Page images
PDF
EPUB

this dose may be doubled or trebled.

When the oil is not

well borne, inunctions may be used.

Hypophosphites, arsenic and iron may be used in some cases, but in many they are not well borne.

1. Holt. Infancy and Childhood.

BIBLIOGRAPHY.

2. Birch-Hirschfeld. Wiener medizin. Blätter, No. 17, 1891. 3. Baginsky. Jahrbuch der Kinderkrankheiten.

4. Comby. Diseases of Children.

5. Taylor and Wells. Diseases of Children.

Clinical and Patbological Notes

A Case of Splenic Myelogenous Leukæmia with Autopsy. Cases of leukæmia are sufficiently uncommon to warrant the publication of any case that may have come to autopsy. This case is of interest because of the presence of a greatly enlarged spleen at a time when the blood examination showed only slight hyper-leucocytosis. The presence in the blood of the following forms of leucocytes, myelocytes, mastzellen, and eosinophiles made the diagnosis leukæmia very probable at a time when it would have been difficult to decide between leukæmia and splenic anæmia, so called Banti's disease. It is to be regretted in this report that the autopsical notes could not have been followed by those of a careful microscopical study of sections of the various organs. Small pieces from all the organs were removed but owing to changing my residence they were unfortunately lost in moving.

August 1, 1892. Mrs C., aet. 55, housewife. Father and mother died of old age. Two brothers living and in good

health.

Personal history: Had whooping cough and measles in childhood otherwise has always been healthy. Twenty-six years ago she lived in a malarial district, but has never had chills and fever or other evidence of malarial infection. Menstruation appeared at sixteen and had always been regular until the age of forty-nine, when it ceased. It lasted only two days, was never profuse, and was without pain. Patient married at 39. Has had but one child, a boy, aet. 13, living and in perfect health. Never had any miscarriages.

In June, 1892, patient suffered from what she believed was an attack of la grippe; had severe pains and aches throughout her body. These pains continued about four weeks when she noticed a fullness in the upper left quadrant of the abdomen. This swelling seemed more apparent on rising in the morning, and was attended with a considerable degree of abdominal distention. During this attack there has been a gradual loss of flesh and of strength. Her appetite has gradually diminished and she became very pale. This condition of extreme weakness, slight emaciation and pallor with loss of appetite, coupled with shortness of breath, pain and discomfort in her abdomen, has continued until the present time. No hemorrhages from the nose, gums, mouth, rectum or uterus have ever occurred. During the course of her illness a watery diarrhoea has occurred, which has been very difficult to control. Never has had headache or dizziness, but palpitation and dyspnoea are quite marked on the slightest exertion. Patient is troubled with hemorrhoids. noticed no difficulty with vision. Hearing is acute.

Has

August 1, 1892. Present condition: Patient is 5 feet 7 inches in height, weight 130 pounds, rather tall and slender. Is extremely pale; lips, ears, finger tips and buccal mucous membrane appear almost bloodless. Limbs moderately developed, but muscles are very flabby. Abdomen protuberant in epigastric, left hypochondriac and inferior axillary regions. No lymphatic enlargement; neither tonsils nor papillæ of tongue are enlarged. Veins of chest and abdomen not visible. No oedema of face or ankles. No evidence of cranial nerve involvement. Ophthalmoscopic examination negative. Drum membranes appear normal. No defect of hearing. Reflexes normal. Examination of lungs negative. Nerves or muscles not tender on pressure. Liver dulness normal. The organ not tender on forcible percussion. Heart's apex in fifth interspace, within mammary line. No increased cardiac dulness. A soft, strictly localized systolic murmur is present in the second left intercostal space. Heart sounds are normal; pulse regular and full. Marked venous hum in both sides of neck. The upper left quadrant of the abdomen presents an area of dulness extending from the level of the eighth intercostal space downward

to the level of the umbilicus and laterally to the posterior axillary line. On palpation a distinct tumor-like swelling is felt, tender, but firm and moving on inspiration, which, from its position and form is doubtless the spleen. No friction fremitus or murmur could be heard connected with this swelling. Marked tenderness on percussion of the sternum and long bones is present. The urine, apart from containing an

excess of uric acid, is perfectly normal.

Examination of the blood showed only a moderate leucocytosis, the ratio of whites to reds being 1 to 40. No poikilocytosis, no nucleated red cells. No differential count of the white corpuscles was made; there appeared, however, to be about an equal number of mast cells, neutrophiles, myelocytes, together with a few eosinophiles.

February 17, 1893. Patient's condition has remained about the same, with periods of apparent improvement, soon to be followed by periods in which all the symptoms were aggravated. Blood examination showed hæmoglobin, 55 per cent; red cells 3,140,000; relation of whites to reds, I to 15. No deformity of red cells. A few nucleated reds were observed. The leucocytes consisted mostly of mastzellen, myelocytes, large lymphocytes, together with a few eosinophiles and polynuclear cells.

