permitted to secure arrest through outdoor employment in favorable regions. Many who are less fortunate than their fellows in their financial equipment, possess other compensatory factors of favorable prognostic import, and with slight assistance in the beginning, are restored to their former usefulness and activity. This course of remark is presented to emphasize the fact that a moderately restricted income is not in itself an insurmountable obstacle to success.

SOCIAL ENVIRONMENT

Few factors pertaining to the future welfare of the patient are of more importance than a hopeful and cheerful social atmosphere. In some cases the presence of the husband or wife may be of inestimable benefit in promoting the comfort and contentment of the invalid, and in guarding against indiscretions. In other cases, no matter how well conceived the intention or devoted the service, incalculable injury is inflicted through absence of tact, perversions of judgment, and obliquities of disposition. Little children may be regarded in all instances as decided incumbrances to the progress of the patient, although mothers are prone to insist upon their decided influence for good, and protest strenuously against even a temporary separation. There is imposed a demand for careful individualization under such circumstances, precipitate action not always improving the immediate prospects of the invalid. In general, children, regardless of their intelligence or gentleness of disposition, are of necessity a source of added care and anxious responsibility and cannot fail to disturb to a marked extent the quiet régime of invalidism. Segregation of the patient insures, in the majority of cases, more satisfactory results than are otherwise attained. The ready adaptation of the consumptive to a proper social environment affords in part a favorable estimate as to the possibility of final arrest. It should be remembered that it is not the patient alone whose temperamental peculiarities demand thoughtful consideration, but, unfortunately, the accompanying relatives as well. Many invalids are compelled to pay the penalty for the perversity, ignorance, and delusions of members of their family. In such cases the prognosis varies according to the keen discernment of the physician and his insistence upon removal of unfavorable social influences through such isolation as may be reasonable and practicable. While patients are not always ready to accept at once the wisdom of such advice, if presented firmly and tactfully, the difficulties of its execution often are removed.

PERSONAL EQUATION IN MEDICAL SUPERVISION

From the foregoing considerations it is easy to comprehend that the welfare of the patient is influenced to a remarkable extent by an interested, painstaking regard for detail on the part of the medical adviser. The best results can be obtained only through a certain inherent aptitude of the physician, a devotion to the work in which he is engaged, and a personal solicitous interest in the individual. To discharge properly the many obligations incident to the care of the consumptive, and to assume with composure and confidence the anxious, vexatious responsibilities imposed, the physician must possess to an unusual degree patience, determination, vigilance, sympathy, tact, and enthusiasm.

The extent to which such endowment is possessed determines largely the welfare of the patient and frequently is sufficient to change impending failure into ultimate success.

CHANGE OF SURROUNDINGS AND CLIMATE

As a general rule, the chances for recovery are greatly enhanced if opportunity is afforded for suitable change of environment. Patients are much less likely to do well at home, as the difficulties in maintaining a proper régime are sufficiently great to interfere with the accomplishment of the best results, and to suggest the impracticability of the attempt, when possible to avoid it. Not only are the social conditions non-conducive to an unbroken period of nervous and physical relaxation, but the incidental interruptions, by friends and relatives, unavoidably impair the good effects of a systematic régime. The situation of the dwelling with relation to other buildings often is not such as to afford a sufficient amount of fresh air and sunshine. Atmospheric contaminations may exist by reason of smoke, dust, and other impurities. Assuming an advantageous location of the residence, there may be lacking ample porch accommodations, preventing the possibility of attaining rest and fresh air jointly. The perfect fulfilment of these cardinal features of management is likely to be achieved only when special provision is made for the reception of pulmonary invalids.

Due cognizance should be taken of the value of the psychic element attending a change of environment. The novelty of radically differing surroundings is a factor of the utmost importance in inspiring the patient with a degree of hope far in excess of that evinced at home. The invalid is forcibly impressed with the fact that something definite and tangible is being done to promote recovery, and often an abiding confidence is thereby established. This is especially likely to be the case if brought in contact with others who, through the force of example, instil an ambition to pursue an appropriate routine and, through the recital of their favorable progress, infuse transcendent faith in the attainment of similar results. A consideration of no slight importance relates to the direct educational influence exerted upon the patient in properly managed local institutions. Residence in sanatoria, even without the involvement of climatic change, is a factor of unquestionable prognostic value.

