CHAPTER IX

.

SURGICAL DISEASES COMMON TO MAN AND THE DOMESTIC ANIMALS (CONTINUED).

TUBERCULOSIS.

The most important and frequent of the infectious diseases common to animals and man is _tuberculosis_. This appears usually as a subacute or chronic affection, although in a small proportion of cases it assumes an acuteness of type which may make it fatal within as short a time as fourteen or fifteen days, or even less, from the first recognizable symptom. Tuberculosis is more prevalent than any other form of disease, and is the cause of death of a proportion variously estimated at from 20 to 30 per cent. of mankind. It is a disease which perhaps concerns the surgeon more than the physician, inasmuch as it is also the most common of the so-called surgical diseases. Its frequency varies in different parts of the country. In the average surgical clinic of the United States probably 20 to 25 per cent. of cases are manifestations of this affection.

Surgical tuberculosis covers the entire range of diseases formerly described as _scrofula_. The term scrofula is now expurgated from medical terminology. All of the active manifestations formerly regarded as scrofulous are known to be due to tuberculosis.

To the presence of tubercle bacilli in the tissues is due that distinctive aggregation of cells which constitutes the so-called _miliary tubercle_. Its presence and arrangement are apparently the direct outcome of the irritation produced by these minute foreign bodies, and its method of grouping is so characteristic that it may be everywhere and usually easily recognized. Its centre is composed of one, possibly several, _giant cells_, whose nuclei are generally arranged around its margin, with perhaps degenerative changes going on in the interior of the cell itself. In this giant cell, as well as outside of it, may be seen one or several _tubercle bacilli_. Around this centre are clustered a number of large cells known as _epithelioid_, which may also contain bacilli. These cells are probably derived from epithelium when at hand, or from the endothelium of the vessel walls, or from the fixed tissue cells. Outside of these are other, usually spindle-shaped, cells, contained in a connective-tissue network and regarded mostly as _lymphoid cells_. When tubercle is experimentally produced the bacilli seem more numerous than they do in instances of spontaneous disease. This little aggregation of cells constitutes a mass which may be recognized by the naked eye--a minute, usually white point or nodule, which is known as a _miliary tubercle_. It is subject to any one of several changes to be presently considered, and it is usually found in large numbers. The punctate appearance of miliary tuberculosis is perhaps best seen upon the cerebral membranes or the peritoneum in cases of acute miliary tuberculosis. By coalescence of a number of these nodules larger tubercles are formed, and by combination of coalescence and caseous degeneration are produced the large cheesy masses which were formerly called _yellow tubercle_. (See Plate VI.)

The epithelioid cells are by some regarded as modified leukocytes; by others as the product of division of the fixed cells. The giant cell is probably the result of irritation in one of these cells, the stimulus being sufficient to provoke division of the nucleus, but not of the entire cell. As the principal cellular activity occurs in the interior of this nodule the result is a condensation about the periphery which furnishes eventually a sort of capsule, the tissues being hardened and condensed as if for this special purpose. The effect of this is to interfere with vascular supply and finally to shut it off completely. As long as no pyogenic infection occurs, the original tubercle may gradually shrivel down and disappear or caseous degeneration may occur, and it may persist as a cheesy nodule for an indefinite time. As such a tubercle grows old the cells lose their identity, refuse to take stains, and a slow or quiet coagulation necrosis results. In this nest sometimes calcium salts are precipitated, the result being a _calcareous nodule_. On the other hand, during the active stage of this tubercle formation cell resistance may be lowered, either from general or constitutional causes; the original focus disintegrates; tubercle bacilli are liberated, and are now carried hither and thither, _metastatic tubercles_ being the result of their dissemination.

Spontaneous healing of tubercle is possible, and may be due to three different causes:

(_a_) Necrosis and exfoliation of diseased tissue (_e. g._, in lupus);

(_b_) Cicatricial formation;

(_c_) Retrograde metamorphosis.

Looked at from another point of view, the possible fates awaiting the miliary tubercle are the following:

(_a_) _Absorption_;

(_b_) _Encapsulation_;

(_c_) _Cheesy degeneration_;

(_d_) _Calcareous degeneration_;

(_e_) _Suppuration_.

=Absorption.=--Absorption of tubercle undoubtedly is possible under favorable circumstances, but just what constitute these favoring circumstances no one knows, since they occur in cases which do not terminate fatally. To be able to describe them would be to detail minutely the changes which permit of recovery after non-traumatic tuberculous infection, which clinical fact is amply demonstrated by the experience of the profession. Absorption is probably largely a matter of phagocytosis.

