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williams: the traumatic neurosis 


567 


action of pituitary extract on the intestine it is an interesting 
question to decide whether or not its administration is contra¬ 
indicated by the presence of diarrhea. I feel that it is not. While 
it has undoubtedly a stimulating action on the intestine, this will 
not unduly manifest itself in the face of an already existing motor 
excitation. Nor does its introduction into the system entail a 
further pouring of fluid into the intestine; quite the reverse should 
be the case, through the improvement of vascular and general 
tone. The exhibition then of pituitary extract, if it is indicated 
for circulatory reasons, is not contra-indicated by the presence of 
diarrhea. When a satisfactory bowel condition has been reestab¬ 
lished special care should be exercised in the nourishment of the 
patient and provision made for as free elimination as possible 
through the kidneys. 

It is not essential to the value of the action of pituitary extract 
whether it be considered as a true internal secretion or not. Suffice 
it to say that in the posterior lobe of the pituitary body an adren¬ 
alin-like principle is contained which, due to its special organic 
structure, produces and maintains rises in blood-pressure better 
than does adrenalin, and therefore is more reliable in conditions 
of circulatory collapse than is adrenalin. Also in addition to this 
action its selective action on involuntary muscle as a whole should 
not be overlooked, and more especially in the present connection 
its stimulating action on the intestinal musculature. 


THE TRAUMATIC NEUROSIS. 

By Dr. Tom A. Williams, M.B., C.M. (Edin.), 

CORRESPONDING MEMBER, SOCIETIES OF NEUROLOGY AND PSYCHOLOGY, PARIS, 
ETC.; NEUROLOGIST TO EPIPHANY DISPENSARY, WASHINGTON, D. C. 

Physiological Fundamentals. Traumatic neurosis is a com¬ 
plete misnomer; the condition is psychogenetic, therefore it is not 
neural; and the trauma is not physical. An injury in itself cannot 
cause a “neurosis,” meaning a psychosis. This condition occurs 
only when the patient broods over the injury and imagines that he 
is a very sick person. To represent to oneself feelingly a disease 
is to make oneself feel very sick, even although the disease one 
conceives may not itself be manifested with verisimilitude. The 
patient then, having the idea that he is sick, acts so and feels so; 
so that after a while he actually is sick. 

This is on account of the fact that the idea of pain is capable of 
arousing the concomitants of pain, namely, depression of vegeta¬ 
tive functions. This occurs because of the emotional reactions 



568 


williams: the traumatic neurosis 


inseparable from the concepts which experience has associated with 
them. The situation is merely that of the dog in which Pawlow, 
during his experiments, suppressed the flow of gastric juice by 
merely showing a Avhip. It is a “conditioning” of a reflex, and is 
feasible with any dog. 

This fact makes manifest how erroneous is the common opinion 
that the “conditioning” of affective reactions in a morbid fashion 
requires previous morbidity for its accomplishment. This is usually 
stated in the formula that traumatic neurosis occurs only in the 
predisposed. The real factor in its induction is the momentum of 
the conditioning stimulus. A homely illustration is that used by 
the penetrating dramatist Augustus Thomas, in The Harvest Moon, 
where he makes a hard-headed lawyer, against his will, the victim 
of the suggestion that he is dangerously ill. 

Of course it should be obvious that the patient, although a 
victim of imagination, may become really ill physically; just as 
it is obvious that Pawdow’s dog, a mere victim of imagination, is ill 
therewith to the extent of an incapacity to secrete gastric juice, 
which means very ill indeed. Indeed, psyehogenetic physical illness 
of this kind may reach such a degree as to cause death, as has been 
experimentally shown by Crile and others. 

Furthermore, if the reactions have gone too far the removal of 
the cause will not save the life of the animal. Short of death, 
secondary organic changes may occur, so that recovery will be 
incomplete. 

But even when the stimuli are insufficient to produce organic 
changes the cure of the subject demands more than a mere material 
removal of them, for the stimuli live in memory, where they have 
become associated with many elements of the environment; so 
that the cause is not really removed until a complete reconditioning 
is effected of all the associational reactions which have gathered 
around the initial dread-bringing circumstance. 

