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WEAR AND TEAR
[JUNE 17,
ORIGINAL ARTICLES WEAR AND
were
TEAR*
standing
in
waterlogged trenches, to reply,
Germans, without ammunition
1950
shelled by the’ while later the
long-drawn-out ordeal of trench warfare was punctuated by massacres, such as the battle of the Somme.
LORD MORAN M.C., M.D. Lond., F.R.C.P.
I became interested in the manner in which the men to this stress in the following manner. I was I HAVE chosen "Wear and Tear" as my title, because medical officer to the 1st Royal Fusiliers in France. I want to be at liberty to dip into the underworld of One in 1914, at Armentieres, when we were waiting medicine where aberrations of the mind are found. In to day to the trenches to relieve a battalion, word was go up England, medical students are sometimes poorly schooled brought to me that there was a sergeant in his billet in these matters, and I ain under the impression that who was not well. I asked him what was He physicians, broadly speaking, are obsessed with the said " nothing-he was all right." He waswrong. a morose scientific approach to medicine. We have forgotten the fellow and I could get nothing out of him. I examined Greek saying that a doctor has opportunities of studying himbut found nothing. He did not appear to carefully human nature which are given to no-one else, wherefore be ill. I told him he could stay in his billet until the a philosopher ought to begin his life as a doctor, and a battalion came out of the trenches. But when we had doctor should end his life by becoming a philosopher. he blew his head off. This man was -not afraid to gone, I must begin by a search for physical evidence of wear but he had found he could not face war and was die, and tear ; and I have to admit at the outset that the uncertain what he might do, and had taken the matter stresses and strains of everyday life on individual organs into his own hands before he did something dreadful are difficult to assess, because we have only a vague that might bring disgrace on himself and on the regiment. knowledge of their functional reserves. Just where we I had a feeling that I had been responsible for this might expect the fret of life to leave its mark-on the fellow’s end, that he should have been sent down the circulation-we find little that is tangible. James line sick. I began to ask : what was happening in mens Mackenzie said that he had never seen a strained heart, minds ? How were they wearing ?‘ For four years I and Thomas Lewis affirmed that the circulatory organs tried to find answers to those questions, which are of were built to stand the strains which they themselves everlasting consequence in war. create. While Abrahams, working with a competent From the autumn of 1914 until the spring of 1917 I radiologist, found that the heart of the athlete appears was with the 1st Royal Fusiliers, a fine battalion of to be smaller, not bigger, than the average for his height a famous regiment, and I have recorded the results and build. of my long vigil in a short chapter of The Anatomy of The response of elastic tissue is another story. The Courage, that I called The Birth of Fear. In retrospect signs of wear and tear are obvious, for any distensible I am delighted by the poverty of my description of the organ when subject to prolonged strain loses its elasticity. signs of wear and tear in that battalion. During the The- lungs of a patient with chronic bronchitis become battle of the Somme there were no sick, none would ask emphysematous, the blood-vessels suffer in hypertension, for an easy ticket to the rear. But if little was found I the bladder in chronic urinary distension does not do not think much was missed. I was with one of the escape. companies during the Somme battle, went with the men If we include in a record of wear and tear changes in on raids, and lived with them. In short, what I have the suprarenal gland in response to alarm stimuli which said in their praise I saw with my own eyes. What was are transient and in the nature of physiological responses, found on the debit side ? it seems reasonable to refer to the effect of emotion in Once, I remember, a subaltern developed a facial tic. inhibiting the peristaltic movements and secretion of the Yet he did hisjob, and as the months went by without gastro-intestinal tract. Thirty years ago, when I was anything happening my doubts were gradually lulled to working in Bickel’s laboratory in Berlin, there was a dog rest. But after the Somme there seemed to be a change by my bench with a Pavlov stomach. It was eating in him. He began to get irritable at some little thing, some meat contentedly so that I could see the gastric sometimes even at nothing, and then one day he was juice flowing freely. Then the door opened and a cat found in an epileptic fit. And I remember another The dog leaped forward until restrained was brought in. young officer, a gay, carefree boy, but one night I shared by his chain ; the secretion of gastric juice ceased. a dugout with him and was roused from my sleep by his Since that time many observers have recorded the effect shouts and yells. I went to wake him from his dreams : of emotion on peristalsis and on secretion. For my then, with my hand on his shoulder I stopped. He would part, when I look back on those thirty turbulent years, not wish to share his secret with anyone. A week later and on the inhibitions I must have suffered, I find he was killed. myself asking, is there no scar left, no structural trace of The absence of obvious signs of wear and tear in this those agitated interruptionst But I must end my battalion during that time is in striking contrast to my search for objective evidence by reminding you that the experience in the autumn of 1917 