LECTURE XL.

ABDOMINAL TUMOURS.-Enlargement of abdomen not always the result of actual disease-causes to which it may be due.-Abdominal tumours-from enlargement of the liver, by albuminoid deposit, by hydatid growths, by malignant disease— from malignant disease of the kidney-from enlargement of the spleen-from psoas abscess.-Cases in illustration.

The Cachexia of early life.-Syphilis, Scrofula and Rickets.

INFANTILE SYPHILIS--its symptoms-characters of the syphilitic cachexia-morbid appearances supposed to be due to it-tendency of the symptoms to return after apparent cure.-Treatment.

AMONG the anatomical peculiarities of early life, none is more remarkable than the great size of the abdomen, as contrasted with the undeveloped state of the thorax on the one hand, and of the lower extremities on the other. Though most striking in the newborn infant, it still continues to a great degree during the whole of the first years of childhood; nor does it altogether disappear until, with advancing age, the pelvis enlarges, the spinal column acquires its proper curvature, the limbs gain their due development, and the chest expands in a measure commensurate with the demands made upon the thoracic viscera for the vigorous performance of their functions.

The anxiety of non-professional persons is often needlessly excited by the large size of the abdomen in childhood, while those even who are conversant with medicine do not always bear in mind the very different causes to which an increase of its bulk may be due. It will, therefore, I think, be no waste of time to notice briefly the circumstances in which enlargement of the abdomen may occur in childhood, and to give you what little information I may be able to furnish with reference to those diseases that occasion distinct abdominal tumours.

The abdomen sometimes appears preternaturally large, wholly independent of any disorder of the general health, but as the result of the child's growth and development having gone on slowly, so that its body retains its infantile proportions but little altered at the age of two or three years. If, as often happens, this tardy

development should be associated with feeble health, with a somewhat impaired performance of the digestive functions, and with a constipated condition of the bowels, flatus is almost sure to collect in the intestines, and the enlargement of the abdomen is thus rendered still more considerable. With such a state of health, too, some of the minor degrees of rickets are often associated; and even though no serious deformity mark the existence of the disorder, yet to its influence are due the undeveloped chest and the small pelvis; while the contracted and misshapen thorax, which is produced by the advance of the disease, makes the abdominal enlargement appear more striking, and causes the child, according to MM. Rilliet and Barthez' apt comparison, to resemble the toy tumblers which Italian image boys sell about the streets.

In cases such as have been referred to, you will save yourselves and your patient's friends much needless anxiety, if you bear in mind that tabes mesenterica is exceedingly rare before five years of age, while this condition of general abdominal enlargement is met with chiefly between the commencement and the end of the first dentition. Further, you will find that, in these circumstances, the abdomen is perfectly soft and painless; you will learn that no symptom of tubercle has shown itself; while if you strip the child, which in doubtful cases you ought to do, you will probably see more or less distinct indications of the action of rickets, either in deforming the skeleton, or in disordering its proportions.

Enlargement of the abdomen is a much more frequent attendant on tubercular peritonitis than on mesenteric disease. The tense, and tympanitic, and painful state of the abdomen, the sensation of adhesion between the abdominal walls and the subjacent viscera, the loss of flesh, the frequently recurring diarrhoea, the febrile symptoms, and the more or less well-marked indications of tubercular disease which attend it, usually stamp the nature of that affection too clearly for the attentive observer to fall into error.

But besides these cases, in which there is a general enlargement of the abdomen, there are others in which its increase of size is mainly due to the presence of a distinct and well-defined tumour. A good many instances of this sort have come under my notice at different times, though, as often happens in Dispensary and Hospital practice, the number of those is but small in which I have had the opportunity of watching the affection to its close, and of confirming or correcting by an examination after death the diagnosis formed during the lifetime of the patient.

In spite, however, of the imperfection and incompleteness of

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my opportunities for observation, I think that I may safely say that the diagnosis of abdominal tumours is attended by far smaller difficulties in childhood than in adult age. Either the liver, the spleen, or more rarely the kidney, is the almost invariable seat of any tumour discovered in the abdomen before puberty, and each is marked by signs too distinct, and accompanied by constitutional disturbance too characteristic, to allow much room for error.

The liver is by far the most frequent source of abdominal tumours in early life. It may sometimes be discovered projecting far lower than natural in early infancy, and especially in infants brought up by hand, and its increased size is then generally due to the existence of fatty deposit in its substance. In such conditions it is important as a sign of the imperfect assimilation which is going on, and as indicating the necessity of a change from the too exclusively farinaceous diet on which the infant had been fed, but it is one which has to be looked for, since it is never so considerable as to attract attention merely by the size of the organ. Again, in childhood, just as in adult age, very considerable enlargement of the liver follows chronic valvular disease of the heart, and its presence and degree govern in great measure our prognosis.

But the only forms of enlargement of the liver in which it attains so considerable a size as to force itself on the notice even of the unobservant, are those which are due either to the so-called albuminoid or amyloid degeneration of the organ; or to the development of cysts in its substance; or to the existence of malignant disease.

