USA > Ohio > Hancock County > Findlay > Twentieth Century History of Findlay and Hancock County, Ohio, and Representative Citizens > Part 158
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FIG. 6 .- Gyn. Path. No. 15613. This section shows a portion of the recurrent tumor which is purely sarcomatous in char- acter. Note the number of large atypical cells.
FIG. 7 .- Gyn. Path. No. 15613. This shows a section through the thickened and nodular omentum. The adenocarcinoma is well marked. The stroma shows no evidence of sarcoma.
THE BLOOD-PICTURE IN HODGKIN'S DISEASE. By C. H. BUNTING, M. D.
(From the Pathological Laboratory of the University of Wisconsin.)
e blood-picture of Hodgkin's disease, as manifested in trious published cases, has been critically considered by n' in a recent article, and his findings are summarized lows :
The most frequent blood-picture found in the course dgkin's disease is a polymorphonuclear neutrophile leu- osis of moderate grade.
The blood-picture may be unmodified (about one-fifth cases).
In about one-fifth of the reported cases there is a more s well marked leukopenia, either present throughout the course, or transitory, and if the latter occurring more ently in late stages.
Qualitatively, the blood shows a relative neutrophile tytosis-that is, an increase in percentage up to 99 per nd more; with a corresponding decrease in lymphocyte tage to 3 per cent and, in two cases, to practically 0 nt; most frequently at the same time with an absolute ytosis, at times with a leukopenia and, rarely, with a 1 count.
In about one-fourth of the cases there was an eosino- usually slight or moderate, seldom of marked degree. Very seldom one may find a mastzell increase.
Scattered myelocytes were noted-very rarely enough mate.
In one case an enormous increase in blood-platelets ted.
At times, though usually transitory, a slight, rarely :ed, lymphocytosis may be noted.
In the course of the disease there develops a second- emia, at first moderate, but later pronounced.
an's general conclusions from his study of these cases while there may be characteristic features of the blood-
her klin. Wchnschr., 1910, XXIII, 1515; Centralbl. f. allg. 911, XXII, 145.
picture in Hodgkin's disease, they are not constant enough to be of diagnostic value, and that in further study an attempt should be made to correlate the blood picture and that found in the glands. During the past three years the author has been making such a study in conjunction with Dr. J. L. Yates, of Milwaukee, and, while his findings are in general in agreement with those of Fabian, yet, on the other hand, they are sufficiently at variance to seem to warrant publica- tion. There are two features of this study which may be emphasized, and which add to its value. In most of the cases at least one blood count has been made just previous to the removal of a gland for section, and further, all the smears have been examined by one person, the author, who has used the same staining and counting technique throughout.
In a previous paper' I have emphasized one of the most marked characteristics of the blood smears of Hodgkin's dis- ease, that is, the presence of a large number of blood-platelets, inclusive of unusually large platelet forms, practically meg- alokaryocyte pseudopodia. This has been observed in all the eleven cases forming the basis of this report, both in early and in late cases, and over considerable periods of time in cases on which blood counts have been made at intervals.
From this constant finding and from pathological findings in autopsy material from cases of Hodgkin's disease, it was suggested in the previous report that the toxin of the disease acted as strongly upon the platelet-forming elements as upon the lymphocytes. An eventual necrosis of megalokaryocytes in the bone marrow was found. One might have predicted from this finding that in late cases an exhaustion of platelets might take place, resulting in a low platelet count in the circulation. Such a case had not occurred in the author's series at the time of publication of his first report, but since then Case V of the series has shown such a change. After
' Johns Hopkins Hosp. Bull., 1911, 114.
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370
JOHNS HOPKINS HOSPITAL BULLETIN.
having shown a high platelet content of his blood in counts at intervals from November 9, 1909, to September, 1910, the boy returned to the Columbia Hospital, Milwaukee, in April, 1911 with serious hæmorrhages from the mucous membranes, with a secondary anæmia, a leukopenia-3500 to 4000-and fewer platelets than leukocytes, as shown by repeated ex- aminations made during April and May. However, while exceptional or terminal cases may show this platelet exhaus- tion, the excessive number would appear to be constant in the course of the disease.