when I was sent to onset of diabetes and of hyperthyroidism may be Boulogne to find out how the wastage from mustard associated with an emotional disturbance. gas could be checked. With James Mackintosh I THE MIND IN WAR published in the Quarterly Journal of ]ýfedicine an analysis of a consecutive series of 1500 mustard-gas casualties Even an untutored eye can detect the imprint of pain admitted to No. 7 Stationary Hospital between Jan. 1 and hard usage on a friend’s face, and yet my search for and Oct. 31, 1918. There was a mortality of 2% ; on physical signs of wear and tear has not been very the other hand, we found that 87% of the men could But when I turn from the and productive. away body half a mile to a convalescent march camp in their ask what is the effect of prolonged stress on the mind, I can quote a classical experiment which is pat to my equipment within a month of gassing. In them the organic lesions were negligible or absent, it was the mind purpose. The severity of the strain to which a battalion that had suffered hurt. was subjected in France in the first world war was, I Gas, after July 1917, partly usurped the r6le of high think, greater than anything the infantry experienced shell in bringing to a head a natural unfitness for explosive the last in of war. For the winter 1914 the men during war, or less frequently a fitness sapped by exceptional stress * Based on an address to the American College of Physicians of experience in the field. In many cases where the signs of on April 17. gassing. cleared up in a few days, we had to deal with a 6616 AA CONSULTING PHYSICIAN TO ST.
MARY’S HOSPITAL,
LONDON
responded
"
1100 condition of mild gas shock, comparable to the slighter shock which reach a Casualty Clearing Station after an action. This condition, with its accompanying functional nervous disorders, was an expression of trench cases of shell
fatigue." There
were
113,000 casualties from mustard gas, and,
if our investigations were a fair sample, nearly a quarter exhibited a functional nervous disorder which reacted promptly to suitable treatment. We found every kind of manifestation of hysteria, from hemiplegia to hysterical aphonia. (In our series there were 108 cases of hysterical aphon,ia.) What was the explanation of the disparity between the behaviour of these misfits in war and of the men of the Royal Fusiliers ? The men in that battalion were in a sense picked men. They had joined the Army in time of peace partly from a sense of adventure, rather than spend their lives in an office ; they were not securityminded. And they were fortified too by a regimental spirit, an esprit-de-corps, to which I testify in my little of the men book, which is their epitaph. The majority " were who left the front line in 1917 frankly gassed frightened. They were the military rubbish, which is found in every democracy. Incidentally, in the Royal Air Force in the last war it was found that in two-thirds of the pilots who broke down there was evidence of a flawwhich was inborn ; the way a man is made matters more than the risks he runs. "
THE NATURE
OF NERVOUS FATIGUE IN WAR
Watching for the signs of wear and tear through all those months, it was perhaps inevitable that one came to ask-could nothing be done to fortify these men to meet strain ; and what was the nature of this nervous fatigue and how was it caused‘ In the Royal Air Force the mental strain of flying, Symonds has said, is precisely in proportion to the danger. Where the danger was greatest, as in Bomber Command, there the number of pilots who broke down was also greatest. It is not however quite accurate to say that the strain is in proportion to the danger, for if a man’s threshold to fear is high, he may go through hazards with impunity ; while if he is easily frightened, he -may break down when the danger is of no consequence. The Greeks knew this, for Aristotle said that fear is the normal response to the instinct of self-preservation to danger and that it only becomes morbid when it is out of proportion to the degree of the danger. It would be more just to say that the fear of flying is a measure of the strain. Put differently, it is the long-drawn-out control of a persistent state of fear which ends in a pilot’s defeat. In the history of the English Army, the threshold of fear has been gradually falling. Five centuries ago Shakespeare said of our men at Agincourt, " If these -English had any apprehension they would run away." The strength of those yokel soldiers lay in their vacant minds ; they did not stop- to And then the measure their chances of survival. centuries passed, and, as these men became eivilised and more open to impressions, their threshold to fear fell, until Thomas Hardy wrote of the soldier of our time : " More life may trickle out of a man through thought than through a gaping wound." It is not true of course that all men with a high threshold of fear have vacant minds. I remember after the last war receiving an invitation to lecture to the Staff College of the Royal Air Force. I found about 140 pilots gathered in a hall, the pick of the survivors pf the war; every man seemed to possess the decorations which the discriminating value, and I recall a sense of incongruity that I, an elderly apothecary, should have to admonish these men on morale. I invited them to answer a questionnaire, to put on paper in the order of their importance the qualities which in their experience make a good pilot in war. Their assessment is, I believe, worth recording on account of their unique authority in this particular field. -
1. Calmness : in their jargon, the man who does not flap. 2. Determination : the man who does not give up easily. 3. Dependability : the pilot who can be relied on to do a ’
4. 5. 6. 7. 8. 9. 10. 11.
