Page images
PDF
EPUB

glands and enlargement of the liver and spleen.

Soon there

occur diffuse finely crepitant rales, but on the whole, the pulmonary lesion does not explain the high rate of respiration and cyanosis. Bronchial breathing is not present, nor are there any signs of consolidation. After death, which occurs very shortly, the post mortem examination reveals a diffuse miliary tuberculosis, attacking all organs excepting the brain and its coverings. This class of cases constitutes the most rapid form of tuberculosis in children and lasts from ten to fourteen days.

A second sub-acute form also exists. In these cases, the digestive symptoms are so urgent that they may at times. cover the true pathological condition. There may be anorexia alternating with a voracious appetite; diarrhoea, alternating with constipation. Vomiting sometimes occurs. But in almost every case, there is present a cough of a hacking nature, pains in the chest and abdomen, rapid breathing combined with a certain amount of dyspnoea. The breathing and dyspnoea are here also entirely out of proportion to the small amount of chest lesions that may be discovered, consisting only, as they do, of slight catarrhal conditions. During sleep, sighing respiration and moaning occur frequently. The spleen increases markedly in this condition. As the disease progresses, the temperature becomes remittent at first, rising every third day, but finally remaining present every day, with an evening rise and morning fall. The temperatures are generally quite high. Death occurs as a result of cedema of the lungs or of an acute colliquative diarrhoea.3 In the earlier months of life, tuberculosis may remain latent for some time. The children appear to be, as it is popularly termed, delicate. They do not increase in weight, or only slightly so. Much more frequently progressive emaciation takes place. Cough and temperature are not frequent. Some of these cases resemble marasmus so closely that it is almost impossible to differentiate them during life. However, in a number of these cases, the disease extends over a sufficiently long space of time to allow implication of the lungs to

We then find all the signs of pulmonary disease with temperature. The peculiarity of this temperature, however, consists in this, that it is never hectic, nor is it very high.'

[ocr errors]

Here again, as in the other cases, there is a marked increase in the number of respirations with dyspnoea and much more so than one can explain by the pulmonary lesions and temperature. The form of the chest disease in these cases is that of broncho-pneumonia, or a bronchitis. There are also a number of digestive symptoms that are, however, not at all .characteristic. They are never or only rarely due to any tubercular infection of the intestinal tract, but rather to the lowered condition of the patient. These symptoms, for the most part consist of vomiting and of greenish diarrhoea. In another class of cases, occurring generally in older children, we find a period of greater or less duration preceding the tuberculosis, during which there are presented no other symptoms than a distaste for any exercise, considerable fretfulness and a persistent anæmia.

After this state is continued for some time, there appears a temperature of a sub-acute type, there is some dryness of the tongue, sordes on the lips and even delirium and a general typhoid condition. This form is not complicated with. tympanites, nor are there, of course, any rose spots, a fact that should immediately suggest tuberculosis, as rose spots are only exceptionally absent in the typhoid of children. After several weeks, with the increase in the disease, it is possible to make out a focus in some one organ, in the large majority of cases, in the lungs. Or the process may be still longer deferred, the patient apparently recovering to a certain extent, but not regaining his full strength. If the temperature be taken regularly, it will be found that there is always present a certain amount of pyrexia. This may be called the remittent stage, and may last for some time, three or four weeks. Generally the patient becomes soon worse again, the temperature now becoming high, there being evening exacerbations and morning remissions, accompanied by wasting, until finally, there develops a broncho-pneumonia, tuberculous in its character, or less frequently, a meningitis or lymphatic infection of the same character.

Among the special organs of the child that may become tuberculous, the lungs rank first in importance and frequency of attack. Infection may take place in the lung itself or it may be secondary to the forms of general tuberculosis already

mentioned, to a local tubercular process, to the acute infectious diseases or to repeated attacks of simple bronchitis or broncho-pneumonia. The tuberculosis may take the form of pulmonary miliary tuberculosis or of an acute, sub-acute or chronic broncho-pneumonia.

In the acute miliary tuberculosis of the lungs, the symptoms already mentioned under the head of general tuberculosis hold good. The asthenia, the high rate of respiration, the cyanosis, the irregular temperature, the slight catarrhal lung symptoms are all present. Typhoid symptoms develop frequently and are so marked that a diagnostic error is often possible until the development of a tuberculous meningitis clears it up. In the acute and sub-acute forms of bronchopneumonia, infiltration is soon to be detected. This process is scattered over various small areas, generally in both lungs.3 The patient suffers from a very distressing and incessant cough. The temperature is very irregular, the respiration is rapid, reaching 50 or 60 per minute.

