spleen in the formation of the white blood corpuscles by counting the
white corpuscles in the afferent and efferent vessels of the spleen. It
was thought that the blood-forming power of the spleen was proved by the
larger number of corpuscles in the vein as compared with the artery. The
results of these enumerations however are very varying; the
investigators who found a relative increase in the vein are opposed by
other investigators equally reliable; and with the experience of the
present day one would not lay any value on these experiments.
We must emphasise the fact, established by later researches, that after
extirpation of the spleen, an enlargement of various lymphatic glands
occurs. The alterations of the thyroid, which have been observed by many
authors, cannot be described as constant.
Further, the blood investigations which Mosler, Robin, Winogradow,
Zersas and others have carried on in animals and man after removal of
the spleen must here be mentioned. These have already proved that a
leucocytosis occurs after some considerable time. Prof. Kurloff carried
out detailed investigations in 1888 in Ehrlich's laboratory, and
carefully studied the condition of the blood after extirpation of the
spleen. As the work of Prof. Kurloff has so far only appeared in
Russian, his important results may be here recorded more fully. For his
researches, Kurloff employed the guinea-pig, as this animal by its
peculiar blood is specially suited for this purpose.
In order to give a systematic account of the results of these
important investigations, we must first shortly sketch the
normal histology of the blood of the guinea-pig according to
Kurloff.
In the blood of the healthy guinea-pig the following elements
are found.
I. Cells bearing granules.
1. =Polynuclear, with pseudoeosinophil granulation.= This
granulation, which Ehrlich had previously found in the rabbit,
is easily distinguishable from the true eosinophil, since it is
much finer, and stains quite differently in
eosine-aurantia-nigrosin mixtures. One principal distinction
between these two forms of cells lies in the fact that,
according to Kurloff, this granulation is very easily dissolved
by acid, but remains unchanged in alkaline solutions; doubtless
an indication that the granulation consists of a basic body
soluble with difficulty, which with acids forms soluble salts.
The true eosinophil granulation remains, on the other hand,
quite unchanged under these conditions.
=These pseudoeosinophil, polynuclear cells, correspond
functionally to the neutrophil polynuclear of man=; their number
amounts to 40-50% of the total white cells. The red bone-marrow
is to be regarded as the place of origin of this kind of cell.
It contains very many pseudoeosinophil cells, and indeed all
stages are to be found in it, from the mononuclear cells
bearing granules to the fully formed polynuclear.
2. The typical =eosinophil leucocytes=, which fully correspond to
those found in man, and amount to about 10% of the number of
the white.
3. The "=nigrosinophil cells=," as they are called by Kurloff. In
their general appearance, in the size of the cell and the
granulation, they completely correspond to the eosinophil cell.
The only distinction between them consists in a chemical
difference in the granulation. These cells stain in the colour
of nigrosin in the aurantia-eosin-nigrosin mixture, whilst the
eosinophil cells become red. The two granulations always show
different shades in the triacid preparation as well; for the
nigrosinophil cells stain a blacker hue.
II. Cells free from granules.
([alpha]) Cells with vacuoles.
This is a quite peculiar group, characteristic for the blood of
the guinea-pig. It shews transitions in the blood, from large
mononuclear to transitional and polynuclear forms, but is
marked by the lack of any kind of granulation. Instead of the
latter, we find in these cells a roundish, nucleus-like form in
the protoplasm, which also takes the nuclear stains, and
possibly is to be considered an accessory nucleus. We have
received the impression that we have here to deal with a
vacuole filled with substance secreted by the cell. In a large
series of preparations, it is possible to obtain some
elucidation of the development and fate of these appearances.
They first appear as point-like granules in the protoplasm,
bearing no relation to the cell nucleus; they gradually
increase, and acquire a considerable circumference. When they
have attained about the size of the cell nucleus, they, or
rather their contents, appear to break through the protoplasmic
membrane and to leave the cell.
The number of the vacuole containing cells is 15-20% of the
colourless blood corpuscles.
([beta]) Typical lymphocytes.
Their appearance completely corresponds with that of human
lymphocytes as described above. They make up 30-35% of the
total number of leucocytes.
Now Kurloff in the course of extremely careful and laborious
researches, estimated the total number of leucocytes, and then
from the percentage numbers, the total quantity of
pseudoeosinophil, neutrophil, eosinophil, vacuole containing
cells, and lymphocytes, and could thus demonstrate that in
uncomplicated cases of removal of the spleen, where
inflammatory processes, accompanied by an increase of the
polynuclear neutrophil corpuscles, were avoided, a =gradual
increase of the lymphocytes= alone in course of time results.
