F- CLINICAL ASPECTS OF SPINAL CORD INJURIES
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apathy, all too often misinterpreted as being 'unco-operative' or of 'bad type'. This was
seen especially in traumatic paraplegics demoralized as a result of inadequate treatment
and neglect, who were admitted with articular contractures, sores and urinary infection.
They resented at first any active treatment and wanted to be left alone having resigned
into their disability and with no will to live. Sometimes, sudden and unmotivated out
bursts of irritability and rudeness may be the first sign of a pyrexial attack. Real toxic
psychosis was found to be very rare. A man of 59 with a complete transverse lesion at Tio
developed on three occasions, during acute deterioration of his sacral and trochanteric
sores, a toxic psychosis of paranoid acoustic hallucinatory type, which promptly dis
appeared after excision of deep fascial sloughs with fat necrosis. The family history of this
patient did not reveal any mental abnormalities. Most striking improvement of mental
conditions, especially apathy, also followed blood transfusion in cases with anaemia due to
toxic absorption.
(2) Reactive mental disorders
(a)
Stage of shock
The sudden conversion of a vigorous person into a helpless wreck, naturally leads to
severe psychological shock. The immediate effect is a state of daze in which clear thinking
is retarded, if not completely abolished, and the flow of ideas is more or less slowed down.
The traumatic paraplegic and even more the tetraplegic is, as a rule, incapable of realizing
the whole extent of his disability. This stage may last for hours and days. Whether this
can be explained by 'an unconscious protection against too massive or too rapid a
perception of the traumatic and overwhelming reality' (Gunther, 1969) is a debatable
point. Gunther attempts an interesting psychoanalytical theory of the mental alteration
occurring during the acute trauma: 'During the stage of acute trauma, the patient with
draws all his emotional energy and interest from the outside world, thereby interrupting
his relationship with it. This is probably an adaptation mechanism to maintain the
integrity of the ego's original image of the body (and sense of self) in the face of an
overwhelming disaster to the body and in the face of the loss of some of the normal
sensory impact to the ego. This necessary protective adaptation of the ego at this stage
is probably subject to little alteration by direct intervention from the medical personnel.'
Our observations did not substantiate this theory that the interruption of the paraplegic's
relationship with the outside world in the stage of shock following injury is due to his
conscious or subconscious withdrawal of all his emotional energy and interest from the
outside world to maintain the integrity of the ego's original image of the body. On the
contrary, there are certain facts which do not seem to correspond with this psycho
analytical assumption. Patients may arrive at the Centre or hospital under the influence
of drugs, such as morphia, which they have received during first aid and which add to
their mental retardation caused by the traumatic shock. Moreover, the paralysed patient
may be confused by the presence of phantom sensations, a not uncommon incidence,
which he misinterprets as true feeling and active movements of the paralysed limbs. In
tetraplegics, the mental retardation is intensified by oxygen deficiency as a result of the
