The Anatomical Facts and Clinical Varieties of Traumatic Insanity
Case 1. L.H.S. Born 1831. Father and two aunts were insane. No accurate history is available. In 1898 the patient is said to have had a sunstroke. He then stopped working. During the last months he has become very perverse; he would get up and build a fire in the night thinking it was day, and go out on the street and sometimes stay out all night; he would get excited and did not let his wife have wood and coal. He wandered away from his home to an adjoining town and walked six miles to his daughter's, saying he was going home. The physicians found him exhausted and restless; slow in answering and talking irrelevantly; he walked about the room, went to the window and looked out and laughed.The patient was admitted January 12, 1900. He was restless, walking about the hall, saying little except: “I guess I will go home this evening.” He was inclined to resist his bath but submitted to the rule; at supper, however, he refused to eat because he was offended at having been bathed. When he is requested to do something he is very contrary and irritable and inclined to fight. He requires to be pushed into the dining room; then he is too angry to eat; he walks about the room; refuses to be seated, takes off his coat without any reason except “it is none of your business.” He requires constant watching lest he take off his clothes and shoes; but January 14 and 15, the attendant has to undress him. After the interview he refuses to leave the room.Physically he claims to feel well; he is rather tall, somewhat emaciated and sallow; he has varicosities of the legs, thickened and tortuous radials, beginning arcus senilis, no heart lesion; a barrel-shaped chest and scaphoid abdomen. The hands and forearms shake and the tongue has a gelatinous tremor, and the gait is relatively slow and tottering.In conversation the patient is suspicious and evasive and irritated by questions and unable to grasp the whole situation, takes the examination for a “mess of lawyers,” frequently answers “None of your business.” Or to the question, where are you, he says “Don't you know? Well, I won't tell you; well I would give up my business,” and when he was told it was the Worcester Insane Hospital, he said: “I would like to know why.” The date was given as Friday, in “November, ain't it,” 1890, 1889 or 1890. The localization in time both of remote and recent events is very defective and variable. “I shall be 70 the 30th of this month, November. I was born in Boston, and went to school for a year; I had two brothers and two sisters; the youngest sister is only three years old”; and the brothers' age he does not remember. His father is living in S. and 73 years old. When the discrepancy was pointed out he said: “Can't you take a record from the Bible?” When did your father die? “Well, he is living and was living—and you want to get me mixed up in a scrape—well, I had just as lief as not.” He says his wife is in B., Mass. (correct) and he has four children; two days later he says his wife lives in S., Vermont, and that she is 26 years old, that he has no children and can't tell “exactly” when he was married, “I think 6 years ago.” January 15, he takes this place for the Horticultural Building in Boston. He thinks he has been here not more than three or four weeks (two days). He mentions no definite delusions or complaints.January 17, 1900, the patient fell on the floor on the back of his head. He immediately straightened out and stopped breathing until the attendant performed artificial respiration. He remained unconscious about half an hour, then became gradually clear, and in about three hours said to the attendant he was all right. He fell asleep, but at 4 a.m. the physician found him lying flat on his back with open mouth, fixed eyes, deep breathing and slight rattling. There were no symptoms of paralysis, no difference of pupils. During the examination there were several hiccoughs. Nothing was found in heart or lungs. No fracture of the skull was detected. The temperature was 100.2°; pulse, 80; respirations, 15. At 9 a.m. there was much flickering of the muscles of the thigh and leg on both sides and on the right an occasional contraction of the muscles. The toes are in dorsi-flexion which is increased on plantar stimulation and especially hard to overcome on the right; cutaneous and tendon reflexes about normal. There is withdrawal from pricks only at the sole of the feet, hardly at all in the arms and hands, slightly in the face. Forward movement of the jaws stops rattling. Towards evening he could be roused partially by calling his name and he swallowed fairly well, but he became more and more comatose and the temperature rose to 105° in the course of two days. He died at 11 p.m., January 19, 1900.Autopsy. No fracture of the skull was found, but several hyperostoses on the inside of the frontal bones, especially marked on the left and several others in a depression just behind the bregma. To these regions the dura is firmly adherent. The inside of the dura appears free in the frontal part; over the right parietal and all around the pole of both occipital lobes there are, however, marked clots inside the dura and a rather large blood clot on the right cerebellum and a more limited membrane over the left. Only in the left frontal fossa is there a small clot and in either temporal fossa several diffuse membranes and a few small clots. The blood-vessels are hard at their exits from the canals only. There are marked contusions especially of the region of the fusiform lobe on the left and a little less under the right third temporal gyrus. Brain as a whole weighs 1,260 g. The floor of both temporal lobes proves greatly contused to the ventricle.The lungs weigh 450 and 570 g, with thickened pleura at the apex, are slightly edematous, and there are bronchopneumonic foci in both lower lobes. The left pleura has several ecchymoses and a small amount of fluid in the cavity. The heart weighs 250 g and has a decided thickening of the edges of the mitral flaps, with small rough nodules; no atheroma of the aortic valves or the beginning of the aorta, but a number of ulcers in the descending aorta.The kidneys have a few small cysts and weigh 100 and 104 g; old adhesions of the ascending colon and omentum to the abdominal wall; 12 gallstones.
