USA > Ohio > Hancock County > Findlay > Twentieth Century History of Findlay and Hancock County, Ohio, and Representative Citizens > Part 171
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Popular works on tuberculosis are des- ined to play an important part in the nlightenment of the people, and the American people seem to be particularly usceptible to such education.
hope we may deserve this gracious ompliment paid to the American people by the great Koch.
And now, in conclusion, a few words on the personal side of this great man. In the evening of the 11th of April, 1908, Koch was the guest of the Ger- nan Medical Society of New York. It vas indeed a distinguished gathering. Professor Karl Beck, as the president of the Society, was the oastmaster of the evening. Your own distinguished eacher, Professor Welch, eing one of Koch's first upils, welcomed the great cientist to our shores, and spoke in eloquent words of the chievements of his master. Equal praises were bestowed upon Koch by the Nestor of the New York and the entire American medical profession, Professor Abraham Jacobi. Andrew Car- egie, the philanthropist, who had given 500,000 marks for the Koch Institute in Berlin, praised Koch as a hero of civili- ation and peace, far greater than a hero in war, and concluded y saying :
Every age has its ideals, and the servants and saviors of man- Ind are our present-day ideals, for I firmly believe that service ' mankind is the highest service to God.
4
acter that I believe it to be worth while to reproduce it in the original words. I will repeat it here in German as it was delivered, and translate it into English as exactly as possible :
Wenn ich alles zusammenfasse, was hier zu meinem Lobe gethan und gesagt worden ist, und die grosse Auszeichnung, die Sie mir zu Theil werden liessen, in Betracht ziehe, dann entsteht in mir ein Bedenken, ob ich auch wirklich berechtigt bin, mich so feiern zu lassen. Manches von dem, was mir Rühmliches nach- gesagt wird, kann ich, wie ich glaube, mit gutem Gewissen ak- zeptieren. Aber ich habe nichts anders gethan, als was Sie jeden Tag thun, nüm- lich ich habe gearbeitet was ich konnte und meine Pflicht und Schuldigkeit gethan. Wenn etwas mehr dabei heraus- gekommen ist. so liegt das daran, dass ich auf meinen Wanderungen durch das medizinische Gebiet auf Strecken stiess. wo das Gold noch auf dem Wege lag. Es gehört allerdings Glück dazu, das Gold von dem Unedlen scheiden zu kon- nen; das ist aber kein besonderes Ver- dienst. Es freut mich besonders, Herrn Carnegie hier zu sehen, dessen hochher- zige Spende zur Koch-Stiftung allen- thalben einen tiefen Eindruck gemacht hat. Ich möchte Herrn Carnegie meinen bescheidenen aber herzlichen und war- men Dank aussprechen. Die meinen Na- men tragende Stiftung ist berufen, grosse Resultate auf dem Gebiete der Erfor- schung der Tuberkulose zu zeitigen. Während die Gründung von Kranken- häusern und Sanatorien in der Bekämp- fung der Tuberkulose von lokaler Bedeut- ung sind, soll die Koch-Stiftung uns er- möglichen. in das Wesen der Krankheit tief einzudringen, um so Vorteile zu schaffen. die der ganzen Menschheit zu Gute kommen. Herr Carnegie ist für mich die Verkörperung der besten Eigen- schaften des Amerikaners. Er hat seinen Blick gerichtet auf dic höchsten und edelsten Ziele.
R. Koch. 1/ 1910
TRANSLATION.
When I now consider the honor you have con- ferred upon me here this evening, when I consider all that has been said and done in my praise, there arises in my mind a doubt as to whether I am really entitled to such distinction. Some of the kind things which have been said of me I believe I may accept with a clear conscience, but I have done nothing else than what you are doing every day. I have worked as hard as I could and have fulfilled my duty and obligations. If the success really was greater than is usually the case, the reason for it is to be found in the fact that in my wanderings through the medical field I came upon regions where gold was still lying by the wayside. Fortune is necessary to be able to distinguish gold from the base metals, but that is no great merit. I am glad
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JOHNS HOPKINS HOSPITAL BULLETIN.
