T H E D U B L I N JOURNAL OF

M E D I C A L SCIENCE.

S E P T E M B E R 1, 1896.

PART I.

ORIGINAL COMMUNICATIONS.

ART. IX . - -~Leueoey t l zcera la . a By JAMES CRAIO, M.D., F.R.C.P.I. ; Physician to the Meath Hospital.

A BoY died in the Mea~h HospitM on the 27th of January last, a victim to the comparatively rare but generally rapidly fatal form of ]eueocythmmia, known as the lymphatic type.

The purely splenic, or lymphatic, or medullary form of leukmmia is seldom met with; more usually mixed types occur, in which two or perhaps all three varieties are com- bined, the commonest of all being the spleno-medullary, but still when you have examined the films of stained blood that are placed under t;he microscope, I think you will agree with me in regarding this case as belonging to th~ purely lym- phatic type. In a paper read before the l~edical Section of this Academy in 1891, Dr. WaIlace Beatty recorded a case of the purely medullary form, and for the recognition of which, in the absence of external signs to prompt him, he deserves the greatest credit. Unfortunately, at that time but little had been done in the direction of distinguishing the different kinds of leucocytes to be found in the blood, so that although these cells were, as a whole, greatly increased, still the particular variety met with in that case has no~ been recorded.

�9 Read before ~he Medical Section of the Royal/kc~demy of Medicine in Ireland, l~riday, May 8, 1896.

VOL. CI I . - -NO. 297 , THIRD SERIES. N

188 Zeucocythcemla.

The boy, who was nineteen years of age, was an Italian by birth, an image-maker by occupation, and his fatal illness, which was of an acute nature, extended only over two months altogether.

On observing the photograph [exhibited] yon will note par- ticularly the thickness of his neck, the swelling of the parotid region, the tnmours in the axill~e--all of lymphatic origin--and the distension of his abdomen. The enlargement of lymphatic glands was universal. The spleen and liver were both in- creased in size, and the tonsils were swollen and painful.

The pallor of his skin was probably accentuated by a naturally sallow complexion peculiar to his countrymen. As the illness progressed, dyspnoea became more marked. Profuse epistaxis occurred, and with this a diarrhoea so persistent that the treatment of the case was mainly directed to combating these two distressing symptoms. Severe epigastric pain was constant, which, with evident intestinal distension, as well as the persistent diarrhoea, suggested an inflammation of the colon that was not verified by the Tost-mortem examination. There was no tenderness over the sternum.

Priapism--an occasional symptom in such cases--was observed. A venous hum was present in the neck, and a soft systolic murmur was audible over the mitral area. About a week before his death the lower extremities became oedematous, and the glandular swelling was considerably diminished. The temperature was variable, ranging from 99 ~ to 103 ~ F , and as death approached it fell to 97 ~ F.

The case on admission was thought to be one of Hodgkin's disease, or lymphadenoma, and undoubtedly many of the cases described as such were similar in nature to the present one; but if we take it that permanent increase of white blood cells is characteristic of leucocythmmia, while mere diminution of the cellular elements of the blood is a feature of the other, then we are in a position to discriminate between these closely-allied affections--lymphatic leucocy- tb~emia, and lymphadenoma.

I shall not weary you with details of the repeated examina- tions of the blood which were made; suffice to say that the red cells were reduced to at least one-third of their normal number--a condition for which the epistaxis was probably

By DR. JAMES CRAIG. 189

largely accountable, while the white ones were both abso- lutely and relatively increased, the proportion of white to red being about one to twenty instead of one to three hundred.

In the slides which are placed under the microscopes, and for the staining of which I am indebted to Dr. M'Weeney, you will observe at a glance this increase of white cells, but in addition to the increase it is possible also to distinguish between the different varieties of these corpuscles. One preparation is stained with acid haematoxylin and eosln, and the other with Ehrlich-Biondi triple stain of methyl green, acid fuschin, and orange.

You are aware that the leucocytes of human blood are not all of the same size, and that they differ also in other respects, in some the protoplasm is granular, in others it is without granules; in some the granules are large, in others, again, they are small. :But, in addition to these peculiarities, it has been found that the granules in some cells stain with acid dyes, while in other cells they stain only with basic dyes. I may add that the latest investigations in this con- nection go to show that the granules of certain cells, which were supposed by Ehrlich to stain with neutral dyes alone, aud hence called by him neutrophiles, are now found to stain not with neutral but with acid dyes.

