Twentieth Century History of Findlay and Hancock County, Ohio, and Representative Citizens, Part 93

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

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A week after admission he had a convulsion at 9 p. m., accom- panied by a rise of temperature to 102° F., and complained of pain radiating from the bladder to the renal region. There was pain and tenderness in left lumbar region. Subsequently the temperature showed an evening rise. Blood examinations showed a leucopenia, the counts varying from 4400 to 7800. A cysto- scopic examination showed that there was a severe cystitis pres- ent. The capacity of the bladder was but 90 cc. A diagnosis of " cystitis, probably tuberculous, secondary to tuberculosis of kid- ney," was made. On December 10, complaint was made of ab- dominal pain, and on December 12 death occurred. The post mortem was made three hours after death.

Briefly stated the result of the autopsy was that a generalized acute miliary tuberculosis involving the lungs, spleen, liver, peri- bronchial and mesenteric lymph glands, kidneys, adrenals, pan- creas and aorta was found. The bladder and kidneys showed both chronic and acute tuberculous changes.

In the thoracic part of the aorta there were a few fatty streaks, and at the beginning of the descending arch there was one calcified plaque. The abdominal aorta showed an almost completely healthy appearance except at a point 10-15 cm. above the bifurca- tion, at which point were two small raised areas on the intima

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that had the appearance of recent vegetations and which meas- ured about a millimeter in diameter. There was no tuberculous focus in the vicinity of the aorta in the neighborhood of these nodules.

Microscopic examination of the vegetation-like nodules in the aorta showed that they were really intimal tubercles, composed of epithelioid and small round cells, a partial endothelial covering, and a central area of caseation. In them were large numbers of acid fast rods of typical and atypical form, but no giant cells. Beneath these tubercles the media and adventitia were apparently normal, except immediately in the base of the tubercles where there was evidence of a minimal degree of degeneration in the adjacent part of the media.

In the lesions I have studied the bacilli were more numerous in the peripheral parts, and several were observed in the immediate vicinity of the lumen of the vessel. It is possible that some had entered the blood stream, but not in sufficient numbers to cause the appearance of the myriad lesions in other organs.

A further observation of some interest relates to the form of the bacilli in the intimal tubercles. In the cases in the literature, I have not been able to find reference to any other then presumably typical rods. In my case, however, many of the rods were far from typical. Quite a large proportion were of irregular form, and while no actually branching ones could be found, some of them showed bizarre figures that suggested branching.

I believe that in this case the generalized miliary tuberculosis, of which the aortic lesions were a part, was the result of dis- tribution of the organism from the older foci in the kidney, and that it did not result from distribution of tubercle bacilli from the aortic tubercles. The case therefore belongs logically with the group of acute hematogenous aortitides.

It is difficult to account for the lodgment of the organism in . these acute cases unless one presupposes at least an incipient degeneration of the cells of the intima, and the formation of ever- so little fibrin in which the bacilli may become entangled. It is very possible that in all cases of general infection and toxemia, more damage is done to the endothelial lining of the blood vessels than we can readily appreciate, a possibility which Baldassari has shown to exist by his observations on the endocardium in cases of infection and intoxication. Certainly it seems simpler to look at the process in this way than to suspect that normal endothelial cells in the aorta are fortunate enough to be able to seize single organisms from the rapidly flowing stream of blood that passes them.

CONCLUSIONS.

1. The case here reported is the eleventh of acute tute culous endaortitis.

2. The aortic tubercles were the result not of extensiez but of metastasis from chronic lesions in the kidney.

3. The general miliary tuberculosis that co-existed with the chronic tuberculosis, was not the result of dissemination c: organisms from the aortic lesions.

4. The bacilli in the aortic lesions showed bizarre forme with a tendency to branching.

ILLUSTRATIONS.

FIG. 1 .- Intimal tubercle. Drawn with camera lucida to shor the general microscopic appearance.

FIG. 2 .- An edge of the intimal tubercle showing the finer stros ture of the nodule.

FIG. 3 .- Examples of acid fast bacilli showing bizarre shapes.

REFERENCES.

Longcope: Johns Hopkins Hosp. Bull., 1901.

Benda: Lubarsch u. Ostertag's Ergebnisse, 1899. --. Berl. klin. Wchnschr., 1899.

Blumer: Am. J. M. Sc., 1899, Albany M. Ann., 1899.

Schmorl: München. med. Wchnschr., 1902.

