At my visit I found the child lying in bed with her face turned away from the window, as the light, she said, hurt her eyes. There was no sal lowness of complexion. Her expression was placid, and not at all anxious or distressed. The tongue was a little furred on the dorsum, and rather red at the tip and edges. She was thirsty, but had no desire for food. The abdomen was soft, without tenderness or distention. The spleen was very indistinctly felt; it seemed to be slightly enlarged. There was no rash of any kind on the body, nor any oedema of the legs. The urine was not al buminous. The heart sounds were healthy. There was no rhonchus, nor any other abnormal sign about the lungs. Respiration regular, 24 ; pulse regular, 108 ; temperature, 101° (at 4 P.m.).
This case, which was seen on the seventh or eighth day of the illness, when the ordinary eruptive fevers could be excluded, might have been acute tuberculosis, typhoid fever, or acute gastric catarrh. The occur rence of fever, with a history of previous delicacy of health, was quite in keeping with the ordinary course of tuberculosis. There was, however, no family history of any such complaint, and this important fact, together with the complete absence of distress or anxiety in the expression of the child, and the absence also of any (edema of the extremities, was held sufficient evidence to exclude the presence of this formidable disease.
Between typhoid fever and acute gastric catarrh the distinction was more difficult. The temperature, it is true, although always elevated, had not followed the course of the temperature in a typical case of enteric fever ; but in children this fe ver is often mild, and frequently deviates from the ordinary type. Again, the absence of eruption did not exclude typhoid fever, for the eighth day is early for the rash to appear, and in children ty phoid spots are sometimes absent altogether in undoubted cases of the dis ease. On the other hand, the state of the spleen was doubtful. Some slight enlargement was suspected ; if this was so, the fact pointed distinctly to typhoid fever.
In favour of acute gastric catarrh was the slight snuffling, the mild sore throat, the complete absence of delirium or of apparent discomfort, and the irregularity of the fever. Altogether, the symptoms pointed, perhaps, more decidedly to gastric catarrh than to the more serious disease, but it was impossible to exclude typhoid fever ; therefore, a guarded opinion was expressed as to the nature of the case. The temperature fell on the follow ing (eighth or ninth) day. This early termination seemed to decide the question in favour of catarrh, for it is only in very exceptional cases that typhoid fever subsides before the fourteenth day.
When gastric catarrh, instead of occurring in one solitary attack, as in the above instance, recurs -repeatedly at short intervals, the diagnosis is more easy. This recurrent form is well illustrated by the following case
which was sent to me by Dr. Lister, of Croydon.
A little girl, aged seven years, pallid in appearance and ill-grown, had been wasting slowly for eighteen months. During the whole of this time she had suffered every two or three weeks from attacks of feverishness. In these illnesses the symptoms were the same. The temperature rose to 103° and 104°. The child looked sallow in the face, and was very irritable and languid. She was thirsty, but refused her food. Sometimes she vomited, but in the earlier attacks the bowels were never relaxed. She got thinner and weaker, and looked ill. A few months previously she had had a severe attack at Lowestoft, in which she had been slightly jaundiced. Six weeks •before her visit to me she had had a still more violent attack, which had left her completely jaundiced. This had been followed for the first time in her experience by diarrhoea ; and for a fortnight the motions were green and slimy, and sometimes contained clots of blood. They were passed with straining and some pain. At the time of her visit, the looseness had in a great measure subsided, but the child still had a faint yellow tint of the skin. Her heart and lungs were healthy, and there was no sign of en largement of the bronchial glands. Between the attacks of illness the child was said, as a rule, to be fairly well. On the subsidence of the fever her appetite would return, and she would begin to regain flesh. Unfortu nately, before her strength could be said to be thoroughly restored, it would be again reduced by a new access of fever.
Jaundice in children after the period of infancy, is, in the large majority of cases, catarrhal. In this child, its occurrence with the two last attacks of fever helped greatly to explain the nature of these attacks, and the cause of the ill-health from which the child was suffering. Moreover, in the most recent illness, a new feature had been noticed in the diarrhoea which had followed the jaundice and still further delayed convalescence. In this diarrhoea, the characters of the stools, which contained mucus and blood, and were passed with straining and pain, pointed to a catarrh of the lower bowel. Explaining, then, the earlier attacks in the light afforded by the latter, it was evident that the child's sensitiveness to changes of temperature showed itself in the form of repeated attacks of acute gastric catarrh, ac companied by fever. This fact being once established, the treatment of the case was conducted upon the principles to be described, and the child had no return of her feverish symptoms.