Sometimes cases of acute gastric catarrh may present considerable re semblance to acute tuberculosis in its early stage. Not long ago I was consulted about a boy, seven or eight years of age, who had at one time suffered to my own knowledge from slight consolidation of the right apex, the consequence of an attack of catarrhal pneumonia. The boy was of scrofulous type, thin and pale. He was said to have been losing flesh for some time and to have had a poor appetite. For more than a week his appetite had been exceptionally bad ; his temperature had been raised, and he had had a hacking cough. I saw the boy at 5 P.A., with Dr. J. N. Miller, whose patient he was. The boy's temperature was then 100.2°. He was pale with no flush on his cheeks ; and his face was bright and lively with out any sign of distress. His chest was everywhere perfectly normal, except for a little dry rhonchus about the back. His belly was not dis tended. There was no enlargement of the liver or spleen, and no swollen mesenteric glands could be felt. He had no sore throat. The tongue was furred, and the breath had a faint unpleasant smell. There was no albu men in the water, nor any trace of oedema of the legs. The spirits of the child were said to be remarkably good ; and I was told that that morning he had been seen attempting the acrobatic feat of standing on his head. This latter fact, joined with the bright expression of the boy's face, the signs of gastric derangement, and the absence of all evidence of pulmonary mischief, appeared to me to afford sufficient ground for excluding tuber culosis. I accordingly expressed an opinion that the boy was suffering merely from a subacute attack of gastric catarrh. Shortly afterwards I heard that the febrile symptoms quickly disappeared.
According to my experience, children suffering from the development of tubercle are invariably dull and spiritless, and usually show signs of distress in the face, If a boy jumps about and plays boisterously, as if he were well, acute tuberculosis may be excluded with a high degree of prob ability.
The detection of acute tuberculosis depends in a great measure upon the absence of symptoms capable of explaining differently the serious con dition of the patient. If a child is brought with a history of fever and wasting of some weeks' duration, if he looks with a distressed haggard face, and if a careful examination of the whole body discovers no disease of organs, the state of the child is evidently not to be attributed to any local cause. In such a case the diagnosis will lie between typhoid fever and tuberculosis, and if from the duration of the illness, or for reasons given elsewhere (see page 83), typhoid fever can be excluded, we shall be reduced to tuberculosis as the only other probable explanation of the child's state. In a badly fed infant who has been irregularly feverish from teething, and whose nutrition has been some time defective, the history of wasting and' pyrexia may raise suspicions of tuberculosis. But in such a
case the child will not look haggard and pinched like one suffering from that disease ; the irregular and often greatly elevated temperature of den tition is unlike the moderate pyrexia of the tubercular affection, and will be sufficiently explained by inspection of the gums. Moreover, the history of the illness, which will almost certainly include several attacks of diar rhoea or sickness, and the account of the child's diet will furnish an amply sufficient explanation of his continued indisposition. In an infant acute tuberculosis is almost always accompanied by oedema of the legs. At this period of life the combination of wasting, moderate pyrexia, and oedema of the lower limbs is a very suspicious one. .
Even when the case is first seen in its later stage, after signs of local dis 'ase have become evident, the diagnosis is not always easy. The physi cal signs of tuberculous bronchitis have no special character distinctive of their specific origin, and they must be read in the light afforded by the history and course of the illness in order that they may be rightly inter preted. In tuberculous bronchitis the temperature is higher than is found in an uncomplicated case of the catarrhal disease. In simple capillary bronchitis the pulmonary affection is seldom accompanied by marked pyrexia, and the mercury rarely rises higher than in the evening. In tuberculous bronchitis, on the other hand, a temperature of 104° is not uncommon. The chief point, however, is the occurrence of the bronchial disorder in a child worn and weakened by illness of undefined character and accompanied by fever and wasting. If this illness have succeeded after a variable interval to an attack of whooping-cough or measles, the fact alone should raise a suspicion of the tuberculous nature of the pulmonary complaint. So, also, if broncho-pneumonia supervene, with spots of local consolidation, the history of previous ill health is essential to a right un derstanding of the nature of the child's complaint. In either case the onset of symptoms pointing to intracranial mischief is of the utmost value in confirming our suspicions ; and if convulsions occur, followed by squinting, ptosis, unequal pupils, and rigidity of the joints, the tubercu lous nature of the disease may be considered to be established (see also page 440).
In tuberculosis of the bladder the child's distress is usually attributed to the presence of a vesical calculus. There is, however, one diagnostic point of considerable importance. The irritation excited in children by p, stone in the bladder is rarely a cause of noticeable pyrexia, while, when the symptoms are due to vesical tuberculosis,- the evening temperature may reach 102° or higher. Moreover, digital examination after the manner re commended by Volkmann, already referred to, will sometimes detect a tuberculous nodule in the fundus of the bladder.