Recognizing that inebriety is a well defined condition, we can define the inebriate state as follows: (a) Inebriety is an expression of nervous weakness, the nervous weakness being inherited, a psycho-neurotic fault; founded on this weakness, manifestly a defect, is a habit we call drunkenness. (b) The inebriate is therefore the sum total of his personality or make-up, and the symptoms which we call drunkenness. (c) Inebriety can be considered technically as a form of a disease in the sense above described, a condition which implies a graded responsibility, the degree of responsibility being determined after a consideration of the individual case. THE INSTITUTION. tain head, of the system demands first consideration. On the threshold of our contemplated plan for the practical care of the habitual drunkard, it appeared to us that our work should be directed: first, to the extension of individual treatment of cases; second, to the securing of remunerative employment for cases which were under our care and treatment; third, to the compiling of accurate histories of those who had been discharged from the hospital; fourth, the establishment of after-care, which department should be an integral part of the hospital. (b) Sufficient plant for industrial training. (c) A tract of land of sufficient continuity so that there will be an opportunity for the segregation of the diverse cases. (d) Adequate provision for both male and female inebriates. It is, therefore, at once apparent that something more than the mere housing of the individual is needed. An institution for the purpose must be adaptable; it must have distinctive qualities and be especially built and equipped for the class of persons for which it is intended; in other words, certain conditions are required, There is a popular belief that institutional departures from the character of an ordinary care is all sufficient for those unfortunates who institution; and lastly, the institution should be are mentally or physically diseased; especially so constructed that it can adequately treat the has institutional care been recommended for varied types of inebriety committed to its care. those persons who are resistive to the ordinary The requisites of such an institution are:methods usually employed for the care and (a) A sufficient area of land to provide for treatment of chronic disease. Inebriety has agricultural development and for outside embeen no exception to this rule; indeed, if one ployment for the patients. would review the history of the management of the drunkard he would doubtless be surprised to find that an appreciation of the chronicity of the condition has existed from the earliest times. and that this alone has been responsible for the demand for the segregation or imprisonment of the drunkard. This method of management. with little or no variation, has been handed down from generation to generation, and as no practical substitute has been offered, the timehonored system, punishment, or coercion, in some form, for the drunkard has been continued. I do not deny that many honest attempts, both preventive and remedial, have been advanced to solve the problem. These attempts. due largely to the failure to recognize that voluntary or coöperative methods are superior to enforced or punitive measures, have met with little success. We must remember that today we are better prepared to meet the problem. The knowledge that the inebriate is an entity and our understanding of the benefits from individual treatment, have given us valuable weapons to fight with, weapons which, if considerately used, are of considerable range and value. Acting on these recommendations, a large tract of land was purchased in Massachusetts. The area selected has natural advantages; in other words, the land is largely undeveloped, thus allowing for considerable work for the inmates and affording an opportunity for affiliation and coöperation with the forestry, agricultural and other State Commissions. This cooperation in our estimation is an essential part of our educational scheme and is also of sufficient economic importance so that the economies have been helpful in building and equipping the plant. The acreage, over one thousand acres, is sufficiently large so that the requisites before mentioned have been met. The cottage or colony is the pivot centre of our scheme. Three different colonies are considered. First, a hospital colony for men, which will take care of the hopeful cases; second, a detention farm colony which will provide for the more chronic and resistive type of patients; third, a hospital for women. Briefly expressed, the colony groups would care for the following types of patients: Any plan which is put into practice for the treatment or amelioration of drunkenness should be controlled and administered by the state. The magnitude of the problem and the closely The cottages for men would receive:interwoven economic questions argue against local or municipal control. The successful care and treatment of inebriety demands the inauguration of a definite policy 1. Patients who come voluntarily or who are committed by the courts. 2. Young habitual drunkards placed on probation by the courts on condition that they which includes both institutional and non-insti- spend a specified period at the hospital. tutional departments, both of these departments 3. Suitable cases transferred on parole from being inter-related. The institution, or foun- the detention colony. The cottages for women would receive:1. Patients who come voluntarily or who are committed upon application. 2. Cases placed on probation by the courts on condition that they spend a specified period at the hospital. 