-REPORT- 
OF CASE OF HODGKIN'S DISEASE. 
BY 
J. S. BEALE, M. D., WASHINGTON, D. C. 
Read before the Medical Society of the District of Columbia. 
Judd & Detweiler, Printers. REPORT OF CASE OF HODGKIN'S DISEASE. 
BY J. S. BEALE, WASHINGTON, D. C. 
(Read before the Medical Society of District of Columbia.} 
Weight or Tumor, 1 pound 2 ounces. 
Clarence Albert Ballenger, aged 7 years and 3 months, 
red hair, fair complexion, a vigorous, healthy-looking boy. 
His family history is good. Never knew a day's sickness 
until August 26, 1880, when he fell while swinging on a 
rail fence, fracturing his left clavicle about junction of 
middle and inner third. He was not seen for three days, 
when a physician was called, who, recognizing the fracture, 
adjusted the bones, which united readily. About three 
weeks after, the mother discovered a small lump near the 
lower jaw on the left side, which was red and tender. About 
a week after, the redness and tenderness disappeared, but 
the lump gradually increased until, at the expiration of six 
months, it was the size of a hickory nut; it was movable 
and not inflamed. About fifteen months after fracture, his 
parents first noticed the appearance of several small lumps 
around the original one, which was rather in front of ster- 
no-mastoid muscle. During the next six months these 
glands appeared to increase in size rapidly, disfiguring the 
boy, and causing him to be greatly disturbed during his 
sleep, talking and screaming, and sometimes walking about 
the room half conscious apparently. He would frequently 
come in from play during the day and complain of feel- 
ing sleepy; he would throw himself on the bed, sofa, 
floor, or anywhere, and almost immediately go to sleep, 
sleeping three or four hours and waking fretful and crying. 
During the last month the boy would frequently come in 
from play, sit down in the house, and suddenly grow very 
pale, have nausea, and large drops of perspiration would 
roll off his head. He never complained of pain about his 
neck, nor would he admit any tenderness. Three weeks be- 
fore the operation he commenced to have croupy attacks in 
his sleep, and on three occasions his mother feared he would 
choke to death. I first saw the boy August 10, 1883, and 2 
found an immense mass of enlarged glands, varying in size 
from hen's egg to size of a pea, very movable and appar- 
ently easily separated from each other, soft to touch, extend- 
ing in front and behind sterno-mastoid, resting on clavicle 
and reaching round under chin, and pressing upon trachea 
to such an extent that, upon using laryngosopic mirror, 
could see a velvety appearance of mucous membrane on 
left side, caused by pressure, no doubt, and which in part 
accounted for the fits of coughing he had. One of the 
glands under chin appeared so soft and fluctuating I thought 
it contained pus, and passed a sharp-pointed bistoury into 
its centre without, however, any result other than slight 
hemorrhage. The symptoms being urgent, I advised the 
immediate removal of the mass, and on August 13, 1883, 
operated in the presence of, and ably assisted by, Drs. Lin- 
coln, McKim, and Ober. The incision, about six inches, 
extended obliquely across the sterno-mastoid muscle, and 
after the extirpation of the superficial chain of glands was 
obliged to sever that muscle in order to get at the mass of 
tumors which seemed innumerable beneath, and extending 
behind and below the clavicle, around to back of the neck, 
up to angle of lower jaw, and along that bone to chin under 
the tongue. Feeling obliged to proceed cautiously so near 
the carotid, considerable time was consumed, and the hem- 
orrhage troublesome, but not large, necessitated the placing 
of ligature upon the facial and occipital arteries. Mean- 
while, the boy ceased breathing, and through the timely in- 
terference of Dr. Ober, who resorted at once to artificial 
respiration, and by the injection of brandy hypodermically, 
and other treatment of three-quarters of an hour's duration, 
the boy breathed again, much to my relief. The operation 
was a most tedious and complicated one, owing to the deep 
location of many of the tumors, they being held in such 
tight embrace by the deep cervical fascia, and requiring so 
much care to avoid injuring the important structures met 
with in the superior carotid triangle, that two and a half 
hours elapsed before the patient was put to bed. 
