and that of morality, we earnestly appeal for a more vigorous control of the drink traffic and for power to diminish the facilities for obtaining it which glare with specious temptation at nearly every street corner.

A REVIEW OF THE MENTAL SYMPTOMS ACCOM

PANYING APOPLEXY.

BY CHARLES RICKSHER, M. D.,

Clinical Assistant, The Sheppard and Enoch Pratt Hospital.

Very little attention has been given to the study of the mental symptoms preceding, accompanying or following an apoplectic attack and in the majority of works on nervous diseases little is to be found on the subject and what is written is often vague, indefinite and frequently apparently based on very imperfect observations. In a great measure this is due to the fact that in the majority of cases the symptoms pass unobserved or, if of sufficient intensity to attract attention, are looked upon simply as accidents. The causes of the lack of detailed observations of these symptoms are not only the fact that the early cases are seen by the general practitioner or neurologist who has not had sufficient training in psychiatry to recognize any but the most obvious deviation from the normal, but also to the lack of interest in any but the physical manifestations present. Too often the symptoms are not continuous but may occur at varying intervals of time and be seen by different men who have no way of comparing notes. In this way many valuable points are lost. In very few cases are prodromal symptoms, even when observed, given the important place they deserve in the light of subsequent events. Very few cases are on record in which the prodromal and post-apoplectic symptoms are placed in sequence.

The psychic alterations in apoplexy are the most varied of all those resulting from definite organic derangements of the brain, if we except possibly brain-tumor. The psychopathic alterations are not determined apparently, as far as observations which have been recorded show, either in degree of intensity, duration or character by any definite anatomo-pathologic process. The psychologic reactions after apoplexy depend as much on the former condition of the nerve cells as on the superadded lesion.

Many cases of hemorrhage and thrombosis show no symptoms of mental derangement on superficial examination, but practically every case will, on careful investigation, show an alteration in the thought processes. Disturbances in the psychic sphere are almost always associated with sensory and motor changes, but while the latter are usually the direct effect of the lesions, the pathogenesis of the former seems comparable to that of epilepsies and toxic paralyses, in which a diffuse morbid impregnation of the cortex provokes localized reactions (Dupré).

In practically every case of hemorrhage or softening there is an underlying arterio-sclerotic condition of the vessels of the brain which is the cause of various nutritive disturbances and gives rise to the prodromal and many of the succeeding symptoms. There is no pathognomonic difference between the early symptoms of hemorrhage and of softening. Benon found that the intellectual disturbances were practically the same in right as in left hemiplegics-51.5 per cent for right, 48.9 per cent for left.

The etiological factors most often noted were alcoholism and syphilis. Benon, in 392 hemiplegics in the Asile de Maison Blanche and the Asile Clinque, obtained a history of alcoholism in II per cent and of syphilis in 5 per cent. Heredity was noted only in four cases, but he states that this figure is probably too low.

The prodromal symptoms in the great majority of cases pass unnoticed. They are essentially arterio-sclerotic in origin and may be present for several months before the stroke. Rostan notes them as constant in softening. Durand-Fardel notes them in half the cases of softening and a little less than half the cases of hemorrhage. They may be divided into two groups, the disturbances of motility and psychic disturbances. Lwoff states that at a period, of greater or less duration, before the lesion is established one notes transient, partial feebleness and paralytic phenomena in different parts of the body. The patients often complain of tingling in the ends of the fingers, of neuralgias, of diffuse or localized cephalalgias. Often there is a glare of light or a mist before the eyes. More often yet there is a whistling or humming in the ears. Disturbances of smell and taste are rare.

The prodromal psychic troubles are usually partial and intermittent and are extremely variable. Generally some months or weeks

before the attack there are periods of partial amnesia, the patient becoming absent-minded, forgetting to put on various articles of clothing, to carry out commissions, etc. The patients suffer an unaccustomed distraction. They err greatly in their calculations and make great mistakes in the letters which they write. They are incapable of any sustained effort. Often there is a diminution in the faculty of judgment, patients sustaining the most unjust causes with puerile and ridiculous reasons. The character undergoes great modifications, the patients becoming distrustful, suspicious, irritable, agitated, then suddenly sad, depressed, apathetic, indifferent, they lose interest in their friends and family. They may become quite emotional and laugh and cry with hardly any provocation. According to Starr it is common for these symptoms to be associated with headache and to be of a temporary character passing away with the pain. Very often the patients have a clear insight into their condition and bewail the fact that they are unable to remember events, to perform various tasks or to control their emotions. True delirious ideas sometimes appear; most often they are melancholic in tone, or are ideas of persecution which remain for a longer or shorter period.

Savage has reported a case in which there were pronounced, prodromal, persecutory ideas. A man, æt. 55, when first seen was suffering from sleeplessness, some neuralgic pains fixing themselves chiefly in the eyeballs. About the same time he became irritable, and his servants were constantly being changed. He became emotional and his memory failed. After these symptoms. had existed for several weeks, the sleeplessness continuing, hallucinations of hearing became marked, so that on several occasions he got up at night believing that a bell had rung, and his wife was unable to convince him of the contrary. These hallucinations troubled him mostly at night in the way of bell ringing, but during the day he had other annoyances which he said were due to his unusual keenness of hearing, so that he declared that he could hear his servants talking in the kitchen, which was impossible. A change of scenery benefited him for a time but on his return home he very soon relapsed into his former condition.

After a time he became somewhat better, he was less emotional and irritable and slept better, but he was loquacious and was excessively fond of talking of his own worries and ailments. His