Part 25

Naturally an ordinary leucocytosis may be combined with a lymphæmia. We have already mentioned elsewhere (see page 102) that in the leucocytosis of digestion or of diseases of the intestine in children, such a coincidence occurs.

The so-called agony leucocytosis we do not regard as a true leucocytosis, but only as the expression of a stoppage of the circulation caused by that condition. This produces an accumulation of the white corpuscles on the vessel walls, especially in the peripheral parts of the body which are as a rule used for clinical investigation. A leucocytosis is thus simulated.

It is also of interest to notice the behaviour of the eosinophil cells in the passive form of leucocytosis, lymphæmia. À priori both conditions could be combined. As C. S. Engel has established in the congenital syphilis of children a simultaneous marked increase of lymphocytes and eosinophil cells is found. The lymphocytosis in these cases is probably due to the anatomical changes of the lymph glands, and the eosinophilia to specific chemiotactic attraction.

In his monograph on Bothriocephalus anæmia Schauman, with reference to the behaviour of the eosinophil cells, states that he has found them in but few cases of this disease.

This view has lately received striking confirmation from the interesting experiment of Bäumer, who produced on himself by means of continued stimulation with Urticaria ureus a considerable increase in four days of the mast cells in the irritated portions of the skin.

That a well-marked basophil leucocytosis has not so far been observed may be thus explained. The substances which attract the mast cells are very rarely produced in the body; much more seldom than the corresponding substances attractive for the eosinophils. In morbid conditions, where substances attracting the mast cells were present, it might be possible to find a suppuration of mast cells, or a mast cell leucocytosis as well. In this connection an observation of Albert Neisser is of the greatest interest. He met with (private communication) one, out of numberless cases of gonorrhoea, in which the purulent secretion consisted entirely of mast cells.

Unger has recently published completely analogous observations on the human breast for the mast cells. Under the influence of stagnation of the milk he saw an invasion of the gland tissue by typical mast cells.

A very interesting observation of Goldmann's deserves mention here. Goldmann found in preparations of the pancreas of proteus sanguineus, containing parasites, that the eosinophil cells in the neighbourhood of the encapsuled parasites were much increased, whereas they were sought for in vain, in more distant parts.

A case observed some time back by Ehrlich may here be mentioned as a characteristic example. A woman received a blow in the region of the spleen by a fall from the roof, which gradually led to a marked splenic enlargement. As no other symptoms appeared, the surgeon in charge proposed splenectomy, on the assumption of a pure splenic leukæmia. Examination of the blood, however, shewed a condition fully corresponding with myelogenic leukæmia, and thus prevented surgical interference.

Ehrlich was once able to recognise, by balancing the different forms of cells, the blood preparations after the loss of their labels from some ten cases of leukæmia.

Literature given by A. Fraenkel.

V. DIMINUTION OF THE WHITE BLOOD CORPUSCLES (LEUKOPENIA).

Diminution of the white blood corpuscles plays--comparatively with their increase--a very unimportant rôle in clinical observations. It occurs in but few groups of diseases, and but seldom attains a marked degree. Koblanck has described a most marked fall in the number of the colourless cells, in the following remarkable blood condition. In a strong man, 25 years of age, whose internal organs were found to be healthy, short epileptiform attacks occurred, in one of which death took place. The autopsy gave no indication of the cause of death. Two examinations of the blood were made in the course of the three days he was under observation. In one of these, out of =ten cover-glass preparations, not a single white blood corpuscle was found=, and in the second only one example.

We have mentioned this case here, because it is remarkable as an extreme leukopenia never before observed. An explanation however is impossible owing to the obscurity of the general clinical condition.

For the rest the conditions, under which a considerable diminution of the leucocytes occurs, are very well-known. We distinguish two chief groups:

1. Leukopenia from =destruction of a portion of the white blood corpuscles= (Löwit);

2. Leukopenia from =deficient inflow of white corpuscles=:

. in anæmia etc. from =defective action of the bone-marrow=.

We have entered more fully into the leukopenia experimentally produced by Löwit, in the chapter on leucocytosis. We there explained, that according to present views, we have to deal, not with an actual destruction of the white elements, but merely with an altered distribution within the blood-stream.

Amongst the infectious diseases where an hypoleucocytosis occurs, typhoid fever must first be mentioned. The diminution is chiefly at the expense of the polynuclear cells. Uncomplicated measles too, generally runs its course with a marked leukopenia, specially distinct during the breaking out and at the height of the exanthem. These cases of infectious leukopenia are to be explained, not by a destruction of white corpuscles, but rather by a diminished inflow, brought about by the circulation of substances negatively chemiotactic for the polynuclear elements.

Leukopenia has still another meaning in certain cases of severe anæmia, where it indicates a highly unfavourable prognosis. Ehrlich has described (Charité Annalen 1888) a case of posthæmorrhagic anæmia ending fatally, where an extreme diminution of the leucocytes occurred. Exact figures shewed that the greater proportion (80%) of white blood corpuscles consisted of lymphocytes, whilst the polynuclears amounted to 14% (instead of 70-72% normally). Eosinophil cells and nucleated red blood corpuscles were entirely absent. Ehrlich explained these phenomena by a deficient activity of the bone-marrow, which found expression in the insufficient formation of red and white blood corpuscles. As the anatomical basis of this deficient activity, he conjectured that in this case the fatty marrow of the big long bones could not have been changed to blood forming red marrow, as is the rule in severe anæmias. In two cases the autopsy fully confirmed this diagnosis made during life.

The blood platelets.--The hæmoconiæ.

The ~blood-platelets~ were first described by Hayem, later by Bizzozero, as a third formed element of normal blood. They are roundish or oval discs free from hæmoglobin. They are extremely unstable under mechanical, thermal, and chemical influences. Their size amounts to some 3 µ. Specially characteristic is their tendency, the result of their extraordinary stickiness, to run together into largish clumps, "grape clusters." This circumstance greatly facilitates the distinction of the blood platelets from the other formed elements, but renders their enumeration most difficult. The apparatus usually used for counting the blood corpuscles is, for this reason, deceptive; for the platelets rapidly cling to its walls and remain there. All early authors (e.g. Bizzozero) endeavoured to obviate this error by some particular diluting fluid; but a number of these elements still remained fastened to the walls of the capillary tube of the mixing apparatus.

Recently Brodie and Russell have recommended a new mixture in which the platelets remain quite isolated, and are stained at the same time. They allow the drop of blood as it comes from the puncture to enter a drop of the fluid, and then estimate the relative proportion of red blood corpuscles to platelets. The prescription for their solution is as follows:

Dahlia-glycerin, 2% solution of common salt ... equal parts.

Another method, used by the majority of more recent authors, is the relative enumeration of blood platelets in the stain dry specimen. Ehrlich found that the blood platelets were picked out by their deep red colour, corresponding to the amount of alkali they contain, in preparations treated by the iodine eosine method (see p. 46). Rabl's new method is much more complicated and in no way more serviceable, depending on a stain with iron hæmatoxylin recommended by E. Haidenhain for demonstration of the centrosomes. A process of Rosin's, not yet published, is more convenient. It consists in fixing the dry preparation for 20 minutes in osmic acid vapour, and staining in a concentrated watery solution of methylene blue.

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With regard to the significance of the blood platelets, most authors, of whom we should before all mention Hayem, Bizzozero, Laker, assume justifiably that they are preformed in the living blood. The view opposed to this, advocated more particularly by Löwit, that these forms first arise in the blood after it has left the vessels, we may describe on the grounds of our own extensive observations as inaccurate.