Luksch: Centralbl. f. allg. Path., 1904 (Ref.).

Forssner: Ibid, 1905 (Lit.).

Simnitsky: (Cited by Forssner.)

Gaylord: Allbutt's System of Medicine, 1909 (cited by ForssDE: and Longcope).

Schuchardt: Virchow's Archiv, 1882.

Marchand: Cited by Weigert. Virchow's Archiv, LXXXVIII. Huber: Cited by Weigert. Virchow's Archiv, LXXXVIII.

Hanot: Sem. méd., 1895.

Hanot et Levi: Arch. d. med. exp., 1896.

Flexner: Johns Hopkins Hosp. Bull., 1891.

Stroebe: Centralbl. f. allg. Path., 1897.

Aschoff: Verhandl. d. deutsch. path. Gesellsch., 1899.

Buttermilch: Lubarsch u. Ostertag's Ergebnisse, VI. Kamen: Ziegler's Beiträge, XVII.

Dittrich: Cited by Blumer.

Hanau u. Sigg: Lubarsch u. Ostertag's Ergebnisse, V. Baldassari: Centrabl. f. allg. Path., 1909.

REPORT OF A CASE OF EXTENSIVE TIERSCH SKIN GRAFT.

By W. D. GATCH, M. D., Assistant Resident Surgeon, Johns Hopkins Hospital, Baltimore. (From the Clinic of Professor W. S. Halsted.)

The case herewith reported has two points of chief interest : the large size of the area grafted, and the demonstration by repeated trials, that only homografts would take in this patient.

CLINICAL HISTORY.

J. C., colored, was admitted to the Johns Hopkins Hospital on November 21, 1909, for flame burns of the back and of the left forearm and hand which he had received fourteen hours before admission. The burn of the back was of the second degree, the others of the first. The photographs show the situation and extent of the former lesion. The area of this

was 430 square inches. As the total area of the patient's body is about 2800 square inches, the burn occupied betweer a sixth and a seventh of his entire cutaneous area.

The patient recovered from the immediate effects of the injury rapidly and with very little general systemic distur'- ance. While the sloughs were separating the wounds wert dressed with a single layer of dry gauze, which was left i: place for periods of a week or more, and then changed after giving the patient a prolonged warm bath. Absorbent dres ings, changed as often as necessary, were placed over the gauze. This dressing proved very clean and comfortable. Iz

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PHOTOGRAPH TAKEN DEC. 13, 1910, JUST BEFORE THE APPLICATION OF THE FINAL GRAFT.

PHOTOGRAPH TAKEN AFTER HEALING WAS COMPLETE.

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we Works the burned surface was covered with healthy granulations. Now followed a long series of attempts to cover the large raw area with skin. These I shall sum- marize briefly.

On December 16, 1909, 130 " pinch " grafts of rather large size were cut from the patient's thighs and planted over the lower part of the burn. About 110 of these lived, and, to- gether with the epithelium which spread from them, covered an area of very considerable extent.

On December 23, 1909, at the suggestion of Dr. John Staige Davis, the experiment of grafting amniotic membrane was tried, but the epithelium of this failed to take.

On March 1, 1910, and again on March 18, 1910, large numbers of small whole-thickness grafts, obtained from two cases of lipectomy performed by Dr. Kelly, were applied, but these also were all unsuccessful.

On April 1, 1910, several large Tiersch grafts, cut from the patient's thigh, were spread over the granulations covering the right side of the chest. Most of this graft took, although the condition of the granulations was not so good as when the last two grafts were done.

On April 12, 1910, the granulations over the right scapula and the region immediately below were curetted away, and a large Tiersch graft, obtained from another patient, put over the curetted area. As had been the case with all the other isoplastic grafts, none of this lived.

No further attempts at grafting were then made for over five months. During this time the granulations became very deep and œdematous. In places they formed a gelatinous layer half an inch thick, the deeper parts of which were trav- ersed by wide venous sinuses. About one-third of the total burn had now been covered by grafts. It was obvious that before further grafting could be done the granulations must be got rid of. Therefore the patient was anæsthetized (October 25, 1910) and the granulations curetted away down to the fascia, the bleeding being controlled with dry gauze. The cautery was found to cause as much hemorrhage as the curette. The patient was allowed to recover from this severe operation, and the curetted area to cover with fresh granula-

tions. Following this at three separate operations the entire lesion was successfully covered with Tiersch grafts cut from the back of the thighs, and the left arm. These operations were done on November 9, November 23, and December 13.

