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Christopher D. Green
York University, Toronto, Ontario
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By William H.R. Rivers (1920)
Posted April 2000
HYSTERIA OR SUBSTITUTION-NEUROSIS
In the last chapter I have considered two modes of solving the conflict between instinctive tendencies and controlling forces which furnishes the basis of the psycho-neuroses. In each case the mode of solution, which is successful in one case and unsuccessful in the other, is an attempt to reinstate the suppression which had previously existed in health. In other forms of neurosis the solution is attempted on different lines, and in this chapter I shall deal with the case in which the organism seeks to escape from the conflict by substituting another form of instinctive reaction for that which has been brought into activity, or which tends to be brought into activity, by the conditions which have acted as the immediate precursors of his disorder. This mode of solution is one in which the sufferer regains happiness and comfort, if not health, by the occurrence of symptoms which enable him to escape from the conflict in place of facing it. The form of neurosis to which I refer is that usually known as hysteria. As this term is ordinarily used it applies to a very large and varied group of manifestations of which paralyses, contractures and anæsthesias are among the most frequent and characteristic. These physical manifestations have been regarded by Freud as due to the conversion of the energy engendered by conflict, and in consequence he has proposed "conversion-neurosis" as a term for the state. This term is now widely used and seems to be in many respects appropriate, but I hope to bring the subject into line with the biological scheme put forward in this book in such a way as to suggest a more appropriate term. [p. 128]
I will begin by referring to the chief manifestations of the process by which the conflict is solved or the solution attempted. I will at first limit my attention to the form which the disorder assumes when it occurs as the result of the accidents of war. Among the most frequent results of shock and strain in war are paralyses, often accompanied by contractures and anæsthesias. The paralysis may attack almost any part of the body, but paralysis of speech is especially frequent, while the anæsthesias may affect not only the skin, but also the special senses of sight and hearing, and less frequently of taste and smell. All these occurrences have the common feature that they unfit their subject for further participation in warfare, and thus form a solution of the conflict between the instinctive tendencies connected with danger and the various controlling factors which may be subsumed under the general heading of duty.
Paralysis and anæsthesis may be regarded as crude reactions by means of which a person is protected from danger. It has been objected to this view that when these states occur on the battlefield, they do not protect, but may even increase the danger by producing conditions incompatible with the activities which form Man's normal reaction to danger. To this objection there are two answers. One is that in the vast majority of cases these protective reactions do not occur on the field of battle, but it may be a few days, it may be months, after the shock, wound, or other event of which they are the sequel. When they occur in this manner they fulfil in great perfection the protective purpose which is the special function of the danger-instincts.
Sometimes, however, these disabilities immediately follow some shock or strain and occur on the field of battle. It then becomes necessary to find some other answer to the objection that these reactions which I suppose to be instinctive fail of their protective purpose, or at the least are but ill-adapted to this purpose. This is one of the problems which will have to be settled by any scheme of explanation which can be regarded as satisfactory. I shall begin the study of the subject [p. 129] by considering the relation of the state characterised by the occurrence of these paralyses and anæsthesias to the processes of suppression, dissociation and suggestion.
One prominent manifestation affords a most definite example of suppression. Anæsthesia is one of the most frequent accompaniments of hysteria. Insensitiveness of the skin ranging from mere blunting to complete loss of all sensibility is a very general symptom and loss of hearing or vision often occurs. The paralyses may also be regarded as examples of suppression, the character of suppression being especially obvious when the paralysis affects the organs of speech, but it is really quite as definite in a monoplegia or an astasia. Equally striking is the suppression of affect. In the most characteristic form of hysteria, as it occurs in warfare, there is no anxiety or depression. The patient is relatively or positively happy. He is unaware of any relation between his apparently physical disability and any of the dangers of warfare preceding the event which acted as the antecedent of his illness. He is content to regard his illness as the natural result of the shock or injury after which the paralysis or other hysterical manifestation developed. If we regard hysteria as a solution of the conflict between instinctive tendencies and controlling forces, we must regard the state as one in which there is suppression of the affect accompanying the instinctive tendencies, while in many cases there is suppression of all memory of the events in which the morbid state had its origin. That there is such suppression of affect is strongly supported by a frequent consequence of curing the paralysis or other physical manifestation. In many cases, especially where the disappearance of the morbid symptom raises the probability that the patient will again have to take part in warfare, a definite state of anxiety and depression takes the place of the physical disability.
