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common in America than in Europe. His figures showed 11:3 among 10,000 cases of all sorts, and only one of his cases was acute. It is therefore imperative that all cases of acute leukæmia should be described as minutely as possible, and I have to thank my friends Dr. Charles Workman, Dr. W. K. Hunter, and Dr. Alec R. Ferguson for their kindness in enabling me to give a careful record of the anatomical and histological details. My thanks are also due to my former house physician, Dr. James Scott, for the following clinical history :

Henry M., æt. 19, single, a van driver, was admitted to Ward 12 of the Glasgow Royal Infirmary on 16th January, 1902, complaining of weakness of a month's duration.

History of illness. He had an attack of diarrhea about two months

ago, which forced him to give up his work. The illness lasted about a week, but after that he was unable to get any work, and as he had spent all his money he was unable to get either food or shelter. He knocked about doing nothing, getting any food that was given to him by his neighbours, and sleeping on stairs or in hay-lofts, or, indeed, anywhere that he could get shelter.

About a month before admission he had a boil on the right leg which forced him to seek admission to the Parliamentary Road Parochial Hospital, where he remained for five days. After this he was sent to Kilmun Convalescent Home for a fortnight, and since his return he had been living in Watson Street model lodging-house with some money that had been given to him by friends. On the 8th inst., on account of increasing weakness, he went to the Royal Infirmary dispensary, and was advised by Dr. James Dunlop to get a subscriber's line and come into the Infirmary.

Previous history.-He states that he has always enjoyed excellent health, and was never laid up before the onset of the present illness.

Family history.—His father died of bronchitis, and his mother of ulceration of the stomach ; he has one brother and three sisters alive and well.

Present condition.—He has a very pasty complexion; the mucous membranes are very pallid; the skin is hot and covered with beads of perspiration. Though he is rather fat, the muscles are very soft and flabby, and, altogether, he looks a very ill-nourished lad. The pulse is regular but of very low tension, numbering 100; the respirations number 18; and


the temperature ranges about 100° F. The pupils are medium, active, and equal; the sclerotic is of a markedly pearly white colour; and he is very deaf. The tongue is covered with a dirty brown fur on the dorsum. The gums are very soft and spongy, and here and there actual blood-clots are sticking to them. The teeth are in a very bad state, and there are many decayed stumps. Over the surface of the body there are a number of shotty nodules of a “ blae” colour. They are situated in the skin and can be pinched up between the fingers. There is no discolouration of the legs.

Heart.—There is a diffused but very weak impulse in the fourth space, 3 inches to the left of the middle line. Pulsation is also visible and palpable in the third interspace. The upper border of dulness cuts the third rib, the right is half an inch to the left of the middle line, and the left, at the level of the fourth interspace, lies 3] inches to the left of the middle line, the transverse measurement being 31 inches. On auscultation at the apex no murmur is heard, but the sounds are very rapid and weak. Over the pulmonic area a soft blowing systolic murmur is heard. A rather harsh systolic murmur can also be heard in the vessels of the neck.

Lungs.No area of dulness is made out, and the respiratory murmur is everywhere normal.

Liver. The upper border of hepatic dulness cuts the sixth rib in the mid-clavicular line, and the lower lies 1 inch beneath the costal margin, the vertical measurement being 4 inches.

Urine.—In the first specimen passed there was a quantity of blood - clot. A subsequent specimen had the following characters :-Colour, muddy amber; mucous deposit; reaction, slightly acid ; specific gravity, 1022 ; albumen, a cloud; no blood; no sugar.

Blood examination.—There is a marked deficiency in fibrin formation, a slight prick of the skin being sufficient to give exit to a large drop, and pressure being required to stop the flow. The dry film specimen shows the white cells to be almost equal in number to the red discs. The following is the result of the blood count:

Red blood corpuscles,

15 per cent.
766,000 per

White ,

1 Deafness is said to occur in chloroma.

CLINICAL NOTE BY DR. LINDSAY STEVEN. 22nd January, 1902.—The patient is greatly exhausted, and his appearance is suggestive of the most profound anæmia. The eyelids are slightly puffy, with small crusts of dry blood adhering to them. The gums present a pale bluish colour; many of the teeth are much decayed, and the appearance of the gums at the crown of the tooth suggests recent bleeding at many points. The tongue is coated with a thick brownish dry fur, and the breath is most offensive, The adipose tissue is not greatly diminished, and the contours of the body are well rounded. The most striking feature on inspection of the anterior surface of the trunk is the appearance of a number of small rounded steel-coloured nodules, about twelve in all, varying in size from a millet-seed to the circumference of a threepenny piece, and irregularly distributed over the sur One such nodule is situated on the front of the upper arm, and another, the largest of all, is situated on the small of the back to the left side. These nodules are in the skin, and can be felt as little tumours between the finger and thumb, and have all the appearance of multiple melanotic sarcomas of the skin. Anteriorly the neck seems to be somewhat full, and this is found to be due to a moderate but irregular enlargement of the sterno-mastoid glands. "The axillary glands are moderately enlarged, particularly on the left side. There is also distinct enlargement of the inguinal glands. The spleen is certainly not palpable, but its area of dulness is thought to be increased, extending from the seventh rib above to the tenth below in the mid-axillary line, its anterior border being about 11 inch behind the point of the eighth rib. The liver is not enlarged. The abdomen generally is of normal shape and tension, and no evidence of abdominal tumour can be obtained. The apex beat is very visible, and normal in situation. The cardiac murmurs described in the report are pretty clearly functional or hæmic. The fresh specimen of blood examined this morning has very distinctly the characteristics of leukæmia, but the type of the leukæmia is left for further investigation. The temperatures have steadily risen during residence, and during the last two days have ranged between 101° and 102° F. The pulse has averaged at least 110; and the bowels have responded to castor oil.