12. 13. 14. 15. 16.
thorough job. Discipline : willingness
to carry out orders.
Keenness.
the hallmark of the " ace " pilot. Confidence. Decisiveness : the ability to make up the mind quickly. Initiative : resource, the ability to cope with new conditions. Cooperation : working harmoniously with a crew. Influence : respect. Sense of humour : ability to laugh at oneself. Appearance and bearing. Smartness. Power of self-expression. A good mixer. Breadth of outlook. Wide interests.
Aggressiveness :
command represented there gave their votes personal attributes which bring success in air operations, while at the bottom of the list, huddled together, are the qualities which we have come ta associate with worldly advancement-further confirmation, if it were needed, that success in war and success in peace are not necessarily due to the same qualities. A sense of humour comes out poorly, though the Day Fighters supported it. The Night Fighter was the strongest advocate of the value of confidence. In brief these men were not security-minded, and their attitude to life seemed to raise their threshold to fear. While the threshold to fear has steadily fallen through the centuries, sapped by the spread of education and the stirring of the imagination, there has been what Wilfred Trotter would have called a biological drift to stiffen the citizen for the ordeal by battle. Trotter, in some of his most persuasive and eloquent pages, records a growing tendency to accept selfishness as a test of sin, and consideration for others as a test of virtue. He affirms that, throughout the incalculable ages of man’s existence as. a social animal, nature has been hinting to him in less. and less ambiguous terms that altruism must become the ultimate sanction of his moral code, the supreme moral law. The historian may decide that the democracies, confronted by the menace of the fanaticism of Germany and Japan, were saved by altruism, which Trotter defined as the capacity to make the interests of another individual one’s own. The physician is more concerned with finding a physical basis for those signs of wear and tear which I have described as the consequence of the secret battle between fear, or the instinct of selfpreservation, on the one hand, and control, or willpower, or courage, or whatever you like to call it, on the other.
Every
for the
WHAT HAPPENS IN THE BODY AS THE RESULT OF
THIS MENTAL CONFLICT
There is no sign of any lesion in the central nervous Is there any evidence connecting the suprarenal gland with this nervous fatigue ? Some careful workers in England have been doubtful whether there is any proof as yet of the involvement of the adrenal gland. They argue that the reports that fatigue and stress were accompanied by increased loss of ketosteroids in the urine were backed by figures which are not outside the range of possible error of the method of estimation. They say again that parallel experiments by the Royal Air Force, during and since the war, have failed to confirm these figures ; while to give a man Compound E does not help him to resist stress. But apart from Pincus’s highly suggestive work, if there is no direct proof, there is much circumstantial evidence supporting Selye’s hypothesis. It provides an explanation for things which have been inexplicable. I
system.
1101 as an illustration. Once I have attacked when been year, aggressively in debate, I have experienced a sharp pain in the small of my back lasting, perhaps, thirty seconds. I ascribed this pain to muscular spasm until one day I was having I was hot in pain and I was thinking a tooth stopped. of other things with my eyes closed when suddenly I What are you felt this familiar pain in my back. doing" I asked, opening my eyes. And the dentist answered that he was injecting adrenaline. Half an hour later, when I had forgotten the incident, I had the same pain again and found that he was again injecting
shall or
give
twice
a
personal experience
a
"
adrenaline. Since my- return from America, Dr. Peter Bishop has been -kind enough to send me an account of a similar personal experience. He writes : "
I had a curious experience two or three days ago in which I think you may be interested. I was driving home to Harpenden, where I live, and the roads were wet. Suddenly I ran into a skid which I controlled only within 100 yards, nearly having picked off a cyclist in the meantime. Once I was in control of the car again I sat back relaxed and relieved. I then began to realise that I was suffering from an acute pain which I eventually located bilaterally in the costophrenic angles. I suppose this must have been -due to congestion of my adrenals as the result of Selye’s alarm reaction, possibly induced, as you suggested, by release of adrenaline."
