NationalLibraryOfScotland/medical-history-of-british-india huggingface dataset:
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Kurloff (59) in the non-granular cells of guinea pig blood, which have been
supposed by some to be accessory nuclei. They are certainly not accidental
cell inclusions, nor do they resemble the tags of nuclear matter so often seen in
polymorphonuclear and eosinophile leucocytes.
VI.—THE EXAMINATION OF SPLENIC BLOOD.
In a previous paper we have recorded the result of an examination of the
splenic blood taken at an early stage in the course of an attack of Black-water
Fever. The most prominent feature in this case was the presence of phagocy-
tosis of red blood corpuscles, many of them quite normal in appearance,
both as regards the absence of parasites and the possession of their full hæmo-
globin value. Since this observation we have had further opportunities of study-
ing the splenic blood in Black-water Fever. The examination of splenic blood
in regard to the existence of a special parasite and evidence of malarial infection
we have already recorded ; in our present connection it is the changes likely to
throw light on the nature of the mechanism of Black-water Fever, which concern
us.
The red cells.—Unfortunately puncture of the spleen in Black-water Fever,
except in one case, has given us only sufficient blood for the preparation of
films. In case XXVI, however, sufficient blood was obtained to enable us to stain
a portion by the neutral red method already described. In this case the
characteristic small dark cells were far more numerous than we have seen under
any other condition, but they still formed only a small proportion of the whole.
Spherocytes have been a marked feature in almost every case, reaching
a proportion to the total cells much greater than in the peripheral blood.
In one case at least there was a distinct tendency for the red cells to be
gathered into groups (agglutination), such as is seen in the case of dogs injected
with specific hæmolysin (Part III, Chapter II).
Splenic cells. —Many distinct types of splenic cells are distinguishable, and it
only appears necessary to refer to those that seem concerned in the Black-water
Fever process—
Type (1).—Large cells with a nucleus somewhat resembling that of the
large mononuclear leucocytes, but considerably larger, and with
more or less voluminous finely granular protoplasm. Two varieties
of these cells are seen ; those whose protoplasm is compact like that
of the ordinary mononuclear leucocytes, and others in which the
protoplasm is full of vacuoles resembling bubbles of all sizes.
87
But the compact and vacuolated forms have similar nuclei and may not
infrequently be seen as neighbour cells in a detached fragment of
endothelium. If our conception of their nature be correct, they are the product
of the fixed visceral endothelium. They are extremely active phagocytes, and
actively engage themselves in the engulfment of red cells, and more espe-
cially of red cell shadows. Cells resembling these but usually of the smaller type
are seen in the peripheral blood ; they are also very abundant in the capillaries
of the liver, where they are seen laden with malaria and blood derived pigment.
Type (2).—Cells with irregular or polygonal nuclei similar to type (3)
described as occurring in the peripheral blood.
Type (3).—Very large cells with round nuclei and voluminous more or less
granular and homogenous protoplasm, often showing many inclusions.
They often contain masses of malarial pigment and are not seen in the
peripheral blood.
Phagocytic endothelial cells. —Quite distinct from the large apparently "fixed"
macrophages are cells which take a much more active part in. the phagocytosis
of red cells. Prior to the inclusion of red cells, they are seen as quite small cells
somewhat resembling lymphocytes. They constantly show a projection of
their somewhat scanty protoplasm indicating that they are actively amœboid
in nature. Their nuclei and protoplasm also show certain differences which
enables one easily to distinguish them from lymphocytes. Many of these small
cells are seen to contain a single red blood corpuscle, a body which would seem
almost too large for them to ingest. With their included red cell, they appear
of circular outline ; their protoplasm being stretched in a narrow arch round the
engulfed erythrocyte, whilst the nucleus from the pressure of this same body had
become crescentic.
In spite of the apparent discrepancy between the amount of their protoplasm
and the size of the bodies they include, these cells ingest sometimes two, three, or
more red corpuscles and all stages are seen up to cells that have engulfed a dozen
or more of these. Even in the latter case, the nucleus is still quite small ; and
the protoplasm is only just sufficient to retain the engulfed corpuscles. The exact
nature of these cells is not clear ; but they appear to he concerned especially in
red cell phagocytosis. They are rarely seen in the peripheral blood.
