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DISEASES OF CHILDREN.
THE BRITISH MEDICAL ASSOCIATION.
failed. As must always happen when classification of a disease proceeded upon clinical and pathological rather than ’upon etiological lines the literature of dysentery was burdened with an interminable mass of appellations indicating either the nature of the disorder or the individual author’s conception of its pathological anatomy. Dysenteries, however, were now divided by the chief writers into several groups depending upon the clinical history or the mode of prevalence. Thus Osler wrote of the acute catarrhal,
wanted.
613
Given
a predisposing cause a very small exciting needed to develop lateral curvature. One patient he had cured who having taken to fencing relapsed. When the fencing was stopped the patient at once improved. Mr. Noble Smith advocated fencing with both hands alternately. He then dwelt on the great value put by employers on ambidexterity in all trades and arts. For this reason pianoforte players were superior to their fellows as they were able to use both hands. There was a popular idea that right-handedness was natural. There were disadvantages in onesidedness, as it led to over-work of one-half of the brain. It was curious and interesting that evidence showed that if the left hand was being educated the right hand did better work also, especially in drawing and writing. He then drew attention to the production of deformity by the use of one side, hand, and arm, especially in lateral curvature of the spine. It was noteworthy that in so many of these cases there was a bend to the right of the upper part of the spine. The exciting
cause
was
tropical or amcebic, the diphtheritic, and the chronic dysentery. Davidson considered the subject under two headings ; first according to prevalence, as epidemic, as endemic, and as the dysentery of war and famine ; secondly, and clinically, as acute, as fibrinous or pseudo-diphtheritic, and Kartulis described endemic, epidemic, as chronic dysentery. and sporadic varieties. Manson spoke of catarrhal and ulcerating dysentery; whilst Delafield distinguished at least five distinct types of the disease as occurring in the environs of New York, and only one of these five types appeared to be due to a specific agent, the amoeba coli. The history of the causes were mainly unilateral, standing on one leg, playing bacteriological investigation of dysentery was then referred the violin, wrong position in sitting, and use of the right to, but the majority of the micro-organisms enumerated, arm. In his experience shortness of one leg had produced except that described by Chantemesse and Widal, did not lateral curvature in many cases, the lumbar curve being the appear really to be possessed of any specific properties. chief and primary one, the dorsal one being the secondary Investigations carried on by Ogata in Japan in connexion one. The left leg was the short one most frequently. The with an epidemic of dysentery had given more convincing onesidedness in such patients was undoubtedly a great results. Ogata had isolated a fine bacillus, which stained by cause of curvatures. They seemed to have a great tendency Gram’s method, which liquified gelatin, and which to lean to the left and to .walk in the dark or when they caused intestinal ulceration in guinea-pigs and cats. had lost their way to the left, the right side leading, so Vivaldi in Padua had isolated from cases of dysentery to speak. He here mentioned cases of right- and lefta bacillus which resembled Ogata’s, but the organism sidedness among the lower animals and mentioned that had not been isolated again. Shiga investigated the flies seemed to move to the right, as they always flew into dysentery which occurred in Tokyo in 1897, and suc- his left eye. The PRESIDENT (Dr. FREDERICK TAYLOR of London) ceeded in isolating from the intestinal dejecta and from the mesenteric glands a bacillus which appeared to bear a questioned whether they might not be retrograding in causative relation to the cases of disease in which it occurred, civilisation by becoming ambidextrous after one hand He then and which resembled a bacillus which Professor Flexner had got so specialised for many generations. himself had isolated from cases of dysentery occurring dwelt humorously on the many inconveniences which might amongst American troops in the Philippines. In the Philip- occur if bimanualism became common, the difficulties of pines the disease had occurred mainly in two forms-the knowing which hand to shake hands with, how to place the the
acute and the chronic. Amoebas were either absent or very difficult to find in the dejecta from the acute cases, whilst they were commonly found in the chronic cases in which ulceration was present. In the chronic cases, however, they were variable both as to occurrence and as to the number of them present. Large hepatic abscesses, usually single, were met with in a number of these cases. In the bacteriological examination of both acute and chronic cases pyogenic bacteria were always present, but their presence was held to be accidental. From many of the cases a bacillus undoubtedly identical with that isolated by Shiga from cases of dysentery in Japan was identified. The cultural characteristics of this organism, its morphology, and the evidence connecting its presence with the causation of the disease were then fully described. In concluding, Professor Flexner said that he was disposed
to view
tropical dysentery
as
including
a
bacillary variety
and an amœbic variety, separable both in their early and later stages by their clinical history, by their etiology, and by their morbid anatomy. Whether epidemic dysentery might have a simpler etiology future studies would be necessary to decide. Dr. PATRICK MANSON (London) in his remarks on Professor Flexner’s paper, agreed that they must look for more thun a single cause for cases of dysentery. There were clinical varieties of dysentery, each of which probably had its specific cause. He felt sure that recurring or relapsing dysentery was not always due to the presence of amœba coli. Papers by Dr. LAZARUS-BARLOW (London) on Lipomata of the Kidney and by Dr. WILFRED J. HARRIS (London) on the Pathology and Significance of the Argyll-Robertson Pupil concluded the proceedings of the section.
