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A CASE OF LEUKÆMIC POLYNEURITIS.
122
Clinical Notes : MEDICAL, SURGICAL, OBSTETRICAL, AND THERAPEUTICAL.
by pressure on the nerve fibres. Clearly it was an instance of toxic degeneration of the peripheral nerves, though, as in so many unexplained forms of "toxic polyneuritis," the source and nature of the toxin remain obscure. rS-83 _________
A CASE OF
OPHTHALMIA NEONATORUM BEFORE BIRTH
A CASE OF
LEUKÆMIC POLYNEURITIS. BY WILFRED HARRIS, M.D.
CANTAB., F.R.C.P. LOND.,
SENIOR PHYSICIAN. ST. MARY’S HOSPITAL, LONDON.
BY GRACE H. GIFFEN D.P.H.
DUNDAS, F.R.C.S. IREL., CANTAB.,
MEDICAL OFFICER TO MATERNITY AND CHILD
WELFARE,
MIDDLESBROUGH.
Iz’ SEVERE forms of anaemia, cachexia, and senility Mrs. X., a 2-para, was admitted to the Municipal been stated occasionally to produce definite multiple Home, Middlesbrough, on Oct. 6th, 1920. Maternity neuritis, though the occurrence of well-marked poly- Labour pains had commenced ten hours previously. neuritis in lymphatic leukaemia has not, so far as I The child was born two hours after the mother was In haemophilia admitted. I saw it within five minutes of its can ascertain, hitherto been recorded. birth, neuritis has been ascribed to the pressure of the when it was found to have neonatorum. ophthalmia effused blood on nerve trunks, but the resultant The lids were red and oedematous, and pus was disneuritis would be local, asymmetrical, and quite unlike from both eyes. The obstetric sister who charging the usual form of toxic polyneuritis. Similarly, unithe delivery reported the case as left conducted lateral facial paralysis has been described in leukaemia. The case described below illustrates symmetrical occipito-anterior. The following history was obtained from the mother :polyneuritis as an early and prominent symptom in a ’ Her first child was born healthy; a creamy discharge " comcase of lymphatic leukaemia, before the definite menced before the second pregnancy and continued during the a fortnight before labour pains set in "the waters diagnosis of the blood condition was possible to pregnancy; began to come away, dribbling all the time," so that the patient establish. "never dry." The case was evidently one of intra-uterine was W. J., a youth aged 17, attended the out-patient department early infection made possible by the draining away of the liquor amnii, in April, 1920, on account of weakness of the legs, saying that for the and presumably the presentation had been a brow converted into past five weeks he had noticed that his legs were becoming stiff, an occipital during labour. Labour pains only lasted 12 hours, but followed two weeks later by unsteadiness on his feet, and numbness the brow must have been in contact with the infected cervix and tingling of his finger pads. The spleen was noticed to be for some time previous to the commencement of the pains. The definitely enlarged, about three fingers-breadth below the costal mother’s puerperiam was normal, and she left the home at the end margin, and the notch easily felt, A slight degree of anaemia was of a fortnight to be treated by her own doctor. The child’s eyes evident, and he was sent into the hospital, being admitted on April received the usual treatment, including hourly saline irrigation, 15th. His gait was weak and unsteady, and there was definite and the discharge began to clear up ; intracellular diplococci were weakness of dorsiflexion of the feet, the electrical reaction of the demonstrated in the pus. Apart from the eyes the child seemed leg muscles showing partial reaction of degeneration. Tests of healthy at birth and weighed 6 lb. 12 oz., but on the third day it sensation showed diminution to touch and pin-prick on the feet began to refuse its feeds, and was slightly cyanosed. The cry was and legs up to the knees, though the vibration sensation to a large feeble ; twitching of the facial muscles occurred several times; the tuning-fork placed on the tibias was normal. The knee-jerks, power to suck gradually disappeared, whereupon the child was Achilles, and forearm-jerks were all absent, nor could any plantar spoon-fed with the mother’s milk. The temperature remained reflexes be obtained, though the cremaster reflexes were present. subnormal; the child gradually became more feeble and more
have
"
