All three papers discuss the pathology of the condition. Dr. Bewley and Mr. Scott look upon the attacks of temperature as due either to invasion of micro-organisms or to the effects of some poison formed during the spread of the growth. Dr. Musser, on the other hand, believes that Hodgkin's disease is in all probability a lymphatic tuberculosis, and that the recurrent attacks of fever are merely a symptom of the infection. Dr. Shaw similarly rejects the view that lymphadenoma with recurrent fever is a special form of disease-as seems to be suggested by the unfortunate name, "Ebstein's Disease," which is sometimes applied to it-and further points out that the specific agent causing lymphadenoma, whatever its action may be, is not responsible for the fever. He considers that the condition is due to a terminal infection occurring any time during the last year of life of patients affected with lymphadenoma, and that the nature of the infection varies in different cases. No explanation of the remarkable periodicity of the fever is offered by any of the writers. JAS. W. RUSSELL. PERFORATION OF THE STOMACH BY ULCER. (Continued). BY F. AND G. GROSS. IN the majority of cases, perforation occurs in subjects having a long preceding history of gastric trouble, often with classical symptoms of ulcer. Weir and Foote say 92 per cent. F. Brunner says 90 per cent. In some cases trouble appears to have subsided when perforation occurs, whilst others have antecedent symptoms suggestive of perforation. Other cases, which are rare, have an insidious onset, the ulcer remaining latent, and perforation occurring suddenly. F. Brunner, in 286 cases, showed 13, i.e., 43 per cent., arising in persons of apparently sound health. Traumatism is rare, but has happened from a fall from a ladder, reduction of umbilical hernia during an attack of vomiting, fit of coughing, sneezing, a false step, when dressing, getting into bed, ascent of a ladder, even during sleep; generally occurs a short time after food, i.e., during repletion, but has also been noted when stomach is empty. Mitschel records one occurring in a patient who was being fed exclusively per rectum in consequence of an attack of hæmatemesis. Symptomatology is important, and is divided into two stages: 1. Lasts twenty-four hours-the perforation and the issue of gastric contents; 2. The subsequent peritonitis, i.e., after twenty-four hours the symptoms are those common to general peritonitis. 1. (a) Sudden pain of an intense nature, resembling a knife thrust. Sometimes a burning or tearing pain in belly, and so intense as to double the patient up with agony. Sometimes so intense as to cause fainting. There are rare cases in which the pain has lasted several hours, and even days, often with exacerbations after a meal, and then suddenly becoming very severe; and in these cases the question is that of leaking ulcer. Other cases there are where the patients have after the primary pain been able to go on with their work, and on going home call in a doctor. The pain may, after its first violent onset, diminish for some hours, but more often it goes on progressing, with exacerbations after the ingestions of food or liquid. The pain is situated primarily in the epigastric region, sometimes towards the umbilicus or to one or other hypochondrium. F. Brunner notes 106 cases in which side is recorded eighty-six on left side, i.e., more frequently at cardiac end. Palpation in initial stage gives a greater tenderness over region of initial pain. Even when general diffusion has occurred, this disappears when the peritoneal symptoms are manifest. Pain in remote regions has been noted, as :— Broadbent, a pain in left clavicular region, when ulcer is in lesser curvature and towards cardia. Faure calls attention to the thoracic pain in one or other shoulder or between shoulders when peritonitis of region above umbilicus exists. ་་་ This, he states, always exists at first, but disappears when the other phenomena develop. There is a similar condition of clavicular or scapular pain existing in gall bladder, and pancreatic lesions involving local peritoneal complications. 66 Vomiting. The importance of this has been differently interpreted by various authors in the symptomatology of perforation. It can be absent entirely. Its rarity or absence has been noted by Roux, Jaboulay, and Viennay. Apparently it is rare in first twenty-four hours; then appears, and is due to the consecutive peritonitis, and ought not to be considered as due to the perforation. Certain authors, with Traube, have considered that vomiting is impossible in perforation because the contents of the stomach escape by the perforation. Ebstein considers that it is only possible when the perforation is obliterated in some way or is very small. Poncet cites a case where the vomiting, which had been continual, ceased altogether on the appearance of abdominal symptoms. Hartman also makes a similar observation. Roux and Ackermann have recorded cases in which the patient has vomited two or three times food and bile has emptied his stomach," then nothing has appeared until the vomiting of peritonitis. According