(case 4) as we had with Dr. Munford's case (case 2) reported above. The section from the two cases did not differ in any particular. There was a diffuse hyperplasia of the lymphocytes and the differentiation between the germinal follicles and the remaining lymphoid tissue was impossible. Examination of the stained blood film did not help us to make the diagnosis, the cells had much the same appearance of the lymphoblast seen in acute lymphatic leukemia and I was inclined to think leukemia the most probable diagnosis but as Dr. Wilson has stated the marked improvement of the patient made the diagnosis of leukemia untenable and confirmed his first impression that it was infectious mononucleosis.

Case 5. Agranulocytic angina.
Report of case with autopsy findings.

Presented by Dr. S. F. Service

The patient, a young man 27 years of age, came to the clinic complaining of sore throat and mouth. This began four days before his admission, he went to this physician who applied silver nitrate crystals to the mucous membrane of the mouth and throat. On admission he was seen first by the dentist who made a diagnosis of Vincent's gingivitis and films made from the exudate in the throat and mouth showed many of the spirals and large fusiform bacilli associated with this disease. He gave a history of having contracted syphilis six months ago for which he had received treatment immediately, the treatment consisting of 10 intravenous injections of salvarsan and 10 injections of bismuth. It is since the development of the sore mouth that this treatment was discontinued. There had been gross blood in the urine for several days. On physical examination. the skin had a bronze tint but the sclerae were clear, the right jaw was greatly swollen and on examination of the mucous membrane of the mouth it was found to be

badly ulcerated with a greyish green foul smelling slough extending from the mouth into the throat although a satisfactory examination could not be made as the patient was unable to open the mouth very wide. The blood count showed 4,150,000 erythrocytes, 53% hemoglobin and only 1800 leucocytes of which 74% were lymphocytes. There were no abnormal cells. A transfusion was done but this had little, if any, effect. The leucocytes continued to decrease in number and reached the low figure of 400 per cu. mm. with 85% lymphocytes. The color of the skin deepened. He developed a broncho pneumonia and the leucocytes increased to 600 with no change in the lymphocyte values. He died in coma two days after the onset of the pneumonia. Blood cultures were negative, urine cultures showed a pure culture of a staphylococcus albus. Albumin, casts and gross blood were found in the urine during the whole time he was in the hospital. On one occasion there was a marked hemorrhage from the nose which necessitated packing. The diagnosis of agranulocytic angina was made and inasmuch as little is known of this condition various chemical examinations of the blood were done. There were some rather interesting findings, for instance the blood cholesterol was only 80 whereas the normal will average 200. The blood calcium was low also, only 7.5 mg. per 100 cc. of blood. Other findings were as follows: Blood sugar 135 mg. per 100 cc., urea nitrogen 22 mg. The uric acid and creatinine content was normal. The plasma bicarbonate was 64 volumes per cent. The icterus index was 5, the Fouchet test was negative, the Van den bergh positive, sedimentation time of the blood was 19 minutes, the coagulation time 4 minutes, and the bleeding time 26 minutes.

Autopsy findings: Dr. W. S. Thomas

The body was that of a well developed but rather poorly nourished young white

man. The right side of the face particularly in the region of the lower jaw was markedly swollen; in the center of the swelling there was an area of bluish discoloration about 3 cm. in diameter. Scattered over the anterior surface of the chest particularly on the left side were numerous tiny petechial hemorrhages and there are a few similar hemorrhages on the inner aspect of the right arm.

Abdomen: The peritoneal surfaces were smooth and slightly dry. The organs were normally disposed except that the liver extended a hand's breadth below the ensiform and about 2 cm. below the costal margin in the mid clavicular line.

Thorax: The lungs were distended and met in the mid line almost completely covering the heart, the pleural cavities contained no fluid. The pericardium contained about 25 cc. of clear straw colored fluid, there were a few small hemorrhages in the parietal wall.

Heart: The heart weighed 325 gms. the surface was studded with small petechial hemorrhages. The chambers contained a small amount of thin fluid blood. All valves were thin and delicate and appeared competent. The wall of the left ventricle measures 15 mm. in thickness and on section was a uniform dark reddish brown.

Lungs: The left lung was greatly distended and much frothy fluid escaped from the bronchus. The surface was smooth and moist except for an area about 5 cm. square on the anterior surface of the upper lobe where it was granular and hemorrhagic. There were many small hemorrhages scattered about over the surface. On section the tissue was grey but scattered about were many dark red solid nodules the largest measuring about 7 mm. in diameter. These were particularly numerous in the lower lobe and near the lower border of this lobe they were so numerous as to give a semi-solid consistency to the portion. The right lung was similar to the left.

Spleen: The spleen weighed 300 gms. On section it was mottled dark and light red. There was no increase in splenic pulp. The splenic nodules were slightly large and were not sharply circumscribed. The stomach, pancreas, duodenum, gall bladder and adrenals showed no abnormalities.

Liver: The liver weighed 2200 gms. The capsule was thin and the edges rounded. On section the cut surface was cloudy, the lobules were distinct, the color was greyish red.

Kidneys: The left kidney weighed 250 gms. The capsule stripped readily leaving a smooth greyish red surface. It was soft and flabby to the touch and on section the cut surface was very cloudy. The cortex was 10 mm. in thickness and the striations were regular. In the pelvis the mucous membrane was very hemorrhagic. The right kidney was similar to the left.

Urinary bladder: The urinary bladder showed numerous small hemorrhages on the mucous membrane.

Bone marrow: The bone marrow from the shaft of the femur was greyish red, there were small areas of yellow fatty tissue but in general the fat was slight in amount. Some areas were quite red.

Buccal cavity: The mucous membrane of the right cheek was replaced by a greenish grey foul smelling slough.

Cultures from the heart blood, lungs, spleen, liver and kidneys all showed a great variety of organisms the identity of which has not been determined at this time.

The autopsy was performed two hours after death.

The microscopic examination of the consolidated areas in the lungs showed the alveoli filled with red blood cells and serum with only an occasional leucocyte. In the bone marrow there was considerable replacement of the fat by marrow cells. chiefly myeloblasts and myelocytes. The liver and kidneys showed no change from the normal except for the cloudy swelling.

Discussion: Dr. W. S. Thomas These cases are rare and little or nothing is known about the condition. The majority of the cases reported in the literature have occurred in middle aged women and most of them have died. They have been characterized by a mouth or throat infection accompanied by a marked leukopenia with the destruction of the granular cells the most striking feature of the blood picture. All of these characteristics were present in this case.

We were bold enough to prognosticate a fatal outcome provided that the leucocytes dropped below 500 and the polymorphonuclear leucocytes went below 5%. Our reasoning was as follows: We believe the polymorphonuclear leucocytes constitute one of the greatest methods of defense of the body against infection. They destroy invading organisms and dissolve them so

that they can be absorbed and act as antigens for the production of antibodies. We also know that antibodies do not last very long in the blood, that if the supply is not replenished they soon disappear. With the disappearance of the polymorphonuclear cells not only is the invading organism not restrained but the supply of antibodies is not kept up and so the defenses are broken down and the body becomes a prey to the first virulent organism that enters and finds a soil suitable for its growth. If we can judge by the extraordinary number of bacteria found in all of the organs examined at autopsy the body defenses in this case had disappeared altogether or were greatly reduced. It will be kept in mind that the autopsy was performed and the cultures made within two hours after death. In this short time secondary invasion could scarcely account for the number of organisms found.