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THE BLEEDER AND THE LABORATORY

DIFFERENTIATION of the various haemorrhagic diseasesis not always easy. Prof. L. J. WITTS, addressing theHalton Medical Society on May 2, ran over the mostrecent tests, some of which carry latent therapeuticpossibilities. Following Macfarlane’s recent review, heexplained haemostasis from capillary bleeding as due totwo factors : the contraction of the capillaries and thesubsequent sealing by coagulation. In purpura haemor-rhagica capillary contraction is at fault, the bleeding timeprolonged and snake venom relatively ineffective. Inhaemophilia the capillaries contract well and the bleedingtime is normal, but when the capillaries relax hgenior-rhage recurs from failure of coagulation ; snake venomis of value in preventing this recurrent bleeding. Inpurpura haemorrhagica the capillary lesion may appearto be localised ; Professor Witts described one case inwhich epistaxis and another in which menorrhagia wasthe presenting symptom. This localisation is probablynever absolute, however, and other symptoms such asskin purpura may be elicited on inquiry though theyhave been too slight to attract the patient’s attention.Splenectomy probably exerts a beneficial effect on thecapillaries as well as on the platelets. Menstruation hasa harmful effect on the capillaries ; quite apart frommenorrhagia, purpuric symptoms are worse at this timeand this is at any rate one factor in vicarious menstrua-tion. In Professor Witts’s experience bleeding rarelyceases immediately after splenectomy, and he has seen itcontinue for anything from 3 days to 3 weeks after theoperation. He therefore advised against instant opera-tion in purpura with a short history ; in acute casestransfusion is the sheet anchor of treatment.

TESTS TO BE APPLIED IN CASES OF 1-1EMORRHAGIC DISEASE

The tests (see table) he is now using in the investigationof haemorrhagic diseases can all be applied to the patientat one sitting. The inclusion of a differential whitecount is a reminder of the importance: of leukaemia as acause of purpura. We should be chary of diagnosing anidiopathic purpura haemorrhagica after middle life ;neoplasm, or drugs such as Sedormid, should then besuspected as possible causes. The time of bleeding froma needle puncture is a valuable indication of the haemor-rhagic tendency. A bleeding time above 10 min.implies a haemorrhagic tendency and makes it fairlycertain that the patient will give trouble if any operationis carried out. Unfortunately there is a considerableoverlap between the normal and the abnormal, and indoubtful cases, as suggested by Ivy, it might be useful toapply a tourniquet at 40 mm. Hg. and carry out theneedle puncture below this.

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The Dale and Laidlaw test, and similar tests ofcapillary-blood coagulation, have the theoretical advan-tage that there is something like the normal sequence ofevents-the blood streaming over the injured tissues.In practice they give misleadingly optimistic results inhaemophilia and during heparin treatment. The diag-nosis of haemophilia is often called in doubt when there isno family history of the disease. This is not uncommon

because the haemophiliac woman transmits the tendencyto only half her sons and half her daughters, so that itmay skip several generations. In such cases confusionmay be made worse by indecisive results from capillaryblood coagulation tests ; it is then essential to examinevenous blood.The mechanical resistance of the capillaries is tested by

placing the sphygmomanometer cuff round the arm at80 mm. Hg for 5 min. and noting the number of petechiein a circle 2-5 cm. in diameter (the dimensions of a half-penny) placed 4 cm. below the bend of the elbow. Up to7-10 tiny petechise are normal, but the test has little diag-nostic value. It was originally devised as a test for scar-latina and may be positive in people with no other signofhaemorrhagic tendency and negative in frank thrombo-cytopenia. Many attempts have been made to improvethe estimation of the capillary resistance-such as

Gothlin’s modification of the tourniquet test, and thesuction test. There are physiological variations incapillary resistance in different parts of the body, andmoreover the capillaries are affected by exposure to sunand wind, by the menstrual cycle, by previous distensionand by the occurrence of purpura or bleeding. The suctiontest has been widely used as a measure of the scorbutictendency or of vitamin-C reserves, but the results are soflatly contradictory that some of the observers musthave been ignorant of the fallacies inherent in the method.Crandon showed no increase in capillary fragility in spiteof the development of manifest scurvy on an experi-mental diet lacking in vitamin C, and Scarboroughdemonstrated that the capillary fragility in malnourishedpatients can be repaired by vitamin P but not by vitaminC. There is little correlation between the large subcu-taneous haemorrhages of scurvy and the fragility of thecapillaries of the skin. Some of the confusion may have ebeen caused by the use of natural sources of vitamin Cwhich also contain vitamin P, but in any event vitamin Pis not known to have any real therapeutic value. Inthe Peck test the resistance of the capillaries to the toxicaction of snake venom is measured. This test oftenconfirms the presence of a haemorrhagic tendency, butthe standards are ill-defined and there is great overlapwith the normal.

