NationalLibraryOfScotland/medical-history-of-british-india huggingface dataset:
76
Films of different bloods made with as great uniformity as possible were used,
and portions were chosen for observation where the red cells were distributed so as
to be a little distance from one another. The cells were then passed slowly across
the field of a screw micrometer eye-piece, partially occluded by means of an Ehrlich's
stop, and each cell measured carefully. This method though rough gave fairly uni-
form results which enabled one to ascertain better than by mere microscopic exami-
nation, variations in the size of the different cells.
An improvement in the method consisted in the use of a Leitz drawing eye-piece
whereby accurate tracings of the outlines of corpuscles in a number of microscopic
fields were made, and afterwards measured and compared.
Hayem (57) has described cells of three sizes, large, medium and small,
measuring 6.5, 7.5, and 8.5 microns, respectively, of which the proportions in normal
blood were large and small 12.5 per cent. each, and medium 75 per cent. In our
cases it was easy to distinguish three sizes of cell, but the greater number measur-
ed about 6.7 microns, only a few being below 6 microns and a somewhat larger
number about 8 microns. At times all three measurements were proportionately
increased but never diminished. Apart from polychromasia, associated always in
our experience with an increase of large forms of red cell, these observations
have not shown any obvious variation in the proportions of the different sizes
in Black-water Fever, or in those exposed to black-water conditions. But a
peculiar phenomenon we have several times observed may be here remarked upon.
In comparing the drawings described above it became evident in several instances
that in series of films taken at short intervals within the first twenty-four hours
of the onset of Black-water Fever, all the elements of the blood, both red cells and
leucocytes, were on a larger scale in those taken later on the attack than in the
earlier ones. At first it was thought that some accident might account for this
condition ; but careful scrutiny of the films did not bear out this supposition, for
our films from long practice exhibit very little variation in the conditions under
which they are made, and the increased anæmia of the later stages would lead us if
anything to give less pressure to the needle at the time, so that a reduction, not an
enlargement of the elements, should therefore be expected. While at the present
moment we do not care to place too great stress upon this phenomenon, which we
intend to study more closely, we believe it indicates some definite change, either
in the cellular elements or in the plasma.
Shadow corpuscles.— Shadows of red cells are frequently very indefinite and
may easily escape notice. They are sometimes exceedingly large, pale, and
irregular, appearing at first sight like mere empty spaces among normal
corpuscles ; for careful scrutiny shows these spaces to be occupied by corpuscles
77
which have evidently become enormously swollen and softened, apparently during
the process of dissolution, for they stain very faintly except at the periphery
where they become moulded by the normal corpuscles surrounding them.
At other times shadows are but little larger than a normal corpuscle ; but
they almost always appear diffluent and are moulded by surrounding corpuscles.
In addition to these large shadows there are even more characteristic quite
small fragments, markedly irregular stellate or elongated in form evidently of very
soft consistence and staining more feebly than normal red cell substance.
That these are not artifects we are convinced, for we do not find them in our
films of normal or malarial blood, nor in the blood of Black-water Fever cases
except at certain stages. Many of the small shadows also exhibit appearances
that we do not find even in carelessly or badly made films, where of course
shadows and fragments may be numerous.
Spherocytes and other abnormal conditions of the red cell seen early in the
dis-ease.—Small deeply staining round cells have been described by many authors. In
pernicious anæmia and other conditions very small corpuscles may be present, but
these are not necessarily of the type to which we are now referring, so that the term
microcyte would be ambiguous. These cells it is true when seen in films are smaller
than the normal red cells ; but this appearance is due mainly if not altogether to
changes in their elasticity, which prevent them from becoming as flattened as the
normal corpuscles.
As such cells, as we shall see later, are a sign of most important pathological
changes, we have thought it desirable to have a name to designate the condition
and have termed them spherocytes.
Though a spherocyte can be picked out from among normal cells by its small
size, associated with its altered staining properties, there is no hard and fast line of
demarcation between a normal cell and others showing in various degrees this
change. Restricting ourselves to the well marked condition we can note the follow-
ing alterations as characteristic of spherocytes. (1) They are among normal
corpuscles conspicuous from their regular circular outline. This is not infre-
quently accentuated by a circular crack produced by shrinkage of the serum from
the unyielding corpuscle. (2) They not only stain more deeply, but frequently
show a gradually increasing depth of colour towards the centre of the cell. (3) In
fresh films they resemble the " globuli-rossi " seen in malaria and can be picked
out by their darker tint and the absence of the plate-like appearance of normal
corpuscles.
