CHAPTER ITHE TRAUMATIC PSYCHOSES
Traumatic affections of the nervous system have been recognized in a general way for centuries, although the psychoses resulting directly from injuries have been given very little consideration or attention in the past. Concussion of the brain, referred to in the writings of Hippocrates, Galen and Celsus, was first studied postmortem in 1705 by Littré. It is now discussed in all textbooks on surgery. Usually milder forms are described with evidences of shock or collapse—a brief period of unconsciousness, partial or complete, with visual and auditory disturbances, dizziness, muscular relaxation or temporary paralysis, respiratory symptoms, dilated pupils, weakness of the pulse, lowered temperature, etc. Delirium and stupor or coma are associated with more severe injuries. If the cortex is lacerated, twitchings or convulsions often occur. Returning consciousness shows various reactions—headache, vomiting, amnesia, etc., and may be succeeded by convulsions, encephalitis or mental disturbances. DaCosta[147]says that some cases are followed by a complete change in the personality, forgetfulness, headache, insomnia, attacks of depression, lassitude and vertigo with increased susceptibility to alcohol, heat and physical exertion. Acute surgical injuries, and compression due to growths, hemorrhages, fractures, etc., have been exhaustively studied. Compression has been differentiated surgically[148]by the later appearance of a gradual unconsciousness, more definiteparalysis, usually on the side opposite the injury, slow pulse and stertorous respirations, unequal immobile pupils, choked disc, convulsive movements, etc. Traumatic encephalitis and meningitis have long been recognized but present no definitely characteristic symptoms which distinguish them from simple inflammatory reactions.
One of the earliest accurate descriptions of brain injury associated with mental symptoms was that of the well-known "crowbar" case. It will be recalled that while blasting in Vermont in 1848 a man by the name of Gage had an iron bar driven through the frontal region of his skull, making a complete recovery and living for over twelve years after the accident. An autopsy showed that only the prefrontal cortex was involved. A very interesting report on his mental condition was made by Dr. John M. Harlow:[149]"His contractors, who regarded him as the most efficient and capable foreman in their employ previous to his injury, considered the change in his mind so marked that they could not give him his place again. The equilibrium, or balance, so to speak, between his intellectual faculties and animal propensities seems to have been destroyed. He is fitful, irreverent, indulging at times in the grossest profanity (which was not previously his custom), manifesting but little deference for his fellows, impatient of restraint or advice when it conflicts with his desires, at times pertinaciously obstinate yet capricious and vacillating, devising many plans of future operations, which are no sooner arranged than they are abandoned in turn for others appearing more feasible. A child in his intellectual capacity and manifestations, he had the animal passions of a strong man. Previous to his injury, though untrained in theschools, he possessed a well balanced mind, and was looked upon by those who knew him as a shrewd, smart business man, very energetic and persistent in executing all his plans of operation. In this regard his mind was radically changed, so decidedly that his friends and acquaintances said he was 'no longer Gage.'"
Various other cases reported have established the fact that mental deterioration usually follows extensive injuries to the frontal lobes. Witmer[150]summarizes this as consisting of "slight intellectual degradation, moral and emotional perversion, deficiency of attention, and volitional inefficiency."
A work by Ericksen in 1866 on "Railway Injuries to the Nervous System" and Page's book in 1882 on "Injuries of the Spine" pointed the way to an extensive study of the so-called traumatic neuroses. This characterization of the functional disturbances of the nervous system following injuries was apparently the result of a monograph by Oppenheim on that subject in 1889. They had previously been considered as purely organic in origin. Traumatic hysteria was discussed very fully at various times by Charcot, whose work is so well known as to require no comment. In 1892 Friedmann described a vasomotor complex due to concussion. This is accompanied by such symptoms as headache, dizziness, loss of capacity for both physical and mental work with an increased fatigability, irritability, memory defects, and changes in personality, such as sensitiveness and eccentricity with a marked intolerance to alcohol. This condition appears some time after the symptoms of concussion and shock have subsided and may last for some months. Friedmann looked upon this as purely a vasomotor disturbance. It is probably an important factor, in somecases at least, of "shell shock". Traumatic epilepsy may result from foci of softening or other local areas of injury to the brain. Neurasthenia, hysteria and other neuroses are now generally looked upon as being essentially functional and not organic in origin, although they may follow a trauma. The simulation of these conditions has led to a great deal of discussion, notwithstanding the fact that Oppenheim found them in only about four per cent of his cases. Köppen (1897) made a very elaborate study of the postmortem lesions in the "traumatic neuroses". He found that violence to the skull often resulted in small injuries at the base of the frontal area, at the apices of the parietal lobes or in the occipital region. The pathological changes involved represented localized encephalitis with hemorrhagic infiltration. Foci of softening were often found in the cerebral cortex. He noted coma and convulsions with only minute areas of destruction of the basal cortex at autopsy. This would indicate a severe irritation, probably due to circulatory disturbances. The resulting symptoms he thought were very likely to be confused with general paresis. In cases of extreme dementia following traumatism he often found no pathological lesion other than a cicatrix in the cerebral cortex.
