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War Surgery and Medicine



Association of Neurosis with Hypertension

It is a remarkable fact that while anxiety neurosis was the commonest single cause for down-grading on discharge from the Army following the 1939–45 War, the somatic symptoms complained of never localised themselves to the heart as they did in the previous war. To date some 7600 cases of anxiety neurosis have been treated which arose during or were the result of the 1939–45 War, whereas only 241 cases discharged for ‘Effort Syndrome’, Da Costa's Syndrome, ‘DAH’ or neurocirculatory asthenia have been discovered.

Therefore, in a survey of cases drawn from servicemen of either war it is not surprising to find that many have suffered or are suffering from one of the functional disorders so prevalent. Anxiety neurosis is responsible for 18 per cent of all disabilities of the 1939–45 War. However, it would be a mistake to assume that these diseases affect the incidence of hypertension.

This survey is based upon information gained from the files of patients who apply for treatment. The types of service patient who most frequently seek treatment are, amongst the older patients of the First World War, the chronic bronchitic and the neurasthenic with his protean symptoms, and up till the present the anxiety neurosis case of the Second World War. Therefore, if the hypertension cases are found mostly in these types of case seeking treatment, a false deduction might be made regarding the relative frequency as compared with healthy individuals or those suffering from other diseases.

In the list of Carbery cases cited above as definite cases of hypertension, 13 per cent suffered at some time from neurasthenia, 24 per cent from DAH, and 63 per cent from neither disability.

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Amongst the deaths, those who had suffered from neurasthenia died at an average age of sixty-five years while the DAH and other cases each died at an average age of sixty-two.

It was noticeable that only a few of the DAH cases had been pensioned continuously since 1918, whereas most of the cases had been described as normal in the years from 1918 to 1922. Only in subsequent years had they re-applied for pension because of shortness of breath. While in the great majority of cases the blood pressure was recorded for some years before there was any abnormal rise, in the others it was noted high on the patient's re-application for pension, but in no case was the patient under forty years of age when the hypertension first appeared.

Of the 787 First World War files examined, 669 cases were found to have had no abnormal blood-pressure record. The following list gives the number of cases under each disability which have had abnormally high blood pressures.

Diseases of the lungs 27
War neurosis 21
DAH cases 2
Peptic ulcers 11
Rheumatic diseases 11
Trauma (GSW and AI) 26
Other diseases 20

By the New Zealand standard of S. 160 and D. 100, 118 or 15 per cent of the 787 cases suffer from abnormally high blood pressure. By the standard used by the American observers, 86 or 9.15 per cent of the 787 cases suffer from hypertension.

By comparison with the above, 21 of 142 war neurosis cases, or 14.8 per cent, suffer from high blood pressure, or by the American standards 12 of the neurosis cases would be accepted as hypertension cases and this represents 8.45 per cent.

Two of the 27 DAH cases, or 7.4 per cent, have high blood pressure, but these two cases are each sixty-one and seventy years of age.

There have been mentioned above 164 cases of servicemen, non-pensioners, who died of blood pressure during 1951–52. Examination of their files shows that none ever suffered from neurosis, and in five cases only was there any record of DAH. In three cases the condition had ceased in 1918, one was pensioned until 1919, and one until 1924. One died aged fifty-seven, two at sixty-four, and two at seventy-one years of age, four from cardiac and one from cerebral vascular accidents.

In 787 cases whose ages varied from approximately fifty years to seventy-five years, 9.15 per cent or 15 per cent were found to page 684 have an abnormally high blood pressure, according to whichever standard is used. These were all males and had various disabilities, but 15 per cent does not seem to be unduly high for the age groups and is probably representative of any similarly aged cross-section of the ordinary male civilian population. Actually the cases who had suffered from either neurosis or DAH showed a slightly lower incidence of hypertension.

There is no evidence from this survey of 1914–18 War cases that either war neurosis or DAH is an etiological factor in the production of hypertension. Generally speaking, the neurasthenic case of the 1914–18 War who did not rehabilitate himself is now a case of inadequate personality content to allow others to provide for him. He suffers no tension and, if mental tension is a cause of arterial hypertension one is not surprised to find there is no increased incidence of this condition amongst this type of individual.

However, stress has been laid upon the fact that in the survey of 1914–18 War cases only files of individuals past middle life were included. Thus, perhaps, if a survey had been made twenty or thirty years ago, different conclusions might have been drawn. Therefore examination of files of the 1939–45 War at this early period is useful to bridge that period missing after the first war.

Over 6000 cases of anxiety neurosis have occurred amongst army personnel who served overseas, but there has never been any suggestion of an increased incidence of abnormally high blood pressure amongst these patients even during the early stages or later relapses of their ‘Anxiety’ periods, when it would be expected their mental tension was greatest.

