THE Canadian Practitioner FORMERLY "THE CANADIAN JOURNAL OF MEDICAL SCIENCE." EDITORS AND PROPRIETORS: A. H. WRIGHT, B.A., M.B., M.R.C.S. England. J. E. GRAHAM, M.D., L.R.C.P. London. W. H. B. AIKINS, M.D., L.R.C.P. London. SUBSCRIPTION, $3 PER ANNUM. Literary Communications may be addressed to any of the Editors. TORONTO, JUNE, 1886. Original Communications. HODGKINS' DISEASE, TWO CASES.* CASE I.-Patrick O'Connor, aged 8. Parents poor, father intemperate. I saw him first at the Toronto Dispensary, in June, 1883. He was pale, thin and weakly in appearance. There were enlarged glands on both sides of neck. They were hard, smooth and painless, about size of almonds, with little, if any, resiliency. All the other glands of the body seemed normal. He had simple stomatitis. The case was thought to be one of scrofula on account of the state of the mouth. He was not seen again till Oct. 1st, about three months later. The cervical glands were then in about same condition. The axillary glands greatly enlarged; those in the groin, popliteal spaces and on surface of abdomen considerably larger than normal; they were all hard. Two very large glandular masses could be felt in the abdomen, one on each side of the umbilicus. No increase in size of liver or spleen could be detected, but tympanitis was so marked as to render it impossible to obtain an accurate outline of these organs. In the lungs and heart nothing abnormal was to be found. There was great emaciation and pallor, as much from improper nourishment as the disease, pro *Read before the Toronto Medical Society, March, 1886. bably. The blood contained 40 per cent. normal number of red corpuscles, and considerable increase in number of white. Temperature was slightly elevated. Respirations normal. Taking but lttle nourishment. Unable to leave his bed. Death occurred suddenly on Oct. 10th. No post mortem could be obtained. CASE II.-Grace Waterman, aged 7. Parents She was poor, but she was well cared for. brought to the Toronto Dispensary, Dec. 23, 1884. Her mother was 66 'poor blooded" when young, but is strong and well looking now. There are four other children, healthy; one died of measles. Father healthy. Grace has been ailing for about six months, gradually losing color, strength and appetite. Two or three weeks ago "lumps" began to appear in the neck. They grew rapidly to near their present dimensions. They are now so large as to give the neck the appearance of being larger than the head. Surface very pale; They are soft, doughy, painless, and quite movable. The posterior cervical, axillary and inguinal glands are somewhat enlarged and hard. The spleen appeared to be slightly increased in size; liver, perhaps, slightly so. Lungs normal; heart, hæmic murmurs at apex, base and alcng large vessels. Temp. 100.6°; pulse 124; respiration 24. lips and conjunctiva anæmic. Blood was carefully examined with Gowers' hemacytometer. Contained 816,000 red corpuscles and 183,000 white as the average of several counts, i.e., 1 white to 4 red. The white corpuscles are nearly all very small; there are a few large There are also a good number of small ones. granules. Liq. arsen. and Vin. Ferri were ordered. On 26th and 27th she vomited a good deal, the vomited matters containing small black fibrinous elots; similar clots keep forming in the mouth. Respiration, sighing. Cervical glands greatly reduced in size. Temperature 100.4° F.; pulse 124. Vertigo, of which she has complained for a few days, has disappeared. An examination of the blood showed about the same number of red corpuscles while scarcely any white could be found. 30th.-Death occurred to-day, with signs of heart failure. Autopsy five hours after death. Only a partial one was permitted.-Emaciation moderate. A few hemorrhagic spots on arms. The cervi cal, axillary and inguinal glands vary in size from a pea to a filbert. They are all hard, the cervical being in the same condition as the others. Very little blood in the vessels. Lungs healthy. About 2 ounces fluid in pericardium Heart of normal size, surface thickly studded with hemorrhagic spots, giving it a mottled appearance. Small, partly discolored clot in right ventricle; valves healthy. Liver slightly enlarged and pale, no appearance of lymphoid growths seen. Spleen about twice normal size; structure healthy. Surface of small intestine has a grayish, mottled appearance, from enlarged, Peyers' and solitary glands; kidneys and suprarenal glands, healthy; retroperitoneal glands enlarged and hard. These two cases, though presenting such strong contrasts, are, nevertheless, I think, examples of the same disease. They serve to illustrate the extremes of the phenomena presented in Hodgkins' Disease; in the one the local glandular changes first attract attention and predominate throughout the course; in the other case the anæmia and debility were the chief symptoms, except during the few days the cervical glands were so greatly enlarged. In Patrick's 's case the disease ran the typical course, beginning with enlargement of the cervical glands, the usual seat of