DISEASES OF CHILDREN. THURSDAY, AUGUST 2ND. Mr. NOBLE SMITH
Replying
to the
read a paper on Method ofTeaching Children.
(London)
Ambidexterityas
a
President’s
-
query concerning fencing in the discussion upon lateral curvature he said that there were a few cases in which lateral curvature had been attributed to its influence, but more evidence was
knife, fork, and spoon on a table, and the like. Mr. W. GREEN (Portsmouth) made a few remarks. Mr. MUIRHEAD LITTLE
(London)
drew attention to the
great slowness with which the left hand learned any
new
movement. In reply Mr. NOBLE SMITH said that he had only dealt with the fringe of the subject and hoped to pursue further
investigations.
Mr. MUIRHEAD LITTLE read A Series
an
analysis
of
of Cases of Infantile Paralysis with
some Notes on Treatment. There were over 115 cases with 147 limbs involved. The palsies were much more severe in the legs. The palsy was on the left side in 78 cases and on the right in 68 cases. One-third of the cases occurred in the second year of life. In some there was no acute loss of power. In 43 there was a sudden paralysis. In 19 the child was found palsied in the after morning having been put to bed all right overnight. There were convulsions (fits) only in four cases and there was unconsciousness in six others. Teething was hardly ever a cause of infantile palsy. Accidents, including falls, accounted for nine cases. One case only was said to come from sitting There were 20 cases of talipes equinus, on damp grass. 20 cases of talipes varus, 14 of talipes equino-valgus, 5 of talipes calcaneus, 18 of talipes calcaneo-valgus, 21 of talipes valgus, 14 of pes cavus, 15 of "flail ankle," 1 of weak foot, and 1 of weak knee. In four cases the upper extremities were involved. Probably the proportion given was not a true one of the ratio of affection of the upper limbs, because disease of the upper portion of the spine was more likely to kill and deformities of the feet and legs were more likely to be brought before the notice of the surgeon by the parents. Among the principal muscles affected were the following : the flexors of the great toe in 64 instances, those of the four outer toes in 66 cases, the tibialis posticus in 90 cases, the tibialis anticus in 100 cases, the extensor proprius pollicis in 79 cases, that of the four outer toes in 88 cases, the peroneus longus in 74 cases, the triceps cruris in 55 cases, the flexors of the knee in 66 cases, and the quadriceps extensors in 52 cases. Attention was drawn to the cases wherein a wasted thigh was succeeded by a welldeveloped and well-nourished leg and calf. Under the head of treatment Mr. Muirhead Little considered tenotomies and
614
THE BRITISH MEDICAL ASSOCIATION.
the suitable training of weak muscles. Eight cases were dealt with by tendon grafting, of which details were quoted. In four cases a stiff ankle was purposely made. Mr. NOBLE SMITH remarked on the transplantation of tendons, or rather the transference of muscular power from This should be considered, to be one place to another. successful, as, in fact, an addition to their methods of treatment, not as a substitute. The deformity should be removed first, then the tendons might be transplanted. The improvement in the nutrition of the foot was very marked after tenotomy, although the operation was not on or very near the palsied muscles. This fact suggested whether it might not be well to try doing tenotomy ot the palsied muscles in order directly to affect their nutrition in the same way. Mr. JACKSON CLARKE (London) was glad that the question had been brought forward by Mr. Little as Mr. Little’s father had introduced the subject of the surgical treatment of paralysis to the profession. He discussed the effects of the transplantation of tendons. Mr. NOBLE SMITH related one case of transplantation of tendons with complete success. Mr. MUIRHEAD LITTLE, in reply, dwelt more fully on the tenoplastic operations. He was always careful to get reduction as far as possible of the first. He also advocated the use of instruments after the operations to support the new tendons.
