376 PSEUDO-LEUKEMIA 



The ratio of white cells to red cells which is set up as a limit (namely, 1 to 

 200 or 1 to 100) allows wide space for variations in individual opinions; 

 indeed, such a ratio is often found in well-recognized cases of leukemia. 



Further, it is not easy to determine during life that the glandular enlarge- 

 ment actually depends upon lymphadenoid proliferation. Even if an en- 

 larged gland is extirpated, and these proliferations are found in it, we cannot 

 conclude with certainty from this that in all the other enlarged glands the 

 same changes, and only these, are present, and that the condition is not due 

 in part to other processes, particularly tuberculosis, a combination which has 

 been actually observed (Askanazy, Fischer, Freud weiler and others). Fur- 

 ther, the blood conditions designated as characteristic by Ehrlich and Pinkus, 

 an increase of lymphocytes without much if any increase of the leukocytes is 

 not constant, a fact of which I have convinced myself in at least one case after 

 prolonged observation. The proportion of the mononuclear to the polynuclear 

 leukocytes varies, and for a time may be even normal. The increase in l5mipho- 

 cytes is not always present from the onset. Finally, I do not believe that we 

 can exclude the possibility of finding the blood-picture required by Ehrlich 

 and Pinkus, in connection with glandular enlargements which do not show 

 the pure leukemic character, i. e., with tuberculosis or sarcomatosis of the 

 glands, and especially with the complicated or mixed forms previously men- 

 tioned. [The Ehrlich-Pinkus formula certainly is not present in every case 

 of pseudo-leukemia — and is not at all uncommon in other diseases — e. g., in 

 debilitated and neurasthenic conditions, in variola, in some syphilitic cases, 

 and in some acute septic enlargements of the lymph-glands. — Ed.] 



The greatest difficulty is always experienced in the differentiation of tuber- 

 culosis of the lympli-'glands from true lymphomata, and it is rarely possible 

 (except when a gland has been extirpated and examined) to decide this ques- 

 tion with certainty. As points of support for a prohable diagnosis the fol- 

 lowing may serve: Tuberculosis of the glands is rare in those beyond the 

 twenty-fifth year of life. The appearance of glandular enlargements without 

 any other symptoms in later life would therefore be evidence against the 

 tubercular nature of the affection. Pain and tenderness in the enlarged glands 

 is frequently observed in tuberculosis; it is rare or does not occur at all in 

 lymphomata. Tuberculosis of other organs is greatly in favor of the assump- 

 tion of a glandular tuberculosis, and also fever, which, as I have already said, 

 is certainly absent or appears very rarely in the non-tubercular form. En- 

 largement of the spleen, in the absence of fever, is against tuberculosis. 

 Finally, tubercular lymph-gland enlargements adherent to their surroundings 

 usually break down from caseation, and if they are superficially situated rup- 

 ture externally. In a case of this kind it is easy to make the diagnosis. But 

 caseation and abscess formation do not occur at the onset, but only, if at all, 

 after a lapse of time; hence until this happens this criterion for diagnosis is 

 not present. Apart from this there is a form of glandular tuberculosis which 

 leads to very slight caseation or none at all; I refer to the indurative form. 

 The nature of such cases is obviously difficult to determine. In short, the 

 differentiation of tubercular adenitis from lymphoma, or the so-called lymph 

 adenomata, is very frequently difficult or impossible during life. 



