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Lymphomas, leucemias, and allied disorders in children
LY1VIPHOMAS, LEUCElV[IAS, A N D A L L I E D DISOR.DEP~S IN C H I L D R E N LLOYD F. CRAVER,M.D. NEw YORK, N. Y. relates to a cursory survey of our current cases, and T ofH I Scasesdiscussion admitted since 1931, of t t o d g k i n ' s disease, ]ymphosarcoma, ]eucemia, a a d allied conditions, occurring in children up to the age of ]5 years. A n y figures that are quoted p e r t a i n i n g to this group are not to be r e g a r d e d as statistiesl but are given merely for purposes of illustration and comparison. I-IODGKIN 'S D I S E A S E
I n this group were eight cases, of which one was lost to follow-up within three months. The ages of these patients at onset varied f r o m 2 (Figs. 1A and 1B) to 14 years. Two were under 5 and three were over 10 years of age. The axerage age of our entire group of H o d g k i n ' s cases is about thirty-five years. I t is of some interest that this p a r t i c u l a r group of children with H o d g k i n ' s disease consisted entirely of males, whereas in our entire group the p r o p o r t i o n of males to females is as 1.4 to 1. The sites of the earliest signs of the disease were as follows: the cervical nodes in five, the axilla in one, the abdomen in two. In the latter cases the condition was disclosed by e x p l o r a t o r y laparotomies p e r f o r m e d in other hospitals, in one instance for supposed appendicitis, in the other for supposed renal tumor. All these cases were treated by means of radiation, usually high voltage x-rays. One was treated with the r a d i u m element pack, and two received, as p a r t of their treatment, irradiation in small doses over the entire body in the Heublein unit. Two died, 61~ and 10 months respectively, following admission, and one was lost to follow-up within 3 months. F i v e are living, 11~, 3, 31/r 31/2, and 1 3 8 8 years since admission. The p a t i e n t surviving for 131~ years requires special mention. As a boy of 91/2 he first applied in 1924, when, u n f o r t u n a t e l y , we were a t t e m p t i n g to t r e a t m a n y of these cases without benefit of biopsy, relying on the since discredited " t h e r a p e u t i c t e s t . " However, he has been closely followed; a. biopsy of a node in 1930 was i n t e r p r e t e d as suggestive of H o d g k i n ' s disease, and a second biopsy in 1934 was definitely reported as H o d g k i n ' s disease. H e received 49 roentgen treatments to the l y m p h node regions and in August, 1935, a small dose of general irradiation. The continuity of his clinical course justifies the belief that his disease has been H o d g k i n ' s disease throughout. R e a d b e f o r e t h e S e c t i o n of P e d i a t r i c s , N e w Y o r k A c a d e m y of M e d i c i n e , Dec. 9, 1937. 332
CRAVER:
L Y M P H 0 1 V I A S , L E U C E M I A S ~ A N D A L L I E D DISORDERS
333
I n assessing results in the treatment of t I o d g k i n ' s disease and other lethal diseases of the lymphas group, we speak of 5-year survivals r a t h e r than cures. Our entire I I o d g k i n ' s disease group shows a 5-year survival rate of 17 per cent. I n t I o d g k i n ' s disease in children m a n y similarities to the disease as it is found in adults m a y be noted. I t has the same general clinical features and course: ]ymphadenopathy, fever, itching, eachexia, and anemia. I n observing children with this disease, we derive the same ideas as to the site of the origin of the process as we do in observing adults ; namely, that it most commonly arises internally, about the u p p e r or lower r e s p i r a t o r y or gastrointestinal tracts and that cervical, axillary
A.
B.