transient and ought to be regarded as physiological reactions rather than lesions.There is evidence of overactive autonomic response, and the disorder may be said to lie in the borderlandbetween normal and abnormal vegetative function. Selye has then made an interesting contribution to scientific thought, and his concept has given an experimental background to psychosomatic medicine. *
*
*
My final reflections are of a more general nature, underlining the danger of dogmatism in the field of science. I am thinking of a man of repute in the scientific hierarchy who scoffed contemptuously when told that a woman with rheumatoid arthritis had received miraculous relief from a visit to Lourdes. We can understand now how an intense psychological stimulus may have led to an increase of the adrenal steroids in the blood, so that within six hours this woman felt better and her joints became more mobile. Perhaps she was so elated by the improvement in her condition that she received another stimulus which continued the improvement, and she had probably left Lourdes before she relapsed. It was said of Frederick Taylor that at the end of his life he was, so conscious of the possibility of error that he never ventured to make a diagnosis. Certainly as we grow older we come to see that all knowledge is provisional. And on that note of caution I shall bring to an end these discursive remarks. For even if it is proved, as I believe it will be proved, that in man under stress there is a suprarenal reaction, it is doubtful whether this will lead to any helpful action in fortifying him to meet the strain. We may at the most be able to stiffen his resistance for a few hours, but he will have to pay for it later. Nor can man’s behaviour under stress be explained away by any endocrine response. A man with Addison’s disease living in adrenal poverty, will often behave with great courage, taking no thought of the fact that a slight infection might be fatal. The truth is we do not yet possess any physical explanation of man’s behaviour when under stress.
Again I need not remind those who are familiar with the behaviour of the eosinophils after alarm stimuli that the experienced physician who used to follow the course of pneumonia by taking daily blood-counts knew that the patient had turned the corner when the eosinophils reappeared in the blood. Incidentally I find that the description of the behaviour of soldiers under stress, which I described in 1914-35 years ago-bears an interesting resemblance to the language in which Selyedescribes his adaptation syndrome. I spoke of the exhaustion of will-power : he speaks of the exhaustion of nervous energy reserve. I said that in a battle " somehow the horror of this business of war was not felt. Nature has the stop on : we must be half doped-to come through it at all." Selye calls it" the mental stupor of the shock stage." INFLUENZA: A STUDY IN MICE * Again, we speak now of the euphoric condition after an alarm stimulus, which we ascribe to the increased S. FAZEKAS DE ST. GROTH output of adrenal steroids. Thirty-five years ago I M.D. Budapest, Sc.M. described a similar emotion when I heard my first shell. From the and Eliza Hall Institute of Medical Research, Walter It came into the room of a farmhouse, in front of Australia Melbourne, Armentieres, when we were lying in reserve, two hundred OVER the two research in our laboratory past years yards from the Germans, and it killed three men and has been focused on the factors wounded five others. When I had got the wounded governing susceptibility and resistance to experimental influenza. I try to away I ate heartily and I remember being filled with compunction that I could be so callous. On that day, give here a coherent picture of the pathogenesis and Dec. 20, 1914, I wrote in my diary-" And, in spite of immunogenesis of influenza emerging from these studies. The broader approach adopted involves inevitably the three dead men, I could not help feeling cheerful much repetition, since the recently developed and now that it was over. It was as if I had achieved improved techniques had to be applied to all the problems. something, though I had done nothing." As a result, many of our findings are not more than a Nor can I claim to be the first to paint a clinical picture restatement in quantitative terms of earlier observations. of the symptoms and signs that may follow alarums and However, they help in viewing the integrant processes excursions. Caesar said that he could make a man a in their true context, and provide a background coward by starving him for three days. That was a good many centuries before Selye found in rats that against which the novel facts and concepts can be fasting is particularly effective in increasing their assessed. Some justification is needed perhaps for our choice sensitivity to alarm stimuli. of experimental animal. Although influenza is not a We may then say that if the relationship of Selye’s adaptation syndrome to any disease occurring in man natural disease of the mouse, most human strains of has yet to be proved, he has demonstrated that delayed virus can be adapted without difficulty to this host. reactions to trauma may occur in the bodies of Experimental infection with such strains closely parallels animals, clearly showing that those reactions are related the human condition, the differences being quantitative to activity of the adrenal cortex. Though histological * Substance of a lecture in the series "Methods of Biological changes in the central nervous system and endocrine Research," given on Feb. 25, 1950, in the University of glands have never been demonstrated in man, it seems Melbourne. The work was aided by a grant from the probable that there is in him a corresponding pituitaryNational Health and Medical Research Council, Canberra, adrenal response to alarm stimuli. But the effects are Australia.