With but one exception all the grafts were applied to healthy granulations prepared by simple irrigation with salt solution. The skin from which the grafts were cut was pre- pared by scrubbing with soap and water which was rinsed off with alcohol, and the latter with sterile salt solution. Silver foil dressings, which were usually left in place for ten days, were used. These were covered by very heavy rolls of ab- sorbent cotton and gauze, all held in place by a crinoline jacket.

At present, two months after the last graft was applied, the new skin is freely movable on the fascia beneath. There is no tendency to keloid formation. The mobility of the back is practically normal. The areas from which the grafts were cut are very darkly pigmented. This was true for a time of the grafts also, but the latter are gradually fading to the light chocolate color of the rest of the skin. The total area grafted, determined by tracing its boundaries on a piece of moist crinoline applied over it, is 212 square inches in extent.

None of the isografts applied to this patient lived, though applied under the same conditions as the homografts, prac- tically all of which did so. Dr. J. S. Davis, who has reviewed the cases of skin grafting at the Johns Hopkins Hospital (The Johns Hopkins Hospital Reports, vol. XV, page 307), found that in 499 cases of homodermic Tiersch grafts there were but 13 failures, or 2 3-5 per cent, while in 42 cases of isodermic Tiersch grafts there were five failures or 12 per cent. It has been demonstrated that isografts of highly specialized tissues take far less readily than homografts .* The same is true, but to a less degree of skin grafts.

I desire to thank Mr. Ives and Mr. Fullerton, of the present fourth year medical class of the Johns Hopkins Medical School, for their careful daily dressings of this case for over three months.

* W. S. Halsted, Journal of Experimental Medicine, 1909, XI, 175.

TWO CASES OF CONGENITAL HÆMOLYTIC JAUNDICE WITH SPLEN- OMEGALY. OBSERVATIONS ON HEMOLYTIC JAUNDICE.

By WILLIAM S. THAYER, M. D., Professor of Clinical Medicine, Johns Hopkins University,

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

In 1900 Minkowski reported the history of a group of indi- fiduals belonging to one family, all of whom showed a remark- ble syndrome characterised by chronic acholuric jaundice, plenomegaly and urobilinuria. The appearance of these Imptoms could be traced through three generations affecting least eight members of the family. The general health of

these individuals was not essentially impaired and no impor- tant changes were observed in the blood.

Bettmann, in the same year, described a similar case in which the jaundice displayed marked variations in intensity, deepening after exercise, food, drink and excitement, especially anger, and also after exposure to cold. An experimental

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hæmoglobinuria might be produced in this case by the appli- cation of cold.

Pick (1903) and von Kranhals (1904) reported like cases, the latter having observed a family of which nine members in three generations showed a chronic congenital splenomegalic jaundice. In all instances the stools were of normal color. The urine which was of a dark color, was free from albumen, blood and hæmoglobin; it showed constantly the presence of urobilin, but never of bile. The number of red corpuscles was below normal, 2,300,000 and 3,500,000 respectively, in the men, and, on one occasion, as low as 1,000,000 in one of the women. The hæmoglobin ranged between 55% and 65%. The red blood corpuscles were irregular in contour and varied in size from 6 to 10 p. There were no nucleated reds but well marked polychromatophilia.

Minkowski was fortunate in obtaining a necropsy of one of his patients. No especial changes were found in the liver, and the bile passages were quite clear. A small pigment stone was found in the gall bladder. The spleen was enlarged, and microscopically there were simple hyperplasia and hyperæmia. The kidneys showed a brownish discoloration produced by a granular pigment deposit in the epithelial cells of the convo- luted tubules. Not only did this pigment give an intense re- action for iron, but there was a large amount of material united with proteids which gave the reaction only after boil- ing with ammonium sulphide. From but one kidney about 0.95 grammes of pure iron was obtained. Similar pigmenta- tion did not appear in any other organ.

Minkowski regarded the condition as dependent on an anomaly of the blood pigment transformation, perhaps conse- quent upon a primary change in the spleen.

