Thomas[196] states that: "The symptoms following acute vascular lesions of the brain, whether the process be the rupture of a vessel or its occlusion, are in many respects identical; and clinically it is often impossible to determine which process has been effective." He calls attention to the fact that in thrombosis the final closure of a vessel may occur suddenly and the symptoms develop with great rapidity. On the other hand, the rupture of a vessel may mean the escape of only a small quantity of blood and after an embolism the circulation is not always stopped immediately. In an analysis of 401 apoplectic attacks Thomas found no loss of consciousness in 202 cases, although it was interrupted or markedly disturbed in 199. Jones found a complete loss of consciousness in 47.7 per cent of 201 cases of cerebral embolism and a partial disturbance in sixty per cent. He reported consciousness affected in seventy-five per cent of his cases of cerebral hemorrhage and in 45.5 per cent of those of thrombosis. When it occurs it is usually not the initial symptom in his experience, being preceded by headache, vertigo, weakness in certain parts of the body, etc. An analysis of the cases of embolism reported by Virchow, however, showed a sudden loss of consciousness as the initial symptom to be the general rule. Gowers is of the opinion that an initial softening is a more common occurrence than hemorrhage.
In the young, apoplectic attacks are usually due to cerebral softening, thrombosis following acute disease or embolism resulting from endocarditis. Between the ages of twenty and forty apoplexies usually mean syphilitic thrombosis. In the later decades of life, either hemorrhage, thrombosis, embolism or softening may occur. Thomas[197] collected from various hospitals, statistics of 840 cases. Of these, 499 showed hemorrhages and 341 softenings. He is of the opinion that the presence of premonitory symptoms for some days indicate thrombosis, while shorter prodromal periods point to a hemorrhage. Rapidly developing coma suggests hemorrhage, while a widespread paralysis without much disturbance of consciousness is more common in thrombosis. A marked fall of temperature and rise of blood pressure as a rule means a hemorrhage. Repeated convulsions are more often associated with softening or embolism. If the symptoms indicate a capsular lesion it favors hemorrhage, and if of a cortical type, softenings are more likely. A positive Wassermann reaction suggests thrombosis or softening. The presence of endocarditis with heart murmurs points to embolism. Thomas finds that, while the patient may recover from either of these conditions without apparent intellectual defect, he is liable to be petulant, emotional, depressed and tire easily.
In psychoses following hemorrhage, thrombosis and embolism Kraepelin[198] as a rule finds very little relation between the nature of the lesion in question and the symptoms to be expected. Immediately following the seizure the patients become dull, clouded, confused and disoriented, and peculiar in their behavior. This is followed by an active excitement with loud cries, resistiveness and struggling. These acute disturbances usually subside, leaving, however, evidences of the arteriosclerosis or syphilitic endarteritis which caused the hemorrhage or thrombosis. Embolism may leave an apparently permanent mental deterioration with aphasic and paraphasic manifestations which often entirely clear up. In lesions of younger persons due to syphilis, mental enfeeblement may follow.
Our knowledge of the psychoses accompanying paralysis agitans is very inadequate. The disease was first fully described by Parkinson in an English publication in 1817, although, according to Camp, similar cases were reported by Schwarz in 1766. The etiology of this condition is unknown and the pathology is not at all definite. It seems to be the rather general opinion of neurologists that mental disturbances are quite rare in Parkinson's Disease. Camp,[199] for instance, has the following to say on this subject:—"Mental conditions have also been described, but usually the patient's mind is entirely clear. In the very old the changes incident to senility, such as irritability, childishness, etc., insomnia and memory changes, might be expected and may require special treatment. Often these patients are emotionally unstable and spells of forced weeping or laughter occur." Krafft-Ebing refers to mental weakness in paralysis agitans and speaks of the frequency of melancholia with hallucinations and suicidal impulses occurring intermittently and appearing with exacerbations of the disease. He speaks of premature senility as playing the most important etiological rôle. McCarthy[200] expresses the opinion that: "Beyond a tendency on the part of some patients to adopt a whining and complaining manner, the mind remains very clear; in fact, the good nature and complaisance of most of the patients, in spite of the severity of the symptoms, is a matter of common observation. Dementia may, however, complicate a case of the disease." On the other hand, Parant, a French writer who made an elaborate study of this subject in 1883, described three distinct varieties of mental disturbance observed by him. In the milder cases he found changes in the personality. This is shown by irritability, egotism, restlessness, suspicion, undue sensitiveness regarding their disease, mild persecutory ideas, tendencies to depression, indifference and apathy. The second class of cases described included mental deterioration with difficulty of thought, loss of memory, etc. The third group includes definite psychoses characterized generally by depressions with or without hallucinations and delusions. Hallucinations of sight are said to be common. Delusions of persecution are prominent and hypochondriacal and somatic ideas frequently occur. Suicidal tendencies are very pronounced. According to Ball, these episodes come and go "with the aggravation of the sensory symptoms, and they seem to disappear when the tremor decreases or ceases entirely." The usual tendency in these cases, as shown by Parant, is to terminate in complete deterioration.
