Complete Text (Part 11)

4 5 Put 0.5 cc of suspension into c \ach of^ tubes, O Q Q Q if o 1 , No. 2 serum undiluted 0.5 cc , No. 2 serum 1-20, 0.5 cc 'a Ivpe 1 . . . . +--1- — — — Di s solved Tvpe II . . . lia, III) IIx + ++ — Dissolved Dissolved Tvpe III . . — — + Dissolved Type IV... — — — Di s solved ( Incubate ' for 1 hour at 37 deg. C.) 136 Precipitin ieM. For this test tlie peritoneal wash- ings are centrifngalized until the superuatent fluid is water clear. The clear tluid is pippetted off and the following set-up made: Tube 12 3 4 Put 0.5 cc of supernatent fluid in each tube. Tvpe I — Tvpe II . . . ++ lia, lib IIx — Tvpe III.. — Tvpe IV... — u: zn Ul CD o <x> o Si i-s 1— 1 i-S 1— 1 i-j gM ^ ^^^ S3 ^^3 "n? on ? o? P- to o to Ci Jj3 ++ ++ + (The precipitin reaction usually occurs at once. If it does not, incubate.) 2. Sputum cultures. Obtain a specimen of sputum as free from saliva as possible and wash through six solutions of sterile salt solution. A blood-tinged flake is the one of choice. After washing the flake place a small portion of it upon a blood agar plate and break it up Avith a platinum wire bent at a right angle. Streak three agar plates with the wire without reinoculation. Incubate for 24 hours and then look for small colonies with a green zone about them. Pick colonies, inoculate broth tubes, and carry out agglutination test as given. 3. Precipitin test in the urine. This test is often 137 positive within 12 lioiirs after the initial chill and remains positive for some days. When it is posi- tive it furnishes a rapid and accurate method of determining the group of the organism. For this test 0.5 cc. of urine are placed in each of three test tubes. To the lirst tube is added 0.5 cc. of Group No. 1 serum undiluted; to the second, 0.5 cc. of Group Xo. 2 serum undiluted, and to the third, 0.5 cc. of Group Xo. 3 serum undiluted. If a precipi- tate does not come down immediately, incubate at 37 deg. C. for one hour. The presence of the pre- cipitin reaction in the urine indicates a severe in- fection and is of bad omen, especially if it increases from day to day. 4. Avery's method. (Jour. A. M. A., Vol. 70, Xo. 1, Jan. 5, 1918, page 17.) This method is based upon the fact that carbohydrates and blood proteins when added to suitable media accelerates the growth of the pneumococcus, and also that bile dissolves the organism. Special media for the test: Meat infusion broth, 0.3 to 0.5 acid to phenolphthalein (sterilized in arnold sterilizer on three consecutive days) . 100 cc. 20% glucose (sterile) 5 cc. Defibrinated rabbit's blood (sterile) 5 cc. Tube media in small tubes about 4 cc. to the tubo. A kernel of sputum the size of a bean is selected and washed in six changes of sterile salt solution, emulsified in broth and inoculated into one of the tubes of special media. Incubate at 37 deg. C. for five hours and streak a blood-agar jDlate for the isolation of the organism and subse<|uent confirma- tion of type. Remove the blood cells from the spe- cial media by slow centrifugalization. Remove 3 cc. of the bacterial emulsion to another centrifuge tube and add to it 1 cc.of sterile ox bile. Incubate till 138 the solution of the piieuiiiococci has taken place and perform the precipitiu test, using 0.5 cc. of serum and bile solution. If ox bile is not obtainable, per- form the agglutination test after the cells have been removed. 5. Krumwiede and Valentine's method. (Jour. A. M. A., Vol. 70, No. 8, Feb. 23, 1918, page 513.) This method is based upon the fact that many sputums are comparatively rich in soluble antigens, and these antigens are not destroyed by heating to boiling. From 3 to 10 cc. of sputum are placed into a test tube, Avhich is then placed into, boiling water till the albumins are coagulated ; that is, if the specimen is a suitable one. Break up the coagulum with a platinum Avire and add just enough ]N^/]S"aCl to carry out the test after it has been centrifuged. In some instances no saline is necessary, for suffi- cient fluid separates to carry out the test. After the coagulum has been broken up agitate it in the saline and place again into boiling water for a few minutes to extract the antigen, shaking gently. Cen- trifugalize and use the supernatent fluid for the test. Place 0.2 cc. of the undiluted anti-pneumococcus serum in narrow