grey, contained, besides normal red blood corpuscles, very numerous coloured structures. The rest of the vascular system contained sometimes more red clots, sometimes more white,-upon the whole, having the greatest number of white corpuscles. Remarks. This must certainly be regarded as a very remarkable case, presenting all the phenomena observed in the condition of the blood, recorded in Cases I. and IV., without enlargement of spleen, but instead, great hypertrophy of the lymphatic glands distributed throughout the body. Virchow also speaks of certain free nuclei in the blood, the nature of which, without a figure, it is very difficult to understand. We have previously seen, however, that in Case I. the lymphatic glands were enlarged, and the appearance of their cell-elements is represented Fig. 5. I presume that these with their nuclei free are the bodies to which Virchow alludes. The case proves that leucocythemia may be produced independent of enlargement of the spleen, although hypertrophy of other glands, abounding in similar cell-elements, seems necessary. The shut sacs, resembling the Malpighian bodies of the spleen, found in the liver, constitute altogether a new production, unlike anything observed before or since. No tendency to hemorrhage from the mucous membrane is noticed in this case, the whole of the symptoms being pulmonary, evidently associated with the lesions which existed in the lungs. CASE VII.-Leucocythemia detected after Death; Hypertrophy of Spleen and Lymphatic Glands; Tuberculosis. Heinrich Hoensch, journeyman joiner, ætat. 38, received into the Charité Hospital, Berlin, February 28th, 1848, under Professor Wolff. Seventeen years ago he suffered from an intermittent fever of ten weeks' duration. Four years ago, in consequence, as he says, of cold, he felt a stitch in the left side of his abdomen, together with diarrhoea and abdominal pain. These symptoms disappeared and returned at intervals. Nine months after they were more constant, and two months since the large swelling was first observed, which occupied the whole left side of the abdomen. Its margins were easily determined, and pressure caused no great pain. Diarrhoea continued; the appetite was normal; he sleeps well, and is somewhat debilitated. In the middle of March headach and epistaxis appeared and frequently returned. On the 26th he lost a quart of blood by epistaxis, which was arrested by plugging, but produced great weakness. During April there was no recurrence of bleeding. The pulse rose gradually, and the strength improved; the tumour also diminished. He had an anemic appearance, and was very fretful, and left the hospital on the 13th of June. He returned in a fortnight. Slight fever came on, which increased, and after the 21st July there was an evening exacerbation. The tumour again enlarged, and slight epistaxis returned. Accurate examination showed that the tumour was from half an inch to an inch larger in diameter in the morning than in the evening. Pulse in the morning was 104, in the evening 120; urine 1 Archiv für Pathologische Anatomie und Physiologie. 2te Band. P. 587. NEW SERIES-NO. XIII. JANUARY 1851. E contained a considerable sediment of urate of ammonia and phosphates. The fever became aggravated, with occasional epistaxis, till October, when headach, dizziness, dyspnoea, cough, with deep inspiration, came on. There was diminished respiratory murmur in the left breast inferiorly, and in one part crepitation. 10th October, he was cupped on the affected part. Pulse frequent, especially in the evening; there was cough, with deep inspirations; the sputa were tenacious and rusty coloured. The symptoms went on increasing till, on the 26th October, copious bilious diarrhoea supervened, the fever continued, and he died on the 2d of November. Sectio Cadaveris.-Body emaciated-fat disappeared. The internal table of the cranial bones was thickened by osteophytic deposits. In the longitudinal sinus the blood presented somewhat of a greyish coagulum. Considerable effusion of serum in the enlarged ventricles, the walls of which were softened by imbibition. The capillaries presented no apparent accumulation of colourless blood-corpuscles. Thyroid gland tolerably large and pale. A few tubercles in the right lung. Recent tuberculosis of left lung and pleura, with fibrinous exudation. In the heart, which was normal, were a great many fragmentary coagula, which presented an inferior mass, moderately thick and red, and a superior one, like coagulated pus, of a white colour. These clots were continued into the arteries. In the veins was fluid grayish-red blood, along with similar yellowish-white clots. Examined microscopically, the red blood-corpuscles were mixed everywhere with numerous colourless ones, which in the white clots occurred almost alone, or were associated with fatty molecules. The colourless corpuscles were of the usual size, slightly granular, displaying, with acetic acid, single nuclei or several small ones, with all intermediate gradations. Very often the transition forms were horse-shoe shaped or crescentic. The spleen occupied the whole side of the abdomen, and the diaphragm was adherent to its upper surface. Externally it was very firm, bluish-red, and at its outer margin were two yellowish-white tubercles. On section, it was homogeneous, pale grayishred, almost flesh colour. By careful examination it displayed small white corpuscles. Pulp very resistent and dense. When examined microscopically, there was found, among normal cells