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Christopher D. Green
York University, Toronto, Ontario
ISSN 1492-3173
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By William H.R. Rivers (1920)
Posted May 2000
APPENDIX IV
WAR-NEUROSIS AND MILITARY TRAINING[1]
Discussions concerning the causation of the war-neuroses usually deal with two main topics. Either they consider the predisposition to nervous disorder of those who have broken down under the shocks and strains of warfare, or they are concerned with the relative shares taken by physical and mental factors as the immediate antecedents of these failures. In connection with the first topic, various writers have discussed the part taken by congenital or acquired tendencies to nervous or mental instability as shown either by family history or by the occurrence of nervous troubles before joining the army. Under the second heading have been considered especially the part taken by exhaustion, concussion or emotional shock as the immediate precursors of a nervous or mental collapse, or by conditions of strain and anxiety which have lowered the resistance of the soldier to the shock or illness which was the immediate antecedent of his failure.
These two topics do not exhaust the causes of war-neurosis. Between the time that a man joins the army and that at which he breaks down, he passes through a special experience, very different from that of any form of civilian life. He is first subjected to a special training, and when this training has reached a certain degree of perfection he meets another set of experiences, perhaps even more remote from those of civil life, in which he has to perform the military duties he has learned during his training.
Two separate problems must be distinguished: one, the relation of military training and the nature of military duties to [p. 206] the occurrence of neurosis; the other, the part taken by these factors in determining the special form which the neurosis takes. There is little question that one of the chief causes of the great prevalence of nervous disorders in the war is that vast numbers of men have been called upon to endure hardships and dangers of unprecedented severity with a quite insufficient training. There is equally little doubt that the special nature of the duties involved in trench warfare has taken a large part in determining the great frequency of neurosis.
It is not, however, the purpose of this report to deal with the problem of the part taken by military training and military duties in the causation of neurosis in general. Its aim is to deal only with the second of the two problems stated above. For this purpose it is necessary to consider briefly the varieties of war-neurosis, the main headings under which the almost infinite variety of its symptoms can be classified.
Excluding from the category of neurosis cases of simple exhaustion or concussion and disorders of circulation or digestion due to infection, and excluding also definite psychoses, cases of war-neurosis fall into three main groups, though intermediate and mixed examples are of frequent occurrence. The first group comprises cases in which the disorder finds expression in some definite physical form, such as paralysis, mutism, contracture, blindness, deafness, or other anæsthesia. The characteristic common to all these symptoms is that they are such as can be readily produced in hypnotism or other state in which suggestion is especially potent. I propose later to consider how far the considerations to be brought forward in this report help us towards a satisfactory nomenclature. In the meantime I shall be content to speak of this group as hysteria, the term by which it was generally known before the war and one which, in spite of its unsatisfactory character, is still widely used.
The second group consists of cases in which the disorder shows itself especially in lack of physical and mental energy, in disorders of sleep and of the circulatory, digestive, and urogenital systems. On the mental side there is usually depression, restlessness, [p. 207] irritability and enfeeblement of memory, and on the physical side tremors, ties, or disorders of speech. This group is usually known as neurasthenia in this country, but in this case I shall anticipate the results of my later discussion and speak of it by the term anxiety-neurosis.
The third group, with which I shall have little to do in this report, is characterised by the definitely psychical form of its manifestations. This group comprises a number of different varieties. In some cases the most obvious symptom is mental instability and restlessness with alternations of depression and excitement or exaltation, similar to those of manic-depressive insanity. In other cases there are morbid impulses of various kinds, including those towards suicide or homicide. In some the chief symptoms are obsessions or phobias, while others suffer from hallucinations or delusions. The special feature of all these cases is that the symptoms resemble in kind those of the definite psychoses, but have neither the severity nor the fixity which makes the seclusion of the patient or any legal restriction in the management of his affairs necessary.
There is no evidence that the psycho-neuroses of the third group are especially liable to affect either officers or men, but the other two groups show a remarkable difference in this respect which I propose to take as my guide in the treatment of the subject. The group which I have provisionally labelled hysteria is especially apt to affect the private soldier, Pure cases of this kind are rare among officers who, as a rule, only suffer from this form of disorder as complications of states of anxiety, or when there is some definite, physical injury to act as a continuous source of suggestion. Anxiety-neurosis is not similarly limited to officers, but affects them more frequently, and usually more profoundly, than the private soldier.
