Twentieth Century History of Findlay and Hancock County, Ohio, and Representative Citizens, Part 172

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

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Another experiment, that of stretching the nucleus was tried in order to see whether what appears to be one lobe could be drawn apart into several. Pollitzer claims that what appears to be but one lobe of nucleus is really many pieces of the nucleus lying close together (Fig. 24), and made to seein as one by the stain. Slides were scratched with emory paper and then the drop of blood drawn slowly across these scratches in order if possible to catch and tear the cells in the scratches. Although the cells of these preparations were badly torn and stretched the neutrophilic blood picture remained the same as when smears from the same subject had been prepared in the usual manner. Figures 25 and 26 show the neutrophile badly stretched but the nucleus is also stretched and does not give a greater number of lobes than normally.

2. The normal blood picture in man and in guinea pigs.

Smears were prepared from about thirty different subjects whose condition was, as far as known, normal. These different blood pictures gave indices, which varied slightly from each other and yet varied within a small range, which could be called normal. This blood picture corresponds as far as the neutro- philes are concerned very nearly with that of Arneth, which was taken from a large number of cases.

Smears were obtained from a few subjects at different times of day extending over periods of a week or several weeks and in two cases extending at intervals over a period of two years. The results in these cases, show indices, which vary but not definitely enough to be attributed to any one cause and the amount the index varied was usually so slight as to still come within the normal blood picture, which for man is

Class I II III IV V 5 22 42 26 5 22

L.L. S.L. R. B. W.B.C. 18 8,000

Ten guinea pigs were studied, for a period of two weeks. Smears were made from drops of blood taken from the ear every two or four hours during each daytime. The results gave a blood picture comparable to that of man except that the neu- trophile usually has a larger number of lobes than in man.

Class I II III IV V VI L.L. S.L. E. B. W.B.C. Index 5 20 84 80 6 5 10,000 42:58

The blood picture as shown by guinea pigs varied so much more for the individual animal than it did for the individual person, that in all experiments with guinea pigs smears were made from the animal each day for a week or ten days before the experiment in order to obtain the normal for each animal. 3. The effect upon the neutrophilic blood picture by inocu- lation of virulent cultures of tuberculosis bacilli.

Guinea pigs were inoculated subcutaneously with varying amounts of an emulsion of a culture of virulent tuberculosis bacilli. They all gave a blood picture much like the one which follows, except, that those animals, which received a larger quantity or a stronger emulsion of the bacilli, showed the

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432

JOHNS HOPKINS HOSPITAL BULLETIN.

[No .:

typical tuberculosis condition more quickly, while those, which received a smaller quantity or a weaker emulsion reached that condition more slowly.

Guinea Pig VI, Inoculated with 3-Cmm. Strong Emulsion of Tuberculosis Bacilli.

VII

VIII

W.B.C.

Index

Before inoculation ..

6 6

5 5

9,000 9.000

40-60 41-59 80-70

12 hours after ....

10,200

13-87

24 hours after.

15,000

16-84

48 hours after

8 3

14,000

34-66

8 days after.

18.200

41 59

12 days after.

13.400

49-51

18 days after.

12.000

84 : 16

25 days after.

13,000

87: 13

Killed-Lungs, liver, and spleen full of tubercles.

These blood pictures show that within a few hours after the inoculation there is an increase in the number of neutrophiles with the larger number of lobes to the nucleus, i. e., the blood picture shifts to the right, and then follows an increase in the number of leucocytes. The shifting to the right of the blood picture remained a few days and then gradually returned to normal. After ten days or two weeks, in some cases longer, the number of lobes of the nucleus began to decrease, i. e., the blood picture began to shift to the left while the number of leucocytes remained about the same or increased very much in dying cases. This condition continued until there were present in the blood only those neutrophiles with a nucleus of one, two or three lobes.

4. Blood on agar media with tuberculosis bacilli.

In 1908 it was found that bone-marrow cells, or blood cells will live and divide when kept on an agar medium (agar 0.5 gm., bouillon 20 cc.+ Locke's sol. 80 cc.) in a Petri dish at. 37° C.

A large drop of fresh flowing human blood was placed on an agar plate; to one side of the drop was placed a very small point of virulent tuberculosis bacilli. The agar plate was then kept at 37° C. and smears were made every five minutes from the side of the drop next to the bacilli as well as from the side away from the bacilli. The blood pictures showed an increase in the number of lobes of the nucleus of the neutrophiles from the side of the drop which touched the bacilli in as short a time as 10 or 15 minutes, while the nucleus of the neutrophiles from the side away from the bacilli remained normal. Leu- cocytes washed free from the plasma by the same method as is used in the opsonic work give the same results as the blood leucocytes.

