134 



REMAUKS ON KALA-AZAK 



The nielhod 

 recommcndetl 

 for punciiire 



Appearance 

 of the blood 

 Nv itbdrawn 



The method umployed for splenic punctui'u was careful cleansing of skin, luiiuls, 

 and sterilisation of an all-glass hypodermic syringe, with a hypodermic needle about 

 1^ inches long. 



The site of puncture was carefully located before the little operation. The patient 

 was told to take a deep breath and hold it ; several ])reliminary exercises were carried 

 out, so that he fully understood what was required and that lie was not to let go his 

 breath till the needle was withdrawn. The needle was then inserted rapidly and at 

 right angles to the spleen, and several drops of blood were at once drawn off. The 

 proceeding did not cause pain to any degree, :ind the whole performance was finished in 

 about five seconds or less. 



In some cases the lax and thin abdominal wall allows of the spleen being more or 

 less fixed against the lower ribs by inserting the hand under its edge and pressing firmly 

 upwards and outwards, and in these cases inspiration need not be employed. The cases 

 where danger may occur are those who are very nervous or very young ; my small 

 experience does not seem to point to advanced antemia being a cause of danger ; many 

 patients punctured were extremely anaemic. In such cases, should sudden expiration 

 take place, it is of the utmost importance, I believe, to hold the syringe very loosely, 

 so that the movement of the syringe in the direction of the long axis of the spleen is 

 in no way hindered, and thus the needle with the spleen is not fixed ; if held firmly 

 and fixed, the needle might be very liable to cause a rupture of the splenic capsule. 



It was found that if the syringe rapidly filled with blood, the chances of finding 

 parasites were small, and the blood usually had more or less the characteristics of 

 peripheral blood ; probably in these cases the blood came directly from a splenic sinus. 



In a few cases it was found almost impossible to draw off any blood, in one case 

 even after three punctures ; usually, however, enough was obtained, though not sufficient 

 to make a good film. In these cases it was noticed that the spleens were not easy to 

 puncture, and tlie difficulty was probably due to a thickened capsule. By giving a few 

 slight lateral movements to the needle the splenic pulp is slightly damaged, and blood 

 can, in some cases, be drawn off, as in puncture of a lymphatic gland, though such a 

 procedure should be avoided unless absolutely necessary. 



A positive spleen puncture settles the diagnosis, but a negative result still leaves 

 one in doubt. 



In three definite cases, and in several that were clinically kala-azar, the blood 

 withdrawn had, to tiie naked eye, the appearance of slightly clouded serum, though 

 undoubtedly coming from within the spleen itself ; this was noted especially in severe 

 and rapid cases of kala-azar. 



The method employed for splenic puncture has been given in some detail, but it 

 must be kept in mind that this method was used with natives, who are not highly strung, 

 and either do not show or do not feel pain as the civilised white races do. Hence tlie 

 method of taking a deep breath and holding it, by means of which the spleen is depressed 

 and held downwards towards the pubis, might quite well with a hyper-sensitive white 

 person be most dangerous, as the natural inclination of a person who has not full 

 control of himself would be to let go his breath on puncture, and thus a more serious 

 tear occur in the splenic capsule than if no previous deep inspiration was taken. 



In dealing with an individual of a white race, especially if of a nervous temperament, 

 I would suggest that it would be better to produce a reflex cessation of respiration by 

 telling him to take a series of deep breaths and so produce a condition of apnoea for 

 the puncture. 