I propose to take this difference in the incidence of the two chief forms of neurosis as a clue to the better understanding of the nature of these states. I hope to show that this difference can be largely explained by differences in the character and effects of military training and -military duties. For this purpose it will be necessary first to state the general theory of the [p. 208] neuroses of warfare upon which my treatment of the subject will he based. This theory is that the neuroses of war depend upon a conflict between the instinct of self-preservation and certain social standards of thought mid conduct, according to which fear and its expression are regarded as reprehensible. From infancy the influence of parents and teachers is directed to bring about the repression of any manifestation of fear, and since the ordinary life of the modern civilised adult rarely presents any features which come into conflict with the instinct of self-preservation, this repression meets with little opposition and rarely produces any serious conflict. The child has many experiences which tend to call forth the emotion of fear in its cruder forms, but once adult age is reached, occasions which tend to produce fear rarely occur, and there is little in the ordinary life of the modern civilised man which tends to set up any conflict between the instinct of self-preservation and acquired social standards.
The business of the soldier, on the other hand, is one which necessarily brings its follower into the presence of danger, and as we shall see, one of the chief objects of military-training is to fit the soldier to meet the special assaults upon the instinct of self-preservation to which his calling will expose him. In one of the two chief forms of war-neurosis the conflict is solved by the occurrence of some disability-paralysis, contracture, mutism or anæsesthesia -- which, so long as it exists, incapacitates the patient from further participation in warfare and thus removes all immediate necessity for conflict between instinct and duty. Anxiety-neurosis, on the other hand, is a state or process in which the conflict has not been solved but is unduly active, the controlling social factors having been weakened by exhaustion, illness, strain or shock, so that the motives arising out of the instinct of self-preservation have gained in power, while in many cases the social factors have produced new conflicts and causes of anxiety which may be as potent as the primary conflict with the instinct of self-preservation.
The object of this report is to consider the part taken in this conflict by the processes of military training and military [p. 209] duties, but before considering this, it will be well to inquire whether the life of officer and man before the war provides any reason why the two should be affected in different ways by the strains and shocks of warfare.
One possible cause may be found in difference of general education. On the whole the officer is more widely educated than the private soldier; his mental life is more complex and varied, and he is therefore less likely to be content with the crude solution d the conflict between instinct and duty which is provided by such disabilities as dumbness or the helplessness of a limb. The histories of officers suffering from anxiety-neurosis often show the existence of temporary mutism, paralysis or other functional disability in the early stages of their illness, but these solutions of their conflict do not satisfy them and their disabilities speedily disappear, to be replaced sooner or later by symptoms directly dependent on anxiety.
Another possible cause is to be found in the quality of the education, and especially the school education of officer and man. Fear and its expression are especially abhorrent to the moral standards of the public schools at which the majority of officers have been educated. The games and contests which make up so large a part of the school curriculum are all directed to enable the boy to meet without manifestation of fear any occasion likely to call forth that emotion. The public school boy enters the army with along course of training behind him which enables him successfully to repress, not only expressions of fear, but also the emotion itself. A similar schooling forms part of the education of the primary schools whence the majority of private soldiers have come, but it has been less extensive and less systematic than in the public boarding schools, though it is probable that the popularity of certain games has done much to lessen the difference in recent years.
If the behaviour of the officer and private soldier after they have become the victims of neurosis is any guide to their standards before the war, the private soldier has far fewer scruples about giving expression to his fears, this expression being both more explicit and less subject to repression. [p. 210]
These differences must only be taken in the rough and as applicable on a large scale, but there is little doubt that the average private enters upon his military training with less aversion from the expression of fear than the average officer, and that his simpler mental training makes him more easily content than the officer with the crude solution of the conflict between instinctive and acquired motives which is provided by some bodily disability.
The liability of officers and men to different forms of war-neurosis is thus partly capable of explanation by differences in the conditions to which they have been exposed before the war. It is the object of this report to show that these or any other conditions[2] existing before the soldier joins the army are greatly assisted by differences in the nature of the training of officers and men and of the duties which fall to their lot. I will begin by considering the general aims and character of military training. Its two chief aims are to fit each individual soldier to ad in harmony with his fellows, and to enable him to withstand the stresses and trials of warfare. Military training is designed to enable the soldier to act calmly and methodically in situations which would naturally tend to upset the balance of his conduct and in the face of dangers which would arouse the instinct of self-preservation. Its aim is to free the soldier, not merely from the danger of succumbing to the collapse of terror or the blind flight of panic, but also from those minor disturbances of efficiency which are due to apprehensions or to doubts concerning the issue of a combat. The ideal military training should bring the soldier into such a state that even the utmost horrors and rigours of warfare are hardly noticed, so inured is he to their presence and so absorbed in the immediate task presented by his military duties.