=Encapsulation.=--Encapsulation has already been spoken of, the capsule being formed by the condensation of the original cells of the tuberculous agglomeration, the infectious organisms being thereby imprisoned as long that they are practically starved and finally die. The tubercle bacilli, however, may long lie latent in such a cellular prison, and should anything occur to break the prison wall they may escape and still prove actively infectious. In this way are to be accounted for the fresh eruptions from old miliary or other deposits.

=Caseation.=--Caseation comprises a series of changes in the chemical constitution of the cells by which an albuminoid mass much resembling casein in composition and appearance is produced. The English equivalent _cheesy_ well describes many of these masses, which both cut and appear very much like domestic cheese. They have a yellowish color, and are met with in masses in size from a pin’s head up to a robin’s egg. These are the yellow tubercles of the older writers, and such a cheesy tumor has been called _tyroma_.

=Calcification.=--Calcification refers to a peculiar deposition of calcium salts within the interior of these nodules, the first precipitation occurring usually in the centre of the giant cell, which is itself the topographical centre of the miliary tubercle. It may spread from this until a mass easily recognizable by the naked eye and detectable by the finger is produced. Such calcareous particles are frequently found in sputa, and are always an index of the tuberculous character of the case. They differ markedly from the yellow calcareous nodules found in the pus of actinomycosis, the circumstances under which they are likely to be confused being met in pulmonary disease.

COLD ABSCESSES.

=Suppuration=, as indicated, is the result of a mixed or secondary infection with pyogenic organisms. In the previous chapter tubercle bacilli were grouped as among the facultative pyogenic bacteria, yet pus is not formed in this disease except in consequence of coincident

## activity of other bacterial organisms. Suppuration of tuberculous foci

is of importance to the surgeon, because thereby is produced a distinct class of so-called abscesses--namely, the _cold_ or _congestion abscesses_. These are of the chronic type, and are generally free from the ordinary signs of abscess formation. They are invariably the result of local infection, sometimes perhaps by the tubercle bacilli alone, but frequently by the combined action of these with pyogenic forms. For their formation a previous tuberculous lesion is essential. Wherever old tuberculous lesions are encountered cold abscesses also may form. No tissue or organ is exempt: they are found in the brain, in the bones, viscera, joints, skin--in fact, in all parts of the body.

Cold abscesses have not only a significance of their own, but for the most part an identity. Their distinguishing feature is a _limiting membrane_, which forms whenever sufficient time has elapsed. Much has been written about it, and much error has been perpetuated with regard to it. This is the membrane formerly considered and called _pyogenic_, under the misapprehension that by it the pus or contents of the abscess were produced. I desire to emphasize in every possible way that this is a mistake. This membrane does not act to produce pus, but is rather the result of condensation of cells around the margin of the tuberculous lesion, forming, as it were, a sanitary cordon, for the absolute and definite purpose of protection against further ravages. I would suggest that the term pyogenic membrane be abolished, there being no such membrane under any circumstances, and that, this be known as that which in effect it is--namely, a _pyophylactic membrane_. _It is a protection against pus_, and were it not for its presence there would be no limit to the spread of tuberculous invasion. A lesion thus surrounded is shut off from most possibilities of harm, rarely encroaches, except by the most gradual processes, and, on the contrary, often contracts and reduces its dimensions, the watery portion of its contents being gradually absorbed and the more solid and cellular portions becoming condensed into matter which undergoes caseous degeneration, so that eventually recovery may ensue as the consequence of a metamorphosis of an original cold abscess into a caseous nodule surrounded by the old pyophylactic membrane, which is now serving as a capsule.

