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cock and controlling the flow by pressing 8. Results where patient's lungs are inthe rubber tubing of the extension between sufficient or abnormal. the thumb and finger, being very careful 9. Angio-neurotic edema. not to get within two inches of the end of I have not mentioned air bubbles or the rubber tube, as the assistant's hands chances of direct infection with living orare not supposed to be clean. The opera- ganisms, as both are entirely avoidable and tor, being comfortably seated, introduces quite inexcusable. the very sharp needle detached. It is bet- Vein tearing is an accident usually ter to introduce it through the skin along- caused by trying to introduce the needle side the vein, and not try to enter the vein into the vein at too small an angle, or by while going through the skin. With the using a dull needle. If the needle at first utmost deliberation the point is now turned fails to engage the wall of the vein it may slightly toward the vein and pressure grad- scratch a larger hole in the vein than the ually increases until the needle enters the needle can fill, the result is a leak and a side wall. Nine times out of ten it will puff in the tissues, a signal to remove the enter without a tear and there will be no rubber tube from the needle and to replace leak around the needle. If the vein is very the tourniquet. If you then get a good large, it is better to enter at a greater flow of blood through the needle and can angle, as it is the large vein that gives a maintain this while pushing the needle little tear and causes about the only trou- further up in the lumen of the vein you may ble which ever occurs when using this be able to continue without increasing the technique.
leak but usually you cannot do this.
If both walls of the vein are penetrated As soon as the needle enters the vein the blood will spurt through it and at the sight it is at times possible to rectify the trouble of this the asssitant, who is still holding by slowly withdrawing the needle and pushthe rubber tube compressed in his left ing it further up into the lumen of the vein, hand, detaches the tourniquet with his
this may fail. right hand and almost at the same mo
If failing in either case the best method
is to leave the needle in situ and make ment passes the rubber tube in his left hand to the operator who adjusts it over the butt
another "stick" with another needle, several With the needle full of of which should be ready in the sterilizer. blood and the tube full of salt solution, Should you remove the needle which has there is no possibility of air bubbles, and
failed you will have a small hemorrhage with the needle having no chamber, there
into the tissues when the tourniquet is re. is very small chance of a clot forming or
applied, leave it hanging until through. If the needle becoming stopped up. As soon
you cannot make another successful stick as it is apparent that the salt solution is
in that arm remove your needles and close flowing intravenously without trouble the
the needle holes with collodion, turn the salvarsan is turned on, and after the sale operating table and wash up the other arm. varsan has been given the vein is washed
Clogging of the needle and a consequent with the salt solution in the usual manner.
slow flow or stoppage of the flow rarely When the needle is removed the patient occurs with the needle I use as it has no should hold the arm perpendicularly for chamber for the blood to clot in. But at half a minute, and as soon as it has been
rare intervals it will happen that a particle cleansed with a wet sterile towel, a small
of fat may get into the lumen at the point spot of collodion will close the needle hole
and clog the needle. When this occurs do in the skin perfectly. The opening in the
not try to clean your needle with the wire
as an embolus might be caused. vein being from one-fourth to one-half an inch from that in the skin, the tissues close
your needle in situ and use another needle the former without trouble. The technique higher up. is thus very simple, but like all simple
Invisible veins in a fat subject cause things it must be followed carefully and difficulty only to a beginner who will soon skillfully to avoid possible difficulties.
learn that this is the easiest "stick” of all.
If the vein can be palpated, no matter how Some of these are as follows:
deep, one has only to proceed as if he sees 1. Vein tearing.
it and he can readily introduce the needle 2. Penetrating both walls.
by the sense of touch alone. Such a vein 3. Clogging of the needle.
is not movable, but is as safely held by the 4. Invisible vein.
fat as a specimen imbedded in parafin for 5. Vein too movable.
the microtome. The vein can not move so 6. Results from old distilled water.
the stick" is easy. 7. Results from too rapid flow.
The contrary is the case in a thin subject with no fat and a small movable vein tient suffers a slight dyspnea. A man which runs around under the skin like a weighing over 180 pounds can take 250 cc. fishing worm. Here is where the stick into his circulation in four minutes without looks easiest but is most difficult. Nothing feeling at all different but if the same but practice will enable you to negotiate aniount is given to a small patient weighsuch a vein successfully. The beginner willing 100 pounds or less and having only nearly always go through both walls. about half as much blood as the large pa
The water used for intravenous medica- tient, six or eight minutes should be taken tion should always be distilled the day it to administer the dose.
