THE INEBRIATE[2]
By George H. Freeman, M. D.Superintendent of the Minnesota State Hospital for InebriatesWILLMAR, MINNESOTA
[2]Read at the 46th annual meeting of the Minnesota State Medical Association, St. Paul, October 1 and 2, 1914.
[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, oftheir 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:
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 minorityof 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.
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.
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.
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 withDr. 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 curesdisease. I find that the Towne-Lambert treatment is an excellentmentaltreatment 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 thishospital 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.
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 withDr. 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 curesdisease. I find that the Towne-Lambert treatment is an excellentmentaltreatment 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 thishospital 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.