and nuclei, a slightly granular mass of exudation. Liver, with exception of small tubercles, normal. Kidneys flabby, with miliary tubercles. Epigastric lymphatic glands enlarged, flabby, somewhat oedematous. Internal mucous membrane presented here and there tubercular ulcerations. Remarks. In this case, associated with the leucocythemia, there was enlargement of the spleen, without hypertrophy of the liver. The lymphatic glands are said to be enlarged and oedematous. Whether they were, or were not, similar to the hypertrophied glands formerly noticed, is not stated. Tubercular exudation existed also in various tissues, and especially tubercular pleurisy. Here, again, we observe epistaxis to be a leading symptom, followed by fever and copious diarrhoea. CASE VIII.1-Leucocythemia discovered during Life; Hypertrophy of Johanna Sheen, aged 69, a fruit-seller in the streets, was admitted into the North London Hospital under the care of Professor Parkes. Has never had any serious illness or malarious disease. Towards the end of 1848 had swelled feet, and shortly afterwards pain in the left side of abdomen. She then first perceived a considerable swelling below the false ribs on the left side. She had no sickness, 1 Medical Times, June 8, 1850. shivering, or fever. She entered the hospital in January 1849, and remained under treatment there (blisters, iodide of potassium, and morphia) until the end of February, when she was discharged. On several occasions during this period she had morning sickness, and vomited a little blood. In November, when in the street, she was knocked down by a cart, and suffered some pain in the abdomen for four weeks in consequence. On re-admission, December 13, 1849, "we found her thin and shrivelled, without oedema or enlargement of veins; there was a peculiar dusky, yellowish-brown colour of the skin, most evident on the trunk, and less marked on the face and extremities; the conjunctivæ were clear; there were no head symptoms; and no pulmonary symptoms, with the exception of a little dry friction low down on the left side; there was a feebly acting heart, in its right position, and without bruit; the pulse was 72, regular; the radials not visible. A large tumour, evidently an enlarged spleen, filled the left side of the abdomen, descending from the lower border of the seventh rib, nearly to the ilium, bulging into the posterior left lumbar region when she lay on her back, and reaching nearly to the umbilicus on the right; falling over considerably to the right of the umbilicus when she lay on the right side; with a prominent, rigid, smooth, lower border; very hard throughout, and tender; the extreme length of the dull percussion-note was 8 inches; no splenic murmur was ever audible. The height of the hepatic dulness (vertical line from nipple) was 48 inches; the lower edge was 1 inch below the false ribs; to the left of the middle line the hepatic dulness confounded itself with the splenic, that is to say, with the dulness of the tumour. There was no fluid in the peritoneum, no nausea; the appetite was good, the tongue clean; there were no intestinal or uterine symptoms. She had had no epistaxis at any time; no hæmoptysis; a little hæmatemesis, apparently, when she was in the hospital previously; no melæna, hæmaturia, or mennorrhagia. "During the patient's stay in hospital, viz., till the 17th of March, she remained nearly in the same condition. Occasionally she suffered from severe frontal headaches; she also had, on several occasions, sharp stabbing pains in the abdomen, both over the spleen and liver, for which leeches were applied, the bleeding from which was profuse and not very easily arrested. On four or five occasions, also, she had moderate shivering, followed by heat and sweating; these attacks were not very regular, seemed to observe no certain times, and were separated from each other by long intervals. On the 27th of Febru ary, according to her own account, she passed a pint of blood with a stool; but this, and another stool passed subsequently, were thrown away accidentally, and were not seen by any one; the next stools were free from blood. With this exception, she had no bleeding from any part of the body, and none into the substance of the skin. On the 17th of March the patient left the hospital, nearly in the same state as on admission." Blood drawn from the finger evidently presented, from the excellent description given by Dr Parkes, the same appearances represented in Figs. 6 and 7. The venous blood was analysed on two occasions, by a process closely resembling that adopted by Dr Robertson of Edinburgh; first, on the 20th December, the blood being taken three hours after food, when the composition of the blood in 1000 parts was as follows: Fibrin (with probably adherent white corpuscles), ... Red particles, with a number of white corpuscles which could ... Coagulable organic matters of serum, Incoagulable, Soluble salts of the serum, Insoluble salts of the serum, 7.08 101.63 63.03 3.08 8.63 ⚫48 816.07 1000.00 "The composition of the serum was as follows. The reaction was strongly alkaline: Coagulable organic matters, 70.71 Incoagulable, 3.46 Soluble salts, 9.68 Insoluble (obtained by incinerating the dried albumen), *55 915.6 1000.0 "A small portion of serum was examined for uric acid in the ingenious method devised by Dr Garrod, viz., by the addition of a little acetic acid to a portion of serum in a watch-glass, at the bottom of which lies a fine hair. No crystals of uric acid could, however, be perceived. "On the 15th of February the patient was bled again three hours after food; the fibrin was estimated by washing the clot. The composition was as follows:Fibrin (with probably adherent white corpuscles), Red particles (with undetermined white corpuscles), Organic solids of serum, Inorganic solids of serum, Water, ... 