May 18. All symptoms decidedly worse, extreme pallor, peripheral veins distended, soft oedema of the ankles. Body considerably emaciated, sternum and long bones exquisitely tender on percussion. Bones of skull not tender on percussion. No hæmorrhages have occurred, no patches of purpura. Has had of late marked feelings of weakness and depression and several attacks of faintness, without loss of consciousness. Splenic dulness extends from posterior axillary line to left iliac region, the spleen evidently resting in the iliac fossa. Liver dulness extends 1 1⁄2 inches below free border of ribs. No enlarged lymphatic glands detectable. Soft systolic pulmonic murmur; venous hum in both sides of neck. Background of eyes normal; hearing perfect.

July 2, 1895. Patient more emaciated; face very thin; sub-conjunctival tissues oedematous. All the superficial veins are greatly distended. Slight pulsation of jugular veins exists. Beneath middle third of right clavicle is situated a

lymphatic gland of moderate size, which has developed during the past few weeks. No other lymphatic glands palpable. Has had, during past few months, many faint attacks. Ankles very œdematous. Splenic dulness extends vertically from the sixth rib, in mid-axillary line, down to left iliac fossa, and transversely from post-axillary line to an inch to the right of the umbilicus. Region of liver very tender on percussion; enlargement, vide supra. General bone tenderness as before. An irregular febrile movement was noted, ranging from 100° to 130°. Dulness at base of chest due to slight hydrothorax. No ascites. Cardiac dulness not increased. Urine contains no albumen, sugar, casts or blood; uric acid increased.

Red cells,

Ratio

Blood examination: Hæmoglobin, 40 per cent. 2,135,000 per c. cm. Nucleated red cells present.

Differential count of whites:

of whites to reds, I to 5.

[merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][ocr errors][merged small][merged small][merged small][merged small][merged small]

66

12

Polynuclear leucocytes.. July 20. No material change save patient is much weaker; remains absolutely recumbent. The slightest exertion brings on marked dyspnoea. Face much swollen; lips, mucous surfaces and finger tips livid. Temperature, 1021⁄2°. Respirations 40. Pulse, 90, soft, easily compressible but regular. muscle or nerve tenderness; reflexes normal. Vision perfect. No evidence of leukæmic retinitis; hearing excellent..

No

Patient died rather suddenly on July 25. Autopsy 5 hours after death, by Dr. Donald Buchanan: General emaciation. Skin of a light yellow hue; soft oedema of hands, arms, feet and legs. No rigor mortis: slight post-mortem lividity in dependent parts. Slight panniculus adiposus. Muscles of thorax and abdominal walls pale and atrophic. Intestines universally tympanitic, peritoneal surface glistening and free from adhesion. A small amount of free fluid in peritoneal cavity. Stomach undersized and very pale. Liver enlarged; right lobe reached two inches below costal margin.

Gall

bladder contained about an ounce of yellow bile free from stones. Cystic and common duct patent. Liver, on section, appeared pale as if fatty. Lungs oedematous, slight pleural adhesions; small amount of serum in chest cavities, otherwise normal. Bronchial glands not enlarged. Pericardium contained about three ounces of fluid. No evidence of former pericarditis. No adhesions. Heart not enlarged. Myocardium soft and flabby. The slight sub-pericardial fat was of a greenish yellow hue. Right auricle and ventricle contained a very large chicken fat clot of grenish hue. Blood in chambers of left heart fluid, valves all appeared normal.

Myocardium of a pale brown color, and very soft. Kidneys of normal size, capsules unadherent, normal relation between the pyramidal and cortical substance. Spleen very large, filling whole left side of abdomen and extending into right side. Capsule apparently thickened, and contained numerous points of perisplenitis. Splenic substance was very friable, its outer surface was of a deep blue color. No infarcts were discovered. No enlarged lymphatic glands. The bone marrow taken from the tibiæ and sternum was of a yellowish color.

89 FOURTH STREET, TROY, N. Y.

HERMON C. GORDINIER.

Correspondence

VIENNA LETTER.

VIENNA, AUSTRIA, November 20, 1899.

One of the great privileges of medical study abroad is the opportunity of hearing the great teachers and of seeing their methods. In the realm of internal medicine is this especially instructive. A foreigner cannot receive personal instruction from these men and the only chance to see and hear them is to attend their lectures. These are purely clinical and I have yet to hear a didactic lecture on medicine. The general plan is to call down a student who questions and examines the patient and is in turn questioned and examined by the professor, who goes over the case very thoroughly, dwelling

« PreviousContinue »