With the appearance of the onset, after a greater or lesser period of time, the other symptoms of the disease usually manifest themselves. The slight, dry, hacking cough becomes more pro nounced and productive of a thick, muco-purulent expectoration; it may either be increased or decreased by Mug down or upon assuming certain positions, and in many instances causes great pain, particularly aggravating that of the usual then existing pleurisy. The den, convulsive movements to which the thoracic contents are subjected result in more or less trauma. As softening and breaking down take place, the expectoration becomes more profuse. Cough is Nature's effort at drainage; it is her attempt to rid the organism of an offending substance, no matter whether that be an irritating area of pleuritic in flammation in the first stage of the dis ease or broken down and softened lung tissue—in other words, sputum—in the later stage. It is an accompanying pro vision for this breaking-down process and for the emptying of night accumu lations occurring in cavities. Many pa tients after this morning cough, which rids them of the excess of sputum ac cumulated during the sleeping hours, this resulting from decreased reflexes. pass the remainder of the day in com parative comfort. The cough may be of such severity as to produce vomiting. and is apt to become worse at night after the patient has gone to bed; he may have several attacks before morn ing. These occur with some degree of regularity and produce loss of sleep, while sweating follows the violent exer tion.
Pain in the chest, usually localized and corresponding to an area of pleurisy: sharp, knife-like, and sudden; increased upon exertion, cough, or breathing. may persist for days or weeks or it may be transient.
Rapid emaciation and loss of weight is found in nearly every instance at some stage of the disease; it is frequently the first thing to attract the patient's atten tion to himself, and, taken alone, is one of the surest guides of the progress of a case.
Spulum.—The sputum varies greatly in quality and quantity, and depends somewhat upon the rapidity with which destruction is going on, and whether or not there be a mixed infection. It may be mucoid, muco-purulent, or purulent, then watery; or may contain the thick, yellowish, lump-like masses which sink and which may have created suspicion of the real nature of the trouble. Bacilli are found in varying numbers and are particularly numerous in the cheesy par ticles which show up plainly when a layer of sputum is spread upon a smoked glass. There may be calcareous masses or chalk deposits in which bacilli exist in great numbers — those representing cast-off foci. Elastic tissue is evidence of destruction; it may be seen with the naked eye, and under the microscope it is often possible to determine its source, whether from blood-vessel, bron chus, or alveolus. In cases showing mixed infection there may be seen the various forms of pus-organisms. Red blood-cells are not uncommonly found, particularly after blood-spitting, and the migrating white cell is rarely absent.
Stress is laid on the importance of an early diagnosis, on examination of the sputum and the respiration; other phys ical signs not recognized. The examina tion must be made daily, and sometimes it will be only after the twenty-fifth or thirtieth time that the exact scat of the complaint can be located. Osier (Med.
Rec., Sept. 9, '99).
The fever of tuberculosis varies with the stage of the disease and the rapidity of the process. In incipient cases the thermometer may register normal for the greater part of the day, and show only a slight rise toward evening. A constant evening rise of temperature of from one-half to one degree, particu larly if the patient is debilitated or shows signs of dyspepsia, should excite sus picion. The maximum temperature oc curs about four o'clock in the afternoon, the minimum about four o'clock in the morning; but there are many irregu larities, and the temperature-curve, as well as the disease, is erratic. Not commonly, in the advanced stage when marked asthenia exists, the thermometer fails to register by mouth, while, at the same time, the rectal temperature will be above normal; this is more likely to occur in the morning. The tempera ture-curve may simulate that of malaria; hut, with the beginning of the breaking down and softening process and with the absorption of fever-producing products, it becomes continuous, showing marked irregularity and the tendency to evening exacerbations. When mixed infection with the pus-cocci is present, there is the characteristic temperature of pus-absorp tion. In far-advanced phthisical pa tients, rest in bed, in many instances, converts a remittent temperature-curve into one that is intermittent; and, vice versa, following exercise, an intermittent curve may become continuous and as sume the remittent type. The pulse, as the fever, varies with the degree and rapidity of the process; it is usually rapid and soft, and such a pulse may have been the first thing to cause sus picion of the disease. The veins become more prominent, owing to the wasting of their tissue-beds and the pale, anmmic background upon which they are seen.
The importance of chlorannmia as a sign of the pretuberculous state is em phasized particularly when this condi tion of the blood is associated with poor chest-development or decreased respira tory capacity. Abnormally low weight, chest-development, and respiratory ca pacity have no great value in themselves, but they are of distinct importance when compared with the height of the indi vidual. In a normal man the product obtained by dividing the weight ex pressed in pounds by the height expressed in feet should be 26, in a normal woman 23. The average measurement of the chest, one measurement being taken at full inspiration and the other at full expiration and the mean used as the average should equal at least half of the height; and the amount of air (in terms of cubic inches) that a man can exhale after a full inspiration should have a ratio to the height of the man (in inches) of 3 to 1, in case of a woman of 2 to 1. Reduction in any or all of these normal ratios should lead to a suspicion of pre disposition to tuberculosis, as should persistent digestive disturbance that otherwise seems causeless. The pulse in the pretuherculous stage is characteris tic, in that it is not influenced in its rapidity by change of position and is of feeble tension. Henry P. Loomis (Med. Rec., Dec. 10, '9S).