For instance a tachycardia produced by fear, if long continued, 
should not be less injurious to the heart and bloodvessels than is 
excessive athletics; an outpouring of an excess of substances from 
the adrenals should just as likely produce vessel sclerosis or exhaust 
the gland when it is the result of chronic anxiety as when it is due to 
a physiological stimulus of more direct kind; a dyspepsia or chronic 
constipation is just as likely to lead to malnutrition and toxemia 
when it is the result of mental depression as when it is due to sluggish 
habits or some disease. 

The mechanism by which the modification of reaction occurs is 
usually that of suggestion. The dog which secretes gastric juice 
when it hears a bell does so because of the suggestion that meat will 
be presented him forthwith. It does not know why a bell brings 
meat; it mistakes it for a reaction of cause and effect, like that of 
a wetting when it enters the water. The process is not one of 



WILLIAMS: THE TRAUMATIC NEUROSIS 509 

genuine reasoning. The person who is hypochondriacal after an 
accident has as little reason in calling accident cause and neurosis 
effect as has the dog in believing bell cause and meat effect. It is 
belief without proper ratiocination, received blindly, credulously, 
from someone else without criticism ; that is, by suggestion. This 
is, unfortunately, the commonest method by which opinions are 
acquired by human beings. Indeed the vast majority acquire their 
beliefs in no other way; and only a few scientists and still fewer 
superior minds have eliminated this manner of appraising the 
facts they encounter. It is small wonder then that the conditioning 
of reactions becomes morbid so easily, for we find morbidity all 
around. It is often dramatically impressive and frequently comes 
home to us by association with the deepest affections. Hysteria, 
then, which is merely the “effects of suggestions when these cause 
disease,” is necessarily very widespread, and the circumstances that 
give rise to it and the forms that it takes are proportional to their 
impressiveness, which means suggestive power, and in accordance, 
with fashion and the Zeitgeist of the country and time. 

The mechanism is always the same, and the victim is not aware of 
the systems of ideas and associated affects which constitute his 
psychosis. 

The Induction of Suggestion Psychoses. Tiie Emotional 
Consequences. Cases and Discussions. In the gross these are 
most clearly manifest in what our attitude of detachment easily 
enables us to label the superstitions of alien peoples. Thus the 
sufferings induced by the “gnawing fox” of the Japanese are made 
possible only by a deeply rooted belief in its existence. For example, 
a woman after labor declared she felt the “fox coming,” this was 
her interpretation of the after-pains she felt. The great parade by 
the neighbors in attempting to prevent the fox’s attack only rein¬ 
forced the patient’s apprehension, and soon a horrible convulsion 
signalized her seizure by the fox. Terror and convulsions held 
her until the exorciser was called. He declared that the fox would 
leave her at four o’ocloek the next day provided certain offerings were 
placed on a certain tomb for it to eat. This simple suggestion caused 
her to dismiss her terror suddenly at the hour designated. The 
crudeness of the mechanism in the case of this ignorant peasant need 
not make us smile, for our Western case is very little better, as the 
following illustration shows: 

It is the familiar case of an incapacitated railroad employee to 
whom we were called to determine whether or not there was organic 
disease of the nervous system. The fact that there was not is shown 
elsewhere in the full report of the case. The psychogenesis of the 
man’s condition was evident in his fixed idea, due to the common 
belief of railroad employees that serious nervous disease may slowly 
ensue upon an accident. This common belief was strengthened by 
the injudicious sympathy and inquiries of his friends and the 



570 


williams: the traumatic neurosis 


doubtful prognosis of some medical men he had consulted. He 
“answered a thousand questions a day,” he “did not know what 
to think about his health,” and worried about his condition and 
circumstances; he was “too much preoccupied with his health 
even to miss his wife;” he had lost weight and appetite, had a sore 
throat, and wept much; and finally his attitude was strengthened by 
lawyers who sought redress for him. He was cured within a month 
as a result of one interview, during which he was instructed in the 
role of ideas over bodily activity and the effects of worry and 
anxiety upon nutrition. In the certificate it was stated “there is 
and has been no disease of the spinal cord or peripheral nerves at 
play in the induction of any of the symptoms which I find. The 
erroneous belief that there has been such an injury powerfully 
contributes to the anxiety which maintains his present state.” 