The contents of the cold abscess are, in some instances at least, of acute origin, and consequently may have been originally pus or its near ally. On the other hand, in cases which have occurred very slowly this material is not real pus, but is a semifluid debris having certain properties which remind one of pus. It has been my effort hitherto to devise for this material a name which should distinguish it from pus and indicate what it really is. Inasmuch as most of it has been of a puruloid character, at least at one time, I have suggested that it be called _archepyon_ (_i. e._, originally pus or puruloid). As this flows from such a cold abscess, it is more or less watery and contains caseous, sometimes calcareous, nodules in masses of considerable size, and not infrequently sloughs of tissue and old shreds of white fibrous tissue which resist decomposition for a long time. This material has been thus imprisoned, sometimes for months or even years, and consequently has lost most of its resemblance to what it was originally. The organisms which first produced it have long since died, and it is practically sterile. If any organisms survive, they are the tubercle bacilli, which are more resistant and tenacious of life than the ordinary pyogenic organisms. This is why most culture experiments fail, and why even inoculation with the contents of an old cold abscess is often without effect even on most susceptible animals. _Nevertheless the bacilli which the semifluid contents do not contain may yet linger in the meshes of the pyophylactic membrane; and here lurks the greatest danger in dealing with these lesions._

In old cases the pyophylactic membrane is very tough and very adherent by its outer surface. It can sometimes be peeled off in strips of considerable extent, at other times cannot even be separated, or sometimes is so placed as to render it impossible to follow it to its termination. There must be _complete extirpation of this membrane_, or at least destruction; and when its removal is impracticable, failure to remove it should be atoned for by some powerful caustic, such as zinc chloride, nitric acid, caustic pyrozone or the actual cautery, which should be made to follow it to its ultimate ramification. The membrane and the tissues underlying, when thus cauterized, will separate as sloughs, and these will be replaced by presumably healthy granulations, which should be encouraged until the original cavity is filled or the surface healed.

Acute abscesses, as indicated in the previous chapter, have no real limiting membrane, although there is more or less condensation of tissues about the focus of infection. A typical membrane is distinctive of tuberculous abscesses, and is to be regarded always as their natural protection and a barrier against their further encroachment--a membrane whose inner surface may harbor active organisms which cannot escape through its outer texture. Consequently, to simply incise it or inefficiently scrape it is to do a worse than useless thing; and one should never attack it unless he is prepared to extirpate it or destroy its integrity, and in this way dispose of it.

Cold abscesses when near the surface cause a bluish or dusky discoloration of the overlying skin, while the superficial and subcutaneous veins of this region are usually enlarged. Fluctuation is also a prominent phenomena in connection with them when they can be palpated. Deep collections of this kind may be mistaken for cysts or tumors, in which case the aspirator needle may be used to facilitate diagnosis. They vary in size from the smallest possible collection of fluid to abscesses which may contain a gallon or more of puruloid material or archepyon. They are known often as _gravitation abscesses_, because by the weight of the contained fluid they tend to elongate or spread themselves in the direction in which gravity would naturally carry a collection of fluid. Thus cold abscesses originating from tuberculous disease of the lower spine frequently work their way along the psoas muscle and present below Poupart’s ligament as _psoas abscesses_, or elsewhere about the thigh, while those which come from similar disease of the uppermost cervical vertebrae may present behind the pharynx, as the so-called _retropharyngeal abscesses_, and those from the dorsal spine present not infrequently as _lumbar abscesses_. These are but two or three familiar examples of what may occur in any part of the body.

=Treatment.=--Aside from the treatment of cold abscesses, already indicated by radical measures, other means have been suggested, and

## particularly for the treatment of those in which such extreme measures

are impracticable or impossible. It is sometimes efficacious to simply tap or remove by aspiration the contents of such a cavity. It may never refill, or but slowly, and after repeated tapping alone a very small percentage of such cases will subside into inactivity and the lesion be subdued, if not absolutely cured. Treatment by injection of emulsions of iodoform has found favor with many surgeons. I have never been able to secure the good results reported by others, and consequently have abandoned it; yet it deserves mention here because of the repute it has enjoyed.

This is based upon the alleged specific properties of iodoform as being peculiarly fatal to tubercle bacilli, presumably by liberation of free iodine. A cavity to be thus treated should be first emptied as completely as possible, after which may be thrown into it a glycerin emulsion or an ethereal solution, or a suspension in sterilized oil of 5 to 10 per cent. of iodoform. From 25 to 200 Cc. of some such preparation is introduced, while the walls of the abscess are more or less manipulated in the endeavor to completely disseminate the mixture. The cannula through which it has been introduced is then withdrawn; and this can usually be done with but little unpleasant iodoform effect. This is due to the pyophylactic membrane, which limits the activity of the drug as it has done that of the previous contents of the abscess. Such cavities have also been treated by washing out through a trocar with an injection of various antiseptic or stimulating solutions, among which may be mentioned hydrogen peroxide, weak iodine solutions, etc. My own advice is to treat all tuberculous lesions radically when such measures are not contra-indicated by their multiplicity or by too great depression of the patient, and so long as lesions are accessible to ordinary operative procedures. This same advice pertains also to those which have already spontaneously evacuated themselves, or where the overlying skin is threatening to break and permit escape of contents. Almost any case where this is imminent is one in which the surgeon, as such, ought to interfere. On the other hand, in deep collections and in debilitated individuals the treatment by injection may be tried.

