Active exercise, meaning by this a fairly rapid walk of from two to four miles upon a level road, increases the bodily temperature to some extent, even in health. In convalescence, anaemia, chlorosis, and other constitutional states, temperature may reach as high as 100.5° F. A temperature above this is almost always indicative of tuberculo sis. All suspected cases in which active exercise was followed by a temperature above this, were invariably found to be tubercular. Penzoldt (Med. Rev.; Amer. Med. Comp., July, '99).
Night-sweats are common, and are one of the features of the disease; they may follow violent coughing-spells or the subsidence of the fever. In the early hours of the morning the patient awakes to find himself covered with moisture; his night-garment may be saturated and the bedclothing moist. These sweats are chiefly the sweats of exhaustion.
After the initial hremorrhage, in the beginning of the disease, there may be an absence of symptoms for months or years, or recurrent limmorrhages, which are usually slight, may occur and may be a special feature in the case; a blood tinged expectoration which lasts for weeks, producing more or less and gradual exhaustion, is quite com mon. Oftentimes haemorrhage comes on independent of exertion, while the patient is in bed or is quiet, and in many instances there is subsequently a marked general improvement, while in others the disease may rapidly progress and the patient pass on to an advanced stage. The bleeding which occurs early in phthisis is usually slight. and death from haemorrhage is rare; later, after ulceration and cavity-formation have taken place, erosion of a large vessel not uncommonly occurs, and the respiratory tract may be inundated and the patient die of asphyxia. A cavity may fill with blood, and the weak condition of the patient prevents him from raising it, under which circumstances it remains concealed. The disease may terminate by syncope, coma, or asphyxia, but the latter is a rare condition, and death most often occurs from exhaustion.
Physical Diagnosis.—In any well-ad vanced case of ulcerative phthisis path ologically there may be seen at the same time all stages of the disease which, for convenience of clinical study, will be ar ranged in the following order:— The first, or incipient, stage, or that of infiltration and beginning of consoli dation. The second, or moderately-ad
vanced stage, or that of advancing con solidation and the beginning of soften ing. The third, or far-advanced, or that of softening, break-down, and cavitv-formation.
—There is slight de fective percussion resonance over the affected area, and, on palpation when standing behind the patient and placing the hands in the supraclavicular spaces, a slight increased vocal fremitus over the diseased apex is revealed. This in creased fremitus is usually first appre ciated over the apex posteriorly. On auscultation there is a slight increase of vocal resonance.
Inspiration loses its breezy character and is partially suppressed, generally be coming broncho-vesicular in character, its duration shortened, and there is a slight interval between its termination and the beginning of expiration. The latter is high in pitch and is prolonged; jerky, cog-wheel, or wavy respiration is often heard.
The following method of examining the lung will reveal a very small lesion. The patient's hand is placed on the op posite shoulder, the ear is placed over that portion of the lung uncovered by the scapula, viz.: just above and ex ternal to where the bronchial tubes are given off; there will be heard prolonged tubular breathing and fine r5les on coughing. This is the very first physical sign of tuberculosis—an evidence which will make a diagnosis possible weeks be fore the signs are evident in front and beneath the clavicle. The tuberculin test is useful both in making the diagnosis of a beginning ease and in deciding if a case is cured. It is to be applied in the following manner: The patient's tem perature is to be taken every six hours for a few days to see he has no diurnal temperature above normal; then'/, milligramme of tuberculin is injected and his temperature is taken every four hours ' during the next twenty-four hours. At the end of two days, if there has been no temperature above one degree, a sec ond injection of 2 milligrammes should follow; if there is still no reaction after two days more, a third and final injec tion of 5 milligrammes is given. If there is still no reaction, the patient is free from tuberculosis. H. P. Loomis (Med. Rec., vol. liii, No. 21, '98).