Part 3
Dr. W. A. Jones (Minneapolis): I wonder how many members of the State Association have visited the hospital for inebriates at Willmar. I would like to ask all those who have, to hold up their hands. Five or six of this audience, representing the twelve hundred doctors belonging to this Association. That gives one a fair estimate of those familiar with the State farm for inebriates. I should like to know further how many members of the legislature have visited this institution, and how many have tried to condemn it or perhaps to take it for a tuberculosis hospital. That is what they will do unless we physicians stand by Dr. Freeman and the institution.
There is too much sentiment, too much sympathy among friends, relatives, courts, juries, and charity workers, as to the inebriate; but once he gets to Willmar and is under a proper regimen, his attitude changes totally toward himself and toward the world. After one has watched the treatment at Willmar and has seen the benefit these patients derive, he wonders why so many women and so many men are sent to quack institutions for inebriety and drug habits. Willmar costs the patient practically nothing, except a small per capita borne by the State. The average quack institution charges $150.00 for a cure, so called, whether the cure lasts for three days, or, as in some of the more conservative (?) quack institutions, the period is extended to ten days, and in the notoriously drink-habit cures, to thirty days. This ought to appeal to a doctor forcibly, inasmuch as all these claims of cures made by quack institutions are limited to thirty days at the outside, an absolutely absurd statement, and, for that reason, if for none other, we should all support and entertain anything that tends to increase the efficiency of the State farm for inebriates at Willmar.
One thing which Dr. Freeman wants to emphasize is the necessity at times of forcible restraint in a building especially constructed for detention cases. There is a small class of people who are, perhaps, suffering from a disease state, who are irresponsible. Most of them are common drunkards, who create all sorts of disturbances and who really need discipline--who need to be detained forcibly for a sufficient length of time to enable them to recover their normal physical tone, and until they recover something of their natural mental tone. If this could be incorporated in the rules and regulations of the governing body of the inebriate farm it would make a great increase in the total number of improvements and recoveries.
Dr. Freeman has emphasized the necessity of getting the physical condition up to a high point. He has said all that is really needed on the subject. I believe drugs and drink should be reduced rapidly in almost every case. If you look over some of the literature of some institutions that take these people, you will find they reduce the morphine down from fifty grains to forty, and then to thirty-nine, until, finally, after a period of so many weeks or months, they cut it down to the two-hundredth of a grain, and give it hypodermically. You can readily see the absurdity of that treatment. The average man can have the total reduction made within thirty-six or forty-eight hours.
I hope you will take more interest in the inebriate farm, and see that your legislator is interested as well.
Dr. Haldor Sneve (St. Paul): I have listened with a great deal of pleasure to Dr. Freeman’s paper, and especially because there are some statistics as to what can be accomplished in such an institution even in a comparatively short time. Personally, I think that six months as an average time to stay in this institution would be too short. It will be found, however, in time, whether this is true, but just now the institution is in the experimental trial stage.
A great many legislators are, as Dr. Jones said, trying to convert this institution either into an insane asylum or a tuberculosis sanatorium; and it is up to the profession of the state to back up the establishment of this institution for the treatment of a class which is growing.
Personally, I think drink is a vice and not a disease, and until we can eradicate from the minds of the laity and from the minds of some physicians the idea that a man who drinks is some sort of a nervous invalid, the sooner we shall get better results in the handling of this question. Even the dipsomaniac has periodic brain-storms, which Dr. Ball has likened to attacks of migraine; that is a good simile, they do not always take to drink, but go off in other ways.
I have treated from twenty to fifty cases of delirium tremens at the City Hospital every year for twenty years, and I have had considerable experience in institutions; and yet I cannot find anything to criticize about the principles of treatment that Dr. Freeman has put forth here today. The idea in the minds of the laity is that inebriety is a disease, and they want drugs for it to make them well, and that is one reason why so many patients go to Keeley cures and get well. They go there because they find a drug that cures _disease_. I find that the Towne-Lambert treatment is an excellent _mental_ treatment for the inebriate in private practice. It can be used in the institution at Willmar, as well as in private practice, and putting a patient upon the Towne-Lambert treatment satisfies his desire to cure the disease he is suffering from.
I think the profession will have to keep their eyes on the legislators, perhaps on the new governor, and see that this institution is not thrown into the waste-basket, so to speak, or converted into some other sort of institution, because we need a place of this kind. Even if Minnesota can go prohibition pretty soon--and I rather think it will--we shall not get rid of our drunkards for that reason. We shall still have to have a hospital for the treatment of the morphine, cocaine, and alcoholic habits. The doctors who send patients to Willmar, I think, ought to be careful, and not try to help some municipality out of taking care of old battered hulks, who cannot hope to recover, who cannot be made well simply because they have been drinking for so many years, and their other habits of life have resulted in such a deterioration of the brain that there is no possibility of bringing them back and making really good citizens of them. Those patients should be kept in a work-house or in a special department at Willmar or some other place. We should try to reclaim all of our young men and young women habitues.