Amongst the 34 deaths from hypertension which have occurred, 3 cases had suffered from an anxiety state during some of the years following discharge and are represented by cases 4, 7, 9 in Table XI.

Of the total 309 cases reported as possible hypertension cases, 26, or 8.4 per cent, had suffered from anxiety neurosis, and of the actually accepted 189 cases, 18, or 9.5 per cent. When it is remembered that 18 per cent of all disabilities was anxiety neurosis, a not undue proportion of these cases is found to develop hypertension. Further, even during the war and since, the age groups found to supply the hypertension cases follow the same pattern as has long since been found amongst the ordinary civil population.

Amongst the 1936 Second World War files surveyed, 28 per cent suffered from anxiety neurosis. It has been shown that from these 1936 cases there are only 8 cases of hypertension, with 13 potential cases. There were approximately 500 cases of neurosis amongst the page 685 1936 cases, and they produced only 1 case of hypertension and 3 potential cases.

That excitement may produce a temporary rise in the blood pressure is well illustrated by the following 46 cases. In 1943 some 3000 overseas servicemen, presumably fit men, were returned to New Zealand for furlough with the expectation that they would be returned overseas again. However, various factors, political and sentimental, delayed their final disposal, and in the meantime several hundred were discharged on account of anxiety neurosis. As the immediate cause of the neurosis was inactivity and anxiety as to their disposal, this group made a very rapid recovery in most instances once they were rehabilitated back into civilian life. These cases were not found to be suffering from hypertension. On the other hand, some 46 cases, not exhibiting anxiety symptoms, were discharged on account of hypertension. On the pressure reading at the discharging medical examination all but three would be accepted as having abnormally high blood pressure for their age group by the American standards. After discharge, in 35 cases out of the 46, the follow-up readings during the next two or more years were all normal and the men working normally without symptoms. In five cases the men returned to work, symptomless, but with a diastolic pressure 110 to 115 when last recorded in 1944. In two cases they were overweight, one 207 lb. with height 6 ft. 1½ in., and the other 217 lb. with height 5 ft. 11 in.

In six cases the blood pressures have remained abnormally high, having first been discovered at routine boarding. These cases have all been considered in the general survey.

Incidence Amongst Maoris

Dr Bridgman of the Rotorua Hospital and Dr Sligo of Tauranga Hospital, who both see a great many Maori patients, have stated that they seldom see a Maori suffering from essential hypertension.

In this survey only five Maori cases are found amongst the 1939–45 War records, while one appears amongst the Carbery list.

One case who saw overseas service enlisted in 1943, aged 21 years with a B.P. 150/90. His weight was 138 lb. and height 5′ 2½′′. At discharge in 1946 he had no complaints but his B.P. was 186/120 but on resting reverted to 160/100. In 1947 the B.P. was 130/80 and he was engaged as a carpenter.

One case enlisted in 1940 aged 28 years, height 5′ 8′′, weight 301 lb., and B.P. 160/90. Details have already been stated above. In 1948 his weight was 329 lb.

One case, served in N.Z. only, enlisted 1940 aged 25 years. Height was 5′ 5′′, weight 178 lb., and B.P. 148/95.

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1945 B.P. 142/110. Weight 195 lb. He suffered no symptoms of hypertension but was discharged for deafness in both ears.

One case, served in N.Z. only, enlisted 1940 aged 22 years. Height 5′ 10 ½′′, weight 235 lb. B.P. 165/115.

1944 Discharged with no complaints of ill-health. B.P. 180/105. Weight 243 lb.

1945 Weight 252 lb., B.P. 160/100.

One case, served in N.Z. only, enlisted in 1941 aged 53 years, weight 238 lb., height 5′ 8′′, and B.P. 204/128.

1943 B.P. 180/160. Feels in good health. Discharged on account of deafness.

One case, served in the 1914–18 War. Enlisted 1918 aged 28 years. Height 5′ 9′′. Weight 196 lb. He suffered a G.S.W. leg and ankle.

1933 Suffering from chronic ulcers on leg.

1934 Weight 238 lb. B.P. 180/100

1938 Weight 238 lb.

1949 Died of cerebral haemorrhage.

Only the first case does not exhibit a condition of overweight, and after his discharge the blood pressure fell to normal. All other five cases exhibit obesity, and it appears possible that this plays a very important part in producing hypertension in a race which ordinarily is not at present very susceptible to the condition.

Only eight females occur in this survey, and as their numbers do not materially affect the figures and findings the survey is referred to as one of a male population. Only one female case served overseas, and she was enlisted at the age of fifty-three with a B.P. 170/110.