227 H. D.
U
78
Among corpuscles stained by adding a few drops of blood to a saturated solu-
tion of neutral red in 3 per cent, citrate of soda solution, are some which take on a
deep brown as compared with the light yellow tint of the great majority of cells.
Most frequently cells which stain in this way appear to be spherocytes ; but we
cannot definitely state that this peculiar reaction is one confined to spherocytes.
Cells of normal size, but showing an irregular, often pear-shaped outline and
pale stained centres are also seen. Cells of normal size and shape but with
markedly pale staining centres are also occasionally observed.
The most distinct feature of the blood in Black-water Fever is the occurrence
of the shadows we have referred to.
Spherocytes are by no means conspicuous in the peripheral blood ; though as
we shall see they may form a very important feature in the blood from the spleen.
Late changes.
Polychromasia and allied conditions.—A peculiarity of red cells which under
suitable conditions of stain causes them to take on a bluish or slate colour, instead
of the ordinary eosin-red, has been termed polychromasia. Maragliano (73),
Castellino (73), and Ehrlich (73) have considered the condition a sign of degenera-
tion. But Engel (73) and others look upon these cells not as degeneration forms,
but as a stage in the formation of the ordinary red cell ; and according to Engel
polychromatic cells appear when very rapid formation of red cells is demanded.
We have every reason to believe that the polychromasia seen in Black-water
Fever is quite unconnected with degeneration and is due to regenerative changes.
Cells showing polychromasia in its most marked form are of very large size,
measuring up to 10 microns or more, and taking on with most Romanowski's stains
a more or less pale bluish purple colour. They are rarely of normal shape, being
more or less irregular and showing a distinct tendency towards lobulation, a feature
which may be accentuated by an appearance of three or more faint lines which
divide up the cell into several portions. In the most extreme cases there is a central
stippling with Romanowski red, arranged in a more or less stellate manner. Though
such cells may form quite an appreciable percentage of the whole, the majority
of the polychromatic cells exhibit these features in a lesser degree. Associated
with, the polychromasia there are always a considerable proportion of more or less
normal cells of a larger size than usual and others exhibiting every gradation bet-
ween normal and polychromatic cells. Unless associated with the presence of
tit
79
spherocytes, there is therefore with presence of polychromasia a general increase
in the size of the red cells, very noticeable under the, miscroscope at the first
glance.
During the early stages of Black-water Fever, polychromasia is rarely seen ;
it begins to be apparent after the second or third day and reaches its maximum
most often when the patient is convalescent, usually several days after the
cessation of the hæmoglobinuria.
Nucleated red cells are not usually seen, if at all, until late in the disease ;
except that they contain a nucleus they resemble in all respects polychromatic
red cells. In certain cells of this nature the usual densely staining circular
nucleus is not present, but its place is taken by a pair of small densely staining
nuclear masses, one invariably larger than the other, but never measuring more
than about 2 microns. These nuclear masses are always associated with the
reddish stippling of the cells before alluded to.
So called basophilic degeneration has been recorded in Black-water Fever.
In our experience it is a late and somewhat rare condition generally associated
with polychromasia ; and we doubt if it has any relation to susceptibility to
destruction of the red cells, a suggestion sometimes made.
The extent of these changes will best be gathered from the following case.
But the discussion of the significance of the condition is best postponed until we
have studied our subject on a basis of experiment
—
ase XX.—Hæmoglobinuria continuing for three days. A case in which we were
able to examine the blood early on the first day of the attack and regularly
on the succeeding days until the patient was convalescent. Examination of
the blood on the first, second, and third days, respectively, showed among
20,000 red cells counted on each occasion the abnormalities noted below—
First day.
Second day.
Third day.
Large shadows
..
..
15
51
2
Small shadows
..
. .
20
35
27
Anæmic cells
..
. .
35
35
15
Deformed cells of normal size
..
105
48
84
In this instance it will be noticed that the blood changes were not by any
means marked, although at the time when the blood films were obtained hæmo-
globinæmia was present.