Fig. I.--A. Hodgkin's disease. F. H., aged 5 years. Onset was at 2 years of age. Enlargement of cervical nodes was the first sign to be observed. He was treated elsewhere first for tuberculous lymphadenitis. Later he had a cough, fever, and hemoptysis. On admission at the age of 5 years, he presented marked generalization
of Hodgkin's disease (verified by biopsy). B. M a r k e d r e g r e s s i o n of e n l a r g e d n o d e s r e s u l t e d f r o m t r e a t m e n t . However, the patient died three months after this picture was made (ten months' survival following admission).
or inguinal adenopathies are usually somewhat ]ate signs of a process that has been going on internally for some time. There is the same need in observing children to look sharply for various complications and obscure loci of granulomatous disease, as illustrated in Table I, proved eases of H o d g k i n ' s disease of all ages, in our series.
334
TI-IE JOURNAL OF PEDIATRICS TABLE I
SOI~IE COMPLICATIONS O]~~ J:[ODGKIN~S ]DISEASE OCCURRING IN A SERIES OF 220 ~ASES VERIFIED BY BIOPSYt ADA{ITTED BETWEEN JAN. 1, 1918, AND ]DEC. 31t 1935 Lesioi~s of t h e l u n g P l e u r u l effusion Ascites J~tundice
29% 17% 8% 6%
Itching V a r i o u s c u t a n e o u s lesions V a r i o u s neurological lesions L e s i o n s of t h e bones
29% 13% 12% 18%
I n this group of eigh t children, gross, roentgenologically detectable bone lesions were suspected in one patient, now deceased, and are fairly definite in one of the living patients. I n H o d g k i n ' s disease as a whole, the highest reported percentage of such gross bone lesions runs a r o u n d 16 per cent, but I feel that, if all cases could be watched to termination and such lesions were routinely sought, the percentage would be f o u n d to be much higher. Recently, a study of blood phosphatase in these cases suggests that we m a y be in possession of a test that will serve sometimes to indicate bone lesions before they a r e clearly demonstrable roentgenographically. F u r t h e r data m a y prove or disprove this possibility, but nevertheless in a n u m b e r of cases with demonstrable bone lesions, we are finding abn o r m a l l y high phosphatase values. The blood count in some children m a y show the leueocytosis and polynucleosis that are seen fairly commonly in adults, but the tendency to relative lymphocytosis t h a t occurs in younger children m a y render them less likely to show relative polynucleosis. I n children there' seems to be more eommonly an eosinophilia, a f e a t u r e which we do not r e g a r d as at all usual in H o d g k i n ' s disease iI~ the adult. The monocyte count m a y be increased. LYMPHOSARCOMA
Seven cases were considered verified by biopsy. One was a case of m a l i g n a n t lymphoeytoma with a blood count on admission with no unusual features. F o u r days before this p a t i e n t ' s death the blood count showed 6,600 white blood cells with 95 p e r cent lymphocytes. This case is a example of the a p p a r e n t t r a n s f o r m a t i o n of lymphosarcoma into lymphocytic leueemia (leucosarcoma), t h a t is p a r t i c u l a r l y likely to be observed in young patients. P r o b a b l y such a ease should be classed with lymphocytic leueemia. Two cases were diagnosed f r o m sections simply as lymphosareoma, the type not being specified. One showed "malignant t u m o r " b y aspiration biopsy, the clinical features (presternal mass, mediastinal mass, and cervical nodes, a n d the course) serving to substantiate the classification with lymphosarcoma. Three were reticulum cell lymphosareomas. The ages at onset in these seven cases varied f r o m 3.3 to 15 years (one was u n d e r 5 years and four were over 10). F i v e patients were boys, two were girls.
CRAVER:
LY2cIPHO3/LAS~ L E U C E M I A S t
A N D A L L I E D DISORDERS
335
The first a p p a r e n t sites of the disease were as ~ollows: over 9the right scapula in one, in cervical and preaurieular nodes in two, in the mediast i n u m in two, and in the abdomen in two.
B.
F i g . 2 . - - A . R e t i c u l u m cell l y m p h o s a r c o m a . c h a n g e s i n t h e skull. B. A. L. O s t e o l y t i e c h a n g e s in t h e pelvis.
