THE REFERENCE LIST

(2) Da Costa, J.M. (January 1871) "On Irritable Heart," The American Journal of the Medical Sciences, p.18-52; J.M. Da Costa's research article of 1871 provides the basis for the diagnostic criteria for a set of symptoms, which is why it was later named after him as Da Costa's syndrome. The symptoms were chest pains, dizziness, breathlessness, palpitations, and fatigue, typically brought on by strenuous exertion, and were associated with a poor physique and a thin chest, and tended to occur during or follow such things as viral infections, or the physcial strains of marching at double quick pace, and hard field service, and the waist belt and knapsack had something to do with it. The pulse was influenced by position, stooping, laying on the left and right side in some cases, and the back in others, and the condition was relieved by improved physique. Recommended treatment included not wearing clothing which constricts as it was liable to retard or prevent recovery. He gives the typical case of a man who was on active duty for several months or more and then contracts an annoying bout of diarrhoea or fever and then, after a short stay in hospital, returned to active service and soon found that he could not keep up with his comrades in the exertions of a soldier's life as previously, because he would get out of breath, and would get dizzy, and have palpitations and pains in his chest, yet upon examination some time later he looked like a man in sound condition". He also provided the general example of a seizure of distressing palpitations, chest pains, headache, dimness of vision, and giddiness which were . . . "most readily excited by exertion, and might be then so violent, that the patient would fall to the ground insensible". Although the digestive disturbance which preceded the syndrome usually passed away, the other symptoms, particularly the abnormal response to exertion, would persist, sometimes for a long time afterwards. In his study of up to 300 cases he examined 200 of them in regard to the predisposing cause of this syndrome and he came to the conclusion that many factors seemed to overlap, but close study revealed that it was "Fevers" 17%, "Diarrhoea" 30.5%, "Hard field service, particularly excessive marching" 34.5%, and finally, "Wounds, injuries, rheumatism, scurvy, ordinary duties of soldier life, and doubtful causes" 18%. After the condition had been induced by such factors it tended to prevail in the short term and in some cases for long periods of time, but Da Costa also gives an example of complete recovery; in particular, Case 48 enlisted aged 17 with a thin chest of 27 inches, and suffered dizziness, cardiac pain, shortness of breath, and palpitations while on picket duty, and on one occasion while marching when he dropped out and discarded his knapsack and extra clothing, yet still struggled to keep up with the regiment. He was hospitalised and recovered but recommended for the veteran reserve. When examined in civilian practice 8 years later he was a tall, broad chested man who had spent most of the intervening years working in the open air as a mounted soldier. He only had two bouts of palpitations associated with bilious spells, and occasional colds, and otherwise had perfect health with no other symptoms at all, and could run up and down stairs without getting short of breath. Da Costa added that it was difficult to assess the cause and nature of the ailment and there was room for doubt and difference of opinion, however he concluded that "it enforces the lessons" of not sending troops "just convalescent from fevers, too soon to active work" and the importance of training young recruits in exercise and marching to accustom them to fatigue before they are called upon to undergo the wear and tear of actual warfare and the rapid and incessant manoevering of troops. ." (In a later article by another author the seizures described by Da Costa occurred in recruits at training camps when they were required to sprint along an obstacle course with a fully laden knapsack strapped to their backs, and collapsed to the ground after 50 yards with their hearts pounding, reaching for breath, faintness, dizziness, and extreme restlessness, which persisted for 20 minutes or more, and required several weeks in hospital to recover from - source unknown. M.B).- such a violent response to that type of sudden or rapid exercise is a diagnostic criteria which can be used to distinguish Da Costa's syndrome response to effort from the normal response to exertion seen in healthy athletes at the end of a 100 metres race in the Olympics, which involves reaching for breath, rapid but forceful pounding of the heart, partial collapse onto hands and knees for the purpose of resting, and a brief period of recovery. It also explains why most patients avoid exercise althogether, or drop out of inappropreately designed exercise training programmes where they are asked to ignore their symptoms and keep increasing the rate until they reach normal levels.© 27-12-17 & 29-1-08M.B.)

(3) Charles F.Wooley M.D. "Where are the Diseases of Yesteryear? DaCosta's Syndrome; Soldier's Heart, the Effort Syndrome; Neurocirculatory Asthenia - And the mitral Valve Prolapse Syndrome," Circulation, 1976, vol. 53, pp.749-751. This article refers to cases which are associated with thin physique, and "in some the chest is long and narrow, or flattened and associated with a kyphotic curve."The chest pain was sharp and lancinating, frequently referred to the left side, fatigue was almost universal, and "during exhausting work such as running , patients developed significantly high blood lactate concentration" . . . and "Describing the signs and symptoms as contrasted with those of heart disease" . . . he quotes "'Lewis T. (Sir Thomas Lewis) who commented 'it is because these symptoms and signs are largely, in some cases wholly, the exaggerated physiological response to exercise . . . that I term the whole the 'effort syndrome.'" He also quoted Da Costa regarding what he called seizures of palpitations and chest pains where "The seizures' were . . . most readily excited by exertion, and might be then so violent, that the patients would fall to the ground insensible." . . . and . . . "The rapid action was often commented on; but a slow, hard beat of the heart was also spoken of." Wooley adds "The fits of palpitation were associated with cardiac uneasiness and pain, headache, dimness of vision, and giddiness." The article also reports that the condition affects sedentary workers, soldiers, especially those who came from sedentary occupations, and athletes, and was more common in women. This author also presented his account of the history of Da Costa Syndrome by commenting on the discussions relating to various chest sounds which were occasionally reported in previous studies, such as "the apical impulse was quick, abrupt or jerky, 'sometimes the sounds of the heart are split . . . in (one case) the impulse was very irregular; there were double beats and intermissions", and other odd sounds, and in some cases there were systolic murmurs above the apex.
He compared these sounds to the systolic gallop rhythm and systolic clicks which were recently being designated as the nonejection systolic click. These sounds also occurred frequently in young subjects where there was no evidence of heart disease or psychoneuroses, and in nervous people.
Wooley had also been involved in another more recent area of study of mitral valve prolapse syndrome and wondered if it was a new disease. He noted that a similar set of symtpoms were involved, namely chest pains, palpitations, breathlessness, and fatigue, and he was able to trace the condition back through reports by Wood, White, and Lewis, to Da Costa where he found that many of those cases involved descriptions of symptoms and sounds that would "certainly" fit the description of mitral valve prolapse syndrome. Ongoing studies showed that some of the heart sounds which were previously interpreted as coming from outside the heart were associated with billowing of the tricuspid leaflets, electrographic ST segment, T-wave changes, abnormal electrographic stress test results, arrhythmias, conduction defects, and abnormal valve motion and ventricular contraction patterns. Wooley's purpose was "merely to establish the link between DaCosta, Lewis, neurocirculatory asthenia, an mitral prolapse . . . and to recall Lewis' challenge to bring attitudes of deferred judgment and critical enquiry to our current investigations."

(4) R.L.Dickinson M.D., Brooklyn (Nov 5th 1887) The Corset Questions of Pressure and Displacement, The New York Medical Journal: Presents a comprehensive review of corset and posture pressure measurements. http://en.wikisource.org/wiki/The_Corset Scroll down to Figure 15 on that webpage, which is related to the impairment of blood flow caused by corsets, postural pressure on the chest and abdominal cavities, and leaning forward in sedentary activities such as writing and sewing, which was up to double, breathing patterns became thoracic, and respiration reduced by one fifth. See also: Valsalva maneuver http://en.wikipedia.org/wiki/Valsalva_maneuver
(5) Limner,L., Esq, Madre Natura Versus the Moloch of Fashion, 4th edition, Chatto and
Windus, Picadilly, London, 1874, pp. 70-73. A list of more than 60 symptoms and ailments attributed to tight corsets by more than 30 eminent medical men
(6) Withington, E.T., Hippocrates with an English Translation, Vol.3, William Heinemann, London, and Hippocrates (460-377 BC): On Joints XL1-XL2. Observations that spinal deformity above the diaphragm disposes to lung disorders and hoarseness, and those below the diaphram dispose to kidney and intestinal disorders.
(7) Bulwer John (1650) Anthrompometamorphosis, London, U.K.- For the effects of natural and artificially produced variations in the shape of the human body on health,
(8) Kellogg J.H.(1904) The Ladies Guide in Health and Disease, Echo Publishing Co.Ltd. Melbourne. - For a comprehensive review of the effect of tight waisted corsets on womens health in the nineteenth century. The diagram of the internal anatomy of a corseted woman was presented on facing page 244 of this illustrated 690 page book which had an attached booklet of diagrams and was widely available on public distribution in the U.S, the U.K. and Australia, and probably played a significant part in bringing the corset era to an end.
(9) Maisel E. (1990) The Alexander Technique: The Essential Writings of F.Matthias Alexander, Thames and Hudson, London - For an account of Alexanders discovery of the postural cause of his voice problem, and how he cured it with a postural improvement tequnique.
(10) Edith Sitwell (1930) Alexander Pope (Biography) First published by Penguin Books, Hammondsworth, Middlesex, U.K. in 1948. Describes Alexander Pope's thin physique, upper and lower spinal deformities and scoliosis, wore a Corset, and wrote in his later years that he was dying of a hundred symptoms, and "writing is becoming very painful to me, if I would write a letter of any length. In bed, or sitting it hurts my breast; and in the afternoon, I can do nothing, still less by candlelight". also Halsey W.D. (Editorial Director) (1962) Collier's Encyclopedia Vol.19 p.241-242 The Crowell Collier Publishing Co. U.S.A. - For a summary of Pope's health problems.

(4a) Wilson, W.D. (1904) Report on the medical arrangements in the South African War. HMSO; London, UK: 1904, p.73. This reference presents evidence that DAH was more likely to effect sodiers who had beem recruited from non-physical occupations, e.g.sedentary occupations, and were not given sufficient physical training prior to being sent on long arduous marches etc. . ."In the latter stages of the war, a large number of small columns were deployed against the Boers so that medical units had long periods of continuous marching to keep up with the widely spread engagements. It was concluded that the prolonged strain of carrying heavy weights and the pressure of straps on the chest had damaged the heart. An official report also argued that 'cardiac exhaustion cases were much more frequent among men of volunteer companies than the regulars, probably due to the great difference of their usual daily occupation from the life of a soldier on active service".

(4b)Baker Doris. M. (1955) Cardiac Symptoms in the Neuroses; H.K. Lewis & Co., Ltd. London : This small book describes the symptoms of Da Costa's syndrome in clear detail and identifies it as a distinct diagnostic entity, and a common condition. Effort syndrome and neurocirculatory aasthenia are used as synonyms, and the symptoms include left-sided chest pain, palpitations, and sighing respiration occurring in response to effort, but also sometimes independently of effort.

(11) Paul Wood, M.D., (May 24th 1941) Da Costa's Syndrome (Or Effort Syndrome), The British Medical Journal, Vol.1, 1941 p.767-772. . . (Paul Wood was then "Physician to Effort Syndrome Unit, E.M.S ; Physician to Out-Patients, National Hospital for Diseases of the Heart, and the following information is from the first of his three Gaulstonian Lectures to the Royal College of Physicians of London, 1941). The article mentions that the condition has also been called 'the irritable heart of the soldier', neurocirculatory asthenia, and 'autonomic imbalance'. In world war 1 the British Forces had 60,000 cases of which 44,000 received pensions. It notes that it is also common in civilian life, and more common in women than men, and refers to the five classic symptoms of Da Costa's syndrome, and syncope (fainting) in 34.5% of patients, 'significant gastro-intestinal symptoms' in 26%, and nightmares in 23%. The article includes the following information about the cause of the typical left sided chest pain of Da Costa's Syndrome. "A complete review of the English and American literature, from the heated discussion in the British Medical Journal of 1858 (C.Coote; Inman; Fuller) to the latest remark by Spillane (1940), reveals the astonishing fact that not only the cause but also the site of origin of left inframammary pain is unknown . . . There have been, and still are, four main views as to its origin" namely that it has a cardiac origin, or is referred pain from faulty muscles or ligaments near the spine, or is caused by fatigue of the muscles associated with respiration, or that it is imaginary. He adds "There are three good reasons why the pain is not imaginary". Firstly the nature of the pain is too uniform, and secondly "medical colleagues who have suffered from it are good witnesses to its reality", and thirdly it can be abolished by certain injections inserted into the correct location. He also studied the physical possibilities and "Investigated the method of respiration in 150 cases of Da Costa's syndrome. The cause of left sided chest pain was "elusive" but he found it to be within the muscular and fibrous structures of the anterior chest wall, and, although "very few patients had pain while these measurements were being made" it was related to functional disturbance and poor movement of the diaphragm, especially incomplete expiration, poor expansion of the chest, especially the lower chest, and was often associated with laying on the left side, "a posture which rests the thoracic muscles of respiration on that side at the expense of the diaphragm". Similar pains sometimes occurred on the right side, and in other parts of the chest wall, and a more severe type of pain was reported in relation to muscular strains such as cranking a lorry engine or lifting a heavy weight. The article also contains a reference to an 1858 report associating the pain to scoliosis (sideways curvature of the spine) with concavity to the left, but Wood was unable to confirm that, and in his final sentence he concludes "it is predisposed to by poor physique in Da Costa's syndrome; it is maintained and exaggerated by the belief that it arises in the heart. (It can be said that if all of the symptoms of Da Costa's syndrome were incorrectly regarded as imaginary, and if the real cause of two of them has been investigated and found, then it follows that the real cause of the remaining will eventually be investigated and found, because they are all part of the same ailment, in the same patients, with the same minds, and the same truth in the words they speak. M.B.).