On the third day after onset polychromasia began to be conspicuous and
large cells measuring 8 microns were as numerous as medium sized cells. On
80
the sixth day there was an extraordinary degree of polychromasia, large poly-
chromatic cells forming a considerable proportion of the total. Basophiles were
also present.
A comparative count gave.
Per cent.
Markedly polychromatic cells
. .
. .
. .
. .
18
Large sized corpuscles
„
. .
. .
. .
. .
23
Medium
,, ,,
..
. .
..
..
53
Small
,,
,,
. .
. .
..
..
4
Case XXI. —(1) In films on the first day, six hours after the onset of hæmoglobi-
nuria, the following were found, among 20,000 red cells :—
Large shadows
..
. .
. .
. .
. .
156
Small shadows
..
. .
. .
. .
. .
33
Anæmic ..
. .
. .
. .
..
16
Deformed cells of normal size ..
..
. . ..
129
(2) A second film taken on the same day but several hours later showed no indica-
tion of blood destruction, for in an examination of 120 microscopic fields (approxi-
mately 20,000 red cells) we were unable to find either shadows, microcytes or
anæmic cells, and only 15 marked poikilocytes.
(3) A third specimen of blood obtained after a further sixteen hours with hæmoglo-
binuria still continuing showed among 20,000 red cells—
Large shadows
..
..
. .
..
. .
.. 12
Small shadows
..
..
..
. .
. .
. .
6
Anæmic cells .. ..
..
. .
. .
..
..
6
Deformed cells of normal size
..
..
..
. .
.. 21
It may be noted that during the interval between the taking of the second and
third specimens a slight rigor had occurred.
In this case it is of special interest to note that at no time during the passage
of hæmoglobinuria in this primary attack, did the blood show the presence of
polychromasia, granular degeneration of the red cells, or nucleated red corpus-
cles. But five days later a relapse took place and at this time polychromatic
red cells were present in large numbers, together with numerous nucleated red
corpuscles of various sizes and a marked general poikilocytosis of the erythro-
cytic elements.
Case XXIV.—(1) Examination of films taken some hours after onset shows nothing
abnormal. No shadows or spherocytes or other observable change.
81
(2) Films taken on the third day, while hæmoglobinuria was still in active progress
show :—
Per cent.
Large shadows
. .
. .
. . . .
. .
. .
.4
Small shadows
. .
. .
. .
. .
. .
. .
1.1
Sperocyte
. .
..
. .
. .
. .
..
.3
Microcytes
. .
. .
. .
..
..
. .
.05
(3) Films taken on the fourth day after cessation of the hæmoglobinuria showed no
shadows.
These observations are in accord with those described by Grocco (45) in
paroxysmal hæmoglobinuria, in which he found little or no evidence of blood
destruction on microscopical examination, although marked hæmoglobinmia was
present in the plasma at the time.
V.—CHANGES IN THE LEUCOCYTES.
Specimens of the blood taken very early after the commencement of an
attack of Black-water Fever generally exhibit a relative large mononuclear
leucocytosis, consisting chiefly of the ordinary typical large cells with kidney
shaped, or incurved, and somewhat eccentrically placed nuclei, an increase of
which has been so often noted as occurring during the course of a malarial attack.
Sometimes as has been remarked elsewhere certain of these cells may be found
containing malarial pigment. A little later in the attack certain large mono-
nucleated cells of a different type appear in the general circulation ; and it is
coincident with the appearance of these new elements that phagocytosis of red cells
and shadow corpuscles may be observed.
At a still later stage enormous irregular endotheliab plaques appear, giving
rise to the impression that a more or less extensive lesquamation of the end-
othelium has taken place. With the cessation of hæmoglobinuria and the ap-
pearance of polychromasia and nucleated red cells there is a more or less rapid
disappearance of these abnormal types of cell from the blood, though the ordinary
large mononuclear leucocytes may still be found in excess. At this stage also
true lymphocytes and eosinophiles which have been reduced almost to the
vanishing point during the paroxysm of hæmoglobinuria once more appear, some-
times in increased numbers. Many of the polymorphonuclear neutrophile elements
which have possibly shown diminished granular staining of their protoplasm
during the attack, now appear more densely granulated, a condition shared by a
large number of the transitional and mononuclear elements, many of which latter
approach the myelocyte type. Some of these also show a distinct tendency
to eosinophile granulation ; and should perhaps be described as eosinophile
myelocytes.
