Twentieth Century History of Findlay and Hancock County, Ohio, and Representative Citizens, Part 141

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

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The child was small, fairly well nourished, with marked dyspnea and tachypnea, respirations fluttering, 100 to the minute. The alæ nasi were dilating, the lips cyanosed, and with each expiration there was a short grunt. The head was negative; there was no mastoid tenderness, nor signs of aural or meningeal disease. There was moderate general glandular enlargement.

The thorax was rounded; a rickety rosary was palpable;

there was a tendency to "pigeon breast." The respire: movements were mainly abdominal and the thoracic erpe: was limited on the right side. The vocal fremitus wa: tested. Percussion revealed Skodaic resonance at the right : tympany over the upper portion of the right lower lole. impaired resonance in the axilla, merging into dultes- the base behind. On the left side Skodaic resonance wa: ent over the front as far as the third rib, though there " normal resonance below. Behind, dulness was present the apex to the mid scapular region; there was slightly paired resonance as far as the angle of the scapula, and : : resonance below. There was nowhere absolute flatness auscultation, intense tubular breathing was heard over upper fronts and backs, also over the lower right back .. numerous consonating crackles were audible in the dal' at the end of inspiration. Over the middle and upper; of the right lower lobe medium and coarse moist rar: a leathery friction rub were heard.

The cardiac dulness was not increased. There was c.

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below the costal margin in the right mammillary line, re a firm edge was readily palpable.

In November 24, there was a generalized clonic convulsion 1 unconsciousness, blepharospasm, turning of the head and jugate deviation of the eyes to the left, and loss of sphincter ;rol. After it had lasted fifteen minutes, the paroxysm aborted by immersing the child in a hot mustard bath. ty November 27-the eighteenth day of the illness-the s of consolidation at the apices had practically disap- ed, but dulness, with tubular respiration and crepitation, still present over the right lower axilla and back, and for the first time a to-and-fro friction rub was audible this area. The signs of consolidation were made out on left side, from the apex to the angle of the scapula, and over the lower front and axilla, where too there was a nery rub. Two days later, the condition was more grave, over the right mastoid, involving the tissues over an about 5 cm. in circumference from its tip, there was a e ruptured bleb with brawny induration and tenderness it it, and the associated lymph glands were tender and len. The right tympanum was now tense, red, and erless. At 7 p. m. the child began to vomit and at 7.25 . suddenly expired.

uring the disease the temperature ran an irregular course nd 103º F., showing marked remissions after the sponges, fever occasionally falling as much as 3ºF. in two hours. pnea was marked and persistent, the respiratory rate ing from 60 to 106 to the minute. Tachycardia was also ounced, the pulse ranging from 140 to 195 to the minute. nis clinical picture is common-a case of pneumonia with of its most usual complications, mastoiditis-but the I findings make the case of interest.

1 admission, the red blood cells numbered 4,860,000 :mm., the hæmoglobin was 87 per cent (Sahli) and the cytes 130,000 per cmm. Seven hours later, the leucocytes 144,000 per cmm .; on the morning of November 24, had increased to 183,000 per cmm. and that evening ed a maximum of 206,000 per cmm. During the ving four days they varied between 126,000 and 156,000, with the onset of the mastoiditis again rose to 192,000 mm.

e marked leucocytosis caused us to suspect the presence purulent focus, or the possibility of a leucemia with a nal pneumonia. The former we had no reason to le, inasmuch as there were no signs of pus anywhere, idence of an empyema, of a sinus infection, of otitis or stoiditis, the latter not appearing until the day of death. ¡sible leucemia was excluded by the differential counts : "lich Stain .- The red corpuscles showed very little poly- atophilia, no marked anisocytosis or poikilocytosis, few blasts and no megaloblasts. The white cells, in general, readily classified, one type, however, being difficult to fy, i. e., a rather large cell with pale homogeneous, pink- ng, non-granular cytoplasm, and a slightly lobulated

in 500 cells counted there were :

Nov. 24.

Nov. 26.

Nov. 29.

Polymorphonuclear

Cells. %

neutrophiles

260

280

300

270

Polymorphonuclear

eosinophiles

Lymphocytes

120

105

100

110

Large mononuclears ..

0.6

1.6

Transitionals

Myelocytes

14.0

Unclassified

4.4

2.4

500 100.0

500 100

In 500 white cells counted there were:

Normoblasts

Megaloblasts

The relative lymphocytosis is not unusual during an acute infection in a child of four, and the presence of 12 per cent of myelocytes does not necessarily militate against a diagnosis of leucocytosis as differentiated from leucemia (Cabot, Mus- ser and Steven). Moreover, the absence of a marked anæmia and the post mortem findings exclude a leucemic process.