(11a)) Paul Wood, O.B.E., M.D. (Melbourne), F.R.C.P. (London), (revised edition 1956) Diseases of the Heart and Circulation, Eyre & Spottiswoode, London p.937-947 . . . Paul Wood, O.B.E., was Director, Institute of Cardiology, London . . . He wrote . . . "The syndrome is characterised by a group of symptoms which unduly limit the subject's capacity for effort" . . . " The cardinal symptoms" . . . of effort syndrome, neurocirculatory asthenia, irritable heart, soldier's heart, disordered action of the heart (D.A.H.), etc. are "breathlessness (93%), palpitations (89%), fatigue (88%), left inframamary pain (78%), and dizziness (78%), or syncope (fainting) (35%)" . . . (the) Left inframammary pain is commonly described as aching or as sharp and stabbing in quality . . . and arises locally in muscle or fascia . . . It may be initiated . . . by fatigue or strain of respiratory muscles in cases with strain of certain muscular attachments . . . by incessant minimum trauma from . . . faulty posture" . . . and with regard to the breathlessness "It is not only a question of breathlessness on effort, but patients will say they are not able to obtain a satisfying breath, and may take "frequent deep sighs". This can sometimes occur at night when it "may be confused with bronchial asthma or paroxysmal cardiac dyspnea". and "A a simple and illuminating test" for the symptom involves forced hyperventilation where "The patient is asked to breath deeply and rapidly for one minute." When a healthy person is asked to stop he feels breathless for about 20 seconds, but a patient with Da Costa's syndrome "continues forced breathing, explaining later that he felt breathless." i.e. there is "Dyspnoea instead of apnoea after forced breathing", and "Normal subjects have no difficulty holding the breath for at least 30 seconds, but patients with Da Costa's syndrome usually give up very quickly, 30 per cent of them in less than 10 seconds; moreover, in contrast to controls, they show little distress when the reach the breaking-point." . . . With regard to the fatigue the patients often do not feel refreshed when they wake up in the morning, as if their sleep has been of no value, and they may "feel tired and listless during the day, and are unduly fatigued by effort. " . . . (and) . . . Orthostatic dizziness is related to orthostatic hypotension . . . "The effort-tolerance test (for effort-intolerance) consists of stepping on and off a chair ten times, and counting the pulse rate before, immediately after, and subsequently at minute intervals until the resting speed is regained. The deceleration time is abnormal (over 2 minutes) in 33% of these patients." . . . and . . . "Physical signs of autonomic dysfunction are helpful in . . . assessing the severity of the case." . . . The photo of a painting of a Da Costa's syndrome patient, which shows the typical round and sloping shoulders, thin chest, and kyphotic (or stooped) spine, is included on page 941.

Paul Woods Psychological Considerations of cause and effect: Paul Wood also discusses the cause and effect aspect by referring to the similarity of the symptoms of the effort syndrome with those of anxiety in healthy people, and also of the similarity of the symptoms to those of heart disease, and therefore suggests a psychosomatic cause. He advised the doctor not to mistake the left inframammary pain with angina pectoris as that will introduce or aggravate the patients fear of heart disease, which is based on a similar misinterpretation. He suggests that during childhood these patients were timid, and were mollycoddled by their mothers, and that later, in their school years, were protected from the hazards of sport and gymnastics, and developed anxieties about such things into adulthood. He adds "This constant anxiety, operating consciously or subconsciously every second of the day, and night, increases the severity of the psychosomatic symptoms. Under these circumstances the syndrome is maintained long after resolution of the original anxiety" . . . "until finally distressing autonomic reactions are so ingrained and so divorced from conscious thought as to be practically ineradicable". In his summation he writes "Treatment is never easy, and is the more difficult the longer it is delayed. Failure is certain if any essential factor in the development of the symptoms is overlooked . . . First he must feel that at last he has met a doctor who thoroughly understands his case" . . . "The objective is to convince the patient that the symptoms are emotionally produced. One may point out how sudden fear causes palpitations, sweating, alteration of breathing, and sometimes a fainting attack. He will agree with this, but may object that he feels no such fear. One should then explain that great fear acting for a few seconds may be more than equaled by a tiny remote fear acting over weeks, months, or years, a state called anxiety". (The advantage of Wood's observations are that they provide evidence of the physical basis, however his interpretation of psychosomatic cause does not take into account the fact that the symptoms of the effort syndrome sometimes affect individuals who were formerly professional sportsmen or athletes, as was inferred in Charles Wooley's 1976 essay "Where are the diseases of Yesteryear", "the syndrome is not peculiarly . . . an athletes malady", " as has become more evident since. It is therefore evident that the physically based symptoms are not caused by a fear of exercise, but may result in concerns about the heart in some, but not all cases. M.B).

(12) Edwin O.Wheeler, M.D., Paul D.White, M.D., Eleanor W.Reed and Mandel E.Cohen, M.D., Boston (1950), Neurocirculatory Asthenia et.al. (1950) - A Twenty Year Follow-Up Study of One Hundred and Seventy-Three Patients., Journal of The American Medical Association, 25th March 1950 p.870-889 . . . This research and the twenty page report was partially funded by a research grant from the Medical Department of the United States Army, and was produced by medical researchers from the Cardiac Research Laboratory, Massachusetts General Hospital and the Departments of Medicine and Diseases of the Nervous System, Harvard Medical School,.and was read before the section on Internal Medicine at the Ninety-Eighth Annual Session of the American Medical Association, Atlantic City, on June 8th 1949. The article includes references to associated studies which comment on the typical thin physiques, and long, narrow chests of the patients, the vasomotor response to exercise was below normal, with a lag in blood pressure and pulse response to standard exertion, and high blood lactate concentration, low oxygen consumption and low ventilatory efficiency during exhausting work. Most patients completed questionaires, and of the 60 who attended medical examination 11.7% were well, 35% had symptoms, 38.3% had mild disability, and 15% had severe disability. There was less co-morbidity, and longer life expectancy than average, perhaps because they were private patients who probably had above average incomes and sought the advice of a cardiologist, and many of those who reported partial or severe disability led quiet or moderate lifestyles. They reported that they never could do anything strenuous, and that they tired easily and rested often, and they worked slowly, took time off work, changed jobs, or resigned from work, including sedentary work (writing, nursing, teaching), or stopped working at night. In situations of strenuous or sustained activity or lifestyle their health deteriorated, so they resumed their former quiet lifestyle and recovered, and in several cases two or three times throughout their life before recognising and accepting the necessity and value of doing so. Some patients reported that it took several weeks each time, or more than a month, and in one case up to a year to recover from the severe episodes.

Wheeler's Psychological Survey Conclusions: The study also considered personality aspects of the patients to determine the relevance of psychological factors in relation to the course of the ailment, and Wheeler summarised "from a personal and social point of view they seemed to be reasonably well adjusted citizens" and "Although these patients all have what is called "anxiety" . . . "they did not experience to any conspicuous extent any of the illnesses which are supposed to develop in persons with anxiety . . . such as peptic ulcer, diabetes mellitus, rheumatoid arthritis, asthma, ulcerative colitis, and hypertension.. . . "It is concluded that there is no evidence that anxiety causes these diseases."
However, some patients, when originally consulting a cardiologist, "had a fear of heart disease which  played an important role in aggravating their symptoms", and reassurance "that they had no heart disease . . . was an important factor in making them feel better", but . . . "It is true that some patients were never convinced that they did not have heart disease".  . . . and there is "no consistent or conclusive evidence that patients treated by  . . .(prolonged psychotherapy etc,) )  . . . got along any better than patients who have had little more therapy than simple reassurance and the passage of time." The other treatments which were reported as not being any more effective than simple reassurance in the long term were adrenal gland denervation, electric convulsive procedure, frontal lobotomy, and sedatives and other medications etc.

(13a) Sir Thomas Lewis (1918) The Soldiers Heart and the Effort Syndrome, Shaw & Sons, London p. 20-29: A large percentage of soldiers who developed the Effort Syndrome had poor physiques and long, narrow or flat chests associated with a kyphotic curve (hunchback spine) and many came from sedentary occupations. "It is unquestionable that many men recruited from sedentary occupations were affected by the condition before joining, although previous to that event in their life-history symptoms had never manifested themselves. The question naturally arises as to the extent to which sedentary work predisposes to the affection; no conclusive answer can be returned from the data at our disposal, though these strongly suggest sedentary work a a predisposing cause". Some of those soldiers experienced giddiness when standing up suddenly, or more rarely, even when laying down, and "a number of tested patients complained of equal giddiness when moved on a swingboard into the lying position" . . . and this . . . "seems to be associated with faulty distribution of the circulating blood during the period of giddiness".

(13b) T. Lewis (1919) The soldier's heart and effort syndrome, New York, Paul B.Hoeber. Observations from World War 1. He called it the effort syndrome because in some cases the symptoms were "largely, in some cases wholly, the exaggerated physiological response to exercise . . . that I term the whole the 'effort syndrome'." The condition was associated with a thin physique, a long and flattened chest and other chest wall deformities, and a kyphotic curve.

(14a) T. Lewis (1933) Diseases of the heart, New York, The MacMillan Co. p.158-164. Not necessarily a soldier's or an athletes malady "and is one of the commonest affections of sedentary town dwellers" and "Most of the soldiers came from sedentary occupations and a large percentage of the patients was affected by the condition in civil life many years before joining the Army", and he considered the possibility that several distinct but similar syndromes were being confused at the time making it difficult to provide useful subdivisions.

(14b) Sir Thomas Lewis (1937) Diseases of the Heart 2nd edition, MacMillan and Co., Limited, London p.97-98 and p.158-164: There is a rare type of postural faintness which is associated with the faulty distribution of blood which tends to accumulated in the abdominal veins. This is closely related to cases where the person feels faint when they stoop down to lace their boots or lift heavy weights, and it occurs because the mechanical or muscular action compresses the abdomen and squeezes the blood out of the abdominal veins. When they stand up again the blood takes a few moments longer to fill the veins, and in the meantime blood flow to the heart and brain is diminished.

(15) Volkov V.S. (1980) Psychosomatic Interrelations and their clinical importance in patients suffering from cardiac type NCD., Soviet Medicine (11) p.9-15, English abstract ( and a translation): A comparative study of exertional capacities of healthy subject in relation to 228 patients with three stages of severity of the effort syndrome which was referred to as neurocirulatory dystony, NCD1, NCD2, and NCD3, where healthy males had an average of 1176 kg/min, and stages 1, 2, & 3 for NCD were 1161, 940 & 591 respectively for males, and for healthy females was 834, and the stages of NCD were 854, 621 & 420 kg/min. respectively, indicating that the severity of the condition was related to the efficiency of circulation and exertional capacity. 87.2% of patients tolerated 600 kg/min. or more, but 14 of the others had to stop because of overwhelming, irradiating heart pain, and would stop because of general fatigue and "fear for their hearts". 15 other patients stopped their test prematurely because of changes in their heart rates which reached sub-maximal levels.

(16) Banfield M.A. et.al., (Dec. 20th. 1982) SA study matches Russian results, Adelaide "News" p.18: As reported by journalist Diane Beer, Similar findings to Volkov (1980) were made at the South Australian Institute for Fitness research and Training, with regard to the measurements of fitness levels of patients with chronic fatigue. An exercise programme was designed on the basis of the assumption that previous attempts to determine the effects of exercise had been unsuccessful because the organisers had assumed that there was nothing physically wrong with the patients, or that they were simply unfit from lack of exercise, and that they should be able to participate in a normal exercise programme where they were required to gradually improve their fitness to normal levels, and hence return to normal health. The patients were probably reaching a level where they started to get distressing symptoms, and therefore lost faith in the reassurances of the course directors and dropped out of the programmes too soon to get meaningful results. The South Australian programme was designed on the basis of the assumption that the patients could train if they exercised and continued to improve within their own limits. Several programmes were started 3 months apart, and ultimately 80 patients were medically assessed on an ergometric cycle where load was increased over several intervals of rest, and pulse was recorded at each level to produce a graph which provided the standard scientifically reliable estimate of physical exertional capacity which was objectively independent of other factors. In the first year 11 started but did not complete three months training. Four of those were examined six months later and were found to have much the same results. 9 completed three months training for two hours, twice per week, and 5 completed six months or more. Significant improvement was seen in three cases which started below 400 kgm/min, and 3 cases improved but plateaud below 600 kgm after the third month indicating chronicity. One of the initial trainees entered a six mile marathon 12 months later and completed it. The newspaper article and several others between 1982 and 1983 presented a generalised news account of those findings. CFSoriginalResearchIFRT1982-84 The study added to the Russian results by measuring the aerobic capacity before commencing a fitness training programme, and again after, to determine the effects of exercise. The study also found that in one group where six people trained for three months in the same class there position on the walking or jogging track corresponded to their measured level of aerobic capacity, and those who reported that they had to restrict their lifestyle before starting the programme were found to have low aerobic capacity, and those whose lifestyle had been unchanged had normal to above average results. It was also noticed that there was some inconsistency in physique where not all of the participants in the programme had the thin and stooped profile sometimes described as typical in the literature.

