Chapter II: Part 2

I have endeavored to present the subject in a condensed but general way without burdening you with technical details of species, genera or life history. The subject is a vast one and to which the best minds of the scientific world are devoting themselves. To those who are or may become interested in bacteriology and particularly to those who study the relation of these germs to disease, is held forth the reward which is sure to come to those who work persistently and intelligently.

The method which I shall employ to-night is eclectic. Doubtless each investigator will find fault with some parts of the process and perhaps suggest a better one. The following, however, has in my hands worked well and given entire satisfaction, so far as I know, to those who were and are most interested.

The apparatus necessary is as follows:

One two-inch glass funnel.

One package filter papers to fit same.

Four medium size test tubes.

Two glass or porcelain staining glasses.

One glass or agate mortar and pestle.

One cover holder.

One pair pincetts.

One alcohol lamp.

Package of wooden toothpicks.

The cover holder may be easily made by taking a piece of thin platinum, two inches long and one-eighth wide, splitting one end for half an inch up and bending into a Y shape, then lashing to a small handle (I use a match). This little tool is most convenient for floating cover glasses in staining fluids.

The reagents necessary are as follows:

A five per cent. solution of nitric acid in alcohol (95 per cent.).

Saturated alcoholic solution of fuchsine.

Saturated alcoholic solution of methyl blue.

Small quantity of alcohol, 80 to 95 per cent.

Pure colorless aniline oil (anilin).

The method is as follows:

First pour enough aniline into a test tube to cover the bottom and half fill with water, shake violently for two minutes, and filter through funnel, which has previously had wet filter paper fitted. It is essential that the filter paper be saturated with water, else the aniline oil will separate during filtration. Our next step is to deposit specimen of sputum in mortar (if very viscid, add a few drops of water), and triturate thoroughly in order to break up encapsulated colonies, and distribute evenly through the specimen.

Now remove an amount which will just cover end of toothpick, and deposit it on a previously cleaned cover glass, which should not be over 1/100 inch thick, and thinner if possible; immediately cover with another cover glass, allowing sputum to spread by capillarity or slight pressure, and separate by sliding apart, and put aside to dry without heat. I have found that specimens dried without heat (and consequent coagulation of albumen) will show a much larger number of bacilli than when heat is used. I believe this is due to the fact that the fuchsine penetrates more thoroughly through the albumen when not coagulated, or that when it is coagulated by heat it to a greater or less extent it protects them from the action of the stain. While the covers are drying we will pour out a sufficient quantity of the aniline water, which by this time has filtered into one of the staining glasses, and add one or two drops (not more) fuchsine solution. Now, placing one of the cover glasses on our cover holder, sputum side down, we lower it into the staining fluid and withdraw holder from the side, and repeat the operation for the other cover glass. It is my habit to allow the covers to remain in this solution for at least eight hours or over night. The time may be reduced to ten or fifteen minutes by heating the red stain to about 140 or 150 F., but the result is not so brilliant, nor is it sure, as I have frequently failed to find the bacilli by the short method, but have been able to demonstrate their presence by the long one.

At the end of either of the above periods of time, the cover glass is lifted out of the staining solution and, without washing, immersed in our five per cent. solution of nitric acid and alcohol. It is this part of the process, if any, which will give trouble, as the time of immersion is governed by the thickness and general character of the sputum. My custom is to hold the first cover immersed until the color has just disappeared, or say fifteen seconds, and the second five seconds longer; but a very little experience will remove any difficulty from over-decolorizing.

From the decolorizing solution they are immediately immersed in water and thoroughly washed, when they may be again floated in the contra-stain, which is prepared by filling the other staining glass with water to which a few drops (three or four) of our methyl blue has been added. They should remain here for from five to eight minutes, when they are again removed with the pincetts, and a few drops of alcohol poured over them to wash off the surplus stain. Again wash in clean water, and dry by gentle heat (which will now do no harm) over the alcohol lamp, and place sputum side up on table.

