COLUMBIA LIBRARIES OFFSITE wa __ HEALTH SCIENCES STANDARD HX64 157539 RC636 .B45 1 91 5 The blood and its di IxtO/Vr ^m< J^ THE ^ O irBRARfES ^ HEALTH iw-" Digitized by the Internet Archive in 2010 with funding from Open Knowledge Commons http://www.archive.org/details/blooditsdiseasesOOberg THE BLOOD AND ITS DISEASES. HENRY IRVING BERGER, M. D. 1915. Published by BATTLE & CO. ST. LOUIS. MO. TABLE OF CONTENTS ^. Page Diseases of the Blood: 1 . Simple or secondary anemia 5 2. Progressive pernicious anemia 7 3. Chlorosis 9 4. Leukemia 20 5. Hodgkin's disease 13 6. Splenic anemia (Banti's disease) 15 7. Scurvy yi 8. Hemophilia 19 9. Purpura 20 10. "Blood poisoning" (Sapremia and Septicemia)... 23 11. Erythremia (Vaquez's disease — Polycythemia) ... 2.5 The Blood: Definition, color, reaction, composition 26 Volume index and blood plasma 27 Formed elements, enzymes, gases 28 Blood pressure 28 Hypertension and hypotension 29 Specific gravity 33 Red blood cells: — Morphology, pathological cells 34 Counting 07 01 Color index 3g White blood cells :^ — Varieties 39 Number, classification 42 Significance of leucocytosis 43 Significance of leucopenia 44 Counting and differential count 44 Preparation of blood smears 45 Staining 4g Hemoglobin ^9 3 TABLE OF CONTENTS— Continued Page Hemoglobinemia and hemoglobinuria 49 Hemolysis 51 Coagulation of blood 52 Examination of blood for Bacteria and Parasites 55 Tests for pus in blood. (lodophilic reaction) 67 Blood tests in Diabetes 68 Griiber-Widal reaction in Typhoid 69 Bass & Watkin's reaction in Typhoid 69 Blood tests for Syphilis i 70 Abderhalden's Sero-Diagnosis of Pregnancy 85 Forensic Medicine. (Tests for Blood) 88 1. Morphological test 89 2. Julius Von Kossa's test 89 3. Van Deen's Guaiac test 90 4. Schaer's test 90 5. Phenolphthalein test 91 6. Teichmann's Hemin Crystals 92 7. Spectroscopic tests 92 8. Precipitin reaction 95 Differentiation of Blood from Iron Rust 97 Differentiation of Blood from Red Paint 97 Opsonins 98 Hematemesis (Gastrorrhagia) 100 Hemoptysis 104 Hematuria 106 Hemorrhage into the Brain 110 Uterine Hemorrhage (Menorrhagia and Metrorrhagia) . . . 114 Epistaxis 118 Melcena (Enterrhagia) 119 "Ecthol" 123 CHAPTER I. DISEASES OF THE BLOOD 1. SIMPLE OR SECONDARY ANEMIA DEFINITION: Anemia denotes an insufficiency in the amount of blood especially in the number of red cells and in the per- centage hemoglobin. The causes of all secondary anemias are known. The most frequent cause is hemorrhage. In simple anemiia, regeneration of blood occurs in a normal manner. CLASSIFICATION AND ETIOLOGY: 1. Surgical Hemorrhage. (Operations.) 2. Traumatic Hemorrhage. (a) External or visible hemorrhage. (b) Internal or concealed hemorrhage. 3. Pathological conditions and other causes (a) Hemorrhages from gen ito-uri nary tract. (x) Hematuria. (See p. 106.) (y) Menorrhagia. (See p. 114.) (z) Metrorrhagia. (See p. 114.) (b) Hemorrhage from gastro-intestinal tract. (y) Hematemesis. (See p. 100.) (z) Meloena. (See p. 119.) (c) Hemorrhage from respiratory tract. (y) Hemoptysis. (See p. 104.) (z) Epistaxis. (See p. 118.) (d) Hemorrhagic diathesis. (e) Infectious diseases. (f) Diseases associated with albuminuria. (z) Acute and chronic Bright's disease. (g) Chronic suppurative diseases. (h) Toxic Conditions: (y) Mineral poisoning especially lead. (z) Acute rheumatic fever, (i) Parasites: (x) Malarial. (y) Bothriocephalus latus. (x) Anchylostoma. (j) Bad hygienic conditions and improper food. DIAGNOSIS: The typical blood-picture is: 1. Reduction in percentage hemoglobin (oligochromemia) and a corresponding decrease in the number of red cells (oligocythemia). These deviations as a rule run parallel. 2. Clianges in the erythrocytes: (a) Poikilocytosis is slight. The more severe the anemia the more marked is the altera- tion in size and shape of the R, B. C. (b) Polychromatophilic degeneration. Varies greatly, but is best marked after hemorrhage. (c) Nucleated red cells (normoblasts). Micro- blasts also found especially in connec- tion with malignant tumors of the intestinal tract. 3. Absence of leucocytosis. But after hemorrhage a "relative leucocytosis" occurs. 4. Eosinophilia, if anemia be due to parasites. SYMPTOMATOLOGY of Hemorrhagic Anemia: 1. General Remarks: Anemia varies with rapidity of the blood lost and individual peculiarity of the patient. Bleed- ers recuperate quickly. Women stand the loss of blood better than men. If one-half the total vol- ume of blood be lost death will ensue. 2. Pallor. The more blood lost the greater the whitening of the skin and mucus membranes of the eyes and lips. 3. Dyspnea. Respirations increased. 4. Sweating and corresponding thirst. 5. Vertigo and nausea. Shock and collapse in proportion to amount of blood lost. The same symptoms occur in concealed as in external hemorrhage. Circulatory symptoms. Pulse: Weak at first due to loss of volume of blood which is necessary for the heart to work with. Saline infusions restore this necessary vol- ume. If patient becomes exsanguinated the pulse becomes imperceptible. Functional murmurs: (a) Hemic: are systolic in time, untransmit- ted and heard best over base. (b) Continuous venous hum (bruit au diable). By pressure over jugular vein it may be made to disappear. Note: When the anemia improves these murmurs disappear. Amenorrhea. In chronic cases in women there may be a suppression of menses. 2. PROGRESSIVE PERNICIOUS ANEMIA. (Addison's Anemia — ^Biermer's Disease.) DEFINITION. An "idiopathic" anemia growing progressively worse characterized by abnormal regeneration of the blood and by hemolysis. It usually occurs after the age of 36. Although the Bothriocephalus Latus may cause such an anemia it is amenable to treatment. DIAGNOSIS. "It is a large cell anemia." (A) BLOOD PICTURE. Changes in the red cells. (a) Normoblasts and megaloblasts. As a rule the megaloblasts out-number the normoblasts. "Crises" of either of these forms may occur. (b) Poikilocytosis very exaggerated, (c) Polychromatophllic degeneration extensive. (d) Oligocythemia. The absolute count of both R. B. C. and W. B. C. is reduced from 20 to 50%. Leucopenia. The reduction in the white count runs parallel with the reds. Hemoglobin relatively increased. Color index is therefore high since the R. B. C. are decreased. (B) SYMPTOMS. The disease develops insidiously with: 1. Progressive general weakness without notice- able emaciation. 2. Gradually increasing profound anemia. Lemon- yellow, puffy face associated with an increase in weight is very characteristic. 3. Pronounced cardiac enfeeblement, dyspnea, ver- tigo, palpitation, breathlessness on exertion very marked. Hemic murmurs may occur even with- out valvular lesions. Advanced cases may end up with fatty degeneration. 4. Digestive disturbances with periodical attacks of diarrhea occur in 50%. Nausea and vomiting very frequent. Diarrhea may be associated with paroxys- mal pains in the stomach. Depraved appetite and yet the patient lays on weight and flesh. 5. Slight edema of the subcutaneous tissues. Usually first perceptible about the ankles and feet. 6. Involvement of the spinal cord causes: Tingling and numbness of the extremities. Neuritic pains at times. Some show features of lateral sclerosis with spastic features and increased reflexes, while Others resemble tabes: lightning pains, girdle sensation, areas of anesthesia, loss of reflexes. 7. Subcutaneous hemorrhages in the form of petechia are not as common as retinal hemor- rhages. 8. Fever. Slight and variable. 9. Periods of remittency. But the symptoms soon return. 8 3. CHLOROSIS. DEFINITION. A primary anemia without cachexia, occurring ex- clusively in young girls and in young women, charac- terized by a greenish coloration of the skin and a great reduction in hemoglobin. DIAGNOSIS. Confirmed by a blood examination. 1. Hemoglobin tremendously lowered. 2. Changes in red cells: (a) Pessary or ring-shaped cells predominate. They are called "dropsical cells." (b) Macrocytes and some microcytes but no nu- cleated cells. (c) Polychromatophilic degeneration. (d) Poikilocytosis in severe cases only. (e) Total blood count normal or perhaps slightly be- low. Usually about 4,000,000. Color index is therefore low. 3. No change in leucocytes. 4. Blood plates increased in number. .5. Blood plasma increased. Normally the corpuscular and plasma elements of the blood are equal in vol- ume. In chlorosis the plasma is raised to 75% and the corpuscular volume reduced to 25%. 6. Specific gravity reduced. May be as low as 1030. SYMPTOMS. 1. Pallor. Face varies in color from a pale yellow to a greenish hue. The swelling under the eyes gives the patient a "nephritic" appearance. 2. Stomach symptoms. (a) Depraved and perverted appetite. (b) Hyperacidity with or without gastric ulcer. (c) Obstinate constipation. 3. Neuralgias: (a) Occipital and supraorbital. (b) Gastralgia and intercostal neuralgia. 4. Amenorrhea. 5. Palpitation very prominent in many cases. 9 PHYSICAL SIGNS. 1. Tissues pit on pressure (edematous infiltration), 2. Systolic functional murmurs which disappear as soon as the disease is cured. Murmur is heard best over pulmonary artery but is not transmitted, and second pulmonic sound is not accentuated. The bruit-au-diable is heard over the sterno- clavicular articulation. Rapid heart and rapid pulse. The heart may ul- timately enlarge. 4. LEUKEMIA. DEFINITION. A progressive, chronic and permanent disease of the blood and hematopoietic organs (marrow, spleen and lymph glands) especially those concerned in the genesis of the white corpuscles which are found to be enormously increased in number. The leucocytosis here is permanent whereas in other diseases it is more or less transitory. VARIETIES. (A) Spleno-medullary leukemia ("myelemia"). (B) Lymphatic leukemia C'lymphemia"). SPLENO-MEDULLARY LEUKEMIA. BLOOD PICTURE. 1. Changes in the white cells. Tremendous increase in the absolute count. Average is 350,000 per c.mm. The differential count is (according to Webster) : (a) Neutrophilic myelocytes. These average 35% of the total white count. These cells are large mononuclear cells with neutrophilic granules. They appear in two forms: 1, Large myelocyte of Cornil. Has a large, pale eccentric nucleus which is poor in chromatin. These cells are only diagnostic of this disease. 2. Small myelocyte. Is about the size of a nor- mal polynuclear leucocyte, has a centric round nucleus staining deeply with the vari- ous aniline dyes. Note. — All gradations are seen between these two types, 10 (b) Polynuclear neutrophile leucocytes. These are "relatively" decreased in number. The absolute count is increased. 60,000 to 75,000 of these cells may be present. They average 46% of the total white count. These cells vary greatly in size: something never seen in ordinary leucocytoses. They are frequently degenerated, their nuclei being pale and showing karyokinesis, (c) Eosinophiles. Usually increased but their per- centage relation to the other white cells is un- altered. Average is 57^. They vary greatly in size. (d) Basophiles. The mast cells are increased, the absolute count in some cases being greater than that of the eosinophiles and always proportion- ately higher. (e) Lymphocytes. As a rule the percentage is re- duced to an average of 10 '>o. The absolute count is however increased. Large cells predominate over the small cells and in both forms degenera- tive changes are frequent. 2. Changes in the red cells. (a) Oligocythemia. The absolute count is decreased from 10 to 409c. The cells approach the chlo- rotlc type. (b) Nucleated reds are numerous. Normoblasts only. If megaloblasts and gigantoblasts be present the prognosis is bad. The larger nucleated red cells never exceed the normoblasts in number. (c) Polychromatophilia is more or less common. Many cells show basophilic granulations. The following equations will elucidate the diagnosis: (a) in health: W.B.C.: R.B.C.: : 7,000:4,500,000 (b) inleukemia: W.B.C.: R.B.C.: : 350,000: 3,500,000. A ratio of 1:650 in the first case as compared to 1:10 in the latter. 3. Hemoglobin reduced. Average is 40%. 4. Color index is low. Average is 0.6. 5. Low specific gravity. The blood is pale and sticky. 11 SYMPTOMS OF SPLENO-MYELOGENOUS LEUKEMIA. Onset. General malaise, weakness, pallor, some ema- ciation and .digestive disturbances. 1. Progressive dyspnea due to progressive increase in size of the spleen. 2. Early enlargement of the spleen. It is usually pain- ful and progressive. 3. Those symptoms due to splenomegaly itself. (a) Ascitic accumulations in abdomen. (b) Dropsical infiltration of extremities. (c) Recurrent hematemesis. 4. Hemorrhages into the skin and mucous membranes may follow^ the appearance of the splenic tumor. Bleeding from the nose is very common. A hemorrhage or a free diarrhea may reduce the size of the spleen. The lymph glands may also enlarge after the spleen has enlarged but not always. Gastro-intestinal disorders. Obstinate priapism very frequent. Defective hearing and vision. (Leukemic retinitis). Febrile and afebrile periods common. The liver may also become enlarged. LYMPHATIC LEUKEMIA. BLOOD PICTURE. 1. An absolute leucocytosis with a preponderance of lymphocytes. Average leucocyte count is 145,000. 2. In contrast to the spleno-myelogenous form in which the granular cells are increased, we find here an in- crease in the nongranular mononuclear cells. 3. Both large and small lymphocytes are present depend- ing upon the stage of the disease. 4. These leucocytes show degeneration of both proto- plasm and nuclei but only few cells show mitosis which is so common in the other form of leukemia. 5. The lymphocytes constitute about 95% of the total white count, the polymorphonuclear cells therefore being insignificant in number. 6. Anemia is of a severer grade than in the other form. The average hemoglobin percentage is 37. 7. In exceedingly grave cases only, do we find nucleated red cells. 12 10 SYMPTOMS IN LYMPHATIC LEUKEMIA. (A) ACUTE LYMPHATIC LEUKEMIA. (Young people usually affected.) 1. Hemorrhages into the skin. 2. Rapidly developing cachexia and anemia. 3. Angina. (Usually of the ulcerative type.) 4. Swelling of the glands. Usually cervical. 5. Fever. 103" to 105\ (B) CHRONIC LYMPHATIC LEUKEMIA. 1. Occurs later in life. 2. Gradual, progressive and painless enlarge- ment of the lymph glands usually first af- fecting the glands of the neck, then the axillary and in time become generalized. 3. Spleen and liver may also be enlarged. 4. Anemia approaches gradually. .5. Hemorrhage and fever are rare. 6. Pruritus may be very intense. 7. Bones are very tender. 8. Metabolism practically unchanged. 9. Small lymphocytes predominate. 5. HODGKIN'S DISEASE. DEFINITION. A disease of the lymphatic structures having the following characteristics: 1. Cervical glands enlarged. (a) The glands of the neck are first to enlarge (sometimes one at the angle of the jaw.) (b) Only one side at first involved. (c) From this point all the other glands are in- volved progressively downward, i. e., axilla, el- bow, groin, etc. Characteristics of these glandular enlargements: (a) Progressive increase in size. (b) Painless throughout the disease. (c) First soft, later becoming hard. (d) Discrete: each gland can be mapped out from the adjacent gland. (e) Freely movable under the skin. 2, Splenomegaly not as marled as in leukemia. 13 3. Those features of a secondary anemia. Red cells usually between 3 and 4 million But, the more pronounced the cachexia the greater the oligocythemia. White ceils normai or perhaps slightly increased. Average is about 10,000. Exaggerated leucocytosis of leukemia is absent. A relative lymphocytosis is diagnostic. May be diagnosed from spleno-medullary leu- kemia by the fact that in Hodgkin's disease the rela- tion of lymphocytes to polynuclear cells is 3 to 1 in- stead of normal, 1 to 3. Those cases in which the leucocytes are increased the prognosis is unfavorable. Hemoglobin reduced in proportion to R. B. C. 4. Pressure symptoms. (a) Dyspnea. (d) , Ascites. (b) Hydrothorax. (e) Swelling of extremities. (c) Dysphagia. (f) Jaundice. DIFFERENTIAL DIAGNOSIS. HODGKIN'S DISEASE. Lymphatic hyperplasia is gen- eral but the cervical glands are the starting point. It is first unilateral and sub- sequently involves the other ' side. The glands grow rapidly but always remain discrete. The glands are first soft and elastic, later becoming hard. TUBEKCULAR CERVICAL ADENITIS. A localized disease, the cer- vical glands are more often tubercular than any other glands of the body. It is never generalized. Bilateral from the start but more marked on one side than on the other. The rule is that the gland- ular "kernels" become matted together. At first hard and the skin is freely movable over the ker- nels. Later, the glands soften and suppurate. When sup- puration ensues the glands become adherent to the skin, 14 DIFFERENTIAL DIAGNOSIS— Continued. HODOKIN'S DI8EASK. Not only are the lymph nodes affected but also the spleen. Large nodular growths are found in this organ, in the liver, etc. This internal lymphatic hyperplasia causes various pressure symptoms: ascites, jaundice, dyspnea, etc., according to location. An excised portion of a gland shows lymphoid structure. J CJiKKCULAK CKRVICAL ADEJNITIH and discharging fistulae may form. Lymph glands only affected. Tubercle structure. Note — Both diseases are common in children and in both may the tuberculin reaction be obtained. It is, however, obtained only in advanced cases of Hodgkin's disease when the cachexia is very marked. 6. SPLENIC ANEMIA— BANTI'S DISEASE. DEFINITION. A special form of anemia, chronic in nature, asso- ciated with enlargement of the spleen (splenomegaly) but without palpable lymphatic glandular hyperplasia and by occurring by preference in children. DIAGNOSIS. 1. Tendency to hemorrhage, especially epistaxis. 2. Enlargement of the spleen associated with secondary enlargement of the liver due to cirrhosis. The texture of the spleen is hard and it increases with the pro- gress of the disease. Splenomegaly is never as great as in spleno-medullary leukemia. 3. Jaundice and pigmentation of the sl d o 73 ©._ •^ O O © J- • So T3-e O cS o"d bed « <1 I I I © O i- •oS © d Sh © S-i ©—^ © «« S © d s- .2o o ©-- Orn c6 Oo cSO So oq o ©o • -o £. di^ d © dog 3^P o^ d > ft«wTj O CO © s "^ e tj Ph ^ O^ . i^-^ MS!-gS S S&5ftO 0\Da ft^ £ !^ d ^ OS d S^ o CS © t, ij:J .^ o d £© © ®-d d >^ ^'d © © P? ft ©>.2 "© >» ■if ^ © d o jO ft tn . © rj_a! © o'^ , a3 r< © O'd H o 2 d ggdo C^ ft 03 02 ?■ © o3 ;-3 .pH © 4;> 4j . o s-e ^ o^ ^ +^ © .5 d do-SoOO ^ d d ©N?© PQ O O O bCbc© d:dM ■-SO . X d eS © c ■p'd ft^ d d oj'C ©-^ © © fH iH © d ;^ O ©-d o tH © © .5 ^ © elativ eased lor in « t- © © © .d S cS t« ^ rJ2 Q 2hW 16 7. SCURVY. DEFINITION. An acquired nutritional disease characterized by de- bility, anemia, spongy gums and a tendency to hemor- rhage, probably due to a lack of vegetables or vegetable acids in the foods. CLASSIFICATION. (A) Scorbutus or scurvy. (B) Infantile scurvy or Barlow's disease. DIAGNOSIS OF SCORBUTUS. 1. ONSET. Very insidious. Early symptoms are: Progressive loss in weight. Weakness and pallor. 2. CHANGES IN THE MOUTH. (a) Gums swollen, bleed easily, tend to ulcerate, very painful. In severe cases the gums present a fungous appearance. (b) Teeth loosened and may fall out. (c) Fetor oris, salivation and stomatitis. 3. HEMORRHAGES. (a) Mucous membranes. Especially in mouth but not as frequent as from other places. Epistaxis is very frequent. (b) Subcutaneous. Usually petechial in form. Most commonly on lower extremities. After the lower extremities are involved then the arms and trunk become involved. The hemorrhages take place more frequently in and about the hair follicles. Deeply situated hematoma may occur and then may ulcerate through the skin. (c) Subperiosteal. Irregular nodes are formed. These may also ulcerate and break through the skin. (d) Arthritic. Hemorrhage into the joints. 4. CACHEXIA AND ASTHENIA. Palpitation, feeble and irregular pulse. Skin also becomes dry. Severe secondary anemia. No abnormal cells. 17 5. Rheumatoid arthritic pains. Knees and ankles most often affected. Edema around ankles very common. 6. Advanced cases may show: Bone necrosis and in young persons separation of the epiphysis. Necrosis of the jaw is not common. 