4.75 97.93 69.27 8.25 819.8 1000.00" The urine was subjected in this case to a series of careful observations, but nothing unusual was observed. Remarks. In this case, which was under careful observation for three months and a-half, there were observed occasional slight accessions of fever, but none of the epistaxis, or violent hemorrhages and diarrhoea, we have seen to constitute such leading symptoms in previous cases. At one period, indeed, she is said to have had hematemesis, and at another a bloody discharge from the bowels; but the latter is doubtful. The further progress of this woman's case is a matter of some interest. As regards the analyses of the blood, they show increase of the fibrin, and very slight diminution in the amount of the corpuscles,-in the latter respect exhibiting a marked difference from the results obtained by Dr Robertson in the Edinburgh cases. The two following cases are recorded by Dr Fuller : CASE IX.1-Leucocythemia detected during Life and after Death; Hyper trophy of Spleen and Liver. On the 31st December 1845, a man was admitted into St George's Hospital, who had been seized eight months before with dyspeptic symptoms. Six weeks later, a small, firm, painless tumour appeared in his left hypochondrium, which in three months rapidly increased. The dyspnoea continued, he lost appetite, occasional vomiting came on, and his bowels were costive. There was constantly recurring bleeding at the nose, and since the middle of December diarrhoea has continued. He died on the 8th of January 1846. Sectio Cadaveris.-Spleen and liver very much enlarged. All the bloodvessels enlarged, and the blood grumous, of a remarkable gray colour. The blood which was examined before death showed, besides its normal corpuscles, abnormal spherical bodies, of a finely granular appearance, colourless, 37 without visible membrane or nucleus; some of the usual size of corpuscles, CASE X.-Leucocythemia; Encephaloid Tumour of the Abdomen. An encephaloid tumour of the abdomen was removed from a girl, nine years of age, who became an out-patient, under Dr Fuller, at St George's Hospital, in February 1850. She had enjoyed tolerable health till July. In a few weeks after this a tumour was perceived projecting from under the ribs on the left side downwards towards the pelvis. It increased very rapidly, and pressed upon the rectum and neck of the bladder,-thus producing much distress. When brought to the hospital, the abdomen was enormously enlarged, the right side tympanitic, the left dull on percussion. Protruding from under the ribs on the left side, and causing them to bulge considerably, was a firm, solid tumour, which could be traced down the abdomen on the left side, dipping into the pelvis, its anterior margin being irregular. It was regarded to be an enlarged spleen. She was greatly emaciated, and her legs oedematous. She died on the 30th of March. The encephaloid tumour was seen occupying the whole of the left side of the abdomen. Superiorly it pressed against the diaphragm, and encroached considerably upon the thorax. Inferiorly it dipped into the pelvis between the rectum and the bladder. It was irregularly oblong, knobby on its surface, and larger at its superior than inferior extremity. It weighed four pounds nine Its cut surface was in most parts of a cream colour, firm and elastic to the touch, but in parts of a dark mottled appearance, and somewhat softer. The bladder was greatly distended, and was above the brim of the pelvis. The ureters were considerably dilated, also the pelvis of either kidney. The structure of the kidneys was much diminished by pressure. The other viscera healthy. ounces. The tumour itself presented nothing of particular interest, but showed that a condition of the blood, which had been supposed peculiar to certain forms of disease of the spleen, may be seen in other disorders. The peculiarity consists in the presence of large numbers of colourless, granular, spheroidal globules, varying in size from that of a common blood corpuscle to twice or three times that size, as shown by actual admeasurement. Whether these globules be merely the colourless corpuscles of the blood in an altered condition, or altogether of abnormal production, there can be no doubt that their presence is indicative of an unhealthy state of the blood. These globules Dr Fuller had observed in every case of enlarged spleen, unconnected with ague, in which the blood was examined; and satisfied by repeated examination that they do not exist in the blood of persons having enlargement of the spleen as the result of ague, he had supposed them peculiar to that form of enlargement of the spleen which occurs independently of malarious influence. But as the same condition of blood was found in this case, it is obviously not peculiar to, or diagnostic of, the disease alluded to; and it becomes a question of considerable interest as to the conditions under which these globules make their appearance. Remarks.-These notices of cases leave much to be desired. Still the facts mentioned are important. With regard to the latter case, Report of the Proceedings of the Pathological Society of London. Fourth Series. Pp. 224, 225. |