TWO CASES OF LYMPHADENOSIS, OR HOMS DISEASE, WITH OBSERVATIONS, 15 V GEO. K. JOHNSON, M. D., OF GRAND RAPIDS, MICH. Head before the Mich. State Medical Society, June 11. 1871'. [Reprint from the Thirteenth Annual Report of the Society.] TWO GASES OF LYIPHADEISIS, OR HOMS DISEASE, WITH OBSEJRATATIOISrS, BY GEO. K. JOHNSON, M. D., OF GRAND RAPIDS, MICH. Read before the Mich. State Medical Society, June 11, 1879. [Reprint from the Thirteenth Anmml Report of the Society.] TWO CASES OF LYMPHADENOSIS, OR HODKIN’S DISEASE: WITH OBSERVATIONS. G. K. JOHNSON, M. D., OF GRAND RAPIDS. I lay before the Society brief histories of two cases of the disorder designated by the title of this paper. Case I.—Herbert Morse first observed a slight swelling on the right side of his neck in the summer of 1874. He was then 15 years of age, and had been previously healthy. He had not inherited, so far as could be ascertained, any morbid predisposition. During twelve months after its inception the swelling in- creased slowly but perceptibly. After the lapse of that period it took on a more rapid growth, and other tumefactions appeared in the vicinity. A little later the patient began to look pale and to show signs of lowering health. I first saw the case in October, 1876, a little more than two years after the first noticeable tumefaction. Many of the cervical lymph glands of the right side, both superficial and deep, were then enlarged. A few of the swellings consisted of single hypertrophied glands, but most of them were multiple, and presented the form of lobulated masses, the largest of which was then about the size of the fist. These tumefac- tions, large and small, and involving both deep and superficial ganglions, occupied the entire side of the neck, from clavicle to mastoid process. There were no adhesions to the integu- ment, end the smaller swellings seemed to float loosely in the areolar tissue. Some of the larger masses seemed to have tolerably firm attachments beneath. There was neither pain nor morbid sensibility in any of these growths. They were elastic and moderately firm, but not indurated. 4 Lymphadenosis, or Hodkin’s Disease. The solar print hero shown presents quite faithfully the appearances at that time. I should add that this photograph was taken from a pencil sketch by Dr. Edie of Grand llapids. At no time were the lymph glands of any other external region involved. The spleen was a little enlarged. Its out- lines were felt beyond the costal margins. The patient be- came cachectic in appearance, and this appearance grew more and more decided. From the beginning of the disease until within three months of the close the appetite wras tolerably good, and digestion apparently but little or not at all impaired. At no time did the glandular neoplasms tend to soften or suppurate; nor did the integument above or the tissue about them inflame. From the time the case came under my observ- ation until within a few weeks of the finale, the temperature ranged from 101° to 103°. The patient suffered but little from pain, but was all along weak and incapable of any pro- longed exertion. Epistaxes occurred two or three times during the illness. Pemphigus appeared over the body eight or ten months previous to the end. The general ill condition grew slowly worse. The feet be- came edematous and the weakness extreme. During the last two or three months pyrexia was almost continuous, but with daily exacerbations, during which a hectic flush would cover the cheeks. Death took place in January, 1879, four years and five or six months after the inception of disease. Circumstances pre- vented a post mortem examination. Case 2.—James McK. is now six years old, and of healthy parentage. Twenty-one months ago a small swelling appeared on the right side of his neck. Three months previously he had been down with scarlatina, but recovery had been prompt and complete. The swelling, which consisted of a tumefied lymph body, has slowly gathered volume until now. Other glands in the vicinity have been invaded one after another, until at last the whole side of the neck, from the clavicle to the occiput is in possession of the abnormal growths. Some of the swellings are single; others are multiple and lobulated. One large mass is composed of the glands which lie between the sterno-mastoid rud the trapezius, and is posterior to a line falling vertically from the lobe of the car. I present here front and back photographic views of these timers. In this case, as in the first, the enlargements have an irregular outline, and an clastic, tolerably firm feel. But there is no distinct induration ; nor is there any tendency to softening, suppuration, or caseation. The lymph bodies in Lymphadenosis, or Bodkin's Disease. 