7.' SCURVY SCLEROSIS oftenest seen in the legs. It is an infiltration of the subcutaneous tissues and muscles forming a brawny induration. The over- lying skin may be blood stained. DIAGNOSIS OF INFANTILE SCURVY (BARLOW'S DIS- EASE). 1. Subperiosteal hemorrhages in the child's lower ex- tremities occur first. The child lies motionless and its feet are kept drawn up in flexion. These subperiosteal hemorrhages appear as ill- defined swellings. They are not necessarily symmetrical. Usually located around the shafts of long bones beginning above the epiphyseal junctions. The bulk of the limb increases gradually and visibly. 2. Pseudo-paralysis. As the swelling progresses the lower limbs change from the original position of flexion to one of extension and eversion and the limb lies motionless and flaccid. V/eakness of the back follows shortly after. 3. Swelling of one or both scapulas may then appear. 4. Swellings in upper extremities are next to appear. They are not as extensive as in the lower. Usually seen about the wrists and in the neigh- borhood of the epiphysis of the humerus. Usually symmetrical. 5. Crepitus. May be elicited in several cases at the junc- tion of the epiphysis with the daiphysis. Usual places are: upper and lower ends of fe- mur; upper end of tibia. 6. Chest now begins to sink "en bloc." 18 7. Periosteal thickenings may now appear on the skull and hones of the face. 8. Eye symptoms. Proptosis of one eyehall with pufRness and stain- ing of upper lid. Within a few days the other eye may show the same. 9. Profound anemia in proportion to the intensity of the involvement of the limbs. 10. Emaciation is not marked but asthenia is pronounced. 11. Fever. Usually 101° to 102° but very erratic. 12. Teeth. If the teeth have appeared, the gums may be spongy. (Tiie essential lesion is subperiosteal blood extra- vasation which causes thickening and tenderness in the shafts of the long bones.) 13. The disease usually follows the prolonged use of pro- prietary foods especially malted and condensed milk but may also develop in the breast-fed. 8. HEMOPHILIA. DEFINITION. A hereditary and constitutional disease characterized by a marked tendency to uncontrollable hemorrhage oc- curring spontaneously. A very insignificant injury may cause a severe hemor- rhage. DIAGNOSIS. 1. By the history of "bleeders" in the family. The un- affected female is the conductor of the disease. In- herited tendency of the male to bleed. 2. EPISTAXIS is the usual form of bleeding in 50%. Next in frequency is hemorrhage from the mouth and bowels. Hematoma may form under the skin. Hemorrhages into the joints, especially the knee cause painful anemic swellings which are liable to result in deformities and ankylosis. They are very apt to be mistaken for tubercular arthritis. These bloody effusions develop with remarkable rapidity. 19 3. The first hemorrhage occurs before the second year. The early signs in children may be: umbilical hemorrhage; marked bleeding during ritual circum- cision; bleeding during teething; menorrhagia in older children. 4. Coagulation of blood delayed. 5. The blood shows no typical changes other than that seen in secondary anemia due to hemorrhage). 6. "No solitary hemorrhage, however inexplicable, should be regarded as hemophilia; it is necessary to show that the individual has been repeatedly attacked, if not from birth, from infancy." (Bulloch & Fildes.) 9. PURPURA. DEFINITION. A symptom denoting hemorrhagic extravasation into the skin and not caused by traumatism. CLASSIFICATION. Petechia. Are pin-point hemorrhagic spots. Ecchymoses. Are large spots resembling bruises. COLOR. All eruptions vary in color according to age of the purpuric eruption. In the beginning they are bright red or scarlet. Before disappearing, they pass through the various colors as seen after ordinary bruises, becoming blue- black, greenish-black or brownish. Purpuric eruptions cannot be made to disappear on pressure. With the absorption of the effused blood and the hema- tin, no trace remains to mark the site of the extravasation. In some forms of purpura the coagulation time is re- tarded. CLINICAL CLASSIFICATION (Osier). 1. SYMPTOMATIC PURPURA. (a) Infectious. (b) Toxic. (c) Cachectic. (d) Neurotic. (e) Mechanical. 20 2. ARTHRITIC PURPURA. (a) Purpura simplex. fe) Schonlein's disease (peliosis rheumatica). 3. PURPURA HEMORRHAGICA (Morbus maculosis Werlhof). 1. SYMPTOMATIC PURPURA. Typhus and cerebro-spinal fevers are commonly known as "spotted fever" by virtue of the petechial rashes so commonly found in these affections. Those cases here- tofore called Brill's disease are now recognized as being only typhus in a mild form. Plots has succeeded in isolating an organism (typhi-exanthematici) in typhus fever. Embolic processes into the skin from pyemia, septi- cemia or ulcerative endocarditis also give rise to petechia. In the last named condition, ecchymoses may also be very marked. T.ess commonly, these rashes occur in small-pox, meas- les and scarlet fever— the so-called hemorrhagic or "black" forms of contagious diseases which are very dangerous. These petechial eruptions and ecchymoses occur in addi- tion to the characteristic rashes and are associated with bleeding elsewhere. Under the toxic variety, we include snake venom, copaiba, quinine, belladonna, mercury, ergot, iodides, ben- zol poisoning in workers on rubber tires, etc. The cachectic variety is the most common variety and is found in the cachectic states of cancer, tuberculosis, Bright's disease and in old age. The spots are in these cases usually confined to the extremities. It may also occur in connection with organic diseases of the nervous system: tabes, myelitis and also in hys- teria. As a mechanical symptom it may be present in w^hoop- ing cough, epilepsy and in venous stasis. 2. ARTHRITIC PURPURA. (a) PURPURA SIMPLEX. It is the mildest form and occurs most com- monly in children. Crops of petechial spots appear on the legs, especially on the flexor aspect and less com- monly on the trunk and arms. 21 Joint symptoms are not severe. Diarrhea usually present but no fever. Recovery in from 7 to 10 days. (b) PURPURA (PELIOSIS) R H E U M A T I C A (SCH5NLEIN'S DISEASE). Multiple arthritis. Many kinds of eruptions: Usually urticaria and erythema exuda- tivum. Sometimes purpuric. Often purpura and urticaria. Rashes first appear on affected joints or on legs. Males usually affected (20 to 30 years of age). Articular pains are severe, especially when the rashes come out. Fever: 101° to 103°. Sore throat very common. Recovery is the rule but the sore throat may persist. VISCERAL LESIONS IN PURPURA. May occur in any form of purpura. (a) Gastro-intestinal crises of pain, vomiting, melaena and diarrhea so that an attack may be mistaken for appendicitis or intussusception. Purpura as- sociated with colic is called Henoch's purpura. (b) Splenomegaly usually present in these cases. (c) Albuminuria and acute nephritis may occur and be the most serious symptoms. PURPURA HEMORRHAGICA. (MORBUS MACULOSIS OF WERLHOF). 1. Includes all cases of purpura associated with hem- orrhages from the mucous membranes. 2. Usually occurs in young and delicate girls but adults may also be attacked. 3. Prodromes. For a few days there may be weak- ness. 4. Onset. Purpuric spots on the skin which rapidly increase in size and in number. 22 5. Hemorrhages from any mucous membrane in the body. Usual forms are epistaxis, hematuria and hemoptysis. Hemorrhages cause a severe anemia and may prove fatal. 6. Fever. Usually present but slight. 7. Favorable cases recover after 10 to 14 days. 8. Purpura fulminans. Death may occur within 24 hours. This usually occurs in children. Hemorrhages are usually cutaneous. Death occurs even before hemorrhages occur from the mucous membranes. 10. BLOOD POISONING. Sapremia and Septicemia. DEFINITION. Blood poisoning is an indefinite term and is not ac- cepted as a cause of death. It is best described under the headings of sapremia and septicemia. 1. SAPREMIA. Such an infection as occurs after the re- tention of blood clots or fragments of membranes in the uterus after labor or abortion. The bacteria thrive on this decomposed materia! in the womb. 2. SEPTICEMIA. This is further subdivided into: (A) Toxemia or septic intoxication. In which toxins alone are absorbed from the focus of growing pathogenic or pyogenic bacteria in the living tissues. (B) Progressive septicemia or bacteremia. This occurs when bacteria enter the circulation. PYEMIA. Signifies secondary multiple metastatic abscesses in the tissues dur- ing the course of septicemia. DIAGNOSIS OF SAPREMIA. The saphrophytic bacteria acting upon the dead ma- terial in the womb, produces toxins which are discharged into the circulation with the following results: 1. Intense chills, high fever and rapid pulse. 23 2. Flushed skin and dry coated tongue. 3. Change in lochia and tenderness over uterus. 4. By proper cleansing of the womb of the decomposed material all symptoms abate. 5. Usually occurs 2 to 3 days post-partum, DIAGNOSIS OF SEPTICEMIA AND PYEMIA. 1. Fever, chills and sweats. Fever is remittent in character. Highest in pyemia and in this form distinctly "septic" in char- acter. Chills that precede or accompany the elevation of temperature are quite severe. The fever occurs in paroxysms but not with the same regularity as in malarial fevers. The fever in septicemia is much lower than in sapremia and yet the patient feels worse. The orderly sequence of chill, fever and sweat is not as characteristic as in malaria. Diaphoresis is most marked in pyemia. 2. Enlarged and painful spleen. 3. Septic diarrlnea and vomiting. 4. Septic arthritis is pathognomonic of pyemia. It is usually associated with skin eruptions, the most fre- quent being petechia. 5. Septic endocarditis is a very common complication. 6. Septic nephritis may occur in pyemia. Even when nephritis does not occur the urine al- ways contains albumin. 7. Intense nervous manifestations. There may be de- lirium, prostration and coma. Many pass into the so-called "typhoid state." 8. Metastatic abscesses as above described (in the skin, kidney, joints, endocardium) are diagnosed by an in- crease in the severity of the symptoms and signify pyemia. 9. Blood. Marked leucocytosis with an increase in per- centage of polynuclear cells. Blood cultures taken directly from a vein may show staphylococci, streptococci, colon, gonococci or pneumococci. Repeated cultures should be made if the first be negative. 24 11. ERYTHREMIA. Vaquez' Disease — Polycythemia Vera. DEFINITION. A persistent increase in the R. B. C. associated with plethora, splenomegaly and at times cyanosis. It is a disease of the bone marrow (of the erythroblastic tissues as compared to the leucoblastic tissues in leukemia. Hyperglobulism in consequence to high altitudes is not included under this head. DIAGNOSIS. 1. FACIAL APPEARANCE. Superficial blood vessels, capillaries and veins look full. Skin is therefore congested. In warm weather the face is brick-red in color. In cold, it is cyanosed. 2. SPLENOMEGALY not as great as in leukemia. The enlargement is hard, firm and painless and may vary in size from time to time. It may cause ascites. 3. HYPERGLOBULISM. The corpuscular volume greatly exceeds that of the plasma. The polycythemia ranges from 7 to 12 million R. B. C. per c.mm. Red cells are usually normal in size and shape. A few nucleated reds may be present. Hemoglobin ranges from 130 to 160%. Color index relatively low. Specific gravity is high. Moderate leucocytosis without any change in the differential count. 4. Headache, flushing, giddiness. Constipation. Albuminuria. High blood pressure. 25 CHAPTER II. THE BLOOD. DEFINITION. A fluid tissue circulating in closed vascular channels regulated by the activity of the heart and having certain well defined functions: (a) Nutrition. (Maintaining life). (b) Excretion of v^aste matter via skin and kidneys. (c) Regulation of body temperature. (d) Respiration. Its hemoglobin content forming loose combinations with oxygen and carbon dioxide. (e) Distribution of internal secretions. COLOR. Due to a ferruginous substance: hemoglobin (Hb.) : Arterial blood is a bright scarlet color. Venous blood is a purplish blue. Bright cherry-red color occurs in certain forms of poisoning especially carbolic acid. Brownish-red or chocolate color occurs in poisoning with chlorate of potash and aniline. Whitish-red or milky colored blood occurs in leukemia. Pale and watery blood is seen in hydremia and in chlorosis. REACTION. Alkaline to special indicators. A lowered alkalinity occurs in diabetes and is a very bad prognostic sign. During diabetic coma, the re- action may even be acid. COMPOSITION. Plasma — 50% of the volume of the blood. Formed elements floating in the plasma — 50%. Relation of Volume of Cells to Plasma: By means of Daland's hematocrit which consists of 2 calibrated tubes, the divisions of which are 100 equal portions, each division approximating 100,000 cells, the blood is centrifuged and the plasma becomes separated 26 from the morphological elements. It gives us, therefore, a rough blood count. If the cellular portion stops at point 50 on the tube it means a red count of 5 million. (50x100,000.) VOLUME INDEX. With Daland's hematocrit point 50 represents the nor- mal, because the volume of the plasma equals the volume of corpuscles. Supposing the cellular portion stopped at point 40. 40 The volume per cent, would be t^=^ 80%. Label this volume percentage "A." It is to be the numerator in the determination of volume index. Now count the number of R. B. C. (see page 37). Suppose we counted 4,500,000. Since the normal red count is taken at 5,000,000, we must, in order to get the per- centage proceed as follows: Label this percentage 4,500,000 ^ 45 _ 9 5,000,000 50 10 ~ "B." It is to be the de- nominator. The volume index is therefore the quotient of the volume per cent. (A) as obtained by the hematocrit and the actual blood count per cent. (B). Thus, in the above instance: A Hematocrit volume of red cells in '/o f Volume in- — = = -' dex of red B Percentage counted red blood cells [ cells. Then inserting figures: ^^^ =-t~- Normally it is 1. 90% 9 According to Capps, this volume index is constantly increased in pernicious anemia. The color index never exceeds the volume index. In primary and secondary anemias this factor is decreased and oftentimes the color index falls below the volume index. Color index is de- scribed on page 38. COMPOSITION OF BLOOD PLASMA. Plasma is the liquid portion of the circulating blood. When blood clots (see page 52) the liquid which exudes from the clot is called serum. Serum consists of: Proteids: serum albumin and serum globulin. Glucose, extractives, calcium salts, sodium and po- tassium chlorides, carbonates, phosphates, etc, 27 The chief extractives are: Fat, sugar, urea, uric acid, sarco-lactic acid, lecithin, cholesterin, glycuronic acid, creatin, car- bamic acid, glycogen, hippuric acid. THE MORPHOLOGICAL OR FORMED ELEMENTS OF THE BLOOD. fRed cells (R. B. C). } White cells (W. B. C). ( Blood plates. ENZYMES in the blood. ' Glycolytic ferment. Lipolytic ferment. (Fat synthetizing.) . Oxidases. -{ Proteolytic properties of leucocytes. Internal secretions as adrenalin, etc. Amboceptors. ^ Complements. GASES of the blood. f Oxygen. \ Carbon dioxide. ( Nitrogen. Arterial blood. Venous blood. Oxygen 21.6% 6.8% Carbon dioxide 40.3% 48.0% BLOOD PRESSURE. NORMAL FIGURES. (Janeway's). Infants 75 to 90 mm. Hg. "] Children over 2 years. ... 90 to 110 mm. Hg. ! Maximum Young adults 110 to 130 mm. Hg. { systolic Older adults 110 to 145 mm. Hg. j HOW TO OBTAIN NORMAL B. P. Consider a person aged 20 as having a B. P. of 120. for every 2 years above this age add 1 mm. Hg. Hence: — At 40, the B. P. would be 130 mm. Hg. At 50, the B. P. would be 135 mm. Hg. Permissible variations which occur normally. Seventeen mm. Hg. above or below would be the nor- mal figure for any given age. 28 THE SPHYGMOMANOMETER IN LIFE INSURANCE. 1. In those applicants who are overweight the blood pressure tests determine whether the company should take the risk. 2. It is a recognized fact that permanent changes in the kidney cannot exist without causing an increase in the B. P. So that, if an applicant does show a faint trace of albumin and casts are present in scanty numbers, this evidence alone will not cause an ab- solute rejection unless his B. P. is decidedly increased. 3. Signs of beginning pathological change in the cardio- vascular-renal system can be recognized by this in- strument long before we can demonstrate any ab- normal findings in the heart, pulse or urine. 4. A blood pressure exceeding 145 in a person before middle life, or a reading of 160 after middle life has passed must be considered as abnormal. (Janeway). TO OBTAIN THE MAXIMUM SYSTOLIC B. P. To obtain the maximum systolic blood-pressure a broad arm piece should be used. When the pulse at the wrist is obliterated the height of the mercury column is equivalent to the maximum systolic pressure. Many ob- servers claim that it is better to accept the reappearance of the radial pulse after obliteration than the initial dis- appearance of the radial pulse. The Janeway apparatus and the Tycos' sphygmomanometer are best recommended. The minimum diastolic blood-pressure is obtained by let- ting the pressure fall 5 mm. Hg. at a time and at the same time watching the amplitude of the pulsations of the mer- cury column or oscillations of the needle — and at that point where the greatest amplitude occurs, that point registers the diastolic blood-pressure. The auscultatory method may also be employed. HYPOTENSION. Definition: A blood pres- sure reading that is lower than what it should be at any given age and under ordinary conditions. In recent years hypotension has come to be looked upon as both a diagnostic and a prog- nostic factor. If one will only HYPERTENSION. Definition: A very notice- able increase in blood pres- sure above the average for any given age. It may reach the 300 mark and it may be temporary or permanent. It is only a symptom and it is our duty to investigate the cause. It is also well to re- 29 HYPOTENSION. bear in mind that whenever vaso-dilatation occurs in con- sequence to a vaso-motor paresis, the blood vessels be- come excessively dilated and consequently the blood pres- sure falls, it will be very easy to interpret the meaning. Such a vaso-motor paresis is the cardinal factor in shock and collapse. In these condi- tions the greater the fall in blood pressure the more dan- gerous does the patient's con- dition become. Hypotension is a recent ad- ditional diagnostic point in typhoid fever. In fact, of all the acute infections which may be accompanied by a low pressure, typhoid ranks first and pneumonia second. It has also been noticed here that the hypotension bears a rela- tion to the toxic symptoms. As the intoxication increases (provided certain complica- tions are absent) the blood pressure falls (vaso-motor paresis). On the other hand with the advent of a compli- cation like a perforative peri- tonitis the blood pressure will rise. Then, again, the blood pressure reading will easily differentiate between a hem- orrhage of the bowel and a perforation followed by peri- tonitis. Intestinal hemor- rhage is always accompanied by a low blood pressure, whereas perforative peritoni- tis causes an elevation of blood pressure. HYPERTENSION. member that it is often a salu- tary and beneficent condition not to be interfered with. A patient whose arterial tension exceeds 260 mm. Hg. is liable to die suddenly. The usual causes of hyper- tension are found resident either in the cardio-vascular system or in the kidneys. A good vv^orking rule is as fol- lows: A permanent increase in blood pressure in a young adult or in one in early mid- dle life, in the absence of or- ganic changes in the heart, blood vessels or kidneys, must be explained by the presence of a chronic toxemia, or a poisoning arising from some error in metabolism, either intestinal, urinary or both. With the advancement in years the blood pressure naturally increases progres- sively. The Sphygmomanometer also has its uses in obstetrics. It has been employed to de- tect the development of the toxemias of pregnancy and nephritis occurring in those conditions. After exhaustive clinical study, we must con- clude that the taking of blood pressure readings is just as important as the repeated urinary examinations and pelvimetry in