Several of the most characteristic manifestations of hysteria can thus be regarded as results of the process of suppression. The paralyses and anæsthesias are characteristic examples of this process, while the contractures are due to the overaction of certain mechanisms which takes place when the activity [p. 130] of other mechanisms has been suppressed. In dealing with hypnotism I suggested that the suppression of motility and sensibility which are so characteristic of this state might be regarded as manifestations, highly modified it is true, of the instinct of immobility, and it is evident that such a conclusion holds still more naturally of the suppression of hysteria. In the case of hypnotism we do not know of any direct connection between its exhibition of suppression and the presence of danger, but in the case of the similar suppressions of the hysteria of warfare this connection is definite. The paralyses and anæsthesias of this state may be regarded as partial manifestations of a process which, if it were complete, would produce immobility and insensibility of the whole body. According to this view the paralysis and anæsthesia of hysteria are modifications of one of the most definite of the various instinctive processes by which animals react to danger.
The view that hysterical symptoms are modified forms of the instinct of immobility has been reached by attending only to one aspect of hysteria, viz., the production of certain of its symptoms by the process of suppression. It is now necessary to attend to other aspects of the disease, and especially to its intimate connection with suggestion. According to current views suggestion is the most prominent agency in the production of hysteria, and I myself have laid such stress on this feature that I have proposed "suggestion-neurosis" as a term for the state.
Moreover, hysteria is undoubtedly accompanied by greatly enhanced suggestibility, and it is therefore natural to regard this suggestibility as an important, if not essential, factor in the production of the state. I have attempted to show that an important factor in the production of the hysteria of war is the enhanced suggestibility which results from military training. One of the chief purposes of military training is to enable the individual soldier to act immediately and automatically to command so as to ensure unity of purpose and action in the section, platoon, company or other group of [p. 131] which the individual is a member. The success of such a training depends upon the utilisation of instinctive tendencies promoting unity within the group, and since the chief of these agencies is suggestion, the result is enhancement of suggestibility. It is, therefore, absolutely necessary that any theory of hysteria shall take into account its close connection with suggestion and suggestibility.
In this connection it will be useful to consider a characteristic feature of hysteria, viz., its mimetic character. According to the definition of suggestion employed in this book, mimesis is a special aspect of the more general process of suggestion, the term being used for the motor or effector side of the process whereby one animal or person influences another unwittingly. The tendency of the hysteric to exhibit symptoms similar to those of other persons in his environment is thus thoroughly in accord with the close relation between hysteria and suggestion. It would seem as if the chief difference between hysteria and hypnotism is that, while in hypnotism the manifestations are due to the suggestion of another person, they are in the case of hysteria the result of the unwitting process of mimesis which forms one aspect of suggestion.
When considering hysteria in relation to suppression I was led to regard the disease as a modification of the instinctive reaction to danger by means of immobility. It is now necessary to consider through what means the original instinctive process has been modified. According to the views put forward in this book, the primitive instincts subject to the "all-or-none" principle have been modified in two directions and by two different agencies, one intelligence and the other suggestion. We have seen that anxiety- or repression-neurosis, at any rate in some of its forms, is due to conflict between the primitive instinctive tendencies and factors based largely or altogether on intelligence. Intelligence may be regarded as a modifying principle, highly successful in the usual calm of our modern civilisation, which has broken down as the result of the excessive strains and shocks of modem warfare. I have now to suggest that hysteria is the result of the abrogation of the modifying [p. 132] principle based in intelligence, leaving in full power the other and more or less opposed principle of suggestion.
Let us now consider in more detail whether there are any reasons why suggestion should be so prominent in the production of hysterical manifestations, and whether its activity is able to explain some of the more characteristic features of the hysteria of warfare. Warfare is essentially a collective form of activity. As I have already pointed out, military training is especially directed towards the perfection of collective activity and towards the consequent increase of suggestibility which is essential to the success of the gregarious instinct. There are thus definite factors in warfare which tend to produce the predominance of suggestion and assist the abrogation of the more intelligent forms of reaction which are so prominent in the production of repression-neurosis. As I have-pointed out elsewhere, hysteria tends to occur especially in the private soldier, and repression-neurosis in the officer.
I have explained this, partly by the greater intelligence and education of the officer, partly by the fact that it is the private soldier whose suggestibility is especially enhanced by military training and his military duties, while the training and duties of the officer are directed more to the development of initiative and independence.
If now we turn to the symptoms which are especially prominent in the hysteria of warfare, we find that some of these can be referred definitely to the protective end which I suppose to be the essential function of hysteria. One of the most frequent features of the hysteria of warfare is mutism. A soldier who has been buried or otherwise disabled by a shell-explosion will emerge from his experience with complete absence of all power of speech, which may continue for months or even years. Let us consider how the prominence and frequency of this symptom can be connected with the view that the protective function of hysteria is connected with the gregarious instinct.
