THE JOURNAL-LANCET
The Journal of the Minnesota State Medical Association
and Official Organ of the
North Dakota and South Dakota State Medical Associations
PUBLISHED TWICE A MONTH
VOL. XXXV Minneapolis, March 1, 1915 No. 5
* * * * *
FEEDING OF THE HEALTHY INFANT[1]
By E. J. Huenekens, A. B., M. D.
Instructor in Pediatrics, University of Minnesota
MINNEAPOLIS
[1] Read before the Hennepin County Medical Society, Nov. 2, 1914.
The science of infant-feeding has been revolutionized in the last
twenty years, and, in the process, it has advanced too radically in
many directions. Lately, the pendulum has been swinging backward, so
that the most advanced knowledge of today probably represents a middle
ground between extreme radicalism and extreme conservatism. In no other
direction is this more manifest than in the feeding intervals. The
religious adherence to the four-hour feeding interval is giving way
to a more rational system. I am one of the firmest adherents of the
longer interval: the food is better digested, the stomach has a period
of rest, and the general well-being of the infant is better furthered
than with more frequent feedings. But there are certain infants who
do not receive enough nourishment in this interval, especially young
breast-fed infants in whom it can be demonstrated by accurate weighing,
before and after nursing, that they receive considerably more milk
in twenty-four hours with the three-hour interval. This is the more
important in that Rosenstern has demonstrated that a large proportion
of infants up to the age of six weeks require more than the usual 100
calories per kilogram of body-weight. One hundred calories represents
150 grams of breast-milk, so that a five-kilo, or eleven-pound, baby
should receive a minimum of 750 c.c. of breast-milk in twenty-four
hours.
By far the best food for the healthy infant in every way--and this
cannot be emphasized too strongly--is mother’s milk. There are
certain alimentary disturbances in which it may be advisable to
replace breast-milk with certain artificially prepared foods, such,
for instance, as albumin milk in alimentary intoxication; but this is
never true of the normally healthy infant. While, as regards growth
and freedom from digestive disturbances, certain artificially prepared
foods may, when used with exceeding care, produce as good results as
breast-milk; nevertheless, this is only one function of breast-milk.
The other function which can be imparted to no artificial food is the
passive immunization of the child against infection. Ehrlich (_Zeit.
f. Hyg. u. Infectionskr._, 1892, xii, 183) has proved that antibodies,
antitoxin, and agglutinins are transmitted directly through the milk
from mother to child; and it has been shown that the blood of a
breast-fed child is considerably more bactericidal than the blood of a
bottle-fed infant.
The practice of weaning the baby for trivial reasons has increased in
the last decade, and can be laid largely at the door of the medical
profession. For all practical purposes the only absolute indication
for weaning the baby is open tuberculosis in the mother. For the last
few years I have been making a systematic inquiry at the University
Dispensary and Infant Welfare Stations as to reasons for weaning
young infants; and in nine cases out of ten, the answer has been that
“the milk gave out.” In only a very small proportion of cases has
an ordinarily well-nourished mother insufficient milk; far oftener
the fault lies with the child. Insufficient and late development of
the sucking reflex prevents these infants from completely emptying
the breast, which in time “dries up.” This period can be tided over
by nursing from both breasts, by temporarily increasing the number
of nursings, or temporarily employing “allaitement mixte.” In cases
in which, after long, patient effort the supply of milk is still
insufficient, either supplementary or complementary feeding of cow’s
milk can be given. Where this mixed feeding is employed a minimum
amount of cow’s milk should be given; and the opening in the nipple
should be as small as possible, otherwise the child gets too much cow’s
milk, and with too little effort, and gradually refuses the breast.
Another excuse, and one fostered to some extent by physicians, is, that
certain breast-milks are “poison for the baby.” This has even less
foundation in fact; and here again the fault must be looked for in the
baby rather than in the mother. Outside of certain variations in the
fat-content, all breast-milks are alike in composition. In proof of
this Finkelstein has fed these babies at the breast of tried wet-nurses
with absolutely no benefit, while the children of the wet-nurses would
thrive at the breast of the “poison-milk mother.”