pregnancy. In these cases, where hyperten- sion is found, we can explain its presence by a toxemia by virtue of the metabolic waste products being absorbed in the system. As far as it is 30 HYPOTENSION. In passing it may be stated that Barach has found the blood pressure in enteric fever usually below the century mark, and it does not bear any relation to the pulse rate nor the temperature. Before dismissing the sub- ject of hemorrhage, it is well to remember that with the exception of cerebral hemor- rhage, all other hemorrhages (either visible or concealed) must be accompanied by a lowering in pressure. The lowering is in direct propor- tion to the quantity of blood lost'. However, in favorable cases where regeneration of the blood takes place, the vol- ume of the blood (its watery constituent) is soon restored almost to normal, the hypo- tension is only short lived. It is, therefore, a valuable prog- nostic as well as diagnostic feature. Returning to pneumonia, we may state that we are also dealing with an intoxication which may cause vascular paresis. The best way to de- tect such a failure in the cir- culation is by daily and fre- quent blood pressure readings. Circulatory depression in con- sequence of such a toxemia is always accompanied by a fall in blood pressure, whereas it has been noted that typhoid bears no relation between the pulse rate and the blood pres- sure, we do find in pneu- monia such a correlation. Ac- cording to Gibson, the situa- HYPERTENSION. possible to lay down rules in these cases, we may say that a blood pressure below 125 could be disregarded; a pres- sure from 125 to 150 needs careful watching and moder- ate eliminative treatment; and that a pressure over 150 needs very active eliminative treatment and will, in all probability, especially if it shows a tendency to climb higher, require the induction of premature labor. In concluding the subject of hypertension, the diag- nostic value of this phenome- non can readily be seen in cases of cerebral hemorrhage. This increased blood pressure is the most reliable and diag- nostic sign. It is readily dif- ferentiated from cerebral em- bolism by the fact that this latter condition is accom- panied by a low pressure. The elevation of the blood pressure in cerebral hemor- rhage bears a direct relation to the increase in intra-cra- nial tension so that in cases where the hemorrhage in- creases in size the pressure increases in proportion. On the other hand, if the cranial encroachment is a slow and chronic process like a tumor there is no effect upon the blood pressure. Finally, as before stated, cerebral hem- orrhage is the only hemor- rhage which is accompanied by hypertension; all other forms of hemorrhage are ac- companied by a diminution in blood pressure. HYPOTENSION. tion in pneumonia may be summed up as follows: "When arterial pressure ex- pressed in millimeters of mer- cury does not fall below the pulse rate expressed in beats per minute, this fact may be taken as excellent augury, while the converse is equally true." Although a high blood pres- sure is invariably associated with aortic regurgitation, it is only valvular disease which has hypertension as a diag- nostic feature. In all the other valvular lesions, as well as all organic lesions of the heart, we find hypotension. Emerson's findings in tu- berculosis of the lungs is as follows: Hypotension in pul- monary tuberculosis is (1) a very marked and constant fac- tor in advanced cases; (2) present but not so very mark- ed in moderately advanced cases; (3) and it can often- times be demonstrated in the incipient stage, and even be- fore the development of physi- cal signs. Therefore, it may be inferred that the longer the disease has existed the more marked will the lower- ing in blood pressure be. He also claims that in those cases where the trend is towards re- covery we will note a progres- sive return to a normal pres- sure. We are very frequently call- ed upon to differentiate the various forms of coma and the 32 HYPOTENSION. task is not always very easy. Edgecombe has remarked the noticeable frequency of hypo- tension in epileptic coma in contrast to hypertension which accompanies uremia. In conclusion, it is well to add that wherever life is low as in cachectic states, the blood pressure tends to fall progressively. SPECIFIC GRAVITY. Varies from 1.050 to 1.062. In children it is nearer to 1.050. The average is 1.055. According to Schmaltz, the sp. gr. is in direct rela- tion to the amount of hemoglobin and the volume of the red cells (excepting in nephritis, circulatory disturbances, leukemia, post-hemorrhagic anemia and inanition. His figures are: With a sp. gr. of 1.059 Hb. is 100% With a sp. gr. of 1.0575 Hb. is 90% With a sp. gr. of 1.056 Hb. is S07c With a sp. gr. of 1.0535 Hb. is 75% With a sp. gr. of 1.052 Hb. is 70% With a sp. gr. of 1.051 Hb. is 65% With a sp. gr. of 1.049 Hb. is 60% With a sp. gr. of 1.048 Hb. is 55% With a sp. gr. of 1.0455 Hb. is 50% With a sp. gr. of 1.0425 Hb. is 45% With a sp. gr. of 1.041 Hb. is 40% With a sp. gr. of 1.038 Hb. is 35% With a sp. gr. of 1.035 Hb. is 30% With a sp. gr. of 1.030 Hb. is 20% Hammerschlag's Method of Determination of Sp. Gr. Make a mixture of chloroform (sp. gr. 1.526) and ben- zol (sp. gr. 0.889) so that it is almost like that of normal blood (1.050 to 1.062). A drop of fresh blood from a capillary blood pipette is allowed to fall into this mixture. It will either sink or rise. If it sinks to the bottom, add chloroform drop by drop; and if it rises or floats add benzol drop by drop; until the drop of blood remains stationary in the mixture. Filter very quickly because evaporation will occur, and read the sp. gr. by means of a hydrometer inserted into the mixture. 33 RED BLOOD CORPUSCLES. (ERYTHROCYTES.) MORPHOLOGY. 1. In mammals, they are flat, circular, non-nucleated discs, iy2 microns or 1/3200 of an inch in diameter, having a pale central area. In fresh blood, the red cells show a tendency to "coin-roll" formation. As fresh blood dries upon the slide, the red cells become crenated; that is to say, spinous projections from the cell appear like a cogged rim. 2, In birds, reptiles, amphibians, camels, they are bi- convex, oval and nucleated. The largest cells are found in the amphiba. PATHOLOGICAL RED CELLS. 1. Pessary or ring cell. Large pale central area with a small rim of pro- toplasm. They are called "dropsical cells" and are very diagnostic of chlorosi^. 2. Nucleated red cells. (A) Normoblasts. (Trachyochromatic erythroblasts) . A matured normoblast can thus be recognized: Size and shape about that of a normal R. B. C, but it has a nucleus. If a trifle smaller in size it is called a mlcroblast. Both together signify REGENERATION of the blood and are especially found after hemor- rhage. Normoblasts stain more intensely. Its nucleus is about one-third of its diameter. It is densely stained, more homogenous, sharply defined, spheroid and devoid of chromatin net- work. It is usually situated towards the peri- phery. An immature normoblast shows a very dis- tinct network, is larger and lighter in color and the chromatin fibers are radially arranged and frequently shows mitotic figures. (Howell.) (B) Megaloblasts. (Amblyochromatic erythroblasts). Size: larger than normoblasts. Protoplasm: usually swollen and enlarged. Hemoglobin: as a rule in excess. 34 (For Drawings) oO Usually poychromatic, the shade of the stain varying from yellow to purple. Nucleus: very large, varying from 6 to 10 microns and may assume many forms. As a rule it is ill-defined and shows feeble basic stain- ing properties. Megaloblasts signify abnormal DEGENERA- TION. They appear in leukemia, pernicious anemia, infection with the Bothriocephalus Latus, nitro- benzol poisoning, severe anemia, etc. When the nucleus of a nucleated R. B. C. exceeds 20 microns it is termed gigantoblast of Ehrlich. 3. Poikilocytosis. The simultaneous variation in both size and shape of the red cells. It is very character- istic of pernicious anemia. 4. Microcytes and macrocytes. The normal sized R. B. C. is also called a normocyte. If a cell is a little smaller it is a microcyte. If a little larger than a normocyte, it is a macrocyte. These cells occur in grave and in pernicious anemia. 5. Polychromatophilia or polychpomasia. The normal red cells, when a smear is fixed and stained, stains only with acid dyes. Hemoglobin is therefore said to be acidophilic. Abnormal red cells not only show affinity for acid dyes but basic dyes. These red cells instead of ap- pearing monochromatic (one color) will appear with several colors : gray, slaty, purple, violet, etc. There are two distinct forms: Polychromatophilic degeneration of Gabritscliew- sky. In which there is a diffuse basophilic staining of the cells. Polychromasia of Maragliano in which the baso- philia is punctate. It is very closely related to the basophilic degeneration of Grawitz. 6. Basophilic degeneration. (Grawitz.) Granules of vary- ing size appear in the body of the R. B. C. and stain with basic dyes. Very diagnostic of lead poisoning. It is also common in diabetes, myelogenous leukemia, pernicious anemia, severe secondary anemias espe- cially those following malignant disease, eruptive fevers and malaria. 36 7. Microcyte is a red cell smaller than a normal cell. Diameter varies from ZV2 to 6/a. 8. Macrocyte is a cell larger than a red cell. Size varies from 9V^ to 12;Ct. NUMBER OF RED BLOOD CELLS. Males: 5,000,000 per c.mm. Females: 4,-500,000 per c.mm. Oligocythemia: Pathological reduction in number. As a rule there is a corresponding decrease in Hb. It occurs in nearly all forms of anemia and as a re- sult of the toxins of specific fevers. Polycythemia (Polyglobulia): increase in number of R. B. C. High altitudes. 50,000 cells for every 1000 feet as- cension. Watery diarrheas. Severe diuresis and ascites. Numbers 2 and 3 cause increased concentration of the blood. 4. Cardiac diseases. All forms of cyanosis. 5. Drugs causing vaso-constriction. Diseases of the adrenal glands. Phosphorus poisoning and acute yellow atrophy of the liver. Hepatic insufficiency. COUNTING THE NUMBER OF R. B. C. Prick the tip of finger or ear, and with blood pipette No. 101, draw blood up to the 0.5 mark. Now draw enough Hayem's solution up to 101 mark and shake vigorously for at least one minute. This gives a 200 dilution. Discard the first few drops and then blow one drop on to the center piece of the Thoma-Zeiss hemocytometer and adjust the special cover-slip carefully in place until Newton's rings are visible. Examine first with low power lens to see if the red cells are evenly distributed. If not make a new specimen. With high power lens, begin at upper left-hand cor- ner and proceed downward, being guided by the ruled lines, then upward, then down again and count the num- ber of R. B. C. in 80 squares. To this factor add 4 37 ciphers. Providing the dilution is 200, this number repre- sents the number of red cells per c.mm. If we counted 325 cells, the count would be 3,250,000. If blood has been drawn past the 0.5 mark, for ex- ample 0.6, proceed as follows: Divide the number of red cells counted in the 80 squares by the division stopped at and multiply by 5000. Suppose we counted 390 cells. Dividing this by 0.6 w^e get 650. Then 650x5000 equals 3,250,000. Owing to the presence of bichloride, the fluid cannot be mixed with an aniline color- ing substance to stain the leucocytes, and it is there- fore not applicable to the combined counting of red and white cells. Hayem's Solution consists of: Bichloride of mercury. 0.5 Sodium sulphate 5.0 Sodium chloride! 1.0 Distilled water 200.0 Toisson's Fluid consists of: Sodium chloride. . Sodium sulphate . , Neutral glycerine, Distilled water. . , Methyl violet 5 B, 1.0 G. 8.0 G. 30.0 c.c. 160.00 c.c. .025 G. This colors the white cells and with it both red and white cells can be counted. Objections to this fluid are (1) it may cause hemolysis at times; hence the red count is worthless; (2) spores develop readily in it and in order to use it must flrst be filtered. Each filtration further weak- ens the solution. COLOR INDEX. (Value of corpuscles.) Represents the relative amount of hemoglobin con- tained in each red cell as compared when a normal num- ber of erythrocytes obtains. In other words, it is the quotient of the percentage of Hb. divided by the per- centage red cells. The latter factor is obtained by divid- ing the number of red cells counted by 5 million. Examples: What is the color index when one counts 2,500,000 red cells and the Hb. is 50%? 2,500,000 ^ 14 = 50%; and 50 1 = Color Index. 5,000,000 '" ' 50 What is the color index when one counts 3,000,000 red cells and the Hb. is 40% ? 3,000,000 5,000,000 — 3/. 2.L 60%; and 38 40 60 % = Color Index. What is the color index when one counts 1,500,000 red cells and the Hb. is 45%? 1,500,000 ,, _^. ,45 _. ^ , ^ . -^^^^^^=.Vio = 30% ; and - = IV. = Color Index. A very simple method of obtaining the percentage of red cells of the normal 5,000,000 is to multiply the num- ber of hundreds of thousands of the red cells counted by two. Thus if 2,650,000 cells were counted, we multiply 265 by 2. This equals 53%. WHITE BLOOD CORPUSCLES. (LEUCOCYTES.) MORPHOLOGY. In the fresh specimen, they appear as highly refractive, nucleated cells, having a variable amount of clear or granular cytoplasm, possessed of ameboid movement with a phagocytic property. They are larger than the R. B. C. CLASSIFICATIONS. 1. Mixed or present classification of today: (a) Polymorphonuclear neutrophile. (b) Lymphocytes: large and small. (c) Mononuclear. (d) Transitional. (e) Polynuclear eosinophile. (f) Polynuclear basophile (mast cell). 2. According to granules: f Polymorphonuclear neutrophile. (a) Granular } Eosinophile. (a j trranuiar <;^ Basophile. 1^ Myelocyte. r Lymphocytes. (b) Non-granular ..< Mononuclear. i Transitional. 3. According to nuclei: {Neutrophile. Eosinophile. Basophile. (b) Mononuclear. . . .AH the rest. 4. According to staining of protoplasm: (a) Neutrophile. (b) Eosinophile. (c) Basophile. 39 LEUCOCYTES DESCRIBED. (a) POLYMORPHONUCLEAR NEUTROPHILE. (Finely granular cells of Scliultze.) Constitute 65 to 75% of the total white cells. Twice as large as a red cell. Nucleus or rather nuclei vary greatly in shape and are stained blue (basophilic). Protoplasm contains numerous irregularly placed and irregular sized granules stained pink (acido- philic). When outside the blood vessels they form pus. (b) LYMPHOCYTES. Constitute 20 to 30% of the total W. B. C. Large lymphocyte. One and one-half times the size of R. B. C. Nucleus deeply stained. Has more cytoplasm than a small lymphocyte. Small lymphocyte. Is about the size of a red cell. Its nucleus also deeply stained. Has a small rim of cytoplasm. (c) LARGE MONONUCLEAR. About 3 times as large as a red cell. Has a round or oval faintly stained nucleus, which is basophilic. Considerable reticulated cytoplasm, few meta- chromatic granules. (d) TRANSITIONAL. (c) plus (d) equal 6% of the total W. B. C. These cells resemble the former excepting that the nuclei are kidney shaped (notched) and pale. (e) POLYMORPHONUCLEAR EOSINOPHILE. (Coarse- ly granular cells of Schultze.) Constitute about one-half to 3% of total W. B. C. Is as large as a polymorphonuclear cell. Has large, coarse, red granules arranged in mosaic form in its protoplasm. It stains with acid dyes. The nuclei are coarsely reticulated, usually bilobed, and rather indistinct, 40 {For Drawings) 41 (f) POLYMORPHONUCLEAR BASOPHILE OR MAST CELL. Constitutes one-half per cent, of total W. B. C. Is as large as a polymorphonuclear cell. Nucleus is indistinct. Cell appears as if it were bespattered with ink. It also has metachromatic granules. The mast cells are best stained by Ehrlich's dahlia stain or by Turk's iodine method. NUMBER OF LEUCOCYTES. Normally: 5,000 to 10,000 per c.mm. Average 7,500. Leucopenia: Reduction in total white count. Leucocytosis: Increase in total white count. May be (a) Absolute: Increase in total number of W. B. C. (b) Relative: A proportionate increase of any given variety of colorless corpuscles, the total white count remaining unaltered. CLASSIFICATION OF LEUCOCYTOSES (Modified after Lim- beck) . 1. PHYSIOLOGICAL LEUCOCYTOSIS. (a) Digestive. Unless cancer of the stomach exists a leucocytosis of the polynuclear type averaging 10,000 occurs after eating. (b) Pregnancy. Average count is 15,000. Occurs in more than 50 9o of the cases. Especially marked in primiparse. All the white cells excepting eosinophiles are increased. (Mixed leucocytosis.) Count returns to normal within 10 to 14 days after delivery providing no such complica- tions like fever, hemorrhage, etc., arise. (c) New-born. Average 15 to 20 thousand. Disappears as child begins to gain in weight. The small mononuclears constitute 40 to 60% of total W. B. C. 2. PATHOLOGICAL LEUCOCYTOSIS. (a) Inflammatory. All forms of suppurative inflam- mation except when an abscess is well walled off. In septic conditions the polymorphonuclear cells predominate. 42 The common diseases associated with leuco- cytosis are: acute lobar pneumonia, acute articu- lar rheumatism, scarlet fever, whooping cough, erysipelas, cerebro-spinal meningitis, pus infec- tions, etc. (b) Cachectic (due to malignant tumors). More often after cancer than sarcoma. (c) Posthemorrhagic. Polymorphonuclear cells pre- dominate. White count may reach 20,000 w^ithin one hour after a severe hemorrhage. It is, how- ever, transient, disappearing long before regen- eration of the blood has occurred. 3. Leucocytosis from medicinal and therapeutic meas- ures: baths, drugs, exercise. 4. Leucocytosis from other causes: cyanosis, shock, vac- cine injections, etc. IVIIXED LEUCOCYTOSIS. An increase in both granular and non-granular cells but its more common interpretation is an increase in the number of neutrophile myelocytes. Best seen in spleno-myelogenous leukemia. In no other conditions excepting leukemia do we ever find more than 1,000 mye- locytes. In leukemia it may reach 150,000. SIGNIFICANCE OF RELATIVE LEUCOCYTOSES. EOSINOPHILIA. To be called a true eosinophilia there must be over 250 such cells per c.mm. (a) Parasitic infections: as trichinosis, intestinal worms, hydatids, chronic malaria. (b) Bronchial asthma at time of paroxysm. (c) Spleno-myelogenous leukemia. (d) Many skin diseases. Seems to depend more upon extent of lesions than upon nature. Common dis- eases are: pemphigus, urticaria, purpura, eczema, psoriasis. (e) Bone diseases: osteomyelitis, osteomyalacia, sar- coma. (f) Malignant disease. (g) Gonorrhea: both in blood and discharge. LYMPHOCYTOSIS. (a) Children. From birth up to puberty the lymphocytes constitute 50 to 65 9^ of W. B. C. Gradual reduction to the normal 20 to 30 7o by the time puberty is reached. 43 (b) Lymphatic leukemia. Acute forms: large lymphocytes predominate. Chronic forms: small lymphocytes predominate. (c) Typhoid. Uncomplicated cases show leucopenia with lymphocytosis. (d) Syphilis. Also found in the spinal fluid in syphilitics. MYELOCYTOSIS. A myelocyte is a mononuclear cell which is distinctly granular. These granules are usually neu- trophilic or eosinophilic. But in myelogenous leukemia they may be basophilic. The size of myelocytes varies from that of a R. B. C. to a large mononuclear. The myelocytes are not normally found in the circulation but they are found in the bone-marrow. (a) Spleno-myelogenous leukemia. (b) Pernicous anema. (c) Bone disease: syphilis, tuberculosis, tumors. (d) Malignant tumors of gastro-intestinal tract. (e) Empyema in children. (f) Some acute infectious diseases: Lobar pneumonia (8 to 12 7o). Diphtheria: (bad prognosis). LEUCOPENIA. White count reduced below 5,000. (a) Typhoid: uncomplicated cases only. (b) Measles: after the rash. (c) Malaria: but lymphocytes may be slightly increased. (d) Tuberculosis. (e) Mumps unless suppuration of the gland occurs. (f) Starvation and malnutrition. (g) Chronic poisoning with heavy metals, morphine, al- cohol, cocaine. (h) Grippe if uncomplicated. Thus, can be diagnosed from pneumonia in which leucocytosis occurs. (i) Pernicious anemia and splenic anemia. COUNTING THE WHITE CELLS. Draw blood up to 0.5 mark in pipette No. 11. Draw up sufficient amount of 0.5% acetic acid solu- tion up to the 11 mark. (Acetic acid destroys R. B, C.) Examine as described under red cells (page 37), but count the entire 400 squares and use low power lens. The dilution as given above is 20. 