This may be a two- or threefold increase, whereas the numbers
of all other elements remain unchanged.
Kurloff obtained his figures as follows: first he estimated the relative
proportion of the different kinds of white blood corpuscles one to
another in a large number of cells (500 to 1000). A count of this kind
however gives no evidence as to whether one or other kind of cell is
absolutely increased or diminished. A fall in the percentage of the
lymph cells may be brought about by two quite different factors: (1) by
a diminished production of lymphocytes, (2) by an increased influx of
polynuclear forms, which naturally lowers the relative count of the
lymphocytes. It was therefore necessary to obtain a method which would
show alterations in the absolute number of the individual forms of
leucocytes. Kurloff used for this purpose the "comparative field"; that
is, he counted by the aid of a moveable stage the different forms which
lay on a definite area (22 sq. mm.) of the dried blood preparation. This
procedure gave very exact results, as only faultlessly prepared, and
regularly spread preparations were used. The following figures (from
Exp. II.) illustrate the method and its results:
April 12 52% pseudo-eos. 10% lymphocytes counted.
Sept. 2 (one month
after the operation) 22% " 53% " "
By the aid of the comparative surface, these figures were supplemented
by the following averages. On each surface used for comparison were
found:
April 12 38 white = 19.8 pseudo-eos. 10.6 lymphocytes.
Sept. 2 81 " 18.0 " 46.9 "
From this example it follows without doubt, that the =total number of the
white blood corpuscles had about doubled itself=, but that in this
increase the lymphocytes exclusively were concerned, and the
pseudo-eosinophil cells had not undergone the smallest increase.
The results which Kurloff obtained by means of this method in animals
whose spleens had been removed, may be illustrated by one of his
original researches and its accompanying chart and table.
Exp. I. Young female, weight 234 gr. Number of red corpuscles
in a cubic millimeter of blood 5,780,000. Number of white
10,700. On April 19, 1888, the spleen was removed, the wound
healed by first intention. The results of the further
investigation of the blood are found in the following table.
From the chart and table, the number on the surface of
comparison of the white blood corpuscles is seen to have more
than doubled itself in the first seven months, and that this
increase was solely dependent on the flooding of the blood by
lymphocytes. The nucleated or bone-marrow elements and the
large mononuclear cells remained continuously at the same level
during the whole period. The changes in the percentage
proportions ran somewhat differently. The percentages rose from
35 to 66% for the lymphocytes only, whilst for the other forms
they distinctly fell: for the nucleated from 44% to 22% and for
the large mononuclear from 18% to 9%. It was only in the course
of the second year that a very considerable relative and
absolute increase of the eosinophil cells appeared: the values
rose gradually from about 1.0% to 28.9% or from 0.5 to 13.9 on
each comparison area. The last examination of the blood in this
animal was made on April 30, 1890, that is, two years after the
removal of the spleen. The animal was quite healthy, bore four
healthy young guinea-pigs by a father whose spleen had been
removed. The young have a completely normal spleen, and their
blood likewise shows no abnormalities.
[Illustration: CHART TO EXPT. No. I. (cp. Table, page 89. The figures in
the chart refer to comparative surfaces.)
Thick line--total number of leucocytes
Broken line--lymphocytes
Thin line--number of nucleated, pseudo-eosinophil cells
Double line--large mononuclear cells
Dotted line--eosinophil cells]
TABLE I.