The Posture Theory and the Mechanism for Orthostatic Hypotension, Orthostatic Intolerance, Effort Intolerance, and Exhaustion; Evidence and Proof of Concept from 1916 © February 2008 According to The Posture Theory, when individuals with stooped spines and flat chests lean toward a desk and bend forward at the waist, they compress the air in their chests and impede the flow of blood from their feet to their hearts. This produces repetitive resistance to blood flow and ultimately strains and stretches the walls of the leg and abdominal veins. In the early stages the person may notice that when they stand up suddenly they feel faint and dizzy for a few seconds. That happens because the sudden weight of blood stretches the weakened walls of the veins so that the blood temporarily pools in them instead of continuing toward the heart and brain at the normal flow rate, and the brain is deprived of its full blood supply until the widened veins fill and full flow starts again. Similarly, when a person suddenly sprints in a race the heart pumps blood out into the arteries with great force and when it enters the veins they stretch abnormally, the blood pools in them, and the return of blood to the right side of the heart is weaker, so it pounds excessively and the person feels suddenly faint, dizzy, breathless, and exhausted, and may feel heart pain, despite the fact that there is nothing wrong with the heart itself. (The heart pounds and races to compensate for the abnormal fall in blood pressure during sudden exertion). The slower flow of blood through the lungs results in an insufficient exchange of oxygen and carbon dioxide which affects the blood chemistry, and doesn't meet the demands of the exertion, so that an oxygen debt accumulates in the blood until flow stops or a threshold is reached, and the person stops running, falls to the ground and begins forcefully gasping for breath, which probably has the effect of forcing oxygen into the small amount of blood passing through the lungs. The persons heart would continue pounding and racing, and they would continue to be exhausted, faint, and gasping for breath until the blood flow returned to normal levels and sufficient oxygen had been inhaled and transferred into the blood stream. Also, if the blood flow slowed in the early part of the sprint there would be less pressure on the incoming side of the heart valves, which may dispose to temporary functional valve prolapse. These features have all been observed and recorded in research studies, but the forced breathing has generally been regarded as anxiety induced hyperventilation and the changes in blood chemistry has been interpreted as evidence in support of the idea that hyperventilation is the cause, and the mitral valve prolapse has been generally interpreted as the cause of symptoms instead of vice versa, The sense of faintness which a person feels when standing up suddenly is due to the temporary lowering of blood pressure and is therefore called Orthostatic Hypotension, and it can effect healthy people if they don't drink sufficient water and stand out in the hot sun for long periods of time, or suffer from dehydration. or any factor which reduces the volume of blood in the veins. It can also affect teenagers who grow too tall too quickly, and mild forms of orthostatic hypotention can effect people with varicose veins in the legs, or those who wear tight safety harness straps around their legs which impairs the flow of blood from the feet to the heart. However in more severe forms, where the veins of the legs and the veins of the abdomen are weak or dilated, the person may get the severe symptoms in relation to exertion, which is called Orthostatic Intolerance, Postural Orthostatic Tachycardia Syndrome, or Exertional Intolerance. Such people may feel well while resting, but if they start jogging they may get a sense of uneasiness in the chest, as the flow of blood returning to the heart slows, and that feeling may deter them from running faster, and hence a good way of controlling the condition involves exercising within certain limits, which is called 'pacing'. M.B. (17) Wintrobe M.W. et. al. (editors) (1970) Harrison's Principles of Internal Medicine; 6th edition, McGraw-Hill Book Company, New York. p.106-108 & 225: reference to intra-thoracic pressure - tussive syncope (fainting caused by coughing), and tight collars, tilt table tests, varicose veins and gravitational blood pooling as a cause of orthostatic hypotension, and refers to vasovagal or vasodepressor fainting in relation to conditions which favor vasodilation, and as a symptom of neurocirculatory asthenia. . . . and chronic hypotension as a cause of lethargy, easy fatigueability, presumably due to decreased perfusion of the brain. See also; reference 20, M.A.Banfield April 1980, Hypothetical Shock Mechanisms, Australasian Nurses Journal p.16-18. (35) Mackenzie, Sir James M.D. (January 18th. 1916) Discussion On The Soldier's Heart, Therapeutical and Pharmacological Section, Proceedings of the Royal Society of Medicine, Vol.9, p.27 -36; Evidence for the Posture Theory and the relationship to Orthostatic Hypotension and Exertional Intolerance is seen in the following quote from Sir James Mackenzie M.D. in 1916 - regarding the symptom of exhaustion "There is a persistent over-action of vasomotor influences" . . . and sometimes . . . "flushes of heat pass over the body, and warmth may tend to overfilling of the peripheral vessels. This is seen in people who faint when standing in a warm room, or who speedily become exhausted or even faint when exertion is made. In these, the blood tends to accumulate in the peripheral veins of the limbs and in the large abdominal veins, with consequent anaemia of the brain. It is because of this anaemia of the brain that the sense of exhaustion and syncope are provoked". The author presented this description to show that this type of exhaustion is related to vasomotor disturbance and was not the same mechanism which produced exhaustion of the heart itself. He also referred to the importance of the judicious use of exercise which should involve the simple principle of exercising "so long as it gives him pleasure and causes no distress or discomfort, but to stop or slow down as soon as he experiences the sense of exhaustion, breathlessness and pain." (The fact that blood accumulates in the abdominal veins is evidence of the posture theory in regard to abdominal vein dystonia M.B.). (42) Streeten David H.P. (Sept.1998), The Nature of Chronic Fatigue Syndrome (CFS), J.A.M.A. v.280, n.12, 23-9-98, Editorial. (David Streeten is from the Department of Medicine, State University of New York Health Science Section, Syracuse) David Streeten presented an article in the September 23rd edtion of JAMA explaining that the fatigue reported by Da Costa and Lewis were early descriptions of a "newly recognised" delayed form of orthostatic hypotension which is a feature of some types of Chronic Fatigue Syndrome. He stated that "as a working hypothesis", the fatigue was due to abnormal pooling of blood in the lower limbs which delayed and reduced the flow of blood and oxygen supply to the brain. That effect was compounded by a reduced circulating red blood cell mass. He then emphasised that it is essential to identify these physical abnormalities by repeatedly measuring the patients blood pressure in recumbency and after standing for ten minutes or tilt testing, and that "it is inappropriate to consider that CFS is a manifestation of mental disorder" unless those physical causes are excluded. He added that the expense of these tests was not unreasonable considering that almost every type of work or lifestyle required a person to stand for six hours per day without experiencing the symptoms associated with reduced blood pressure. He then concluded the instigating cause remains unknown, and that effective and safe treatments for the debilitating symptoms are still not available and that further research is required. (49) Krzysztof Narkiewicz (1998) Chronic Orthostatic Intolerance; Part of a Spectrum of Dysfunction in Orthostatic Cardiovascular Hoeostasis?, Circulation 98:2105-2107. This paper reports on the study of postural orthostatic tachycardia syndrome, and attributes to the gravitational pooling of blood in the lower limbs caused by "impaired venous tone" where "It is generally accepted that autonomic dysfunction is a hallmark of this disorder."

(18) Banfield M.A. (March 1979) Introduction to Essays on Effort Syndrome, Australasian Nurses Journal, Port Adelaide, South Australia. p.26-27: A commentary on the interrelated subjects of Da Costa's Syndrome, Hyperdynamic Circulatory State, Neurocirculatory Asthenia, Pono Palmosis, Shell Shock, Battle Fatigue, Traumasthenia, Vasoregulatory Asthenia, Anxiety Neurosis, Cardiac Neurosis, Cardiophobia, War Neurosis, Cardiac Asthenia, Cardiovascular Neurasthenia, Disorderly Action of the Heart (D.A.H.), Functional Cardiovascular Disease, and Irritable Heart.

(19) Banfield M.A. (Dec.1979) Some Hypothetical Mechanisms for the Symptoms of Neuroses During Pregnancy and Exercise, Australasian Nurses Journal, Port Adelaide, South Australia. p.30-31; A theory on postural compression of the chest cavity as a mechanistic Valsalva's Maneuver with manifestations of dysautonomia.

(20) Banfield M.A. (April 1980) Hypothetical Shock Mechanisms, Australasian Nurses Journal, Port Adelaide, South Australia. p.16-18; A theory presenting a sequel of emotional stress, chest cavity compression, vena caval and peripheral vascular dystonia and abnormal dilatability, gravitational circulatory derangement (orthostatic hypotension), non-hypo volemic shock, ending with manifestations of dysautonomia.

(21) Nixon P.G. (Oct.1993) The grey area of effort syndrome and hyperventilation: from Thomas Lewis to today, Journal of the Royal College of Physicians of London, Oct;27(4);377-83. "Lewis used the diagnosis 'effort syndrome' for subjects whose ability to make and sustain effort had been reduced by homeostatic failure", and he regarded it as a systems disorder with a metabolic element which was important to recognise in order to prevent "the invention of fanciful, unphysiological diagnoses". His ideas were dismissed at the time because the metabolic abnormality was not apparent at rest and only occurred during physical exertion. Today, effort syndrome is still a useful description for the condition . . . and . . . "it may be a mistake to treat chronic fatigue syndrome and unspecific illness without including it in the differential diagnosis".

(22) Wolf S. (Nov. 1947) Sustained Contraction of the diaphragm, the mechanism of a common type of Dyspnoea and precordial pain. Journal of Clinical Investigation, Vol. 26, p.1201: These findings were presented at the Proceedings of the Thirty-Ninth Annual Meeting of The American Society For Clinical Investigation held in Atlantic City, N.J. on May 5, 1947: Regarding "respiratory distress characterized by inability to get a full breath": Flouroscopic observations showed that the diaphragm function was abnormal in patients who were anxious, and others who were not . . . and when some of them were put in discussions of situational conflict the changes in inspiration and expiration were evident, and when the diaphragms contractile state during inspiration was such that adequate inspiration was no longer possible, breathlessness occurred with a feeling of inability to take a full breath. The spasm of the diaphragm was often accompanied by pains in the chest and shoulder, occlusion of the lower end of the esophagus, and difficulty swallowing.

(23) Cohen M.E., Johnson R.E., Consolazio F.C., and White P.D. et.al, (Nov.1946) (from Massacheusetts General Hospital, Harvard Medical School, and the Fatigue Laboratory, Harvard Graduate School of Business Administration): Summary: Low oxygen consumption and low ventilatory efficiency during exhausting work in patients with neurocirculatory asthenia, effort syndrome, anxiety neurosis, v.25 (6) (1946) p.920, and the full article Studies Of Breathing, Pulmonary Ventilation And Subjective Awareness Of Shortness Of Breath (Dyspnea) In Neurocirculatory Asthnia, Effort Syndrome, Anxiety Neurosis. Nov.23 (1946) p.339-342, and Blood Lactate Response During Moderate Exercise In Neurocirculatory Asthenia, Anxiety Neurosis Or Effort Syndrome Dec.23 (1946), Journal of Clinical Investigation: A comparative study of 20 men with N.C.A. and 20 healthy men on a treadmill found that during hard muscular work, "N.C.A.. patients consume less oxygen, have a lower ventilatory efficiency and show a higher blood lactate than do healthy control subjects of comparable age. Some of the tests were conducted on a larger number of patients. The data are all consistent with the idea that aerobic metabolism in hard muscular work is abnormal in N.C.A. and suggests high oxygen debt." Comparative studies for three minutes running on a treadmill were maximum oxygen consumption per kgm. body weight and minute with an average of 36.8 ml. for N.C.A., and 47 ml.. for healthy patients of the same age. The data was taken each minute for three minutes, and for each minute was 33.8, 40, & 37.7 ml/kgm body weight for N.C.A. and 35.0, 43.9 & 46.5 ml/kgm. for healthy men of the same age, showing a progressively greater difference with the duration of the run. Also, in blood samples taken 5 minutes after the run the average was 1.31 mgm. of blood lactate per 100 ml of blood and second of running for the N.C.A. patients, as compared to 0.60 mgm. for healthy men, and ventilatory efficiency was lower at all times in the N.C.A. patients. However this particular study did not determine if this was due to poor general health, poor fitness, or lack of training, and "An attempt to train some of these men was unsuccessful as the men did not train properly" Studies by other authors concluded that this was "simply a matter of lack of "persistence"" but this study showed that "this lack of persistence is usually associated with a chemical abnormality - that is, increased blood lactate concentration", and although the exact mechanism cannot be determined yet "our evidence. . . suggests deficient aerobic metabolism and excessive oxygen debt." (This review was prepared from my references and notes associated with my 1982 research paper; re; "An attempt to train some of these men was unsuccessful as the men did not train properly" . . . and . . . these patients showed "lack of persisence" in physical training; Why?)