23rd January, 1902.—Last night the patient was very critically ill. Drowsiness was great, and in the evening he vomited a considerable quantity of coffee-ground material. This morning he was obviously dying; the pulse being

extremely rapid and of strikingly low tension, and the respirations rapid and shallow. He died at 11 A.M.



Summary.Leukæmia. Spleen moderately enlarged, weighing about 8 ounces. Lymphatic glands of neck and abdomen much enlarged. Clots in heart and vessels of a most remarkable greenish-white colour.

External appearances.-A well-developed but considerably emaciated body. Post-mortem rigidity is present. The skin generally is unduly pale. Over the front of the abdomen there is some grey discolouration, and here and there over the front of the body there are several subcutaneous nodules, from one-eighth to about half an inch in diameter, which are freely movable over the muscles, and present a dark grey colour through the skin. On cutting into them they are found to have a greenish-grey colour, and to be of the consistency of lymphatic gland tissue. The lymphatic glands of the neck and axillæ are much enlarged, and on cutting into them they are found to have a greenish-grey colour, but are not

Thorax.—The pericardium contains only a small quantity of somewhat greenish serum. Both layers of the pericardium are the seat of a purpura-like eruption. The thymus gland is unusually large and has a greenish tinge. All the blood in the great vessels has clotted, and has a greenish colour, resembling solidified green pus.

Heart.— The aortic and pulmonary curtains are competent, and present healthy characters. The aorta seems to be somewhat smaller than usual. The mitral and aortic valves are normal in size, and healthy. The muscular wall shows very pronounced fatty degeneration, with a purpuric mottling beneath the endocardium. The heart appears normal in size, and has no more fat over its external surface than normal.

Lungs.—These organs are free from pleuritic adhesions, and are fairly voluminous. They show slight emphysema at their borders, and are moderately ædematous. The blood in their vessels is mostly consolidated, and is also like green pus. The bronchi appear fairly healthy. The mediastinal glands are not enlarged.

Abdomen. The omentum and peritoneum appear healthy, but the mesenteric glands are much enlarged and prominent. A few of them show some caseous-like necrosis.

The spleen is moderately enlarged, weighing about 8 ounces,

and shows a large cicatrix of an old infarction. On section the organ has a deep brown red colour.

The liver is considerably enlarged. Its substance has a rather brownish red colour, but shows to the naked eye no appearance of mottling from lymphoid infiltration. There is a slight degree of cloudy swelling. The gall-bladder is normal in size, and contains fluid bile.

The suprarenal bodies are normal in size. The right is somewhat larger than the left, and on coarse section presents healthy characters; the left shows a few minute nodules like miliary tubercles.

The pancreas is of good consistence, and appears healthy.

The kidneys are large. Their capsules strip off without much difficulty, exposing a smooth surface. În the cortex there are a number of small round patches of dark colour, like the nodules under the skin, and in the right there are one or two small urinary cysts.

The stomach is somewhat hour-glass in shape. The mucous membrane is very rugous, and is mottled with little purpuric or hæmorrhagic patches, almost of a papular character. The peritoneal surface appears healthy.

The mucous membrane of both large and small intestine has a slatey colour, perhaps due to the fact that the patient had been treated with doses of citrate of iron and ammonia. Peyer's patches are a little more prominent than usual, but no ulceration or very marked thickening exists. The vermiform appendix appears thicker than usual, but is otherwise healthy. Its colour shows nothing remarkable.

Head.-On removing the calvarium, which is rather thin, the dura is found to be very adherent, and is removed with it. The pia-arachnoid shows, especially over the cerebellum, a purpuric hæmorrhagic mottling like that of the heart, and there are some small hæmorrhages in the substance of the brain, one especially in the posterior part of the left internal capsule.

Bone-murrow.—The femur, the right humerus, and one of the ribs are examined. The bone-marrow has a most remarkable appearance, not being very fluid, but having the dark greenish colour seen in the lymphatic glands and in the nodules under the skin.

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Blood films were stained with triacid, and with eosin and methylene blue stains.

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