The correct diagnosis of phthisis depends upon the harmony of general symptoms and physical signs, and while a complete array of symptoms, or very strong evidence derived from signs, may lead to the conclusion that in all probability this disease is present, a combination of the two can alone justify a decided opinion. To this subject we must again recur. (See Chap. EX., 9, Phthisis palmonalis.) Much attention ought to be given to the liability to hereditary transmission, which certainly in some families is verb marked; strict inductive evidence of its relative power is yet wanting, and its subordination or superiority to other predisposing causes is not determined: but the existence of scrofula or tuber cles in the parent is a sufficient ground for leading us to suspect their presence in the child when other indications point in that direction.
§ 4. Tubercles in the Peritoneum.—Next, perhaps, in frequency and importance, is the development of tubercle in the peritoneum. In children it sometimes occurs alone, or with scrofulous tubercle in the mesenteric glands, when there is no corresponding deposit in the lungs : in adults, it is seldom separable from phthisis. Its symptoms are those of peritonitis—which will be detailed in a subsequent chapter ; and it is enough to say. here that the tuber cular form is to be distinguished by its gradual and insidious incursion, and by the presence of general symptoms correspond ing to those seen in phthisis, if due allowance be made for the difference of the region in which the tubercular matter has been developed. Thus there are the same quickness of pulse, accom panied by perspiration, the emaciation and languid feelings, and very often the diarrhcea of early phthisis; to these are superadded, a sense of tension in the abdomen, which has a tumid feeling, and does not bear pressure without pain; the tongue is very commonly furred, but not to any great degree. Evidence of tubercle in the lungs is of much value in aiding diagnosis; as is also the pre sence of diarrhcea, because it is less common in simple peritonitis, and is probably caused by the existence of tubercle in its very common locality—the solitary glands of the intestine. But we
may be defeated in our endeavor to form a correct diagnosis, either by the history recording that the attack has been, or has appeared to be, sudden, or by limited suppuration, in the form. of deep-seated and confined abscess of the peritoneum, producing symptoms of hectic. To this it must be added, that perplexing symptoms sometimes present themselves as the effects of pressure on the nerves, the bloodvessels, or the absorbents, or as the more remote consequences of adhesions between the various coils of intestine. Perhaps our best guide is to be found in the general adynamic character of the symptoms throughout, and in the pre vious existence of the cachectic state which preceded them.
1 5. Tubercles in the Brain.—When we come to diseases of the brain, we shall have to discuss a form of meningitis, which is unquestionably related to the scrofulous and tubercular diathesis ; clinical observation and post-mortem examination alike proving that inflammation of the brain attended with the effusion of serum. and hence often called hydrocephalus acutus, is constantly associated with the presence of tubercle in other organs. We shall then, also, have to consider the symptoms which may result from the actual presence of a tuberculous deposit in the brain itself; but we may remark that the tubercle is often solitary, and that it may have attained a very considerable magnitude without making its presence manifest by any symptoms until the more state disease supervene; it is only rarely that its absolute size or peculiar position impedes by pressure the transmission of nervous energy, so as to produce paralysis or loss of sensibility.