ACUTE MILIARY TUBERCULOSIS Miliary tuberculosis resembles an acute infectious disease, and occurs at every stage of childhood. We meet with it in infants present ing the same picture as in adult life.
Etiology and Pathogenesis.—Milia•y tuberculosis is almost never primary in origin. It follows some tuberculous focus in the body,—most commonly cheesy bronchial lymph-nodes. The primary focus may be recent or of long standing. Every person who harbors tubercle bacilli runs the danger of developing a fatal miliary tuberculosis. This develop ment generally is spontaneous but may follow some operative procedure. All that is necessary is that the bacilli obtain entrance to the blood stream in large numbers, as readily happens when a cheesy lymph-node ruptures into a vessel.
The tubercle which causes the general infection may lie in the ves sel (see Fig. 136) or as just mentioned may rupture from without into the blood or lymph stream. Naturally the blood vessels of a diseased lymph-node are most endangered.
About S or 10 days following the dissemination of bacilli, charac teristic tubercles appear throughout the body. The sites of predilec tion are the serous surfaces, as well as the spleen, the lungs, the bone marrow, the liver, the kidneys, etc. No organ and no part of an organ is immune from infection. The number of tubercles varies, but is gen erally large. Following the primary dissemination, there may be a second or a third, and even more if the patient lives sufficiently long. This may be deduced from the various sizes and stages of development of the tubercles which we find at autopsy.
disease may set in a-cutely without any pro dromal stage, and attack an apparently healthy child. At other times the child complains of indefinite symptoms for a week or more, is apathetic, lacks appetite, and may have an occasional rise of temper ature, until suddenly the seriousness of the ailment begins to impress itself upon us. The fever quickly becomes marked but presents no characteristic curve.
In some cases the fever rises gradually, and remains high with remission of 1 or 2 degrees until death. However it may begin with a
rise to F. or over, and he characterized by marked and repeated remissions. The pulse is rapid in comparison with the temperature. If the meninges are involved early in the disease, we may find a slow or irregular pulse at the onset.
Percussion and auscultation of the lungs afford little aid in the diagnosis. At times there is a slight tympanitic note. Bronchitic riles point to involvement of the lungs. The breathing is rapid and a considerable degree of cyanosis may be present.
The cough may be very distressing and dry; in small children, however, it is frequently absent or of no moment. Expectoration when present is scanty. The spleen is almost always enlarged and is hard and firm in consistency. The urine at times contains tubercle bacilli and frequently gives the diazo reaction. Involvement of the meninges may lead to early cerebral symptoms. Indeed these may dominate the clinical picture to such a degree that one considers the case one of tuberculous meningitis.
The difference between tuberculous meningitis and miliary tuber culosis with meningeal involvement is generally not clearly defined. We should speak of tuberculous meningitis when the miliary tubercles are confined to the meninges with but one or at most a few tuberculous foci in the entire body. In true miliary tuberculosis there is to a cer tain extent a general dissemination of tubercles. In tuberculous men ingitis the picture is distinctly cerebral in type; in the miliary form, death frequently intervenes before the cerebral symptoms are very marked. Miliary tuberculosis is equally prevalent throughout all stages of childhood, tuberculous meningitis is most common between the ages of two and six.
diagnosis of miliary tuberculosis is certain only when we find tubercule bacilli. This however is not possible in most of the cases, for the sputum does not contain bacilli, as the foci do not generally communicate with the bronchi. Sometimes we may find tubercle bacilli in the urine, but failure to find them does not affect the diagnosis.