*

Though it is only quite recently, and mainly by the acuteness of Dr. Budd, that the albuminoid enlargement of the liver has been recognised as a distinct form of disease, yet its symptoms are very characteristic. Often in connection with scrofulous caries of some or other of the bones, or at any rate with a more or less marked scrofulous taint in the system; associated with imperfect nutrition, and in its more advanced stage, with albuminuria, ascites, and enlargement of the spleen, the liver is found enlarged, hard, its surface smooth, its edge sharp and defined; respects in which, as well as in its greater size, it differs from the characters it presents when it has undergone fatty degeneration. The date of its first occurrence is often difficult to ascertain, for its early stage is marked

In his Treatise on Diseases of the Liver, at p. 304; where, and in Henoch's Klinik der Unterleibs-Krankheiten, vol. i., Berlin, 1852, p. 130, and in Frerich's Klinik der Leberkrankheiten, vol. ii. Braunschweig, 1861, p. 165, is to be found the best account of this affection.

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by no distinct symptoms; and I have sometimes discovered its existence when previously unsuspected while examining the abdomen of a child who was supposed to be suffering merely from general ill-health.

In the majority of instances which have come under my notice the children were between the ages of five and ten years, but it is probable that the affection had often begun much earlier, and the researches of Dr. Gubler* of Paris have proved that it frequently accompanies congenital syphilis; the liver having been found by him presenting the characteristic alterations within five weeks after birth. In rickety children, too, this form of enlargement of the liver is met with, though the affection of the organ is often partial, and the size which it attains is not so considerable as I have found it in other cases.

The disease is one essentially chronic in its course, and the size which the liver attains is sometimes very considerable before the general health is seriously disturbed. Thus, I remember a little girl about ten years old who was received into St. Bartholomew's Hospital on account of very great enlargement of her abdomen. She looked very pale, and the distension of the superficial veins of her chest and abdomen, and the livid congestion of her face, showed that there existed some serious obstacle to the circulation. Her abdomen had been gradually enlarging for many months, and at the time of her admission into the hospital the margin of the liver was distinctly traceable below the umbilicus; her bowels were habitually constipated, but the evacuations were natural in appearance, and the child was well-nourished, cheerful, and active, being but little annoyed by her great size. I saw her again two years afterwards, and her condition was then quite unaltered, and her health not at all more impaired. Her case was indeed, in this respect, somewhat exceptional, but though in every instance the condition is associated with obvious indications of a scrofulous habit, and nutrition is usually but ill-performed, it yet seems to have no tendency to endanger life so long as the peculiar deposit to which the enlargement of the organ is due continues limited to the liver, or to that organ and the spleen. But in some instances a similar deposit takes place in the substance of the kidneys, blocking up their tubules, and interfering with the proper discharge of their functions; albumen then appears in the urine, which is secreted in very small quantities, anasarca and ascites come on,

* Mémoires de la Société de Biologie, Paris, 1853, 8vo. p. 25.

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and death takes place eventually, as the result of the renal disease, not of the mere affection of the liver.

There are still many points unsettled concerning both the nature and the seat of this peculiar deposit. All that we can at present determine about the disease is that it is a sign and a consequence of the scrofulous or of the syphilitic cachexia, generally slow in its development, and comparatively unimportant in its results so long as the kidney is unaffected by it; but then becoming dangerous to life, and being amenable to no kind of treatment. Fresh air, appropriate diet, cod-liver oil, and the iodides of potassium and iron, are the only remedies which I have employed; and under their use I have seen much improvement take place in the general health, and some diminution in the size of the enlarged viscus; but when the kidney is involved I have never seen any abiding amendment, while the patient's state has generally fluctuated in proportion as the secretion of urine was more or less abundant.

I once met with a hydatid tumour of the liver in a girl aged 13 years, in whom, two years and a half previously, a swelling had begun to form at her right side, without any sign of general indisposition, though the subsequent increase of the growth had been attended with occasional attacks of severe pain. At the time of my seeing her she had gone through a variety of treatment, which consisted chiefly in leeching and the inunction of iodine ointment, without any benefit; but her general health was good, although she was small for her age. On removing her dress, the lower part of her chest and the upper part of her abdomen were seen to be much enlarged by a growth, the lower margin of which could be felt a little above the umbilicus, and which seemed larger on the right than on the left side. At this time the circumference of her chest, on a level with the nipple, was 25 inches, and 25 inches four inches lower down; but three years and a half later, and a short time before her death, she measured 32 inches at the former, and 33 at the latter point. Even when I first saw her, the respiratory murmur ceased to be audible on a level with the nipple, and the cavity of the chest became still more encroached on with the advance of the disease. Fluctuation was distinctly perceptible over nearly the whole of the tumour in the chest as well as in the abdomen, and continued so during the whole of the patient's life. It was in May 1840 that the patient first came under my notice, and no change whatever took place in her condition until February 1842. At that time, after severe pain in the tumour had