subsequent sleep is frequently disturbed. Night-sweats may be a factor in the production of insomnia, the patient reposing quietly until awakened in the midst of a drenching perspiration. The discomfort. incident to this distressing symptom is usually such as to preclude an immediate resumption of sleep. In many cases the origin of the insomnia is traceable to nervous excitation incident to external causes. Animated conversation late in the evening, a controversial argument, exuberance of spirits through injudicious social indulgence, card-playing, and enlivening music often act as exciting causes. Among some pulmonary invalids the sleeplessness, although exhibiting variations in degree, may be more or less continuous and constitute a clinical manifestation of considerable importance. With other patients it is of purely temporary duration. Comparatively few consumptives suffer from insomnia as a result of worry over their unfortunate condition. There may be sources of fleeting anxiety and disquietude, but these disturbances in many instances are occasioned by trifling affairs, as fancied grievances and personal slights, which are often exaggerated until they assume prodigious proportions. These mental obliquities are far more apt to cause nervous excitation and induce loss of sleep than is actual fear regarding the future. The attitude of many patients when unruffled by disturbing trifles is apparently that of complacent acquiescence.

Among patients suffering from confirmed insomnia regardless of exciting causes there are some who find it hard to fall asleep, but finally secure their rest after the lapse of several wakeful hours. Others experience no difficulty in going to sleep shortly after retiring, but invariably awaken a few hours later, to toss and turn during the remainder of the night. It is quite characteristic of a large class of patients who are troubled with insomnia to awaken unreasonably early in the morning. Many invalids possess the happy faculty of sleeping during the day as well as by night. Some of these will average from two to three hours daily without apparently detracting from their ability to enjoy peaceful repose at night. The favorable prognostic import of this gift is almost inestimable. With some patients its attainment appears an absolute impossibility.

Sleep is not infrequently broken by disturbing dreams. These are more likely to be unpleasant than otherwise. In the more advanced cases of pulmonary phthisis the sleep may become a heavy stupor, the patient remaining for hours in a state of semicoma. Taken as a whole, the insomnia of consumptives depends largely upon the temperament and nervous state of the invalid, and though influenced to some extent by associated disturbances, is not inherent to the tuberculous infection. In fact, when present, it is more a result of the environment than of the physical condition, and responds to management directed to the individual rather than to the disease. The ability to sleep is sometimes affected strikingly by the influence of climate. It should be borne in mind, however, that the result is not always to be attributed to the climate itself, but often to the psychic influence and change in environment. It has been my observation that prolonged and refreshing sleep is more easy of attainment in high altitudes than at sea-level. Many patients, shortly after arrival, express surprise and gratification at an ability to sleep to an extent previously unknown. The reverse is sometimes true, though less frequently. In some of the latter cases suggestion plays an impor

tant part, as the invalids are often told before leaving home that they may experience difficulty in sleeping at high altitudes. In 1898, in a paper entitled "Functional Nervous Disturbances in Pulmonary Invalids," I called attention to the very frequent association of consumption with the various forms of functional nervous disturbances, and from an analysis of 350 cases endeavored to study the relation existing between the two. It was found that in almost no case were the manifestations of nervous disorder displayed for the first time in Colorado. But few suffered an aggravation of the nervous symptoms after arrival, and many of these exhibited a satisfactory improvement. Some patients displayed a persisting insomnia, and in these cases the gain was slow and interrupted by periods of vexatious exacerbations. The continued loss of sleep was found to be of decidedly unfavorable influence upon prognosis, not merely from the entailed exhaustion, but, also, as an expression of the more profound nervous irritability with general susceptibility to all depressing or exciting influences. The few who displayed increased nervous excitation did so coincidently with a corresponding loss in the general condition. Some presented evidences of nervous disturbance attributable directly to external causes, which would be operative in any climate, as excessive dissipation, extreme burden of business cares, and unfortunate domestic relations. A reasonable interpretation of my analytic study at that time, which has been confirmed by subsequent observation, suggests that the influence of the climate upon the nervous condition is especially advantageous in a large proportion of cases by virtue of the increased nutrition and resulting general improvement. It can be assumed that the tuberculous invasion may render more pronounced all preëxisting nervous disturbances, may increase individual susceptibility to such conditions in those already predisposed, and may provide a greater likelihood for their acquired development through the influence of impaired nutrition and general exhaustion. Likewise the existence of well-marked functional derangement affords additional opportunities for the extension of the tuberculous infection through the lessened resistance of the individual. Impaired general nutrition, while often a result, is also a most important factor in the causation, of each diseased condition. It is thus evident that the nervous disturbance may be expected to diminish almost invariably in proportion to the degree of arrest of the tuberculous process and the gain in the general strength.