Case 3. F.T., mill operator, married, about 38 years old, of cheerful, sociable disposition, about January, 1897, was struck on the head by a 57 lb. weight. He was not knocked down, but there was a hematoma of the scalp. Since then the patient has had attacks of headache and dizziness, a few times he vomited his coffee in the morning. His character changed; formerly jolly and active in social enterprises (theatricals), he became silent and non-responsive, at times he wandered away for several hours at a time and would stone the friends who followed him; about June his work became less efficient owing to the headaches; he thought the workmen put things in his way; it was their fault that he could not do things. About June 25, he had a violent outbreak, in which he nearly succeeded in killing his wife with an axe and smashed furniture. July 2, he had to be committed; in an attack of headache he again had become excited, complained of being full of electricity and that his wife and children might injure him; the pictures on the wall bothered him; he ordered everybody out of the room.Under observation he showed on admission (July 2, 1897), and for nearly three weeks a condition of sulky delirium with vehement blind outbreaks; he would get up and rush to the window and smash the glass, or clutch the steam-pipe and shake it violently to “shake out the steam.” He talks deliriously in German, says he sees faces, one piece of furniture on the ceiling, another hanging from the window, the children all topsy-turvy, and breaking all the windows—“That won't do, Mary.” In the struggle with attendants the patient broke a rib and was restrained in bed. He was inaccessible to conversation till July 23, when he began to listen and to give an account of his headaches and the injury. He still would lie on the floor, was indifferent or sulky, diffident, urging unreasonably to go home. July 28, he gave a patient 15 cents with which to buy tobacco, and when he did not get it, he said “fool me,” had a violent outbreak and began to beat his head against the wall, and had to be restrained. He is found in great distress. “Help me, help me, for heaven's sake, help me—take off the fetters, take off—take off—the—the—the—, these fearful flies eat me up—I—I—I don't do any thing. I am one of the best of men.” Can't you be reasonable? “I am reasonable.” You must stay in bed. “I can't stay in bed; the bed oppresses me. I will never leave my bed—I want to go home to my wife and to my baby (the patient has five children living); I do not cry; I do not cry—my baby—my baby—my children, children, children, etc.”; quite inaccessible to reason. He complains of fearful dreams; one morning he kept shouting: “Everything is dry in the garden,” one night he was “dead in the lower world.” At times his good-will can be held for a few moments, but he rapidly drifts into shouting, clamoring for his wife, or he makes a sudden assault. August 2, disclaimed all memory of assaulting the physician two days before, was much surprised, and said quickly if he did so he was sorry. The next day he was lying on his back with the bed sheet drawn tightly from the feet to the head, the ends tucked under him, the hands folded in prayer; he could not be diverted.The first physical examination was essentially negative. The patient was a short man of tremendous muscular power without any nervous or other symptoms.The further observation showed that relatively quiet periods with fair orientation but unreasonable general attitude would, with or without attacks of severe headache (which yielded slightly to phenacetin 0.80, but were aggravated by acetanilid), show sudden outbreaks either of fault-finding, or a blind attack without warning, or dream states. A nocturnal noise upstairs started him to claim the next day: “The ceiling is coming down; I am oppressed.” He complains that he cannot understand the people, that he has forgotten all he learned at school, cannot learn to read English. At times he keeps a promise to abstain from violence, but is easily irritated again. “If you want to kill me now, kill me; I cannot stand this now any longer; I don't know what this means; I want to go to my children.” He claims he can work in the mill. At times he has a summary remembrance of his troubles. Thus, on December 9, he admitted “I fought with the attendants but I do not remember why.” “That is an old affair, I had rather not speak of it. It is not my nature to speak so freely of my own affairs. I do not remember why I struck; they laughed at me, and I got tired of it.” “I would like best if I could shut my eyes.”A renewed examination of the head showed nothing but very slight lateral nystagmus on extreme turning of eyes, and on tapping the scalp with a hammer a painful spot over the right parietal protuberance. The headaches are mostly right-sided. A permission for an exploratory operation was obtained, and it was carried out by Doctor Homer Gage as follows, on December 27, 1897:The shaving of the scalp exposed a small scar over the right parietal prominence near the “painful” spot; the usual incision was made with this scar in the center; the skull was found intact, both the external and the internal plate. The dura appeared somewhat bluish and, on incision, brownish fluid escaped, and brown, half gelatinous material was found. A second trephine opening was made further forward and the same material of partially organized clot was exposed. It seemed possible to remove practically the whole through the somewhat enlarged opening. The pia appeared normal. The fluid contained small hematoidin needles and very few leukocytes. Its amount was difficult to judge, the thickness of the layer was hardly more than 5 mm, and the whole mass probably not more than 25 or 30 cc. The wound healed perfectly smoothly.The patient did well. December 30, in the evening he was sulky, irritated by “foolish” questions; he had rather severe headache, but was relieved by phenacetin 0.80. It reappeared a little for a few days only. The patient remained rather diffident and impatient, and only once (January 28, 1898), when being photographed he burst out suddenly: “Ich will nicht, ich will nicht; ich will nach Hause gehen”; he took off his coat as if for a fight and started against the photographer. He attributed the outbreak to his impatience.On his discharge, January 30, 1898, the patient was unappreciative. He did well until March, 1898, when, after an alcoholic excess, he broke up the furniture in the house and threatened the family; and in December, 1898, he was arrested for disturbing the peace (intoxication) and sentenced to three months in jail. Since then he has done well when abstaining from drink.Summary. Traumatism without marked primary results, except hematoma of the scalp. Change of character; sulkiness, irritability; intolerance to alcohol, attacks of headache with violent outbreaks with only summary remembrance. Removal of an old subdural clot over the right frontal lobe. Disappearance of headaches and outbreaks of violence; but residual susceptibility to alcoholic excitement.
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