Part 4

Remember that the most gentle and considerate of people will say and do things when sick unwittingly, that in health they would sooner cut out their tongues or destroy a limb than say or do. The mind is sick as well as the body, and the patient not responsible. Cultivate forbearance and endeavor to sear all your tender points. Be ever ready to excuse and believe that no slight was intended, unless it is reiterated and you are forced to believe it.

The physical and mental strain which you are at times called to bear will be very great; that you may be able to endure it, you must give special care to your health. You have been taught the laws of health, and yours is so arduous a calling you must observe them strictly. Dame Nature is a stern mistress, and if you disobey her you will surely suffer for it. When you are out of employment you will need recreation and diversion to keep both body and mind in the best condition. When you are in charge of a patient, the time away from the bedside is not yours to do with as you please, but for rest and fresh air; as you owe it to your patient to give the best possible service, and thus only can you do it.

You must cultivate the habit of observing the least change in your patient’s condition, so as to be ready to meet any emergency; it will not do to sit down and watch your patient as a cat would a mouse. Yet in severe cases your eye should hardly ever be off your patient; this should be accomplished and can be done in such a way as to be almost imperceptible to the sufferer. Every little change should be noted, and if any importance may attach to it, it should be written down as soon as you can conveniently do so. You are the physician’s eyes, ears, and hands while he is absent; you cannot therefore be too watchful.

Each one of us has certain vulnerable points of character, but it is not always easy for us to see them. If we would be self-possessed we must seek to discover these weak points in our armor by seeing ourselves as others see us; then by learning how to cover them, and not be disconcerted when our weak point is attacked. No _one_ virtue is of more value in your arduous calling than this one of self-possession.

In this world of care and trouble much can be done to ameliorate suffering and soften the sting of pain by tender, sympathetic care; your patients will expect less of you if all you do is done with ease and quietness and thoughtful tenderness. You will then be likely to gain a friend in every patient; the patient will feel that a friend has gone when you depart.

A cheerful character rides smoothly over many rough places in this world that otherwise would jolt terribly. A bright, cheery nurse is better than many a dose of medicine for the patient; therefore be always cheerful. By cheerful I do not mean frivolous, as levity is the last thing that should appear in a room where such mighty elements are at work as in the sick-chamber. Therefore be cheery, but not mirthful or giddy.

There are some words in the dead languages which it is almost impossible to put into English without, in a great measure, losing their meaning because they contain so much in themselves; they are so difficult to define. So there is one little word in the English language that contains so much in itself that it is impossible to define it in a few words, and after using many you feel that you have only sailed around it without getting at the central and most important part of it—that word is _tact_. But it is the want of that which has consigned some of the brightest and noblest minds that I have known to oblivion. I call to mind just now one of the best read and most highly cultured and gifted men that the medical profession of Brooklyn has ever known. He lived and died among us, unappreciated except by the few who knew him best, little sought after by those who needed balm for their diseases, which he was better able to apply than most of his companions, and with scanty maintenance, while medical sky-rockets about him were riding into lucrative practices. The suffering continued to suffer, when, if they had only known it, skilled and efficient help was at hand, in a man who did not know how to so bear himself as to win the confidence of the community. Had he possessed a little tact his name would have been known to the world.

I want to say to each one of you, consider well if you propose to follow this arduous calling, pause and consider whether you really feel that it is your vocation, and feel equal to its physical and mental demands.

An ideal to strive after is good for us all. I will lay before you to-night one that was realized in the history of a friend who is now in a better and happier clime than this, and whom I would be glad to have each one of you strive to emulate.

Some years ago, before, as far as I know, there were any trained nurses in this city, I was asked to go to see a lady in a neighboring village, who had been confined to her bed for more than a year, and was supposed to be incurable. A year from that time she was able to be about, and six months later she determined to devote her time to the care of the sick poor. She did so, and I never had any one who would, or could, take better care of every case that fell to her charge. I always felt that, as far as human skill and strength could do it, my directions would be carried out to the very letter. Her last case was that of a little girl who had been burned over about three-quarters of her body, a degree of burning usually considered fatal; but in this case it did not prove so; and for months this noble woman dressed this suffering child, and would let no one else do it. Little Tina dreaded to have any one else touch her. The child was almost well, and this good woman was just finishing her morning dressing of the burn, when she suddenly fell back and expired. The soldier died at her post of duty.

“Like a star which maketh not haste and taketh not rest, let each be fulfilling his heaven born hest.”

THE ETHICS OF OPIUM HABITUES.

