more or less marked arteriosclerosis, as is so often the case. It must be borne in mind that senile dementia has for its basis a process of atrophy which is wholly independent of vascular disease. Focal symptoms, recurrent seizures, persisting mental insight, also stationary condition and duration over five years, all point to cerebral arteriosclerosis. Senile dementia is but exceptional before the age of 60 years, while cerebral arteriosclerosis often begins at 50 or even earlier.

The course of cerebral arteriosclerosis in most cases extends over a number of years, even ten or twenty years. It is irregularly progressive, as already described. In any case sudden death may occur from embolism, apoplexy, or from exhaustion following convulsions. Kraepelin speaks of a grave progressive form which is characterized by rapid development of extreme dementia and an early fatal termination.

The prognosis of all forms of arteriosclerotic brain disease is unfavorable for recovery from established defect symptoms; sudden or gradual progress of the disease is to be expected to occur sooner or later, though the condition may remain approximately stationary for months or even years, especially under favorable conditions.

The treatment is purely symptomatic. Rest, freedom from worry or excitement, moderation in eating and drinking, abstinence from alcohol, proper regulation of the bowels may stave off progress of the disease or the occurrence of seizures.

CHAPTER XIV.

TRAUMATIC PSYCHOSES.

TRAUMATISMS may play a part in the etiology of psychoses essentially of a constitutional nature, and they have been known to cause the development of general paresis in syphilitic persons; it is believed also that they can precipitate an attack of delirium tremens in an alcoholic person. Such cases are not included here under the designation of traumatic psychoses, but only those in which the traumatism constitutes the essential, if not the sole, cause of the mental disorder.

As already stated in the chapter on general etiology, traumatic psychoses are comparatively rare in psychiatric practice: but 0.6% of all first admissions to the New York state hospitals during the year ending September 30, 1913, were cases of traumatic psychoses.

The immediate results of head injuries come more frequently under the observation of surgeons than psychiatrists, and it is interesting to note from such statistics as are available that insanity, or at least that which is recognized as such by surgeons, is a strikingly rare complication of head injuries; thus according to the statistics of the medical report of the German army concerning the experiences of the

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.)