(23a) Cohen M.E. and White P.D. (May 1947) Studies Of Breathing, Pulmonary Ventilation And Subjective Awareness Of Shortness Of Breath (Dyspnea) In Neurocirculatory Asthenia, Effort Syndrome, Anxiety Neurosis, Journal of Clinical Investigation, Vol.26(3), May 26th 1947) p.520-529; (Received for publication December 23, 1946: "In neurocirculatory asthenia, anxiety neurosis, or effort syndrome many respiratory symptoms occur in high incidence. This constitutes a characteristic and therefore diagnostic feature of the disorder; the absence of such symptoms makes the diagnosis of N.C.A. improbable. The complete mechanism of these symptoms is unknown but it is of interest that when respiration is investigated objective abnormalities are found, just as when other symptoms of N.C.A. are investigated with objective methods, which demonstrates that the abnormalities are not all in the subjective sphere". The respiratory abnormalities at rest are few but during exercise the abnormalities become more pronounced; the deviations from the normal becoming greater as the rate and amount of exercise increases. "It is of interest particularly since the patient's' disability involves especially hard work." In their more detailed account of the condition Cohen and White report that the higher incidence of breathing symptoms in N.C.A. is more pronounced in the chronic cases than in acute forms, and when the patient is required to wear a gas mask or when swimming. Respiratory rate is greater but breathing is shallower and sighing is more frequent than normal. "The resting minute respiratory volume, with persons seated and breathing air, is slightly but significantly higher in patients". . . and "Both the awareness of and outward appearance of shortness of breath are related in N.C.A. to some factor or factors, other than amount of pulmonary ventilation". During walking there is higher pulmonary ventilation and a lower ventilatory efficiency, and the difference between the total ventilation of patients compared to healthy controls become greater "as the pace of exercise becomes more rapid" . . . and is "more marked after exercise than during exercise". "Not only do more patients feel shortness of breath but they also report feeling a greater degree of shortness of breath". The study of respiratory rate and tidal volume showed that there was a difference in minute respiratory volume between healthy controls and N.C.A. which incicated that it was due to the greater respiratory rate. Also subjects awareness of dyspnea and distress as related to ventilation iindex shows that for the same range ventilation index a higher incidence of patients reports shortness of breath or discomfort as compared with controls. "This shows that the incidence and degree of dyspnea in N.C.A. is not only out of proportion to the amount of exercise, but also is out of proportion to the amount of ventilation and ventilation index". The results of this study showed "that during running ventilation starts higher but ends lower; as the run progresses, ventilatory efficiency is low at all intervals of run for N.C.A. ". In summarising the study of ventilation, it was found to be higher in N.C.A. patients doing moderate work, compared to healthy people, and "it is higher as hard work begins but becomes lower as hard work progresses." The ventilation was disproportionately high after exercise and "may be related to other evidence of increased oxygen debt in N.C.A. and high blood lactate after exercise." "The evidence of poor ventilatory efficiency corresponds interestingly, although it may not explain, another symptom which patients have which is that they 'can't get in enough air' or that 'air doesn't seem to do as much good as it should'". The concluding discussion mentioned that if the type of N.C.A. breathlesness is to be studied effectively the definition of the word dyspnea needs to mean the same thing to all who use it and . . . "it should be used uniformly to mean the same thing by all observers". . . and by implication involve the same response to exertion. (Like many authors, Cohen and White refer to the fact that the study of symptoms needs to be based on clear descriptions of them, so that they are not mixed in with other groups of similar but slighlty different symtpoms, which would make studying them confusing and give inconsistant, variable, and therefore meaningless results.M.B.)

(24) Baker D.M. (1942) Cardiac Symptoms in the Neuroses, H.K.Lewis & Co., London. This small book provides individual chapters on each of the main symptoms of Da Costa's syndrome.

(25) Fulcher Kathy.Y. & White Peter.D. (June 7th 1997) (of the National Sports Medicine Institute, St Bartholomew's, and the Department of Psychological Medicine of the Royal London Medical School, London) Randomised controlled trial of graded exercise in patients with the chronic fatigue syndrome, British Medical Journal, June 7th, 314(7095):1647-52; Criteria for the study . . . The chronic fatigue syndrome related to physical deconditioning, sleep deprivation and psychological distress. The physical deconditioning may result from reduced physical activity, and this may have detrimental physical and psychological effects which can be improved by fitness training. ("A similar programme improved symptoms and physiological findings in an open study of patients with the 'effort syndrome'"). . . . Results of the study . . . "66 patients with the chronic fatigue syndrome (according to the Oxford criteria) who had neither a psychiatric disorder nor appreciable sleep disturbance" were randomly allocated to 12 weeks of graded aerobic exercise, or flexibility exercises and relaxation therapy. Only five of the original 71 refused to start the trial, and the remaining all gave valid informed consent to participate. The exercise programme was supervised with each patient being prescribed a starting level determined by their existing capacity, and was gradually improved each week "to a maximum of 60% of peak oxygen consumption", and each patient was provided with an ambulatory heart rate monitor and instructed not to exceed their prescribed heart rate targets. "The main exercise was walking, but patients were encouraged to take other modes of exercise, such as cycling and swimming. Patients were advised not to exceed prescribed exercise during a good phase. If patients complained of increased fatigue they were advised to continue at the same level of exercise for an extra week and increase when the fatigue had lessened". Four patients doing the exercise programme, and three doing the flexibility training dropped out before completing the course. However, according to the self rating scores of patients who did complete the programmes, "Fatigue, functional capacity, and fitness were significantly better after exercise than after flexibility treatment", and 32 of 47 patients rated themselves as better three months after completing supervised exercise treatment, and 35 rated themselves better one year after completing the training, and only one patient claimed to be worse off, with the conclusion that "support the use of appropriately prescribed graded aerobic exercise in the management of patients with the chronic fatigue syndrome". It was noted that the improvement in the aerobic capacity of patients with CFS who trained, was 13%, which was greater than the 5-10% improvement seen in healthy sedentary people who participated in similar courses. Also, in the CFS patients "Both physiological and perceptual improvements occurred at submaximal treadmill stages after exercise treatment . . . This is clinically important as submaximal activities such as walking are functionally more important than maximal activities such as running". "The only other treatment of the chronic fatigue syndrome to show promise is cognitive behaviour therapy, which improves functional capacity and symptoms more than both standard medical care and relaxation therapy". The authors end by discussing the problems in comparing the benefits of exercise treatments with other studies because they may include patients with differences in perceived physical incapacity and co-morbid psychiatric factors. This BMJ paper is supported by 32 references, and had been cited by 40 research journal and other articles.

(26) White P.D. (1951), Heart Disease, 4th. edition, MacMillan, New York, N.Y., p.578-591: In 1913 Paul Dudley White was offered a Harvard traveling fellowshipship to study cardiovascular physiology with Thomas Lewis in 1913, and then he had extensive experience working as a military doctor in Word War 1, and was a founding member of the prestigious American Heart Association, and president of that organisation in 1941, and became emeritus professor of Harvard in 1949. In 1951 the fourth edition of his book "Heart Disease" contained a chapter on "Neurocirculatory Asthenia", because, as he explains, the symptoms are similar to heart disease, but are not the same, and he adds, that they are also similar to, but can occur in the absence of anxiety, and therefore need to be discussed separately.
He gives the definition of N.C.A. as the typical group of symptoms of breathlessness, often with sighing, palpitations, precordial aches and pains, exhaustion, and related symptoms such as dizziness and faintness, which are precipitated by excitement or effort, and "it constitutes a kind of fatigue syndrome" . . . and in some cases . . . "it is more or less a chronic condition" . . . and . . . "That such a state of ill health exists there can be no doubt, no matter what its pathogenesis or exciting factors."
"The effort syndrome, though easily induced, might be at first thought to be unworthy of any special discussion" as it is not apparently organic, and may occur in perfectly normal persons, but it is important, because in some individuals "it is very easily induced." and it can be "completely incapacitating". . . "and it is not a normal response to effort. Also the symptoms are not exactly like those produced by effort in a normal healthy person. Some of these individuals are "unable to maintain any degree of physical effort, and quickly accumulating respiratory inefficiency and an excess of lactic acid on exercise." Also, in some patients the neurocirculatory symptoms are prominent but in others it is gastrointestinal or cerebral symptoms, but the reason for those differences "has not been explained". The general causes of the condition appear to include such strains as worry over business, social, or family matters, emotional conflicts, physical or nervous fatigue, and exhaustion from acute infections or illnesses. The organic basis is not known although it may involve a disorder of the autonomic nervous system. Other possibilities which have been considered in the past 25 years, include thyrotoxicosis, low-grade infection, adrenal hyperactivity, hyperventilation, and lack of salt, but none have been confirmed, and there is no known pathology. However many of the patients have thin physiques with an "unusually vertical position of the heart", an easily induced oxygen debt on exercise, and "Another interesting finding is abnormality of shape of the capillary loops at the base of the nail". . . "It is common to find that the close relatives and recent ancestors of patients" have had similar problems, and "Recent studies have suggested that neurocirculatory asthenia belongs to the Mendelian dominant group of inherited disorders." It was common in World War 1, occurred in civilians as well as soldier's, and it is generally seen in young adults, but can occur at any age, and is more common in women than men.
Regarding the symptoms, the breathlessness is subjectively unpleasant, and sometimes involves abnormally rapid breathing, and another feature is a characteristic type of sighing which occurs occasionally and can be used to distinguish it from heart disease. "The left breast tenderness is distinctive evidence" of the condition and the precordial pain occurs in that area and is sometimes an ache, and on some occasions there may be sudden, brief, sharp, stabbing pains. The fatigue sometimes produces more incapacity than heart disease, and in some cases results in complete disability. "It is a real and not an imaginary incapacity, even though at first glance it may have appeared imaginary in World War 1 (1914-1918) when it was sometimes labelled 'malingering,' and even though in civilian practice it has frequently been diagnosed as 'mere nervouseness'." It is milder in civilian life than in war and it is so commonly associated with psycho-neurosis of the anxiety type "that the two conditions have sometimes been confused one for the other or considered to be synonymous, the term anxiety neurosis having come to mean for many the same collection of symptoms which identify neurocirculatory asthenia."
The course of the condition is variable, but does not appear to effect life expectancy. Treatment involves rest for days or months or as long as required, and elaborate psychotherapy is generally not needed. "In fact, since this condition is neither heart disease nor mental disorder, both cardiologist and psychiatrist are well kept away after the diagnosis has been established, so that the patient may not develop unnecessary fears about either heart or mental state."
"The condition must be discussed seriously, not lightly as if it was of no importance", and it is equally wrong to dismiss it as negligible or imaginary, as it is to to regard it as dangerous or serious and a threat to life which demands bed rest. Careless disregard will alienate patients and have them seeking advice from charlatans. "The plan of life for the patient needs to be worked out with care" where usually normal but quiet work and play are required, with the avoidance of late nights, excessive efforts, and long hours of work or taking on new or burdensome tasks. "Often the patient himself is aware of this necessity, but he has perhaps disliked to humor his symptoms or to fall behind his fellows in strenuous living in the business, professional, or social world. With clear medical advice, however, he realizes the wisdom of doing so, and gradually he adjusts himself to suit his symptoms, and is surprised at recapturing a feeling of well being." (This review of chapter 22 of P.D.W.'s book was prepared from my notes associated with my 1982 research paper, and placed on this web page on 25-1-08. M.B.)

(27) Mandel E.Cohen, M.D., and Paul D.White M.D. (1972), Neurocirculatory Asthenia: 1972 Concept, Military Medicine, April, p.142-144; The classic symptoms of chest pains, breathlessness, palpitations and fatigue were defined with the comment "The symptoms are not identical with the symptoms of fear, effort, thyrotoxicosis, or convalescence, although there are some resemlances." The condition was also discussed with reference to the history of the subject using the usual terms of Da Costa's syndrome, effort syndrome, soldier's heart, etc,. with the added comment "so many terms have been used for conditions featuring these symptoms that the diagnosis may be obscured by too many names. Although many of the diagnostic terms change or even disappear, the syndrome persists and is common in both war and peace."
They noted that the patients generally had thin physiques and were poor athletes and especially poor swimmers, and they mentioned that when they were medically assessed at rest "there are only a few abnormalities" but "in response to a variety of stresses and stimuli, many definite and interesting abnormalities appear" especially during exercise when breathing rate increases and becomes disproportionally shallow . . . and . . .evidence showed that "aerobic metabolism was defective in these patients" . . . and . . . "Attempts to train patients to better performance were not successful in our observation." Also, "It has been known since World War 1 that these patients have been particularly intolerant to carbon dioxide" and when they rebreath an accumulated mixture there is "a significant increase in sighing respiration . . . and . . . the appearance of 'anxiety attacks'". "These 'anxiety attacks' did not occur in healthy controls subjected to breathing carbon dioxide" . . . and . . . "pain, cold, muscular effort, carbon dioxide, noise, flash, and 'anticipation'" produced abnormal physiological responses at low levels. They concluded with the comment that "The Viennese physician who first used the term 'anxiety neurosis,' now fairly obsolete, stated that 'the symptoms of these patients are not mentally determined or removable by analysis" and they referred to a 20 year follow-up study which found that "simple kindly reassurance . . . worked as well as various types of 'psychotherapy or psychoanalysis.'"
In their assessment the condition had two forms with the minor type being referred to as neurocirculatory asthenia, and the more severe type being called "big NCA" because they generally did not respond well to reassurance, and had the additional feature of the symptoms of depression.
They noted that "Manic-depressive disease is supposed to show only classic symptoms of 'psychological' abnormality", but with "about one half" of these patients there are "spectacular medical-like symptoms, such as chest pain, shortness of breath, fatigue," etc.
These people "are incapacitated partially or completely even for office work" and have additional "psychological-like complaints" which "include worry, nervousness, indecisiveness, loss of confidence, feelings of guilt, depressed mood, thoughts of suicide and death by suicide. Almost all patients who commit suicide have manic-depressive disease." and tend to have short stocky physiques, expressionless faces, and "stooped posture". In such cases treatment involves the use of "sodium amobarbital for mood disturbance and chloral hydrate for sleep." In some cases they need to be protected from their attempts at suicide by being confined to "a locked ward hospital" and "There are myriad newer, more expensive and more toxic drugs, with almost no good scientific data to recommend them" and "Electrotherapy is often indicated."
In their concluding discussion they reported that "objective abnormalities - clinical, anatomical, physiological, and biochemical - have been observed" . . . and . . . "there is a more realistic way of classifying neurocirculatory asthenia, despite the mixed-up and fictional psychiatric nomenclature with which we are currently saddled."
They also noted that research was continuing in Sweden, Israel, Japan, and other countries, and they emphasised the importance of determining "what provokes an attack, what makes symptoms worse, what disables," as it "can be crucial" regarding the benefits to be gained by avoiding such factors. "Most patients believe that attacks are precipitated or made worse by emotion-provoking situations, medical illness, unaccustomed or involuntary hard muscular work, pregnancy, and military service", and the authors added "infection . . . and . . . extremes of heat and cold as probable provoking 'stresses'". in their review of their experience, history, and the War of the Rebellion, "we encountered the same stresses; to quote 'double quick movements of camp, effected under full burden of arms and accoutrements . . . particularly when the individuals were debilitated from . . . diarroea . . .typhoid fever . . . (and) . . . nervous excitement." (This review the 1972 concept was prepared from my notes associated with my 1982 research paper, re;"Most patients believe that attacks are precipitated or made worse by . . . unaccustomed or involuntary hard muscular work," . . . and . . . Attempts to train patients to better performance were not successful in our observation.". Why? and placed on this web page on 27-1-08. - Another reference; source lost, reported "these patients could not or would not train". Why? M.B.)