The post mortem findings were as follows (Dr. Winternitz) : Anatomical Diagnosis. - Broncho-pneumonia, bilateral. General lymphoid hyperplasia and hyperplasia of the bone marrow. Acute mastoiditis, right, with thrombosis of the superior petrosal sinus and of the adjacent sinuses of the brain. Congestion of the brain, especially of the right hemi- sphere. Cloudy swelling of the liver and of the kidneys.

The body is that of a fairly well nourished child 93 cm. in length. Rigor mortis is present. Over the right mastoid there is swelling with reddening of the skin, the upper layers of which are broken.

The peritoneal cavity is normal except for a great enlarge- ment of the mesenteric lymph glands, which, on section, have a gelatinous, homogeneous appearance.

The left pleural cavity contains a slight excess of straw- colored fluid ; the right is partially occluded by recent fibrinous adhesions.

The thymus is small and pinkish brown in color.

The heart is not enlarged; the myocardium and the valves are normal.

Lungs: the left lung is pale, voluminous, and retains its shape after removal. It is everywhere crepitant except over a few small areas of consolidation in the posterior portion of the lower lobe. The bronchi contain an excess of fluid, and the bronchial lymph glands are much enlarged. Right lung: the pleural surface is covered with a friable grayish exudate which is several millimeters in thickness. Two-thirds of the lower lobe is occupied by areas of consolidation which, on section, are dry, granular, and slightly translucent, and there are a few small areas of like character in the upper lobe.

The spleen measures 9 x 4 x 2 cm. and retains its shape after removal. Its capsule is delicate and the red splenic pulp is seen through it. On section, the Malpighian corpuscles are gray and tremendously enlarged; so much so, that neighboring

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ones are almost in contact. Neither the fibrous tissue nor the pulp is much increased.

The stomach, the duodenum, the pancreas, and the intes- tines are normal. There is no hyperplasia of Peyer's patches or of the solitary follicles.

The liver measures 19 x 12.5 x 5 cm. The capsule is thin and delicate. The liver parenchyma is purple in color, and on section the lobules are large and distinct. The gall bladder is normal.

The brain: the dura mater is thick and adherent. The right cerebral hemisphere is covered with dilated vessels; the left is pale and only a few of the vessels are injected. The superior and inferior petrosal sinuses on the right are dis- tended and filled with thrombi. There is a large amount of pus in the spongy portion of the bones of the right middle ear, and the ossicles lie free in a necrotic sequestrum. The brain tissue is normal except for the congestion of the right hemisphere.

Microscopic Examination .- Lungs: the pleura is covered by an exudate consisting mainly of polymorphonuclear leucocytes. The alveoli of the lungs are filled with an exudate varying from a very cellular material in which mononuclear cells predominate, to one almost purely fibrinous in character, and where the latter type is present the alveolar walls are involved. In places there are zones of coagulation necrosis.

The thymus shows well preserved gland tissues with con- spicuous Hassal's corpuscles.

Sections of several lymph glands show a marked dilatation of the sinuses, in which there are many large mononuclear cells with pink-staining cytoplasm and vesicular nuclei. A few of these cells show definite granular inclusions. The lymphatic strands are coarse and show an increase of the mononuclear clements. The centers of the lymph follicles stain deeply and uniformly with eosin.

In the anterior and middle portions of the hypophysis are cyst-like areas which contain colloid in excess, and in one of these areas there is a fibrous thickening in which there are a few typical mucous glands.

The liver cells are swollen and there is an infiltration of the parenchyma with mononuclear cells, some of which have deep pyknotic nuclei. Polymorphonuclear leucocytes are less numerous, and only an occasional myelocyte is seen. The stellate cells of Kupfer are enlarged, and in some places have taken on phagocytic activity. The predominating cell in the blood clots is the large mononuclear lymphocyte.

The bone marrow shows marked hyperplasia, but there are still some areas of fat remaining. In the smears and sections the large neutrophilic myelocyte is the predominant cell. The erythroblastic tissue is increased somewhat less than the myeloblastic and relatively few normoblasts and megalo- blasts are seen. The polymorphonuclear neutrophiles are relatively few and there are many giant cells. With Ehrlich's stain only a few myeloblasts are seen. In the marrow there are several small areas of hæmorrhage, and near the areas of softening a few small thrombi are found.

