iably by increasing dyspnea and cyanosis, and is frequently exhibited by patients suffering from an acute bronchopneumonic complication. In some instances these cases from the beginning are found to partake of the characteristics of acute pneumonic phthisis. It is not altogether unusual to observe the development of an acute pneumonic extension of the tuberculous process in patients previously manifesting a chronic type of consumption. A patient who for years had been afflicted with pulmonary tuberculosis exhibiting subjective and physical evidences of a quiescent infection experienced, without warning, a severe rigor, followed by an abrupt rise of temperature to 104° F. Examination of the lungs shortly disclosed a distinct pneumonic consolidation in the left front. At no time afterward did the temperature recede in the morning more than one or two degrees, while the dyspnea increased, emaciation became rapid, and cyanosis with exhaustion were increasingly apparent. At the end of one week the physical evidences of softening were recognized in the consolidated lung, and expectoration, which previously had been absent, became very profuse. At the time of his death, which took place three weeks. after the initial onset of the pneumonic extension, cavity signs were readily detected. Sometimes cases are observed in which the temperature is decidedly irregular. The chief clinical characterization, as far as fever is concerned, may relate to an elevated temperature in the morning, followed by an evening remission. In some cases, however, this so-called inverse type of fever may be followed for several days by morning remissions and evening exacerbations. Such irregularities of temperature may develop in patients who previously exhibited no fever whatever. This suggests the possibility of a general miliary infection supervening in the course of the pulmonary disease. The fever may be associated with vague, indefinite symptoms of malaise, languor, indisposition, and digestive disturbances simulating typhoid, or it may be attended by headache, pain in the back of the neck, delirium, stupor, and motor symptoms of meningeal tuberculosis. It may also be accompanied by cough, with slight expectoration and a disproportionate dyspnea and cyanosis, the physical signs being those of a widely diffused bronchitis. This latter combination of symptoms is highly suggestive of a miliary infection with predominant manifestations in the lungs. Other types of fever have been mentioned by various observers, and a fixed clinical significance attached to the respective varieties. A comparison of the forms above enumerated is sufficient to convince one of the obvious difficulty in discriminating sharply between some of these clinical types. Further efforts directed toward a conventional classification lead to increased confusion. Summary conclusions as to unvarying pathologic association are not warranted by the results of clinical observation. It must be remembered that the essential consideration in the production of fever is the entrance into the circulation of the toxic products, and that the extent of their absorption does not always correspond to the character of morbid change. It is not always easy to distinguish the exact nature of the secondary infection. In some cases streptococci are found in abundance in the sputum, as are also the staphylococci, pneumococci, and other microorganisms. Examinations of the blood may disclose the particular type of septicemia present, as may also examinations of the pleural exudate. Not infrequently the sputum, collected in sterile bottles after thorough cleansing of the mouth before the ingestion of food, has shown numerous streptococci and other microorganisms, although not the slightest clinical evidence of sepsis had been established. On the other hand, many patients have displayed the characteristic temperature of mixed infection, with associated chills and sweats, without the recognition of secondary microorganisms in the sputum. This subject will be considered under Mixed Infection. CHAPTER XX EMACIATION AND LOCAL OBJECTIVE SYMPTOMS EMACIATION Loss of weight is one of the important symptoms of consumption. It bears several definite relations to the tuberculous process. Emaciation, with corresponding impairment of the general resistance, renders the patient distinctly more susceptible to the original tuberculous invasion. The infection once established, contributes almost unavoidably to a further loss of weight. Finally, the only rational method of securing an ultimate arrest of the tuberculous process is the maintenance of an improved nutrition. On account of these established relations between the weight and the pulmonary condition it is easy to appreciate the overwhelming importance of judicious superalimentation. With but few exceptions does the emaciation go hand in hand with an advancing activity of the tuberculous infection. It is true that some patients exhibit physical evidences of rapidly extending pulmonary disease without displaying for a time any considerable impairment of body weight. Occasionally I have noted wide-spread involvement of the lungs with extensive destruction of tissues in very corpulent individuals, but such instances are decidedly exceptional. Rarely are patients fortunate enough to secure an arrest of the tuberculous process without the attainment of greatly improved nutrition. If so, it is found, upon investigation, that success, as a rule, results not after an attempted failure to increase body weight, but despite the lack of any effort in this direction. In other words, the patient possessing wellmarked powers of resistance chances to secure the arrest of an incipient infection without being