’
’
ORIGINAL ARTICLES WEAR AND
were
TEAR*
standing
in
waterlogged trenches, to reply,
Germans, without ammunition
1950
shelled by the’ while later the
long-drawn-out ordeal of trench warfare was punctuated by massacres, such as the battle of the Somme.
LORD MORAN M.C., M.D. Lond., F.R.C.P.
I became interested in the manner in which the men to this stress in the following manner. I was I HAVE chosen "Wear and Tear" as my title, because medical officer to the 1st Royal Fusiliers in France. I want to be at liberty to dip into the underworld of One in 1914, at Armentieres, when we were waiting medicine where aberrations of the mind are found. In to day to the trenches to relieve a battalion, word was go up England, medical students are sometimes poorly schooled brought to me that there was a sergeant in his billet in these matters, and I ain under the impression that who was not well. I asked him what was He physicians, broadly speaking, are obsessed with the said " nothing-he was all right." He waswrong. a morose scientific approach to medicine. We have forgotten the fellow and I could get nothing out of him. I examined Greek saying that a doctor has opportunities of studying himbut found nothing. He did not appear to carefully human nature which are given to no-one else, wherefore be ill. I told him he could stay in his billet until the a philosopher ought to begin his life as a doctor, and a battalion came out of the trenches. But when we had doctor should end his life by becoming a philosopher. he blew his head off. This man was -not afraid to gone, I must begin by a search for physical evidence of wear but he had found he could not face war and was die, and tear ; and I have to admit at the outset that the uncertain what he might do, and had taken the matter stresses and strains of everyday life on individual organs into his own hands before he did something dreadful are difficult to assess, because we have only a vague that might bring disgrace on himself and on the regiment. knowledge of their functional reserves. Just where we I had a feeling that I had been responsible for this might expect the fret of life to leave its mark-on the fellow’s end, that he should have been sent down the circulation-we find little that is tangible. James line sick. I began to ask : what was happening in mens Mackenzie said that he had never seen a strained heart, minds ? How were they wearing ?‘ For four years I and Thomas Lewis affirmed that the circulatory organs tried to find answers to those questions, which are of were built to stand the strains which they themselves everlasting consequence in war. create. While Abrahams, working with a competent From the autumn of 1914 until the spring of 1917 I radiologist, found that the heart of the athlete appears was with the 1st Royal Fusiliers, a fine battalion of to be smaller, not bigger, than the average for his height a famous regiment, and I have recorded the results and build. of my long vigil in a short chapter of The Anatomy of The response of elastic tissue is another story. The Courage, that I called The Birth of Fear. In retrospect signs of wear and tear are obvious, for any distensible I am delighted by the poverty of my description of the organ when subject to prolonged strain loses its elasticity. signs of wear and tear in that battalion. During the The- lungs of a patient with chronic bronchitis become battle of the Somme there were no sick, none would ask emphysematous, the blood-vessels suffer in hypertension, for an easy ticket to the rear. But if little was found I the bladder in chronic urinary distension does not do not think much was missed. I was with one of the escape. companies during the Somme battle, went with the men If we include in a record of wear and tear changes in on raids, and lived with them. In short, what I have the suprarenal gland in response to alarm stimuli which said in their praise I saw with my own eyes. What was are transient and in the nature of physiological responses, found on the debit side ? it seems reasonable to refer to the effect of emotion in Once, I remember, a subaltern developed a facial tic. inhibiting the peristaltic movements and secretion of the Yet he did hisjob, and as the months went by without gastro-intestinal tract. Thirty years ago, when I was anything happening my doubts were gradually lulled to working in Bickel’s laboratory in Berlin, there was a dog rest. But after the Somme there seemed to be a change by my bench with a Pavlov stomach. It was eating in him. He began to get irritable at some little thing, some meat contentedly so that I could see the gastric sometimes even at nothing, and then one day he was juice flowing freely. Then the door opened and a cat found in an epileptic fit. And I remember another The dog leaped forward until restrained was brought in. young officer, a gay, carefree boy, but one night I shared by his chain ; the secretion of gastric juice ceased. a dugout with him and was roused from my sleep by his Since that time many observers have recorded the effect shouts and yells. I went to wake him from his dreams : of emotion on peristalsis and on secretion. For my then, with my hand on his shoulder I stopped. He would part, when I look back on those thirty turbulent years, not wish to share his secret with anyone. A week later and on the inhibitions I must have suffered, I find he was killed. myself asking, is there no scar left, no structural trace of The absence of obvious signs of wear and tear in this those agitated interruptionst But I must end my battalion during that time is in striking contrast to my search for objective evidence by reminding you that the experience in the autumn of 1917 when I was sent to onset of diabetes