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Chapter XXI

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 constitute a syndrome to which various names have been given. The term "neurocirculatory asthenia" was accepted for it by the Surgeon General in 1918.1 There can be little doubt but that the symptomology is best described under this name. MacFarlane2 proposed the name "Neurocirculatory myasthenia," which possesses all the disadvantages of the official term without being so inclusively correct. While the "effort syndrome" described by Lewis3 may conform to the type of the syndrome recognized by British observers, it falls far short of describing the form chiefly seen by us, in which the condition was usually well established before any unusual military effort had been demanded. The still more unsatisfactory term of "disordered action of the heart," briefly known, after the British manner, as "D. A. H.," long held its own in the British service, but it is extremely inadequate in every respect.

The term "irritable heart," originally proposed by Da Costa,4 is perhaps the best of the shorter names applied to the condition. This, however, definitely suggests that the disorder is essentially a cardiac one, which it certainly is not, and the further modification of this term, "the irritable heart of the soldier," is even less desirable, since the condition occurs alike in civil and military life, except that the complex becomes most apparent and perhaps most disabling under military requirements.

Many other terms, variously applied to the condition, the "nervous heart," the "hyperthyroid heart," "shell-shock heart," and the like, are most unsatisfactory, in so far as defining the condition is concerned. Unfortunately, before and during the World War the condition was reported under all sorts of headings, depending very largely on the degree of misunderstanding of the condition which existed in the mind of the author. This so confused the classification of the subject that it is quite impossible 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 officially adopted by the Surgeon General incorrect recognition made it impossible to form a correct appraisal of the universal occurrence of the condition. The unfortunate failure of most authors of textbooks on medicine to recognize the condition at all resulted in a very inadequate appreciation, in both civil and military practice, of the importance of the syndrome.

PRE-WAR OCCURRENCE

Most of the early references to the condition now known as neurocirculatory asthenia are to be found in American literature, especially in that based on experiences during the Civil War. Thus, in the official Medical Department history of that conflict one finds the following important statement under 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 irritable heart or cardiac muscular exhaustion was the most notable production of the war." Da Costa studied a series of 300 cases of this disease in his hospital at Turners Lane, Philadelphia, whither cases of this condition were referred for his observation.4 Smiley found that cases of this type which he studied at Hilton Head, S. C., occurred chiefly in every young man of feeble constitution, probably taxed beyond their strength.6,7 McKelway6 said of the condition as it appeared during the Battle of Williamsburg: "Disease of the heart appears to have been developed in several cases from overexertion preceding the battle and excitement and effort during its continuance." The text of the history5 goes on with the statement that "Overaction of the heart during an engagement was due perhaps as much to nervous excitement and anticipation of danger as to overexertion."

Hunt is quoted as saying concerning the name "irritable heart"7: "The term is a misnomer; yet, as I have already shown, it was employed in 1,200 certificates of disability. In all cases the objectionable phrase described a heart far too rapid in its action, the pulse ranging from 120 to 150, frequently attended by dyspnoa, vertigo, or syncope, but revealing no abnormal sounds either on percussion or auscultation. The convenience of this collocation of words was perhaps the strongest reason for its employment. It saved an extended historical notice of each case upon the limited space of the certificate of disability. In reality these were cases of disturbance of the function of the heart dependent upon causes foreign to the organ itself."

A full recognition of the condition as distinct from that of dilatation 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 of the heart, incident to military service, in the hospitals at Keokuk, Iowa.7, 8

Nothing better has ever been written concerning the subject than the contributions by Da Costa,4 Hartshorne,5,9 and of Stillé,10 all names since famous in American medicine. None of the studies originating from the World War have added materially to the clinical description furnished by them. Only the advance of medical science as a whole has contributed viewpoints essentially improving or modifying the understanding of the condition as expressed by these observers. The heart sounds and murmurs which occur in this syndrome have never been so accurately or graphically described as by Da Costa, so that nothing further need be said of them. The essentials of successful treatment are also outlined in this remarkable contribution as definitely as in any of the more recent studies of the syndrome.

Furbinger11 mentions the occurrence of a similar condition in the German Army in the campaigns of 1870-71, and Wilson12 calls attention to the fact that in 1864 the British Government appointed a committee to investigate the subject, and particularly the relationship which the equipment of the soldier might bear to its occurrence. This last subject had been already carefully considered by the medical officers of our own Army in the War of the Rebellion. White13 goes so far as to state that the condition was old as the study of medicine, and that it was described by Hippocrates, Galen, and other ancient masters.


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OCCURRENCE IN THE WORLD WAR

The great importance of the subject as it appeared among our recruits was very early apparent, as indicated by the numerous communications and articles which immediately began to appear from almost all mobilization centers. It is very regrettable that professional unfamiliarity with our own military medical history led to so much loss of time and effort before an adequate understanding of the subject was reached by the average medical officer.

During the entire period of the World War, neurocirculatory asthenia was one of the most frequent causes of rejection and of disability. The degree to which this was true can not be appreciated adequately from statistics collected by the Surgeon General's Office, due largely to the diversity of diagnosis of the condition in the early stages of mobilization, noted above, and the lack of proper classification. Even after the disease was fairly well recognized by medical officers, it was so infrequently grouped under the single term, neurocirculatory asthenia, until well into 1918, that the available statistics for the Army as a whole give but a very meager picture of the problem during mobilization.

Musser,14 after a study of 424 cases of tachycardia from the 38th Division, classified these cases, etiologically, as myocardial, 69 cases; hyperthyroid, 9 cases; neurotic, 180 cases; nervous (emotional), 28 cases, and toxic, 36 cases. This probably gives a fair estimate of the relative occurrence in most divisions in which the condition was carefully studied by competent medical officers. No valuable estimate of occurrence in draft boards and mobilization recruiting stations is available. It was certainly very great.

AGE

The syndrome is notably one of youth and early adult life. Its appearance has been noted in children, usually in the offspring of nervously defective parents,15 but it is most notable in about the years of military service. Ceconi16 found in the Italian troops that most cases occurred between 19 and 25, a few were observed over 25, but none over 30. This corresponds pretty closely with the writer's observations, except that in groups of older soldiers, for the greater part officers of the various corps, frequent cases were found over 30 years of age. In civil life it occurs in much older persons, though still most prevalent and disabling in the late teens and early twenties. This fact admits of the simple explanation that in civil life by the time individuals reach 30 years of age they have either succumbed to some disease condition, to which these persons are particularly prone, such as the infections, or they have adjusted their conditions of life to their physical capabilities to such a degree that they are able to carry on fairly effectually. Under such favorable conditions many cases go on to substantial cure, and even when submitted finally to the rigors of military life, as was the case with many reserve officers and volunteers, they were then able to hold the symptomatic picture in abeyance.

Every practitioner who has carefully studied the condition in civil life recognizes that it is quite as frequent here as in the Army, though less apparent, usually because of the greater possibilities of adaptation permissible under civil as compared with military conditions. This observation was emphasized


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by Neuhoff.17 Schlesinger,18 on the other hand, from his experience in a cardiac hospital near the front, believed that he could show a lower occurrence of real cardiac disease in the Army and a proportionately higher appearance of the nervous forms. Fully one-fourth of this class of cases, however, had suffered from the condition prior to mobilization. The writer's own experience led him to feel that the occurrence in the Army was precisely similar to that in civil life except that the rigors and restrictions of military life often caused the syndrome to become apparent, where it might have remained in abeyance under civil conditions.

