremunerative, and entirelyinadvisable procedure, they should be organized into companies or battalionsunder the command of junior medical officers who are well familiar with bothprofessional and general military life and procedures. A temperate but firmmilitary discipline should be maintained in these organizations, and they shouldbe graded in so far as possible so that severe instances are not grouped withthe milder types of the disturbance. A promoting system from the more severelyaffected companies to the less disabled ones should exist, and the constant hopeand expectation of eventual full military duty should be held out to these men,although of course this is practically not a probability.
These men should be drilled in the school of the soldier, thelength and type of the drill being adjusted to the possibilities of the company,and an attempt should be made to constantly, though very cautiously, increasethe work. Meantime each man should be selected and classified for some specialduty which he might subsequently take over after a preparatory course oftraining. It was found very important in the treatment of these groups at CampUpton to constantly hold before the men that they were to be considered assoldiers under training. They must live under military conditions, as closelysimulating those of the regular battalion as possible, and minor military dutiesand ceremonies may be undertaken by the more advanced classes. The definiteimprovement in self-respect and general morale under such conditions is verymarked. In the treatment of this class of cases an appeal to the spiritual andmental attitude of the patient is necessary. Very close individual attention maybe exercised by the medical officers in command of these training battalions.The food must be selected with greater care than is necessary in regular linetroops, and greater care is necessary in its preparation. The bowels must bekept well opened, comfortable sleeping quarters must be provided, and regularityin every respect must be especially insisted upon. All foci of infection must beeliminated and all secondary disease processes must receive treatment. Tobaccoand alcoholics are permissible in temperance only.
Experience has shown that a real military r?gime is far thebest in any large concentration camp, but particular discretion must beexercised in all disciplinary measures, and chronic offenders should behospitalized as being in a way irresponsible. All cases of this kind should besent to the psychiatrist.
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He will find very much material of this unstable character inthese groups. Initial cases which require hospitalization, either because oftemperamental vagaries or because of physical inadequacies, should be dischargedfrom the service as soon as possible.
Medicinal treatment in initial cases is a failure except asdrugs may be employed for the mitigation of transitory conditions or forsymptomatic reasons. As a rule, digitalis, even given in massive doses, affectsthe action of the heart little or unfavorably. The same is true of other cardiacstimulants, while strychnia, caffeine, and similar drugs almost invariably makethe condition worse rather than better. Sedatives act much more satisfactorily,and since protracted employment is to be expected if any benefit is conferred itis necessary for this purpose not to employ, except for very transitory use,drugs of the opium group. Bromides act very well in many cases, but sooner orlater lose their beneficial effect if long employed. Luminal has been used withgood effect. No drugs, in our experience, have conferred other than transitorybenefit. The use of various endocrine preparations in early cases admits of acomplete theoretical justification. In cases associated with obesity small dosesof thyroid cautiously employed has acted well, especially if associated withpituitary preparations also. Stoney51 claimed good results from X-raytreatment of the thyroid. Various preparations of the sexual glands have alsobeen recommended, and their use is at least apparently without any detrimentaleffect. If associated with close supervision of the case, particularly withcontrol of physical and mental activities, excellent effects are to be expectedin early cases from the treatment of this syndrome along endocrine lines.Hospitalization of initial cases is to be avoided, except when absolutelynecessary, but in some instances it has given excellent results. Great care inhospitalization cases must be exerted to prevent the development,intensification, or fixation of various phobias. It must be particularlyinsisted upon throughout that the disease is not one of the heart.
The treatment of cases which have developed under the stressof service is distinctly a military problem, and such cases should not bedischarged, at least until they have received the maximum benefit possible undertreatment. The degree to which this may be attained depends not only on theseverity of the breakdown and on the status of the patient, but also verylargely on the character of treatment which he receives and especially on theintelligence and vigor of the early management of these cases. The firstessential is rest. This should be made as complete as possible, and ifpracticable the patient should be evacuated back at least out of the army zonejust as soon as it can be safely accomplished. Sedatives should be employed,and such as will control the nervous manifestations present should be promptlyused to their therapeutic effect. Later the more powerful ones should bereplaced by less powerful drugs, but the effect desired should be attained. Onlywhere doubt exists as to the integrity of the heart muscle should digitalis begiven. The ice bag may be placed over the precordium, where it relieves eitherthe pain or the tachycardia. The patient should in all possible cases be put tobed in as quiet surroundings as possible. He should be relieved in so far aspossible from military discipline for the time being, and where it is possibleto evacuate him to home hospitals
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this should be done, but he should be held under militarymedical supervision and treatment. After a rather protracted period of resttreatment he should be slowly relieved from hospital restraint, though not frommedical supervision, and as soon as the cardiac and nervous symptoms permit heshould be advanced to graduated exercises and finally to the trainingbattalions, through which a gradual restoration to normal military life may beattained. He should not, however, except under very exceptional circumstancesand through military necessity, or because of some especially valuablequalification, be returned to line duty, but he should be reclassified andassigned to such service as he may be particularly fitted for, preferablywithout the active army zone.