Hyperleucocytosis in the sense of excessive leucocytosis is not uncommon and counts of 80,000 or more leucocytes per

cmm. have been reported in many conditions. Lewor_ mias of over 100,000, except in leucemia, however, are .: paratively rare. The following may be cited as the met .. counts found in a cursory survey of the literature : : subject :

Limbeck,' quoted by Sisto,' noted a leucocytosis of 1?). in a patient with multiple carcinoma, and Kast reparei. identical count in a similar condition.

Hirschfeld and Kothe' report a leucocytosis of 1% (56 per cent polymorphonuclears and ? per cent myelo y. in a case of appendicitis gangrenosa complicated i: hæmorrhage from a duodenal ulcer. This is a most phenc. enal finding, as may be seen from the exhaustive stu !! Busse.‘

Felsenthal " counted 148,229 leucocytes per cmm. in a d with gangrenous diphtheria and petechia.

Osler® cites a case of lobar pneumonia with 114,000 r: cells, and Læhr, quoted by Emerson,' Arneth and Tis found 115,000 leucocytes per cmm. in a similar case, and t:+4 authors could find no more marked leucocytosis in pnenr .: reported in the literature as late as 1904. Cabot' ment : a case of broncho-pneumonia complicating pertussis, it girl aged six years, where the leucocytes reached 94,6[0 ; cmm. and another case where they were 185,000 per it"

The most marked leucocytosis in pneumonia in the row of the Johns Hopkins Hospital is 105,000 per cmin. i. man aged 25 years.

Fletcher and Sappington 1º reported a case of spleno-hepat cirrhosis in which there was a leucocytosis of 136,000 per cr." (89 per cent polymorphonuclears) and this is cited by Cat " as the most marked polymorphonuclear leucocytosis he e .. find on record.

Those who have reviewed the literature on leucocytes : to have overlooked an article by Steven " on broncho-pr. monia in childhood, in which a case is reported witt; leucocyte count of 236,000 per cmm. (33.6 per cent polyz. : phonuclear, 50.2 per cent lymphocytes, 15.2 per cent lars mononuclears, 0.57 per cent eosinophiles). This case, it : seen, is practically identical with the one here described. i. a child twenty-two months old, with cyanosis, dvspt- tachypnea (103 to minute), crepitant râles over both lus .: and convulsions.

To sum up, we have here a phenomenal hyperleucoeros. occurring in a case of broncho-pneumonia in childhood.

The formula as determined by repeated differential conz: shows a marked mononucleosis and a moderate myelocytosis- a picture neither uncommon nor unique in this disease.

Leucemia is definitely excluded by the history, by + physical findings and by the necropsy.

The case seems worth recording, as this hyperleucocytes: is second only to that reported by Steven in a similar Cas -

REFERENCES.

1. v. Limbeck, R. R .: Pathology of the Blood. New Sydenbar Society, 1901, 174.

2. Sisto, P .: Contribuzione allo studio delle pneumoniti asteza che. Policlin., Roma, 1907, XIV, sez. prat., 993.

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:comose, W .: Die Leukocytose eine Schutzvorrichtung des pers gegen Infektion. Arch. f. Gynaek., 1908, LXXXIX, 1-120. Felsenthal, S .: Hæmatologische Mittheilungen. Arch. f. derh., 1892-93, XV, 78-91.

Osler, W .: American Text-Book of the Theory and Practice Medicine, 1894, 212.

Emerson, C. P .: Clinical Diagnosis, 1906, 568.

195.

10. Fletcher, B. K., and Sappington, S. W .: Spleno-hepatic fibrosis with a remarkable leucocytosis. Am. Med., Phila., 104, VIII, 239-242.

11. Cabot, R. C .: Osler's Modern Medicine, 1907-10, IV, 1608.

12. Steven, J. L .: Acute Infantile Broncho-Pneumonia. Lan- cet, 1902, II, 791-795.

IE VIABILITY OF PARASITIC OVA IN TWO PER CENT FORMALIN, WITH ESPECIAL REFERENCE TO ASCARIS LUMBRICOIDES.

By ROGER S. MORRIS, M. D. Associate in Medicine, The Johns Hopkins University.

(From the Clinical Laboratory of The Johns Hopkins Hospital.)

t has been a routine procedure for several years in the ical laboratory to preserve stools, for purposes of demon- tion, with formaldehyde. The fæcal material is finely iminuted in water so that a relatively thin suspension is tred. Commercial forty per cent formalin is then added the fæcal suspension in such quantity that the resulting ture contains the reagent in a strength of two per cent. most purposes stools are well preserved in this way and en tightly stoppered in bottles, may be kept for an almost efinite period. Putrefaction and fermentative changes inhibited successfully.

