NOTES OF A CASE IN WHICH MARKED 
ENLARGEMENT OF THE LIVER, AS- 
SOCIATED WITH SYMPTOMS RE- 
SEMBLING THOSE OF TYPHOID 
FEVER, OCCURRED IN A YOUNG 
CHILD. 
By A. D. BLACKADER, M.D., 
Professor of Pharmacology and Therapeutics, and Lecturer on 
Diseases of Children, McGill University, Montreal. NOTES OF A CASE IN WHICH MARKED ENLARGEMENT 
OF THE LIVER, ASSOCIATED WITH SYMPTOMS RE- 
SEMBLING THOSE OF TYPHOID FEVER, OCCURRED 
IN A YOUNG CHILD.* 
BY A. D. BLACKADER, M.D., 
Professor of Pharmacology and Therapeutics, and Lecturer on Diseases of 
Children, McGill University, Montreal. 
The usual conditions under which notable enlargement of the 
liver may occur in children are well recognized, and on its ap- 
pearance we look for symptoms pointing to the presence of syph- 
ilis, tuberculosis, leukaemia, alcoholic or malarial poisoning, or 
amyloid or cardiac disease. Slight enlargement from congestion 
may sometimes be due to the absorption of ptomaines from the 
intestinal tract in cases of faulty digestion; to the administration 
of food containing articles more or less irritating to the hepatic 
cells; or to the action of toxins generated in the system during 
the course of some of the infectious fevers. 
In the following case the enlargement was very notable. It 
began toward the close of the second week of fever, reached 
its maximum about the fourth week, and then slowly receded. 
It was associated with no tenderness, no ascites, no symptoms 
of jaundice. A careful examination, twelve weeks after the com- 
mencement of the attack, failed to reveal any undue enlargement 
of the liver, or irregularity in its borders. 
In a very imperfect review of the literature on the subject, I 
have failed to note any reference made to a similar condition, 
with the exception of some cases reported recently in the Journal 
de Clinique et de Therapeutique Infantiles, Paris, April 16, 1896, 
by Dr. Edouard Tordeus, of Brussels. This writer gives the 
history of five cases of lobar pneumonia, in which a very notable, 
but temporary, enlargement of the liver made its appearance a 
few days after complete defervescence had taken place. In two 
of these the firm, smooth edge could be distinctly felt as low 
down as the level of the umbilicus. There was no tenderness 
on palpation, no icterus, no ascites. The spleen was not en- 
larged, the appetite remained excellent, and the patient was in 
*Read before the American Pediatric Society, Montreal, May 26, 1806. Blackader : A Case Resembling Typhoid Fever. 
good spirits. Under suitable regimen the enlargement disap- 
peared in a few weeks. 
In my own case, although some of the symptoms simulated 
those of pneumonia, at no time was I able to obtain, by physical 
examination, definite symptoms of any consolidation, and the 
continued pyrexia appeared to oppose any such hypothesis. 
The history of the case was as follows: 
On the evening of March 8, 1896, I was summoned to see 
F. S., a bright, precocious child, aged two and a half years, 
whom I had attended at intervals from a few weeks after birth. 
Her parents were both in good health. The paternal grandfather 
died from interstitial nephritis of gouty origin; the father is a 
dyspeptic, and suffers from neuralgic attacks, probably also of 
gouty origin. The mother is of a nervous temperament, but is 
otherwise well. The child herself was nursed by the mother 
till the end of the third month, when, under my directions, she 
was gradually weaned. Artificial feeding proceeded very satis- 
factorily. The child, weighed every week, showed a steady 
gain in weight. Dentition was normal, and so far she had 
escaped all the eruptive fevers. Six weeks previously she had 
suffered from a slight influenzal attack, which had left her look- 
ing pale, and for which at the time I had prescribed a ferruginous 
tonic. On the evening of my visit 1 found her with flushed 
face and slightly coated tongue; pulse, 120; respiration, 24; 
temperature, ioi|°. There was no complaint of pain, nor did a 
thorough examination reveal any abnormal condition. A simple 
alkaline mixture was prescribed. The temperature rose slowly, 
and on the evening of the fourth day reached 103° F. Respira- 
tions were now decidedly quickened, and the child appeared to 
have occasional attacks of pain, but the site of this was obscure, 
and appeared to be variable. The nights were restless. On the 
sixth day respiration still remained quickened. There was slight 
diarrhoea, associated with some pain, and greenish colored stools 
containing more than a normal amount of mucus. The abdomen 
was slightly distended, but no special tenderness was elicited 
on pressure. Splenic dulness was present. No abnormal phy- 
sical signs were detected after repeated examinations of the 
chest. No rose spots were visible on the body. On the even- 
ing of the eighth day, as the diagnosis was still uncertain, Dr. 