BY J. B. MATTISON, M. D.,

Read before the Society of Medical Jurisprudence and State Medicine, June 14, 1888.

“All men are liars,” said the writer of ancient days, and the revised version of modern times is, “All men—who take opium—are liars.”

The writer—whose initial acquaintance with this question dates back nearly two decades, and whose professional experience for several years has been exclusively devoted to a large and enlarging clientele of this class—has long held this opinion to be a mistaken one. Years ago he wrote—“Clinical Notes on Opium Addiction,” read before the Kings Co. Med. Soc., 16th January, 1883—“Nor do we share in the opinion, largely held, that no reliance is to be placed on the word of opium habitués. That the habitual use of opium, in many cases, does exert a baneful influence on the moral nature we are well aware, but we also know that in the ranks of these unfortunates are those who would scorn to deceive, and whose statements are as worthy of credence as those upon whom has not fallen this blight.” Increasing attention to this topic has only confirmed that belief, and the recent statement—unwarranted and untrue—of a medical writer and teacher, that “no morphia habitué can be depended on to tell the truth,” with the courteous invitation of your honored President to present you a paper, has prompted me to offer some thoughts on this subject—the result of observation, reflection and applied common sense.

Putting the query—why do men take opium?—the answer to-day is that made nearly twenty years ago by Dr. Joseph Parrish, Pres. Amer. Assoc. for the cure of Inebriates—“men take it for a physical necessity.” In an experience covering the history and treatment of hundreds of cases, I have noted only two exceptions.

Let it be distinctly understood that my remarks apply only to the better class of habitués, who have become such by force of conditions beyond control. With those who, viciously indulgent and lacking alike in principle and purpose, take opium from mere sensual desire, we have nothing to do.

This physical necessity, the great genetic factor in an opiate using, it need scarcely be said, has its rise in painful disorder of body or mind. For this opium in some form is given, which, when the legitimate need for its action is ended, entails a demand for continued taking that will not be denied.

The larger share of responsibility then rests on the medical man who prescribes—very properly it may be—this valued drug, though the main measure of his responsibility depends not on the initial using, but upon the case being dismissed without full thought as to the ultimate result of the opiate taking, and with a neglect to warn the patient against the danger of continued using, and insisting upon—giving to this his personal attention—the entire narcotic disusing when the proper need for its taking is ended. Vide “The Genesis of Opium Addiction,” _Detroit Lancet, 1884_, and “The Responsibility of the Profession in the Production of Opium Inebriety,” _Med. and Surg. Reporter, 1878_.

Granting this correct, on what principle of equity or right can one be held accountable, and so culpable, for his use of the drug when, unaware of its ensnaring power, and, confiding in the counsel of his medical adviser he avails himself of the relief it affords?

Another and most important auxiliary factor obtains in these cases—one of which the laity knows little or nothing, and the profession appreciates less than it should—and that is the power opium possesses to create a necessity of its own. Of this, I venture to assert that no one, other than the subject of a painful personal experience, or of large observation, can form a fully adequate idea. The writer has been studying opium and opium habitués for more than sixteen years, with an annual experience, of late, as regards number of cases, that is probably unequalled in this country, and yet he stands more and more in awe of this peculiar power with every case that comes under his care.

Granting a painful physical necessity, and the daily or semi-daily use of opium—especially morphia, subcutaneously—for a few weeks or months, and there are few, if any, who can withstand the ensnaring, enslaving power of this drug. Men stronger of brain and brawn than we have gone down before it. I have known a superbly athletic specimen of physical manhood, able to resist the wintry rigor of a polar expedition, succumb to the power of morphia in less than a month. I have seen a man so generously endowed that he survived the horrors of Salisbury when the death rate averaged eighty per cent., go down before the same resistless power in four weeks. It was my pleasure to see this gentleman recover, and take the lecture platform to tell of his bondage and escape, and this is what he said:

“I proclaim it as my sincere belief that any one afflicted with neurotic disease of marked severity, and who has in his possession a hypodermic syringe and morphia solution, is bound to become, sooner or later, if he tampers at all with the potent and fascinating alleviative, an opium habitué. The first dose is taken, and mark the transformation. This overmastering palliative creates such a confident, serene, and devil-may-care assurance, that one does not for once think of the final result. The sweetness of such harmony can never give way to monotony. Volition is suspended. You may not think of it when the pain for which it was taken subsides. But when distress supervenes you go at once for the only balm that abounds in Gilead, and every additional dose is but another thread, however invisible, of which the web is made that binds us fast as fate.”

