[The heart goes to the war: a review of the so-called "soldier's heart" or "irritable heart of soldiers" syndrome]. / Il cuore va alla guerra: rivisitazione della sindrome detta "cuore del soldato" o "cuore irritabile del soldato".

The paper deals with a form of functional heart disorder that caused substantial disability among men in military service. By viewing the condition through the dual lenses of history and modern medical knowledge we can analyse the syndrome and trace the changing medical and social attitudes to it. The disorder is still now present after harrowing events, including natural disasters, assault of individuals, episods of mass violence and combat. A historical review of the syndrome is also useful in extending our understanding of the natural history of stress reactions, their prognostic indicators and the way in which we can intervene to reduce the effects of trauma.

Effort syndrome: hyperventilation and reduction of anaerobic threshold.

Effort syndrome is an entity in danger of being subsumed into "chronic fatigue syndrome" and lost to sight. Its distinctive feature is the reduction of the anaerobic threshold for work by depletion of the body's alkaline buffering systems through hyperventilation. This article describes the history and clinical features of effort syndrome and reports a study in which capnography is used to identify the anaerobic threshold by registering the respiratory response to the onset of metabolic acidosis. The patients' thresholds are low, and provide a goal for rehabilitation. In other forms of chronic fatigue syndrome, the pathogenesis and logic of therapy are unclear.

Darwin's illness: a biopsychosocial perspective.

Throughout an illustrious scientific career, Charles Robert Darwin (1809-1882) suffered from a mysterious and disabling malady. The illness, which was characterized by depressed feelings and violent and uncomfortable cardiac palpitations, gastric upsets, and headaches, began shortly after Darwin returned from a five-year voyage to South America as the naturalist of the Beagle. One explanation for Darwin's symptoms is he suffered from Chagas' disease as a result of being bitten by an insect common to South America. More psychodynamically oriented theorists speculate that Darwin's illness was an expression of repressed anger toward his father. Others have noted a familial vulnerability to the symptoms Darwin described. The author examines these theories and suggests that they all may have validity in explaining the mysterious illness of Charles Darwin.

Da Costa's syndrome or neurocirculatory asthenia.

The syndrome variously called Da Costa's syndrome, effort syndrome, neurocirculatory asthenia, etc has been studied for more than 100 years by many distinguished physicians. Originally identified in men in wartime, it has been widely recognised as a common chronic condition in both sexes in civilian life. Although the symptoms may seem to appear after infections and various physical and psychological stresses, neurocirculatory asthenia is most often encountered as a familial disorder that is unrelated to these factors, although they may aggravate an existing tendency. Respiratory complaints (including breathlessness, with and without effort, and smothering sensations) are almost universal, and palpitation, chest discomfort, dizziness and faintness, and fatigue are common. The physical examination is normal. The aetiology is obscure but patients usually have a normal life span. Reassurance and measures to improve physical fitness are helpful.

Jacob Mendez DaCosta: medical teacher, clinician, and clinical investigator.

J. M. DaCosta, a scholarly, well-trained and observant clinician, was recognized during his lifetime as a well-known authority on physical diagnosis and had an unexcelled reputation as a clinical teacher. Chairman of Medicine at the Jefferson Medical College for 19 years, president of the College of Physicians of Philadelphia in 1884 and again in 1895, he was one of the original members of the Association of American Physicians and its president in 1897. Earlier in his career, his extensive Civil War study of "a form of cardiac malady common among soldiers . . . the study of which is equally interesting to the civil practitioner" was described in his 1871 paper "On Irritable Heart; A Clinical Study of a Form of Functional Cardiac Disorder and Its Consequences." Soon labeled DaCosta's syndrome, the irritable heart lineage can be traced through the soldier's heart, the effort syndrome, and neurocirculatory asthenia in World War I, anxiety neurosis in World War II, and the mitral valve prolapse syndrome in the second half of the 20th century.