Reprinted from the New York Medical Journal for March 24, 1906. PROGNOSIS IN TUBERCULOSIS OF THE LUNGS.* By JOSEPH WALSH, M. D, PHILADELPHIA. Prognosis must be regarded from two points of view, namely, absolute and practical cure. Absolute cure considers the elimination of all tubercle bacilli from the body, the practical cure relates only to usefulness and signifies that the disease has been arrested and is capable of being held arrested while the individual pursues ato useful occupation. " The tuberculous lesion cures by nature throw-* ing a scar of connective tissue about the lesion, the connective tissue becoming thicker and thicker until we have nothing but a scar through and through. This requires for a lesion the size of a walnut at least two years, and for a lesion larger than a walnut a geometrically progressive time, so that it is scarcely likely that a lesion two inches in diameter will ever be absolutely cured. In regard to absolute cure, therefore, the most important element in the prognosis is that of in- volvement. Prognosis as to usefulness is a very different thing, and is what we ought to consider in the prognosis of tuberculosis. The primary factors in the prognosis of tuber- culosis in regard to usefulness are the amount of involvement, the activity, the duration of the dis- ease, the susceptibility to the toxine as mani- fested by rapid pulse, high temperature and loss * Read before the Philadelphia County Medical Society, Feb- ruary 14, 1906. Copybight, 1906, by A. R. Elliott Publishing Co. Walsh: Tuberculosis of Lungs. of weight, the dissemination and the association of complications. What might be called secondary factors, though in individual cases they become of prime impor- tance, are: Age, sex, race, condition of life, in- telligence, temperament, occupation or environ- ment, and financial resources. Among the primary factors the least impor- tant is probably the amount of involvement, un- less this is so great as to interfere with the phys- iological action of the lungs. The patient who, when first seen, manifests an involvement of only one or two inches at the top of the lung, may die if other symptoms are severe; while another with practically complete involvement of a whole lung may recover so as to lead a useful life for an indefinite number of years. Activity is usually manifested by moist rales about the lesion, and until they clear up, the prognosis should be somewhat guarded. Duration of the Disease.-The length of time the disease has lasted has an important bearing on a case from a prognostic standpoint, and the history of the duration of the disease must be gone into carefully. Other things being equal, the longer the patient has had the disease, the more slowly it is evidently progressing and the more easily therefore it will be arrested. In other words, if a patient can without effort and while taking, no special precautions hold his dis- ease in check for a number of years, it is likely that with definite effort on his part and extraor- dinary precautions he can arrest the disease en- tirely. It is not sufficient to take the patient's state- ment in regard to the duration of the disease, but the previous diseases must be studied, and even the physical examination must be taken into consideration. For instance, the man who 2 Walsh: Tuberculosis of Lungs. has been of delicate build all his life will tell you he has been sick three months, though he had pleurisy three years ago, or has had walking typhoid every year for the last three years, or three years ago he had a cold that lasted for a whole year, or that five years ago he had haemo- ptysis, etc. In regard to the physical examination it is rea- sonably safe to say, if the patient has been feel- ing ill only several weeks, has been working up to within a comparatively short period and the physical examination shows a cavity, that the disease has lasted at least over a year. I do not know how short a time a cavity may excavate under acute conditions, but in a chronic case I think it perfectly safe to put the shortest time at one year. I personally doubt if it is ever worth while looking for the history of the contagion within six months of the finding of the lesion. It appears to me that the case would have to be ex- tremely susceptible or be working in very bad surroundings to develop an evident lesion in six months. We find that when a healthy man marries a tuberculous woman, or vice versa, he or she de- velops tuberculosis not within the year of mar- riage and usually not within two years, but from three to ten, or even more years later. It is not uncommon to find a consort developing symp- toms five or ten years after the death of the mate. The statistics of the duration of tuberculosis have been gradually lengthening so that the average duration is, I believe, now between five and ten years. It is not uncommon to have a case come for the first examination with a perfect history of twenty years' duration without knowledge of the cause of the symptoms. With an involvement either local or dissemi- nated of any size, associated with marked toxic 3 Walsh: Tuberculosis of Lungs. symptoms, as rapid pulse, high temperature, and either rapid or considerable loss of weight, the prognosis is bad, at least until the toxic activity is controlled, or susceptibility to it eradicated. Acute miliary tuberculosis, even when limited to the lungs, is as a rule fatal, not on account of the involvement, but on account of the intoxica- tion, death being due in the majority of these cases to the same cause that produces death in typhoid fever, diphtheria, or other intoxication. Even in acute miliary tuberculosis the prognosis becomes good if the patient conquers his sus- ceptibility to the toxine, though such an occur- rence is rare. In other words, no matter how small or how