to these authors, one will see all varieties, from complete absences to continual vomiting. "If," say they, in the majority of cases vomiting is completely wanting, is rare, slight, or only attempted, the observations made in which they are frequent or continual are sufficiently numerous to be taken into consideration." It appears that the complete absence is the rule in cases of perforation in the neighbourhood of the cardia, and frequency of vomiting to perforation immediately above or below the pylorus. According to F. Brunner, vomiting exists in one-third of cases. Vomit of first few hours consists of food, bile, sometimes without blood. Regurgitations without vomiting appear rare, while discharge of flatus, etc., is arrested with the onset of peritonitis. 66 Retraction.Tension, rigidity, and, above all, retraction of the abdominal wall, are well marked. The muscles are fixed. There is no abdominal respiration; the diaphragm is immobilised. This contraction of muscles is not only voluntary, but also reflex. Roux holds that the retraction of the abdominal wall is particularly pronounced where the stomach is concerned, since this organ is more intimately connected with the diaphragm. The degree of retraction is augmented by the fact that the diaphragm is held in forced expiration by the same reflex which contracts the abdominal muscles; the stomach is thus held fixed between the two planes. It is to be noted, however, that of this fixation there are varieties; thus one rectus may be more fixed than another, or the upper half only may be fixed, and in some cases it is wanting altogether. There may also be a certain amount of ballooning, which disappears at the end of twenty-four hours. F. Brunner states that in one half it goes at the end of ten hours. This ballooning is not accompanied by distension of the bowel, as in general peritonitis, but is caused by first escapes of gas into the peritoneum. Prehepatic Resonance.—The importance of the disappearance of the liver dulness is not to be over-estimated, since it can be easily imitated by the transmitted resonance of distended gut under a tense abdominal wall, and its ease of elicitation depends upon the amount of escaped gas, while it may be altogether absent. Liver dulness may also be wanting, and there be no perforation, as cited by Barker. F. Brunner estimates liver dulness persisting in one quarter of the cases; liver dulness diminished in one quarter; and liver dulness disappeared in one half the cases; but in this he does not count the time after perforation when signs of peritonitis may cause its absence. Abnormal dulness in flanks in first twenty-four hours and in dependent parts; thus it may appear at Poupart's ligament, but this sign is more than that of general peritonitis. Respiration is costal in type, superficial and accelerated, while there is a certain amount of what may be termed phrenic dyspnoea. Pulse is generally good, in spite of the gravity of the situation-a fact which is not generally recognised. D-Arcy Power shows that it augments in frequency every half-hour. Temperature.-Nothing constant. In the first few hours after perforation a subnormal temperature has frequently been recorded, or one nearly normal; more often the commencement of a febrile rise. With the onset of peritonitis, the temperature rapidly rises. The general state is at first that of great shock, determined by the amount of pain and the effect of the gastric contents on the peritoneum and sympathetic ganglia; also by the air in the peritoneal cavity. It seems to depend upon the intensity of the irritation, its rapidity and extent, and therefore depends somewhat upon the amount of the escaped gastric contents. As a matter of fact, severe shock is by no means constant, for some patients may remain after the first pain in a fairly satisfactory state; may even continue their work, whilst others show extreme collapse, with cold extremities; rapid, small, feeble pulse; subnormal temperature; cold sweat all over body, the legs flexed on abdomen and avoiding the least movement. Complications and Sequelæ :· 1. General peritonitis, with classical symptoms. 2. Local peritonitis, i.e., localised abscess. The shorter the time after perforation that these local abscesses form, the more dangerous the condition. Symptoms may be quite similar to general peritonitis at first, and the distinction is not easy. When, however, the general peritonitis manifestations lose their hyperacute characterthe tenderness, ballooning, pulse, etc.-but the fever persists with remissions, one must think of a localised abscess, needing careful search to find it, since there are often no local manifestations, no sensibility to pressure, or, as in the case of subphrenic abscess sometimes, no recognisable dul ness. Diagnosis -Perforated ulcer of duodenum. This is almost impossible to distinguish from perforation of pyloric end of stomach, but the following are peculiar features :— Previous history more often wanting. F. Brunner says 24 per cent., occur in apparently healthy persons, instead of 8 per cent., or even 4 per cent., as in case of stomach perforation. |