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ROYAL MEDICAL AND CHIRURGICAL SOCIETY,
615
pathological
Medical Societies. ROYAL MEDICAL AND CHIRURGICAL SOCIETY, Ac?tte MéniM’c’s Symptoms in Leucocythæmia. A MEETING of this society was held on Feb. 27th, Dr. G. FIELDING BLANDFORD, the Vice-President, being in the
chair. Dr. F. PARKES WEBER read
a
paper
on
and clinical classification of such cases; the
nature, however, of the pathological condition in the ear could not often be determined with certainty merely from the symptoms observed during life. Dr. F. W. MoTT narrated particulars of a case resembling exact
Acute Meniure’s
Symptoms in Spleno-medullary Leucocythasmia, with special reference to the Anatomical Changes found in Acute Leucocythsemic Affections of the Ear (a pathological report on the internal ears being supplied by Mr. Richard Lake). The patient was a man, aged 3l years, suffering from advanced leuoocythsomia (this term being used as synonymous with was admitted on March 31st, 1898, to the German Hospital with great enlargement of the spleen and liver. He had had malaria six years previously. He died on Oct. lst, 1898, from collapse following internal bmmorrhage. During life the ophthalmoscope showed the presence of the so-called "leuksemic retinitis." About six months before his death he was attacked with acute ear symptoms
leukasmia). He
(headache, vertigo, and vomiting). Examination of the patient’s hearing, &c., pointed to the symptoms being probably due to a leucocythæmic affection of the
that of Dr. Weber’s in some respects, though differing in others. The patient was a man, aged 38 years, who was admitted into Oharing-cross Hospital on Nov. 10th, 1899. He was said to have had a severe attack of "influenza"" two years before, since which date he had been in bad health. Six months before admission he was seized with sudden pain in the left side of the abdomen, and a little later with pain in the head and deafness, with loss of power of maintaining his equilibrium. The deafness came on suddenly, first in the left and then in the. right ear. On admission he looked dull and was a little cyanosed, the temperature being 97° F. He gave his answers very slowly. The abdomen was distended, and the liver and spleen were very large. The lymphatic glands were also enlarged. The blood contained only 54 per cent. of hæmoglobin, but the main change was an enormous increase in lèucocytfs, of which there were almost as many as red corpuscles. There were large nnmbers of multipartite nucleated white cells, very few lymphocytes, and a good many myelocytes (with big nuclei). The muscular power of the patient was good ; there was no loss of coordination in the arms, but be could not balance himself in walking and could not stand at all with his eyes shut. He was at first thought to have hremorrhage into the cerebellum. The knee-jerks were absent on both sides. Vision was very imperfect. Accommodation was good, but the right reflex was sluggish. The fundi showed slight changes. The hearing improved considerably. Taste and smell were normal. He responded to questions in a drowsy manner. Seven days after admission he was found to be stone deaf in both ears on waking in the morning. Three days later he died comatose. At the necropsy the liver weighed five and a half kilogrammes and the spleen 1’8 kilogrammes. The blood was of a dirty brick-red colour ; there were haemorrhages into the brain which was congested. Both the petrous bones were soft and friable from rarefaction of the bone. The spinal cord and nerves showed no degeneration. There was hmmorrhage into the posterior spinal roots and hæmorrbage into the cochlea. The hæmorrhage into the semicircular canals accounted for the loss of equilibrium. This and the deafness were accounted for by hæmorrhage into the cochlea and labyrinth. Dr. Mott’s paper was illustrated by lantern slides. Mr. RICHARD LAKE, in replying, remarked that the ligamentum spirale had not previously been described as being ossified, but this lesion existed in Dr. Weber’s case. It was the perilymphatic spaces in the semicircular canal which had been nearly filled up with newly-formed fibroid and bony tissue (microscopic specimens were exhibited). In Dr. Mott’s case there was wanting any new formation of bone ; but the haemorrhage had produced the same symptoms. He would like to ask what the porosity of the bone was to be attributed to. Dr. MOTT, in replying, said that his case resembled myelogenic leukasmia. The proliferation of the bone-cells was prcbably in some way connected with the fragility of the bones. Dr. WEBER remarked that in Dr. Mott’s interesting case the three distinct attacks differed from most cases. The fact that the organ of Corti was preserved accounted for the recovery of hearing. The Ienis was an organ liable to be early attacked in leukremia and priapi&m was sometimes the first symptom of the disease to attract attention.
