Virchow, is objectionable, because, in the first place, as is correctly stated by Dr Parkes, the blood is not white, but presents its usual red tinge when drawn from the arm. The colourless clots occasionally observed, will certainly not warrant the application of this term to the blood generally, as they are frequently present without the morbid condition under consideration. Besides, the same name (white blood) has been given with more propriety to the fatty blood, examined by Drs Traill, Christison, and others, which presents a milky, opalescent appearance. What is required to be expressed is, that the blood abounds in colourless corpuscles, and this is, I think, done by the term Leucocythemia-from AEUKòs, white; KUTOS, cell; and aipa, the blood-literally, white cell blood, which expresses the simple fact, or a pathological state, and involves no theory.

I propose, in the first part of this paper, to bring together all the cases I have been able to collect of this newly discovered disease; and, in the second part, to give a systematic account of what is known of its symptoms, pathology, and treatment. The cases may be arranged in two divisions,-1st, Undoubted cases, in which the Leucocythemia was proved to exist by a microscopic examination; 2d, Probable cases, in which, though the blood was not examined physically, it still presented such appearances as to warrant our deriving from them considerable information, in drawing up a systematic account of the disease. To these I shall add, thirdly, a few cases for the purpose of showing that the spleen may be greatly enlarged, without necessarily occasioning the peculiar condition of the blood under consideration.

PART I.

I.-CASES OF LEUCOCYTHEMIA, IN WHICH THE DISEASE WAS POSITIVELY PROVED TO EXIST BY MICROSCOPIC EXAMINATION.

The three following cases are those which have been under my own observation. In the first one, the blood disease was only discovered after death; in the other two, it was proved to exist by a physical examination of the blood during life.

CASE I.-Leucocythemia discovered after Death; Hypertrophy of the Spleen, Liver, and Lymphatic Glands.

John Menteith, aged 28, a slater, admitted into the clinical ward of the Royal Infirmary, February 27, 1845, under the care of Dr Christison. He is of dark complexion, usually healthy and temperate; states that twenty months ago he was affected with great listlessness on exertion, which has continued to this time. In June last he noticed a tumour in the left side of the abdomen, which has gradually increased in size till four months since, when it became stationary. It was never painful till last week, after the application of three blisters to it; since then, several other small tumours have appeared in his neck, axillæ, and groins, at first attended with a sharp pain, which has now, how

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1845.

Originally published in the Edinburgh Medical and Surgical Journal. October

ever, disappeared from all of them. Before he noticed the tumour, he had frequently vomiting in the morning. The bowels are usually constipated, appetite good, is not subject to indigestion, has had no vomiting since he noticed the tumour; he has used chiefly purgative medicines, especially croton oil; employed friction with a liniment, and had the tumour blistered. On admission, there is a large tumour, extending from the ribs to the groin, and from the spinal column to the umbilicus, lying on the left side. It is painful on pressure near its upper part only. Percussion is dull over the tumour ; pulse 90; states that for three months past he has not lost in strength. There is slight oedema of the legs. To have two pills of iodide of iron morning and evening.

March 1.-Urine of yesterday somewhat turbid when just passed, natural in colour, acid to litmus; sp. gr. 1013. Sediment presents cubic crystals under the microscope, disappears almost entirely on the addition of aqua potassæ, but is unaffected by nitric acid. The filtered urine is not affected by aqua potassæ, and yields only a slight white haze when boiled.

March 9.-Edema of legs increased. They have been bandaged with flannel rollers. B. Potasso Carbonatis, 3i.; Spiritus Etheris Nitrici, ziv.; Aqua Mentha, Ziij.; Aquæ fontis, 3ij. M. Sumat unciam ter in dies.

March 10.-Tormina and considerable diarrhoea; urine not increased. Habt. Haustum ex Olei Ricini, 3ss. statim; et exactis quatuor horis, Opii, gr. ii.

March 13.-Attacked this morning with heat of skin; thirst; pulse 110, full, very compressible. The diarrhoea, which had been checked, returned yesterday; none this morning, after taking an opium pill. Urine, 100 ounces. Omittantur medicamenta. Sumat statim Pulveris Ipecacuanhæ et Opii, gr. x., et repetatur dosis singulis semihoris ad tertiam vicem.

March 14.-No sweating from the powders; diarrhoea still rather troublesome; pulse, 100, softer; tongue, dry and brown; febrile expression of countenance, resembling that of typhus. B. Aqua Acetatis Ammoniæ, 3vi.; Solutionis Morphic, 3i.; Aquæ fontis, 3iij.; Syrupi, 3j. Sumat unciam quartá quáque hord. Habt. Decoctum Hordei pro potu.

March 15.-Died suddenly in the morning.

Sectio Cadaveris.-March 19 (four days after death).- Externally, the body presented a considerable prominence of the ensiform cartilage and false ribs on both sides. The abdomen was contracted; considerable dulness on percussion on left side, which had previously been marked out by a line formed with nitrate of silver. No ascites nor oedema of the limbs.