The role of the idea of shock in perturbing this man’s emotional 
life is strictly comparable with that of the gnawing fox of the 
Japanese folklore. In both cases too there was the period of reflec¬ 
tion and incubation of the morbid notion, a familiar feature of 
such cases which has been insisted upon by Souques. It is rare 
that the symptoms ensue until after a time of meditation, during 
which the complex is systemitized. 

The cure was not so simple as that of the Japanese exorcist. 
But it was a definite one, for the railroad breakman was taught to 
understand the mechanism of his affection and thus to overcome 
any future harm from the credulity in which he had grown up . 1 The 
Japanese woman, on the other hand, remained liable to another 
attack, as her belief in the fox was only reinforced by the manner 
of its removal. 

A contrasting case where therapeutics failed will further push 
the lesson home. A government employee was injured by a falling 
case and remained barely able to walk even after his bruises of head 
and shoulder had healed. Called in consultation we explained the 
mechanism of his present incapacity and directed how to remove it. 
His family physician’s acquiescence to our directions was only 
formal, as his bent was not psychological enough to grasp the 
principles at work. The fearful solicitude of the man’s wife too 
constantly reinforced his timidity, so that in spite of a considerable 
temporary improvement he did not progress to full recovery, but 
remained lacrymose, depressed, and relatively incapable on account 
of the persistence of his false belief about his health and powers. 

Loss of “Nerve” after an Accident. Again, a railroad 
freight conductor was sent to me for care from North Carolina 
by the Southern Railway Company. He had fallen off a truck and 
had been much shaken and bruised. Unlike most persons in such 
case he did not complain of pain or paralysis, but merely stated, 


1 Five years later the man continues at work, well. 



WILLIAMS: THE TRAUMATIC NEUROSIS 


571 


what was truth, that he “could not sleep, and remained in a state 
of nervous agitation which would even cause him to cry at times 
and made life unbearable, from incapacity, weakness, and mental 
depression, so that he felt utterly unable to return to work, feeling 
that he could not perform it.” In his happy domesticity there were 
no extrinsic psychological factors except the mental habitus of 
hyperconscientiousness of ambitious type. There was an entire 
absence of roughness often seen in men of that occupation. In its 
essence the situation was that the man felt unable to, and did not 
want to, lead again the arduous life of a railroad man, for which he 
was in reality temperamentally unsuited. 

But even in this case adaptation to the unpleasant environment 
might have been accomplished had not the pernicious influence of the 
struggle for indemnification preponderated so as to interfere with 
psychological reconstruction. Instances of this kind are numerous. 
Isolated examples spring to the mind of every railroad surgeon; 
but an extensive comparison between cases equal in value to a 
deliberate experiment is best afforded by the observation of a train 
wreck in which 200 passengers were injured, about half of them 
severely. Only about 20 of these passengers developed traumatic 
neurosis. Some of these received heavy damages, upon which 
their health was immediately restored. In one case, however, a 
cure was effected by Dr. Bevan, the observer, without recourse to a 
lawsuit; but even this was done against the active protestations 
of the patient and only by extraordinary perseverance and deter¬ 
mination on the part of the physician, whose method of persuasion 
was so insistent as to make the patient weep. 

Compensation Not Curative. But it is not always that the 
indemnity effects the cure. There is a case w T elI known in Wash¬ 
ington where $17,000 was allowed by the court to a man in whom 
a street-car accident induced the belief that he was incapable of 
locomotion. This lasted for seven years, during which the patient 
went about in a wheel-chair administered by a solicitous wife. His 
wife’s belief that he could not walk was rudely disturbed after 
the plaster had fallen from the roof while they were asleep in 
bed one night, when she found her husband seated in the corner 
of the room twelve feet from the head of the bed. She argued 
that if he could walk while asleep at night he could walk while 
awake by day. This he did in trembling fear after insistent per¬ 
suasion by her, and eventually recovered in a few days. 

