Acute tuberculosis may present a very close resemblance to enteric fever in the child, especially as we sometimes see a rose spot here and there on the bodies of tubercular children which, except for being rather larger than the typhoid spot, and perhaps a little less delicate in colour, may be, and indeed has been, mistaken for it. In both tuberculosis and enteric fever diarrhoea may be a prominent feature ; in both there is fever ; and in both the general symptoms may be very indefinite. Often, in these cases we cannot decide, but must wait for time to relieve our uncertainty. But in many cases we may venture upon an opinion, for in tubercu losis the absence of any definite time of beginning ; the less elevated tem perature, the bodily heat being rarely higher than 101° in the evening ; the distressed expression of the patient ; the absence of inflation of the abdo men, and the natural size of the spleen are all points in which that form of illness differs from typhoid fever, and may serve to help us to a conclusion.
Sometimes enteric fever may be mistaken for tubercular meningitis. The illness may begin with drowsiness and sickness ; the headache may be severe and provoke cries from the child such as are common in the intra cranial inflammation ; the vomiting may persist, and the bowels may be obstinately confined. Still, the belly is distended, and has not the doughy, flaccid condition of the parietes so peculiar to tubercular meningitis ; the pulse, until convalescence begins, is not slow and intermittent ; the respi ration is not sighing ; the pupils do not become unequal, and there is no squint. The temperature, too, is much higher in the case of typhoid fever, for in the earlier stages of tubercular meningitis the bodily heat is seldom greater than 101°. Later, none of the symptoms of the third stage of tuber cular meningitis can be discovered.
Acute gastric catarrh, accompanied as it is in scrofulous children with pyrexia, may cause some embarrassment, but here the temperature is less high than in enteric fever, and does not undergo the same alternations ; there is no distention of the abdomen, and no enlargement of the spleen. Still, in many cases, before the fever subsides on the ninth or tenth day, we cannot say positively that we have not to do with the more serious disease.
When the purging is severe the case may be confounded with one of inflammatory diarrhoea, and it is possible that in young children under three or four years of age the mistake is often made. I think, however, that the shorter course of a non-specific muco-enteritis, the severity of the purging from the first, the haggard aspect of the patient, and, if the dis ease last long enough, the absence of splenic enlargement, of the rosy rash, and of the signs of pulmonary catarrh, should be sufficient to furnish a distinction.
Simple or tubercular ulceration of the bowels with enlargement of the mesenteric glands may be also mistaken for enteric fever. But in these
disorders the temperature is less elevated than in typhoid fever, and the history of the illness is very different. Their course, also, is very much longer. There is, besides, absence of the rash, of the splenic enlargement (unless, as may happen, there is tubercular disease of the spleen) and of the signs of pulmonary catarrh. Further, in tubercular ulceration lungs are generally the seat of consolidation and the emaciation is extreme.
Chronic tubercular peritonitis, with its rough harsh skin, its pseudo fluctuation, and the caseous masses to be felt on palpation of the abdomen, can scarcely be confounded with enteric fever.
Lastly, the distinction between typhoid and typhus fevers is now suffi ciently established. In the latter disease the onset is always abrupt, the rash, abundant and quite different in its appearance from the rosy typhoid spots, appears on the fifth day ; the face is dusky ; drowsiness and stupor are early symptoms ; and the end—whether favourable or the reverse— comes in a sudden crisis.
Prognosis.—It has been already said that comparatively few children_ die from this disease ; but small as is the percentage of mortality, it is greater than it need be. This is partly due to the way in which the disease begins, and the mildness of its early symptoms making diagnosis doubtful. It is also owing in part to the character of the early symptoms, and the abuse of domestic remedies. A child is found to be poorly ; he vomits and complains of headache. Immediately he is treated to a dose of castor-oil or other aperient ; and as the symptoms are not found to be relieved by this measure, the dose is repeated, perhaps several times. There is no doubt that such treatment is excessively injurious ; and in hospital practice the cases which terminate fatally generally have a history of active purgation having been adopted before admission.
However severe the symptoms may be, we may look forward hopefully to the issue provided perforation has not occurred. Children respond well to stimulants in typhoid fever ; and a patient who is seen stupid and drowsy and profoundly depressed on one visit, may present a very different appearance on the next under the free use of brandy. I think even muscular tremors have not the same unfavourable meaning in the child that they have in the adult. Still, if the tongue quivers when pro truded, the lower jaw trembles when the mouth is open, and general tremulousness of movement is pronounced, we have reason to fear the presence of a deep ulcerative lesion in the intestine. Our apprehensions. are strengthened if at the same time the belly is much distended, and the temperature remains persistently elevated after the end of the third week.. In such a case the danger of perforation is imminent.