internal ears; and in a very short time the man became quite deaf. Post-mortem examination of the ears proved that a portion of the scala tympani (one side only examined) and the perilymphatic spaces of the semicircular canals (both sides examined) were filled up with newly formed tibroid and bony tissue. The scala vestibuli, canalis cochleae, and vestibule showed only comparatively slight changes. Transverse sections of the nerve trunks showed A short account was given of similar no obvious change. cases which had been published. From a comparison of the various cases it was concluded that the pathological appearances presented by the internal ears after death differed in different cases, partly in accordance with the length of time which had elapsed between the onset of the acute aural symptoms and the death of the patient. In most cases of acute leucocythæmic affection of the internal ears post-mortem investigation suggested that the following was the sequence of events: the commencement of the aural symptoms (vertigo, headache, vomiting, and deafness) marked the occurrence of more or less extensive extravasations of blood in the semicircular canals and the cochlea, the process being doubtless nearly alwa3smore or less symmetrical and simultaneous in the two ears. In such cases, though apparently lymphocytic infiltration and bmmorrbages might be found in various parts of the ears after death, the labyrinthine haemorrhage was probably the essential lesion which gave rise to the acute aural phenomena in question. Subsequently vascularisation and organisation proceeded in the usual manner, with the result that the clot became gradually replaced by newly formed connective tissue, closely connected by its blood-vessels with the endosteum of the bony labyrinth. In process of time (if the patient lived long enough) more or less ossification occurred in the newly formed tissue, and irregular processes of bone projected inwards from the walls of the bony labyrinth. At this stage of the pathological process transverse sections of the bony semicircular canals mostly showed the membranous canals surrounded by a meshwork, or by irregular masses of newly-formed bone and fibroid tissue, completely filling up the perilymphatic spaces. Besides the striking cases in MEDICAL SOCIETY OF LONDON. which acute (apoplecticiform) Meniere’s symptoms occurred there were also leucocythæmic patients, as pointed out by Adjourned Discussion on the Pathology and Treatment of Schwabach, who presented aural troubles of a less severe or Appendicitis. less sudden nature. These lesser symptoms might be in part of the but in A of this MEETING altogether independent leucocythsemia, part society was held on Feb. 26th, Dr. due to small haemorrhages and patches of lymphocytic (leu- F. T. ROBERTS, the President, being in the chair. The discussion on the Pathology and Treatment of cocythæmic) infiltration in various part of the auditory apparatus. Dr. Weber drew attention to the light thrown Appendicitis was resumed, the PRESIDENT remarking that by leucocythsemic cases of Muniere’s symptom-complex on speakers were invited to discuss the subject under four cases associated with constitutional disorders other than headings : (1) the non-operative treatment ; (2) the indicaleuoocythasmia (such as arterio-sclerosis, syphilis, chronic tions for operation ; (3) the nature of the operation advised ; gout, renal fibrosis, and the various cachectic conditions in and (4) the after-treatment of the case. Mr. MARMADUKE SHEILD congratulated Mr. Lockwood on which haemorrhages often occur). He sketched a rough
pathological
Medical Societies. ROYAL MEDICAL AND CHIRURGICAL SOCIETY, Ac?tte MéniM’c’s Symptoms in Leucocythæmia. A MEETING of this society was held on Feb. 27th, Dr. G. FIELDING BLANDFORD, the Vice-President, being in the
chair. Dr. F. PARKES WEBER read
a
paper
on
and clinical classification of such cases; the
nature, however, of the pathological condition in the ear could not often be determined with certainty merely from the symptoms observed during life. Dr. F. W. MoTT narrated particulars of a case resembling exact
Acute Meniure’s
Symptoms in Spleno-medullary Leucocythasmia, with special reference to the Anatomical Changes found in Acute Leucocythsemic Affections of the Ear (a pathological report on the internal ears being supplied by Mr. Richard Lake). The patient was a man, aged 3l years, suffering from advanced leuoocythsomia (this term being used as synonymous with was admitted on March 31st, 1898, to the German Hospital with great enlargement of the spleen and liver. He had had malaria six years previously. He died on Oct. lst, 1898, from collapse following internal bmmorrhage. During life the ophthalmoscope showed the presence of the so-called "leuksemic retinitis." About six months before his death he was attacked with acute ear symptoms
leukasmia). He
(headache, vertigo, and vomiting). Examination of the patient’s hearing, &c., pointed to the symptoms being probably due to a leucocythæmic affection of the
that of Dr. Weber’s in some respects, though differing in others. The patient was a man, aged 38 years, who was admitted into Oharing-cross Hospital on Nov. 10th, 1899. He was said to have had a severe attack of "influenza"" two years before, since which date he had been in bad health. Six months before admission he was seized with sudden pain in the left side of the abdomen, and a little later with pain in the head and deafness, with loss of power of maintaining his equilibrium. The deafness came on suddenly, first in the left and then in the. right ear. On admission he looked dull and was a little cyanosed, the temperature being 97° F. He gave his answers very slowly. The abdomen was distended, and the liver and spleen were very large. The lymphatic glands were also enlarged. The blood contained only 54 per cent. of hæmoglobin, but the main change was an enormous increase in lèucocytfs, of which there were almost as many as red corpuscles. There were large nnmbers of