Coincident with this platelet study, careful study of the leukocyte picture in the disease has been made and has led to the conclusion that in the combined platelet and leukocyte picture one has features that are very characteristic and, in fact, almost pathognomonic of Hodgkin's disease. While from my experience I believe that the diagnosis may be made from examination of the blood smear, I would not recommend the method to the exclusion of the histological examination of an excised gland. The latter method is too simple to neglect, but, where glands are inaccessible, or where per- mission for removal is not obtained, the examination of blood smears is very helpful, and is especially convincing if backed by a negative von Pirquet reaction.
In this study, blood smears from eleven cases of Hodgkin's disease have been carefully examined and differential counts made. In a few cases several counts have been made at in- tervals of some months, giving confirmatory evidence of the value of the picture. The cases have varied in their stage of development from early cases to those a few months from the. fatal termination, so that it has been possible to note the changes which take place in the blood-picture with the de- velopment of the disease.
.
The blood smears have been stained with Wright's stain for the purposes of the counts, although Ehrlich's triple stain has been used for the determination of certain features. Five hundred cells have been the routine and the smallest number counted, but in some cases this has been exceeded. The leukocytes have been grouped into seven classes, except in a few of the early counts where but six were made. These groups are: (1) Polymorphonuclear neutrophile (N.) ; (2) Eosinophile (E.) ; (3) Basophile (mastzell) (B.) ; (4) Small lymphocyte (S. L.) ; (5) Large lymphocyte (L. L.); (6) Large mononuclear (I .. M.) ; (7) Transitional (Tr.).
While the first three groups need no explanation, a word may be due as to the divisions of the so-called mononuclear or non-granular groups. Study of blood smears from normal individuals, stained with the Romanowsky stains, shows four distinct types of mononuclear cells. However, in studying large numbers of these cells, one finds that the distinctions in size and staining reaction are not always sharply made; that is, the groups overlap somewhat, so that the separation becomes more or less arbitrary. This is especially the case in regard to the small and large lymphocyte groups, and in regard to the large lymphocyte and the large mononuclear. In the earlier counts the last two groups were included under a single head. Although this grouping may be artificial and
arbitrary, the same standards were employed throng: - forming a judgment, and the separation may be ce value.
The groups are characterized as follows:
(1) Small Lymphocyte .- A cell with deeply === nucleus, which scarcely exceeds a red-blood cell in der- and with a scant rim of basophilic protoplasm.
(2) Large Lymphocyte .- A cell usually almost the sa a neutrophile leukocyte with nucleus larger than the: preceding class, and with protoplasm more abunda basophilic as a rule, and containing numerous coars, times almost rod-like metachromatic granules.
(3) Large Mononuclear .- A cell larger than a next leukocyte, with large round or oval nucleus and corsi protoplasm, staining a fairly deep blue and contar .; times a few fine metachromatic granules.
(4) Transitionals .- The largest cells of the groups nuclei of various shapes, from simple indented na .. lobed, mulberry-shaped, or even ring-shaped nuclei; ari abundant clear, light-blue protoplasm thickly dotted : metachromatic granules which do not stain with Et :. triple stain.
As the transitional leukocyte forms a prominent fes: the differential picture in Hodgkin's disease, a furt:3 in regard to it seems necessary. It is quite evident;r : named, for it bears no relation to the polymorphic: neutrophile. To one " brought up " medically on the E: stain, this cell as revealed by Wright's stain comes a: 8: prise. With the Ehrlich stain, the nucleus is but f .: stained and its structure is poorly brought out, wb .- protoplasm usually appears as an unstained halo, or w .: a slight tint and with but an occasional granule. Wright's stain, however, the nucleus stains sharply. massive and of a protean variety of shapes-knobbel,: twisted, folded, ring-shaped. So complex are the no: least in Hodgkin's smears, that one is at first inclic- believe he is dealing with a foreign cell. Yet the : present in normal smears to the extent of from 6 ti cent of the leukocyte count, and the nuclei appear six not fully as complex as in Hodgkin's smears. The ! plasm of the cell stains a clear blue and is crowded wi azure granules finer than those of the neutrophile leuk. They are finer also than the platelet granules, but bai- same tint. As noted above, they are unstained by the E:" stain. I do not desire to discuss the relation of the : tional cell to other cells or to enter into the question :. origin, further than to say that cells morphologiesi; . tinctorially similar may be found in smears from D: lymph glands.
