REMARKS UPON A CASE OF LEUKEMIA. BY JOHN WINTERS BRANNAN, M.D. REPRINT FROM American Medico=Surgical Bulletin, May 15, 1894, TO CONTRIBUTORS. Contributions of Original Thought and Experiences, on Medical and Surgical Topics, are desired by the AMERICAN MEDICO-SURGICAL BULLETIN on the following conditions: 1. -Authors of Scientific Papers or Clinical Reports accepted by us will receive-according to their own preference expressed with each communication, either: a:-A number of Reprints of their article in neat pamphlet form 'pocket size); or, 6:-Instead of the above, an Equivalent value therefor in Cash. 2. -All contributions are received only on the express understanding: a:-That they have not been printed anywhere, nor communicated to any other journal. l>:-That, if they have been read anywhere to "an audience, this fact be stated in full detail by a note on the manuscript. Contributors will serve their own interest by heeding the following suggestions; Write Concisely and Clearly. 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REMARKS UPON A CASE OF LEUKEMIA.* By JOHN WINTERS BRANNAN, M.D. THE case I have to present this even- ing is one of spleno-myelogenous leukemia. Before proceeding to its consideration it may be well to run over briefly the different varieties of primary or essential anemia. By the term primary anemia is meant a disease in which the in- itial lesion is seated in the blood itself, or in one of the blood-making organs, viz : the spleen, the lymph-nodes, and the bone mar- row. Primary anemias may be conveniently divided into six classes. These are chloro- sis, simple anemia, pernicious anemia, Hodgkin's disease or lymphatic anemia, splenic anemia, and leukemia. Chlorosis. A diminished percentage of hemoglobin is the essential blood change in chlorosis. The red cells are usually normal in number and size, but deficient in coloring matter. Poikilocytosis may be present in severe cases. Simple anemia. The red cells and hemo- globin are both diminished, and, approxim- ately, to the same degree. There is poiki- locytosis and nucleated red cells (normo- blasts) are also observed. Pernicious anemia. The red cells are enor- mously decreased in number, with poiki- locytosis. The hemoglobin, though abso- * Read at a meeting of the Section on Practice of the New York Academy of Medicine, April, 1894. 3 lutely diminished, is relatively increased. Nucleated red cells of large size, megalo- blasts, are always present in greater or less numbers. Hodgkins disease, also called lymphatic anemia or pseudo-leukemia. This disease is characterized by a progressive enlargement of the lymph-nodes throughout the body. Later there is well marked simple anemia. The spleen may or may not be enlarged. Splenic anemia. There is great enlarge- ment of the spleen, conjoined with the blood changes of simple anemia. This is a very rare disease, and is considered by some writers as the pure form of Hodgkin's dis- ease. I have had one case under observa- tion for the past eight months and had hoped to present it this evening. The splenic enlargement had caused it to be mistaken for a case of leukemia, but ex- amination of the blood showed simply a great diminution in the number of red cells with changes in their size and shape. The hemoglobin was also much diminished. Under treatment with iron and arsenic the red cells have increased from 1,106,000 to 4,290,000 per ccm., and have become normal in appearance. The hemoglobin has risen from 35% to 75%, and in all re- spects the patient seems in good health. The spleen, however, remains of the same size as at the beginning of treatment. Leukemia. The distinguishing character- istic of leukemia is, of course, the great increase of the white cells. The red cells and hemoglobin are at the same time much diminished. There is also poikilocytosis. Cases of leukemia are further subdivided according to the relative increase of the different varie- 4 ties of white cells. Four divisions are some- times made, but they may with advantage be consolidated into two main groups, lym- phatic leukemia and spleno-myelogenous leukemia. Lymphatic leukemia is very rare and is characterized by predominance of cells de- rived from the lymph-nodes, hence called lymphocytes. Spleno-myelogenous leukemia is the form commonly met with, and is distinguished by the presence of myelocytes, that is, cells derived from the bone marrow. Our patient, as I have said, is an instance of this latter form of leukemia. I first saw her in August, 1893. She had noticed for some months a gradual increase in the size of her abdomen, and