Franco-Prussian war, cited by Meyer,1 of a total of 8985 cases of head injury only 13 led to insanity.

The nature of the injury in cases of traumatic psychoses is variable: fractures with depression of fragments and destruction of brain tissue by direct violence; compression or brain tissue destruction resulting not directly from the injury but indirectly from an intra-cranial hemorrhage following it; severe concussion in cases with linear fracture without encroachments on the cranial cavity or even in cases without fracture; bullet wounds, etc. Complicating infections naturally bring with them febrile or infectious deliria the manifestations of which it is difficult, if not impossible, to separate from the symptoms directly attributable to the injury.

Many cases of head injury undoubtedly occur without any considerable injury to the brain and this in part accounts for the rarity of marked and lasting mental complications; yet it is also true that fairly extensive injury to the brain may occur without giving rise to such complications. It would seem that mental symptoms are determined by the diffuse effects of concussion, compression, or bruising, rather than by any special localization of circumscribed lesions.

The first effect of a head injury is a dazed, stunned, or completely unconscious condition which comes on either immediately or, where due to an intra-cranial hemorrhage, after an interval following the injury. This lasts from a few minutes to sev

1 Adolf Meyer. The Anatomical Facts and Clinical Varieties of Traumatic Insanity. Amer. Journ. of Insanity, Jan., 1904.

eral hours, after which consciousness may be fully regained or the patient may remain somnolent for several days and then recover. Cases of very severe injury often die without regaining consciousness.

Traumatic delirium. Delirium following head injuries is observed either immediately after the initial coma or stupor or after a brief interval of comparative lucidity. It is characterized by restlessness, which may be slight and readily controllable or may become aggressively violent, disorientation, disconnectedness of utterances, more or less relevant but peculiarly absurd and irrational responses, and tendency to fabrication; psycho-sensory disturbances may occur but do not seem to be as prominent as in other deliria.

The possible terminations are death, complete recovery, and recovery with mental or physical residuals. The duration of cases which survive usually extends over several weeks, and in some cases convalescence lasts for weeks or even months after the acute period of the illness. In the treatment the advisability of early surgical interference should always be considered; not only may an immediate amelioration be often produced by raising depressed parts of bone, removing intra-cranial blood extravasations, etc., but also some of the possible sequelæ may be prevented. The danger of craniotomy is now so slight that its performance in doubtful cases would seem justifiable even merely for exploration.

Traumatic neurasthenia. This is the commonest of the above-mentioned mental residuals which may

persist after recovery from traumatic delirium; it is also frequently found in cases in which no delirium at all has developed after the initial coma or stupor. The condition has been well described by Köppen1 as one of irritability, forgetfulness, diminished working capacity, inability to concentrate attention, and increased susceptibility to alcohol. "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 forgetfulness may be so marked that "frequently everything must be written down." "These patients are unable to concentrate their attention even in occupations which serve for mere entertainment, such as reading and 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." Physically there are apt to be pain or feeling of pressure in the head and a tendency toward dizziness. "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.

1 Arch. f. Psychiatrie, Vol. XXXIII. (Quoted by Adolf Meyer, loc. cit.)

Patients feel best when in the open air, inactive, and undisturbed."

Traumatic epilepsy. In many cases ordinary epilepsy is wrongly attributed to an obviously inadequate traumatism. However, the existence of true traumatic epilepsy is hardly to be questioned. The seizures may be slight, or partial, or Jacksonian, or without complete loss of consciousness, or, on the contrary, exactly like those of idiopathic epilepsy; the intervals at which they occur are variable; they may come on spontaneously or only following physical exertion, indulgence in alcohol, or febrile or gastro-intestinal ailments. The mental condition is apt to be much like the above described neurasthenia with the addition of confused or delirioid states occurring in connection with seizures; in cases with frequent seizures there is apt to be a slowly progressive deterioration like that of idiopathic epilepsy.

Traumatic dementia.

This consists mainly in an exaggeration of the memory and attention defects, general incapacitation, and loss of interests of the above described traumatic neurasthenia.

Aphasia, deafness, paralyses, and other neurological symptoms, depending on the localization of the brain injury, may, of course, also be observed.

CHAPTER XV.

MISCELLANEOUS GROUPS.

DELIRIA OF INFECTIOUS ORIGIN.

THE mental disorders which appear in the course of infectious diseases are brought about by the combined action of several factors: elevation of temperature, congestion of the nervous centers, and poisoning of these centers by microbic toxins. The most important factor appears to be the poisoning of the nervous centers.

One cannot fail to notice the striking clinical resemblance existing between the toxic deliria, properly so called, and the infectious deliria; indeed the resemblance is so close that without the somatic symptoms peculiar to each condition it would be difficult or even impossible to make the differentiation. Notes on such cases almost always describe the same symptoms: clouding of consciousness, confusion, numerous illusions and hallucinations, motor agitation.

Moreover, the infection itself, independently of hyperpyrexia and probably of any meningeal lesion, may cause grave mental disorders (infectious de

1 Klippel et Lopez. Du rêve et du délire qui lui fait suite dans les infections aiguës. Rev. de Psychiatrie, April, 1900.- Desvaux. Délire dans les maladies aiguës. Thèse de Paris, 1899.