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to see Mr. Carnegie here, whose generous gift to the Koch Foundation in Berlin made everywhere such a deep impres- sion. I would wish to thank Mr. Carnegie with all my heart. The foundation which is to bear my name is, I hope, destined to show great results in the field of tuberculosis research. While special hospitals and sanatoria for the treatment of tuber- culosis are of local importance in the combat against tuber- culosis, the Koch Institute or Foundation is destined to study the underlying causes and as yet unsolved problems of the disease and thus will benefit mankind at large. Mr. Carnegie is to me the embodiment of all the best qualities of an Ameri- can. His ideals are the highest and noblest.
Koch had a remarkable genius for research work, yet his aim was always eminently practical and his sympathies genu- ine and real. By hard work and diligent application he revealed to us the hidden mysteries of disease.
Koch was not privileged to see the foundation for further tuberculosis research work, bearing his name, completed. He died on May 27, 1910, surrounded by devoted pupils and friends. By indubitable right he now takes his place with the Immortals and his name will be handed down through genera- tions to come as one who lived and labored for the good of mankind.
In accordance with Koch's last request, his funeral was of the simplest kind, and as an enthusiastic sanitarian he had directed his body to be cremated. His admirers and pupils gathered the ashes of the beloved master and enshrined them
in a mausoleum located in the Institut für Infektionsin heiten in Berlin, of which Koch had been a director for re: years.
I venture to say that for generations to come, al physique. and likewise the many men and women outside of the fession who are interested in scientific or preventive mela. will, on visiting Berlin, deem it a pious duty to make a: grimage to this last resting-place of the ashes of Robert K.
When Professor Koch wrote me the last time he haite me by sending his photograph taken a short time before bes. ill. This picture is considered by all who knew Koch one?". best. He graced it with his signature dated February 9. !! In availing myself of the permission granted to me to por- you with an enlarged reproduction, I beg you to amy from one of the thousands of humble disciples of the . master as a feeble tribute to him and as a token of ri- for the officers and members of your society.
Let this portrait, which shall henceforth grace the #i . of this great university, this likeness of a prince of wiez. a teacher of teachers, one of the greatest physicians of . time, remind present and future members of the Lat .: Society and all the students of this great university of K. motto in life: Nunquam otiosus (Never be idle). 1, it be to all of us, to you and to me, an inspiration, an ito. tive to work and a reminder of the fact that though much !. been done, there is still more to do.
THE BLOOD PICTURE IN TUBERCULOSIS. By MARGARET REED LEWIS, Baltimore.
The fact has long been established that a cell reacts to its environment and that the condition of any cell at any one time depends upon its environment. The assumption that the cells of the blood would react to the condition of the plasma, might have been made, but it was not until 1896 that Holmes first called attention to the fact that there is a definite relationship between the state of the leucocyte of the blood and the progress of the disease in tuberculosis. Holmes studied the entire cell and while he perceived the metabolic changes of the leucocytes as shown by their granules and even in some cases mentions the condition of the nucleus, he did not observe that there is a definite relationship between the state of the nucleus and the condition of the cell.
To quote Holmes, " A careful study of 100 cases of tuber- culosis has shown conclusively that the laws, which bring about. disintegration in a tuberculosis patient, bring about the same process at an earlier date in tubercular leucocytes. In these cases, I have found a marked disintegration going on in all varieties of leucocytes and a great decrease in the number of young cells. The tissue forming power of these cells is imper- fect. Many of the young cells present is a good sign of recupe- rath ouwer on the part of the patient."
Sonship between the state of the nucleus and the
metabolic processes of the cell has been investigated by m2 . observers as for instance, Korschelt found that the forn.s. of chitin in insects is associated with nuclear changes. G.> wood found the elaboration of digestive fluids in cells is ?. termined by the nucleus. Maximow found that the sette." granules in the serous cells of the salivary gland originate the inner surface of the nuclear membrane. Mathews shin that the zymogen granules of the pancreas cells are form -. the expense of nuclear fibrillae. The relationship between. : metabolic processes of the cell and the nucleus has not - definitely worked out but the observations of Jacquet, Spits Loeb and R. Lillie seem to demonstrate that the nuclea especially concerned in the oxydative processes of the cell.
Soon after Holmes' work appeared, Arneth observel : there is a relationship between the state of the nucleus of : neutrophile of the blood and the condition of the patien" tuberculosis. In 1905, Arneth published all his obserra. upon tuberculosis patients as a monograph, "Die Lar. schwindsucht," in which he states clearly his conclusion : form of a neutrophilic blood picture, which is adapted clinical use.
