DISCUSSION

Dr. C. R. Ball (St. Paul): I have been very much interested this afternoon in this symposium on the treatment of fractures, the last word in obstetrics, and the inebriate, only it seems to me the Program Committee put the cart before the horse, and should have put the inebriate first, and the other things would naturally follow afterwards.

Dr. Freeman has splendidly presented his work and results at the Willmar institution. It is a subject to which I think medical men pay too little attention. I have more and more come to look upon the inebriate as a type of nervous disease and, in the great majority of cases, a functional nervous disease. It may be classified as we classify nervous diseases. We classify in one way functional nervous diseases as to their cause,—acquired, hereditary and acquired, or wholly hereditary.

The inebriate may be also classed in the same way. There are perhaps a few cases in which the habit of taking alcohol is absolutely acquired, but they are comparatively few. There are also a few cases of nervous prostration or functional nervous conditions from overwork, from a depleted condition, where the nervous condition comes on; and we may say it is acquired, and the prognosis in both of these cases is good. It requires but little effort to put them on their feet. Then we have that larger class of neurasthenic or functional nervous conditions, belonging to the second group, in which the nervous disease, as well as the inebriety, is partially acquired and partially hereditary. There is a large class here. They have an unstable nervous system, and whether they drink or break down depends a great deal upon the environment and physical condition. This type of inebriate must be treated along the same broad lines that we treat a person who is a neurasthenic, who is subject to repeated nervous breakdowns.

There is another type which, unfortunately, is rather large; and this is the wholly hereditary, and in this type we may classify the dipsomaniac. I have looked for a long time upon dipsomania as a periodical nervous disturbance, similar to periodical attacks of migraine or epilepsy, or periodical attacks of insanity. Often where a son is an inebriate we find a history of migraine in the mother. Very often there is insanity, and very often there is epilepsy, so that when we come to consider the dipsomaniac we have a tremendous problem. He does not drink for the fun of it, but chiefly because of mental depression, mental restlessness, which is so great that he turns to alcohol to buoy up his spirits and get rid of the feeling which rather than suffer with, he would often prefer to die. I have a man of that description who came to me, and said that at a certain time he became depressed and suspicious, began to hate himself, went along the back streets, absented himself from his usual associates, and always did this at the beginning of his drinking bout. That is the case with all dipsomaniacs. It is a disease similar to epilepsy, and our success in treating this type is just about as good as in treating epilepsy. It is not the alcohol: it is an inherited condition; it is a periodical nervous disturbance, just as epilepsy and migraine are.

We hear a great deal about the prevention of tuberculosis, and much is done to prevent it. I think we hear much more about the evil effects of syphilis than of alcohol, but, in my experience, I would place alcohol at the top of the list as being the most damaging both to the individual himself and to his offspring. We have heard a great deal about the effect on the offspring. In my clinic at the Free Dispensary I have many epileptic children, and I should say in sixty per cent of the cases one parent is an alcoholic. An address of Dr. Rogers, of Faribault, with reference to the ill effects of one intoxication, when a conception occurs during that time, put the subject of drinking before me in a new light. Much interesting experimentation has within recent years been done with rabbits and guinea-pigs to show the harmful effect of a single dose of alcohol given to either the male or female parent before conception, on the after-coming litter.

Not long ago I read an article by some man in New York in which he stated he had traced seven cases of epilepsy to the evil results of a single intoxication in seven different parents. That was something rather new to me, as I thought, in order to get the bad effects, on the descendants, of alcohol, it was necessary to be a chronic alcoholic, and I believe very few of the laity understand that, if conception happens to occur during one drunk, the parent being otherwise a temperate person, the ill effects may be visited on the offspring to as great an extent as if the parent were a chronic inebriate. These are some of the things which would do good if given publicity.

In regard to the treatment: I can fully agree with Dr. Freeman in everything he has said. There is certainly no specific when you come to consider the nature of the trouble. The treatment must be carried along the same general lines of physical and moral upbuilding as those we seek to follow in functional nervous disease.

Dr. W. A. Jones (Minneapolis): I wonder how many members of the State Association have visited the hospital for inebriates at Willmar. I would like to ask all those who have, to hold up their hands. Five or six of this audience, representing the twelve hundred doctors belonging to this Association. That gives one a fair estimate of those familiar with the State farm for inebriates. I should like to know further how many members of the legislature have visited this institution, and how many have tried to condemn it or perhaps to take it for a tuberculosis hospital. That is what they will do unless we physicians stand by Dr. Freeman and the institution.