It has often been asserted that the existence of insomnia and other nervous manifestations contraindicates recourse to moderate or high altitudes for the consumptive. This position is entirely in opposition to the logic of actual experience in such localities. Such statements predicate the assumption that improvement in the functional disturbance must precede gain in the general condition. This advances the argument at the same time that the nervous derangement is of more immediate significance than the tuberculous infection. It is decidedly more rational to regard the tuberculous involvement as the factor of essential importance. Insomnia and other nervous disturbances in pulmonary invalids indicate an especial necessity for strict. supervision of the details of management, the environment, and mode of life.

NERVOUS ENERGY

There is a vast difference in the degree to which pulmonary invalids retain their nervous energy. This does not always vary in accordance with their physical endurance, nor with the progress of the pulmonary disease. Some exhibit an astonishing vitality almost to the very end, although their physical strength may be impaired very seriously. disproportionate energy may often be observed, despite the existence of considerable dyspnea, loss of weight, fever, and night-sweats. It must not be assumed that the inordinate nervous vigor of such people is due to the influence of the disease itself. As a matter of fact, it exists in spite of advancing tuberculosis. Some individuals who have been endowed by nature with an excess of nervous force retain a surprising degree of vital energy notwithstanding the unceasing drain incident to pulmonary tuberculosis. It must be admitted that in many cases the overflow of nervous energy is simulated rather than real, as some patients, in their transparent effort to deceive themselves, manifest an undisguised pride in their show of apparent strength. Upon the other hand, many invalids early exhibit pronounced nervous debility.

There is no stimulating effect upon the nervous system inherent to pulmonary tuberculosis. On the contrary, impairment of nervous energy usually results. Often this precedes loss of physical capacity, and sometimes the appearance of symptoms referable to the tuberculous invasion. Many patients complain of lassitude, indisposition, fatigue, loss of ambition, and extreme weariness for months before the appearance of cough, fever, or other manifestations distinctly suggestive of consumption. They usually awaken in the morning more or less tired, having secured no refreshing invigoration from their sleep. It is an effort for them to get out of bed, they do not enjoy work, their usual vocations appear distasteful, and minor obstacles are magnified to large proportions. They are often unable to think consecutively, the power of mental concentration being diminished to a considerable extent. They frequently lack decision or will power, and vacillation is sometimes. quite apparent. Upon the definite clinical onset of pulmonary tuberculosis these evidences of impaired nervous force increase with the advance of the disease. It is not unusual to observe a very manifest disinclination to go out-of-doors, some invalids preferring to remain in the house and die comfortably rather than to make an effort to secure fresh air.

CHAPTER XXV

SYMPTOMS REFERABLE TO THE GENITO-URINARY TRACT

TUBERCULOSIS of the genito-urinary system will be found discussed in some detail under Complications. Non-tuberculous nephritic disturbances are considered in connection with Mixed Infection. A description of the symptoms of accompanying renal disease, as well as

those pertaining to tuberculous infection of the genito-urinary tract, therefore, will not be detailed in this chapter.