It will be remembered that when describing the reaction to danger by means of flight, I mentioned the cry as one of its manifestations, and I assigned to this cry the function of warning [p. 133] the other members of the group. It would seem as if the individual reaction by flight has become closely associated with a mode of reaction, by means of which the individual warns the rest of the group of the danger from which he is himself reacting instinctively by means of flight. The cry may be regarded as a feature of the flight-instinct arising out of the gregarious habit. If however, a group of animals should adopt the reaction to danger by means of immobility, the cry would be wholly out of place. If only one of the herd or other group were to utter the warning cry which belongs to the instinct of flight, it would wholly destroy the virtue and success of the alternative instinct of immobility upon which the group is now dependent for its safety. If a group of animals is to adopt successfully the instinct of immobility, it is not only essential that all tendencies to the movements of flight shall be suppressed; it is just as essential that every one of its members shall suppress the warning cry which serves so useful a purpose on other occasions. If, therefore, hysteria be primarily a variant of the instinct of immobility, it is natural that one of its earliest, if not its earliest, need should be the suppression of the cry or other sound which tends to occur in response to danger. I suggest, therefore, that the mutism of war-hysteria is primarily connected with the collective aspect of the instinct of immobility. When it persists, as it often does, after removal from immediate danger, this is because it provides a means of protection from further participation in danger, and is therefore utilised, not consciously, but in that unwitting manner which is characteristic of instinctive forms of behaviour.
In those rare cases in which paralysis of a limb, or even of all limbs, occurs on the field of battle, and thus prevents the movements by which the soldier would normally escape from danger, it is necessary to suppose that the reaction is due to the coming into play of an instinctive form of behaviour, which is ill-adapted to the special conditions by which it has been produced. It may be regarded as an incomplete, and therefore unsuccessful, adoption of an instinctive form of reaction to danger. It is obvious that, if in such a case the reaction of immobility were [p. 134] complete, it might be successful as a means of simulating death, and the whole reaction of immobility may be, and often has been, supposed to have this end. Where the immobility is only partial, therefore, we may regard it as an incomplete form of reaction which if it were complete would serve a useful purpose.
I have now considered the rôle in hysteria of the instinctive processes of suppression and suggestion. I have regarded the state as primarily one of suppression, as a means of promoting safety, which has been greatly modified through the process of suggestion coming into action through gregarious needs. I have now to consider its relation to another instinctive process -- that of dissociation. According to the customary method of using the concept of dissociation, hysteria is a manifestation of this process. It is customary, at any rate in this country, to speak of the hysterical symptoms as the result of dissociation. It is therefore necessary to consider this point, and to inquire how far the hysterical state accords with the definition of dissociation adopted in this book.
If dissociation implied only the independent activity of suppressed experience, there might be some justification for the idea it underlies the paralyses and anæsthesias of hysteria. If we regarded these states as positive phenomena, we might look on them as the results of the activity of suppressed experience. But even here the position would not be altogether satisfactory, for we should be driven to regard the process of suppression to which the paralyses and anæsthesias are due as itself a mode of activity of the suppressed experience. If, in place of regarding dissociation as a state of independent activity, we hold independent consciousness to be a necessary part of the concept of dissociation, it is evident that hysteria wholly fails to answer to the definition, for there is no evidence whatever of such independent consciousness. In the absence of any evidence of alternate consciousness, it is doubtful whether anything is gained by bringing hysteria within the category of dissociation.
I have, therefore, no hesitation in excluding dissociation from the connotation of hysteria, and in regarding this state as a [p. 135] product of the two processes of suppression and suggestion. I have already pointed out its close relation to hypnotism, from which it differs in being unaccompanied by independent consciousness, thus bringing it still nearer than the hypnotic state to the instinctive reaction to danger by means of immobility. I have pointed out that the paralyses and anæsthesias, which are the most characteristic manifestations of hysteria, may be regarded as localised manifestations of the suppression of the instinct of immobility, of which sleep and hypnotism are other forms. According to this view the symptoms of hysteria are due to the substitution, in an imperfect form, of an ancient instinctive reaction in place of other forms of reaction to danger. If this way of regarding the matter were accepted, the term "substitution-neurosis" would become an appropriate and convenient term for the "hysteria" of general usage or the "conversion-neurosis" of Freud.
I have so far treated hysteria, or substitution-neurosis as we know it through the effects of warfare. The theory of this state which I have put forward differs so profoundly from that generally held that I cannot abstain from considering how far it can be utilised to explain the hysteria of civil practice.
According to my view hysteria is primarily due to the activity of a danger-instinct, to the coming into action of an instinct whose primary function is protection from danger. I have now to consider whether the hysteria of civil practice can also be referred to danger, or whether it is the result of the transference of the reaction from a connection with the danger-instincts to some other instinct. My own experience of civil practice is too small to enable me to deal adequately with this problem, and I must leave it to those with more knowledge to discover how far this form of hysteria can be led back to an origin in the awakening of the danger-instinct.