and of hyperthyroidism may be Boulogne to find out how the wastage from mustard associated with an emotional disturbance. gas could be checked. With James Mackintosh I THE MIND IN WAR published in the Quarterly Journal of ]ýfedicine an analysis of a consecutive series of 1500 mustard-gas casualties Even an untutored eye can detect the imprint of pain admitted to No. 7 Stationary Hospital between Jan. 1 and hard usage on a friend’s face, and yet my search for and Oct. 31, 1918. There was a mortality of 2% ; on physical signs of wear and tear has not been very the other hand, we found that 87% of the men could But when I turn from the and productive. away body half a mile to a convalescent march camp in their ask what is the effect of prolonged stress on the mind, I can quote a classical experiment which is pat to my equipment within a month of gassing. In them the organic lesions were negligible or absent, it was the mind purpose. The severity of the strain to which a battalion that had suffered hurt. was subjected in France in the first world war was, I Gas, after July 1917, partly usurped the r6le of high think, greater than anything the infantry experienced shell in bringing to a head a natural unfitness for explosive the last in of war. For the winter 1914 the men during war, or less frequently a fitness sapped by exceptional stress * Based on an address to the American College of Physicians of experience in the field. In many cases where the signs of on April 17. gassing. cleared up in a few days, we had to deal with a 6616 AA CONSULTING PHYSICIAN TO ST.
MARY’S HOSPITAL,
LONDON
responded
"
1100 condition of mild gas shock, comparable to the slighter shock which reach a Casualty Clearing Station after an action. This condition, with its accompanying functional nervous disorders, was an expression of trench cases of shell
fatigue." There
were
113,000 casualties from mustard gas, and,
if our investigations were a fair sample, nearly a quarter exhibited a functional nervous disorder which reacted promptly to suitable treatment. We found every kind of manifestation of hysteria, from hemiplegia to hysterical aphonia. (In our series there were 108 cases of hysterical aphon,ia.) What was the explanation of the disparity between the behaviour of these misfits in war and of the men of the Royal Fusiliers ? The men in that battalion were in a sense picked men. They had joined the Army in time of peace partly from a sense of adventure, rather than spend their lives in an office ; they were not securityminded. And they were fortified too by a regimental spirit, an esprit-de-corps, to which I testify in my little of the men book, which is their epitaph. The majority " were who left the front line in 1917 frankly gassed frightened. They were the military rubbish, which is found in every democracy. Incidentally, in the Royal Air Force in the last war it was found that in two-thirds of the pilots who broke down there was evidence of a flawwhich was inborn ; the way a man is made matters more than the risks he runs. "
THE NATURE
OF NERVOUS FATIGUE IN WAR
Watching for the signs of wear and tear through all those months, it was perhaps inevitable that one came to ask-could nothing be done to fortify these men to meet strain ; and what was the nature of this nervous fatigue and how was it caused‘ In the Royal Air Force the mental strain of flying, Symonds has said, is precisely in proportion to the danger. Where the danger was greatest, as in Bomber Command, there the number of pilots who broke down was also greatest. It is not however quite accurate to say that the strain is in proportion to the danger, for if a man’s threshold to fear is high, he may go through hazards with impunity ; while if he is easily frightened, he -may break down when the danger is of no consequence. The Greeks knew this, for Aristotle said that fear is the normal response to the instinct of self-preservation to danger and that it only becomes morbid when it is out of proportion to the degree of the danger. It would be more just to say that the fear of flying is a measure of the strain. Put differently, it is the long-drawn-out control of a persistent state of fear which ends in a pilot’s defeat. In the history of the English Army, the threshold of fear has been gradually falling. Five centuries ago Shakespeare said of our men at Agincourt, " If these -English had any apprehension they would run away." The strength of those yokel soldiers lay in their vacant minds ; they did not stop- to And then the measure their chances of survival. centuries passed, and, as these men became eivilised and more open to impressions, their threshold to fear fell, until Thomas Hardy wrote of the soldier of our time : " More life may trickle out of a man through thought than through a gaping wound." It is not true of course that all men with a high threshold of fear have vacant minds. I remember after the last war receiving an invitation to lecture to the Staff College of the Royal Air Force. I found about 140 pilots gathered in a hall, the pick of the survivors pf the war; every man seemed to possess the decorations which the discriminating value, and I recall a sense of incongruity that I, an elderly apothecary, should have to admonish these men on morale. I invited them to answer a questionnaire, to put on paper in the order of their importance the qualities which in their experience make a good pilot in war. Their assessment is, I believe, worth recording on account of their unique authority in this particular field. -
1. Calmness : in their jargon, the man who does not flap. 2. Determination : the man who does not give up easily. 3. Dependability : the pilot who can be relied on to do a ’
4. 5. 6. 7. 8. 9. 10. 11.