Saw patient three hours after operation, and found him 
suffering from some shock, with feeble pulse and imperfect 
sighing respiration; warmth and circulation were restored 
by proper measures. 
Saw patient ten hours after operation. Temperature 
99.2°; pulse 110; patient restless and complaining of much 
pain. McMunn's Elixir ordered and wet cloths to wound, 
which was dry and hot. 3 
Twenty-four hours after operation. Temperature 102°, 
}Tulse 130; ordered carbolized dressings, and quinine in five 
grain doses every four hours. 
August 15, 1883, 8 a. m. Temperature 102.8°, pulse 120. 
Ordered quinine, five grains every two hours till 3 ss is 
taken. 
August 16, 8 a. m. Temperature 100°, pulse 112. Wound 
looks well. Normal amount of discharge. Patient taking 
beef tea and milk in sufficient quantities. 
August 17, 5 p. m. Temperature 99.8°, pulse 110. Pa- 
tient restless. AVound looks swollen. Removed tent, which 
closed counter opening (which was made at time of opera- 
tion for drainage,) and a great quantity of healthy pus 
flowed and patient seemed much relieved. 
August 18,12 m. Temperature 99.6°, pulse 108. Patient 
allows some motion to be made of the head by turning 
back and forth on the pillow without much pain. 
August 19. Temperature 99.6°, pulse 100. Removed the 
ligatures. Wound looks healthy. Union nearly complete. 
Small discharge through counter-opening. From this time 
he rapidly progressed towards convalescence, with compara- 
tively slight drawback, except an abscess on the fleshy part 
of the left fore-arm, caused by the hypodermic injection of 
brandy, which, sloughing out, exposed a foul, deep ulcer, 
interfering to some extent with the movement of the left 
arm. 
Lymphadenoma, with coincident enlargement of the 
spleen, seems to have been recognized as far back as 1669 
by Malpighi, and also in 1752 by Morgagni, although the 
nature of the glandular change was first carefully described 
by Craigie in 1828, and the general clinical history of the 
affection was pointed out by Hodgkin in 1832, also by 
Willis in 1856. Important subsequent observations were 
made by Virchow in 1864; Wilkes, 1865; Trousseau, 1865; 
Wunderlich, 1866, and Murchison in 1870. 
AV. R. Gowers, in an article recently published, writing of 
the nature of the enlargement of the lymphatic glands in 
Hodgkin's disease, says they seem to consist at first of mere 
hyperplasia, and subsequently of fibroid induration. A few 
glands only may suffer, or every gland in the body may be 
enlarged. The former cases have the character of a local 
growth; the latter is distinctly a general disease, for which 
the term lymphadenosis seems the most exact. In writing 
of the aetiology of the disease he says: In two-thirds of the 
cases of lymphadenoma no cause can be traced, and the as- 4 
certainable antecedents of the disease in most of the re- 
maining cases evidently constitute only a small part of thfj 
influences to which it is due. Hereditary transmission has 
not been distinctly proved. It is three times as frequent in 
males as in females. It occurs, but not especially frequently, 
in children under ten years. Many writers say it is doubt- 
ful whether the disease has any relation to constitutional 
syphilis. Most frequent cause is local irritation. 
Morris Longstreth, M. I)., in his revision of Sir James 
Paget's article on Tumors in the last edition of Holmes' 
Surgery, says: The lymphomata have their origin from 
lymphoid or adenoid tissue similar to that of the lymphatic 
glands. These growths most commonly occur in situations 
in which lymphatic glands are present normally; lympho- 
matous growths occurring in other places were formerly re- 
garded as of heterologous origin, until investigation showed 
that lymphatic or adenoid tissue is far more widely distrib- 
uted in the parenchyma of the various organs than was 
previously known. Such growths, in fact nearly every lym- 
phomatous growth, must now be looked upon as of homolo- 
gous origin. Two varieties of lymphomata may be de- 
scribed : 
1st. Those consisting of hyperlastic or hypertrophied 
glands. 