5. Neutrophilic blood picture in the opsonic work with tuberculosis bacilli.

Many of the slides studied were obtained through the court- esy of Dr. Park of the Board of Health, New York City, and others were prepared by the observer. A standardized emul- sion of dead bacilli was used with washed leucocytes and in- cubated 15 minutes at 37° C. In all cases the blood picture from these smears showed a decided increase in the number of lobes of the nucleus of the neutrophiles. Neutrophiles with

nuclei of 6, 8, 10, 12 and in one case 16 lobes were found - Figs. 27 and 28). On the other hand sterile washed letosv: without the addition of the bacilli, incubated 15 minutes not undergo any change with regard to the neutrophilie !'", picture.

An interesting observation in this experiment is that L neutrophiles taken from tubercular subjects show a great ference in their ability to react to the tuberculosis bacili - this manner, which shows itself by an increase in the Doc. . of lobes of the nucleus of the neutrophile. Washed leuco ;. from. a subject in an advanced stage of tuberculosis d: react at all. The fact that neutrophiles from different iz- react in different degrees shows that the serum of the bee ;. not the only important factor in the greater or less resistzz of the individual to bacteria and quite agrees with the !: ment presented by Vietch, in his paper on a new ops method, that it is a surer as well as a simpler method to t. the leucocytes from the same individual as the serum : tained, on the ground that the serum is but one part et blood, while the whole blood is concerned in the resisten Although it is at present impossible to say just what this chut. of the nucleus of the neutrophiles means, the fact that it ! - change at all, shows that the neutrophile is sensitive to its .: vironment and probably plays an important part in the r- ance. It is possible that this may show what Arneth clat . i. e., that the older forms are used up by coming in bir."." with the bacilli. However, this reaction is in no way ([ .. degenerative fragmentation, as may be seen from Fige. 2: .: 28. The nucleus of 8 or 10 lobes is as healthy looking s- one of 3 or 4 lobes.

6. Effect of contamination.

Blood drawn from the end of a finger purposely made . and smeared on a slide, which was not clean, gave at. picture which showed a slight increase in the number of ... of the nucleus of the neutrophile. Blood was drawn frc. sterile finger and placed both in small glass chambers. were sterile and in others, which were dirty and inech. 10 minutes. That in the sterile chambers gare a n.f. neutrophilic blood picture while that in the dirty chaz. gave a blood picture in which some of the neutrophiles nucleus of 8 or 10 lobes (Figs. 29 and 30).

Guinea Pig X developed an open abscess at the point of entre .. the needle, and the subsequent blood pictures instead of resic !. those of the tubercular guinea pig showed a decided shifting : right, due to the infection with a pyogenic bacterium.

7. Effect of inoculation with snake venom.

Guinea pigs or rabbits were inoculated with small qua" of snake venom and smears made from blood from the e!". from the bone-marrow cells. The blood pictures from" smears showed all the neutrophiles with nuclei of mar. and often so many lobes that the nuclei had the appears a rosette.

The conclusions from these experiments are, first .. neutrophile is a delicate organism, which reacts qu'il .. definitely to its environment and that this reaction !" measure be judged by the condition of the nucleus, i. ..

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...

- 10

16 400

21-79

4 days after.

0822 3

13,200

74:26

21 days after.

: : :

. .

10 000

8 hours after ..

At time of inocultn.

FIG. 1

FIG. 2

FIG. 3

FIG. 4

FIG. 5

FIG. 6

FIG. 7

FIG. 8

FIG. 9

FIG. 10

FIG. 11

FIG. 12

FIG. 13

FIG. 14

FIG. 15

FIG. 16

FIG. 17

FIG. 18

FIG. 19

FIG. 20

FIG. 21

FIG. 22

. FIG. 23

FIG. 24

FIG. 25

FIG. 26

FIG. 27

FIG. 28

FIG. 29

FIG. 30

DESCRIPTION OF FIGURES.

'igs. 1-20. Neutrophiles whose nuclei show the number of pieces ording to the classification of Arneth's blood picture. ig. 21. Neutrophile with a bent nucleus, which is counted as one igs. 22 and 23. Neutrophiles with a bent nucleus, which is counted wo lobes.

Fig. 24. Drawing taken from Pollitzer's paper to show many pieces of the nucleus. Figs. 25 and 26. Torn neutrophiles with stretched nuclei. Figs. 27 and 28. Neutrophiles with many lobed nuclei ingesting tuber- cle bacilli. Figs. 29 and 30. Neutrophiles with many lobed nuclei due to con- tamination.

