ON THE

ENLARGEMENT OF THE VISCERA WHICH OCCURS IN RICKETS.

BY

WM. HOWSHIP DICKINSON, M.D. CANTAB., F.R.C.P.,

PHYSICIAN TO THE HOSPITAL FOR SICK CHILDREN; ASSISTANT-PHYSICIAN TO ST. GEORGE'S HOSPITAL.

Received June 3rd.-Read June 22nd, 1869.

It has long been known that with rickety children certain of the abdominal organs are apt to increase in bulk. Dr. Whistler, who gave in his dissertation De Morbo Puerili Anglorum,' published in 1645, the first account which we have of the rickets, as the complaint was even then popularly termed, described an enlargement of the liver and spleen as pertaining to the disease, and considered the "obstruction" in these viscera as the first departure from health. introduced the more than sesquipedalian word Pædosplanchnosteocace, as indicating that this disorder of childhood affected both the viscera and the bones.

1

He

Glisson, in his elaborate treatise upon rachitis, published five years later, refers to enlargement of the liver and mesenteric glands as belonging to the complaint, but considers that the spleen is not affected except as an accidental complication.

I Some interesting information concerning the bibliography of rickets is given by Dr. Gee in the Bartholomew's Hospital Reports,' vol. iv, p. 79.

Dr. Bright,1 in the year 1838, described an enlargement of the spleen as occurring especially in early childhood, though he did not associate it with the rickety condition. He described this organ as becoming hard like a half-ripe apple, as having on section the lustre of damson cheese, as presenting numerous opaque whitish granules (apparently the enlarged Malpighian corpuscles), and as being swollen to such an extent as often to occupy the greater part of the abdominal cavity.

It appears, however, that little attention had of late years been directed to the state of the abdominal organs in rickets until Sir William Jenner, in his well-known lectures,2 dwelt upon their changes in bulk and texture, and attributed them to an albuminoid infiltration. He pointed out that in the rickety enlargement the organs differ from the lardaceous or amyloid state in the absence of reaction with iodine, and, as regards the spleen in particular, in the absence of the sago-like transformation of the Malpighian corpuscles. He, however, made only a partial separation between the two conditions.

It seems that the alteration which the viscera undergo in rickets is still imperfectly understood, and is generally confused with the more common lardaceous or amyloid change, to which it bears a superficial resemblance while severed from it by essential differences.

I will now proceed to describe the changes which occur in the liver, spleen, and lymphatic glands in rickety children.

During the progress of rickets, if the disease be severe, and particularly if it be attended with emaciation, the liver is often found to extend below its normal situation, occasionally as low as the umbilicus, the smooth surface of the organ being very evident to the touch beneath the thin abdominal walls. The spleen under the same circumstances becomes enlarged, more frequently and to a greater extent, often acquiring seven or eight times its normal bulk and ''Guy's Hospital Reports,' vol. iii, p. 401.

2 Medical Times,' 1860.

occupying the greater part of the left side of the belly. This organ, dragged down by its increased weight, often lies with more of its bulk below than above the navel, the upper edge of the spleen being below and nearly parallel to the lower edge of the liver. A swelling often takes place at the same time in the absorbent glands, particularly in those of the mesentery. The glands which lie near the surface of the body are often evident to the touch like shots under the skin, but the swelling is seldom such as to cause visible protuberance.

Before dealing with these changes in their clinical results their morbid anatomy may be taken into consideration.

The liver, to commence with this organ, undergoes an increase of size evenly throughout its whole bulk. It becomes less friable than in health, hard, dense and elastic. It is usually pale in colour, containing little blood. The acini, themselves of yellowish colour, are often each surrounded by a thin pinkish or grey line, so that the cut surface is covered with a fine uniform polygonal pattern, such as may be produced when from any cause there is an increase in the fibrous tissue. Sometimes in these cases it is evident to the naked eye that there is an increased quantity of loose material surrounding the smaller branches of the portal vein. The alterations which have been described are, in fact, produced by a general increase in the fibroid tissue which belongs to the organ. Within the smaller portal canals this change is very evident to microscopic examination, the fibroid sheath being, perhaps, of twice its normal thickness. The alteration described is well shown in the accompanying plate. Plate IV, fig. 1, shows the general appearance of a section of liver affected as described, showing the great increase of the portal fibrous tissue. The section of a healthy liver prepared in the same manner, and belonging to the same period of life, is annexed. The woodcuts from the same preparations (page 362) show under a higher power the proportion which in disease and in health the fibroid tissue bears to the vessels it surrounds. Accompanying the portal vessels, and extending beyond them, the fibroid tissue

stretches between the lobules, circumscribes them more or less completely, and causes the demarcation which is so often evident to the naked eye.

FIG. 1.

X 100

Portal canals in rickety liver, showing increase of fibroid tissue.

FIG. 2.

X100

Portal canals in healthy liver, showing relation of fibroid tissue to vessels.

In some cases it appears that the cell-holding network of the acini is more closely packed than in health, as if from an excess of epithelial growth. The epithelium is sometimes fatty, sometimes almost free from oil. In this respect there is no constant change.

With the spleen the increase of bulk is usually greater than with the liver. A spleen which ought not to weigh an ounce may come to weigh half a pound. The texture and colour are changed. The soft friability of the organ is replaced by a resilient hardness, in extreme cases resembling, to use the simile of Bright, the consistence of a half-ripe apple. The colour is generally a deep red or purple, besprinkled with smooth white spots, which are enlarged Malpighian corpuscles. When the enlargement is great the section is sometimes mottled with a pale buff material, finely intermixed with the deeper colour. In some cases the colour and texture are thus altered, although the increase of bulk is trifling or absent. The amount of blood

in the vessels is generally less than in health.

The microscope shows that the minute structure of the spleen is modified in the following respects.

There is an increase in the delicate reticulum in which the splenic pulp is immediately contained. This network in the healthy spleen is of extreme tenuity, the threads slender, the interspaces comparatively large. In the rickety spleen the trabeculæ are often irregularly swollen, sometimes to such an extent that where the threads are thickest they may be as wide as the spaces they enclose.

The accompanying drawings show the change which has been described. (Plate IV, fig. 3.)

The larger fibrous divisions of the spleen are often widely separated by the swelling of the tissue between them, but in other particulars they are usually unaltered. In the case of a rickety dwarf, who died at the age of twenty-six, they were found to have become thickened.

In a case where the spleen was characteristically altered in consistence, but not increased in bulk, it was found that while the reticular basis of the organ was abnormally de