2d. Independent growths which, arising from glands or 
other lymphatic tissues, proceed more or less continuously 
to a great development, which frequently have, as a cause 
of accompaniment, a dyscrasic condition of the blood ; and 
which, either from themselves or from the dyscrasia, termi- 
nate fatally. All grades of these growths are found within 
the limits of these two varieties in respect to their cause, 
course, size, and malignancy. 
Tubercle, scrofula, and syphilis are especially frequent 
causes of such glandular enlargements. There is a form 
which, attacking a collective group of glands, for example, 
the cervical, develops into a lobulated tumor of firm con- 
sistency of slow growth, so slow as to appear nearly station- 
ary. Each lobule of the mass corresponds to one of the 
original normal glands, which become intimately matted 
together, and also with the nerves and vessels of the part, 
so that the complete removal of the growth is a matter of 
difficulty, if not impossible. This form of tumor, if not 
interfered with, exhibits at least for a long period a very low 
degree of malignancy. It is often a difficult matter to dis- 
tinguish it from scrofulous disease, and it is sometimes im- 5 
possible. Unless subsequent to an operation the growth 
returns with rapidity, accompanied by malignant phenom- 
ena. 
Green, in his Introduction to Pathology and Morbid 
Anatomy, page 124, says of the development of lymphomata, 
that they originate for the most part from lymphatic tissue, 
being simply overgrowths of pre-existing lymphatic struc- 
tures, mainly of the lymphatic glands. They are, therefore, 
usually homologous; they may, however, be heterologous, 
either owing to the new tissue extending considerably beyond 
the confines of the old, or to its growth in situations where it is 
normally almost entirely wanting. This latter condition 
obtains in Hodgkin's disease, and in certain forms of lym- 
phoma, which are malignant. In considering the develop- 
ment of these growths, it must be borne in mind that en- 
largements of lymphatic structures are most frequently of 
an inflammatory nature, being due to some injury; and 
histologically, as already indicated, there is but little differ- 
ence between these inflammatory growths and lymphoma- 
tous tumors. The inflammatory growths, however, tend to 
subside, the tumors continuously to increase. Further, the 
development of the tumors may, like that of the inflamma- 
tory growths, be determined by some injury, the injury pro- 
ducing, perhaps, some inflammation and enlargement of the 
gland, but this instead of subsiding continues more or less 
rapidly to increase. He says further, of the secondary 
changes, the lymphomata do not undergo marked retrograde 
changes. There is no fatty degeneration, caseation, or soften- 
ing, such as occurs in scrofulous glands. Of the clinical 
characters of lymphomata, Green says they sometimes ex- 
hibit malignant properties. This is especially the case in 
those richly cellular, soft, rapidly growing forms which are 
sometimes met with. Such growths may rapidly infiltrate 
the surrounding structures, involve the neighboring lym- 
phatic glands, and even infect distant parts. They corres- 
pond with Virchow's lympho-sarcoma. 
Green says, of the Hodgkin's disease, there is a diminu- 
tion in the number of red corpuscles in the blood, and that 
the new growths are precisely similar, histologically, to 
lymphoma. This new growth of lymphatic tissue extends 
beyond the confines of lymphatic glands. In the spleen, 
new growth originates in the Malpighian bodies, and so 
gives rise to disseminated nodules. In addition to these, 
wedge-shaped infarctions surrounded by a zone of hyperse- 6 
mia are sometimes met with, similar to those which are 
often seen in leukaemia. 
With regard to the pathology of the disease, it is un- 
doubtedly obscure. The development of the new growth 
cannot in most cases be regarded as the result of infection 
from a primary centre, as the process is for the most part 
confined to the lymphatic structures, and many and widely 
distant groups are often simultaneously involved. The dis- 
ease appears to occupy a different pathological position to 
that of the malignant tumors. It is possible that there is 
some special weakness of the lymphatic structures generally 
which renders them prone to undergo these active develop- 
mental changes, the process being determined by some con- 
stitutional state or by some local injury to the glands. The 
progressive anaemia, which accompanies but does not pre- 
cede the gland affection, is due to the progressive implica- 
tion of the lymphatic structures and to the consequent in- 
terference with the formation of the blood corpuscles. 
Report of Microscopical Examination of the Gland in Hodgkin's 
Disease, from Dr. Beale, September 29, 1883. 
