THE
PROGNOSIS
OF
PULMONARY
TUBERCULOSIS.1
J. J. The
Lucas, M.D.,
B.A. Lond.
I have chosen for this short paper is one which by those more capable of forming
subjcct
has been
S.
much discussed
so
opinions
than I am, that you may consider it
my part draw
to do more than formulate their
presumption
opinions,
or
at
on
most
compilation of statistical results. I however do not intend to do this, but as I have possibly seen more pulmonary tuberculosis than any other serious disease, I am venturing to give you a few of the impressions I have deductions
to
formed and
from
points I take into consideration phthisical patient. Some of these prognosing have undoubtedly been impressed upon my mind by previous reading and confirmed by experience, while others may be erroneous and due to forming conclusions from peculiar groups of cases chance occasionally throws in one's way. some
of the various
the future of
in
In
the
first
pulmonary tuberculosis very
will
that it is unwise for
opinion Once
I
place
a
to
ever
consumptive, always thing for a patient
a
a
rare
say that
patient
I
consider himself
who has
the had
a
sound
man.
I
think, a is, physical signs of lung
consumptive.
a
formed
definitely
have
who has It
tuberculosis and the presence of tubercle bacilli in his sputum to get well and remain perfectly well for many years while
attending
to
his former
A
occupation.
patient
under
sana-
torium treatment may lose all his symptoms and the disease may remain quiescent for a long period, but sooner or later,, if he tends to drift into former habits, a relapse which eventually may prove fatal. Within the last few months I have had five patients of this kind. All of them have
more
especially
occurs
broken down after having had 1
Read at
a
meeting
of the
no
Society
active on
physical signs
February 14th, 1906.
nor
THE
PROGNOSIS
OF
PULMONARY
TUBERCULOSIS.
13
symptoms, not even a cough, for more than a year?one for nearly four years. Three of these have got practically well again, one is improving to some extent, while the fifth is rapidly course, that
getting worse. I know, of of hospital post-mortems show mischief
at an apex, but
healed
all of these
nearly
a
large percentage
evidence of were
tuberculous
not
diagnosed,
large number would have been undiagnosable, due allowance being given for the shrinkage during the contraction in healing. It is certainly rare to find evidence of healed mischief beyond this such as would have been easily diagnosed, as for
and
a
instance that which would have given infra-clavicular signs. Having made a diagnosis, one of the most important points in influencing the prognosis is, I think, the appearance of the and the
patient
configuration
of the chest.
Anyone by inhaling
dose of bacilli may generate the I suppose the major portion of sanatorium patients
a
sufficiently large
and
disease, are
of
not
a
typical phthisical
appearance. Persons however of the old tubercular and scrofulous
types
-?especially the former, those with a lively temperament and long, narrow chests?unless they are most carefully looked after ?do somehow
other
or
develop consumption.
prognosis is certainly very bad. way of stopping the disease, and In these year or so. if I and examined hereditary,
only for
a
only slight
There seems, life is
cases
In as
prolonged
these a
rule,
the no
at the most
the constitution is
generally
of this type and found but definite indications of active tubercular mischief
patient
a
I should tell his friends that in would
again
probably gradually
lose
spite of treatment the patient ground and would never be fit
previous duties. hand, in a patient with
to resume his
On the other and
prominent history and who possibly one of his
a
well-developed
infra-clavicular regions, who had
lungs
had
developed
after extra hard
or
a
chest
good family tubercular patch on a
unhealthy work, I should activity, to give the
be inclined, if there were no signs of great best of prognoses, viz. that with suitable
treatment he
would
lose most, if not all, of his symptoms, and with care would probably live many years, and during that time would be capable of doing a good deal of useful work.
I
DR.
14 Of
J. J.
the
two of
early symptoms
LUCAS
s.
most
suggestive of
the further
haemoptysis and dyspepsia. In my experience hemorrhage in the early stages generally indicates a chronic form. Very often, of course, no physical signs indicating phthisis can be found at first, but when they do assert themselves they seem to be of the fibroid type, and the disease tends to run a prolonged course with intervals of good of the disease
course
are
health.
Dyspepsia,
the other
on
hand,
is
a
bad
sign.