The clinical picture was not a new one. Similar observa- tions had been made before by Murchison (1883), Wilson (1890) and Le Gendre (1897), and the syndrome appears to be similar to the Chronic Simple Jaundice with Splenomegaly of Gilbert and the Chronic Infectious Jaundice of Hayem (1898). It was, however, Minkowski's observation and necropsy report that first brought this condition sharply before the medical world. During the seven years following Min- kowski's original communication, a considerable number of similar observations found their way into the literature: Chauffard (1901) ; Barlow and Shaw (1902) ; Mason (1902); Widal and Ravaut (1902); Arkwright (1903); Lortat-Jacob and Sabaréanu (1904) ; Caporali (1905) ; Claus and Kalberlah (1906) ; Strauss (1906) ; Benjamin and Sluka (1907).

These cases seem to bear a striking resemblance one to another and suggest a common cause. The absence of evidence of hepatic disease and the existence of extensive siderosis, es- pecially of the kidney, in some respects analogous to that seen in Addisonian anæmia, on which Hunter especially has in- sisted, point to an increased blood destruction as a primary cause of the disease-an hypothesis adopted by most of these authorities.

In 1907 Chauffard made an interesting contribution to

the study of this syndrome by the discovery in a similar cke. of a marked fragility of the red blood corpuscles on expoezt: to hypotonic solutions of sodium chloride according to the method of Vaquez and Ribierre. This observation he w: able to confirm in two patients presenting a similar syndroz: in the wards of his colleague Widal. Thus, while with t .: normal red blood corpuscles hæmolysis begins at .42%-+!" and is complete at .32%, in these three cases the beginning and end of hæmolysis were respectively .62% and .36%, .015 and .34%, and .52% and .18%. The average size of the re: blood corpuscles was somewhat diminished.

Widal and Philibert on further study, were unable to de monstrate the presence of any hæmolytic properties in &: serum of their own patients, either with regard to their or. corpuscles or those of other individuals. This fragility of the red blood corpuscles, so marked toward hypotonic salt sola- tions, was also evident in respect to other hæmolytic st- stances. The diminished resistance of the red blood cor- puscles has been a constant feature in the considerable number: of cases of this malady which have since then been reported.

A few months later Chauffard described another interestin: hæmatological feature which he had observed in all cases ! this disease which had come under his observation, namely: the presence, on vital staining of a peculiar basophilic grant- lation of the red blood corpuscles. Chauffard's first studies were made by staining freshly made and fixed smears of blo: with Pappenheim's (pyronin and methyl-green) solution. Many of the red blood corpuscles which are of a slightly gratis color and barely visible, having lost their refractiveness with their hæmoglobin, show a fine granulation of a bright re: color. These dots, generally arranged about the periphery, are sometimes scattered throughout the cells in the form of a des- nite granulation. The granular corpuscles are usually som- what larger than their neighbors; they may be demonstrated well by the method of vital staining of Widal, Abrami an: Brulé.

Four to six drops of blood are allowed to fall into a test tube containing 10 drops of a basic coloring matter which is quite ist- tonic and contains in addition oxalate of potassium to prevent the coagulation of the blood.

Oxalate of potassium, 20%, 2 cc. Unna's polychrome methylene blue, 100 drops

} =- 0

The fresh corpuscles are allowed to remain for 10 to 20 minutes in contact with the solution, after which the mixture is centrifa- galized, the supernatant fluid is removed, and the corpuscles drawn up with a pipette and placed upon slides upon which they are spread as an ordinary drop of blood; the covers are then dried and fixed by heat. Such preparations may be preserved indefi- nitely.

The distribution of the granules is irregular. Sometime: scattered, they are usually collected in groups of two and three. Sometimes they are arranged in the form of a wreath or crown at the periphery of the corpuscle; they are general; distributed in such a manner as to suggest filaments wound around within the cell and showing frequent varicosities; the: are unequal in size and of irregular form. Not infrequent's

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"granular net-work is gathered together toward the pe- ery or near the centre of the cell in such a manner as to jest grossly a nucleus.

abrazès has called these corpuscles " granulo-reticulo-fila- tous." The apparent reticulum is very adherent to the blood corpuscle. If a dried and stained specimen be washed pure water the corpuscles lose their blue color, while the tular filamentous appearance remains. Indeed, in some 3 the reticulum may be found outside the corpuscle, lying reen other well preserved elements. Widal, Abrami and lé have thought that the polychromatophilia which is pres- to a certain extent in these cases, bears a close relation to presence of granular corpuscles, but this does not appear e an absolute rule.