Splenic anœmia.—All that has been hitherto said has been somewhat of a preliminary and introductory nature leading up to the important subject which we have now more especially to consider-viz., that in which the enlargement of the spleen is associated with profound anæmia and which has been named "splenic anaemia" " The name is unfortunate for two reasons : first, that it seems to imply or assume what really is not yet proved, that the ansemia in some way depends upon, and is caused by, the affection of the spleen; secondly, because the same term is applied to two entirely different clinical affections-the one a rare disease affecting adults chiefly and only very rarely children and so far as I know not recorded at all in very young children and in infants, and the other a not uncommon disease to which infants are especially liable, though it may continue from infancy through the first two or three years of life. In either case splenic anaemia has many synonyms-e g., splenic cachexia,
.
splenic pseudo-leucocythæmia, lymphadenoma splenica, splenomegalie primitive, and many others-names which, on the one hand, indicate the difficulties of diagnosis and, on
the other, show how much there is still to be learnt of the real nature of the disease. If the term "splenic anaemia"be retained we must distinguish the two groups as splenic anæmia of the adult and splenic anæmia ot the infant. deformity I do not think it is necessary in this connexion to enter into any details of cases of splenic anæmia of the adult, for thev are so rare in children. FRIDAY, AUGUST 3RD. Splenic anœmia in the infant.—The nature of the case is Dr. SAMUEL WEST (London) introduced a discussion upon often clearly indicated by the peculiar anæmia and the enlargement of the abdomen. The complexion has a Enlargement of the Spleen in Children, peculiar, waxy, ivory-like colour with a tinge of olive-green as follows. Children are subject to the same enlargements in it which is very characteristic. The abdomen is tumid of the spleen as adults, but with a frequency which and the enlargement of the spleen is often obvious to the varies according to the degree to which they are exposed to eye. The child ia usually not emaciated and may be plump, the common exciting causes. In childhood growth is active; but is very feeble. The blood shows no changes but those this presumes active growth in the blood and blood-making of simple anaemia, and there is little or no general enlargeThe child is brought organs to keep pace with the general demands of the body. ment of the lymphatic glands. Active growth implies instability of structure, so that slight under observation usually on account of general illcauses may produce great disturbing effects. It might health, weakness, and pallor, occasionally on account of therefore a priori be expected that children would be subject respiratory catarrh or gastro-intestinal disturbance or to enlargements of the spleen of a kind and with a frequency some other accidental complication, but only rarely uncommon in the adult. Most of the other Besides this, enlargements of the because the abdomen is enlarged. spleen are more easy to detect in the child. In what now symptoms are accounted for by the extreme anemia. follows I shall address myself to enlargement of the spleen The splenic enlargement is easy to make out ; it may be as it is met with in children, drawing attention to the points enormous, so that the organ may extend forward beyond the in which adults and children differ, and finally dealing fully umbilicus and downwards as far as the anterior superior iliac with the forms of splenic enlargement which are more or spine. It moves freely on respiration, is smooth on the less peculiar to children and infants. surface, and even when much enlarged is not tender to In all the specific fevers and the septic diseases alike palpation. The changes in the blood are those of simple post-mortem observation proves the spleen to be almost ana3rcia, the cells being greatly reduced in number but without exception enlarged, though it is by no means retaining their relative proportion to each other. The always easy to demonstrate this enlargement during life. I number of red cells may fall as low as 40 per cent. of the do not know that there are any post-mortem statistics to normal; if below this the result is almost invariably fatal. prove that enlargements of the spleen are more common in The red cells retain their normal amount of haemoglobin, these fevers in the child than in the adult. though some writers maintain that it is reduced as in Malaria.