THE DIAGNOSIS OF TRICHINOSIS BY 
MEANS OF THE GREAT INCREASE 
OF THE EOSINOPHILES IN THE 
BLOOD; REPORT OF THE FOURTH 
CASE. 
BY 
THOMAS R. BROWN, M.D., 
OF BALTIMORE, MD. 
THE MEDICAL NEWS, 
FROM 
January 7, 1899.  Reprinted from The Medical News, Jan. 7, 1809.] 
THE DIAGNOSIS OF TRICHINOSIS B Y M EA N S 
OF THE GREAT / N CREASE OF TH E E 0 SIN- 
OPH/LES IN THE BLOOD; REPORT 
OF THE FOURTH CASE. 
By THOMAS R. BROWN, M.D., 
OF BALTIMORE, MD. 
In 1897, in reporting the great increase of the eosino- 
philes in the blood in a case of trichinosis 1 this being the 
first mention ever made of an association between trichi- 
nosis and eosinophilia, I made use of the following words: 
“ The presence of such quantities of eosinophiles in the 
blood suggests their possible diagnostic value in trichi- 
nosis, and perhaps, ,if it be found on further studies to be 
characteristic of this disease, may help to clear up the 
cases which are regarded intra vitam as rheumatic in 
nature and which, years afterward, the autopsy-table 
shows to have been cases of trichinosis.” That the dis- 
ease is not such a rare one in America as is usually sup- 
posed and that it may be definitely diagnosed by the re- 
markable increase of the eosinophiles in the blood is 
amply proven by the results obtained since that time. 
In 1898 I reported2 two additional cases wherein, from 
the eosinophilia alone, the condition of trichinosis was 
diagnosed, and in all three cases, living, actively motile, 
non-encapsulated trichinae were found in small pieces of 
muscle removed from the patient. The concluding sen- 
tences of that article may be of interest in this connec- 
tion : “ From these observations it is fair to conclude: 
“Ist. That there is a marked increase in the percentage 
of eosinophilic cells in the blood in trichinosis. 
1 Johns Hopki7is Hospital Bulletin, pp. 79-81, April, 1897. 
2 Journal of Experimental Medicine, vol. iii, No. 3, pp. 315 347. 2 
“2d. That the increase may be used as a diagnostic 
sign in this disease. 
“3d. That this diasease in its sporadic form is more 
common than has hitherto been supposed, as shown by 
Percentage of Various Forms. 
Date. 
1898. 
Leucocytes, 
per 
c.mm. 
Polymor- 
phonu- 
clear Neu- 
trophiles. 
Small 
Mononu- 
clears. 
Large 
Mononu- 
clears and 
Transi- 
tional 
Forms. 
Eosino- 
philes. 
Aug.' 8. 
18,100 
Aug. 10. 
48 
Aug. 13. 
43 
7-3 
i-7 
48 
Aug. 28. 
8200 
45 
14-5 
2 
38-5 
Sept. 4 
7900 
49 
18.5 
2.5 
3° 
Sept. 18. 
55-2 
19,6 
2 
23.2 
Sept. 25. 
9600 
61.5 
16 
2*5 
20 
Oct 2. 
8750 
54 
195 
2-5 
24 
Nov. 5. 
49 
40 
2*5 
8.5 
Nov. 13. 
645 
27. 
3 
5-5 
Nov. 20. 
6l 
27 
4-5 
7-5 
Result of Blood Examination in a Case of Trichinosis. 
(J. L., Case IV.) 
the discovery of the three cases above described within a 
comparatively short period at the Johns Hopkins Hos- 
pital. 3 
4th. That a systematic examination of the blood should 
be undertaken in cases with indefinite intestinal, muscu- 
lar or articular symptoms in the hope that in some, at 
least, of the hitherto doubtful cases a diagnosis may be 
made. ” 
I have now to report another case of this disease, diag- 
nosed entirely by means of the blood examination, the 
diagnosis being verified by the subsequent removal of a 
small piece of muscle and the finding of living, actively 
motile trichinae therein. 
J. L., white, aged thirteen years, was admitted to the 
Johns Hopkins Hospital, August 4,1898. He complained 
of headache and pain in the legs; he had never been sick 
before. On July 30th he commenced to have headache, 
which was still present at the time of his admission. 
On July 31st he had a slight nose-bleed, while during two 
days, July 30th and 31st, he had had pains in the 
shins. He had a good appetite, the bowels moved regu- 
larly every day, and he had not had chills, nausea, nor 
vomiting. 
The physical examination showed the patient to be a 
small boy of dull appearance, with eyelids somewhat 
swollen. His heart and lungs were negative. There 
was no abdominal tenderness; no rose spots. The spleen 
was not palpable; tongue thickly coated; considerable 
gurgling in the right iliac fossa. There was neither 
swelling nor tenderness in the muscles of the arms or 
legs; the throat wras negative. The temperature range 
was between 98 and 100.2° F. during the first four days 
and the case was at first regarded as a mild febricula of 
doubtful origin, possibly typhoid fever. 
On August 10th an examination of a specimen of 
freshly taken blood was made, and one was at once 
struck by the large number of eosinophiles present, these 
cells with their large, highly refractive granulations being 
unmistakable. A differential count made on dried speci- 4 
mens, stained with the Ehrlich stain, showed that 48 per 
cent, of all the white blood-cel Is were eosinophiles, and 
this at once led to a diagnosis of trichinosis being made. 