Hygienic
may in some cases successfully combat this, but. many of the cases cannot be checked, and persistent early indigestion, especially if attended by vomiting, is often the
treatment
precursor of a progressive fatal illness. A high temperature at one examination I do not consider of much
importance
104??in
temperature?say the
the
to
I have two recent A doctor's
school,
Her mother asked not
feeling
to be a "bit
nurse
and
Bacilli
living
were
lungs
suggested have
regular
but
they
are
his doctor
steadily lost developed, and
the
pooh-poohed
was
wrong. health since, he is
now
In
spite
physical
in
a
pre-
temperature chart in treatment is
two or more
rare
found in his sputum..
with at the time
month the outlook is bad.
the rule.
boarding,
a
to go when I chanced to look in..
ready
lungs.
was
evening temperature this,
pneumonia^ as examples-
in mind which may serve going away from home to
well known to need comment, and when
to
This is
and
me
his
carious condition. The value of a
a
high
Another young fellow came to consult me for He had a temperature over 103?, but no
he
phthisis,
in both
for
a
appreciate
off colour."
typhoid
of treatment, however, he has
signs
possibly
to see her before she went, as she wasI found her temperature to be 104?, and examination showed tubercle bacilli. She only
general malaise. physical signs in idea of
patient
is
who does not
very well.
her sputum on lived six months.
A trained
was
dressed
was
exception
worst forms of
cases
daughter
and
The a
only feels
and who
fact,
somewhat akin
rule.
as a
and
degrees
under treatment above normal
too an
persists certainly seen exceptions may perhaps be said to prove
I have
CN
THE
OF
PROGNOSIS
TUBERCULOSIS.
PULMONARY
From the point of view of prognosis, the is of more importance than the temperature. phthisis I saw in private practice was that of a
of 80 and
pulse
temperature
a
years ago, and he is still alive and at occasionally has remissions he is well
marriage (against On the other
rapid
advice). hand, cases
influence I have
commoner
of
laryngeal
seen
young That
enough
man
with
was
five
although
and
work,
I have
seen
be accounted for lost
invariably rapidly
Of the
a
he
contemplate
to
my
than could
almost
to my mind The first case of
pulse
ioou.
over
15
by ground.
complications tuberculosis
on
the
with
pulse
more
temperature
have
a
I should like to refer to the
the
I should divide these
From
prognosis. into
cases
cases
least three
at
(2) swelling and ulceration of parts above the cord especially affecting the mucous membrane between the arytenoids, the ary-epiglottidean folds, and more rarely the epiglottis, and (3) general ulceration m the late stages of phthisis in which the trachea is often extensively involved with the other portions. varieties:
Ulceration of the cords alone,
(i)
Ulceration of the cord alone does not appear to influence the prognosis. It sometimes occurs at the earliest stages, and I have seen some cases get well.
certainly
Perhaps the commonest variety is swelling and ulceration in This is apt to spread and cause a outer arytenoid region. good deal of huskiness in the voice, a certain amount of pain from involvement of the cartilages, and often dysphagia. Nothing, as far as I know, can do much good for these, and the interesting point is that the lung physical signs are
the
often
masked.
In Mr. Lake's book
the front page, is extensive
a
laryngeal well that
Perfectly only find slight
a
drawing and
of
a
tracheal
Laryngeal Phthisis,
specimen
days before this of disease in the
man
I
remember
died
lungs,
on
mounted of
I
ulceration.
few
traces
on
we
but
could at
the
post-mortem examination both were riddled with cavities. I have a similar case at the present time of a man dying with Phthisis with a throat of this kind. Over six months ago his sPutum
have
was
swarming with bacilli,
told him his chest
was
and since then two doctors
intact.
He is
developing
a
few
36
THE
PROGNOSIS
physical signs
OF
feel certain there is much
I
but
now,
mischief than these indicate.
Why
to small inlet of air into the
lungs,
kind I
conclude that the
generally
examination of them Before
ending
TUBERCULOSIS.
PULMONARY
this is
is
so
and with
lungs
indicates, disjointed
these
due
throat of this
much
are
and that the
a
more
probably worse
prognosis
than
is bad.
I should like to
remarks
consider how the effect of treatment should influence
briefly prognosis.
the
If after
few weeks'
a
treatment
there
be
to
seems
no
deterioration, a change of sanatorium is indicated; and if the result is similar, then after two or three different localities have been tried, it is perhaps better to allow the patient to please himself how he ekes out the
improvement,
but rather
last little bit of his wretched existence.
majority however, I suppose, improve for a time under hygienic treatment anywhere. In some this improvement is The
only transient, with are
and
maximum is reached in
a
steady decline in health afterwards. very unsatisfactory, and usually in them
almost
as
bad
as
in those who do not
improve
a
few
weeks, patients prognosis is
These
a
the at
all.