A third form, a chronic tuberculous pneumonia, occurs, extending over several years.

The primary attack is slow in subsiding. The child is subject to that condition that is popularly termed a "cold.". A very slight exposure produces a bronchial irritation with cough. In many cases the cough has not ceased with the primary attack.

Some dullness may persist over the area originally diseased. If the process has approached the surface of the lung, pleural friction sounds are constantly present.

In a few weeks or months, a second attack occurs with involvement of a fresh area of lung, generally contiguous to that implicated in the first attack. This again subsides

partially leaving more pronouncd physical signs than the first.

These attacks may repeat themselves several times, until finally there occurs an attack of acute tuberculous pneumonia, or a miliary tuberculosis, especially after an additional infection with whooping cough or measles, a tuberculous meningitis, or a very extensive fatal simple acute bronchopneumonia.1

Chronic tuberculosis with formation of cavities is not very frequent among children. When it does occur, it shows no

noteworthy deviation from the process to be observed in the adult.

DIAGNOSIS.

The diagnosis is frequently very difficult, especially in early infancy. In many cases, the diagnosis is only possible at the autopsy table. When the family history and surroundings point to tuberculosis, we are justified in suspecting it in cases that present symptoms described under general tuberculosis. In differentiating from typhoid fever, the absence of rose spots and Widal's reaction will frequently establish a diagnosis of tuberculosis. If, in addition, there are present tubercles of the choroid, it will be certain. It will also be an aid to recollect that typhoid fever in children less than two years old is practically unknown, and therefore, suspected cases under this age are much more frequently tuberculosis than typhoid. Marasmus can generally be explained by improper food or want of care. In the wasting of tuberculosis of infants such causes may be wanting. In tuberculosis, diarrhoea and vomiting more frequently occur near the end of the disease than at the beginning. Fever is irregular and develops generally rather slowly. In the acute and subacute tubercular pneumonias, the differentiation from simple pneumonia is made by the resistance of the disease to treatment, the great wasting, the marked infiltration of the lung tissue and possibly the complication of tubercular meningitis.

The sputum, when obtainable, which, will be rarely so, will at once definitely decide the question. At other times, it may be possible to obtain tubercle bacilli from the feces, when of course implication of the stomach and intestines must be excluded.

PROGNOSIS.

The prognosis of the general forms is absolutely fatal. Of the other forms occurring in the lung, the prognosis is always bad, although there are undoubtedly cases that recover.

PROPHYLAXIS.

Since children so readily contract the disease and so speedily succumb to it, it is of the utmost importance that

proper prophylactic measures be instituted wherever the surroundings are such that the infant may become contaminated. All sputum from tubercular individuals about the infant or child should be rigidly collected and destroyed. Tuberculous patients, including the mother especially, should not be allowed to kiss the child, nor should the mother in such a case nurse the child.

In the selection of a wet nurse, the greatest care should be exercised in obtaining a woman about whom there is not the slightest suspicion of tuberculosis.

Milk from dairies not under constant veterinary supervision should be exposed to a temperature sufficiently high (170 degrees) to destroy any possible tubercle bacilli.

Occurrences of inflammation of the mucous surfaces, especially of the respiratory apparatus should be watched with the greatest care. The danger of infection with measles and pertussis should be avoided. Enlarged tonsils, adenoids and the ordinary diseases of the nose and throat should receive the earliest possible attention. The child should be early accustomed to outdoor life. The living rooms should be kept at an equal temperature. They should never be overheated. The diet should consist of the most nutritious foods, such as milk, and at the proper time, of eggs and beef. In the winter, it is wise to add to these, a pure cod liver oil, not emulsified.

TREATMENT.

After the tubercle bacilli have once gained entrance, the child should be removed, if possible from the city to a dry, warm climate. If this is not possible, he should be taken into the air as much as possible, no matter, if there is present fever or cough. In his home, he should have the airiest and sunniest room at his disposal. As diet in this case, milk ranks first. When digestion is unable to do its work, some preparation of milk, as Koumyss or Matzoon, may be substituted.

Among drugs, but two can be said to be of service. They are cod liver oil and creosote.

In very young children, creosote is best given in an emulsion and in very small doses, 1⁄4 to 1⁄2 drop. In older children,

« PreviousContinue »