The appetite is generally lessened in the early stages. The ac customed food is refused and in spite of all efforts the infant will not take its nourishment regularly. In some cases, enlargement of the cervical lymph-nodes or of those situated about the oesophagus may cause pain in swallowing (see Plate 34 c).
The fever is not of a regular type, and may throughout the disease be absent or at least remain very slight. The following illustrates this point : M. B., born July 7th, admitted on August 10th, 1001, for ocular blennorrhcca, and perforation of the left cornea. Died on September 17th, 1901. Mother had tuberculosis. During the infant's 39 days stay in the hospital its temperature remained almost normal (see Fig. 14S). Weight on admission 2:330 Gm., falling to 2000 Cm., on ficial feeding, and, as the result of changing to human milk, gradually reaching 2310 Gm. on the day of her death. No pulmonary symptoms, no cough. Sudden death with symptoms of collapse. Autopsy showed: submiliary, miliary, and larger tubercles in the lungs, beginning tuber cular pneumonia, cheesy bronchial lymph-nodes, miliary tuberculosis of the spleen, liver and kidneys, tuberculosis of the retroperitoneal lymph-nodes.
Nevertheless, continued taking of the temperature, especially when it is clone every two hours, is of value in making the diagnosis. We find that the variations day by day are greater than we are accus tomed to note in children. At one time the rectal temperature will be subfebrile, at another it will be 97° F. In other cases the temperature may suddenly shoot up to 102° F. or even higher, and may thus give the alarm. In the last stages of the disease we generally find an irreg ular remittent fever corresponding to the involvement of new areas. We frequently meet with a continuous fever in tubercular pneumonia.
The skin of tuberculous infants often presents a striking appearance. It is frequently of exceptional dryness, so much so that this may be the first sign to awaken suspicion as to the nature of the illness. Again we may find tuberculids, lichen serofulosorum, scrofulodernia, and especially a tuberculous folliculitis, which even in infants may present the appearance of a sluggish furunculosis.
Of diagnostic importance are the small nodules, not as large as the head of a pin, situated beneath the cutis, most often in the umbilical region. These may also be present in an atrophic condition not
dent on tuberculosis. I have seen tuberculous ulcers about the rectum mistaken for syphilis. Careful examination of the skin cannot be too strongly urged, as it very frequently offers important diagnostic aid. Examination of the lungs reveals varying conditions. We may find nothing but a slight tympany over both lungs, accompanied by some intensification of the respiratory murmur. This may be expected in miliary tuberculosis where there is a diffuse dissemination of tubercles. If the tubercles conglomerate, and there is a definite invasion of the pulmonary tissue, we find slight dulness and especially a sense of resistance on percussion. Ausculation reveals diminished or slightly bronchial breathing.
Where a pneumonia, tuberculous or otherwise, is superadded to the miliary tuberculosis, we hear fine crepitant or subcrepitant rAles, which may be more or less coarse according to the extent of involvement of the bronchial tubes. Not rarely, especially at the onset of a miliary tuberculosis we may hear diffuse coarse rhonchi.
Cavities may be formed without evincing symptoms. However, at times I have been able to diagnose even small cavities. I have often heard loud bronchial breathing and the so-called "cracked-pot" sound, which changes in pitch when the mouth is opened. At times the excellent conductivity of the infant's chest wall leads us astray in interpreting the localization of the lesions.
Pleurisy is frequently found, as we should expect considering that it is almost always involved in miliary tuberculosis; it is frequently of the fibrinous variety, leading to early adhesions. This accounts for the fact that we rarely meet with true empyemata. Such areas as break into the pleural space become at once encapsulated, so that pleuritic friction sounds are of short duration.
Respiration is always accelerated in extensive tuberculosis; we may, however, not infrequently find a moderate degree of cyanosis. Cough may be practically absent. At the onset there is frequently a dry hacking cough; where there are greatly enlarged bronchial lymph-nodes we may have attacks of coughing resembling whooping-cough.