A. L., a 13-year-~)Id
boy.
Osteolytic
336
~HE
J O U R N A L OF P E D I A T R I C S
The treatment was by means of high voltage x-rays mainly, and, to some extent, with the radium element pack. The results of x-ray therapy were less satisfactory than in Hodgkin's disease. All these seven patients are now dead, having survived from 1/~ month to 29 months following admission and averaging only 6.7 months. Certain complications that occurred in this group are of interest. One patient, aged 61~ years, died in another hospital after one month, of intestinal obstruction, presenting a marked general lymphadenopathy. One patient, aged 14 years, died in less than one month with invasion of the cranial cavity by lymphosarcoma growing by way of the ethmoid sinuses, and producing paralysis of the facial and third cranial nerves. This child also had a marked sepsis terminally. One boy, aged 13 years, showed bilateral infiltration of his testicles by ]ymphosareoma, and also had extensive destructive lesions of the bones, particularly of his skull and pelvis (Figs. 2A and 2B). One boy, aged 15 years, developed toward the last part of his 2 ~ year course a bilateral palsy of the vocal cords, with spilling of ingested material into the trachea. LEUCEMIA
There were 10 eases of ]eucemia, all of the acute lymphatic type. An autopsy was done in four cases and in each case the classification of lymphatic ]eucemia was verified. The ages of these patients varied from 4.9 to 15 years at the onset of the disease. There were eight boys and two girls. This disease is usually extremely acute in children. Radiation is apparently Of little or no value in prolonging life in children with acute leucemia ; in fact, it must be used very cautiously , as overdosage may be disastrous. Used judiciously, however, it may be of distinct palliative effect. Oftentbnes these patients have arthritic pains and swellings closeiy simulating rheumatic fever, but evidently part of the leucemic process. Small doses of radiation over the painful joints may quickly abolish pain and swelling. There is a remarkable tendency for the total white cell count and the differential count to fluctuate widely without reference to irradiation. The average survival in this particular group was only 0.9 months following admission, varying between I day and 3 months. The total course of the disease, from the time of apparent onset to the time of death varied from 8 days to 2 years. Excluding the 2-year case, the average total course was only 3 months (Figs. 3A and 3B and Figs. 4A, 4B, 4C and 4D). ENLARGED THYMUS
No attempt will be made to discuss here the controversial points regarding the relationship between the symptoms usually ascribed to by-
A.
B.
Fig. 3.---A. Patient H, L. 1~., acute lymphatic leucemia probably thymic, mass. B. Patient I~I. L. ]~., marked regression following very mediastinum.
with
a large
small
dose
mediastinal,
of x-rays
over
338
THE
J O U R N A L OF P E D I A T R I C S
p e r t r o p h y or persistent enlargement oi the t h y m u s and the actual state of the thymus. There were 16 cases, 14 in male infants and 2 in females, v a r y i n g in age, at the time of a p p a r e n t onset, f r o m birth to 6 months, with the exception of one case arising in a girl nearly 7 years old. (This child had pertussis and measles at 4 years of age. The roentgenograra of her chest showed a wide mediastinum and some infiltration at each hilum. The question arises whether she m a y not have had tuberculosis of the tracheobronchial l y m p h nodes. ) I n only two eases was there no evidence of mediastinal widening by roentgen r a y examination. As a rule, these eases were treated f r o m one to three times by small doses of roentgen rays directed to the anterior mediastinum, and as a rule there was p r o m p t and m a r k e d relief of symptoms.
~.
B.
Fig. 4 . - - A . P a t i e n t C. Z., s e v e r e n o m a in l y m p h a t i c l e u c e m i a , Oat. 30, 1935. C. Z. in profile.