(28) Caughey J.L. Jnr., M.D. (April 1939), Cardiovascular Neurosis; A review. Psychosomatic Medicine,Vol.1 No.3, April 1939, p.311-324; This author was from the Department of Medicine, College of Physicians and Surgeons, Columbia University, and the Presbyterian Hospital, New York City, He reviewed the literature of internal medicine on the subject of cardiovascular neurosis which refers to "cases in which symptoms and signs of circulatory origin are present but cannot be explained on the basis of pathological changes in the cardiovascular apparatus". He mentioned the similarity of previous terms such as effort syndrome and neurocirculatory asthenia and gives a description of each of the symptoms individually, and presents a typical example of the past and present physique, health, and personal history of such a civilian patient. He was generally aged 30, and previously did clerical work but was currently unemployed, who had a thin build and long chest, was never robust, got frequent sore throats and colds as a child, had his tonsils and appendix out, and was "unable to sit and lie quietly", and had a weak stomach, and had his kidneys damaged by Scarlet fever, and there were frequent fluctuations in the color and volume of his urine. His blood pressure was unstable, and he may show obvious signs of abnormality in peripheral circulation, with pale fingers, toes, ears or nose in cold weather, as in a Raynaud's-like disease, and have dermatographia (from derma = skin, and graph = write) where dragging the finger nail lightly across the chest will leave a red line due to blood rising just below the skin, enabling the person to literally write their name on their skin. He will also have poor memory, and difficulty concentrating or thinking clearly. "He has always been nervous and easily fatigued", and he "was never allowed" to take part in competitive sports and has felt physically inferior to others of his own age. In a typical case he contracted a respiratory infection 3 years earlier, but never recovered properly, and since then has had gradually increasing pain in his heart, shortness of breath, dizziness, faintness and weakness. All of his symptoms were "made worse by exertion or nervous strain". The author states that the breathlessness "is not true air hunger, but literally a 'shortness of breath' a feeling that deep breath cannot be achieved. The patient usually localizes this sensation in the chest wall itself, and describes a constant dissatisfaction similar to the transient annoyance which a normal person has after attempting to sigh but not quite attaining the complete expansion desired," and it accounts for the tendency to sigh and hyperventilate. This author also notes previous exercise tests which indicate "a physiological abnormality in the patient as compared to the normal person", but he refers to that response to exercise as "no more dependent on the amount of exertion than it is on the emotional reaction he has, the fear he has that the test will injure seriously his already weakened heart." In describing the lack of stamina he suggests that there are two groups of patients, the first who never developed the ability to persevere against the challenges and adversities of life, and those who tried but gave up, in both cases concluding that "the present is bad, and that the future is to be even more dangerous and difficult". "He also explains that many theories have been used in the past to explain the cause of the condition, with widely varying opinions which may each have a "fragment of truth" in them. He lists ten which include; "Pressure from clothing . . . prolonged physical strain . . . infections of various sorts . . . hyperirritability of the autonomic nervous system . . . unfavorable environmental influences in childhood . . . and psychic instability." The author believes that the patients have a basic weakness in their constitution which is added to by the response to some physical effort, or emotional strain or some physiological reaction to a viral infection, which causes an instability of their physical responses in the future, which is then interpreted as having a serious effect on their health or their heart, and they continue to believe that the symptoms are due to disease despite thorough medical examination which eliminates all of those possibilities. He suggests that a normal person forgets such symptoms but the neurosis patient remains concerned as the result of misinterpreting them as serious because of "some instinctive anxiety", or "some psychological necessity for using the symptoms as a protection against the pressure of environmental forces." He then discusses the problems which doctors have to consider when dealing with such patients which include the increasingly and economically competitive nature of modern society and the diversification of disability benefits, and the growth in the medical knowledge of patients which is due to health campaigns, and newspaper articles and books written by popular medical authors. He says that such knowledge is small, but enough to create anxieties in the "uncritical audience" about "the integrity of his own vital processes." He then adds that these factors come to the physician "like a spark into a box of tinder", where the patient who has noticed some heart symptoms during a physical or emotional event is likely to have his fears accentuated and instilled by the doctors facial expression as he examines blood pressure. He suggests that it is important to discuss the matter carefully. He adds "No less dangerous are physicians who for one reason or another have never accepted the idea that important, sustained and disabling physiological abnormalities may occur in the absence of any organic disease." He also states "the doctor may contribute to a later cardiovascular neurosis, by failure to limit the patients physical activities during the convalescent period of vasomotor instability", or by failure to convince the patient that the symptoms are normal or temporary. He then concludes that the syndrome is due to complicated aspects of the total personality of the patient, and that the symptoms need to be thoroughly separated from those of heart disease by medical and laboratory examination, and then reconditioning the patients interpretation.

(29) Nixon P.G. (June 1994), Effort syndrome: hyperventilation and reduction of anaerobic threshold, Biofeedback Self Regulation, June 1994; 19(2): 155-69; "Effort syndrome is an entity in danger of being subsumed into 'chronic fatigue syndrome' and lost to sight". It is a distinct entity insofar as it features a reduction of the anaerobic threshold for exertion due to depletion of the alkaline buffering systems via hyperventilation. "In other forms of chronic fatigue syndrome, the pathogenesis and logic of therapy are unclear."

(30) Saish S.G., Deale A., Gardner W.N., & Wessely S., (June 1994), of the Department of Thoracic Medicine, Kings College School of Medicine and Dentistry, London, UK; Hyperventilation and chronic fatigue syndrome, The Quarterly journal of medicine, June 1994, 87(6): 373-4; A study of 31 patients with Oxford, and Joint CDC/NHC criteria for CFS who had "profound fatigue and fatigueability associated with minimal exertion" found that 66% developed the condition after an infection. They were tested "by capnograph or mass spectrometer via a fine catheter taped in a nostril at rest, (and) during and after exercise", and "Twenty two patients (71%) had no evidence of hyperventilation during any aspect of the test". One had hyperventilation associated with asthma, and four had hyperventilation associated with panic, and only one with agoraphobia had no other obvious cause, and five had borderline hyperventilation. The results of the testing showed that "There was no association between level of functional impairment and degree of hyperventilation.There is only a weak association between hyperventilation and chronic fatigue syndrome."

(31) Sharpe M.C. (February 1991), A report - chronic fatigue syndrome; guidelines for research, Journal of the Royal Society of Medicine, Vol.84 p.118-121; On the 23rd. March 1990 Professor Anthony Clare, Clinical Professor of Psychiatry, Trinity College, Dublin, chaired a meeting of 27 medical specialists from a variety of fields of study to discuss the problem of researching fatigue, insofar as there were too many definitions being used for too many different ailments which included too many different types of fatigue in their symptomology, so the assessment and comparison of data was becoming confused. The objective of the meeting was to establish the criteria for defining the problems so that research could progress more effectively in the future. They decided that there were two broad groups which could be called "chronic fatigue syndrome" CFS, and a sub-type of "post-infectious fatigue syndrome" PIFS, and specified that . . . "In reporting studies it should be clearly stated which of these two syndromes is being studied". They set the criteria of CFS for consideration, and added the post-viral aspect to the second criteria. It included "fatigue as the principle symptom" with a definite onset which is not life long and persisted for at least six months. The fatigue should "be disproportionate to exertion" . . . and . . . "represent a change from a previous state" and be categorised as "mild, moderate, or severe" . . . and "it should be stated whether the fatigue is greatly increased by minor exertion and whether it occurs at rest". . . and "each of the symptoms should be carefully distinguished from one another". Other related criteria were mentioned and in conclusion it was stated "The contributors hope that these guidelines will provide a basis for fruitful research studies, and for inter-disciplinary collaboration essential for this field of research. The guidelines are preliminary and will undoubtedly require further refinements and revision. The authors would welcome comments and suggestions." (Most, but not all cases of the Da Costa's, (also called the Effort Syndrome) fit the criteria of representing a change from a previous state, where the change followed physical strain or a viral infection or scurvy etc., after which there were abnormal impediments to physical exertion which involved four specific symptoms of chest pains, palpitations, breathlessness, and fatigue. Therefore Da Costa's syndrome, or the Effort Syndrome is a distinct sub-type of the chronic fatigue syndrome which needs to be studied separately with regard to it's four classic symptom, and exertion specific nature. M.B.)

(34) Oglesby Paul (1987) Da Costa's syndrome or neurocirculatory asthenia, British Heart Journal, Vol. 58, p.306-315: In 1987 Paul Oglesby from the Bringham and Women's Hospital, Harvard Medical School presented a ten page account of Da Costa's syndrome research in The British Heart Journal. He states "Da Costa's syndrome or neuorcirculatory asthenia has a long and honourable history in the medical literature". It is rarely mentioned nowadays and is unlikely to have disappeared, and in fact is still a common and distinct disorder with the same four main symptoms, but is more likely to be labeled as "anxiety state" or "anxiety neurosis". He then writes "What has been forgotten should not remain forgotten" and then begins to outline the controversies of the time. He starts his study by predating Da Costa to 1863 with other sources that deal with similar ailments, and then threads his way through the effort syndrome and neurocirculatory asthenia to the hyperventilation, anxiety state, systolic click and late systolic murmur syndrome, mitral valve prolapse syndrome, and dysautonomia theories. Along the way he describes the typical thin physique of sedentary workers who enlisted in the army and were not given any physical training, and were required to carry their soldier's field pack weighing over 60 lbs. strapped to their bodies in a manner which "constricted the circulation" as they were marched into military campaigns with "great and prolonged exertion with the most unfavorable conditions possible - privation of rest, deficient food, bad water and malaria". In attempting to keep up with the other troops they became severely exhausted and were hospitalised with months of fatigue which featured "shortness of breath after moderate exertion and a rapid pulse on slight effort", "palpitation", and "intercostal neuralgia" where a small number recovered and returned to full duty, but the majority were put on light service or pensioned off as being physically unfit for military service. Military administrators tried to prevent those problems in subsequent campaigns by altering "the weight and strappings of the soldier's packs" and by providing physical exercises at training camps to develop the strength and stamina of new recruits to accustom them to the strenuous exertion which would be required later in actual warfare. Da Costa recommended "provision for adequate convalescence for those with acute infections before they returned to duty." Another typical case was that of a 22 year old man who, since the age of 17 did light bench work and had palpitations and breathlessness on exertion. In 1914 he enlisted in the army and developed the symptoms when "doubling or hurrying" and in 1915 he went to France and developed the same symptoms "all on marching" and was admitted to hospital with no abnormal physical findings, and again returned to full duty 8 months later but was no better. In 1920 Sir James Mackenzie studied 2000 soldiers with the syndrome and found that in 80% "the first onset of their illness began with a complaint of some infectious nature", and the remainder were due to "want of rest". However P.D.White found that infective cause did not appear to be responsible for most cases in civilian practice. In 1941 Paul Wood began studying and reporting on Da Costa's syndrome in the British Medical Journal, and he concluded that the symptoms more closely resembled those of fear than effort, and that the abnormal response to effort was due to a misinterpretation of the normal symptoms of exercise as evidence of heart disease, and a fear of heart disease, or was due to conditioning, and hysteria. He suggested that the syndrome should be regarded "as an emotional reactive pattern peculiar to psychopathic personalities, and to subjects of almost any form of psychoneurosis". Also, in his opinion, "hyperventilation was not responsible for the symptoms and signs" and that they depended "on central stimulation, not upon hypersensitivity of the peripheral autonomic 'gear'", and that the central stimulation was generally caused by the emotion of fear. His views became influential and were significant in reducing the interest in, and use of the term Da Costa's syndrome during World War 2 where it was replaced by a variety of psychiatric diagnostic terms. In 1966 C.K. Friedberg wrote "The underlying cause appears to be a fundamental ego insecurity arising from psychological problems which began in infancy and childhood". In 1972 Cohen and White presented a summary of their own findings and concluded that the cause was unknown and that there may be two forms of the disorder where the milder type was called neurocirculatory asthenia, and the more severe type was manic-depressive disease. However some patients with anxiety or depression do not have the four classic symptoms of Da Costa's syndrome, and vice versa. Also the rebreathing of a mixture of added CO2 reproduced the symptoms and it was stated "The symptoms of neurocirculatory asthenia were considered not to be identical with those of fear alone".
Oglesby also noted that some patients with neurocirculatory asthenia also had mitral valve prolapse, which according to some authors may be the cause, but some MVP patients have no symptoms at all, or if they do the proportions of the four symptoms are different. He concludes that despite there being controversies about cause, and a large and wide variety of physical and psychological concomitants, and despite the label being rarely used and the syndrome being almost lost amongst many other labels, the effort related condition which Da Costa described in 1871 still existsed and was still common, affecting 2-4% of the population, and is usually easy to recognise and diagnose. (This article also refers to the symptom of breathlessness or 'smothering' occurring in crowds, without comment, but implying a fear factor - panic attacks - however that would be due to the excess amount of CO2 being exhaled by large numbers of people in a confined space, with the CO2 being responsible for the abnormal respiratory distress in patients with N.C.A.. Some entertainers take oxygen bottles on stage to deal with that problem themselves M.B.).