Change of climate in properly selected cases, with or without recourse to sanatorium control, is of far-reaching importance in the effort to secure an enduring arrest. While improvement in many incipient cases assuredly may take place by virtue of intelligent systematic management in relatively unfavorable climates, the chances for such happy results are not equal to those presented in more healthful resorts under the same conditions of management. There can be no question upon the basis of actual experience that the prognosis is wonderfully improved by removal to a suitable climate. Not only are the opportunities for arrest of the tuberculous process immeasurably greater, but stranger assurances are afforded for its enduring maintenance upon the active resumption of a useful occupation.

CHAPTER XLIV

CONSIDERATIONS PERTAINING TO THE DISEASE

MUCH importance attaches to the history of the present illness, the physical signs, the evidences of apparent immunity, the extent of systemic disturbance, and the development of complications.

HISTORY OF PRESENT ILLNESS

Rigid inquiry concerning the early history of the disease will often disclose data of vital prognostic interest. The method of onset may be suggestive of the subsequent type and termination. Many cases with an abrupt invasion after the manner of acute pneumonic phthisis or acute miliary tuberculosis may be expected to pursue an exceedingly rapid course, with a correspondingly unfavorable prognosis. When the onset is characterized by other acute manifestations, at least an intimation may be afforded concerning the clinical course; thus acute septic disturbances, if predominating early in the disease, often persist to the very end. While initial hemorrhages usually call emphatic attention. to the pulmonary condition and induce a more ready adaptation of the invalid to a suitable environment, it cannot be assumed that the existence of early pulmonary hemorrhage exerts any inherent influence upon prognosis. Pulmonary tuberculosis supervening immediately upon an attack of influenza is usually of serious prognostic import. The individual resistance at such a time is comparatively slight, and the disease, in the larger number of cases, advances rapidly to destructive tissue change and pronounced constitutional impairment. Within certain limits it is safe to assert that the more acute the onset, the less favorable the prognosis and the more insidious the invasion, the greater likelihood of effecting an arrest.

Exclusive of the manner of onset, a review of the extent and nature of systemic disturbance is also of considerable value in establishing a reasonable prognosis. The history of progressive loss of weight and strength, with fever, chills, night-sweats, and increasing dyspnea, suggests, of course, a far less favorable prognosis than obtains in afebrile cases without constitutional impairment.

The previous duration of the disease is not without some significance, although it is scarcely true that the longer the condition has persisted. the less favorable the prognosis. If the infection has been of long duration and unattended by progressive pulmonary invasion or by symptoms of severe constitutional derangement, it may be assumed that the invalid possesses unusual powers of resistance, and that these fighting qualities, under proper management, may be later directed to a successful issue. After a period of disastrous delay, however, there inevitably must come a time, soon for some, later for others, and finally for all, when the patient becomes utterly unable, even with strenuous efforts of management, to display anything like former combativeness against the disease. It thus follows that while a prolonged duration, in the absence of distinctly unfavorable manifestations, may be construed as a favorable prognostic consideration in some cases, yet delay in the adoption of rational management results in a decided loss of opportunity in the effort to secure arrest.

PHYSICAL SIGNS

The physical signs are of signal importance as indicating the area of tuberculous infection, the nature and activity of the process, the extent of destructive change, and the amount of tissue fibrosis. The morbid pulmonary changes thus disclosed, although of essential value in an approximate estimate of the final results, are sometimes of far less prognostic importance than the accompanying symptoms. view of the striking lack of conformity between the physical signs and the subjective symptoms, it is apparent that the former alone are quite inadequate for the purposes of prognosis. Many patients exhibiting extensive active areas of involvement display wonderful powers of resistance and secure an ultimate arrest of the infection. Others with comparatively slight evidence of pathologic change in the lung nevertheless decline rapidly to a fatal issue, despite the best conditions of management and environment. The physical signs are of especial prognostic value in connection with the associated evidences of constitutional disturbance, when their significance becomes of vital impor

tance.

