After a time local symptoms arise. These often point to cerebral irri tation. An attack of convulsions occurs, followed by squinting ; the pupils are dilated ; there is drowsiness and rigidity of joints ; and the child dies with all the symptoms of tubercular meningitis. It other instances the cranial cavity escapes, and symptoms are noticed showing implication of the lungs.
The first local sign of acute pulmonary tuberculosis is cough. This is short and hacking, and in the earlier period not very frequent. It may be accompanied by some hurry of breathing ; but the respirations are not always increased in rapidity, and even at an advanced stage of the disease, if there be only a moderate amount of catarrh, may be little, if at all more rapid than in health. The cough at this time is not accompanied by any abnormality of physical signs. Repeated examination of the chest discovers no dulness on percussion ; and an occasional click of rhonchus or a sibilant wheeze may be the only phenomenon present. In some cases the child dies without any fresh symptoms ; but usually a secondary bronchi tis develops after a time. The breathing then becomes rapid, the face is haggard and livid, and the naves dilate in inspiration. The pulse is small and rapid, and there may be some slight perversion of the pulse-respira tion ratio ; but this never occurs to the degree noticed in cases of broncho pneumonia. The temperature rises, and ° may reach in the evening, sinking to 100° in the morning. With the stethoscope we now find the breath-sounds covered by a crisp, bubbling rhonchus, which occupies the whole extent of both inspiration and expiration. If the breathing can be beard through the rhonchus, it is not bronchial although the expiration is perhaps prolonged. There is no dulness if collapse be absent ; but sometimes local collapse of small extent occurs at the apex ; and we may find a little local dulness at the supra-spinous fossa, or above the clavicle, with faint bronchial breathing. There is nowhere any increased resonance of voice or cough.
The above signs may persist without alteration to the close. Often, however, the inflammation passes into catarrhal pneumonia. Patches of dulness are then discovered at the apex or elsewhere. At these spots the breathing is blowing or tubular ; the rhonchus becomes crisper, finer, and more crepitating in character ; and the vocal resonance may be intensely bronchophonic. The patches of consolidation, as in cases of the non
tubercular inflammation, may coalesce until large areas of tissue are solid ified.
The occurrence of broncho-pneumonia is also indicated by increased severity of the previous symptoms. The lividity deepens ; the breathing becomes laboured ; the soft parts of the chest and epigastrium sink in at each inspiration ; the nails become purple, and the superficial veins of the extremities are fuller than in health. The temperature also rises to a higher level, and may reach 104° or 105° in the evening. When these symptoms are noticed the illness is very near its close ; indeed, the child seldom survives longer than a day or two. Death may be preceded by a fit of convulsions, due either or asphyxia.
A little girl, aged ten, with a consumptive family history, was a pa tient in the East London Children's Hospital. The child was said to have suffered when quite young from measles, whooping-cough, and scarlatina, but had recovered perfectly froth each, although the latter had been fol lowed by dropsy. She had also had an attack of ague when between two and three years of age. Still, the child had been in fair health until six weeks before admission. Her illness had begun suddenly, but the symptoms at first were not marked. She had seemed generally poorly, but did not lose flesh to any considerable extent ; nor was she troubled with cough for the first three weeks. When the cough began it was short and dry, but not distressing. Three clays before admission it had become loose, and the child had expectorated some yellow phlegm. After the cough began she was noticed to waste and to be feverish, sweating much at night. For a week her feet had been a little swollen.
On admission the child's expression was anxious. There was some lividity of the face, and in the evening her cheeks flushed brightly. Her tongue was clean and her bowels regular. Temperature at 7 P. M., 100.4°. On examination of the chest the percussion-note was slightly high-pitched above the clavicles, but' elsewhere was normal. Everywhere about the chest the breath-sounds were concealed by a metallic bubbling rhonchus. This was coarser behind than in front, and occupied the whole extent of both inspiration and expiration. The vocal resonance was normal. A rhonchal fremitus could be felt everywhere about the chest.