Infants do not expectorate. By tickling the epiglotis with the fingers we can excite a fit of coughing, so that by swabbing out the entrance of the larynx we may obtain some sputum for examination. We do not see the greenish yellow expectoration which we are accus tomed to find in adults. Even where cavities exist we cannot expect to find characteristic sputum.
The digestive tract in many cases offers no symptoms. Digestion progresses normally, although where there is marked intestinal involve ment we may have diarrhoea which persists in spite of breast-feeding. Palpation of enlarged and cheesy mesenteric lymph-nodes is possible only in case of greatly emaciated children. Tabes mesenterica is rare in infancy. When we do find enlarged mesenteric lymph-nodes these are frequently not tuberculous but due to other causes.
The spleen is generally enlarged and extends below the free border of the ribs for two fingers or more. The diagnostic importance of this phenomenon is lessened both on account of the frequency of enlarge ment of the spleen in infancy and its frequent lack of enlargement in tuberculous individuals. The liver is likewise not infrequently enlarged, either on account of simple stasis, or through tuberculous involvement ; in the latter case we may expect icterus.
The ears are often involved in the tuberculosis of infants. We meet with peristent and intractable otitis. multiple perforation of the drum, loosening of the ossicles and marked destruction of the bony structures of the inner ear.
The urine may be normal; but generally towards the end of the disease the kidneys become involved. We may then find tubercle bacilli in the urine, and almost always albumin and casts. However, tubercle bacilli may be present without involvement of the kidneys.
In spite of the rather frequent involvement of the meninges and even of the brain, cerebral symptoms arc not prominent. True meningitic phenomena are rare in infants. Tubercles of the chorioid are occasion ally seen. [Chorioidal tubercles do not generally appear until the miliary tuberculosis is well advanced. In some cases they alone may enable the clinician to make the diagnosis as to the nature of the meningitis.—H.] diagnosis may be established from the symp toms described above. Tuberculosis occurs at every age and must always be borne in mind.
The history should be given sufficient weight. A consideration of the general condition of the child combined with that of the physical examination does not frequently permit of a rapid and certain diagnosis. As regards the physical signs, I consider only one pathognomonic, namely, the finding of a pulmonary cavity. It is frequently difficult and sometimes impossible to demonstrate the presence of tubercle bacilli.
The bacilli should be sought for patiently and repeatedly. If there is a lack of expectoration, the method mentioned above may be resorted to.
The urine and stools should be examined in this regard. Sometimes we may find tubercle bacilli in the cerebrospinal fluid, in the absence of all signs of meningitis.
Where there is no fever, tuberculin should be used to determine the diagnosis. Especially in infancy may this test be resorted to, for the prognosis is so poor that we do not need to fear doing any harm, and, in the second place, young children bear large doses of tuberculin well. The temperature generally falls quickly to the normal, as we
usually arc dealing with uncomplicated cases. Where fever is present tuberculin cannot of course be used.
In the differential diagnosis, typhoid fever must be considered, as where this disease is prevalent it. is very commonly met with among infants, and pursues an atypical course. The Widal reaction must be resorted to in order to establish a diagnosis. Chronic bronchitis and chronic pneumonia may simulate tuberculosis; besides, I have fre quently seen empyema mistaken for tuberculosis. However, in tuber culosis we do not find dulness of such marked intensity; in ease of doubt the needle will decide. On the other hand, the other chronic pulmonary diseases can be differentiated only if the patient improves markedly or if, on the contrary, we find tubercle bacilli in the excreta. Finally, there are certain forms of sepsis that resemble tuberculosis. Furthermore, a toxic intestinal catarrh, if seen only for a short period and without the aid of a reliable history, may be mistaken for tuberculosis.
Sometimes the tuberculosis of infants proceeds without symptoms, and sudden death occurs, the cause of which is unsuspected before autopsy.
prognosis of tuberculosis in infancy is bad.
We do not know of a single case which resulted in cure. Indeed there is not a positive instance where a tendency toward the limita tion of the disease was observed. The tissues of the infant do not seem to be able to respond by protective inflammatory reaction. The result is that the lesions do not become circumscribed nor calcified. The youngest child whose organs showed processes which may be char acterized as defensive in nature was one 15 months old. In this case a zone of inflammation with the formation of new vessels surrounded the tuberculous area (Plate 35).
The duration of the disease is very variable. It may progress rapidly and towards the end assume a foudroyant form as we see in the acute miliary type of adults. It may progress slowly, lasting months. Therefore it is best not to venture to make a statement as to the possible duration of the disease even when the diagnosis is certain.
Treatment. —We can use only prophylactic measures, as there is no treatment for the disease. The two main prophylactics are breast feeding and improvement of the congested dwellings of the poor.
We can hardly combat the individual symptoms successfully. If the fever is high, and the infant restless, we should resort to hydrotherapy, in the form of packs or lukewarm baths. The best antipyretic, should we wish to give one to an infant, is pyramidon given as follows: Pyramidon, 1.0-2.0 Gm. (15-30 gr.), syrup, 30 c.c. (1 oz.), aquae ad 100 c.c. (3 oz.) one half to one teaspoonful every hour until the temperature falls. Convulsions may make one wish to prescribe nar cotics; in such an event, chloral hydrate 0.5 Cm. to 100 c.c. (71 gr. to 3 oz.) may be given by rectum.