ACUTE MILIARY TUBERCULOSIS. 255 



health, or those whose chronic pulmonary affection has hitherto 

 escaped attention. It then not unfrequently begins with repeated 

 rigors, great frequence of the pulse, and severe . constitutional disturb- 

 ance, symptoms often hard to interpret, as they are attended by no 

 tokens of local disorder. The frequence of the pulse often becomes 

 exceedingly great, abundant sweats set in, the patient sinks visibly 

 from day to day, the tongue becomes dry, the sensorium deranged, he 

 becomes delirious or lies supine in a state of stupor. A rapidly-increas- 

 ing prostration, cough, and dyspnoea accompany these symptoms, it is 

 true, but the most persistent physical examination of the chest reveals 

 nowhere that the substance of the lung is infiltrated. No sounds can 

 be perceived, save a few fine rhonchi and scanty rales. The symp- 

 toms which we have depicted are so very like those of typhus, that 

 the most experienced diagnosticians acknowledge to having met with 

 instances in which a diagnosis between the two was absolutely impos- 

 sible, and where patients dying with a diagnosis of typhus really had 

 died of tuberculosis, and conversely. The less violent the symptoms 

 of catarrh in acute miliary tuberculosis, the smaller the clew afforded 

 by the spleen, the more rapid the march of the malady, so much the 

 more difficult does the distinction become. The patient may succumb 

 to miliary tuberculosis, after the lapse of a fortnight, or a few days 

 longer, or about in the same time in which patients usually die of 

 typhus. More rarely death does not take place until the end of the 

 fifth or sixth week. The patient perishes, as we have said, consumed 

 by fever, just as he falls a prey to fever, too, as a rule, when he dies 

 of typhus. The pulse becomes smaller and more and more frequent ; 

 finally, the pulmonary veins are no longer able to pour their blood into 

 the imperfectly-emptied heart, and oedema of the lungs, palsy of the 

 bronchi, and suffocative effusion are established. If tuberculous basilar 

 meningitis accompany the attack, its course is modified (see appro- 

 priate chapter) and the fatal termination takes place with even still 

 greater rapidity. 



DIAGNOSIS. At the outset of the disease, if the chills recur with 

 some degree of regularity, it may be mistaken for intermittent fever. 

 We shall soon observe, however, that the intermissions are not com- 

 plete, that quinine fails in its effect, that the complaint is attended 

 by a disturbance in the respiratory function, which is unusual in inter- 

 mittent ; that the frequence of the pulse is constantly on the increase, 

 and that the entire character of the complaint is more pernicious than 

 that of simple intermitting fever. 



In other cases the disease, at its commencement, resembles an ex 

 tensive bronchial catarrh, accompanied by fever, especially if the cough 

 be very violent and distressing ; but here, too, all difficulty of distinr- 



