Besides pain, another important indication is obtained by noticing the degree of mobility retained by the spinal segments. The child holds his back stiffly, and avoids all movements which necessitate bending of-the spine. Thus, when laid down on his back and told to get up, he does so by turning slowly upon his hands and knees, keeping his back straight, and then getting carefully on to his feet. If required to pick up a small article from the floor, he turns sideways to the object and lowers and raises himself by bending and straightening his knees, keeping the spine straight and almost erect. Movements such as these are of great value, and in doubtful cases the child should be put through a series of exercises, so as to test thoroughly the mobility of his vertebral column. He should be re quired to turn round quickly as he walks, to climb a chair, or to touch his toes with outstretched fingers while his knees are straight.
Another important symptom is the attitude assumed by the patient when, at rest. If there be much disease of the bones, the child will en deavour to relieve the spine by supporting his head or diverting the weight of the body from his back to his arms. Thus the favourite attitude of a child whese cervical vertebra are affected is to sit with his elbows on the table supporting his head with his hands. In other cases of the disease the weight of the body is transmitted through the arms. Mr. Howard Marsh, who has devoted much attention to this subject, describes two char acteristic attitudes assumed by a child the subject of caries of the dor sal and lumbar spines. In one of these he places the palms of his hands on a chair, and leans over forwards with his arms straight and shoulders raised. By this means weight is taken off the spine and transmitted through the arms. Another position is equally characteristic. The child rests his weight on one toe, with the heel slightly raised and the knee flexed, and placing his hand on the middle of the thigh, leans over, so as to convey weight from the shoulder down the arm to the limb.
Attention to the above points will give very valuable information. Other symptoms are less trustworthy. Thus tenderness on pressure over the spines of the diseased vertebrre is sometimes present ; but it is not characteristic of caries. Striking with the knuckles down the centre of the back is a very fallacious test. In cases of undoubted caries there may be no response ; and a child may shrink when the spine is tapped even though the bones are sound. In the same way the application of a hot sponge to the spine as a test of tenderness is unsatisfactory, and in the case of a child little information is to be gained by this means.
Whenever spinal caries is suspected we should never forget to look for iliac or psoas abscess ; for in cases where the ulceration is limited to the surface of the bodies of the vertebrre, an abscess may form before any curvature can be detected in the spine.
Caseation of Glands. —One of the most familiar consequences of the scrofulous diathesis is a chronic enlargement of the lymphatic glands. In all subjects these glands are liable to enlarge upon slight irritation ; but in ahealthy constitution the swelling subsides when the cause which gave rise to it has passed away. In the child of scrofulous tendencies the cause exciting the morbid process may be so feeble and transient as to escape notice. But, the unhealthy action once set up runs a protracted course, and the enlargement continues until some further change takes place which causes it Co disappear. The steps by which the affected gland becomes converted into a cheesy mass have already been described. The process is a purely local one, and does not necessarily produce any ill effect upon the patient. It is evidence, no doubt, of a constitutional ten dency, and as such may excite apprehensions of other and more formida ble manifestations of the diathetic state. Of itself, however, unless the swollen glands be so situated as to press injuriously upon parts in the neighbourhood, or to threaten by setting up inflammation around to injure a vital organ, it is seldom attended with danger.
The glands most commonly affected are the cervical, the bronchial, and the mesenteric.
Chronic enlargement of the cervical glands is excessively common, on account of the many scrofulous lesions to which the head and face are liable. But these lesions do not all act with equal energy in promoting the glandular swelling. Inflammation of the pharyngeal mucous mem brane is found to produce this result far more frequently and readily than an irritant occupying any other part of the head and face. A skin affec tion may exist for a long time without causing enlargement of the glands, but a pharyngitis causes them to enlarge very quickly. Chronic glandular swellings arc seen as round or oval masses, firm to the touch, and usually freely movable. The skin over them retains its normal colour and is not adherent. They are generally to be seen behind the ear, beneath the lower jaw, and sometimes extending down the neck to the collar bone. The masses may be formed of single glands ; but more often several of these unite and are bound together by thickened and condensed cellular tissue. Such swellings may reach the size of a small apple. Usually, after a time, tenderness begins to be noticed ; the skin becomes adherent and red ; fluctuation is felt; and eventually the abscess bursts and dis charges its contents externally. Scrofulous abscesses are slow to heal. Often a discharging cavity is left from which a thin pus escapes ; or the opening enlarges, and we see a sluggish ulcer with thickened undermined edges. In bad cases several of these may be seen at the same time at each side of the neck.