There is too much sentiment, too much sympathy among friends, relatives, courts, juries, and charity workers, as to the inebriate; but once he gets to Willmar and is under a proper regimen, his attitude changes totally toward himself and toward the world. After one has watched the treatment at Willmar and has seen the benefit these patients derive, he wonders why so many women and so many men are sent to quack institutions for inebriety and drug habits. Willmar costs the patient practically nothing, except a small per capita borne by the State. The average quack institution charges $150.00 for a cure, so called, whether the cure lasts for three days, or, as in some of the more conservative (?) quack institutions, the period is extended to ten days, and in the notoriously drink-habit cures, to thirty days. This ought to appeal to a doctor forcibly, inasmuch as all these claims of cures made by quack institutions are limited to thirty days at the outside, an absolutely absurd statement, and, for that reason, if for none other, we should all support and entertain anything that tends to increase the efficiency of the State farm for inebriates at Willmar.

One thing which Dr. Freeman wants to emphasize is the necessity at times of forcible restraint in a building especially constructed for detention cases. There is a small class of people who are, perhaps, suffering from a disease state, who are irresponsible. Most of them are common drunkards, who create all sorts of disturbances and who really need discipline—who need to be detained forcibly for a sufficient length of time to enable them to recover their normal physical tone, and until they recover something of their natural mental tone. If this could be incorporated in the rules and regulations of the governing body of the inebriate farm it would make a great increase in the total number of improvements and recoveries.

Dr. Freeman has emphasized the necessity of getting the physical condition up to a high point. He has said all that is really needed on the subject. I believe drugs and drink should be reduced rapidly in almost every case. If you look over some of the literature of some institutions that take these people, you will find they reduce the morphine down from fifty grains to forty, and then to thirty-nine, until, finally, after a period of so many weeks or months, they cut it down to the two-hundredth of a grain, and give it hypodermically. You can readily see the absurdity of that treatment. The average man can have the total reduction made within thirty-six or forty-eight hours.

I hope you will take more interest in the inebriate farm, and see that your legislator is interested as well.

Dr. Haldor Sneve (St. Paul): I have listened with a great deal of pleasure to Dr. Freeman’s paper, and especially because there are some statistics as to what can be accomplished in such an institution even in a comparatively short time. Personally, I think that six months as an average time to stay in this institution would be too short. It will be found, however, in time, whether this is true, but just now the institution is in the experimental trial stage.

A great many legislators are, as Dr. Jones said, trying to convert this institution either into an insane asylum or a tuberculosis sanatorium; and it is up to the profession of the state to back up the establishment of this institution for the treatment of a class which is growing.

Personally, I think drink is a vice and not a disease, and until we can eradicate from the minds of the laity and from the minds of some physicians the idea that a man who drinks is some sort of a nervous invalid, the sooner we shall get better results in the handling of this question. Even the dipsomaniac has periodic brain-storms, which Dr. Ball has likened to attacks of migraine; that is a good simile, they do not always take to drink, but go off in other ways.

I have treated from twenty to fifty cases of delirium tremens at the City Hospital every year for twenty years, and I have had considerable experience in institutions; and yet I cannot find anything to criticize about the principles of treatment that Dr. Freeman has put forth here today. The idea in the minds of the laity is that inebriety is a disease, and they want drugs for it to make them well, and that is one reason why so many patients go to Keeley cures and get well. They go there because they find a drug that cures disease. I find that the Towne-Lambert treatment is an excellent mental treatment for the inebriate in private practice. It can be used in the institution at Willmar, as well as in private practice, and putting a patient upon the Towne-Lambert treatment satisfies his desire to cure the disease he is suffering from.

I think the profession will have to keep their eyes on the legislators, perhaps on the new governor, and see that this institution is not thrown into the waste-basket, so to speak, or converted into some other sort of institution, because we need a place of this kind. Even if Minnesota can go prohibition pretty soon—and I rather think it will—we shall not get rid of our drunkards for that reason. We shall still have to have a hospital for the treatment of the morphine, cocaine, and alcoholic habits. The doctors who send patients to Willmar, I think, ought to be careful, and not try to help some municipality out of taking care of old battered hulks, who cannot hope to recover, who cannot be made well simply because they have been drinking for so many years, and their other habits of life have resulted in such a deterioration of the brain that there is no possibility of bringing them back and making really good citizens of them. Those patients should be kept in a work-house or in a special department at Willmar or some other place. We should try to reclaim all of our young men and young women habitues.

