Case of chronic fatigue syndrome after Crimean war and Indian mutiny

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.¹ It was introduced partly as an acceptable clinical alternative to the term myalgic encephalomyelitis, which described a similar presentation and had been coined in 1956 in the aftermath of an outbreak of illness among the nursing and medical staff of the Royal Free Hospital.² The condition was widely assumed to be a new addition to the medical scene. In the popular press, and occasionally in the professional publications, attempts have been made to explain chronic fatigue syndrome as a product of the unwelcome features of modern life, such as pollution, stress, working practices, and new infections.

Attention has recently been drawn to the often striking similarities between chronic fatigue syndrome and myalgic encephalomyelitis and the condition formerly known as neurasthenia, a term first coined independently in 1869 by the neurologist George Beard and psychiatrist E Van Deusen.³ Like its modern variants, neurasthenia was believed to be a physical disorder, largely caused or aggravated 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.⁴ In this article, we suggest that conditions resembling either chronic fatigue syndrome or neurasthenia have an even older provenance, and draw attention to the cases of two British soldiers who served in the Crimean war and in India at the time of the mutiny.

Summary points

• Chronic fatigue syndromes existed before the description of neurasthenia in 1869

• These syndromes are not limited to the civilian population but occur in the military as well

• Soldiers awarded a pension as a result of fatigue syndromes continued to suffer from these symptoms when in receipt of payment

• Physicians of the time were unable to find convincing explanations for these syndromes

• Context is important in the way that these disorders are interpreted even when the symptoms are relatively stable

Methods

We surveyed the first 4000 pension files of the Royal Hospital, Chelsea to identify soldiers who had been medically discharged from the army with unexplained symptoms. Although most of the files relate to the Boer war, 11 examples of functional debility were found that referred to earlier campaigns including Afghanistan, Egypt, and the Sudan. We selected a single case from the Indian mutiny for further study because of its age and detailed medical reports. While researching the War Office cavalry discharge papers, we discovered another possible example from the same regiment.

Clinical description

This paper is about a sergeant who served in the Eighth King's Royal Irish Hussars, a cavalry regiment that was founded in 1685 from Londonderry Protestants. The Eighth Hussars served in the Crimea from May 1854 until April 1856, returning to Britain for a short period before being ordered to India in September 1857 to suppress the mutiny.

Charles Dawes, who had enlisted at the age of 18 in October 1854, was posted to the Crimea as a reinforcement and served there for six months, although apparently without taking part in a major battle.⁵ He then went with his regiment to India and remained there for six and a half years. Having returned to the United Kingdom in May 1864, Dawes suffered from increasing fatigue. He reported the following symptoms: exhaustion, weakness, tremor, pains in his legs when walking, and pain in his joints, particularly knees, elbows, and shoulders. He had a persistent cough and experienced visual difficulties in his left eye. Dawes became so fatigued that he was eventually discharged from the army in February 1872 with a diagnosis of general debility, imperfect vision, and rheumatism, for which a disability pension of 12d (5p) a week was awarded. The army physicians who had examined him concluded that his “service of seventeen years in Turkey, India and at home, and the general hardships of a soldier's life during the Indian Mutiny” were the reasons for his declining health.⁵ It was speculated that cold and general exposure in a country in which malaria was endemic may have been the cause, although there was no clinical evidence to suggest that Dawes had contracted malaria. His visual problems were later diagnosed as iritis, and by 1923 he was almost blind in his left eye.

Despite the judgment of a medical board in 1872 that Dawes was “permanently unfit for contributing to his own support,” he returned to his former career of house painter, albeit on a casual basis. Later, he worked as a commercial traveller before ill health forced him to give up employment. In June 1885, his physical condition was described as “very unsatisfactory indeed,” and three years later the examining physician commented that although he was then able to earn a livelihood, Dawes “is likely at any moment to be quite unable to do so.” In April 1900, he was assessed as being “more debilitated” and not long afterwards as “feeble.”