Preliminary to the detailing of the blood count: ir Hodgkin's cases examined, it should be said that al. smears, with the exception of the late ones in Case I .. very abundant platelets and in every case also large !" forms and pseudopodia were present. The leukocyte ." nations and the brief clinical points necessary, follow:
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0
C 1
;kin's changes. 1 counts:
Gradual improvement under treatment.
Date. 20, '08 ..
R. b. c. 5,804.000 4,968.000
W.b.c. N. 7.500 51.2
E 8.2
B. S. L. L L. 1.6 25.4 0.8 23.6
10.
6.6
11, '09.
5,800,000
7,000 65.8
2.8
0.0 16.8
7.6
1.2
5.8
16, '10 ...
5 800,000
7.000 59.8
4.0
1.4
15.4
1.8
9, '11 ...
8,500 65.0
2.6
1.2 21.2
0.6
SE II (Dr. Yates) .- Male, white, 10. Large mass of dis- glands in left cervical region of at least one year's dura- previous to removal, November 10, 1908. Glands show marked Hodgkin's picture. Von Pirquet reaction negative ver 8, 1910. Gradual improvement under treatment. Blood :s:
Date.
R. b. c. 4,712.000 5,250,000
W.b.c. N. 9,500 56.2
E 8.6 8.6
B. S. L. L. L. 0.4 16.4 0.0 12.0
7.4 11.0 6.8
12. '10.
8, '10 ..
4 960,000 9,800 53.2
58.4
5.2 5.2
1.0 13. 0.4 27.8
12.0 16. 4.
2.0 1.8 1.4
BE III .- April 1, 1909. Male, white, 30. Seen 2 weeks after d operation for glands of neck. First operation 6 months ous at Rochester. Diagnosis, Hodgkin's disease. Blood
ate. R. b. c. W.b.c. N.
'09 ... 4,560,000 10.000 79.4 0.2 0.4 5.8 3.4
E. B. S. I .. L. L. L. M. Tr. 10.8 JE IV (Dr. Tupper, Eau Claire, Wis.) .- February 5, 1910. le, white, 40. Onset, - months previous in right inguinal s. Subsequent involvement of left inguinal, left axillary, ind right cervical glands. Test gland shows well-marked > Hodgkin's picture. Death in October, 1910. Blood count: Date. 5, '10 ..
N.
E. B. S. L. L. L. L. M. Tr. 0.2 89.2 10.6 2.8 10.6
E V (Dr. Yates) .- November 9, 1909. Male, white, 8 years. gement of cervical glands began 5 months previous to Left inguinal glands also enlarged. Test gland, November 909, shows hyperplastic stage of lesion. January, 1910, :al glands removed. October, 1910, von Pirquet test nega -.
April, 1911, mucous membrane hæmorrhages, anæmia. counts:
Date. 9, '09.
R. b. c. W.b.c.
N.
E. 4.6
B. S. L. L. L. 0.4 21.8 0.6 26.8 0.4 22.4
8.6 7.2
8.8
'6, '10 ..
5,000,000
5,000 55.2
59.4
1.
1.2
5.
:1, '11.
5,160,000 8,456,000
4,800 63.2
1.8
1.
1.4 17.8
isfused.
'4, '11.
3,176.000 2.624 000
8,800 54.
8,300 67.6
1.4 1.4 6.8
0.6 12.6
isfused.
5. '11 ..
2,760.000 3,200,000
4,000 50.8
4.
1.6 25.8
0.6 10.8
isfused. 0, '11 ..
0.4 14.2
3 '11.
...
3.400.000 8.712,000 3,680,000
.. 8,500 8.400 3,600
55.8 56.4
8.2 0.0 19.8 3.6 3.4 1.6 18. 8.1
1.2 0.6 11.8
E VI (Dr. Sullivan, Madison, Wis.) .- March 1, 1910. Male, 16. Left cervical glands much enlarged. Marked indura- f neck. Enlargement noted for only 1 month, but the t of sclerosis in test gland suggests greater duration. 10, wound resulting from removal of gland for diagnosis nhealed. May 13, wound healed but induration of neck 1. Blood counts:
Date.