The most recent work on the subject is a paper by Kanthack and Hardy. They classify these cells into five varieties, as follow : - -

AcidophileS,or i Oxyphiles, granules

stain with F.osin

1. Coarsely granular, polynuclear or horseshoe-shaped nucleus (Ehr- lich's eosinophiles)--2.8 per cent. 10"0 ~ in di~.

4. Hyaline cells, free from granules, mononuclear, and generally spherieal--ll per cent. 8"5-10"0/~ ,,

b. Lymphocytes with single nucleus, a very little protoplasm--24 per cent. 6'0 ]~ ,,

2. Finely granular, irregular-branch- ing nucleus (Ehrlmh's neutro. philes)--62 per cent. 8-9"0 ~/~ ,,

Basophile, } granules

stain with 3. Finely granular, ~rilobed nucleus-- Methylene 0'7 per cent. 7"0 ~ ,,

blue

190 .~eucocytt~mi~z.

The percentages here represent the proportion of: each variety found in the blood in health.

All of these cells occur in normal blood, and, roughly speak- ing, in splenic leuk~emia No. 1 are greatly increased, in the lymphatic form the increase is in No. 5, while in the medullary form other cells are observed that are not present in health, namely, mononuclear cells, larger than Nb. 4, but unlike them in containing granules which stain only with neutral dyes. These are called myelocyfes, from their supposed origih in the bone marrow.

Tow, in these films, prepared from the Italian boy's blood, you will notice that, practically speaking, the small lympho- cytes only are increased, although a few of at least 1, 2 and 4 can be seen as well, but the total increase of leucocytes in the lymphatic form is never found to be so great as in the splenomedullary form. So much for the blood.

The main facts revealed by the autopsy were these : - -The organs generally were pale and bloodless, all the subcutaneous lymphatic glands were enlarged, some not larger than a marble, others the size of a walnut. About a quart of serous transudation lay in the pleural sacs and a few ounces in the pericardium. A mass of lymphoid tissue lay in front of the lower end of the trachea, and a larger mass surrounded the right bronchus. The lymphatic glands along the whole course of the intestinal tube were much enlarged, the liver and spleen were considerably increased in size, the pancreas was white and bloodless, the stomach and intestines were distended with gas, and the mucous membrane of the latter was pale, while Peyer's patches and the solitary follicle~ were enlarged and sharply defined. Under the microscope the liver and spleen were found to be impacted with lymphocytes, which accounted for their increased bulk.

The case is of interest in several particulars. In the first place this lymphatic variety is rare, and where it does occur is generally, as in the present instance, found in young sub- jects, and it usually runs through a rapid and fatal course.

In the splenic or splenomedullary forms the insidious and slowly progressive nature of the affection, as it is com- monly met with, affords an opportunity for treatment, so that cases of improvement or recovery are not infrequent.

A Case of Fracture of the First Rib. 191

I have several such patients whose blood has improved and whose spleens have returned almost, if not quite, to their normal dimensions under the free administration of arsenic, so that they are able, af ter a number of years, still to follow their daily avocations. In this case, however, I was obliged to drop the arsenic on account of the diarrhoea, and to t reat symptoms instead.

In the next place, the acute nature of the symptoms pointed to an infective cause, and it is highly probable tha t before long we may have the presence of a micro-organism, or its poisonous products, demonstrated in the blood to account for the grave changes that are present in leucocy- thmmia.

A n d lastly, the advances that have been made within recent years in the study of the white-cell elements of the blood render it a fairly easy mat ter now to distinguish in stained preparations the particular form of the affection nnder observation, although it is true that much has yet to be added before our knowledge becomes at all perfect.

ART. X . - - A Case of Fracture of t/~e First .Rib, complicated by Abscess opening into the Lung, with ltemarks on Fractures of the First Rib. ~ By G. J ) . ~ s o N JOHNSTOn, M.A., M.B. ; Assistant Surgeon, Richmond Hospital.

E N., female~ aged forty-five, was carrying a fender on Saturday, 11th February, 1898, when~ stepping from the footpath to the roadway, she missed her :footing, staggered forwards for a few yards, and fell on the fender. Her le~ft ring finger was caught between the fender and the ground, and received a compound comminuted fracture of its distal phalanx. She was so much con- cerned about the latter injm T that she was unable to give an exact description of the other, but stated that the corner of the fender struck her under the inner part of the left collar-bone, and that the left side of her fac~ was hurt. At the time she felt nothing give way.

The following ]~Ionday she attended the dispensary of the Richmond Hospital, and had her finger dressed. The dressing was repeated on Wednesday. During the succeeding days she

�9 This ease was under the care of Sir Thornley Stoker in the Richmond Hospital.