According to Arneth the neutrophile enters the blowxd : myelocyte or at least as a neutrophile having but a single ".
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the older have four or five pieces. The mature neutro- are constantly used up and the younger forms constantly the blood, so that if at any time more of the mature forms ed up, it is shown by a larger proportion of the neutro- with one or two lobed nuclei than is usually present.
: pieces of the nucleus are of two types, the round piece Kernteile," which does not divide again and the bent or "Schlingen," which may divide again. Arneth's 'ations upon human blood show that the neutrophiles can 'ided into five classes according to the number of pieces : nucleus and those classes subdivided according to the of pieces in each class, as is seen in the following table.
ARNETH'S BLOOD PICTURE.
NEUTROPHILES.
CLASS I.
with 1 round piece (1 Kerntelle). Fig. 1. with 1 bent pfece (1 Schlingen). Fig. 2.
CLASS II.
with 2 round pieces (2 Kernteile). Fig. 3. with 2 bent pieces (2 Schlingen). Fig. 4. with 1 round piece and 1 bent piece (1 Kerntelle und 1 Schlingen). g. 5.
CLASS III.
with 3 round pieces (3 Kernteile). Fig. 6.
with 3 bent pieces (3 Schlingen). Fig. 7.
with 2 round pieces and 1 bent piece (2 Kerntelle und 1 Schlingen). g. 8.
with 1 round piece and 2 bent pieces (1 Kernteile und 2 Schlingen). g. 9.
CLASS IV.
with 4 round pieces (4 Kerntelle). Fig. 10.
with 4 bent pleces (4 Schlingen). Fig. 11.
with 3 round pieces and 1 bent plece (3 Kernteile und 1 Schlingen). g. 12.
with 2 round pieces and 2 bent pieces (2 Kernteile und 2 Schlingen). g. 13.
with 1 round piece and 3 bent pieces (1 Kernteile und 3 Schlingen). g. 14.
CLASS V.
with 5 round pieces (5 Kerntelle). Fig. 15.
with 5 bent pieces (5 Schlingen). Fig. 16.
with 4 round pieces and 1 bent piece (4 Kerntelle und 1 Schlingen).
3. 17.
with 3 round pieces and 2 bent pieces (3 Kerntelle und 2 Schlingen). 3. 18.
with 2 round pieces and 3 bent pieces (2 Kernteile und 3 Schlingen). 3. 19.
with 1 round plece and 4 bent pieces (1 Kernteile und 4 Schlingen). 3. 20.
clinical purposes Arneth arranged the various forms in 100 neutrophiles as a neutrophilic blood picture as S :
M. Class 1 Class II Class III Class IV
IK 1S 2K 28 1K-18 8K 382K-ISIK-28 4K 488K-182K-281K-38 Class V 5K 5S 4K-18 3K-28 2K-38 1K-4S
h neutrophile as he observed it was counted under the ision of the class in which it belonged; as for instance, rophile with a nucleus as in Fig. 8 would be placed under vision 2K1S of Class III. If any myelocytes were ob- they would be placed under M as myelocytes or embry- utrophiles.
th finds the neutrophilic blood picture of normal per- be-(the numerous sub-divisions are not quoted in this -:
3.C. M. Class I Class JJ Class III Class IV Class V
5 26
36 28 5
aberculosis the older neutrophiles are continually used so the large proportion of neutrophiles shifts to the left this picture as
Llen 11 the patient recovers and so uses up fewer of the older forms, the proportion of neutrophiles again shifts to the right side of the picture. According to Arneth, every case where there is even a slight shifting to the left of the neutrophiles can be diagnosed as tuberculosis, but our observations show that this is probably not so and that other conditions than tuberculosis may give the neutrophilic blood picture with only a slight shifting to the left, so that for diagnosis or prognosis the other blood cells as well as the neutrophiles must be con- sidered.
Investigation was undertaken at the Bellevue Hospital, New York City, under the charge of Dr. J. Alexander Miller, head of the Tuberculosis Out-Patient Department, to determine whether this work of Arneth's was of practical value clinically, especially whether it had any value in regulating the use of tuberculin. In this work over 200 cases were observed with an average of 30 counts on each case. Some of these cases were observed for a period of three years, and on each of these about 100 counts were made.