44 To find the number of W. B. C. multiply the number of cells counted in all the squares by 20 and then by 10 (the depth of the examining chamber). In other words, multiply the number of cells counted by 200. If blood be drawn past the 0.5 mark, divide the num- ber of cells counted by the division at which we stopped and multiply by 100. Suppose we counted 42 cells in 0.6 c.c. blood. There- fore ^ X 100 = 7,000 W. B. C. O.b DIFFERENTIAL WHITE COUNT. First ascertain the total white count as above. Make a thin blood smear, fix, stain and examine with a microscope. (Wright's stain is best for differential count). Count 200 leucocytes and as each one is seen place a mark along the side of the name of the cell in the list as arranged below: Polymorphonuclear neutrophile. Large lymphocyte. Small lymphocyte. Mononuclear. ^ Transitional. Polymorphonuclear eosinophile. Polymorphonuclear basophile. Unclassified cells. Pathological cells. Now then, assuming that 150 polymorphonuclear neu- trophiles were counted in the 200 squares the percentage therefore is 75. The percentages for the other cells are determined in a similar manner. BLOOD SMEARS: Preparation and staining. Cleanse part from which blood is to be drawn. Puncture skin with a Hagerdorn needle and wipe off the first drop of blood which appears. Apply a clean slide to the bleeding point and permit one drop to adhere to the slide at a point about %-inch from the smaller edge of the oblong slide. With another clean slide, held at an angle of 45% bisect this drop and wait until the blood has spread along this angle by capillarity. 45 When the angle has almost completely been covered draw the second slide across the first using firm and steady pressure. The object is to get a thin smear. Before any of the morphological elements of the blood can take up any stain the smear must first be FIXED by any process which will coagulate the proteid constituent of the blood. The air dried film is exposed to heat or to chemicals. Fixation by methyl alcohol (C. P.) for 3 to 5 minutes is one of the best methods. STAINS FOR ROUTINE PURPOSES. f These stains are the best 1. Eosin-methylene blue. | because they are simple in 2. Eosin-hematoxylin. ■{ technic and show clear-cut 3. Wright's stain. | pictures of all the important [ blood elements. 1. EOSIN-METHYLENE BLUE STAIN. 1. Fix smear in pure methyl alcohol for 3 minutes (If we find later that the nuclei are indistinct fix for a longer period.) 2. Stain in i^'/o alcoholic (709o) solution of Grubler's "French pure" eosin for 3 to 5 minutes. (This brings out the neutrophilic granules distinctly). 3. Wash in distilled water and dry between filter paper. 4. Deposit slide for % to 1 minute in a small bath containing: 20 drops of a %9o aqueous solution of methy- lene blue (B. pat), and 10 drops of the above eosin solution. 5. Quickly w^ash (briefly) w4th distilled water. 6. Dry at once between filter paper or over flame. 7. Mount if desired in Canada Balsam or examine di- rectly with high power lens. With this stain the morphological elements are thusly recognized: R. B, C. and eosinophilic granules of W. B. C: bright red. Neutrophilic granules: pink to bright red. (The granules being smaller than that of the eosinophiles.) 46 Nuclei, mast-cell granules, bodies of lym- phocytes, platelets, malarial organisms, trypano- somes and filaria: varying shades of blue. Note. — For malaria it is not a very good stain because it does not stain the chromatin very good. It is better than any of the Romanowsky's stains or its modifications. 2. EOSIN HEMATOXYLIN STAIN. Best adapted for examination of nuclear structures. Two solutions are required. Stain with solution No. 1 for i^ minute. Wash in water but do not dry. Deposit slide in solution No. 2 for 1 to 3 minutes. Wash in water, dry and mount. Solution No. 1. ^% Griibler's blood eosin in 70% alcohol. Solution No. 2. Delafield's hematoxylin solution which consists of: Hematoxylin crystals 4 G. Absolute alcohol 25 c.'c. Ammonium-alum crystals C. P...'.".'.'.* 52 G. Distilled water 400 c.c Glycerine, C. P .' ' * ,' ,'ioo c c Methyl alcohol, C. P *...*.'.'. 100 c.c! HOW TO PREPARE DELAFIELD'S HEMATOXYLIN SOLU- TION : 1. Rub up hemotoxylin crystals with alcohol until dis- o Ol V GO. , 2. Place this solution in a loosely corked bottle and ner- mit to stand 4 days exposed to the lig-ht. 3. Dissolve the ammonium-alum crystals in 400 c c water and allow to stand as the above. " ' 4. After 4 days mix both bottles and shake vigorously 5. After 3 hours, filter. 6. Now add the glycerine and methyl alcohol to the filtrale and allow this to stand over night. mxraice 7. Filter this mixture again, catching the filtrate in a clear bottle. After standing in the light for six weeks It ripens and is ready for use. 3. WRIGHT'S STAIN. 1. Flood the smear with the stain for one minute A definite number of drops should be dropped on the slide by means of a medicine dropper. 47 2. Add the same number of drops of distilled water. (See that no fluid runs off by using proper amounts.) (It stains the eosinophilic granules beautifully.) 3. Wash in water for 30 seconds, or until the thinner portion of the film becomes yellow or pink. 4. Dry between filter paper; mount if desired and examine. Note. — for malarial parasites the decoloriza- tion should not be so long because it affects the chromatin. The formed elements are thusly colored: R. B. C orange or pink. Nuclei of W. B. C blue or dark lilac. Neutrophilic granules lilac. Eosinophilic granules red or pink. Fine basophilic granules deep blue. Large mast-cell granules. purple Protoplasm of lymphocytes robin's-egg blue. Bacteria blue. Malarial and other parasites blue. (The chromatin elements varying from lilac to ruby-red to black.) Polychromatophilia and granular degenera- tions. . . .: blue. PREPARATION OF WRIGHT'S STAIN. Place into a suitable flask 1 G. methylene blue (B. X. or "medicinally pure") for every 100 c.c. of 0.5% solution of sodium bicarbonate. Heat this mixture for 60 minutes in a steam sterilizer at 100° C. After heating, permit to cool. Filter a.nd remove tlie precipitate. To each 100 c.c. of the filtered mixture add 500 c.c. of a 0.1 '/o aqueous soltition of "yellowish, water-soluble" eosin and mix thoroughly. Collect the abundant precipitate (which appears im- mediately) on a filter. When this precipitate is dry dissolve in methyl alcohol (Merck's reagent) in the proportion of 0.1 G. to 60 c.c. of alcohol. This is the stain and should be kept well stoppered to prevent evaporation of the alcohol. HEMOGLOBIN. (Hb.) A complex proteid containing iron. It is the pigment which gives color to the blood. It forms loose combina- tions with oxygen and plays an important part in res- piration. AMOUNT. For every 100 c.c. blood we find on an average of 13.77 G. Hemoglobin (symbol Hb.). In man it is nearer to 14 G. In women it is nearer 13 G. Clinically 14 G. is regarded as lOC/V. The estimation of the percentage hemoglobin is ar- rived at by comparing the color of that patienfs blood to certain standard solutions of blood or standardized color charts or scales. The hemoglobinometers recom- mended are Pleischl-Miescher's, Sahli's, Gower's, Dare's, Oliver, Tallqvist's, etc. (The reader is now referred to page 38 for the dis- cussion of "color-index," and to Schmaltz's figures for percentage Hb. based upon specific gravity. P. 33.) HEMOGLOBINEMIA AND HEMOGLOBINURIA. Normally red cells are being constantly disintegrated but is very insignificant. Under certain conditions the destruction is so rapid and the blood pigment accumulates so rapidly in the blood (hemoglobinemia) that the liver is unable to convert it into bilirubin. With hemoglobinemia there must be hemoglobinuria (the pigment passes out through the urine). It may occur In the following conditions: 1. Poisoning. Phenol, chlorate of potash, pyrogallic acid, antimony, hydrochloric ,and sulphuric acids, coal-tar products, sulphonal, etc., either by hypodermic injec- tions or large doses internally. 2. Certain diseases. Scarlatina, typhoid, intermittent fever, icterus gravis, syphilis. 3. After transfusions of the blood of animals into man, and after severe burns and exposure to cold. 4. Anesthetics are also hemolytic poisons. Urine. The urine in hemoglobinuria is usually turbid. Varies in color from bright red to almost black. It must not be confounded with hematuria. Chemical tests cannot differentiate them. Micro- 49 / J scopically in hematuria we find the red blood cells. In hemoglobinuria the urine should be immediately centrifuged. Few or no red cells should be in the sediment, TESTS FOR HEMOGLOBIN AND DERIVATIVES. (A) HELLER'S TEST. 1. Add NaOH to a few c.c. of urine so as to make it strongly alkaline. 2. Heat. A brownish-red precipitate is thrown down. Color due to the presence of hematin. Precipitate consists of the phosphates and car- bonates of the alkaline earths. 3. In case the urine contains a large amount of foreign pigment, the red cells may not be easily noted. In that case, filter off the precipitate and redissolve it in acetic acid. In the presence of blood it becomes red but fades on standing in the air. Note. — This test will indicate one part oxy- hemoglobin in 4,000 urine. (B) DONOGANY'S TEST. 1. To 10 c.c. urine add 1 c.c. ammonium sulphide and 1 c.c, pyridin. In the presence of blood the urine becomes orange-colored, 2. Hemoglobin having thus been converted into hemochromogen we can recognize same by its characteristic absorption bands. (See page 94.) 3. This test shows one part blood to 8,000 of urine. 4. If the urine contains fresh blood, the spectrum will be that of oxyhemoglobin while in case of hemoglobinuria or of hematuria of renal origin, the spectrum is that of methemoglobin. (Web- ster,) 5. For the spectroscopic examination of urine it is necessary that the urine be acid, PAROXYSMAL HEMOGLOBI NEMIA. 1. Cause is unknown but usually follows catching cold. 2, Attack is paroxysmal and ushered in by persistent yawning, pain in limbs, headache, nausea and vomit and coolness of the periphery, 50 3. Temperature quickly rises to 102" and is associated with a severe chill. 4. Severe hepatic pains at times. 5. Splenomegaly very characteristic. 6. Slight jaundice towards end of the attack. 7. After 10 to 12 hours, the fever falls and is followed by sweating. 8. Urticarial eruptions frequently seen during attack. 9. Urine very characteristic. (During and directly after the paroxysms.) Color: varies from brownish-red color to black. Reaction: invariably acid. Specific gravity: usually low: 1008-1012. Boiling: will decompose the Hb. and a brown coagulum of albumen is formed. Spectroscopy: fresh urine shows Hb. spectrum and sometimes that of methemoglobin. Casts: usually present. (Hyaline and some con- taining hemoglobin granules.) NO RED BLOOD CELLS ARE FOUND IN THE URINE. 10. Blood during the paroxysm. Tendency to "coin-roil ' formation less marked. R. B. C. pale and often devoid of color. Poikilocytosis. If blood be withdrawn and allowed to clot, the serum which exudes will be red-tinted instead of straw colored as normally. HEMOLYSIS. DEFINITION. The dissolution of the red cells with the passing out of its hemoglobin into the plasma or other medium in which the R. B. C. are suspended. Hemolysis may be produced by certain physical agents: distilled water, freezing and thawing, tempera- ture of 55° C. for 30 minutes. It may also be brought about by certain chemical agents: most organic acids, mineral acids, all alkalies, bile salts, bichloride of mercury, etc. 51 Also by animal venoms: snakes, bees, spiders, etc. Hemolysis by serum. This is quite different from hemoly- sis caused by the above forces. The serum of one animal may be hemolytic to the red cells of another or several animals. Its action depends upon the presence of two substances in the serum: am- boceptor and complement, both being mutually dependent upon each other in the process by which the red cells are destroyed. IT FORMS THE BASIS OF THE SERUM DIAGNOSIS OF SYPHILIS. (See p. 71.) The red cells float in the plasma which has an os- motic pressure the same as that which exists within the red corpuscles. It is only when the osmotic pressure be- tween plasma and corpuscles are disturbed. that hemolysis can occur. If red cells are suspended in a normal physiological salt solution (0.9 7f NaCl) which is isotonic with that of the blood, hemolysis will not occur. COAGULATION OF THE BLOOD. NORMAL COAGULATION TIME. (HEMATOPEXIS.) Within 2 to 8 minutes after the blood leaves the blood vessel it clots or coagulates. After 9 minutes, it is called delayed coagulation. COAGULATION TIME IS DELAYED IN: Anemia. Scurvy, Hemoglobinemia, Jaundice, Hemophilia, Cobra bite. Anasarca, Asphyxia, Purpura, Toxemias, COAGULATION OCCURS QUICKER IN: Conditions associated with stasis. Repeated hemorrhages. Transfusions. Hunger. After using calcium chloride, coagulose. horse-serum, gelatin. TESTS FOR COAGULATION TIME: 1. Several drops of blood are allowed to fall on a clean slide. 52 At intervals of one minute a broom straw or white horse hair (which has previously been boiled in alcohol and ether) is drawn lightly through each drop until a thread of fibrin is seen clinging to the straw or hair. This is a rough method. 2. Rudolph's Method. (Reader referred elsewhere). This is more accurate. The normal coagulation time with this method is 8^/^ minutes. Intravascular clotting. Blood never clots within a normal blood vessel under normal circumstances. Intravascular clotting may be hastened by the in- troduction into the blood stream of foreign bodies or air which cause thrombi; or by injuring the endo- thelium of the arterial wall; by the injection of macerated lymph gland or horse serum, etc. Methods of preventing extravascular clotting: 1. Freezing, which destroys the enzymes. 2. Drawing blood into concentrated magnesium sulphate solution. It combines with calcium. 3. Sodium oxalate (0.1% sol.). Combines with calcium. 4. Sodium fluoride. 5. Drawing blood into an oiled vessel and stirring with an oiled rod. i PHYSIOLOGY AND CHEMISTRY OF CLOTTING. -r, ,, v.- , r thrombokinase Thrombin Prothrombin -|- J zymoplastic substances fibrin ferment Calcium salt-j- 1 (^ Thrombin -|-fibrinogen=fibrin (the clot). Explanation of these equations: Prothrombin. Is inactive. Exists in the blood as a pre- cursor of thrombin, just as inactive trypsinogen is a precursor of trypsin. Calcium salts. When absent clotting will not occur. It can readily be proven by adding ammonium oxalate to precipitate the calcium. /^' Thrombokinase. Derived from the tissues, the blood plates or the corpuscles and are the agency by which inactive prothromhir is converted into active throm- bin in the presence of calcium salts. Fibrinogen. A normal constituent of all blood plasma. This reacts with the newly formed thrombin and forms the clot which is called fibrin. Fibrin (Clot). The clot is a network of fibrin in the plasma. In the meshes of the clot many red cells are entangled. The network is oftentimes seen to radiate from the blood plates. When blood is first drawn into a vessel it be- comes transformed into a semi-solid gelatinous mass. Later, the clot shrinks and a straw-colored liquid (plasma) collects at the top. Plasma differs from serum in that it does not contain fibrinogen which was consumed during coagu- lation. 54 CHAPTER III. EXAMINATION OF THE BLOOD FOR BAC- TERIA AND PARASITES. TAKING BLOOD FROM A VEIN FOR CULTURE PURPOSES. 1. Ten c.c. of blood is withdrawn from the median basilic vein by means of a sterile Liier syringe. 2. Transfer this blood immediately to an Erlenmeyer flask containing 1.50 c.c. broth (either plain or 1% glucose) and shake. 3. Incubate for 36 hours at a temperature of 37' C. 4. Shake, remove 1.5 c.c. and place into a centrifuge. 5. After 20 minutes centrifuging, decant the supernatent liquid and with the sediment inoculate agar slants. TYPHOID FEVER. 1. The bacilli may be isolated from the blood even when a Widal reaction may not be positive. 2. Of the 10 c.c. blood taken for culture purposes, place 1 c.c. into each of 2 Erlenmeyer flasks containing 150 c.c. broth and into 2 more such flasks place 2 c.c. blood. We thus have 2 flasks with a dilution of 1:150 and 2 more with a dilution of 1:75. 3. Incubate for 24 to 36 hours. 4. Make a hanging drop examination for motile bacilli. If negative incubate for another 24 hours. 5. When the bouillon has become cloudy, make sub- cultures in milk and glucose bouillon and test again with an actively agglutinating serum. Another method. 1. Add blood to sterilized ox bile in proportion of 1 c.c. blood to 5 c.c. ox bile, 2. Incubate 12 to 15 hours at 37° C. 3. Transfer a few loop fulls to either the Drigalski-Con- radi or the Modified Endo Media. 4. The colonies which then develop are then subcultured and agglutination tests made. 55 With these media, positive agglutination tests are absolutely diagnostic of typhoid. No germs are found in the blood after the third week. Widal Reaction. (See p. 69.) PNEUMONIA. 1. The finding of the diplococcus of Fraenkel in the blood has more of a prognostic than diagnostic value. 2. Fraenkel claims that if 1 c.c. of the patient's blood be spread on agar plates and a luxuriant growth of colonies develop, we may infer that death from sepsis may occur or else metastasis to other organs may take place. 3. On the other hand, if the growth be small, and it be- comes necessary to take larger volumes of blood to demonstrate the presence of diplococci and to grow them in bouillon instead of agar, the prognosis is much better. 4. The organisms can be demonstrated as early as 12 hours after the initial congestive chill. 5. The rule is that the diplococci disappear after the crisis. 6. Instead of using agar, Rosenow uses blood agar. The diplococci, when grown on blood agar plates produce greenish hemolytic zones. This distinguishes the pneumococcus from the streptococcus pyogenes which causes hemolysis without pigment production. 7. Rosenow also has a special stain to bring out the cap- sule of the pneumococcus. ANTHRAX. 1. The bacilli are usually present in such large numbers that they may be found by simply making and stain- ing a blood smear. 2. The stain consists of: Concentrated sol. methylene blue 30 c.c. Potassium hydrate sol. (1:10,000) 100 c.c. 3. Stain with this for 5 or 10 minutes. 4. Wash in 0.5 9'c acetic acid sol. for 10 seconds. 5. Wash in alcohol and dry. In doubtful cases, a guinea-pig should be injected with some of the patient's blood, and if anthrax be present a luxuriant growth takes place in this animal. 56 GONORRHEAL INFECTIONS. 1. Neisser's organisms may be found in the blood in cases associated with gonorrheal involvement of the endo- cardium, joints, etc. SEPTICEMIA AND PYEMIA. 1. Streptococci may be found in the blood especially when the endocardium is involved. 2. These germs form typical chain-like growths. 3. In doubtful cases, one c.c. of venous blood should be injected intraperitoneally in a mouse. General septicemia will follow. PUERPERAL INFECTION. 1. Blood cultures will show streptococci and staphy- lococci. 2. "Doderlein's cultures" from the uterus should also be made. SCARLET FEVER. 1. Especially in severe and complicated cases strepto- cocci may be found in the blood. THE MALARIAL PARASITES. PLASMODIUM VI VAX is associated with the tertian form of intermittent fever in which the paroxysms occur every 48 hours. PLASMODIUM MALARI/E is associated with the quartan form of intermittent fever in which the paroxysms occur every 72 hours, PLASMODIUM FALCIPARUM is associated with estivo- autumnal fever. Duration of cycle segmentation varies from 24 to 72 hours. Note. — The parasites are recognizable in both the un- stained and in stained smears. For staining, the thionin, Nocht and Wright stains are preferred. The parasites are easily recognized in the unstained smears. TERTIAN PARASITE UNSTAINED. YOUNGEST (OR HYALINE) FORMS appear as Small (2 microns), colorless, non-pigmented disc. 57 This shows an undulating rim of protoplasm, which encloses a single large nuclear body. This body is surrounded by a ''milky zone." It is actively ameboid and changes its shape and position. WHEN 12 HOURS OLD. Ameboid motion very active so that pseudopodia may be seen which are very refractile. Pigment now appears in the parasite. They are light-brown granules with a rapid danc- ing motion. These granules seem to be especially gathered in the ends of the pseudopodia. Size: increases and also the R. B. C. WHEN 24 HOURS OLD. Size: fills about Vs of the R. B. C. Still actively ameboid. Pigment increased. Pigment is darker. Less actively motile. Scattered all over the parasite. AT 40 HOURS THE PARASITE IS FULLY DEVELOPED. Size: 8 to 10 microns. Shape: round. Less distinct than the red cell. Pigment: more abundant and evenly distributed. The R. B. C. at this stage. Is about IVz times its normal size. Its outline can hardly be recognized. PRESEGMENTAL STAGE. Pigment: collects in the form of irregular clumps, the granules moving in irregular lines. Outline: periphery of parasite slightly crenated and refractive dots appear on its border. R. B. C: disappears and the parasite becomes more dense and highly refractile. 