B. P a t i e n t
One patient, treated by r a d i u m applicators, showed very slow response and seven years later had to have excised an area of skin damaged by radiodermatitis. I n another case the roentgenograms failed to show an enlarged thymus, and, since the tonsils were h y p e r t r o p h i e d and tonsillectomy seemed inadvisable, the tonsils were treated once by x-rays. This child showed no improvement at the end of six weeks and did not return. I N F E C T I O U S lVlONONUCLEOSIS
There was one ease in a girl, a little over 5 years of age, first seen in September, 1933, and still being followed. She had suffered pain in the
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L Y M P H O M A S , L E U C E M I A S , A N D A L L I E D DISORDERS
339
lower abdomen a n d vomiting for two weeks, and on admission she had enlargement of cervical and axil]ary l y m p h nodes and an enlargement of the liver. H e r blood count was 7,900 white cells, with 51 per cent lymphocytes. The heterophile antibody test was positive, a n d even three years later, in October, 1936, it showed agglutination in 1:64 dilution, She has had no t r e a t m e n t other t h a n general hygienic measures and a tonsillectomy nine months a f t e r admission. Gradually, the signs of the disease have disappeared. She now appears to be a healthy child.
Fig. 4 . - - C a n d D. P a t i e n t C. Z., s e v e r e n o m a in l y m p h a t i c l e u c e m i a , s e v e n d a y s l a t e r , Nov. 6, 1935.
SUMMARY AND CONCLUSIONS H o d g k i n ' s disease, ]ymphosarcoma, and leucemia occurring in children u n d e r 15 years of age present m a n y similarities to the same diseases as they are f o u n d in adults, but also some i m p o r t a n t differences. As in the case of m a l i g n a n t neoplasms, in general, in childhood these diseases tend to be more r a p i d in their course. Leueemia, for example, is nearly a l w a y s e x t r e m e l y acute and rapidly fatal, and it cannot be treated b y radiation in a w a y comparable to the t r e a t m e n t of chronic leucemia of the adult. I n general, in children H o d g k i n ' s disease offers a f a r better prognosis for palliation and length of survival t h a n does lymphosarcoma or leucemia. I n this p a p e r are discussed certain features of the course and treatment of 8 cases of H o d g k i n ' s disease, 7 cases of ]ymphosarcoma, 10 cases of leucemia, 16 cases of enlarged thymus, and 1 case of infectious mononucleosis observed in children at the Memorial Hospital since 1931. 772 MADISO~r AVENUE
I n this group were eight cases, of which one was lost to follow-up within three months. The ages of these patients at onset varied f r o m 2 (Figs. 1A and 1B) to 14 years. Two were under 5 and three were over 10 years of age. The axerage age of our entire group of H o d g k i n ' s cases is about thirty-five years. I t is of some interest that this p a r t i c u l a r group of children with H o d g k i n ' s disease consisted entirely of males, whereas in our entire group the p r o p o r t i o n of males to females is as 1.4 to 1. The sites of the earliest signs of the disease were as follows: the cervical nodes in five, the axilla in one, the abdomen in two. In the latter cases the condition was disclosed by e x p l o r a t o r y laparotomies p e r f o r m e d in other hospitals, in one instance for supposed appendicitis, in the other for supposed renal tumor. All these cases were treated by means of radiation, usually high voltage x-rays. One was treated with the r a d i u m element pack, and two received, as p a r t of their treatment, irradiation in small doses over the entire body in the Heublein unit. Two died, 61~ and 10 months respectively, following admission, and one was lost to follow-up within 3 months. F i v e are living, 11~, 3, 31/r 31/2, and 1 3 8 8 years since admission. The p a t i e n t surviving for 131~ years requires special mention. As a boy of 91/2 he first applied in 1924, when, u n f o r t u n a t e l y , we were a t t e m p t i n g to t r e a t m a n y of these cases without benefit of biopsy, relying on the since discredited " t h e r a p e u t i c t e s t . " However, he has been closely followed; a. biopsy of a node in 1930 was i n t e r p r e t e d as suggestive of H o d g k i n ' s disease, and a second biopsy in 1934 was definitely reported as H o d g k i n ' s disease. H e received 49 roentgen treatments to the l y m p h node regions and in August, 1935, a small dose of general irradiation. The continuity of his clinical course justifies the belief that his disease has been H o d g k i n ' s disease throughout. R e a d b e f o r e t h e S e c t i o n of P e d i a t r i c s , N e w Y o r k A c a d e m y of M e d i c i n e , Dec. 9, 1937. 332