W.b.c. N. E. B. S. L. L. L. L. M. Tr.
10, '10.
18,000 81.6 27,000 80.6
1.6
0.0 7.8 2.8 0.8 6.4
VII (Dr. Bennett, Oregon, Wis.) .- January 5, 1910. , white, 64. In October, 1909, general glandular enlarge-
Date.
R. b. c. W.b.c. N. 4,480 3,200,000
E. B. S. L. L. L. L. M. Tr.
X. 24, '09. I. 5, '10.
51.8 4.2 0.4 20.0 9.8 1.6 9.2
CASE VIII (Dr. Yates) .- Male, white, 33. Onset in March, 1907, with supraclavicular glandular enlargement. In September, 1908, supraclavicular and left axillary glands most enlarged. Some enlargement of right cervical, axillary and inguinal glands. October 30, 1908, excised gland shows typical and, advanced Hodgkin's disease. Death occurred May 20, 1909. Blood count: Date. N. E. B. S. L. L. L. L. M. Tr. I. 10, '09. 76.2 1.4 0.6 7.6 6.0 8.2
CASE IX (Dr. Yates) .- October 3, 1910. Male, white, 5. Marked enlargement of left cervical glands of 5 months dura- tion. Test gland shows well-marked Hodgkin's changes. Death from shock at operation. Blood count:
9.8 8. Date. R. b. c. W.b.c. N. E. B. S. L. L.L. L. M. Tr.
X. 8. '10. .
5,160 000 4,200 54.4 2.4 0.2 22.6 8.6 2.4 9.4
CASE X (Dr. Yates) .- Male, white, cervical Hodgkin's. Count made 2 months previous to death of patient.
W.b.c. N. E. B. S. L. L. L. L. M. Tr.
Date. IV. 80, '10.
14,800 84. 0.0 0.0 8.8 1.0 1.0 10.8
CASE XI (Dr. Baird, Eau Claire, Wis.) .- December 8, 1910. Male, white, 22. Enlargement of supraclavicular gland noted one year previous. Axillary glands enlarged at date. Test gland shows definite Hodgkin's picture. Blood count:
Date. XII. 8. '10.
N. E. B. S. L. L. L. L. M. Tr.
81.8 0.2 0.6 2.6 2.6 1. 11.2
When one examines these counts critically in an attempt to correlate the counts with definite stages of the disease process, he is confronted with difficulties arising from the facts that all parts of the lymphoid tissue are not affected, and further, that, of any large group of glands affected by the disease, the individual glands may show different stages of development of the process. Yet there are some points in the counts which stand out definitely. The most striking feature per- haps is the constant high percentage of the so-called transi- tional cells. This high percentage occurs not only when the total leukocyte count is approximately normal, but also is maintained even when there is a sharp leukocytosis. With a normal total count of leukocytes the percentage of transi- tionals approximates 10; with a very marked leukocytosis, as in Case VI (27,000), one may have a reduction (6.4 per cent) ; while in a leukopenia, as in Case V, the percentage rises to 17.8 in a total of 4800. The series indicates, then, that throughout the disease there is a relatively large num- ber of these cells in the circulation. When one recalls that similar cells are found in smears from normal lymph glands, and also that in Hodgkin's disease there is a marked prolif- eration of the endothelial elements of the glands, it is diffi- cult not to draw the conclusion that such a proliferation results in this excessive transitional content of the blood. Such a suggestion, however, cannot be considered as proved.
The lymphocyte count has varied much in these cases, but there is a definite tendency for a percentage decrease from a normal or slightly increased count in early and active stages to a very low count in later stages. Thus in Case IV we find
Digitized by
10.2
10, '09.
9,900 59.4
50.8
5.8
1.4
9.2
2.0 9.4 10.4
7, '10.
16.4 10.2
6.6 4.6
1.8 14.6
2. 122
4.500 51.6
2.6 18.8 7.6 6.4
0.6 0.8
17.6
0.4 18.8
2, '11 ....... ..
60. 58.2
9.8 4.8
8.2 6.8 6.4
16.4
4, '09 ..
4.800 55.2
2.4
8.8 3.
8.8 6.4
L.M. Tr.
1. '09.
22, '10 ..
