SYMPTOMS AND BLOOD-CHANGES 351 



tion; less frequently pain occurs in the splenic region, or even inflammatory 

 phenomena which manifest themselves in peritoneal friction sounds in this area. 



In some of the cases, most frequently in lymphocyte leukemia, lym,p]i- 

 gland enlargement occurs. [I have never seen lymph-gland enlargement ex- 

 cept in lymphocyte leukemia.— Ed.] As a rule, the glands of the neck and 

 axillary region, more rarely those in other areas of the periphery or the inter- 

 nal lymph-glands, are afEected. The glandular tumors are moderately hard, 

 the skin covering them is movable and not reddened. If the mesenteric and 

 retroperitoneal glands are hyperplastic, they may be occasionally felt through 

 the abdominal walls. In case the enlargement affects the tracheal and bron- 

 chial lymph-glands, at least a probable diagnosis of this result of the leukemia 

 may be made, provided the symptoms of tracheal or bronchial stenosis, of 

 paralysis of the vocal cords, the result of pressure upon the recurrent laryn- 

 geal nerve, or difficulty in deglutition, arise. In marked cases of swelling 

 of the tracheo-bronchial lymph-glands or of the persisting thymus gland, the 

 percussion note over the manubrium is dull and the bone is arched outward. 

 In the adenoid tissue of the tonsils and also in the adenoid follicles at the root 

 of the tongue hyperplasia and swelling may likewise be noted. 



Besides the spleen, the various lymph-glands, and the other adenoid organs, 

 the hone-marrow is almost always afEected by anatomical changes. Accord- 

 ing to the experiences gathered up to this time, changes in the bone-marrow 

 are invariably present in leukemia. In lymphocyte leiikemia we find, espe- 

 cially in the lymph-glands, in the spleen and eventually in the liver, but 

 invariably also in the bone-marrow, proliferations of the lymphoid tissue, 

 which in these cases may become so plentiful that the production of the poly- 

 nuclear cells in the bone-marrow and the passage of the same into the blood 

 may be prevented by the overgrowth of the lymphocytes in the marrow. As 

 soon as the lymphocytes begin to enter the blood, floating in from the bone- 

 marrow, hyperplastic lymph-glands and spleen (quite passively as we must 

 assume from Ehrlich's convincing deductions), the picture of lymphocyte leu- 

 kemia develops. 



The implication of the bone-marrow in the leukemic processes can never 

 be determined with certainty intra vitam by the sensitiveness of the bone to 

 pressure, but only when the microscopic examination reveals in the circulating 

 blood mononuclear, granular marrow cells, the origin of which from the bone- 

 marrow is certain, and also large quantities of nucleated red blood cells. 



Besides the three above-named organs which are particularly affected in 

 leukemia, other portions of the body, although less frequently, are involved in 

 changes which are in direct relation to leukemia. In the majority of cases 

 the liver, in consequence of leukemic-cell infiltration between the acini, is 

 enlarged. The surface is smooth, its consistence moderately hard. Marked 

 grades of ascites and jaundice are only to be expected if the periportal lymph- 

 glands are enlarged and press upon the portal vein and biliary passages. As- 

 cites, that is, the transudation of a large amount of fluid into the peritoneal 

 cavity, may also be caused by a leukemic nodular infiltration of the peritoneal 

 layers'and of the omentum. This is, however, not frequent. 



Leukemic infiltrations occur also in the stomach and intestine; they arise 