Key to columns:
A - Leucocytes
B - Pseudo-eosinophil cells
C - Lymphocytes
D - Large mononuclear cells
E - Eosinophil cells
F - Nigrosinopil cells
G - On comparative surfaces
---------------------------------------------------------------------------
|| A || B || C || D || E || F |
------------------------------------------------------------------
Date ||Total| G|| % | G || % | G || % | G || % | G || % | G |
---------------------------------------------------------------------------
1888 || | || | || | || | || | || | |
April 19|| 500|--||44.7| -- ||35.4| -- ||18.4| -- || 1.1| -- || 0.5| -- |
23|| 990|24||40.4| 9.7||35.6| 8.5||21.6| 5.2|| 1.9| 0.4 || 0.4|0.09|
May 1|| 858|28||47.0|13.6||32.6| 9.1||18.0| 5.0|| 0.9| 0.2 || 0.3|0.08|
8|| 934|28||45.2|12.6||40.3|11.3||14.3| 4.0|| 0.6| 0.2 || 0.4|0.1 |
16|| 1122|30||38.4|11.5||47.7|14.3||10.3| 3.1|| 3.3| 0.9 || 0.2|0.06|
24|| 1722|35||40.1|14.0||35.0|12.2||23.6| 8.3|| 1.0| 0.3 || 0.1|0.03|
30|| 900|30||36.6|10.9||44.4|13.3||18.4| 5.5|| 0.1| 0.03|| 0.3|0.09|
June 5|| 825|33||28.4| 9.4||49.3|16.2||20.0| 6.6|| 1.7| 0.6 || 0.4|0.1 |
12|| 1314|33||28.0| 9.3||49.0|16.2||20.0| 6.6|| 2.2| 0.7 || 0.8|0.3 |
19|| 917|37||32.4|11.9||52.3|19.3||14.5| 5.4|| 0.6| 0.3 || 0.2|0.07|
28|| 802|42||30.5|12.8||56.4|23.7||11.7| 4.9|| 0.7| 0.3 || 0.4|0.2 |
July 2|| 1062|56||16.5| 9.2||57.1|31.9||25.6|10.3|| 1.2| 0.7 || 1.2|0.7 |
9|| 1245|51||17.6| 8.9||59.1|30.1||21.8|11.1|| 0.8| 0.4 || 0.8|0.4 |
16|| 974|69||17.5|12.0||66.4|45.8||15.7|10.8|| 0.2| 0.1 || 0.2|0.1 |
23|| 1156|58||21.7|12.6||67.2|38.9|| 9.5| 5.5|| 1.5| 0.9 || 0.2|0.1 |
30|| 802|54||20.2|10.7||65.4|34.6||12.8| 6.8|| 1.4| 0.7 || -- | -- |
Aug. 6|| 910|52||21.7|11.3||67.3|34.9|| 9.7| 4.9|| 1.0| 0.5 || 0.3|0.2 |
Sept. 6|| 815|51||23.0|11.7||65.3|33.5|| 9.8| 4.9|| 0.9| 0.5 || 0.4|0.2 |
Oct. 5|| 625|62||26.4|16.3||64.4|39.9|| 8.5| 5.2|| 0.6| 0.4 || -- | -- |
Nov. 4|| 800|58||22.5|13.0||66.4|38.5|| 9.6| 7.3|| 0.9| 0.5 || 0.5|0.2 |
|| | || | || | || | || | || | |
1889 || | || | || | || | || | || | |
April 10|| 700|--||29.8| -- ||53.3| -- ||14.8| -- || 1.2| -- || 0.6| -- |
June 6|| 900|71||28.2|20.0||50.1|35.6||12.9| 9.1|| 8.2| 5.8 || 0.6|0.4 |
Aug. 1|| 670|62||30.6|18.9||44.2|27.4||15.2| 9.4|| 9.6| 5.9 || 0.4|0.2 |
Dec. 4|| 731|63||36.0|22.0||38.3|24.1||11.3| 7.1||13.3| 8.7 || 0.6|0.4 |
|| | || | || | || | || | || | |
1890 || | || | || | || | || | || | |
Feb. 2|| 622|51||32.3|16.5||30.1|15.3||11.1| 5.6||26.0|13.2 || 0.5|0.2 |
April 30|| 500|48||36.5|17.5||24.5|11.7|| 9.4| 4.5||28.9|13.9 || 0.6|0.3 |
---------------------------------------------------------------------------
The results of further investigations, which we here shortly repeat in
tabular form, shew that in this experiment No. I. we are not dealing
with an abnormal phenomenon of an exceptional animal.
------------------------------------------------------
| Number of white blood corpuscles
No. of |---------------------------------------------
Expt. | Before the | At the end of | At the end of
| splenectomy| the first year| the second year
------------------------------------------------------
1 | 10,700 | 14,200 | 18,000
2 | 12,000 | 27,600 | 32,000
4 | 15,000 | 19,200 | 19,000
------------------------------------------------------
Average | 12,600 | 20,333 | 23,300
By estimating the percentage proportion of the single kinds of white
corpuscles, Kurloff obtained the following result:
Key:
A - Number of the Experiment
B - Polynuclear granular cells
C - Lymphocytes
D - Mononuclear
E - Eosinophil
----------------------------------------------------------------------------
|| Before the operation || At the end of the || At the end of the
|| || first year || second year
A || B | C | D | E || B | C | D | E || B | C | D | E
----------------------------------------------------------------------------
1 || 4782| 3788| 1969| 117|| 4232| 1568| 2101| 170|| 6570| 4410| 1692| 5202
2 || 6276| 3360| 2244| 72|| 5464|16615| 2980|2539|| 5824|20861| 2688| 2240
4 || 6715| 5250| 2595| 450|| 6568|10041| 3686| 96|| 7108| 3009| 2138| 7543
From these researches we draw the following conclusions.