Of the inflammatory conditions of the meninges Kraepelin[201] makes special reference to mental disturbances associated with tuberculosis. The patient is depressed, anxious, irritable and apathetic, often with the first appearance of the disease. Dulness and memory disturbances become more and more apparent. The patient soon becomes clouded and disoriented, confused and delirious. Occasionally hallucinations appear. The disturbance of consciousness becomes more and more marked. The patient becomes incoherent, restless, noisy and often violent. The excitement may reach the stage of an actual mania with delirious confusion. Sometimes the symptoms are strongly suggestive of katatonia. In alcoholics a condition very similar to delirium tremens develops, terminating as a rule in stupor and coma. Speech disturbance, aphasia, convulsions, hyperesthesia or muscular weakness may be observed in such cases. Other forms of meningitis are quite similar but more rapid in development and of shorter duration. In some instances, as after epidemic cerebrospinal meningitis, states of mental enfeeblement may follow the disease.
It must be admitted that our information on the subject of multiple sclerosis is far from being complete. In a discussion of the mental symptoms accompanying this condition, Henderson[202] expressed the following views:—"Cases of disseminated sclerosis which present definite, well marked psychoses are extremely rare. When mental symptoms do occur, they usually come on when the condition is well advanced, the most common symptoms are mild euphoria, labile mood, apathy and dullness, and a slightly defective memory. In some cases, however, depression has been described as the outstanding feature, while hallucinations of sight and hearing are not uncommon accompaniments. In certain cases the mental symptoms may come on early, and these are usually of excessive severity and are rapidly followed by complete dementia." Dunlap has described cases associated with general paresis and showing the characteristic lesions of both diseases at autopsy. According to Kraepelin[203] mental disturbances sometimes appear before physical symptoms are observed. These take the form of depression, anxiety, fear, with occasional deliria, hysterical manifestations, emotional dulness, variable moods and a marked irritability. Later in the disease more marked euphoric or depressive tendencies appear, with excitements and confusional states. Delusions of a persecutory nature, or ideas of grandeur may be observed. Hallucinations are infrequent. According to Kraepelin, from ten to thirty per cent of the cases terminate in a general mental enfeeblement which is not usually of an advanced degree. He also describes a lobar cortical sclerosis with much more marked mental disturbances suggesting dementia praecox.
Various mental conditions have been attributed to tabes. Sachs[204] speaks of depressions and neurasthenic conditions with irritability as a special symptom. He has observed paranoid states and manic attacks, sometimes with periods of "transitory dementia" with or without aphasia. He also expresses the opinion that tabetics may develop all of the symptoms of general paresis, although he says that the coexistence of the two diseases is rare. Kraepelin[205] speaks of milder forms of psychoses characterized by uncertainty of memory, fatigability and emotional instability. Many cases exhibit a hopeless, gloomy attitude with depression and fears, or they may be surly, irritable and quarrelsome. Others show a surprisingly good humor. The emotional disturbances often suggest general paresis. Kraepelin, however, describes the characteristic psychosis of locomotor ataxia as assuming a paranoid form and quotes Meyer as reporting paranoic conditions in twenty-six tabetics and depressions of various types in fourteen. He also speaks of hallucinatory excitements resembling alcoholic conditions. These are characterized by a sudden anxiety and restlessness with hallucinations of both hearing and vision. The patients complain of poisoning and sensations of electricity, but are cheerful in mood and well oriented. This condition may last for weeks or months, ending in a sudden recovery, often with relapses. Shorter hallucinatory delirious states resembling crises are also referred to by Kraepelin. More chronic conditions are noted, with hallucinations, persecutory delusions and ideas of grandeur. Delirium tremens, manic-depressive attacks, katatonia or senile psychoses may be associated with tabes.