Owing to the absence of proper writeups about this hospital it is not generally known throughout the state that pay-patients can be received and treated just as in any sanitarium and at very moderate rates.
Dr. Freeman (closing): I really have nothing to add in closing except to say a word with regard to prohibition. I have a second-hand statement from the police of one of the Twin Cities that he is positive in his city there are five thousand drug-users from his experience in the police court.
With regard to the maintenance of discipline at the institution: We have sufficient law or authority for discipline, but we have not the facilities. The thing in my opinion that we mostly require is a building where we can take care of a man who is incorrigible, or a man who runs away. For two reasons: In the first place, I have known a number of men who came there unwillingly, who later were greatly benefited by their compulsory stay; second, the effect of disciplinary measures upon the population in general. If a man knows that, when he goes there, he must stay, he naturally gets over his constant thought that he is going to sneak away, and put it over. The custodial cottage to take care of forty people would allow, in all, four classes of patients. We should have a reception-ward in which to examine all new patients; one ward for the incorrigible; and we should have two other places to care for two classes of men received. This would prevent the influence of the older men who have gone further in their habits upon the young boy who has just started.
DIAGNOSIS OF INTRACRANIAL COMPLICATIONS IN DISEASES OF THE MIDDLE EAR AND ACCESSORY SINUSES OF THE NOSE[3]
By Joseph C. Beck, M. D. CHICAGO.
[3] Read before the Sioux Valley Medical Association, July 22, 1914, and published in these columns at the request of the Association.
The most important causes of intracranial complication from the middle ear and nasal accessory sinuses, are suppurations, consequently I shall confine my remarks to that subject, and not take up the neoplasms, trauma, etc.
In the diagnosis it is most important to recognize suppurative disease of the ear and sinuses, but this subject is not within the province of this paper, therefore I shall satisfy myself by mentioning only that the presence of the pus from the middle ear and nose, and Röntgenographic examination, are the most important signs of affections of these structures. The one symptom more than any other on the part of the patient of a threatening extension into the cranial cavity, is localized pain or headache, which is very persistent, instead of periodic. Especially important is this in connection with the cessation or diminution of the discharge. The knowledge of the pathological change present in the sinuses and middle ear and mastoid, is of additional value as, for instance, tuberculosis, syphilis, and cholesteatoma.
The frequency of intracranial complication in suppuration of the middle ear is much greater than that following sinus disease, about twenty-five to one in my experience.
The intracranial complications which I shall consider are--
1. Meningitis. 2. Sinus thrombosis. 3. Brain abscess.
The meningitis may be serous or suppurative, and later localized or diffuse.
The sinus thrombosis may be partial or parietal, and complete with or without involvement of the jugular bulb and vein. The brain abscess may be extradural or genuine within the brain substance proper. The complications may be further divided as to bacteriologic or etiologic factors as, for instance--
Streptococcic Staphylococcic Pneumococcic Tuberculous Syphilitic
These complications may arise following acute, or chronic and acute, exacerbation of chronic suppuration of the ear and sinuses. Meningitis and sinus thrombosis (this latter condition is very frequently associated with a localized meningitis) are usually complications following acute, or acute exacerbation of chronic, suppuration of the ear and sinuses. Brain abscess, however, is most frequently associated with the chronic form of the ear and sinus disease; but these become more manifest following an acute attack of ear or sinus trouble. Tubercular or syphilitic meningitis is chronic inflammation _per se_; but these conditions are also lit up by the acute processes within the ear and sinuses.
The cardinal symptoms of any intracranial complications are--
1. _Pain or headache._--This may be localized or diffuse; it is, however, very persistent and quite intense. It is in the recognition of this symptom that has helped me more than any other in suspecting intracranial trouble.
2. _Nausea and vomiting._--This symptom is quite constant, especially early in the disease; and projectile vomiting is quite characteristic of intracranial pressure or irritation.
3. _General septic appearance._--This of course will vary in the different conditions under consideration, but in all is it quite manifest.
4. _The vision_ is very frequently affected due to the choked disk that is present.
5. _Temperature, pulse, and respiration_ are very frequently disturbed.
6. _Definite focal symptoms_ of brain localization are of the utmost importance in the diagnosis.
7. _Blood and spinal fluid examinations_ give very valuable information.
