Two years ago, while attending my cousin’s high school graduation party, I was talking to one of my doctor uncles about books and he recommended I read The Anatomy of Courage. It’s written by Lord Moran, a physician and medical officer in WWI, who later became Winston Churchill’s doctor during WWII. Published in 1945, this book called much-needed attention to the effect of war on soldiers, 30 some years before the term “post traumatic stress disorder” (PTSD) was even coined. (I believe “shell shock” was the term in use). Soldiers were returning home, with a range of physical injuries, but even if these injuries healed, the humans that remained were severely broken. Lord Moran proposed that these soldiers had run out of *something* akin to mental stamina, drive, emotional energy, courage. The latter is obviously the prime term of interest, but he parses it in a way that it fortunately doesn’t get reduced to some sentimental connotation.

I was six months out from having my colon removed, was living with an ostomy bag, and still had 2 surgeries left, when my uncle recommended this book. I had also just returned from living and working in South Carolina for 5 weeks, but being back in Pittsburgh meant pre-surgery appointments and trying to somehow mentally prepare after hearing my surgeon say, “the 2nd surgery will be as bad as or worst than the 1st.” (The 2nd surgery *would* end up being far worse than the 1st in terms of a long, painful recovery and multiple complications, but they weren’t even predicting those bumps in the road at this point). My uncle and I must have been talking about this, because I was trying to articulate that I felt really spent already, drained of the…whatever you want to call it…mental stamina? Courage? Lifeblood? Ability? To get through it. That even if my body could get through it, some “I” could not get through it. This scared me. A lot.

Everyone is familiar with that maxim, “What doesn’t kill you makes you stronger.” I unflinchingly believed that for the first few years of my disease, before I started to consider those words in a literal physical sense. The years of disease and medications and treatments? No, they didn’t kill me, but they definitely made me, in terms of my physical body, much weaker. So I proceeded to interpret this maxim, particularly the word “stronger,” with psychological or emotional underpinnings instead. These years made my body weaker, but my mind/spirit stronger. Not in spite of getting through it all, but because of getting through it all. I believed that for a few years too. When my uncle suggested reading The Anatomy of Courage, I had stopped believing even that. I felt weak in the body and weak in the head and was absolutely terrified of *anything* bad happening to me health-related, even something “normal” like breaking a bone or getting the flu, because I felt “done” in my head. Just “done” in the sense of having run out of that *something* necessary for getting through subsequent health challenges, but I couldn’t explain why I felt that way, how I got there, or when it happened. But I felt it.

I cannot possibly imagine what it is to become a soldier or fight in a war, but for what it’s worth, I am fascinated by and in awe of those that do. While there is not comparable physical overlap between what a soldier is going through when at war, and what a person is going through when faced with serious chronic disease, I think there is overlap on a psychological/emotional level. I didn’t read The Anatomy of Courage for another 18 months, partly because I was scared this book would tell me what I already felt, that maybe I should just recognize my dwindling courage supply and admit defeat.

In The Anatomy of Courage, Lord Moran sets out do the following: find out how courage is born, how it is sustained, and what can be done, if anything, to delay or prevent its “using up.” This last one is what my uncle talked about, the idea of there being a finite amount of “courage” in a human being, that it can be used up and and cannot be replenished. This is something I had independently, and at times subconsciously, been thinking about for many of my ill years: my body would be so broken but not “done,” whereas my spirit was broken and did appear to be/feel “done.” Like I had reached a tipping point at the top of the “what doesn’t kill you makes you stronger” bell curve and I was on my way down.

In the first few pages, he writes:

“How is courage spent in war? Courage is will-power, whereof no man has an unlimited stock; and when in war it is used up, he is finished. A man’s courage is his capital and he is always spending.”

“There seemed to be four degrees of courage…: men who did not feel fear; men who felt fear but did not show it; men who felt fear and showed it but did their job; men who felt fear, showed it and shirked.”

(Note: all bolded quotes are Lord Moran’s words and from this book)

Moran isn’t certain the first degree can exist, that perhaps there is no such thing as “fearlessness,” but rather only something like the third degree, the courage of control.

“Do they really feel less than we do or have they attained a peak of control which is beyond our reach?”

This is key! And I think this is what happens after so many years of chronic disease; one/I fine tunes this sense of control to such an extent that onlookers equate it with fearlessness or a substantial and potentially limitless amount of courage. “How do you do it??” they will ask. The only answer to this I can ever come up with, other than a shrug of the shoulders, is: I don’t have a choice (and in regards to the experiencing of disease) I feel it, but I don’t think it. I feel ALL of it, illness permeates every inch of my body in a physical way, but I try not to let it permeate every inch of my mind. This is the “control” mentioned above. And it is really hard to create and maintain. In this book Moran writes, in regards to a soldier exemplifying this control:

“…a way of looking at things which alone makes it possible to carry on. His business is to become insensitive, to give up thinking. The wise man lives only for the hour…. He looks just like a boy who is beginning an illness with the shivering attacks, and in the frankest way he will tell you he is just petrified by the business. But I don’t worry much about him, because in the intervals his mind is quite normal. He neither thinks too much of what is gone nor of what may come. He just gets as much out of life as he can. While this lasts he won’t crack however much he is scared.”

The alternative?

“But sometimes the shadow of fear drove men in just the opposite direction, into sheer recklessness. There is drink, a last crazy effort to get something out of life while it lasts. Was this fellow breaking because he was drinking or was he drinking because he was breaking? Was alcohol a cause or a symptom of defeat? Not that it mattered, for once that game began the man was done.”

What (sometimes just temporarily) delays the loss of courage and journey to recklessness and despair?

