Children who fall victims to acute tuberculosis, although often of deli cate appearance, are not necessarily thin and feeble-looking. In many cases the nutrition of the patient is very good, and the child is considered to be way a healthy subject until the disease appears. It is not at all uncommon, especially in cases where the chief violence of the malady is expended upon the cerebral meninges, to find that up to the time of his illness the child had never suffered from a day's indisposition. In Other cases the patient has been noticed to be sensitive to chills and prone to at tacks of indigestion. These latter children are often of frail appearance and have the "tubercular aspect." Their skin is thin and transparent, their hair fine and silky, their features regular and delicate, their bones small, and their shoulders narrow and sloping.
Acute tuberculosis may begin gradually or suddenly. In exceptional cases the disease has an abrupt beginning. There is high fever, headache, epistaxis, relaxed or confined bowels, and the child is very restless and stupid. But this mode of beginning is very rare. In the large majority of instances the onset is so insidious that there is a difficulty in fixing upon a date for the beginning of the attack. The earlier symptoms, as has been said, are so slight and vague, and the child passes so gradually from health to sickness, that the mother is usually quite unable to determine when she first noticed any signs of indisposition. She will say that for some weeks the child had seemed to be less brisk and lively than was his wont ; that he would often lie about instead of playing ; and that his appetite had seemed to fail ; but that no special importance was attached to these symptoms until something more definite was noticed which excited alarm. The first influence of the disease is upon general nutrition. The child be gins to look pale, with a curious transparent pallor. His conjunctivze have a bluish tint, and the lower eyelid is discoloured. He loses his sprightli ness and gets dull and moping; his appetite is poor, and he falls off in his flesh. A certain amount of fever usually accompanies this condition. In the the cheeks may be brightly flushed, and the hands and feet feel hot to the touch. At this time a thermometer in the axilla marks be tween 100° and 101°. The patient is thirsty, and often asks for water in the night. In the morning the temperature is normal ; but the child when he leaves his bed generally looks pale and distressed. The anxious ex pression of the face in these cases is indeed commonly a noteworthy phe nomenon ; and if combined with mildness of the general symptoms, and complete absence of all signs of local discomfort, is an indication of illness of very serious moment. In some cases there are repeated attacks of chilli
ness followed by heat ; and these may have a periodicity which suggests suspicions that the child is suffering from ague. The chilliness, however, seldom amounts to shivering, and sweating is scanty or absent. Loss of flesh is never very long in showing itself. The wasting is often very gradual, unless some relaxation of the bowels is present, and in the major ity of cases is intermittent. In hospital patients, under the unaccustomed influence of good food and nursing, it is not uncommon for a child to re gain some of the flesh he had last, although all the time the fever con tinues and the general disease is pursuing its regular track. Even in children who are living in better circumstances the progress of the illness is often very unequal—the child seeming to be alternately better and worse, and the temperature fluctuating curiously from day to day. Some times, indeed, the pyrexia is found entirely to subside, and for a few days the improvement may be such that recovery is confidently anticipated. The intermission is usually, however, of short duration, and the patient relapses into his former state. At this time a common symptom is oedema of the legs and sometimes of the face, and the urine may contain a trace of albumen. In young babies the only symptoms of the disease for a con siderable time may be slight fever, pallor, some loss of flesh, an inelastic state of the skin, and a little (edema of the extremities.
For the first few weeks the above general symptoms are all that can be discovered ; and the most careful examination detects no cause to which the evidently serious condition of the child can be referred. He is thin, pale, weakly, and listless ; but his tongue is clean, and although feverish and restless at night, he sleeps fairly well, is not light-headed, and in the daytime makes no complaint. His abdomen is normal, rather flattened than distended ; there is no enlargement of the liver or spleen—at least during the first few weeks of the illness ; and pressure of the belly elicits no sign of tenderness. In some cases a few rosy spots, rather more red than the typhoid spot, and of a larger size, are noticed on the abdomen and chest. The skin generally is dry and harsh.