SYMPTOMS AND BLOOD-CHANGES 353 



ized by an extremely tortuous condition of the veins, a band-like opacity of 

 the retina, and hemorrhages into the same, as well as by opacity, indistinct 

 contours and bluish-yellow color of the optic nerve papilla. Not rarely the 

 veins are accompanied by white streaks, and white areas intermixed with hem- 

 orrhages are visible in the macula; the hemorrhages are circular in shape, 

 with a prominent yellowish-white center. Occasionally there is a tendency to 

 the development of numerous large hemorrhages which may also occur in the 

 vitreous body, so that the ophthalmoscopic picture may resemble that of 

 thrombosis of the central vein of the retina. Such a thrombosis may occur 

 simultaneously with hemorrhages around the optic nerve and in the latter 

 itself, and may also develop in the orbital portion of the optic nerve. Func- 

 tional disturbances are present to only a slight extent. 



The changes in the urine observed in leukemia are of great importance 

 in diagnosis, as well as in the study of the disease. 



Apart from the occasionally observed albuminuria, which is in part the 

 result of the anemia, in part the consequence of lymphomatous infiltration of 

 the renal substance (which is indicated by the presence of casts and of a large 

 number of leukocytes in the sediment of the urine), a change in the excretion 

 of the solid constituents of the urine is more or less frequently found in leu- 

 kemia. An absolute and relative increase of the excretion of uric acid (up to 

 8 grams per diem) has been almost invariably observed. 



This increase of uric acid in leukemia is certainly not, as was formerly 

 supposed, the result of insufficient oxidation in the organism. This opinion 

 is contradicted not only by the results of the investigations of Pettenkofer and 

 Voit, but also by the fact determined by Stadthagen, that in the body of the 

 patient suffering from leukemia the sodium urate which has been administered 

 per OS is capable of further oxidation. Neither can the excessive production 

 of uric acid be considered due to the enlargement of the spleen commonly 

 present in leukemia, as patients with chronic splenic tumor excrete uric acid 

 in normal amounts in contrast to leukemia with enlargement of the spleen, 

 in which the excretion of uric acid is markedly increased. As we know now 

 that uric acid originates from the nuclein which is liberated in the decompo- 

 sition of the cellular nuclei, especially by oxidation of alloxur bases which are 

 contained in nucleinic acid, the conclusion is obvious that the increase of uric 

 acid excretion in the course of leukemia may be referred to the destruction of 

 a relatively greater number of leukocytes than under normal conditions. How- 

 ever, the increased excretion of uric acid may also be an expression of in- 

 creased function, that is, of metabolism of the superfluous leukocytes, so that 

 an increase of uric acid excretion in the course of leukemia is by no means a 

 proof of great decomposition of leukocytes and their nuclei. 



The excretion of wrea usually does not differ from the normal; in two 

 cases of severe leukemic cachexia in my clinic Fleischer and Penzoldt noted 

 an increase of urea excretion, but this was in the late stages of leukemia, when, 

 as in carcinomatous cachexia, a marked decomposition of organic albumin 

 with increase- of the excretion of nitrogen occurs. Hematuria is also observed 

 in the course of leukemia. 



This symptom is connected with the general hemorrhagic diathesis of the 

 24 