tubes and upon each layer an equal quantity of the supernatent fluid. Place in a water batli at 55 to GO deg. C. and observe in several min- ute^\ If a great quantity of the antigen is present in the sputum, a ring y\Hl be observed in a short time, but if snmller quantities are present, longer incubation will be necessary. The advantage of this test and of the other tests is to determine the group of the organism and the employment of serum in tlie treatment should it be Group No. 1. HI. Meningococcus. See monograph by Simon Flexner on ''Mode of Infection, Means of Prevei;- 139 tion, and Specific Treatment of Epidemic Menin- gitis," the Rocli:efeller Institute for Medical Re- search, 1917. ''The meningococcus enters and leaves the body bv way of tlie nasopharyngeal membrane." Mode of idcntificatiou. The West tube is used to swab tJie nasoi)harynx. Tliis tube consists of a glass tube about 7 mm. inside diameter and bent at nearly a right angle at one end. A copper wire carrying a cotton swab at one end and a loop on the other is inserted into the tube, which is then plugged at both ends and sterilized. The nasopharynx is swabbed by inserting the glass tube up behind the soft palate, then pushing the cotton swab out against the pharyngeal wall and swabbing it, and finally pulling the cotton into the tube again and with- drawing the whole tiling. The object is to prevent saliva from getting on the swab, which is destructive to the organism. The inoculated swab is then run over a series of three plates of sheep serum agar, which should be made as follows : Melted meat infusion agar with a plus 0.4 to phenolphthalein and cooled to 50 deg. C. 100 cc. Dextrose 1 % Sheep serum 1 part, distilled water 3 parts (sterilized at 15 lbs. for 10 minutes) 20 cc. Avoid chilling the ])lates and incubate at ">7 deg. C. for from IG to 20 hours. A medium more favorable for growth is made as follows : Nutrient agar melted and cooled to 50 deg. C. 100 cc. Sterile rabbit's blood 5cc laked in sterile distilled water 40 cc. 20 cc. The colonies of the meningococcus are small, deli- cate and their outlines fade away into the medium. Make smears and stains of susi)icious colonies 140 and transfer to laked-blood or sheep sernra agal' slants. The meningococcus together Avith M. catar- rhalis, flavns and phar^ngis-sicctis are gram nega- tive. Incubate the slant inoculations for 24 hours, and then emulsify in salt solution and subject to the following agglutination : Polyvalent 1-50 1-100 1-200 1-500 1-1000 1-2000 Serum 0.8 cc. 0.8 cc. 0.8 cc. 0.8 cc. 0.8 cc. 0.8 cc. Emulsion 0.2 cc. 0.2 cc. 0.2 cc. 0.2 cc. 0.2 cc. 0.2 cc. Incubate at 55 deg. C. for 16 hotirs and read. Any culture which is agglutinated in a dilution of 1-200 and ferments glucose "and maltose with acid production, but does not ferment saccharose, is considered provisionally as meningococcus and the person from whom it Avas isolated is regarded as a carrier. Some differential points between meningococcus and other gram negative organisms of throat: Micrococcus flavus : Colonies velloAv and opaque ; indiscriminate agglutination, agglutinated by normal horse serum in a dilution of 1-50 and by polyvalent serum in a dilution of 1-100 or slightly higher. Micrococcus caturrhalis : Exerts no action on glu- cose, and no agglutination in higher dilutions of specific sera. Other indefinite gram negative micrococci: Fer- ment saccharose. Olitsky method for the identification and isola- tion of the meningococcus. (Jour. A. M. A., Jan, 19, 1918, A^ol. 70, Xo. 3, page 153.) Tins method takes adA^antage of a fluid medium Avhich serAes to eliminate other organisms resem- bling the meningococcus and reduces the time nec- essary for tlie identification to about 12 hours. 141 Medium: Glucose broth, 1% (made from veal infusion and having acidity of from I)lus 0.5 to 0.7 phenolphthalein ) • 100 cc. Sterile, clear, unheated, normal horse serum 5 cc. Tube this medium in 8 or 10 mm. tubes, about 1 cc. to the tube. Suspicious colonies are fished from a plate inoculated with the nasopharyngeal secretion of a suspected carrier and are seeded into these tubes, a colony to a tube. The tubes are then incubated 12 hours, and at the end of this time a great many negatives can be eliminated. Organisms which must be eliminated : 1. Micrococcus flavus, crassus, pharyngis-siccus and unclassified gram positive bacilli will show firm agglutination below and slight turbidity above. 