Ulceration of lung and the formation of cavities is not a common con sequence in early life of acute pulmonary tuberculosis. In infants in whom the disease runs a rapid course this lesion is very exceptional. It is, how ever, sometimes met with. Thus, in an infant, aged eight months, with four teeth, who died in the East London Children's Hospital of acute gen eral tuberculosis with secondary bronchopneumonia and meningitis, tu bercles, gray and yellow, were found after death occupying all the cavities in the body. They were discovered at the base of the brain, on the peri toneum, in the substance of the liver, spleen, and kidneys. The lungs were completely stuffed with them, and in the lower lobe of the left lung a small cavity had formed of the size of a hazel-nut. Such a condition is, however, not common. Even in older children, although the duration of the illness is longer, breaking up of the lungs, as a consequence of acute tuberculosis is comparatively rarely seen.
In the intestines the gray and yellow granulations are seated especialii, in the smaller bowel, and involve principally the ilium and the part of the cfccum in the neighbourhood of the valve. The nodules lie in the sub mucous tissue, and in the acute form of the disease do not, as a rule, give rise to ulceration. In the liver the tubercles are developed on the smallest ramifications of the hepatic artery. They may be seen under the serous coat, and are also found in the interlobular spaces and in the interior of the lobules. They are usually few in number. In addition to being the seat of tubercle, the organ is often found to present other pathological characters not especially distinctive of the tubercular disease. Thus, it may be enlarged from a simple hypertrophy or from fatty infiltration, and is sometimes the seat of a cirrhotic change. In the latter case it may give rise to ascites.
The spleen is one of the organs most commonly attacked by tubercle. Gray and yellow granulations and large cheesy masses may be found, so that the size of the organ is considerably increased. In the kidneys mili ary nodules may be thinly scattered through the parenchyma. The little masses are developed, as elsewhere, in the sheath of the smallest arteries_ Sometimes more extensive disease is met with, and large masses of cheesy matter are formed which soften and give rise to tuberculous ulcers. These: may penetrate deeply into the renal tissue. According to Rindfleisch the disease begins in the papillary portion of the gland, spreading from the mucous lining of the calices. In extreme cases the kidney is converted into a thick-walled sac, with hemispherical protrusions, each of which cor responds to a pyramid. The bladder is sometimes involved, al though comparatively rarely in early life. Miliary nodules appear in the submucous tissue and soften, giving rise to circular ulcers the edges of which are found on examination to be infiltrated with closely packed gray and yellow granulations.
In addition to the lesions which have been mentioned, the bronchial and mesenteric glands are always enlarged and cheesy. Sometimes they are softened.
How far the cheesy matter, which is often found in large quantities in the more prolonged cases of pulmonary tuberculosis, is to be regarded as tubercular is a question upon which opposite opinions are held. Virchow and his followers look upon all such caseous matter as the consequence of catarrhal pneumonia ; and there is no doubt that the miliary nodule is primarily an extra-alveolar growth, while the caseous masses, such as are found in cheesy pneumonia, take their origin from a proliferation of the epithelial elements in the air-cells. Before the giant-cell was known to be a constituent of other than strictly tubercular structures, the presence of this cell was held to be confirmatory of the tubercular nature of the pathological product. Now the presence of the bacillus is considered by many to point to the same conclusion. But is the question one which can be determined solely upon anatomical grounds ? The clinical history of the disease is surely a not unimportant element in the solution. It is gen erally admitted that the closest examination discovers in the gray granula tion no peculiarity of structure which can be relied upon to separate the nodule from other bodies having a like appearance, and under the micro scope all cheesy matter has very similar characters. The case is one in which the clinical features of the malady should have an exceptional value in determining the nature of the pathological product ; for if two diseases are found to differ widely in the mode of origin of the attack, in the nature of the symptoms, and in the course of the illness, we may hesitate to ad mit identity of nature, however close may be the resemblance in the ana tomical conditions.
Symptoms.—Primary tuberculosis in the child commonly assumes the form of an acute general disease. It excites moderate pyrexia and marked interference with nutrition, and from the indefinite character of the earlier symptoms and the absence of any manifestation of local distress, often presents great difficulty in the diagnosis. Sooner or later signs are dis covered pointing to disease of special organs: cerebral symptoms arise, or there are indications of pulmonary mischief. Tubercular meningitis and cerebral tubercle are described at length in special chapters. The present description is confined to cases where the disease is general, and where the local symptoms are limited to the lungs and other organs not elsewhere referred to.