Abscess of both breasts may force a temporary cessation of nursing,
but the breast should be regularly emptied until the inflammation has
subsided; and then the nursing should be re-established. Cracked or
sunken nipples may render nursing impossible, but they do not stop the
flow of milk. In both these latter conditions the milk may be manually
expressed or removed with the breast-pump. In this connection I wish to
recommend the improved Jaschke pump, in which, by means of a releasing
valve, the sucking movements of the child can be very closely imitated.
Where artificial feeding must be started early, cow’s milk is almost
universally employed. Whenever possible, “certified milk” should be
used; the ordinary milk, however, can be boiled with little or no
harm. In diluting and preparing this milk, we have the choice of
several methods. The so-called percentage feeding, favored in America,
is difficult and cumbersome, and has no advantages over its simpler
rivals. Pfaundler’s rule may be safely employed. It is as follows:
One-tenth body-weight of milk, one one-hundredth body-weight of sugar
diluted up to one liter; give 200 c.c. five times in twenty-four
hours. Even simpler is the following: One-third milk for the first
month, one-half for the second month, two-thirds for the third and
fourth months, each with the addition of 4 to 6 per cent sugar. Either
milk-sugar or ordinary granulated sugar may be employed. The malt
sugars and extracts should be reserved for sick children. After the
second month, oatmeal water may be used as a diluent in place of plain
water.
Recently Friedenthal, a Berlin physiologist, has attempted an exact
imitation of mother’s milk, including that important element, the
salt, which had, until recently, been entirely neglected. Langstein is
very enthusiastic over this milk as a food for healthy infants; but
Finkelstein, in a personal communication, assured me that it has not
as yet proved itself. Schloss, dissatisfied with the results of the
Friedenthal milk, has modified it in the direction of casein milk by
replacing the milk-sugar with the malt preparations, and increasing
the protein content. He claims good results, and is supported by
Leopold, of New York, who has used it extensively. But we must leave
the final word as to both these milks for the future to decide. From
the sixth to the ninth month for both breast-fed and bottle-fed
babies, cooked cereals, toast, and vegetables should be gradually
added to the diet. At the ninth month, unless this is one of the hot
summer months, the nursling should be weaned, and a small amount of
cow’s milk substituted. The weaning should be gradual by omitting one
nursing period each week. The one important exception to the foregoing
rules for the first year of life, is the premature infant. In the
ninth month of fetal life, reserves of calcium and iron are stored
up in the body, which the infant gradually uses up during the first
nine months of extra-uterine life. The premature infant lacks this
store, and manifests it in different ways. As early as the second or
third month a breast-fed premature infant may develop a most extensive
craniotabes. This is not due to a true rachitis, i.e., disturbance of
calcium metabolism, but to a want of calcium in the body. Small amounts
of cow’s milk, which contains much more calcium than human milk, or
calcium in the form of calcium lactate or chloride, will remedy this
condition. A similar process happens in the case of iron. The premature
infant is born with a hemoglobin percentage of 100 to 110; by the third
or fourth month this may sink to 40 per cent, and for this reason green
vegetables should be added to the diet as early as the fourth month.
The diet of healthy children in the second year should include cooked
cereals, vegetables, toast, cooked fruits, and meat-juices; and the
quantity of cow’s milk should be limited to one and one-half pints
in twenty-four hours. The question of the addition of meat to the
diet is important. Some authors have recently advocated the giving
of meat as early as the ninth month. During the past year, working
in Finkelstein’s laboratory, I have been able to gather some facts
which have a direct bearing on this question. (_Zeitschrift für
Kinderheilkunde_, July, 1914.) By means of the new electrometric
determination of absolute acidity (that is, the number of H ions), I
was able to show that the acidity of the stomach before the eighteenth
month of life is insufficient to permit any peptic, i. e., protein,
digestion. Solomon, working in the same clinic, in a report not yet
published, has shown the same thing from a clinical standpoint. He
found that on a meat diet up to the end of the second year large
quantities of muscle fibers passed through with the bowel-movement
unchanged; but after that age they rapidly decreased in number. It
is, therefore, worse than useless to add meat to the diet before the
beginning of the third year.
Eggs frequently produce profound disturbances in young infants,
perhaps on account of the absorption of egg albumin, unchanged, in the
blood-stream; and they should be kept from the diet-list until the
beginning of the fourth year.