SEX

As a military disease the complex is naturally seen mostly among men. This is due to the fact that women in the military personnel are so relatively few in number, and, to some degree, because certain of the dominant traits of the complex, while always noteworthy in men, would hardly be remarked in women, in whom one accepts certain emotional instabilities as normal feminine reactions. In nurses and other groups of women engaged in the more stressful theaters of warfare, as in mobile operating units, evacuation hospitals, shock and operating teams, and the like, the occurrence of the complex appeared to be about the same as in men. In civil life the writer's observations have led him to feel that sex in itself plays no real rôle in the determination of occurrence especially when women are subjected to the same rigors of life demanded of men, which in all instances cause the disease to become most apparent.

RACE

As observed at Camp Upton, N. Y., during the mobilization of the 77th Division, there was a very definite racial influence apparent in the occurrence of the disease. From a special study of this racial influence at Camp Upton, it was found that the syndrome occurred far more frequently among the Hebrews, notably among the Russian Jews, than among other races. Next in occurrence came those of Italian birth or origin, then the Irish, the Americans, the English, Scotch, German, and, last of all in point of frequency of occurrence, the negro. In an entire brigade of negro troops mobilized at Camp Upton and largely selected from the adjacent territory, but augmented by several small contingents from the Southwest, but one case of clearly defined neurocirculatory asthenia presented itself at the base hospital during the writer's service there. Cases were seen by him in the field hospitals operating with the 92d Division in France, but they were definitely less in number than developed among usual white troops. The complex would then appear to bear a very definite relationship to the emotional status of the various peoples. Roughly speaking, one may say that the greater the emotional status of a 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 to the physical types; and while to a certain extent study of large groups appears to bear this out, it will be found much nearer the truth to make such a distinction on an emotional rather than an intellectual basis.


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HEREDITY

Hereditary influences are definitely traceable in most instances. Conner,19 in his analysis of cases rejected for cardiac defects, mentions the not well-recognized fact that constitutionally inferior recruits suffered mostly from this complex. The relationship of this status to hereditary influences is fully established. Clerc and Aimé20 21 emphasized constitutional predisposition. Oppenheimer and Rothschild22 stated positively that there is a definite family history of factors predisposing to the psychoneuroses in most cases. They particularly urged the importance of a fundamental inferiority in the development of the complex. Robey and Boaz23 were of like opinion. While the establishment of this important fact was often very difficult in the stress of mobilization and military activity, the writer has been amply able, from a study of the condition in civil life, to completely establish heredity as a very important determining factor. One or both parents show, usually, traits of nervous or endocrine instability of one sort or another. They may be hysterical, hyperthyroids, neurasthenics, hypertensives, insane, or they may, like their offspring, show the manifestations of the complex itself. A definitely obvious hereditary influence of instability of some sort is almost always obtainable of the nervous, endocrine, or circulatory systems.

GEOGRAPHICAL DISTRIBUTION

Study of the statistics from the Surgeon General's Office throws no apparent light on this question, but the syndrome appears to be more frequent in urban as compared with rural populations, and of course the racial influences already mentioned play a rôle 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 without notable exception successful men suffering from neurocirculatory asthenia are found in the ranks of mental in contradistinction to physical occupations. Marshall24 called attention to the fact that nearly all cases had neglected athletic training and had followed sedentary occupations, as the writer believes through necessity rather than through choice. As a rule it will be found also that when persons suffering from this condition are engaged in laborious occupations they are failures to a greater or lesser degree. On the contrary, many of them stand very high in the professions and in occupations in which dominant mental or emotional characteristics are qualifying rather than otherwise. This was particularly manifest in the National Army draft. In divisions, for example, the percentage of cases found among bandsmen was much higher than in the infantry or mounted forces. The same status was noted in most of the allied forces. Thus Thomas25 reports as follows on 1,000 cases under his observation: "Light work, 25.6 per 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; Army and marine, 5.5 per cent; undetermined, 2 per cent." In civil life the very frequent occurrence among successful musicians, artists, actors, writers, and similar classes is striking and to a very convincing


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degree emphasizes the association of the complex with emotional activity. For the most part those engaged in physical occupations found to be afflicted with the status were almost without exception inferior or ineffective workmen. Where it was possible in the assignment of soldiers to take cognizance of these tendencies, often men entirely unable to undergo the stress of 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 of soldiers who were unable to carry on in line duties were most effectively employed in positions in the rear, as in the Services of Supply. This selective tendency has been manifest in sports. As a general rule, in both military and civil classes, it is found that few of these individuals are found, as, for example, in colleges, on football or baseball teams. On the contrary, as a class subjects of this condition, through obligation or by selection, elect sports demanding more emotional and temperamental, rather than physical, prowess. While unable as a class to endure prolonged physical stress, some excellent tennis players, golfers, and the like must be included as belonging to this classification.

RELATION OF OCCURRENCE TO MALINGERING, "CONSCIENTIOUS," AND OTHER "OBJECTORS," AND TO COWARDICE

Neurocirulatory asthenia is manifestly a disease of the emotionally unstable. It is to be expected, therefore, that it would be found associated 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's observation it has shown little or no relation to malingering. Malingering is a condition certainly associated with definite tendencies, and it is no more frequent among those suffering from this disease than in any other class, social or physical. Conscientious objectors present a quite different question. Inasmuch as this class of genus hominis can be divided roughly into those more or less mentally or morally defective and those of a criminal type, it will be thought natural that in the first classification more than an ordinary percentage of endocrine aberrations will appear from the close association of neurocirculatory asthenia to such disorders. Our observations at Camp Upton amply substantiated this surmise in so far as those who based their lack of willingness for service on real religious belief or on emotionally based theories of other varieties. This was notably true of hyperthyroid types that constituted a high percentage of enthusiasts of all varieties. As to the more frequent criminal type of "objector," no particular relationship to the complex appears to exist. Evasion of service was naturally attempted by some individuals suffering from neurocirculatory asthenia; but, in so far as the writer's observation goes, fully two sufferers from this disorder were attempting subterfuge to enter the service to one who was attempting to evade it. While doubtless frequently of an emotionally unstable character, cowardice was by no means notable among neurocirculatory asthenics, and decorations for particularly courageous service were awarded in several instances in the writer's observation to outspoken examples of this disorder.


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ETIOLOGY

After the economic and military features, the chief interest in 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 purely civil practitioners in regard to the syndrome. It has been rated and described almost exclusively as appearing under conditions of military activity. It is very obvious that the condition appears as a dominant problem only under conditions of mobilization, or of great emotional stress. It seems fair, then, to assume primarily that emotional stress and excitement bear an important rôle in the evolution of the complex, notwithstanding its great civil occurrence.

One of the most striking features which was apparent to every student of this condition in the United States was the marked difference in the conditions under which these cases developed in the camps of mobilization in this country, as compared to the published accounts of the conditions, particularly as they appeared in British literature. In so far as one may judge from the British accounts, cases of the syndrome appeared practically only, or certainly most frequently, in men after the stress of battle experience. In this country, in practically all of the mobilization camps, it was found as a very frequent 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 itself could have had no possible bearing on the condition, unless it be through the highly emotional tension which prevailed in our society at large during those times.

Perhaps to a considerable degree this emotional tension was a result of the excitement and emotional cataclysm which attended enrollment and departure from home to the training camps. Large numbers of these men were found at the very first examination to be entirely unfitted for military service of any kind, and were forthwith discharged or sent to the base hospitals for treatment and observation. Clinically these cases, none the less, completely resembled those which developed under the stress of service, except that the British reported almost unanimously that rest gave great relief in their cases which had developed under heavy service conditions, while in our cases little or no improvement took place under rest treatment in the mobilization areas. Observation later on of our cases which also broke under the stress of active war operations proved abundantly that the British observations were entirely correct, but that these cases represented minor or undeveloped degrees which broke under military stress, while cases which manifested the disease before any real 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 cases which appeared so numerously in our mobilization camps and those which subsequently appeared in men who had stood reasonably well the strain of mobilization but who broke under battle stress. Between these two classes lies another smaller group which broke under the weight of military training. Many or most of these men were able to carry on in a very satisfactory manner if transferred to less arduous duties, as to the band, to clerkships, or to domestic quartermaster duty. Some who had borne the stress of training poorly as enlisted men were able to get on very well as noncommissioned and commissioned officers.