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provaviy muurcaves some immediate reaction of the neutro- iles to a change in their environment, such as snake toxin the presence of some bacteria. Third, that when the neutro- iles have nuclei with fewer lobes than normal, they are prob- ly reacting slowly to some change in their environment, so at the neutrophiles with the larger number of lobes of the cleus are used up and only those with the fewer lobes are t in the circulating blood or else that the neutrophiles fail react in such a way as to cause a change in the nuclei and remain in almost the same condition as that in which they ered the blood. Fourth, that the neutrophilic blood picture lex, shows the condition of the nuclei of the neutrophiles and ce the condition of the nucleus is probably an indication of : condition of the neutrophiles of the blood, we can judge to ne degree by the means of the neutrophilic index of the con- ion of the patient.

In the spring of 1910, Dr. Miller turned over to Mr. C. J. let, an expert statistician, all the blood pictures as well as the clinical evidence upon the cases observed at the Bellevue spital and from this data Mr. Diolet formed a number of tisties and charts, which will appear in a paper in collabora- 1 with Dr. Miller. A few of the most interesting of these briefly quoted below.

. The number of leucocytes in incipient tuberculosis is be- en 9874 and 10,209 ; while this is slightly higher than most ervers have found, it is not markedly different. There is a inct increase in the number of leucocytes with the progress the disease. Moribund cases show a marked leucocytosis of 300. The number of leucocytes in tuberculosis is tself of much prognostic value since in these observations r number corresponds with the subsequent (2 years) ory.

. The percentage of neutrophiles varies from 64.4 in non- ercular cases to 78.5 in dying tuberculosis cases. This in- se of the neutrophiles in the more unfavorable cases is very ·ked and indicates an unfavorable prognosis.

. The large lymphocytes according to the statistics show .pparent relationship with the progress of the disease.

. The small lymphocytes on the other hand did show a very e connection with the course of the disease and this connec- might of itself be used as a means of prognosis. In non- ircular cases and in incipient cases, those cases with good nosis and those cases whose subsequent history showed im- ement gave between 9 and 11 per cent of small lymphocytes. more advanced cases show between 4.1 and 6.2 per cent, e the moderately advanced cases and those with doubtful nosis stand between and have between 7.5 and 7.9 per cent. The eosinophiles decrease with the progress of the disease 1 in dying cases they are entirely absent. The basophiles give no definite results.

The neutrophilic blood picture was represented only by ndex. The average index for non-tubercular cases is 54-46, far-advanced cases 75.25 and all stages in between have a sponding shift to the left in the index. The changes

of the usual clinical signs and symptoms. In diagnosis the usefulness of the neutrophilic blood picture is not great when taken by itself as other conditions may give a slight shifting to the left, but when considered in connection with the other blood cells and when more than one observation is made, it may be of diagnostic value. In prognosis, however, both at the time of examination and during the course of the disease, the degree of shifting to the left is an exceedingly sensitive indica- tion of the resisting power of the individual and of the progress of the disease.

Cases with slight lesion but unfavorable blood picture almost invariably do badly, but, on the contrary, those with extensive lesions and fairly good blood picture show a marked tendency to resist the disease. Moreover, it has been found during the clinical observation of a case that its real progress, in one direction or the other, can usually be more accurately antici- pated by the change in the blood picture than by any other clinical means. Even clinically apparent cures are insecure unless the blood picture has come to approach the normal.

1. Non-tubercular cases.

W.B.C. Neutrophiles 10,209 64.4

L.L. 17.5

18.8

S.L. E. 5.8 .53

B. Index 54-46

2. Incipient tuberculosis. 9,874 72.4

14.4

8.7

.52 64 38

3. Advanced tuberculosis. 10,200 74

15.9

7.9

2.4

.52 67-33

4. Far advanced tuberculosis.

18,208

77.9

18.9

6.2

1.5 .44 75-25

Cases with good prognosis. 9,898

71.8

14.8

9.1 8.7 .53 60-40

Cases with poor prognosis.

12,488 77.1

18.4 7.5 1.6

.35 72-28-

Cases which showed subsequent improvement. 71.6 14.9 9.9

9,828

3.0 .56 60-40

Cases which subsequently did badly.

18,897 77.8

14.5

5.9 1.86 .48 75-26

Through the kindness of Dr. George Lockwood and Dr. William Draper, of the Bellevue Hospital, a number of ob- servations were made in connection with Dr. J. Alexander Mil- ler upon cases of pneumonia and later through the kindness of Dr. Lewellys F. Barker, the same work was continued at the Johns Hopkins Hospital. So far the results have not proved definite from the statistic side, but in the individual case it is of prognostic value; especially is it of value in determining whether a case of delayed resolution is tubercular or not. Some cases showed a marked shifting to the right and the lobulation of the nucleus reached 7 or 8 pieces. Such cases showed puru- lent infection at the post mortem examination. The eosin- ophiles remain normal during acute stages, but increase after- wards, especially in cases of delayed resolution.