“In the presence of danger man often finds salvation in action. To dull emotion he must do something; to remain immobile, to stagnate in mind or body, is to surrender without terms. Whereas movement, work of any kind, helps to deliver him from those feelings which are traitors to his better nature.”

Again, this is the “courage of control,” or how I always thought of it, “I feel it but I don’t think it.” When I think back on all of my disease years, they are somewhat unbelievably jam-packed with “action” and “movement,” with few instances of stagnation. Moran found that soldiers who were engaged in active warfare, like in a fighter plane, were able to keep going longer than those in observation roles or “on watch.” It’s not a coincidence then that the concept of PTSD comes “after” or “post”; the action and commands are gone and there is only time to think and analyze and make choices.

“Courage is a moral quality; it is not a chance gift of nature like an aptitude for games. It is a cold choice between two alternatives, the fixed resolve not to quit; an act of renunciation which must be made not once but many times by the power of the will. Courage is will power…in Gaelic hope and courage are the same word.”

With chronic disease, sometimes I do have that “fixed resolved not to quit,” but other times it’s a less conscious addiction to action/movement, i.e. an addiction to distractions. No matter how productive, pragmatic, or fulfilling, they are still distractions serving to prevent thinking about disease “stuff.”

…as Hippocrates taught, there is a certain antagonism between physical and mental pain. In a battle somehow the horror of this business of war is not felt. Nature has the stop on; perhaps we are half-doped to come through it all. In this war, Critchley has noticed in sailors the same mental viscosity–a kind of blinkers effect–while the danger lasts, so that only in retrospect does the full force of the ordeal emerge.”

Only after reading the above did I finally understand that something related to PTSD happens with chronic disease, this idea of being half-doped (sometimes literally!) and not feeling while IN it. Every time I am in the hospital, I go through the motions as if on autopilot and don’t “lose it” too often because I have programmed myself to “come through it all.” But when inevitably “only in retrospect does the full force of the ordeal emerge”…well, it’s awful and overwhelming. Sometimes this full force hits me a week later, a month later, even years later. Driving past my hospital and I have to pull over because I feel paralyzed. Declining ice in a drink because it reminds me of subsisting on 1 cup of ice a day in the hospital. Finding a salt packet in my purse and crying because I remember that I’d add them to my “meals” of vegetable broth and lick every salt granule off the bottom. Not being able to look at jello without getting nauseous. Hearing the succession of beeps of a truck backing up and comparing it to the beeps and the same length of silence in between of the IV machine. Vehement opposition to fluorescent lights.

Before I read this book, before someone said to me that what I was feeling was akin to PTSD, I just got mad at myself for reacting in “dramatic” ways. How could a mere salt packet reduce me to tears for a half hour?? I hated it. And I kept thinking, I got through it. I survived. It’s over. What’s wrong with me? Why am I not over it yet? When will I be completely over it? I recently read The Yellow Birds, which is Kevin Power’s recounting of his time in Iraq and subsequent debilitating PTSD: “My memories would seem closer the farther I got from the circumstances that gave birth to them.” Exactly.

“Can it be said that we are defeated by our own thoughts? Are we not most fearful often when there is no danger?”

I’m unsure of the context here, but Moran quotes Thomas Hardy: “More life may trickle out of men through thought than through a gaping wound.”

So what to do, when thinking and thoughts cannot be avoided?

“When we did think, we lived in the past, for it was clearly unwise to live in the present. We could only cheat our present distress by a flight into other times, away from all the dreary tribulations of the passing hour. Only humour helped. Humour that made a mock of life and scoffed at our own frailty. Humour that touched everything with ridicule and had taken the bite out of the last thing, death. It was a working philosophy that carried us through the day, a kind of detachment from the ‘insubstantial pageant of the world.’”

It’s the same for me, with disease: humor is employed, or an attempt to time-travel out of the present, with varying degrees of success.

The words chosen and the semantics involved, when people talk about disease, are often characterized by war terminology: fighting, battling, winning, losing. The Arthur Frank books I’ve read and written about before on this blog have touched on this. While Frank doesn’t exactly agree with this way of speaking or talking about illness happening within, I’m not sure where I stand; the emotional parallels I have found in the book I just wrote about in this post definitely add some interesting elements to that debate.

I also don’t know where I stand when thinking about Moran’s belief that one can run out of courage, without the option of refueling. I don’t want to believe it, you know? Because there are too many times that I feel so close to running out. How close to that threshold am I? All of the above questions and observations, combined with my recent 19 months of nursing prerequisite science courses, remind me of the making of and administering of vaccines. By definition, vaccination is artificial active immunity. The vaccine usually consists of a virus that is either inactivated, or live but modified to stimulate the immune system just enough to destroy the virus and remember it. How much of the inactivated virus is necessary for properly stimulating a response? Is there a quantifiable threshold or tipping point? Healthy people usually react to the live versions (which last longer, immunity-wise) in a safe and predictable way. People with less than stellar immune systems like myself can’t get the live version of the flu vaccine, for instance, because even though it’s modified, it might be strong enough to wreak serious havoc, potentially fatally. How much of this live version would be too much for the compromised immune system? That threshold is presumably different for different immune systems.

There is a fine line then between a vaccine literally encompassing “what doesn’t kill you makes you stronger” and just flat out killing you. Being able to identify that threshold would be the end. Perhaps it is the same with courage, will power, hope: you try to stay as far from that threshold as possible, even though you can’t pinpoint where it is. And maybe it doesn’t even exist, unless you make it exist out of fear. Lord Moran writes:

“A lost battle is a battle that one believes lost.”

In lieu of wanting to definitively “win” the persistent battle in my mind (and eradicate the possibility of any future mind battles), I would like to believe that I will never succumb to the sheer power of my thoughts and definitively lose.