The picture just referred to has another side. The disease is not always progressive. There is reason to believe that its progress is sometimes arrested. It ceases to progress in some cases from self-limitation. In a certain proportion of cases recovery takes place. What, then, is the basis for a favorable prognosis? In general terms, it is the absence of the unfavorable prognostics which have been mentioned. The prognosis is favorable in proportion as the action of the heart is but little disturbed, the temperature of the body non-febrile, the appetite and digestion but little affected, the complexion not much changed, and the nutrition of the body fairly maintained. The inference under these circumstances is that the disease does not tend to progress, and that the existing pulmonary affection is well tolerated. The ground for encouragement is greater the less in amount the pulmonary affection; but even if the symptoms and signs show the latter to be considerable or even large, encouragement is warrantable so long as there is evidence of non-progression and tolerance. It is not, however, to be forgotten that there is always more or less danger of a renewed tuberculous eruption.
The suspension of menstruation belongs among the unfavorable events, but alone it has not great significance. Its occurrence as respects the previous duration of the disease varies much in different cases. In some cases menstruation continues nearly to the close of life. The return of menstruation after its suspension for a greater or less period is a favorable prognostic.
The occurrence of certain complications is of marked importance with reference to the prognosis. Perforation of lung followed by pleurisy and pneumothorax is in most instances speedily fatal. On the other hand, simple pleurisy with effusion, in some instances at least, seems to have a favorable effect upon the pulmonary affection. Tuberculous ulcerations of the intestine preclude the expectation of improvement and hasten the fatal termination. Tuberculous peritonitis is a fatal prognostic. Chronic laryngitis, if it interfere with alimentation, is a serious complication, but if that effect be wanting it is not unfavorable as regards its significance in prognosis. Perineal fistula is not unfavorable, to say the least. Renal disease, and any accidental complication sufficient in itself to tell more or less against the powers of life, must be regarded as telling proportionately upon the prognosis.
What influence has the evidence of a congenital tendency and heredity upon the prognosis? It is commonly believed that the chances of arrest and recovery are less in proportion to this evidence. There is doubtless truth in this belief, but it has sometimes too much weight in the minds of both patients and physicians in individual cases. The disease is by no means always progressive even when the antecedents of the patient afford the strongest evidence of an innate predisposition. The following instance is given by way of illustration: In 1861 a young woman, eighteen years of age, affected with phthisis, came under my care. The disease had existed for two years, and she had tried various climates—namely, Cuba, Florida, Minnesota, Kentucky, and Ohio. The case ended fatally in 1863. The mother of this patient and two sisters had died of tuberculous disease. The father was tuberculous at the time of her death, and he died soon afterward with an intestinal complication. There remained two sisters and two brothers. The elder of the brothers, aged seventeen, was attacked in 1861 and died in 1863. The climate of Minnesota was resorted to in this case with no benefit. The younger brother, aged sixteen, in 1861 had a dry cough, which after a short time ceased, and he became apparently well and robust. The physical signs at that time showed a small tuberculous affection at the summit of the left lung. In the winter of 1863 the cough returned, and the signs now showed a tuberculous affection of the summit of the right lung. He was immediately sent to Europe, and he passed the winter and spring at Nice. He returned and went to South America in 1864. He passed the winter of 1865–66 in New Orleans and France, making the voyage in sailing ships. He passed the winter of 1866–67 in St. Paul, and died in the following spring. Of the two remaining sisters, the previous history in the case of the elder, aged thirty, seemed to warrant a retrospective diagnosis of a small phthisical affection which had ceased to progress and from which she had recovered. There were slight dulness of the summit of the chest on the left side and broncho-vesicular respiration. This one of the sisters has been well for the twenty-three years which have elapsed since the date of the supposed phthisical affection. The younger of the two sisters at the age of twenty-two had a cough with small expectoration and a moderate bronchial hemorrhage in the winter of 1862. There was abnormal dulness on percussion at the summit of the chest on the right side, with weakened respiratory murmur, some crepitation, and increase of vocal resonance. After a few weeks the pulmonary symptoms ceased. In this case there was no treatment, medicinal nor hygienic; she had passed the winters in the city and summers at attractive places of resort, entering with zest into social enjoyments, and she has been in all respects well up to the time when I last saw her, in the spring of 1881, twenty years after the phthisical disease.22
22 Since that date a recurrence of the affection has taken place, but without being progressive.
The last two cases are instances of recovery from phthisis irrespective of any medicinal or hygienic agencies; that is, a recovery by self-limitation. Considering the evidence of a family predisposition, a favorable prognosis at the outset would hardly have been justifiable. From my records of cases other instances might be selected illustrative of the caution not to allow too much weight in the prognosis, in individual cases, to the evidence of an innate predisposition.
It might be supposed, from the greater liability to phthisis between the ages of twenty and thirty years, that its occurrence at this period of life affects unfavorably the prognosis. Facts, however, do not appear to sustain this supposition. So far as the ratio of recoveries bears upon the point, the study of a limited number of cases shows it to be not larger after than before the age of thirty.23
23 Vide Phthisis, in a Series of Clinical Studies.
The liability to a recurrence of the disease after recovery is important to be considered in connection with the prognosis. Of 44 cases of recovery among those which I have recorded and analyzed, recurrence had taken place in 6 up to the time of the analysis. In one of these 6 cases the disease had recurred twice. The patient recovered from the second recurrence, and is now well, more than ten years having elapsed. In all the other cases the recurrence proved fatal. The recurrence took place after periods ranging from one and a half to over six years from the date of the recovery. So far as these cases warrant a conclusion, it is that in cases of recurrent phthisis the prognosis is very unfavorable. This conclusion might be materially modified by the study of a large number of cases. The fact that after recovery there is considerable liability to a recurrence of the disease has an obvious bearing upon the prophylactic management.
Facts pertaining to the duration of phthisis come properly under the head of prognosis. Of 44 cases of recovery which I have recorded and studied, the duration varied from six months to ten years. In more than one-half of these cases the pulmonary affection was small; in 4 cases it was moderate in amount; in 10 cases it was considerable; and in 1 case it was large and advanced.24 These facts show that the prospect of recovery is much better when the tuberculous affection is small or moderate, but that a considerable and large affection does not preclude recovery.