The gland, of which preparations were made, was about 
three-quarters of an inch long by five-eighths of an inch in 
its shorter diameter; in which direction the sections were 
cut. It was surrounded by an investment of fibrous tissue, 
very slightly, if at all, altered from the normal appearance, 
and about one-half the area of the section showed the nor- 
mal structure of a lymphatic gland, while the remaining 
area was occupied by detached foci of cell-aggregation, and 
the stroma also was altered. While traces of the gland- 
structure were still apparent in these spots, the shape and 
arrangement of the cells indicate a new growth closely allied 
to cancer, and one liable to recurrence. 
Edward M. Schaeffer, M. D. 
The following discussion is extracted from the Maryland 
Medical Journal: 
Dr. J. S. Beale read a paper on 
a case of hodgkin's disease. 
He also presented the specimen and the patient. 7 
In the discussion which followed, 
Dr. C. E. Hagner asked what was the condition of the 
child which demanded surgical interference ? Was dyspnoea 
caused by pressure on the larynx and trachea or by nerve 
pressure, and was this the reason of the operation ? 
Dr. Beale replied that the tumor pressed on the trachea 
and the nerves, causing croupy symptoms. 
Dr. Hagner said the case was interesting, and we should 
congratulate Dr. Beale on getting the tumor out of such a 
position. He was reminded of a case seen some years ago 
with Dr. W. P. Johnston. The trachea was flattened out, 
and the pressure on the nerve so great that symptoms simu- 
lating laryngismus stridulus prevailed. With the laryngo- 
scope he discovered the tumor bulging in the trachea below 
the vocal chords. He gave it as his opinion that the tumor 
could not be removed; but this was before Billroth had re- 
moved the larynx. He thought that as she was suffering 
only from pressure on the recurrent laryngeal, the patient 
might live a long time. She was taken to Boston, operated 
on and died upon the table. 
Dr. Schaeffer said the only case like this he had seen 
was one reported to this Society by Dr. Triplett. In that 
case he had been struck by the freedom from cachectic ap- 
pearances, though the white corpuscles were found to be 
largely in excess upon a microscopical examination. 
Dr. King thought it was interesting to observe that a 
fractured clavicle seemed to be the starting point. A slight 
enlargement of the glands followed soon after. It wa$ con- 
tended by some that the marrow of bones has the function 
of blood making, the same as is usually ascribed to the 
spleen. In Burlington, Vermont, he had assisted at the re- 
moval from an old lady of sixty, of a tumor which dipped 
down below the clavicle, and at the bottom of the wound 
the pleura could be distinctly seen to flap at each act of 
respiration. The patient recovered. 
Dr. Beale had not been able to find the co-incident en- 
largement of the spleen. The exciting cause, he thought, 
must have been the fracture. 
Dr. Prentiss saw a case about 18 years ago where Dr. 
Lincoln was obliged to tear the tumor away from the large 
vessels of the neck. The patient is now walking about. 
Saw a child three years old with a tumor over the parotid. 
It spread downwards until it finally compressed the trachea 
and interfered with respiration. Tracheotomy was per- 8 
formed, as the child was in a condition akin to the last 
stage of membranous croup. It lived for six weeks, though 
death was finally caused by extension of the disease to the 
brain through the orbit, he thought. 
Dr. Thompson thought it very questionable if the cases 
just mentioned were examples of Hodgkin's disease. Many 
large tumors in the cervical region have a different pathol- 
ogy. The case of Dr. Beale would seem to be a true one, 
though the patient was young. Its tendency to return is in 
favor of the doctor's diagnosis. This disease is supposed to 
be a deposition of tubercle in the lymph cells. Had seen a 
number of cases die after an operation. It is now considered 
useless to operate except to relieve urgent symptoms, as Dr. 
Beale did. Only a few years ago he operated on a man for 
this disease, but it returned afterwards in the abdominal 
cavity and he died. The large glands of the mesentery and 
the dulctess glands are sometimes the seat of disease. In- 
deed, the deposit sometimes occurs where there is no gland. 
There are a few cases reported where a single tumor existed. 
These, however, are of doubtful diagnosis. 
The discussion closed.