SYMPTOMS AND BLOOD-CHANGES 355 



leukocytes. N'ucleated red blood cells and megaloblasts, although found in 

 the blood in lymphocyte leukemia, yet, compared with their usual abundance 

 in leukocyte leukemia, are by no means prominent. 



According to the course of the affection, two varieties must be differen- 

 tiated, the acute and the chronic. 



Acute lymphocyte leuheinia {"acute hjmphemia"), the recognition of 

 which we owe above all to Ebstein and A. Fraenkel, is characterized by its 

 rapid, often febrile, course, resembling a severe infectious disease. Besides the 

 usually insignificant enlargement of the spleen and lymph-glands, the other 

 clinical phenomena of leukemia are present, stomatitis, retinitis, etc. Most 

 prominent in the clinical picture is the hemorrhagic diathesis, so that the 

 affection has the appearance of purpura hemorrhagica and may be confounded 

 with this, all the more so as the hemorrhages occasionally occur before the 

 characteristic blood picture of acute lymphemia is formed. The blood picture 

 itself is highly characteristic: Preponderance of the lymphocytes, especially 

 of the large ones, very rarely of the smaller, with a vesicle-like, sometimes 

 deeply indented nucleus; erythroblasts are present although few in num- 

 ber ; the polynuclear cells are not only relatively but also absolutely decreased. 

 The number of white blood cells compared to the red ones may be extraordi- 

 narily great (up to 1 to 1 !). [In the majority of cases, however, it is not 

 excessive — much less than in myelogenous cases. — Ed.] The affection may 

 terminate fatally in a few days or a few weeks. 



Chronic lymphocyte leukemia is differentiated from the above-described 

 form by its greatly protracted course : Gradual enlargement of the lymph- 

 glands, especially those of the neck, also enlargement of the spleen to a greater 

 or less extent. In rare cases, even in a very chronic course (in one case 

 under my observation the affection lasted at least two years), only insignificant 

 enlargements of the glands appear. The lymphoid hyperplasia of the bone- 

 marrow is present here, as in the acute form. The hemorrhagic diathesis is 

 also quite marked in the chronic form of leukemia, and as consequences of 

 anemia there may be a great variety of symptoms, such as dilatation and 

 insufficiency of the heart, etc., which may threaten life. The blood picture 

 in the main resembles that of the acute form, i. e., mononuclear lymphocytes, 

 but usually the small forms are most prominent, whereas the other colorless 

 blood cells are almost absent. Large lymphocytes are also found in chronic 

 lymphocyte leukemia during the entire course of the affection, and in rare 

 cases, as in the acute form, they may even dominate the blood picture. 



2. Leukocyte leukemia, by far the most frequent form of leukemia, may 

 be easily differentiated from both of the last-mentioned varieties of leukemia by 

 its entirely different blood picture. The increase of the white blood cells is 

 usually very marked; here, however, the polymorphonuclear leuhocytes are 

 greatly increased in the microscopic picture: neutrophiles, and, above all, 

 eosinophilic polynuclear cells are, as Ehrlich has found, always ahsolutchj in- 

 creased. There is invariably an absolute increase of the mast-cells which occa- 

 sionally are twice as numerous as the eosinophiles, and their determination is 

 of great importance in a diagnostic respect because a marked increase of the 

 mast-cells is only observed in leukemia. [The absence of mast-cells was espe- 