These rules for feeding are generalized, and there may be many
exceptions. Each child is to some extent a law unto itself, and this is
especially true of those children with nervous or exudative diathesis.
In conclusion, I wish to make a plea for greater uniformity in our
rules for infant-feeding. Even more than in strictly medical affairs
has the public the right to demand information. Heretofore, every
new book and every public lecture on infant-feeding has deviated
markedly from its predecessors, until the confused laity, and even
general practitioners, have turned in disgust to proprietary foods and
formulas. Pediatrics is a new science, and as such is bound to undergo
rapid changes and conflicting opinions. But that need not hinder us
from agreeing on certain fundamental facts which can be given as guides
to the general practitioner and to the public.
I believe that the simple rules for infant-feeding here laid down
are neither too conservative nor too radical to serve as a basis
of agreement upon which the medical profession may show to the
public a united front on this important question. Such uniformity of
opinion--and the sooner it can be reached the better--will not fail to
have a beneficial effect on both the profession and the public.
DISCUSSION
Dr. Jacob Hvoslof: I would like to ask about the value of lime-water
added to the milk. I recently had an experience where I mixed an ounce
of lime-water to a pint of milk, as I thought that would improve it.
but for some reason or other the baby would not digest his milk. After
a while I left the lime-water out, and everything went well. Whether
this is a “post” or “propter” I should like to find out.
Dr. O. R. Bryant: In case of an exudative diathesis, where you
probably will start solids early, you will also be able to use meat
earlier. An infant that does well on solids at six months can probably
have meat once a day at fifteen months and show a normal stool.
Dr. S. R. Maxeiner: I would like to ask Dr. Huenekens where he classes
eggs and egg albumin.
Dr. C. G. Weston: I have been very much interested in Dr. Hueneken’s
paper. I care only for the babies during the three or four weeks after
birth; and of late years many of them have passed from me directly
into the hands of the pediatrists. I formerly had the babies nursed
every three hours, but finding that the baby specialist immediately,
on assuming charge, put them on the four-hour schedule, I changed,
about a year and a half ago, to that interval; and I thought my
troubles would cease, but such has not been the case, and it has been
my impression, as well as that of the nurses who have had the care of
the infants, that it has made very little difference.
The four-hour schedule is not a new thing in Minneapolis. Many of the
older members of this Society may remember that twenty years ago Dr.
R. O. Beard always fed his babies in this way.
It seems to me that we should make no hard and fast rules for the
feeding of babies, except the one that mother’s milk should be used
whenever possible. We should individualize with the babies. If they
do well on the four-hour schedule, follow it, as it makes the care of
the child easier for the mother; if, however, the child does not get
sufficient milk on this interval to properly nourish it, diminish the
latter to three hours.
The only way to accurately determine how much milk the nursing infant
is getting, is to weigh the baby before and after nursing. One is
often surprised at the varying amounts obtained by the same baby at
different nursings with no obvious difference in the condition of the
breasts. We have had a baby obtain as much as three ounces in the
first five minutes of nursing, and at the next feeding take only one
or one and a half ounces in twenty minutes.
The green and frequent stools, with evidences of colic, etc., are
often found to be due to too much milk, or taking it too rapidly; and
the weighing method is the only way to determine this.
I most heartily endorse what Dr. Huenekens said with reference to the
importance of encouraging in every way maternal nursing. Many a mother
gives up the attempt to nurse her baby on account of some soreness of
the nipples or because she has thought she had too little milk to be
of any use. Most of these cases may become, by the means recommended
by the reader, good milkers, and many a baby’s life may thus be saved.
Dr. E. K. Green: I would like to ask a question in regard to putting
babies on cow’s milk. I have adhered very closely to the principle
that modified cow’s milk is absolutely the best food for infants, if
it is impossible to get mother’s milk, but many times when I have had
the opportunity to follow these cases carefully I have had all sorts
of stomach and bowel disturbances on cow’s milk until someone would
suggest some other food, such as malted milk, or Mellin’s Food, or
even condensed milk, which seems to be the farthest from the natural
food, and then the babies would get along fairly well. Is this a
common experience, or is there something wrong with my method? We
have in our own home two children brought up on the bottle, one with
malted milk and the other with Mellin’s Food. In both these cases I
tried, not only once, but several times to use the modified cow’s
milk, but failed absolutely. I would like to know if you consider the
fault usually with the modified milk, or does the individual have
considerable to do with the case?