In studying the coagulation of venous blood andretraction of the clot, it must be remembered thatcoagulation is only a potential quality of the blood, anddoes noL occur unùl1 ùne oiooa is exposed ùO aonormal

conditions. As Nygaard has emphasised, these tests areaffected not only by intrinsic haematological factors butalso by extrinsic factors such as cleanliness, quality andsize of glassware and the like. The normal coagulationtime (Lee and White) appears to be about 6 min., with arange of 3 t--1 0 min. Clot retraction is often deficient inpurpura haen3.orrha.gica, but this finding is not diagnosticsince retraction is occasionally absent in normal men.The fibrinogen content of the blood is of no practicalimportance in the heemorrhagic diseases ; 10% of thenormal amount is sufficient for clot formation in theordinary way, and the level in the haemorrhagic diseasesnever sinks below that. Congenital nbrinopenia is

excessively rare and will probably be shown up by thelow sedimentation-rate. Nor is calcium of any practicalimportance because the critical value for blood coagula-tion is lower than that necessary for survival.Much information has been gained recently by the

study of oxalated or citrated plasma ; such plasma willclot if recalcified, and this is a more elegant way ofmeasuring coagulation than by using whole blood.Clotting can be accelerated by the addition of tissueextracts such as emulsion of brain, and such acceleratedclotting tests (Quick) are believed to give some indicationof the amount of prothrombin in the plasma. Lack ofprothrombin.is the cause of bleeding in jaundice and-inmelena neonatorum, and it can sometimes be correctedby the administration of vitamin K. Tissue extract orthromboplastin appears to consist of a water-soluble,heat-labile protein and a fat-soluble, heat-stable lipoid.The separate effect of the two factors can be simulatedand studied by the use of snake venom (water-solublefraction) and lecithin (fat-soluble fraction). Such studiessuggest that haemophilia is associated with shortage ofthe water-soluble factor and purpura haemorrha.gica withshortage of the fat-soluble factor. Nevertheless otherinterpretations can be placed on the facts, such as the

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presence of interfering factors in the plasma. Thestudies are of interest because they enlarge our diagnosticpowers and also because they reveal a humoral defect inpurpura haemorrhagica ; haematologists have alwayssuspected that a single lesion may underlie the plateletdeficiency and the capillary disorder.Professor Witts ended by expressing the hope that on

such lines effective medical treatments may be found forthese disabling diseases.

In England NowA Running Commentary by Peripatetic CorrespondentsLISTS of successful candidates for the various post-

graduate degrees make those of us who have been sweptup in the machine of military medicine take stock ofexperience gained at the cost of nearly two years of civilmedicine, and look-not without a little anxiety-to ourfuture prospects. Have we gained on the swings whatwe lost on the roundabouts, or are we taking a slow butslippery course downwards from the eminence reachedafter seven years of hard work and hard play as medicalstudents and housemen ? .

For my part, and I have been lucky, I make thebalance about all square ; and after managing the wine-books of a mess for nine months one should be able tobalance anything. The first winter was rough, but Iliked it ; lath and plaster were not made to resist thecold of three months of snow and wind. "

Bundling " *was the official method of bedding out several thousandyoung men, but in most cases, during the cold weather,the bundling board disappeared in favour of three in abed for extra warmth. Body-musters of batches of men,with the sick-bay thermometer registering 22 degrees offrost, are not pleasant for either party, yet few seemedto suffer any ill effects. To hear the chief petty officerintoning, in broad Lancashire, his instructions to eachclass to drop their pants to their ankles and raise theirhands above their heads on seeing the medical officerwas a daily tonic, accentuated on the day when the firstScotsman to arrive in his native dress non-plussed ourfriend, and solved the problem of what a true Scot wearsunder a kilt. Then there was the man who joined up ina bowler hat. Other impressions that stick are the finephysique of the early lot who volunteered, mostlymembers of the R.N.V.R. before the outbreak of war,the high standard of health throughout the followingthousands, although the mark of the coalmines or of someof our great northern industrial areas had been left

indelibly on many, and the great improvement in generalwell-being a mere five weeks of good food, plenty ofexercise and no mental worries, can bring about. Everyone of these men put on weight-many over a stone infive weeks. Surely no harm could come of a spell of thistype of life for every boy leaving school in the futuredays of peace ?