It would be idle to pretend that these were deliberate simulators 
for gain. They were honest pretenders, just so much as is any 
genuine hysterical the victim of a suggestion that he is incapaci¬ 
tated. These cases must be carefully differentiated from those who 
intentionally imitate symptoms in the hope of gain, even although 
the gain be merely the sympathy, attention, or notoriety from other 
people. The first type we call malingerers, the second mytho- 



572 williams: the traumatic neurosis 

maniacs, fantasticals, or pathological liars; neither of these types has 
immunity from the psychological reaction of suggestibility, which 
may eventuate in the genuine medical hysteria. 

The initiator of symptoms may, of course, be an actual accident 
or disease; and equally so it may be derived from the mere idea 
of injury or of disease, so that the clinical problem to be analyzed 
may be exceedingly complex. Besides this the patient may refuse 
access to his psychological ground work, perhaps merely on account 
of shyness or shame of thoughts concerning which he fears misun¬ 
derstanding or ridicule, and entirely apart from any question of 
venality. This phenomenon is found very commonly in psycho¬ 
analytic work, and it is the shame-faced reticences of patients which 
have led to the need of the use by some analysis of mechanistic 
expedients, such as the association-experiment (Jung), the dream 
unravelling, and the frec-flow association. 

These genuine psychoneurotics are entirely curable, quite apart 
from any question of indemnity in itself; but the struggle for 
indemnity cannot be given up without loss of self-respect in the 
implied confession of dishonesty or at least of the gross error of 
psychological interpretation concerning the role of the accident 
itself as the provoker of the illness; so that there is a preoccupying 
search by the patient for facts to ratify his belief that the accident 
had damaged him. This inevitably leads to imaginations, exag¬ 
gerations, and falsifications inevitable for a mind not scientifically 
trained. It is only when the patient has a glimmering of his mis¬ 
take that he begins in desperation to defend it by conscious self- 
deception in order to bolster up a psychosocial attitude the nega¬ 
tion of which would, he believes, be derogatory. 

The construction of this state of mind is thus described in my 
article before the 1913 International Congress of Medicine: 

“Especially prone to this damaging sequence are persons whose 
imagination has been made rampant by the cultivation of the 
credulous fears of childhood; their fear-reaction to that which they 
do not understand is a dominant one, arid they are easily beset by 
an idea linked with fear. The commonest of the fears which result 
from accident or injury is that of bodily harm. It is difficult for 
a person of this type, when ignorant of his own structure and func¬ 
tions, to shake off the foreboding created by an impressive catas¬ 
trophe; and it must not be forgotten that what others regard as 
trifling the victim may look upon as catastrophic, judged by its 
possible effect on him. Prepossession by the idea of one’s own 
disability is an inevitable consequence. This leads to abstraction 
from and inattention to the affairs of ordinary life, which, if not 
trifling by comparison in the patient’s mind at least cannot claim 
the attention properly needed. Hence ensues the well-known 
diminution of the capacity to think, work, or take part in social 
life. This incapacity', when the patient becomes aware of it, leads 



WILLIAMS: THE TRAUMATIC NEUROSIS 57o 

him to still further accentuate the result of his injury and thus to 
augment his alarm about his health. Thus is constituted the vicious 
circle of hypochondria. Even a nosophobia may ensue, such as 
the fear of lost manhood, insanity, paralysis. Alarm at this im¬ 
pending disaster must, of course, be distinguished from the primary 
alarm due to the accident itself.” 

Forensic Presentability. This mechanism is so simple that it 
can clearly be grasped by any intelligent person even without medical 
training; it has been very convincingly popularized by Mr. Addington 
Bruce in the Outlook of May 9, 1914. There should be no diffi¬ 
culty, then, in convincing a court of the nature of these cases and of 
their curability when properly dealt with, and this should lead to an 
equitable appraisement for damages for loss of time and distress of 
mind. That this is not at present the case we believe to be due to 
the want of knowledge of many expert witnesses concerning the whole 
subject of the psychoneuroses. The point of view here set forth is 
entirely foreign to a mind of which the habit has been to be content 
with the farrago of confusions which was all that the older text-books 
afforded concerning functional nervous affections. Besides this, 
the appraisement of the functional nervous affection is inextricably 
interwoven with the whole subject of neurological diagnosis. A 
physician who is not thoroughly conversant with modern neurology 
is sure to give the jury a false impression of the status of his case 
unless he strictly confines himself to concrete facts observed by 
himself and leaves their interpretation to the neurological expert 
who follows him. In the conduct of such cases counsel should en¬ 
tirely discard the antiquated and misleading accounts in text-books 
of medicine and neurology; the issue should be presented solely by 
concrete facts elicited from the patient himself as observed by 
medical men and others, and the interpretation of these aside from 
all technical concepts in the plane of simple good sense, which 
means good psychology. A striking instance of this error has just 
transpired in the District of Columbia, where a case carefully 
outlined on this basis was thrown into confusion by the intro¬ 
duction of a general practitioner who, without adequate knowledge, 
took it upon himself to instruct the jury concerning neurological 
and psychopathological interpretations of which his hazy knowl¬ 
edge was only second-hand. 