4. Non-criminal habitual drunkards com- out-patient physician, while others are visited mitted by the criminal courts or received volun- at intervals by the physician of the out-patient tarily as a condition of probation. department. As before stated, particular attention is paid to the social readjustment of the patient, and every effort is made to secure for him congenial work and an environment suitable to his condition. During the past year 3286 shops of discharged patients, and over one hunvisits have been made to the homes and workdred permanent positions have been obtained for The cottages, which are units, are built in them. In order to emphasize the importance of groups distributed over the large tract of land. the work of this department the following figA centralization of the administrative and serv-ures, covering one year's work, are given :— ice group is necessary. For purposes of economy these buildings, with the ordinary service buildings, form a central group. I would at this point emphasize that the essential part of our housing scheme is the cottage. These cottages must be so situated and constructed that they will readily lend themselves to the needs of the patient groups. OUT-PATIENT DEPARTMENT. Visits to office Visits to homes of patients who are at the hospital Visits to homes of patients who have been discharged from the hospital 471 105 516 ...2770 Visits to employers relative to work for dis- ... admission to hospital Men applying at office, refused admission to hospital Patients reporting at office, abstinent and working tients ..298 481 470 367 360 137 184 473 76 891 At an early period in our institution career we recognized that the mere training of a patient at the hospital was in itself an inadequate provision, when a discharged patient was compelled immediately to return to adverse conditions. Accordingly, five years ago an outpatient department and clinic were developed. Men applying at office, recommended for Modest in its beginnings, it has rapidly grown in extent and its usefulness has progressively increased. The Norfolk State Hospital has now established in metropolitan centers two such departments which are serving definite areas of the state. The department, which is in charge Men drinking whose return was advised of a physician who is assisted by non-medical Men drinking whose return was refused Inquiries workers, is a fixed part of the hospital. An active vocational bureau is maintained, visits Consultation with outside parties are made to the homes of discharged patients. Letters sent out relative to discharged paaid is supplied to dependent families and every effort is made to reinstate the patient in his business interests and domestic relations, for unfortunately it is often the case that the victim of habitual drunkenness has lost not only his own self-respect, but has forfeited the respect of others. At this point a strong helping hand is needed. This was the fundamental reason for the beginning of our out-patient work. Another feature of the department is the medical and social clinical work. An increasing number of persons apply for advice, and it is quite often feasible to treat such persons outside The plan as developed by Massachusetts, and of the institution, reserving the hospital or cus- which is now in part in active operation, can be todial treatment until conditions demand it. described as follows: First, a state hospital for Furthermore, the out-patient department serves the treatment of alcoholic and drug habitués, as a central educational focus, acquainting the developed on the colony plan, with a sufficiently public with the aims and purposes of the hos- ample and flexible equipment so that appropripital. This department has rendered valuable ate care and treatment can be given to the difaid in carrying out the educational and medico- ferent types of inebriety; second, an out-patient social work begun at the hospital. Every pa- department and clinic with broad and welltient at the time of his discharge is impresed defined duties; third, detention hospitals and with the idea of coöperating with the out-patient hospital clinics having specialized features for department. Some of these discharged men re- the care and treatment of cases of acute alcoport to the hospital, others at the office of the holism. Another branch of the parent institution which should be considered is the establishment of hospital clinics or detention hospitals. It is not necessary that these hospitals should be especially built for the purpose, as arrangements can frequently be made to coöperate with general hospitals which are already established. In such branch hospitals should be treated cases of delirium tremens or cases of acute alcoholism, which either voluntarily present themselves for treatment or are brought in as emergency cases. A substantial start has been made. The Mas- or eight weeks. Under usual conditions this sachusetts central state institution has been in man would not relapse for four or five months, part built, out-patient departments have been therefore the report of the result of hospital established and the coöperation of the hospitals treatment should be suspended for a consideris assured. To the trustees and to those of us able period; at least, a final report on the case who are interested in the proposition the real in- should not be made until one or more of the centive for the contribution of our work is our man's episodical attacks of drinking have been conviction that the public believe in the integ- successfully combated. On the other hand, if a rity and stability of the system as planned six man who had been a regular or irregular drinker before his hospital treatment, is abstinent for a considerable period after his discharge from the hospital (we have tentatively placed this period at six months), we are justified in considering the man as improved. years ago. I feel that my paper would be incomplete if I failed to describe our method of treatment. Believing as we do, that the inebriate condition has for its basis a distorted mentalization, our efforts are directed in an endeavor to interest the patient in his individual case and, having accomplished this, to make the interest self-sustaining. Our experience has shown us that the success of hospital treatment depends upon :-(a) The ability of the patient to coöperate in treatment. (b) Our ability to introduce into the patient's mentality some tangible substitute for the desire for artificial stimulation. 