Dawes was not a malingerer and, in fact, had been something of a model soldier. Captain John Chaplin commented in 1870 that “you have always done your duty since you have been in my troop and squadron very conscientiously and well.”⁵ His conduct was assessed as “very good,” and he committed only one offence in his military career—that of sitting when on sentry duty. He earned regular promotion, rising to the rank of sergeant in December 1865. Once discharged from the army, Dawes became an enthusiastic member of the Birmingham Military Veterans' Association, and during the first world war he was active as a recruiting sergeant, travelling to meetings throughout the Midlands. He also toured convalescent hospitals with a concert party and collected money to provide warm clothes for sailors in the North Sea. Although he complained of chronic rheumatism, when he was examined at the age of 85 no swelling was detected in any joint, and all had full and free movement. He was then described as being “well preserved for his age,” no abnormalities being found in his heart and lungs. Dawes lived to 96, dying in August 1932 of cardiac failure. The established nature of his functional impairment, together with the presence of multiple somatic symptoms, would today have qualified Dawes for the diagnosis of chronic fatigue syndrome.¹

The second case concerns Farrier Major John Dyer, who in June 1862 was medically discharged from the Eighth Hussars with “general debility, the result of long and arduous service.”⁶ Dyer had enlisted in November 1833 at the age of 16 and served throughout the Crimean campaign, taking part in the battle of Balaklava, although it is unclear whether he participated in the ill fated charge of the Light Brigade. Dyer then sailed with his regiment to India, where he served in the campaign to suppress the mutiny. In the absence of detailed medical records, it is difficult to reach a firm conclusion, although the presentation suggests chronic fatigue syndrome. Dyer and the 10 other cases of debility in the Chelsea pension files imply that Dawes may not have been an isolated example.

Sunstroke

Dawes did not offer an explanation for his debility, and it is tempting to assume that he accepted his physicians' opinion that general hardships in India were the cause. A well founded fear of sunstroke or apoplexy existed in the army, and the Eighth Hussars were particularly exposed to the effects of high temperatures. E troop, for example, led by Captain George Clowes, was reputed to have travelled over 3000 miles in pursuit of rebels,⁷ including a forced march of 251 miles in 11 days.⁸ In June 1858, a squadron commanded by Captain Clement Heneage attacked a rebel force at Kotah-ki-Serai, near Gwalior, led by the inspirational Rani of Jhansi. In the battle that followed she was killed by a trooper of the Eighth Hussars whose identity was never discovered.⁹ 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.”¹⁰ Sunstroke was an important cause of death among troops in India.¹¹ Because its aetiology was not properly understood, several unusual health beliefs flourished. To protect himself from the sun's rays, one officer dressed in heavy clothes more suited to a winter's day in England, while Captain Clowes argued that, protected by a “wicker helmet and well covered, no one need fear sunstroke.”¹²

In the American civil war and the Boer war, soldiers exhibiting chronic fatigue syndromes, sometimes precipitated by the stress of battle, were occasionally diagnosed as suffering from the after effects of sunstroke.¹³,¹⁴ The rigors of military service in India were a potential cause of psychological problems and gave rise to the popular term for madness “doo-lally.” Regular soldiers who had served their time were sent to a depot at Deolalie, where they often had to wait for several months before a troop ship called at Bombay to take them back to the United Kingdom. Without any duties, men became bored and frustrated in the transit camp, which sometimes led to odd behaviour and psychiatric disorders.¹⁵

Conclusion

The two clinical histories suggest that chronic fatigue syndrome and its earlier classifications can be traced through two lineages: one military and one civilian. Had Sergeant Dawes presented in 1915, he might have been diagnosed as experiencing disordered action of the heart, and had he been a Vietnam veteran, he might have been classified as having post traumatic stress disorder or suffering from the effects of exposure to Agent Orange.¹⁶ We suggest that context is all important. The way that we categorise symptoms and how we construct disorders is open to considerable variation, even if the clinical presentations are relatively stable. Victorian soldiers serving in a hostile environment in distant India or conscripts on the western front in 1917 may have received a different set of labels from those that might now be given to, say, an ambitious graduate manager working for a large business corporation. What can appear to be a new disease may, in fact, be an existing disorder or a closely related symptom cluster given a new title and reinterpreted in the light of different health beliefs. Although the medical knowledge that we can draw on is far greater than that available to 19th century physicians, the clinical dilemmas that surround unexplained symptoms remain almost as challenging.

Figure.

CORBIS

The hazards of war in the Crimea included diseases not yet named

Figure.

THE BRIDGEMAN ART LIBRARY

The diseases affecting Victorian soldiers had different labels because of different beliefs about health