The division of the neutrophiles into classes according to the lobes of the nucleus sounds simple, but when a number of counts had been made, it was found almost impossible as well as of no especial value to keep to Arneth's sub-divisions, so it was decided to note only the class in which the neutrophile belonged and not the kind of lobes. The threads connecting the lobes of the nucleus are of varying length and thickness and the bending of the lobe to form "Schlingen " is also of varying degrees, so that the decision as to whether a bent lobe shall constitute one lobe or two lobes of the nucleus, will always vary according to the personal equation of each individual in- vestigator. In these observations all bent lobes of the nucleus, where the nuclear bridge was large enough to admit of good nuclear network, Fig. 21, were classed as one lobe, but where the nuclear network is condensed into a coarse thread, Fig. 22, or a fine thread, Fig. 23, they were classed as two lobes. The question as to whether one lobe of the nucleus is on top of another was always decided by careful focussing with a high power. Any very questionable case was not counted. The study of the blood smears, to obtain the neutrophilic blood picture soon showed that changes were to be noted among the other cells of the blood, so a blood picture was made, which would include all the white blood cells, but as no definite change was found in the other cells only the number of each present was noted.
Two hundred neutrophiles were usually counted, never fewer than 100 and the number of the other kind of white blood cells observed while counting these were noted, making a blood picture as follows :
Neutrophiles of Class I, Class II, Class III, Class IV, Class V. Large Lymphocytes. Small Lymphocytes. Eosinophiles, Basophiles and the number of white blood cells. Smears from the blood of a normal person give a blood picture as follows :
Class I II III IV V L.L. S.L. E. B. W.B.C. 5 22 48 26
22
5 18 1 0 8,000
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1.
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430
JOHNS HOPKINS HOSPITAL BULLETIN.
In case a differential blood count is desired it can easily be computed from the complete blood picture.
Many schemes for an index were devised for tabulation pur- poses and it was finally decided that the changes in the blood picture would be more clearly shown if the number of neutro- philes in Class I+Class II and one-half of Class III, as compared with the number in one-half of Class III + Class IV + Class V was used as an index. This same index was used in some observations by Bushnell and Treuholtz, which appeared later. In the normal blood picture there is about the same number of neutrophiles on each side, i. e.
5+22 + + 42= 48 + 42 +26 + 5= 52 Index =48: 52
From a study of the neutrophilic blood pictures from over 30 supposedly normal persons, the normal blood picture was found to be
I II III IV V L.L. S.L. E. B. W.B.C. Index 5 22 42 26 &
But the study of these blood pictures showed that a blood picture with an index anywhere between 45: 55 and 55:45 may be considered normal.
The index is usually written as the number on the left side in tabulations.
The blood pictures from a few of the tuberculosis patients are given below.
PATIENT A. - A young woman who was clinically considered a favorable case. She has neither gained nor lost, but has seemed to improve slightly under the tuberculin treatment. The blood picture shows an improvement after her return from the country, but she returned to work against advice and soon returned to her earlier condition. This patient died during the late summer of 1909.
Date
1 2
3
4 5 6 L.L.
S.L.
E. M.
Leuc.
Index
Remarks
1907
May 6 ..
21 41 27
0
0
0
0
75.5
Tuberculin.
May 20.
28 43 20 9 0
0
0
0
0
81
May 24.
26 41 24 12
0
0
0
0
0
May 31
24 40|27 10
2
0
0
0
0
0
11.000
77.5
June 7
25 37 20 14
2|
0
0
0
0
0
12,000
72
June 24. . . 20 41 28|11| 0 0
11
23
8
1
10,000
75
Sept. 31.
8:38|26 22| 6| 0
17
20
3
2
8,000
59
Oct. 14.
10 36 89 12
8| 0
28
6
2
4
11,200
66.5
Oct. 18.
16 37 31 12
0
12
11
2
R
13.600
68.5
Oct. 21.
10 37 33 15
5
0
25
16
7
1
10,000
63.5
Nov. 1 ..
9 47 38 6
4
0
18
12
4
1
12.800
72.5
Nov. 11.