The best way to treat accessible tuberculous lesions is by extirpation, as this hastens convalescence and leads to more permanent results.

THE GUMMAS OF TUBERCULOSIS.

The other and essential characteristic of tuberculous disease is the _infectious granuloma_ to which it gives rise. This is a term first applied by Virchow to new formations of granulation tissue which are the result of the presence of invading and specific irritants. This tissue varies little in type from that already described under Ulcers, and is common to the neoplasms which are found in tuberculosis, syphilis, leprosy, glanders, and other local infections. So little does the tissue type vary in these different instances that it is difficult to distinguish by microscopic sections of the unstained tissues, or at least those unstained for bacteria, to which class of lesions they belong.

[Illustration: PLATE VII

Lupus of Skin. (Gaylord.)

_a_, fresh tubercles containing numerous plasma cells; _b_, mature tubercle with giant cells. Below are accumulations of plasma cells about the vessels. Low power.

Unna’s polychrome methylene blue.]

This tissue may be met with in any of the tissues of the body, but is less seen upon the serous membranes of the cranial and peritoneal cavities, whereas in the joint cavities it is common. It is provoked, as just stated, by the presence of tubercle, and has the power of penetration into and substitution for almost all the other tissues of the body. Thus in a primary tuberculous focus within the bone a granuloma will form and extend its limits, while the surrounding bony tissue melts away before it; and it is by the growth of this tissue in a particular direction that tuberculous products from within the bone cavity are finally carried to the surface. When this material has escaped from bone, or from tissues without the bone, toward the surface its presence is marked by induration, by livid discoloration of a limited area of skin, with elevation of the surface, which finally breaks down and shows discolored, bleeding, and pouting granulations, which in the absence of restraint now proliferate more rapidly, and often to the point where they loose their former blood supply, and consequently necrose upon the surface. This is the _fungous granulation tissue_, especially of the German writers, and may be met with upon the surface, or is frequently seen in opening into joint cavities and other tissues infected by tubercle. The appearances of this fungous tissue are modified somewhat by environment and pressure: in joints flat and radiating masses of it will be found, extending along the synovial surfaces and into the articular crevices. This fungous tissue may grow in any direction, but apparently advances in the direction of least resistance. It leads to complete perforations of the flat bones, like those of the skull, while tuberculous masses from the dura may cause multiple perforations, the granulation tissue finally escaping through the overlying skin. In tuberculosis of synovial sheaths and bursæ it extends along and may completely fill and even distend them. It will separate tissues which were united together, and it may lead to disintegration and disorganization of the firmest textures in the body. So long as it is not exposed to the air nor to pyogenic infection, it will preserve its characteristics for a considerable length of time. Immediately upon exposure it is likely to break down, and infection will travel speedily along it into the deeper cavity whence it has sprung. A mass of this tissue contained within the normal tissues, condensed more or less by pressure, uninfected, and not freely supplied with blood, is entitled to the name of _tuberculous gumma_, whose tendency, however, is too often to break down and suppurate. Such gummas may be found in any part of the body, and differ only in unessential respects from the diffuse and more or less infiltrated masses of granulation tissue which occupy serous cavities or which extend in various directions.

The lesions of surgical tuberculosis, except those already spoken of as constituting cold abscess, are so essentially connected with the presence of granulation tissue, just described, or of this form of the infectious granulomas, that no student can appreciate the subject until he is familiar with this tissue in its various phases and in various locations. Of such great importance is it that this be realized that some of the local manifestations of this new tissue must here be considered, although they may be rehearsed in other form in succeeding chapters.

_In the skin and subcutaneous tissues_ and _in and under mucous membranes_ this granulation tissue may be studied at places where it is free from most mechanical restraints to growth, and where, in other respects, its appearances are typical. The most characteristic manifestations in the skin occur as _lupus_, a disease considered cancerous or of uncertain etiology. Lupus is always a cutaneous manifestation of this protean disease. (See Plate VII.)