'he chief purpose for which we have employed formalin been the preservation of material containing parasitic

Eggs of the commoner cestodes of man-Tania saginata, nenolepis nana, and Dibothriocephalus latus, have retained r morphology fairly well, though the thin-shelled ova of last two have shown greater alteration than those of lia saginata. To all appearances, the eggs have been killed, o evidence of further development has been observed.

rematode material has been more scanty, as we have only specimens of Schistosoma hæmatobium and Schistosoma nicum. The former has shown less change in shape, and oth specimens the eggs appear to have been killed.

ith nematode ova, there have been rather interesting Its. The eggs of the hook worm, Ankylostoma duodenale Necator americanus, exhibit a certain amount of distor- of the shell. The formalin apparently does not kill the at once. Faces containing eggs in the two-, four-, and -cell stages have been found later to have ova which in majority of instances have passed beyond this stage, though I must be reasonably prompt, as we have never found yos within the shell or free in the fæces. Inasmuch as ame stool has been examined by eighty to ninety or more nts simultaneously, some of whom have studied several trations, it seems probable that embryos would have observed, if present. Eggs of Trichuris trichiura and cyuris vermicularis have presented no signs of develop- in fæcal suspensions containing two per cent formalin.

Findings of special interest have been met with in connec- tion with the ova of Ascaris lumbricoides. In January of 1909, while demonstrating a stool containing the eggs of Ascaris lumbricoides to the class, it was noted that many of the ova contained embryos which frequently exhibited active motility within the shell. The stool was of unknown source, unlabeled, and had been on a shelf exposed to the light but not to the direct rays of the sun for an unknown length of time. It had probably been preserved with formalin (odor). The same specimen was demonstrated to classes in June, 1909, January and June, 1910, and again in January, 1911, and on each occasion actively motile embryos were observed within the shell. In fact, they were so numerous that there was practically no difficulty in demonstrating them in every prep- aration examined. Embryos which were well preserved but non-motile during the short period of inspection were much more abundant than those seen in a state of active motility. Often an ovum containing a living embryo had lost the albuminous envelope. A few embryos which had escaped from the shell were observed but in all instances they were dead. An examination of the stool on May 19, 1911, demon- strates that living embryos still persist, i. e., about twenty- nine months after they were first observed in the specimen. How much longer they have been there it is impossible to say.

An opportunity to confirm the results just narrated presented itself some time ago. O. R., Surgical No. 25086, white, æt. 13, was admitted to the surgical service of Profes- sor Halsted on December 4, 1909, on account of double cataract. The routine fæcal examination disclosed the pres- ence of " many Ascaris lumbricoides ova in the stool." The eosinophiles amounted to seven per cent. On December 9, 1909, a specimen of fæces was suspended in water and for- malin was added so that it was present in a strength of two per cent. Microscopic examination at that time showed an enormous number of ova of Ascaris lumbricoides, both fertilized and unfertilized, the former predominating. The stool was demonstrated to the class in January and June, 1910. The ova were well preserved and no suggestion of

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embryo formation was noticed, although carefully looked for. January, 1911, the specimen was used again for class demon- stration and at this time a few fertilized ova were found which contained embryos, some of them actively motile. On May 19, 1911, examination of the specimen shows an ap- parent increase in the number of eggs which possess embryos, and in the first preparation studied an active parasite was seen. All seem to be well preserved morphologically and in the more mature embryos it is probable that prolonged inspec- tion would reveal definite signs of life. Since the specimen was first obtained, it has been kept in a brown glass bottle, securely corked, on a shelf in the laboratory where it has been constantly exposed to the light but, like the preceding specimen, protected from the direct rays of the sun. It is unfortunate that examinations have not been made at more frequent intervals to determine how soon the living embryos first appear. They probably developed sometime between the sixth and thirteenth month.

That the ova of Ascaris lumbricoides are extremely tena- cious of life has long been known. Davaine1 showed that the eggs may be viable and still exhibit no sign of develop- ment for a considerable period of time. From the faces of an infected child he recovered the eggs of Ascaris lumbricoides by washing the dejecta. They were then transferred to water on October 8th. The material was examined from time to time and it was not until the following April 14 that signs of development were noted. Three weeks later the embryos

were seen in the shell. Later Davaine' showed that the ec. bryos may remain alive in the shell for three years. Stilest: Gardner ' have recently demonstrated that ascaris eggs & quite resistant to decomposition. In fæcal matter kept !: four months (117 to 121 days), about eighty per cent of te ova appeared to be dead. Leuckart' proved that the ora ca: withstand desiccation, which, however, arrests the embryoge. process.