If this be true—and it is true—what justice is there in the charge that these unfortunates continue the use of opium from an innate propensity to evil, or a merely vicious desire? What right have we to set ourselves up in judgment to note the beam in our brother’s eye, when the only reason it is not in our own—when the only reason you and I are not opium habitués—is because a kind Creator has so conditioned us that this physical necessity, and consequent opiate need, does not, with us, obtain?

Having thus touched upon the etiology of this disorder, let us reason together regarding the special ethical point involved, and note the reason—if reason there be—for the commonly accepted idea that all men who use opium are liars. While admitting that the habitual need and use of this drug does, in many cases, warrant such assertion, I hold that the leading factor in this moral obliquity is the principle of self protection—the habitué’s desire to shield himself from that censure which the prevalent opinion—uncharitable and untrue—that he is simply the victim of his own vicious indulgence, involves.

There are various proofs that this holding is correct, and, too, without resorting to the opinion held by Lahr, Fiedler, and some others, that opium habitués are the subjects of a mental alienation, both in the creation and continuance of their addiction, and therefore absolved from culpable wrong—an opinion in which I do not share. Nor do I believe, for reasons given, with another German observer, that “the morbid craving for morphia ranks among the category of other human passions, such as smoking, gambling, greediness for profit, etc.,” for if this were true, the impulse to protect one’s self would not so largely prevail.

The opium habitué realizing that he is looked upon as one who has given himself up to a vicious habit, a habit in which he persists from mere desire to enjoy the pleasures of opium—pleasures which, be it ever remembered, soon give place to its pains—and so liable to the censure which a vicious indulging involves, is impelled—by a feeling common to us all of guarding our good repute—to yield to the protective temptation to untruth.

But to this there are numerous exceptions, for many a captive to this drug, though well nigh crushed by his captivity, and that “cruelty of ignorance,” which the unjust reproaches of should-be friends entails, still refuses to seek refuge behind such subterfuge, and scorns to tell a lie.

And do we not note this same impulse to deceit in most non-habitués who, lapsing from the right, make effort to avoid the sequence of their sin? Does the swindler always confess his swindling? Do the thieves, the forgers, the rascals of any degree, never deny their wrong doing? And while, in these cases, such double wrong may be the outcome of a general depravity, that, of itself, tends to prove that if the pernicious effect of opium in this regard were due solely to its baneful effect upon the morale in general, we should note the same tendency to lying along the various lines of life, whereas, it is a fact that on any question other than one involving his opiate taking, and consequent accountability, the habitué may be, and often is, a very prototype of truth.

What is the bearing of this question on the medico-legal status of these cases? If they be held culpable for the inception and furtherance of their condition, whatever outcome there may be affecting the jurisprudence of their action, must, from such erroneous view of the situation, fail of that legal justice which a correct appreciation of their case demands.

The writer was recently called upon to testify in the case of a physician who had been under his care for treatment of narcotic inebriety. This gentleman was the subject of delusions and hallucinations, so marked, that, in my opinion, he was not accountable for his conduct. Suit for separation was brought against him, and the referee’s remarks during the trial, and his final decision, were in keeping with the belief that the defendant was responsible for the consequences of his alienation.

Again, a right appreciation of the status of such patients will lessen the labors of the doctor and the lawyer in their legal aspect, and remove the risk of failure to determine the true physical condition of the habitué where the question of narcotic taking is the leading issue in the case. To illustrate. Granting a general acceptance of my assertion that the class to which this paper pertains are the subjects of a disturbed organism, beyond their control, and for which they are blameless; and granting an appreciation of this belief by the patients themselves, then their main motive for concealment will be removed, and no more reason for untruth exist than if they were the victims of any other functional disease.

Again, the present general opinion of these patients is such that once a case comes into court to settle the question of an opiate using, the defendant, desirous of protecting himself, by denying his drug taking, makes it essential that evidence be secured to disprove his statement, and if certain signs be wanting, the habitué may quite outwit the medical expert. The writer noted a case of this sort last summer. A lady, cultured and refined, who had fallen a victim to morphia years before, and who was party to a suit in court, was examined by two well-known female physicians of this city, who, failing to apply the one infallible test of an opiate using, testified that she was not an habitué. They were mistaken—the lady was taking morphia, though she has since recovered. The point involved, to spare the chagrin of such an error, is obvious.

Lastly, what is the trend of a more rational view of this question as regards the treatment of these cases? Reference has been made to the statement that “no morphia habitué can be depended on to tell the truth”—a statement so often at variance with the fact that it must be the outcome of an experience with the baser class of cases—and I submit the wrong of regarding _all_ as liars because _some_ fail to tell the truth; or, added evidence of the “cruelty of ignorance;” or, an unwarranted libel on a worthy class of unfortunates, who, Heaven knows, have enough to bear without loading them with the reproach such an injustice implies.