Most cases showed a moderate shifting to the left of the neutrophilic blood picture, giving an index anywhere from 60-40 to 80-20, which index tends to return to normal upon defervescence with good resolution.

In six cases of delayed resolution the index 64-36 continued

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JOHNS HOPKINS HOSPITAL BULLETIN.

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high, while the number of leucocytes decreased to normal or below normal, and the number of large lymphocytes decreased. These cases gave a typical tuberculosis blood picture and later the bacilli were found in the sputum.

In the three cases of appendicitis, the blood picture showed a decided shifting to the right, and neutrophiles with nuclei of 6, 7 and 8 lobes were present. Upon operation these cases showed a purulent condition of the appendix, while in one case where the blood picture was practically normal the operation showed no infection of the appendix.

Several cases of abscess showed the shifting to the right in the early stages. The following are a few typical blood pictures.

Class I II III IV V VI VII L.L. S.L. E. B. W.B.C. Index 26 5 22 42 1 0 48-52 8.000 10

Normal . 5

Tuberculosis .. 14

10 ..

0 12,000

72-28

Pneumonia. ..

40 30

24,000

27-78

The conclusions from these observations may be briefly stated as follows :

The neutrophile is an organism, which reacts quickly and definitely to its environment and the condition of the nucleus as shown by the number of lobes, may be taken as an indica- tion of the condition of the neutrophile. Under normal con- ditions the nucleus does not show more than five lobes, but the presence of certain abnormal conditions may cause it to show as high as 8 or 10 lobes, while certain other conditions, such as tuberculosis, may prevent it from having more than 1, 2 or 3 lobes. These changes of the nucleus together with the other blood cells and the number of white blood cells form a picture, which can be used to determine the condition of the patient.

This neutrophilic blood picture together with the differential blood count is of great value in prognosis in tuberculosis, but

not of much value in diagnosis. It is of value in determin .. the presence of pyogenic bacteria in pneumonia or an der and may be of value in detecting a purulent condition of t- appendix. In connection with the number of white blood @ l- and the number of lymphocytes it is of value in distinguish"; between a case of poor resolution in pneumonia and tube ?. losis.

It is of especial value in the prognosis of any disease whee it is of use to determine the metabolic activity of the petie: or the resistance to disease as any condition of lowered vital: is quickly detected by this blood picture.

BIBLIOGRAPHY.

1. Arneth, J .: Die Lungenschwindsucht, etc. Leipz, 1905. J : Barth.

2. Bushnell, G. E., and Treuholtz, C. A .: Med. Rec., 1906, LICI 471.

3. Greenwood, M .: J. Physiol., 1886, VII, 253; 1887, VIII, S: 1890, XI, 573.

4. Holmes, A. M .: Med. Rec., 1896, L, 325; 1897, LI, 369; ! Am. M. Ass., 1897, XXIX, 828.

5. Jacquet, A .: Arch. f. Exper. Path. u. Pharmakol, 19: XXIX, 386.

6. Korschelt, E .: Naturwissenschundschau, 1887, 409. Ze. Jahrb. Anat. u. Ontog., 1889, VI.

7. Loeb, J .: Arch. f. Entwckingsmchn. d. Organ, 1899. VIJ: 689.

8. Lillie, R. S .: Am. J. Physiol., 1902, VII, 412421.

9. Maximow, A .: Arch. f. Mikr. Anat., 1901, LVIII, 1, 52

10. Mathews, A. P .: J. Morph., 1899, XV, Suppl., 172.

11. Pollitzer, H .: Deutsches Arch. f. klin. Med., 1907, XCII, ! 12. Spitzer, W .: Arch. ges. Phys., 1897, LXVII, 615.

13. Vietch, R. M .: J. Path. & Bacteriol., Gt. Brit. & Ire, 198 XII, 353.

NOTES ON NEW BOOKS.

A Text-book of Gynecological Surgery. By COMYNS BERKELEY, M. D., M. R. C. S. (Eng.), etc., and VICTOR BONNEY, M. D., F. R. C. S. (Eng.), etc. (New York: Funk & Wagnalls Co., 1911.)