Phagocytosis of red cells.— P h a g o c y t o s i s o f r e d c e l l s h a s b e e n d e s c r i b e d i n a
number of diseases. A certain degree of this condition has been found even in
health, especially in old age. In several spleens of more or less pathological
interest and in the spleen of animals we have found a certain amount of red cell
88
phagocytosis, but in proportion negligible, when compared to the extent of the
condition present in Black-water Fever.
Several distinct conditions are to be seen—
(a) Engulfed cells more or less normal in appearance.
(b) Large, clear, circular spaces, that have been occupied by red cell
stromata, now completely decolourised.
(c) Numerous small fragments of red cell substance, and small vacuoles
which appear to owe their derivation to previously ingested red cells.
The included red cells in these circumstances are either quite normal in
appearence, or partially decolourised, but rarely shrunken or deformed. Many such
cells are evidently spherocytes. In the case of the phagocytic endothelial macro-
phages, cells containing hæmoglobin seem to be engulfed, and to undergo decolour-
isation within the ingesting cell. If for example a phagocyte of this type is seen
to contain several red cells, one may be unaltered, while the others show all grada-
tions between this and complete decolourisation.
But the cells of large mononuclear type and mononuclear leucocytes, though
found with apparently unaltered cells, are most frequently seen to contain a
number of the decolourised stromata described. The appearance presented by these
cells is therefore in considerable contrast to that of the larger phagocytes, whose
protoplasm is stretched by unaltered and partially altered red cells.
The actual observations, so far made, have been as follows:—
Case XIX.—Extremely mild. Spleen punctured shortly before the hæmoglobinuria
ceased, and about 8 to 10 hours after the onset—
per cent.
Large shadow corpuscles
. .
. .
. .
. .
. .
.05
Small poikilocyte shadows
. .
. .
. .
. .
. .
.2
Spherocytes
..
. .
. .
. .
. .
. .
. 1 5
No tendency to agglutination of red cells observed.
Engulfment of red cells and stromata fairly conspicuous, included cells being nearly
all very small spherocytes.
Case XX.—A severe case. Spleen punctured about nine hours after first rigor and
about 48 hours before cessation of hæmolgobinuria
—
Large shadow corpuscles
Not at all conspicuous.
Small poikilocyte shadows
Spherocytes
..
. .
. .
. . .7 per cent.
Tendency to agglutination not observed.
89
Engulfment of unaltered red cells by phagocytes extremely noticeable ( vide case
in appendix). The small type phagocyte containing a single red cell very
conspicuous. Shadow inclusions less conspicuous though numerous.
Case XXII. —A severe case. Spleen punctured about 30 hours after onset of the hæ-
moglobinuria which was still in progress—
per cent.
Large shadow corpuscles
..
..
..
.. .15
Small poikilocyte shadows
..
..
..
.. .15
Spherocytes
..
..
..
..
..
..
.1
Large pale cells apparently decolourised and not resembling
polychromatic cells
..
..
. .
.7
Agglutination not noticeable.
Immense macrophages, with included red cells and engulfed small mononuclear elements.
Macrophages contain a considerable amount of malarial pigment (malignant tertian
including segmenting reliquats, but red cell inclusion not very noticeable.
Vacuolated macrophages of mononuclear type contain numbers of colourless red
cell stromata.
Case XXIV. —Case seen on fourth day. Hæmoglobinuria continuing, but showing
signs of clearing up.
Splenic blood examined.
Shadows very numerous, but film having been made from very small amount of blood
artifects cannot be excluded.
Spherocytes
. .
. .
..
.. .. 6.6 per cent.
Agglutination of red cells very distinct, the cells being in clusters such as those
observed in dogs injected with agglutinating serum.
Blood more profoundly altered than in any case yet seen. Recent severe malignant ter-
tian infection evidenced by the abundance of segmentation reliquats (pigment
blocks) and by the finding of a segmenting malignant tertian parasite.
Case XXVI. —A severe case seen on second day. Spleen punctured about 36 hours
before hæmoglobinuria ceased.
Large shadow corpuscles
.. .. .. ..
.1 per cent.
Small poikilocyte shadows
. .
..
.. ..
.05 , ,
Spherocytes
..
..
..
.. ..
. 4 , ,
Agglutination marked.
Red cell phagocytosis conspicuous. Engulfed colourless stromata in large vacuolated
macrophage of mononuclear type very noticeable.