2. The conduct and attitude of the patient after his discharge from the hospital. Under this caption we consider the ability of the man to earn his livelihood, and his success in readjusting himself to society. 3. The willingness of the patient to coöperate with hospital authorities after his discharge from the hospital. Guided by these rules, we have carefully investigated the present condition of all patients discharged and have made careful comparative tests. Such a result is brought about by attention to the patient's mental and physical hygiene, and necessarily depends on the educational measures The following figures, therefore, have been inaugurated at the hospital and continued by compiled after continual and prolonged observathe patient after he leaves the institution. The tion of discharged patients; these do not include treatment must necessarily be considered as in patients who have not been discharged for a the realm of physiologic therapeutics, which is maximum period of six months. During the supplemented by the simplest form of sugges- past five years 1174 patients have been investition. The suggestion is really an auto-sugges- gated as above described. Out of this 1174, aption, the result of a correlation of impressions proximately 753, or 64%, are today working and which the patient receives from his association either totally abstinent or drinking so little as with the physicians and from his relation to the not to interfere with their work. Practically all hospital environment. The physician is con- of these men had, before coming to the hospital, cerned in an analysis of the individual case, dropped below the class of the self-supporting. which is made possible by encouraging the patient to coöperate in his own recovery, by strengthening his self control. The successful treatment of the inebriate in a state institution may, therefore, be said to be dependent, first, on an appreciation of the true I have reserved for my concluding paragraphs nature of the condition; second, on a realization an account of our work extending over a period that the inebriate, dependent on the degree and of five years. Considering the result of hospital intensity of the condition, demands specialized treatment, it must be borne in mind that the treatment; third, the necessity for active and total number of discharges is considered. No continued coöperation with those interests which attempt has been made to differentiate cases. are genuinely concerned in the problem; fourth, Each case has been considered individually, the diligent and consistent work and an adherence following conditions determining the final re- to the principle established by a definite method port of the result of treatment. of control; and lastly, the education of the pub 1. The type of inebriety, divisible for prac-lic to a proper realization of the status of the tical purposes into three classes : (a) The regular drinker,-one accustomed to the use of stimulants daily. (b) The irregular drinker,-one accustomed to the use of stimulants at short intervals. (c) The periodical drinker,-one accustomed to drink at periodic intervals, periods of months or years elapsing between the periods of insobriety. Thus a man whose period of drinking occurs at intervals of six months may be admitted to the hospital in a state of acute intoxication, re institution to the community. AN ELECTRO-MOTOR BONE OUTFIT AND BY FRED H. ALBEE, M.D., F.A.C.S., NEW YORK CITY, cuperate rapidly and leave the hospital in six his bone grafting operation for Pott's disease, 1. Calipers. 2. Doyen washers or guards for motor saw. 3. Spray and guard for saw. 4. Twin saw. 5. Dowelling instrument or lathe with cutters of two sizes in place. 6. Right angle twin saw. 7. Wrenches for twin saw and drill chuck. 8. Drill with guard to prevent it penetrating too deeply. 9. Drill chuck and small drill in place. 10. Burr for drilling fractured neck of femur for peg graft. 11. Small circular saw. 12. Large saw. 13. Carver's gouge. 14. Lowman fracture clamp. 15. Berg fracture clamp. Wide osteotome for splitting spinous processes for the insertion of bone graft for Pott's disease. 17. Surgical electric motor. 18. Compasses. 19. Lambotte fracture clamp, large and small. 16. the bone transplant had been so infrequently In removing the graft with the chisel and malused as a surgical agent that no special technic let, the graft must many times be handled and had been developed for its removal. The electric shaped after its removal, whereas with the cirmotor circular saw (Doyen) had been used for cular motor-driven saw a pattern marked in the skull work, driven by either a flexible shaft from periosteum with a scalpel can be followed accua motor on a nearby stand, or by the Hartley-rately and the graft shaped in situ during its Kenyon apparatus, where the cutting tool is at- removal. The graft pattern is usually obtained tached directly to the motor shaft, and, so by bending a flexible probe or leaden bar into far as the author is aware, it had not been used the prepared graft-bed, whose shape is transin any systematic way for the removal or the ferred to the tibial surface from which the modelling of bone transplants. transplant is to be removed. The author began his spinal work by removing In modelling the graft into dowels, wedges, inthe graft from the tibia with chisel and mallet, lays, and in making use of the different welland later others made use of the Gigli saw. It known mechanical devices, such