Complete Text (Part 19)

probably found in disturbances in the coagulation factors of the blood. 2. Idiopathic Purpura. It was formerly thought that : 1. Purpura simplex or Werlhoff's Disease, 2. Purpura rheumatica or Schonlein's Disease, 3. Henoch's Purpura, and 4. Peliosis hemorrhagica were all seperate diseases, which view has been 248 largely abandoned. There is great confusion in the literature, and it is probably necessar}' to retain the terms until more precise knowledge is at hand concerning the idiopathic purpura (Morbus maculo- sus ) . Occurrence of True Purpura. There were 41 cases in 18,000 admissions in J. H. H. They occur more in the fall and winter months. More in males than in females — young rather than old. There is a clear-cut heredity role. Causes : 1. Vascular injury. 2. Infection with bacteria. 3. Pathological condition of the blood, vfarticularly coagulation factors. In any case of pathological hemorrhage certain blood studies are of prime importance, yiz : 1. Estimation and enumeration of platelets. Be- low 60,000, bleeding apt to occur; below 20,000, bleeding certain. Best method is to use fresh blood. Minot — Prei^are slide with film of cresyl blue (1-300) dried. This will keep a long time. Secure drop of blood upon a coyer-slij) inyert upon the prepared slide. Platelets and retic- ulated forms show well. The platelets stain a characteristic blue. 2. Determine the bleeding time. Vena puncture (Dr. Howell). Be sure to hit the yein on the first try. 1 cc. of blood in a clean tube (8 mm. in diameter). Xormal blood can be inyerted in 7-10 minutes. Also note when the first signs of coagulation begin (slight concayity). The length of the coagulation time does not run parallel Ayith the tendenc}' to hem- orrhages. 3. Retractility and Firmness of the Clot. In hemorrhagic states either failure to re- tract, or soft, fiabby clot occurs. Flabby clot N indicates decreased thrombin or fibrinogen. Xon retractilit}^ indicates decreased platelets. Sometimes "reclottiug" occurs. Remove clot and serum again clots. This is associated Avith lack of retractility. 4. Other studies of mucli value when possible are : 1. Effect of addition of calcium on the coagu- lation time. 2. Determination of the pro thrombin time. o. Determination of the anti thrombin and fibrinogen. 4. Determination of fibrinolytic ferments. Purpura Simplex. This is a disease with skin symptoms exclusively and slight pains. There may be a few eruptions coming out in crops. Duration 6 to 8 weeks. Purpura Rheumatica or Schonlein's Disease, Peliosis Rheumatica. The term has been horribly misused. It is applied to any condition of arthritis with purpuric, erythe- matous, or urticarial lesions. It is best to adopt the term ''Simple purpura with arthritis." Clinically : 1. Young adult males. 2. Average duration, five weeks. 3. Recurrent arthritic signs, polyarticular rheu- matism, especially of the knees and ankles. 4. Simple purpura. 5. Fever slight or absent. 0. ^^ever fatal. 7. History of previous rheumatic fever, rare. 8. Salicylates not helpful. 9. Purpuras rare in true rheumatic fever. 10. Association of urticaria, erythema, and angio neurotic oedema. Henoch's Purpura. 1. Recurrent purpura. 250 2. Abdominal crises, melena, hematemesis. ."). Arthritis coiiijnon. 4. Nephritis coinmoii aud severe. Occurs iu males in early life. Recurrent attacks. Beware of early operations. Blood picture. Purpura simplex, Purpura rheu- matica, and Henoch's Purpura differ only in de- gree, frequency and extensiveness of the purpura. S. A. picture, platelets normal or increased. No coagulation disturbances evident. Purpura Hemorrhagica — Aplastic Anaemia. The condition is idiopathic or acquired, acute, subacute, or chronic. Tendency to hemorrhages under the skin and mucus membrane anyAvhere. Skin eruptions, diminished blood platelets. Delayed bleeding time. Xon-retractility and often flabby clot. Often true hereditary tendency. Aplastic Anaemia. This is a true disease entity. It is acute with pro- gressively downward course (3 to 6 weeks). Occurs in young males. Rarely associated with arthritis. Clinically there is no evidence of blood destruction. Some unknown toxic substance inhibits all the mye- loid elements. C. I. below 1. (.8 to .9.) Platelets absent, or, if not absent, curiously large. Leuco- paenia, lymphocytes increased relatively. Tendency to purpura, but not to bleeding. In PurjDura hem- orrhagica only one myeloid element is inhibited, i. e., platelets. The white count is increased with true P. M. N. increase. Other myeloid elements show increase. Signifies intravascular destruction. Both diseases. Purpura Hemorrhagica and Aplastic Anae- mia, occur in same people. Some cases of the former turn into the latter. 