58 SEGMENTAL STAGE. Striations: from the crenated border radial lines ap- pear in so-called "rosette" or "daisy-head" form. These radii are directed toward the center of the parasite and between these divisions we see highly refractile dots. The segments become more and more distinct. They finally separate into circular bodies hav- ing a central refractile dot. Pigment: irregularly scattered between these seg- ments. (Each segment is a hyaline form ready to attack another R, B. C.) Besides the above-described intracellular hyalines, 'we occasionally find extracellular forms of the tertian parasite. There are two varieties. (a) DEGENERATIVE FORMS. These are extruded intracellulars which have died. If it leaves the cell, the Hb. passes out of the cell, leaving a corpuscular shadow. But this does not always occur, so that we usually find "dumbbell-shaped" organisms in the plasma. During extrusion, the pigment is in active mo- tion but ceases as the parasite dies. Sometimes the parasite breaks up into frag- ments forming pigmented spherical bodies. Or, they may be deformed and vacuolated — they are then called ''sporulating forms." (b) GAMETOCYTES. Usually present in the blood a few days after the Infection sets in. There are 2 forms 1. Female or macrogamete. 2. Male or micrcgamete. 1. Female or macrogamete. Three or four times the size of a red cell. Pale, indistinct but actively ameboid. Abundant pigment. Some show no trace of the R. B. C. Nucleus is 31/2 microns and is sometimes seen in the fresh specimen. 59 It is recognized by the fact that it is the only portion of the parasite which is not in- maded by the pigment granules. The female is formed from a flagellum of the parent cells, the microgametocyte. The microgametocyte or parent cell is Smaller than its offspring (female) be- ing only 8 to 10 microns in diameter. Its pigment is at first active. It soon forms a circle around the center and becomes motionless. Sometimes it pushes out several flagella which are the microgametes. 2, Male or microgamete. Two or 3 times the size of a R. B. C. Often contains pigment granules. These flagella break away from the parent cell, the latter then appearing as a small cell with central motionless pigment. Flagellation does not occur in fresh speci- mens but occurs 15 to 20 minutes after the blood is drawn. QUARTAN PARASITE UNSTAINED. EARLY HYALINE FORMS cannot be differentiated from tertian but are easily recognized when pigment ap- pears. Pigment is coarser, darker in color, not so actively motile. AS THE PARASITE GROWS— Protoplasm: highly retractile. Pseudopodia: very distinct. Motility: less active. R. B. C. : become smaller; margins crenated. WHEN 24 HOURS OLD. Shape: round or oval and very distinct. Slightly ameboid. Pigment: blackish-brown. Peripheral location especially on one side. Not motile at this stage. (In the tertian the pigment is scattered all over.) R. B. C: very small, crenated, brassy in color. 60 AS IT CONTINUES TO GROW— It becomes rounder and motility ceases. Protoplasm very distinct and highly refractile Fills 1/3 to 1/2 of the R. B. C. DURING THE THIRD DAY. ^" ^brass ^""^^ ^ ^^^ '^ ^^"' ^^^ '^'^ '^ ^^""^ ^^*^ The parasite is full grown (7 microns). Pigment: travels from the periphery to the center in definite radial lines like the spokes of a whe^l the pigment granules forming the spokes. But the pigment soon collects in the center This is the presegmenter form. The parasite now becomes opaque and "rosette" de- marcations appear. There are 6 to 12 segments. These segments are more perfect than the tertian' they become detached as hyaline forms and are ready to attack red cells again. Gamete forms: Rarely seen here. Resemble the tertain but usually smaller. ESTIVO-AUTUMNAL PARASITE UNSTAINED. HYALINE FORMS. Resemble the other forms but slightly smaller pearance'mth''ltrer.""'" '° '°™ '""' ■■^'^'" *- ^P" ceUs'toSk.)™" "^' '"'■""^ '" "^^' " ^^"-^ «^« ^^a .in.i',' *^""""'' "'°™ '"" quartan by its smaller dimen- Those rings which do not show the signet-ring ap- pearance always present 2 nuclear bodies lying at opposite poles or close together. ^ opposite AS THE PARASITE DEVELOPS. Pigment: slight amount appears; usually motionless- located at periphery or at inner edge of the bi- concavity. Size: occupies 1/5 of cell. R. B. C: exceedingly shrunken, crenated and brassy even m the early stages. The infected R. B. C. 61 now disappear from the peripheral circulation and migrate to the lymph glands, especially the spleen, there to continue its development. Blood from a splenic puncture will show: Pigment: greatly increased, coarser and darker, thus greatly resembling the quartan. Size: parasite increased to 5 microns. When full grown its pigment is in the center. (Never diffuse as in the tertian.) (More peripherally located than in the quartan.) Rarely seen in peripheral circulation. Segmentation. Similar to other forms. Usually 15 very small segments. SEVENTH DAY OF THE DISEASE (in the peripheral blood). CRESCENTS AND OVOIDS APPEAR. CRESCENTS. Crescentic in shape with rounded ends. Slightly longer than a R. B. C. Very retractile. Pigment in center. Granules usually coarse and rod-shaped. The crescents frequently change their shape to oval, dumbbell, circular and then re- sume the original form. A small portion of the degenerated R. B. C. is attached to the crescent. OVOIDS Have no corpuscular remnant. Protoplasm not so refractile. TERTIAN PARASITE STAINED. YOUNG HYALINE FORMS of the parasite. Protoplasm: ring-shaped, stained blue. Achromatic area: a colorless "milky" area enclosed in the protoplasm. Nucleus: a reddish-violet punctate spot at the thin- nest portion of the ring which is shaped like a "signet-ring." Size: 2 to 3 microns. Location: in the center of a R. B. C. Non-pigmented. 62 A PARASITE 24 HOURS OLD. "Milky area" increases in size. Chromatin dot begins to break up into groups of nuclei. Pigment appears in the form of fine grains. R. B. C. grow larger and paler. MATURED OR FULL GROWN PARASITE. Chromatin: completely broken up and diffusely scat- tered over the R. B. C. in the form of strands or masses. These chromatin clumps divide into 15 to 20 dense round masses. Around these masses protoplasm begins to collect. In this stage, the protoplasm is devoid of color and it is always so in the segmenting cell. Each of these chromatin clumps has a milky zone. Pigment: greatly increased. Size: at 48 hours the parasite occupies almost the entire swollen R. B. C. Segmentation: occurs between 40 and 48 hours. Pigment: collects centrally "en masse." Protoplasm: divides in rosette or "daisy-head." Note. — Some full-grown tertian parasites do not divide into segments. These forms contain actively dancing pigment granules in the unstained specimen. (See p. 58. j QUARTAN PARASITE STAINED. Resembles tertian para- sites but Chromatin mass is indistinct in the hyaline forms and in the older forms appears as an irregular clump of granules. As it continues to grow, the parasite takes a form extending across the cell and occupies the major portion of the R. B. C. which has become shrunken and irregular in shape. SEGMENT FORMS are more distinct. (a) They show more regular and geometric lines of cleavage with the chromatin exactly in the center of the crenated surface. 63 (b) The pigment granules are coarser and much, more distinct and more peripherally located. Note. — Some full-grown parasites do not segment. ESTIVO-AUTUMNAL PARASITE STAINED. HYALINE FORMS. Chromatin: appears as 2 or more dots or filaments. Protoplasm: scantier than in the other forms. Thick- ening of the protoplasmic layer opposite the chromatin mass is very diagnostic. GAMETE FORMS. Are distinctly spherical, being of the same thickness all the way round. Nucleus forms a portion of the ring but does not pro- ject as in the asexual parasites. The R. B. C. in these sexual types do not show any coarse granu- lar stippling. CRESCENT FORMS. Very diagnostic of this form of malaria. (a) Male crescent. Chromatin: occupies the major portion of the cell. Appears as a loose net-work. Protoplasm: little and stains blue. Pigment: universallj^ scattered throughout its body. Shape : somewhat kidney-shaped and shorter and broader than the female, fb) Female crescent. Size: larger and narrower than male. Chromatin: compact and centrally located. Pigment: in a ring around the nucleus or in a clump at the center. Protoplasm: abundant and bluish in color. CIRCULAR FORMS. Two types are present: 1. Microgametocyte. Size: smaller than a R. B. C. Shape: distinctly spherical. Chromatin: in center in a large irregular mass or in several dense masses near the periphery. These masses containing chromatin are later extruded and form the flagella or mi- crogametes. 64 2. Macrogametocyte. Size: 2 or 3 times the former. Shape: often triangular. Protoplasm: abundant and blue-staining. Chromatin: in a single mass at the periphery and is surrounded by a circle of pigment. THE MALARIAL FEVERS. 1. For description of the parasites, see pages 57 to 64. 2. Enormous reduction in the number of R. B. C. occurs in acute attacks. A count of one million may be ob- tained on the first day. 3. In chronic cases we find features of a secondary anemia. Polychromatophilia and granular degeneration of the R. B. C. progress steadily. The estivo-autumnal parasite may create a blood picture closely resembling that of pernicious anemia. The quartan and estivo-autumnal parasites cause a shrinking of the R. B. C. and these cells assume a brassy tone. 4. Absence of leucocytosis. But, relative lymphocytosis just as in typhoid. 5. In the afebrile period and sometimes throughout the disease eosinophilia occurs. 6. Pigmented leucocytes very common. (Phagocytes.) RELAPSING FEVER. 1. In fresh blood, actively motile, cork-screw organisms are readily seen. 2. A dried smear stained with fuchsin or the aniline dyes depicts the Spirochetae of Obermeier plainly. 3. The spirilli can only be found during the febrile paroxysm. In the fresh specimen it is seen to move slowly among the R. B. C. but does not molest them. 4. With each successive paroxysm the spirilli increase in number. 65 5. A leucocytosis is very characteristic of this disease, especially just after the crisis. The disease is also called "Seven-day Fever." TRYPANOSOMIASIS. (SLEEPING SICKNESS.) 1. A nucleated, fusiform, flagellated parasite, the trypan- osoma Gambiense, having an undulating membrane may be seen in the blood but never within the cor- puscles. 2. The parasites vary greatly in number from day to day. 3. Best stained with the polychrome dyes. They show — (a) nucleus, which is large and red. (b) Centersome, intensely stained and located in a vacuole-like area near the blunt end. (c) Line of chromatin running down the edge of the undulating membrane and terminating in the flagellum. The chromatic line and flagellum are both stained red. (d) Protoplasm of the body is distinctly blue. 4. In genuine cases, the parasites should be found in the cerebro-spinal fluid. FILARIASIS. 1. The filaria sanguinis hominis (Bancrofti) are seen under the microscope in active motion. However, they lose their motility very quickly. 2. The embryo is surrounded by a sheath which is con- siderably larger than the parasite and shows fine cross striations. 3. They are about the thickness of a red cell and about l/90th of an inch long. 4. All examinations must be made at night, their num- bers gradually rising to a maximum about midnight. 5. Only the embryos are found in the blood; the adult forms remaining in the lymphatics where they ob- struct the flow of lymph and cause lymph-scrotum, hematochyluria, etc. 6. A thick blood smear is essential. 7. Eosinophilia is very characteristic. 66 SYPHILIS. 1. The spirochaete pallida can be demonstrated in both peripheral blood and in the blood from a splenic punc- ture and in certain skin lesions when a dark field il- luminator is used. 2. Best stained with Goldhorn's stain. Technic. 1. Fix smear with pure methyl alcohol for 1.5 minutes. 2. Flood with polychrome methylene blue 3 to seconds. 3. Drain the excess off. 4. Place slide slowly in clean water (film side down) and keep in this position 5 seconds. 5. Shake in water to remove excess of the dye. The spirochaete appear violet colored. 6. By staining with Gram's iodine solution for 15 to 20 seconds, washed and dried, and examined with oil-immersion lens, the organisms give up their violet color and become bluish-black. 3. Other good stains are: Giemsa's and Levaditi's. ROCKY MOUNTAIN SPOTTED FEVER. (Tick fever.) 1. The parasite, the piroplasma hominis attacks the red cells. 2. Three forms of this intracellular ovoid parasites occur. 3. Best stained with polychrome dyes. TEST FOR PUS IN THE BLOOD. (lODOPHILIC REACTION.) 1. A dried unfixed blood smear is first exposed to the vapors of solid iodine until it assumes a brownish color. 2. Then mount with this titration: Iodine 1 G. Potassium iodide 3 G. Dist. water 100 c.c. To which a sufficient amount of gum arable is added to make a syrup (a brownish, ropy fluid). 3. One drop of this titration is sufficient. The cover slip should be pressed tightly. 4. After 15 minutes examine with oil-immersion lens. 67 Positive reaction. Brown or mahogany colored granules within the poly- morphonuclear leucocytes. The protoplasm may also at times show a diffuse brown stain. Although the reaction is usually confined to the neu- trophiles, the mononuclear cells may also be tinged brown. This so-called intracellular reaction is more important than the extracellular reaction in the blood plates. Negative reaction. In the absence of pus, the protoplasm of the leucocytes are stained bright yellow and the nuclei are much lighter. BREMER'S BLOOD TEST IN DIABETES. 1. A thick fresh blood smear is fixed by dry heat and al- lowed to cool. 2. Then flood with a 1% aqueous solution of congo-red for a few minutes. 3. Wash in water. Normal blood: stains bright red. Diabetic blood: either refuses to stain or else takes on a faint yellowish or greenish hue. May be obtained before glycosuria becomes marked. A positive reaction may occur in other diseases, e. g., leukemia, goitre, Hodgkin's disease, etc., hence it is not a specific test. Note. — A 1% solution of Biebrich Scarlet will stain diabetic blood intensely, whereas normal blood does not take up the stain. In diabetes, the blood shows lipemia. Extracellular fat globules are seen. WILLIAMSON'S TEST IN DIABETES. 1. Dissolve 2 drops of blood in 4 drops of water. 2. Then add 1 c.c. of a 1:6,000 aqueous solution of methylene blue. 3. To this add 4 drops of a 6% solution of liquor potassae. 4. The test should be performed in a test tube. At this point place the test tube in boiling water for 4 minutes. Normal blood: color remains deep blue. Diabetic blood: decolorizes the solution. Diabetic urine: gives same reaction. Note. — Do not use more blood than what is stated above because decolorization will occur with larger quantities. 68 GRUBER-WIDAL REACTION IN TYPHOID. THE "HANGING-DROP" OR MICROSCOPIC METHOD. 1. With a special capillary pipette with a central bulbar enlargement, draw up 15 to 20 drops of blood from a pricked ear. 2. Lay the pipette fiat until coagulation occurs. The serum which exudes is preferable to whole blood. 3. Serum may also be obtained by using cantharides so as to cause a blister. 4. Dilute this serum with physiological salt solution (performing this on watch crystal) so as to make one dilution of 1:25 and another one of 1:50. (This means one drop of serum and 24 and 49 drops of salt solution.) 5. Take one platinum loop full of each dilution and mix with one loop of a standard suspension of typhoid germs. The dilutions are now 1:50 and 1:100. These typhoid suspensions must be fresh and the germs must be actively motile. Strains which have passed through several generations on artificial media are the best. 6. From the above last 2 dilutions, hanging-drop prep- arations should be made and examined. Reaction. With a dilution of 1:50, and within a period of one hour, a marked clumping together and complete loss of motility of these typhoid germs signifies a positive reaction. THE TIME and DILUTION ARE VERY IMPORTANT. MACROSCOPIC METHODS. Cultures which have been killed by heat, formalin, carbolic, etc., are employed. Clumps of bacilli settle to the bottom of the test tube leaving a clear supernatent liquid. Picker's Typhus Diagnostikum very good. It is sold by Merck & Co. BASS AND WATKIN'S MODIFICATION OF THE MACRO- SCOPIC METHOD. 1. Mix a full drop of blood serum with 4 drops water. 2. Add 4 drops of the following suspension to the above. (10,000 million killed typhoid germs per c.c. in 1.7% NaCl to which 1% formaline is added.) 3. Tilt slide from side to side so as to keep the mixture flowing back and forth. 69 Positive reaction. Grayish, mealy sediment within one minute. This sediment appears in the fluid and around the edges and tends to collect there. If the agitation he continued, the clumps increase in size for 2 or 3 minutes. Negative reaction. Absence of agglutination of the mix- ture. It remains clear. If the reaction fails to ap- pear within 2 or 3 minutes it will not appear at all. Advantage. Can be quickly performed at bedside. Reliability. BLOOD TESTS FOR SYPHILIS. 1. JUSTUS'S TEST. A rapid reduction in the percentage hemoglobin (10 to 20%) follows mercurial treatment (inunction or injection) in florid syphilitic patients. It lasts from a few hours to a few days. Objection. Mercury salts alone may cause an anemia in consequence of their hemolytic action upon the red blood cor- puscles. 2. SERUM COLOR REACTIONS. 1. To 0.1 c.c. serum add enough physiological salt solution to bring the quantity up to 3 or 4 c.c. 2. Then add 1 drop perhydrol (as an oxidizer). 3. Mix this with 0.5 c.c. of SchUrman's reagent (prepared fresh) : Carbolic acid 0.5 5% aqueous solution ferric chloride 0.62 Distilled water 34.5 Positive reaction. As the reagent is allowed to trickle down the test tube, a dark brown color will be ob- served at the junction of the fluids. On shaking, the mixture appears very thick. To be of value, the re- action must occur within 1 or 2 minutes. Normal blood serum. A slight green ring occurs at the junction of the liquids. But, it disappears almost en- tirely on shaking. The mixture also remains clear and transparent. Note. — Landau's serum color reaction is now in its experimental stage. Reports thus far do not affirm its specificity for syphilis. 70 3. WASSERMANN'S REACTION. 1. The Wassermann test or any of its modifications, when positive, is a specific test for lues. A negative reaction does not rule out syphilis. Repeated examinations are necessary. 2. The Noguchi modification is superior to the Wassermann test because the percentage of positive results is some- what higher. 3. Under vigorous mercurial treatment and with "696" a positive test once obtained may disappear, but it does not mean that the patient is cured. 4. All tests are based on the Bordet-Gengou phenomenon of complement fixation to determine the presence of the syphilitic antibody in the patient's blood serum. The tests are interpreted according to the degree of hemolysis visible in the test tubes. THE A-B-C OF THE SERUM DIAGNOSIS OF SYPHILIS. DEFINITION OF TERMS. HEMOLYSIS. Dissolution of the red blood corpuscles and the passing out of the red coloring matter (hemoglobinj into any medium in which the erythrocytes may be sus- pended. Hemolytic substances are those substances capable of producing hemolysis. (See page 51.) Fresh blood of many animals is hemolytic for the R. B. C. of some, but not all, other species. Hemolysis depends upon three factors: 1. Amboceptor. 