DEMENTIA PARALYTICA. Depression less intense. Little or no affect. Retardation and fear absent. Deterioration rapid. RETARDATION OF THOUGHT. Disturbances of the train of thought are uniformly frequent in the different forms of insanity. Unfortunately, however, they have hitherto been insufficiently investigated. The simplest form is the flagging of the course of ideas through diminution of intellectual activity. In the first place there arises a more or less powerful retardation of thought, with which further on changes are associated, especially monotony and distractibility. Light grades are found in fatigue-severe forms in poisoning by narcotics. Further, intellectual paralysis forms the general characteristic feature in the most varied forms of deterioration-as dementia paralytica, dementia precox, senility, etc. In retardation the elaboration of external impressions is effected laboriously and slowly; the train of thought is powerfully delayed and prolonged; and the store of ideas is exceedingly imperfect. Sometimes this mental constraint can proceed to almost complete cessation of thought. Patients clearly perceive the resistance which they have to combat. They do not lack mental activity; they are not obtuse and indifferent like weak-minded or deteriorated patients, but are unable, even with the greatest exertion, to overcome the constraint and narrowness of their thought. We encounter this disturbance most distinctly in the depressive and mixed forms of manicdepressive insanity; possibly also certain disturbances of thought in epileptic stupor are to be included here. THE USE AND ABUSE OF BROMIDES IN THE TREATMENT OF MENTAL DISEASES. A. R. DEFENDORF, M.D., MIDDLETOWN. The occurrence of six cases of bromism among the admissions to the Connecticut Hospital for the Insane during the past three years offers a sufficient excuse for calling the attention of the general practitioners of this State to the common abuse of this drug in the treatment of mental diseases, its profoundly toxic effects when used in excessive doses, and some unusual symptoms of bromism observed in these cases. From time to time since the discovery of the physiological effects of this important drug by 'Graf and Huette and its later adop tion by Brown-Séquard as the remedy par excellence in the treatment of epilepsy, warnings of this sort have been sounded, notably by Voisin, Weir Mitchell, Hodges and Alexander. Hare in the last edition of his Materia Medica and Therapeutics says, "I know of no other drug, with the exception of those that produce habits, such as morphine, cocaine, etc., that is so enor mously outraged as the salts of bromine are. It is only necessary to see the colossal mental and physical depravity that sometimes results from the ignorant administration of this drug in minor ailments, and some 2 Huette. Recherches sur les proprietes physiologiques et therapeutiques de bromure de potassium. Mem, de la Societe de Biologie-1850. Vol. II. 3 A. Voisin. De l'emploi de bromure de potassium dans les maladies nervenuses. Paris.-1875. 4 Mitchell, On the Exceptional Effects of Bromides Tr. Ass'n. Am. Phys., Phila.-1896. XI, 195. 5 Hodges. 6 Alexander. Maryland Med. Jour.-XXV, p. 384, 1896. Alienist and Neurologist.-XVII, p. 279, 1896. times even in epilepsy to fully appreciate this statement." The chief purpose in presenting five of these six cases is to record some unusual symptoms of bromism and to offer additional safe-guards to the practitioner in detecting its symptoms when administering this drug. The first case was that of an unmarried man twenty-one years of age with a slightly defective constitutional basis (Father and sister convergent strabismus, mother diabetic, one sister suffered from excessive headaches for twenty years and one sister excessively obese), but with a good personal history, except for one attack of gonorrhea at twenty years. At twenty-one he began to suffer from what was diagnosticated as petit-mal, and was immediately placed on the bromides, which were gradually increased to one hundred and eighty grains daily. Two months after beginning this treatment he developed bromism with thickened speech, staggering gait and emaciation, but no somnolence. The bromides were continued in slowly diminishing doses, but these symptoms increased, and two and one-half months after the appearance of the bromism, were accompanied by hallucinations of hearing (people made slurring remarks about him), and three and onehalf months later by hallucinations of sight (people were seen dodging behind trees and strange men about the house). He then began to show mental apathy, thought and mental application became difficult, and he was suspicious of his surroundings, but gave no evidence of definite delusions. Meanwhile the bromides were continued in doses of about one hundred and fifty grains daily to the end of the sixth month, or the fourth month from the onset of bromism. At this time somnolence appeared for the first time, and food began to taste salty. The bromides were then withdrawn. After five days somnolence disappeared, but the hallucinations of sight and hearing, and delusions of persecution increased in intensity and definiteness. In the course of six days insomnia appeared, and there developed great fear as the result of constant hallucinations which impelled him to move restlessly about in search of persecutors or taking refuge from them. There were also hallucinations of smell and taste. At this time he was committed to our care. His consciousness was somewhat clouded, and he was partially disoriented for time, place, and persons. His memory was only moderately impaired, and that mostly for events occurring during the recent weeks. Mental action was very sluggish, and it required considerable time for him to recall well-known facts. He had very little control over his motions, frequently weeping, and at times crying when angry. His movements were slow and sluggish, and he rarely moved except in reaction to his numerous hallucinations. The physical symptoms of bromism had gradually increased during these four months until his speech became very thick and indistinct and his ataxia so pronounced that he could barely stand alone. There was also great muscular weakness. The deep reflexes were much exaggerated, the pupils widely dilated and reacted very sluggishly to light.. There was a considerable fine muscular tremor involving the extremities and the muscles of the face and tongue. The skin was pale and anemic, the breath typically bromic and the secretion of saliva greatly increased. The heart's action was feeble, the pulse rate increased and the arteries compressible. During the first week the patient became alarmingly weak and once fell into a state of collapse, from which he was revived with great difficulty. From the third week his physical condition improved gradually. In one month the speech had become more distinct, and the pupils normal, but the great muscular weakness and ataxia continued, necessitating his confinement in bed for three months. Mental improvement was also very gradual. At the end of two and one-half months after withdrawal of the bromides his consciousness had become clear and most delusions had disappeared. Hallucinations were still present mostly at night. He would say that women came into his room and prodded him in the buttocks to make him mad, that men filled his stockings with feces, etc. He overheard men say that he had murdered a colored boy and had better run to escape the police. At the end of the third month the hallucinations and fear had mostly disappeared, but he still remained languid and had no energy for mental application or desire for social intercourse. He retained only a partial memory for the events of his psychosis. His reflexes were still much exaggerated at this time, when he was removed from the hospital. The patient fully recovered in the course of five months from the time the bromides were withdrawn. The next patient was a woman, thirty-nine years of age, who developed epilepsy at the age of three, and from that time until thirty-two suffered from only nocturnal petit-mal. At thirty-two she had one severe seizure of the grandmal type, which necessitated her confinement in bed for five days. At thirty-nine again she had a series of seventeen convulsions of moderate severity, and following this an attack of influenza. The patient at this time and for some months previously had been taking "enormous doses of potassium bromide." Immediately following the influenza she developed hallucinations of sight and hearing with fear, at the same time showing a profound disturbance of nutrition with great loss of weight, and in the course of five weeks became stuporous. Meanwhile there appeared a characteristic bromide eruption and such marked ataxia and general muscular weakness that she was confined to bed. She was received at the hospital two weeks later, at which time the condition of stupor was pronounced; she was entirely unable to comprehend her surroundings, her responses to questions were mostly incoherent and irre |