(35) Mackenzie, Sir James M.D. (January 18th. 1916) Discussion On The Soldier's Heart, Therapeutical and Pharmacological Section, Proceedings of the Royal Society of Medicine, Vol.9, p.27 -60; part of a series of discussions on Soldier's Heart; In his study of 400 cases of World War 1 soldiers with cardiac like symptoms Sir James Mackenzie M.D., who opened the discussion, found that only 10% of them had actual heart disease. The remainder had similar symptoms of a different unknown cause. He described the typical patient as having thin physique, vasomotor instability, and cold, red, or blue hands and noses. If they rested and ate they became fat and breathless. They feel unwell, "out of sorts", or "rotten", and "a sense of fatigue or exhaustion easily induced is common to all. Breathlessness on moderate exertion is frequent; pain over the region of the heart less frequent". Heart rate is normal in some but in others it is persistently high, up to 120 beats per minute, and "exertion, sometimes slight, may produce an undue rapidity", due to excitability of the heart. Various systolic murmurs were frequent, and some of the patients had edema of the legs, and were irritable, depressed, or brooding over their health or woes.
The same ailments occur in civilian life where "we find identical conditions for instance, in people recovering from an exhausting illness, such as typhoid fever, or influenza, or after a severe surgical procedure", or "in people who have suffered a long mental or physical strain, particularly with insufficient sleep, as in a daughter who has for long periods nursed an ailing mother". Typically the soldiers "will say they were in the trenches and felt well and fit, until one day they felt seedy and ill, and this continued until they were compelled to seek medical advice, when they were found to have a raised temperature". After a few days rest they returned to the strenuous life in the trenches and soon collapsed with faintness, breathlessness and pain. The preceding illnesses included diarrhoea, measles, or other infections which accounted for most cases, but some, with no history of infection were gradual in onset, and the remainder "give an account of a very strenuous life".
An example was given of a soldier in the trenches suffering "appendicitis". He had surgery and returned three months later, and spent two weeks in the trenches again being constantly shelled and was always repairing parapets, rarely getting any sleep at night and only a few hours during the day, and often going 24 hours without sleep. One day a shell exploded nearby and knocked him unconscious. After regaining consciousness he kept working until he was too weak and ill to continue due to pain in his heart. It was concluded that a combination of an infection, and physical and mental strain caused the ailment.
Another example was that of an officer who spent a few hours each day for several days practising for a foot race and collapsed on the track. When medically examined he reported feeling "rather seedy" and unwell before, and was exercising to shake off the feeling. He was found to have an elevated temperature, attributed to an infective illness, and was advised to rest. He recovered, returned to perfect health, and resumed training.
Mackenzie suggested that the chronic type of this ailment may not be caused by the microbial toxins, but be due to the infection causing some changes "in the economy of the blood, central nervous system, or heart muscle", and that maybe a vaccine could be developed to prevent the problem, and that treatment should include the removal of the infection or toxins, and improving general health and strength with mild enjoyable exercise such as "bowls or quoits or skittles" in the "fresh air".
He referred to the importance of the judicious use of exercise which should involve the simple principle of exercising "so long as it gives him pleasure and causes no distress or discomfort, but to stop or slow down as soon as he experiences the sense of exhaustion, breathlessness and pain."
(As a final matter this article includes some information which is suitable as Evidence for the Posture Theory and the relationship to Orthostatic Hypotension and Exertional Intolerance. This is seen in the following quote - regarding the symptom of exhaustion "There is a persistent over-action of vasomotor influences" . . . and sometimes . . . "flushes of heat pass over the body, and warmth may tend to overfilling of the peripheral vessels. This is seen in people who faint when standing in a warm room, or who speedily become exhausted or even faint when exertion is made. In these, the blood tends to accumulate in the peripheral veins of the limbs and in the large abdominal veins, with consequent anaemia of the brain. It is because of this anaemia of the brain that the sense of exhaustion and syncope are provoked". The author presented this description to show that this type of exhaustion is related to vasomotor disturbance and was not the same mechanism which produced exhaustion of the heart itself. This type of fatigue often starts following an infective or exhausting illness where the person tends to feel exhausted and giddy. "If they stop, sit, or lie down the sensation speedily disappears. If they attempt a more violent form of effort, such as walking quickly, or up a hill, or running upstairs, they may be pulled up by breathlessness or palpitation". According to The Posture Theory, many years of postural compression of the chest, impedes the upward flow of blood and damages the abdominal veins. This Mackenzie paragraph provides the evidence that blood is pooling in the abdominal veins during exertion, and he suggests it is the cause of the fatigue symptoms. M.B.)

Dr. R.M.Wilson contributed to the Mackenzie discussion with his statement "a careful study of upwards of 200 cases of the condition has brought me to the same conclusions", and he "met with what I can only regard as a definite clinical picture, sharply defined and differentiated" with "The cardinal symptoms" of exhaustion, breathlessness and rapid pulse especially on slight exertion, praecordial and left chest pain, vasomotor instability, and also tendencies to giddiness, nervous symptoms, and high blood-pressure. He commented on the history of the disorder with reference to an 1864 British Government committee convened by Earl de Grey, three generals, and two doctors who concluded that "an old form of accoutrement restricted the heart's action" which caused what they called "irritable heart" where "on the least exertion its action becomes irregular, and the man becomes breathless". Their recommendation that the accoutrements (in the knapsack) be held to the body by braces instead of waist straps "was later adopted". In 1864 Henry Harthorne described a condition in "The American Civil War" in the American Journal of the Medical Sciences with emphasis on "the acceleration of the heart's movements on the slightest exertion" and breathlessness, which he attributed to an injury to the heart caused "by long-continued over-exertion, with deficiency of rest and often of nourishment; and he pointed out that several months of rest and treatment in hospital failed to do more than improve, without really curing, a large proportion of well-marked cases". Later, in 1870 Dr. Arthur Myers of the Coldstream Guards gave a similar description and "he also regarded accoutrements as the exciting cause of the trouble", but the best known contribution to the subject was that of J.M. Da Costa who made the same observations from 300 cases.
In 1876 Arthur Davy attributed the problem to "'Setting-up drill', by over-expanding the chest, caused dilatation of the heart, and so induced irritability". Although the idea gained support, there were some soldiers who developed the condition without doing any drill, and the change in accoutrements and drill were deemed ineffective in reducing the incidence of the problem. The next theory was that a bacterial agent was causative, followed by the idea of a faulty thyroid gland being responsible, but nothing could be confirmed other than treatment was more effective in a cheerful situation with pleasant activities rather than depressing situations.
Dr. Philip Hamill wrote "I think that the more one sees these patients, the more one realizes that the true irritable heart of the soldier is a very definite condition". . . and . . . "In most cases irritable heart can be traced back to some undue exertion during some febrile attack - it may be called a cold or influenza" . . . and . . . "It is surprising , however, how high a proportion of soldiers with irritable hearts give a history of diarrhoea". There is usually no evidence of heart disease but the pulse rate is generally elevated . . . "A common rate is 100". Slight excitement seems to increase the rate, such as the mention of a cardiograph test. Hamill gives the example of a Territorial officer who joined the Regular Army cavalry regiment, and was also a boxer. One day while doing a long march he felt unwell and "fainted by the wayside, and had to lie down" to recover. "The same thing happened on another march" so he was sent to hospital and upon examination nothing but slight dilatation was found so he was found fit for duty, but a senior medic advised him that it would be unwise to continue in the army. He became a medical student but was restless and couldn't maintain concentration for long and constantly thought about his "discomforts and disability". He was keen to rejoin the army but when he applied he was rejected on medical grounds because of slight cardiac dullness, a pulse-rate which reached 120, and oedema of the ankles without albuminuria. "This student's symptoms were greatly accentuated after a bomb from an aircraft fell near his room" . . . and . . . "His pulse-rate readily rose to 140 per minute after moderate exertion, and remained high for a long time". His symptoms became worse while studying for an examination, so it is unlikely that "a man badly broken down on a march is ever likely to be fit again for heavy duty", and "however much these men improve, they are always ready to relapse when the favouring circumstances recur". He concludes that a large proportion of these men probably have permanent heart damage that will impede their capacity for heavy duty in the future but further research is needed by future generations, and in the meantime the best treatment is pleasant moderate exercise in the fresh air and green fields. Similar treatment was recommended for soldier's with shell shock.
Dr.Alexander Morrison contributed to the discussion with his report from a hospital where three wards, or half the beds were allocated to these soldiers, and he dealt with the question of cause by stating about the heart; "one can find nothing amiss with its size, rhythm, or mechanical structure" and he added that despite this these soldiers had an incapacity to undertake those exertions which were formerly undergone without discomfort. Therefore some factor has been introduced which renders these men incapable of their duties as soldiers". . . and . . . "that there is a valid incapacitation which they evince is undoubted", although "The heart itself in such cases shows, as a rule, absolutely no evidence whatever, clinically or otherwise, of physiological disturbance", and was previously regarded as a disorder of the nervous system. He also commented on the possibility that the condition was caused by a cryptic organism, a microbial infection, toxaemia, or diarrhoea, but he found cases with those preceding problems who did not have soldier's heart and vice versa, although he could not confidently rule out such possibilities.
Dr.O. Leyton stated "I believe that the condition is not due to a single cause", and after stethoscopic examination he believed that some cases arise from an affliction of the heart and others from a disorder of the vasomotor system.
Dr. Florence A. Stoney noted the similarity and possible connection between the symptoms of soldier's heart and thyroid disease.
Sir James Mackenzie concluded the meeting with the hope of getting a hospital devoted exclusively to the study of this subject which attracted medical researchers who were specially qualified "to investigate this subject thoroughly", and that the lines of study had been established and would lead to more definite findings in the future.

(I have highlighted the aspects of the meeting of Sir James Mackenzie in 1916 which provide evidence consistent with The Posture Theory and my views on the subject, with an additional comment that teatment in fresh air and green fields involves maximum oxygen and the absence of excess CO2 which is more prevalent in crowds or closed buildings, and which dsiposes to symptoms in these patients. M.B.)