initial lesion, and gradually spreading till nearly all the glands became affected, some of them attaining great dimensions. Accompanying the gland changes was the progressive anæmia. Grace Waterman's case presents a rare and interesting phenomenon in the disappearance of the leucocytal excess simultaneously with the sudden disappearance of the enlargement of the cervical glands. It is to be regretted that the case did not come under observation earl er, so that the condition of the blood could have been ascertained before the rapid enlargement in the cervical glands occurred. It is probable, however, that there was little, if any, excess in the white corpuscles, and that the great increase found was due to and derived from the rapidly enlarged glands. A very limited number of glands may induce a leukæmic state of the blood.* This case appears to be a striking illustration of the truth of that statement. It is not unusual for enlarged glands to undergo a remarkable reduction in size during the last few days of life both in leukæmia and Hodgkins' Disease. And a case may present the greatest variation in the number of leucocytes in the blood from day to day, but I am not aware that any case has been recorded in which there was such coincidence in the reduction of enlarged glands and the complete disappearance of leucocytal excess as was observed in this case. Cases of Hodgkins' Disease are recorded in which the blood has suddenly become leukæmic before death; also cases of leukæmia in which the leucocytic state of the blood has disappeared while all the general symptoms persisted. † Goodhart reports a case of remarkable variation in the ratio of white and red corpuscles from day to day. At the first examination the ratio was 60 white to 100 red; a week later 72: 100; three days later 18: 100; and after a few days more the ratio was normal. In this case the spleen was enlarged, and the liver and kidneys contained lymphoid growths. Such cases show the necessity of repeated examinations of the blood in order to be fully cognizant of the changes it may be undergoing. They also indicate the essential unity of Hogdkins' Disease and leukæmia or leucocythemia. It would probably be well were they treated as *Gowers in Reynold's System; Am. Ed., vol. iii., 511. + Osler in System of Pract. Med, by Amer. Authors, vol. iii., 895. Lancet, 1876, Vol. 2. clinical varieties of the same disease. They are both diseases of the blood-making organs, though their force is spent on different sets of these organs. They are characterized by such common symptoms as progressive anæmia, irregular febrile disturbance, absence of marked emaciation, progressive debility, hemorrhages, derangement of stomach and bowels, their almost invariably fatal termination, etc. The micro scopic examination of the blood furnishes the only means of diagnosticating them from each other, and this may lead to a diagnosis of leukæmia one day and Hodgkins' the next, So much attention has been paid to the blood state that the common features of these two diseases have in a large measure been lost sight of. The case of Grace W. might perhaps more properly be looked upon as one of leucocythe mia than of lymphdenaosis, as many of the symptoms point rather to the former. There was an absence of the great gland hypertrophy that usually characterizes Hodgkins' Disease. In leucocythemia the glands are often found in just such a condition as they were in this case. Hemorrhages are rare in Hodgkins', while they usually occur in leukæmia. They were not profuse in this case, but they were pretty general, and they occurred from the same parts as in leukæmia, viz.: hemorrhagic spots on arms, and from nose and the digestive tract. There were spots on the heart; such are not given as occurring in leukæmia, in which there are also usually hemorrhages in various vis. cera and muscles-of these there were none so far as the post mortem revealed. Then gastric disturbance is much more common in leukæmia; with it there is usually also diarrhoea. The symptoms common to both that were present were the anæmia, the increased irregular temperature, slight œdema of feet and legs, the dyspnoea due to the anæmia; and, we might add, the fatal termination. The marked diminution in the size of the glands is not character istic, it may occur during the last few days of life in either disease. The one symptom left to consider is the great excess of white corpuscles -were there evidence to show that this condition existed for some time, the case would be clearly one of leukemia; but it is very pro bable that the excess was co-incident with and due to the rapid enlargement of the cervical glands, judging from the simultaneous disappearance of the leucocytal excess and enlargement of the glands. The character of the leucocytes indicates their origin from the glands-they were small and pretty uniform in size. These are the leucocytes met with in lymphatic leukæmia, as pointed out by Virchow. This case illustrates the marvellous rapidity with which the white corpuscles may disappear from the