Dr. A. S. Fleming: I would like to ask if in the case of the healthy
infant the mother’s diet would modify the constituents of the milk
otherwise than in the facts stated. For instance, will it modify
the character of or the percentage of the sugar, or will any of the
aromatic constituents disturb the infant’s digestion?
Dr. M. J. Jensen: Dr. Huenekens dealt with the feeding of the healthy
infant only. I would like to ask if it is not true that nearly all
infants born alive, are born as healthy and sound as any infant
ever is, so far as the functions of its organs and tissues are
concerned? Nature frequently decides on producing premature births
and “still”-births, rather than running the risk of producing a sick
or sickly infant. In young infants it is very often difficult to
determine when to classify them as healthy or unhealthy, realizing the
conditions of their environment and usual care that is given in the
homes.
In regard to the sterilization or boiling of cow’s milk: I do not
think that children fed on pasteurized or boiled milk develop as well
as those who are fed upon raw milk as it comes from the cow. Dr.
Palmer, of Chicago, fed seven hundred children on raw milk during the
midsummer months and only lost three of the number. The miserable,
atrophied children began to live the moment treatment with raw milk
was begun. If the process of milking was carried out in a sanitary
manner, or by means of a suction apparatus, then cooled, and placed
in sterilized bottles, I believe we would prohibit the development
of bacteria, and save the food which exerts so marked a protective
influence upon the infant’s organs.
When raw milk free of all objections cannot be obtained, it is
sometimes advisable to use another milk product namely, buttermilk.
Dr. S. Marx White: There is just one point I have been thinking about
in the discussion on the question of infant-feeding, and that is
whether Dr. Huenekens really means us to believe that in practically
all cases the mother can furnish sufficient milk for the child. He
passed that over in saying that in nine out of ten cases the mother
gave as a reason for discontinuing the milk that the milk gave out. Is
it not true that in a good many instances the mother needs treatment
quite as much as the infant? I do not mean medical treatment, but
management. Is it not true that an overworked, tired, nervous,
worrying mother is unable to supply sufficient milk for the child? It
has been my impression from a very limited experience in this field,
that the mental and nervous and physical state of the mother is a
very large factor in the production of the milk. When upset and under
deleterious influences she is really not a proper producer for the
child; and the management of the mother is often quite as important a
factor as any other.
Dr. W. H. Aurand: In such cases as Dr. White just mentioned, what are
we going to do to increase the supply of milk? Also, I would like to
ask Dr. Huenekens if he means to feed to the new-born baby 200 c.c. at
a feeding?
Dr. Huenekens (closing): As regards lime-water: I cannot recommend its
use. Wherever there is a specific demand for calcium, as in premature
infants or spasmophilic cases; or where it may help to produce a firm
stool; or, as in diarrheal disturbances, it may be of great value, but
in the normal healthy infant it is of no benefit whatever.
Dr. Bryant mentioned the giving of meat in exudative diathesis: His
statement that such infants can probably have meat once a day at
fifteen months, and show normal stools, is beside the question. A
normal macroscopic stool does not necessarily mean that the meat has
been digested. However, I am now working on this problem, that is, to
determine whether an early solid diet produces an earlier digestion of
meat.
I would classify eggs and egg albumin as proteins, and therefore
not digestible until the beginning of the third year: but, over and
above this, there is danger of anaphylaxis from the absorption of the
unchanged egg albumin into the blood-stream.
What Dr. Weston says of the feeding intervals is very interesting. I
do not want to be considered an enemy of the four-hour feeding, for I
use it wherever possible, and I think it the best interval; but when
the infant cannot get enough in that period, we have to choose between
two evils. I think the lesser evil is to give the child more milk at
shorter intervals, and take the risk of a slightly poorer digestion.
We should, also, wherever possible, control the amount of breast-milk
by weighing the child before and after nursing. It is highly important
to determine whether the baby is getting too much or too little.
As to Dr. Green’s statement, “Modified milk” is a very general term.
What is usually meant is milk with a high percentage of fat and a
low percentage of sugar, while malted and condensed milk have a high
percentage of carbohydrate. In my opinion, if he had used cow’s milk
without the addition of cream and with large amounts of cane sugar, he
would not have had this trouble. But a large number of children will
not do well on this diet. We have special rules for abnormal children
with exudative and nervous diathesis.