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It must not be supposed from this statement that the condition was unfamiliar in the commissioned personnel. It is the writer's observation that it was relatively quite as frequent among officers as among enlisted men, and the number who eventually broke was probably relatively as large, though perhaps not quite so manifest because of the class pride which caused the officer to fight off the tendencies perhaps with more determination than was exercised by the average enlisted man. During the period of collapse there was no essential difference between the various types of the disease where it developed as a result of battle service, or was manifest on enlistment. The former, however, offered a much better prognosis as to ultimate result. Some of the cases which developed under the sudden weight of training were able to recover and finally to return to satisfactory but more gradual training. This was especially true of persons who had been taken suddenly from sedentary pursuits to be placed at once under the severe physical exactions of military training.

Throughout it was noted that the emotional type of recruit was that which suffered most acutely. Phlegmatic men were far less prone to break, and yet it must be conceded that it is from the former class that many of the best soldiers were developed. Somewhat similar epidemic forms of the complex become manifest, for example, in schools and colleges at the time of examinations and the like. The disease is definitely not a military one, then, but one which becomes only more numerically manifest during war, because of the selective character of military service and of the existing conditions which now become necessarily more insistent than is the case under mere civil life.

Certain observers, among them Lewis,3 pointed attention to the probable rôle of the infections in the genesis of the condition. It can not be disputed that infections which, among many other factors, lower the resistance of the body against any pathological process may act as an exciting or precipitating factor, but it is extremely improbable that they have any direct etiological rôle in the development of the condition. Briscoe and Diamond26 conducted a series of experiments to determine if bacteriemia was present, but met with negative results. There is no definite evidence in favor of this theory except the frequent associated occurrence of the infections with the disease. It is conceded, however, by most writers that the existence of the syndrome greatly lowers resistance against infections, and the observation of the writer corroborates the almost universally conceded point that patients with this disease have a much lowered resistance against certain specific infectious processes, as tuberculosis.

Musser14 pointed out that soldiers who had been gassed were particularly prone to develop neurocirculatory asthenia, and a great many other similar factors, undoubtedly also through lowering of general resistance or through abnormal production of exhaustion, act similarly. Forced marches, heavy firing, and the general commotion and unrest of the front, as pointed out by Thomas,25 are also undoubted predisposing but not causative factors. Attention has long been directed to the possibility of predisposition being excited by unaccustomed physical effort with the production of severe degrees of exhaustion. During the Civil War and again in the World War, attention was directed to the possibility of uncomfortable uniforms, too heavy and improperly adjusted


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equipment, and the like, being factors in the induction of the syndrome, but again these must be considered as predisposing and not elementally etiological factors.

Tedeschi,27 among others, has drawn attention to the well-accepted fact that digestive disturbances induced either by unaccustomed or improperly prepared food, might be a factor of inductive nature. Clerc and Aimé (P)21 mention the effects of the excessive use of tobacco and of alcohol in the production of the disease. Merkel28 even states that it was found more frequently among Bavarian than among Prussian troops because of the larger amounts of beer consumed by the former. Our observations at Camp Upton showed that the syndrome occurred quite as frequently among nonsmokers as among those who use tobacco. Marshall24 also coincides in this observation. It is, none the less, the impression of the writer that the abuse of tobacco does exaggerate the symptom complex, notably the tachycardia. Many observers, however, dissent on this point. Tea and coffee, with even less basis, have been urged as important etiological factors.

A relationship between previous cardiac disease and neurocirculatory asthenia has been noted by some authors, but in most instances reference to previous cardiac disturbances rather than to definite cardiac lesions is cited. The relatively frequent occurrence of the syndrome in myocarditis, myocardial degeneration, and adhesive pericarditis has been cited occasionally, but the number of cases in which these anatomical lesions have been found associated with the complex is very small, as is well illustrated by the exceedingly low death rate in the syndrome. Certainly most cases of definite organic disease of the heart had been eliminated in the selection of soldiers, and the association of the syndrome with the development of organic heart disease is so relatively low as to be unimportant and to quite definitely serve to class this syndrome as no instance of cardiac disease. This point was apparently definitely decided in the Civil War, but it is continually being revived. It must be admitted, however, that these cases have a lowered cardiac reserve, just as they have also a lowered muscular, nervous, mental, and general physical reserve.

Many observers, among them the writer, have called attention to the association of the disease with thyroid instability, or definitely with hyperthyroid activity. Certain cases are so dominated by the symptoms of hyperthyroid activity that it is very easy to fall into the error, as the writer originally 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 The writer believes that hyperthyroid activity is an essential part of the syndrome in many instances, as is indicated by the very frequent occurrence of hyperthyroid symptoms in the cases, but he no longer feels that this relationship is etiologic or universal. Sturgis, Wearn, and Tompkins,34 reported an increased metabolic rate in many of these cases and stated that the Goetch reaction is presented by them with considerable frequency. Spiller,35 appeared to feel that hyperthyroid activity, probably in association with other endocrine disorders, plays an important rôle in the complex, perhaps through fixation 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 the conditions to some of the types of thymus disease has already been pointed out by the writer. Evidence of adrenal disturbances has been remarked by many observers. There can be no doubt but that profound instability and incoordination of action of the various endocrines is present in the disease. The preponderance of evidences of thyroid instability is the most striking of all, but at present appears to be but a part, not the sole, etiological factor concerned in the production of neurocirculatory asthenia.

Very closely allied to the last mentioned factors is the striking relationship of the sufferers from this complex to early exhaustion, both physical and nervous, and particularly to a combination of these with emotional exhaustion. The close relationship of the whole to "shell shock" is another bit of evidence pointing in the same direction. His38 pointed out its close similarity to the traumatic neuroses. Excitability of the sympathetic system, lowered threshold of sympathetic stimulation response (MacIlwain39), all closely allied to endocrine fault, have been cited as of primary bearing in the complex. Various theories relative to the fixation of the salts of the blood, notably of the calcium, have been propounded, but these lack both adequate laboratory and clinical substantiation.

Undoubtedly the theory as to basic etiology which has best stood the test of study is that originally proposed by Oppenheimer and Rothschild,22 who asserted that the complex is certainly not a disease entity. They found that in half the cases there was a family and previous history of factors predisposing to the psychoneuroses, and in almost 70 per cent of these there was a history of constitutional asthenia. They pointed out that normal individuals when they break down under the complex present symptoms chiefly of exhaustion; the relatively inferior individuals show both excitation and exhaustion. Oppenheimer and Rothschild then particularly stressed the importance of a fundamental inferiority in which doubtless endocrine imballance or inadequacy play an important determining part.

Given this primary tendency, under emotional and physical strain such as is exacted particularly under battle stress, loss of sleep, responsibility, prolonged shell fire, and the numerous other similar conditions which the soldier must meet, individuals showing perhaps but minor inferiority initially, break and develop the complex. Other soldiers, who primarily represent a greater grade of fundamental inferiority, especially in their endocrine and general physical make up, fail under much less stress. If their primary defect be sufficiently marked, under stress well borne by the normal individual, they fail and may present the characteristic clinical picture of neurocirculatory asthenia.

Although the writer agrees in the main with the assumption that we are not dealing with a disease entity in neurocirculatory asthenia, it seems certain that we are concerned with a fairly well-defined and readily recognized clinical condition based, not on a definite pathology perhaps, but on a chemical fault or status founded on a congenital defect in pronounced cases and developed in less marked instances by exhaustive chemical conditions which have definitely to do with the endocrine system.