9,600 63.6
8,700
6.8 0.2 17.8 4.8 9.6
0.6 18.8
9, '11.
volunta ou, Lavo, showed early
L. M. Tr. 8.6 11.4
0.6 0.4 4.2 8. 1.6 8.6 18, '10. .
L. M. Tr.
36. 0.6
372
JOHNS HOPKINS HOSPITAL BULLETIN.
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49.8 per cent of small and large lymphocytes in an active phase; in Case V, 31.6 per cent; in Case IX, 31.2 per cent. On the other hand, in the advanced cases, X, XI, III, we find from 4 to 8 per cent.
With this decrease in lymphocyte percentage, we find a corresponding increase in the polymorphonuclear count, from a relatively normal count during the course of the disease, to a relatively high count (76.2, 79.4, 81.8, 84 per cent) in the terminal stages or when the periglandular infiltration and induration are marked. The neutrophiles appear there- fore to be unaffected except by extra-glandular processes and not by the changes taking place within the glands themselves.
Quite the opposite is the relation of the disease to the eosinophile. Eosinophiles are found in the glands in large numbers. Remembering that the count of cells in the per- ipheral blood represents but the ratio of supply to demand, it is not surprising to find very low counts of eosinophiles during the active progress of the disease (0.6 per cent or less in six of the cases). In reactive or quiescent cases, how- ever, the count is higher, either toward the upper limit of normal, or slightly above. The highest count found was 8.6 per cent in Case II, if one excepts the 9.8 per cent found in Case V twenty-four hours after transfusion. If, as seems probable to the author, from a study of lymph glands at autopsy in a variety of conditions, the products of destruc- tion of lymphocytes are positively chemotactic for eosino- philes, and if the findings above are not exceptional, the eosinophile count in cases of Hodgkin's disease would seem a good index of the progress or activity of the disease.
There is no striking change in the basophile count, or in that of the large mononuclears.
While these deviations of the Hodgkin's blood-picture from the normal are pronounced, the question naturally arises as to how they compare with counts in other diseases of the lymph glands. My series of counts in other conditions is not large,
but in none of the conditions have I found the co platelet-leukocyte picture that has been found in Hoc disease.
In tuberculosis of the gland the platelet count is bigc. in smears from four cases I have not found the large !- which are common in Hodgkin's. The transitional 2. cytes are on the upper limit of normal or slightly The four differential counts are as follows:
W.b.o. N. 9.000 41.6
2.4
E. B. S. L. L. L. L.M. Tr. 0.0 43.2 4.4 0.4 B 1.8 0.9 26.4 5. 8. 54
3
63.
1.2
0.6 19.
6. 2.9
.....
...... 64.8
1.8 0.2 19.4 6. 1.
In two cases of relatively acute non-specific lymph following throat infections, the following differentials obtained :
N. 72.9
1 ...
.. ...
47.8 4.
E. B. S. L. L. L. L.M. Tr. 0.2 0.2 14.6 2.2 1.8 &! 0.6 30.6 5.4 1.6 M .:
In these one finds quite the picture seen in actie. early stages of Hodgkin's disease as far as the lenkere. concerned. This is what one might expect, if the act - of the Hodgkin's picture given above is correct. In : these cases the striking platelet-picture of Hodgkin's was lacking.
Finally, in one case of chronic simple sclerosis of the != glands of obscure origin, there was obtained the fi. .. count, with a low number of blood-platelets:
N. E. B. 8. L. L. L. L.M. Tr. 0.8 11.8 1.4 0.4 5.6
72. 10.0
These counts are too few to establish a blood-picture for. various conditions, yet they do not vitiate the generi' clusions of the author from his study of Hodgkin's de: · that the blood-picture is characteristic, is indicative of v is transpiring in the glands, and may be, if carefully we .; a help in diagnosis.
THE TRANSPLANTATION OF FREE FLAPS OF FASCIA. AN EXPERIMENTAL STUDY.
By JOHN STAIGE DAVIS, M. D., Instructor in Surgery, The Johns Hopkins University. (From the Hunterian Laboratory of Experimental Medicine, The Johns Hopkins University.)
Introduction .- For some time I have been interested in the methods brought forward for replacing and for reenforcing weakened or defective tissues, and while some of the methods are admirable, all are limited in their application. It seemed worth while to search for a material which would accomplish the same purpose but would have a wider field of usefulness.