is exceedingly interesting to see how closely these observers e in their descriptions of this granulation with the careful ies of Vaughan (1903). Although originally described by penheim,* the first careful studies upon the vital staining le red blood corpuscles were made by Vaughan, who found this granulation was present in somewhat under 1% of red blood corpuscles of normal individuals. In the new- 1, where they are most frequent, the highest percentage but one exception (7%) was 4%. In pernicious anemia i active regeneration, they were found in great numbers :e as high as 18%). In congenital icterus with splenomeg- the percentage is usually over 10%, and figures as high 0% have been reported. Chalier, however, in his excellent ograph, is inclined to regard these figures as excessive, rting that he, himself, has never seen a percentage above

This granulation, it is needless to say, is quite distinct 1 the basophilic granulation of Grawitz and others. The ules are different in shape and arrangement and are not : stained in the fixed specimen. They are, of course, quite net from the remarkable Schüffner's granules which ap- with Romanovsky's stain in certain parasitiferous cor- es in tertian and æstivo-autumnal malaria.

is probable that this phenomenon is simply an indication tive blood regeneration (Vaughan, Ferrata), but there are rently few conditions in which the frequency of these ilar corpuscles compares with that in congenital jaun- -a fact which seems to give them a real diagnostic

ese observations have been confirmed by a considerable er of observers, and the picture of this disease, which fard has called hæmolytic jaundice, is sufficiently definite regarded as a distinct clinical entity.

: patient often belongs to a family other members of have suffered from the same condition. Early in life, mes immediately after birth, but in other cases later, is not until puberty, a jaundice appears. This jaundice lly of a moderate degree varying from a pale lemon hue tell marked golden yellow. It is remarkably variable, 1.

3 subject is well discussed by Ferrata who, however, in with every continental author, ignores Vaughan's excel- @k.

increasing often under physical effort or emotional excitement. The stools are of normal color or pleiochromic, especially under those conditions associated with increase in jaundice.

The urine is of rather high color, often of a brownish almost mahogany hue, but free from bile. Urobilin is usually demon- strable. The blood shows an anemia of moderate degree, generally between 3,000,000 and 4,000,000 red corpuscles, al- though in one case a blood count of under 2,000,000 is re- ported. There is usually considerable anisocytosis, but little or no poikilocytosis. The average size of the corpuscles is sometimes rather below the normal, a point upon which Chauf- fard particularly has insisted. The color index is somewhat re- duced. Polychromatophilia is usually well marked. On vital staining the granulation described by Pappenheim, Vaughan, Sabrazès, Chauffard and others is present in a large number of corpuscles. The percentage of granular elements is usually above 10% and may be as high as 20%, or even more. The serum is of a clear, yellowish color, and the test for bilirubin is positive. Urobilin is generally undemonstrable. The leuko- cytes are usually of normal number or slightly increased. The differential count shows nothing remarkable beyond evidences of increased marrow activity as manifested by a high per- centage of eosinophiles and the occasional presence of myelo- cytes and nucleated red cells-normoblasts.

The serum shows a rather high degree of hypertonicity. Starkiewicz regarded this condition as a mechanism of defense on the part of the organism to protect the fragile red cor- puscles. Troisier, however, believes it to be the result of exosmosis of the corpuscular salts as a result of the fragility of the red cells.

The remarkable feature of this interesting condition is that subjective symptoms are usually absent despite the constant anæmia. The patients are generally unconscious of any dis- ability. They appear to adapt themselves so well to their con- dition that it is only occasionally that a complaint is elicited. There is a complete absence of all the ordinary phenomena of biliary intoxication : there is no bradycardia; no pruritus; no tendency to hæmorrhage; no xanthelasma. The patients are, indeed, as Chauffard has gracefully said, " à peine des mal- ades-plutôt des ictériques que des malades "-barely pa- tients, rather icterics than patients.

There is one exception to this rule. Many of these indi- viduals suffer from attacks of abdominal pain suggestive of biliary colic. These pains, localized in the epigastrium and in the region of the gall bladder, are often accompanied by fever and by an aggravation of the jaundice. In a number of instances they have been so severe as to lead to operation. In many cases it is probable that the attacks are due to the pres- ence of small pigment stones in the gall bladder, such as have been found in four of the six cases of congenital jaundice that have come to necropsy-every instance but one in which the gall bladder was examined.

In the last several years the authors have had the oppor- tunity of observing two striking cases of congenital hemolytic jaundice which appear to be worthy a note of record.

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Twentieth Century History of Findlay and Hancock County, Ohio, and Representative Citizens, Part 93

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

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