1. The spleen is not an indispensable, vitally important organ for the
guinea-pig, since that animal bears splenectomy without loss of health,
developes normally, and gains well in weight.
2. The hypertrophy and hyperplasia of the lymph glands, particularly of
the mesenteric glands, which develop after the operation correspond to a
=lymphocytosis=, which makes its appearance in the course of the first
year after the operation so constantly that it may be looked upon as a
=characteristic sign of the absence of the spleen=. This increase may
amount to double and more. We must therefore assume that the deficiency
of splenic function may be met by the lymphatic glandular system. This
period of lymphaemia may doubtless in some animals persist for years in
exceptional cases; in the majority, however, the lymphaemia diminishes in
the course of the first year, and indeed subnormal quantities of
lymphocytes may then be produced.
3. The cells of the bone-marrow, on the contrary, and the polynuclear
pseudoeosinophil cells do not show the least variation in the course of
the first year. Bearing in mind that under normal conditions these cells
are met with exclusively in the bone-marrow, and that inflammation in
animals after removal of the spleen is accompanied by an acute
pseudoeosinophil leucocytosis, exactly as in normal animals, one must
admit that the production and function of this kind of cell are quite
independent of the spleen. Hence there can be no doubt about their
myelogenic nature.
4. It is especially important that the mononuclear and the leucocytes
associated with them, undergo no increase. As these cells under normal
circumstances occur both in the spleen and in the bone-marrow, we must
assume that normally also the bone-marrow is responsible for the
majority of this kind in the blood, and that the deficiency in the
splenic contribution can be easily covered by a slightly raised activity
of the bone-marrow. Were the share of the spleen important, from
general biological considerations, an over-production of the kind of
cell in question must occur in the vicarious organs.
5. The increase of the eosinophil cells, which constantly makes its
appearance in the second year after the operation, is highly
interesting, and leads to a really enormous rise in their absolute and
relative numbers. Their percentage number once rose to 34.6%, and their
absolute quantity amounted at the end of the second year on the average
to 30-50-fold their original number (see table).
=Hence it follows from Kurloff's researches that the spleen of the
guinea-pig plays quite an unimportant part in the formation of the white
blood corpuscles, and that after splenectomy in the first year
compensation occurs only in the lymph-glands, followed in the second
year by a great increase of the eosinophil cells. It is to be
particularly insisted once again that the spleen has nothing at all to
do with the formation of the pseudoeosinophil polynuclear cells, which
are the analogues of the polynuclear neutrophils of man.=
* * * * *
How do observations on man stand in the light of Kurloff's observations,
which might be regarded as depending on peculiarities of the particular
kind of animal?
Completely analogous material is afforded by cases, in which in healthy
people a splenectomy has been necessary in consequence of trauma.
Unfortunately the material available for this purpose is extremely rare;
and it would be of the utmost value if the alterations of the blood in
such a case were systematically studied for a period of years. We have
ourselves begun our observations in two patients directly after the
operation, but were unable to continue them, as death occurred within
the first week after the extirpation. Up to the present only seven cases
of rupture of the spleen with subsequent splenectomy have been
published, as is stated in the collection of cases of v. Beck. In two
only, of these seven cases, one of Riequer's (Breslau) the other of v.
Beck's (Karlsruhe) was a cure effected. Through the courtesy of the
above-mentioned gentlemen, we were able to investigate specimens from
these two patients.
In the case of v. Beck the operation was performed on June 15,
1897. We received a dry blood preparation about 6 months after
operation. Investigation showed a considerable lymphaemia: the
bulk of the lymphocytes belonged to the larger kinds: the
eosinophil cells were certainly not increased. For other
reasons an exact numerical analysis could not be undertaken. We
hope to be able to follow the further course of this case.
In the second case the operation was performed on May 17, 1892,
by Dr Riequer of Breslau, for trauma, and later described. We
made counts in oldish and fresh preparations. It is worthy of
notice that this case is not uncomplicated, as an amputation of
the thigh was performed shortly after the splenectomy on
account of gangrene.
We found the following figures.