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THE PHYSICAL TYPE

The physical appearance of these men is quite characteristic in all fully developed instances, in most of which it is in itself conclusively diagnostic.

The syndrome occurs in two chief types of figure. In the one the 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 is frequent. The pelvic girdle is notably narrow. The extremities are long and slender; usually the muscles are soft and flabby and very poorly defined in form. 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, notably in the nose and ears, is delayed. As a rule the skin is thin and soft. There is usually 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 the usual male type. The external genitals are usually small and poorly formed.

The other type, which is far less frequent, is of coarse build. The trunk may be flat and broad, almost thin. The skin is very coarse and rough, covered with scanty, bristlelike hairs, again more female than male in type of distribution. The deposit of fat in this type is occasionally large, and sometimes the head, hands, and feet suggest an early acromegalic type. The distribution of fat is commonly small but occasionally this type may show a considerable deposit of loose, flabby adipose. Hernia is very common in both types. The thyroid gland is prominent in most cases and in some of either type a certain degree of exophthalmus is present. The facial expression is anxious and worried, but the lining of the face is not ordinarily deep or the attitude 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 death in these subjects occurred from concurrent or complicating conditions, the resulting material was not such as to permit of conclusive deductions in regard to the basic state itself. Furthermore, the pathologists were occupied with more pressing problems, so that undoubtedly the subject did not receive the amount of attention which it merits.

In so far as the writer has been able to find, no characteristic pathological lesions exist either generally or in any special organ in neurocirculatory asthenia. Note has already been made of the enlarged thyroid present in many instances, but histological examination in these cases has shown only the changes of a parenchymatous hyperplasia. In no instance was the goiter of the cystic variety.

Post-mortem examination of the heart showed no typical changes, though in the ordinary case the heart as a whole appeared to be hypoplastic rather than otherwise. Smith,40 after a teleoroentographic study of the heart, considered that in instances which had persisted for a long time, the heart was smaller than normal. The long, narrow, or "drop" heart was not the predominating form, in his experience, and the small heart might vary in shape as much as in the normal. The smaller hearts were found in men whose musculature also


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was below the normal. The cases studied, which developed the condition under service stress, showed silhouette measurements that were well within the range for area and volume. Where a persistent tachycardia develops, myocardials changes must appear eventually, notably fibrosis, fatty and parenchymatous degeneration. Notwithstanding the dominance of nervous and cerebral signs and symptoms in the disease, no actual lesions in the organs of the central nervous system appear to have been described.

RELATION TO OTHER DISEASE PROCESSES

Men suffering from this complex showed, in practically all respects, a lowered resistance against other disease processes, particularly the infectious diseases. So definitely was this evident that many observers considered neurocirculatory asthenia as caused either by a general or specific infection. The peculiar susceptibility of these men to the acute respiratory infections has been mentioned. This tendency appeared to exist particularly with regard to tuberculosis. There is a possibility of easy confusion of the condition with tuberculosis because the physical characteristics of the two conditions in some respects appear quite similar, but beyond this there is a very 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 any organization that the first groups of men to succumb to these diseases were those who had the stigmata of this basic condition. General infections, as of wounds, also ran a more unfavorable course than should normally be the case. The same was true of surgical conditions. Wounded men of this type were found to recover less rapidly and they were also often prostrated by relatively minor traumatic conditions.

Japhs and Meakins41 made a study of cases of irritable heart associated with amebic dysentery in troops returned from the British Mediterranean force. They found that treatment of the dysentery by salts of 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 our observation definite acromegalic stigmata developed. Susceptibility to trench foot, trench fever, nephritis, and similar diseases was noted by various observers. The general statement may be made that men suffering from this condition have a lowered resistance toward practically all disease conditions.

After what has been said, it appears unnecessary to point out that the physical endurance of these men is definitely subnormal, and no matter how determined or how well trained men might be, many of them broke under the stress of military service. This was particularly notable in certain officers of the 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 to the severe test of military life as it existed in the war.

The frequency of fear complexes was notable and the exaggeration of emotional stimuli sometimes led men otherwise exceedingly well fitted for


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military responsibility to become men of poor judgment, and with low grade powers of analysis. Recalling the elementary unstable mental and emotional tendencies of this type of man, it is entirely to be expected that they would furnish a high percentage of the cases of so-called shell shock and of war neuroses of all kinds. Once ideas of this kind become impressed on a subject of this complex, they are eradicated with much greater difficulty than would be the case in normal men. This tendency was found of particular import in the treatment of these cases in that if they had once been impressed with the idea that they were suffering from cardiac disease it was found extremely difficult, even with highly intelligent men, to disabuse them of the idea. The ease with which men of this type might be persuaded to the adoption of any theory of a serious condition was very striking as compared to the extreme difficulty with which any such phobia could be dislodged. Even courageous and determined men of this type of infirmity found themselves possessed often by periods of fright altogether out of proportion to the normal reaction called for in any emergency.

LABORATORY FINDINGS

The urine.-No detailed studies of the urine are available; in the cases under observation at Camp Upton nothing in any way characteristic was found. From studies of the urine made at the Hamstead Military Hospital it was found that the urine was hyperacid, and showed excess of phosphates and calcium oxalates, as in other neuroses.

The blood -A deficiency in the buffer salts of the blood was advanced by Lewis and his coworkers as explanatory of the breathlessness observed in many cases.36 This symptom, however, is unrelieved by the administration of the alkalies, and Adams and Sturgis42 found a normal or combining capacity of the blood in their cases, concluding that the dyspnea was of neurotic type.

In a small group of unselected cases Levy43 found that the red 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, a count of 5,900,000 or over. The hemoglobin percentage was for the most part below normal, the average reading being 93.4 per cent.

Leucocytosis of moderate degree, with usually more or less relative lymphocytosis, was found by Briscoe.44 Gay's findings were similar, but he reported also a slight eosinophilia. Laubry and Esmein45 reported a mononucleosis in 22 out of 30 persons suffering from the cardiac instability.

Blood pressure -The blood pressure in the cases studied was lower, as a rule, than in most normal groups. Some cases, particularly when in a marked state of exhaustion, showed definite hypotension, but under emotional excitement the pressure varied much, but still well within normal limits.

Electrocardiography -An electrocardiographic study of 12 cases was made by Peabody, Clough, Sturgis, Wearn, and Tompkins.46 The most 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 were found, but they have probably little general significance.

Gastric test meal - Musser14 found that subjects of this complex showed a very definite increase in the total gastric acidity and in free hydrochloric acid,


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as compared to normal controls. The figures, however, do not represent definitely pathological degrees of hyperacidity.

Aside from these relatively inconclusive studies, very little has as yet been done in the way of routine clinical laboratory work in connection with the complex, and it would appear that little of value is likely to result from this line of study.

SYMPTOMS AND SIGNS

CARDIAC DISTURBANCES

It is because of cardiac signs and symptoms that most cases appear for examination, and it is also because of these dominant manifestations that most cases become inadequate. Again, most of the suffering, in so far as actual physical distress is concerned, is due to cardiac disturbances, and much of the mental agony and apprehension is likewise caused by heart signs and symptoms.

Tachycardia is the most striking of the cardiac signs. It is also one of the most constant marks of the disease. It is developed typically under emotional stress, and while it may also appear in some instances under physical stimulus, especially in the exhausted type of case, in many instances it is diminished or slowed under mild physical exercise, such, for example, as the usual tests for cardiac muscle reserve.

Sturgis, Wearn, and Tompkins,34 showed that in cases of irritable heart, after the injection of atropin there was a short preliminary drop in the pulse rate, followed, as in normal men, by an increase in pulse rate which was proportionately somewhat greater in the cases of neurocirculatory asthenia.

