After admission the physical signs persisted with little alteration. The dulness disappeared from the apices and none could be detected elsewhere. The pulse was very rapid, 150-168; respirations, 60-68 ; temperature each evening, 101°--102.4°. After a few days the lividity deepened ; the child became very restless, and she died on the ninth day—the fifty-first clay of her illness.
On examination of the body gray or yellow miliary nodules were found in the liver, spleen, and kidneys. Gray granulations were also seen under the serous coat of the small intestine, and were numerous on the pia ma ter. The lungs were stuffed with tubercle throughout, and the nodules formed projections on the surface underneath the pleura. The nodules varied in size, the largest not exceeding a hemp-seed in diameter. The lung tissue between them was of a deep red colour and tore readily. It, however, floated in water. The mecliastinal glands were enlarged and cheesy, and one or two were softened.
Besides the parts which have been mentioned, tuberculosis sometimes involves the urinary apparatus. The kidneys indeed are often affected, and the consequent congestion is no doubt a cause of the slight albuminuria which is a common symptom of the affection. But besides the kidneys, tuberculosis may occur in the bladder. This lesion is more common in the adult than in younger subjects, but is met with from time to time in the older children. As it gives rise to many of the symptoms of vesical calculus this form of tuberculosis must not be passed over without a word of mention.
The presence of miliary tubercles in the bladder sets up a cystitis, and gives rise to symptoms which are attributed almost invariably to stone. There is great irritability of the bladder and increased frequency of mictu rition ; and according to Guebeard, these symptoms are more marked at night than during the day. At the end of the flow of urine some pus may be passed, or a drop of blood may appear at the extremity of the urethral canal. There may be pain, which is referred to the region of the bladder, and the passage of urine is often accompanied by uneasiness. Sometimes mictarition is only effected by straining, during which the rectum may pro lapse. The urine may be normal, but often is cloudy and thick. It may
contain a trace of albumen. The temperature and general symptoms of tuberculosis are present in these cases. Exploration of the bladder with a sound discovers no calculus ; but digital examination by Volkmann's method (i.e., passing a finger into the rectum and palpating with the other hand above the pubes) sometimes detects a tubercular nodule at the fun dus of the bladder.
In the stomach, intestine, liver, and spleen the development of tubercle rarely gives rise to sufficient local symptoms ,o furnish grounds for diag nosis. In the stomach the lesion may excite digestive trouble ; but even. this is an uncommon consequence of the disease, and when present is sig nificant merely of catarrh of the mucous membrane. Bignon, indeed, has reported a case in which a child died after vomiting a large quantity of blood, and on examination of the body an ulcer was found at the larger curvature surrounded by tuberculous nodules.- This case is, however, a very exceptional one. In the intestine the lesion seems to excite no symp toms whatever. The spleen, if thronged with masses of tubercle, may be enlarged ; but the liver is rarely increased in size from this cause. It is, however, sometimes the seat of fatty infiltration.
The duration of acute tuberculosis in the child is seldom prolonged. In infants it may last six weeks or two months ; in older children some what longer. The length of the illness principally depends upon the du ration of the early stage, for when local symptoms occur showing im plication of special organs, the disease usually runs rapidly to its close.
Diagnosis.—The disease with which acute tuberculosis is most apt to be confounded is typhoid fever. This is especially the case when the tu bercular affection begins abruptly with high fever, headache, and bleeding from the nose. A diagnosis is then impossible at the first ; indeed it is often only by the after-course of the illness, and the prolongation of the pyrexia beyond the time when in typhoid fever a fall of temperature may be looked for, that suspicious are excited of the real nature of the disease. The diagnosis between an ordinary case of acute tuberculosis and typhoid fever is given elsewhere (see page 83).