2. Complement. 3. Corpuscles. Amboceptor cannot act without complement. Complement cannot act without amboceptor. Both combined must act on the R. B. C. 71 COMPLEMENT. 1, It is one of the factors necessary for hemolysis. 2. It is always present in fresh sera. 3. It is destroyed by heating for one-half hour at 55° C. Serum thus heated becomes inactivated. 4, If the serum be taken from a guinea-pig, it is called guinea-pig complement. Inactivation. Depriving fresh serum of its complement. Reactivation. 1. When fresh serum is added to an inactivated serum the latter again becomes activated. 2. Complement can always reactivate the serum of the same species from which it is derived. But, not every complement can activate the sera of other species. However, guinea-pig com- plement is characterized by its remarkable ability to reactivate sera of alien species. It is, there- fore, used whenever it becomes necessary to sub- stitute the complement of one serum for that of another which has become inactivated or has de- teriorated. AMBOCEPTOR OR HEMOLYSIN. 1. The serum of the blood of an animal which has been immunized with R. B. C. of another species gives us amboceptor. The injected animal develops in its serum anti-bodies. 2. It is one of the three factors necessary for the pro- duction of hemolysis. 3. It is stable; not being destroyed by heating as is the case with complement. 4. Amboceptors are specific. They can act upon the R. B. C. of one animal only. The prefix "anti" is usually added to the name of the species which has been used to bring about the immunization. 5. Some sera contain several kinds of amboceptors. Thus one particular serum may have amboceptors for sheep, for rabbits, for dogs, etc. 6. Natural amboceptors. Are those amboceptors already existing in the serum of a given animal. 72 7. Immune amboceptors. By repeatedly injecting an ani- mal with R. B. C. of another alien animal, we may create specific amboceptors for this animal, or, we may increase the amount of natural amboceptor al- ready present. When red blood cells are injected, the amboceptors created are also designated as hemolytic amboceptors for the purpose of contrasting to bacteriolytic ambo- ceptors which are produced when bacteria are in- jected into an animal. The dissolution of the bacteria (whereas in the other case it is the corpuscles) is known as bacteriolysis as compared to hemolysis. After immunization, the serum of the immunized animal gradually loses its hemolytic power, but may be rapidly increased by a few injections of the red cells first used in the process of immunization. ANTIGENS. 1. A general term applied to a group of substances cap- able of producing specific antibodies (w^hen injected into a suitable animal). Diphtheria toxin is an antigen because injections thereof are followed by the ap- pearance of a specific antitoxin in the horse. Red blood cells and bacteria may also act as antigens. 2. These antibodies are specific for the substances from whence they are derived. Given a known antibody we can determine the unknown antigen owing to this specificity. COMPLEMENT FIXATION. 1. A disappearance of the complement in a mixture of antigen and antibody. 2. A distinct. relation exists between the combination of antigen and antibody with that of complement. The R. B. C. (as antigen) acted upon by ambo- ceptor (antibody) becomes so altered as to absorb the comxplement and undergo hemolysis. In the same way, bacteria as antigen, having been acted upon by amboceptor (antibody), take up the complement and become dissolved. 3. Sera of various animals show marked differences in their power of complement fixation. 73 4. Whereas a given serum might possess the property of reactivating the hemolytic amboceptor of an in- activated serum, tliis same serum of tlie given species may possess little or no fixation property. This fact is very useful in diagnosis. Guinea-pig's complement is very readily fixed. Rabbit's complement possesses the best reactivat- ing property for the rabbit's amboceptor. 5. By means of the complement fixation reaction, antigen may be detected indirectly. Antigen may also be de- tected directly because of the specificity of antibody and antigen. 6. Five factors enter into the complement fixation reac- tion in the diagnosis of syphilis. i. Red blood cells. ii. Hemolytic amboceptor. iii. Complement. These three are collectively designated as the ''hemolytic system." iv. Syphilitic antigen or extract of syphilitic liver. Whereas the R. B. C. are also antigens, we do not refer to these antigens vv^hen the term antigen is used, but to syphilitic antigen. V. Antibody. Whereas hemolytic amboceptor is also an antibody, antigen as used in the test, refers to antibody present or absent in the serum under investigation for syphilis. ANThCOMPLEMENTARY SUBSTANCES AND ANTI-COM- PLEMENTARY ACTION. Substances possessing the power of reducing or totally removing the action of the complement are designated as anti-complementary. Most acids, alkalies and certain salts have such action. Such substances may also be present in certain sera. Human serum gradually acquires this property on stand- ing. Repeated injections of fresh serum into an animal of another species causes the production of such sub- stances. (Ehrlich and Morgenroth). Bacterial infection may cause the serum to become anti-complementary but it is said that heating to 56° C. for 30 minutes rids the serum of this difficulty. 74 BASIS OF THE WASSERMANN REACTION AND ITS MODI- FICATIONS. The complement, which is essential for the production of hemolysis (dissolution of the red cells) is fixed so that it cannot take part in this process. The result is that no hemolysis can take place. Inhibition of hemolysis is not necessarily complete. Our conclusions are based upon the degree or extent of the inhibition of hemolysis. The results are expressed in percentages or by a variable number of plus ( + ) signs. 1. The Original Wassermann Test. 1. ANTIGEN. A watery extract is used in the original test. (a) The liver or spleen of a congenitally syphilitic fetus is cut up into small pieces and minced in a meat grinder. (b) For every part of tissue add 4 parts normal salt solution to which carbolic acid is added in the proportion of O.o7c. (c) Shake the mixture well in a dark bottle for 24 hours by means of a shaking machine. (d) Centrifuge. The brownish opalescent super- natent liquid is antigen. It must be preserved m a rubber-stoppered brown bottle in a refrip-- erator, ^ On standing, a precipitate sediments. This should neither be used nor disturbed. When in need of antigen, decant the required amount of antigen and replace balance in refrigerator. Do not expose to light. (e) Titration of antigen. Use 0.8, 0.6, 0.4 and 0.2 c.c. of the extract m the presence of 1 c.c. complement, twice the hemolytic dose of the amboceptor and 1 c.c. of 5% sheep's corpuscles for its anti-complementary properties, and in the same quantities plus 1 c.c. of 5% sheep's cells for its hemolytic qualities. If the antigen be not hemolytic in 0.4 and not anti-complementary in 0.4 according to the rule of Weil and Nakayama, this antigen will be employed in one-half of 0.4 c.c. (equals 0.2 c.c). 75 2. PATIENT'S SERUM. Blood is obtained from a vein. It is permitted to clot and the serum is collected. Serum is inactivated by heating to 56° C. for 30 minutes. Inactivation must be performed within 12 hours. The native complement is thus destroyed. If cerebro-spinal fluid be employed, do not in- activate. The test doses are 0,1 and 0,2 c,c. 3. COMPLEMENT. One c,c, of guinea-pig's serum in 1:10 dilution. It must not be older than 12 hours, 4. AMBOCEPTOR. Rabbits are immunized against sheep's R, B, C, by intraperitoneal injections. One unit of ambocep- tor should be determined by titrating against 1 c.c. of 5% suspension of washed R. B. C, of sheep, using 0,5 c,c, of the above diluted complement. In the actual test use 2 units. 5. CORPUSCLE SUSPENSION. One c.c. of a 5% suspension of washed sheep's corpuscles. Should be kept on ice and not older than 24 hours. Sheep blood is drawn into a sterile wide-mouthed bottle, in which are a number of glass beads, and vigorously shaken immediately so as to defibrinate the blood and prevent clotting. 76 Q o H 5 1^ ^ ? > > > •^ '^ 2 o 2 2^ s^^"^ S =3 o o MW ^^ O O O c aj J-, ~ +:3 +i 4J +J ■C'S+i O O G C '/) x r. v. '/:■ 7j i* C/ O O c o c, a o o WrJH - p ^ j: o c c c c 5 X 'T. X X X X x :,o^--w ^-w--xx ^ W ^ .^ ^ .^ V ,zz .iqgiu J9AO 9J8m (3985^ puB JojBjaSupj oj saqnj 8aoui8j uaqx s;u8juoo 9q!^ xii\; Avou SI gqnj qo^a ;o auinioA aqx ^ c ■Koix.nra oooi-t (ooos^T ajrxix) aox -IXN V aKllKR I ■sa^T:osncra:oo SijaaHS aaHSTAi q4T.vi -0 g 6; dn iqSnojq avou st aqnqi qoBa jo'auinxoA aqx "xoixinia OPT iii I XKc^rKaxa^d[ -KOD ow-YaKmt) ■aaATT 1 Y K a o K a o xoYHXxa AaaxYAv -TXKY SY) aaAii orxniHJAS 5o xoYHxxa AaaxYAv oo ^^ X Si Eh = w 5 w > S? HJ2 Hi; EhS Phqq; rH C] ,-f Tt< -O rTwo Ml— l?D O lO £ c a; ij c ci c ^I^M^-M-^-^w CCCOOOC CC^iOO Ph X .T' ^ ^ ^' ^ '"^ ^1 Z 7 ^ '^ '-'^ '-S t^ X C C -H ■M rc-f LC i-( 1— I 1-1 -'^ ,_H ,-( ,H r- 1— I rl fM ■M 'M ^^1 ^J C^^ I-l V. O <^1 sqoaxKoo 77 WASSERMANN TEST WITH SIX TUBES. 1. Arrange 6 tubes in pairs as shown under the discus- sion of the Noguchi modification on page 83. 2. In No. 1 and No. 2, place 0.2 c.c. of the Inactivated serum of a known syphilitic. 3. In No. 3 and No. 4, place 0.2 c.c. of the inactivated serum from the patient in question. 4. In No. 5 and No. 6, place 0.2 c.c. of the inactivated serum of a known normal person. 5. To all of the tubes add 0.1 c.c. of fresh guinea-pig complement. 6. To the tubes in the front row (Nos. 1, 3 and 5), add one unit antigen. 7. To all of the tubes add 3 c.c. normal salt solution. 8. Shake all tubes vigorously. 9. Incubate at 37° C. for one hour and then remove. 10. To all of the tubes add 2 units of amboceptor and 1 c.c. of the suspension of sheep's red blood cor- puscles. 11. Incubate 2 hours. 12. Remove and then place on ice 20 hours. REACTION. Hemolysis should be complete in the rear row of tubes and in the tube No. 5 in the front row containing normal serum. Complete inhibition in No. 1. No. 3, containing the patient's serum, will show in- hibition of hemolysis of various intensities if the patient be infected with syphilis. DEDUCTIONS FROM THE WASSERMANN TEST. Note. — The syphilitic antibody present in the pa- tient's serum may vary in amount, hence the comple- ment may be fixed to a variable degree. When com- plement is fixed, it can no longer act in conjunction with amboceptor in that process known as hemolysis. In other words, hemolysis in inhibited in varying degrees depending upon the amount of syphilitic anti- body present. (a) If complete inhibition of hemolysis be present in the tube containing 0.1 c.c. serum and 0.1 c.c. antigen, the result is expressed by Citron thus: + + + + . 78 (b) If not complete in the tube containing 0.1 c.c. but complete in the tube containing 0.2 c.c, the result is expressed thus: + + + . The results in (a) and (b) are called STRONGLY POSITIVE. (c) If hemolysis be complete in tube containing 0.1 c.c. serum while that containing 0.2 c.c. shows complete inhibition, the result is expressed thus- + +. (d) Incomplete inhibition in the tube containing 2 c.c. is expressed thus: +. The results in (c) and (dj are called WEAKLY POSITIVE. (e) When inhibition in the tube containing 0.2 c.c. is doubtful, the result is expressed thus: ±. 2. Noguchi Modification. It has been found that human serum contains a variable amount of natural sheep amboceptor. For this reason, Noguchi employs an anti-human hemolytic system to replace the anti- sheep hemolytic system of the original Wassermann. Five factors enter into the Noguchi modification (as in all others) : — ^ 1. ANTI-HUMAN HEMOLYTIC AMBOCEPTOR. Rabbits are immunized with human R. B. C. Preparation. Rabbits are injected (intraperitoneally) with in- creasing doses of washed human R. B. C. allowing 5 days to elapse between each injection. 1st injection 5 c.c. washed human R. B. C. 2nd injection 8 c.c. washed human R. B. C. 3rd injection 12 c.c. washed human R. B. C. 4th injection 15 c.c. washed human R. B. C. 5th injection 20 c.c. washed human R. B. C. The serum is collected from the immunized ani- mal 9 or 10 days after the last injection by bleeding the rabbit (from carotid artery). [The corpuscles must be washed at least 3 times with large amount of saline solution (0.9%).] 79 Having collected the blood, allow same to stand at room temperature for several hours during which time coagulation occurs. If the clot does not con- tract within 4 or 5 hours and remains adherent to the sides of the tube, insert a platinum needle (sterile) between the clot and the walls of the tube and detach the clot. Allow this to remain 4 or 5 hours again at room temperature. Now place in refrigerator for 24 hours. Cen- trifuge. Decant supernatent serum. For about 3 days after, some more serum will exude and this can be also utilized. These daily sera may be mixed to- gether. If the serum be not clear, it may be clarified by centrifugalization or by permitting the tube to stand — when sedimentation occurs and then decanting. Amboceptor must be titrated. The titre of the serum is expressed by the smallest amount of serum which is found to be necessary for complete dissolu- tion of a fixed amount of red blood corpuscles and a fixed amount of complement. A good preparation will have the value of one unit in something less than 0.001 c.c. of serum, that is, 0.001 of serum or less, will cause complete hemo- lysis of 1 c.c. of a 1% suspension of human R. B. C. when combined with 0.02 c.c. of guinea-pig's fresh serum (0.1 c.c. of 209o dilution). 2. PATIENT'S SERUM TO BE TESTED. With a Hagedorn needle puncture the skin over the last joint of the middle finger (ventral aspect). Collect the exuding drops in a Wright's blood capsule through the curved end of same. Seal the straight capillary end by a flame and shake the blood down into this end after the capsule has cooled. Then seal the other end. The blood clots in the capsule and serum exudes. When ready for the test break the capsule. 3. HUMAN CORPUSCLE SUSPENSION. Into a 10 c.c. graduated centrifuge tube place 9 c.c, of the following citrate solution. 80 Sodium citrate 20 G Normal salt sol. (O.dVo) .".1000 c.c. Permit the blood of a normal person to drop into this mixture until the volume in the tube registers 10 c.c. Mix well and centrifuge. Pour off the supernatent liquid and fill tube again with salt solution. Mix again, centrifuge, and again decant super- natent fluid leaving a deposit containing corpuscles freed from serum. Now resuspend the corpuscles in salt solution To make a 1% suspension, add 100 c.c. salt solution To make a 10% suspension, add 10 c.c. salt solution! We may use these standard suspensions in the proportion of 1 c.c. of the 1% solution or 1 c c of the 10% solution. The latter one is preferred. 4. GUINEA-PIG'S SERUM AS COMPLEMENT. Bleed the normal guinea-pig at the carotid artery allowing blood to flow into large Petri dish. Cover dish and allow to stand at room tempera- ture for a few hours when coagulation will have oc- curred and serum exuded. To complete the separation of the serum, the dish may be placed in a refrigerator. After 5 to 10 hours decant the serum into a test tube and keep in a refrigerator when not in use. Since complement deteriorates in 24 hours, blood may be aspirated directly from the guinea-pig's heart. The dilution used is 40%. One c.c. of comple- ment is mixed with 11/2 c.c. of physiological salt solution. (The guinea-pig will stand the loss of 5 to 10 c.c. blood but don't puncture again until after 28 days have elapsed.) 5. ANTIGEN. (Preparation.) Extract a mashed paste of liver, heart or kidney of man, ox, guinea-pig, rabbit or dog with Ten parts absolute alcohol at 37" C. for several days. Filter through filter paper and collect the filtrate. Allow the filtrate to evaporate to dryness with the assistance of an electric fan. 81 Take up the dried residue with ether and permit the turbid solution to stand in a covered dish in a cool place over night. In the morning, the turbidity will have disappeared. Decant the clear etherial solution into a clean beaker and concentrate by evaporating most of the ether. Mix this concentrated solution with 10 volumes of pure acetone. Allow precipitate to settle and decant supernatent fluid. This antigen is a slightly brownish precipitate which gradually becomes sticky on exposure to air. This acetone-insoluble portion of the tissue extract containing antigenic lipoids must be examined for its quality and strength and more especially with re- gard to its hemolytic and anti-complementary actions. By anti-complementary action, we mean a diminu- tion or a destruction of the activity of the complement. To make a stock solution: 3/10 G. of this acetone-insoluble fraction is dissolved in 1 c.c. ether and mixed with 9 .c.c. methyl alcohol. If any precipitate forms or is left undissolved, remove by centrifugation. The stock solution contains 3% of lipoids from which an emulsion can be made when ready for it. The emulsion is made by mixing 1 c.c. of the stock solution with 9 c.c. physiological salt solution. This produces a clear opalescent solution con- taining 0.3% of the original lipoids. We only use 1/10 c.c. of this emulsion in the test. The antigenic property of the extract must be determined, that is, its power of production of complement fixation in the presence of syph- ilitic serum. 1. Test for hemolytic action of antigen. Antigen emulsion 0.4 c.c. Salt solution 0.6 c.c. 10% corpuscle suspension 0.1 c.c. Incubate at 37° C. for 2 hours. 82 2. Test for anti-complementary action of antigen. Antigen emulsion 0.4 c.c. Salt solution 0.6 c.c, 40% complement o.l c.c. Amboceptor 2 units Incubate at 37" C. for 1 hour. Corpuscle suspension 10% 0.1 c.c. Incubate at 37'' C. for 2 hours. 3. Test for antigenic property. Antigen emulsion (1 : 10) 0.2 c.c. Salt solution 0.8 Syphilitic serum 0.02 (1 drop from a capillary pipette) 40 % complement 0.1 Amboceptor 2 units Incubate at 37° C. for 1 hour. 10% corpuscle suspension 0.1 c.c. Incubate at 37° C. for 2 hours. Noguchi claims that at least 4 antigen doses must be used. To obtain this he recommends the use of a 0.1 c.c. of a 0.3% suspension of acetone-insoluble tissue lipoids. In this quantity there will be at least 5 antigen doses (0.1 c.c. ^0.02 c.c. =5). TECHNIC (of the Noguchi modification). Arrange 6 test-tubes in pairs as shown in the il- lustration. z 4 6 3 Into No. 1 and No. 2 place one drop (0.2 c.c.) (from a capillary pipette)' of the patient's serum to be tested. Into No. 3 and No. 4 (which are to serve as positive controls) place one drop of the serum of a per- son known to be syphilitic or who have given a posi- tive reaction. Into No. 5 and No. 6 place one drop of the serum of a normal individ- ual. These are called neg- ative controls. 83 To each of the 6 tubes add 1 c.c. of the suspension of washed human corpuscles and 0.04 c.c. fresh guinea- pig serum as complement. To tubes 1, 3 and 5, add one drop of the antigen solution. Shake all tubes vigorously and incubate for 1 hour at a temperature of 37° C. Then add 2 units of anti-human amboceptor to each of the six tubes and shake well. Incubate all the tubes at 37° C. for 1 hour more. Remove 'from incubator and permit to stand at room, temperature for the next 10 or 12 hours during which time the reaction may be watched as it progresses and read. Deductions. The 3 even-numbered tubes should show complete hemolysis. The color should be uniformly red but no corpuscular sediment. Tube No. 5 should show complete hemolysis be- fore the final reading is made. Tube No. 3 will be clear. Tube No. 1: if it resembles No. 3, reaction is positive; if it resembles Nos. 2, 4 or 6, reaction is negative. 3. Method of Cyrus W. Field. He employs cholesterinized antigen. The velocity of the test seems to be increased thereby. Each c.c. of the diluted antigen contains 0.1 mg. of the combined lipoids and choles- terin. It is easily prepared and is rarely, if ever, anti-com- plementary or hemolytic as are the Wassermann and Noguchi antigens. The essential point in this method is the standard- ization of antigen, which means that irrespective where the test is made, whether in New York, San Francisco or New Orleans, the results will always be the same. Antigen. Alcoholic extract of a large number of guinea-pig's hearts with one-half saturation with cholesterin. 