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fects than in failure of the mitralis. The symp- toms of mental disturbance here partake more of the nature of mania, and resemble the delirium of alcoholic pneumonia. Extreme irritability, ex- citement, fretfulness, restlessness, inconsistency, querulousness, make it allopurinol 20 mg sometimes very difficult to control- the patient. The contrast between his usual ways of acting allopurinol online and thinking, and the ob- served change in temper not infrequently amount- ing to violence, is so striking, that suspicions of allopurinol cost insanity even enter the mind of cost of allopurinol those who take buy allopurinol online care of him. These suspicions are often too well founded, and become confirmed in the outbreak of a real mania with all the distressing features and consequences of this special form of psycho- sis. Troublesome and exhaustive sleeplessness is especially noticeable in aortic insufficiency. A strict correspondence between the variety of heart disease and the allopurinol rxlist form of insanity, is naturally not to be expected, allopurinol 150 mg although Mickle" has made the attempt to divide the different cardiac affections in nine groups, according to the more or less typi- cal mental disorders that they are apt to produce. It is not always that these disorders run the same course in the cardiac aft'ections with which they are connected. Almost every case of mania, as has been rightly said, commences with a stage of depression. Hypochondriacal ideas may grad- ually and ultimately allopurinol uk develop into delusions, gen- eral irritability turn into maniacal excitement. A classification of mental and cardiac disturb- ances in their respective dependence on one an- other would, therefore, prove a difficult and un- grateful task. Looking over the literature of the subject, in which the bulk of contributions belongs to the alienists, we find that the mental disturbances in cardiac patients have not escaped the attention of both the specialists and the clinicians in gen- eral. Aside from the standard te.xt-books on medicine which devote from a few lines to half a page to this complication, mention of it is, of course, largely made in most of the works on mental diseases. Altogether, one gets the im- pression that not much importance is attached to the direct influence of valvular and heart dis- orders on the appearance and development of ab- normal mental conditions. Osier' says : "In gen- 'VV. Julius Mickle, Insanity in Relation to Cardiac and Aortic Disease. Gulstonian Lectures, Lancet, 188S, p. 9:1; also Tuke's Dictionary of Psychological Medicine. 'Principles and Practice of Medicine, 3d Ed., p. 713. July 2y, 1901.] ZEDERBAUM: MENTAL DISTURBANCES. 157 eral medical practice we seldom find marked men- tal symptoms (in connection with heart affec- tions), except toward the close of the disease, when there may be delirium, hallucinations, and morbid impulses. We do meet insanity, break- allopurinol brand names ing out in patients with aortic and mitral disease, in the stage allopurinol brand name of compensation, which appears to be related definitely to the allopurinol generic name cardiac disease." In the most excellent French cyclopaedia of Charcot, Bouchard, and Brissaud", in the chapter on mania, melancholia, and other forms of psychoses, car- diac disease is not enumerated among the setio- logic factors occasionally responsible for these mental conditions. In the chapters on anaemia and hyperemia of the brain, Brissaud'" considers it probable that circulatory derangements orig- inating allopurinol pharmacology from heart disease may sometimes have something starting allopurinol allopurinol tablets 100mg to do with insanity, but he adds that there is not always foundation in what is allopurinol 300 mg the belief that the mental excitability in these cases is actually associated with congestion. Yet, the expression folie cardiaque is of French origin (Lasegue, Hu- chard), and designates the acute delirium ob- served in connection with cerebral congestion when the heart is asystolic. Savage^^ is more ex- plicit on the allopurinol 50 mg subject. He says : "With aortic, or brand name for allopurinol both aortic and mitral disease, the symptoms may be either melancholic or maniacal ; but I am in- clined to think order allopurinol that with simple aortic disease, with hypertrophy of the left ventricle, it is at least not uncommon to meet with acute mania and ex- altation of ideas. In doubtful cases of men with exaltation of ideas, I expect to find allopurinol iv post mortem hypertrophy of the left ventricle and atheroma of the aorta with more or less brain change." Most of the writers express themselves very cautiously with regard to the close relation be- tween mental and cardiac disturbances. That incompetency of the aortic valves is more liable to affect the brain than pathological conditions of

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