In reply to Dr. Fleming’s question regarding the mother’s diet and
its effect on her milk: What the mother eats has absolutely no effect
on the composition of the milk in any way whatever, except perhaps
in the percentage of fat. Now-a-days we do not advise any particular
foods for the mother’s diet,--anything she likes, and can digest, plus
large quantities of fluid;--otherwise there is no single food we
advocate--none that will make the milk richer or better, or increase
the quantity.
I cannot agree with Dr. Jensen that raw milk is so far superior
to boiled milk. Of course, wherever it is possible, we should use
certified milk, which does not require boiling; but, if we have
inferior cow’s milk contaminated with bacteria, we can boil the milk
with very little harm. It is just as well digested, and the food value
just as great. There is of course slight danger of scurvy; but that is
very easily diagnosed, and very easily cured by a little fresh milk or
small doses of orange juice. Where we have inferior milk, it should be
boiled in every case.
Dr. White brought up a very interesting point in regard to nervous
mothers. Their milk supply is subject to wide fluctuations; but,
if the breasts are well emptied at each nursing, they will secrete
sufficient milk. I will admit that these cases are difficult to
handle, for the infants usually have nervous diathesis, and do
not respond well to ordinary food. The one important point is to
completely empty the breasts; and that is the only measure we can take
to increase the supply of milk.
In reply to Dr. Aurand: I would feed a new-born infant 200 c.c. at a
feeding if the milk is sufficiently diluted. The liquid part of the
food passes very quickly into the duodenum, so that, before the infant
has finished feeding, a part of this quantity has already left the
stomach.
In conclusion: We have an opportunity in our infant-feeding to
practice the really scientific prophylactic medicine of the future.
We can do more in preventing infant-mortality by proper feeding than
by any other single measure; and we should encourage mothers to bring
their new-born infants to the physician for advice on feeding, and
to continue to consult him at longer or shorter intervals during the
whole of the first year of life.
THE INEBRIATE[2]
By George H. Freeman, M. D.
Superintendent of the Minnesota State Hospital for Inebriates
WILLMAR, MINNESOTA
[2] Read at the 46th annual meeting of the Minnesota State Medical
Association, St. Paul, October 1 and 2, 1914.
The Minnesota Legislature of 1907 passed a bill establishing the
Hospital Farm for Inebriates, placing its management under the State
Board of Control, and providing for its maintenance by setting aside
2 per cent of the saloon-license money for that purpose. Later, a law
was enacted providing for the issuance of certificates of indebtedness;
and active construction work soon commenced. The Hospital was opened
on Dec. 26, 1912, with Dr. Tomlinson, formerly Superintendent of the
St. Peter State Hospital, at its head. Through his untimely death, five
months later, Minnesota lost one of her most faithful officials. The
principles underlying the work at Willmar, are, with but slight change,
those that he so earnestly advocated.
This paper is based upon the study of the patients admitted from the
opening of the Hospital until the close of the biennial period, on July
31, 1914,--approximately eighteen months.
Patients are admitted to the Hospital following an examination in a
probate court. In such cases there is no expense to the patient’s
relatives, except that they are expected to furnish clothing, and a
little money for the purchase of tobacco and small luxuries. Voluntary
patients are also received following their own application in a probate
court. They pay at the rate of $1.00 a day, each month in advance. No
distinction is made in the treatment of the two classes of patients,
except that a voluntary patient cannot be detained if he wishes to
leave. Any resident of Minnesota who is habitually addicted to the use
of alcohol, morphine, cocaine, or other narcotics, may be admitted to
the institution, provided the history of the patient, as furnished by
a probate court, indicates that the man can be benefited by treatment.
It is presumed that anyone can be benefited who wants to be, unless
afflicted with irremediable chronic disease.
The requirement that the history be furnished, and the ability to
refuse admission, have kept out of the Hospital many undesirable
individuals who could be cared for only under the discipline of a
well-regulated reformatory. However, some, no matter how carefully the
history is taken, slip by. The majority of those discharged as not
proper subjects, come from that class. As there are no accommodations
for individuals suffering with tuberculosis, no one known to be
suffering with that disease is admitted. Once in a while a tuberculosis
individual gains admittance, but, if not too ill to be released, he is
discharged.
