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In 3 cases the feces were quite white and fatty. In 2 they were of a grayer color, but were greasy and showed microscopical evidence of fat. The 3 cases positively spirochetal had brown-colored stools.
(k) The Blood Picture. But few complete records were obtained. The hospital was at one time without blood-examining apparatus.
The finding in one spirochaete-positive case:
White blood cells 12,300; polymorphonuclears 75 per cent; lymphocytes 24 per cent; eosinophiles 1 per cent.
Agglutinations. (Inoc. T. A. B. (2) four months ago.) Typhoid T, 1/500; paratyphoid A, 1/250; paratyphoid B, 1/50.
The findings in a second were: Red blood cells 5,900,000; white blood cells 12,200; polymorphonuclears 88 per cent; small mononuclear 9.5 per cent; large mononuclear 2 per cent; eosinophiles .5 per cent.
Agglutination against /S typhosus, paratyphoid A and B was negative. The patient had never been injected with vaccine. Records of other cases were:
Red Blood Cells White Blood Cells Differential Count. %
1. 3,328,000 17,600 pmn. 85.5; Iym. 11.5; tr. 4;eos. 4
2. 5,976,000 7,000 pmn. 55 ;Iym. 38; tr. 6; eos. 1
3. 4,480,000 11,200 pmn. 73.5; Iym. 20; tr. 3.5; eos. 5
4. o 14,000 pmn. 79; Iym. 21; tr. 5; eos. 3
5. o 5,200 pmn. 64; Iym. 29; tr. 5; eos. 1
No cells foreign to the normal blood were seen. Absence of anemia in the early stages with a moderate increase in the white blood cells, but with no constant change in the differential counts, seemed to be the most usual picture in the cases examined.
Course oj tbe Disease—Temperature—Termination. Recovery is the rule. By the fourth and fifth day improvement in all directions takes place. The 2 fatal cases, both with the symptoms of icterus gravis well marked on admission, never rallied and died on the seventh and eighth day of their illness respectively. Both showed a curious lack of febrile reaction. The cases not complicated with a relapse quickly regained their normal state. The relapse cases were all noted as showing a persistent pallor and weakness during convalescence. Complications are few. One myositis, 2 instances of arthritis, 1 pleuritis, 1 broncho-pneumonia comprised the range of secondary accidents.
In 8 of the 14 cases the acute febrile period of the illness showed but a single phase. It is probable that both the fatal cases had some short spell of fever before the subnormal reaction became evident. The usual duration of the fever wave was from three to eight days. Six cases, or 37.5 per cent, showed definite evidence of relapse with recurrence of fever, and this secondary fever was in 5 cases of greater duration than the primary wave; with the febrile recrudescence, deepening of the jaundice, headache, delirium, muscle pains, abdominal pains, bleeding at the nose, and herpes were observed to occur. The prostration seemed less than at the onset of the disease; vomiting and diarrhea were conspicuous by their absence. In 2 cases both liver and spleen could be more distinctly palpated during the relapse. In 1 of the 3 positive spirochetal cases the parasite was found during the fever of relapse.
In 2 instances crisis-like falls of temperature were seen to occur within twelve and twenty-four hours, but in the majority of cases a gradual rise and fall of the fever was noted. The highest temperature recorded was 104 (2) (in a relapse). The low temperatures of the icterus gravis-like cases have been already commented upon.
Some pulse rates coincident with elevated temperatures were the following:
Case Temperature Pulse rate
In both fatal cases, comatose and deeply jaundiced, an average pulse rate of 80 to 90 was recorded during their afebrile course. In 1 a sudden rise to a 140 per minute was recorded for twenty-four hours before death. It can be seen that in both the febrile and afebrile type of cases a certain degree of inhibition of the pulse rate is evident.
Notes on the Detection of the Parasite in the Circulating Blood. In no great number of human infections is the laboratory able to demonstrate living protozoan parasites in the circulating blood. Relapsing fever, malaria, trypanosomiasis, trichiniasis have thus far represented our successful performances in this line, and to have another possible field in view should not fail to arouse our utmost endeavor.
The natural tendency is to rely upon animal inoculation for the production of jaundice, and the subsequent demonstration of the parasites in the animal's liver, kidney, or heart's blood, since in this way the demonstration is undoubtedly easier, and probably more certain. Dark field illumination is necessary. In our 2 positive cases
100 to 80. Positive spirochetosis.
we drew 5 to 10 c.c. of blood, collected the serum after clotting, rapidly centrifuged it and with no more trouble than is frequently experienced in demonstrating the estivo-autumnal type of malarial parasite were able to find and follow a dozen spirochetes in their wanderings over the field. As further showing the parasite's right to be called a blood parasite, we were able to find living specimens in a drop of blood taken under simple precautions from the ear tip of an infected animal.