12 46 32 10
0
26
15
6
11,000
Nov. 22.
10:40 31 17
2
0
17
6
5
0
13.200
65.5
Dec. 16.
. .
:
:
...
1908
Apr. 3 ..
14,43|34 9 0 0
18
9
3
1
12,000
74
May 4.
23 44 28
1
21
8
0
12.000
81
Nov. 15.
18,49 25
7| 11 0
20
2
10,200
79.5
Nov. 25.
9 38 38 13 9
0
12
2
0
14.600
66
1909
Feb. 28.
17 43 30
2
0
17
Mar. 9 ..
8.48 34 14 4 0
21
14
i
0
13,200
68
Mar. 23.
11|37|42 8| 2| 0
15
9
4
0
12.000
64.5
Apr. 27.
11 37 32 16 3 0
17
9
4
1
12,800
64
May 18.
9 44 33 18 1
0
15
8
1
1
14,000
69
ring the summer.
PATIENT B. - A young woman who has shown decided impronte under the tuberculin treatment. She has returned to wow :. except for a bad cold has been well all winter.
Date
1
2
3
4
5
6
L.L.
S.L. E. M.
Lenc. b ::
1907
May 3.
9
38
36
16
0
0
0
0
0
May 6 ..
8
39
85
17
1
0
0
0
0
0
May 17.
9
38
10
3
0
0
0
0
0
May 29.
6
20
37
29
8
0
0
0
0
0
May 31.
5
27
37
28
8
0
31
93
4
0
June 7 ..
8
36
35
19
9
0
0
25
23
1
0
June 24.
10 ! 27
29
25
9
0
36
8
24
1
0,000 !
Oct.4 ....
4
Gone back to work.
Has bad cold.
8 | 84 | 83 1 18 | 2
90
18
3
0
10.000
Away at work.
1908
March 16 .. ...
5
21
43 26
5
0
38
39
8
0
10,008
PATIENT E. - A married woman with two children whose busbris died with tuberculosis some years before. This patient receive: " tuberculin treatment, but never improved noticeably, and fax died in February, 1908.
Date
1 2 34 56 L.L.
S.L.
E. M.
Leuc.
Index
1907
June 14. ..
16,40 24 16
4
0
18
12
3
19,000
68 Tuterre:
June 21 . . . |17 49 23|11
0 0
10
12
4
0
11.600
73.5
June 24. . . 23,41 |26|
8
0
10
4
1
19.200
Sept. 31 ...
92 37 29 12
0.
0
25
7
2
0
77.5
Oct. 4.
23 42 23 8
4
0
9
7
0
2
10,600
79.6
Oct. 14
21 51 20
9
2
0
27
8
4
0
10,000
77
Nov. 1. .. . 26 48 16 10
12
1
0
12
8
5
0
12,600
Nov. 11 ...
Nov. 15. .. 17 38 28 15
2
0
16
5
5
1
12,000
Nov. 18. .. 10 49 26 15
0
0
22
0
12
4
5
0
15,000
Nov. 22. .. 20 50 20 10
III.
Dec. 16 .. .. 24|49 20
Dec. 20 ..
25 48 19
8
0
0
15
4
3
1
14,000
1908
Jan. 10 .... '26 52 18
0
0 0
6
1
1
0
18,000
84.5
May 17 .. .. 22 34 80 12
2
0
0
0
0
71
..
13
18
2
1
11,000
66.5
Oct. 28 ..
10 48 31 10
1
0
16
5
4
2
12,600
78.5
Nov. 8 ..
16 83,83 17
1
0
24
4
6
2
10.000
65.5 74
Nov. 18.
Nov. 29.
Dec. 2 ..
16 41 27 14
0
28
9
2
0
12,000
70.5
May 25
16 51 25 60
0
19
0
0
12,200
79.5
Nov. 22.
Nov. 29.
:
:
14,200
...
4
0
13.000
75
Mar. 21.
Reacted to tuberculin.
8
8
0
14,000
69
Apr. 8. .
10 88 83 18 1
12
3
1
18,400
$9.5
May 4 ..