eyes and discs normal. The blood examination showed a red cell count of 3,400,000, with haemoglobin content 60 per cent., the colour index being 0’88. There was a degree of leucopenia. the white cells numbering only 5800, though the differential count showed the polymorphs to be reduced to 23 per cent., the lymphocytes amounting to 68 per cent. Wassermann test negative. Numerous small lymphatic glands soon became palpable in the posterior triangles on both sides of his neck, and one of these was removed for microscopical examination. The healing of this wound was very troublesome, recurrent h2emorrhage occurring for several days, and his temperature, which previously had been normal, now began to show oscillations, with rises to 99’5° to 100° F. Gradually he became weaker, and he died on May 29th. Post mortem, the spleen was found considerably enlarged and soft, the liver fatty and weighing 74 oz., while microscopical examination revealed leukaemic infiltration of the liver, nerves, and kidneys, with lymphocytes. ’,
Sphincters normal ;
cyanosed, and died on the tenth day. Within 18 hours of the death I received permission to do a limited post-mortem. On removing the calvareum
The extreme intracranial congestion was found. sinuses were full of fluid blood, and injection of the pia mater was intense. When the brain was removed a purulent exudate was found on the middle of the base of the skull extending from the optic commissure backwards. There was no disintegration of the globe of either eye. The secondary condition was evidently due to infection by blood or lymph stream.
Remarks.
A CASE OF
admission presented a diagnosis pretty problem. Splenic anaemia with combined sclerosis was negatived by the fact of the absent reflexes, normal vibration sense on the legs, with no involvement of the sphincters, while the clinical picture was indeed characteristic of polyneuritis. The recognition of the type of anaemia was more difficult, the leucopenia being suggestive of splenic anaemia, but the greatly inverted lymphocytic preponderance was against this diagnosis, and was more suggestive of One of lymphatic leukaemia or lymphadenoma. the slightly enlarged glands was therefore excised for microscopical examination, but the pathological report was that it was normal, and again we were The troublesome haemorrhage from the at fault. small wound in the neck made by the surgeon was more suggestive of leukaemia than of lymphadenoma, but the diagnosis of leukaemia was not established until the tissues were microscoped after the post mortem. The extremely rare combination of wellmarked polyneuritis with leukaemia makes it desirable to place this case on record. What exactly is the association between the two conditions is perhaps hard to say. The symmetry of the polyneuritis and its resemblance to many forms of toxic polyneuritis preclude the possibility of the neuritis being due to leukaemic infiltration of the nerves producing paralysis
AMŒBIC DYSENTERY IN A BOY AGED THREE.
The
of the
case on
BY M. L. HOUSE
YOUNG, M.B., B.CH. CANTAB.,
PHYSICIAN, PADDINGTON GREEN HOSPITAL, LONDON.
CHILDREN’S
THE age of the patient and the absence of any obvious source of infection are noteworthy features of this case. Stanley K., aged 3 years, was admitted to the Paddington Green Children’s Hospital Ion Nov. 3rd, 1920, with the following history, During the six weeks prior to admission he had suffered from persistent diarrhoea, sometimes passing as many as seven stools in the 24 hours, and during the latter four weeks streaks of bright red blood and some slime had been noticed by the mother in almost every stool. Throughout this period of six weeks the boy had been bright and happy, and there had been no complaint of pain or discomfort. When admitted to the hospital he looked a perfectly healthy and unusually high-spirited boy. During the first 24 hours four loose stools were passed containing a large amount of mucus, well streaked with bright red blood, but very little fascal matter. Laboratory examination of a stool revealed the presence of the Entamaeba histolytica, much blood and mucus, and a relatively small amount of pus; no dysentery bacilli were found. It was then decided to proceed with a course of emetine hydrochloride by hypodermic injectton : 1/12th gr. was given on the first occasion, and during the following 24 hours one loose stool was passed containing much mucus but less blood. A second injection of 1/6 gr. was then given, and resulted in further improvement. Two more injections of 1/6th gr. at intervals of 24 hours were given, and a semi-solid partially formed stool was examined and found to contain a considerable quantity of mucus, a few red blood cells, and
Clinical Notes : MEDICAL, SURGICAL, OBSTETRICAL, AND THERAPEUTICAL.
by pressure on the nerve fibres. Clearly it was an instance of toxic degeneration of the peripheral nerves, though, as in so many unexplained forms of "toxic polyneuritis," the source and nature of the toxin remain obscure. rS-83 _________
A CASE OF
OPHTHALMIA NEONATORUM BEFORE BIRTH
A CASE OF
LEUKÆMIC POLYNEURITIS. BY WILFRED HARRIS, M.D.
