Twentieth Century History of Findlay and Hancock County, Ohio, and Representative Citizens, Part 123

Author: Jacob Anthony Kimmell
Publication date: 1910
Publisher:
Number of Pages: 1189

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55. Strauss: Beitrag zur Kenntnis der Wirkung des Schar- lach R. auf das Epithelwachstum. Deutsche med. Wchnschr., 1910, p. 895.

55. Strauss: Pansements des plaies avec la solution de la pommade Rouge R. Arch gén. de chir., 1910, p. 810.

56. Werner: Ueber den Einfluss des Scharlachrotes auf Maus- entumoren. München. med. Wchnschr., 1908, p. 2267.

57. Wessley: Ueber die Wirkung des Scharlachrotols auf die menschliche Epidermis (Selbstversuch). Med. Klin., 1910, p. 542.

58. Wolfrum und Cords: Ueber die Anwendung von Scharlach- rot bei Augenaffektionen. München. med. Wchnschr., 1909, p. 242.

59. Wyss: Zur Wirkungsweise der Scharlachöl Injectionen (B. Fischers) bei der Erzeugung karzinomähnlicher Epithelwucher- ungen. München. med. Wchnschr., 1907, p. 1576.

ON CERTAIN LIMITATIONS IN INTERPRETING THYROID HISTOLOGY

By DAVID MARINE, M. D., and C. H. LENHART, M. D. Cleveland, Ohio.

(From the H. K. Cushing Laboratory of Experimental Medicine, Western Reserve University.)

Any discussion of the limits of histological variation within which a thyroid gland-whether mammalian, avian, reptilian, amphibian or piscine-may be considered normal is largely of academic interest.

It has long been recognized and frequently emphasized by us that the thyroid tissue is extremely labile-reacting quickly to relatively slight physiological variations in the body metab- olism and for this reason may show even daily histological changes within narrow limits. The knowledge of this fact, as applying to the thyroid just as truly as to the blood tissue, has made it unnecessary to write long papers to attempt to define in fixed and exact language the strictly normal thyroid or blood tissues. The thyroid tissue being exceedingly active and well endowed with the power to undergo hypertrophy and hyperplasia, one may observe in any animal group in- sensible gradations in epithelial hypertrophy and hyperplasia from the smallest amount of thyroid tissue compatible with normal body function (the normal) up to marked degrees of thyroid overgrowth. With such gradations in hypertrophy and hyperplasia it is clear that a histological standard of

normal must be, within narrow limits, somewhat arbitrary and this fact explains why different observers have adopted somewhat different standards .. It has long been evident that a standard of normal could not be ascertained purely by the histological examination of glands taken at ran- dom. In the case of mammals the best way to obtain an accurate conception of the least amount of thyroid tissue compatible with normal body function (the normal) is to give minute doses of iodin to a pregnant bitch through- out the pregnancy and after birth to continue the same with the pups up to the sixth month of extra-uterine life; then examine their thyroids histologically, estimate the iodin con- tents and the relation of the thyroid weight to the body weight. Even then one may not find all the thyroid follicles containing colloid of uniform staining reactions or the lining epithelium of uniform shape and size. One will find that the variations are slight, considering that the measuring rod is unusually delicate as compared with that of most body tissues.

From our six years' experience with the anatomy, the phys- iology and the chemistry of the thyroid tissue in all the

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JOHNS HOPKINS HOSPITAL BULLETIN.

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classes of animals and their orders from the cyclostomes to man we have adopted the low cuboidal epithelial cell as most nearly conforming with the normal type of thyroid epithelium although this type of gland cell may be depressed to a still lower degree of physiological activity following prolonged iodin administration or in senile states.