The area of involvement, regardless of other considerations, is not always of vital prognostic import, the size of the infected region being of much less moment than the character of the tuberculous process and its degree of activity. A diffused infiltrative tubercle deposit without definite consolidation, abundant moisture, or softening offers a far more hopeful outlook than a circumscribed area of infection associated with advancing destructive change. The extent of bacillary distribution in pulmonary tuberculosis becomes of especial prognostic interest in proportion to the degree of secondary inflammatory disturbance and accompanying degenerative change. Other features of prognosis being equal, it is, of course, true that the outlook is better among patients exhibiting comparatively small areas of infection. A limitation of the disease at one apex is of more favorable import than a bilateral involvement. It is insisted, however, that efforts to forecast the future of the invalid strictly according to the boundaries of tuberculous infection are without warrantable basis. Attempts of this kind represent a profound misconception of the nature of the various pathologic processes, the influence of constitutional symptoms, and other prognostic data.

Chief importance attaches to the character of the lesions, the activity of the infection, and the tendency to cavity formation. Infiltrative processes are more susceptible to complete arrest through fibrous tissue. proliferation than are areas of massive consolidation, in which subsequent softening with excavation is likely to take place. In the latter event the constitutional symptoms are often more severe, the tuberculous extension rapid, and the course of the disease comparatively short. In some cases, however, consolidation, even of an entire lobe, may continue indefinitely without resulting cavity formation or persisting systemic disturbance. A conspicuous example of this phenomenon is shown by the following case:

In June, 1897, a gentleman of forty-eight, a patient of Dr. Babcock, came to Colorado, exhibiting a massive consolidation of the entire left lung with abundant moisture throughout. There were marked emaciation, physical exhaustion, fever, and rapid pulse. He returned to

Indiana in May, 1903, thirty pounds heavier, without fever or other evidence of constitutional disturbance, exhibiting not the slightest physical evidence of remaining tuberculous activity, although the consolidation was complete and the function of the lung entirely suspended. He has continued without retrogression to the present time.

While successful results of this character are sometimes observed, the prognosis, as a rule, is unfavorable in cases of gross pulmonary consolidation.

Scattered areas of pneumonic consolidation supervening in the course of pulmonary tuberculosis are occasionally followed by apparent resolution, but softening and cavity formation are the usual sequelæ. If arrest of the tuberculous process eventually takes place, there is necessarily an enduring loss of functional activity throughout the diseased area. In some instances the prognosis, as a result of the functional impairment and the physical incapacity of the invalid, relates chiefly to a prolonged period of restricted activity. Corresponding to the degree of respiratory limitation, the patient may either be permitted to enjoy a useful career, or be doomed to a life of complete invalidism.

The activity of the infection is disclosed to a great extent by the amount of moisture within the bronchial tract. Despite pronounced indications of general improvement, rather definite information concerning a remaining active tuberculous process is afforded by the recog nition of fine and medium-sized moist râles. No tuberculous deposit can be regarded as arrested or even quiescent so long as these physical evidences persist.

There is no invariable relation between the state of the tuberculous lesions and the amount of cough or expectoration. I almost daily observe patients exhibiting moist râles upon examination, yet having but slight cough without expectoration. In the presence of bubbling râles the tendency to further extension of the tuberculous process is greatly enhanced, irrespective of subjective symptoms. Waiving temporarily a consideration of other elements influencing prognosis, it is fair to assert that the chances for recovery are improved in proportion to the diminution of moisture in the infected area. Prior to its complete disappearance favorable prognostic indications consist of a reduction in the size of the râles, a lessening of their distinctly bubbling character, and their non-recognition save upon the act of coughing.

The extent of tissue destruction as represented by pulmonary excavation adds greatly to the danger of hemorrhage and the likelihood of septic absorption. This, with the accompanying evidence of advancing infection, constitutes an important factor in prognosis. In some cases the cavity per se, even if it be of considerable size, may possess but little significance regarding the probable outcome. If surrounded by indurated lung tissue, it may gradually diminish in diameter through interstitial contraction to such an extent as to prevent its further recognition. The unfavorable import to be attached to cavity formation relates to the rapidity of development, the progressive increase in size, the accompanying moisture, and the subjective symptoms. Aside from gurgling râles over the site of the excavation, an indication of the activity of the infection is found in the amount of moisture present within an adjacent zone. Coarse bubbling râles in close proximity to the cavity suggest a further extension of the destructive process. Even rapid cavity formation may not always be construed as of unfavorable import,