CANTAB., F.R.C.P. LOND.,
SENIOR PHYSICIAN. ST. MARY’S HOSPITAL, LONDON.
BY GRACE H. GIFFEN D.P.H.
DUNDAS, F.R.C.S. IREL., CANTAB.,
MEDICAL OFFICER TO MATERNITY AND CHILD
WELFARE,
MIDDLESBROUGH.
Iz’ SEVERE forms of anaemia, cachexia, and senility Mrs. X., a 2-para, was admitted to the Municipal been stated occasionally to produce definite multiple Home, Middlesbrough, on Oct. 6th, 1920. Maternity neuritis, though the occurrence of well-marked poly- Labour pains had commenced ten hours previously. neuritis in lymphatic leukaemia has not, so far as I The child was born two hours after the mother was In haemophilia admitted. I saw it within five minutes of its can ascertain, hitherto been recorded. birth, neuritis has been ascribed to the pressure of the when it was found to have neonatorum. ophthalmia effused blood on nerve trunks, but the resultant The lids were red and oedematous, and pus was disneuritis would be local, asymmetrical, and quite unlike from both eyes. The obstetric sister who charging the usual form of toxic polyneuritis. Similarly, unithe delivery reported the case as left conducted lateral facial paralysis has been described in leukaemia. The case described below illustrates symmetrical occipito-anterior. The following history was obtained from the mother :polyneuritis as an early and prominent symptom in a ’ Her first child was born healthy; a creamy discharge " comcase of lymphatic leukaemia, before the definite menced before the second pregnancy and continued during the a fortnight before labour pains set in "the waters diagnosis of the blood condition was possible to pregnancy; began to come away, dribbling all the time," so that the patient establish. "never dry." The case was evidently one of intra-uterine was W. J., a youth aged 17, attended the out-patient department early infection made possible by the draining away of the liquor amnii, in April, 1920, on account of weakness of the legs, saying that for the and presumably the presentation had been a brow converted into past five weeks he had noticed that his legs were becoming stiff, an occipital during labour. Labour pains only lasted 12 hours, but followed two weeks later by unsteadiness on his feet, and numbness the brow must have been in contact with the infected cervix and tingling of his finger pads. The spleen was noticed to be for some time previous to the commencement of the pains. The definitely enlarged, about three fingers-breadth below the costal mother’s puerperiam was normal, and she left the home at the end margin, and the notch easily felt, A slight degree of anaemia was of a fortnight to be treated by her own doctor. The child’s eyes evident, and he was sent into the hospital, being admitted on April received the usual treatment, including hourly saline irrigation, 15th. His gait was weak and unsteady, and there was definite and the discharge began to clear up ; intracellular diplococci were weakness of dorsiflexion of the feet, the electrical reaction of the demonstrated in the pus. Apart from the eyes the child seemed leg muscles showing partial reaction of degeneration. Tests of healthy at birth and weighed 6 lb. 12 oz., but on the third day it sensation showed diminution to touch and pin-prick on the feet began to refuse its feeds, and was slightly cyanosed. The cry was and legs up to the knees, though the vibration sensation to a large feeble ; twitching of the facial muscles occurred several times; the tuning-fork placed on the tibias was normal. The knee-jerks, power to suck gradually disappeared, whereupon the child was Achilles, and forearm-jerks were all absent, nor could any plantar spoon-fed with the mother’s milk. The temperature remained reflexes be obtained, though the cremaster reflexes were present. subnormal; the child gradually became more feeble and more
have
"