13 40.85 9 2
0
10
5
1
1
18,000
70.5
The study of the many blood pictures made from : cases together with the clinical data showed that all the where, through several observations, the blood picture pr shifting to the left without an increase in the number of : lymphocytes and without a decided leucocytosis, the til- losis bacilli were either found in the sputum or the ;" showed the clinical signs of tuberculosis. However, wher. t. was but a slight shifting to the left with one observatint." cases sometimes developed into something other than tr losis. Also a number of cases of poor resolution in poet: gave the tubercular blood picture except that in these (ifn. number of large lymphocytes usually remained higher thx: tuberculosis and the number of eosinophiles increased. .. observations led to the conclusion that this blood picture. not of great value in diagnosis except where a number. servations could be made. In this case then, Arneth's philic blood picture which takes no account of the other of the blood can have no diagnostic value. It was hap .: this blood picture would prove of great value in dete. cipient cases where the clinical signs were not ekz. unfortunately the blood picture is not of much diagnoet .. there. The study of these blood pictures did show, hi
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Away for summer.
Sept. 81.
2 | 13 [ 31 | 4]
22 42 | 27
5
0 0
31 80
0
0
June 10.
8
18
31
11
0
0
E
..
2
0
Dec. 13.
Oct. 11 .. . . 26 45 17 11
18
2
1
1
13,200
82
Oct. 25. . . . 24 41 24
0
0
84
18
4
0
19.000
16
Nov. 8. . . . 26 39 22
0
14
1
1
0
16
6
4
1
18,000
7
0
0
6
8
1
13,000
73.6
19.000
1
9.000
June 10. .. 20 31 31 17 1
0
0
:
10,800
....
12.000
10,800
2874 2 7 4
:0
12.000
Mar. 27.
12 37 30 18 30
Apr. 22.
8 2
0 0
......
......
Away to country.
5 18 2 1 8,000 48:52
...
42
1
18
:
-
'hese observations upon tubercular patients suggested a aber of experiments in order to understand as far as possi- the changes which take place in the blood picture. These eriments were largely carried out at the Institut für Infec- skrankheiten, Berlin, Germany. A few of the most inter- ng are given below.
.
. Various fixing and staining experiments.
his was partly suggested by a paper of Pollitzer's which eared in 1907 and condemned Arneth's work on the ind that the lobes of the nucleus were artifacts due to ng and fixing and especially to Wright's method of dif- ntial staining, and also partly suggested in an attempt to the best method for preparing the blood smears so as to the clearest nuclear picture for the blood count. Blood ars from three subjects whose neutrophilic indices were 52 and 60 were spread as thinly and as evenly as possible n slides, which were absolutely clean and as sterile as con- ons permitted. These smears were killed in most of the
known cytological methods such as osmic acid, strong nming, formalin, corrosive acetic, hot alcohol acetic and ous others, also many were dried and then treated with nyl alcohol. One slide from each of the above methods of ng was then stained either with Wright's differential blood 1, Jenner's blood stain, methylene blue and eosin, iron atoxylin, Delafield's hematoxylin and eosin or with safra- acid fuchsin and orange G. All the slides gave a more or clear nuclear picture. Those killed with strong Flemming imic acid and stained with iron hematoxylin were the least factory, while those killed with hot alcohol sublimate and ed with iron hematoxylin gave the clearest and best nuclear ire, but of course this method is useless for bedside work. ;ht's was the most satisfactory method because it was the lest and gave a very good nuclear picture as well as entiated the different types of leucocytes. Jenner's was useless in that the nuclear picture was poor. The methods gave good nuclear pictures, but not better than ht's. The slides prepared were all counted with a key at at the time they were counted it was not known from 1 of the three subjects the smear had been made. All the rs from any one of the three subjects gave practically the index and the indices for the smears from the three sub- remained the same regardless of how the smear had been and stained. These experiments establish the fact that ate the nucleus of the neutrophile assumes in the killed tained cell is something definite and dependent upon the of the living cell and is not dependent upon the d of preparation. They also show that Wright's method best method of preparing smears for the neutrophilic picture. It was found that blood cells will live on an medium sometimes for several days and in observing living cells it was seen that there are certain times when icleus shows up as a clear refractive body surrounded by anules and in preparations made from the blood of normal
made over an agar plate and this is passed over chloroform vapor, the nucleus stands out as above and this preparation will give the same neutrophilic count that the stained prepara- tion from the same subject gives.
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