Thus, it is evident that the viability of Ascaris lumbricoides ova is not easily destroyed under the conditions usually t .: with in nature. It might therefore be supposed that & eggs would prove less susceptible to antiseptics than the- of the other common intestinal parasites of man. IFi formaldehyde, at least, this is the case. An incomplete revis of the literature on Ascaris lumbricoides has failed to mevai similar observations.

REFERENCES.

1. Davaine, C .: Recherches sur le développement et la propa- gation du trichocéphale de l'homme et de l'ascaride lumbricoite Compt. rend. Acad. d. sc., Par., 1858, XLVI, 1217.

2. Davaine, C .: Nouvelles recherches sur le développement la propagation de l'ascaride lumbricoïde et du trichocéphale de l'homme. Compt. rend. Soc. de biol., Par., 1862, IV, 261. 3. Stiles, C. W. and Gardner, C. H .: Further Observations cz the Disposal of Excreta. Pub. Health Rep., U. S. Pub. Health Mar. Hosp. Serv., Wash., 1910, XXV, 1825.

4. Leuckart, R .: Die menschlichen Parasiten, Leipzig az: Heidelberg, 1876, II, 210.

ANTERIOR POLIOMYELITIS-NOTE.

The Rockefeller Institute for Medical Research, of New York City, announces that it will devote its resources very largely during the present season to the study of anterior poliomyelitis (infantile paralysis) and to the treatment of acute cases of this disease in its hospital. Physicians and health officers desiring to co-operate in this investigation may do so by sending information concerning the occurrence and prevalence of this disease, or by referring acute cases to the Hospital of the Rockefeller Institute. Dr. Flexner renews his request of last year that whenever possi- ble a portion of the spinal cord and of the naso-pharyngeal mucosa derived from fatal cases of the disease be sent to him. Specimens should be preserved in glycerin and sent by mail to Simon Flexner, M. D., 66th Street and Avenue A, New York City.

Anterior poliomyelitis * is, so far as known, a communicable disease, being communicated from one patient to another and also by means of a third person. It occurs in epidemics and tends to spread along the lines of greatest travel. There is reason to be- lieve that it is prevented from spreading by quarantine, and with the very great prevalence of the disease in the summer of 1910 it is the opinion of this committee that it is essential that it should be made a reportable disease in all States in order that its presence may be detected and its spread guarded against.

* Circular issued by the American Orthopedic Association and the American Pediatric Society in reference to acute epidemic poliomyelitis, and addressed to health authorities and boards of health.

Of particular significance are the so-called abortive cases, where indefinite ailments occur in children in communities where fraci paralysis also exists. These abortive cases of infantile paralys: are undoubtedly a source of infection, and their record and study is of much importance. In a community where cases of infantil paralysis occur, cases of illness with sudden onset of ferer ! meningeal symptoms should be closely watched and regarded # possibly infectious. In such cases even recovery without part. sis does not establish the fact, that the case was not abortire infantile paralysis.

All cases of infantile paralysis should be strictly quarantine: sputum, urine and feces being disinfected, and the same rig. precautions being adopted as in scarlet fever. This quaranti» should, in the opinion of the committee, last for four weeks i: the absence of definite knowledge as to when the infection ends Children from infected families should not be allowed to go to school until the quarantine is abandoned. The transportation c: transfer of acute cases in public conveyances should be strict: forbidden. It would be very desirable to adopt provisional qua antine measures in suspicious cases in a community where sn epidemic prevails. The report of all cases of infantile paralge's to the public health authorities should be enforced by law, 12. all deaths from this cause should be properly described sz: registered. A careful study of epidemics by public health authorities is strongly advised.

(Signed) ROBERT W. LOVETT, M. D., Chairman HENRY KOPLIK, M. D., H. WINNETT ORR, M. D., IRVING M. SNOW, M. D., Secretary.

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VIVA AIR AND FUR OUTDOOR SLEEPING."

By S. ADOLPHUS KNOPF, M. D.,

Professor of Phthisiotherapy at the New York Post-Graduate Medical School and Hospital.

Every physician interested in the treatment of tuberculosis nows how difficult it is to have anything in the line of addi- onal porches or verandas built onto a city home. First of l in cities, like New York for example, wooden constructions :e not permitted. The vast majority of houses are tenement r apartment houses, and even if there should be space, the wner would not permit any addition.

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Twentieth Century History of Findlay and Hancock County, Ohio, and Representative Citizens, Part 141

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

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