blood. What becomes of them is a mystery. Are they essentially the same as the normal white corpuscle? Did they live out the natural period of existence of a white corpuscle, or were they prematurely destroyed by some unknown agency? To these interesting questions no answers can be given in the present state of science. It is well to note here that there are certain general conditions not belonging to this group of diseases in which there is an increase in the white corpuscle. Osler, in American System of Practical Medicine (page 920), says: "In supuration there may be marked leucocytosis, also in cancer and in protracted cachectic conditions, as phthisis. In cases with large cancerous masses about stomach and omentum, or where, as occasionally happens in chronic phthisis, a greatly enlarged amyloid spleen, if the white corpuscles are much increased, care is necessary to escape making diagnosis. In diphtheria the white corpuscles may be much increased; also in peurperal fever leucocytosis not uncommon." Pathology.-Some have looked upon this disease as depending on a preceding blood affection -of this view Wilks is the most noted advocate. Others with Trousseau believe it may also arise from a local irritation. That the latter view is correct in some few cases is supported by such cases as that of Patrick, where localized gland enlargement apparently results from a local irritation, as stomatitis, and is followed by a generalization of the gland disease. In the majority of cases, however, the disease begins by a generalized outbreak in the lymphatic glands, which may be preceded by anæmia, thus lending support to Wilks' views. The changes occurring in the glands are not distinctive of Hodgkins' Disease. The same kind of histological change occurs in leukæmia, and are only distinguished by the difference in degree. In lympho-sarcoma, the microscopical char acters are also identical, and the distinction is often difficult, in some impossible. Osler in American System thus sums up the section of pathology of Hodgkins' Disease. for five or six years at least, and drank moderately even before that time. Sometimes drank large quantities at a time. He has a puffed-up, debauched appearance, with a red face, full of acne roacea. Had been from home for six weeks, and it is believed had been drinking hard. Came home two days before; was the worse of liquor when he came off the train, and was in my office pretty drunk at 11 o'clock the night before I was called. His wife said that he had eaten literally nothing since he came home. Treatment.-Procured sleep with Wyeth's syrup of chloral, followed with potass. bromid. Ordered feet to be put in hot water, and cold cloths to be applied to the head. After sleep a saline purge to be given, and plenty of liquid nourishment in the form of cold beef tea, milk and raw eggs, with ice to suck-and to be kept quiet in a darkened room. Called during the afternoon and found him dancing through the house. An old friend had prescribed some We may recognize in the lymphatic glands 1st. The local benign growth, which seems nothing more than hypertrophy, lymphadenoma, and which may persist for years. 2nd. A local malignant growth, lympho-sarcoma, which invades contiguous structures, and may be followed by metastasis, but there is not a general involvement of the lymphatic tissues. 3rd. There is a generalized lymphoma involving groups of glands in succession, and the adenoid tissues throughout the body, usually accompanied by anæmia alone, in which case we term it Hodgkins' Disease; sometimes by an excess of colorless corpuscles as well, when we call the affection lymphatic leukæmia. whiskey-a pint having been punished between Unfortunately cases occur lying in the border-them-hence the revelry. Left in disgust. line between the lympho-sarcoma and Hodgkins' Disease, which baffle the most skilled diagnostician to assign them to their true place. A CASE OF ACUTE ALCOHOLISM. BY J. CAMPBELL, M.D., C.M. (M'GILL), L.R.C.P. EDIN., SEAFORTH, Ont. Was called at 7 p.m., saying that he was worse. The whiskey having evaporated, the trembling spasms returned. Treatment as before until sleep had been procured. Four men stayed with him. Was dealing extensively in wheat until he went to sleep. Called in the morning and found that he had a good night, though the medicine had to be repeated several times. Had taken a large amount of liquid nourishment as before. Dr. Elliot, of Lucknow, was with me and considered that he was doing well. This was on the morning of the 4th. Treatment continued during the day. Trembling spasms were always allayed by the medicine, and the nourishment was retained. A purgative was again ordered. Patient kept quiet. Saw him, with Dr. Elliot, in the evening. Spasms had returned still complained of the pain in top of his head. Quite sensible in the intervals between the tremors. Was annoyed at our statement that his trouble had been brought on by drinking. On the advice of Dr. E. added one of Wyeth's pellets (gr. 1) to our previous treatment-eggs, milk, and beef tea as before. We