CRAVER:
L Y M P H 0 1 V I A S , L E U C E M I A S ~ A N D A L L I E D DISORDERS
333
I n assessing results in the treatment of t I o d g k i n ' s disease and other lethal diseases of the lymphas group, we speak of 5-year survivals r a t h e r than cures. Our entire I I o d g k i n ' s disease group shows a 5-year survival rate of 17 per cent. I n t I o d g k i n ' s disease in children m a n y similarities to the disease as it is found in adults m a y be noted. I t has the same general clinical features and course: ]ymphadenopathy, fever, itching, eachexia, and anemia. I n observing children with this disease, we derive the same ideas as to the site of the origin of the process as we do in observing adults ; namely, that it most commonly arises internally, about the u p p e r or lower r e s p i r a t o r y or gastrointestinal tracts and that cervical, axillary
A.
B.
Fig. I.--A. Hodgkin's disease. F. H., aged 5 years. Onset was at 2 years of age. Enlargement of cervical nodes was the first sign to be observed. He was treated elsewhere first for tuberculous lymphadenitis. Later he had a cough, fever, and hemoptysis. On admission at the age of 5 years, he presented marked generalization
of Hodgkin's disease (verified by biopsy). B. M a r k e d r e g r e s s i o n of e n l a r g e d n o d e s r e s u l t e d f r o m t r e a t m e n t . However, the patient died three months after this picture was made (ten months' survival following admission).
or inguinal adenopathies are usually somewhat ]ate signs of a process that has been going on internally for some time. There is the same need in observing children to look sharply for various complications and obscure loci of granulomatous disease, as illustrated in Table I, proved eases of H o d g k i n ' s disease of all ages, in our series.
334
TI-IE JOURNAL OF PEDIATRICS TABLE I
SOI~IE COMPLICATIONS O]~~ J:[ODGKIN~S ]DISEASE OCCURRING IN A SERIES OF 220 ~ASES VERIFIED BY BIOPSYt ADA{ITTED BETWEEN JAN. 1, 1918, AND ]DEC. 31t 1935 Lesioi~s of t h e l u n g P l e u r u l effusion Ascites J~tundice
29% 17% 8% 6%
Itching V a r i o u s c u t a n e o u s lesions V a r i o u s neurological lesions L e s i o n s of t h e bones
29% 13% 12% 18%
I n this group of eigh t children, gross, roentgenologically detectable bone lesions were suspected in one patient, now deceased, and are fairly definite in one of the living patients. I n H o d g k i n ' s disease as a whole, the highest reported percentage of such gross bone lesions runs a r o u n d 16 per cent, but I feel that, if all cases could be watched to termination and such lesions were routinely sought, the percentage would be f o u n d to be much higher. Recently, a study of blood phosphatase in these cases suggests that we m a y be in possession of a test that will serve sometimes to indicate bone lesions before they a r e clearly demonstrable roentgenographically. F u r t h e r data m a y prove or disprove this possibility, but nevertheless in a n u m b e r of cases with demonstrable bone lesions, we are finding abn o r m a l l y high phosphatase values. The blood count in some children m a y show the leueocytosis and polynucleosis that are seen fairly commonly in adults, but the tendency to relative lymphocytosis t h a t occurs in younger children m a y render them less likely to show relative polynucleosis. I n children there' seems to be more eommonly an eosinophilia, a f e a t u r e which we do not r e g a r d as at all usual in H o d g k i n ' s disease iI~ the adult. The monocyte count m a y be increased. LYMPHOSARCOMA
Seven cases were considered verified by biopsy. One was a case of m a l i g n a n t lymphoeytoma with a blood count on admission with no unusual features. F o u r days before this p a t i e n t ' s death the blood count showed 6,600 white blood cells with 95 p e r cent lymphocytes. This case is a example of the a p p a r e n t t r a n s f o r m a t i o n of lymphosarcoma into lymphocytic leueemia (leucosarcoma), t h a t is p a r t i c u l a r l y likely to be observed in young patients. P r o b a b l y such a ease should be classed with lymphocytic leueemia. Two cases were diagnosed f r o m sections simply as lymphosareoma, the type not being specified. One showed "malignant t u m o r " b y aspiration biopsy, the clinical features (presternal mass, mediastinal mass, and cervical nodes, a n d the course) serving to substantiate the classification with lymphosarcoma. Three were reticulum cell lymphosareomas. The ages at onset in these seven cases varied f r o m 3.3 to 15 years (one was u n d e r 5 years and four were over 10). F i v e patients were boys, two were girls.