A very small drop of thin benzole balsam is now placed in the centre of each cover, and a cleansed slide gently lowered over one in such a position that both covers may be mounted on a single slide. As soon as the slide has been sufficiently lowered to come in contact with the drop of balsam, it spreads by capillarity, and draws the cover close to the slide without the slightest danger from air bubbles being engaged, and the slide may at once be inspected by a _dry_ objective.

I have found it necessary to use an objective at least as high as one-fifth or one-sixth, with central illumination without diaphragm, as cases will frequently occur where the staining is so faint, that with a lower power they will escape observation, though a good, wide angle, four-tenths inch, will show them well when strongly stained.

I have endeavored to explain the method with perhaps too strict a regard to detail, but am sure that one who follows the various steps once or twice cannot fail to acquire the necessary technique without occupying more than fifteen minutes of working time; that is to say, five minutes to the first staining, and then the following morning to prepare and mount for observation.

171 GATES AVE., BROOKLYN.

ADDRESS TO THE GRADUATES OF THE LONG ISLAND COLLEGE HOSPITAL TRAINING
SCHOOL FOR NURSES, DELIVERED JUNE 12, 1888.

BY GEORGE G. HOPKINS, A.M., M.D.

_Ladies and Gentlemen and Class of 1888_: We are apt to claim the trained female nurse as the outcome of the more rational treatment of disease, in modern times, but this is wide of the truth. So far as I can ascertain, in my researches among the ancient Vidas of Hindostan, and the literature of Egypt, Greece and Rome, I find no allusion to female nurses as a class, until the third century of the Christian era. Surgery and medicine had attained a high degree of perfection, many operations which to-day we claim as new to the nineteenth century were successfully performed 4,000 years ago; but the special nursing of them seems to have been done by the medical student, or by the practitioner himself. The earliest record I can find of women devoting themselves to the care of the sick, and attending to all the duties of a trained nurse, is that of Empress Helena, mother of Constantine the Great. This noble woman, who lived nearly fifteen hundred years ago, not only founded a hospital and endowed it, but herself, with the ladies of her court, there gave the most devoted and tender care to the sick poor. The Emperor Valens presented the most beautiful grounds and buildings in the neighborhood of Cæsarea to Archbishop Basil, “for the benefit of the poor whose bodies were afflicted with disease,” as being those who stood most in need of assistance. And as early as A. D. 373, the Archbishop had organized at Cæsarea an immense hospital, called the “Basilides,” which Gregory Nazienza thought worthy to be recorded among the wonders of the world; so numerous were the poor and sick who came thither, and so admirable was the care and order in which they were served. The charge of these sufferers was not at first assigned to humble hands; the most illustrious ladies of the empire participating in the offices of mercy.

At Constantinople the Empress Flacilla, wife of the elder Theodosius, in the year 380 was watching with solicitude over all those whose bodies were mutilated, or who had lost limbs. She visited them in their own dwellings, waited upon them herself, and supplied their wants. She repaired with the same zeal to the public hospitals of the church, where she attended the sick, made ready their culinary utensils, tasted their broth, carried the dish to them, broke the bread, divided the meal, washed the cups, and performed for them all the offices which usually devolve upon servants. One might justly be proud to be in such royal company, and regard, as she did, nothing degrading which is necessary to be done for a sick patient.

In modern times, the revival of nursing by trained women is due in great measure to that noble and accomplished woman, Florence Nightingale. As early as 1844, at the age of twenty-one years, she began to exhibit her interest in and the alleviation of suffering, and the improvement of the care of the sick poor in the hospitals of Great Britain. She visited and inspected the hospitals of Europe, and in 1851 entered into training as a nurse, in the institution of Protestant Deaconesses, at Kaiserworth on the Rhine. On her return to London she put into thorough order the Sanitarium for Governesses, in connection with the London Institute. She served ten years of apprenticeship before entering on her life work.

In the spring of 1854 war was declared with Russia, and an army of 25,000 men was despatched to the Crimea. The faulty arrangements of the British government for the care of the sick and wounded furnished the theatre in which Florence Nightingale was to win her first laurels. The hospitals were soon crowded, and the mortality in the wards so great that the casualties of the fiercest battles were as nothing in comparison.

