Traumatisms may play a part in the etiology of psychoses essentially of a constitutional nature, and they have been known to cause the development of general paralysis in syphilitic persons; it is believed also that they can precipitate an attack of delirium tremens in an alcoholic person. Such cases are not included here under the designation of traumatic psychoses, but only those in which the traumatism constitutes the essential, if not the sole, cause of the mental disorder.
As already stated in the chapter on Etiology, traumatic psychoses are comparatively rare in psychiatric practice: but 0.44% of all male first admissions and 0.06% of all female first admissions to the New York state hospitals during the year ending June 30, 1917, were cases of traumatic psychoses.
The immediate results of head injuries come more frequently under the observation of surgeons than psychia-trists.
The nature of the injury in cases of traumatic psychoses is variable: fractures with depression of fragments and destruction of brain tissue by direct violence; compression or brain tissue destruction resulting not directly from the injury but indirectly from an intra-cranial hemorrhage following it; severe concussion in cases with linear fracture without encroachments on the cranial cavity or even in cases without fracture; bullet wounds, etc. Complicating infections naturally bring with them febrile or infectious deliria the manifestations of which it is difficult, if not impossible, to separate from the symptoms directly attributable to the injury.
Many cases of head injury undoubtedly occur without any considerable injury to the brain, and this in part accounts for the rarity of marked and lasting mental complications; yet it is also true that fairly extensive injury to the brain may occur without giving rise to such complications. It would seem that mental symptoms are determined by the diffuse effects of concussion, compression, or bruising, rather than by any special localization of circumscribed lesions.
The first effect of a head injury is a dazed, stunned, or completely unconscious condition which comes on either immediately or, where due to an intra-cranial hemorrhage, after an interval following the injury. This lasts from a few minutes to several hours, after which consciousness may be fully regained or the patient may remain somnolent for several days and then recover. Cases of very severe injury often terminate in death without return of consciousness.
Delirium following head injuries is observed either immediately after the initial coma or stupor or after a brief interval of comparative lucidity. It is characterized by restlessness, which may be slight and readily controllable or may become aggressively violent, disorientation, disconnectedness of utterances, more or less relevant but peculiarly absurd and irrational responses, and tendency to fabrication; psycho-sensory disturbances may occur but do not seem to be as prominent as in other deliria.
The possible terminations are death, complete recovery, and recovery with mental or physical residuals. The duration of cases which survive usually extends over several weeks, and in some cases convalescence lasts for weeks or even months after the acute period of the illness. In the treatment the advisability of early surgical interference should always be considered; not only may an immediate amelioration be often produced by raising depressed parts of bone, removing intra-cranial blood extravasations, etc., but also some of the possible sequelae may be prevented. The danger of craniotomy is now so slight that its performance in doubtful cases would seem justifiable even merely for exploration.
The following case is quite typical:
Adrien D., mason, aged thirty-five, without abnormal family or personal antecedents, fell from a scaffolding about five meters high upon unpaved but dry and hard ground. He was picked up unconscious and taken to his home.
Externally was found only a small contused wound at the top of the head, without lesion of the bone, which healed in a few days.
After being in coma eighteen hours the patient gradually regained consciousness, but for eight days remained in a state of marked confusion. He is stupid, dull, completely disoriented as to place and time, and dreams a good deal, especially at night. He reacts to physical stimulation (pricking, pinching), but does so slowly and feebly. He does not respond to questions unless they are very simple. - He has become oriented as to place but is still completely disoriented as to time. His attention is difficult to gain and impossible to hold. Recollection of occurrences preceding the accident is labored and inaccurate. He has complete amnesia for the accident and what followed. Actual impressions are fixed in his mind for but a very short time: at the end of five minutes he forgot that he had been visited by the physician. He often brings his hand up to his head without saying anything, and when asked if it hurts him says, "Yes, a little." In the day time some illusions are noted, the patient mistaking persons for one another.
