The American Medical Association The Diagnosis and Treatment of Tuberculosis of the Kidney When is "Early" in Operating for Appendicitis?. 494 BY FRANK SWOPE, M. D., CARTHAGE, TENN. No. 1 s well known, leukemia is a fatal disease, having slow but certain tendency to death. There is marked increase in the leucocytes of the blood. There is also enlargement and proliferation of the nphoid tissues of the spleen, lymphatic glands, and bone marrow. The disease is attended with progressive anemia. Internal hemorrhage is a prominent feature, coupled with gradual exhaus on of the powers of life. There are several forms of this disease, to-wit, amygdaline, in which the tonsil plays an important part; Fraenkel's, or the acute form; hepatic, intestinal, or that form associated with disease of the liver and spleen, and bone marrow; lymphatic, that form which involves the lymphatic structures most prominently. Etiology. As yet we know but little of the cause or causes that produce this most fatal disease. Fortunately, it is a very rare *Paper read at the meeting of the Middle Tennessee Medical Association at Lebanon, Tenn. disease on this continent. Locality seems to play but little part in its production. It occurs oftenest among those in the middle period of life. However, no age is exempt. It has been known to occur in children of eight to ten weeks, and in the old up to the eightieth year. Males seem to be more prone to it than females. In females the climacteric period seems to invite an attack. It has been known to develop during or following pregnancy. It seems to be endowed with hereditary tendency. Cameron reports a patient that passed through three pregnancies and bore non-leukemic children. However, the grandmother, mother, and a brother had it. One of the patient's children died before the mother showed any symptoms, and another one died of the disease. It is thought by some that malaria is a factor in its production. In 150 cases analyzed by Gowers, thirty had had malaria. Osler, out of seventeen cases reported, found malaria in seven cases. The lower animals are not exempt; it has been known to exist in horses, cattle, hogs, and even cats and rats. The first account we have of this disease came from the pens of Craigie and Bennett. In the October number of the Edinburgh Medical Journal for 1845, or about sixty years ago, Osler Virchow, Rokitansky, Fuller, Bichat, had reported cases in 1801, Velpeau in 1827, Coventon in 1828, Andral in 1839, Both in 1834. In 1847 Virchow gave it the name it now bears. Bennett, in 1851, gave this disease the name of leucocythemia, and claimed priority. Virchow, however, holds this distinction. The principal forms are due to the organs first involved. These have been spoken of in the outstart. Symptoms. This disease steals on the patient, as a rule, insidiously. One of the first complaints will be the gradual enlargement of the spleen. The liver is not often implicated, but may be. Shortness of breath may be a prominent symptom. The symptoms have been divided into two or more stages by some writers. But these will be found to be very irregular, and so far as my observation goes, we will not find the symptoms to come on with any degree of uniformity. The gastric symptoms will not be present in all cases. In fact, in the case reported by me, the stomach continued to perform its functions up to three weeks before death. Diarrhea is common, but was not present in my case as a symptom. The liver will in the last stage become more or less enlarged, but ordinarily not. Ascites is not often a feature, but may be present to that extent where tapping will be called for. The nervous system will frequently be involved. Dizziness, due to the anemia, may be marked. The mental faculties do not seem to be disturbed. While the patients may be gloomy, as a rule they are hopeful. Hemorrhage is liable to occur at any stage, but more freThis will most often be from the quently in the late stage. stomach or bowels or nose. Deafness has been reported by several writers as an early symptom. The pulse is always quick, ranging from 80 to 100, and later 110 or more, even 150 to 160. Edema of the ankles is the rule in the late stage, and general anasarca may follow. We may have effusion into the pleural cavities. Hemorrhage, says Osler, may destroy life before a diagnosis has been made out or suspected. Respiration is not disturbed except in the very last stage. The temperature is low, and fever may not be present except from septic causes. This may be periodic. The kidneys usually will be normal in amount, but acid in reaction, with increased specific gravity. Enlargement of the spleen, reaching to the mons veneris, which may adhere to the abdominal wall and other organs. It may vary in size from two to eighteen pounds. Sooner or later the glands of the neck, together with the axillary and femoral regions, will show increasing growth in proportion to the spleen. The average course of the disease is from one to two years, but may go beyond this. Asthenia is the common mode of death. Hemorrhage is often fatal. Diagnosis. This disease can only be differentiated from Hodgkin's disease and splenic anemia by examination of the blood. Treatment. If the disease is due to malaria, quinine and arsenic would be the rational treatment. Tonics containing iron. should be pushed. Fowler's solution has given better results. than any other one drug. Excision of the spleen has been practiced without benefit. After all, it seems to be incurable. REPORT OF A CASE OF LEUKEMIA. Mrs. D., aged 55 years, first consulted me for a nodular eruption of the skin resembling urticaria, and confined then to the forehead and scalp. This eruption soon became general, extending well over the body. I treated this in the usual manner, without success, for several months- some seven or eight. The digestive system seemed to be in good shape. Her weight was 140 pounds, and her general health had been good, in fact, extra. In about one year the glands in the axillary and femoral regions began to enlarge, followed very soon by involvement of the glandular structures of the neck. When this condition came on, I suspected leukemia, and so announced my belief to the husband, and advised that an examination of the blood be made at once. Dr. John A. Gaines, of Nashville, was then consulted. He called to his assistance, Dr. Louis Leroy, who made an examination of the blood and confirmed my diagnosis. The first blood count, made April 28, 1904, showed the following condition: Red blood cells, 5,318,000 per cu. m. m. White blood cells, 105.100. Hemoglobin, 110 per cent. Proportion red to white, 50.6 to 1. Hemoglobin index, 1.03. Further examination showed a great preponderance of lymphocytes, with the polymorpho-nuclear neutrophiles reduced to a few present instead of the normal 70 per cent. A very few myelocytes were observed, and only two neucleated cells. The |