, Medical experience was rather limited, but vaccinationproved an unexpected stumbling-block, producing somefierce and slow-healing ulcers with an incidence of about8% of fever, headache and malaise on the twelfth day ;one case had a lobster-like rash. It was good to see themiraculous improvement in the prognosis of meningo-coccal meningitis. In our small series of cases allrecovered, and the gratitude of relations during a tryingthree months was heartening. A well-to-do parent whoseson had survived but had been left with a fleetingfacial..paralysis, was the only one who showed us anyantagonism. It was interesting to get five peptic ulcerperforations ; and was it just coincidence that theycoincided with increased number and severity of air-raids ? Summer brought glorious days under canvas,nursing the sick in bell tents ; helping to wield thatpowerful word " requisition," delving into water tanks,septic tanks, drainage tanks, electric power and allmodern conveniences ; and eating salmon produced byone of the sick-berth staff without going too carefullyinto its origin.Now at sea, I have almost lost touch with medicine.

Reading without colleagues with whom to discuss thesubject becomes drv and sterile. A nehtina’ shin cannot

* Under "Bundle" the O.E.D. says: " .. To sleep in one’s clotheson the same bed or couch with (as once was customary withpersons of opposite sexes, in Wales and New England), 1781."-Ed. L.

afford to carry sick passengers for longer than necessary,and the complete absence of a chance to follow up casesis annoying and strange. But there are things on thecredit side : knowledge of shipmates gained from livingclose to them for six months or more without sight of avillage or a tree ; and glimpses of bird life hundreds ofmiles from anywhere, snow-bunting landing on thefoc’sle, skeins of geese and even swans migrating ; thechance to learn that " kittiwake " is neither the name of aNorth American tribe nor a gambling term, and that afulmar is not just another aircraft. All the romance ofthe sea, of shipping and commerce can be savoured inthe meeting of a convoy somewhere at sea, in escortingit for days through dangerous waters, or in passing a loneship heavily laden and homeward bound.

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Last Saturday night’s fire at St. Stephen’s wasannoying but in no way comparable to the fire of Oct. 16,1834, when the old Palace of Westminster was burnedout completely with the exception of St. Stephen’s hall.Fire had previously played a part in the life of the Houseof Commons, for it was after the fire of 1512 that thepalace ceased to be used as a royal residence and thecommoners met in St. Stephen’s chapel for the next threecenturies-those who could stay the course. The vastnew palace which rose on the cinders between 1840 and1867 was like York Minster built of Magnesian limestonewhich catches the rosy tint of the setting sun and some-times glows of itself like a Dutch holy babe. But soperishable is the stone in the acid fumes and soot of agreat city that much of the elaborate carving fell awayand was taken by members for their rockeries. Theill-natured bomb will have solved the vexed question ofventilation in the debating hall which members havealways used as an excuse for cold feet and hot heads.At first air was pumped into the chamber from an intakeat the top of the Victoria Tower where it was presumedto be clean and the vitiated air was extracted throughapertures in the ceiling-a combination of feeble plenumand heat exhaust which was both inefficient and noisy.In 1854 the system was reversed, both Victoria and clocktowers being used as upcast shafts, with a furnace at thefoot of each. The incoming air was warmed, filtered andhumidified and engineers came from far to see thisparagon of ventilation. Nevertheless the ladies’ gallerycomplained of the smell of horse manure drawn in fromthe court and members on the floor of the house werereminded exasperatingly that their less conscientiousfellows were smoking tobacco outside. This led to a newinstallation of the plenum system which left the airstagnant in some parts of the house and draughty inothers. And finally the National Physical Laboratorywas called in to ascertain on a model how a gentlecirculation of air over members’ faces could be achievedwithout the sensation of draught. They hardly expectedthis Hitler-sent opportunity of starting from scratch.

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A week or so ago the Times gave space to several lettersobjecting to the use of the word " contact " in broadcastsand elsewhere as a transitive verb, meaning " to get intouch with." The word owes its popularity in somemeasure to its aeronautical and electrical associationsand to some extent supplies a want ; and it may be askedwhen have these purists of Pall Mall, these letter-writersfrom country houses, ever been known to supply us inour hour of verbal need ? For we are badly in need ofsome new words. To take an elementary instance,people often have to refer to some connexion like abrother-in-law’s brother. Why not " bilber " ? Similarly" bilser," " sil," and " mil." Of course mil and sil haveother meanings but the context will generally make itclear that one is discussing an in-law, not a millilitre ora yellowish pigment used by ancient painters. For ourmore immediate needs we should have more words ofthe " boycott " type, words that are like one-act playsand tell a whole story : something for the grey squirrel-ling of the Japanese, the young cuckooing of the Germansin puppet states, the ichneumon methods of theirembassies and legations. We need a word to describethe defence mechanism which makes a family or nationdraw together in times of disaster, and its opposite whenthey quarrel and become strangers to each other inprosperity, possibly by a dispersal mechanism. Thereis a story from the Boer War of an old colonel at the Staff