Sleep is scarce, and the greater part of the night is passed in a dream state, chiefly occupational: he thinks it is time to go to his work, asks for his clothes, gets up and looks for his tools, converses with imaginary persons, complains that the cords have not been properly placed, that the mortar is too thick, etc.
After the first week attention and memory improved a little. The patient retains some few impressions; yet the amnesia of fixation, though no longer complete, as in the preceding period, is still very marked. The disorientation of time persists. A most active and mobile tendency to confabulation has appeared. One month after the accident, when the patient had not yet left his bed, he told of having been eight days before at the fair in X., where his brother-in-law, a cattle dealer, had gone to sell some oxen. In response to leading questions he gives minute details, which vary from one moment to the next and become contradictory. When the contradictions are pointed out to him he admits readily that he may have been mistaken as his memory had failed him. The realization of his abnormal state is, however, but transitory and weak. When told that he is sick and must take care of himself he shows an irritability not previously noted, falls into violent anger, refuses medicine which is offered him, saying he has had enough and wants to go.
He has a vague idea that he has been in an accident, but, although it has been spoken of many times in his presence, cannot tell the exact circumstances of it. Until the sixth week he knew only that he had fallen, but from where, what height, how, he did not know: perhaps from a roof, or a ladder, or a scaffold - such things, he said, happened often in his trade. Sometimes, by way of confabulation, he becomes more specific. Thus about five weeks after the accident he told how he had fallen from a carriage while he and his master were on their way to see what work there was to be done. Another day he told that a heavy brick had fallen on his head. (In fact he had had a brick fall on his head about two years previously, but from a very low height and without causing any appreciable harm.)
He inquires from time to time if his insurance has been paid, but does not occupy himself effectually with the defence of his rights and does not seem to be interested in the progress of the negotiations concerning this matter.
Physically there is to be noted, aside from the headache mentioned above, only a general muscular weakness and some vertigo. No signs of any localized cerebral lesion. No convulsive manifestations.
The patient's condition remained almost stationary for about three months. After that, gradually, attention improved, memory was restored, the pseudo-reminiscences became more rare and were spontaneously corrected. Finally at the end of six months he could be considered convalescent, there remaining but occasional vertigo, a certain mental and physical fatigability, and an amnesic gap commencing very sharply a few instants before the accident and ending imperceptibly somewhere in the course of the second month by giving place to some fragmentary and vague recollections which grew gradually more complete and more precise.
This is the commonest of the above mentioned mental residuals which may persist after recovery from traumatic delirium; it is also frequently found in cases in which no delirium at all has developed after the initial coma or stupor. The condition has been well described by Koppen 1 as one of irritability, forgetfulness, diminished working capacity, inability to concentrate attention, and increased susceptibility to alcohol. "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 forgetfulness may be so marked that "frequently everything must be written down." "These patients are unable to concentrate their attention even in occupations which serve for mere entertainment, such as reading and 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." Physically there are apt to be pain or feeling of pressure in the head and a tendency toward dizziness. "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."
1Arch. f. Psychiatrie, Vol. XXXIII. Quoted by Adolf Meyer. The Anatomical Facts arid Clinical Varieties of Traumatic Insanity. Amer. Journ. of Insanity, Jan., 1904.
In many cases ordinary epilepsy is wrongly attributed to an obviously inadequate traumatism. However, the existence of true traumatic epilepsy is hardly to be questioned. The seizures may be slight, or partial, or Jacksonian, or without complete loss of consciousness, or, on the contrary, exactly like those of idiopathic epilepsy; the intervals at which they occur are variable; they may come on spontaneously or only following physical exertion, indulgence in alcohol, or febrile or gastro-intestinal ailments. The mental condition is apt to be much like the above described traumatic constitution with the addition of confused or delirioid states occurring in connection with seizures; in cases with frequent seizures there is apt to be a slowly progressive deterioration like that of idiopathic epilepsy.
This consists mainly in an exaggeration of the memory and attention defects, general incapacitation, and loss of interests characterizing the above described traumatic constitution.
Aphasia, deafness, paralysis, and other neurological symptoms, depending on the localization of the brain injury, may, of course, also be observed.