Stimmuttous
change

528

IIOPCKIN'S DISI-'ASI-

Ivor,, vi

their local oiigin. Plasma cells m;t\ also be present. Small areas of
necrosis occur, and wiih the passage of time progic-ssive (ibrosis occurs.
In some cases Ihe lymplioi'.rantiloma undcrj'ocs ;i sarcomatous change,
and "Hodgkin grunulomif becomes "Hodgkin sarcoma', which living
compared to the sequel of squnmous-cclled carcinoma in lupus vulgaris.
In three out of Hodgkin's original seven cases histolorjeal exainination
in 1926 showed the characteristic changes (I;o\).

6.-CIJNICAI, PICTURF,
The onset of lymphadcnoma is nearly always gradual, and usually slight
enlargement of the superficial lymphatic nodes above the clavicle, in
the posterior triangle of the neck, in the axilla, or groin is detected
before symptoms of malaise, undue fatigue, loss of weight, anaemia,
or dyspepsia are noticeable. The enlargement begins on one side and
subsequently becomes bilateral.
Glands The aflected glands are round, smooth, discrete, freely movable,
seldom tender or painful, and not adherent to each other or the skin,
unless there has been a secondary infection, pyogenic or tuberculous.
The largest nodes lend to lie towards the centre of the mass; those at
the periphery may be small and even shotty. The supraclavicular,
axillary, and inguinal glands are those most often clinically obvious,
but enlargement may appear first in other positions, for example, the
epilrochlear gland at the elbow. When glands at the root of the neck or
in Ihe axilla are involved in a morbid process, palpable enlargement of
glands lying on the costocoraeoid ligament below the clavicle has been
found to be an important differential diagnostic sign in favour of
Hodgkin's disease.
Enlargement of the superficial lymphatic nodes may disappear under
treatment, entirely or partially, for a time, while insidious enlarge-
ment of the deep nodes progresses and the patient becomes anaemic,
emaciated, and goes steadily downhill. Similar and temporary diminu-
tion or even disappearance of glandular enlargement may follow acute
infections, such as erysipelas, lobar pneumonia, or influen/al pneumonia;
that improvement may also occur in these circumstances in leukaemia
is of interest in connexion with their common membership of the
lymphoblastoma group, with Symmere's view that Hodgkin's disease
and myeloid leukaemia are 'probably different quantitative responses
to the same type of provocative agent', and with W. B. Coley's treat-
ment of Hodgkin's disease by the mixed toxins of erysipelas and
Chromobacterium prodigiosum and by the application of radium.
Shod In the earlier stages there may be no change in the blood, but later a
progressive secondary anaemia develops. It has been stated that the
degree of anaemia runs parallel with the hepatic enlargement. In the
late stages it may become so severe as to require blood transfusion. This
anaemia may in different cases be explained by one or more of the