CHAPTER I

THE 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 definite paralysis, 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 the schools, 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 some cases 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 a result 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.;