CRAVER:
LY2cIPHO3/LAS~ L E U C E M I A S t
A N D A L L I E D DISORDERS
335
The first a p p a r e n t sites of the disease were as ~ollows: over 9the right scapula in one, in cervical and preaurieular nodes in two, in the mediast i n u m in two, and in the abdomen in two.
B.
F i g . 2 . - - A . R e t i c u l u m cell l y m p h o s a r c o m a . c h a n g e s i n t h e skull. B. A. L. O s t e o l y t i e c h a n g e s in t h e pelvis.
A. L., a 13-year-~)Id
boy.
Osteolytic
336
~HE
J O U R N A L OF P E D I A T R I C S
The treatment was by means of high voltage x-rays mainly, and, to some extent, with the radium element pack. The results of x-ray therapy were less satisfactory than in Hodgkin's disease. All these seven patients are now dead, having survived from 1/~ month to 29 months following admission and averaging only 6.7 months. Certain complications that occurred in this group are of interest. One patient, aged 61~ years, died in another hospital after one month, of intestinal obstruction, presenting a marked general lymphadenopathy. One patient, aged 14 years, died in less than one month with invasion of the cranial cavity by lymphosarcoma growing by way of the ethmoid sinuses, and producing paralysis of the facial and third cranial nerves. This child also had a marked sepsis terminally. One boy, aged 13 years, showed bilateral infiltration of his testicles by ]ymphosareoma, and also had extensive destructive lesions of the bones, particularly of his skull and pelvis (Figs. 2A and 2B). One boy, aged 15 years, developed toward the last part of his 2 ~ year course a bilateral palsy of the vocal cords, with spilling of ingested material into the trachea. LEUCEMIA
There were 10 eases of ]eucemia, all of the acute lymphatic type. An autopsy was done in four cases and in each case the classification of lymphatic ]eucemia was verified. The ages of these patients varied from 4.9 to 15 years at the onset of the disease. There were eight boys and two girls. This disease is usually extremely acute in children. Radiation is apparently Of little or no value in prolonging life in children with acute leucemia ; in fact, it must be used very cautiously , as overdosage may be disastrous. Used judiciously, however, it may be of distinct palliative effect. Oftentbnes these patients have arthritic pains and swellings closeiy simulating rheumatic fever, but evidently part of the leucemic process. Small doses of radiation over the painful joints may quickly abolish pain and swelling. There is a remarkable tendency for the total white cell count and the differential count to fluctuate widely without reference to irradiation. The average survival in this particular group was only 0.9 months following admission, varying between I day and 3 months. The total course of the disease, from the time of apparent onset to the time of death varied from 8 days to 2 years. Excluding the 2-year case, the average total course was only 3 months (Figs. 3A and 3B and Figs. 4A, 4B, 4C and 4D). ENLARGED THYMUS
No attempt will be made to discuss here the controversial points regarding the relationship between the symptoms usually ascribed to by-
A.