localized the involvement, a rapid loss of weight, high temperature and rapid pulse are bad prognostic features. These symptoms also call for absolute rest in bed until the tem- perature and pulse rate become normal, and if this can be accomplished the prognosis becomes gradually favorable. The reverse is also true, namely, the more nor- mal the temperature, the more normal the pulse and the more normal the weight the better the prognosis. One single finding of a reasonably high tem- perature does not make the prognosis bad, though it may' make the prognosis guarded. By high temperature is meant a temperature over toi° or 102° every day for two or three weeks or longer. The pulse rate elevated by the excitement of a physical examination may not indicate the true condition, yet even under these circumstances over 130 should make the prognosis guarded. A loss of weight equal to one third the body weight is also bad. Underweight counts prac- tically the same or even a little more than loss of weight. A man who had been thirty pounds under weight all his life does not stand so good 4 Walsh: Tuberculosis of Lungs. a show as a man who has just lost thirty pounds. I remember several cases like the following: Male, thirty-five, six feet tall, high weight 115, pres- ent weight 109, pulse no, temperature in the afternoon ioi°, with only a small lesion at the top of the right lung with slight activity. Yet in this particular case from experience with others I gave a bad prognosis merely on account of his marked under weight. He went to a private sanatorium, and though the utmost care was taken of him, the condition advanced and he died within six months. Any one of these symptoms does not count for much, provided all the other symptoms are good, unless that symptom is extremely marked. For instance, a man may have complete involvement of one lung with all other symptoms good and recovery be possible; he may have lost over one third the body weight, yet the involvement being small and the temperature and pulse good, he may make a ready recovery. I recall a woman whose high weight was 115 and who went down to 67 in weight, yet made a good re- covery. She is the wife of an opulent farmer up the State and has had no symptoms in three years. Sometimes many symptoms may be bad yet the involvement being small, recovery results. I recall a patient, man of twenty-eight, who working in a bad environment came with a loss of forty-three pounds in weight, respiration 36, pulse 140, temper- ature 100.4° and an involvement of both apices. He made a perfect recovery after two months in bed and six months of care and has now been working at his old trade for two years without a symptom. Laryngeal tuberculosis has usually been con- sidered of bad prognostic import for the reason that laryngeal tuberculosis is a rare primary con- dition and is commonly associated with consider- able lung involvement. Primary laryngeal tu- berculosis or laryngeal tuberculosis associated with affection of one apex is guardedly favorable but laryngeal tuberculosis associated with ad- 5 Walsh: Tuberculosis of Lungs. vanced tuberculosis of the lungs makes the prog- nosis very bad. Intestinal tuberculosis makes the prognosis bad, though the diagnosis of intestinal tuber- culosis is practically impossible to make with any degree of certainty. Diarrhoea and continuous pain in the abdomen associated with pulmonary tuberculosis make the diagnosis of intestinal tuberculosis suspicious but by no means assure it. At the Phipps Institute we have found the following in relation to intestinal ulceration: Out of fifty-nine cases studied; the bowels were loose in twenty-six patients, of these fifteen showed intestinal ulceration; the bowels were constipated in twelve patients, of these three showed ulceration; the bowels were regular in twenty-one patients and of these five showed ulceration. Tuberculosis of the lungs with a history of tuberculosis-of the cervical glands in childhood makes the prognosis generally speaking favor- able, because, unless the resistance is entirely ex- hausted, the chances are that since the patient recovered once he can recover again. Moreover, this shows the very protracted duration of the disease and thus improves the prognosis. Tuberculosis of the lungs associated with fistula in ano makes the prognosis better, though for what reason we do not know. It has been claimed that the open sore allows the discharge of certain poisonous products which would be otherwise absorbed. Yet it does not seem to me that this explanation explains why fistula in ano has a good influence on tuberculosis of the lungs. A previous or existing pleurisy also appears to make the case more chronic and therefore more hopeful in regard to usefulness. Pleurisy with effusion according to the seriousness of the ef- fusion makes the prognosis worse until the ef- 6 Walsh: Tuberculosis of Lungs. fusion clears up. Peritonitis and meningitis are of course of bad prognostic import. Complications.