DISCUSSION

Dr John H. McCassey, Dayton: Along the line of treatment outlined by the essayist I might relate an experience or two of mine while I was superintendent of the State Insane Asylum at Topeka, Kansas, that is, treatment by suggestion. These wrong ideas have gotten into the mind, and the treatment should consist in getting them out by putting in correct ideas. I found in a number of cases which I treated that the best treatment consisted in argument, simple argument with the patient in regard to their wrong ideas. I found that the more time I could give to a patient in arguing him out of his false ideas, providing he had intelligence enough to understand anything, and which they usually do at first, the quicker and better the results. Of course when the stage of dementia is reached such treatment is out of the question. I had one case of melancholia which came from a county in the western part of the State of Kansas. This patient who was a woman was under the impression that something awful was going to befall her, her husband and her children. In order to carry out this treatment certain conditions are necessary. In the first place the room in which the treatment is given must be of the proper temperature, the windows not opened sufficiently to admit noises, the arguments must be given by someone in whom the patient has confidence, and there must not be more than one or two persons present at that time. I had tried, in the case above referred to, to get the patient to sleep for three or four nights with large doses of chloral and bromide of potassium, but without effect. I decided to try the argumentative plan of treatment and went into the hall with a view of carrying out my idea. A nurse went with me, and when we entered the hall the patient came toward crying. I took her by the hand and walked into her room. I said, "My dear lady, you are a sick lady, and you have come here to be cured. I am the man who is going to cure you. In your home in Graham County your husband and your children have been out for a ride, it has been snowing, and they have come in and are sitting beside the fire getting warm. You are all getting sleepy and you cannot help it, you must go to sleep.' I assured her that all was well and that no evil had befallen her or her family, that she was in the hospital to be cured, and the thing to do was to quiet down, accept my argument that all was well, that after a few

us

nights' sleep she would recover and be able to go to her home before long. She rolled over and went to sleep (this was in the afternoon) and slept until supper time. I had to repeat that argument to her every day for a week and then she began to go to sleep for herself. She got well in four or five months and then went home.

Another case I had was a man from New York who had property out in Kansas. He became melancholic and got ideas into his head that real estate men were after it and had evil designs upon him. I carried out some such treatment as above outlined and the man recovered in a month. I might mention a number of such cases in which I applied this suggestive treatment with the greatest benefit to the patients, all of them recovering and returning home cured.

Dr R. H. Grube, Grape Grove: Science goes before art, and science has been trying for nearly a hundred years to break away from the dualism that has held our minds in bondage through so many ages. We no longer regard mind and matter as separate entities, but as different manifestations of the same entity. Bain has well expressed it by comparing them to the two sides of a coin. This being true, every case of insanity is but the expression of a pathologic change in the brain, and while the pathologists are not always able to find such changes, they are nevertheless there, and the time will come when they will be able to do so, and then we will be able to treat the insane by treating the diseased brain. More than that, I believe the time is coming when much of that which is now regarded as crime will be recognized and treated as the result of brain disease.

I am glad that I heard this paper, and I am glad also to say that I am heartily in accord with the spirit of it, and only regret that it was not much longer.

Dr Charles S. McDougall, Athens, closing Discussion: In my paper I did not intend to deal with the treatment of insanity, but mainly wished to call attention to the fact that scientific alienism has gotten beyond the old notion of insanity being purely a disorder of mind, and for it the credit was largely due Dr Charles Mercier, a protege of Hulings Jackson. His first work, The Nervous System and the Mind, intended as a corrollary and extension of Herbert Spencer's Principles of Psychology, was written after he began his work on Sanity and Insanity. This he deemed

essential, as he found in attempting to formulate the fundamental principles of a science of alienism, that the necessity of interposing a statement of the normal process whose disorder it is that constitutes insanity became so frequent that they destroyed the continuity of his text, consequently he wrote this work (mainly devoted to the association of mind and nervous action) as a foundation for his work on Sanity and Insanity. I think every physician that peruses these works (and I wish every physician in Ohio was familiar with them) would soon learn that the study of insanity has been brought within our comprehension.