When the pa. is used. After the salt has been added to tient's lungs are insufficient or abnormal it or even after it has been poured into the solution being introduced into the veins clean bottles it should be resterilized. If and carried through the lungs will frethe distilled water stands a few days organ- quently cause a temporary irritation. I isms will be found growing in it. This have seen this in patients with only partial may be a fungus like organism, but any of lung capacity. One patient especially with the sa prophitic germs will at times be one permanently collapsed lung and several sound and the result to the patient will be others who were suffering from bronchitis practically the same, no matter what or- have been inclined to cough slightly during ganism has chosen to grow in the distilled the intravenous administration. This can, water. If the water is very old the results in the former case, be remedied by lowerof plant life will show in it sufficiently to ing your apparatus and slowing up the adcause even a careless operator to filter the ministration, but where the lung is inflamed water before using it. If filtered, the or- or bronchitis exists it is better to get ganism itself is removed but it leaves the through with the operation as quickly as water a solution of toxins which have been possible. generated by such colonies. There is no In one case intense nervousness and fear way to remove the toxins from distilled and also an over-loaded stomach in a pawater except by re-distillation. Neither tient after a recent attack of indigestion boiling nor filtering can affect toxins. When seemed to cause an attack of angio-neurotic a solution made of old distilled water is edema during the administration.
The administered intravenously the toxins that others, three in number, have also occurred are thus injected will cause a reaction very while the patient was on the table. One of promptly. Sometimes such a patient will these was quite severe and the patient's have a chill before he reaches his room. This eyes were closed by the swelling of the lids. paroxysm from a toxin that is injected with In fact her entire face looked as if many the medicine will never be slower in coming bees had stung her. The only precaution on than twenty or twenty-five minutes we can take to avoid such an unpleasant while the reaction caused by a toxin gen- occurrence-for it is decidedly unpleasant erated in the patient's system by the kill- though harmless in the end-is to refuse ing of organisms will be an hour and a half to administer an intravenous dose of any. or two hours in coming on. A great many thing to a patient who is manifestly frightphysicians through the country are using ened or who has just eaten a large meal. old distilled water, and some are even using The fact that the angio-neurotic edema ordinary tap water. Of the two it would does not seem to ever occur with the first be better for the patient to use deep well dose would suggest anaphylaxis, but I feel water freshly drawn which has not had certain, on the contrary, that the nervous time to become the home of any sa prophitic condition of the patient is entirely respongerms, than to use the old distilled water. sible, though a full stomach is also a preThe chemical substances contained in deep disposing cause. well water would probably not interfere I can think of no other difficulties which with the solution of the remedy to be used may occur in a carefully carried out intraand after it had been properly sterilized it venous administration and those that I would be safer than the old water that had have mentioned are certainly not of great been distilled even.
consqeuence. A too rapid flow into a vein may cause a One rule should be adopted by any one slight quickened breathing on the part of doing intravenous work and that is to rethe patient and a feeling of oppression. member always to be just as careful in This is due to the fact that in diluting the every particular in giving your thousandth blood in the right heart to too great an dose as you were in giving the first. extent the fluid pumped through the lungs
DISCUSSION. is largely the fluid being administered and DR. R. L. SUTTON: Several years ago, beas it has no oxygen carrying power the pa- fore the discovery of salvarsan, we had an effi
cient treatment for syphilis in ordinary mercury very much whether anybody has ever died diand some of the arsenical preparations, and for rectly from the effects of the intravenous use of that reason I feel that it is indefensible to use salvarsan. Any man with myocarditis or with a salvarsan in the manner in which it is used by weak heart is liable to die after drinking a cup some practitioners, imperiling the lives of our of coffee or anything else. Such coincidences patients when we possess other therapeutic should not stand in the way of the absolutely agents that can be employed with such excellent perfect results obtained in most cases and beneresult. I have administered considerably over one ficial effects in all cases from the administration thousand doses of the drug up to the present