20 c.c. of this cholesterinized extract is evaporated and dessicated and the residue weighed. The extract is then used in such dilution that 1 c.c. thereof represents 1 mgm. of the cholesterin lipoids. 84 CORRECTION. Transpose line 9 which reads "Add the antigen, comple- ment (v/hich is usually 0.5" immediately before line 14.^ It will then read: — Add the antigen, complement (which is usually u.5 c.c. of a 1:8 dilution) to the serum and incubate for 40 to 50 minutes at 37° C. SB«^w:_ Anti-sheep hemolytic amboceptor. Complement in the dilution of 3:8. At least 2 units of am- boceptor and 21/^ units of complement should be used. Technic: Racks holding 8 tubes are set up. Label consecutively from 1 to 8. Into each of 7 tubes place 0.1 c.c. of the patient's serum. Add the antigen, complement (which is usually 0.5 Into the 8th tube place twice that amount (0.2). (Tubes No. 1 and No. 8 are used as controls.) To the other 6 tubes add antigen in the following amounts: (expressed in c.c.) 1, 0.8, 0.6, 0.4, 0.2 and 0.09. c.c. of a 1:8 dilution) to the serum and incubate for 40 to 50 minutes at 37' C. Mix the amboceptor and the suspension of R. B. C. in their proper proportions and add sufficient salt solu- tion so that each c.c. of the mixture represents at least 2 units of amboceptor and 0.5 c.c. erythrocytes. The mixture is incubated at least 30 minutes before being mixed with the serum-antigen-complement mixture. The results are read off as soon as the 2 control tubes show complete hemolysis and labeled according to the following scheme: 0. Represents complete hemolysis, while 1. Slight inhibition of hemolysis, w^hile 2. Marked inhibition of hemolysis, while 3. Complete inhibition of hemolysis. SERO-DIAGNOSIS OF PREGNANCY. Abderhalden's Test. The DIALYZATION METHOD is preferred to the Optic Method. The basis of the test consists in the conversion of colloidal non-dialyzable placental proteid into dialyzable products through the activity of certain ferments. These products may then be detected by simple color reactions in the dialysate. 85 THINGS NECESSARY FOR THE TEST. 1. Fresh coagulated placental proteid (albumin). 2. Blood. Ten c.c. venous blood from suspected female is centrifuged. Serum is drawn off into a clean sterile tube. Note.^ — Since the amino acids which form during digestion may give a positive reaction with triketohy- drinden hydrate, all blood specimens should be taken before breakfast. 3. DIalyzing tubes. The dialyzing thimbles must be per- meable for peptones but not for albumin. TECHNIC. 1. Into each of 3 thimbles place 1 G. of coagulated pla- cental proteid (albumin) which has been washed in distilled water, dried between filter paper and ground up in a mortar. 2. To thimble No. 1, add 2 or 3 c.c. of hemoglobin-free serum to be tested. Overlay this mixture with toluol. 3. Place thimble, et al., in a sterile dialyzing tube con- taining 20 c.c. distilled water which should stand slightly higher than the fluid in the thimble. 4. Overlay the external fluids with toluol and plug the dialyzing vessel with cotton to hold in place the thread which suspends the shell. 5. Incubate at 37° C. for 18 hours. Then test the dialy- sate for peptone. 6. Thimbles number 2 and 3 are controls. In Thimble No. 2. Place 1 G placental albumin and 2 c.c. of a serum of a known positive control. Overlay with toluol and proceed as above. In Thimble No. 3. Place 1 G placental peptone and 2 c.c. of a known negative serum or with the in- activated (heated to 60° C.) serum used in the test. Serum control. A thimble containing only 2 c.c. serum. TESTS FOR THE "CLEAVAGE PRODUCTS" OF ALBUMIN. (A) Biuret test. (B) Ninhydrin or Triketohydrinden Hydrate reaction. This is preferred to the Biuret test. 86 NINHYDRIN REACTION. 1. Remove 10 c.c. of the dialysate by means of a pipette dipping below the toluol and place this in a large test tube. 2. Add 0.2 c.c. of a watery solution of ninhydrin (1%). 3. Heat rapidly to boiling point and keep boiling 1 minute. Positive reaction. A deep blue color appears imme- diately or after standing a short time. Negative reaction. Either no coloration at all or perhaps a slight yellow. Time of appearance. Reac- tion may be obtained in middle of the second month. Reaction disappears in from 10 to 15 days after delivery. BIURET TEST. 1. Remove 10 c.c. of the dialysate as in other method. 2. Add 5 c.c. of 33% sodium hydroxide solution and mix. 3. Titrate from a biuret with 0.25% copper solution drop by drop in such a manner as to form a "contact ring." Positive reaction. Peptone yields a violet red to a pure red contact ring sharply differentiated from the lower colorless and upper blue solutions. Negative reaction. bluish ring. Distinct 87 CHAPTER IV. FORENSIC MEDICINE. Tests for Blood. INTRODUCTION. In medico-legal cases, no tests for blood should be performed until the following points have been noted: 1. The exact time and exact part of the clothing or other object from which the specimen was taken. 2. If the blood is to be scraped from an instrument, de- scribe fully. 3. Note shape and size and direction of all stains. (The small part of the spatter points to the opposite direc- tion of the hemorrhage. 4. Specimens sent to you must have been properly sealed; the sender's name recorded; date and time of delivery noted, and seal must be unbroken. 5. Examine only a small portion of the specimen. Keep the remainder for corroborative evidence. SPECIAL REMARKS. 1. Before giving an opinion, it is well to remember that blood cannot always be differentiated with absolute certainty from blood from other sources. 2. Blood appearing on one's person may be there acci- dentally by reason of one's occupation, e. g., butchers. Or, in women, menstrual blood must be considered. 3. Time not only alters the appearance of blood, but also influences the tests for blood. 4. Blood stains upon a knife or other metal must be dis- tinguished from rust or lemon stains. All weapons should be examined immediately, 5. Blood stiffens all fabrics. Under a hand microscope, blood stains on linen give a dark crimson reflection, are glossy, smooth or reddish brown. 6. The action of various substances such as mortar, brick, lime, strong acids or alkalies, leather, chemicals in wall paper, starched clothing, etc., may so change the blood or impair its reactivity to certain tests so that no definite conclusions can be drawn. 88 1. Finding Red Cells in Dissolved Stains. (Is the Surest Proof of Blood.) COMPARATIVELY RECENT STAINS, Are soluble In cold water. The R. B. C. are, however, somewhat deformed but present the morphological characteristics described on p. 34. Mammalian R. B. C. with few exceptions are circular and non-nucleated. Oviparse are ovoid in shape and show a central ag- gregation of granules resembling a nucleus. Mammalian corpuscles are the smallest of all ex- cepting the musk-deer (1/12,000 of an inch). The corpuscles of reptiles are the largest. The central granules above described can be made more distinct by adding acetic acid. The corpuscles are small in elephants, pigeons and toads. When a stain is dissolved in water, the color of the solution is found to vary with the age of the stain. A very recent stain produces a bright red solution owing to the passing out of the Hb. from the R. B. C. into the water (hemolysis). OLDER STAINS. Hemoglobin is less soluble and methemoglobin is the result. EXCEEDINGLY OLD STAINS. Insoluble in water; soluble in dilute citric acid and in ammonia water. A clot can be disintegrated by dissolving its albumin with a 33 7o solution of KOH or a 50 Sc glycerine solution. The best examining fluid is Marx's fluid. It stains the R. B. C. red. It consists of: Quinine hydrochlorate (1:1,000 sol.) 10 c.c. Potassium hydrate (339c sol.) -. 10 c.c. Eosin, q. s, to tint. 2. Julius von Kossa's Test. 1. Take 10 c.c. of the watery solution to be tested. 2. Add 10 c.c. of 907c alcohol and 5 c.c. chloroform. 3. Mix gently but DO NOT SHAKE. 89 Positive reaction. The hemoglobin is dissolved and appears on top of the layer of chloroform as tiny red droplets. For urine. Use 10 c.c. urine, 10 c.c. distilled water, 5 c.c. alcohol, 5 c.c. chloroform and mix gently. 3. Van Deen's Guaiac Test. 1. To any volume of the watery solution to be tested add an equal volume of freshly prepared guaiacum resin in al- cohol. 2. By floating either (a) peroxide of hydrogen, (b) ozonized oil of turpentine, or (c) oil of eucalyptus a blue sapphire color is immediately formed at the point of contact and on shaking the color will spread throughout the mixture. 3. If the stain be very old, apply the chemicals direct on the fabric and immediately place a piece of filter paper on the spot and the latter will turn blue. Note. — The blue color must occur after the peroxide is added. It is a good confirmatory test. Test may not be obtained after stain is 2i/^ years old. It is more reliable in its negative phase than when positive because many other substances give a positive reaction. They are: Potassium permanganate. Peroxide of lead. Peroxide of manganese. The halogen group. Nitric and chromic acids. Ferric chloride, Copper salts. Potassium ferro- and ferri- cyanide. Gum acacia. Gluten. Unboiled milk. Raw potato pulp. Pus. Any living cell or its intra- cellular enzymes. 4. Schaer's Test. Teclinic. Similar to that of the guaiac test excepting that a 1 to 4% solution of aloin in alcohol is used instead of guaiac. Positive reaction. 1. When the tincture of aloin is added to the suspected solution a red color appears, quickly assuming a cherry-red appearance when ozonized oil of turpentine is added. 90 The pink color should develop within a short time. There are substances which produce this coloration in a few hours. Note. — The tincture should be freshly prepared because such color changes occur spontaneously of itself on standing. 5. Phenolphthalein Test. 1. To 1 part of the watery solution of blood to be tested add 2. Two parts of the following reagent prepared thus: (a) Mix 1 c.c. of N/10 NaOH with a few c.c. distilled water, with a slight excess of phenolphthalein. (b) Shake thoroughly and filter. (c) To the filtrate add: Sodium hydrate 20 c.c. Peroxide hydrogen (3'/o) 0.1 c.c. And make up to IQO c.c. Allow to stand a few minutes. Note. — Fresh solutions are devoid of any pink coloration but will be so in time. Positive reaction. A pink to a red color depending upon the amount of blood present. The test is so delicate that it will detect blocd even in the proportion of one part blood to eight million of water. Testing for blocd in the secretions and excretions. 1. Extracts of various animal tissues or various secre- tions of the body interfere with the test so that blood cannot be recognized in such great dilutions as when watery solutions are employed. 2. Boiling these solutions prior to the test removes most of the objections. Or, 3. If the secretions be treated with a thick cream of aluminium hydrate suspension, the precipitate will carry down the blood pigment and thus concentrate it. A small amount of this precipitate (whether de- rived from urine, feces suspension, exudates, etc.), will show a decided color when added to 2 c.c. of the reagent. 91 6. Teichmann's Hemin Crystals. 1. Place some dried blood on a slide and add a drop or two of glacial acetic acid. Cover with cover slip. 2. Two drops of common salt solution (2 grains to 8 ounces of water) are added in case the blood is very old. 3. Heat the slide gently so that the fluid steams but does not boil. As the acid evaporates, allow more to run under the cover slip. 4. After the slide cools mount in glycerine. Positive reaction. Dark brown rhombic plates and prisms appear. Star-shaped clusters with rounded angles are also quite common. The crystals cross each other so as to resemble the letter "X." The reaction may thus be expressed: Hemoglobin -(-acetic acid-j-NaCl=globin-|-HCl+hematin; Hematin-|-HCl=Hemin crystals (hydrochlorate of hema- tin). Note. — If blood be mixed with iron rust, the hematin test will be negative. 7. Spectroscopic Absorption Bands. Introduction. The various solutions of hemoglobin and its derivatives produce characteristic absorption bands which always occupy definite and constant positions with rela- tion to the Fraunhofer's lines. These lines are vertically placed and appear as dark slits. They are 8 in number and lettered from A to H. Recent stains. If on fabric, cut it in small strips and place into glass- stoppered vials (capacity of i/4-ounce, but only % full with distilled water). When the solution becomes red or reddish brown remove some of it by means of a capillary pipette and insert it into the cell chamber of Zeiss's Microspectro- scope and examine for absorption bands. It is to be especially noted that bands are only visible when the solutions are of a certain strength and certain depth (depth of 1 cm. and strength of 0.85 to 0.65%). 92 Oxyhemoglobin. In the above dilution and depth 2 bands are seen between the D and E positions. The alpha band nearest D being narrower but darker than the beta band nearest E. In weaker dilutions, the beta band disappears first. With greater concentration, the two bands become broader and the space between them narrower and the blue and violet ends of the spectrum disappear. By adding a particle of ferrous sulphate, a particle of Rochelle salt and a little ammonia, the two bands are reduced to one band. This is called reduced hemoglobin or Stoke's band (the ingredients given above forming Stoke's reagent. Hemoglobin, also called reduced hemoglobin, is more soluble than oxyhemoglobin. Its solutions are more violet or purplish than those of oxyhemoglobin of the same strength. Hemoglobin solutions absorb the blue and violet rays to a less extent than those of oxyhemoglobin but they strongly absorb the rays lying between the C and D lines. As before stated, with proper dilution, its spectrum is that of one broad band not clearly defined between D and E, lying towards the red end of the spectrum a little over the D line. Old stains. Oxyhemoglobin having been converted into hema- tin which is insoluble in water, it becomes necessary to add a few drops of acetic acid and the bottle must be per- mitted to stand in a warm place for several hours. Examine some of this solution for acid hematin bands. The bands can be reduced by Stoke's reagent. ACID HEMATIN shows 4 bands: 1. Between C and D. 2. 1 Another broad band not clearly defined between D 3. J and F, which, under certain conditions divides into 2 narrower bands. 4. A fourth band between D and E, which is nearer D and very weak. ALKALINE HEMATIN: One band between C and D which reaches out to some extent between D and E. 93 If this alkaline solution be reduced with, ammonium sulphide we obtain the spectrum of hemochromogen. HEMOCHROMOGEN. Shows 2 bands: 1. Is very sharp and dark betv\^een D and E, 2. Paler and broader band covering the E line. HEMATOPCRPHYRIN. Is isomeric with bilirubin and is formed when hema- tin is treated with concentrated sulphuric acid in the pres- ence of air. It loses its iron constituent. It is insoluble in water. In acid solution. Two bands. 1. A faint and narrow band between C and D but nearer D. 2. Another darker, sharper and broader band in the middle between D and E. In dilute alkaline solution. Four bands. 1. One band between C and D. 2. A broad band covering D but its broadest portion be- tween D and E. 3. Between D and E, nearly at E. 4. A fourth band, broad and dark between E and F. Importance. Medico-legally very important because certain old stains can be identified only by its spectrum. METHEMOGLOBIN. In watery or slightly acid solution. Its spectrum resembles that of acid hematin but with this difference: it easily is converted into hemoglobin by reduction with alkali. On the other hand, when acid hematin is reduced it is converted into hemochromogen. In alkaline solution. Its spectrum resembles that of oxyhemoglobin but with this difference: that the band nearest E is stronger than that at D. According to Hammersten a third band occurs between C and D. Significance. Occurs in cases of poisoning with: potas- sium permanganate, potassium ferricyanide, chlorates, nitrites, nitrobenzol, acetanilide, antipyrin, turpen- tine, sulphonal, arsenic and in cases of cyanosis with diarrhea. Hemorrhagic transudates and cystic fluids due to spontaneous decomposition of blood. 94 CARBON MONOXIDE HEMOGLOBIN. Two bands between the D and E lines but they are situated more to the left (violet end) of the spectrum. It cannot be reduced. It is found after coal gas or illuminating gas inhala- tion and may even be demonstrated for a short time after death. In severe but not fatal cases it may persist for sev- eral days. 8. The Precipitin Reaction. NOTE. — This test is used medico-legally for the detection of blood and blood serum, but in reality it is a specific test for blood proteid and not for blood. Other tests must prove the presence of blood. Soluble proteid may give this test at a period as late as 50 years. It is a very delicate test. BASIS. The serum of an animal injected with blood or blood serum of another animal, shows the property, when added to an homologous serum, of precipitating the albumin of this serum in the form of a light flocculent precipitate. Of course, human serum is used in medico-legal cases. TECHNIC. 1. Add a sufficient amount of NaCl to the dried blood to get it in solution. If the stain is upon clothing, cut the stain out, tease it and allow it to stand in salt solu- tion one hour, (Old stain 24 hours). 2. Filter these solutions twice. Once through hardened filter paper. Then through a small Berkefeld filter. 3. Add a sufficient amount of salt solution to make ap- proximately a 1:1,000 solution of the stain. This fil- trate must be clear and neutralized by adding some tartaric acid or sodium carbonate solutions. 4. Take 10 test tubes of equal size and thickness. Label them from 1 up to 10. Fill as follows: Tube No. 1. 1 c.c. of the above solution of the stain. Tube No, 2. 1 c.c. of the above solution of the stain. Tube No. 3. 1 c.c. of a 1:1,000 dilution of a known fresh human blood in normal salt solution. 95 Tube No. 4. 1 c.c. of a 1:1,000 dried human biood in 0.9% salt solution. Tube No. 5. 1 c.c, sterile salt solution. Tube No. 6.^ Tube No. 7. I 1 c.c. of 1:1,000 dilution of either fresh Tube No R ^ ^^ dried blood of such domestic ani- ■ I mals as chicken, dog, horse, sheep. Tube No. 9. J Tube No. 10. 1 c.c. of physiological salt extract of the matter upon which the stain was found. To every tube except No. 2, allow 0.1 c.c. anti- serum (see below) to trickle down from a graduated pipette along the side of the tubes. To tube No. 2, add 0.1 c.c. of normal clear rabbit serum. Positive reaction. Within 2 minutes, tubes 1, 3 and 4 which contain human blood become turbid. The others do not contain blood, hence are clear. (Contact-ring turbidity.) Preparation of Anti-Serum for the Precipitin Reaction. This is the serum of the animal immunized against the proteids of a particular species of animal. 1. Inject a rabbit intraperitoneally with 5 to 10 c.c. of whole blood or serum. 2. Repeat said injections at intervals of 3 to 5 days until 6 or 8 injections have been made. 3. Allow one week to elapse after the last injection. 4. Obtain a few drops of blood by puncturing rabbit's ear and allow same to clot in a small test-tube and the serum which exudes is then tested for its potency. (a) First make a 1:1,000 dilution of homologous blood in physiological salt (0.9% NaCl). Only 1 c.c. is necessary. Place in test tube. If the dilution has been properly made, a foamy layer forms on shaking and if 1 c.c. of this dilution is taken and to it 1 drop of a 25% nitric acid solution added a slight opalescence will occur. (b) Add the anti-serum to the above dilution. If a turbidity appears within 1 to 2 minutes the serum is sufficiently potent for the test. 5. Bleed the animal. (Either partially or total exsan- guination.) 