With the tachycardia in some cases, again particularly those of the exhausted type, arrythmia develops. As a rule, unless the case is complicated by some true anatomical cardiac lesion, this arrythmia is of the sinus variety, and it is in such instances probably unaccompanied by any real cardiac pathology, though in long-standing cases such may eventually develop. The subjective symptoms of cardiac disturbance, as a rule, are more dominant than the demonstrable signs. In general these may be included under the signs and symptoms of cardiac palpitation as described in the textbooks. A sense of distress 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 true dyspnea is present except in severe instances of exhaustion or where some true lesion is present. This will be readily detected by subjecting the patient to temperate, physical exercise, which, in uncomplicated cases, either slows the rate or leaves it unchanged. On the other hand, emotional stress gives rise to marked accentuation of these symptoms, especially of the dyspnea. Often a considerable degree of physical exercise may be tolerated without any distress whatever. Occasionally the cardiac distress takes on the character of a sharp stabbing pain which may become so intense that the patient is forced to stop and to 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 intercostal spaces over the entire precordium. Schlesinger18 states that marked irri-


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tability of the pectoral muscles may be present. The soldier almost 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 or modification of rhythm. Physical examination of the heart showed, as a rule, clear, sharp muscle tones, but in cases of great rapidity a blurring indistinctness of the tone was present. In instances in which great physical exhaustion was also present the character of the muscle tone was so indistinct that the diagnosis of a presumable myocardial degeneration seemed justified.

Various cardiac murmurs were often present, even in cases which subsequent study demonstrated to be free from either muscle or valve lesions. These murmurs were very inconstant in character, differing from moment to moment, modified after exercise, and oftentimes entirely removed by it, especially in numerous instances in which exercise steadied and slowed the action. The most frequent murmur was heard at the apex, was systolic in time, and was not transmitted from the point of greatest intensity. Soft blowing systolic murmurs at the second right interspace were common. Sometimes they were transmitted up into the carotid on the right side and frequently they were audible across the manubrium sterni, and at times were heard with maximum intensity in the left second interspace. After a study of the murmurs in cases of irritable heart, King47 stated, correctly, that they have probably only accidental relationship to the basic condition. Exercise, as a rule, greatly modifies all these adventitious sounds, and often entirely obliterates them. Change of posture also usually effects some change or causes disappearance. Of course many instances are associated with all manner of circulatory lesions of a true organic character. In such, of course, there are present diagnostic signs of a character which often greatly confuses the recognition of neurocirculatory asthenia. Molle48 called especial attention to the frequency with which venous femoral bruits are found in cases of 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. The writer's experience has been that while it may be either, largely depending on concommitant or associated disease or temperamental conditions, in pure cases it is more commonly low, but under certain stimuli, particularly under mental stress or emotional excitement, it may become markedly elevated. In practically all instances blood pressure shows more variation than is usual in normal cases.

ARTERIAL TENSION

Laubry and LeConte,49 from cases of cardiac instability studied in Professor Vaquez's service, delineated three groups according to their arterial pressure: (1) The unstable, which represents about two-thirds of the patients examined. Their tension varied from one day to another. (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 had abnormal arterial tension at first, but this usually became normal under the influence of rest and diet. They never found durable, permanent hypertension. Variation


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in pressure was not especially marked in those with great cardiac instability or tachycardia. There was no relation between the degree of tachycardia and hypertension.

A striking sign occasionally present was the absence of a definable lower limit of diastolic pressure so that a condition of sphygmomanometry very similar to that seen in double aortic endocarditis was manifested. At times also a pulse very closely simulating that of the Corrigan or water-hammer variety was present. The tremendous effect which psychic factors produced on blood pressure was notable in most instances. A soft, irregular, at times a dicrotic, pulse may occur in any case and apparently without any essential anatomical disease.

FLUOROSCOPIC FINDINGS

Fleuroscopy of the heart often discovers extremely interesting data in the study of the syndrome. Wide, active contractures of the auricles, plainly visible on the screen, are the most striking of these findings. Occasionally ventricular hypertrophy is present, occasionally a true dilatation. In the typical uncomplicated case the size of the heart is not as a rule modified; more frequently than otherwise the heart, even in large individuals, is relatively small, long, and narrow, and often definitely of the hypoplastic type. As compared with the aortic arch, the heart often seems notably hypoplastic, for dilatation of the aorta seems to be present in a considerable number of cases. This anatomical finding, often not demonstrable post 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 of the other circulatory disturbances usually shown in the syndrome. Throughout and manifest in every certain instance of the syndrome is a very unstable neurovascular control. This is shown by marked dermographia, which is as striking, varied in type, and constant as in any group of cases of certain hyperthyroidism or goiter. The hands and feet are cold, usually cyanosed, though the 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, and frequently the entire body. Even when the surface of the skin is cold it may be covered with large globules of sweat.

These manifestations were notably emphasized when the soldier was under considerable excitement, as when undergoing an examination, considering discharge, or the like. Frequently the face was flushed, bright red in color, this being quickly succeeded by a wave of paleness associated with cold. Occasionally these dermal manifestations were accompanied by an intense but usually very transitory pruritus, commonly most marked over the anterior and lateral thorax and over the face. Other cases were associated with the formation of large wheals where the pressure of the clothing was marked or when slight blows were inflicted. Heat or cold may precipitate these lesions.


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These striking evidences of neurovascular disturbance were often accompanied by certain nervous phenomena to be described elsewhere. This association seemed to indicate that probably similar vascular disturbances appear also in the deep viscera, thus explaining a large group of central signs and symptoms. Physical factors rarely precipitated these symptoms, though occasionally they would appear in their most exaggerated form after drill or otherwise when more or less physical exhaustion was also present. They were always most evident when cardiac disturbances were most annoying. They showed throughout a very definite association with emotional and nervous factors.

Very closely allied with these circulatory symptoms, and probably dependent on precisely identical factors, were certain urinary symptoms, such as are also commonly associated with such signs and symptoms appearing with like conditions in other diseases, as in various neuroses and in hyperthyroidism. The most striking of these was polyuria, which occurred during or immediately after the most violent attacks of tachycardia or syncope, or was associated with the dermal manifestations. This hypersecretion was apparently similar to that which appears in paroxysmal tachycardia. The urine so voided was commonly light in color and in weight. Tenesmus might follow or precede the voiding of the urine, which was ejected only with difficulty and with more or less pain, as though from contraction of the urethra. Small quantities only might be voided at a time, but the insistence of the desire was so imperative that complete urethral control was not always present. A good many of these cases showed enuresis nocturni.

ENDOCRINE SYMPTOMS

Endocrine symptoms and signs were dominant throughout all these cases, and the natural inclination of an observer familiar with this type of disease and not familiar with the syndrome itself was at once to class these men as of an endocrine dyscrasia, usually as instances of hyperthyroidism. The writer, early in his experience in the war, was also definitely of this belief, and reported his first group of cases under the heading, "Hyperthyroidism in the recruit."50 The same error was made by many other observers, among whom are Caro,30 Barr,33 and Stoney.51 While a close study of large groups of the syndrome, especially of the instances which developed in battle, is almost certain to eliminate this idea, in many respects it is rather well founded and one may well read into the interpretation of the disease many factors, signs, and symptoms definitely of an endocrine type. For the greater part these signs and symptoms may be best grouped under the heading of "Signs and symptoms of hyperthyroidism." In a considerable number of cases more or less goiter was present. Aschenheim31 found it in 50 per cent of his cases. This was particularly evident in the cases which presented the well-developed syndrome on their induction into service, but it was much less definite in the instances which developed under the stress of service. Most cases will respond also to the so-called Goetsch test for hyperthyroidism. Peabody, Clough, Sturgis, Wearn, and Tompkins46 found a positive response in 60 per cent of their cases, doubtful or suggestive in 10 per 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 the mental attitude of these men was similar to that of those of mild hyperthyroidism. Again, there is a definite relationship to endocrine disorders in the heredity of the cases. Analysis of this element in the mobilization camp at Upton showed a very certain factor of this nature.50 Careful study of large groups of the cases will, however, quite definitely indicate that though there are certain clear indications of endocrine defect or imbalance in neurocirculatory asthenia, it is not a pure thyroid problem.