compelled to resort to a method which is invaluable to the majority of cases. It may be added that patients recovering from consumption without manifesting gain in weight are almost invariably free from fever and have not displayed any appreciable loss of their average weight. The relation of fever to general nutrition is of vast significance, the loss of weight usually corresponding to the height and persistence of the temperature elevation. This relation exists not only because of the impaired appetite and digestion, but also by virtue of the fact that both the fever and the emaciation are directly dependent upon the absorption of toxic products. As long as the fever continues it is While these factors in the absorption of toxic products may be accepted in their general application, there exist certain modifying conditions, capable in some instances of producing diverse results. Thus the absorption from a large area of infection may be much less than from a small focus, by virtue of changes in the tissue immediately contiguous to the tuberculous process, serving effectually to impede peripheral absorption. These changes may relate in some cases to the impaired absorptive capacity or to an obliteration of the finer blood-vessels. At other times a barrier to absorption may be established through the concentration of the poisons in the tissues immediately adjacent to the infected area. Again the degree of activity and the character of pathologic change may not be correctly represented by the degree of fever. Rapidly advancing caseation is often unattended by fever, provided there is ample exit for the products of disorganization through free communication with a bronchial tube. Pulmonary cavities may be unaccompanied by fever, although the destructive change is quite extensive. This is particularly true if the excavation is surrounded by thickened, indurated tissue, affording scant opportunity for absorption. Further, the absorptive power of individuals varies according to their age, the state of the general circulation, and the degree of stasis in the immediate neighborhood of infected areas. Finally, the specific nature of the microorganisms constituting the secondary infection influences to a considerable extent the character and degree of fever. These considerations suggest a partial though superficial explanation of the vagaries of temperature in consumption, but the more complete elaboration of their production is left to others. Irrespective of its precise origin, which may be incapable of authoritative explanation, the fact remains that the fever of phthisis is a decidedly variable quantity. It is often present in the early stages, only to disappear later in the disease. This is attributable in part, though not entirely, to the enforced rest, which is insisted upon after the patient. comes under competent observation. As a rule, an excessive elevation of temperature is observed only after the tuberculous process has become well advanced, or in the presence of inflammatory or septic complications. The afebrile state of some individuals may be interrupted temporarily by various causes, as an intercurring influenza, an acute digestive disturbance, the development of bronchopneumonia, pleurisy, or pneumopyothorax, and by extension of the tuberculous process to hitherto uninfected areas. Ephemeral elevations of temperature are observed as a result of personal indiscretions relating to injudicious exercise, fatigue from any cause, and nervous excitement. In some patients a short walk or sitting up in bed, the entertainment of callers, card-playing, mental irritation, grief, anger, or an absorbing book are sufficient to produce moderate fluctuations. Fever is often present during the period of menstruation, although a normal temperature is exhibited at other times. Noticeable differences of temperature are noted according as the record is taken out-of-doors, after physical exercise, the swallowing of hot drinks, the ingestion of ice-cream, or the holding of bits of ice in the mouth. The temperature taken with. the patient in the cold air is almost invariably lower than within doors. It also is elevated perceptibly after moderate exercise, but is difficult of recognition unless taken by the rectum. In mouth-breathers particularly it is almost impossible to obtain an accurate record after exercise on account of the appreciable cooling of the buccal and lingual membrane incident to exposure to cold air. The mouth should be closed during the entire time that the thermometer remains in position. An interval of at least five minutes should elapse before this is removed, else the record becomes extremely unreliable. Rest, both physical and nervous, is almost a sine qua non in the effort to effect a continued reduction of fever. The maintenance of the recumbent position in bed during the twenty-four hours of the day is often attended with remarkable results in far-advanced cases. Without attempting too great refinement in a classification of the various types of fever observed among consumptives, it perhaps is sufficient to enumerate briefly the following varieties: The first class comprises patients whose temperature is normal in the morning and rises to the neighborhood of 100° F. or 100° F. in the afternoon. Such invalids are frequently unaware of the existence of fever, and often deny this possibility most emphatically until convinced by the use of the thermometer. There may be no flushing of the cheeks, no greater sense of warmth, or other evidence of discomfort from the increased body-heat. Others present the history of slight chilly sensations preceding the rise of temperature, followed by flushing and burning of the cheeks, dryness of the