Blood. The blood throughout the body was much changed. In the right cavities of the heart, pulmonary artery, venæ cave, vena azygos, external and internal iliac veins, and many of the smaller veins leading into them, it was firmly coagulated, and formed a mould of their size and form internally. In the cavities of the heart and venæ cave, the blood, when removed, was seen to have separated into a red or inferior, and a yellow or superior, portion. The red portion was of a brick-red colour; it did not present the dark purple smooth and glossy appearance of a healthy coagulum, but was dull and somewhat granular on section, and when squeezed readily broke down into a grumous pulp. The yellow portion was of a light yellow colour, opaque and dull, in no way resembling the gelatinous appearance of a healthy decolorised clot. When squeezed out of the veins, as was sometimes accidentally done where they were divided, it resembled thick creamy pus. In some portions of the veins, the clot was wholly formed of red coagulum. In others it was divided into red and yellow. In a few places the yellow formed only a streak or superficial layer upon the red, or covered the latter with spots of various sizes. Whether this coagulum existed in all the veins could only have been ascertained by a complete dissection of the body. It was seen, however, that the femoral veins, after passing under Poupart's ligament, were empty and perfectly healthy as far down as the Sartorius muscle. The external and internal iliac

veins, as well as the pelvic veins, were full and distended. The azygos, both axillary and jugular veins, were full, also the longitudinal, the lateral, and other sinuses at the base of the cranium, and veins ramifying on the surface of the brain. In this last situation some of the veins appeared as if full of pus, whilst others were gorged with a dark coagulum-(see the coloured plate, which will be published in the next Number of the Journal). In the aorta and external arteries were a few small clots, resembling those found in the veins. These vessels, however, were comparatively empty. The basilar artery at the base of the brain was distended with a yellow clot.

Vessels. The arteries and veins themselves were perfectly healthy. Although carefully looked for, in no place could thickening or increased vascularity be observed. Nowhere was the clot adherent to the vessels, but, on the contrary, it readily slipt out when an accidental puncture was made in them.

Head.-On removing the dura mater, the veins which empty themselves into the longitudinal sinus were considerably engorged, especially posteriorly. Some were filled with the red and others with the yellow clot previously described. Others, again, were half filled with red and half with yellow coagulum, the passage of the one into the other being clearly perceived. Both hemispheres, with the longitudinal sinus and fala in situ, were removed by a section across the brain, as low down as the division of the cranium would permit. The brain was then discovered to be very soft uniformly,-a circumstance accounted for by the time which had elapsed since death. The part removed was put aside, in order to be preserved and hardened in spirit. The lateral ventricles were found healthy, contained no serum, and the choroid plexus was perfectly normal. At the base of the brain the basilar artery was seen distended with the yellow coagulum, as were also a few of the arteries, but to a very slight extent. The substance of the brain itself was throughout healthy. All the sinuses at the base of the cranium gorged with the red coagulum.

Chest.-A few chronic adhesions united the pleuræ on both sides, which were easily torn through. Both lungs were slightly engorged posteriorly and inferiorly. The anterior margin of the left lung emphysematous, but to no great extent. On section, the yellow coagulum of the blood was observed to occupy all the ramifications of the pulmonary artery. In some places it was so consistent as to be drawn out, exhibiting an arborescent form; in others, it was more soft, and exuded from the cut surface like thick pus. Heart somewhat enlarged; weighed, when freed from coagulum, eleven and a-half ounces. Its texture was healthy; the valves normal. The right auricle much distended, and gorged with a firm coagulum, the upper third of which was found composed of the yellow, and the two inferior thirds of the red clot formerly described. The right ventricle and pulmonary artery were similarly distended; portions of the clot closely embraced the columnæ carneæ, but were in no place adherent. The coronary arteries and veins were normal.

Abdomen. On the inferior surface of the diaphragm there existed a firm, almost cartilaginous, deposit about a line in thickness, of a white colour, oval form, two inches long by one and a-half broad, with irregular margins, which were composed of several rounded tubercular bodies, the size of a small pea, and of a similar structure. The liver enormously enlarged from simple hypertrophy. Its structure throughout healthy. Gall-bladder enlarged, and distended with a clear pale yellow bile. The whole weighed ten pounds twelve ounces. The spleen also enormously enlarged from simple hypertrophy. It was of a spindle shape, largest in the centre, tapering towards the extremities. It weighed seven pounds twelve ounces. It measured in length fourteen inches; in breadth, at its widest part, seven inches; and in thickness, four and a-half inches. Towards its anterior surface was a yellow firm exudation, about an inch deep, and three inches long. The peritoneum, also covering a portion of its anterior surface, was thickened, opaque, and dense over a space about the size of the hand. Both kidneys healthy. The stomach and intestines healthy through

out. About four inches from the anus the superior hemorrhoidal veins were distended on both sides external to the rectum. They formed two chains of tumours about three inches long, consisting of, on the one side, three swellings as large as a walnut; on the other, of one swelling somewhat larger. They were filled with a red coagulum, broken down into a grumous mass. The lymphatic glands were everywhere much enlarged. In the groin they formed a large cluster, some being nearly the size of a small hen's-egg, and several being that of a walnut. The axillary glands were similarly affected. The bronchial glands were not only enlarged, but of a dark purple colour, and in some places black from pigmentary deposit. The mesenteric glands were of a whitish colour, some as large as an almond nut. A cluster of these surrounded and pressed upon the ductus communis choledochus. The lumbar glands were of a greenish yellow colour, also enlarged, forming a chain on each side, and in front of the abdominal aorta, more especially at its bifurcation into the iliacs. No collection of pus could be found in any of the tissues.

