FAR-ADVANCED CASES.
Improved 3 Stationary 3 Unimproved 60 Died 9 75 Therefore it is seen that of the in cipient cases 58 per cent. were cured or the disease arrested, of the moder ately-advanced cases 9 per cent. were cured or the disease arrested, while in the far-advanced stage only 4 per cent. were at all benefited.
Bacteriological examinations throw some light upon prognosis, and promise to become more valuable in the future. Much can be learned from the size, shape, number, and arrangement of the tubercle bacilli; the presence or absence and the relative number of the various cocci and leucocytes, and the presence of blood or elastic tissue.
When there is a gradual diminution in number of bacilli extending over long periods of time, passing from numerous to moderate, to few and finally to none, improvement may be inferred. But to base an opinion upon one microscopical examination of sputum, either for prog nostic or diagnostic purposes, is not un commonly homicidal to the patient. How often do we meet with instances in which a final and an erroneous verdict has been rendered after only one exami nation of sputum, which specimen hap pened to be negative, and the patient, in ignorance, has continued his pursuits and method of living, which may have been the deciding factors in his case! As for the arrangement of the bacilli, there appears to be some reason for asso ciating a sputum in which the bacilli are congregated into clumps, with few scattered throughout the field elsewhere, with an effort on the part of Nature and her ability to cast off individual foci; and it seems as if the protecting cells were able to prevent a general inroad upon the tissues, and had confined the invaders to individual bands and to local points of attack. This appearance is certainly common in incipient cases which are becoming rapidly improved.
The specimen of sputum which is thin, with numerous bacilli evenly distributed throughout the field, with a noticeable reduction of the corpuscular elements, the few that remain granular failing to take well the stain, is a vicious sputum, and the thinness of it and the absence of the cells probably mean that the protect ing phagocytes show such little resistance that the vast majority are broken up in the struggle, and the few- remaining show a tendency to become disintegrated, thus demonstrating the poor resistance of the invaded tissue. Such a sputum is indica
tive of a low tissue-vitality, and it is the general character of this sputum upon which most reliance is placed.
When studied in sputum, tubercle ba cilli present the following well-marked varieties of form, with more or less complete gradations between: 1. A very short, relatively-broad, rod. 2. A long form represented by a chain of rods. 3. A long form homogeneous in struct ure. 4. A long form of a beaded appear ance, as if composed of a string of spores. The author believes that the form of tubercle bacillus, as it is dem onstrated in the sputum, is an important indication of the virulence of the tuber culous process, and he considers it a useful guide to prognosis.
The short, deeply-staining rod or chain of rods of moderate length is the usual form in many active cases. The long rods, particularly if irregularly broken, betoken a milder process, and the chains of spore-like beads characterize the very chronic cases which make one wonder at their tenacious hold on life. if there be a good form of the tubercle bacillus it is a rather long, slender rod, ill staining or staining irregularly, as if the body of the microbe were irregularly corroded on the sides. It is found in cases ap parently passing on to cure. Sputa of the same individuals, examined month after month, have seemed to vary in their bacillary characters with the state of the patient as regards the disease. Henry Sewell (Med. News. Mar. 1901).
Complications affect the prognosis very appreciably. Diabetes, Bright's disease, or very decided functional disorders of the heart or an affection of the meninges, as well as destructive tubercular involve ment of the epiglottis or larynx, are among those that render the prognosis absolutely fatal. On the other hand, slight tubercular disease of the intes bladder, and kidneys is amenable to treatment. Tubercular involvement of the larynx, even if ulceration be pres ent, if no extensive destruction of tissue has occurred, yield a fair percentage of Cures.