Pseudoleukemia.
Synonyms:—Hodgkin's disease; lymphosarcoma; lymph-adenoma; anemia lymphatica.
Definition:—A condition in which there is extreme enlargement of the lymphatic glands, both from swelling and from an overgrowth of lymphoid tissue, together with a progressive anemia, and lymphoid growths also in the other blood-making organs.
Etiology:—But little can be said of the etiology of this disease. Notwithstanding persistent investigation in its pathology, no light has been thrown upon its actual causes. The disease occurs in early middle life, and is more common among males than in females in the proportion of about three to one. Chronic diarrhea, rickets, scrophulosis or tuberculosis are all thought to be contributive causes. Chronic disease of the mouth, resulting in glandular inflammations, has been thought to act as a first cause. Chronic malaria and syphilis have been found to be preexisting conditions in many cases, but no positive proof has been adduced as to their acting as exciting causes. The disease is more apt to appear among those who live in unhealthy localities with unhygienic surroundings, and who are careless of their health and are uncleanly. No advance has been made whatever in the study of the causative influence of infections or micro-organisms.
Symptomatology:—With these cases there is at first enlargement of the glands of the cervical region; it may appear uniformly upon both sides, but is usually observed first on one side. Very early in the history of the disease is an increase of the temperature, and if a study be made of the fever it will be found most interesting. Usually there is a period of increasing temperature until 104° F. or 104.5° F. is reached within three or four days. Then in a few days more this will decline to normal or subnormal, making a complete intermission. There will then be a sudden exacerbation, so that in a single day a high temperature will be reached, and this may last or it may decline slowly for a period of from ten to fourteen days, when the normal point will have been reached again, and the fever will disappear, to recur, occasionally, in much the same manner, after varying periods, and continuing for a longer or shorter time with each exacerbation. In this the condition closely resembles malarial disease, except that the paroxysms are by no means regular. It more closely resembles a relapsing fever, especially that of relapsing typhoid, as the author has met it in practice. Those cases which are characterized by a prolonged period of high temperature in each exacerbation are more likely to run a more rapid course and terminate earlier. With the fever there is early loss of appetite, progressive debility, lassitude, a heavily coated tongue, and disturbed digestion. This sometimes becomes a complicating factor. With the appearance of the anemia there are more or less heart symptoms, with difficulty of breathing, loss of breath or sighing respiration and palpitation, on exertion. There may also be paroxysms of cough. Many of these symptoms develop later from the extreme enlargement of the glands. This mechanical compression results in pain, if upon the nerves, and if upon the trachea and bronchial tubes will induce pain in the chest, difficulty of swallowing, difficulty of breathing, and at times will interfere materially with talking. The pressure applied upon these organs, and thus interfering also with the circulation in the vena cava and in the jugular veins, results in venous congestion, which may become extremely serious. This may be most pronounced in the head and upper extremities, resulting in edema. These tumors may cause displacement of the heart and interfere materially with its action, or they may induce serious perversion of the functional action of other important organs. Interference with the digestion is common, and jaundice occurs as a direct result of obstruction of the bile ducts from pressure. This same cause interferes with the circulation in the kidneys, and results in an early albuminuria, and this, combined with obstruction of the femoral veins, results in edema of the feet and legs. Interference of the function of the suprarenal capsules is supposed to cause the peculiar bronzing of the skin which is quite a constant symptom in this disorder. The spleen is not as greatly enlarged as is observable in leukemia; but it is always involved in the disease, and may extend toward the navel and be distinctly outlined. There is also in occasional cases enlargement of the thyroid and thymus glands, and rarely there are corresponding heart lesions, which seem to depend upon the disease of the thyroid. Itching of the skin is not an uncommon symptom.
In the development of the enlargement of the lymphatic glands there are some cases in which the cervical glands, are among the first to show signs of enlargement, and with all the concomitant symptoms, will increase in size quite rapidly for a number of weeks. Then all accompanying symptoms abate, and there is no advancement, and the patient is in reasonable health for several months, when another group of glands becomes involved, and all the symptoms recur, to be followed later on with another abatement of the active phenomena, but by little if any reduction of the size of the glands. The anemia is usually progressive from the first, but is by no means as pronounced as in the disorders that have been previously named. There is no reduction of the red corpuscles, nor any marked change in their characteristics, nor of the hemoglobin also, and the leukocytes are not greatly increased; in fact, in a few cases they have been found to be actually diminished. In the final stages of the disease the condition of the blood is very similar to that of an extreme case of secondary anemia.
Diagnosis:—It will be readily seen that pseudoleukemia in its early stages could be mistaken for tubercular adenitis; but the exacerbations in this disease, with the irregularity and intermittency of the temperature, and somewhat sudden enlargement of the glands are characteristic; furthermore, this disease is most common in adult life, while the former disease is common in childhood. Again, in adenitis the glandular enlargement is usually confined to one side and suppuration is common, while in Hodgkin's disease there is a uniform enlargement of the cervical glands on both sides, and while the glands are soft suppuration does not occur. Enlargement of the spleen, with pronounced anemia, will assist in the diagnosis of this disorder.
A comparison of the character of the blood in this disease and that of the various forms of anemia heretofore described will be of important assistance in making a correct diagnosis.
Prognosis:—The prognosis is always unfavorable when there is an acute development of the phenomena. The disease runs its course within a few months. In the more chronic cases, or in those in which the intermissions between the periods of progressive development are longer, the case may last for two or three years.
Treatment:—But little benefit has been obtained from treatment in this disorder. The use of arsenic is advised by all the writers of the old school as being of unquestioned value. There is no doubt that good results will occur from the use of phosphorus, especially if given in conjunction with iron. A syrup of the oxid of iron, combined with phosphorus and strychnin, will delay the progress of the disease. I would emphasize the remarks I made in the treatment of leukemia concerning the selection of our specific remedies whenever there are pronounced specific indications for their use. There are some of our writers, in whom we have confidence, who claim to cure tubercular adenitis with the use of our vegetable alteratives combined with phytolacca, which is given in full doses internally and applied externally, and it is but consistent with our methods of treatment that we should apply these remedies in this disease, where they are so strongly indicated, and carefully observe their result. Amelioration of the symptoms has been accomplished with the use of electricity, and also from the influence of the X-ray.