—Malarial enlargement of the spleen in this chlorosis. Nucleated red cells and megalocytes are often country is certainly rare in children, for ague is rare, but not present in small numbers, but the eosinophile cells do not It may then be vary. If there be any increase in the number of so in countries where malaria is common. found where there is little or no evidence of definite malarial white cells it affects only the lymphocytes and this stands in direct relation, it appears, with the fever. The attacks. Leucocythœmia is usually met with in the middle periods affection commences almost invariably in infants or very of life and is comparatively uncommon in children and very young children, and when discovered for the first time in rare in the very young, yet well-marked instances have been older children has in all probability dated from infancy. recorded in infants of a few weeks-e.g., from eight to ten The liability of the sexes is equal. The affection runs a weeks old. chronic course, lasting some months, but in the end many With Hodgkin’s disease the difficulties are greater but they patients get quite well. But on the ultimate prognosis in arise chiefly from the indefinite character of the disease general very varying opinions are held by different writers. itself. Hodgkin’s disease occors fairly frequently in children The treatment is that of anasmia, and consists of good but it is very rare before the age of eight years and is, I food, plenty of light and air, cod-liver oil, hypophosphites, believe, unknown in infants. Regarded as the cause of iron, and similar remedies. Quinine is useful in malarial splenic enlargement the difficulty of diagnosis with Hodgkin’s cases, mercury and iodide of potassium in syphilitic cases, disease is not nearly so great as it appears, for the spleen but the specific remedies, especially mercury, not only do no becomes enlarged as a rule only subsequently to the enlarge- good, but are actually harmful where the specific cause is ment of the lymphatic glands in general, so that there is this absent. Arsenic is a favourite remedy as in other forms of anaemia, but is far inferior to iron. general glandular enlargement to aqsist the diagnosis. The association of enlargement of the spleen with rickets Titberole.-The spleen is almost the favourite seat of ’, tubercle and rarely, if ever, escapes when tubercle is dis- and syphilis has been already mentioned, but it is important seminated either in the acute or chronic form. In the to consider the relation in which these conditions really chronic form the enlargement may be considerable, for the stand to one another. Enlargement of the spleen is almost spleen may be stuffed with caseous nodules as large as a constant in active syphilis of the child. Among infants with cob-nut. congenital syphilis it is found in at least 50 per cent, and in Syphilis.—Syphilitic enlargement of the spleen is of a yet larger percentage among still-born syphilitic fcetnses. clinical importance in one class of cases only--viz., that of The association of syphilis with enlargement of the spleen is, as already stated, held by many to be unfavourable and it i infants and very young children.
I
failed. As must always happen when classification of a disease proceeded upon clinical and pathological rather than ’upon etiological lines the literature of dysentery was burdened with an interminable mass of appellations indicating either the nature of the disorder or the individual author’s conception of its pathological anatomy. Dysenteries, however, were now divided by the chief writers into several groups depending upon the clinical history or the mode of prevalence. Thus Osler wrote of the acute catarrhal,
wanted.
613
Given
a predisposing cause a very small exciting needed to develop lateral curvature. One patient he had cured who having taken to fencing relapsed. When the fencing was stopped the patient at once improved. Mr. Noble Smith advocated fencing with both hands alternately. He then dwelt on the great value put by employers on ambidexterity in all trades and arts. For this reason pianoforte players were superior to their fellows as they were able to use both hands. There was a popular idea that right-handedness was natural. There were disadvantages in onesidedness, as it led to over-work of one-half of the brain. It was curious and interesting that evidence showed that if the left hand was being educated the right hand did better work also, especially in drawing and writing. He then drew attention to the production of deformity by the use of one side, hand, and arm, especially in lateral curvature of the spine. It was noteworthy that in so many of these cases there was a bend to the right of the upper part of the spine. The exciting
cause
was
