After the history has been taken, an inspection of the patient should aid us in the diagnosis. Not infrequently, especially in chil dren near puberty, we meet with the typical plithisical liabitus. The peculiar build and carriage recognized even by the laity, tells us that we are dealing with a tuberculous individual. These children are tall for their age, or at least appear to be, on account of the disproportion between the width of their chests and their height. The long and thin extremities and scrawny necks enhance this effect. The fingers, too, are long and thin, the distal digits being thickened and club-shaped. The chest is flat, expanding feebly upon deep inspiration. The scap uhe are situated low and the shoulders converge anteriorly; the ribs stand out prominently (Figs. 13S-141).
Although the picture is shocking when it presents itself in its most extreme form, it may be even attractive in the ease of certain individuals. Artists have frequently pictured a beautiful type of eon sumptive. Only recently. I saw a little girl (Plate 32) whose long eye lashes, bright eyes, wealth of hair, and sweet expression made her a picture of loveliness. The same plate shows the wasted figure of the child when seen unclothed, and gives a schematic drawing of the extent of the lesions which were found in the lungs. Children under ten years of age are more rarely of this type. But even very Young persons may have the phthisical habitus. In them it generally pre sents itself as extreme emaciation. Further inspection may reveal bone or joint diseases, perhaps of the knee or hip, or we may notice a spina ventosa or involvement of the superficial lymph-nodes, espe cially of those cervical nodes which lie close to the lower jaw or in the supraclavicular region. Scars in this region may tell of lymph-nodes which have ruptured in this area.
The skin is often grayish yellow, discolored, and of striking dryness. Tuberculids, lupus, or peculiar furuncular lesions, which remain in a stationary state for weeks or months, or show no tendency to heal, have of late been frequently described as concomitant symp toms of a general tuberculosis. In young children a peculiar odor, the cause of which is not yet known, is frequently noticeable.
Palpation will disclose the lymph-nodes just mentioned. Their lack of tenderness speaks against simple inflammatory origin. The spleen is often much enlarged, especially in general tuberculosis, although it cannot be considered a pathological symptom.
The fever is in no way typical. It is rather dependent upon infection due to secondary microorganisms. There are indeed cases of tuberculosis in children which give rise to little or no fever.
Auscultation and percussion are of great diagnostic value in those cases of chronic illness where an infiltration of the lungs is present.
In childhood, however, we do not find tuberculous infiltrations or tuberculous pneumonias which develop gradually and progress slowly. Physical signs enable us to make the diagnosis of tuberculosis only when we find a cavity. Hamloptysis. provided we are sure of its pulmonary origin, also allows of this diagnosis. The respiration in tuberculosis is by no means characteristic. The cough may at times be suggestive, for example, paroxysmal attacks point to tuberculosis of the bronchial lymph-nodes. It may, however, resemble in every respect the cough of other pulmonary affections. Examination of the urine does not supply any definite diagnostic criteria. Indicanuria points to tuberculosis, but its absence is not positive evidence against the presence of the disease. Convulsions, which in miliary losis usher in the end, and those focal symptoms which originate from solitary tubercles in the brain, are worthy of mention. scopic examination of the fundi, in exceptional cases, shows the ence of chorioid tubercles early in the disease, and thus clinches the diagnosis. [This examination is not infrequently of diagnostic value in the differentiation of cerebrospinal and tuberculous meningitis and should not be omitted in cases where the etiology is not clear.— A. F.
Whereas the methods of examination which we have thus far men tioned afford us only exceptionally absolute proof of the nature of the disease, we must now consider two pathognomonic tests: first, the finding of the tubercle bacillus, and second, the injection of tuberculin.
Finding the tubercle bacillus in childhood is associated with far greater difficulties than in the case of adults; for, whereas the latter generally suffer from open tuberculosis, that is, from a form of the dis ease which communicates with the bronchi and upper air-passages children more often are affected with the closed variety. Furthermore, babies swallow their sputum. flowerer, under all circumstances where tuberculosis is suspected we should try to find the bacillus. If no sputum can be obtained we may tickle the entrance of the larynx with a bit of cotton held by a forceps, in order in that way to excite an attack of coughing which may bring up some mucus; or we may introduce a catheter into the larynx and aspirate material for examination. Some have recommended washing out the stomach, especially early in the morning, in order to obtain bacilli which may have been swallowed in the course of the night. In the case of older children we may resort to Blume's method of having the child cough upon a glass slide, in order to obtain a few drops for microscopical examination.