Another
very annoying group of cases are those who are sent out of sanatoria "cured" or "much improved," who begin to lose ground
directly they come home and resume their necessary duties, although generally under more improved conditions than This unfortunately includes a large portion of before. I have repeatedly had cases under my charge and patients, who have been sent cumbed in of
a
home from sanatoria
few months
to
satisfactory improvement
at their
homes and to
breaking down. These, gentlemen,
foretelling from
earn
are
and
diseases,
beyond
only
be able to live
livelihood for months without
few of the
points
and
intentionally the effect
I consider in
omitted the influence of
on
the scope of the paper.
prognosis of the position in the lungs,
the
amount of the tuberculous mischief and its
This is
to
a
ideas first hand, and have concurrent
a
patients
suc-
real test
consumptive. They are I know far purposely so. I have simply given a few
the future of
complete,
a
is for
well who
as
The
the disease.
The disease is
a
very
DEFECTIVE
-deceptive to be too
RESPIRATION.
accidents may
Many
one.
definite.
NASAL
happen,
To make my remarks
17
and it is unwise
quite clear,
I will end
by enumerating the various points mentioned :? (1) A phthisical patient should never consider sound,
least not for
at
of all
some
years,
even
himself
after loss
symptoms.
(2)
The appearance of the patient, the shape of his chest, and his family history are of the greatest importance
(3)
Of early symptoms
in
prognosis.
sign, .(4)
haemoptysis by itself dyspepsia is a bad one.
while
Fever at
one
prognosis,
examination but
as
a
is rather
rule does not
a
good
help
persistent evening temperature
the
for
a
month is bad.
{5) (6)
A
rapid pulse
Of throat
is
one
of the worst of
complications,
does not indicate much ;
>,(7)
The
much
more
lungs
are
effect
swelling in the larynx is physical signs in the
and the
serious,
often
omens.
ulceration of the cords alone
deceptive
in these
cases.
be gauged only by the patient several months after he has sanatorium, and has undertaken duties he
of treatment
can
condition of the left the
intends to
perform
for the rest of his life.
PROGNOSIS
OF
PULMONARY
TUBERCULOSIS.1
J. J. The
Lucas, M.D.,
B.A. Lond.
I have chosen for this short paper is one which by those more capable of forming
subjcct
has been
S.
much discussed
so
opinions
than I am, that you may consider it
my part draw
to do more than formulate their
presumption
opinions,
or
at
on
most
compilation of statistical results. I however do not intend to do this, but as I have possibly seen more pulmonary tuberculosis than any other serious disease, I am venturing to give you a few of the impressions I have deductions
to
formed and
from
points I take into consideration phthisical patient. Some of these prognosing have undoubtedly been impressed upon my mind by previous reading and confirmed by experience, while others may be erroneous and due to forming conclusions from peculiar groups of cases chance occasionally throws in one's way. some
of the various
the future of
in
In
the
first
pulmonary tuberculosis very
will
that it is unwise for
opinion Once
I
place
a
to
ever
consumptive, always thing for a patient
a
a
rare
say that
patient
I
consider himself
who has
the had
a
sound
man.
I
think, a is, physical signs of lung
consumptive.
a
formed
definitely
have
who has It
tuberculosis and the presence of tubercle bacilli in his sputum to get well and remain perfectly well for many years while
attending
to
his former
A
occupation.
patient
under
sana-
torium treatment may lose all his symptoms and the disease may remain quiescent for a long period, but sooner or later,, if he tends to drift into former habits, a relapse which eventually may prove fatal. Within the last few months I have had five patients of this kind. All of them have
more
especially
occurs
broken down after having had 1
Read at
a
meeting
of the
no
Society
active on
physical signs
February 14th, 1906.
nor
THE
PROGNOSIS
OF
PULMONARY
TUBERCULOSIS.
13
symptoms, not even a cough, for more than a year?one for nearly four years. Three of these have got practically well again, one is improving to some extent, while the fifth is rapidly course, that
getting worse. I know, of of hospital post-mortems show mischief
at an apex, but
healed
all of these
nearly
a
large percentage
evidence of were
tuberculous
not
diagnosed,
large number would have been undiagnosable, due allowance being given for the shrinkage during the contraction in healing. It is certainly rare to find evidence of healed mischief beyond this such as would have been easily diagnosed, as for
and
a
instance that which would have given infra-clavicular signs. Having made a diagnosis, one of the most important points in influencing the prognosis is, I think, the appearance of the and the
patient
configuration
of the chest.
