A little girl, aged eight years, was a patient in the East London Chil dren's Hospital under the care of my colleague, Mr. R. W. Parker. The girl's father had died of consumption, and she herself had been suffering from strumous disease of the right astragalus for six months. The child was much emaciated and very anaemic and feeble. Her skin was harsh and dry, her eyelids were swollen ; and the cervical and inguinal glands of each side could be felt to be enlarged. The finger ends were somewhat thickened. There was no albumen in the urine. The temperature was usually normal in the morning, but would rise towards night to between 101° and 103°. At Mr. Parker's request I examined the child's chest, and found the signs of a cavity at the Upper part of the right lung, with evi dence of considerable consolidation over the lower lobes. The left lung was also diseased, although to a less extent. A moist crackling rhonchus was heard over both sides of the chest. Although this child was evidently suffering from tuberculo-pneumonic phthisis, and the pulmonary mischief was very extensive, the system was obviously so greatly distressed by the irritation and pain of the diseased ankle, that Mr. Parker decided upon amputating the foot. After the operation the temperature, which on the previous evening had been 101.6°, fell to 98° at 6.30 P. nr., and remained for the most part at a normal level while the child remained in the hospi tal. The clicking rhonchus also ceased to be heard in the chest ; the face lost its distressed look ; and nutrition improved in a surprising manner, the patient gaining between six and seven pounds in three weeks. Unfor tunately, after the child left the hospital and returned to her own poor home, the improvement was not maintained, and in a few months we heard that she was dead. Still the remarkably good results which followed the removal of the diseased joint are very instructive, and fully justified the operation.
The majority of cases of pulmonary phthisis are seen in children of six or seven years and upwards ; but younger children and even infants are subject to the disease. In very young patients ulceration of the lung is not always easy to recognise. Serious disease may be present without giv ing rise to any characteristic symptoms. The child is no doubt feeble and wasted, but loss of flesh and strength are common in very young chil dren with almost any form of illness. Cough may be trifling and the breath ing not obviously interfered with. Even a physical examination of the chest may yield us little information, for over the site of a cavity the per cussion note may be merely tubular (tympanitic) and the breathing bron chial with moist clicking sounds. Moreover, the occurrence of softening in a cheesy pulmonary deposit is usually a signal for the occurrence of secondary deposits elsewhere ; and cheesy and ulcerating intestinal glands with the consequent diarrhoea may completely draw away the attention from the lungs. When pulmonary phthisis occurs in the young child, it runs a comparatively rapid course. It is in the large majority of cases primarily
of the catarrhal form, and is most commonly the consequence of an attack of sub-acute broncho-pneumonia succeeding to measles or whooping-cough.
Diagnosis.—In the diagnosis of pulmonary phthisis in the child an accu rate account of the beginning and course of the illness is very important. At the same time it is necessary to remember that a history of cough with persistent loss of flesh is no sufficient proof that the child is suffering from pulmonary consumption. Scrofulous children and others with a like sus ceptibility to chills, are very subject to attacks of pulmonary and intestinal catarrh. Such patients may be troubled with continual cough, and lose flesh steadily without any organic mischief being set up in the lung. They may even be feverish at the onset of every new chill without this additional symptom being evidence of phthisis. No doubt the condition of such chil dren is one of danger, for they often eventually develop pulmonary dis ease ; but until this has actually taken place, ordinary precautions for the avoidance of chills will quickly cause the symptoms to disappear.
Even if examination of the chest discovers slight dulness at the supra spinous fossa of one side with a high-pitched or faintly bronchial quality of breathing, these signs are not necessarily due to phthisical consolida tion. Weakly children are very liable to temporary collapse at the apices of the lungs from insufficient expansion. In such cases the morbid signs are limited strictly to one aspect of the chest—the back or the front—and can often be made to disappear if the child is instructed to take two or three full inspirations in rapid succession.
In young subjects consolidation, as a result of catarrhal pneumonia, may be met with at all parts of the lung. It is seen as often at the base as at the apex, both in front and behind. In all cases, therefore, it should be made a rule to search the chest completely before we allow ourselves to exclude the existence of a cheesy deposit. If this be done quietly and gently, as directed elsewhere (see page 13), the examination can usually be carried to a successful issue. In infants, as has been already remarked, phthisis may be present although but few symptoms of the disease have been noticed. The cough may be insignificant, the breathing quiet, and a looseness of the bowels of some standing may seem to explain sufficiently the pallor and wasting of the body and the distressed expression of the child's face. If, however, at the same time the evening temperature is higher than natural, the symptom is a suspicious one ; and if the state of the stools indicates the existence of ulceration of mucous membrane (see page 662), we must remember that this condition is often dependent upon chronic pulmonary mischief. In every case the physician, if he do his duty, will take nothing for granted, but will make systematic examination of all the organs of the body.