as tongue and was soon found that these methods were not only groove joint, dove-tail joints, mortices, etc., the slow and inaccurate, but that they presented the motor outfit is still more indispensable. An acdangers of bruising, cracking, or fracturing the curate cabinet-maker-fit may mean success in graft or tibia, or both. This is especially true in many instances where an ordinary crude coadult patients, on account of the brittleness and aptation would mean failure. Especially is this thickness of the cortex. In the child, on account true in ununited fractures. of the small diameter of the bone, the danger of The skepticism as to the value of the graft, fracture is evident, although the graft is ob- plus the difficulty in obtaining and moulding it, tained by means of hand tools with much less has undoubtedly delayed the earlier developdifficulty and much less likelihood of fracturing ment of the use of this most valuable surgical it. agent. It is difficult to give an adequate reason Also, in obtaining grafts 8 in. or more in why in the rapid advance of surgery the work of length, it was found that the hand-tool methods osteoplasty has, until very recently, stood for so were crude, requiring too much time, tiring the long a time practically at a standstill, especially surgeon, and unnecessarily shocking the patient. in view of the fact that Ollier, in 1858, from ex tensive animal experiments and surgical work,- ficially or in a deep wound; whether the work to although working in the pre-antiseptic era,- be done is the procuring of the graft, the prepafurnished abundant evidence that the autoplas- ration of its bed, the drilling of holes, the retic bone graft survived and lived when consist-moval of bone for the correction of deformity or ing of cortex, periosteum, and endosteum, and disease, or to allow the proper approximation implanted into a bony defect where it had func- and alignment of bone fragments in cases of tion to perform. fracture. 4. It should permit easy and convenient control of the electric current. As in many other fields of endeavor, electric 3. It should permit accurate control and power has been the chief means of placing this guidance of the motor cutting tool in all wounds valuable agent at the disposal of the surgeon. and at all angles. In recent years the generalization of the use of electricity for lighting, heating, and power purposes in most hospitals, private dwellings, etc., 5. It should be light in weight, small in bulk, has also been a potent influence, and has enabled and permit of easy transportation. the surgeon always to be in reach of the neces- 6. The motor should be universal and adaptsary power for operating his motor outfit-ed to all types of electric current. whether he is operating in the city, suburban 7. The motor instruments,-saws of different hospital, or private dwelling. The electric auto-types, drills, dowel shapers, etc.,-should be held mobile or storage battery can also be made to j in place in the motor by an automatic catch fafurnish a movable source of supply, which can voring their speedy interchange. be utilized at any time, or place. wire to the electric wall fixture. The foot switch control. The FIG. 2.-The manner of holding the motor saw. The connecting sterilizable connecting wire to the motor. The sterilized rubber tube connecting the tank of normal saline solution and the spray attachment above the saw. The author's broad thin osteotome for splitting the spinous processes and the calipers for determining the length of the graft are on instrument table. The ideal surgical electro-motor outfit should measure up to the following requirements: 1. It should permit of the thorough sterilization of every part which comes in contact with the surgeon or the field of operation, including the electric cable for transmitting the power. 2. It should permit of ready application to all types of osteoplasty, whether situated super 8. The motor-cutting tools should be constructed similarly to those long-used by the artisan for working hard materials, and should be of sufficient variety to meet every requirement of bone carpentry. The twin saw for inlay work should be so constructed that it can be readily adjusted,-to the fraction of a millimetre,-by the gloved hands of the surgeon at the operating table. The dowel cutters, with drills of corresponding diameters, should vary in size sufficiently to meet all requirements. 9. The motor should furnish enough power to drive rapidly a saw or large drill through the thickest human cortex without tendency to stall. The author's outfit, described in this chapter, has been carefully devised and perfected with the coöperation of the Kny-Scheerer Company, to fulfil all of the above-mentioned requirements. The motor tool is attached directly to the motor shaft; the motor is covered by an adjustable sterilizable shell, enabling the surgeon to hold the motor in his hands while the tool is cutting: the weight of the outfit has been found to be an advantage rather than a detriment in its application, and it is believed that it completely fulfils every demand. DESCRIPTION OF OUTFIT. The author's electric operating bone set consists of a small universal motor, i.e. one which will operate without readjustment on all types of electric currents, such as direct, alternating. and of varying cycles. If it is to be used on a 220 volt current, a 100 c.p. 220 volt lamp should be placed in series with motor. Electrical engineers have found it impossible to construct a light motor which will resist deterioration from repeated boiling of the motor itself, or any other safe type of sterilization. Both the insulating material and the carbon brushes are liable to disintegration from repeated subjection to heat. Therefore, the Hartley-Kenyon method of removable, sterilizable shells has been adopted, as it seemed by all means the most desirable. |