The above remarks while drawn particularly from work on the mammalian thyroid have been found to apply as well to the piscine thyroid. Zoological literature contains many ex- cellent descriptions of the histology of the fish thyroid and in them one notes the same variations in anatomical structure that have so long been known for the mammalian thyroid. Our experience with the thyroid of Teleosts (bony fish) com- prises a rather extensive acquaintance with 93 species and we have also noticed great differences in the histological appear- ance of the thyroid epithelium even in fish living wild in the streams, lakes and oceans. It has been ascertained by experi- ment that the thyroid changes do not take place so rapidly in the fish as in mammals, but the range of histological variation is just as great and the still more recent studies in compara- tive pathology of the thyroid gland have shown that in arti- ficially reared carnivorous fish (the trout and salmon par- ticularly) the thyroid is capable of relatively as great over- growth as in any other order of vertebrates. This excessive overgrowth which has thus far been observed only in arti- ficially reared fish has of late created much interest on ac- count of the expressed views of several observers, that it is carcinoma. This conclusion is based on the fact that the thyroid overgrowth presents the histological appearance of invasion of the surrounding structures (bone, muscle, car- tilage, etc.). In some recent publications' we pointed out that, owing to the absence of any capsule and the normally wide distribution of the thyroid follicles in fish, invasion did not have the same significance as it would have in circum- scribed and encapsulated tissues and in tissues less well en- dowed with the power of hypertrophy and hyperplasia, and that in view of these facts other criteria than histological ap- pearances must be provided before a frank diagnosis of cancer could be made.

In a paper by Gudernatsch ' he rather infers that we claim the priority for pointing out the fact that the thyroid gland in fishes was not encapsulated. This was not our intention as excellent accounts of the fish thyroid in a great many species are to be found in literature ' dating back as far as 1844, and for that reason we wished only to emphasize the fact that in a non-encapsulated tissue like the fish thyroid any overgrowth

Johns Hopkins Hosp. Bull. 1910, XXI, 95; J. Exper. Med., 1910, XII, 311; J. Exper. Med., 1911, XIII, 455.

' Johns Hopkins Hosp. Bull., 1911, XXII, 152.

' Simon, J .: Philos. Trans. Lond., 1844, Pt. 1, 295; Baber, E. C .: Philos. Trans. Lond. 1876, Pt. 2, CLXVI, 557; and Ibid., 1881, Pt. 3, CLXXII, 577; Maurer: Morphol. Jahrb., 1885, XI, 129; Dohrn: Studien, XII, Mitteil. Zool. Stat. Neapel., 1887, VII, 301; Mueller, W .: Jenaische Zeitschr., 1871, VI, 428; Mackenzie: Proc. Canad. Inst., 1884, 134; Thompson, F. D .: Philos. Trans. Lond., 1910, Series B, CCI, 91.

might give the histological appearance of cancer without actually being cancer. Experimental work with this orer- growth has amply justified that assumption.

In this connection we wish also to correct a misquotation that appeared in the above mentioned article as follows: " Thus Marine and Lenhart's statement that the normal follicles invade the bones is not appropriate, etc." We hare never made such a statement nor could any one read into our descriptions of the normal fish thyroid such an interpretation without distortion. This author further states "In their paper Fig. 6 demonstrates this fact [that normal follicles do not invade bone] definitely, although it is supposed to show a true invasion." The author has evidently completely missed the point we wished to picture as the legend for this illustre- tion clearly states that it represents the effect of iodin on the marked hyperplasias, i. e., the return or involution of the active and extreme epithelial overgrowth to its colloid or rest- ing state. In this given fish the thyroid tissue had invaded bone, muscle, cartilage and had grown up to and elevated the pharyngeal mucosa. There was also extensive absorption of bone and erosion of cartilage which the microphotograph in question does not picture.

In another instance the author does not grasp the meaning we wish to convey when he says "if all glands, the follicles of which spread out far from the main bulk even into the gil region, are highly hyperplastic, then, according to Marine and Lenhart, the colloid material should be nearly or entirely absent in them. Yet it is present throughout the gland." There are all degrees of active epithelial hyperplasia and a: the colloid content (as determined by staining and estimating the iodin content) in general varies inversely with the degree of active hyperplasia there are also all degrees of lessening of the colloid content. Now after extensive hyperplasia ha: taken place and the thyroid tissue has infiltrated all the sur- rounding structures including extensions into the gill arches. recovery may take place either spontaneously or from iodin administration, i. e., the active hyperplasia may cease from further growth and the epithelium return to a cuboidal form with the filling up of the follicles with colloid. This recovery implies the return to the colloid or resting state or the nearest normal state that such a thyroid can assume. The distribu- tion of these now colloid follicles is, of course, just as exten- sive as when these same follicles were in their actively hyper- plastic state, i. e., if the follicles have invaded bone, muscle, gill arches, etc., during their actively hyperplastic state they will remain in these locations throughout the life of the fish although the epithelium becomes cuboidal instead of columnar and the colloid content increases to the normal amount. In other words physiological recovery from the condition pro- ducing thyroid overgrowth (goitre) does not and cannot en- tail an absorption and disappearance of the follicles.

