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In 211 days there were nine paroxysms of fever of an average duration of thirteen to fourteen days, with afebrile intervals of ten to eleven days, making the intervals between the highest temperatures about twenty-four days. During the attacks the temperature rose slowly and sank rather suddenly, the defervescence often being accompanied by sweating. The appetite was lost during the paroxysms, but became ravenous in the intervals. The spleen was enlarged, and became even larger during the attacks of fever, but the lymph glands were not enlarged. After the tenth attack the temperature remained raised for twenty-two days, and then fell, but rose again almost immediately, and the patient died five days later in a state of collapse. Post mortem, white nodules were found in the pleura ; the bronchial and mediastinal glands were enlarged, and there were nodules in the spleen, liver, and kidneys. Ebstein regarded the case as one of malignant lymphoma.

Dr. Musser publishes two similar cases of his own, and notes of another are given by Dr. Shaw. In the first of Dr. Musser's the illness lasted eighteen months. There was enlargement of the spleen and lymph glands. The temperature is summarised as follows :

Febrile period.—November 27 to December 3 (6 days).
Afebrile period.—December 3 to December 12 (9 days).
Febrile period.—December 12 to December 21 (9 days).
Afebrile period.—December 21 to January 1 (11 days).
Febrile period.January 1 to January 9 (8 days).
Afebrile period.—January 9 to January 20 (11 days).
Febrile period.—January 20 to January 30 (10 days).

From subsequent inquiry it was known that the temperature was subnormal on February 4, that there was a transient rise just before the 12th, and that it was normal again on the 19th. The next recorded febrile period began on March 4 and continued till the 11th, but had ceased some time before the 18th. An afebrile period of fourteen days followed, but on the 25th the temperature rose to 104°, becoming subnormal again on April 8. Death ultimately occurred from

or

exhaustion. During the paroxysms the glands in the neck and axilla became swollen, and a heart murmur developed. The patient had loss of appetite, nausea, and vomiting, and emaciated rapidly. Towards the end of the attack there was slight jaundice, with bile in the urine. During the intervals the swelling of the glands subsided, the appetite returned, and the patient ate ravenously and increased in weight. There was some reduction of red cells, but no leucocytosis. In Dr. Musser's second case similar symptoms were present, but the case gave evidence of general tubercular infection—a condition which was also present in one of the previously-recorded cases.

The case published by Dr. Bewley and Mr. Scott is that of a man, thirty-five years of age, who first had an attack of fever, supposed to have been enteric, lasting four weeks, followed by two relapses of ten days' duration each, with periods. normal temperature in between.

A second attack occurred two months later, accompanied by an irritating cough, which was believed to be due to enlargement of some of the intra-thoracic glands. A blood count showed 3,570,000 red cells, and one or two white to 2,288 red cells. The hæmoglobin was 90 per cent. The fever continued for some five or six weeks, and it was thought that the patient was going to die, when the temperature fell to normal in three days, and in a week he was to all appearances practically well. A month later there was a relapse, with another period of apparent recovery, only to be followed by a further prolonged period of fever, at the end of which the patient died of exhaustion. Post mortem, a large mass was found' behind the sternum arising from the mediastinal glands, with: another small mass attached to the inner pleural surface of the right upper lobe, and extending into the lung substance: Enlarged glands were also found at the attachment of the mesentery round the aorta. There was a small grey spot in: the liver, and the spleen was mottled and irregular. Microscopically, the growths were composed of fibrous tissue strands, with a few cells lying in the interspaces. No microorganisms could be found.

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., 4! 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.

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.

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.

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

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