SEX CHARACTERISTICS

Beginning, as this complex does, during the period of sex development, and extending, as it does, throughout the period of greatest sexual activity, it is quite natural to expect that these cases as a class early manifest certain sexual aberrations which appear to bear some definite relationship to the complex. A study concerning this phase of the subject was made by Goddard52 at Camp Upton, N. Y., during the mobilization of the 77th Division. He found that a considerable percentage of well-marked cases of this disease had little or no normal sex instinct. Many had had no sex experience or desires, and a considerable number presented definite perversion or 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 on sentiment and emotional proclivities than on a normal sex appetite. Development of the genitalia was found defective in a surprisingly large number of these men, and only a very few showed such dominant sex craving as is the rule among ordinary virile soldiers. A consideration of this phase of the question in civil life convinced the writer as to the accuracy of these studies. Observations of a similar trend were recorded by Aschenheim.31

Observations by the writer and by others in civil practice suggested that the capacity for fecundation is lower in those suffering from this tendency than among ordinary subjects. That this phase of the question bears a definite relation to other evidences of endocrine aberration so very manifest in this disease seems certain.

DIGESTIVE SYMPTOMS

Among the more prominent gastrointestinal aberrations which appear in the course of the disease, undoubtedly the most frequent and annoying is spontaneous attacks of diarrhea, which frequently mark the more violent attacks of the syndrome. These diarrheal attacks may be followed by short periods of constipation. Nearly all soldiers afflicted by the permanent form of this disease showed gaseous eructations to a greater or lesser degree. In most cases this symptom was accompanied by more or less swallowing of air. Occasionally acid eructations took place as in ordinary gastric hyperacidity. As a rule, cases which were investigated in this respect were found to show more or less gastric hyperacidity. Musser14 verified this finding by his careful study. Borborygmi and annoying gaseous distention of the gut, especially of the colon, was present in some cases. The use of alkalies or washing of the lower 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, finicky and complaining about their diet. While most cases were in thin, rather malnourished men, there was another type of persons, who though not usually large eaters, were none the less obese. As a rule, sufferers from this complex were tall rather than short, slim rather than stout, undernourished rather than overnourished.

RESPIRATORY SYMPTOMS

Very few symptoms of the respiratory tract were manifested except those of rapid and shallow respiration. That this had no organic basis was readily shown, inasmuch as a little training served usually to cause breathing to become absolutely normal. The shortness of breath, dyspnea from which all complained most piteously, was not a true dyspnea, and it was not accentuated by reasonable exercise except, of course, in cases in which a real cardiac exhaustion or lesion had developed.

Adams and Sturgis42 made a study of the vital capacity of the lungs and of the combining capacity of the blood in cases of effort syndrome. Their study, which was conducted on a group of 100 cases, tended to show that the vital capacity of the lungs of these men was but little below what has been accepted as normal, corroborating the well-established clinical observation that these patients do not suffer with a true dyspnea, but that their complaint of shortness of breath is founded on a neurosis and doubtless somewhat dependent on early muscle exhaustibility. Similarly, this was corroborated by the findings of these investigators that the combining capacity of the blood is found to be well within normal limits. This apparently shows that Lewis's theory of a decrease in the buffer salts in the blood as an explanation of shortness of breath is not well founded.

Levine and Wilson,53 on the other hand, found that the average vital capacity of the lungs was slightly but definitely reduced in the severer cases of "D. A. H." They believed that the discomfort which deep breathing brings on in these persons was a factor. Exercise, they found, considerably reduced the vital capacity of the lungs, probably due, at least in part, to fatigue.

Drury54 found that the percentage of carbon dioxide in the alveolar air, taken at rest, is within the lower limits of normality, or is decreased in these cases. The reaction of the alveolar carbon dioxide pressure to exercise is similar to and of the same order as that found in the healthy subject. The time during which the breath could be held is much less than in healthy subjects. The percentage of carbon dioxide in inspired air which produces intolerable hyperpnea is below normal, except in very mild cases.

A certain number of these men were held under the suspicion of being tuberculous. This diagnosis has usually been considered because of the general build of the man, from his asthenic attitude and improper carriage, and from his easy exhaustability rather than because of suspicious pulmonary signs. Quite naturally low stamina, particularly against the infections, is clearly a complication and not a part of the disease itself. These men appeared also to be particularly 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 the syndrome. Few cases are free from this group of symptoms, which, to a considerable extent and in many instances, entirely dominated the case. Roughly, from a mental standpoint, one may group all the cases under two heads. The larger group is composed of men who are hypersensitive, neurotic, imaginative, often to the point of genius-all were unstable in a nervous way. These soldiers are quick in perception, overly intelligent in many ways, but too imaginative to permit them to become made over into stable line soldiers. Yet these very characteristics made them often very desirable as bandsman, clerks, stenographers, and the like. Several officers of brilliant records were definitely of this classification, and there can be no question but that in some circumstances the very defects which are part of this disorder become attractions 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 and weak 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 not sufficiently intelligent for line duty, even had they had the physical or moral stamina demanded of the good soldier; they were not sufficiently teachable even to learn any less complex duty, and at the same time they possessed all the nervous instability of the first-mentioned group. They would become hysterical on the slightest provocation and were subject to attacks of melancholia and depression which made them a nuisance in any position, a very positive detriment to the whole Military Establishment. Associated with these characteristics and present in both groups was an intense sense of apprehension, a fear complex which in men of a higher type was controlled and often conquered by a sense of duty, patriotism, and self-sacrifice, but which, in the lower classification, made these men of a particularly difficult type to adapt in the military organization. Of this obese, pituitary-hypothyroid type was composed a considerable list of "conscientious objectors," their objection being primarily based on a fear complex, but in a so low-grade mentality that one could 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 the disorder are various tics, tremors, twitchings of the face and extremities, strongly suggestive at times of chorea, and sometimes a disseminated sclerosis is closely simulated. Sbrocchi55 emphasized the importance of tremor of the eyelids when the eyes are closed, and directed attention to an attenuation of the conjunctival and pharyngeal reflexes. As a rule all the normal reflexes are increased, the knee, ankle, wrist, and arm jerks are especially exaggerated, and there is a hyperexcitability manifest in practically all reactions. The frequent association of hysteria in these individuals is very striking. Exaggeration is a mental trait of these persons, so much so that little trust could be imposed on them, notwithstanding the honesty of their desire.

Sleep, in sufferers from neurocirculatory asthenia, is commonly fitful and insufficient. Many patients are haunted by dreams which more or less visualize


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the worries and stresses of the day. Yet soldiers are more than ordinarily dependent upon sleep and rest, and no doubt a considerable factor contributing to the break of these men under battle condition is loss of sufficient sleep.

Closely associated with the nervous manifestations of the disease is a condition of asthenia, or early exhaustibility, which was evident in every branch of activity, mental or physical. The researches of King,56 using the white vasomotor reaction of Ryan, indicate the rapid and profound exhaustion in the subjects of this disease. The fatigue, in his opinion, may thus be measured, and is of actual physical nature and not purely of psychic origin. These studies tend to corroborate the clinical observations concerning the disease in the early studies of Da Costa. Few of these men would attempt anything in the nature of competition in physical sports; or if they did, they would quickly develop inaccuracy in physical or mental judgment, breathlessness, pain in the heart, and great muscle uncontrol. The gait, as a rule, was weak and shuffling, like that of a person convalescent from some grave disease. Even mental effort caused a degree of prostration altogether out of proportion, while the intense emotional episodes, such as anger, were followed by a very profound reaction. In subjects who have broken under stress, and in a limited number of spontaneous cases, exercise gradually introduced and intelligently supervised greatly increased endurance and strength. This effect was particularly manifest in some of the training battalions and was very evident to us in the base hospital at Camp Upton, where, for a short time, we were able to carry out tests of this character.