In carrying out the two chief aims of military training certain definite agencies are called into play. In fulfilling the first aim of adapting the soldier to act as one of an aggregate in complete harmony with its other members, one agency is habituation. [p. 211] The elementary drill of a soldier consists of processes in which this agency plays a most important part. The soldier is thoroughly drilled in certain relatively simple evolutions until he has acquired the habit of immediate and unreflecting response to a command by means of which his reactions correspond with those of all the other members of the aggregate; all act together as if there were one mind in common to the whole. The individual soldier has to sink his individuality in order to act without hesitation or reflection as one of a section, platoon, company, battalion, or still larger group. The requirements of modern warfare are leading to some modification of this mechanical aspect of military training, but such modification only begins after the soldier has been subjected to a prolonged course of drill designed to adapt him to act as one of an aggregate.
An agency working with habituation, and one far more important from our present point of view, is suggestion.[3] The process by which an individual comes to act promptly and harmoniously as one of an aggregate is simply one variety of the process by which individuals come to act as members of social aggregates in general. A person who is being drilled is taken from our highly individualistic community, in which spontaneity and independence are encouraged, and is subjected to a course of training calculated to produce a state allied to that of existing communistic peoples or of animals which are accustomed to act in herds: One result of such a training, if it be not indeed also its chief aim, is to enhance the responsiveness of each individual to the influence of his fellows, and the form which is taken by military training is especially designed to enhance his responsiveness to those who are immediately above him in the military hierarchy. From one point of view the most successful training is one which attains such perfection of this responsiveness that each individual soldier not merely reacts at once to the expressed command of his superior, but is able to divine the nature of a command before it is given and [p. 212] acts as a member of the group immediately and correctly, even when the conditions of warfare might produce uncertainty if he relied entirely on the actual words or definite gestures of command. The process by which a capacity for such immediate response comes into being resembles very closely, if it be not actually identical with, the process we call suggestion. In the hypnotic state, in which the power and efficacy of suggestion reach their acme, the individual responds immediately and without question or hesitation, not merely to the command of his hypnotiser, but even to a desire or impulse of the hypnotiser's mind which is not expressed by speech or obvious gesture. The resemblance between the two states is so close that there is little doubt that one result of military training, and especially that of the more elementary forms of drill, is to enhance the suggestibility of those who are subjected to the process. It produces a modification of character which makes the soldier more immediately responsive to suggestion, whether this emanate from an individual officer or from the general body of the group, whether platoon, working-party, company or other body which forms the aggregate of which he is a member at the moment.
This enhanced responsiveness is well exemplified in certain well-known incidents occurring in the army which has carried the more mechanical aspects of military training to an extreme length.[4] The success of the Captain of Koepenick could only be possible in an army whose members had through a special course of training reached such a pitch of responsiveness to the commands of one in uniform that they obeyed without question the ludicrous orders of a cobbler.
The other aim of military training, which especially touches the liability to different forms of neurosis, is to fit the soldier to withstand the trials and stresses of warfare. One of the chief instruments by which this aim is met is that already considered, [p. 213] which makes the individual soldier act as a member of the aggregate to which be belongs in a closer sense than holds good in civil life. This does away with or diminishes greatly the tendency of any one individual in the group to react to fear or other emotional state in a way which would interfere with his military competence. In carrying out the aim of adapting the individual soldier to withstand the dangers of warfare, the first instrument is identical with that by which his actions come to be performed with the requisite immediacy and harmony. I have now to consider the other processes by which the soldier collectively is assisted to withstand the stresses of warfare. These processes bring into action two chief agencies, repression and sublimation.
In considering the process of repression in its relation to military training, two varieties must be distinguished. In the first variety an attempt is made to thrust some part of the mental content, some feeling, thought, memory or sentiment, from consciousness. In the second variety the effort is directed rather to the repression of the outward expression of some mental state, especially of feeling or emotion. There is no hard and fast line between these two forms. One who endeavours to control the expression of an emotion will also try to banish from his mind thoughts or memories likely to call the emotion forth. Since, however, it is the expression of an emotion which is appreciated by others, the repression of the outward manifestation bulks more largely in the process in so far as it is a feature of military training. There are probably great individual differences in the way in which different persons treat the conscious elements of the mental content in their efforts to subdue their outward expression. As I have pointed out elsewhere,[5] repression forms a necessary part of all education and adaptation to social life. Perhaps the most important feature on the repression of military training is the relatively late period of life at which it takes place. The older a person is, the more difficult it becomes for him to give up habitual modes of thought and action. It is where repression is [p. 214] incomplete and is the source of persistent mental conflict that it becomes a factor in the production and maintenance of neurosis. If the repression which forms part of military training is complete, it probably helps greatly towards the success of the repression which will become necessary when the soldier enters upon active service, but if it is incomplete, so that the soldier enters upon active service accompanied by the active conflicts so aroused, his success in the necessary repression of warfare will be prejudiced.