12. 13. 14. 15. 16.
thorough job. Discipline : willingness
to carry out orders.
Keenness.
the hallmark of the " ace " pilot. Confidence. Decisiveness : the ability to make up the mind quickly. Initiative : resource, the ability to cope with new conditions. Cooperation : working harmoniously with a crew. Influence : respect. Sense of humour : ability to laugh at oneself. Appearance and bearing. Smartness. Power of self-expression. A good mixer. Breadth of outlook. Wide interests.
Aggressiveness :
command represented there gave their votes personal attributes which bring success in air operations, while at the bottom of the list, huddled together, are the qualities which we have come ta associate with worldly advancement-further confirmation, if it were needed, that success in war and success in peace are not necessarily due to the same qualities. A sense of humour comes out poorly, though the Day Fighters supported it. The Night Fighter was the strongest advocate of the value of confidence. In brief these men were not security-minded, and their attitude to life seemed to raise their threshold to fear. While the threshold to fear has steadily fallen through the centuries, sapped by the spread of education and the stirring of the imagination, there has been what Wilfred Trotter would have called a biological drift to stiffen the citizen for the ordeal by battle. Trotter, in some of his most persuasive and eloquent pages, records a growing tendency to accept selfishness as a test of sin, and consideration for others as a test of virtue. He affirms that, throughout the incalculable ages of man’s existence as. a social animal, nature has been hinting to him in less. and less ambiguous terms that altruism must become the ultimate sanction of his moral code, the supreme moral law. The historian may decide that the democracies, confronted by the menace of the fanaticism of Germany and Japan, were saved by altruism, which Trotter defined as the capacity to make the interests of another individual one’s own. The physician is more concerned with finding a physical basis for those signs of wear and tear which I have described as the consequence of the secret battle between fear, or the instinct of selfpreservation, on the one hand, and control, or willpower, or courage, or whatever you like to call it, on the other.
Every
for the
WHAT HAPPENS IN THE BODY AS THE RESULT OF
THIS MENTAL CONFLICT
There is no sign of any lesion in the central nervous Is there any evidence connecting the suprarenal gland with this nervous fatigue ? Some careful workers in England have been doubtful whether there is any proof as yet of the involvement of the adrenal gland. They argue that the reports that fatigue and stress were accompanied by increased loss of ketosteroids in the urine were backed by figures which are not outside the range of possible error of the method of estimation. They say again that parallel experiments by the Royal Air Force, during and since the war, have failed to confirm these figures ; while to give a man Compound E does not help him to resist stress. But apart from Pincus’s highly suggestive work, if there is no direct proof, there is much circumstantial evidence supporting Selye’s hypothesis. It provides an explanation for things which have been inexplicable. I
system.
1101 as an illustration. Once I have attacked when been year, aggressively in debate, I have experienced a sharp pain in the small of my back lasting, perhaps, thirty seconds. I ascribed this pain to muscular spasm until one day I was having I was hot in pain and I was thinking a tooth stopped. of other things with my eyes closed when suddenly I What are you felt this familiar pain in my back. doing" I asked, opening my eyes. And the dentist answered that he was injecting adrenaline. Half an hour later, when I had forgotten the incident, I had the same pain again and found that he was again injecting
shall or
give
twice
a
personal experience
a
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adrenaline. Since my- return from America, Dr. Peter Bishop has been -kind enough to send me an account of a similar personal experience. He writes : "
I had a curious experience two or three days ago in which I think you may be interested. I was driving home to Harpenden, where I live, and the roads were wet. Suddenly I ran into a skid which I controlled only within 100 yards, nearly having picked off a cyclist in the meantime. Once I was in control of the car again I sat back relaxed and relieved. I then began to realise that I was suffering from an acute pain which I eventually located bilaterally in the costophrenic angles. I suppose this must have been -due to congestion of my adrenals as the result of Selye’s alarm reaction, possibly induced, as you suggested, by release of adrenaline."