of this drug. time, and thus far have not had a fatal result. I have given over 1100 intravenous doses ; have A case was recently reported by a prominent given them in my office and allowed the patients New York man, whose patient died on the table to walk to their homes and to come back and rewhile receiving an intravenous injection of sal- port the next day. I have never had any unvarsan, and we have had three or four similar pleasantness. However there were several narcases in Kansas City. I recently examined the row escapes. One patient absolutely refused to brains of two patients who died following the in- take salvarsan when I was getting ready to give travenous injection of the drug. It is a ques- it to him. That night at the supper table he had a tion in my mind whether, in a disease like syph- stroke of paralysis. I asked him the next day, ilis, for which we possess other efficient reme- “What if I had given you salvarsan?” He redies, we have a right to imperil the lives of our plied that if I had done so no power would ever patients by the employment of a method which have convinced him that the “606" had not parcan bring about such results. In my first one alyzed him. Another patient went out to Mineral hundred cases I tried practically every form of Wells, Texas, to stay a week before returning administration that had been recommended, and for salvarsan. She had been there only a few now I use only the intramuscular route. In some days when she had her first epileptic seizure. If instances, when the intravenous method was em- she had been given salvarsan before going to ployed, the patient's lips became blue and there Mineral Wells the drug would have been blamed. were other signs of collapse, although, fortun- Personally, I do not think there is any danger ately, no serious complications ensued. Some of whatever to be feared from the intravenous adthe symptoms and some of the results encoun- ministration of salvarsan, if properly carried tered in the intravenous administration of sal- out. varsan will frighten even an experienced surgeon, and, considering the results that some men get, he has good cause to become frightened.
A PLEA FOR THE EARLIER RECOGNIDR. H. P. COLLINGS: As Dr. Martin did not
TION OF CERTAIN NERVOUS AND MENspeak particularly of the technic of the administration of salvarsan in his paper, I would like to
TAL CONDITIONS. say a word or two regarding it. The instrument I use now is a little different from the one the
E. P. BLEDSOE, M. D., Little Rock, Ark. doctor uses, and the apparatus is much simpler.
Although this is the age of preventive It is the one, I believe, Dr. Fordyce now uses. It consists simply of a mixing tube, which is medicine, and much is being said and writgraduated in cubic centimeters both ways. It has ten regarding the prevention of disease, the å rubber cork and through this cork is a glass field of mental and nervous medicine is tube reaching to within about one inch of the bottom of the vessel or graduate, and another generally presumed to offer little either as which reaches just through the cork about half
a result of treatment or prophylaxis. The an inch. The medicine is dissolved in the grad- reason for this erroneous presumption is uate, the rubber cork with its two glass tubes is due largely to the marked lack of interest fitted in and the whole is turned bottom side up; a soft rubber tube leading to the vein is kept at
in anything approaching the field of Neutached to the short glass tube, and to this is rology or Psychiatry-a condition brought clamped a small clamp so as to cut off the flow of about by our medical schools which only the liquid until the proper time. The needle is recently have recognized the importance of introduced and the tube is then attached to the needle, and that is all there is to it. Neosalvar
proper instruction in these two important san or 914, instead of 606, takes less water, about
branches of our profession. 150 c.c., is less irritating, and is supposed to be As a result, we might say that the field less dangerous, and no salt is necessary. When of nervous and mental disease is far behind the solution is made with distilled water it is
other branches of medicine, as regards ready for intravenous injection and does not need the addition of soda solution.
either early or accurate diagnosis. Unfor.
tunately, it is only by the early recognition DR. E. H. MARTIN (closing): I cannot agree with Dr. Sutton. If we all believed the same
of many nervous and mental conditions that thing there would be no advancement, but I we may hope to accomplish results either think Dr. Sutton exaggerates the dangers of the curative or prophylactic, while in others, intravenous ađministration of salvarsan. Cer- lack of early diagnosis often leads to incurtainly a patient dying on the table must die from
able disesae. some fault in the administration and not from the drug administration when the drug is harm
There is no field of medicine of which less in other cases.
