Chapter 12

2. =In pemphigus.= Neusser first recorded that an extraordinarily great, indeed a specific eosinophilia was found in many cases of pemphigus. This interesting observation has been confirmed on many sides, in particular by Zappert, who once observed 4800 oxyphil per mm.^{3}

3. In acute and chronic =skin-diseases=. Canon was the first to notice that in a fairly large number of skin-diseases, especially in prurigo and psoriasis, the eosinophil cells are increased up to 17%. The observation of Canon is worthy of attention, that the increase of the eosinophils is connected with the degree of extension of the disease, rather than with its nature or local intensity. In a case of acute widely distributed urticaria, A. Lazarus found the eosinophils increased to 60% of the leucocytes, a number which after the course of a few days again sank to normal.

4. =In helminthiasis.= The first observations on the occurrence of eosinophilia in helminthiasis we owe to Müller and Rieder, who obtained fairly high values (8.2 and 9.7%) in two men suffering from Ankylostomum duodenale. Shortly afterwards Zappert stated that he had found a considerable increase of the eosinophil cells in the blood, reaching 17% in two cases of the same disease; at the same time he demonstrated Charcot's crystals in the fæces. In a third case of Ankylostomiasis Zappert found no increase of eosinophil cells in the blood, nor the crystals in the fæces. Almost simultaneously, Siege made similar observations.

For a detailed working out of this important branch we are greatly indebted to Leichtenstern. Under his direction Bücklers established the interesting fact that Ankylostomiasis in its relation to eosinophilia does not occupy a special place in diseases caused by worms. All kinds of Helminthides, from the harmless Oxyuris to the pernicious Ankylostoma, may bring about an increase of the eosinophil cells in the blood, often to an enormous extent[28]. Bücklers reports an observation of 16% eosinophils in Oxyurides, of 19% in Ascarides; and Prof. Leichtenstern, as we learn from a private communication, has quite recently found 72% eosinophil cells in a case of Ankylostomiasis, and 34% in a case of Tænia mediocanellata.

It is well worthy of note that Leichtenstern was able to observe numerous eosinophil cells in the blood in those cases where Charcot's crystals were abundantly contained in the fæces. Since eosinophil cells and Charcot's crystals have elsewhere been observed to be interconnected phenomena (for example in bronchial asthma, in nasal polypi, in myelæmic blood and bone-marrow) one must fall in with Leichtenstern's supposition that eosinophil cells ought also to be found in the intestinal mucus in cases of Ankylostomiasis. Positive observations on this point as yet are wanting.

T. R. Brown, who worked under direction of Thayer, has lately communicated the interesting observation that in =trichinosis= there is constantly an extraordinary relative increase in the oxyphil leucocytes in the blood, up to 68%. The absolute figures were also much raised, and attained values (20,400 for example) which are by no means frequent even in leukæmia.

Brown regards this astonishing phenomenon as pathognomic for trichinosis, so much so, that in a case that was clinically obscure, he made, from the marked eosinophilia, the diagnosis of trichinosis which was later fully confirmed.

5. =Post-febrile form of eosinophilia= (after the termination of various infectious diseases). In the section on polynuclear neutrophil leucocytosis we have already mentioned that at the height of most of the acute infectious diseases, with the single exception of scarlet fever, the eosinophils undergo a relative decrease and may even entirely disappear. In the post-febrile period, however, abnormally high values for the eosinophil cells are often found, or even a well-marked eosinophil leucocytosis, which generally attains but moderate degree. Türk for example in pneumonia found a post-critical eosinophilia of 5.67% (430 absolute), after acute articular rheumatism 9.37% (970 absolute); Zappert in malaria, one day after the last attack 20.34% (1486 per mm.^{3}).

