Morbid Anatomy.—When enlarged from simple hypertrophy the spleen retains its normal shape. It is firm and smooth ; its capsule is thickened ; and a section shows a pale red or reddish purple surface, with the Malpighian bodies more or less distinctly visible.
Sy7nploms.—The existence of enlargement of the spleen is at once in dicated by the complexion of the child. The whole body—both skin and mucous membranes—is pale and bloodless ; but the tint of the face is characteristic. It has something of the colour of ivory or wax, with the addition of a faint olive cast which is not found in either of these substances. Often we notice a curious transparency, especially about the mouth and eyelids. The belly is large and the spleen can be readily felt as a smooth, firm mass. If the increase in size is great, the tumour projects diagonally across the abdomen, and presents on its inner surface the abrupt edge broken towards the middle by the notch. Usually the organ projects up wards and to the back as well as downwards, and its limits in these direc tions can be estimated by percussion. Sometimes it is freely movable by the hands, and it always descends when a deep breath is taken, rising again in expiration.
Although pale and bloodless the child has often a considerable amount of flesh, and is greatly wasted only in exceptional cases. He is, however, weak and languid. The bowels are often irritable, and in children of three or four years old the appetite is capricious and perhaps perverted, so that the patient shows a curious tendency to eat cinders, chalk, slate-pencil, and other gritty or even disgusting substances. CE dema of the lower limbs and eyelids is sometimes noticed, and petechim and bruise-like patches may be present in the skin. There is also a marked tendency to epistaxis.
On examination of the blood the red corpuscles form in the usual manner ; but tested by the hminacytometer their number is found to be reduced considerably below the normal average, and the white cells are often appreciably increased, although seldom to the degree observed in cases of leucocythetnia. Sometimes both red and white corpuscles are irregular in shape.
A little boy, aged one year and seven months, was said to have been born strong and healthy. He was the youngest of four, his elders being
all strong and well. He did not snuffle after birth, nor Were any spots noticed at that time on the buttocks. Until the age of ten months the child excited no anxiety, but he then began to get pale and to lose flesh. He had been lately very restless at night.
On, examination the infant was seen to be very anieinic over the whole body, and his complexion was of a dull yellowish-white, especially on the cheeks. He was thin although not emaciated, and his expression showed no sign of distress. The child was the subject of slight rickets, he had only two teeth, his chest was a little flattened laterally, and there was in significant enlargement of the epiphyses of the long bones. His legs were small, and he had never been able to walk. The fontanelle was about half an inch in diameter. The frontal bone was rather prominent on each side of the middle line, and there was some inconsiderable thickening of the parietal bones. Cranio-tabes was well marked.
The belly was very full and prominent, especially on the left side. As the child lay on his back, the lower border of the spleen was found to reach to the left crest of the ilium, and the inner margin passed obliquely down wards from beneath the ribs to within two fingers'-breadth -breadth of the right anterior superior spine of the ilium. The notch was felt just above the umbilicus. The organ was freely movable, descending appreciably in in spiration, and it could be pushed upwards until its lower border was on a level with the navel. Its substance was firm and hard, and its surface smooth. The upper border, estimated by percussion, rose to within two fingers'-breadth of the inferior angle of the left scapula. The edge of the liver was one inch below the costal margin. A small nodule could be felt on each side behind the ramus of the lower jaw ; otherwise there was no enlargement of the lymphatic glands. A little blue mark, like a bruise, was noticed on the forehead, and there was another on the back, but there were no petechim present on the skin. There was no oedema of the legs. The child's appetite was good, and he was not suffering from digestive dis turbance. An examination of the blood showed no excess of white cor puscles.