2. Bacillus influenzae will not grow for the want of hemoglobin. 3. Micrococcus catarrhalis grows with a dense turbidity, and often shows a pellicle on the surface. 4. The gram positive staphylococci grow with dense turbidity, show agglutinated masses in the sediment, and often have a pellicle. 5. Streptococci grow with a clear or turbid supernatent fluid, but show an agglutinated sediment. The meningococci give a faint turbidity and a slight sediment forms which emulsifies uniformly when the tube is shaken. The suggestive positive tubes are separated from the definitely negative ones, and to the former is added 0.1 cc. of a 1-10 dilution in 0.85 saline of a high titer polyvalent antimeningococcus serum. Incubate the tubes at 37 deg. C. for two hours in the water-bath and the tubes containing meningococci will show definite agglutination, and those which do not will remain 142 luicljaiiged. From the positive tubes cultures can be obtained for fiirtlier identification. \y. Diphtheria bacillus. It is important to re- meiiiber tliat tliere are organisms in the thvoat of h-altliy persons wliich have the morphological char- acteristics of tlie diphtheria bacillus, but which pro- (luci: no toxin, tlie>e being the diphtheroids; also, that one examination of a diphtheretic throat may give negative results: hence, upon the ability to produce toxin should rest the final diagnosis of the organism and one examination should not suffice in sus])icious cases. P /< Diphtheroid The throat is swabbed Avith a small piece of cot- ton and the surface of a serum agar plate is streaked with it. Incubate from six to eight hours when the diphtheria colonies will be visible and contami- nating organisms will not. Make smears from colo- nies and stain w^ith Loffler's methylene blue. Stained specimens of the cultivated bacillus show the typical beaded appearance Avith clubbed ends. For more careful study use Neisser's stain. V. Bacillus mucosus capsulatus. This gram neg- ative non motile bacillus varies from coccoid forms to longer bacilli. They are surrounded by a large capsule which is easily demonstrable. They groAv easily on plain agar, which growth is mucoid and sticky. They often cause a A^ry fatal broncho or lobar pneumonia J the sputum of Avliich is slimy and stickA\ 143 ^^T. Tiitiueiiza bacillus. This is a very short, mod- erately thick, gram negative bacillus which grows singly in pairs or sometimes forms threads. It has 2 polar bodies which make it resemble a gram neg. diploccns. It is a frequent secondary invader in respiratory and pulmonary infections, such as chronic bronchitis, bronchiectasis and tuberculosis. The orbanisms grow best on blood agai*, upon which the colonies appear as small, colorless dewdrops. It has not yet been proved to be the cause of influenza epidemics. Avery's influenza .media : Delibrinated blood, centrifugalized and cells resuspended in amount of broth equal to original volume of blood 1 cc. Agar (sterile) 95 cc. Sodium oleate 2% (neutralized and auto- claved) 5 cc. This media is said to inhibit other organisms of the throat and to enhance the growth of the influ- enza bacillus. VII. Spirochaeta pallida. This organism is some- times found in the mouth in association with syph- ilitic lesions there. It must be differentiated from S. dentalis, S. buccalis and S. refringens. In gen- eral it may be said that under the dark Held illumi- nator these other spirochaetes have a much livelier movement than the pallida, which hardly moves out of the field. It has a lashing motion, a spinning motion about its long axis and a slight backward and forward motion. It is usually easy to identify the pallida from these characteristics. YIII. Spironema vincenti. This organism is found in Vincent's angina in association with a cigar- shaped bacillus. They are both readily stained with dilute carbo-fuchsin and gentian violet. 144 Sputum in various diseases. 