Local symptoms depend upon the locality and extent of the tubercular deposits in the various viscera. While many organs are invaded, some are more apt to give symptoms than others, and the organ most invaded will give a leading character to the local symptoms.

If the meninges are involved, the local symptoms will be those of meningitis. It is important to remember that in children tubercular meningitis is acute miliary tuberculosis with symptoms of meningitis, while in adults it is possible for it to be a local lesion without involvement of other organs. Involvement of the pleura gives rise to pleurisy. A double pleurisy with effusion or a hemorrhagic effusion is highly characteristic.

Involvement of the lungs can be described as occurring in three stages. There is first a fine bronchitis of the smallest tubes over both lungs, especially at the apices, and associated with dry pleurisy in patches. The physical signs are those of fine bronchitis and dry pleurisy. As the tubercles increase in number they coalesce, so that parts of the lungs, especially the apices, become consolidated, giving rise to areas of dulness, to bronchial voice and breathing, and to increased vocal fremitus. In the third stage the coalesced tubercles break down to form small cavities, so that the breathing becomes broncho-cavernous and there are gurgles. The subjective symptoms consist of cough, rapid breathing, rarely a feeling of dyspnoea, slight cyanosis, and an expectoration of muco-pus sometimes admixed with blood and containing bacilli.

Involvement of the peritoneum is shown by ascites, tympanites, constipation, and sometimes by pain. In other cases there may be no symptoms although the peritoneum be extensively involved.

Tubercles in the choroid can be detected by expert ophthalmologists.

In all cases the diagnosis is made by adding the general to the local symptoms. In some cases the general outweigh the local symptoms, and the disease resembles malarial or typhoid fever. In other cases the local symptoms are the more prominent, and the cases resemble meningitis, pleurisy, broncho-pneumonia, or peritonitis.

Types of the Disease.-I. Fever Type.-The disease begins like typhoid and runs for three or four weeks, with enlarged spleen. There are no hemorrhages and no spots; bronchitis is more marked, the pulse and breathing are more rapid, and the mind is clear. At the end of this time the patient may die, and the diagnosis may be difficult unless advancing lesions in the lungs and bacilli in the sputum can be demonstrated. Other cases go on for three or four months, with high remittent fever, developing areas of consolidation and breaking down in the lungs, and die exhausted. In these cases the lungs are the seat of the chief deposits. Other cases run the same course, but we have in addition the local symptoms from other organs (see Pl. 11). In still other cases the temperature at the onset is intermittent, resembling malarial fever.

2. Meningeal Type.-Here the picture is that of tubercular meningitis. The difference between tubercular meningitis in children and in adults has been alluded to.

3. Mania or Delirium Type.-Acute mania or active talkative delirium may be the first symptom, associated with fever. Stupor and coma follow, and death results, usually within three weeks.

4. Pulmonary Type.-There may be a pleurisy with fever out of proportion to the apparent lesion, or the disease may begin as a bronchitis or a broncho-pneumonia. Any bronchitis which persists for some weeks, with high fever, rapid pulse, and respiration with fine râles heard especially at the apices, should be regarded with suspicion.

5. Any of the preceding types may be complicated by symptoms of a pre-existing local tubercular lesion.

Diagnosis is aided by the following characteristics: In most cases there is a previous tubercular lesion. There is evidence of a diffused disease, such as meningitis, double pleurisy, and bronchitis, in the same patient. Objective symptoms are more marked than are the subjective ones. The patient "feels all right" and yet is evidently sick. most cases bacilli can be demonstrated in the sputa and tubercles can be seen in the choroid.

There is an advancing lesion in the lung, with diffused fine rales, both bronchial and pleural; later, consolidation and breaking down in small areas.

In all cases the disease runs a progressively downward course and terminates fatally. Removal of pleuritic or ascitic accumulations is followed by a return of the effusion.

Prognosis. The disease is surely fatal. Some cases are fatal in from seven to ten days; more commonly they run for three or four weeks or as many months, and very rarely for a year. Meningeal cases are more rapid than the fever or the pulmonary type.

Treatment is entirely symptomatic. The patient is to be fed, nursed, and made comfortable.

The sputa should be sterilized to prevent the spread of the disease.

MALARIAL FEVER.

Definition.-Malarial fever is a specific, non-contagious disease caused by the plasmodium malariæ, and is characterized by paroxysmal fever, enlargement of the spleen, and a tendency to extreme anæmia.

Etiology. The plasmodium malariæ, discovered in 1880