The Project Gutenberg eBook of The Journal-Lancet, Vol. XXXV, No. 5, March 1, 1915, by Various This eBook is for the use of anyone anywhere in the United States and most other parts of the world at no cost and with almost no restrictions whatsoever. You may copy it, give it away or re-use it under the terms of the Project Gutenberg License included with this eBook or online at www.gutenberg.org. If you are not located in the United States, you will have to check the laws of the country where you are located before using this eBook. Title: The Journal-Lancet, Vol. XXXV, No. 5, March 1, 1915 The Journal of the Minnesota State Medical Association Author: Various Editor: W. A. Jones Release Date: July 11, 2021 [eBook #65823] Language: English Character set encoding: UTF-8 Produced by: SF2001, and the Online Distributed Proofreading Team at https://www.pgdp.net (This file was produced from images generously made available by The Internet Archive) *** START OF THE PROJECT GUTENBERG EBOOK THE JOURNAL-LANCET, VOL. XXXV, NO. 5, MARCH 1, 1915 *** 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 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, [1] 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 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 .. [2] 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. 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 an...