During military training much may be done, especially by means of games, to exercise the repression of fear and its expression, but during this part of his training other kinds of repression are more in evidence. In order to act as one of the aggregate to which he now belongs, the recruit has to repress any tendencies to individual action which would interfere, or are supposed by military tradition to interfere, with efficiency, and failure of these repressions has much to do with the production of war-neurosis. Thus, a frequent factor in the production of war-neurosis is the necessity for the restraint of the expression of sentiments of dislike or disrespect for those of superior rank, and these restraints become particularly trying when-those who are disliked or despised are the instruments by which the many restrictions of military life are imposed or enforced.
When the soldier is brought into contact with actual warfare, a new set of repressions come into action. It may become necessary to control and inhibit the expressions of emotion consequent upon the dangers of warfare. In some persons, especially those already well schooled in such repression, this process seems to take place with no obvious conflict, but in many cases the necessity for such repression is continually present, while in a far larger number this necessity comes into existence as the result of strain, the presence of a conflict in this respect being in many cases the first symptom of his abnormal state that the soldier notices. He may notice that whereas at one time he was hardly aware of shelling or other incident of warfare, he now tends to duck his head or [p. 215] perform some other involuntary movement whenever the noise of a shell is heard, thus betraying the presence of a conflict. A state in which such a tendency persists and requires continual repression is one of the most frequent forms taken by the early stage of war-neurosis.
When the soldier has been in the trenches for some time, a new necessity for repression may arise and may affect those who have not previously found it necessary to repress fears or apprehension, or in whom such repression, in so far as it has been present, has aroused no conflict. The soldier may undergo some particularly trying experience; some disgusting sight, or the death and mutilation of a friend, or other experience may be so painful that it continually intrudes itself upon him while he unavailingly strives to banish it from his mind.
The last agency to be considered is that made up by sublimation and side-tracking. To the soldier these words may be strange, but not so the processes which they denote. By sublimation is meant a process in which an instinctive tendency, more or less fostered by experience, which would normally find expression in some kind of undesirable conduct, has its energy directed into a channel in which it comes to have a positive social value. By side-tracking we mean a process in which the energy so diverted acquires no special social value, but is altogether harmless, or at any rate less harmful to the welfare of the individual and community than that expression in which the energy would otherwise find its outlet.
One of the simplest and most frequent forms of side-tracking is the oath. The "strange oaths" or other forms of lurid language of the soldier are nothing but the relatively innocent means by which an outlet is given to superfluous energy. The form of energy which is perhaps most frequently thus released is that arising out of the repressions which form part of military training. Another form of side-tracking is to be found in the conviviality and relative freedom from restraint in certain directions which form so frequent an accompaniment to the life of the soldier.
One of the chief means of diverting spare energy, however [p. 216] this may be produced, takes the form of games and athletic competitions. Since these are of definite military value, they must be regarded as a means of sublimation. These exercises do not merely train the mind and body and thus add to the efficiency of the soldier, but they also have the most important function of utilising spare energy, whether derived from the activity of suppressed complexes or the product of some more healthy process.
A most important instrument of sublimation is to be found in the development of esprit de corps. There is thus produced a body of sentiments which contribute greatly to military efficiency, while at the same time they provide a most valuable means of sublimating energy which might otherwise work in the opposite direction.
In the old army the chief vehicle of esprit de corps was the regiment. The regular British soldier of the days before the war was above everything a member of the regiment. The honour and welfare of his regiment formed one of his chief interests, and the desire that he might do nothing to tarnish this honour or prejudice this welfare stood forth prominently among the means which enabled him to withstand trials and dangers.
This esprit de corps of the old army was chiefly bound up with the institution of "long service." A soldier spent years, including the most impressionable of his life, in one regiment, with the other members of which he came to have relations of comradeship which were even more. efficacious as a protective against fear or other emotion than motives arising out of the more abstract sentiments of honour and duty.
These features of the process of military sublimation have been much changed in the more recent history of the British army, especially during the war, but these changes have only modified the process and have not changed its essential character. They have affected the nature of the unit with which the esprit de corps is associated, the spirit embodied in the regiment or the company being now attached to the battalion or platoon, or other unit which has been brought into existence by the [p. 217] exigencies of warfare. The old spirit based on long years of comradeship has during the present war been replaced by one based on the sharing of common hardships and dangers.
