Bruns did not find psychoses associated very often with frontal lesions. Jacobi, however, in reviewing the literature of growths in that region, found mental symptoms in forty-nine per cent. Schuster observed them in from fifty to sixty per cent of all brain tumors. Redlich[194] described mental conditions as being either incidental and not related to the growth, or definitely caused by it, and was even of the opinion that the neoplasm could in some instances be the result of a psychosis. Two of Redlich's patients, moderately alcoholic, showed a typical Korsakow syndrome. He refers to the fact that in cases reported by Oppenheim, Friedrich and Fürstner, "Witzelsucht," or the tendency to joke, disappeared after growths were removed from the frontal region. A patient of Begerthal, who had hallucinations, delusions and somatic symptoms, recovered after a tubercle was excised from the paracentral lobule. A case of Friedrich's which showed an alteration of the personality, erotic symptoms, sudden explosive laughter, poor memory, etc., recovered after a sarcoma was removed from the right frontal lobe. A patient of Thoma's after three attacks of mental depression showed a gliosarcoma in the occipital lobe at autopsy. Schuster, Bruns and Schönthal have reported cases of brain tumor with hysterical manifestations.
Redlich described the psychoses associated with cerebral growths as being epileptiform in character and origin and resembling post-epileptic psychoses in their symptomatology, with irritability, excitement or violence, confusion, delirium and hallucinations, often followed by partial amnesia. Epileptic manifestations may occur in the form of equivalents during the development of the growth. Bernhardt and Oppenheim have called attention to episodes of vertigo, irritability, excitement, clouding and occasional delirium with amnesia following intense paroxysms of headache. These attacks also strongly suggest the characteristics of epileptic psychoses. Nothnagel, Bernhardt, Oppenheim, Schuster, Ziehen and others attribute the mental symptoms associated with brain tumor to increased intracranial pressure producing an anaemia. Klippel, Maillard, Vigouroux, Kaplan and others believe that they are due to toxins originating in the growth. This view is based largely on the appearance of psychoses similar to the Korsakow syndrome. Knapp in 1906 called attention to the prominence of mental symptoms in growths occurring in the anterior portion of the corpus callosum. These may be associated with intellectual defects, apraxia, speech disturbances and stupor. Gianelli found mental disturbances in 209 of 318 cases examined.
Kraepelin[195] attributes the mental symptoms of growths to an injury of the brain structure, changes in intracranial pressure, circulatory disturbances, and the absorption of toxic substances. A growth of considerable size but of slow development may permit of a readjustment of pressure, etc., and show few symptoms. On the other hand, a small neoplasm on account of its site or rapidity of growth may be accompanied by profound mental disturbances resulting from chemical irritation, obstruction of the aqueduct of Sylvius, or circulatory interferences. Kraepelin quotes Schuster (1902) as finding psychotic symptoms in all cases of growths in the corpus callosum, in two-thirds of those of the hypophysis, in one-third of those of the cerebellum and in one-fourth of the cases with involvement of the brain stem. These he looks upon as pressure symptoms except in the case of the callosal neoplasms. Schuster was of the opinion that growths in the cortex usually lead to actual psychoses and those in the deeper areas to dementia. He found a general mental deterioration in 423 out of a total of 775 cases of brain tumor. The patients were indolent, inattentive, clumsy, forgetful, dull, tired easily and lost more and more their capacity and inclination for sustained exertion. Thought, decision and mental processes generally, required an unusual amount of effort. The patients usually became somewhat confused and disoriented in regard to time, place and person, as well as incoherent in speech. In many cases there is a marked memory disturbance with a tendency to fabrication suggesting Korsakow's psychosis. Delirious states with hallucinations sometimes accompany growths in the posterior lobes. Kraepelin has also observed hallucinations in cases with tumor of the cerebellum. Many develop hypochondriacal ideas, others have delusions of persecution or self-accusation and suicidal tendencies. Rarely there are delusions of grandeur. The mood is usually anxious, depressed and at times irritable or apathetic. Occasionally the patients may, on the other hand, be cheerful in spite of the hopeless condition they are in. They may even show distractibility, flight of ideas, volubility and excitement. There is more often a childish elation with a tendency to joking and facetiousness. Schuster found this more common in frontal involvements. Kraepelin also called attention to restlessness and excitements often leading to violence. This may alternate with mental dulness and cataleptic states. The patients may repeat words and make meaningless response to questions, strongly suggesting katatonia. Mental dulness becomes more and more marked, however, even reaching a stuporous stage. To this is added, according to the location of the growth, focal symptoms of various kinds—headache, disturbance of vision, seizures, paralyses, aphasia, agraphia, articulatory disturbance, ataxia, etc. Special symptoms arise where psychogenic factors play a part,—excitements with paralyses or disturbance of perception, etc. Hysterical stigmata may appear. Cases with growths in the frontal region occasionally simulate general paresis but should be distinguished without difficulty.
The Association's statistical manual has the following to say of psychoses with brain tumor:—
"A large majority of brain tumor cases show definite mental symptoms. Most frequent are mental dullness, somnolence, hebetude, slowness in thinking, memory failure, irritability and depression, although a tendency to facetiousness is sometimes observed. Episodes of confusion with hallucinations are common; some cases express suspicions and paranoid ideas.
"The diagnosis must rest in most cases on the neurological symptoms, and these will depend on the location, size and rate of growth of the tumor. Certain general physical symptoms due to an increased intracranial pressure are present in most cases, viz.: headache, dizziness, vomiting, slowing of the pulse, choked disc and interlacing of the color fields."
The number of cases reaching hospitals for mental diseases is, of course, small. In 49,640 first admissions to the New York state hospitals in eight years there were sixty-seven cases (.14 per cent) of psychoses with brain tumor. In 18,336 admissions to twenty-one hospitals in fourteen other states there were eighteen cases (.09 per cent) diagnosed as psychoses with brain tumor. There were ninety-three cases (.13 per cent) in 70,987 first admissions to forty-eight hospitals for mental diseases in sixteen different states.
Psychoses with Other Brain or Nervous Diseases
Cerebral hemorrhages, thrombosis and embolism are more or less intimately associated etiologically, pathologically and clinically. They all bear a rather definite relation to the general question of arteriosclerosis and may all lead to cerebral softening. Apoplexy is a term which was employed by Aristophanes, Demosthenes and Sophocles and has been in general use for centuries. It was known to Chaucer and was referred to in Shakespeare's works ("Henry IV"). It was studied very elaborately by Sydenham and many other early writers. Charcot and Bouchard in 1864 called attention to the relation existing between miliary aneurysms of the cerebral vessels and hemorrhages. In a study of the cerebral vascular lesions at the University College Hospital, London, Jones (Brain, 1905) found records of one hundred and sixty cases occurring during a period of sixty-five years. Of these, 123 showed hemorrhages; twenty-four, thrombosis; and thirteen were due to embolism.