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ViPONn, M.D. Physician to the Montreal Dispensary, and C. F. Martin, B.A., M.D. Assistant Physician, Royal Victoria Hospital. Altliough cases of Hodgkin's disease are, as a rule, not difficult of diagnosis, there occur at times instances where the peculiarity of the blood conditions renders it not only difficult but even impossible to determine the differentiation between that disease and true leuchaemia. Our report concerns one such case, which further presented other features, rendering the condition worthy of special mention befoi'e this Society. One of us (V.) was called about the middle of November last to see a young Frenchman who complained of cough accompanied by head- ache, of deafness, painful swelling of the left arm and " lumps " on various parts of the body. He was a Canadian, 21 years old, of good habits, and accustomed to light work. He had a previous history of some early " cerebral " disease in which ho lost his eyesight and had been partially blind since the age of four years. He had never had malaria and gave no history of specific disease. There was a family history of tuberculosis. His present illness had commenced less than two months previously and was supposed to have followed some infection of the lips from playing on a friend's flageolet. His lips became swollen and painful, and shortly afterwards the lymph glands about the neck became enlarged. Rapidly the axillary and inguinal glands became swollen and the patient suffered pain in both thighs. This condition was accompanied by epistaxis, progressive anaemia and asthenia, slight dyspnoea, and about four weeks after the onset of the symptoms orthopncea supervened. On November 24th his left arm began to swell, and as his condition became grave he was sent to the Royal Victoria Hospital, where his > Read before the Montreal Medico-Chirurgical Society, January 23, 1896. t condition was noted as follows. (We are indebted to Dr. A. A. Robert- son for careful records of the case, from which we abstract these notes) : Patient is a young man, anaemic and very weak. He has a slight cough with dyspnoi^a, sometimes orthopno'a. He has headache, and pain in the left arm. Temperature 101^", pulse 126, respiration 32. The lymph glands all over the body are much enlarged, fairly movable, painless and without signs of suppuration. There is slight tenderness over the sternum. There is also general anasarca, with marked cedema, especially in the left arm and hand. The heart presents evidence of some dilatation, with a systolic murmur at the apex. There is no disease apparent in the lungs. Over the upper half of the sternum and right half of the pericar- dial area there is definite dulness merging into the cardiac dulness, due evidently to enlarged retro-sternal gland.s. The alimentary tract shows enlarged tonsils, coated tongue, some digestive disturbances, but no diarrhoea. The liver and spleen are palpable to a slight extent below the costal margin. The urine has an excess of uric acid, but is otherwise normal. Examination of the blood by various methods showed red cells l,13i,0db, white 24,000, haemoglobin 21 per cent. The leucocytosis was mainly lymphocytic (76 per cent.) The stained specimens further showed a large number of nucleated red cells, these nuclei often being broken up and showing a condition sometimes resem- bling mitosis. The polynuclear neutrophiles showed a similar pro-- cess of cell division. A number of free nuclei were present and but very few eosinophile cells. Examination of the eyes by Dr. Buller revealed a retinitis pigmen- tosa, with some appearances of a recent change in the disc, and also what seemed like retinal haemorrhages, though the patient's condition precluded the possibility of a satisfactory examination. The patient was treated by hypodermic injections of liq. sodii arsenitis, and for some weeks showed marked improvement. During this interval, however, a few other enlargements occurred, notably over the forehead, subcutaneously. His blood condition varied inappreciably from week to week, and the proportion of white to red cells varied within narrow limits of 1-50 to 1-75 or 1-100. The red cells remained between one and two millions. Towards the end of December his condition again became worse and he suffered from numerous hsemorrhages, chiefly from the nose. f ■f 9 / \ One of these attacks was markedly prolonged, and shortly after it the patient died, about ten or twelve weeks from the onset of the symptoms. A complete autopsy was permitted, and tha following main condi- tions were observed: General enlargement of all the glands, both superficial and deep ; in many of them hsemorrhagos had occurred. The spleen was but slightly enlarged, the kidneys dense and firm from the presence of numerous lymphomata. In the stomach, liver and intestines there were some evidences of overgrowth of lymphoid tissue. On the inner surface of the dura mater, beneath the skin of the forehead, and even in the calvarium, there were multiple hetei-o- plastic lymphoid tumours, many of them being as large as a filbert or even walnut. The bone marrow was distinctly pale. While we are unable as yet to give a complete report on the case, as our investigations are incomplete, we cannot but conclude that the conditions found bring into very close relationship the lympho- sarcomata and some cases of lymphatic leuchoemia. The blood condi- tion, with its numerous nucleated red cells, its leucocytosis of lymphocytes, renders the case extraordinarily like leuchsemia, while the tumours found in various portions of the cranium and other unusual sites give to the case all the characters of a lympho-sarcoma. It may, perhaps, be classed among the cases recorded by Fraenkel as instances of acute lymphatic leuchaemia, and in favour of this view are to be mentioned the sudden onset and early appearance of such symptoms as haemorrhage, etc. The case, however, is more than sug- gestive of the intimate relationship between cases of lymphatic leuchaemia and those of Hodgkin's disease, and it would amply bear out the ideas conveyed by some authors already as to the existence of this interesting relationship. S