Soldier’s heart, shellshock and lack of moral fibre

When I was unwell last year, my husband Brian explained my symptoms in military terms: “You’ve been in the front line, and now you’ve got shell shock.” Brian had researched this condition while editing A Physician in Spite of Himself, the autobiography of DW Carmalt Jones who was in charge of a shell shock hospital during World War 1.

Stressed and exhausted by dealing with a series of medical and surgical emergencies in the family, I had developed a variety of symptoms. Repeated attacks of rapid irregular heart beat and breathlessness accompanied by high blood pressure, on two occasions so severe that I was taken to hospital by ambulance. Separate episodes of feeling very cold, or very hot, shaking all over, or suddenly feeling drained of energy and having to lie down. Loss of appetite and weight. Insomnia. The symptoms were  mainly of a physical nature, but various medical tests did not indicate a definite diagnosis. As a former psychiatrist I knew they might be due to anxiety and depression, but a trial of antidepressant drugs made me worse.

Syndromes of this kind can be triggered by any sort of traumatic experience, especially when there seems no scope for controlling the situation or escaping from it. Most of the early descriptions were carried out on servicemen exposed to great physical and emotional stress in wartime. In the American Civil War, men who complained of palpitations, chest pain, shortness of breath and fatigue but had no signs of organic heart disease were said to have “soldier’s heart”. Other terms included da Costa’s syndrome, cardiac neurosis, and neurasthenia. In World War 1, the condition of “shell shock” could include symptoms in many different bodily systems, for example headache, tremor, confusion, nightmares, loss of balance, impaired sight and hearing, as well as the cardiovascular symptoms listed above. Some sufferers received no sympathy or understanding, being accused of cowardice or malingering and punished by firing squad. Others were sent to field hospitals for a brief period of sleep, food and graded exercise before being returned to duty. In World War 2, British airmen who refused to fly on bombing missions were labelled as “lacking moral fibre” (LMF) and usually demoted to menial jobs. Some of these men would have been suffering from the type of illness described above, others just could not bring themselves to take part in the killing of civilians. LMF was highly stigmatised, and concealed as far as possible, so that when I came to write something about it in my novel Blue Moon for Bombers I found little published information. In more recent conflicts, notably the Vietnam war, attitudes were more sympathetic and it became more acceptable to talk about the psychological side of these conditions. The concept of “post-traumatic stress disorder” (PTSD) was born, and continues to generate a great deal of interest and research.

Body and mind are interconnected, and patients with stress-related illness usually have some combination of physical and mental symptoms. For this reason the orthodox medical system, in which the different specialties are separated, may not be well placed to meet their needs. Patients who present with mainly mental symptoms would often be diagnosed as having PTSD and referred to psychiatrists or psychologists, perhaps without having a medical evaluation to exclude the organic pathology that will in fact be present in some cases. Patients for whom physical symptoms predominate might find their way to cardiac, respiratory, neurological or other specialist clinics, and if no organic disease is found the psychological aspect may not be taken seriously if it is recognised at all. The plethora of terms that have been used for such conditions over the years – psychosomatic, functional, medically unexplained, somatoform, and many more – suggests the difficulty of understanding and managing them. Many patients turn to alternative therapies for a more holistic approach.

There is no specific treatment although different medications, psychological therapies and natural remedies prove helpful for individual patients. Sometimes the illness becomes chronic so I was fortunate that my own symptoms recovered within a year, with support from kind relatives and friends, orthodox and alternative healthcare professionals, and an improvement in my life situation.

Only a minority of people who are exposed to severe stress will develop a stress-related illness. Those who do may well feel ashamed about being over-sensitive and lacking in resilience, as I did myself, even though I have chosen to go public by writing about it in this blog and in a memoir called Across a Sea of Troubles.

My husband’s heart Part 1: North Shore Hospital

It is over thirty years since my husband Brian started feeling breathless after walking up long flights of stairs. He was found to have aortic stenosis and an aneurysm of the ascending aorta. As time went by, occasional repeat investigations showed this pathology gradually getting worse, and several specialists advised cardiac surgery to prevent the risks – including sudden death – associated with his condition. He declined, on the grounds that his symptoms were not too severe and that the operation itself could be fatal or cause some intellectual impairment. His diagnosis was one factor in our joint decision to leave our medical careers in the UK and go to live in Auckland, New Zealand, where Brian had been born and brought up. That was fifteen years ago and over most of this time Brian has continued in good shape – even walking the Milford Track.

on milford track

He continued adamant that he did not want surgery. He asked me and our family doctor not to send him to hospital if the aneurysm burst, but to give him morphine and let him die at home.

In July this year, soon after his 82nd birthday, Brian had a bad attack of flu and we attributed his continued lethargy and reduced exercise tolerance to the aftermath of that. He did seem to be getting better. Then on 4th September, on the way back from an enjoyable evening at the ballet, he said he did not feel well. He refused to let me call for help. Somehow I managed to support him on the walk home, but as soon as I opened our front door he collapsed in the hall. At that point I went against his wishes and rang 111. Time will tell whether I did the right thing.

A skilled ambulance crew arrived promptly, and did an ECG which showed atrial fibrillation with a pulse rate of 160-170 per minute. They started intravenous amiodarone and advised that Brian was likely to die unless he went to hospital. With a little persuasion he agreed to go. After many hours of investigation and treatment in the resuscitation unit of North Shore Hospital he was admitted to a ward and at 4 a.m. I took a taxi home.

The immediate cause of the collapse was not a ruptured aortic aneurysm, but a 70% blockage of the main stem of the left coronary artery. With excellent medical treatment and nursing care, Brian’s condition improved greatly over the next few days, but he was presented with a stark choice – go back home with probably just a few months to live, or undergo surgery which carried a 20% operative mortality but if successful could give him many more years of good quality life. Brian decided to “cooperate with the inevitable” and accept the operation that he had been refusing for so long.

He stayed three weeks attached to monitors in the cardiology centre, not allowed to leave the ward although he was feeling fairly well. Every day we anxiously awaited the news that a place had become available on the surgical unit at Auckland Hospital. On several occasions the proposed transfer nearly happened but was then cancelled – later we would come to understand all too clearly the reasons for this. Brian appeared to benefit from the long rest, and remained in good spirits. He spent much of his time exercising in the corridor, or with his laptop computer composing a self-written obituary for Munk’s Roll.

There is much more to the story, but to avoid making this post too long I will continue next time. Please sign up in the box if you would like to receive future episodes by email. I should add that I am publishing this with Brian’s full knowledge and consent.