cells may or may not be increased, the clinical features of a case of anemica will be strikingly alike, let the cause be in any one of the blood-making organs, all the more important symptoms will be present. To quote cnce more, such common features would be, "the progressive anemia with its group of circulatory symptoms, the irregular febrile reaction, essential fever of anemia, the absence of marked emaciation, the tendency to effusions of serum, the progressive debility, the recurrence of hemorrhages gastric and intestinal, gastric and intestinal disturbances, and the resistance to treatment." These affections that have so many symptoms in common are grouped as distinct diseases under the following headings, viz.: leukemia, Hodgkin's disease (anemia lymphatica), splenic anemia, and idiopathic anemia. Leukemia signifies a hyperplasia of the blood-making organs with anemia, and an increase in the colorless corpuscles. Of this form we have three varieties: the splenic, lymphatic, and medullary. Leukemia is present at all ages; the youngest case recorded by Osler being an infant of eight months. The chief symptoms are insidious onset, anemic appearance, bleeding at the nose or other hemorrhages, frequent diarrhea or other gastro-intestinal disturbance. The spleen is enlarged, gradually increasing in size from the onset, and finally it may interfere with the circulation and cause difficulty of breathing by pressure. Late in the disease the liver is also enlarged. The lymph glands in most cases are affected and sometimes slightly enlarged. The tonsils and follicles of the pharynx are usually enlarged. The lymph glands of the intestines and of the peritoneum are always enlarged. Fever is present and increases as the case progresses, and is usually of the remittent type. But the most important aid to differential diagnosis is the microscopical examination of the blood. This I give in detail in the case that forms the basis of this paper which I will now relate. I was called in consultation by Dr. I. W. Gadd, of this city, to see the child with him the latter part of last month, and the following notes were given by Dr. Gadd. Mamie McC., aged 4 years, had measles when about two years old, and from which she recovered without complication or sequelæ. About August, 1884, the tissue surrounding the eye be came much inflamed and swollen. The swelling increased so much that the eyelid could not be opened for several days. After continued poulticing an abscess formed and broke, discharging a quantity of pus, and continued to do so for a considerable time, but finally healed up with small scar. The child never complained, yet was pale and did not want to play as other children did. I believe this was more due to her disposition than to the effect of any disease. About midsummer, there appeared a rash all over her body, very thick, and resembling the eruption of measles; as it matured, it was crowned by small white caps or heads. The epidermis soon came off in large patches. The child had no fever. As the eruption faded, the mother observed purplish spots, like bruises, making their appearance. These were considered by the parents to be bruises due to falls. No attention was paid to her condition until September 28th, when I was called in the evening to arrest an epistaxis which had existed most of the day. I found the child lying on a sofa, though able to sit up, with blood slowly trickling from the nose, each nostril containing a large clot. The child appeared very anemic, with slight fever, yet did not complain of anything except weakness. The mother stated that the appetite had been very poor for some time past. The bleeding from the nose was very easily arrested by removing the clots, and packing with a strip of lint in each nostril. I also gave the following internally: Acid. gallic.. Acid. sulph. dil. Ext. ergot. fl. Syrup Aquæ.. .gr. xxx. m xxx. M. et sig. A teaspoonful in water every hour. Also ordering her as much milk as she cared to take, with the precaution that she should sip it slowly. Tuesday morning, I saw her, and found her in the same condition, except that the epistaxis had been arrested. I thought it best not to remove the lint packing. It now being, daylight, her mother called my attention to the bruise-like spots over her body. These were in size from that of a two-cent piece to that of a fifty-cent piece, and two of them, situated one over each trochanter, were as large as silver dollars. With the exception of these two, they were all, I believe, situated over the soft parts, such as over the belly of a muscle, and varying in color, according to age, from a bluish-black to a greenishyellow. She still had some fever, and her heart was more rapid in its action than normal; hence I gave her, in addition to the gallic acid and ergot mixture, the following: B Liq. potass. cit.... Spts. æth. nit. Tr. aconiti rad.. Syr. limonis. Aquæ .fl. Zi. .gtt. xv. .fl. iv. M. et sig. Teaspoonful every two hours, Wednesday morning, I found her feeling somewhat better, though still having slight fever, pulse 124 per minute, and moderately weak in character. I did not detect any abnormal heart sounds. I removed the lint packing without any further bleeding, and with much relief to the patient. I then ordered tr. digitalis in three-drop doses every three hours, and also the following: Thursday I found the patient, to use her own language, well; evidently much better. Fever had entirely subsided, the heart's action remained abnormally rapid. The cervical glands were slightly enlarged, but there was no enlargement of the tonsils, and apparently no inflammation of the fauces. Treatment was continued, with the addition of more nourishing food, beef-tea, wine-whey, etc. The child seemed so much better that I said it might come to my office the next morning instead of my going there. Later in the same evening, she took a sudden change for the worse, but I was not sent for until Friday morning. Now the patient was suffering from high fever, 104° F. in the axilla; pulse 134 per minute, compressible. The cervical glands much enlarged and very hard; the bowels had not been moved for twenty-four hours; the tonsils were but very slightly swollen; there were no patches in the throat. Thinking that possibly she was developing a malignant form of diphtheria, I at once put her on the calomel treatment until the bowels were moved, giving her three grains, repeated in two hours, and then two grains, when the bowels were moved freely, and the calomel was stopped. I also gave suppositories of two and a half grains of quinine every two hours, also: I continued the tr. digitalis in five-drop doses every three hours. I also applied hot flaxseed poultices to the enlarged glands, and at noon plenty of beef-tea and milk; but the child did not care for food, and