More important than either esprit de corps in the strict sense or the camaraderie which is so closely associated with it, is the special relation existing between officers and men. Anyone having much to do with those who have taken part in the fighting of the war must have been struck by the extraordinary manner in which an officer, perhaps only just fresh from school, has come to stand in a relation to his men more nearly resembling that of father and son than any other kind of relationship. It seems dear that different battalions show the incidence of neurosis in very different degrees, and this is probably due more than anything else to the nature of the relations between officers and men by which the private soldier acquires towards his officer sentiments of duty and trust, while the officer is actuated, it may be dominated, by interest which could not be greater if those under his command were his own children.
This brief sketch of the aims and methods of military training has led me to distinguish three main processes -- suggestion, repression and sublimation, while others of less importance in relation to neurosis are habituation and side-tracking. I can now consider how those different factors will affect officers and men respectively. The heightening of suggestibility, though probably an inevitable result of any kind of military training, is pre-eminently one which affects the private soldier. It is the private soldier especially who is submitted to prolonged mechanical drill and is continually subject to the commands of others, while the officer is not only less fully drilled, but the periods in which he is subject to the commands of others are relieved by other periods in which he is the dispenser of commands and orders.
Sublimation, on the other hand, has more effect on the officer. It is doubtful how far the honour and welfare of the regiment or other unit appeals to the private soldier in general, though it is perhaps almost, if not quite, as definite among the non-commissioned as among the commissioned officers of the old army. In [p. 218] the new army, it probably means little or nothing to the ordinary soldier, in whose case any sublimation due to military training has its source in comradeship or in his feeling of respect and duty towards his officers, and especially towards either his platoon- or company-commander. It is because the aggregate with which he acts is composed of men with whom he has shared hardships and dangers with many of whom he has become comrade and friend, that this aggregate comes to have an influence upon him, while in other cases the relation towards his officer is more important. In each case, however, the result is the production of a state of dependence which works in the same direction as the factor of suggestibility already considered. The point of especial importance in relation to the incidence of neurosis is that the fact of comradeship to some extent, and far more the state of dependence on his officer, diminish the sentiment of responsibility and thus tend to enhance suggestibility or, perhaps more correctly, work in the same direction as suggestibility. In the case of the officer, on the other hand, the relation towards his men brings with it responsibilities which are perhaps more potent than any other element of his experience in determining the form taken by his nervous disorder, if he should break down. It is these responsibilities and other conditions associated with them which lead to his being so especially prone to suffer from the state of anxiety-neurosis.
The third main factor, repression, is very important in relation to the incidence of different forms of neurosis in officers and men. The officer is driven by his position to repress the expression of emotion far more persistently than the private soldier. It is the special duty of the junior officer to set an example in this respect to his men, to encourage those who show signs of giving way. In the proper performance of this duty, it is essential that the officer shall appear calm and unconcerned in the midst of danger. The difficulty of keeping up this appearance after long-continued strain or after some shock of warfare has lessened the power of control, produces a state of persistent anxiety which is the most frequent and potent factor in the [p. 219] production of neurosis, and is especially important in determining the special form it takes. The private soldier has to think only or chiefly of himself; he has not to bear with him continually the thought that the lives of forty or fifty men are immediately, and of many more remotely, dependent on his success in controlling any expression of fear or apprehension.
A factor of minor importance, but one which is nevertheless worth mentioning here, is that the officer is less free to employ instruments by which the Tommy finds a safety valve for repressed emotion.
The preceding argument has led us to the conclusions that of the three main agencies upon which the success of military training depends, one, suggestion, is especially potent and prominent in the case of the private, while the other two, sublimation and repression, have by far the greatest effect in the case of the officer. One of the chief results of military training is to increase the suggestibility of the private, and this increased tendency in one direction is but little counteracted by sublimation or complicated by the necessity for vigorous repression. The factor of sublimation may even tend to enhance his dependence and suggestibility. In the case of the officer, any increase of suggestibility produced by his training is largely compensated by the necessity for individual and spontaneous action, while the esprit de corps and other means of sublimation only tend in many cases to heighten his sense of responsibility and thus add still another cause for his anxieties. There are many officers, both commissioned and non-commissioned, to whom the honour of the regiment or battalion is quite as potent as responsibility for the lives of others' in producing the state of anxiety which forms the essential element in the production of their neurosis.