The eosinophilia observed as the result of tuberculin injections, we include, in agreement with Zappert, in the group of post-febrile leucocytosis. For it appears only after considerable rises of temperature. During the real reaction period the number of eosinophil cells sinks, and only goes up again after the termination of the fever. The rise may be very considerable. In one case of Zappert's the number of the oxyphils increased to 26.9%; in another of his cases the highest absolute figure formed after tuberculin injections was 3220 per mm.^{3} In a case of Grawitz' the eosinophilia was quite extraordinary. The most marked changes in the blood occurred some three weeks after cessation of the tuberculin injections, of which eight altogether (from 5 mg. to 38 mg.) were given. Investigation shewed 4,000,000 red blood corpuscles per mm.^{3}, 45,000 white. Amongst the latter there were ten eosinophils to one non-eosinophil. The total number of eosinophil cells amounted to some 41,000 per mm.^{3}, whilst the other cells as a whole made up some 4000. Inasmuch as the latter contained polynuclears, lymphocytes and other forms, it follows that in this case the polynuclear neutrophils must have been very much decreased, not only relatively but also absolutely; so that this case represents precisely the contrary condition to ordinary leucocytosis and the infectious form in particular.

6. =In malignant tumours.= In the cachexia from tumours an increase of the eosinophil cells has been observed by various authors. It is however of moderate degree and does not exceed 7-10%. Out of 40 decided cases Reinbach found the eosinophils increased only in four, in a case of sarcoma of the forearm he found 7.8%; of the thigh 8.4%; malignant tumour of the abdomen 11.6%. Besides these he describes a case of lymphosarcoma of the neck with metastases in the bone-marrow, in which an unexampled increase of the white blood corpuscles, and especially of the eosinophil cells was found. The absolute number of the latter amounted on one day to some 60,000! This is an increase of 300 fold the normal, which apart from leukæmia has doubtless never before been found.

7. =Compensatory eosinophilia= (after exclusion of the spleen). We have entered in detail into this form in the chapter on splenic function; and have there already mentioned that the increase of the eosinophils found in chronic splenic tumours by Rieder, Weiss and others, must also be referred to the exclusion of the splenic function.

8. =Medicinal eosinophilia.= Under this group occurs only a single observation of v. Noorden's, who observed the appearance of an eosinophilia up to 9% in two chlorotic girls after internal administration of camphor. In other patients this occurrence did not repeat itself. But probably researches specially directed to this province of pharmacology would bring to our knowledge many interesting facts.

On the origin of ~polynuclear eosinophil leucocytosis~ authors have put forward various theories, which we will here critically discuss in succession.

An experiment frequently quoted as explanatory is that of Müller and Rieder's; these authors do not derive the eosinophil cells of the blood from the bone-marrow, but assume, as very probable, that the finely granular cells grow into eosinophils within the blood-stream. This developmental process seems very improbable for many reasons. Since the polynuclear cells circulating in the blood are all under the same conditions of nutrition, it is _à priori_ inconceivable why only a relatively small portion of them should undergo the transformation in question. And it is quite inexplicable why in infectious leucocytosis, where the number of the polynuclears is increased so enormously, their ripening to the eosinophils should remain completely interrupted.

But the fact, that a transition from neutrophil to oxyphil cells has never really been observed in the blood, is decisive evidence against the hypothesis of Müller and Rieder. Were the hypothesis true, transitional stages ought to be found with ease in every sample of normal blood. Rieder and Müller themselves are unable to bring forward any positive result of this kind, else they would hardly have been contented to fall back on the authority of Max Schultze, who professed to shew the transitional forms between the finely and coarsely granular leucocytes in the circulating blood. The authority of Max Schultze in morphological questions stands high, and very rightly; but one ought not to rely upon it for support in problems that are really histo-chemical, and which should be solved by their appropriate methods.