8. _Röntgenographic findings_ are at times valuable.
9. _Exploratory operation and treatment_, as in lues, is at times necessary to make a diagnosis.
MENINGITIS
(a) _Serous meningitis._--One of the first signs is the increasing headache, at first localized, usually near the seat of the perforation or path of infection, and soon becoming diffuse over the head. The patient loses his appetite, his tongue becomes coated, the emunctaries become sluggish in their action, and nausea is a very common symptom. The temperature rises, and, if the septic form is going to follow, this rise is often quite rapid, so that there may occur small chills from the infection of the cerebrospinal fluid. The pulse and respiration rate is now considerably increased. The patient is very irritable and restless, and does not sleep. As soon as the fluid increases within the cavity there is observed the characteristic syndrome of rolling the eyes, especially upward, the neck is drawn backwards, and finally the leg upon the thigh and thigh upon the abdomen. Attempts to straighten them out is resisted and appears to be painful,--Kernig’s sign.
Stroking the bottom of the feet with some semisharp instrument or the finger-nail will cause the big toe to turn up instead of down,--Babinski’s sign.
Taking the head and tilting it forward against the chest will cause the limbs to be drawn up,--Brudzinski’s sign.
All the other symptoms, as pressing over the peroneal nerve and muscle (Gordon’s sign), which will cause the extension of the toes, the stroking of the anterior tibial surface (Oppenheim’s sign), or the stroking of the region of the external malleolus (Chaddock’s sign), will produce retraction of the toes. All these signs, I say, prove that the upper neuron (within the cranium) is involved. The patient now will lapse into unconsciousness, and be roused with more or less difficulty to again relapse in the same condition. The pupils become sluggish in their action, at first becoming small, then irregular, and finally dilated.
Ophthalmoscopic examination may reveal a choked disk. Spinal puncture shows increased pressure by fluid very frequently coming through the hollow needle with a spurt, and clear or slightly cloudy. Following such a puncture the patient is very often much improved for from a half an hour to a whole day, but the symptoms soon return. A complete examination of the cerebrospinal fluid thus removed, will aid a great deal in diagnosis. This includes the following:
1. Remove about 25 c. c. at spinal puncture.
2. Make several slides and stains for organisms, as septic and tubercular.
3. Examine and count the endothelial cells, leucocytes, and pus cells.
4. Make cultures.
5. Make a Noguchi (butyric-acid) test for excess of albumin.
6. Make a Lange colloidial test.
7. Wassermann, Nonne, and Noguchi tests for syphilis.
8. Test for sugar.
9. Test for total acidity and relative acidity.
10. Cholin may be tested for.
In the serous form one will find the cells increased somewhat, especially the leucocytes, but the micro-organisms are conspicuous by their absence.
The Lange (colloidal-goldchloride) test will show the characteristic color reaction of a septic process.
The Noguchi (butyric-acid) test will be positive. Excess of albumin.
The Wassermann, Nonne and Noguchi tests for syphilis are negative. (Unless such a case should be a complicated one.)
The test for sugar is very important in that in serous meningitis sugar is present.
The relative acidity is not markedly affected, and cholin is not present, or, if so, in only small quantity.
(b) _Septic meningitis._--If this is _localized_, and there is a collateral serous meningitis associated with it, then the symptoms may be the same, as just described; however, the cerebrospinal fluid will show a greater degree of irritation, and the fluid may contain some micro-organisms. The majority of localized septic meningitis cases, however, are not as severe in their course as the serous or diffuse septic forms. The one important symptom is the localized headache, which is quite persistent, and the greater rise in the temperature. There are, undoubtedly, many cases of localized meningitis that show a perfectly normal cerebrospinal fluid, and most of the cardinal symptoms absent; and these are the cases that usually get well or lead to extradural abscesses subsequently.
The _diffuse septic meningitis_ is the most discouraging intracranial complication that we have to deal with, and the diagnosis as a rule is not difficult. It usually is preceded by the serous form, but within a very short time develops the graver symptoms of sepsis. The most positive symptom is the spinal puncture. The fluid comes out under pressure, but not so great as in the serous form, and is turbid. The turbidity varies in degree with the amount of infection. It has the appearance at times of pure pus; in fact, that is what it is. Bacteriologically one will find many micro-organisms of the character of the infection; and leucocytes or pus cells are very numerous.
The sugar reaction is always absent, and the acidity is much increased as is the quantity of cholin.