The war office recognizing the condition of affairs, gladly accepted the offer of Miss Nightingale to go to the seat of war and organize a nursing department.

Her devotion to the sufferers can never be forgotten, she has stood twenty hours at a time, directing and assisting in the care of the sick and wounded. Her unfaltering devotion and incessant work undermined her health; but though sick and feeble, she never left the field of duty until Turkey was evacuated by the English troops. Major Delafield (who with Maj. Mordecai and Capt. Geo. B. McClellan, U. S. A., had been sent to Europe by our government, to study the art of war in the Crimea), in his report to the War Department, remarks, in speaking of the English hospital at Scutari, “It was in this well-arranged hospital that that most estimable lady, Miss Nightingale, exercised her powerful influence in alleviating the condition of the sick and wounded from the battle-field. Women as nurses were employed to attend upon the men in the wards, under the kind and beneficent guardianship of this good lady, with the many advantages that would naturally follow the most gentle, painstaking, and cleanly attendance of women as nurses. Miss Nightingale’s efforts have resulted in the establishing, in connection with the English army, an office known as the ‘Superintendant General of Army Nurses,’ the office to be always filled by a woman. She has under her a corps of female nurses, who take care of the sick in the military hospitals.” The Sanitary and Christian Commission of our late war was the outcome of the volunteer nursing in the English war of the Crimea and the fruit of these efforts in this country are the training schools for nurses which have sprung up all over this land.

Next to our entrance into this world and our departure from it, occasions such as the present, when we have completed our education and are about to enter upon our chosen vocation, are the most important events in our lives. The calling which you have chosen, while not a new one, is comparatively new in having special schools, and courses of study provided for it. Nursing has always been considered peculiarly woman’s work—more or less adaptation to such work is inborn in woman. What man can smoothe the pillow of the sick, or soothe an aching brow as gently and acceptably as one of the gentler sex! Who can move as quietly, and approach the bed of pain so gently as woman!

I have seen sick men, absent from home and friends, sigh for a mother, sister, or wife who is not at hand.

Thanks to this school, and others, everyone can now have skilled female care when sickness and disease are upon them.

You who are about to go out from us to-day, are entering upon a calling which will require all the skill, faithfulness, courage, patience, forbearance, endurance, watchfulness, self-possession, tenderness, cheerfulness and tact, that a human being can possess, and above all, “a conscience void of offence toward God and man.” “To thine own self be true, and it doth follow as the night the day, thou canst not then be false to any other.” You have each and all of you received, at the hands of your admirable Superintendent, and the lecturers of the College, such definite and varied information in all the departments in which you may be called to act, that you ought to be prepared for most emergencies, and have shown by your examinations that you have heard and understood them.

The fault will be yours, and yours alone, if you do not treasure them in your minds, so that you may be not only trained but _skilled_ nurses. The responsibility for the proper management of a sick-room and the patient in it is a very high and grave position, and requires the utmost faithfulness on the part of the nurse. Unless you are willing to put aside everything that may interfere with your giving _yourself_ entirely and conscientiously to the care of your patient, do not assume the charge. But when you once receive that charge remember that you are dealing with that which disease can destroy by your negligence, and no human power can restore—a precious human life. You therefore owe to each case all that a faithful mind can suggest and the body endure; and such faithfulness has not been wanting in the former graduates of this school.

I can never forget the scene when one of our graduates, after having charge of over thirty cases of typhoid fever among some orphan children, and we had to lose one, whom she had nursed as faithfully and tenderly as its own mother could have done, how, when she had done her all and death claimed him, there were tears shed for one who had no mother to shed them. And it was due largely to her unremitting faithfulness that we were able to record but two deaths in thirty-three cases. That woman has not had an idle day to my knowledge in several years.