As a logical consequence of their view, and in decided opposition to Ehrlich, Müller and Rieder assume that the eosinophil cells of the bone-marrow "are far rather the expression of a storage than of a fresh formation there. =The bone-marrow therefore should be regarded in reference to the coarsely granular cells of the blood more as a storage depôt, where these cells serve other purposes, which for the present cannot be more closely defined.="

The chief reason for this assumption, these authors see in the fact, that the majority of the eosinophils in the bone-marrow are mononuclear, whilst those of normal blood possess a polymorphous nucleus. Müller and Rieder should themselves have raised the obvious objection that the same holds good for the nucleus of the neutrophils. They would then have seen the fault in their theory; for according to it the most important blood preparing organ constitutes as it were, not the cradle of the blood cells, but their grave. The simplest and readiest explanation, based too upon histological observation, is surely this: that the mononuclear eosinophil cells grow into polynuclear in the bone-marrow, but that the latter only reach the blood by means of their power of emigration. As this view has been accepted by the great majority of authors since Ehrlich's paper "On severe anæmic conditions," we believe we may content ourselves with the above objections to the Müller-Rieder theory, although it has even quite recently found supporters (_e.g._ B. Lenhartz). H. F. Müller moreover in his paper on bronchial asthma (1893) takes a position different from his earlier, and approaching that of Ehrlich.

In considering the production of polynuclear eosinophilia we may best start from an experiment of E. Neusser's. Neusser found in a pemphigus patient, whose blood shewed a considerable increase of the eosinophils, that the contents of the pemphigus bulla consisted almost entirely of eosinophil cells. Neusser now produced a non-specific inflammatory bulla in the skin by a vesicant, and found that the cellular elements in it were exclusively the polynuclear neutrophil concerned in all ordinary inflammations.

Exactly analogous conditions, occurring spontaneously, have been demonstrated by Leredde and Perrin in the so-called Dühring's disease. The bullæ which appear in this dermatosis contain, so long as their contents are clear, chiefly polynuclear eosinophil cells. In a later stage, as is usually the case, bacteria effect an entrance into the bullæ, which now become filled with neutrophils.

According to modern views on suppuration, the experiment of Neusser and the observation of Leredde and Perrin can only be explained by the hypothesis, that the eosinophil and neutrophil cells, as we have already several times mentioned, are of different chemiotactic irritability. Hence the eosinophil cells only emigrate to those parts where a specific stimulating substance is present. From this point of view experiments and clinical observations known up to the present on eosinophilia may be readily explained. Neusser's experiment for instance may be explained in the following way. In the pemphigus bullæ a substance is present that chemiotactically attracts the eosinophils. Hence the cells normally contained in the blood emigrate into them, and produce the picture of an eosinophilous suppuration. Should the disease assume from the first a localised distribution only, the essential feature of the process is excluded. =A totally different appearance, however, is produced= when the disease has attacked large areas. =Under these circumstances large amounts of the specific active agent reach the blood-stream by absorption and diffusion. Here it exercises a strong chemiotactic influence on the physiological storage depôt of the eosinophils, the bone-marrow; leading to an increase of the eosinophils of the blood to a greater or less degree. The bone-marrow, according to general biological laws, is by the increased emigration now further stimulated to a fresh production, and during a protracted illness can hence keep up the eosinophilia.=

In this way other clinical observations may be explained. Gollasch has found that the sputum of asthmatic patients contains, in addition to Charcot-Leyden's crystals, eosinophil cells only. One must therefore assume that within the bronchial tree there exists material which attracts the eosinophils. This supposition is also supported by the close connection that obtains, according to many observations, between the severity of the disease and the eosinophilia. Thus v. Noorden records that the eosinophil cells are more numerous about the time of an attack. They accumulated in especially large numbers after attacks had rapidly occurred several days in succession. =That the increase of the eosinophil cells in this instance is directly connected with the attacks, and is not the expression of a permanent constitutional anomaly=, is shewn by a case in which v. Noorden found 25% eosinophils during the attack, and a few days later could only observe one example in twelve cover-slip preparations: a diminution therefore of this group of cells.