tropical or amcebic, the diphtheritic, and the chronic dysentery. Davidson considered the subject under two headings ; first according to prevalence, as epidemic, as endemic, and as the dysentery of war and famine ; secondly, and clinically, as acute, as fibrinous or pseudo-diphtheritic, and Kartulis described endemic, epidemic, as chronic dysentery. and sporadic varieties. Manson spoke of catarrhal and ulcerating dysentery; whilst Delafield distinguished at least five distinct types of the disease as occurring in the environs of New York, and only one of these five types appeared to be due to a specific agent, the amoeba coli. The history of the causes were mainly unilateral, standing on one leg, playing bacteriological investigation of dysentery was then referred the violin, wrong position in sitting, and use of the right to, but the majority of the micro-organisms enumerated, arm. In his experience shortness of one leg had produced except that described by Chantemesse and Widal, did not lateral curvature in many cases, the lumbar curve being the appear really to be possessed of any specific properties. chief and primary one, the dorsal one being the secondary Investigations carried on by Ogata in Japan in connexion one. The left leg was the short one most frequently. The with an epidemic of dysentery had given more convincing onesidedness in such patients was undoubtedly a great results. Ogata had isolated a fine bacillus, which stained by cause of curvatures. They seemed to have a great tendency Gram’s method, which liquified gelatin, and which to lean to the left and to .walk in the dark or when they caused intestinal ulceration in guinea-pigs and cats. had lost their way to the left, the right side leading, so Vivaldi in Padua had isolated from cases of dysentery to speak. He here mentioned cases of right- and lefta bacillus which resembled Ogata’s, but the organism sidedness among the lower animals and mentioned that had not been isolated again. Shiga investigated the flies seemed to move to the right, as they always flew into dysentery which occurred in Tokyo in 1897, and suc- his left eye. The PRESIDENT (Dr. FREDERICK TAYLOR of London) ceeded in isolating from the intestinal dejecta and from the mesenteric glands a bacillus which appeared to bear a questioned whether they might not be retrograding in causative relation to the cases of disease in which it occurred, civilisation by becoming ambidextrous after one hand He then and which resembled a bacillus which Professor Flexner had got so specialised for many generations. himself had isolated from cases of dysentery occurring dwelt humorously on the many inconveniences which might amongst American troops in the Philippines. In the Philip- occur if bimanualism became common, the difficulties of pines the disease had occurred mainly in two forms-the knowing which hand to shake hands with, how to place the the
acute and the chronic. Amoebas were either absent or very difficult to find in the dejecta from the acute cases, whilst they were commonly found in the chronic cases in which ulceration was present. In the chronic cases, however, they were variable both as to occurrence and as to the number of them present. Large hepatic abscesses, usually single, were met with in a number of these cases. In the bacteriological examination of both acute and chronic cases pyogenic bacteria were always present, but their presence was held to be accidental. From many of the cases a bacillus undoubtedly identical with that isolated by Shiga from cases of dysentery in Japan was identified. The cultural characteristics of this organism, its morphology, and the evidence connecting its presence with the causation of the disease were then fully described. In concluding, Professor Flexner said that he was disposed
to view
tropical dysentery
as
including
a
bacillary variety
and an amœbic variety, separable both in their early and later stages by their clinical history, by their etiology, and by their morbid anatomy. Whether epidemic dysentery might have a simpler etiology future studies would be necessary to decide. Dr. PATRICK MANSON (London) in his remarks on Professor Flexner’s paper, agreed that they must look for more thun a single cause for cases of dysentery. There were clinical varieties of dysentery, each of which probably had its specific cause. He felt sure that recurring or relapsing dysentery was not always due to the presence of amœba coli. Papers by Dr. LAZARUS-BARLOW (London) on Lipomata of the Kidney and by Dr. WILFRED J. HARRIS (London) on the Pathology and Significance of the Argyll-Robertson Pupil concluded the proceedings of the section.
DISEASES OF CHILDREN. THURSDAY, AUGUST 2ND. Mr. NOBLE SMITH
Replying
to the
read a paper on Method ofTeaching Children.
(London)
Ambidexterityas
a
President’s
-
query concerning fencing in the discussion upon lateral curvature he said that there were a few cases in which lateral curvature had been attributed to its influence, but more evidence was
knife, fork, and spoon on a table, and the like. Mr. W. GREEN (Portsmouth) made a few remarks. Mr. MUIRHEAD LITTLE
(London)
drew attention to the
great slowness with which the left hand learned any
new
movement. In reply Mr. NOBLE SMITH said that he had only dealt with the fringe of the subject and hoped to pursue further
investigations.