Mabon57 made a study of early exhaustibility in neurocirculatory asthenia in a group of 50 well-established cases. The individuals were subjected to as severe work tests as they could be induced to undergo. Pulse and blood pressure studies were made. It was definitely shown that the amount of work which they could do without exhaustion was much below the normal. The pulse and blood pressure studies did not, however, indicate any abnormal myocardiac exhaustion. This study substantiates our clinical contention that the early exhaustibility of these cases is not dependent on cardiac defects but on general muscular and nervous deficiencies.

Laubry and Esmein58 often observed a tendency toward hyperthermia in cardiac irritability. The tendency is not marked, and only slight thermic shifts take place from time to time. It occurs mostly in persons who have indulged in some kind of physical or mental activity just before the temperature is taken. An hour in bed causes it to disappear. They were 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, but which 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 frequently mistaken for it. Because of this confusion with epilepsy, very few individuals who suffer from this particular symptom are admitted to the military service. Either they are rejected because of the history of the attacks or, if attacks occur in recruit barracks, the man is promptly rejected, usually under the diagnosis of epilepsy.


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DIAGNOSIS

Diagnosis depends chiefly on tachycardia, associated with palpitation, heart consciousness, precordial distress, and the very unstable neurovascular reflexes. Sweating, cyanosed or ischemic extremities, all of which develop under emotional rather than physical stimuli, are further diagnostic points of very similar origin. The presence of these conditions without adequate physical explanation are most suggestive. Emotional and nervous instability, fear complexes, hysterical manifestations, tremors, and more or less vagotonia are the chief nervous phenomena of diagnostic value. Some diagnostic assistance may be afforded by the hereditary factors and some by the sexual inadequacies which are likely to be present. Some stress may be justly laid on the physical types mentioned, on early exhaustion, and especially important diagnostically is an otherwise unexplained and always dominant asthenia.

The picture of hyperthyroidism may or may not be present. It is usually demonstrable in the spontaneously developed instances, but often entirely absent in those which have developed under stress. It will be noted, thus, that the most striking diagnostic signs are apparent on inspection and from the history of the patient, developing, as it is almost certain to do, a story of various inadequacies.

Careful physical examination, showing, as it will in most cases, largely negative findings, is very important, particularly since its negative character excludes the other conditions, tuberculosis, pure hyperthyroidism, and diseases of an exhaustive character, such as gastric or duodenal ulcer or neoplasm, which are most likely to be confused with the syndrome. In other words, diagnosis is by exclusion. Fleuroscopy has also been found to be a very helpful diagnostic method, not only because of its value in excluding disease of an organic nature, but also because the hypoplastic and often drop type of heart is most readily demonstrated by this method.

Snap diagnosis is a very dangerous procedure in these cases, tempting as the method is in military practice. When the list of serious organic disease conditions which may be readily confused with this syndrome is considered, the necessity of careful study is fully apparent. One must recall also the frequency with which serious secondary conditions, especially the infections develop in the course of the disturbance. From a military standpoint, however, diagnosis, in so far as value to the service is concerned, is far from difficult. Except for highly specialized types of service, and only in exceptional instances otherwise, these subjects are undesirable for military duty, and the best procedure is their early elimination.

PROGNOSIS

Prognosis, from the military standpoint, does not seem to be a matter of very great difficulty or importance. With few exceptions men affected 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 Military Establishment. Bandsmen of the better type are comprised in considerable part of types either with the syndrome fully developed or likely under the stress of war conditions


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to develop it. If they are not of such a degree as would be likely to fail and to become a charge on the Military Establishment, they may continue in this capacity with full degree of efficiency. They may also be employed in clerical positions, as stenographers, in the rehabilitation activities, and in very many office positions for which their previous occupations 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 are frequently of extraordinary value. They are not, however, a dependable military material. 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 occupational environment. The prognosis as a whole is far better in the acquired cases than in those in which the condition has developed spontaneously or from certain hereditary traits.

Very much in prognosis depends on environment and on the cooperation of the patient. In instances which have developed as a result of war stress obviously rest is the chief essential, and the same is true when for any reason the heart muscle has become seriously compromised. Obviously, then, prognosis may depend essentially on the possibility of securing rest. In the congenital cases, or those which have broken under the stress of ordinary life, more depends on a suitable environment and on adjusted training. On the possibilities of these hangs prognosis. Briefly, the military value of either class is very limited and circumscribed. Their increased vulnerability to all the infections and to shock of all kinds, and their natural limited duration of efficiency and life, must be always considered.

TREATMENT

From a military standpoint the first step in the treatment of this condition is the elimination from line duty of all except the very exceptional soldier, particularly officers whose experience or service has justified the hope that they may again be able to stand the full rigor of military duty. Even these men should be selected mostly for training purposes, rather than for actual line service. From the remaining group should then be selected men who, because of their special training or education, are peculiarly qualified for some particular service with troops and who are not so severely affected as likely to become a charge on the service. Among such men may be mentioned musicians, draftsmen, clerks, suitable for quartermaster or other clerical positions, men trained in telegraphy, telephony, or other work of value to the special corps, stenographers, typists, translators, and cooks. No men not specially qualified should be selected for duty with troops. Next are to be selected men whose training especially fits them for duty with the services of supply, such as clerks, stenographers, architects, carpenters, plumbers, and similar craftsmen, printers, classification and quartermaster clerks, storekeepers, bookkeepers, chemists, artists, and any other whose special services might be found of particular value.


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Among neither of these groups should advanced cases of the syndrome be permitted, for the stress in any of these positions might at any time become so great as to cause a break, and so possibly incommode necessary routine. All other recruits showing this complex should be promptly discharged just so soon as a tentatively correct diagnosis has been arrived at.

Where line soldiers have broken down with the condition under service stress, after adequate treatment in base institutions they should be reclassified and assigned to base or other similar duties. The experience in practically all armies has shown the inadvisability of returning these men to combatant organizations, and for the greater part discharge and return to civilian activities is the better in so far as the Army is concerned.

When for political or other reasons, initial cases of the syndrome are required to be held in the Army, recognizing that this is from a standpoint of military efficiency an expensive, unremunerative, and entirely inadvisable procedure, they should be organized into companies or battalions under the command of junior medical officers who are well familiar with both professional and general military life and procedures. A temperate but firm military discipline should be maintained in these organizations, and they should be graded in so far as possible so that severe instances are not grouped with the milder types of the disturbance. A promoting system from the more severely affected companies to the less disabled ones should exist, and the constant hope and 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, the length and type of the drill being adjusted to the possibilities of the company, and an attempt should be made to constantly, though very cautiously, increase the work. Meantime each man should be selected and classified for some special duty which he might subsequently take over after a preparatory course of training. It was found very important in the treatment of these groups at Camp Upton to constantly hold before the men that they were to be considered as soldiers under training. They must live under military conditions, as closely simulating those of the regular battalion as possible, and minor military duties and ceremonies may be undertaken by the more advanced classes. The definite improvement in self-respect and general morale under such conditions is very marked. In the treatment of this class of cases an appeal to the spiritual and mental attitude of the patient is necessary. Very close individual attention may be exercised by the medical officers in command of these training battalions. The food must be selected with greater care than is necessary in regular line troops, and greater care is necessary in its preparation. The bowels must be kept well opened, comfortable sleeping quarters must be provided, and regularity in every respect must be especially insisted upon. All foci of infection must be eliminated and all secondary disease processes must receive treatment. Tobacco and alcoholics are permissible in temperance only.