Nevertheless it is just such an opinion, and consequent lack of confidence in the honor of these patients that influences their management by some medical men. Looked upon as the victims of their own wrong-doing, or as unworthy the sympathy that should ever exist between physician and patient, or treated on the erroneous belief that such is the only proper method, they are consigned to the brutal ordeal of abrupt and entire opiate disusing, which, while it may end in the desired result, entails such suffering of mind and body as to be utterly inexcusable—because a more humane method will avail—except under conditions peculiar and beyond control.

I am well aware that such coercive measures are the only hope of cure in some cases, but I also know that such patients are not of the better class, and that, once the drug abandoned, the prospect of continued recovery is small, because they lack one of the essential requisites for a permanently good result—that is an earnest desire to be cured.

And the promise of good results from this better way in regarding such patients is more far reaching than on first thought might appear, for the ex-opium habitué forced to stem a tide of distrust—special, as to his cure, and general, as to the permanence of that cure—finds himself hampered in continued well-doing by the lack of that hopeful trust that would largely conduce to his good getting on.

In a recent letter from a lady who honored the writer with her care, nearly three years ago, she referred to the permanence of her recovery, and added—“but as I found it difficult to make every one believe this, much less acknowledge it in my favor, I resorted to the best means I could think of to establish corroborative testimony that _would_ avail, and during _all_ the time I have been in or near—the past two years, I have gone regularly every few days to a physician of prominence here, my old friend and medical adviser of many years’ standing, and had him make every test he desired, placing on record my exact condition, and showing the real truth of the matter. I continue to do this, and intend to do so, and have let people generally know that such a record is being made. I need not tell you that I am proud of my victory. The struggle against ungentle and unfair judgment of those around you make a combination of overwhelming power against the reformed opium taker. It is there that the _real_ conflict begins.”

The writer’s professional work among this class has long been along the line here noted. He has extended confidence—very rarely has it been broken; he has asked for confidence, and the general result can be truly and tersely stated—increasing satisfaction and success.

And now, gentlemen, what are the conclusions of this whole matter? These.

Reason and right alike demand a more rational and correct idea as to the origin of the toxic neurosis we have noted.

This demand complied with—regarding such patients, with certain exceptions, as creatures of conditions beyond control, and so no more culpable than the subjects of other functional disorder—will be most helpful against the protective temptation to untruth.

The medico-legal status of such cases will then be more in keeping with advanced forensic medicine.

The medical care of these cases will tend to a more humane method, with a larger promise of good results, both near and remote.

It will, too, be likely to lessen the increase of habitués, and the number now existing, for a more correct idea as to the genesis of this disorder will prompt medical men to greater care in avoiding the cause, while many a patient—who now shrinks from disclosing his misfortune—feeling he is not denied the charity his case deserves, and that he can command resources both helpful and humane, will be impelled to avail himself of the aid that scientific treatment can surely extend.

314 STATE STREET.

A CASE OF SPINA BIFIDA.

BY JAMES W. INGALLS, M.D.

Presented to the Brooklyn Pathological Society, April 12, 1888.

On September 25th, 1888, was called to attend Mrs. H. in confinement. Patient was a primipara about twenty years of age, and a native of Mexico. Both she and her husband were free from any deformity, and had always enjoyed excellent health. Duration of pregnancy about nine months. Upon examination, I found the breech presenting. Labor progressed favorably, and nothing occurred worthy of special note, except that about half an hour before delivery, while making a digital examination, I discovered over the sacrum of the child a loose flap or fold of tissue, the nature of which at that time I was unable to satisfactorily determine.

After delivery I found the following condition: Over the lumbosacral region were two flaps, each two inches and a half long and about an inch wide; the outer borders were free, the middle portions of the inner borders were attached over the spinal column, and at this point of attachment there was an opening which communicated with the spinal canal. This opening was about large enough to admit the tip of the little finger. The anterior surface of the flaps was simply a continuation of the integument, the posterior surface was a continuation and expansion of the membranes of the spinal cord. The edges of these folds were straight and showed no signs whatever of having been torn or lacerated. There was atrophy and complete paralysis of both lower limbs. No other deformities existed. Flaps were placed in close apposition over the opening into the spinal canal, and upon them was put a thick compress, held in place by a wide bandage. The child continued to do well until the morning of the fourth day, when convulsions developed, and death took place in a few hours.