This work describes briefly but clearly the technique of the various gynecological operations as practiced by one of the leading schools of English gynecologists. It discusses also opera- tive indications and dangers, as well as ante-operative prepara- tion and post-operative treatment and complications. There are numerous black-and-white schematic illustrations and a con- siderable number of colored plates, all of which are of mediocre artistic merit, but nevertheless are quite helpful in elucidating that text. The authors have succeeded admirably in presenting a very complete treatise in a condensed and readable form, which will doubtless be gratefully received by the American profession.

E. H. R.

Dyspepsia: Its Varieties and Treatment. By W. SOLTAU FEN- WICK, M. D. (London). Illustrated. Price, $3.00 net. (Phila- delphia and London: W. B. Saunders Company, 1910.)

This work treats of disorders which are certainly frequent enough to justify a special discussion of their features. One searches at once for a definition of the term dyspepsia, but the author, probably very wisely, does not give one in set words.

Perhaps he considered that the text sufficiently described vt he included under the term. The author points out cera things which are essential to keep in mind if one is to br any clear ideas of this subject. One is that a disorder of d.p: tion is rarely due to primary disease of the stomach. This . one point often entirely disregarded in practice and when i .. more fully recognized there will be a falling off in the Dit: many drugs given for gastric disorders. In this connect. however, the author does not seem to attach enough importar to gastric derangement secondary to general nervous dist ance. He gives the principal place to primary disease c! ! liver, pancreas or bowel. These play a part but it is donk": if it is the main one. Then he takes a fling at the terminal employed for gastric disorders; with this we are in box agreement. He seems to have written a volume on gastric - order without coining any new terms for which commende is due and it is to be hoped the example will be followed those who come after. Of intestinal indigestion he says * it "almost defies chemical analysis," which is a comfor statement when we are in despair over our inability to prof- classify examples of it.

Of this work as a whole it can be said that the disct- is well done, the descriptions accurate and the treatment :. ble. However, there are some statements which should be (. fled. Thus it is not safe to make a diagnosis dogmatica

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0 18.000

75-25

Pus case . .. .

14 18 32 21

orrect. The use of the term gastric neurasthenia is not to be ommended. Why not as well speak of gastric psychasthenia r gastric hysteria? In the discussion of the so-called gastric eurasthenia, the author seems to put the cart before the horse. 'hus the text suggests that the often accompanying mucous olitis is in consequence of the gastric disorder, whereas both re usually results of a common cause.

There is an excellent section on dyspepsia which occurs condary to other diseases with particular reference to the isturbances in tuberculosis. The discussion of the digestive isorders of infancy and old age is useful and worthy of special ote, especially the latter section. The care of the health of le aged is worthy of more attention than it usually receives. Altogether this work is to be commended as an excellent lide in the management of the various forms of dyspepsia. The eatment advised is usually sound but there are some points hich might be given more emphasis. For example the need attention to the teeth hardly seems to have received sufficient ention. Often a dentist is needed more than a physician. gain the question of proper chewing of the food would seem orthy of more notice than it receives. But these suggestions ust not be regarded as serious criticisms and Dr. Fenwick is be congratulated on the excellent volume which he has writ- n on a difficult subject.

ve Practice of Medicine: A Guide to the Nature, Discrimination and Management of Disease. By A. O. KELLY, A. M., M. D., Assistant Professor of Medicine in the University of Penn- sylvania and Assistant Physician to the University Hospital, Philadelphia. Illustrated. (Philadelphia and New York: Lea & Febiger. 1910.)

This excellent text-book is a monument to the industry and ility of its author, who was so recently cut off at the height an active and successful medical career. Although a com- ratively young man, few clinicians were better equipped to ite a text-book on medicine. Dr. Kelly was a keen clinical server and his bedside training was supported by an extensive :hological experience in the autopsy room. His thorough niliarity with medical literature has enabled him to incor- :ate in this volume of 945 pages, practically all the important ent contributions to our knowledge of medical affections. hough the author states that the volume is intended especially medical students and the junior practitioners of medicine, vertheless the teacher of medicine can turn to its pages with ertainty that he will find the most modern views concerning etiology, symptomatology, pathology and management of various medical diseases dealt with.

The subject matter is treated under twelve sections. These arranged in the following order: Infectious Diseases; In- ications; Disorders of Metabolism; Diseases of the Ductless nds and of Internal Secretions; Diseases of the Blood and nopoietic System; Diseases of the Circulatory System; Dis- es of the Respiratory System; Diseases of the Digestive tem; Diseases of the Urinary System; Diseases of the Ner- s System; Diseases of the Muscles; Diseases of the Bones Joints.

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Twentieth Century History of Findlay and Hancock County, Ohio, and Representative Citizens, Part 172

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

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