Just as there are slight departures from follicular uni- formity as regards epithelium and colloid content in the normal thyroid so also in the actively hyperplastic thyroid the follicles show variations in the size of the epithelial cells and in the colloid content relatively more marked than obtains

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vajaquation at present, although it is probable that they are in part dependent upon the blood supply, the lymphatic drain- age and perhaps upon other methods of interference with the follicle's nutrition which modifies the cells' activity. Thus it is well known that in secondary hyperplasia (hyperplasia occurring in a colloid gland) the peripheral or subcapsular zone undergoes hyperplasia earlier than the central portion and Ribbert' has shown in the experimental regeneration of dogs' thyroids following partial removal that the peripheral *Virchow's Archiv f. path. Anat., 1889, CXVII, 151.

wwwJpwwtopic changes earlier than the more cen- trally placed follicles.

These points are mentioned to show that in any phase of the histology of the thyroid one may place a too literal inter- pretation on slight variations in this very labile tissue which could not be detected at all in tissues less well endowed with the power of hypertrophy and hyperplasia. It is the general and predominating type of changes throughout the gland and not the accidental condition present in certain follicles that determine the state of the gland so far as functional activity is concerned.

PNEUMOCOCCUS PERITONITIS. WITH REPORT OF A CASE.

By HARVEY B. STONE, M. D., Baltimore.

Pneumococcus peritonitis, not as a pathological finding, but s a clinical entity, presents a fairly well defined symptom- omplex, which should be better known and more generally ecognized than is the case at present. Although not one of ne exceedingly rare diseases, it is still sufficiently infrequent > deserve reporting. These are the reasons which lead to the resentation of this paper, reinforced by certain features of is particular case which seem of unusual interest. The facts in the case are as follows:

Patient of Dr. Jeffries Buck, female, 5 years old, white. Family History .- Not significant.

Past History .- Measles, whooping-cough, chicken-pox, pneu- onia two years ago, complicated by acute otitis media. After covery from pneumonia, the otitis persisted and became chronic th frequent exacerbations of earache and discharge. The last these flare-ups was on March 26, when the child cried at night th earache, was feverish, and awoke the next morning with isiderable discharge from the left ear.

Present Illness .- On the morning of March 30, following an in- cretion in diet of the previous evening, she was seized with Iden severe abdominal pain and vomiting. There was also er and diarrhea, the stools being of an exceedingly offensive r. It should be noted that other members of the family also 'ered from somewhat similar gastro-intestinal upsets, but hout fever being noted, and with rapid return to normal.

'he child did not improve. The fever and the abdominal pain, ch was generally distributed, but most acute at the umbilicus, the diarrhea persisted, in spite of calomel given to clear up chemical source of disturbance in the intestinal canal. On 'ch 30, the temperature reached 104.5º F. On March 31, Dr. k noted some fullness and tenderness of the abdomen with istence of the former symptoms and requested a surgical sultation.

hysical Examination .- 5 p. m., April 1. Child sleeping. Tem- ture now 102º F., pulse 120, respiration 30. No visible dis- ge from either ear. Lips dry and cracked. Tongue coated. d awakened, but remained notably apathetic and continued uring the illness.

vest .- Heart clear. Lungs entirely negative.

domen .- Slight symmetrical distention in lower half. Res- cory movements limited to chest and upper abdomen. No le peristalsis. On palpation, general tenderness all over men, most intense below level of umbilicus, but no difference

between the two sides. No particular tenderness over appendix region. No masses felt. It was noted that rigidity was slight, much less than the other findings seemed to justify, and that the patient persistently referred the worst pain to the navel. Slight muscle spasm.

On percussion, no areas of dullness were noted. The liver dull- ness was pushed up about two fingers' breadth above the costal margin.

Rectal Examination .- Rectum ballooned. Tenderness all over vault of rectum. Pelvic organs felt normal. Vaginal discharge noted, which was later stained and showed Neisser's organisms. In this connection it should be noted that the child slept with an aunt who was known to have pelvic inflammatory disease.