When any unexpected emergency arises, which to your educated eye teaches you that your patient is in extreme danger, do not alarm the friends unnecessarily; try not to show in your voice or conduct that you are demoralized and have lost courage. While doing the best you can (until the arrival of the physician, whom it was your first duty to have summoned), encourage those around you, and keep them busy if you can, as, unless they are occupied, the coming of the physician will seem to them unreasonably delayed, even though he be at hand when called. Above all, do not let every physician within reach be sent for, unless the situation is one of great urgency, as I believe many patients have been frightened to death by the demoralization of solicitous friends.

If you can show yourself capable and maintain your own composure of mind, you will be able in nearly every instance to avert a panic, and in many cases prevent disastrous results to your patient. But if you fail at times for want of proper courage, do not give up with a feeling that you are unequal to emergencies, only be the more determined not to show the white feather again.

It is a well known fact to military men, that veteran troops who have stood the brunt of the fight in many a battle, become demoralized unexpectedly and retreat, to the utter surprise of their officers. But in their next battle their courage and deeds of prowess again surprise every one. So be it with you.

In the sick-room nothing so distresses the helpless sufferer as a want of frankness on the part of the attendant. You may refuse or neglect to answer, or turn the subject if possible, but never tell what are called “white lies.” One lie always requires another to cover it, and sooner or later you will be caught. If it is not best to tell, say outright it is better for me not to answer that question; or it may be the least of two evils to answer it faithfully as patients often imagine that things are far worse than they are. I believe that we of the medical profession often err in withholding from patients that which it is best in the end that they should know. This is one of our most difficult lines to draw.

If you have not learned or are not determined to learn to endure the caprices and demands of unreasonable men and women in the most unreasonable hour of their lives, you have mistaken your calling; as without Christian patience, I do not believe it possible for a nurse to succeed for any length of time. The trials and vexations of a nurse’s life are so numerous and so constant, that it is a wonder to me that there are so many who are ready to enter this calling in life. There is no need since the revival of professional nursing for women to torture themselves or do penance. Be as ready to minister to disagreeable people as a person who two years ago wrote that she would take a fresh air child, saying “send me one of the dirtiest, most unattractive and unruly of the children, one whom nobody else wants.” An unreasonable, selfish and wilful patient is a purgatorial discipline for both nurse and doctor.

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.

Dissection showed that there was a fissure of the spinal canal extending from the second lumbar vertebra down to the sacrum, the laminæ being absent. Both sciatic nerves were given off in the usual manner.

THE BROOKLYN MEDICAL JOURNAL.

_EDITORIAL._

THE FINANCIAL RESULTS OF MEDICAL PRACTICE.

The medical men of the Bay State have been treated several times during the past decade to the mournful story of the meagre financial results from a life-long practice of medicine in that commonwealth. The detailed cases, narrated by Dr. Cotting, were pitiful enough, for they were proof that a faithful, conscientious and skillful medical career could find little laid aside for the “rainy day” of personal illness or the vacation for the tired brain and body, or the reposeful life of a physician’s family when death had closed in on his labors. In the same strain Dr. Jeffries, in his late annual address before the Massachusetts Medical Society, proclaims that “no man has made a fortune as a physician, I mean no one ever paid his expenses and laid by at interest enough to live on through the practice of medicine.”

This breathes in the atmosphere of complaint as if the profession of medicine were exceptional in life’s vocations; as if it, alone of all the lines of work, did not lead to financial results where “enough to live on was laid by at interest.” It is very pertinent to ask, in what pursuit in life inheres that tendency to make the laborers therein independent of labor? It is equally pertinent to ask, where is there an instance, in the history of labor, where a man, following the duty common to his fellow workers and relying on his own unaided hands and brain, ever acquired the competency to live, in his accustomed sphere, independent of labor? Dr. Cotting’s instances of the poverty of medical men are pitiful, but they are duplicated in the ranks of the promoters of literature, art, science and philanthropic work through historic time and will be multiplied to the end. Great wealth is the possession of but very few and, on the lines of legitimate industry, is always the result of combination and the use made of the labor of others. In the early part of the century, Mr. Astor founded a fortune by buying up pelts from the trappers of the Northwest. Had he depended on what his own hands could have done, his old age would have found him drying his skins and frying his bacon with his own hands in his forest cabin. Mr. Carnegie to-day, utilizing the labor of miners in iron and coal and giving direction to the skill and toil of a multitude of mechanics, is still adding to his fifty millions. Had he depended on the limitations of his own brawn, he might still each evening be washing the grime from his horny hands under the faucet in the hallway of his tenement house lodgings. These great possibilities of combination are in the genius of commercial enterprise, though they are realized by few. They are foreign to the genius of labor where combination is impossible, and where the labor is of such a character that there is no monopoly of skill and many can accomplish it equally well. A medical man’s labor is limited by what he can himself do, personally and unaided. He can neither delegate nor superintend. His income is limited by these personal conditions, modified only by the possession of some exceptional skill and the accidents of popularity or environment. The engrossing character of his occupation hinders him from the experience that justifies outside speculation with acquired capital and restrains him from participation in outside ventures which require freedom both of time and thought. He cannot well add another string to his bow.