multipartite nucleated white cells, very few lymphocytes, and a good many myelocytes (with big nuclei). The muscular power of the patient was good ; there was no loss of coordination in the arms, but be could not balance himself in walking and could not stand at all with his eyes shut. He was at first thought to have hremorrhage into the cerebellum. The knee-jerks were absent on both sides. Vision was very imperfect. Accommodation was good, but the right reflex was sluggish. The fundi showed slight changes. The hearing improved considerably. Taste and smell were normal. He responded to questions in a drowsy manner. Seven days after admission he was found to be stone deaf in both ears on waking in the morning. Three days later he died comatose. At the necropsy the liver weighed five and a half kilogrammes and the spleen 1’8 kilogrammes. The blood was of a dirty brick-red colour ; there were haemorrhages into the brain which was congested. Both the petrous bones were soft and friable from rarefaction of the bone. The spinal cord and nerves showed no degeneration. There was hmmorrhage into the posterior spinal roots and hæmorrbage into the cochlea. The hæmorrhage into the semicircular canals accounted for the loss of equilibrium. This and the deafness were accounted for by hæmorrhage into the cochlea and labyrinth. Dr. Mott’s paper was illustrated by lantern slides. Mr. RICHARD LAKE, in replying, remarked that the ligamentum spirale had not previously been described as being ossified, but this lesion existed in Dr. Weber’s case. It was the perilymphatic spaces in the semicircular canal which had been nearly filled up with newly-formed fibroid and bony tissue (microscopic specimens were exhibited). In Dr. Mott’s case there was wanting any new formation of bone ; but the haemorrhage had produced the same symptoms. He would like to ask what the porosity of the bone was to be attributed to. Dr. MOTT, in replying, said that his case resembled myelogenic leukasmia. The proliferation of the bone-cells was prcbably in some way connected with the fragility of the bones. Dr. WEBER remarked that in Dr. Mott’s interesting case the three distinct attacks differed from most cases. The fact that the organ of Corti was preserved accounted for the recovery of hearing. The Ienis was an organ liable to be early attacked in leukremia and priapi&m was sometimes the first symptom of the disease to attract attention.
internal ears; and in a very short time the man became quite deaf. Post-mortem examination of the ears proved that a portion of the scala tympani (one side only examined) and the perilymphatic spaces of the semicircular canals (both sides examined) were filled up with newly formed tibroid and bony tissue. The scala vestibuli, canalis cochleae, and vestibule showed only comparatively slight changes. Transverse sections of the nerve trunks showed A short account was given of similar no obvious change. cases which had been published. From a comparison of the various cases it was concluded that the pathological appearances presented by the internal ears after death differed in different cases, partly in accordance with the length of time which had elapsed between the onset of the acute aural symptoms and the death of the patient. In most cases of acute leucocythæmic affection of the internal ears post-mortem investigation suggested that the following was the sequence of events: the commencement of the aural symptoms (vertigo, headache, vomiting, and deafness) marked the occurrence of more or less extensive extravasations of blood in the semicircular canals and the cochlea, the process being doubtless nearly alwa3smore or less symmetrical and simultaneous in the two ears. In such cases, though apparently lymphocytic infiltration and bmmorrbages might be found in various parts of the ears after death, the labyrinthine haemorrhage was probably the essential lesion which gave rise to the acute aural phenomena in question. Subsequently vascularisation and organisation proceeded in the usual manner, with the result that the clot became gradually replaced by newly formed connective tissue, closely connected by its blood-vessels with the endosteum of the bony labyrinth. In process of time (if the patient lived long enough) more or less ossification occurred in the newly formed tissue, and irregular processes of bone projected inwards from the walls of the bony labyrinth. At this stage of the pathological process transverse sections of the bony semicircular canals mostly showed the membranous canals surrounded by a meshwork, or by irregular masses of newly-formed bone and fibroid tissue, completely filling up the perilymphatic spaces. Besides the striking cases in MEDICAL SOCIETY OF LONDON. which acute (apoplecticiform) Meniere’s symptoms occurred there were also leucocythæmic patients, as pointed out by Adjourned Discussion on the Pathology and Treatment of Schwabach, who presented aural troubles of a less severe or Appendicitis. less sudden nature. These lesser symptoms might be in part of the but in A of this MEETING altogether independent leucocythsemia, part society was held on Feb. 26th, Dr. due to small haemorrhages and patches of lymphocytic (leu- F. T. ROBERTS, the President, being in the chair. The discussion on the Pathology and Treatment of cocythæmic) infiltration in various part of the auditory apparatus. Dr. Weber drew attention to the light thrown Appendicitis was resumed, the PRESIDENT remarking that by leucocythsemic cases of Muniere’s symptom-complex on speakers were invited to discuss the subject under four cases associated with constitutional disorders other than headings : (1) the non-operative treatment ; (2) the indicaleuoocythasmia (such as arterio-sclerosis, syphilis, chronic tions for operation ; (3) the nature of the operation advised ; gout, renal fibrosis, and the various cachectic conditions in and (4) the after-treatment of the case. Mr. MARMADUKE SHEILD congratulated Mr. Lockwood on which haemorrhages often occur). He sketched a rough