I have now considered how far the different forms of war-neurosis can be traced to the influence of military training and the nature of military duties. It is gradually becoming apparent, however, that the conditions of military training and active service are very far from exhausting the factors by which war-neurosis [p. 220] is produced. A large part, perhaps even a majority of the prolonged cases of functional nervous disorders which fill our hospitals, can be traced directly to circumstances which have come into being after some shock, illness, or perhaps only the ordinary process of leave, has removed the soldier from the actual scene of warfare. I have now to inquire how far the influence of military training and the nature of military duties assist in producing the neurosis of the hospital and the home.
Histories of cases of war-neurosis show that officers after some shock or illness often suffer for a time from those symptoms which I have ascribed to suggestion, but whether owing to treatment or spontaneous change, these symptoms soon disappear. It may be that the failure to be content with a simple but crude solution of a conflict which satisfies the private soldier is due to superior education, but the nature of his training and duties also contribute to this result. If the disability were the unwitting outcome of a conflict between the instinct of self-preservation and a simple conception of military duty, it might suffice to be paralysed or mute, but if the morbid state depends primarily upon sentiments of responsibility towards his military unit or his comrades, such a solution is not likely to satisfy his nature long. His conflict differs from that of the private soldier in that it is founded largely upon acquired experience rather than upon instinctive trends. It is more actively conscious than the process which has produced a paralysis or mutism. These disabilities fail altogether to touch the special anxieties which have taken the foremost place in the production of his illness.
In the state of weakened volition produced by shock or exhaustion it seems to the officer impossible that he will ever again be able to exert the vigour of control and initiative which alone enabled him to maintain the upper hand in the conflict of the trenches, and with this realisation, the former conflict is replaced by one still more painful and enervating, in which sentiments of duty struggle ineffectually against a conviction of unfitness.
In this conflict military training and duty take a most [p. 221] important place. There are many officers whose conflict would be solved, or would never have existed, if it were merely a matter of personal safety. It is the knowledge, born of long experience, that the honour of their military unit and the safety of their comrades depend on their efficiency which forms by far the most potent factor in the production or maintenance of anxiety states. To the private soldier, devoid of such responsibilities, the mere solicitude about his safety forms a less potent motive for conflict, and one which is more easily solved. Once the disability due to suggestion has disappeared spontaneously or by treatment, there may be no obvious conflict left. The instinct of self-preservation, to which his disability has been essentially due, will of course still be there ready to reassert itself if the occasion arise, but any conscious conflict is so readily solved in accordance with obvious standards of social conduct that there is no opening for the occurrence of a state of anxiety sufficiently profound to act as the basis of neurosis.
The conclusion reached in the preceding pages is that the private soldier is especially apt to succumb to that form of neurosis which closely resembles the effects produced by hypnotism or other form of suggestion, because his military training has been of a kind to enhance his suggestibility. The officer, on the other hand, is less prone to this form of neurosis and falls a victim to it only when there is some organic injury which acts as a continuous source of suggestion. On the other hand the officer is especially liable to anxiety-neurosis, because the nature of his duties especially puts him into positions of responsibility which produce or accentuate mental conflicts set up by repression, thus producing states of anxiety, the form taken by his nervous disorder. It will now be well to inquire whether this relation of military training and duties to the form of neurosis points the way to any practical conclusions. Several aspects may be considered here: nomenclature, prophylaxis, and treatment.
The nomenclature of functional nervous disorders is at present in a very unsatisfactory state. Cases of paralysis, contracture, anæsthesia or convulsive seizures, which provide the most striking [p. 222] manifestations of functional nervous disorder, were once universally known under the name of hysteria, because they seemed to be- especially apt to affect women. The words "hysteria" and "hysterical" acquired a meaning which made their use inconvenient for many purposes, and they were gradually replaced in practice by the term "functional," at any rate in this country. This term, however, has so wide an application as to make it of little scientific or practical value. Used originally as a means of avoiding the word "hysteria" it has become a label for a large number of morbid states differing widely from one another in nature, and calling for very different forms of treatment.
Another functional syndrome which is widely recognised is neurasthenia. Even before the war, however, this term was being used in so wide a sense that it was becoming every year of less value, and it has now lost the last remnants of ally scientific value it once possessed by its adoption as the official designation of the army for all forms of functional nervous disorder. A third term, psychasthenia, has been used in most textbooks of medicine, but in a very unsatisfactory sense. The cases usually called neurasthenia present signs of mental as well as of bodily enfeeblement, and if the term "psychasthenia" had been used for those cases in which mental exhaustion is especially prominent, there might have been some sense in its use. The term has been used, however, for cases of obsession, phobia and compulsion in which there is often no sign of general mental exhaustion, cases differing from the so-called neurasthenia in the special direction taken by mental energy rather than in any defect in its amount. All the old terms being thus unsatisfactory for one reason or another, it becomes necessary to find a wholly new nomenclature.