Anyone by inhaling
dose of bacilli may generate the I suppose the major portion of sanatorium patients
a
sufficiently large
and
disease, are
of
not
a
typical phthisical
appearance. Persons however of the old tubercular and scrofulous
types
-?especially the former, those with a lively temperament and long, narrow chests?unless they are most carefully looked after ?do somehow
other
or
develop consumption.
prognosis is certainly very bad. way of stopping the disease, and In these year or so. if I and examined hereditary,
only for
a
only slight
There seems, life is
cases
In as
prolonged
these a
rule,
the no
at the most
the constitution is
generally
of this type and found but definite indications of active tubercular mischief
patient
a
I should tell his friends that in would
again
probably gradually
lose
spite of treatment the patient ground and would never be fit
previous duties. hand, in a patient with
to resume his
On the other and
prominent history and who possibly one of his
a
well-developed
infra-clavicular regions, who had
lungs
had
developed
after extra hard
or
a
chest
good family tubercular patch on a
unhealthy work, I should activity, to give the
be inclined, if there were no signs of great best of prognoses, viz. that with suitable
treatment he
would
lose most, if not all, of his symptoms, and with care would probably live many years, and during that time would be capable of doing a good deal of useful work.
I
DR.
14 Of
J. J.
the
two of
early symptoms
LUCAS
s.
most
suggestive of
the further
haemoptysis and dyspepsia. In my experience hemorrhage in the early stages generally indicates a chronic form. Very often, of course, no physical signs indicating phthisis can be found at first, but when they do assert themselves they seem to be of the fibroid type, and the disease tends to run a prolonged course with intervals of good of the disease
course
are
health.
Dyspepsia,
the other
on
hand,
is
a
bad
sign.
Hygienic
may in some cases successfully combat this, but. many of the cases cannot be checked, and persistent early indigestion, especially if attended by vomiting, is often the
treatment
precursor of a progressive fatal illness. A high temperature at one examination I do not consider of much
importance
104??in
temperature?say the
the
to
I have two recent A doctor's
school,
Her mother asked not
feeling
to be a "bit
nurse
and
Bacilli
living
were
lungs
suggested have
regular
but
they
are
his doctor
steadily lost developed, and
the
pooh-poohed
was
wrong. health since, he is
now
In
spite
physical
in
a
pre-
temperature chart in treatment is
two or more
rare
found in his sputum..
with at the time
month the outlook is bad.
the rule.
boarding,
a
to go when I chanced to look in..
ready
lungs.
was
evening temperature this,
pneumonia^ as examples-
in mind which may serve going away from home to
well known to need comment, and when
to
This is
and
me
his
carious condition. The value of a
a
high
Another young fellow came to consult me for He had a temperature over 103?, but no
he
phthisis,
in both
for
a
appreciate
off colour."
typhoid
of treatment, however, he has
signs
possibly
to see her before she went, as she wasI found her temperature to be 104?, and examination showed tubercle bacilli. She only
general malaise. physical signs in idea of
patient
is
who does not
very well.
her sputum on lived six months.
A trained
was
dressed
was
exception
worst forms of
cases
daughter
and
The a
only feels
and who
fact,
somewhat akin
rule.
as a
and
degrees
under treatment above normal
too an
persists certainly seen exceptions may perhaps be said to prove
I have
CN
THE
OF
PROGNOSIS
TUBERCULOSIS.
PULMONARY
From the point of view of prognosis, the is of more importance than the temperature. phthisis I saw in private practice was that of a
of 80 and
pulse
temperature
a
years ago, and he is still alive and at occasionally has remissions he is well
marriage (against On the other
rapid
advice). hand, cases
influence I have
commoner
of
laryngeal
seen
young That
enough
man
with
was
five
although
and
work,
I have
seen
be accounted for lost
invariably rapidly
Of the
a
he
contemplate
to
my
than could
almost
to my mind The first case of
pulse
ioou.
over
15
by ground.