The observations of Canon in skin-diseases are quite similar, for he shewed that the extension of the disease determines the degree of eosinophilia more than its intensity. And it is the former factor which directly determines the quantities of the specific agent that pass into the blood.

To the Müller-Rieder hypothesis, and the chemiotactic theory of eosinophil leucocytosis a third has lately been added, which may be shortly called =the hypothesis of the local origin= of the eosinophil cells. A. Schmidt has, with special reference to asthma, raised the question "whether in the extensive production of eosinophil cells in asthma, local production in the air passages is not more probable than origin from the blood. One may well regard the increase of the eosinophil cells in the blood of an asthmatic as secondary." This view, which has also been advocated by other authors, rests more particularly on the following facts and considerations:

1. That in various diseases of the nose, especially in mucous polypi and hyperplasia of the mucous membrane (Leyden, Benno Lewy and others), a great accumulation of eosinophil cells is found in these tissues, whilst they are apparently not increased in the blood. This objection is easily laid aside from the chemiotactic point of view. For if in the places in question substances are present which act chemiotactically on the eosinophil leucocytes, in the course of time marked accumulation must occur, without an increase of their number in the blood. One might as well conclude from Neumann's experiment in lymphatic leukæmia, for example, where the artificial suppuration consisted only of polynuclear neutrophil cells, that the polynuclear cells were formed in the tissue, since in the blood they were present in very small percentage. For in this case too the same incongruity between the blood and the particular tissue exists.

2. Adolph Schmidt has urged the converse argument. He shewed that in the sputum of patients with myelogenic leukæmia no more eosinophil cells were present than are commonly to be found in the bronchial secretion, although the blood was unusually rich in eosinophil cells. In our opinion however this observation does not support the hypothesis of local origin, but on the contrary is clear evidence that not the larger or smaller number of eosinophil cells in the blood decides their emigration, but the presence of specifically active chemical stimuli. For we know from our observations on leucocytosis in infectious diseases that the bacterial stimulating substances act on the eosinophil cells rather in a negative than in a positive sense. And if ordinary sputum is not rich in eosinophils in spite of a marked eosinophilia of the blood, this only corresponds to our experience in general. Indeed, this phenomenon is quite similar to Neusser's pemphigus experiment, where the specific foci of disease shewed an eosinophilia, whilst abscesses produced artificially, on the contrary, only neutrophil cells. Finally we may employ, to support our view, another analogous experiment of Schmidt himself. He found numerous eosinophil cells in the sputum of an asthmatic patient, but only neutrophil cells in an artificially produced suppuration of the skin.

Thus we see that the chief reasons brought forward by the supporters of the theory of local origin are not proof against the most obvious objections that can be raised from the chemiotactic standpoint. Moreover, neither histological nor experimental proof has been given for this theory in spite of numerous investigations in this direction. All the same, it should not be out of place to explain the possibilities that are given for a local origin of the eosinophil cells. First, the eosinophil cells might be the result of a progressive metamorphosis of the normal tissue cells. That such a process is possible, is proved by the local origin of the mast cells. These may arise, as Ehrlich and his school have always assumed, by transformation of pre-existing connective tissue cells[29]; but that the same holds good for the eosinophil cells as well, has nowise as yet been proved. Secondly, it is conceivable, that isolated eosinophil cells, pre-existing in the tissues, should rapidly multiply, and so produce the local accumulation only. Numerous mitoses could be considered an adequate proof of this process. But so far no figures of nuclear division have been observed; indeed A. Schmidt, who has directed special experiments thereto from the standpoint of his theory, has found them entirely absent.

As a =third= possibility for the local origin of the eosinophil cells, their direct descent from neutrophil cells is conceivable, and is by many regarded as a kind of ripening. This assumption nevertheless must be described as unsound, since the necessary condition of its foundation, namely the observation of corresponding transitional stages, has not so far been fulfilled.