227 H. D. x
82
The most striking of these phenomena is undoubtedly the appearance of the
large mononuclear cells and macrophages. The disappearance or great reduc-
tion of certain of the leucocytes, and the appearance of transitional forms and
myelocytes, also requires some further mention.
Increase in the large mononuclear elements.— This relative increase which is
also seen to a marked degree in malaria has been sometimes considered a sign
of protozoal infection ; but it has been described by Hayem in a case of met-
hæmoglobinuria of chemico-toxic origin, and it appears to us possible that it
may in some way be related to the occurrence of red cell destruction.
Poch (60) has shown that it occurs in a most marked degree in benign tertian
and quartan infections, being less marked in malignant tertian malaria.
In Black-water Fever the increase is always distinct though not necessarily
very great. The following tabular statement gives the result of counts in Black
-water Fever cases. Most of these counts include, among the large mononuclear
leucocytes, cells of the macrophage type.
Case.
Day of the
disease.
Polymorpho-
nuclears.
Large mono-
nuclears.
Small mono-
nuclears.
Eosinophiles.
Case no. 1
..
..
3
5 7 .
24.9
16.6
1.5
, , 4
. .
..
1
59.
20.5
20.
.5
2
54.3
27.4
18.3
..
3
55.6
21.6
22.8
..
4
53.6
16.6
24.
5.6
, ,
5
..
..
1
49.7
26.3
23.8
.2
, ,
7
..
3
53.8
28.5
17.2
.25
,,
9
. .
. .
1
66.3
27.8
4.7
1.2
, ,
10
..
..
2
48.4
26.6
24.
1.
, ,
11
..
..
2
61.
33.
6.
0.
, ,
12
..
..
3
49.
24.6
21.
5.4
, ,
14
..
..
3
59.4
26.4
8.9
5.6
, ,
15
..
..
4
54.2
24.8
20.8
.2
, ,
16
..
..
2
55.9
14.9
21.1
.4
, ,
17
..
..
2
48.9
20.1 10.7
20.1
.2
4
62.3
22.3
12.7
2.4
83
Case.
Day of the
disease.
Polymorpho-
nuclears.
Large mono-
nuclears.
Small mono-
nuclears.
Eosinophiles.
Case no. 18
..
..
3
65.
18.
..
..
,,
19
..
. .
1
83.
9.6 1.3
6.
0.
2
67.5
8.
18.
6.5
,,
20
..
..
1
63.7
23.
9.3
1.82
2
61.7
28.7
9.5.
2.1
3
57.4
22.
14.
1.65
4
49.4
25.5
19.8
3.
7
7 3 .
9.
9.
5.3
21
..
..
1
73.6
18. 2.2
6.
. 2
2
62.
10.2 7.2
20.6
. 0
,,
24
..
4
75.5
11.7
12.3
. 3
, ,
2 5
. .
3
56.6
13.3 5.5
23.3
.5
Macrophages.— These cells which usually appear within the first twenty-four
hours after the onset of an attack of Black-water Fever are of several types—
Type (1).—Cells resembling the ordinary large mononuclear leucocyte, but
ranging from 15 to 25 microns in diameter.
They possess a large oval, indented, or kidney-shaped nucleus placed
usually a little eccentrically and surrounded by a large amount of hya-
line or faintly granular protoplasm. In the larger of these cells the
nucleus may measure 15 microns in the long diameter. These cells
sometimes contain malarial pigment, and they may also be found
occasionally with engulfed red cell shadows.
Sometimes the nucleus of these cells has divided, forming a pair of round
twin nuclei.
uch cells whose appearance is that of very large specimens of ordinary
mononuclear leucocytes form a marked feature in the blood of Black-water Fevers.
Type (2).—Large irregularly circular cells with a compact roundish or rhom-
boidal nucleus situated more or less centrally in a mass of pale stai
n - i n g p r o t o p l a s m .