(36) Jones E. and Weseley S. (December 1999), Case of chronic fatigue syndrome after Crimean war and Indian mutiny, British Medical Journal, December 1999, Vol. 319, p.18-25; This article opens with the following sentence "Chronic fatigue syndrome was first proposed as a diagnostic label in 1988 to classify a disorder characterised by severe fatigue and exhaustion after minimal physical and mental effort accompanied by other unexplained somatic symptoms". It was introduced to distinguish the condition from myalgic encephalomyetlitis which was similar to an outbreak of illness in the medical and nursing staff of the Royal Free Hospital in 1956. It was widely assumed in the popular media and occasionally in professional journals as a new disease caused by aspects of "modern life, pollution, stress, working practices, and new infections".
However "Attention has recently been drawn to the often striking similarities" between those conditions and the condition formerly known as neurasthenia which was coined independently in 1869 by George Beard and E.Van Deusen, and described as a physical disorder caused by "the selfishness and luxury of modern life, the restlessness and the craving for excitement, the frantic speeding about in motors and other features of industrial society". However the author believes it can be traced further back to soldiers "who served in the Crimean war and in India at the time of the mutiny", and, after examining 4000 pension files in the Royal Hospital Chelsea, two examples were chosen.
The first soldier enlisted in 1854 at age 18 and spent 6 months in Crimea as a reinforcement, "although apparently without taking part in a major battle". He then went with this regiment to India for six and a half years and returned to England, where in May 1864 he "suffered from increasing fatigue" with exhaustion, weakness, tremor, and pains in his knees, elbows, and shoulders, visual problems in his left eye, and a persistent cough, and "was eventually discharged from the army in February 1872 with a diagnosis of general debility, imperfect vision, and rheumatism, and was awarded a disability pension. The army physician attributed his condition to 17 years of army life in Turkey, India, and at home, and the general hardships of a soldier's life during the Indian mutiny. Cold and general exposure in a country where malaria was endemic probably contributed but there was no evidence the he had contracted malaria. His visual problem was diagnosed as iritis and he went blind in his left eye in 1923. His commanding officer described him as a model soldier who had been regularly promoted until he reached the rank of sergeant, and was not a malingerer. After he was discharged by the medical board in 1872, "as being permanently unfit for contributing to his own support" he returned to his occupation as a house painter, but only on a casual basis, and "Later, he worked as a commercial traveller before ill health forced him to give up employment", and in June 1885 his condition was described as 'very unsatisfactory indeed', and three years later his physician remarked "although he was then able to earn a livelihood . . . he . . . 'is likely at any moment to be quite unable to do so'"., and in April 1900 he was described as being more debilitated and soon after, as feeble. During his life he was a member of the Birmingham Military Veterans Association, was a recruiting sergeant in World War 1, toured convalescent hospitals, and collected money and provided warm clothing to sailors. At age 85 he complained of chronic rheumatism although there was no swelling in his joints, and was "well preserved for his age", and he died at age 96. Nowadays he would be given "the diagnosis of chronic fatigue syndrome".
After giving another example it was suggested that the conditions of war in India may have contributed to the ailment, where one troop "was reputed to have travelled over 3000 miles in pursuit of rebels, including a forced march of 251 miles in 11 days". In another example of a military attack on rebel troops it was reported that "So intense had been the heat that "officers and men were so completely exhausted . . . that they could scarcely sit in their saddles, and were for the moment, incapable of further exertion". It was concluded that the soldiers symptoms were an indication of chronic fatigue syndrome, which might have been diagnosed as "disorderly action of the heart" in 1915, and is similar to the diagnosis of "post traumatic stress disorder" given to Vietnam soldiers, or that the symptoms may have been attributed to exposure to Agent Orange, and that the way disease is interpreted and labelled varies according to circumstances but the condition is still the same and might now be given to "an ambitious graduate manager working for a large business corporation" . . . and that despite advances in medical knowledge . . . "the clinical dilemmas that surround unexplained symptoms remains almost as challenging".
(Although the complete set of four classic Da Costa's syndrome symptoms were not specifically referred to in this article, the abnormal fatigueability, and the reference to "disorderly action of the heart" or D.A.H., which is a synonym for Da Costa's syndrome, provides a trace through history to the modern diagnosis of chronic fatigue syndrome. In a general summary the soldier was fit and healthy before joining the army and was able to participate in full and arduous military duties, but after experiencing an infection, and or combined with the extreme exertions or other conditions of military life, he became excessively exhausted. After recovering, he made numerous attempts to return to a normal and full lifestyle, but each time his health deteriorated. He ultimately restricted his activities, which is when his health stabilised and he subsequently led a long and generally healthy life. In the past some physicians would have called his symptoms "just normal tiredness" or "just nerves", and some doctors would have referred to his recurring health problems as 'nervous breakdowns' and some psychiatrists would have diagnosed a series of 'mental breakdowns' in an emotionally insecure patient, and attributed the ailment to a protected and mollycoddled childhood, poor character development, and anxieties or fears of various sorts. However it is clear that when the human body is subjected to extreme conditions such as long marches at double quick pace with poor food and water in extreme heat, and the physical limits are exceeded, the person may recover from the exhaustion, but then they may continue to have a reduced capacity for exertion or strain in the future. If they repeat their attempts to surpass their restricted limit they will become exhausted again, and if they lead a more moderated lifestyle within their limits they may remain reasonably healthy. When questioned about their health problems many fatigued patients will report that they are not anxious or depressed, and that the fatigue is not related to such emotions, and that their health does not suddenly "break down" but that fatigue gradually accumulates until it becomes impractical to continue working, and that if they do, it will become predictably impossible any way, so they stop before any so-called "breakdown". Their sole purpose in seeking treatment is to gain relief or cure of the fatigue so that they can lead a normal lifestyle again, and they don't like the way diagnostic terminology often seems as if it is being used to misinterpret or misrepresent their condition. They say that treatment is not very effective, so they encourage research on the ailment. Some suggest that they want a treatment which is as effective as that for gastric ulcers, which until the 1990's was regarded as a stress disorder which many patients suffered from for 10 years or more despite treatment, and then the microbial cause was found and the condition was curable with two weeks of antibiotics in 90% of cases. Some cases of chronic fatigue are associated with preceding infections and rheumatic muscle and joint pains and others are not, so there may be different types of chronic fatigue requiring different treatments. Nowadays chronic fatigue societies are established world wide and are conducting and promoting their own research programmes. M.B.)

(37) Spillane John D. (Nov. 1940), Observations On Effort Syndrome, The British Medical Journal, November 30th. 1940, p.739-741: Military medical officers of 1940 were well acquainted with soldiers presenting themselves with features of the effort syndrome with breathlessness, left sided chest pain, a rapid heart, and dizzy spells which were "only too common". Previously called soldier's heart, irritable heart of soldiers, and disorderly action of the heart, it was decided to call it neurocirculatory asthenia because it was not specifically a soldiers condition, or a heart ailment, and the other label of effort syndrome which was probably likely to stay, was not covering all aspects. The similarity to the symptoms of organic heart disease was "a paradox awaiting explanation". The often bizarre response of untrained civilians to the extreme exertions of military life, and the abnormal reaction of anxiety cases to exercise were quite different to the response seen in the effort syndrome which appeared to fit somewhere in between. In examining the cause the most obvious observation was that the soldiers had stooped spines, flat chests and poorly developed musculature, and they tended to avoid exertion and hence choose and come from sedentary occupations where they are unfit due to a lack of physical activity or training. However the occasional occurrence of more severe cases of effort syndrome in successful soldiers indicates a non-physique related cause. Examination of specific symptoms showed that the circulation time or velocity of blood flow during exercise was within the normal range, but the characteristic sighing respiration was rare in organic heart disease and common in the effort syndrome. Poor breath-holding power, and irregularity of the respiratory rhythm was common, but according to one paper, only one case of true hyperventilation was found, and "it is almost certainly not a causative factor", but part of several breathing anomalies in general anxiety. Regarding the characteristic left sided chest discomfort it was stated "The cause of this pain is quite unknown". . . but "was prominent and the pectoral muscles were tender and sensitive". . . and "Lewis commented on 'the myotatic irritability of the pectoral muscles' in the more seriously affected cases". During the first world war some study of the psychological aspects were made and there was "much scornful talk", and "from one's personal experience, the complaints of the neurotic still arouse mistrust and his treatment still tends to be of the hearty 'smack on the back' type or else an irritated resort to discipline". Examinations of the heart tend to cause anxieties in the neurotic patient and should be avoided so as not create psychological problems later, and it was concluded that the symptoms were those of a psychoneurotic response in the cardiovascular sphere. He added that the psychological causes are often masked by the patient, and that "patients often deny the existence of any psychological difficulties, and persistent enquiry may be necessary before their presence is acknowledged".
(Although this author concludes that the symptoms have a psychoneurotic cause he is dismissing the patients report that they are not anxious about anything, with an interpretation of masked anxiety or denial of anxiety, which could be found on persistent enquiry, but that is a speculative assumption rather than a statement of fact. However he also provides evidence that the most common features in effort syndrome patients are a stooped posture, flat chest, and thin physique with a history of avoiding exercise. Such features would place the head and shoulders forward and place constant or repeated abnormal mechanical strains on the chest muscles which would explain their general tenderness and irritability and proneness to pain, which is very similar to the tenderness in the back muscles of patients with stooped physiques. Sideways curvature of the spine would account for the muscle tenderness on one side, and scoliosis is a common, although less obvious, and less noticed accompaniment of kyphosis. This reference therefore provides strong evidence in support of the posture theory in relation the left inframammary pain. M.B.)

(38) Wittkower E. and Spillane J.P. (Feb. 1940), Neuroses in War (the effort syndrome), The British Medical Journal, Feb.17, 1940, p.266. Wittkower was a Halley Stewart Research Fellow, and Spillane was a Rockefeller Research Fellow, both of the Tavistock Clinic, London, and their paper referred to Da Costa's observations, soldier's heart, irritable heart, and effort syndrome synonymously "as an abnormal physiological reaction to effort" with the same set of symptoms and a comment on "an undue increase in pulse rate and a delayed return to normal" after exertion. Various previous studies reported that "About one half of these cases began in civil life, under circumstances where physical strain was unimportant". There were comments on the frequency of cases who had poor physiques, were highly strung or depressed, and came from sedentary occupations, and the ailment was apparent for "12 per cent. during the period of training". Sir Thomas Lewis previous studies reported that "In 80% of his cases infectious diseases had preceded the onset of the disorder, although it was only in 30 per cent. that they immediately preceded the onset of symptoms". Other factors discussed as possible causes had been tobacco, alcohol, hyperthyroidism, gas poisoning and shell shock. There were inconsistent opinions about the effectiveness of treatment and "with most authors cases of effort syndrome are highly resistant to any form of treatment. Of 558 cases seen by Lewis about 50% were deemed "unfit for any category of duty", and of 239 followed up for the next 11 months, "only thirty-nine returned to the firing line". "These figures do not correspond with those of the official history of the war, in which it is stated that of 13,408 cases of functional disease of the heart 11,403 were finally disposed of by return to duty. Experience of the results of systematic psychological treatment are not available".
A comment on the discrepancy between medical and official army statistics relating to Da Costa's syndrome
(The official statistics on the history of World War 1 show that 85% of cases of effort syndrome recovered and were sent back to the front line, but the factual research studies of Wittkower and Spillane showed that only 16% recovered fully, which is presumably an indication of the extent to which the condition is being misrepresented to medical consumers and the general public, and may be a reflection of similar methods of disguising the frequency and effect of this condition by changing labels, and using obscure esoteric jargon, mixing the condition in with multiple other poorly defined conditions, and understating the evidence of physical cause, and referring to it as a psychological "all in the mind" ailment, and then repeatedly presenting it after each decade or each war, as a surprisingly new, never before seen or known about rare condition, which must be "just tiredness" or "just nerves" related to the peculiar social conditions of modern life. Also note that Wittkower reported that the results of systematic psychological treatment were not available, probably because the results were poor, and the military authorities did not want the soldiers or the general public to know that, so they instructed the psychologists not to publish them. This is something that medical consumer groups should consider seriously when studying the history of the subject and they should maintain their focus on consistent facts rather than on the ever changing interpretations or opinions which often contradict each other and, or lead nowhere. M.B.)

(39) Wittkower E. & Spillane J.P. (Feb. 1940), Medical Problems in War (part 3, Neuroses in War), The British Medical Journal, February 24th. 1940, p.308-310. Towards the end of World War 1 it was realized that it would be an advantage to the military and society if the recruits who had previous indications of neuroses or psychoses in civilian life were culled out at the initial medical examination. Some of those recruits were more suited to contributing to the war effort by their participation in civilian occupations, but if they were accepted as soldiers and were sent off to war and became ill they were likely to require costly and time consuming medical treatment. If they were returned to the front line after recovering they were likely to relapse during transportation, and would be inefficient and unreliable and "almost hopeless so far as permanent fitness for front-line service is concerned". They would present morale problems for the other soldiers, and if they were returned to civilian life as chronic invalids they would be unable to do any type of work at all. It was also noted that "many of the men who never saw action (had) a more serious aftermath in symptoms than those who were actually in the thick of it".
However many such recruits had been accepted into the army and were sent off to military campaigns and were described as breaking down and being sent to hospital for treatments.
The treatment methods were similar to those in civilian practice except for modification related to the more urgent need of regaining health to recover the manpower and fighting capacity needed for a hostile situation. The two choices were "authoritarian and benevolent methods", and the two aspects were ""covering" and "uncovering" methods"". Covering meant suppressing the symptoms, and uncovering meant finding the actual cause and eliminating it, and the choice of treatment depended on the time and place, "and the personality, training, and psychopathological outlook of the physician".
The over-sympathetic approach was deprecated and new patients were placed in wards where there were improved or cured cases, and the medics, nurses, and visitors were required to present a hopeful but military attitude to recovery.
Some medics regarded the symptoms as ""akin to malingering . . . and . . . treatment was a matter of punishment and included such measures as isolation, severe restriction of diet, transfer to "excited wards" . . . application of painful electrical currents, and prolonged baths until recovery"". Kaufmann gave a three phase treatment which involved (1) preparative suggestion where "the patient was told that painful electrical currents would be applied which were certain to cure his condition", and (2) strong electric currents were applied for one or two hours, and (3) "active military exercises"were combined to give a cure in one session. This treatment became popular until fatalities occurred and the permanency of results became doubtful. Suggestion was also used in "Sham operations carried out under general anaesthesia" and although these were successful in some cases, they were generally rejected on theoretical grounds. Other treatments included boredom, restricted diets, and confinement to darkened rooms. The physicians were advised to avoid giving the impression of punishment and to tell the patients that "these measures were necessary to calm their nerves". The tics, tremors and deafness of shell shock patients often disappeared after about six weeks of treatment.
Other physicians recommended "rest, good food, and firm benevolence, combined with reassuring and encouraging talks about getting well again . . . and . . . an appeal to patriotism and the sense of duty", and engaging them in interesting paid occupations such as policing the hospital, or farm work, "rather than non-productive mechanical routine work such as mat-making". Graduated exercise programmes were also used. Psychiatric treatments given for the different forms of neuroses included analytical cathartic hypnosis and dream interpretation to deal with suppressed emotions which were assumed to exist in relation to the fear of war, and difficulties with authority. A treatment regime for anxiety neurotics included sleeping tablets and sedatives, with the Weir Mitchell diet, and absolute rest and quiet for a few days. After the patients recovered from the worst of the fatigue they were offered hydrotherapy and various distractions to get their mind off the fear and horrors of war, and later discussions about the conflict between the fear of being in the firing line and the sense of duty "assisted in the final adjustment". Where anxiety states did not respond to rest "a modified psycho-analytical method was recommended."
The affect of these ailments on soldiers in World War 1 was significant. "Nearly 66,000 cases were accepted for pension by the Ministry of Pensions on account of functional disorders of the nervous system alone; 29,000 of these still drew pensions in 1938. Wounds and amputations apart, functional nervous disorders ran second in the incidence of disorders for which pensions were being paid. If functional disease of the heart are included they rank first, even exceeding tuberculosis." A survey conducted in 1919 showed that "little more than half of them were able to earn their living. A great number of anxiety and effort syndrome cases tended to be permanently affected". Clerks and professional men made the best adjustment and the rural workers the least. In 1924 many had readjusted to civil life but "effort syndrome remained unchanged".
(This article presents the theme that civilians with mental instability (where patients with the effort syndrome were included in that category), were likely to become more unstable and break down in conditions of war, as much on the way to the front line, as did those actually involved in the battle, which leaves the general impression that anxiety in civil life and the fear of battle were the cause of the ailments. However, most of them had evidence of the ailment prior to the war, and the military activities aggravated their condition, and made it permanently worse, and the health status of effort syndrome patients remained unchanged during the five year follow up study between 1919 and 1924, indicating that the treatment methods, including psychotherapy, were essentially inappropriate because they only provided temporary benefits, with no effect on the long term outcome. Moreover, a person with the effort syndrome was equally likely to develop severe symptoms prior to the war if they participated in a foot race at a country picnic on a sunny day, and the brief excessive exertion would aggravate their vasomotor instability and leave them over reactive for a month or more, during which time they would be likely to over-react to the sudden sound from the backfire of a car engine with the same startle effect as a similar patient on the front line reacting to the sudden sound of gun fire. Regardless of whether the person is anxious or not they are able to maintain reasonable health as long as they avoid exercise, or restrict themselves to moderate exertion, which is the basis for the term Effort Syndrome. Note also that this article gives the impression that treatment relieved the tics, tremors, and deafness of shell shock patients, but they tended to disappear spontaneously after about 6 weeks regardless of treatment. The highlighted text in this review may be of interest to military veterans or medical consumer groups. M.B.)

