350 LEUKEMIA 



1. Lymphocyte leukemia. 



2. Leukocyte leukemia. 



Since the source of the lymphocytes, as has been mentioned, is the spleen 

 and the lymph-glands, and that of the leukocytes is the bone-marrow, the 

 common designations of lymphatic leukem,ia (lymphemia) and myelogenous 

 leukemia (myelemia) may be selected for these two basic forms of leukemia. 

 As, however, the bone-marrow also normally produces typical lymphocytes, 

 and as it has been determined in rare cases that an over-flooding of the blood 

 with lymphocytes may occur by proliferative changes in the marrow without en- 

 largement of the spleen and lymph-glands (myelogenous lymphemia), I pre- 

 fer the less prejudicial division of the leukemic forms into "lymphocyte leu- 

 kemia " and " leukocyte leukemia." 



In the blood at the autopsy, or after prolonged standing of the blood of 

 leukemics, Charcot's crystals are found, usually within the leukocytes, and par- 

 ticularly in the eosinophilic polynuclear cells. Their relation to the last- 

 named cells has lately been determined beyond doubt, so that we' may say : 

 Wherever eosinophile cells are present in large numbers, Charcot's crystals are 

 also found. This at once makes it clear that they are absent in lymphocyte 

 leukemia, and, on the other hand, that the crystals are not only found in leuko- 

 cyte leukemia but in all diseases in which eosinophiles occur in large numbers, 

 nasal polypi, bronchial asthma, etc. The demonstration of Charcot's crystals 

 is, therefore, by no means pathognomonic of leukemia, the less so as they are 

 also found in normal bone-marrow, which is not to be wondered at. 



In comparison with the results of the microscopic examination of the 

 blood, all the other morbid phenomena of leukemia are of decidedly subordi- 

 nate importance, even though in the individual case they greatly aid in the 

 diagnosis. There are cases of leukemia in which, besides the alteration in 

 the blood and the symptoms of anemia in connection therewith, all other 

 objectively demonstrable morbid phenomena are absent, and the diagnosis must 

 be made entirely from the blood findings ! These are, however, under all 

 circumstances, as will be shown later, rare and exceptional cases; the rule is 

 that many organs, especially those connected with blood-formation, suffer 

 marked changes which may be demonstrated by physical examination. 



In this connection we must mention particularly the enlargement of the 

 spleen which is present in the majority of cases of leukemia. The splenic 

 tumor is usually of considerable size; it extends to the median line or beyond 

 and downward to the hypogastric region. On account of its sharp indented 

 margin, the direction of the growth of the tumor, and especially its evident 

 origin from the left hypochondrium, there is rarely cause to doubt that we are 

 dealing with a tumor of the spleen. The diagnosis may be difficult if, as in 

 one of my cases, the large spleen turns so that the hilus appears at the top. 

 The consistence of the splenic tumor is hard ; its circumference, after it has 

 attamed a certain size, is usually constant. Rarely transient shrinkages are 

 noted, or, on the other hand, excessive swelling or rupture of the organ. As 

 a rule the swollen spleen is not sensitive to palpation, and the subjective diffi- 

 culties which the tumor causes are generally slight. At most the patients 

 complain of a feeling of fulness in the abdomen and slight difficulty in respira- 