96 (a) Collect blood in wide-mouthed test tubes and plug with cotton. Allow to coagulate like agar slants. (b) Remove the exuded serum (which must be clear), place in test tubes, plug with cotton, seal with paraffin, store in refrigerator. This is the anti- serum. DIFFERENTIATION OF BLOOD FROM IRON RUST. Take some of the rust on the knife and place in a porcelain capsule containing HCl and heat gently. If iron be present, the solution becomes yellow. To potassium ferrocyanide add 1 drop of the yellow solution and the color turns blue. To potassium sulphocyanide, add a drop of this yel- low solution and a deep red color is the result. DIFFERENTIATION OF BLOOD FROM RED PAINT. The pigments in red paint are usually iron oxide and lead oxide. Dried paint is insoluble in water but soluble in strong alkali solution or oil of turpentine. Take some of this solution and allow to evaporate upon a watch glass. Test for iron as previously described. Lead is recognized by its vermilion color. CHEMICAL TESTS for lead are: 1. The addition of potassium bichromate to any solu- tion containing lead causes the precipitation of a yellow amorphous deposit, soluble in potassium hydroxide and strong HCl, but insoluble in acetic acid. 2. Hydrogen sulphide passed through lead solutions results in the precipitation of black lead sulphide. 97 CHAPTER V. OPSONINS. DEFINITION. Opsonins are certain substances probably belonging to the class of globulins, present in the blood serum which render the various forms of bacteria which invade the body subject to phagocytosis. Phagocytosis signifies the power leucocytes have of incorporating in their bodies and destroying and di- gesting pathogenic bacteria. The leucocytes, therefore, play an important part in immunity. Opsonins may be increased artificially by injecting certain bacterial vaccines. Vaccines are suspensions in physiological salt solu- tion of killed pathogenic bacteria. Vaccines produce an active immunity; that is to say, the patient himself is stimulated to produce his own antibodies. Sera differ from vaccines in that serum already contains the antibodies formed in the body cells of the horse or other animal and are simply supplied to the patient. Thus, passive immunity is established. Sera begin to act shortly after injection w^hile it takes a few days before vaccines begin to act. But, the immunity established by the use of vaccines lasts longer than in the other case. The opsonins differ according to the various forms of bacteria present in the body. Thus, the varying degree of susceptibility of various persons to disease may be explained. Clinically, we find a decrease in the opsonins in certain bacterial infections. Whenever a patient shows a decrease in the phago- cytic power to any organism invading his body and we know these infecting germs, we can increase his phago- cytic power by injecting him with dead cultures of these specific germs. (Vaccines.) Autogenous vaccines are preferable to stock vaccines. By autogenous vaccines we mean vaccines made from the patient's own discharges. For therapeutic use they are better than stock vaccines. It is sure to contain all the germs responsible for the infection. 98 Opsonic Index. Expresses a comparison between the phagocytic power of the patient to that of a normal in- dividual. The number of bacteria incorporated by the W. B. C. of such normal person is regarded as one. Determination of Opsonic Index. Four things neces- sary: 1. Patient's serum. 2. Normal control serum. 3. Washed leucocytes. 4. Bacterial emulsions. Technic. 1. Draw one volume of washed corpuscles into a capillary tube. 2. To it add a similar volume of patient's serum. 3. To this, add a similar volume of the specific bac- terial emulsion. 4. Blow these 3 volumes into a dish and redraw up into the tube. (This insures proper mixing.) 5. Make another mixture like the above, excepting that the control serum is substituted for the pa- tient's serum. 6. Incubate both for 15 minutes at 37° C. 7. Blow 1 drop on a glass slide, make a smear, fix and then stain with any of the polychrome dyes or with special bacterial stains. 8. Count about 100 polymorphonuclear leucocytes and note the number of germs incorporated within their protoplasm. By dividing this number by 100, we obtain the grand average for one leu- cocyte. This number represents the phagocytic index. To obtain the opsonic index, divide the patient's value just obtained by that of the con- trol in paragraph 5 above. Vaccines also used for Diagnostic Purposes. 1. Tuberculin test ^ 2. Moro's test i „ 3. Von Pirquet c '^^^ tuberculosis. 4. Calmette reaction J Luetin reaction For syphilis. 99 K HEMATEMESIS— GASTRORRHAGIA. DEFINITION. A symptom denoting the appearance of blood in the ejected gastric contents. ETIOLOGY. 1. GASTRIC CAUSES. (a) Ulcer of stomach > /■u^ TT1 ^ ^ I Usually chronic. (b) Ulcer of duodenum V . , „ ^ . , Multiple attacks. (c) Cancer of stomach ) (d) Corrosive poisons (e) Trauma to stomach r Usually acute attacks. 2. HEPATIC CAUSES. (a) Cirrhosis of liver, especially atrophic. (b) Passive congestion of liver. (c) Thrombosis of portal vein or compression of portal vein by a tumor. 3. SPLENIC CAUSES. (a) Enlargement, especially spleno-medullary leu- kemia. (b) Splenic anemia. 4. TOXIC CAUSES. (a) Yellow fever ("black vomit.") 5. HEMORRHAGIC DIATHESIS. (a) Hemophilia. (b) Scurvy. (c) Purpura. SYMPTOMS AND DIAGNOSIS. 1. See under secondary (hemorrhagic) anemia, p. 6. 2. For differentiation between hematemesis and hem- optysis, see p. 104. 3. Tests for occult blood in gastric contents. 100 SPECIAL REMARKS: — Atrophic cirrhosis of the liver. Hematemesis occurs here as one of the so-called "obstructive symptoms." In fact, hemorrhage may occur anywhere in the hody. The association of a small liver with ascites, gastro- intestinal catarrh, hematemesis and hemorrhoids is very suspicious of atrophic cirrhosis. Following hematemesis melaena may occur. It is to be specially noted that hemorrhages from the bowel may occur for several years and yet there be no vomiting of blood. An associated enlarged spleen further accounts for the hematemesis. Hepatic congestion. A congested liver is often depleted by an attack of hematemesis. In fact, hepatic congestion most often results from chronic valvular disease and pulmonary affections. Hence such losses of blood are often attended by beneficial re- sults. It relieves the embarrassment of the heart. The improvement is, however, only temporary. A congested liver is enlarged and pulsating. Spleno-medullary leukemia. Hematemesis and epistaxis are the two most frequent forms of hemorrhage. A profuse hemorrhage reduces the size of the spleen. Though intestinal hemorrhage is uncommon a severe diarrhea will nevertheless reduce the size of the spleen. Splenic anemia. Hematemesis is very common and is also associated with splenomegaly. The liver may subsequently be involved in a second- ary cirrhosis which of itself causes further hemorrhage, ascites, jaundice, etc. Malarial cachexia. In malarial cachexia which follows repeated attacks of any of the malarial fevers, fatal attacks of hema- temesis may occur. The spleen is enormously enlarged. (Ague-cake spleen.) 101 o u M H m < o o o §0 1^ +-> 5 :=i h! vn (B m CO J3 Of) M c; S .-So .-I ^ m S QJ O tHtiL'— I o« O o 'rt oj d TS ft m ?=>>, ft 'bfl ^ s^ 2 '^ -— I d (D TO +-) ftPiS p,ra o GJPU ^'ms^9 ft dS > (X) 0) flti a; o d N-*-" X c^ ?^ tw o " tJ3 9*0^ < H CO O z o < -I < H Z UJ oc UJ u. H o p H P O P Q -^-ft •g CD f> O JH ft rf H O >-2 - s O c3 > bJDo o q oj as ft.5 0) I fC >/ o G > d , " OJ+j d TJ m ^: o 133 c d ft^ ■^ oj faCft >^'u d ^ — ( rrt -^ •Cd^2 c^ o :5 ^^ d O o g3 O fto-ii > +j,d d d ^ W (D -BZ ■ m ft>,ro -(-> O (ij 0) 2t ft> d 0) fto) ■+J ft d 'r-l H O O M p:; H m < ^ • 1^1- +-'4d (i^'*-' ^ o M m.2 a ■^ d d --^ ;h o o S--M "^ d^j a; _j -nH f-i ^ 32 Sa^-S-S d>> d 1^ o "pi CO %>:% :3 CO oj o ftrQ bt) s-( o '- >>p-.->-' b m • d bB+-' d ft c^ o3 CD d §a •^ c^ ?? -s?;?2 J^d ^ft5 ;h (Dr-H rj 0+^ d g S Co a CO aft'" >,ft r; M CO.r-l O o +j ^ GO ^:!:!bid cti d-* C^ !^ O O M m a >^-Sft- G3 ;> S (D^ S^ft.ti be- Ol tOq-i SSHI p:; :^S ■u o c^ m d c(3 d^«§ a -"^^s f^ Cv3 ,r^ CD o^ '«di d O f^ ^ «(_i ,ft cs3 +-> O Ph O I— I H P M H 102 -a a c c o O J! m < to o z o < < H Z lU GC UJ U. a- 0- Ji ^ .rH 0) O '(D i4 a o w i^ o o CD ri ^ -- S d o (jj -^ o G -^ ^ '-I a> 0C>^ CO c5 a3 03 O W CC C w c ifflrt o +-> 'cJa^ '^ a.- rt ;; .__ a. w ■i-j p<< - w K -^ .V - O -1-1 " drr-* w -; ■ 1 o --■ CC +J MH -(-> +li (D r^ a m si 003 m a ^ d O <1 w acd-^ cd -l-> ag.S cd H Q H o o xrx 0) cd o -^ ■ .-1 u 5 w cii :3 o) ^H O tn o g aa M m < ^ rt ^ ij lO in +J CO 0) c^ OJ o; ^ '^ ^"^^ J 50 N O 50 Oj 0- 50 U V-. o':^ to to 0) m m o -d O.^ TO (D O O . 5^ > fl c^ CO O u 0) 0) . Pcr-1 -M CD ^Sl '■§2 o ^ CO ^CO o^ H U o >:i ^ H H H 0) w G Ci-t-> %^ o m o +-> +J b£ bi] o -(3 be KJ -(J 3 o a > o ^ o o 'C o-d C +-'>— 1 tf-l O ,_H fi— cti =4-1 O o to Oj-is^ CO •-^ to Jh r; c^ S^t:; o i> M O . ^ ;> O m tS CO ^ -M f-l i^ C^ bJDo CO O M 13 03 5 ?5 "S oj -^.S f- 4-1 t^«H 'C!=(-i " ft -i bc-;2p ^« o Hh o Q h:) Ph ;3 f-i 6 ^ fl oo a; X2 % 03 rj -t-J 0) CO Jh to CO O -< ■^ !:i ce*"^ H- 1 > M CD 2« s,2 o^bi) Ki to O CO 2.2 +-> Ph O Q K Q +J r^ >i 0J}><^CO -M r= CO n3 •rH -is; -i-j _b£) 0) u +-> p^ . HO C8 o © . to 1-1 -MO) MO^ ft o u in . 4; ctf o a* . 0) m j_ M ^3 cs fH Q, 4» 2-^ s PlH b p Q 116 Chronic Endometritis. In consequence to a long-standing congestion from whatever cause, the lining membrane of the womb is stimulated to excessive activity with the formation of polypi or fungosities. These fungosities are directly responsible for the large amount of blood lost and for the prolongation of the menstrual period. This chronic engorgement further incites connective tissue hypertrophy in the uterine musculature, with the result that the uterus becomes enlarged. The other symptoms of this condition are obscured by the underlying pathological cause (which may be displacements, fibroids, lacerations of cervix, gonorrhea, etc.). Retroversion of Uterus. Chronic congestion of the womb resulting from back- ward displacement of this organ results in menorrhagia and dysmenorrhea. The other diagnostic symptoms are: tenesmus, pain- ful defecation, intermenstrual pain due to prolapse of the ovaries. By bimanual palpation, the cervix will be found low down and anteriorly placed. The fundus cannot be pal- pated through the abdomen. Uterine Fibroids. Hemorrhage occurs only when the tumor involves the endometrium. Hemorrhage is therefore profuse in cases of sub- mucus fibroids. The usual term applied to these fibroids is "polypi." Polypi tend to increase the surface area of the endo- metrium thus creating a larger bleeding surface. In addition to menorrhagia we have metrorrhagia which is quite pronounced. Interstitial or intramural fibroids also cause metror- rhagia but the subperitoneal variety does not. When these polypoid masses obstruct the cervical canal we will find symptoms of obstructive dysmenorrhea and intermenstrual pain. Uterine Cancer. Irregular, atypical bleedings at the climacteric are suspicious symptoms. 117 Pain and foul discharge are late symptoms. A lacerated, indurated and eroded cervix which bleeds easily when touched and is firmly attached to the under- lying structures is very suspicious of malignant disease. Post-Partum Hemorrhage. 1. While bleeding after delivery may come from the cer- vix, perineum or vagina, we restrict the usage of this term to hemorrhage from the placenta! site. 2. Post-partum hemorrhages usually occur within the first 24 hours after delivery. 3. The hemorrhage may be visible or invisible. When invisible the blood collects within the womb greatly distending it (hematoma). 4. The uterus is soft and flabby, A strongly contracted uterus is positive evidence against post-partum hemor- rhage. 5. Predisposing causes are: protracted labors, injudicious use of anesthetics, hurried deliveries with or without use of pituitrin or instruments. Also hurried de- liveries of the placenta. EPISTAXIS. DEFINITION. Bleeding from the nose. LOCAL CAUSES. 1. TRAUMATISM. (a) Blows on the nose. (b) Picking the nose causes the erosion of a thin- walled blood vessel on the cartilage of the sep- tum just within the anterior nares about % of an inch above the floor of the nose. (c) Indirectly in fracture of the base of the skull. (d) Operations on nose. 2. SPECIFIC ULCERATIONS. (a) Syphilitic. (b) Tubercular. (c) Malignant. 3. ANGIOMATA. (Bleeding polypi on septum,) 118 4. ADENOIDS. Children who have adenoids are subject to epistaxis and repeated attacks of "cold in the head." By making a digital examination of the naso- pharynx, the finger, when withdrawn, with be coated with a thick white-of-egg-like mucus and blood. 5. FOREIGN BODY IN NOSE. The presence of a one-sided hemorrhage asso- ciated with a muco-purulent discharge" in a child is suspicious of the presence of a foreign body in the child's nose. CONSTITUTIONAL CAUSES. 1. As a diagnostic prodrome of typhoid. 2. In many conditions associated with an increased pulse tension as in cardiac, vascular and renal diseases. In the aged it is often a precursor of cerebral hemor- rhage. 3. Hemophilia, scurvy and purpura. 4. Vicarious menstruation. MELCENA— ENTERRHAGIA. DEFINITION. Bloody stools or hemorrhage from the bowels. ETIOLOGY. 1. Diseases of the rectum. (a) Hemorrhoids. (Internal and external.) (b) Anal fissure. (c) Cancer. (d) Fistulo-in-ano. 2. Gastric and duodenal ulcer. 3. Atrophic cirrhosis of liver. 4. Intussusception. 5. Ulcerations of the bowel. (a) Syphilis. (b) Typhoid. (c) Cancer. (d) Dysentery. (e) Tuberculosis. (f) Ischio-rectal abscess breaking through the bowel. 6. Severe enteritis. (Very rare.) 119 DIAGNOSIS. It is very apparent that from the above enumerated causes that blood appearing at the anal orifice may originate from any portion of the gastro-intestinal tract. As a general rule, it may be stated, that when the bleeding is high up, as for instance in the stomach and in the duodenum, the blood is never bright red in color but a black, tarry or coffee color. The black color is due to ferrous sulphide. If the blood be adherent to scybalous masses or to v^ell formed feces, it is usually derived from the rectum or anus and indicates piles. If it be evenly distributed with the food material and brown in color, it indicates hemorrhage in the stomach or high up in the smaller bowels, especially if the stood be solid. If evenly mixed with liquid stools the colon is usually the site of the bleeding. It is useless to search for red cells in the feces ex- cept in cases of profuse hemorrhage. The chemical tests for occult blood are: guaiac test, Weber's test, Adler's benzidin test, etc. SPECIAL REMARKS. Constipation is a great predisposing cause in the development of piles and at the same time, the passage of hardened feces over these blood tumors is very apt to favor rupture thereof, especially when straining. Conse- quently bleeding results. Repeated hemorrhages may re- sult in severe secondary anemia. In atrophic cirrhosis we find a diagnostic combination of bowel hemorrhages and hemorrhoids in consequence of the existing portal congestion. It is especially so in topers. In these cases, intestinal hemorrhages usually follow attacks of hematemesis. But, hemorrhages from the bowels may occur for several years without hema- temesis. In intussusception blood may appear in the stools spontaneously or after an enema has been administered. It is usually mixed with mucous. In children, the exist- ence of a bloody and mucous diarrhea associated with a palpable abdominal tumefaction and severe tenesmus is very diagnostic of telescoping of the bowel. 120 A free intestinal hemorrhage may occur as a com- plication in typhoid fever. It seems strange that such hemorrhages may not be attended by bad effects. Usually occurs during the second or third weeks. It may be sus- pected if there be a progressive decline in the fever or in blood pressure. It usually comes on suddenly. Fatal collapse may sometimes supervene before the blood ap- pears in the evacuations. In some cases, a slight hemor- rhage may antecede a fatal hemorrhage. The bleeding arises from the sloughing ulcers on Payer's patches. In both forms of dysentery we find a history of bloody stools at one time or other. Usually the stools are watery and blood streaked, but a pure bloody stool may also occur. Mucous may appear before the blood. Tenesmus is very characteristic. Pus in association with blood in the stools usually signifies ulcerations in the bovv'els but it is not very exces- sive. When considerable pus appears in the stools it usually signifies that a neighboring abscess has ruptured into the bowels. Cancer of the rectum and malignant disease of the bowels are invariably accompanied by pus and blood in the bowels. GUAIAC TEST for blood in the feces. 1. Rub up a small portion of the stools with water and then place same in a test tube. 2. Add glacial acetic acid (Vs of the above volume). 3. Shake vigorously and add a few c.c. of ether. 4. Shake thoroughly again and allow to settle. (If blood be present, the ether takes on a brownish color. And, if the ethereal extract be not clear, add a few drops of alcohol.) 5. Stratify upon this ethereal extract a mixture of equal parts of fresh tincture guaiacum and ozonized oil of turpentine and a blue contact ring appears. Note. — This is a good negative test. Meat must be excluded from the diet. WEBER'S TEST for blood in feces. 1. A small portion of the stool is extracted with ether in order to remove the fat. Then it is separated from the ethereal solution, 121 2. Rub up this fat-free feces with water and proceed as in the guaiac test as stated under statements 2 and 3. 3. The ether takes up the hematin wliich can he detected by its absorption bands with the spectroscope. (a) An intense narrow band in the red between C and D. (b) A group of three broader bands: (x) One in the yellow. (y) One in the boundary line between the yel- low and the green. (z) One at the boundary between the green and the blue. This one is difficult to recognize. Note. — A very reliable and sensitive test. In order to avoid any confusion with the spectrum given by methemoglobin or by chlorophyll add al- coholic potassium hydrate, water and ammonium sul- phide solution which reduces hematin to hemochro- mogen. This gives two bands in the green. ADLER'S BENZIDINE TEST. 1. Extract the stool with a mixture of alcohol and ether. 2. Treat with glacial acetic acid. (Vs of its volume.) 3. Shake thoroughly, allow to settle. If blood be present the ether becomes brownish in color. 4. This acid ethereal extract, which now contains the hematin, is treated with 2 c.c. of a saturated alcoholic benzidine solution and 2 c.c. of 3% peroxide of hy- drogen. In the presence of blood an intense green color appears. It will recognize blood in the proportion of one part blood to 100,000 parts water. It is chiefly valuable as a negative test. Hemoglobin must be removed from diet. The same can be said about prunes. 122 ECTHOL. A vegetable product; each teaspoon containing: Thuja Occidentalis 3 grains Echinacea Angustifolla 28 grains Local Action. An astringent antiseptic. Indicated in inflammations of the skin, especially purulent inflammations like boils, carbuncles, abscess, erysipelas, mammitis, chancroid, ulcers and infected cuts. It should be applied undiluted for topical applications. All collections of pus must first be incised and then washed with Ecthol. It is not an antiseptic in the ordinary sense of the word but by its direct action upon the cells it stimulates them to overcome bacterial growth and aids in promoting healing. It is not poisonous like many other antiseptics. Internal or Systemic Action. In many diseases due to infection with pathogenic bacteria, especially the pyogenic variety, Ecthol, which consists of two vegetable products, heretofore regarded as alteratives, apparently stimulates the body cells to greater activity so that more opsonins are poured out into the blood, thus endeavoring to overcome the effects of the invading germs. It may therefore be used in many blood disorders as a systemic antiseptic and a resistance promoter. It is recommended for internal use in acne, furuncle, carbuncle, erysipelas, pyelitis and especially septicemia. Echinacea is also credited with being a febrifuge. Ecthol may therefore be also used in febrile conditions. Dose. — One teaspoon 3 or 4 times a day. BATTLE CSi CO., ST. LOUIS, MO. 123 COLUMBIA UNIVERSITY LIBRARIES 0055756972 Demco, Inc. 38-293