1. Aplastic Anaemia — complete, rapid myeloid de- struction. 2. Purpura hemorrhagica : 251 (a) Contiuiious: 1. Acute (3 days). Always tiud platelets below uormal. 2. Chronic. (b) Intermittent. Clears up and then returns. Platelets low only during attack. 3. Intermediate Group. Intermittent type. There is a tendency for- the platelets to decrease. It does not go onto true aplastic anaemia. Other Diseases. Hemophilia. A blood deficient in pro thrombin and a true or relative excess of antithrombin. Plato- lets normal. Mendelean heredity. Scurvy — unbalanced diet, bleeding tendency, loose gums. Often cured by introducing suitable food. Xo disturbed coagulation picture. Barlow's Disease — Infantile Scurvy. This is a periosteal affair, occurring in the lower extremities. It is characterized by pain in the bone. Look for it in children who stop walking. Essential hematuria. See notes on urine. MATCHING OF BLOOD FOR TRANSFUSION Hemol^^sins : 1. Traumatic. 2. Toxic. Other classification : 1. Heterologous. Exemplified by rabbit and sheep. 2. Autohemolysis — • rarely autoagglutination — noted in R. B. C. counting. 3. Isohemolysis — 90% possess isoagglutinin ; 25% isohemolysis. Grouping is established by the time the individual is two years old and remains unchanged throughout life. 252 Red Blood Cells of T. TI. TIT. IV. . Serum I. 0 0 0 0 (10%) Serum II. + 0 + 0 1^0%) Serum III. + + 00 (7%) Serum IV. + + + 0 (i3%) Even by gross methods one can tell whether agglu- tination takes place or not. Method of matching blood. 1. Cross agglutination. Obtain serum from each patient; also corpuscles washed twice with iso- tonic salt solution and resuspended in salt solu- tion to make a faint pink color. Place a drop of the receiver's serum upon a cover-slip and near it a drop of the donor's r. b. c. Also place a drop of the patient's r. b. c. upon a cover-slip and near it place a drop of the donor's serum* With a small glass rod mix the first two drops, and with another glass rod mix the second two drops. Invert the cover-slips and place over hollow-ground slides well sealed with vaseline. Examine immediately microscopicall}^, and again in an hour. Exclude any donor whose cells are agglutinated by the receiver's serum or whose serum agglutinates the receiver's blood. Usually members of the same group match, but this method is the safest because, sometimes, groups do not match, especially in severe anaemias. 253 2. Using known sera or b. c from groups II. and III. Corpuscles. Group IT. Group III. Serum of pt. 0 a kt 0 u u Agg. a a Agg. Group of pt. I. II. III. IV. Agglutination No Agglutination Serum. Group IT. Group III. R. B. C. of pt. Agg. 0 Agg. 0 Agg. Agg. 0 0 Group of pt. I. 11. III. IV. After finding a donor of the same group as the patient, match their corpuscles and serum as in proceedure 1. The serum may be preserved at least a year if kept on ice. Members of Group I. may be universal recipients. Members of Group IV. may be universal donors. Members of Group IV. should only get Group IV. blood. Group IT. and ITT. very serious. The amount given at a transfusion varies from 500 cc. to 3 liters. CEREBROSPINAL FLUID Up until 1891 no particular importance was placed in spinal fluid examinations but now very important 254 clinical evidence can be obtained thereby. The ex- istence of a tnnior at tlie base of the sknll is only real contraindication advanced against Innibar pnnc- ture. Postnre — lying down. 8ito of pnncture— P>-4 or 4-5 hnnbar spines. Two methods of entrance — mid-line or to right or left of mid-line. Only discomfort is going through skin. There are about 40 to 70 cc. in the average in- dividual. 5 cc. is ample for an examination, 2-3 cc. are enough. Avoid lumbar i^uncture reaction, which consists of severe headache, head pulling backward — relieved by lying down. Often dizziness and nausea follow, (rood routine: 1. Have patient plan to stay in bed for 24 hours following, with only one pillow. 