nnels.

Two cautions, however, have to be borne in mind with reference to both
of these indications of disease. The first is, that the glands in the
groin may be enlarged from mere irritation, independent of actual
disease communicated to them from the glands inside. If, however, you
find the glands at the corner of the lower jaw and those on either side
of the neck enlarged too, you are then driven to the conclusion that the
glands in the groin are enlarged not from mere local irritation, but
from general disease, and that consumption is its cause.

Again, the superficial veins of the belly may be enlarged from any
cause which interferes with the proper circulation through the vessels
inside. Hence they are often enlarged in grown people in dropsy, and
hence too in infants and young children from flatulent distension of the
bowels. But in this case the other signs of consumption are wanting; the
emaciation, the cough, the increase of evening temperature, and the
enlargement of the glands, are all absent.

Sometimes we meet with instances where the child does not digest its
food, does not thrive, does not gain flesh, never passes healthy
evacuations, at length wastes, loses strength, and dies, without having
had any of the signs which I have pointed out as indicative of
consumptive disease, and in fact without having suffered from it. Now,
these cases are connected with imperfect performance of the function of
the liver, and sometimes with an imperfection of its structure. Before
birth the functions of the liver are not called into action in the same
way nor to the same degree as afterwards, and its structure differs in
this respect that it contains a larger amount of fat and a smaller
proportion of bile-secreting cells than afterwards. It sometimes happens
from causes which we do not understand that the liver structure not only
does not undergo that higher development which should take place, but
that the fat cells increase at the expense of the bile cells. In these
circumstances the food is ill-digested and the health is much impaired,
and at last wasting takes place to as great a degree as in the case of
consumption, only there are no cough, no glandular enlargement, no big
superficial veins, no increased temperature, while on a careful
examination the doctor will seldom fail to find the rounded edge of the
enlarged liver coming lower down than natural. In these cases too there
is a disposition to convulsive affect