372 PSEUDO-LEUKEMIA 



several weeks or even months does it become noticeable. By this time the 

 individual gland has attained the size of a cherry or a small walnut, or a 

 group of swollen glands has become conspicuous to sight and touch. 



The swellings are painless. After a latent period of varying duration 

 they begin to increase following a definite course next to be described. First, 

 more glands are involved, usually those in the neighborhood of the one first 

 affected, i. e., those in the lower part of the neck or in the back of the neck, 

 later those in the axilla, at the elbow, in the inguinal region, occasionally those 

 in the popliteal space. Next comes an increase in the size of the individual 

 glands, which may become as large as a man's fist or even larger. The glands 

 of the neck and axilla, which are those first affected, are always most advanced 

 in growth, while those of the inguinal region and of the thigh are less mark- 

 edly enlarged. 



The enlarged glands can usually be felt and defined with ease; in other 

 cases they are more or less matted together; they are more frequently soft 

 than hard in consistence, and in many cases they may be readily 'moved about. 

 As a rule the skin above the glands can easily be raised, but shows no other 

 change. The spleen, as has been said, in this form of pseudo-leukemia, Hodg- 

 kta's disease, is almost always implicated, but to a much less degree than the 

 glands, so that its enlargement cannot always be determined with certainty 

 during the life of the patient. 



Add to these facts the vista of a gradual increase in the glandular enlarge- 

 ment, while almost exactly in proportion to this the general condition of the 

 patient deteriorates so that he becomes anemic, loses his strength and emaciates, 

 and we are in possession of the most important features of the clinical picture. 



But in these outlines the entire symptom-complex is by no means revealed. 

 Indeed it may be very complicated. 



The symptoms are in part purely local consequences of the existence of 

 the tumors, and hence depend particularly npon the pressure which these 

 glands exert, or upon the metastases which they produce. But there are other 

 symptoms of a general nature, which result partly from the anemia and 

 cachexia, partly from the actual nature of the disease which is wholly unknown 

 to us. 



Before recounting the symptoms I must add that, besides the glandular 

 enlargements which are externally visible and palpable, there is almost in- 

 variably an enlargement of the internal lymph-glands, those of the thoracic 

 and abdominal cavities. These internal glands are sometimes large, some- 

 times small and therefore not always clinically recognizable. Cases do occur 

 in which only the internal lymph-gland's are enlarged, the external ones -not 

 at all or to an exceedingly slight degree. I have myself seen a very remark- 

 able case of this type, to which I shall recur later. We must admit' that such 

 cases are not likely to be diagnosticated clinically ; the pathologist designates 

 them as multiple lymphomata or as lymphomatosis, the same title given by him 

 to the external enlargements which occur in Hodgkin's disease. 



It is these internal glandular enlargements which bring about the most 

 severe pressure phenomena, especially in the thorax where there is less room 

 for growth than in the abdominal cavity. Enlarged glands in the anterior 