eyes and discs normal. The blood examination showed a red cell count of 3,400,000, with haemoglobin content 60 per cent., the colour index being 0’88. There was a degree of leucopenia. the white cells numbering only 5800, though the differential count showed the polymorphs to be reduced to 23 per cent., the lymphocytes amounting to 68 per cent. Wassermann test negative. Numerous small lymphatic glands soon became palpable in the posterior triangles on both sides of his neck, and one of these was removed for microscopical examination. The healing of this wound was very troublesome, recurrent h2emorrhage occurring for several days, and his temperature, which previously had been normal, now began to show oscillations, with rises to 99’5° to 100° F. Gradually he became weaker, and he died on May 29th. Post mortem, the spleen was found considerably enlarged and soft, the liver fatty and weighing 74 oz., while microscopical examination revealed leukaemic infiltration of the liver, nerves, and kidneys, with lymphocytes. ’,
Sphincters normal ;
cyanosed, and died on the tenth day. Within 18 hours of the death I received permission to do a limited post-mortem. On removing the calvareum
The extreme intracranial congestion was found. sinuses were full of fluid blood, and injection of the pia mater was intense. When the brain was removed a purulent exudate was found on the middle of the base of the skull extending from the optic commissure backwards. There was no disintegration of the globe of either eye. The secondary condition was evidently due to infection by blood or lymph stream.
Remarks.
A CASE OF
admission presented a diagnosis pretty problem. Splenic anaemia with combined sclerosis was negatived by the fact of the absent reflexes, normal vibration sense on the legs, with no involvement of the sphincters, while the clinical picture was indeed characteristic of polyneuritis. The recognition of the type of anaemia was more difficult, the leucopenia being suggestive of splenic anaemia, but the greatly inverted lymphocytic preponderance was against this diagnosis, and was more suggestive of One of lymphatic leukaemia or lymphadenoma. the slightly enlarged glands was therefore excised for microscopical examination, but the pathological report was that it was normal, and again we were The troublesome haemorrhage from the at fault. small wound in the neck made by the surgeon was more suggestive of leukaemia than of lymphadenoma, but the diagnosis of leukaemia was not established until the tissues were microscoped after the post mortem. The extremely rare combination of wellmarked polyneuritis with leukaemia makes it desirable to place this case on record. What exactly is the association between the two conditions is perhaps hard to say. The symmetry of the polyneuritis and its resemblance to many forms of toxic polyneuritis preclude the possibility of the neuritis being due to leukaemic infiltration of the nerves producing paralysis
AMŒBIC DYSENTERY IN A BOY AGED THREE.
The
of the
case on
BY M. L. HOUSE
YOUNG, M.B., B.CH. CANTAB.,
PHYSICIAN, PADDINGTON GREEN HOSPITAL, LONDON.
CHILDREN’S
THE age of the patient and the absence of any obvious source of infection are noteworthy features of this case. Stanley K., aged 3 years, was admitted to the Paddington Green Children’s Hospital Ion Nov. 3rd, 1920, with the following history, During the six weeks prior to admission he had suffered from persistent diarrhoea, sometimes passing as many as seven stools in the 24 hours, and during the latter four weeks streaks of bright red blood and some slime had been noticed by the mother in almost every stool. Throughout this period of six weeks the boy had been bright and happy, and there had been no complaint of pain or discomfort. When admitted to the hospital he looked a perfectly healthy and unusually high-spirited boy. During the first 24 hours four loose stools were passed containing a large amount of mucus, well streaked with bright red blood, but very little fascal matter. Laboratory examination of a stool revealed the presence of the Entamaeba histolytica, much blood and mucus, and a relatively small amount of pus; no dysentery bacilli were found. It was then decided to proceed with a course of emetine hydrochloride by hypodermic injectton : 1/12th gr. was given on the first occasion, and during the following 24 hours one loose stool was passed containing much mucus but less blood. A second injection of 1/6 gr. was then given, and resulted in further improvement. Two more injections of 1/6th gr. at intervals of 24 hours were given, and a semi-solid partially formed stool was examined and found to contain a considerable quantity of mucus, a few red blood cells, and