In its incipient stages lupus consists of multiple minute nodules of granulation tissue just beneath the surface, containing all the elements of true miliary tubercle, with infiltration of the surrounding skin, even into the subcutaneous fat. The most common location of these lesions is on exposed surfaces. Bacilli are not numerous in them, yet may be demonstrated. The tendency is more or less rapidly to break down, the result being a tuberculous ulcer, which, as it extends, manifests usually a disposition to cicatrize in the centre while enlarging around its periphery. The dermatologists describe several different forms of lupus under the names _hypertrophicus_, _vulgaris_, _maculosus_, etc., all of which are essentially the same in character, the differences being largely constituted by the rapidity or slowness with which the granuloma of the skin breaks down. From the surface these growths may extend and involve parts at considerable depth, even the periosteum. This name should also include the lesions described as _scrofuloderma_ or scrofulous ulcers of the skin, they being all of the same character.

A variety known as _anatomical tubercle_ has been described by some writers, found especially upon the hands of those who frequent dissecting-rooms or handle dead bodies, and is supposed to be the result of local inoculation. It appears usually as a warty growth, which ulcerates and becomes covered with a scab--is usually indolent in character, but is followed by lymphatic involvement, and in rare instances by death from tuberculous disease.

[Illustration: FIG. 20

Tuberculosis of cervical lymph nodes.]

_In the lymphatic structures and lymph nodes_ tuberculosis is a most frequent affection. In these localities it may occasionally be primary, but is almost always a secondary lesion. It is in separating from the lymph stream the tubercle bacilli, which would otherwise be passed into the general circulation, that the lymph nodes, acting as filters, render us the greatest possible service. These filters themselves, however, almost always become infected, and, enlarging, they assume the appearances known to the laity as _scrofula_, which have been generally referred to as _scrofulous glands_. These lesions abound rather about the axilla and the cervical and bronchial nodes than about the lower extremities. Nevertheless, the retroperitoneal, mesenteric, and inguinal nodes are occasionally infected. In these nodes will be found giant cells surrounded with epithelioid cells, containing bacilli and undergoing cheesy degeneration or suppuration. Infection often proceeds from centre to periphery, and then to the surrounding tissues, the filter, as such, having become so choked that nothing seems to pass it. By virtue of this surrounding infiltration (which used to be known as _peri-adenitis_, when lymph nodes were spoken of as _lymph glands_) generalized infection is in some measure prevented, while the natural barriers are altered and natural distinctions between tissues are lost. This makes complete extirpation of these tuberculous foci often very difficult, while the adhesions which they contract, for instance in the neck, are often to the large vessels and nerve sheaths, by all of which their operative treatment is naturally complicated. When infection from the superficial nodes extends toward the surface it is easily recognized by the dusky hue of the overlying skin, the hardness, infiltration, and, later, the fixation, of these masses, accompanied usually by evidences of suppuration.

_In and on the serous membranes_ we find tuberculous lesions, either primary or metastatic, usually miliary in type. In the _pleural cavity_ they produce effusion (hydrothorax), which may necessitate repeated paracentesis, or by a mixed or secondary infection may cause empyema, for which much more radical and even extensive operations are demanded. (See Thoracoplasty.)

In the case of the _peritoneum_ we find (_a_) miliary tuberculosis, (_b_) a slower non-exudative form with firm, sometimes pigmented nodules, and (_c_) a form characterized by small gummas which become caseous, coalesce, and ulcerate, binding together intestinal coils and producing extensive and irregular adhesions, with seropurulent exudation, often enclosed in walled-off sacs. In all of these cases surgical intervention should be considered, while in the more acute miliary forms abdominal section, with flushing, has in many instances afforded relief.

Tuberculous _meningitis_, cerebral or spinal, is in surgical cases practically always of miliary type, accompanied by the inevitable increase of fluid, and, in the cerebrospinal canal, of consequent tension. Inasmuch as the latter constitutes the most formidable feature of these cases, its possible relief by puncture may be considered. And so lumbar puncture (_q. v._) may be practised, and even tapping the cerebral ventricles after making the small trephine opening has been done a few times, though not with encouraging success. (See Hydrocephalus.) Too often tuberculous meningitis is the terminal infection which ends many a case of local tuberculous disease in other parts of the body.

In general the more acute and miliary the lesions presented in tuberculous disease of serous membranes the greater the tendency to profuse watery (serous) exudate, whose volume may demand operative measures for relief.