B.
Fig. 3.---A. Patient H, L. 1~., acute lymphatic leucemia probably thymic, mass. B. Patient I~I. L. ]~., marked regression following very mediastinum.
with
a large
small
dose
mediastinal,
of x-rays
over
338
THE
J O U R N A L OF P E D I A T R I C S
p e r t r o p h y or persistent enlargement oi the t h y m u s and the actual state of the thymus. There were 16 cases, 14 in male infants and 2 in females, v a r y i n g in age, at the time of a p p a r e n t onset, f r o m birth to 6 months, with the exception of one case arising in a girl nearly 7 years old. (This child had pertussis and measles at 4 years of age. The roentgenograra of her chest showed a wide mediastinum and some infiltration at each hilum. The question arises whether she m a y not have had tuberculosis of the tracheobronchial l y m p h nodes. ) I n only two eases was there no evidence of mediastinal widening by roentgen r a y examination. As a rule, these eases were treated f r o m one to three times by small doses of roentgen rays directed to the anterior mediastinum, and as a rule there was p r o m p t and m a r k e d relief of symptoms.
~.
B.
Fig. 4 . - - A . P a t i e n t C. Z., s e v e r e n o m a in l y m p h a t i c l e u c e m i a , Oat. 30, 1935. C. Z. in profile.
B. P a t i e n t
One patient, treated by r a d i u m applicators, showed very slow response and seven years later had to have excised an area of skin damaged by radiodermatitis. I n another case the roentgenograms failed to show an enlarged thymus, and, since the tonsils were h y p e r t r o p h i e d and tonsillectomy seemed inadvisable, the tonsils were treated once by x-rays. This child showed no improvement at the end of six weeks and did not return. I N F E C T I O U S lVlONONUCLEOSIS
There was one ease in a girl, a little over 5 years of age, first seen in September, 1933, and still being followed. She had suffered pain in the
CRAVER:
L Y M P H O M A S , L E U C E M I A S , A N D A L L I E D DISORDERS
339
lower abdomen a n d vomiting for two weeks, and on admission she had enlargement of cervical and axil]ary l y m p h nodes and an enlargement of the liver. H e r blood count was 7,900 white cells, with 51 per cent lymphocytes. The heterophile antibody test was positive, a n d even three years later, in October, 1936, it showed agglutination in 1:64 dilution, She has had no t r e a t m e n t other t h a n general hygienic measures and a tonsillectomy nine months a f t e r admission. Gradually, the signs of the disease have disappeared. She now appears to be a healthy child.
Fig. 4 . - - C a n d D. P a t i e n t C. Z., s e v e r e n o m a in l y m p h a t i c l e u c e m i a , s e v e n d a y s l a t e r , Nov. 6, 1935.
SUMMARY AND CONCLUSIONS H o d g k i n ' s disease, ]ymphosarcoma, and leucemia occurring in children u n d e r 15 years of age present m a n y similarities to the same diseases as they are f o u n d in adults, but also some i m p o r t a n t differences. As in the case of m a l i g n a n t neoplasms, in general, in childhood these diseases tend to be more r a p i d in their course. Leueemia, for example, is nearly a l w a y s e x t r e m e l y acute and rapidly fatal, and it cannot be treated b y radiation in a w a y comparable to the t r e a t m e n t of chronic leucemia of the adult. I n general, in children H o d g k i n ' s disease offers a f a r better prognosis for palliation and length of survival t h a n does lymphosarcoma or leucemia. I n this p a p e r are discussed certain features of the course and treatment of 8 cases of H o d g k i n ' s disease, 7 cases of ]ymphosarcoma, 10 cases of leucemia, 16 cases of enlarged thymus, and 1 case of infectious mononucleosis observed in children at the Memorial Hospital since 1931. 772 MADISO~r AVENUE