It was the case of a woman who after a trifling glass cut and 
a knock on the elbow gradually developed a complete flaccid 
paralysis of the right arm. The allegation of neuritis was easily 
disproved; the joints were not diseased; the spinal cord was 
intact, and the brain centre was not damaged. These were shown 
by complete mobility, absence of wasting, presence of the reflexes 
without exaggeration or spasticity. The psyehogenetic nature of 
the paralysis was very clear, and the patient’s own physician fully 
admitted this in the witness-box, and also that such paralyses often 
occurred without trauma of the body at all. Facts of this kind 



574 


wohl: granuloma fungoides 


are really not difficult to demonstrate to a jury if a properly trained 
psychopathologist is employed. 

This was demonstrated very clearly in the case of Hill v. Chicago, 
Milwaukee & St. Paul Railroad, at Redwing, Minnesota, December, 
1911. Here the psychogenetic nature of an affection which simu¬ 
lated lameness alleged to be due to sacrao-iliac and lumbar injury 
was so clearly shown the jury that instead of $15,000 damages 
demanded the allowance given was merely $1,500 for loss of time 
and stress of mind. This was a particularly “dangerous” case 
from the forensic aspect; but the railroad had become weary of 
paying indemnities for psychological accidents, and made this 
test case. The crucial point depended upon a demonstration by 
the neurologist that the attitude and movements of the patient did 
not conform to a syndrome which should have been present had 
the injury been where believed. This, along with the integrity 
of the reflexes and lack of wasting, convinced the jury that no 
lesion was present. 

In conclusion, let me emphasize the importance of the fact that 
functional nervous syndromes which occur after accidents differ 
in no way from those found in persons who have been subjected to 
no accident at all. The accident then was a red herring across the 
trail of the real cause of the psychoneurosis. These doctrines have 
already been elaborated by me with numerous illustrations. 

BIBLIOGRAPHY. 

Traumatic Neuroses and Babinski’s Conception of Hysteria, Transactions of 
Congress of Industrial Actions, Rome, and Medical Record, 1909. 

Successful Psychotherapy of Traumatic Neurosis, Amer. Jour. Surg., 1909. 

Idea and Affect in Traumatic Neurosis, Jour. Abnor. Psychol., 1910; also Char¬ 
lotte Med. Jour. 

Psychic Affect of Accidents, Transactions of* Southern Railway Surgeons, 1912, 
and Monthly Cyclopedia. 

Occupation Neuroses, International Congress on Hygiene, 1912; Medical Record, 
1.913; Transactions of International Congress of Medicine, 1913; Cleveland Med. 
Jour., 1914. 

Treatment of Hysteria, Jour. Amor. Med. Assoc., November, 1912. 

Hysteria and Pseudohysteria, Amer. Jour. Med. Sci., September, 1910. 

Mental Healing, British Med. Jour., vol. ii, 1913. 


GRANULOMA FUNGOIDES . 1 

By Michael G. Wohl, M.D., 

ASSOCIATE PROFESSOR OF PATHOLOGY AND BACTERIOLOGY, MEDICAL SCHOOL OF 
TEMPLE UNIVERSITY. 

(From the Pathological Laboratory of the Samaritan Hospital.) 

This condition, first described by Alibert in 1834, is a cutaneous 
disease which since then has been the object of investigation by mauy 
authors. Nevertheless, the origin of the disease still remains obscure. 


1 Presented before the Pathological Society of Philadelphia, April 9, 1914.