Mr. MUIRHEAD LITTLE read A Series
an
analysis
of
of Cases of Infantile Paralysis with
some Notes on Treatment. There were over 115 cases with 147 limbs involved. The palsies were much more severe in the legs. The palsy was on the left side in 78 cases and on the right in 68 cases. One-third of the cases occurred in the second year of life. In some there was no acute loss of power. In 43 there was a sudden paralysis. In 19 the child was found palsied in the after morning having been put to bed all right overnight. There were convulsions (fits) only in four cases and there was unconsciousness in six others. Teething was hardly ever a cause of infantile palsy. Accidents, including falls, accounted for nine cases. One case only was said to come from sitting There were 20 cases of talipes equinus, on damp grass. 20 cases of talipes varus, 14 of talipes equino-valgus, 5 of talipes calcaneus, 18 of talipes calcaneo-valgus, 21 of talipes valgus, 14 of pes cavus, 15 of "flail ankle," 1 of weak foot, and 1 of weak knee. In four cases the upper extremities were involved. Probably the proportion given was not a true one of the ratio of affection of the upper limbs, because disease of the upper portion of the spine was more likely to kill and deformities of the feet and legs were more likely to be brought before the notice of the surgeon by the parents. Among the principal muscles affected were the following : the flexors of the great toe in 64 instances, those of the four outer toes in 66 cases, the tibialis posticus in 90 cases, the tibialis anticus in 100 cases, the extensor proprius pollicis in 79 cases, that of the four outer toes in 88 cases, the peroneus longus in 74 cases, the triceps cruris in 55 cases, the flexors of the knee in 66 cases, and the quadriceps extensors in 52 cases. Attention was drawn to the cases wherein a wasted thigh was succeeded by a welldeveloped and well-nourished leg and calf. Under the head of treatment Mr. Muirhead Little considered tenotomies and
614
THE BRITISH MEDICAL ASSOCIATION.
the suitable training of weak muscles. Eight cases were dealt with by tendon grafting, of which details were quoted. In four cases a stiff ankle was purposely made. Mr. NOBLE SMITH remarked on the transplantation of tendons, or rather the transference of muscular power from This should be considered, to be one place to another. successful, as, in fact, an addition to their methods of treatment, not as a substitute. The deformity should be removed first, then the tendons might be transplanted. The improvement in the nutrition of the foot was very marked after tenotomy, although the operation was not on or very near the palsied muscles. This fact suggested whether it might not be well to try doing tenotomy ot the palsied muscles in order directly to affect their nutrition in the same way. Mr. JACKSON CLARKE (London) was glad that the question had been brought forward by Mr. Little as Mr. Little’s father had introduced the subject of the surgical treatment of paralysis to the profession. He discussed the effects of the transplantation of tendons. Mr. NOBLE SMITH related one case of transplantation of tendons with complete success. Mr. MUIRHEAD LITTLE, in reply, dwelt more fully on the tenoplastic operations. He was always careful to get reduction as far as possible of the first. He also advocated the use of instruments after the operations to support the new tendons.
Splenic anœmia.—All that has been hitherto said has been somewhat of a preliminary and introductory nature leading up to the important subject which we have now more especially to consider-viz., that in which the enlargement of the spleen is associated with profound anæmia and which has been named "splenic anaemia" " The name is unfortunate for two reasons : first, that it seems to imply or assume what really is not yet proved, that the ansemia in some way depends upon, and is caused by, the affection of the spleen; secondly, because the same term is applied to two entirely different clinical affections-the one a rare disease affecting adults chiefly and only very rarely children and so far as I know not recorded at all in very young children and in infants, and the other a not uncommon disease to which infants are especially liable, though it may continue from infancy through the first two or three years of life. In either case splenic anaemia has many synonyms-e g., splenic cachexia,
.