some impairment of her gen- eral health. She had borne several healthy children and had menstruated regularly since the birth of the last one. On examina- tion I found the lower borders of the spleen extending some three inches below the costal margin and forward to the para- sternal line. The liver was also enlarged, how much coifld not be accurately deter- mined, as there was a general condition of enteroptosis. Very lax abdominal walls and a ventral hernia have undoubtedly con- tributed to this latter condition. From that day to this the spleen has steadily increased in size, so that now it extends to within a finger's breadth of the umbilicus and very nearly to the crest of the ilium. The notching of the spleen can be distinctly felt. The liver has also gained in all dimensions, dulness beginning at the fourth rib and extending to the median line and two inches below the level of the umbilicus. On intro- ducing the tips of the fingers through the 5 ventral hernia, the spleen can be felt and lifted on the one side and the liver on the other. A count of the blood in August gave 260,000 white and 888,000 red cells to the ccm., a proportion of about 1 to 3. The hemoglobin was j-educed to 30%. Poikilo- cytosis was marked. In October the white cells numbered 237.500 and the red cells 2,818,000 to the ccm., a proportion of 1 to 12. The last examination of the blood, made in March, 1894, showed the white cells reduced to 162.500 and the red cells increased to 4,275,000 to the ccm., a proportion of 1 to 26. The percentage of hemoglobin was 5s. The red cells were normal in size and shape. In spite of this improvement in the con- dition of the blood, the spleen, instead of lessening in size, has grown to the enor- mous proportions already mentioned. I have made no extended reference to the minute changes in the white cells, as Dr. South- worth is to demonstrate them to you this evening. His studies have enabled us to classify this case as belonging to the spleno- myelogenous form of leukemia. The treatment has consisted mainly of arsenic. The patient has taken fifteen drops of Fowler's solution three times a day al- most continuously for several months. Her general health has been good, interrupted at intervals by periods of fever, relieved some- what by quinine. Her menses ceased some three or four months ago, but there are no indications of pregnancy, though she is still within the child-bearing age. The cessation of menstruation has probably contributed to her improvement, though it did not initiate it. 6 A few days ago Dr. Margaret A. Cleaves kindly suggested the employment of galvan- ism in the hope of reducing the size of the spleen. I am sorry that she could not be here this evening to explain the mode of action of the current as well as to give some details of similar cases in which it has proved of benefit. This treatment has al- ready been begun by Dr. Cleaves in this case, and I trust that I may be able to report good results at some future meeting of the Section. New York City ; 54 W. nth St. 7 SEVENTH YEAR. $2.00 per year. American ]V\edico=Surgical Bulletin A SEMI-MONTHLY JOURNAL OF PRACTICE AND SCIENCE. Issued on the 1st and 15th of each month. THE BULLETIN PUBLISHING COMPANY, 73 William Street, N. Y. EblTOKlAL STAFF. WILLIAM HENRY PORTER, M.D., FREDERICK PETERSON, M.D., Chiei Editor. Associate Editor. SAMUEL LLOYD, M D., j. rjddLE GOFFE, M.D., Department of Surget y. Department of Obstetrics, Gynecology WILLIAM FANKHAUSER, M.D., and Pediatrics. I Department of and GEORGE K. SWINBURNE, M.D., A DOLPH ZEH, M.D.. Genito-Urinary Surgery. Pathology and General Medicine. HENRY T. BROOKS. M.D., WILLIAM C. GUTH, M.D., Bacteriology. Pathology and General.Medicine. JOHN WINTERS BRANNAN, M.D., GEORGE G. VAN SCHAICK, M.D., Neurology and Psychiatry. Pathology and Clinical Medicin : IRA VAN GIESON, M.D., W. TRAVIS GIBB, M.D., Pathology of Nervous System. Gynecology. LEWIS A. CONNER, M.D., T. S. SOUTHWORTH, M.D., Neurology. Pediatrics. ALBERT W. FERRIS, M.D., WILLIAM OLIVER MOORE, M.D. Neurology. Ophthalmology and Otology. PEARCE BAILEY, M.D., ADOLPH BARON, M.D , Neurology. Diseases of Children MORTON R. PECK, M.D., HENRY F. QUACKENBOS, M.D., Neurology. General Medicine VENTURA FUENTES, M.D., T. HALSTED MYERS, M. D. Clinical Medicine. Orthopedic Surgery. r LOUIS HE1TZMANN, M.D.. GEORGE THOMAS J ACKSON, M.D., Genera) Medicine and pathology. Dermatology. WILLIAM B. COLEV, M.D. B. HARDENBERGH, M.D., Obstetrics and Gynecology. General Surgery. s JAMES E. NEWCOMB, M.D., OT TO H. SCHULTzE, Lan ngology. Obstetrics and Gynecology.