The various forms of nephritic disturbance are by no means uncommon in pulmonary tuberculosis. There often exist distinct degenerative changes of amyloid character, acute and chronic involvements of the parenchyma, and the chronic interstitial variety of kidney disease. There are frequently no. symptoms of the chronic forms of nephritis until the condition is far advanced, the diagnosis being secured only through periodic examinations of the urine. Very often, in the course of routine examinations, I have found albumin in the urine long before the appearance of any symptom suggestive of the kidney involvement. Hyaline and granular casts have also been recognized in many cases, sometimes before the appearance of albumin. Attention will be directed in another chapter to the frequent detection of tubercle bacilli in the urine of pulmonary invalids. Animal experimentation has shown that inoculation with the urine of consumptives, in entire absence of tubercle bacilli or suggestive clinical manifestations, is followed in many instances by the death of the animal from tuberculous infection. The symptoms of renal disease vary, of course, with the nature and extent of the nephritic change. It is noteworthy that such manifestations as dyspnea, increasing pallor, diminishing strength, slight edema. of the hands, face, or ankles, are commonly attributed to the pulmonary infection, although caused in many cases by an unrecognized involvement of the kidneys. There are often present digestive disturbances as well as changes in the pulse, which may become of high tension. While patients, as a rule, may be expected to succumb comparatively soon after the development of marked renal disease, some, irrespective of the nature and extent of the pathologic change, may linger during a prolonged period of time. I have in mind a man, thirty-four years of age, a patient of Dr. Hugueley, of Atlanta, Ga., who was sent home to die five years ago on account of advanced pulmonary phthisis complicated by chronic nephritis of nearly three years' duration. I recognized the presence of chronic Bright's disease in August, 1900, and was unable to note evidence of substantial improvement at any time during the following two years. In the fall of 1902 there was extensive active involvement of both lungs, with abundant excavation in each, and moderate cardiac hypertrophy. The urine was invariably diminished in quantity and of high specific gravity. There was an enormous amount of albumin, with numerous casts of the hyaline and small granular varieties, as well as occasional leukocytes and blood-cells. Edema, cyanosis, and dyspnea were marked. The patient shortly afterward underwent a double renal decapsulation in the hands of Dr. Edebohls, who reported the results of examination as follows: "Face, anemic; lips, livid. Large cavity and wide-spread infiltration in anterior portion of right lung, middle and lower lobes; smaller cavity with surrounding infiltration in left lung, middle of anterior portion. Râles abundant everywhere over both lungs. Heart hypertrophied, with apex-beat displaced to right; no murmurs. Neither kidney palpable. The urine contained. 30 per cent. of albumin by bulk, and was loaded with casts. It looked like a hopeless case from any point of view, and the patient was so informed." The operation was performed under nitrous oxid and oxygen in October, 1903. The patient is still alive, and enjoying an active business career in Georgia. Not long ago I had opportunity to

examine him while on a brief visit to Colorado. The urine is diminished in amount and contains a large quantity of albumin and innumerable casts. No essential change was noted in the pulmonary condition. It is difficult to realize how life has since been maintained in view of the physical condition of the lungs five years ago, and the complicating renal involvement. His ability to be about on his feet since then has been an ever-recurring source of wonder. I have learned recently of a severe uremic attack which took place at his home, but from which he is now convalescing satisfactorily.

The various forms of chronic kidney disease have been observed to attend more frequently the long-standing cases of consumption exhibiting cavity formation and excessive wasting. Often temporary albuminuria is found coincident with large pleural effusions, acute. bronchopneumonia, or high fever from any cause.

Acute nephritis is not especially uncommon among consumptives. I have seen it follow an influenza infection, and in several instances a comparatively mild tonsillitis. Nine years ago a gentleman with extensive double pulmonary tuberculosis developed a most severe nephritis immediately following a trifling tonsillitis. The acute symptoms persisted during a period of nearly two months, and, contrary to all reasonable expectation, the patient finally made a complete recovery in spite of a long-continued uremic condition.

In 1901 a patient of Dr. Tyson suddenly developed acute uremic symptoms almost immediately upon arrival in Colorado. She remained profoundly unconscious for twenty-three days, and finally recovered. Several other equally striking instances can be enumerated to illustrate the occasional development of severe acute nephritis following apparently trifling causes.

With reference to the sexual organs, perhaps the most frequent clinical phenomenon in consumptives is the disturbance of menstruation. As the disease advances, this function is subject to considerable derangement, which becomes the source of much anxiety and apprehension to the patient. At first the menstrual discharge is noticed to be scanty and of pale appearance. It subsequently becomes delayed, irregular, more scanty, with less color, and finally disappears altogether. As the condition improves with gain in strength and nutrition these symptoms reappear in an inverse order. The menstruation often becomes entirely normal even after its suppression during protracted periods. I have known its reappearance after the lapse of two years.

It is a common belief that the sexual desire in consumptives is increased to a considerable extent, but this opinion is scarcely borne out by the facts. As far as the pulmonary involvement itself is concerned, it can be maintained that no such influence obtains. A partial explanation, however, is found in the essentially passive existence, absence of diverting thoughts, the abundant use of raw eggs, and the daily administration of strychnin. In some cases the procreative power persists almost to the point of death, but, as a general rule, the sexual appetite is diminished correspondingly with the increasing exhaustion. The fact that a few exceptional patients retain their vigor in spite of advanced tuberculosis constitutes no argument capable of general application with reference to any stimulating influence of the disease.