Even if some cases of hysteria in civil life can be referred to onslaughts on the danger-instincts, there can be little doubt that factors connected with sex take a most important part in the ætiology of this state. I can only here deal with the matter very briefly, and will begin by considering a fact which [p. 136] must be explained by any theory of hysteria, but of which current explanations are not satisfactory. It is necessary to explain why hysteria in civil life affects women to so far greater an extent than men. The idea that only women are affected has long been given up, but the experience of war has shown how very prone men are to succumb to hysteria when the suitable conditions arise, viz., conditions which make too great a demand on their danger-instincts. We have to discover why hysteria should be so frequent in women, and so rare in men, under the ordinary conditions of civil life. I have already mentioned the rarity of severe demands on the danger-instincts in the ordinary routine of our modern civilisation. In so doing I see now that I was thinking only of the male element in the population. Women are always liable to dangers in connection with child-birth to which men are not exposed, while the danger-element, real or imaginary, is more pronounced in them than in the male in connection with coitus. That the greater prominence of danger with the consequent tendency to awaken fear should be potentially present in connection with the normal functions of women seems to afford a definite motive for the more frequent occurrence in them of a form of neurosis which, according to the view here put forward, is due to the occurrence, though in modified form, of a definite mode of reaction to danger.
One difficulty for my view of the nature of hysteria is so important that I cannot pass it over in silence. One of the symptoms which has always been regarded as a characteristic manifestation of the hysteria of civil practice is the occurrence of convulsive seizures which are sometimes with difficulty to be distinguished from epilepsy, and share with that disease the exhibition of movements, often of a very violent kind. Such seizures are, of course, wholly incompatible with the purpose in which I suppose hysteria to have had its origin, and they must raise serious doubts concerning the validity of my hypothesis that hysteria is connected with the instinctive reaction to danger by means of immobility. Other manifestations, such as the globus hystericus and the violent emotional expression so frequently associated with the current concept of hysteria, [p. 137] would also be wholly out of place in a state which has the origin I suppose.
In considering this difficulty I must first point out that in my experience, and I believe the experience is general, convulsive seizures of the kind which are known in the hysteria of civil practice are of exceptional occurrence in the hysteria of warfare. The seizures called "fits" which occur in this state are very different from those of civil practice. The patient lies motionless and silent, and in a state quite consistent with a relation to the instinct of immobility. The stupors and cataleptic states which so frequently occur immediately after the shocks of warfare are also, I need hardly say, completely in harmony with the view that the hysteria of warfare is an expression of this instinct.
The convulsive seizures which stood out so prominently in the concept of hysteria held before the war must, however, be accounted for if the hypothesis I am putting forward is to explain all the facts. I can only regard the difference between the two forms of hysteria as dependent upon the modification which the primary process has undergone in the course of its utilisation in the interests of another instinct, although I suppose that many of the manifestations of civilian hysteria can be referred to demands upon the danger-instincts, I have assumed that in general this state depends on disturbances of the sexual instinct. It will be necessary to inquire whether the convulsive seizures, globus hystericus, and emotional attacks do not occur especially in cases which can be definitely referred to a sexual cause. Owing to my own ignorance of civilian hysteria I can only raise this possibility and leave its investigation to others.
I venture, however, to suggest that it would conduce to clearness of thought, and to successful practice, if two distinct varieties of hysteria were recognised, the two differing in the nature of their ætiology. It may then become apparent that two very different concepts have been confused under the heading of hysteria. Here, as is the rule in psychological medicine, intermediate cases will occur, in which convulsive [p. 138] seizures are associated with paralysis, contractures and anæsthesias. It seems possible that the two concepts will turn out to be as capable of distinction from one another as most of the other concepts of psychological medicine where shading and gradations are peculiarly liable to occur owing to the great complexity and intimate inter-relations of the psychical processes concerned.
I should like at this stage to point out an important difference between the psycho-neuroses of civil life and those which follow the events of warfare, which has a definite bearing on the possibility I have just raised. The instinctive tendencies which manifest themselves in the psycho-neuroses fall into two definite classes. One class is composed of the tendencies which in a state of nature would promote the happiness of the individual or the crude necessities of the race, but are in conflict with the traditional standards of thought and conduct of the society to which the individual belongs. The other class of tendencies have a protective character. Their function is to produce immediate pain or unpleasant affect as a means of warning against and avoiding danger. In the psycho-neuroses of warfare the second group of tendencies are predominantly or even exclusively involved, while, if we accept the position that the psycho-neuroses of civil life depend mainly upon disturbances of the sexual instinct, they will involve tendencies of the first class, This difference is so great and far-reaching that it is amply sufficient to account for the different natures of the two kinds of psycho-neurosis. It would alone go far to justify the separation of the two forms of disorder in a scientific classification.
 See p. 223.
 See p. 217.
 See p. 207.