2. For tlrst four hours a glass of water every hour. o. 1 cc. of pituitary extract immediately after puncture. 4. Patient should sit quietly two or three hqurs after the 24, then move about the house, and, upon tlie slightest evidence of headache, go back to bed. Normal Spinal Fluid. Clear, colorless, sparkling, resembles distilled Avater. Normal pressure varies with posture, but markedly increased in certain diseases. 120-140 mm. H20, 6-10 mm. Hg. Increased : 1. Acute meningitis. 2. Poliomyelitis and tbc. meningitis. 3. Intracranial pressure. In some cases absolutely diagnostic, but in most only confirmatory. Inorganic constituents : Chlorides— .5 to ,6 gm. per 1000 cc. 255 Organic constitueuts : Dextrose — .4 to .6 gm. per 1000 cc. Complete absence in C. S. meningitis — of value. Notable increase in diabetes. Protein — probably serum globulin, no readily demonstrable amount of protein. Keactions : 1. Noguclii — butyric acid. 2. Koss-Jones — saturated ammonium sulphate, faint rings between substances. 3. Pandy's — aqueous saturated carbolic. Normal spinal fluid shows no cloud with 1 drop, almost imperceptible with 10. Abnormal fluid shows milk}' ppt. Exclude blood. Increase in protein abnormal, but not specific for any condition. In acute inflammatory conditions of central nervous system, severity usually runs parallel Avith protein increase. Depends upon loca- tion. In syphilis there is increase in globulin. Cytology : 1-5 cells per c. mm, usually of the S. M. type. 8-12 cells, probably an increase. Above 12 cells distinctly abnormal. Method of counting : Cell counts should be made as soon as possible, for they settle quickly and de- generate. The white pipette is used and is filled up to 1 with stain. Giemsa is good as well as .2% methyl violet in water. The uncentrifugalized fluid is then drawn up to 1 1 . Shake thoroughly and count on Fuchs-Rosenthal counting chamber. The cham- ber contains 3.2 c. mm. of fluid. Count all white cells in entire ruled area, multiply by 11 and divide by 32. An ordinary counting chamber can be used with the same method of staining. In this case an entire large square is counted and the result multi- plied by 10, or all gf the 9 large squares can be 256 counted, an average taken, and the result multiplied by 10. Increased in : 1. Infectious meningitis conditions. Usually P. ^i. X. increase. Fluid cloudy. :. The. meningitis. Fluid clear. JS. M. increase. .'). Syphilis. S. M. increase. Cell increase means irritated surface. 4. Tabes. Normal or increased. 5. Paresis. S. M. increase. In tbc. meningitis it is usually possible to find the organism. If the fluid is allowed to stand over night in an ice-chest the organisms will often be found in the |)ellicle which forms. In syphilis of the C. N. S. the Treponema pallidum lias been found repeatedly, Avith the dark field illu- mination. In infective meningitis it is the rule to find the causative organisms in stained smears. Much of the interest in the spinal fluid examina- tion centers around the Wassermann action. The disease may become localized in the C. X. S. and the blood give a negative reaction Avhile the spinal fluid gives a positive. A positive Wassermann is never found in a S. F. which is globulin free. The test is positive in about 100% of paretic tj^pes, 60% of tabe- tic, and 80 to 85% of all C. X. S. lues. After therapy there is at first abundant i)rotein, which tends to de- crease. A positive Wassermann may remain in spite of protein decrease; this is called ''Wassermann fast." Therapy should be continued till the S. F. returns to normal. Xanthochromia. This is a rare finding where the S. F. is a yellow color, a marked cell increase, and the fluid iindergoes spontaneous coagulation. The cause is a tumor in the spinal cord. 257 Colloidal Gold Reaction. This reaction depends upon the globulin and al- bnniin content of the spinal flnid in certain quanti- tative proportions. It is not specific for syphilis, but is of clinical value for its diagnosis neverthe- less. ^lethod of preparing tbe gold solution (L. D. Fel- ton, J. A. M. A. 1917, pg. 73-92.) The glassware should be thoroughly cleaned as follows : 1. Boiled in an ivory soap solution for half an hour. 2. Brushed, rinsed and filled Avitli sulphuric acid- bichromate mixture. 