splenic pseudo-leucocythæmia, lymphadenoma splenica, splenomegalie primitive, and many others-names which, on the one hand, indicate the difficulties of diagnosis and, on
the other, show how much there is still to be learnt of the real nature of the disease. If the term "splenic anaemia"be retained we must distinguish the two groups as splenic anæmia of the adult and splenic anæmia ot the infant. deformity I do not think it is necessary in this connexion to enter into any details of cases of splenic anæmia of the adult, for thev are so rare in children. FRIDAY, AUGUST 3RD. Splenic anœmia in the infant.—The nature of the case is Dr. SAMUEL WEST (London) introduced a discussion upon often clearly indicated by the peculiar anæmia and the enlargement of the abdomen. The complexion has a Enlargement of the Spleen in Children, peculiar, waxy, ivory-like colour with a tinge of olive-green as follows. Children are subject to the same enlargements in it which is very characteristic. The abdomen is tumid of the spleen as adults, but with a frequency which and the enlargement of the spleen is often obvious to the varies according to the degree to which they are exposed to eye. The child ia usually not emaciated and may be plump, the common exciting causes. In childhood growth is active; but is very feeble. The blood shows no changes but those this presumes active growth in the blood and blood-making of simple anaemia, and there is little or no general enlargeThe child is brought organs to keep pace with the general demands of the body. ment of the lymphatic glands. Active growth implies instability of structure, so that slight under observation usually on account of general illcauses may produce great disturbing effects. It might health, weakness, and pallor, occasionally on account of therefore a priori be expected that children would be subject respiratory catarrh or gastro-intestinal disturbance or to enlargements of the spleen of a kind and with a frequency some other accidental complication, but only rarely uncommon in the adult. Most of the other Besides this, enlargements of the because the abdomen is enlarged. spleen are more easy to detect in the child. In what now symptoms are accounted for by the extreme anemia. follows I shall address myself to enlargement of the spleen The splenic enlargement is easy to make out ; it may be as it is met with in children, drawing attention to the points enormous, so that the organ may extend forward beyond the in which adults and children differ, and finally dealing fully umbilicus and downwards as far as the anterior superior iliac with the forms of splenic enlargement which are more or spine. It moves freely on respiration, is smooth on the less peculiar to children and infants. surface, and even when much enlarged is not tender to In all the specific fevers and the septic diseases alike palpation. The changes in the blood are those of simple post-mortem observation proves the spleen to be almost ana3rcia, the cells being greatly reduced in number but without exception enlarged, though it is by no means retaining their relative proportion to each other. The always easy to demonstrate this enlargement during life. I number of red cells may fall as low as 40 per cent. of the do not know that there are any post-mortem statistics to normal; if below this the result is almost invariably fatal. prove that enlargements of the spleen are more common in The red cells retain their normal amount of haemoglobin, these fevers in the child than in the adult. though some writers maintain that it is reduced as in Malaria.—Malarial enlargement of the spleen in this chlorosis. Nucleated red cells and megalocytes are often country is certainly rare in children, for ague is rare, but not present in small numbers, but the eosinophile cells do not It may then be vary. If there be any increase in the number of so in countries where malaria is common. found where there is little or no evidence of definite malarial white cells it affects only the lymphocytes and this stands in direct relation, it appears, with the fever. The attacks. Leucocythœmia is usually met with in the middle periods affection commences almost invariably in infants or very of life and is comparatively uncommon in children and very young children, and when discovered for the first time in rare in the very young, yet well-marked instances have been older children has in all probability dated from infancy. recorded in infants of a few weeks-e.g., from eight to ten The liability of the sexes is equal. The affection runs a weeks old. chronic course, lasting some months, but in the end many With Hodgkin’s disease the difficulties are greater but they patients get quite well. But on the ultimate prognosis in arise chiefly from the indefinite character of the disease general very varying opinions are held by different writers. itself. Hodgkin’s disease occors fairly frequently in children The treatment is that of anasmia, and consists of good but it is very rare before the age of eight years and is, I food, plenty of light and air, cod-liver oil, hypophosphites, believe, unknown in infants. Regarded as the cause of iron, and similar remedies. Quinine is useful in malarial splenic enlargement the difficulty of diagnosis with Hodgkin’s cases, mercury and iodide of potassium in syphilitic cases, disease is not nearly so great as it appears, for the spleen but the specific remedies, especially mercury, not only do no becomes enlarged as a rule only subsequently to the enlarge- good, but are actually harmful where the specific cause is ment of the lymphatic glands in general, so that there is this absent. Arsenic is a favourite remedy as in other forms of anaemia, but is far inferior to iron. general glandular enlargement to aqsist the diagnosis. The association of enlargement of the spleen with rickets Titberole.-The spleen is almost the favourite seat of ’, tubercle and rarely, if ever, escapes when tubercle is dis- and syphilis has been already mentioned, but it is important seminated either in the acute or chronic form. In the to consider the relation in which these conditions really chronic form the enlargement may be considerable, for the stand to one another. Enlargement of the spleen is almost spleen may be stuffed with caseous nodules as large as a constant in active syphilis of the child. Among infants with cob-nut. congenital syphilis it is found in at least 50 per cent, and in Syphilis.—Syphilitic enlargement of the spleen is of a yet larger percentage among still-born syphilitic fcetnses. clinical importance in one class of cases only--viz., that of The association of syphilis with enlargement of the spleen is, as already stated, held by many to be unfavourable and it i infants and very young children.
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