The Japanese observers were successful in detecting the spirochete in the blood of patients on six different occasions. Positive blood findings are also reported by Salvaneschi (9) in the Italian epidemic.
We were successful in finding the Spirocbaeta icterobxmorrhagxca in the urine in only 1 case. In this connection two points are to be remembered: That nonpathogenic spirochetes are regularly found in the secretion about the corona glandis and in the meatus, and that the nuclear network of the cells seen in cellular casts may be most confusing when examined with the dark field illumination; urinary spirochetosis in febrile jaundice undoubtedly occurs, however, and the transmission of the disease to animals by inoculation of infected urine seems to have been done successfully on many occasions.
With stained specimens of precipitated serums we were fortunate in being able to demonstrate several well-formed spirochetes, and we feel that further successful results were forestalled only by the late period of the disease at which we were compelled to make our examination. The transmission to animals by intraperitoneal inoculation of 2 to 3 c.c. of whole blood, taken early in the disease, is easy, and is followed by a large percentage of positive results. The jaundice in the pig is of no uncertain hue and is readily seen in the injected conjunctive or by examining the skin at the root of the hairs. The parasites in the liver may be seen under the microscope at times almost like an actively swarming mass; further details of pathology and histology in both man and animals will appear in a paper by the writer and Major Ower, with whom this study of infectious jaundice—rather superficial from necessity, owing to our surroundings and conditions—was taken up. With him I experienced the pleasure of exploring this chapter of clinical medicine, hitherto but vaguely understood by most of the observers on the Western Front. With him I feel that the laboratory side of infectious jaundice offers a fertile field for both the clinician and the laboratory worker and one that must materially help in unraveling that tangled chain of the jaundices, linked loosely together, in which we find so many conditions ranging from simple catarrhal jaundice to the jaundice with acute yellow hepatic atrophy.
1. Weil, Deutscbe Arcb. jUr klin. Med., 1886.
2. Buck's Reference Hand Book, New York, 1915.
3. "Infectious Jaundice," Boggs; Osier and McCrae, "Systemof Medicine."
4. Inada, Hoki, Ido, et al., J. Exp. M., 1916, Vol. XXII.
5. Stokes, Ryle, Teitler, Brit. M. J., 1916, and Lancet, 1917.
6. Dawson, Hume, Bedson, Brit. M. J., September 15, 1917.
7. Gwyn and Ower, Lancet, 1917.
8. Jobling, Noguchi.
9. Salvaneschi, Riforma Med., 1918.
For the brief bibliography the writer must make apology. Situated as he was at the time of writing in a remote corner of France, in a dismantled hospital, he was quite unable to consult the enormous literature which now exists on the subject.
RECENT DEVELOPMENTS IN THE THERAPEUTICAL USE OF OXYGEN
By J. S. Haldane, M.D., F.R.S., Oxford
IT has been known for long that the administration of oxygen sometimes produces temporary amelioration of the symptoms in cases where dyspnoea or cyanosis is present; but until the experience of the war in the treatment of gas-poisoning cases, and the physiological investigations to which this experience has given rise, there was very little knowledge as to the serious therapeutical use of oxygen, or the indications for its use. In the present paper I shall endeavour to present a short account of the new light which has been thrown on this subject, including a summary of clinical and experimental work carried out by Lt.-Col. J. Meakins of McGill University, Capt. J. G. Priestley of Oxford, and myself, with the support of the Medical Research Committee. This work was initiated at the Canadian General Hospital, Taplow, through its Consulting Medical Officer, Sir William Osler.
In order to understand the therapeutical use of oxygen it is absolutely necessary to have some understanding of both the immediate and remote effects of want of oxygen. Our direct knowledge of this subject is derived partly from laboratory experiments, but largely also from observations of the effects produced by the want of oxygen experienced at high altitudes owing to the rarity of the air, and in carbon monoxide poisoning owing to interference with the oxygen-carrying power of the haemoglobin. The evidence is absolutely conclusive that in both these cases the characteristic effects are due simply and solely to want of oxygen.
The immediate effect of an almost complete cutting off of the oxygen supply to the lungs is, of course, loss of consciousness followed within a minute or two by convulsions and death. With a very moderate diminution, sufficient to produce only very slight cyanosis, the first effect is usually a marked increase in the breathing. This soon falls off, however, and the breathing settles down to a comparatively slightly increased depth or rate, which may not be at all