complications tuberculosis
on
the
with
pulse
more
temperature
have
a
I should like to refer to the
the
I should divide these
From
prognosis. into
cases
cases
least three
at
(2) swelling and ulceration of parts above the cord especially affecting the mucous membrane between the arytenoids, the ary-epiglottidean folds, and more rarely the epiglottis, and (3) general ulceration m the late stages of phthisis in which the trachea is often extensively involved with the other portions. varieties:
Ulceration of the cords alone,
(i)
Ulceration of the cord alone does not appear to influence the prognosis. It sometimes occurs at the earliest stages, and I have seen some cases get well.
certainly
Perhaps the commonest variety is swelling and ulceration in This is apt to spread and cause a outer arytenoid region. good deal of huskiness in the voice, a certain amount of pain from involvement of the cartilages, and often dysphagia. Nothing, as far as I know, can do much good for these, and the interesting point is that the lung physical signs are
the
often
masked.
In Mr. Lake's book
the front page, is extensive
a
laryngeal well that
Perfectly only find slight
a
drawing and
of
a
tracheal
Laryngeal Phthisis,
specimen
days before this of disease in the
man
I
remember
died
lungs,
on
mounted of
I
ulceration.
few
traces
on
we
but
could at
the
post-mortem examination both were riddled with cavities. I have a similar case at the present time of a man dying with Phthisis with a throat of this kind. Over six months ago his sPutum
have
was
swarming with bacilli,
told him his chest
was
and since then two doctors
intact.
He is
developing
a
few
36
THE
PROGNOSIS
physical signs
OF
feel certain there is much
I
but
now,
mischief than these indicate.
Why
to small inlet of air into the
lungs,
kind I
conclude that the
generally
examination of them Before
ending
TUBERCULOSIS.
PULMONARY
this is
is
so
and with
lungs
indicates, disjointed
these
due
throat of this
much
are
and that the
a
more
probably worse
prognosis
than
is bad.
I should like to
remarks
consider how the effect of treatment should influence
briefly prognosis.
the
If after
few weeks'
a
treatment
there
be
to
seems
no
deterioration, a change of sanatorium is indicated; and if the result is similar, then after two or three different localities have been tried, it is perhaps better to allow the patient to please himself how he ekes out the
improvement,
but rather
last little bit of his wretched existence.
majority however, I suppose, improve for a time under hygienic treatment anywhere. In some this improvement is The
only transient, with are
and
maximum is reached in
a
steady decline in health afterwards. very unsatisfactory, and usually in them
almost
as
bad
as
in those who do not
improve
a
few
weeks, patients prognosis is
These
a
the at
all.
Another
very annoying group of cases are those who are sent out of sanatoria "cured" or "much improved," who begin to lose ground
directly they come home and resume their necessary duties, although generally under more improved conditions than This unfortunately includes a large portion of before. I have repeatedly had cases under my charge and patients, who have been sent cumbed in of
a
home from sanatoria
few months
to
satisfactory improvement
at their
homes and to
breaking down. These, gentlemen,
foretelling from
earn
are
and
diseases,
beyond
only
be able to live
livelihood for months without
few of the
points
and
intentionally the effect
I consider in
omitted the influence of
on
the scope of the paper.
prognosis of the position in the lungs,
the
amount of the tuberculous mischief and its
This is
to
a
ideas first hand, and have concurrent
a
patients
suc-
real test
consumptive. They are I know far purposely so. I have simply given a few
the future of
complete,
a
is for
well who
as
The
the disease.
The disease is
a
very
DEFECTIVE
-deceptive to be too
RESPIRATION.
accidents may
Many
one.
definite.
NASAL
happen,
To make my remarks
17
and it is unwise
quite clear,
I will end
by enumerating the various points mentioned :? (1) A phthisical patient should never consider sound,
least not for
at
of all
some
years,
even
himself
after loss
symptoms.
(2)
The appearance of the patient, the shape of his chest, and his family history are of the greatest importance
(3)
Of early symptoms
in
prognosis.
sign, .(4)
haemoptysis by itself dyspepsia is a bad one.
while
Fever at
one
prognosis,
examination but
as
a
is rather
rule does not
a
good
help
persistent evening temperature
the
for
a
month is bad.
{5) (6)
A
rapid pulse
Of throat
is
one
of the worst of
complications,
does not indicate much ;
>,(7)
The
much
more
lungs
are
effect
swelling in the larynx is physical signs in the
and the
serious,
often
omens.
ulceration of the cords alone
deceptive
in these
cases.
be gauged only by the patient several months after he has sanatorium, and has undertaken duties he
of treatment
can
condition of the left the
intends to
perform
for the rest of his life.