Babinski[6] has recently proposed pithiatism, a word derived from the Greek term for persuasion, as a substitute for hysteria. This term has been especially chosen to distinguish the cases formerly called hysteria from other similar states on which persuasion [p. 223] has no effect. Babinski has been influenced in his choice of the word by the need for a term to distinguish functional from organic paralyses, especially from the reflex, paralysis in which Babinski is especially interested. Through this special interest he has been led to ignore the large group of functional nervous disorders which are especially open to the influence of persuasion, but yet differ fundamentally in nature from the cases which the term pithiatism is especially intended to denote. It is also unusual, and hardly satisfactory, to denote a disease on the basis of a feature of its therapy. It will be much more satisfactory if it is possible to find a term based on the ætiological rather than the therapeutical aspect of the syndrome.
One term of this kind which has been used by Freud and his followers is "conversion-neurosis," The use of this term is based on a definite theory, according to which the paralysis or other affection is held to be the outward manifestation of some underlying unconscious tendency which thus finds a more or less dramatic expression. The paralysis, contracture or convulsive seizure is regarded as the product of a process of conversion whereby the energy of some unconscious process is transformed into, and finds expression in, one or more of these symptoms. Partly because the term implies a theory which all will not be ready to accept, but still more because there are other pathological states to which the term would be equally appropriate, it is improbable that this term will find general acceptance. Since it is generally conceded that these functional paralyses, contractures and other manifestations closely resemble, if they be not identical with, the products of suggestion, it would seem that suggestion-neurosis[7] might be an appropriate term. If I am right in my view that the special prevalence of these states in the private soldier is due to his enhanced suggestibility, this term becomes still more appropriate. The term has the advantage that its meaning is at once obvious and does not require recourse to the dictionary. Suggestion, being a common English [p. 224] word, is very unlikely to acquire the inconvenient associations which have become attached to hysteria. Suggestion-neurosis not only carries its meaning on the surface, but this meaning is one which points directly to an essential feature of the state it denotes.
For the other chief form of functional nervous disorder no more appropriate term can be found than that which I have used in this report. The meaning of anxiety-neurosis is also at once apparent. It indicates in direct fashion that anxiety is both the main factor in causation and at the same time one of the leading symptoms. The only disadvantage of the term is that it has been used by Freud and his followers in a somewhat narrower sense than that given to it in this report and in the work of MacCurdy[8] and other writers on war-neurosis. The Freudian usage has, however, had so little effect on the general body of medical practice that this disadvantage is not very great, and the usage now proposed only involves such widening of the connotation of the term as we might expect to be the result of the experience derived from the war.
Anxiety-neurosis is so often accompanied by repression, and so many of its symptoms can be ascribed to this ætiological factor, that repression-neurosis might seem to afford an alternative term. There are, however, many cases of anxiety-neurosis in which repression is not present or is of little importance. In many cases even the opposed process of dwelling too exclusively on the causes of anxiety is in action, so that the use of repression-neurosis would make still another term necessary. It will therefore be more convenient to speak of anxiety-neurosis with or without repression, although in some cases repression is so prominent as to make repression-neurosis a useful term. If-this term is used, however, it must be remembered that the state denoted is only one variety of anxiety-neurosis.
If there is any truth in the foregoing scheme of the influence of military training and duties in the production of the different forms of war-neurosis, it is evident that much might be done in [p. 225] the way of prevention. If the special tendency of the private soldier to suffer from suggestion-neurosis is due to the effect of military training in heightening his suggestibility, it will follow that this training should be carefully reviewed with the aim of modifying those of its features which tend especially to produce this result. It is probable that the necessary changes would correspond closely with those already made necessary by the nature of modern warfare. The encouragement of independence and the less mechanical training which is following the multiplication of the means of warfare should have as one of their consequences a lessening of the tendency to heighten suggestibility, and should therefore diminish the occurrence of suggestion-neurosis.
Much could be done in the prevention of anxiety-neurosis if the commanding officer and the battalion medical officer were alive to the conditions upon which this state depends. If they worked together to utilise this knowledge, many a young subaltern and non-commissioned officer would be saved during the early stages of his disorder by rest or appropriate change of occupation and brought back to health and peace of mind. Such measures are adopted at the present time, but often not until anxiety has produced a state of obvious unfitness, so that the period of rest or change prescribed is quite inadequate to restore stability. If the nature and causation of anxiety-neurosis were more fully understood, it would be possible to intervene at an earlier stage and save many a valuable career, for the victims of this form of neurosis often suffer through excess of zeal and too heavy a sense of responsibility and are likely to be the most valuable officers.