1 . Lobar pneumonia due to the pneumoeoccus. The course of the disease can be followed by the type of sputum. It is blood tinged for the first three or four days and mucoid in consistency. After this blood cells disappear and it assumes a rusty appear- ance from altered blood pigments. This lasts until after the crisis, when it becomes muco-purulent, and later serous. Occasionally one sees x3neunionia without sputum at all. In some cases a green color is noted in the later stages of the disease, due to altered blood pigments. In pneumonia due to the B. mucosus capsulatus the sputum is slimy and sticky and very tenacious. 2. Tuberculosis. This disease may have almost any kind of sputum. As a rule, in the early stages there ma^^ be little or no sputum; later it may be- come mucoid or mucopurulent and blood streaked. On microscopical examination one may find the acid- fast organisms and elastic tissue. In chronic tuberculosis the amount of sputum varies from little to tremendous amounts. It may be bloody, mucopurulent, or purulent. In ulcerative tuberculosis one finds sputum of a feweetish odor, blood clots, a great deal of elastic tissue^ caseous lumps which do not give a bad odor on ci'ushing, and on microscopical examination one mav find all kinds of contaminating organisms. Tn fibroid tuberculosis one may have no sputum, '^ it may be mucoid or mucopurulent. '■, Ab^cesse^. The sputum is abundant, cheesy, u'^c^'ou . and masses of blood may be present. )cca ionally one finds masses of lung tissue and elastic tissue. 4. Gangrene. The sputum is the same as abscess, except that the odor is characteristically very foul and penetrating. 145 5. Infarction. Immediately after the accident the sputum is stringy and mucoid and blood streaked, or there may be a marked hemoptysis. The sputum soon becomes rusty and "prune juice'- in character, which change comes on sooner than in pneumonia. C). Chronic passive congestion. In this condition tlie sputum is thin and abundant. It may be slightly rust;'. On microscopical examination one finds "heart-failure cells," i. e., alveolar epithelium con- taining blood pigments. 7. Asthma. There is no sputum in the early stages of the attack, but when the attack breaks pearls of Lannec (mucoid globules) make their ap- pearance. On careful examination one finds, also, Curslimann's spirals, Cliarcot-Leyden crystals and eosinophiles. 8. Bronchitis. There may be no sputum or there may be present pearls of Lannec and Charcot-Leyden crystals. Fihri)ioifs bronchitis. In this type of bronchitis there may be fibrin casts of the bronchi. Purulent hionclntis. The sputum has a mucoid base with a yellowish appearance from the presence of i)us cells. riccrativc hronchitis. Epithelial cells remain un- changed. Goblet and ciliated cells appear occa- sionally. Tissue fragments and blood may be pres- ent. Chroidc hroucliitis. The sputum is usually thin, may be tinged Avith blood, and may contain Dit- trich's plugs. In the later stages of the disease the sputum may become foul, abundant and muco-puru- lent. D. Bronchiectasis. The sputum usually occurs periodically in large amounts and has a fetid odor. In tlie early stages it is thin and watery, but later (Continued on Page 146) 146 it may resemble the sputum iu abscess, except that there is not so much pus. Cartilage, elastic tissue, clots of blood and tissue masses may be present. Its separation into three layers, viz., top, brownish froth ; middle, clear and mucoid, and bottom, gran- ular ; is not characteristic for this disease, but occurs whenever there are large amounts of sputum. 10. Pulmonary oedema. This is usually a termi- nal event, but frequently occurs after too vigorous thoracentesis. It may start during the tapping and may last from 5 minutes to 24 hours. Huge amounts of fluid are given otf. It is a safe rule not to draw off more than 1500 cc. at one tapping. STOOLS. Constituents of stools. I. Food remnants. These are undigestible or un- absorbed. Xormally, there are some and it is diffi- cult to draw a line between the pathological and the normal under various conditions. When an excess of meat fibres occur, the condition is called creator- rliea ; and when an excess of fat occurs, the condi- tion is called steatorrhea. It is important to be- come familiar with vegetable cells in order not to confuse them with animal parasites or their ova. Fat. Fat occurs as soaps and fatty acids and sometimes as neutral fat. If it occurs as neutral fat, it is yellow and clear ; while as fatty acid, it is wiiite and glistening. Soaps usually occur as the insoluble calcium and magnesium soaps, but