The pressure or irritative symptoms as the Kernig and Babinski tests, as well as the pupillary reactions, are practically the same as in the serous meningitis, only that they soon give away to the paralytic form, namely: pupils dilate, patient is in a constant stupor or coma, and the involuntary urination and bowel movements become very manifest. The patient is, as a rule, unable to take or be given nourishment. The outcome is, in my experience, with one exception, always fatal, due to diffuse cerebritis. I have had a case of diffuse septic meningitis in the early stages of a pneumococcic type which I operated on by the Haynes’ method of drainage of the cyscterna magna, and which recovered; and I believe that the success in that case was due to the very early intervention, because I have operated by the same method on eight other cases more advanced and of streptococcic and staphylococcic type of infection, which ended fatally.
_Sinus thrombosis._--This complication is the one that is recognized as giving the best prognosis because it can be very readily recognized, and even exploration is warranted to make such diagnosis. It most frequently follows, or is associated with, acute infections of the middle ear and mastoid process. The most important symptoms are the chills and fever of a distinct septic type, and, as a rule, increasing in frequency. There is invariably a blood-picture of sepsis, namely, a very high leucocyte count and the polymorphonuclear type in marked excess. Blood cultures are, as a rule, positive of a bacteriemia. If the process has extended to the bulb and internal jugular vein, then one may feel a thickening or cord-like mass along the anterior border of the sterno-cleido-mastoid muscle. The fundus examination often reveals a choked disk, especially on the side where the thrombosis is located. A symptom recently described by Beck, of Vienna, and Crowe, of Baltimore, and proven by me to be of positive value in several cases, is the production or increase of a choked disk by compression of the healthy internal jugular vein. Urbanschitch has shown in quite a number of cases of sinus thrombosis that the blood-clotting time is very much enhanced. This of course is true of any case of bacteriemia or septic phlebitis anywhere in the body. I have proven this test to be of value to me in several cases of sinus thrombosis. The exploratory exposure of the lateral sinus is of distinct value, and the only fact to remember is to expose a sufficient area so that one is able to deal with the sinus in case it be opened accidentally, because such an accident when this precaution was not taken has led to serious consequences.
The diagnosis of a thrombotic sinus when exposed is made first by its discoloration, usually of a grayish pink; secondly, it feels harder than normal and is not resilient when compressed, that is, it does not spring back. It, however, may be soft in case the thrombus has broken down; and in cases of parietal thrombosis it may spring back because there is blood circulating through it. One will at times find a small collection of pus about the sinus, a condition known as perisinus abscess, and in many instances of this condition the sinus itself is not thrombosed. The puncture of the sinus by a hypodermic needle and attempt to withdraw some blood, is not at present considered good practice owing to the danger of infecting a non-infected sinus. An incision is considered a wiser plan, and subsequently packing both sides (torcular and bulb) so they are shut off from the general circulation. There are many instances of secondary infection by embolism, either in or about the joints, and infection into the lungs, spleen, pancreas, etc., with the entire train of symptoms from such complications.
_Brain Abscess._--This is most frequently associated with chronic suppuration of the middle ear and mastoid, and labyrinthine disease. As stated before, we must consider two principal types, namely, those outside the dura and those within. They may exist at the same time, or the intradural abscess may frequently follow, especially in acute exacerbations, the extradural abscess. The paramount symptom is the great pain in the head, most frequently localized at or in close proximity to the abscess. I have, however, found several instances where the patient located the pain in the anterior portion of the head, and operation or post-mortem examination disclosed it in the posterior cerebral fossa. This pain is not at all unlike that in brain tumor, and there are exacerbations in the headaches sometimes at night, other times in the mornings, and in one of my cases the patient would have about ten attacks of severe head-pains within twenty-four hours, and in the intervals be fairly comfortable.
The next group of symptoms of importance are the focal lesions, which will correspond to the anatomicophysiologic locations and actions. These focal symptoms will vary in degree in that they be either irritative or destructive. So, for instance, a small abscess pressing over the motor area will cause clonic contraction and a still larger abscess, especially if it be intradural, will produce paralysis of that portion of the body governed by that particular area. Again, if it be located in the cerebellar region it will cause a train of symptoms of imbalance and loss of interpretation of direction, which must be carefully differentiated from the irritation of the labyrinth. In this department there has been much work done by Barany, Ruttin, Neumann, and other Viennese, and many others to make it possible to make a differential diagnosis; and there is a great deal more to be done. One of the most important recent contributions in this regard is the “pointing test” of Barany in connection with cerebellar lesions; and careful study and experimenting at every opportunity is very much recommended, in order to familiarize one’s self with this test. This in connection with the various labyrinth tests makes the differential diagnosis much more easy. One must remember that both labyrinthian irritation in connection with suppuration of the ear and cerebellar irritation from brain abscess may exist at the same time.