These cases serve to show that in the spleen there is not any greater evidence
of blood solution (cell shadows) than in the peripheral blood. The presence of
agglutination and spherocytes together with the phagocytosis of red cells and
stromata, as will be seen later, are of extreme significance.
227 H. D.
90
Macrophage inclusions. —Since every observation relating to the conditions
present in Black-water Fever may have value, we have studied the inclusions to
be found in the various macrophages.
The most notable are :
—
(a) Included red cells, colourless stromata, and malarial pigment.
(b) Greenish masses undoubtedly derived from red cells which have under-
gone shrinkage and change in staining reaction. This appearance is
seen in other than Black-water Fever conditions, in which disease it is
not a very conspicuous feature.
(c) Particles of substance staining like chromatin. Many of these
resemble blood platelets, to others it is impossible to assign any exact
significance. They are seen in other conditions than Black-water Fever
and are not apparently of any special interest.
(d)
Engulfed cells.
Engulfment of nucleated cells. —In several of our cases this has been a very con-
spicuous phenomenon. The great majority of the included cells are found in the
endothelial plaques, which may contain three or even four or five of these bodies.
The included cells are, in the great majority of cases, very small mononuclear
cells, but occasionally what appear to be polymorphonuclear leucocytes are seen.
Such included cells lie as a rule in a vacuole and the nucleus takes on the very
intense stain characteristic of necrotic nuclear matter. The condition will be re-
ferred to later when discussing the examination of the liver in sections.
VII.—EXAMINATION OF THE TISSUES.
The tissues of Black-water Fever cases have been described by a number of
observers. The most obvious recorded appearances are those due to the preced-
i ng mal ar i a; but cer t ai n changes ar e pecul i ar t o t he Bl ack- wat er Fever pr oces s ,
notably an abundant deposit of yellow pigment in the liver cells, and certain changes
in the kidney.
ur own experience has been limited to two fatal cases now described (cases
I I a n d I I I ) . B o t h o f t h e s e c a s e s w e r e v e r y s u i t a b l e f o r s t u d y i n t h a t d e a t h
occurred during the actual course of the disease and while hæmoglobinuria was
in progress. Unfortunately we were only able to obtain very partial autopsies so
that only the spleen, liver and kidneys have been examined.
Spleen. —In both cases recent malarial pigment was abundant. More important
in our present connection was evidence of red cell phagocytosis. This was most
91
marked in case III, but was also present in case II. In the former almost every
macrophage shewed included red cells, whilst smaller mononuclear cells containing
one or more were frequently seen lying free in the splenic sinuses. Large cells
containing many red corpuscles as well as smaller cells containing one or two of
these were also very noticeable in the radicles of the splenic vein.
Liver. —The lobules showed no marked general changes. In the smaller radicles
of the portal canal system especially in lymphoid like tissue were many cells loaded
with malarial pigment. The lobular capillaries contained an almost continuous
chain of large oval swollen cells, lying free like polypi in the lumen. In many cases
in which the capillaries were seen in cross section these cells appeared nearly to
occlude the lumen. The cells which were quite distinct from the capillary end
-othelium appeared to be attached to it at a single point. Some of these cells con-
tained malarial pigment, others engulfed red cells. Most conspicuous were
included nuclear masses staining an intense black with Heidenhain's hæmotoxylin.
Many such inclusions, seen in every field of the microscope, gave a very peculiar
appearance to specimens viewed under a low power.
Many of the liver cells, but not all, contained granules of a light golden yellow
or dull yellow pigment. The granules lay in clusters, often in vacuolic areas, either
diffused through the cell or more or less aggregated. Many of the liver cells showed
fatty globules.
In the large perilobular vessels were a few macrophages ; and in the hepatic
veins large cells containing many red cells, as well as others containing included
nuclear masses, were not uncommon.
Both the hepatic and portal venous radicles contained a great deal of granular
matter in which apparently normal red cells lay embedded.
Kidney.
The kidneys in Black-water Fever have recently been closely studied by
Werner (58).
The glomeruli and the upper portions of the convulted tubules according to
this author show a finely granular exudation. As the tubules are followed in their
course the granules are seen to become coarser, and in Henle's tubules are seen
coagulation like masses of the same substance. There is also a general distention
of the tubule and in severe cases degenerative changes in the epithelium.