it was difficult to get her to take any nourishment. At mid-day, I noticed for the first time, although I had carefully and frequently listened before, a systolic heart murmur. The temperature was but little affected during the night, and next morning (Saturday), at 7.30 A.M., I found it as high as ever, 104° F. in the axilla. Fearing that endocarditis had set in from the continuance of high fever and the heart murmur, I at once applied a mustard plaster to the pericardium, followed by a poultice, giving internally potassium iodide and ammonium carbonate, continuing the digitalis until noon, when I met Dr. J. M. Keating in consultation. Physical signs showed, in addition to what has been mentioned, an enlargement of the spleen, yet there was no history of malaria. Dr. Keating did not think that endocarditis had set in, believing the murmur to be rather of a hemic character, yet, as a stimulant to the heart, suggested the application of a blister, and internally, very small doses of Basham's mixture every three hours, with the free use of alcohol, beef-juice in small amount, etc., the temperature to be kept down to 102° or lower by means of the wet sheet. On examining a specimen of the urine which had just been passed, and the first that I had been able to obtain, I found it to be of sp. gr. 1.016, of a light-straw color, free from albumin and sugar. The child could not retain either medicine or beef-juice. The nose again commenced to bleed, to prevent which I again plugged the nostrils. Soon large clots of coagulated milk were vomited, the result of its having been given by half-cupfuls at a time, which was entirely contrary to my direction. Her stomach soon became settled, and she took brandy and crushed ice in small quantities. We wrapped her in a wet sheet, and then poured cold water over her until the temperature came down to 101° in the axilla, which required about thirty-five minutes. She was then wrapped in a blanket. In two hours, the temperature was again 104°. We gave several of the wet packs during the afternoon and evening, and notwithstanding we were at the same time giving two and one-half grains of quinine every hour by suppository, the same rise in temperature was observed after each. During the night, she took her medicine regularly; alcohol and water and beef-tea were also administered. Sunday morning (the day of her death), I found her, to all appearance, bloodless, pulse rapid and small, respiration shallow and frequent, temperature rising to 104° after the wet pack, as before. During Saturday night, she had removed the packing from the nostrils, which allowed a slight oozing of blood, and this having been swallowed, gave rise to vomiting of clotted blood; this continued, after the bleeding from the nose had been again checked, at intervals of ten to fifteen minutes, which gave me the belief that there was a slight hemorrhage into the stomach, these clots differing somewhat in form and color from those which I ascribed to the epistaxis. The heart became more rapid-138 per minute-and the patient gradually sank. She died at 6.30 P.M. in great agony, giving two or three shrieks, which were quite loud, considering her weakened condition. Dr. William Osler had kindly examined for me a slide of blood, and reported as follows: "Report on slide of blood sent by Dr. J. M. Keating. Examination about three hours after withdrawal. Red corpuscles present no special alteration in size or shape. "Colorless corpuscles greatly increased in number, fifty or sixty in each field of the No. 7 Hartnack. They present remarkable variations in size; many are small, not more than one-third the size of the larger forms; they resemble the smaller colorless cells which Virchow has noted to be present in cases of lymphatic leukemia. Many of the cells have feeble ameboid movements. Nu cleated red corpuscles not observed. Schultze's granule masses (often abundant in leukemia) scanty." The relation of the increase in number of the colorless corpuscles above noted to the increase in size of the glands and cytogenetic tissue is indeed hard to solve. The increase in size and hyperplasia of the spleen in leukemia and anemia are histologically identical. We must remember that the view that colorless corpuscles are changed into red corpuscles is not fully established; hence, also, that it is not proven that the excess of colorless corpuscles is due to failure in the change to red ones. In such cases, the prognosis, when the disease is detected at its incipiency, may be favorable under rigid treatment of fresh air, suitable diet, iron, quinine and arsenic, and salt-bathing; but in marked cases, that have existed for some time with advanced symptoms, the result is fatal. DR. GOODELL inquired if there were any distinguishing points between purpura hemorrhagica and lymphatic leukemia. If there is a deficiency of red blood-corpuscles, why do red patches occur so easily? DR. KEATING remarked that the subject under discussion was dependent upon certair conditions which physiologists are still debating. In leukemia we have as a diagnostic feature an involvement of the lymphatic system more or less, a hyperplasia of the tonsils, lymphatic glands of the peritoneum and of the intestines, also of the spleen and bone-marrow, all of them being more or less connected with red-cell formation; but the principal diagnostic point is the increase in number of the colorless cells, as is noted in Dr. Osler's report just presented. The hemorrhages in these cases are possibly due to a diapedesis or capillary rupture. In what is known as purpura hemorrhagica, there is an exudation of blood-cells, or the hematin from their destruction, into the rete mucosum and the papillary layer of the cutis. Of course capillary ruptures may occur, with profuse hemorrhage. The blood-cells (red) are usually diseased, they become crenated, or they cease to form rouleaux, and possibly the plasma may be at fault. The microscope alone will reveal the distinguishing features. Purpura may be considered a symptom accompanying a dyscrasia in which the blood itself is involved, not merely the organs of its production. DR. WILLIAM GOODELL exhibited the ovaries from two cases of oöphorectomy, with the following histories: OÖPHORECTOMY FOR OVARALGIA. When the patient, an unmarried woman, aged 30, first consulted him, she weighed 236 pounds, but at the same time she was very weak and could barely walk. She suffered excessive pain at her catamenial periods, which appeared only at long intervals. She bad cataleptic and hystero-epileptic fits, and complained of very constant and acute ovarian pains. Her urine was passed but once a day, and this act was attended with much suffering. The womb was enlarged, and the ovaries were very tender indeed, but nothing else abnormal was discovered. Assa |