mouth and lips, lassitude, slight dyspnea, and more or less actual discomfort. A second class may be described as exhibiting an intensification of the fever of the preceding type. The temperature rises in the afternoon to 102° F. or 103° F., and recedes in the morning to the neighborhood of 100° F., or sometimes to normal. The fever is frequently preceded by chilliness, and attended by other unpleasant sensations, but not invariably. Patients are usually conscious of the elevated temperature, and sometimes experience considerable physical discomfort, as headache, disagreeable sense of warmth, anorexia in the afternoon, and general indisposition. These types of fever may be present during any stage of consumption. In a class of cases the fever may assume still another clinical form. In the morning it is considerably below normal, beginning its ascent more or less abruptly in the middle of the day, and rising until evening to 103° F. or 104° F. The fever of this class is more likely to be preceded by a distinct chill, or at least by pronounced chilly sensations, than that of any other variety. As a rule, the patient is exhausted in the morning, pale or somewhat cyanotic, with marked coldness of the hands and feet. The fall of fever is likely to be associated with drenching sweats, which may occur at any time during the night, but more particularly in the early morning. This is known as the fever of absorption or mixed infection, and is described as hectic, corresponding to the so-called septic fever of surgeons. It has been thought to be attended almost constantly by softening or rapidly advancing excavation, but such is not always the case. I have repeatedly seen this variety of fever, even in early cases, without the slightest suggestion, upon examination, of cavity formation or softening, while patients with advancing infection and excavation often fail to display this type of fever. Another variety of fever is characterized by a continuous high elevation of temperature at all hours of the day. There may be a remission of one or two degrees in the morning, but the recession is rarely to normal. The fever of this class is accompanied almost invar iably by increasing dyspnea and cyanosis, and is frequently exhibited by patients suffering from an acute bronchopneumonic complication. In some instances these cases from the beginning are found to partake of the characteristics of acute pneumonic phthisis. It is not altogether unusual to observe the development of an acute pneumonic extension of the tuberculous process in patients previously manifesting a chronic type of consumption. A patient who for years had been afflicted with pulmonary tuberculosis exhibiting subjective and physical evidences of a quiescent infection experienced, without warning, a severe rigor, followed by an abrupt rise of temperature to 104° F. Examination of the lungs shortly disclosed a distinct pneumonic consolidation in the left front. At no time afterward did the temperature recede in the morning more than one or two degrees, while the dyspnea increased, emaciation became rapid, and cyanosis with exhaustion were increasingly apparent. At the end of one week the physical evidences of softening were recognized in the consolidated lung, and expectoration, which previously had been absent, became very profuse. At the time of his death, which took place three weeks after the initial onset of the pneumonic extension, cavity signs were readily detected. Sometimes cases are observed in which the temperature is decidedly irregular. The chief clinical characterization, as far as fever is concerned, may relate to an elevated temperature in the morning, followed by an evening remission. In some cases, however, this so-called inverse type of fever may be followed for several days by morning. remissions and evening exacerbations. Such irregularities of temperature may develop in patients who previously exhibited no fever whatever. This suggests the possibility of a general miliary infection supervening in the course of the pulmonary disease. The fever may be associated with vague, indefinite symptoms of malaise, languor, indisposition, and digestive disturbances simulating typhoid, or it may be attended by headache, pain in the back of the neck, delirium, stupor, and motor symptoms of meningeal tuberculosis. It may also be accompanied by cough, with slight expectoration and a disproportionate dyspnea and cyanosis, the physical signs being those of a widely diffused bronchitis. This latter combination of symptoms is highly suggestive of a miliary. infection with predominant manifestations in the lungs. Other types of fever have been mentioned by various observers, and a fixed clinical significance attached to the respective varieties. A comparison of the forms above enumerated is sufficient to convince one of the obvious difficulty in discriminating sharply between some of these clinical types. Further efforts directed toward a conventional classification lead to increased confusion. Summary conclusions as to unvarying pathologic association are not warranted by the results of clinical observation. It must be remembered that the essential consideration in the production of fever is the entrance into the circulation of the toxic products, and that the extent of their absorption does not always correspond to the character of morbid change. It is not always easy to distinguish the exact nature of the secondary infection. In some cases streptococci are found in abundance in the sputum, as are also the staphylococci, pneumococci, and other microorganisms. Examinations of the blood may disclose the particular type of septicemia present, as may also examinations of the pleural exudate. |