During the eighteen-month period, 209 men and 32 women were regularly
committed; and 18 men and 3 women were received as voluntary patients.
In addition to those classified as voluntary patients, a considerable
number have, of their own volition, applied for treatment, and,
being unable to pay, have submitted to commitment, in order to obtain
treatment for their habit.
There has been a fairly uniform increase in the number of patients
received each month, which is gratifying, as showing the need of such
an institution and also as an appreciation of the benefit that may be
expected. During the last month of the period, twenty-five patients
were admitted.
While the causes of inebriety are diverse, it is a significant fact
that 182 patients, out of 262, assign associates as their reason for
drinking; and observation of their history clearly shows that they
have drifted along, drinking now and then and more and more each year.
A few assign illness, domestic trouble, or financial worry as a cause
for drinking. In only 6 instances was heredity noted. In 132 cases the
parents were abstainers.
We have found it impossible to formulate any system of classification
of the unfortunates under our care. In order that some idea may be
obtained as to the number using alcohol and the various drugs, we have
constructed the following table:
FORMS OF INEBRIETY
Men Women
Steady drinkers 130 2
Periodical drinkers 76 8
Morphinism 3 11
Alcohol-morphine 5 2
Alcohol-cocaine 3 ..
Alcohol-heroin 3 ..
Alcohol-morphine-cocaine 3 1
Alcohol-morphine-cocaine-heroin 1 ..
Alcohol-morphine-veronal 1 ..
Morphine-cocaine .. 1
Morphine-cocaine-heroin 2 ..
--- --
Total 227 35
The treatment of the inebriate naturally divides itself into two
stages: the treatment, first, of the immediate effects of indulgence,
and, second, such treatment as will tend to prevent a repetition of
the indulgence. The treatment of the immediate effect of alcoholic
indulgence is regarded as the easiest part of the work. While patients
are at times received under the influence of intoxicants, in no case
have they been unruly. For an obstreperous intoxicated person the
quickest soberer is apomorphine judiciously used; but we have never yet
resorted to it. Generally, a fairly rapid reduction in the amount of
alcohol consumed is made, instead of immediate withdrawal. Only in the
most exceptional cases is alcohol given over three or four days. As a
rule, during the first day it is given fairly freely. The treatment
received during this period depends entirely upon the individual; and
the treatment of one may be entirely different from that of another.
Many receive baths at a temperature of 98° to 100° F. for thirty or
sixty minutes for nervousness and sleeplessness. Some receive the
coal-tar hypnotics, veronal or sulphonal; the more restless, hyoscine;
and for others paraldehyde is used,--and occasionally chloral is used
in combination with hyoscine and cannabis indica.
As long as he receives alcohol, the patient remains in bed and receives
only liquid diet. In cases of considerable digestive disturbance,
capsicum is freely used, but we have seldom found it necessary.
All receive preliminary catharsis, but no attempt is made at prolonged
elimination in that way.
For about a month tonic treatment with strychnine nitrate is used in
doses of 1-20 to 1-40 gr. three times a day. Any other medication
depends entirely upon the physical condition of the patient as revealed
on examination. Only under the most exceptional circumstances are drugs
given in alcoholic vehicle.
In morphine or cocaine users, the reduction is usually made more
gradually, requiring a week to ten days. Generally, we find a patient
comfortable with one-half the drug he has been accustomed to taking.
In some cases we find it best to reduce the quantity to about one-half
grain, and then abruptly cease.
Under this plan, diarrhea, cramps, restlessness, and insomnia are much
less marked. We regard the free use of the prolonged warm bath as more
advantageous to those addicted to drugs than to alcohol. Generally, it
is the only measure that seems to offer relief. We particularly do not
use hypodermic medication in any drug users.
Heroin users, who seemingly are more numerous, receive their drug only
once in twenty-four hours. The withdrawal of the drug does not cause
the discomfort that the withdrawal of morphine causes. Vague sensations
of discomfort, some perspiration, and insomnia are met with in such
cases.
No users of cocaine only have been met with, but in mixed forms this
drug is at once withdrawn.
The removal of alcohol or drugs is the easiest part of the work.
