being any signs of rickets or any indication of a cause for the condition. Craniotabes is sometimes due to chronic hydrocephalus; in the great majority of instances, however, it is merely a manifestation of rickets, and it is generally found to some degree in any young baby who has marked rachitic symptoms. The most severe degrees of this condition, however, are rarely found except in children who are syphilitic as well as rickety, and it is believed that syphilis predisposes to its occurrence.

EXAMINATION OF THE NECK.

The neck must be examined for enlarged lymphatic glands, and when these are found their exact position must be noted and the area of skin or mucous membrane with which they are connected examined to discover the reason of the enlargement. If, for example, a number of superficial enlarged glands are found along the posterior border of the sterno-mastoid muscle, there probably is, or has recently been, some irritation in connection with the scalp, such as that produced by pediculi. Enlargement of the submaxillary lymphatic glands, if there is no visible cause for it on the face, generally indicates some irritation from the gums or teeth, and in the same way sores on the chin, the lower lip or on the front of the tongue, give rise to the enlargement of the supra-hyoid gland.

The upper set of deep cervical glands near the angle of the jaw, drain the naso-pharynx, the pharynx, and all the neighbouring parts, and as their area of distribution includes a very large amount of adenoid tissue, they are more frequently enlarged than any other. Their rapid enlargement on one or both sides generally signifies some lesion

in the area which they drain, and conversely, their being of quite a normal size is in favour of there being no serious or acute throat affection.

In examining infants of a few months old, one sometimes finds a hæmatoma of the sterno-mastoid- -or sterno-mastoid tumour, as it is sometimes called-situated in the substance of the muscle. This is due to injury of the muscle occurring during labour, but as the swelling is mainly caused by secondary overgrowth of fibrous tissue-" muscle-callus ". it is generally not discovered until some weeks after birth.

Rigidity of the neck in infants, or its retraction, represent two degrees of an interesting and important symptom, to which we shall return in considering the diagnosis of nervous disease. In older children a stiff neck is often a manifestation of rheumatism; but may indicate the presence of rheumatoid arthritis or cervical caries.

THE ABDOMEN.

Inspection. The infant's abdomen is normally more prominent than the adult's. This is due partly to the great tendency there is to the accumulation of gas in the intestine, and to the walls of the bowel and those of the abdomen being very easily distended by it; partly also to the relatively large size of the liver, and to the fact that the narrowness of the thorax makes the abdomen look, by contrast, even larger than it really is. Chronic dyspepsia gives rise to increased distention of the abdomen with gas, and this is apt to be attributed by anxious parents to serious abdominal disease. Enlargement of the abdomen is of course also often caused by increase in size of some of the organs or by the presence of a tumour or ascitic fluid.

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In inspecting a distended abdomen, it is important to note the exact position of the distention, and if it is uniform. or confined to one region only. It must also be noticed if there is any marked dilatation of the superficial veins, if the umbilicus is protruding, and if there is any tinge of redness about it. In cases of wasting, the skin of the abdominal wall often presents little colourless elevations scattered over its surface. These look like raised nodules, but on feeling them with the finger they are found to be quite soft; they consist of distended lymphspaces. In severe protracted cases of diarrhoea and tuberculosis, we may find small ecchymoses in the skin of the abdomen; they indicate a dangerous degree of weakness.

Retraction or hollowing out of the abdomen is a very significant sign of cerebral disease.

Palpation. In palpating the abdomen, it is important to ascertain if there is any pain on pressure. This is sometimes difficult to discover, because the child may cry, when touched, from general uneasiness. If, however, the presence of tenderness can be ascertained beyond a doubt, it is very significant, and in the great majority of cases indicates the presence of peritonitis. Absence of tenderness is less important. In many cases of tubercular peritonitis there is none, and even in acute peritonitis we may be unable to make sure of its presence.

Enlargement of the abdominal organs and the presence of tumours in this region are much more easily ascertained by palpation in children than in adults, owing to the thinness and softness of the abdominal walls. The investigation by palpation of morbid conditions in the abdomen is greatly

aided by the use of chloroform, and by combined rectal and abdominal examination.

Percussion.-Percussion is useful in determining the state of the stomach and bowels, and in confirming the results of palpation as to the size and position of various other organs. It is also of great value in investigating the presence of free fluid.

The Liver. The lower margin of the liver can usually be made out by palpation as well as by percussion. It reaches further down in children than in adults, usually extending to half an inch below the costal margin in the right mamillary line. This is partly due to the organ being relatively larger than it is in after life, and partly to the ribs lying more horizontal, and consequently leaving more of it uncovered (Sahli.)

Diminution in the size of the liver is exceedingly rare in childhood. It occurs in acute yellow atrophy, and in advanced stages of cirrhosis.

Enlargement is common, and may be due to many causes, of which the commonest is fatty accumulation. It may also be due to waxy disease, cirrhosis, the passive congestion of heart disease or mediastino-pericarditis, to tumour formation, &c.

The Spleen. The spleen is best investigated in children. by palpation. To examine it you stand on the child's right side, and laying your right hand on the left side of the abdomen, with the first two fingers over the left hypochondrium, press inwards and upwards. In some cases where the spleen is normal in size, and always if it is enlarged, its rounded edge will be felt as a soft and readily movable body. It is always well, before beginning to feel for the

spleen, to ascertain the position of the lower costal margin, as the cartilages of the floating ribs may be mistaken for the border of an enlarged spleen. If the child allows you a fair opportunity of palpating the spleen, and you do not feel it at all, you may rest assured that it is not enlarged. If you feel it at or about the level of the costal margins, it is either normal or only slightly increased in size. If, however, it is distinctly below the level of the ribs, it may be regarded as abnormally large. When great enlargement is present, the organ may reach right down into the pelvis. Great enlargement of the spleen is frequently met with in children, and may be due to many causes. In children born with active manifestations of congenital syphilis it is probably always enlarged. In the more common cases,

where the symptoms of that disease only set in after some weeks or months, it may be found before these appear; but often it comes rather late in the course of the active symptoms, and it generally persists longer than any of the other manifestations.

In rickets (q.v.) enlargement of the spleen is also frequently met with and it may attain considerable dimensions. It is enlarged also in typhoid fever, hepatic cirrhosis, malaria, leucocythæmia, pseudo-leucemia, and sometimes in tuberculosis.

The Mesenteric Glands.-Tubercular affection of the mesenteric glands is a very common condition in childhood from a pathologist's point of view. Clinically, however, it is only occasionally that we are able to make sure of its presence during life, as in many of those cases in which the glands are much enlarged there are other changes in the abdominal cavity which render them difficult of palpation.