(40) Goetz C.G., Turner C.M. and Aminoff M.J. editors (1993), Handbook of Clinical Neurology, Vol. 19, 63, p.429 - 447. In chapter 19 of this book H.M.Beumer and G.W. Bruyn trace the history of the Hyperventilation syndrome which they relate to Da Costa's syndrome. They refer to soldiers in the American Civil War who experienced indefinite heart complaints which were attributed to "lack of sleep and bad food". Earl de Grey presented four reports on British soldiers with these symptoms between 1864 and 1868, and attributed them to "the heavy equipment they carried" in knapsacks, or to "the pressure of straps (of the knapsacks) and the tightness of uniforms" which compressed the chest and constricted the action of the heart. Also in 1864, Henry Harthorme observed soldiers in the American Civil War who had similar symptoms which were attributed to "long-continued over-exertion, with deficiency of rest and often nourishment", and in 1870 Arther Bowen Myers of the Coldstream Guards" also regarded the accouterments (the heavy military equipment carried in tightly strapped fieldsacks) as the cause of the trouble and called it neurocirculatory asthenia and cardiovascular neurosis. However "the best known contribution to the subject" was J.M.DaCosta's study of 300 soldiers which reported similar findings and added that the condition often developed and persisted after a bout of fever or diarrhoea. In 1876 surgeon Arthur Davy attributed the symptoms to military drill where "over-expanding the chest, caused dilatation of the heart, and so induced irritability".

(41) Bazelmans E. et. al. (Oct. 1997), The chronic fatigue syndrome and hyperventilation, Journal of Psychosomatic Research, Oct. 1997, 43 (4). p.371-377. E. Bazelman and his colleagues from the Department of Medical Psychology of the University Hospital Nijmegen, The Netherlands, noted that hyperventilation could cause fatigue so they studied the possible role of hyperventilation in causing the chronic fatigue syndrome. They found that although more people with CFS had physiological evidence of hyperventilation than healthy controls . . . "no significant differences between CFS patients with and CFS patients without hyperventilation were found on severity of fatigue, impairment, number of complaints, activity level, psychopathology, and depression" . . . and they concluded that hyperventilation was, in some cases of CFS, a consequence of CFS, rather than the cause. (If many of the patients with CFS do not have evidence of hyperventilation, then hyperventilation cannot be the cause in those cases, and probably not in the others either, so the respiratory disorder in CFS would presumably be different, as evident from other studies. M.B.)

(42) Streeten David H.P. (Sept.1998), The Nature of Chronic Fatigue Syndrome (CFS), J.A.M.A. v.280, n.12, 23-9-98, Editorial. (David Streeten is from the Department of Medicine, State University of New York Health Science Section, Syracuse)
David Streeten presented an article in the September 23rd edtion of JAMA explaining that the fatigue reported by Da Costa and Lewis were early descriptions of a "newly recognised" delayed form of orthostatic hypotension which is a feature of some types of Chronic Fatigue Syndrome. He stated that "as a working hypothesis", the fatigue was due to abnormal pooling of blood in the lower limbs which delayed and reduced the flow of blood and oxygen supply to the brain. That effect was compounded by a reduced circulating red blood cell mass. He then emphasised that it is essential to identify these physical abnormalities by repeatedly measuring the patients blood pressure in recumbency and after standing for ten minutes or tilt testing, and that "it is inappropriate to consider that CFS is a manifestation of mental disorder" unless those physical causes are excluded. He added that
the expense of these tests was not unreasonable considering that almost every type of work or lifestyle required a person to stand for six hours per day without experiencing the symptoms associated with reduced blood pressure. He then concluded the instigating cause remains unknown, and that effective and safe treatments for the debilitating symptoms are still not available and that further research is required.

(43) Rosen S.D., King J.C., Wilkinson J.B. and Nixon P.G.F. (December 1990), Is chronic fatigue syndrome synonymous with effort syndrome?, Journal of the Royal Society of Medicine, December 1990, Volume 83, p.761-764, These authors from the Department of Cardiology, Charing Cross Hospital, London, conducted psychophysiological studies of 100 patients who had "a condition of incapacity for making and sustaining effort, associated with a wide range of symptoms" and had been diagnosed with chronic fatigue syndrome, myalgic encephalomyelitis, and post-viral syndrome. The study method involved recording the breathing pattern and CO2 levels when the patients were at rest, and then after forced hyperventilation (deliberately breathing deeply and rapidly for 3 minutes), and then measuring the levels 3 minutes afterwards to determine the tendency to continue overbreathing, and then, after another 3 minutes had passed, asking the patient to close their eyes and think about previous personal experiences which were "associated with anger, despair, fear, and happiness". At the end of this "think test" the patient was asked to open his eyes and relax, and raise his hand when he felt that his breathing had returned to normal. The results showed that 93 of the 100 patients had the characteristics of chronic habitual hyperventilation or effort syndrome.
They therefore suggested that the other labels "should be withheld until chronic habitual hyperventilation - for which conventional treatment is available - has been definitively excluded". They also suggested that the symptoms of hyperventilation predated the viral infections which were presumed by some patient groups and researchers to be the cause of the chronic fatigue, and that the viral infection simply made it worse. They suggested that "It has long been recognized that hyperventilation-related illness can appear after or be aggravated by injury or infection", and they mentioned the opinions of three authors who regarded normal health as being maintained by leading a moderate lifestyle and staying within reasonable boundaries, and that leading an excessively demanding lifestyle beyond those limits may be the cause of the effort syndrome. They also noted that "the physiological disorders of effort syndrome rarely feature in undergraduate education and sponsored postgraduate meetings" and that "many physicians are reluctant to acknowledge the existence of a condition which formerly was considered to be common", and in the early stages of the ailment "the patients were bitterly resentful at the failure of diagnosis. In the later stages the anger and frustration were replaced by a flat acceptance of disability as the subjects 'give in' or 'gave up' the struggle to be well, and adapted to infirmity". They discussed the possibility that the doctors failure to diagnose the condition made the patients anxious and added to the problem of anxiety induced hyperventilation in the manner of a "vicious circle" which sustained or aggravated the condition. The general view of the authors was that hyperventilation itself was not a pathological process but that the chronic fatigue ailments were due to "the physiological consequences of hyperventilation" in people "who overbreath more vigorously and for longer periods of time, and respond to smaller stimuli when they are overtired or anxious".
They suggested that some patient action groups resented the diagnosis of hyperventilation because they assumed that it was synonymous with hysterical overbreathing "which led to hyperventilation being taken as an insulting suggestion that the illness is "all in the mind"."

(The breathlessness of the effort syndrome or Da Costa's syndrome was once regarded as just subjective, or imaginary until several studies in 1947 identified abnormal function of the thoracic diaphragm - the main breathing muscle, as the real cause. The symptom is commoner in thin patients with long narrow chests and stooped spines suggesting a mechanical strain, effect, or injury, and nineteenth century women who wore tight corsets had the same problem of rapid shallow breathing which was then, and is still now generally misrepresented as hysterical - psychologically based breathlessness. Emotions and exertion increase breathing rates in healthy people, so it would also alter differently in people with abnormally functioning diaphragms. Da Costa defined healthy physically fit soldiers who carried heavy equipment on long marches where they had poor quality food and drank bad water, and contracted typhoid or diarrhea (food poisoning), and became chronically fatigued and incapable of such exertion afterwards, so the viral cause cannot be disregarded by a modern study that suggests the condition predated the virus. Also, emotional factors may predate this sort of ailment, but that does not equate with emotion being the only cause, and the term "habitual hyperventilaion" implies a behavioural problem (which is just a bad habit), which is a misleading way of describing chronic abnormal function of the thoracic diaphragm. There are other studies which provide evidence that hyperventilation is not present in every case and, is not the cause. It is also readily apparent that the vast majority of patients with any debilitating disease struggle to deal with it at the outset, but give up and except their disability sooner or later, after the medical treatment or their own methods have not achieved a cure. Action groups consist of patients who respond to their doctors failure to recognise or diagnose the condition by studying the problems themselves, and they argue with each other, in much the same manner as medical researchers become involved in heated debates, from one doctor or specialist to another, and labels will keep changing every week, or every year, or every decade, and adding to the already large total until a convincing explanation or cure evolves.M.B.)

(44) Meriam -Webster online Medical Dictionary 5-10-08; This dictionary contains the following definition for "Neurocirculatory asthenia; : a condition marked by shortness of breath, fatigue, rapid pulse, and heart palpitation sometimes with extra beats that occurs chiefly with exertion and is not due to physical disease of the heart -- called also cardiac neurosis, effort syndrome, irritable heart, soldier's heart "

(45) E.M. Goudsmit, Howes S. (2008), Pacing: A strategy to improve energy management in chronic fatigue syndrome, Health Psychology Update (BPS), 2008, 17, 1, 46-52. This article examines the benefits of exerciseing at appropriate levels for each individual.

(46) R.Schondorf & R.Freeman (1999) The importance of orthostatic intolerance in the chronic fatigue syndrome, American Journal of Medical Science 317, p.117-123: This paper examines the laboratory findings related to orthostatic intolerance in patients with chronic fatigue syndrome (CFS) or myalgic encephalomyetitis.

(47) Online 'Mendelian Inheritance of Man' (OMIM) Orthostatic Intolerance :604715, http://www.ncbi.nlm.hih.gov/entrez/dispomim.cgi?id=604715, This online website describes one of the causes of orthostatic intolerance as the mutation in the gene encoding the norepinephrine transporter (SLC6A2; 163970) and mentions that the condition has previously been described by Da Costa, and later referred to as 'soldier's heart', 'neurocirculatory asthenia', and 'mitral valve prolapse syndrome', and as "being similar in many respects" to 'chronic fatigue syndrome'.

(48) Cohen M.E., White P.D. (1951). "Life situations, emotions, and neurocirculatory asthenia (anxiety neurosis, neurasthenia, effort syndrome)". Psychosom Med 13 (6): 335­57. This paper refers to the incidence of symptoms occurring during pregnancy on page 346

(49) Krzysztof Narkiewicz (1998) Chronic Orthostatic Intolerance; Part of a Spectrum of Dysfunction in Orthostatic Cardiovascular Hoeostasis?, Circulation 98:2105-2107. This paper reports on the study of postural orthostatic tachycardia syndrome, and attributes to the gravitational pooling of blood in the lower limbs caused by "impaired venous tone" where "It is generally accepted that autonomic dysfunction is a hallmark of this disorder."

(50) Fauci, Anthony S.; et al. (February 2008). Harrison's Principles of Internal Medicine 17th edition. New York U.S.A.: McGraw-Hill Companies Inc., 2703=2704. The text of this summary links the former term "effort syndrome" to the modern condition of "chronic fatigue syndrome" and refers to graded exercise regimes which have "proven" effective in relieving symptoms and improving exercise tolerance.

(51) Hurst, J.W.; R.B.Logue, R.C.Schlant, N.K.Wenber (1974). The Heart 3rd. edition. New York: McGraw Hill Book Co.,, 1552-1555 - The authors of this paper stated "Attempts by Cohen and his associates to alter these abnormalities by physical training were unsuccessful since the patients could not or would not follow the prescribed training programme." and commented that previous studies of a small number of patients by Holmgren in 1959 and Levander-Lindgren in 1964 has shown that training programmes had shown some benefits. It was the comment that these patients "would not or could not train" that prompted me to design a programme that patients "could and would train" if they were instructed to train within their own limits. The article also refers to Da Costa syndrome and other synonyms and notes that the symptoms occur in response to exertion, and that some of the patients are tired all the time. the condition was ore common in women, and was associated with body build and posture, and that there was low oxygen consumptom and excess blood lactate production during exertion and that the infusion of sodium lactate brought on the symptoms in these patients but not in healthy individuals. The symptoms were more likely to occur in trains buses or crowds (probably because of the abnormal response to excess levels of CO2 which occur in confined spaces M.B.), and they prefer sitting in aisle seats in theaters.

(52) Lewis, T. (1918). "Observations upon prognosis, with special reference to a condition described as the "irritable heart of soldiers"". Lancet i (181-3)

(53) Osler, Sir William (1918). "Graduated exercise in prognosis. Letter.". Lancet (1): 231. ( I was not aware of any previous success with fitness programmes at the time of designing the research programme at the South Australian Institute For Fitness Research and Training in 1982 - I found the two papers by Lewis, ref.52, and Osler, ref 53, both from 1918, in late 2009).