_In the bones_ we often find indications of tuberculous disease. It is not much more than sixty years since Nélaton called attention to the frequency of these intra-osseous lesions, and demonstrated the essentially tuberculous character of much that had hitherto been overlooked or considered under that vague term scrofula. All those forms of bone disease comprehended under the names _Pott’s disease_, _spina ventosa_, _tumor albus_, etc., are now known to be distinctly tuberculous lesions. In many instances these follow the slight circulatory disturbances brought about by contusions sprains, etc. This is especially the case in those who are predisposed to this disease.

[Illustration: FIG. 21

Tuberculous spondylitis (caries): _a_, osteogenesis and osteosclerosis; _c_, cavity formed by degeneration of tuberculous focus. (Krause.)]

Tuberculosis of bone always assumes the phase of miliary lesions, followed by the formation of a granuloma, which may gradually encroach upon surrounding tissues or may assume a more fulminating type and spread rapidly. Apparently because of the circulatory conditions these lesions generally occur near the epiphyseal lines of the long bones, apparently seeking the ends of the bones, as pulmonary lesions seek the terminations of the lungs. These lesions may be solitary or multiple. Beginning always minutely, they spread so as to produce foci perhaps two inches in diameter. As the result of the formation of granulation tissue, the surrounding bone melts away and disappears, the result being a great weakening of its structure and expansion of its dimensions in order to make room for the growing mass within. The tendency of this granulation tissue thus imprisoned is always to escape in the direction of least resistance. This carries it sometimes into the joint, sometimes out through epiphyseal junctions, and sometimes through channels in the bone made by its own pressure, with external escape and appearance of the dusky distinctive tissue, felt beneath and then upon the skin. Where bone is so weakened in one direction it is usually strengthened by compensatory deposition of calcium salts at other points, and the result frequently is a striking _combination of osteoporosis_ in the immediate presence of the disease, with _osteosclerosis_, sometimes to a remarkable degree, even to _eburnation_, of an adjoining portion. When this mass undergoes caseous degeneration the progress of the disease is much slower and the pain less. When it undergoes suppuration there are more evidences of inflammation, with more pain and systemic disturbance, as well as local swelling, tenderness, etc. The surrounding musculature is rarely involved, although the periosteum is nearly always so. In fact, it is stated that in an inflamed and suppurating bone lesion, if the muscles are extensively invaded, it may be regarded as of syphilitic rather than of tuberculous origin. The _pyophylactic_ membrane already alluded to is seen in almost every instance of tuberculous disease. The spina ventosa of some writers refers to the expansion of the shaft and medullary cavity of a long bone whose interior is occupied by a mass of tuberculous gumma, which is perforated at one point, and through which opening it escapes as does lava from a crater, to involve the structures on the outer side. The appearance of this granulation tissue in joints as _fungous tissue_ has already been mentioned. In a general way it preserves its fungoid characteristics until attacked by pyogenic or saprogenic organisms, when it quickly breaks down, forming an ulcer if upon the surface, or a cold abscess if not externally open. Tuberculous disease of the bone is most common in the young, and in them the majority of tuberculous joints are those whose bony structures have been first involved. In other words, the majority of cases of tuberculous pyarthrosis are due to primary bone disease. As the result of the tuberculous infection the bones become distorted, which is best illustrated in Pott’s disease of the spine; while, as the result of the constant irritation, joint ends become displaced by chronic muscle spasm, and joint contours entirely altered by expansion of the affected bone and thickening and infiltration of the overlying soft parts.

I have often, for the sake of illustration to medical students, drawn a certain analogy (following Savory) of the gross resemblances between lungs and bones in their behavior when involved in tuberculous disease. In either case the structure is in a measure spongy and contains cavities and networks of tissue; in each case the structures are invested by a resisting membrane--in the one instance pleura, in the other periosteum. Again, each is closely related to a serous cavity--the lungs to the pleural cavity, the bones to the serous cavities of the joints. Tuberculous disease manifests a predilection for the extremities of both organs. Perforation into the adjoining serous cavity is frequent, and previous to perforation collections of serous fluid are frequently noted--in one instance pleurisy, in the other hydrarthrosis. Moreover, these fluids may frequently become contaminated, and then become purulent, constituting empyema or pyarthrosis as the condition may be. One sees, too, in each place the same striking combinations of weakening of tissue and strengthening in order to atone for the undermining of the disease. These are not all of the similarities that might be adduced, but are perhaps sufficient for the purpose of showing that tuberculous disease is essentially one and the same thing, no matter what tissue is invaded.