Microscopic Examination.-The yellow coagulum of the blood was composed of coagulated fibrin in filaments, intermixed with numerous colourless corpuscles, which could be readily squeezed out from it when pressed between glasses. Where the yellow coagulum was unusually soft, the corpuscles were more numerous, and the fibrin was broken down into a diffluent mass, partly molecular and granular, partly composed of the debris of the filaments broken into pieces of various lengths. The corpuscles varied in size from the th to theth of a mill. in diameter; they were round, their cell-wall granular, and presented all the appearance of pus corpuscles. (Fig. 1.) Water caused them to swell and lose their granular appearance, and acetic acid dissolved the cell-wall and caused a distinct nucleus to appear. This nucleus was composed sometimes of one large granule about the 26th of a mill. in diameter, at others of two or three smaller granules, as is seen in corpuscles of laudable purulent matter. (Fig. 3.) The red portion of the coagulum contained a smaller number of these colourless corpuscles, mixed with a multitude of norFig. 1.

Fig. 5.

Fig. 1.-Colourless corpuscles, mingled with a few coloured ones, from the white clot of the blood in Case I.

Fig. 2.-The same bodies, mingled with a larger number of yellow blood corpuscles, in the red clot.

Fig. 3.-Change produced in the colourless corpuscles on the addition of acetic acid, the yellow corpuscles being dissolved.

Fig. 4. Cells in the fluid squeezed from the lymphatic glands, after the addition of acetic acid. Fig. 5.-Blood-vessel giving off a capillary from the pia mater; the latter is seen filled with colourless corpuscles; the former partly with colourless, mingled with coloured, corpuscles. 250 diameters.

mal yellow corpuscles. (Fig. 2.) The colourless corpuscles now described were found in the blood throughout the system. They were seen in the veins and arteries ramifying on the brain, in the coronary veins, hemorrhoidal tumours, and wherever the blood was examined. On stripping off a portion of the pia mater, and examining the capillary vessels of that membrane, all that were not too minute to contain them were found crowded with the same corpuscles. (Fig. 5.) This fact was confirmed by Dr Allen Thomson, to whom I sent a portion of the brain for that purpose.

The cartilaginous deposit on the inferior surface of the diaphragm was composed of dense fibrous tissue, in which numerous granules and molecules were observed. The exudation in the spleen was composed of amorphous fibrin mixed with numerous molecules, granular and imperfect cells. These were intermingled with bundles of filamentous tissue. The enlarged lumbar glands, on being pressed, exuded a fluid that was crowded with corpuscles; some resembling the colourless corpuscles already alluded to; others oval and round, containing a distinct nucleus. (Fig. 4.)

The ultimate textures of the muscles, brain, nerves, &c., were carefully examined, and found normal.

Remarks.-The enormous size which the liver and spleen had attained in this case, caused apparently no great inconvenience. There was only slight oedema of the legs without ascites. Diarrhoea appeared on the 10th, and was present during the subsequent progress of the case. The most important symptom, however, seemed to be the fever which occurred on the 13th, and continued until his death, on the 15th. At the same time, it cannot be said to have been very severe, and it was unattended by prostration of strength. The post-mortem examination was conducted with the greatest care, for the appearances at the time were quite new to me. Nowhere could the slightest traces of phlebitis be discovered; for, notwithstanding the blood was firmly coagulated in the venous system, so far from being adherent to the vascular walls, on making an opening it slipped out from them with the greatest facility. Neither could abscesses, or purulent infiltration of any tissue, be discovered. No observations having been made on the blood during the life of the individual, it was impossible to say how long that fluid had contained the excess of colourless corpuscles which were found in it after death; but I believed at the time that they were formed towards the close of life, and probably when fever became manifest. A similar conclusion was arrived at by Dr Craigie, from his observation of this case, as well as of the one afterwards to be detailed. (Case IV.) That such conclusion was erroneous, however, will be made evident from several other examples of the disease, but especially from the next to be recorded.

CASE II.-Leucocythemia detected during Life; Hypertrophy of the Liver ; Ascites; Phthisis Pulmonalis.

Barney Tinlay, æt. 17, farm-servant, admitted into the clinical ward of the Royal Infirmary, January 25, 1850. With the exception of an attack of scarlet fever, which he experienced about three years ago, he enjoyed perfect health until twelve months since, when he first noticed a swelling in the abdomen, accompanied by some pain. The tumour since this period has gradually increased in size, and