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It has, however, also been customary to include among traumatic psychoses the many cases in which mental disorders have broken out after a traumatism which is in itself but slight, perhaps insignificant, but which is accompanied by an intense emotional shock. This is but an abuse of language. The effectual cause here is the emotional shock. The physical trauma is nothing, the psychic trauma—to use an expression which is more than a mere figure of rhetoric—is everything. This is true to the extent that mental disorders observed in cases of this sort are identical in nature, in severity, and in their course with those known to be produced by a violent emotion acting alone, i. e., independently of any somatic injury. The term "traumatic psychoses ” in application to these cases is, therefore, inappropriate and should be replaced by the term “ emotional psychoses.

Thus one is led to distinguish: a. traumatic psychoses proper, resulting either from a localized cerebral lesion or from a general concussion of the brain; b. emotional psychoses, due to emotional shock with or without a traumatism which is more or less slight and not necessarily involving the brain; to which should be added c. the cases of war psychoses or so-called shell shock, which, as we shall see, are nothing but emotional psychoses.

A. TRAUMATIC PSYCHOSES PROPER. I shall speak but briefly of the psychic manifestations which supervene when an injury results in a localized cerebral lesion.

In one group of cases the cerebral lesion is conditioned by a lesion of the skull-either a compound or a simple fracture. The mental disorders generally consist in psychic paralysis, often beginning with a comatose phase and amounting, in degree, from mere mental dullness to complete stupor or an agitated and delusional state of confusion, depending upon whether or not the psychic paralysis is complicated with exaggeration of mental automatism.

To the mental symptoms are added eventually symptoms of destruction or irritation of the part of the brain affected: paralyses, contractures, focal epilepsy, disorders of speech, etc.

The prognosis quoad vitam depends upon the region injured, the extent of the lesion, and ultimate complications.

The prognosis quoad mentem depends to a certain extent upon the same factors. A very extensive lesion is almost bound to be followed by a definite mental deficit, more or less pronounced. Nevertheless the relation between the magnitude of the cerebral lesion and the gravity of the mental disorders which are its permanent consequence is far from being absolute. Certain destructive and very extensive lesions, notably of the frontal lobes, are particularly well borne from the psychic as well as the physical standpoint. The present war has furnished numerous instances in point. One of the most celebrated is that of Guépin. I have had under my own care a wounded man who had had the greater part of his frontal lobes destroyed by a shell fragment, the case note from the hospital in which he was first treated estimating the loss of cerebral substance at 200 grams. About four months after the injury he showed but slight mental enfeeblement, consisting mainly in weakness of attention and memory, certainly much less marked than one would expect in view of the amount of damage.

In a second group of cases the traumatism likewise produces a localized brain lesion, but the latter is wholly internal without involvement of the skull or integument. The lesion may be a rupture of a blood vessel resulting in hemorrhage. The characteristic symptoms, which generally do not appear until several hours, very exceptionally several days, after the injury—the time in which the effusion of blood takes place--are those of rapidly developing cerebral compression: intense headache, vomiting, slowing of the pulse, confusion, automatic agitation, delirium, finally signs of paralysis ending in death.

The traumatism may also be the starting point of a pathological process of slow development, generally, in such a case, a cerebral neoplasm. The physical and mental symptoms are at first slight or absent, grave symptoms appearing after several weeks or even months. The symptomatology and course are those of brain tumor.

We may dwell at greater length on traumatic psychoses due to concussion of the brain, either by direct violence such as a blow on the head, or by indirect violence such as landing, from a fall, on the feet or on the buttocks.

Reported to the Academy of Sciences on March 22, 1915.

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I shall submit first a clinical example: ADRIEN D., mason, aged 35, 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 18 hours the patient gradually regained consciousness, but for eight days he remained in a state of very 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 has 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 defense 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 case represents a type of traumatic psychoses. In it are found combined the etiological and symptomatological features of the psychopathic states resulting from severe cerebral concussion by violent traumatism: a close chronological relation between the injury and the onset of the symptoms, the latter directly following the former ; period of coma, period of marked confusion with dreams, passing by insensible transition into a semi-confused period characterized mainly by weakness of attention, amnesia of fixation, and confabulations; gradual and slow amelioration of the symptoms of the last period and progress toward recovery, the patient retaining only a definite gap of amnesia for the accident itself, the comatose period, and a part of the period of confusion, and an abnormal fatigability which may persist for years.

Within this type the following variations occur :

Variations in symptomatology, depending on predominance of mental dullness (stuporous form), of delusions and psycho-sensory disturbances (delirious form), or confabulations (paramnesic form); also depending on the superaddition to the basic syndrome of various phenomena, such as epileptiform seizures (convulsive form), paralyses, Jacksonian convulsions, aphasias (localized forms). The phenomena of cortical inhibition or irritation which characterize the localized forms are generally due to small hemorrhagic foci, for the most part subarachnoid, and lumbar puncture, performed in the beginning, reveals the presence of blood in the cerebrospinal fluid.

Variations in intensity: fulminating form of concussion of the brain, in which the patient dies in the comatose stage, and which is but of forensic interest; mild form, in which the comatose period is lacking and the clinical picture is reduced to a transitory mental dullness accompanied by vertigo and ringing in the ears and followed by a brief period of physical fatigue.

Varations in course: demented forin, in which a state of psychic deficit establishes itself definitely. It is probable that in cases of this sort the mental disorders are conditioned by permanent lesions, most frequently hemorrhages, sometimes also irritating lesions, necrotic or neoplastic, which are superadded to the concussion but which, not affecting any of the projection areas, at first pass unnoticed.

Such demented states belong to the organic psychoses and not to psychoses of concussion proper.

Cerebral concussion, resulting from a physical shaking up, should have its anatomic lesions. These are not yet known, doubtless by reason of their minuteness which renders them inaccessible to our means of investigation.

Their mechanism has been made the subject of two hypotheses: one, due to Duret, which assumes a sudden displacement of cerebrospinal fluid, the other, due to Koch and Filehne, which assumes a direct shaking up of the nervous tissues by the traumatic shock.

The prognosis is generally favorable, excepting, of course, the fulminating and demented forms.

The treatment should consist for the entire duration of the acute manifestations-aside from surgical intervention which may be indicated by focal symptoms-in absolute and continuous rest, counter-irritation of the lower extremities, relief of congestion of nervous centers by means of leeches applied to the mastoid processes, and, in cases in which there are signs of general cerebral compression, lumbar puncture or trephining for decompression.

Mental re-education is indicated, at first in moderation, later, upon the disappearance of the confusion, more and more inten

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