The Diagnosis of Trichinosis
Boston Medical and Surgical Journal
The patient, a child nine weeks old, was sent to the Massachusetts General Hospital by Dr. Horace B. Marion, the condition having existed since birth. Upon entrance the temperature was 99.4°, pulse 180 and respiration 30. There was much deformity due to the forward and lateral bulging of the 6kull. . The eyes were nearly hidden by the projecting and overlapping frontal region. The skull had become distended to nearly twice its normal size through the separation of the frontal, parietal and
... , parietal and occipital bones at the sutures, by the accumulation of íerum. The child could not lift its head from the bed, but was constantly moaning or crying, and very restless rolling the head from side to side. No convulsions. The possibility of a tuberculous origin in this case, considered with the favorable results that have followed operative interference in tuberculous peritonitis and the desperate condition of the patient, prompted an attempt at relief by diminishing the intra-crauial pressure.1 Under ether, an incision was made in the soft parts to the dura, and through an aspirator needle pushed about four inches in the direction of the lateral ventricle, lOj ounces of colorless fluid were withdrawn. On examination by Dr. W. F. Whitney, he reported " its specific gravity 1.007 ; a little white sediment ; albumin, a trace ; chlorides in large amount; sediment showed crystals of oxalate of lime and a very fine amorphous material with an occasional blood corpuscle and flat cell." The distention was relieved by the aspiration. The patient became quiet, passed a good night, and on the two following days was much brighter, aud the eyes could be seen. After that, the fluid reaccumulated. As the swelling and pressure increased the child became more restless and uncomfortable. She was crying and moaning incessantly, and each day becoming more feeble. Thirteen days after the first aspiration a second was made. Fourteen ounces of fluid were withdrawn having the characteristics of that from the first puncture. The parietal bones then overlapped three-quarters of an inch. The thermometric variations were insignificant, excepting the night after the second puncture, when 101.5°was recorded. By the following morning the temperature was normal. The pulse was rapid during the whole time she was under observation, ranging between 150 and 170. After the first puncture it sank to 140, aud after the second to 120, regaining rapidity as the fluid reaccumulated and pressure became re-established. Within the following fortnight the fluid had accumulated to as great a degree as at first. Death followed in a few weeks. No autopsy. About ten days ago I went to Cambridge to examine a specimen of blood. The impression I got wa» that I was to look for malarial organisms ; beyond that I had no special impression as to the nature of the case. I did not find any malarial organisms. On makiDg the differential count of white corpuscles, I foui.d 27 per cent, of e08Ínophiles. I should not have had a guess as to the interpretation of this fact but for a communication of Dr. Thayer's about which be wrote me last spring and which has been published in the Lancet of September 25, 1897. They had last spring at the Johns Hopkins Hospital a typical case of trichinosis in which the diagnosis was easily made : great muscular pains and tenderness in special spots were present. A blood examination was made which showed a leucocytosis of 17,700 and an extraordinarily large percentage of eoBinophiles, as high as 68 per cent, of the entire number of leucocytes. A piece of muscle was excised and showed the presence of trichinae. About two months after another case entered with a history of chills, fever, headache and backache, anorexia and weakness. There was edema about the eyes. There was nothing special about the case by which the diagnosis could be made. The spleen was slightly enlarged, no diazo-reaction, a few rose-spots apparently on the abdomen. The case was supposed to be malaria and the blood and splenic pulp were carefully examined but no parasites found. The blood-count showed a slight leucocytosis, 13,000, which led to a differential couut, and the same state of things was found as in the first case, a high percentage of eosinophiles. In both these cases trichinae were found in the muscles. In the second case the diagnosis could hardly have been made without the blood-count for the symptoms were very indefinite. The patient recovered very easily, and shortly after the time of the blood examination he left the hospital and was not traced. With those two cases in mind, when I got this count of 28 per cent, of eosinophiles I telephoned to the doctor to find out the history of the case, which is as follows : The patient had been sent abroad this year for his health, being somewhat run down, aud went to Germany. While in Germany he did not improve very much, but in the middle of the summer had a very severe gastro-intestinal attack and after that a great deal of muscular soreness. When he returned in September his physician found what at first seemed to be neuritis with a great deal of soreness over the muscular bellies of the calves aud biceps. That gradually lessened, but there came on edema of the face and hands. The diagnosis of trichinosis had suggested itself to the physician before the blood-count was made. He had not said anything about it to me because he wanted to see if it suggested itself to me independently. It would be very desirable to take out a piece of muscle to confirm the diagnosis, but the patient is getting well and I fear that he will not be willing to have it done.