both saw him the next morning (5th). ReHistory. He has been a pretty steady drinker ported to have had a good night. Symptoms on Was called to see W. R., aged 42, a grain merchant, at 8 a.m. on the 3rd of April last, and found he had a sleepless night. Was restless and taking at intervals tremors and spasms of all the voluntary muscles. He had a furred He had a furred and tremulous tongue, cool skin bathed in perspiration, cold hands and feet; saw ships sailing; was going to have a great show, at which he would exhibit the now defunct "Jumbo;" some times was buying and selling wheat per telephone; occasionally asked for his revolver. Pupils somewhat contracted, no intolerance of light, pulse steady but somewhat rapid, tongue moist, no albumen in urine. He complained of pain in the top of his head, of a boring nature, and asked me to cut the piece out. the whole unchanged. Still complained of pain in a small spot on the top of the head, and also of our diagnosis. Saw him again at 7 p.m. Found him sitting on the edge of his bed, smoking his pipe. Spoke rationally, but was taking spasms of the voluntary muscles every ten or fifteen minutes, when the bed would fairly shake under him. Symptoms unchanged. He wished to see Dr. Scott, to see if he would alter the diagnosis. Told the friends to get Scott, but as I had an engagement I could not be present. Dr. S. saw him about 8 p.m. Noted the symptoms and watched the spasms. Thought at first that they were partly feigned, but came to the conclusion that they were involuntary Between spasms he talked sensibly, and still complained of the pain, and complained of the name given to his trouble. Dr. S. told him that his disease had been brought on by drink. ing, and the name would not alter that fact. The doctor approved of the treatment, and pro ceeded to give some of my medicine, giving it as his opinion that he would recover, as there were no dangerous symptoms at present. While the doctor was yet speaking he took another convulsion severer and longer than any previous one. The head was thrown back, the eyes turned up, the pulse became weak, intermittent, then imperceptible-respiration ceased-he was dead. Remarks.-(1.) From the manner of death we both concluded that the immediate cause of death was apoplexy, but as no post mortem was allowed our opinion could not be verified. (2.) That the cerebral hemorrhage in all probability had occurred at the spot where the severe and constant pain had been complained of, and that the pain in question had been the result of severe congestion. (3.) That the disease from the first was one form of acute alcoholism, with some anomalous symptoms which are not often present. [Note.-After a discussion in which Drs. Worthington, Sloan and Young took part, and after Dr. Campbell had several questions put to him by Dr. Elliot and others, the Association agreed with both the diagnosis and treatment of the case. se.] Selections. [We are indebted to DR. ZIMMERMAN for the translations from the French and many of the therapeutic notes, and to DR. R. B. NEVITT for the Italian translations.]—ED. PRURITUS VULVÆ. BY M. MARTINEAU. Pruritus vulvæ may occur in very different conditions. Sometimes it is in affections apart from the vulva, such as certain parasitic diseases, (intestinal worms, pediculi pudendi, herpes tonsurans); in vegetations of the bladder, (calculi, etc.), in vegetations and polypi of the urethra. Sometimes the pruritus is due to glycosuria, and arouses the attention of the physician to a possible diabetes. In a second category of facts, the pruritus is consecutive to divers primitive or secondary vulvites, simply local, or arising from a general diathetic or constitutional cause, such as tuberculosis, arthritism, (eczema, herpes, psoriaris, lichen). It can, again, be produced by vulvar zona, epithelioma of the vulva. We observe, again, a purely neurotic pruritus, which occurs without any apparent lesion of the mucous membrane, or the external integument in arthritic or herpetic women; some moral influence, a simple change of temperature, can give rise to it. Vulvar pruritus occurs at all ages, before puberty as well as after the menopause and during the procreative period. As a rule, it is due to local causes in the child, and to diathetic and constitutional causes in the adult. The symptoms vary greatly as to intensity and character: in slight cases the pruritus is slight, bearable, but can become a veritable torment in intensity and persistence : the patient feels an irresistible desire to scratch herself, to resort to severe and repeated frictions of the parts to calm these itchings that she cannot endure. This morbid phenomenon, sometimes so intense and so painful, cannot last long without the general health suffering: also, we soon see insomnia, loss of appetite, dyspepsia, hypochondriasis, and even convulsive attacks in women predisposed to them; often the pruritus Atropine is said to be an antidote to carbolic is associated with vulvar hyperæsthesia and acid poisoning. vaginismus. The duration varies with the |