Tuke, some years ago, stated in his work on Psychological Medicine, that it was not practical to suggest any definition of insanity free from objection, but in his last work, Dictionary of Psychological Medicine, Mercier's definition of insanity is given without reserve, and his works are commented on as a material advance in our knowledge of insanity.

Years of study and practical experience in the care and treatment of the insane have brought me to believe that alienism has advanced to the point that I am willing to go on record before this State Association as saying that the diagnosis of insanity can be worked out with almost mathematic certainty. Without being able to say why or how, but it is capable of inferential proof that consciousness accompanies only the workings of the higher nervous center and that these centers actuate conduct, and these centers must be disordered to have disordered consciousness and disordered conduct, and in this connection I will say a word or two in reference to treatment by suggestion, an argument as recommended by Dr McCassey. I am inclined to think in the case cited by the Doctor that the ride, the temperature of the room and the environments favorable to the hygiene of sleep had more to do with the production of sleep than did suggestion. You can no more argue an insane man out of his delusions than you can pick up your shadow from the ground and throw it away, and the disordered. consciousness will continue until the disordered centers resume their normal condition.

Sporadic Cretinism-with Report of Cases

BY J. P. DeWITT, M. D., CANTON

I wish to give a brief report of three cases of sporadic cretinism, or infantile myxedema occurring in my practice.

Dr Osler reports in the Transactions of the Congress of American Physicians and Surgeons, (Vol. IV.), that he was able to collect 60 cases in this country to May 1, 1897.

Many theories were formerly given as to the pathology and etiology of cretinism, but it is a proven fact that the degree of severity is due to the absence or disturbance of the function of the thyroid gland.

Osler says: "The diagnosis is easy after you have once seen a case or a good photograph of one."

Case I: Casper E., a male, white, American, aged 2 years and 4 months, measures 291⁄2 inches in height, weighs 221⁄2 pounds, and the abdomen measures 191⁄2 inches.

The mother was 38 years old and has always been healthy; the father was 40 years old and has never been sick; the grandparents are living and well, and there is no hereditary disease on either side of the family.

This is the eighth child; the other children are living and well. The labor was normal. The mother has a small goiter which she says appeared after the birth of this child.

The mother noticed that this child from birth was not like the other children, but the attending physician informed her that “it would outgrow it."

On further examination I found the skin all over the body to be thick, swollen, dry, cold, and scaly, and would not pit on pressure. Its color was a pale yellow. The hair was thin, coarse, straight, and brittle. The fontanelles were open. The abdomen was protuberant. The limbs were short and the skin laid in folds, and he made no effort at walking.

His hands and feet were pudgy and undeveloped. The nails were flat and brittle. There were pads of fat above his clavicles. I could not palpate the thyroid gland. The tongue was very large and swollen and protruded somewhat from the mouth (Marcroglossia). The nose was depressed between the eyes, and the nostrils were open. The eyelids and ears were puffy and swollen. His face presented a look of old age with a toad-like appearance.

He had a few teeth in front, but they were ragged and decayed to the gums. There was no perspiration and his mother could not keep him warm, but there was a constant drooling of saliva from his always-open mouth. His neck was short. His appetite was voracious, but all foods had to be put into his mouth, and he showed no desire for certain foods, but would not eat meats. He was usually constipated with occasional attacks of diarrhea.

His mental condition was undeveloped. He would not notice the other children at play, nor would he make any wants known. He has a peculiar sonorous voice and at night was restless and would creep over the bed, making monotonous noises.

Treatment with thyroid extract, one-half grain given three times a day, was commenced at the age of two years and four months, and the photograph shows him at the age of three years and ten months, or after one and a half year's treatment. Improvement was at once noticeable, the tongue becoming smaller