_In the tendon sheaths and bursæ_ we frequently find manifestations of tuberculosis. When seen early these are always in the direction either of miliary affection, or, most commonly, of tuberculous gumma, while when seen late the disease has usually advanced to the point of suppuration, and we now have cold abscess of the affected part.

In many joints and tendon sheaths, particularly the latter, we find certain detached, usually colorless, firmly resistant masses, of smooth and polished surface, lying in a collection of fluid, in size from a minute particle up to that of a melon-seed. These have been known at various times as _rice grains_, _melon-seed bodies_, _corpora oryzoidea_, etc., and for a long time their explanation was a mystery. It is now well established that in the majority of instances these are the result of fungous granulations which have become detached in small pieces, which then, in the absence of infection, have shrunken and become rounded and polished by attrition. The bursal enlargement and distention with fluid in which they are usually found is commonly spoken of as _hygroma_ of that particular bursa. Tuberculosis of these bursæ, however, does not always result so harmlessly as the formation of these bodies, but, on the contrary, tuberculous infiltration may extend beyond the serous limits to the surrounding soft parts, with a tendency finally to external escape, just as in the case of bone lesions. These constitute affections of the soft parts which are more or less destructive, and are difficult, often impossible, to deal with, because of the mutilation which a thorough extirpation of the disease would necessitate.

_In the testicles and ovaries_, particularly in the former, tuberculous disease is frequently met with. In the testicles it begins usually in the _epididymis_, forming a somewhat dense nodule and a distinct tumor, easily observed from the outside, although its minute character may be still concealed. The tendency here is almost invariably to progressive infiltration and breaking down, either into a caseous mass or, more commonly, into puruloid material, while sometimes acute infection supervenes.

It is not always easy to distinguish between syphilis and tuberculosis of the testicle, though the latter is usually characterized by the same tendency to effusion into the adjoining serous cavity, _i. e._, that of the tunica vaginalis, as is manifested in disease of the lungs or bones. When the disease is extensive the overlying skin is involved, and frequently the surgeon is called to deal with cases of perforation and escape of fungoid tissue on the outside.

_In the kidneys, in the ureters, as also in the bladder_, tuberculous lesions are noted, the miliary form being particularly frequent in the former. Tuberculous disease of the kidney leads sooner or later to caseation and a condition of pyonephrosis or its equivalent, which calls practically always for extirpation of the affected organ. Tubercle bacilli are sometimes recognized in the urine, but only when the lesion has an opportunity of discharging into one of the urinary passages.

_In the peritoneum_ tubercle appears usually in the miliary form, leading sometimes to such extensive involvement of and interference with visceral functions as to produce anasarca or more general disturbance prior to death. Acute miliary disease here is as rapid and as essentially fatal as the same affection of the dura or pia, while the more chronic forms are followed by degenerations that may involve the intestines either in agglutinated masses or in ulcerations and possible perforations. The indication in all tuberculous lesions of serous membranes is for exposure by operation, disinfection of the surface, and evacuation of retained fluids. Recovery from tuberculous peritonitis, even of acute type, after abdominal section, is now definitely established as a possibility. The same would probably be true of tuberculous meningitis were we permitted to expose the membranes and attack them or drain them in the same way.

Although a few distinct organs or tissues have here been specifically considered in their relations to tuberculous disease, there is no organ or tissue in the body which is exempt from its ravages and in which evidences of tuberculous disease may not be found. Even the _mammary gland_ occasionally presents tumors composed of tuberculous granuloma which more or less simulate malignant disease, while calling for the same radical treatment (Fig. 22).

[Illustration: FIG. 22

Gross appearance in tuberculosis of the mamma. (Dubar.)]

=Paths of Infection.=--The tuberculous virus may enter the body through various channels. Probably in the majority of instances it gains entrance through the _respiratory tract_, less often by the _alimentary canal_, and _occasionally by air contact of open wounds or direct infection by local agencies_. It is now well established that tuberculous disease is easily inherited, although a predisposition to its ravages is transmitted from parent to children.