In both of our cases similar appearances were present.
In the glomeruli a faint pinkish eosin stained granular substance was present,
containing a few desquamated capsular cells. In the upper convoluted tubules a
92
similar substance was seen with very little evidence of epithelial desquamation.
As one passed downwards profound changes in the epithelium were to be seen,
and the lumen was loaded with cast off cells. Also in addition to the fine granular
matter were granules of a peculiar consistence, and these absent in the upper parts
became larger as one approached the collecting tubules.
In Henle's loops the substance formed a more or less adherent mass lying
around the periphery of the lumen.
In the straight ducts of Bellini the granules were nearly the size of red blood
corpuscles and had somewhat the appearance of red cell substance.
In the vessels of the glomeruli and of the rest of the kidney the red cells ap-
peared normal and there was little or no granular material in the lumen of the veins,
these containing red cells of normal appearance.
A great many of the conditions we have described are evidently but the ne-
cessary results of blood cell destruction.
Thus hæmoglobinæmia of a certain degree is responsible for the hæmoglobinuria
and for the icteric tinge. Other changes may, or may not, be necessary conse-
quences of blood destruction.
It is evident that before we can make use of the data outlined, it is necessary
to study the process of blood destruction or hæmolysis, and especially the
conditions other than Black-water Fever in which hæmoglobinuria occurs.
93
CHAPTER II.
THE RELATION OF BLACK-WATER FEVER TO OTHER HÆMOGLOBINURIAS.
I.—PARASITIC HÆMOGLOBINURIAS.
In the ox, dog, horse, and sheep hæmoglobinurias due to piroplasmosis are well
known. Infection by piroplasma may however occur in an acute or a chronic
form ; it is in the former only that hæmoglobinuria occurs.
Cattle introduced into a Red-water country rapidly contract the acute disease.
The animal is intensely ill, its temperature is raised, and it passes hæmoglobinous
urine. In the case of death the tissues are pale and tinged with yellow, the blood
watery, and the spleen greatly enlarged. In Red-water countries hæmoglobinuria
in cattle is often associated with an attack of Rinderpest ; the explanation usually
advanced being that the Rinderpest, by lowering the resistance of the animal, al-
lows the latent piroplasma infection to assert itself.
Piroplasma infection in the dog is very frequently associated with hæmoglobi-
nuria, especially in the case of susceptible animals. Dogs newly introduced into
a country where piroplasmosis is endemic are very apt to contract the disease a very
short time after arrival. We know of thirty hunting dogs brought out from
England to Madras, all of whom within three weeks of their arrival in India were
found to be suffering from piroplasmosis ; a few weeks later they had all either died
or been destroyed as useless. Native dogs suffer less often from hæmoglobinuria
though the presence of parasites in the blood especially among puppies is very
common.
As in cattle a susceptible dog attacked by piroplasmosis is severely ill. If it
gets over the initial disease it may die after a long period of chronic infection, and
many of those which eventually survive do not recover at all quickly but remain
for a long time emaciated and intensely feeble. In our experience if a dog has passed
the first acute period of the disease he may die but he will not suffer from hæmo-
globinuria.
The hæmoglobinuria is always associated with an immense number of parasites
which, however, may become greatly reduced in number after the access ; but a
young dog may die from a severe infection in twenty-four hours without exhibiting
hæmoglobinuria. In a dog dying of an acute infection there is marked pallor of the
tissues, and in the case of hæmoglobinuria a yellow tint. The blood is watery
and the spleen more or less enlarged. If hæmoglobinuria has occurred, the kidneys
are maroon coloured and swollen ; but this is not present in attacks, however acute,
unaccompanied with hæmoglobinuria.
227 H. D.
2 A
94
With the condition in the horse and sheep we are not familiar ; but parasites
are demonstrable in the blood in both cases without difficulty.
A resemblance of this disease to Black-water Fever is evident ; but closer
examination reveals an important difference in that the experience of all observers
shows parasites to be easily demonstrated both in the blood and organs.
In Black water Fever we have seen that the closest observation fails to show
a piroplasma like parasite in the blood and tissues ; and that this disease is not due
to any direct action of the malarial parasite is shown by considerations already
given. There seems then at first sight but little connection between the mechanism
of parasitic hæmoglobinuria and that seen in Black-water Fever.
I I . — D Y S C R A S I C H Æ M O G L O B I N U R I A S .