5 other external situations are apparently normal. The spleen is somewhat enlarged. The appetite is variable, and there is some emaciation. The boy is pale, but there is yet no decided cachexia. Ilis general health fluctuates, but is constantly below the normal point. The thermometer generally registers 100° or 101°. During the past three or four months there have been several acces- sions of fever, during which the temperature would reach 103° and 103°. At present the boy is very slowly losing ground, both with respect to local and systemic conditions. REMARKS. These two cases are examples of a very interesting and a serious affection. Fortunately it is not of frequent occur- rence. Practitioners, however, now and then encounter it, and are too often baffled by it. Too frequently its real nature and tendencies have not been recognized. The literature of the disease is scanty and fragmentary. Standard authorities, with one or two recent exceptions, give it no place. But dur- ing a considerable number of years past, journals and hospital reports, chiefly English and German, have recorded cases of the disorder and contained papers upon it. A few physicians, and notably Dr. Hodkin of England, have made its investi- gation a special work; and thus, little by little, we are coming to a knowledge of this important ailment. Billroth—Surgical Pathology, Hackley’s translation—dis- cusses the subject in the chapter on Lymphomata. He thinks it difficult or impossible, in the present state of knowledge, to define the disorder with accuracy, and remarks that neither the gross nor the microscopic appearances have yet made clear the cause or the nature of this hyperplasia. The chapter evi- dently describes this particular affection ; but I think it also blends and confuses it with some resembling but not identical disorders; for it is clear that there are cases of swollen and hypertrophied lymph glands, chronic in course, which differ in nearly all essential points from the morbid entity now considered. Craigie—Elements of General and Pathological Anatomy— refers to this disorder in his paragrahs on Vascular Sarcoma of the Lymphatic Glands, but he does not distinguish it clearly from other affections of those bodies. Virchow refers to it under the title of lympho-sarcorna. But the most satisfactory account of the malady yet in print, so far as I know, is the the monograph of Dr. Wm. R. 6 Lymphadenosis, or Hodkin’s Disease. Gowers, in the fifth volume of Reynold’s System of Medicine, recently published. Therein most of the existing knowledge of the subject is fairly summarized. It must not, however, be inferred that the disorder always reveals itself in the form and in the situation taken by the two cases here reported. The hyperplasia does not always fall upon the lymph kernels of the neck. It may affect those of any region of the body. It seems, however, to display certain preferences. It falls most frequently upon the cervical glands; then upon those of the abdomen; then, in the order of fre- quency, upon those of the thorax, of the axilla, of the groin, and of the pelvis. My own limited observation inclines me to think that, after the neck, the abdomen is the most common site of the trouble. The lymph glands of the mediastinum, anterior and posterior, sometimes undergo this change, and expand into tumors which produce perplexing and distressing symptoms. It is probably safe to state that many of the anomalous and undiagnosticated tumors of the several cavities of the body belong to this category. It is certain that not a few of the tumors that originate in or encroach upon the abdominal cavity are of this nature. Not only the glands of the mesentery, but also those that lie along the spine and behind the peritoneum, from diaphragm to sacrum, are quite frequently thus involved. Every practitioner of considerable experience must have seen such instances. Several have fallen under my observation. In one case, a gentleman 55 years of age, prominent in business and in public life, was ailing for eighteen months or two years. His symptoms were insidious and obscure,- and no satisfactory diagnosis could be formed until towards the last. He had pains, sometimes slight, sometimes severe, in the abdomen and back. He slowdy lost strength and flesh, and had sleepless nights. When under my observation, eight or ten months prior to death, the thermometer ranged 301° and 102° most of the time. He was pale and cachectic. His complexion, indeed, bore a marked resemblance to that of Morse, whose case is first above reported. Autopsy revealed enlargement of the lymph glands of the abdomen. Chains of these bodies along the spine were ex- panded into tumors of various sizes. There was neither soft- ening nor ulceration, nor suppuration at any point. I may add that towards the close of the case some of the cervical glands just above the clavicle became enlarged. With this exception, none of the glands in external situations were affected. I must further add, that for the facts of the autopsy Lymphadenosis, or Hodhin’s Disease. 7 in this case, as well as for a part of its clinical history, I am indebted to Dr. Charles Shepard, of Grand Rapids. In another case, a gentleman 41 years of age was out of health for several years, but was able to attend to business until three months before death, lie suffered from obscure pains in the back and abdomen; at times the abdominal pains became very severe. The stomach was irritable, and food was frequently rejected. The patient often complained that his legs felt cold and unnatural, but there was never any paralysis, liis complexion had the peculiar sickly look or pallor which, I believe, is always seen in this disorder after it has made some progress. There was weakness, but no percep- tible emaciation. The external glands of the lymph system were not enlarged, nor were any internal swellings recognized