As a result of the examination, there was a very definite im- pression obtained of some intra-abdominal trouble that might require surgical intervention. The picture was certainly not that of any of the usual lesions, however. Appendicitis, some form of obstruction, pelvic inflammation, and other conditions were considered unlikely, and it was felt that the case was obscure and unusual. As the child's temperature had come down two degrees, and the vomiting had ceased for several hours, and there seemed a general improvement, operation was not urged, but the child was placed in the Hebrew Hospital under observation. Dur- ing the night, the temperature rose again to 104º F., the vomiting recommenced, tenderness and pain became greater, and the leucocyte count was found to be 18,400. An immediate explora- tion was decided upon in the morning.

Operation .- Through a right rectus incision the abdomen was opened, and at once thick greenish-yellow pus welled out, which resembled condensed milk quite closely in color and consistency. It was noted that the pus was odorless. A rapid search of the pelvis, the appendix, the gall-bladder, stomach and small bowel was made. No lesion accountable for the infection could be found. Everywhere the same pus, with numerous thick flakes of fibrin was found. The serous surfaces were noted as being much less injected than one would expect with so much free exudate. There was absolutely no walling off or abscess forma- tion, every surface inspected being bathed in free pus. A diag- nosis of probable pneumococcus peritonitis was made on the char- acter of the pus and the absence of a definite visceral lesion. Cultures were made and stained slides were sent to the labora- tory for examination. Gonococcal peritonitis was considered improbable as the pathological findings at operation all pointed against it. Closure of the abdominal wall, leaving space for free drainage, concluded the operation.

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Bacteriological Report .- Pus from the abdomen showed a Gram- positive, encapsulated organism occurring in pairs and short chains; considered pneumococcus. A culture and smears made from the left ear immediately at the conclusion of the operation were negative. No discharge from the ear was visible at this time. A stain was also made from the vaginal discharge which, as noted above, showed Neisser's organisms-biscuit-shaped, in- tracellular Gram-negative diplococci.

Post-operative Course .- For a short time the patient seemed to rally, but the evening of the day of operation, her temperature rose steadily, she became delirious, and died the next day with all the symptoms of a profound intoxication, the temperature having reached 106.2º F., pulse 170. Post-operative treatment consisted in the same measures adopted for peritonitis in gen- eral-the Fowler position, the Murphy rectal saline solution, nothing by mouth, frequent subcutaneous infusions of normal salt solution. No autopsy was secured.

These are the general facts of the case. There are one or two features worthy of comment and a brief survey of the subject as a whole may not be out of place.

In the first place, here is a case of what has undoubtedly in the past been called " primary," " idiopathic " or " crypto- genic " peritonitis. Careful questioning, however, elicited a history of pneumonia two years before, with a complicating otitis media, the persistence of this otitis in the interval, and finally an acute flare-up of considerable intensity a couple of days before the onset of a peritonitis caused by pneumococci. Such a series of incidents is, of course, strongly suggestive. It is to be regretted that efforts to secure bac- terial evidence from the ear were unsuccessful.

A second interesting point is the laboratory report of pneumococci from the peritoneum and gonococci from the vaginal discharge. An almost identical case was found re- ported by Dudgeon and Sargent,' who comment on this co- incidence with a warning that the finding of specific organisms in the vaginal secretion of such a child does not necessarily mean the existence of a gonorrheal peritonitis. A third fact of note is that this case presents a very typical example of one form of pneumococcic peritonitis, and were such cases not so uncommon the diagnosis would not be extremely difficult be- fore operation. In order to substantiate this statement a summary review of the subject is necessary. No attempt will be made at an exhaustive report of the literature, which is now quite extensive, although the disease is comparatively rare.

The disease was first described by Bozzolo' in 1885, as an autopsy finding, and first operated on by Sevestre' and Néla- ton ' in 1890. Since then numerous isolated cases have been reported, a number of extensive reviews of the subject have been published, and several theses and monographs written. In 1903 von Brunn ' collected 57 cases occurring in children and 15 in adults. Jensen · published an exhaustive article in the same year. Annand and Bowen' in 1906 collected all the cases in children published up to that time, finding 91 under 15 years of age. In the same year von Robbers' re- viewed the history and literature of the condition. Since 1906, in an extensive but not exhaustive review of the litera- ture, 30 cases have been definitely recognized as pneumo-

coccus peritonitis, while a number of papers have probably dealt with this condition, though unrecognized, under titles such as " Peritonitis without ascertainable cause,"" "Genera purulent peritonitis without obvious cause,"" etc.

Pneumococcus peritonitis occurs with marked preponder- ance in children, and especially in the female sex, between : and 14 years of age. Various authorities differ as to the es- planation of this incidence of the disease, but all agree as ty the facts.