In looking about for some suitable tissue in the body which was easily obtainable, which had considerable strength, and at the same time was sufficiently flexible for any desired need, I was led to try the experimental transplantation of free flaps of fascia.
After proceeding with the experiments for SOME .. found that some excellent work had already been done : this line.1 However, my results were sufficiently suge" to warrant a report on the subject, in order to again iz tention to this promising surgical procedure.
1 Kirschner, M .: Ueber freie Sehnen- und Fascien Trans; tion. Beitr. z. klin. Chir., 1909, LXV, 472. Günther: Ueber Duraplastic:
eine klinisch-experior: Studie. Beitr. z. klin. Chir., 1910, LXIX, 740. Hohmeier: Ueber ein neues Verfahren zur Deckung Trachealdefekten. München. med. Wchnschr., 1911. LVIIL. .. Since this paper was handed in for publication the f
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www .- sue part was shaved, washed with green soap ater, then with alcohol and ether. After the skin was ighly dry it was painted with tincture of iodin, 2.5 per The iodin solution was also freely used in the open Is and after suture of the skin.
e black silk was the ligature and suture material used ;hout. The wounds were closed in layers wherever pos- The skin was closed in every instance with the button- itch.
sterile gauze secured by a bandage was used wherever ngs were applied.
fascia was obtained, for the most part, from the thigh, .o-tibial band of the fascia lata being the most satis- / portion to work with, as it is easily separated from the ying tissues. In a few instances the strong abdominal was employed.
fascia was transplanted in both single and double and in one or two instances was twisted.
each experiment where adhesions were not desired the lata (ilio-tibial band) was placed with the inner or : surface exposed. For example, when a flap of fascia aced in a peritoneal defect, the muscle or smooth side irned toward the peritoneal cavity, and it was found ense adhesions were less likely to occur than when the side was turned towards the cavity.
his series, unless otherwise stated, the fascia was trans- d into the same animal from which it was taken.
attempt was made to place free flaps of fascia on the s tissues, in order to test its vitality and obtain an idea possibilities for clinical use.
eriments .- For convenience I have divided the series ght groups. To economize space I will only report a the typical experiments in each group.
I .- TRANSPLANTATION OF FREE FASCIA INTO SUBCU- NEOUS TISSUE ON FAT, MUSCLE, PERIOSTEUM, NAKED )NE, CARTILAGE, TENDONS AND LIGAMENTS.
UMENT 6 .- Male, black mongrel; about 9 months old. tion .- November 22, 1910. A piece of fascia lata was in the subcutaneous tissue of the chest wall. The wound sed in the usual manner. Dry dressing. Condition on the table excellent. Per primam healing.
ary 23. Distemper. The animal was sacrificed. Autopsy. ascia was somewhat thickened but otherwise it seemed It was strong and tough.
ental-clinical articles have appeared. They will be con- fully in another report.
eier, F .: Experimente über Verschluss von Wunden und ickung von Defecten Schleimhauttragender Körpercanäle ilen durch freie auto-plastic. Arch. f. klin. Chix 1011,
F .: Neue Wege der plastischen Chirurgie. (Verschluss erbrückung.) Arch. f. klin. Chir., 1911, XCIV, 326 .; D. & Davis, C. B .: Experimental Direct Transplantation in and Fascia. J. Amer. Med. Assoc., 1911, LVII, 540.
generation.
EXPERIMENT 7 .- Female, white fox terrier; about 6 months old. Operation .- November 28, 1910. The sartorius muscle was ex- posed and a broad band of fascia lata was sutured snugly around it. The wound was closed in the usual manner. No dressing. Condition on leaving the table excellent. Per primam healing.
January 16, 1911. Animal sacrificed. Autopsy .- The fascia was somewhat thickened but otherwise it seemed normal. The fascia band could be easily stripped from the muscle.
Histology .- (Microscopic examination.) The sections showed normal fascia with no signs of degeneration.
EXPERIMENT 8 .- Female, tan mongrel; about 6 months old. November 29, 1910. A flap of fascia lata was removed from the thigh and wrapped in moist salt gauze and then placed in the ice box in a sterile jar.
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