Experience has shown that a real military régime is far the best in any large concentration camp, but particular discretion must be exercised in all disciplinary measures, and chronic offenders should be hospitalized as being in a way irresponsible. All cases of this kind should be sent to the psychiatrist.


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He will find very much material of this unstable character in these groups. Initial cases which require hospitalization, either because of temperamental vagaries or because of physical inadequacies, should be discharged from the service as soon as possible.

Medicinal treatment in initial cases is a failure except as drugs may be employed for the mitigation of transitory conditions or for symptomatic reasons. As a rule, digitalis, even given in massive doses, affects the action of the heart little or unfavorably. The same is true of other cardiac stimulants, while strychnia, caffeine, and similar drugs almost invariably make the condition worse rather than better. Sedatives act much more satisfactorily, and since protracted employment is to be expected if any benefit is conferred it is 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 or later lose their beneficial effect if long employed. Luminal has been used with good effect. No drugs, in our experience, have conferred other than transitory benefit. The use of various endocrine preparations in early cases admits of a complete theoretical justification. In cases associated with obesity small doses of thyroid cautiously employed has acted well, especially if associated with pituitary preparations also. Stoney51 claimed good results from X-ray treatment of the thyroid. Various preparations of the sexual glands have also been recommended, and their use is at least apparently without any detrimental effect. If associated with close supervision of the case, particularly with control of physical and mental activities, excellent effects are to be expected in early cases from the treatment of this syndrome along endocrine lines. Hospitalization of initial cases is to be avoided, except when absolutely necessary, but in some instances it has given excellent results. Great care in hospitalization cases must be exerted to prevent the development, intensification, or fixation of various phobias. It must be particularly insisted upon throughout that the disease is not one of the heart.

The treatment of cases which have developed under the stress of service is distinctly a military problem, and such cases should not be discharged, at least until they have received the maximum benefit possible under treatment. The degree to which this may be attained depends not only on the severity of the breakdown and on the status of the patient, but also very largely on the character of treatment which he receives and especially on the intelligence and vigor of the early management of these cases. The first essential is rest. This should be made as complete as possible, and if practicable the patient should be evacuated back at least out of the army zone just as soon as it can be safely accomplished. Sedatives should be employed, and such as will control the nervous manifestations present should be promptly used to their therapeutic effect. Later the more powerful ones should be replaced by less powerful drugs, but the effect desired should be attained. Only where doubt exists as to the integrity of the heart muscle should digitalis be given. The ice bag may be placed over the precordium, where it relieves either the pain or the tachycardia. The patient should in all possible cases be put to bed in as quiet surroundings as possible. He should be relieved in so far as possible from military discipline for the time being, and where it is possible to evacuate him to home hospitals


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this should be done, but he should be held under military medical supervision and treatment. After a rather protracted period of rest treatment he should be slowly relieved from hospital restraint, though not from medical supervision, and as soon as the cardiac and nervous symptoms permit he should be advanced to graduated exercises and finally to the training battalions, through which a gradual restoration to normal military life may be attained. He should not, however, except under very exceptional circumstances and through military necessity, or because of some especially valuable qualification, be returned to line duty, but he should be reclassified and assigned to such service as he may be particularly fitted for, preferably without the active army zone.

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(7) Medical and Surgical History of the War of the Rebellion, Part Third, Medical Volume, 864.

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(10) Stillé, Alfred: Address Before the Philadelphia County Medical Society, Delivered February 11, 1863, 18. Published by Order of the Society, Philadelphia, 1863.

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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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(17) Neuhof, Selian: The Irritable Heart in General Practice: A Comparison between it and the Irritable Heart of Soldiers. Medical Record, New York, 1919, xcvi, No. 22, 900.

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(20) Clerc, A. and Aimé, H.: Le cour irritable du soldat. La Progrès Médical, Paris, June 29, 1918, xxxiii, 222. Also; Les cardiopathies valvulaires dans leurs rapports aven l'aptitude militaire. Bulletins et mémoires de la Société médicale des hopitaux de Paris, Paris, May 24, 1918, xlii, 516.

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(22) Oppenheimer, B. S., and Rothschild, M. A.: The Psychoneurotic Factor in the Irritable Heart of Soldiers. Journal of the American Medical Association, Chicago, 1918, lxx, No. 25, 1919. Also: British Medical Journal, London, July 13, 1918, ii, 29.

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(29) Lian, Camille: Les troubles cariaques aux armées. Bulletins et mémoires de la Société médicale des hopitaux de Paris, Paris, October 13, 1916, xi, 1582.

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(32) Ehret, H.: Zur Kenntnis der Herzschädigungen bei Kriegsteilnehmern. Münchener Medizinische Wochenschrift, 1915, lxii, No. 20, 689.

(33) Barr, Sir James: The Soldier's Heart. British Medical Journal, London, April 15, 1916, i, 544.

(34) Sturgis, Cyrus C.; Wearn, Joseph T.; and Tompkins, Edna H.: Effects of the Injection of Atropin on the Pulse-rate, Blood-pressure, and Basal Metabolism in Cases of "Effort Syndrome." American Journal of Medical Sciences, Philadelphia and New York, October, 1919, clviii, 496.

(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.

(37) Lewis, Thomas: Soldier's Heart. Lancet, London, March 31, 1917, i, 510. Also: The Tolerance of Physical Exertion, as Shown by Soldiers Suffering from So-called "Irritable Heart." British Medical Journal, London, March 30, 1918, i, 363.

(38) His, W.: Ermüdungsherzen 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.

(41) Jepps, Margaret, and Meakins, J. C.: Detection and Treatment with Emetine Bismuth Iodide of Amobic Dysentery Carriers Among Cases of Irritable Heart. British Medical Journal, London, November 17, 1917, ii, 645.


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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 Hæmoglobin 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.: Équilibre leucocytaire et instabilité cardiaque. Bulletins et Mémoires de la Société Médicale des Hopitaux de Paris, Paris, February 7, 1919-xliii, 115.

(46) Peabody, Clough, Sturgis, Wearn, and Tompkins: Effects of the Injection of Epinephrin in Soldiers with "Irritable Heart." Journal of the American Medical Association, Chicago, 1918, lxxi, No. 23, 1912.

(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 fémoraux et le syndrome "cour irritable du soldat." Le Bulletin Medical, Paris, September, 1918, xxxii, 391.

(49) Laubry and Le Conte: La tension artérielle dans l'instabilité cardiaque. Bulletins et Mémoires de la Société Médicale des Hopitaux de Paris, Paris, July 11, 1919, xliii, 709.

(50) Brooks, Harlow: Hyperthyroidism in the Recruit. American Journal of the Medical Sciences, Philadelphia and New York, 1918, clvi, No. 5, 726.

(51) Stoney, Florence A.: On the Connection between "Soldier's Heart" and Hyperthyroidism. Lancet, London, April 8, 1916, i, 777.

(52) Brooks, Harlow: Neurocirculatory Asthenia. Medical Clinics of North America, September, 1918, 477.

(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.

(57) Mabon, Thomas McC.: Studies of Cases of "Effort Syndrome" with Measured Work. American Journal of the Medical Sciences, Philadelphia and New York, December, 1919, clviii, 818.

(58) Laubry and Esmein: Sur quelques anomalies de la courbe thermique dans l'instabilité cardiaque. Bulletins et Mémoires de la Société Médicale des Hopitaux de Paris, Paris, May 2, 1919, xliii, 376.

(59) Aubertin, Ch.: Les cardiaques du Front en 1917. Présse Medicale, Paris, 1917, xxv, No. 44, 451.

(60) Brooks, H.: Syncope in Neurocirculatory Asthenia. Transactions of the Association of American Physicians, Philadelphia, 1924.