Under the regular discipline of the institution, and the absence of
temptation, the great majority of patients get along without any
trouble because of abstinence. But there is the future to fear. The
patient must go out into the world again, and engage in the daily
struggle for his livelihood. One must aim to put him in such condition
that he may be able to resist the temptations that will surround him on
every hand. Our work, then, is to build up and re-educate, to strive
to form a new character, to encourage a habit of sobriety, instead of
drunkenness, to teach the man to work, to occupy himself, to obtain for
him a new outlook on life, and to teach him his duty to himself, to
his family, and to his neighbor. Here is where our difficulty begins.
Nearly every inebriate has a firm belief in his ability to abstain
from alcohol or drugs at any time and under any condition, because he
thinks he is not really responsible for the condition into which he has
fallen, and that, had not certain things happened, he would not have
been drinking.
He is insistent in iterating and reiterating that he has now made
up his mind to stop drinking, and that is all that is necessary.
Though admitting that, for five, ten, or fifteen years, he has been
going steadily downward, he has full confidence in himself, and he
believes injustice is being done him when his parole is refused and he
learns that he is expected to remain until he has strength to resist
temptation.
In this upbuilding of body and character the following are essential:
regularity of habits, discipline, work, food, and recreation, together
with the personal influence of the physician and those coming into
close and personal contact with the patient.
Regular work is one of the most valuable of the remedial agents at
our command. It should be suited to the individual, and, as a rule,
should not be that to which the man has been accustomed. Particularly
is this true of the man who is used to mental labor only,--the clerk,
the physician, the pharmacist, the merchant, etc. For them out-of-door
work on the farm, lawn, or in the garden, is the very best, and next
comes indoor shop-work. We must provide something that engages time and
attention, that provides some new outlook upon life, and enlarges some
field of endeavor in which the patient has labored before coming to the
Hospital. Thus far the work has been on the farm or the improvement
of the grounds, or has been carpenter, cement, or some construction
work. The women do all the mending, and make all needed articles, such
as bedding, towels, etc. They also work in the laundry. At present we
are teaching embroidery of various kinds, no one of our patients having
ever learned any such work.
The future must see us provided with shops, especially for winter work.
With a capacity of ninety-nine men we are able to keep them fairly well
occupied during the winter months, but any increase will have to be
cared for under special conditions.
A very important factor is the length of time, as mentioned above under
prognosis, that a patient remains under care. As a general thing, it
is expected that the average patient will remain, approximately, six
months. The period of detention is determined only after a study of
the individual. An endeavor is made to consider all factors that may
influence the future life of the patient,--the length of time and the
amount he has been drinking, the effect on his character and physical
health, the surroundings and occupation to which he must return. Some
patients are paroled at the end of six months, some remain seven
months. Drug users require treatment for a much longer period of time
than users of liquor; and they remain from nine months to a year. The
law provides that a patient shall not be paroled in less than two
months, nor shall he be detained longer than two years without parole.
This, of course, introduces the disagreeable aspect of the work. The
detention is compulsory; and in some patients antagonism possibly
over-balances the benefit of detention.
“One of the most pronounced features of inebriety is, however, the
inability of many inebriates to appreciate the necessity for treatment;
and the more severe the inebriety, the less easy it is first to get the
patient under treatment at all, and, secondly, to get him to remain
long enough for any treatment to have a permanent curative effect. One
has only to work among inebriates, no matter to what class of society
they belong, to know that fear of interfering with the liberty of a
subject who has no real liberty, in that he is a slave habitually or
periodically to the drink craze, results in the interference with the
liberty of all those who have to put up with his irresponsible behavior
under the influence of alcohol and other narcotic drugs.
“Were the treatment of the inebriate only possible in a free
sanatorium, only a small minority of inebriates would come under
treatment at all, and these would be of the less severe type.”
(Pathological Inebriety, by J. W. Ashley Cooper, 1913.)
Discipline is of great importance, but great care must be taken in its
enforcement. It is of more value for one to perform a certain duty
because one regards it either as the proper thing or as likely to
benefit one’s self or others.
The personal influence of those who come into close contact with the
inebriate can hardly be overestimated. He is easily influenced, often
easily led, and a few thoughtless words or careless actions can undo
the result of patient work.