this statement is more true than that of Dr. Sutton spoke of a patient with myocarditis mental disease, and yet how seldom are the dying from an intravenous injection. I doubt
earlier symptoms recognized. this very much. I have never seen more than a ten millemeter rise in the blood pressure from
The possibilities of preventive principles eight ounces injected intravenously. I doubt to mental medicine and by mental medicine
-I do not refer to insanity alone, but to all latures, and steps should be taken to prodisorders of the mental process, however vide for the care and instruction of all deslight -are just beginning to dawn on the fective children. medical profession at large. We are be- We are all ready to admit that this is the ginning to realize that certain individuals age of the strenuous, and that many indiare being born into the world poorly viduals fall by the wayside in the struggle equipped to bear the "slings and arrows of for existence. It is this class whose disoutrageous fortune.” Such an individual orders are dependent upon purely psychomay have difficulty in adjusting himself to logical factors who are most apt to develop his environment, so to speak, and in that into troublesome neurotics, or even if uneffort may develop certain mental peculiar recognized, into some type of psycosis. ities, which are as much symptoms of dis- As Dr. Wm. A. White in his excellent ease as the rash in scarlet fever or a Ker- little monograph on "Mental Mechanisms” ning's sign. Allow these danger signals to says: "The individual at some point or go unheeded, with the comforting assur- other comes into conflict with the condi. ance to the parent that the child is just a tions about him, in which he must live and little nervous and will outgrow it all,” to which he must adapt himself if he is to and we have a splendid nucleus for the de- proceed in life with anything like efficiency velopment of a neurosis or psychosis in and he fails to make the necessary adjustlater life.
ment. He is unable for example to reach a How many times have we all been asked, condition of emotional calm after the loss "Doctor, why is my child nervous?" and of a dear friend or relative, or after a dishave replied with some glittering general appointment in love; he cannot get on his ity of heredity or environment, when a care- feet again after being ruined by a trusted ful examination of the child's mental pro- employee; he is placed in a position of too cesses would reveal the fact that he was great complexity for a limited mental struggling against an unsurmountable ob- equipment, and cannot produce results that stacle—that of a retarded mental develop- are up to reasonable expectations. ment.
At these periods of conflict, failure is not This leads me to speak of a subject of infrequently expressed by the development vast economic importance that of the rec- of a psycosis. Failures of this sort, the ognition and special instruction of mentally inability of the individual to square up defective children in our public schools. with the events of every-day life, upon
The work of Binet and Simon has put a analysis are found to depend largely upon method into our hands by which we are faulty and erroneous viewpoints-upon viable to accurately diagnose and classify all cious habits of thought, upon narrow and mental defectives. It is in this class of chil- inadequate ideals, false notions and ambidren, not necessarily imbeciles or Morons, tions, in short upon a biased mental attibut the child just a little below the normal tude toward the world of things and standard, that the potentialities of nervous events." and mental disease lurk. Place this child It is the importance of the early recogniin classes with children with minds up to tion of conditions and types, such as these, the normal standard, and he soon becomes to which I wish to direct your attention to. discouraged and falls behind-the pace is Instead of passing such cases by with a too fast for his slower mental processes and cursory examination and a tonic for their he cannot adjust himself to his environ- 'nerves,” let us inquire more closely into ment. As a result, he becomes nervous and their mental processes, their habits of irritable, develops violent fits of temper fol- thought and ideals of life. The investigalowed by depressed states, and is often sent tions of Jung and the psycho-analytic from the school with the reputation of be- school have shown the value of psycho aning an incorrigible, to finally land in an in- alysis as a diagnostic measure, and often stitution as a care and expense to the state. the mere revelation of some psychic trau
The same child, when carefully tested by ma, unrecognized by the patient gives us the Binet-Simon scale and given proper in- sufficient insight into the case and enables struction for his mental age, will often de- us to stamp out an incipient psychosis. velop mentally and physically into a useful I think I might say without fear of succitizen.
cessful contradiction, that there are many The initiative in this work is in the psychoses dependent upon mental causes, hands of the physician for laymen are slow which if recognized in time, are preventto recognize its importance. Much needed able. laws for the medical inspection of our This is doubly true in cases of recurrent schools should be urged in the state legis- psychosis and one of the strongest argu
ments in favor of the intelligent after-care surroundings is emphasized by Dr. Bledsoe. A of the Insane.
