Digestive disturbances may be noticed. There may be loss of appetite and voinitino.; and sometimes an obstinate watery cliarrhcea comes on, due to amyloid degeneration of the intestine, or to tuberculous or scrofulous ul ceration. The child is usually languid and easily tired. After exertion he is apt to look weary and haggard ; but if kept quiet, his face, although pallid, shows no signs of distress. Often his fingers and toes are clubbed.
A constant symptom of amyloid disease is anoemia, and the poorness of blood is marked in proportion to the intensity of the degeneration. Con sequently, in severe cases, the skin and mucous membranes are pallid, and some cedema, of the legs and feet may be noticed. Still, no doubt, the kid neys in many cases participate in the amyloid disease, and the anaemia and dropsy may be partially dependent upon the renal mischief. Albuminuria and casts may then be seen in the urine, but, as is elsewhere explained, these are not necessary symptoms of alburninoid kidney.
Diagnosis.—Mere enlargement of the liver is at once detected by palpa tion of the belly. It must be remembered that a hepatic swelling often presses up the diaphragm on the right side, and may cause dulness and weak breathing at the base of the right pulmonary region. Such signs (dulness and weak breathing) may be mistaken for signs of a pleuritic ef fusion, more particularly as the signs are detected all round that side of the chest—in front as well as behind. A distinction may be made by noticing that in the case of an enlarged liver the dulness reaches up to a higher level in front than it does at the back (in pleurisy it is higher behind); that the dulness does not pass abruptly into resonance, as it would do in the case of fluid, for the thin border of the lung overlies the upper margin of the liver and produces a modified tubular or tympanitic note at that point ; and, lastly, that there is no alteration of the percussion-note in the dull area when the patient lies on his left side. A dull note replaced by resonance on change of position is characteristic of fluid ; and if the quantity of fluid be small, with little thickening of the pleura, this test of the effect of gravity upon the percussion-note will usually give satisfactory results in the child.
A liver enlarged from amyloid degeneration is smooth and particularly firm and resisting. It often feels hard like wood. Its edge is thin and not
rounded, and pressure upon it produces no uneasiness. Such a liver, un accompanied by jaundice or ascites, and found in a cachectic, pallid child who has a syphilitic history, or has been the subject of bone disease or other form of prolonged suppuration, is in all probability albuminoid. If the spleen is also enlarged, and there is albuminuria with hyaline casts, there can be little doubt of the correctness of this opinion. Absence of splenin dulness does not exclude albuminoid disease, for an amyloid spleen is not always bigger than natural. In half the cases the size of the spleen is not increased.
Hepatic enlargement from congestion rarely occurs in cachectic, anm mic children ; and a fatty liver is soft and yielding instead of hard and resisting ; moreover, it is not accompanied by enlargement of the spleen or albuminuria.
Prognosis.—The presence of amyloid degeneration of the liver in any cachectic child must necessarily be considered as an additional element of danger. There is, however, reason to believe that this form of disease is of less serious augury in the young subject than it is in the adult, pro vided that the source of irritation and suppuration can be removed. It is undeniable that in cases in which enlargement of the liver and spleen exactly resembling amyloid disease complicates old-standing ne crosis of bone in scrofulous children, removal of the bone disease by a suitable operation is often followed by a return of the liver and spleen to their normal dimensions, and, to all appearance, by complete recovery of health. Mr. Barwell has recorded some remarkable cases of this kind. In one of these the urine was also albuminous and contained casts of tubes; but after the operation the urine gradually became normal, and the dis eased organs eventually returned to their normal size. It may be objected that in such cases the enlargement is not due to amyloid disease. That it is so cannot of course be proved, as the crucial test of dissection is wanting. It can only be said that the organs diseased are those com monly diseased in albuminoicl degeneration ; that the symptoms and physical signs are such as are found in cases of this form of illness ; and that the causes which are acknowledged to be powerful in producing al buminoid lesions have been in operation.