3. Just before use the beaker is emptied and rinsed for two minutes with tap water and five times with singly distilled water. Glassware so cleaned can be used for colloidal gold work as long as a month if it is used for nothing else. Preparation of Distilled Water : One cc. of a 10 per cent solution of potassium permanganate and 1 cc. of a saturated solution of barium hydroxide are added to two liters of the water to be distilled. The first quarter of the dis- tillate as well as the last are thrown away. Water thus prepared can be stored away in hard glass containers for an indefinite time. Reagents: Chemically pure potassium carbonate, 2 gm. to 100 cc. Chemically pure gold chloride, 1 gm. to 100 cc. Chemically pure formaldehyde, 1 :40. Technic for 1000 cc. : Gold chloride, 100 cc. Potassium carbonate, 8 cc. Formaldehvde, 6 cc. 258 The potassium carbonate and gold chloride are added to the beaker of cold >Yater. The contents of tlie beaker are then heated nntil they boil briskW and then the formaldehyde is added drop by drop until the development is almost complete, when the remainder of the formaldehyde is thro^vn in. Stir- ring is unnecessary. Should the solution become very alkaline after long standing it should be cor- rected according to Miller and his associates (Bull Johns Hopkins Hos. 1915, 26, :39i.) The Colloidal Gold Test: "Into the first of 11 clean test tubes, reserved es- pecially for that purpose, put l.S cc. of fresh, sterile 0.1 per cent NaCl solution. Into each of the remain- ing 10 tubes put 1 cc. of salt solution of the ame strength. Xow add to the first tube, by mcaiu of a clean, dry, certified 1 cc. pipette, 0.2 cc. of -!-3 spinal fluid to be tested. Mix well. Transfer 1 cc. of the resultant 1 to 10 dilution of spinal fluid to the sec- ond tube, and again mix thoroughly and transfer 1 cc. of this dilution to the third tube. Proceed in this manner up to and including the tenth tube. By this method a series of dilutions of the spinal fluid is secured, in geometrical progression, ranging from 1 to 10 to 1 to 51 20. Xow add to each of the 1 1 tubes 5 cc. of a suitably prepared and standardized col- loidal gold solution, shake each tube thoroughly and set the series of tubes aside for subsequent observa- tions. It will be noted that the eleventh tube serves as a salt control, since it contains no cerebro-spinal fluid." The series can be read fairly accurately with- in an hour, as little change occurs after that time. 259 oz/s~/ 4rl >5 ^ : ^st-l y y i: ^ ^SZil ^^ . 1 .5 ^ ^y ^ 1; s, I' oi.y-1 X N. ^2rr-y s r y ^* 5 ^^ ' ^V^K \ ft o?/-/ r * ' \ ^. ^ ? 1 0 0 \ N ^ .^> o^-/ 1 \ 0; ^ \ \ ^ '^ OZ~f > 0 ^ l« \ C ^ 3 • •J \ ^•J Ol-I p > > ?^ ? ?^ . ^^ 5 ?r .^^!! ^ ^ ^ ^ ^ 0 !^ ^ f^ Ji* k 5 ^ ^5^^« 5 <i 1. i 4"^ 0 0 ll P^ »; t; »: I!. i; \ o o a a; 260 TEEMS, ETC., USED IX THE CLASSIFICATION OF PAEASITES. 1. Kingdom — as Animal, Vegetable. 2. PliyJuith or Branch — a ijrimary division of the animal or vegetable Kingdom. Ex.: Protozoa. Artliropoda or Tcrtelrata. 3. Class — the division next below the Plujlum. Ex. : Insecta or FJageUata. 4. Order — the division next below the Class) and made up of a group of Families agreeing closely in some striking characteristic. (There is no fixed, systematic termination for the divisions above that of the Superfamily, but, as seen from the examples given, many of them end in a. Ex. : Hacmosporidia or Dipt era. 5. Superfatvily — the division next below the Order. Always terminates in oidea. Ex.: Ixodoidea ( — ■ Ixodidae (family) plus Arga- sidac (family). 6. Family — the division next below the Super- family. The name is formed by adding the ending idae to the root of the name of the type genus. In printed matter the family name should appear in Eoman type. Ex. : Strongylidae or Culicdae. 7. SuhfamHy — the division next below the Family. The name is formed by adding the ending inae to the root of the name of the type genus. Kote — Not all Families are divided into Suhfami- lies, or grouped into Superfamilies. Ex. : Strongylidae or Culicrae. 8. Genus — the division next below the Siih family. Separate species of animals which agree in the main characteristics of size, proportion of parts and gen- eral structure are placed in the same genus. Each genus usually contains several species, but may have only one. The generic name should be Greek or