The literature of medicine contains many references to acute chorea. It was referred to, according to Paton, by Plat as early as 1614 and was discussed by Sydenham at some length. Wharton Sinkler, in describing chorea in Pepper's "System of Medicine" in 1886, made the following interesting remarks on the mental changes involved:—"The child is irritable and feverish, cries and laughs readily, or is sullen and morose. Sometimes he is violent to those about him but this is rare. Intellectually the patient suffers somewhat. He is not able to study as before, and the memory may be impaired. Sometimes there is a mild form of dementia." Burr [206] divides these conditions into four groups:—"First (and this includes the vast majority), patients in whom there is peevishness, fretfulness, some loss of the power of fixing the attention, and a slight loss of the moral sense shown by disobedience and selfishness. Second, those showing in addition to the above symptoms, night terrors, and transitory, visual, auditory, or other hallucinations. Third, those with distinct delirium, wild or mild, accompanied with fever. Fourth (and this group is very small when we remember how common chorea is), those showing stupor, or rather stupidity, and an acute dementia, which may follow the condition described under three, or appear without any preceding mental symptoms at all severe, and which is usually accompanied with trouble on articulation not caused by choreic movements of the lips and tongue, but the result of mental hebetude." White[207] refers to the irritability and emotional instability of choreics and describes a psychosis in "chorea insaniens" characterized by an acute confusion, sometimes of a violent type with hallucinations, or a paranoic condition with delusions of persecution. This may develop into a stuporous state. Kraepelin describes the psychotic manifestations of acute chorea as forms of delirium due to infection with characteristic states of clouding, confusion, etc. Wechsler has expressed similar views.
Encephalitis lethargica is a disease which has received a great deal of attention during the last few years. The term was first applied by von Economo[208] to a series of cases observed by him in Vienna in 1917, although, as he has pointed out, similar epidemics occurred as early as in 1712. This condition is characterized particularly by lethargy, facial and oculomotor paralyses and a rise of temperature. Cases were reported from England and France by various observers in 1918 and by Pothier, Neal and others in this country in 1919. It has been suggested frequently that the disease is in some way associated with influenza. The pathological findings have also been confused with the African sleeping sickness due to trypanosomes. After such prodromal symptoms as headache, malaise and drowsiness with muscular weakness for a few days, a lethargic or stuporous state usually develops, interrupted occasionally by delirious attacks. Ptosis has been reported, sometimes with immobility of the pupils. Paralyses of the facial and eye muscles are very common. Buzzard and Greenfield[209] after a review of twenty-two cases suggested the following symptomatological classification:—1. Cases characterized by hemiplegia, hemianesthesia, hemianopsia, etc.; 2. Cases characterized by symptoms resembling those of paralysis agitans:—the basal ganglia group; and 3. Cases characterized by a disturbance of the cranial nerve functions. In a publication issued recently by the United States Public Health Service the various types of the disease were summarized as follows:—1. A clinical affection of the third pair of nerves; 2. Affections of the brain stem and bulb; 3. Affections of the long tracts; 4. The ataxic type; 5. Affections of the cerebral cortex; 6. Cases with evidence of spinal cord involvement; and 7. The polyneuritic type with involvement of the peripheral nerves. The Massachusetts Department of Public Health has recently recommended the use of the MacNulty classification, which is quite similar in some respects:—
1. Symptoms of a general nature referable to the central nervous system with no localizing signs.