Owing to the absence of proper writeups about this hospital it is not generally known throughout the state that pay-patients can be received and treated just as in any sanitarium and at very moderate rates.

Dr. Freeman (closing): I really have nothing to add in closing except to say a word with regard to prohibition. I have a second-hand statement from the police of one of the Twin Cities that he is positive in his city there are five thousand drug-users from his experience in the police court.

With regard to the maintenance of discipline at the institution: We have sufficient law or authority for discipline, but we have not the facilities. The thing in my opinion that we mostly require is a building where we can take care of a man who is incorrigible, or a man who runs away. For two reasons: In the first place, I have known a number of men who came there unwillingly, who later were greatly benefited by their compulsory stay; second, the effect of disciplinary measures upon the population in general. If a man knows that, when he goes there, he must stay, he naturally gets over his constant thought that he is going to sneak away, and put it over. The custodial cottage to take care of forty people would allow, in all, four classes of patients. We should have a reception-ward in which to examine all new patients; one ward for the incorrigible; and we should have two other places to care for two classes of men received. This would prevent the influence of the older men who have gone further in their habits upon the young boy who has just started.

DIAGNOSIS OF INTRACRANIAL COMPLICATIONS IN DISEASES OF THE MIDDLE EAR AND ACCESSORY SINUSES OF THE NOSE [3]

By Joseph C. Beck, M. D.
CHICAGO.

[3] Read before the Sioux Valley Medical Association, July 22, 1914, and published in these columns at the request of the Association.

The most important causes of intracranial complication from the middle ear and nasal accessory sinuses, are suppurations, consequently I shall confine my remarks to that subject, and not take up the neoplasms, trauma, etc.

In the diagnosis it is most important to recognize suppurative disease of the ear and sinuses, but this subject is not within the province of this paper, therefore I shall satisfy myself by mentioning only that the presence of the pus from the middle ear and nose, and Röntgenographic examination, are the most important signs of affections of these structures. The one symptom more than any other on the part of the patient of a threatening extension into the cranial cavity, is localized pain or headache, which is very persistent, instead of periodic. Especially important is this in connection with the cessation or diminution of the discharge. The knowledge of the pathological change present in the sinuses and middle ear and mastoid, is of additional value as, for instance, tuberculosis, syphilis, and cholesteatoma.

The frequency of intracranial complication in suppuration of the middle ear is much greater than that following sinus disease, about twenty-five to one in my experience.

The intracranial complications which I shall consider are—

  1. Meningitis.
  2. Sinus thrombosis.
  3. Brain abscess.

The meningitis may be serous or suppurative, and later localized or diffuse.

The sinus thrombosis may be partial or parietal, and complete with or without involvement of the jugular bulb and vein. The brain abscess may be extradural or genuine within the brain substance proper. The complications may be further divided as to bacteriologic or etiologic factors as, for instance—

These complications may arise following acute, or chronic and acute, exacerbation of chronic suppuration of the ear and sinuses. Meningitis and sinus thrombosis (this latter condition is very frequently associated with a localized meningitis) are usually complications following acute, or acute exacerbation of chronic, suppuration of the ear and sinuses. Brain abscess, however, is most frequently associated with the chronic form of the ear and sinus disease; but these become more manifest following an acute attack of ear or sinus trouble. Tubercular or syphilitic meningitis is chronic inflammation per se; but these conditions are also lit up by the acute processes within the ear and sinuses.

The cardinal symptoms of any intracranial complications are—

1. Pain or headache.—This may be localized or diffuse; it is, however, very persistent and quite intense. It is in the recognition of this symptom that has helped me more than any other in suspecting intracranial trouble.

2. Nausea and vomiting.—This symptom is quite constant, especially early in the disease; and projectile vomiting is quite characteristic of intracranial pressure or irritation.

3. General septic appearance.—This of course will vary in the different conditions under consideration, but in all is it quite manifest.

4. The vision is very frequently affected due to the choked disk that is present.

5. Temperature, pulse, and respiration are very frequently disturbed.

6. Definite focal symptoms of brain localization are of the utmost importance in the diagnosis.

7. Blood and spinal fluid examinations give very valuable information.

8. Röntgenographic findings are at times valuable.

9. Exploratory operation and treatment, as in lues, is at times necessary to make a diagnosis.