358 LEUKEMIA 



teacher noticed, he was sent home. From May 3d to May 6th he still took 

 his food with appetite; then, four days before his death, epistaxis occurred, 

 with yellow discoloration of the skin ; pain in the nape of the neck and tooth- 

 ache appeared, as well as pain in the epigastrium. In the course of the day 

 severe apathy became more and more noticeable, increasing to complete loss 

 of consciousness, so that the patient was brought by his relatives to the Julius 

 Hospital. 



Status prcEsens: The appearance of the patient denoted serious illness; 

 skin and mucous membranes deathly pale ; eyelids and hands markedly edema- 

 tous; the skin over the rest of the body slightly bloated, showing yellow 

 discoloration but not jaundice; conjunctivaj snow-white. Coma. !N^o opis- 

 thotonus, no rigidity of the neck and no spasms. Pupils dilated, reacting 

 normally. Liver and spleen moderately enlarged and hard; sensitive to pres- 

 sure. The muscles of the calves of the legs not especially sensitive to pressure, 

 but the bones of the thigh as well as the sternum extraordinarily so. Lungs 

 normal. The cardiac dulness extended to the right sternal border; heart 

 sounds clear; gallop rhythm, undulation of the veins of the neck. Urine 

 contained traces of albumin; no albumoses, no casts. The ophthalmoscopic 

 examination showed feeble filling of the vessels, especially of the arteries, 

 which were mere threads — "marantic thrombosis of the central artery with 

 numerous disseminated hemorrhages." Temperature 102° F. to 104° F. 



As the symptoms of extraordinary impoverishment of the blood were 

 present, besides a slight enlargement of the liver and spleen, the diagnosis 

 was set down as "severe anemia." On account of the edema of the skin 

 and the presence of albumin in the urine, a nephritis was at first thought 

 to be the cause. This assumption, however, was dropped when it was found 

 that only traces of albumin, but neither blood cells nor epithelium, nor even 

 casts, were present. An acute infection seemed much more likely, and the 

 rapid course of the disease, the severe disturbance of the general condition, 

 the high fever, the enlargement of liver and spleen and the albuminuria were 

 in favor of this. Yet the clinical picture did not correspond to any of the 

 usual infectious diseases. It was obvious that only an exact examination 

 of the blood would clear away these diagnostic difficulties. 



The blood count showed an excessive diminution in the number of eryth- 

 rocytes: 256,000 per c.mm. ! The blood-corpuscles varied in size (with some 

 megalocytes), and the triacid stain showed that some red corpuscles contained 

 nuclei: N'ormoblasts 76, megaloblasts 152, in a c.mm. The amount of hemo- 

 globin of the entire blood was not more than 10 per cent., the hemoglobin 

 contents of the individual blood-corpuscles (color-index) was therefore rela- 

 tively increased. 



The absolute number of white blood cells was scarcely increased, 10,600, 

 though when compared with the total number of the erythrocytes it seemed 

 high, 1:24. The morphology of the leukocytes and the proportion of the 

 individual leukocyte varieties to each other deviated greatly from normal con- 

 ditions, so that the blood picture resembled that of leukemic blood. Besides 

 the usual neutrophilic, polynuclear leukocytes which were present in dimin- 

 ished amounts (4,680), many myelocytes were seen (1,380 neutrophiles and 