Etiologically, the disease, of course, represents a specific in- fection of the peritoneum, but much discussion has risen as to the portal of entry. Two groups of cases are usually rerog- nized : the primary or idiopathic, and the secondary, in which the peritonitis is obviously consequent to some pre-existing pneumococcic lesion elsewhere. Of such lesions, pleuro-pner- monic involvements are naturally by far the most common. and next to these, in frequency, is otitis media. The recogni- tion of a "primary " form as a distinct group does not serra logical. It simply means that the portal of entry, instead ! being obvious as in a precedent pneumonia, is obscure. Tir modes of transmission accepted as proved by various writer- embrace operative infection, transmission by blood and lymp' streams, and direct penetration, with or without perceptil. lesion, of the diaphragm and the walls of the gastro-intentine canal.

Clinically the cases fall into two fairly distinct groups- the encapsulated and the diffuse forms, each of which pr- sents a characteristic picture. The encapsulated form begins with a sudden onset, in a number of cases following an in- discretion in diet, with acute abdominal pain, vomiting and fever. In an overwhelming majority of cases, but not in al. there is diarrhoea generally characterized by the very fetif odor of the stools. The local abdominal signs at this sta ?- and in this form are not very pronounced. The vomitin: stops in from 12 hours to a few days. The fever, never ver. high, persists from 8 to 10 days. The diarrhoea is the last of these early symptoms to cease. After ten days or two. weeks, local abdominal disturbances become more pronounce -! The pain, which may have stopped, begins again, and instes! of being general, becomes localized, nearly always in the hypogastric region. Fullness, gradually but steadily pri- gressing, is noticed. Over this distended area dullness on per- cussion, fluctuation, and occasionally œdema of the abdominal wall develop. These symptoms, again accompanied by fever. become more pronounced, and unless interrupted by death or operation, a spontaneous rupture nearly always through the umbilicus affords escape for the pus. Three stages uns: thus be recognized-peritoneal invasion, accumulation ! exudate, and spontaneous rupture. The prognosis in thi- form, which undoubtedly represents a relatively benign is- fection, is good. Annand and Bowen report 86 per cent nt- coveries in 45 cases of this type.

In the diffuse form of the disease, the symptoms of onset are the same sudden abdominal pain, vomiting, diarrhea. fever-but they are all much more intense than in the local-

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."yo yuve negu, viven ranging well above )4° F. In these cases the virulence of the infection is much 'eater than the natural defence of the individual. Death may cur in 24 hours. Where the course of the disease is less rupt, there is often a brief apparent improvement at the end about 48 hours. In a short time, however, the symptoms 'ow more marked, abdominal distention, tenderness, perhaps ovable dullness become apparent. In short, the picture of tritonitis develops, with interesting qualifications, rigidity

a rule being far less marked than the other symptoms ould seem to justify, and there is diarrhea instead of con- ipation. There is a high leucocyte count, very elevated tem- rature and profound toxemia. The prognosis is exceed- gly grave. No such case has survived unless operated on. nnand and Bowen, in 46 cases, 18 of which were operated , record only 6 recoveries, 14 per cent.

The pathological findings, aside from the determination of e specific organisms, consist in the character of the exudate. his is, in most instances, thick, creamy, greenish-yellow, and orless. In a few cases, however, the pus has been described profuse, thin and of a turbid, dirty brown color. In either rm the presence of numerous flakes and deposits of fibrin characteristic. Several writers have. noted that the degree injection of the peritoneal surfaces seemed slight in pro- rtion to the amount of exudate present.

The treatment of any form would seem to be immediate parotomy and drainage, for the obvious and time-honored irpose of evacuating pus. There are, however, a few dissent- g voices from this opinion. Thus Nobécourt " thinks it un- se to operate too early, as in all cases surviving the first few ys the infection will localize and then there is less danger, in 3 opinion, of its being spread by the operator. Manifestly 's is simply leaving unaided nature to fight its own battle, d if it wins, doing nothing more than forestalling the spon- leous discharge of the pus. The cases which succumb are

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Twentieth Century History of Findlay and Hancock County, Ohio, and Representative Citizens, Part 123

Author: Jacob Anthony Kimmell Publication date: 1910 Publisher: Number of Pages: 1189

Author: Jacob Anthony Kimmell
Publication date: 1910
Publisher:
Number of Pages: 1189