transient and ought to be regarded as physiological reactions rather than lesions.There is evidence of overactive autonomic response, and the disorder may be said to lie in the borderlandbetween normal and abnormal vegetative function. Selye has then made an interesting contribution to scientific thought, and his concept has given an experimental background to psychosomatic medicine. *
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My final reflections are of a more general nature, underlining the danger of dogmatism in the field of science. I am thinking of a man of repute in the scientific hierarchy who scoffed contemptuously when told that a woman with rheumatoid arthritis had received miraculous relief from a visit to Lourdes. We can understand now how an intense psychological stimulus may have led to an increase of the adrenal steroids in the blood, so that within six hours this woman felt better and her joints became more mobile. Perhaps she was so elated by the improvement in her condition that she received another stimulus which continued the improvement, and she had probably left Lourdes before she relapsed. It was said of Frederick Taylor that at the end of his life he was, so conscious of the possibility of error that he never ventured to make a diagnosis. Certainly as we grow older we come to see that all knowledge is provisional. And on that note of caution I shall bring to an end these discursive remarks. For even if it is proved, as I believe it will be proved, that in man under stress there is a suprarenal reaction, it is doubtful whether this will lead to any helpful action in fortifying him to meet the strain. We may at the most be able to stiffen his resistance for a few hours, but he will have to pay for it later. Nor can man’s behaviour under stress be explained away by any endocrine response. A man with Addison’s disease living in adrenal poverty, will often behave with great courage, taking no thought of the fact that a slight infection might be fatal. The truth is we do not yet possess any physical explanation of man’s behaviour when under stress.
Again I need not remind those who are familiar with the behaviour of the eosinophils after alarm stimuli that the experienced physician who used to follow the course of pneumonia by taking daily blood-counts knew that the patient had turned the corner when the eosinophils reappeared in the blood. Incidentally I find that the description of the behaviour of soldiers under stress, which I described in 1914-35 years ago-bears an interesting resemblance to the language in which Selyedescribes his adaptation syndrome. I spoke of the exhaustion of will-power : he speaks of the exhaustion of nervous energy reserve. I said that in a battle " somehow the horror of this business of war was not felt. Nature has the stop on : we must be half doped-to come through it at all." Selye calls it" the mental stupor of the shock stage." INFLUENZA: A STUDY IN MICE * Again, we speak now of the euphoric condition after an alarm stimulus, which we ascribe to the increased S. FAZEKAS DE ST. GROTH output of adrenal steroids. Thirty-five years ago I M.D. Budapest, Sc.M. described a similar emotion when I heard my first shell. From the and Eliza Hall Institute of Medical Research, Walter It came into the room of a farmhouse, in front of Australia Melbourne, Armentieres, when we were lying in reserve, two hundred OVER the two research in our laboratory past years yards from the Germans, and it killed three men and has been focused on the factors wounded five others. When I had got the wounded governing susceptibility and resistance to experimental influenza. I try to away I ate heartily and I remember being filled with compunction that I could be so callous. On that day, give here a coherent picture of the pathogenesis and Dec. 20, 1914, I wrote in my diary-" And, in spite of immunogenesis of influenza emerging from these studies. The broader approach adopted involves inevitably the three dead men, I could not help feeling cheerful much repetition, since the recently developed and now that it was over. It was as if I had achieved improved techniques had to be applied to all the problems. something, though I had done nothing." As a result, many of our findings are not more than a Nor can I claim to be the first to paint a clinical picture restatement in quantitative terms of earlier observations. of the symptoms and signs that may follow alarums and However, they help in viewing the integrant processes excursions. Caesar said that he could make a man a in their true context, and provide a background coward by starving him for three days. That was a good many centuries before Selye found in rats that against which the novel facts and concepts can be fasting is particularly effective in increasing their assessed. Some justification is needed perhaps for our choice sensitivity to alarm stimuli. of experimental animal. Although influenza is not a We may then say that if the relationship of Selye’s adaptation syndrome to any disease occurring in man natural disease of the mouse, most human strains of has yet to be proved, he has demonstrated that delayed virus can be adapted without difficulty to this host. reactions to trauma may occur in the bodies of Experimental infection with such strains closely parallels animals, clearly showing that those reactions are related the human condition, the differences being quantitative to activity of the adrenal cortex. Though histological * Substance of a lecture in the series "Methods of Biological changes in the central nervous system and endocrine Research," given on Feb. 25, 1950, in the University of glands have never been demonstrated in man, it seems Melbourne. The work was aided by a grant from the probable that there is in him a corresponding pituitaryNational Health and Medical Research Council, Canberra, adrenal response to alarm stimuli. But the effects are Australia.
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