Further questioning of the patient elicited the fact that 
about one week previous to his admission to the hospital 
he had had pain in the calf-muscles of both legs, never 
very great, while there had never been any pain in the 
other muscles of the body. The legs had never been 
swollen, but the eyelids had become slightly puffy four 
days before his entrance. He had not had abdominal 
pain or diarrhea. On being questioned as to whether 
he had recently partaken of hog-meat of any kind he re- 
membered having eaten of raw sausage on July 10th, and 
of cooked ham on July 23d. 
On August nth a small piece of muscle was removed 
from the left gastrocnemius muscle under cocain anes- 
thesia; this was hardened in formalin, and subsequent 
microscopic examination showed the same changes as de- 
scribed in full in the preceding three cases (loc.cit. p. 328, 
et seq.); the presence of young, non-encapsulated trich- 
inae in some of the muscle-fibers, about them a fresh, 
active myositis with many eosinophiles among the cells 
present, and various degenerate changes in the muscle- 
fibers themselves, marked swelling and proliferation of 
the nuclei, longitudinal and transverse splitting of the 
fibers, etc. The patient’s temperature varied between 
96.2° and 99.50 F. from the fourth to the twelfth day of 
his stay, after the twelfth day being practically normal. 
The urine was negative throughout and the blood did not 
give the Widal reaction. 
The patient was discharged from the hospital on Au- 
gust 22d, feeling perfectly well. During his stay in the 
hospital his blood showed a leucocytosis of 18,100, while 
upon each of the two occasions on which a differential 
count of the leucocytes was made, it was found that 48 
per cent, were eosinophiles. As in the other cases re- 5 
ported, the nucleus of the eosinophiles was polymorphous, 
i.e., identical in form with the nucleus of the neutrophiles. 
As I thought it would be of considerable interest to 
determine how long the condition of eosinophilia lasted 
after the disappearance of all other symptoms of the dis- 
ease, the patient was persuaded to return on various occa- 
sions within the next three months to have his blood 
examined. Although the number of leucocytes per cubic 
millimeter diminished rapidly and was practically normal 
after the last part of August, nevertheless, the decrease 
in the percentage of eosinophiles was very gradual, and 
even on November 20th, the date of the last count, more 
than three months after the complete disappearance of 
all other symptoms, a slight eosinophilic increase was 
still present, the normal percentage of eosinophiles being 
from Ito 3 per cent. Elsewhere 1 I have shown in the 
third case reported by me that the blood was normal both 
as regards number of leucocytes per cubic millimeter and 
percentage of the various forms five months after the com- 
plete cessation of all other symptoms. 
Where the eosinophiles come from, in trichinosis, is 
still undecided, but a study of the blood and muscle in 
the four cases leads one to the conclusion that they are 
probably derived from the polymorphonuclear neutro- 
philes, those cells normally constituting from 65 to 80 
per cent, of all the white cells of the blood, and that this 
transition takes place in the affected muscles. This is 
supported by the inverse relationship which exists be- 
tween the eosinophiles and the neutrophiles in the four 
cases, by the identical character of the nuclei of both 
forms, i.e., they are both polymorphous and that what are 
apparently transitional forms between the two were found 
in the affected portions of the muscle. Thus the addition 
of this case makes four cases in all in which this associa- 
tion between trichinosis and a very high grade of eosino- 
1 Boston Med. and Surg. Journ., September 1, 1898. 6 
philia was present; in the first case, the eosinophiles 
reached 68.2 per cent, of all the white blood-cells; in the 
second 42.8 per cent., in the third 49 per cent., and in 
the fourth 48 per cent., while the total number of leuco- 
cytes per cubic millimeter reached 35,000 in the first case, 
13,000 in the second, 17,000 in the third, and 18,000 in 
the fourth. 
Just as this article is being brought to a conclusion I 
learn that a fifth case has just been diagnosed by an 
eosinophilia in the neighborhood of 50 per cent., with the 
subsequent verification of this diagnosis by the removal 
of a small bit of muscle and the finding of the actively 
motile parasites therein. 
Of the four cases I have reported, in only one, the first, 
was there anything in the clinical history to make one 
even suspect that the case was one of trichinosis, and it 
was only by means of the remarkable eosinophilia present, 
so easily made out by merely glancing at a fresh speci- 
men of the blood under the microscope, that the diagno- 
sis was made. In fact, the second and fourth cases were 
regarded as probable cases of typhoid and the third as 
estivo-autumnal malaria before the blood examination was 
made. 
Of course in a few other conditions an eosinophilia is 
noted in the blood, notably in bronchial asthma during 
the paroxysm and in splenomyelogenous leucemia, but 
the eosinophilia in these conditions is of not so high a 
grade and moreover, the diagnosis is easily reached by 
means of other.signs and symptoms. But in trichinosis, 
except in the most marked cases or in the epidemic form, 
a diagnosis is impossible without a blood examination, 
and in conclusion I would like once more to suggest the 
great advisability of making the examination in febrile 
cases of doubtful origin and in cases with indefinite intes- 
tinal or muscular symptoms. This examination will re- 
quire but a few moments and by the demonstration of a 7 
marked eosinophilia it may clear up a case now and then 
which otherwise would go down to posterity as another 
of that great class of cases, the undiagnosed. The Medical News 
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