One of the most important contributions to the literature of traumatism as associated with psychoses was made by Adolf Meyer[151]in 1903. Notwithstanding the statements of such observers as Savage, appearing as late as 1905, he expressed the opinion that traumatism and general paresis are not directly related except that injuries may rarely act as precipitating factors. He does not expect to find psychoses resulting from small lacerations or other similar lesions in the cortex. As aresult of his observations Meyer[152]described the following forms of traumatic disorders:—
1. The direct post-traumatic deliria with the following subdivisions:
a. Preeminently febrile reactions;
b. The delirium nervosum of Dupuytren, not differing from deliria after operations, injuries, etc.;
c. The delirium of slow evolution of coma, with or without alcoholic basis;
d. Forms of protracted deliria, usually with numerous tabulations, etc. (with or without alcoholic or senile basis).
2. The post-traumatic constitution:
a. Types with mere facilitation of reaction to alcohol, grippe, etc.;
b. Types with vasomotor neurosis;
c. Types with explosive diathesis;
d. Types with hysteroid or epileptoid episodes, with or without convulsions (such as most reflex psychoses);
e. Types of paranoic development.
3. The traumatic defect conditions:
a. Primary defects allied to aphasia;
b. Secondary deterioration in connection with epilepsy;
c. Terminal deterioration due to progressive alterations of the primarily injured parts, with or without arteriosclerosis.
4. Psychoses in which trauma is merely a contributing factor:
a. General paralysis, with or without traumatic stigmata;
b. Manic-depressive and other transitory psychoses, catatonic deterioration and paranoic conditions, with or without traumatic stigmata.
5. Traumatic psychoses from injury not directly affecting the head.
The most interesting feature perhaps of this classification is the post-traumatic constitution. Meyer[153]quotes Köppen's excellent description of this condition as follows:—"Men who have suffered from a cranial lesion in which there has been a severe damage of the brain, with or without an injury to the cranial bones, on their recovery from the immediate results complain especially of all kinds of sensations in the head, which they describe either as pain or as pressure with feeling of crawling or dullness of the head, more or less definitely located at the point where they were hit. They frequently become dizzy, and at times even faint for a short time without any epileptic attack. Although slight attacks of dizziness may recur frequently, epilepsy with typical attacks need not develop. There is further in our patients a great irritability and nervosity. The formerly good-natured or even-tempered persons become irascible, hard to get along with; formerly conscientious fathers cease to care for their family. The irritability at times increases to excessive violence in which actions occur of which they have no remembrance; the nervous system is not only under the influence of psychic irritation but especially susceptibleto the influence of alcohol or tobacco, in even small quantities. The working capacity of our patients is very poor. It suffers variously, although such individuals often give an impression of perfect capacity; and since the morbid symptoms are essentially subjective, they always arouse doubts whether they could not do something at least, even if they are unable to work in a noisy shop or on a high scaffolding. It is, however, certain that the patients are very forgetful; in giving orders or doing errands they make the most incredible blunders; frequently everything must be written down. Their capacity for thought has suffered, as is sometimes shown, especially in the great slowness of thought. These patients are unable to concentrate their attention, not even in occupations which serve for mere entertainment, such as reading or playing cards. They like best to brood unoccupied; even conversation is rather obnoxious. This point is so characteristic that it gives a certain means of distinction from simulation, which as a rule does not interfere with taking part in the conversations and pleasures of the ward and playing at cards, which means as a rule too much of an effort for the brain of actual sufferers. The patients are usually advised to take light physical work, but even there they are perfectly useless. Excessive sensitiveness of their head obliges them to avoid all work which is connected with sudden jerks, bending over is especially troublesome; and there is hardly any physical work in which this can be avoided; the blood rushes to the head, headache increases, dizziness sets in and the work stops. Patients feel best when in the open air, inactive and undisturbed. There are but few objective signs, such as increase of pulse, flushing of the face, dermatographia, trembling and uncertainty in the Romberg position, such as is shown in all general nervosity. But the complaints are so exceedingly uniform that the uniformity of the subjective complaints justifies the conclusionthat they are well founded. The picture thus is briefly that of a mental weakness shown by easy fatigue, slowness of thought, inability to keep impressions, irritability, and a great number of unpleasant sensations, before all headaches and dizziness."