------------------------------------------------------------------------
Preparations from | Polynuclear | Lymphocytes | Eosinophil | Large
| | | | mononuclear
------------------------------------------------------------------------
June 12, 1892 | 81.9% | 15.9% | 1.3% | --
October 11, 1892 | 80.0% | 13.7% | 4.0% | 1.7%
September, 1897 | 56.8% | 33.1% | 3.5% | 1.5%
------------------------------------------------------------------------
It is much to be regretted that dry preparations only at the beginning
and at the end of the five year period of observation were at our
disposal. It appears from the paper of Riequer as if in this case the
lymphocytosis had established itself one month after the operation, and
had lasted for a very long time, just as Kurloff has found in some
animal experiments. Just as little as a polynuclear increase is
abnormal, is an increase of the lymphocytes remarkable; and in this case
the lymphocytic increase was recognisable after the end of the fifth
year. The eosinophil cells oscillate at this period about the upper
normal limit. From all that we know, it is probable that their number in
the meantime had undergone an intercurrent increase.
The cases are more frequent in which a splenectomy has been undertaken
on account of disease of the spleen. Amongst these, the clearest results
are _a priori_ to be expected from splenic cysts, since the part of the
spleen not affected by the cyst formation often shews quite a normal
structure, and therefore is physiologically active. On the other hand,
the excision of chronic splenic tumours may be--for the blood
condition--of no importance inasmuch as the function of the spleen may
have previously long been eliminated by pathological changes.
Amongst these cases, we must in the first place mention the well-known
and carefully investigated case of B. Crede. In a man 44 years of age
the spleen was extirpated on account of a large splenic cyst. Within two
months of the operation there developed a thoroughly leukaemic condition
of the blood, exclusively brought about by the increase of the
lymphocytes, as is seen from the results of Crede and the table
contained in his paper. It is further remarkable that four weeks after
the operation a painful doughy swelling of the whole thyroid appeared,
which remained, with variations, for nearly four months. With the
general recovery of the patient this shrank to a small remnant. We
notice further that this very interesting swelling of the thyroid,
which doubtless stands in the closest connection with the splenectomy,
is nevertheless no constant accompaniment of this operation, as for
instance in the case of v. Beck, where it was not present.
The most recent work on extirpation of the spleen for tumours is from
Hartmann and Vasquez. As the result of their researches the authors
arrive at the following conclusions:
1. A slight post-operative increase of the red blood corpuscles and a
true acute hyperleucocytosis occur and pass rapidly away.
2. The haemoglobin equivalent of the corpuscles sinks at first but
recovers its original value by degrees.
3. 4-8 weeks afterwards a lymphocytosis of varying duration is
established.
4. Later, after many months, a moderate eosinophilia occurs.
We have ourselves been able to investigate three conclusive cases.
The first was a patient, which we were ourselves enabled to
investigate by the courtesy of Dr A. Neumann. The patient's
spleen was removed by E. Hahn on account of an echinococcus on
Feb. 5, 1895. One may well assume that before the operation the
spleen no longer discharged its normal function. On Sept. 2,
1897, we found the following numerical proportions:
Polynuclear neutrophil 76.5%,
Lymphocytes 18.4%,
Eosinophil 3.4%,
Large mononuclear 1.1%,
Mast cells 0.4%.
A condition therefore which was quite normal. In this
connection it must be mentioned that an incipient phthisis
pulmonum existed at the time, to which we must attribute an
increase of the polynuclear elements, and without which the
percentage figures of the lymphocytes and eosinophils would
perhaps have been greater.
For the knowledge of the two other cases we are indebted to the
kindness of Professor Jounescu of Bucharest. The one case was
of a man of about 40 years of age, in whom splenectomy was
undertaken on Sept. 27, 1897, for an enlarged spleen. Healing
by first intention. The white blood corpuscles were permanently
increased. The proportion of white to red was 1:120 to 1:130,
the average number of red was 3,000,000. Our own examination of
preparations obtained some two months after the operation,
shewed a distinct lymphaemia, and also a preponderance of the
larger lymph cells. The eosinophil and mast cells were plainly
increased. We are unable to give more exact numerical data, as
the preparations sent to us were not spread with sufficient
regularity.
From the second case, which was also operated upon for
enlargement of the spleen, we unfortunately only obtained much
damaged preparations. Nevertheless so much could with certainty
be established--that there was no considerable increase of the
lymphocytes. The eosinophils on the contrary were increased
distinctly, the mast cells to a lesser extent. It is probable
that the increase of both of the latter kinds of cell was not a
consequence of the extirpation of the spleen alone, but rather
the expression of the reactive changes, which had already begun
before the operation, from the exclusion of the splenic
function.
Cases of splenectomy of this kind are transitional to the chronic
diseases of the spleen. The latter present great difficulties, for one
never knows how far in the most chronic diseases the other organs are
damaged or influenced by the general illness.
An increase of the lymphocytes, so long as an affection of the lymphatic
glands may be excluded, should be referred to functional exclusion of
the spleen.