during life. But on post mortem examination both the mesen- teric and the lumbar glands were found in a condition of hypertrophy, forming tabulated masses of considerable size. They had generally a solid and firm feel, but there was one point of softening. But the particular affection now in hand does not consist entirely, nor mainly, of the glandular hyperplasia. That, clearly, is a conspicuous and an important element in it; but the ill habit of body, the dyscrasia, the blood state, are factors at least equally important and quite as character- istic. In clinical history the latter are generally noted at a later period than the former; but it does not hence follow that they are the results of it. They are sequences, but not necessarily consequences of it. Probably such is merely the natural order of pathological development. If this view, which is that taken by those who have given most attention to the subject, be correct, it follows that we are to regard the glandular change and the systemic decline, not the former, as cause of the latter, but both as co-essential factors of the malady. As already stated, this disorder has not generally been dis- tinguished from some others having some resemblance to it, but which are pathologically distinct from it. Different observers and writers have also given to it different names, thus adding to the confusion which has prevailed with respect to it. Most of these terms have signified merely the glandu- lar affection. But the term Lymphadenosis, or Hodgkin’s Disease, more recently employed, is intended to designate the general, idiopathic disorder, of which the enlargement of some of the lymph glands and the ill habit of the body, as briefly described herein, are the notable symptoms. 8 Lymphadenosis, or HodJcin’s Disease. Perhaps it is worthy of remark, that the lymph vessels are rarely or never involved. Lymphadenosis is a chronic affection. Its duration is inde- finite, but it generally runs on through many months or years. It has undoubtedly been sometimes diagnosed as struma, and the swellings as strumous. But such a mistake ought not to be made, since the distinctions are so marked. The history and signs of the strumous diathesis are in general easily made out; besides, strumous swellings are at first harder than those of Hodgkin’s disease, and are never so elastic. There is also and always this specific difference : strumous swellings soften and suppurate or caseate; in the swellings of lymphadenosis this never occurs. The only other disorder with which this is likely to be con- founded is leucocytligemia (leukaemia). Between these two affections there are doubtless some analogies. Some observers have, indeed, regarded them as cognate affections. Both pro- foundly involve the structure and the haßinatosic functions of some of the lymphoid glandular bodies. In both serious blood changes occur; yet, between a typical case of lymphadenosis and a typical case of leucocythaemia there are unmistakable differences. In the latter, the blood change, i. e., the enor- mous increase of the white corpuscles and the diminution of the red, is more marked. The anaemic look of the patient is consequently more pronounced, and hemorrhagic transuda- tions, internal and external, are more frequent. In the latter, also, the spleen undergoes very great enlargement, while the lymph glands are but little or not at all changed. Prognosis is not encouraging. But few recoveries are of record in cases in which the diagnosis was clear. We may hope, however, that the increased attention the disease is now receiving, and the better knowledge of it which will ensue, will finally lead to more successful results. Treatment resolves itself into surgical and medical. When the tumors occupy accessible situations, as in the neck, the axillje, or the groin, excision naturally suggests itself, and it has been many times practiced. In most instances of excision there has been no real arrest of the progress of disease. The general disternperature has gone on without check, and other glands have, after a variable time, taken on the hyperplastic action. In a certain number of cases, a temporary improve- ment, continuing one or several years, has followed. In a few instances, if we may assume that the diagnosis was cor- rect, cures have resulted; at least the patients remained well so long as they were under observation. But surgical opinion Lymphadenosis, or HodJcin? s Disease. 9 is not fully settled on the question of excision. In the present state of knowledge, perhaps the best rule of practice is to extirpate in cases in which the constitutional condition is yet good, and in which, in a surgical view, the operation is entirely feasible. Morse, whose case is here reported, con- sulted eminent surgeons in New York and elsewhere, but no one advised operation. Of drugs, arsenic, cod liver oil, and the preparations of iron and of iodine, have been most relied on. I have found the muriated tincture of iron a good remedy. In doses of two or four drops, three times a day, well diluted and long continued, it has, in my hands, improved the general condition. But it exerts no control over the tumefactions. My purpose, however, is not to discuss treatment, but rather to draw attention to an important disorder of which too little is known.