It is exceedingly interesting to note that Schläger in discussing disorders resulting from concussion of the brain, in 1857, as quoted by Griesinger,[154]makes the following comment on these cases:—"Very often the character and disposition changes; in 20 cases great irascibility, an angry, passionate manner even to the most violent outbursts of temper was remarked—less frequently over-estimation of self, prodigality, restlessness, disquietude; in 14 cases there were attempts at suicide, frequently weakness of memory, confusion." Meyer found, furthermore, in his analysis "all the possible degrees of episodes of more or less dazing and dream states; from a temporary dazed feeling to episodes of hysteriform or epileptoid absences. Apart from the subjective feeling of haziness, the characteristic trait is the occurrence of complete dream interpretations and peculiar fabrications, which color the primary traumatic insanity as well as the subacute and episodic types, and even the paranoic type."
Kraepelin[155]describes concussion and compression, traumatic delirium, traumatic epilepsy and traumatic mental enfeeblement. He finds these conditions due to concussion, compression or injury to the brain substance either at the site of traumatism or at some point opposite. There may be contusions, lacerations of the brain tissue or hemorrhages, usually in the frontal, occipital or parietal regions. Injuries to the cortex are not demonstrable in all cases. The circulatory disturbances he considersan important factor and thinks that they account for smaller lesions of the cerebral tissue in many instances where no gross changes are apparent. More or less disturbance of consciousness is to be expected in these conditions. The patient is somewhat dull, drowsy, clumsy, forgetful and absentminded. Memory is sometimes much affected. In more severe cases there is a complete loss of consciousness which may last a few minutes only or be a matter of hours or days. On waking, the patient is bewildered and confused, with a marked disturbance of apprehension. Perception is involved as in the recognition of complicated pictures or the understanding of long and detailed statements. A clear comprehension of events and surroundings is lacking. The patients may know that they are in a hospital without knowing what hospital it is or why they are there and are unable to recognize persons around them. Occasionally hallucinations of sight or of hearing occur. At times delusional ideas are expressed, usually of a depressive type. They have no realization whatever of their own condition. The memory disturbance may take the form of a Korsakow's complex. Memory gaps appear sometimes for events just before the accident and in other cases cover long periods of time. While as a rule events of the remote past are retained, recent impressions are quickly lost. They cannot repeat what is read to them, do not remember the names of persons about them, and sometimes show evidence of falsification of memory with fabrication. All idea as to time is usually lost. Mental reactions become noticeably difficult. The patient is distractible, cannot count accurately, has difficulty in repeating dates and numbers and forms no correct judgment as to his own personal affairs. Many express themselves, however, on the other hand, with great facility and readiness. Some show considerable fatigability. The mood is often elated with a tendency to facetiousness, although frequentlytearful and anxious, particularly at night. Irritable, faultfinding trends usually appear later. As a rule they are talkative, restless, sensitive, abusive or even insolent. Bonhöffer has reported stereotypies as well as stuporous and other catatonic types. In speech the patients often become incoherent, make mistakes, forget words or coin new ones. Similar mistakes appear in reading and writing. Asymbolism and parapraxia are observed. Residual symptoms of the brain injury are headaches, dizziness, fainting attacks and convulsions. The pupils are contracted and do not react properly to light. The pulse is frequently very slow.