Browne saw her with me in consultation. The daily range of 
temperature was now between 102° and 103° F.; the respira- Blackader : A Case Resembling Typhoid Fever. 
TEMPERATURE RANGE IN A CASE IN WHICH MARKED ENLARGEMENT OF THE LIVER WAS ASSOCIATED WITH SYMPTOMS RESEMBLING THOSE OF TYPHOID 
FEVER, IN A YOUNG CHILD. BlackaDer : A Case Resembling Typhoid Fever. 
4 
tions from 40 to 48; the pulse was weak, 140 to 150. Diarrhoea 
still continued, with about the same characters. Cough could 
hardly be said to be present. Beyond an occasional sibilant rale 
no abnormal physical signs were detected in the chest. We 
both considered the case as possibly one of pneumonia, but no 
absolute diagnosis was made. 
During the following week the symptoms remained about the 
same. The respirations were less rapid, averaging about 40 per 
minute, while the pulse varied from 120 to 140. There were 
two or three relaxed motions per day, of light color, and occa- 
sionally associated with some colicky pain. A cough occurred 
only occasionally, and was very slight in character. Repeated 
physical examinations revealed only a few loose bronchial rales 
toward the base. On the evening of March 22d, the area of liver 
dulness was first observed to be slightly increased, extending a 
full inch below the margin of the ribs in the nipple line. Splenic 
dulness increased, but the spleen was not palpable. The 
abdomen was slightly distended, but no special tenderness was 
detected on deep pressure. 
A specimen of urine was not obtainable without using the 
catheter, but, from the appearance of the diapers, there was 
nothing abnormal either in its amount or its character. 
The enlargement of the liver gradually increased until, by 
the 1st of April, its margin was distinctly palpable half an inch 
below the level of the umbilicus. Its surface and margin were 
quite smooth. No local tenderness was elicited. The enlarge- 
ment was general. The lower margin of the spleen was also 
easily felt, extending one inch below the margin of the ribs. 
There was no icterus, and no ascites. Slight pitting was per- 
ceptible on deep pressure over the tibiae. 
Dr. Lafleur kindly saw the case at this time along with me, 
and corroborated the physical signs I have already noted. An 
examination of the blood, at my request, was made by him at 
this visit. The red corpuscles was found to number 4,666.400 
per cubic mm. The white corpuscles 4,600 per cubic mm. 
There was no poikilocytosis. The red cells were of equal size 
and well formed. The haemoglobin was not estimated. 
The physical signs persisted for another fortnight, when a 
gradual diminution in the size of the liver followed a distinct 
improvement in the general symptoms. Not until the end of 
the sixth week did complete defervescence take place, and could Blackader : A Case Resembling Typhoid Fever. 
convalescence be said to be established. The edge of the liver, at 
this time, was still distinctly perceptible more than two fingers’ 
breadth below the level of the ribs. It was six weeks later before 
I could assure the mother that it had regained its normal size. 
The question of diagnosis in this case must, it seems to me, 
still remain obscure, with the probabilities pointing in favor of 
typhoid fever. The enlargement of the liver is, however, inter- 
esting, whatever be the diagnosis, and the future history of such 
a case will be instructive. That it was an enlargement and not a 
displacement, may be considered as well established as repeated 
examinations, verified by two other physicians, could render it. 
Its origin and character must remain in doubt. 
236 Mountain Street. 
DISCUSSION. 
Dr. Henri Lafleur.—There was only one examination of the 
blood made, and the idea of acute leukaemia could be excluded. 
The total number of leucocytes was 4,600 to the c.c. As regards 
the rest of the condition I corroborate what Dr. Blackader says. 
Dr. August Seibert.—1 would call attention to the report of 
Czerny and Moser, assistants of Prof. Epstein, of Prague, pub- 
lished about a year ago in regard to blood examinations in 
infants suffering from intestinal catarrh. They examined, 1 
think, fifteen cases, and in each case found bacteria in the blood 
that are otherwise found in the intestines. In most of these 
cases secondary swelling of the liver, of the spleen, a slight 
nephritis, and broncho-pneumonia were present. Enlargement of 
the liver and of the spleen, in cases of chronic intestinal catarrh, 
and sometimes following mild acute intestinal infections, 1 have 
seen quite often, and within the last five to eight years have 
looked upon them as general infections entering the body 
through the intestine. This case of Dr. Blackader’s might have 
developed in a similar way. FROM 
ARCHIVES 
OF 
PEDIATRICS 
A Monthly Journal Devoted to Diseases or 
Infants and Children. 
Edited by 
FLOYD M. CRANDALL, M.D. 
“ Pediatrics is the specialty of the 
general practitioner.” 
Volume begins with January. Sub- 
scriptions may begin at any time. 
$3.00 a year in advance. 
E. B. TREAT, - Publisher, 
241 =243 West 23d Street, New York.