By the inductive method then we conclude that a local origin of the eosinophil cells can hardly come under discussion. And this conclusion is strengthened by comparison with the behaviour of the mast cells, which are related to the eosinophils in many points, and only differ from them essentially in the nature of their granulation. The mast cells too, like the eosinophils, form a normal constituent of the bone-marrow, and occur regularly besides in normal blood, though in very small number--according to Canon they amount to 0.28% of the leucocytes. We know that the mast cells are produced in large quantities locally, wherever an over-nutrition of the connective tissue occurs, for instance in chronic diseases of the skin, elephantiasis, brown induration of the lungs. In the case of the mast cells, then, we see the conditions actually realised, which the supporters of the theory of the local origin of the eosinophil cells only assume. We should therefore expect that an increase of mast cells in the blood or in certain inflammatory exudations would be by no means seldom. With this point in mind Ehrlich has subjected the sputum in emphysema and brown induration of the lungs to exact examination for 20 years. Nevertheless he has obtained =entirely negative= results. The special blood investigations of Canon have likewise proved to be practically negative. In 22 healthy persons Canon entirely failed to find the mast cells on nine occasions, in the others he found on the average 0.47%; the highest percentage number obtained was 0.89%. Only in a few cases of skin disease was a slight increase indicated. The average amounted to 0.58%, a number, therefore, which is often to be found in healthy individuals. A leucocytosis of mast cells, comparable with the eosinophil or neutrophil forms of leucocytosis, has not been demonstrated in the cases of Canon or other observers. On the other hand, the mast cells undergo a considerable increase in myelogenic leukæmia, in many cases equalling or even exceeding that of the eosinophils. We shall not err in deriving the mast cells of the blood solely from the bone-marrow, on the grounds of this fact; or in conjecturing that their origin is not from the connective tissue, even when they are there excessively increased[30].

We think we have shewn in the preceding paragraphs that the evidence, so far brought forward for a local origin of the eosinophil cells, does not withstand the objections that have been raised. The task now lies before us, to produce positive proof that the accumulations of eosinophil cells in the organs and secretions must be explained by emigration from the blood.

This proof offers great difficulties in as much as we normally find eosinophil cells in many places. Here then we cannot trace a process step by step, but we have to deal with final conditions. Could we observe the genesis of eosinophil cells in organs usually free from them, it would be easier to clear up this question. Up to the present but a single observation on this point is available. Michælis established the interesting fact, that on interrupting lactation in suckling guinea-pigs, in the course of a few days numerous eosinophil cells collect in the mammary glands, but not in the lumen of the canaliculi. The eosinophil cells are further polynuclear, exactly corresponding to those of the blood, and therefore to be regarded as immigrants. We may explain this condition according to modern views as follows. Under certain conditions the mammary gland is capable of an internal secretion, by means of which substances are produced that are specifically chemiotactic for the eosinophil cells. When the external secretion of milk is disturbed, the internal secretion is abnormally increased. The fact too that in Michælis' researches no eosinophil cells passed into the true secretion of the gland may be thus explained[31].

Exactly similar observations have been made on pathological material, first recorded in the brilliant and fundamental work of Goldmann. In a case of malignant lymphoma Goldmann found a considerable accumulation of eosinophil cells within the tumour, and demonstrated anatomically, that it was brought about by an emigration of the cells from the vascular system. Hence Goldmann concluded that the eosinophil cells pass over into the tissue in question, at the call of certain chemiotactic products. Goldmann, and later Kauter, shewed that these eosinophil cells were not merely due to an ordinary inflammation; for in a large number of other diseases of the lymph glands--particularly the tuberculous, they were entirely absent. Similarly Leredde and Perrin have shewn in their investigations of Dühring's disease, that the eosinophil cells, which are also present in the cutaneous tissue in large numbers, apart from the contents of the bullæ, are due to an emigration from the blood-stream.