By use of the fluoroscope a practiced eye can clearly distinguish areas of the most incipient infiltration, sometimes be fore appreciable by auscultation or per cussion and very often before their pres ence has been suspected. Williams, of Boston, says that, when examining a lung known to be diseased, he has found an unsuspected focus of infection at the opposite apex. The writer has found foci of disease in the lower portion of the lungs in a number of cases under treatment for apical disease. In some instances these spots cleared up; in others auscultatory signs subsequently developed.
In cases of complete dullness, say to the second interspace, with relatively less dullness for one or two interspaces below, a dark shadow will be seen over the first-named region, that of consolida tion, which will gradually shade off con secutively into haziness and normal re flex of light below, the area of haziness corresponding to the limits of relative dullness or infiltration.
Softening or Excavation.—As consoli dation gives way to softening, flashes or spots of light come through the dark ness; then we note a fairly well defined area of light with dark spots scattered through or dark lines or reticuke across its face; this represents disintegrating tissue. And finally the dark spots or lines of debris disappear, and then ap pears the bright reflex of a formed cavity. Cavities appear as more or less well defined areas of brightness amid shadowy tissues. When perfectly round they appear like a full moon behind a cloud. Such small regular-shaped cavi ties may be situated in a large area of dense shadow or merely surrounded by a ring of darkness, the limits of these shadows corresponding to the area of percussion-dullness. It is more difficult to map out or even diagnose positively, large, irregularly-shaped cavities, and very often one must have recourse to the steel rod as an aid, the shading off being too uncertain for the eye alone to de termine the limits of the excavation. In eases of multiple cavities the dense in tervening fibroid tissue will be shown in the form of dark streaks winding be tween the spots of bright reflex. These streaks, or bands, differ in appearance from those seen in areas of softening, in that they throw a darker shadow, and the light does not penetrate them in spots as it does the tissue undergoing disintegration.
lliliarrl Tuberculosis. — This form of phthisis shows itself in scattered dark spots, giving the lung a mottled appear ance; there is nothing regular about the arrangement or size of the spots; when cavation has occurred it is, as a rule, relatively difficult to define the outlines of the cavities.
Prognosis.—It is important to be able to give a fairly-accurate prognosis both as to the ultimate result of disease in a given area, as well as the length of time that will be required for its termination either favorably or unfavorably. Un certainty of prognosis entails positive suffering upon patients and their fami lies. Pulmonary tuberculosis in the ma jority of instances is not necessarily a fatal disease, and the percentage of cures is increasing ever year. The number of cures at the Loomis Sanitarium at Liberty, N. Y., during 1899, is a fair illustration of the fact that a large ma jority of cases in the first and second stages can either fully recover or suffi ciently arrest the disease, or improve their condition so as to resume their usual family and business responsibili ties.
99 The disease is more often contracted by females than males, but the progno sis is more favorable among the former, there being a difference in the percent age of cures of about GO per cent. females to 40 per cent. males. This is due probably to the fact that her social condition allows her to place herself more promptly within proper environ ment for recovery of health.
The prognosis is most favorable be tween the ages of eighteen and thirty Environment has a decided control- ling influence over the results of treat ment. Proper climate, hygiene, and social diversions, as well as mental quietude, all tend toward a favorable result. Probably one explanation of the unfavorable results following various methods of treatment in homes and hos pitals in cities is the lack of proper en vironment.
Heredity influences prognosis unfavor ably if it has given to the patient a lack of vital capacity or corpulence, a mal formed chest, or numerous foci of tuber , culosis manifested during childhood.
The character and location of the pathological process has a strong bear ing upon the results of treatment. The more tendency there is toward fibrosis and limitation of the disease to a given area, the more favorable the prognosis. Lesions of all characters at the apex heal anore rapidly than those located at the base or middle portion of the lung. For instance, even a cavity at one apex will heal more certainly than a consolida tion at the base. Small foci scattered through one or both lungs, accompanied, as they generally are, by systemic dis turbances out of proportion to the phys ical signs, render the prognosis generally fatal.
Allowing for the possibility of over exertion, excitability under examination, and the presence of initial stenosis, all of which accelerate the pulse-rate, the frequency of the pulse is a useful aid in the prognosis of pulmonary tuberculosis. A patient with a pulse-rate of over 100 is not likely to make any approach to recovery from pulmonary tuberculosis during six months. Cases in which a tuberculous area in the lung has been cleared out by excavation, followed by a period of quiescence. during which the cardiac pulsations may not exceed S4 per minute, are suitable for treatment, as there is likelihood that life will be pro longed considerably by six months' resi dence in a sanatorium. A pulse of 100 or more will usually be found to ac company an evening temperature reach ing or exceeding 101° F., and these two signs, of grave import, being persistently present in a ease in which absdlute rest has been enforced fur some time, give little hope of treatment proving of any avail. Thompson Campbell (Brit. Med. Join., June 1, 1901).
The earlier the disease is discovered and the patient placed under treatment, the more favorable the prognosis. Thus, in the pretnbercular and the beginning of the incipient stage nearly every case should be cured unless there be some underlying hereditary influences which render almost nil the power of recuper ation or resistance. The following re sults at the Loomis Sanitarium substan tiate this statement.
There have been 456 cases admitted to the sanitarium since it was opened; of these there were:— Incipient cases 1G3 Moderately advanced 216 Far advanced 77 456 Of these, 407 were discharged and 49 are still in the sanitarium. Those dis charged were in the following condi tion:—