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(13) White, Paul D.: Cardiac Neuroses. Journal of Nervous and Mental Disease, Albany, 1920, lii, No. 1, 241.
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(35) Spiller, William G.: The Soldier's Heart, or Irritable Heart, Cardiac Symptoms in Recruits and Soldiers. The Soldier's Heart and the Effort Syndrome. Progressive Medicine, Philadelphia, Lea and Febiger, September, 1917, 86.
(36) Lewis, Cotton, Barcroft, Milroy, Dufton, and Parsons: Breathlessness in Soldiers Suffering from Irritable Heart. British Medical Journal, London, October 14, 1916, ii, 517.
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(38) His, W.: Erm?dungsherzen im Felde. Medizinische Klinik, Berlin, 1915, xi, 293.
(39) MacIlwaine, J. E.: A Clinical Study of Some Functional Disorders of the Heart Which Occur in Soldiers. Journal of the Royal Army Medical Corps, London, 1918, xxx, 357.
(40) Smith, Bertnard: Teleroentgen Estimations of Heart Size in Cases of Effort Syndrome. Archives of Internal Medicine, Chicago, May, 1920, xxv, 532.
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(42) Adams, Frank D., and Sturgis, Cyrus C.: Note on the Vital Capacity of the Lungs and the Carbon Dioxide Combining Capacity of the Blood in Cases of "Effort Syndrome." American Journal of the Medical Sciences, Philadelphia and New York, 1919, clviii, No. 12, 816.
(43) Levy, A. Goodman: The Red Cell Count and H?moglobin Content of the Blood in Disordered Action of the Heart. British Medical Journal, London, December 1, 1917, ii, 715.
(44) Briscoe, Grace: The Leucocytes in Cases of Irritable Heart. Lancet, London, June 2, 1917, i, 832.
(45) Laubry, C., and Esmein, C.: ?quilibre leucocytaire et instabilit? cardiaque. Bulletins et M?moires de la Soci?t? M?dicale des Hopitaux de Paris, Paris, February 7, 1919-xliii, 115.
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(47) King, John T., jr.: Fatigue in Irritable Heart and Other Conditions. Archives of Internal Medicine, Chicago, April, 1919, xxiii, 527. Also: Auscultatory Phenomena of the Heart in Normal Man and in Soldiers with Irritable Heart. Ibid., July, xxiv, 89.
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(48) Molle: Les bruits veineux f?moraux et le syndrome "cour irritable du soldat." Le Bulletin Medical, Paris, September, 1918, xxxii, 391.
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(50) Brooks, Harlow: Hyperthyroidism in the Recruit. American Journal of the Medical Sciences, Philadelphia and New York, 1918, clvi, No. 5, 726.
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(53) Levine, S. A., and Wilson, N. F.: Observations on the Vital Capacity of the Lungs in Cases of "Irritable Heart." Heart, London, July 29, 1919, vii, 53.
(54) Drury, Alan N.: The Percentage of Carbon Dioxide in the Alveolar Air and the Tolerance to Accumulating Carbon Dioxide, in Cases of So-called "Irritable Heart" of Soldiers. Heart, London, April, 1920, vii, 165.
(55) Sbrocchi, Aristodemo: Come si diagnostica la nervrosi del cuore? Revista Critica di Clinica Medica, Florence, 1919, xx, No. 4, 37.
(56) King, John T., jr.: Fatigue in Irritable Heart and Other Conditions. Archives of Internal Medicine, Chicago, April, 1919, xxiii, 527.
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(58) Laubry and Esmein: Sur quelques anomalies de la courbe thermique dans l'instabilit? cardiaque. Bulletins et M?moires de la Soci?t? M?dicale des Hopitaux de Paris, Paris, May 2, 1919, xliii, 376.
(59) Aubertin, Ch.: Les cardiaques du Front en 1917. Pr?sse Medicale, Paris, 1917, xxv, No. 44, 451.
(60) Brooks, H.: Syncope in Neurocirculatory Asthenia. Transactions of the Association of American Physicians, Philadelphia, 1924.