-The common complications are from the lungs themselves, the heart, the kidneys and the digestive tract. Any other disease of the lungs acts as a complication making the prog- nosis at least guarded. Even a cold does or is likely to increase the activity of the tuberculous process, and until cured it is not safe to give a favorable prognosis. Asthma, essential, cardiac, or renal makes the case less hopeful. Heart weakness associated with acceleration or swell- ing of the feet makes the prognosis unfavorable. A normal slowly acting heart (pulse under 72) improves an otherwise unfavorable prognosis. Albumin and casts in the urine usually make the prognosis unfavorable. A poor stomach in an irresolute individual is bad; in the majority of individuals, however, it can be remedied. The reverse is also true, a very good stomach decid- edly improves the prognosis in any sort of a case. In regard to the secondary factors we may take them in the order commonly followed in the history. Age has an influence in as much as the more acute the case, the worse the prognosis, acuteness is most common between the ages of 15 and 25. Children under 12 and adults past 40 are usually very amenable to treatment.' Chlorotic or hectic looking boys and girls con- siderably under weight with an active outbreak of tuberculosis of the lungs about the age of puberty usually do badly. Comparatively few cases get their first infection after the age of 30, therefore the further past thirty the individual is the longer is the likely duration of the disease, in other words the more chronic and the more easily curable. Moreover, age is of importance from another point of view, namely, it is not uncommon to find 7 Walsh: Tuberculosis of Lungs. the resistance to the disease exhausted at the same age in different members of the same fam- ily ; for instance, we frequently see children of tuberculous parents perfectly well up to the age of eighteen or nineteen and at the age of twenty- two or twenty-three each in succession will die. I have seen four members of the same family die of tuberculosis between thirty-two and thirty- four, though the disease had been very probably acquired in infancy. In these cases it is im- portant that they should be watched a year or two or even longer before this apparent age limit. Race has some influence in as much as He- brews as a rule have comparatively little or no susceptibility to the toxine, while the Irish as a rule show marked and negroes an intense sus- ceptibility. Hebrews become infected practical- ly the same as other people but on account of their insusceptibility to the poison they fre- quently manifest few or no clinical symptoms un- til the disease is well advanced. It is not un- common to have a Hebrew come to the office complaining of comparatively slight symptoms and these over a very short period of time, yet showing to physical examination a well defined cavity at the top of each lung. Just the opposite is true of the negro. You may find him in bed seriously ill with a high temperature, rapid pulse, considerably emaciated from the effects of a lesion that is scarcely more than discoverable. For this reason Hebrews are very curable and negroes scarcely at all so. So far I have per- sonally never seen a negro cured. The condition of life whether married or single has an influence depending on circumstances. A young man without a family with a devoted wife will probably do better than if he were single. A married woman with a devoted husband and 8 Walsh: Tuberculosis of Lungs. no children in the same way will probably do bet- ter than a single woman. Pregnancy and labor aggravate the condition and make the prognosis worse. The intelligence of the patient is of consider- able importance since it is possible to explain in exact terms the seriousness of the case and the necessity for continued care even after recovery so as to prevent relapse. Temperament is also of importance since a happy, contented disposition which does not worry and which makes the best of the existing circumstances is more favorable for cure than either a phlegmatic or pessimistic turn of mind. Moreover, the prognosis is better in a man of firm determination than in the flighty and ir- resolute. Another important element in the prognosis is the environment in which the patient has been living. The better the environment in which he has been living, the worse the prognosis. Our only remedy for the prevention and cure of tuber- culosis is a regular life with sufficient rest, fresh air, and good nourishment. If the patient has had these and his tuberculbsis has developed in spite of them his susceptibility is so great that cure is not likely. If the patient has been living, however, under very bad circumstances, for in- stance, working in a sweat shop for ten or twelve hours during the day, sleeping in confined quarters with others at night, and getting very little nourishment, his tuberculosis may have de- veloped because of the bad conditions and his personal resistance may be found very good if he is put under proper conditions. It usually happens, however, that when such patients are cured they find it necessary for pecuniary reasons to return to the old environment and the chances 9 Walsh: Tuberculosis of Lungs. of relapse are great. Consequently the worse the environment the better the prognosis as to re- covery, though the greater the likelihood of eventual relapse. An item that must be put in the prognosis by itself is the financial resources of the patient. If the pecuniary circumstances are so poor that, when a patient returns to work, he will be obliged to make his work continuous in spite of minor ailments like, for instance, a cold, he stands almost no chance of permanent recovery even as to usefulness. The following represents a typical case of a patient remaining cured despite an ad- vanced condition: Male, fifty-four, with cracked pot tympany from the top of the right lung to below the fourth rib, in other words a very large cavity with infiltration taking up the whole of the right upper lobe. I saw him first on March 16, 1903. He has been working since June 8, 1903, at carpentering on an average of ten hours a day with three exceptions, when he was off work from ten days to two weeks on account of a cold. It is at least necessary that the patient have sufficient pecuniary backing to be able to drop work at any time that acute symptoms develop until these acute symptoms subside. If he has not the opportunity to do this there is no hope of permanent recovery. With good financial back- ing and the ambition to live, considerable can be done with even an advanced case. 632 Pine Street. 10