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 susceptible to 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 conclusion that 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 considers an 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 frequently tearful 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 mental efforts, 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.