They vary in size from 15 to 20 microns or more, while their nucle
generally measure 10 to 12 microns in diameter. The larger cells
84
of this type are frequently vacuolated while many of them contain
the debris of what seem to be red cells along with distinct red cell
shadows. The smaller cells of this type are evidently markedly
phagocytic and may sometimes be found containing engulfed red
blood cells, but little altered in appearance.
Such cells resemble except in size the small mononuclear leucocytes with hya-
line protoplasm.
Type (3).—Large cells with irregular or polygonal nuclei, which lie either
to one side or stretch right across the cell body.
They may attain enormous dimensions, often measuring from 20 to 30
microns in diameter. They also possess phagocytic properties frequent-
ly being found with engulfed and altered red cells, and what appears
t o b e r e d c e l l d e b r i s .
Endothelial plaques. —The macrophages described above which appear
comparatively early, usually within the first twenty-four hours of Black-water
Fever and are still to be found in diminishing numbers after the actual
hæmoglobinuria has ceased, appear to be free cells which have for some reason
appeared in the peripheral circulation. But there are certain cells which seem
to be desquamated endothelial plaques. Many of these cells are of very large
size, and plaques composed of two or more joined together side by side are not
uncommonly seen.
The nucleus of these cells-is large and frequently stretches nearly across the
cell and exhibits considerable irregularity of outline. The protoplasm which
is hyaline in nature often shows extensive vacuolation and may contain red
cells, debris, and shadows. Such cells resemble those found in the splenic and
hepatic veins post mortem and endothelium cells of the visceral capillaries.
Their presence in the peripheral circulation appears to point to the action
of some irritant (possibly free hæmoglobin) upon endothelium as a result of which
a more or less extensive shedding of its elements takes place.
Reduction in number of certain forms of leucocytes. —Coincident with the
increase in large mononuclear elements, which is most marked during a fall in the
patient's temperature, but is usually persistent throughout the attack, there is
generally a decrease in the polymorphonuclear leucocytes. A most interesting
phenomenon, which we find to hold good in a number of cases, is the great
reduction of true lymphocytes, as opposed to small mononuclears, and the frequent
partial or total disappearance of the eosinophile cells during the early stages
85
of the disease followed by the reappearance of these elements, sometimes in
considerable numbers at a later stage.
Transitional cells and myelocytes. —Towards the end of the attack a large
proportion of the polymorphonuclear cells contain nuclei much less lobulated
than normal, and such cells appear to be immature forms of polymorphonuclear
leucocytes. Other cells of similar nature are of more or less purely mononuclear
type, and as we have noted, appear to be neutrophile myelocytes. Their presence
at this late stage of the disease seems to indicate an attempt on the part of the
blood forming organs to repair a loss occasioned by an extensive destruction
of the polymorphonuclear forms during the earlier stages of the malady.
Red cell phagocytosis in the peripheral blood. —Although red cell phagocytosis
may not be conspicuous on casual examination of the blood of Black-water
Fever cases, some evidence of its occurrence can invariably be found on careful
search especially during the earlier stages of the disease.
Such evidence is generally in the form of large clear engulfed stromata of red
cells which are more or less devoid of hæmoglobin. But in a few instances mac
-rophages may be found containing but little altered red cells. Later in the dis-
ease when endothelial plaques have made their appearance, a large proportion of
these elements may be seen containing one or more engulfed and decolourised
red corpuscles.
Extrusion of nuclear matter in certain types of cell. —Before leaving the question
of the blood changes observed in Black-water Fever we must record a peculiar
feature of the small mononuclear leucocytes observed in one case only in blood
films taken on the fourth day of the disease.
In these specimens a large proportion of the small mononuclear leucocytes
which possessed a considerable amount of protoplasm exhibited a deeply staining
mass of nuclear like substance lying for the most part just within the protoplasm
at the periphery of the cell. In some instances there was an indication of some
fine protoplasmic threads extending from this body towards the cell nucleus, and
in one it appeared as though the body might have been just extruded from
the cell. In general these masses were quite minute, measuring no more than one
to two microns in diameter, though a few which appeared to be of a more
elongated shape were slightly longer. Judging from their appearance and staining
reactions it is probable that they are of the nature of nuclear extrusions
associated possibly with cell proliferation. The slightly indented form of the
nucleus of the leucocytes containing them seems to give some warrant for this
idea. It is possible that they are analogous bodies to those described by
227 H. D. Y