Here we are dealing with something that is born in that child, a minus deindividuals whose whole metal equilibrium
velopmental compensation, that does not meet the
standard of educational requirements, or the enhas undergone a powerful shock. Often vironmental requirements of the day. A common these patients are discharged from the teaching training curriculum today is fixed as a hospitals apparently normal, but, when
standard. This standard is based on the past called upon to meet the conditions of the
achievements of strong, healthy children of su
perior mental endowment. From the highly enevery-day struggle of life, their mental dowed educational possibility to the inferior processes are too weakened to stand the grades of educational possibilities all are urged strain of the sudden change of environment.
to acquire the mental memories, lifting the same Recognition of this fact has led to a system gradings to meet this fixed requirment. Physio
mental loads in the same way to make the same of after-care of this class of patients, logically and psychologically this is an impossiwhich
has given excellent results, and bility in the biological frailties. The overstrain which should become a part of the institu
and overstress can do violence to the fundamentional care of the insane in every state.
tal structures essential to mental acquirements, In this brief paper, I have merely touched
causing, possibly, a disassociated chemistry of
the primitive elements. Accordingly these chil. on a few phases of this question. In- dren fall behind instead of being educated, stances might be multiplied time and again,
trained and graded according to their own deand the answer would always be the same.
velopmental possibilities. Here it would seem What is the remedy? The answer is, Edu
possible for attempted educational refinement to
plant the seed of evolutional decay, namely, decation. First of all of the physician him- mentia precox. Dementia precox belongs to the self. We must begin to realize that "nerv. juvenile epoch. The recognition of its symptoms ousness” is only a symptom of some under
later is to acknowledge the presence of a termin
al pathology resulting from the unseen initial lying pathological condition, often physi- chemical structural twists which Dr. Bledsoe cal it is true, but more often mental, and would have us recognize early and retwist to the in either case, usually preventable. The normal trend, fortifying the physiological weakphysician must learn to recognize not only
ness with educated physiological resistance. How
many of these children can be saved by institutphysical but mental symptoms in his pa- ing an early educational prophylaxis, before an tients and, having recognized them, it is atomic and a chemic and later an anatomic and only a step to the removal of the cause. pathologic retrogression has displaced the primiThen, the individual himself must be
tive upbuilding, developmental process? That educated, and it is upon the physician that
question is embodied deep down in Dr. Bledsoe's
paper. this burden must necessarily fall. Many Ďr. Cotton's demonstration before the recent cases are mere individual problems, which
Psychological Association alightened us on the may call for a detailed study of character present status of the histopathology of the brain
cortex in mental disease. He showed the value and a process of re-education along certain and limitations of Nissl's method and the newer lines, while others may assume vast socio- and the additional findings by the Charlach R. logic and economic importance, such as the
method, illustrating the heretofore overlooked question of defective children.
fatty degeneration of the neuro-fibriles in de
mentia precox with the gradual change from a Last and most important of all, the pub- functional disturbance to an organic condition. lic must be educated to realize the fact that This reminds us first of a functionationally disit is by the neglect of such problems as turbed developmental process to be followed in child labor, state care of epileptics, etc.,
time, if the disturbance remains uncorrected, by that our asylums are filled with insane and
a retrogressive blight of that function with the
final terminal pathologic changes. our jails with criminals. Much of this
The essayist correctly accuses us of studying might be prevented for many cases have symptoms postponed till an irreparable condition their incipiency in childhood, often under has become fixed; till the gradual change from the eyes of the school teacher and the fam
the functional disturbance to what amounts to ily physician. Finally, it is the physician
a pathologic change has been established. As in
the highly sensitized cortex of the child that has on whom both the public and individual a proverbial “worm spasm," a "teething spasm.” must depend for the solution of these great This hypersensitization, unabated, initiates an problems.
abnormally irritable, therefore, an overly reDISCUSSION.
sponsive cortex to the ordinary ingoing impulse
messages from the exterior. At first the disturbDR. S. GROVER BURNETT: Dr. Bledsoe has ance is functional and the "worm spasm" was called attention to the fundamentals of psychia- the danger signal, heeded or unheeded. The tric eugenics in the formative epoch. He refutes spasm recurring between 5 and 8 years of age is the old “beautiful diagnosis and bad prognosis” the alarm of a condition, meaning more than a in neurologic and psychiatric work. It is not true disturbed function. Recurring again between today. It was only true in the past for the sim- 10 and 15 years of age means the unprotected ple reason that no diagnosis was made until irre- hypersensitized cell, always irritable, therefore parable damage had been done. Any one can stressed, has developed a changed and fixed make a diagnosis after the condition is fully es- molecular and chemic morbidity with a probable tablished.
neuroglia proliferation around the cell, making The inability of the child to adjust itself to its the child an epileptic for all time. This does not