All factors that may influence the future life of the patient must be
taken into consideration,--the length of time and amount he has been
drinking, the effect on his physical health and character, and the
surroundings and occupation to which he must return. Very often the
cause of the commencement of the patient’s excessive drinking may be
removed or may have disappeared. Such would favorably influence the
prognosis.
The presence or absence of irremediable disease is important. For
instance, a woman recently committed to our care suffered from what was
supposed to be, or was, neuralgia. She still has occasional twinges of
pain; but we believe when the dentist has finished his work these will
disappear, and her prospect be reasonably bright. A man, 56 years of
age, four years ago, suffering from stone in the bladder, was given
morphine, following an operation. The bladder condition was permanently
relieved, but he became a morphine user. Such a case is a promising
one. In him the destruction of character is but little marked.
A boy, chasing around the city, acquired the cocaine habit, and became
a loafer, drinker, and follower of loose women. For him the future
offers practically no prospect. Were he a little younger, and had the
attempt to rescue him been made earlier, there would have been much
more promise. But I doubt whether he can withstand the lure of his
former life. With a few drinks, his judgment becomes paralyzed, and he
is back to cocaine again.
Another man, an alcoholic, a printer, became nervous and exhausted
after six months of linotype work. He probably will not get over his
drinking permanently unless he changes his occupation.
One of the most important factors as regards recovery is the length of
time a patient remains at the Hospital. It is sheer folly to expect
that in a few short weeks a man shall have entirely recovered from the
effect of excesses extending over a period of years, to expect him to
regain a lost will power in that time.
Another important factor is the insight a patient obtains into his
own condition. We cannot claim to make a man stop drinking. All we
can do, is to place him in such mental and physical health that it is
unnecessary for him to resort to stimulants.
RESULTS
The result of treatment in a disease of the nature of inebriety, can
hardly be estimated in such time as the Hospital has been open. Our
statistics are simply offered to show possibilities. As the statute
under which the Hospital operates, contemplates a period of detention
and treatment for not less than two months,--and that period is even
too short in the vast majority of cases,--anyone resident in the
Hospital for less than two months has been placed in a separate class,
and we can learn that only two of these are doing well. Of 172 men,
aside from those who have been discharged as not proper subjects, 54
were paroled, of whom 37, or 68 per cent, are reported as doing well,
27 were released under bond, of whom 17, or 63 per cent, are reporting.
Over one-half of the voluntary patients are reporting.
Averaging all, we find 57 reporting as doing well; 30 fail to report;
29 are escaped, and we can learn nothing of them; and 56 were here less
than two months, 38 of these being escaped; 7 voluntary patients; and
8 were released under bond. A percentage of abstainers of 25, is to be
regarded as most excellent; and as one-third of those who have left
here are still abstaining, the greater number of failures occurring in
the first month, the outlook for the future is very encouraging.
So far, we have been speaking of what we are trying to do for the more
hopeful class of patients. But what are we to do in the future with the
incurable, the recidivists? Are we to send them back into the world
time and again, let them abuse themselves, perchance their families,
and let them be, as it were, a constant menace to society? No, society
has a right to protect itself and to protect an individual against
himself. There should be provision made for this class. They should
be cared for in an institution under strict discipline, and made to
support themselves there and to contribute to the support of those who
may be dependent upon them.
As soon as considerable numbers are received at an institution, the
more apparent becomes the need of means for classification, especially
as to character. It is decidedly unwise to allow the intermingling of
the young lad who has just commenced to drink, with the incorrigible or
the sodden, whose every thought may lie bestial.
The most practical means of classification is by the use of cottages;
and it is on that plan that Minnesota’s institution has been started.
If two cottages were built at Willmar we should be able to make four
groups of patients with decided advantage to our inmates. Not more than
forty inmates should be cared for in each cottage: and I am strongly in
favor of separate rooms for sleeping-quarters, instead of dormitories.
SUMMARY
The essential in the treatment of the inebriate as we meet him, is
upbuilding of body and character, which requires time, and in which
drugs play only a small part.
Compulsory abstinence is of great value if we expect to care for a
majority of the inebriates.
It would be wise for the State to undertake the custody, care and
control of all non-criminal inebriates in one institution, provided
adequate facilities for classification were available.
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.