Another line in which much might be done towards the prevention of anxiety-neurosis is suggested by the part which repression takes in the production of this state. If the soldier were taught the dangers of repression from the outset of his postpone a breakdown to make it far more severe whenever it comes. The influence of repression in the production and maintenance of anxiety-neurosis suggests that from the beginning [p. 226] of his training the soldier should be encouraged boldly to face in imagination the dangers and horrors which lie before him. A most successful officer has told me how in the early days of the war he encouraged his men to "think horribly," to accustom themselves in imagination to the utmost rigours and horrors of warfare, with the result that they were highly successful in bearing the exceptional trials of the Gallipoli campaign. It is difficult to gauge how far this success was due to the course advised and how far to other conditions arising out of the personality of the officer who advised it, but the experience suggests that much might be done in this direction. We can at least be sure that a soldier who steadfastly refuses to face in imagination the trials that lie before him is very unlikely to cope successfully with the reality. Many of those who pass unscathed through modern warfare do so because of the sluggishness of their imaginations, but if imagination is active and powerful, it is probably far better to allow it to play around the trials and dangers of warfare than to carry out a prolonged system of repression by which morbid energy may be stored so as to form a kind of dump ready to explode on the occurrence of some mental shock or bodily illness.
If the argument of this report is sound, that the cases of functional nervous disorder hitherto labelled hysteria are largely due to suggestion and depend on the enhanced suggestibility of the private soldier, it might seem at first sight the obvious course to make use of this heightened suggestibility in the treatment, and to use suggestion, either with or without the production of hypnotic state. If, however, suggestion be used in the ordinary crude way to remove symptoms, this line of treatment will only tend still further to heighten the suggestibility of the patient and to increase the tendency to similar disorders whenever he returns to the field. If at the time that the symptoms are removed, suggestions are given against the occurrence of similar disabilities in the future, more could be said for this line of treatment, but this of course would not affect the heightened suggestibility which is the root of the evil.
The argument of this report points rather to a course in [p. 227] which treatment should be directed to lessen the suggestibility by a process of re-education. This process should be so designed as to make the soldier understand the nature of the disorder which has afflicted him. He should be made to realise the essentially mental basis of his trouble and be thus put into a position in which, even if the disability recurs, he will not long be satisfied with it as a solution of the situation. This line of treatment has the disadvantage that it sometimes succeeds in doing away with the paralysis or other symptoms only to replace the physical disability by a state of anxiety; but a soldier in whom the conflict between the instinct of self-preservation and duty is so pronounced as to lead to this result is very unlikely to show any more real success if treated by suggestion. Here, however, as in so many other departments of psychotherapy in connection with the war, we are hampered by our almost total ignorance concerning the after-history of soldiers who have been subjected to different modes of treatment. It is possible that there are sufferers from suggestion-neurosis who are capable of long and valuable service if the symptoms due to suggestion are treated by means similar to those by which they have been produced.
In cases of anxiety-neurosis the lines of causation considered in this report offer less help in treatment than in prevention. The knowledge of the process by which his state has been produced often greatly helps a patient, especially in removing or diminishing depression, or even shame, consequent upon failure. If he can be brought to see that his illness is the outcome of definite agencies over which he has had no control, or has been due to excess rather than defect in certain good qualities, the symptoms may be greatly relieved and the patient set upon a path which, if the exigencies of military service allow, may enable him again to perform his military duties. The knowledge of causation set forth in this report is useful in thus providing a groundwork for the process of re-education.
Footnotes
[1] A report to the Medical Research Committee, London. Published in Mental Hygiene, vol. ii, No. 4, pp. 513-533, October 1918.
[2] Among other possible conditions, those arising out of the influence of heredity should not be neglected.
[3] Another process or agency which might be considered here is imitation, but this process is probably only important in military training in so far as it depends upon suggestion.
[4] Ferenczi (see Contributions to Psycho-Analysis, Boston Badger, 1916, p. 58) has incidentally alluded to the similarity between he command of an officer and the suggestion of a hypnotist. He records how during his military service he saw an infantryman instantaneously fall asleep at his lieutenant's command.
[6] See J. Babinski - and J. Froment, Hysteria or Pithiatism, and Reflex Nervous Disorders. London: University of London Press, 1918.
[7] I leave this proposal in the text of this Appendix, though I prefer the term "substitution-neurosis," founded on the pathology of the state which I have put forward in Chapter XVI.
[8] War Neuroses, Cambridge, 1918.