SYMPTOMS AND BLOOD-CHANGES 361 



formation of the red as well as of the white cells, so that the embryonic forms 

 of the red and white cells did not come to maturity. These cells, i. e., of the 

 (nucleated) normoblasts and megaloblasts as well as of the myelocytes,' appear 

 to have emigrated into the blood before their transformation into normal, 

 finished blood cells could be completed. 



Another striking feature of the case was that (besides the neutrophilic 

 or eosinophilic granular myelocytes) non-granular myelocytes and even, what 

 is more conspicuous, non-granular polynuclear cells could be demonstrated 

 with certainty in the circulating blood — a fact that may perhaps be explained 

 by supposing that in this rapid and abbreviated hematopoietic process not 

 even granulation could take place, much less complete maturity of the leuko- 

 cyte forms produced in the bone-marrow. 



While the individual points in the blood picture of our case which have 

 been described up to this time can be brought into genetic connection only 

 with a severe damage in the function of the bone-marrow, this source of 

 disturbance of the blood formation is questionable because of the remarkable 

 relative increase of the lymphocytes in the blood (40 per cent, of lymphocytes 

 compared with 44 per cent, of polynuclears). 



We might at first suppose the latter to be only an expression of the mark- 

 edly diminished production of the polynuclears in the bone-marrow, i. e., a 

 relative increase of the lymphocytes because the formation of polynuclears in 

 the bone-marrow is reduced, while that of the lymphocytes in the spleen and 

 lymph-glands continues unhindered — and this corresponds to the important 

 fact which Strauss determined — the relative increase of the lymphocytes in 

 pernicious anemia. The circumstance that 35 per cent, of large, and only 

 5 per cent, of small, forms were found in the blood is opposed to this view. 

 Therefore a disturbance in the formation of lymphocytes must in this case 

 be assumed. It has lately been regarded as certain that lymphocytes are nor- 

 mally produced not only in the spleen and in the lymph-glands but also in 

 the bone-marrow; hence it appears rational to hold the damaged function 

 of the bone-marrow responsible also for the disturbance in lymphocyte forma- 

 tion which, in our case, no doubt existed. But, in my opinion, this is im- 

 possible, since the lymphocytes in the bone-marrow, examined post mortem, 

 were very few, while, in contrast, the tissue fluid taken from the spleen one 

 hour after death contained profuse amounts of large and small lymph-cells. 

 It appears to me, therefore, that any other view than the following would be 

 forced, namely, that the increase of lymph-cells in the hlood was due to a 

 greater formation of these cells in the spleen. This idea is the more plausible 

 since the lymph-glands in our case were everywhere absolutely unchanged. 



The results of the analysis in this case may, therefore, be summarized 

 as follows: 



A simple pernicious anemia was not present, in spite of the fact that the 

 blood showed the characteristic changes of pernicious anemia in the hemoglo- 

 bin-containing cells circulating in the blood, the erythrocytes. Against perni- 

 cious anemia was the enormous production of myelocytes and their transporta- 

 tion into the blood, the scanty presence of megaloblasts in the bone-marrow, 

 and the absence of siderosis of the liver. But the diagnosis of leiTkemia does 