In fractures at the base of the brain there is likely to be a hemorrhage from the ears and deafness from injuries to the labyrinth. Involvement of the pyramidal tracts may cause unilateral weakness or even paralysis, with increased knee-jerks and occasionally a Babinski reflex. Usually the mental symptoms appear promptly after the injury. Sometimes, however, there is for a while only a slight dulness. The patients are unable to go about the house unassisted, and act peculiarly, becoming clouded or delirious after a few hours or days. Improvement begins to show itself in a few weeks as a rule unless some intercurrent affection intervenes, but the symptoms may persist for several months. Meningitis or abscess formation often causes death. These developments are usually indicated by a marked delirium or coma. There may also be paralysis, convulsions, disturbances of speech, rise of temperature, etc. The subsidence of active delirious symptoms is sometimes succeeded by Kraepelin's traumatic neurosis. Following the traumatic delirium or concussion psychosis described, mental enfeeblement sometimes appears. Clouding of consciousness is not a factor in this condition. There is usually a complete change in the psychic personality. The patients tire easily, are incapable of sustained mentalefforts, forgetful, absentminded, complain of dizziness, dulness, noises in the ears, pressure in the head, migraine, palpitation, etc. Or they may be irritable, with outbursts of anger often alternating with apathy. Some are depressed, anxious or hypochondriacal. There is a greatly increased susceptibility to alcohol and intoxication often induces excitements, epileptiform attacks, stupors or rarely actual dreamstates.
Wildermuth found a history of traumatism in 3.8 per cent of his cases of epilepsy. The statistics of the German Army show 4.2 per cent. When the convulsive manifestations are in the foreground and the picture is one of traumatic epilepsy, advanced mental deterioration may be exhibited, with impairment of mental capacity and disturbance of memory. These cases remain apathetic, forgetful, dull, irritable and childish. At autopsy there are often no evidences of any great injury to the brain. Occasionally extensive areas of softening may, however, be found. Usually there is a widespread destruction of the nerve cells and their associated fibres. There is often a proliferation of the glia, with changes in the vessel walls which may be thickened and dilated, with capillary hemorrhages and softenings. Extensive areas of the cortex may be involved. Bleuler's description of the traumatic psychoses is not essentially different from that of Kraepelin.
The differentiation of these conditions as suggested in the statistical manual of the American Psychiatric Association is as follows:—
"The diagnosis should be restricted to mental disorders arising as a direct or obvious consequence of a brain (or head) injury producing psychotic symptoms of a fairly characteristic kind. The amount of damage to the brain may vary from an extensive destruction of tissue to simple concussion or physical shock with or without fracture of the skull.
"Manic-depressive psychoses, general paralysis, dementia praecox, and other mental disorders in which trauma may act as a contributory or precipitating cause, should not be included in this group.
"The following are the most common clinical types of traumatic psychosis and should be specified in the statistical record of the hospital:—
"(a) Traumatic delirium: This may take the form of an acute delirium (concussion delirium), or a more protracted delirium resembling the Korsakow mental complex.
"(b) Traumatic constitution: Characterized by a gradual post-traumatic change in disposition with vasomotor instability, headaches, fatigability, irritability or explosive emotional reactions; usually hyper-sensitiveness to alcohol, and in some cases development of paranoid, hysteroid, or epileptoid symptoms.
"(c) Post-traumatic mental enfeeblement (dementia): Varying degrees of mental reduction with or without aphasic symptoms, epileptiform attacks or development of a cerebral arteriosclerosis.
"(d) Other types."
We have not as yet, unfortunately, sufficient data at our disposal to warrant intelligent conclusions as to the frequency of the various forms of traumatic psychoses. One hundred and twenty-seven cases reported from the New York state hospitals during a period of six years were classified as follows:—
Undoubtedly with a more definite understanding as to the delimitation of these different conditions more complete information will be available later. We are nevertheless justified in feeling that the frequency of the traumaticpsychoses considered as a group can be determined with a fair degree of accuracy. Of 49,640 first admissions to the New York hospitals during a period of eight years, 161, or .32 per cent, were definitely ascribed to traumatism. Twenty-one other hospitals in fourteen different states reported forty-five cases of traumatic psychoses (.24 per cent) in 18,336 admissions. Two hundred and seventeen cases (.3 per cent) have therefore been reported in a total of 70,987 first admissions to forty-eight state hospitals for mental diseases in this country.