The results of combination in trade and the income from professional labor are issues from distinct and opposite sources and have no right to be compared or made the subject of invidious reflection. A number of lawyers, each an expert in a special department, may form a partnership, occupy a common office, each helping the other, the emoluments going to the common fund. This is a sort of combine. But the time is not yet ripe, and probably will never come, for the incorporation of a great Medical Trust, with the names of a specialist in eye, ear, throat, nose, lungs, liver, sphincter ani, corns and fallopian tubes, and so on to the minutest subdivision, with the addition of some general practitioners and apothecaries, displayed around the casings of some common front door, to scoop in the community and pool the receipts on a graded tariff. Trade is essentially selfish and works for the individual. “If you don’t work for number one, number two will be working for you.” The accumulation of money is neither end nor contingent in professional life. The pursuit and application of medical science are on the higher level with the learning of jurists, scientists, educators and literateurs, whose mission is the unselfish search for knowledge for the immediate benefit of mankind and the advance of civilization.

While it is true that very few in any calling “lay by at interest enough to live on,” a very small number of that few do actually retire from active work and live on that interest, and this for two reasons: First, a man in successful professional life is in receipt of an income which enables him to live in luxurious surroundings, gratify tastes and enjoy recreation, which income, considered as interest, would represent a capital sum exceptional even among the results of successful trade, stock gambling or railroad wrecking. Such a man, and he is one of many, could live on what he “has laid by at interest,” if he saw fit to live in less luxury and sacrifice the gratification of tastes which have been cultivated and become necessary to his comfort. He could live on his interest, but he does not care to live in idleness. On the other hand, the conditions of a cultured life are of an ever widening horizon, and it is characteristic of medical men that their intellectual sense is inquisitive, keen, appreciative and alert in their own sphere of action, less satisfied with what is and more anxious for better results, beyond the genius of any other professional life, and this for the distinctive reason that every new discovery in medical science promotes accuracy in the application of medical art. Working becomes a passion with medical men; the more they know the more eager they are to work. This passion is not to “lay by at interest enough to live on.”

It is quite in the sentiment of medical addresses to bewail the profession as ill-paid, and that, for a learned and self-sacrificing body of men, its labor and accomplishments are very inadequately rewarded. The exact contrary is, probably, very much nearer the truth. There are many learned men in the profession and there is a wide range of special learning which is the common property of the profession, and all are more or less adept in the use of agencies of the art. There is, likewise, a vast amount of patient and uncompensated care given in the routine of practice, which is a natural outcome of the practice of the medical art. It would be absurd to claim the diploma as representing a liberal education or even high special attainments, as it would be ridiculous to assert that a dispensary patient regularly received the attention given to the German Kaiser or General Sheridan. There are instances of failure and poverty among medical men, but when the doctors in the country stand to the population in the proportion of 1 to 580, the assumption is that they have become needful, each to his 580. Doctors have many book charges that are not collected. Laborers are swindled by their bosses, and every business man meets his unlucky customers; the parish gets behind with its rector. The doctor is no worse off than the rest, and besides he has no salary list, and no accommodation at the bank to make good.