Hæmolgobinuria occurs in man in other conditions than Black-water Fever.
The most important from our point of view is paroxysmal hæmoglobinuria.
Paroxysmal hæmoglobinuria was first studied by Harley in 1864 (61), Since
then many observers have contributed to our knowledge of the condition, the exact
nature of which is still unknown. After an exposure to cold, the patient has a violent
rigor with chattering of teeth and spasmodic action of the respiratory muscles ;
at the same time the lumber and hypogastric regions become painful. The face
and extremities are cyanosed. The urine at first reddish becomes later dark or
blackish in colour. it is devoid of blood cells and contains both hæmoglobin and
met-hæmoglobin.
After the crisis the urine becomes clearer again but is somewhat darker
than normal; and contains albumen. The crisis is accompanied by a rise in
temperature. Tumefaction of the spleen is frequently present ; and there may be
some enlargement of the liver. In severe attacks there is a subicteric tint of the
integuments ; but no Gmelin's reaction is to be obtained with the urine. Uro-
bilinuria is in these cases habitual.
An ordinary attack of paroxysmal hæmoglobinuria lasts a few hours only.
An autopsy described by Hayem showed the kidneys sepia coloured, with
the convoluted tubules and loops of Henle infiltrated with hæmoglobin.
We have then a disease which except in its ætiology and its comparatively
mild nature is a close counterpart of Black-water Fever ; and as Black-water Fever
is generally induced by quinine, so this condition is precipitated by so simple a
cause as exposure to cold. The serum in paroxysmal hæmoglobinuria has been
observed by Ehrlich.(62) and others to possess a" r o u g e c e r i s e "c
o l o u r a n d a n "a
s p e c t
laque." But Bensaude (63) notes that this is not constant, while in one case the
95
serum was more coloured in the intervals between the attacks than during the attacks
themselves. This "rouge cerise" colour is also seen in other affections, notably
certain infectious diseases. As previously pointed out we have seen it when the
blood received into citrate solution and centrifuged showed no hæmoglobinæmia
to the present.
Bensaude states that the reason for the phenomenon is the solution of the clot
in the serum; this we have seen does not take place in Black-water Fever.
In paroxysmal hæmoglobinuria the blood destruction is an indirect effect of
the cold which has induced the attack ; for blood exposed to cold does not exhibit
hæmolysis. Bensaude also points out some difficulties in the way of the ordinarily
accepted view of the disease. He shows that the actual red cell destruction and
the hæmoglobinæmia is small and yet hæmoglobinuria results ; whereas in the dog
it is necessary to inject distilled water to the extent of twice the total volume of
the blood before hæmoglobinæmia is intense enough to cause hæmoglobinuria.
The most recent work on paroxysmal hæmoglobinuria is that of Widal and Rostaine
(64), who satisfy themselves that the condition is due to a lack of protective body
" antisensibilisatrice" in the blood, a condition which they were able to rectify by the
prepared serum of a rabbit containing excess of this substance. The result of
this treatment was that after the injection of the rabbit's serum the patient could
plunge her hands into ice-cold water, without bringing on an attack ; whereas
previously such an act was always followed by a crisis.
Hæmoglobinuria of the same nature has been observed in connection with
Raynaud's disease. Barlow (65) records a case of Raynaud's disease in which there
was hæmoglobinuria, epigastric pain, and temporary splenic enlargement ; and
Dickenson (66) notes a case where an attack of paroxysmal hæmoglobinuria
was replaced by local axphyxia of one hand. Jaundice is also recorded
following local asphyxial conditions.
It is interesting to note that Barlow calls attention to the relation of " ague"
to Raynaud's disease, several cases having occurred at short periods after
recovery from tertian ague.
Another condition in which hæmoglobinuria occurs is after extensive burns.
The earlier observations on the blood in such cases, ascribed the distortion, sub
- d i v i s i o n a n d g r a n u l a t i o n o f t h e r e d c e l l s p r e s e n t i n t h e c o n d i t i o n t o t h e e f f e c t s o f
trauma. Later observers do not find sufficient changes in the red cell to account
for their death and believe toxic substances to be developed in the blood and tissues.
Locke (67) shows that an immediate decrease of 1,000,000 to 2,000,000 red cells
may take place in severe cases and up to 4,000,000 in fatal cases.