In what this predisposition consists is not always easy to say. As the tubercle bacillus grows in the tissues, it is by preference an anaërobe, and it seems to be lowered in activity or banished by access of oxygen. It has been shown that in those individuals in whose pallid skin, long bones, flabby muscles, and pale conjunctivæ we recognize a predisposition to this disease, the heart is disproportionately small as compared with the weight and size of the lungs. This means a relatively feeble pumping power, and is perhaps the best explanation for what is accepted as a fact. The _mucous membranes of the nose_ and _throat_ are usually the first lodging places for germs carried by the air, they finding here the warmth and moisture necessary for their detention, development, and growth. As long as these membranes are unbroken and healthy, infection is rarely possible; but let tubercle bacilli become caught in the crypts of the tonsils or in adenoid tissue in the nasopharynx, and the other disturbance, set up by irritant organisms of various species, will usually bring about conditions favoring their growth and incorporation into the living tissues. This lymphadenoid tissue is often the port of entry for these organisms. The explanation for local and surgical tuberculosis in bones and other accessible tissues probably is connected with causes determining at these points an area of least resistance, in which the germs find tissues more susceptible than elsewhere, and in which they may live and thrive.

Not the least interesting and important of the considerations regarding tuberculous disease is the possibility of an _acute outbreak of tuberculosis after long latent or chronic manifestations of the disease_. This means, in effect, the onset of _general miliary tuberculosis_ which soon terminates fatally, and death is not the infrequent result of such extremely rapid outbreaks from tuberculous disease of joints, bones, ovaries, etc. For the disease when it has assumed this extremely rapid type there is, so far as known, no relief.

=Diagnosis.=--So far as the general recognition of tuberculous disease is concerned, it is not often difficult. It is accompanied usually by more or less marked cachexia (at least this is the case when infection is serious and widespread), one of whose principal characteristics is the so-called _hectic_ (habitual) fever of old writers. This was a fever of a remittent type, accompanied also by more or less colliquative night sweats, with dryness of the skin during the daytime, and flushing of the face. Hectic fever, as a matter of fact, often accompanies tuberculous disease, but is seldom encountered until pyogenic infection has occurred and suppuration is taking or has taken place. There is now much reason to consider hectic fever as an auto-intoxication from absorption of morbid products. In advanced cases we may find evidence of _amyloid_ changes, although these are seldom recognized prior to autopsy. It is seldom difficult to recognize tuberculous disease except when at a considerable depth. Here, as long as there is no suppuration, there is little tendency to _leukocytosis_, by which diagnosis as between _sarcoma_ and _tuberculous_ infection may perhaps be made. Sometimes when in doubt the exploring trocar or an exploratory incision may be resorted to, it being always best to be prepared at the same time to proceed with whatever further operative procedure the findings may indicate.

=Treatment.=--It is well to emphasize, first of all, that _tuberculous disease when circumscribed and accessible is a distinctly curable affection_. If this is accepted, it puts a much more hopeful aspect upon the condition than it formerly bore. It moreover justifies operations of a more radical nature than were formerly practised. Treatment should be divided into the hygienic and constitutional and the local and operative.

Of all the natural remedies, _oxygen_ undoubtedly ranks first. This means the best of _ventilation_, an outdoor life if possible, and preferably in localities and at altitudes free from dust and well supplied with ozone. When this is impossible inhalations of dilute oxygen are capable of doing much good. The two canons of successful treatment of pulmonary tuberculosis are equally of value in surgical tuberculosis, viz., _abundance of oxygen and hypernutrition_. The diet should be rich and nutritious, at the same time capable of complete digestion. The emunctories should be stimulated and elimination favored in every possible way. Undoubtedly the old standard remedies--cod-liver oil, compound syrup of hypophosphites, etc.--are beneficial, and much good may be accomplished by their proper use.

Certain remedies have been at various times supposed to be endowed with specific properties, and for many years clinicians have endeavored to find that substance with which the system could be safely saturated and prove inimical to the parasite causing this disease. Such agent has not yet been discovered; nevertheless, much has been done in this direction. Of the remedies highly spoken of for this purpose, _creosote_ and _guaiacol_ are considered the best. These are somewhat difficult of administration, but if the latter is given in the form of the carbonate, generally known as _benzosol_, it comes the nearest to the ideal for which we are striving. _Benzosol_ should be given to the adult in doses of at least a gram a day, perhaps more. It is better tolerated and less offensive than the guaiacol from which it is made. I have never seen anything but benefit result from its use, and yet would not extol it as a positive cure. Nevertheless in conjunction with other local and constitutional measures its administration may be followed by complete recovery.

Of the various _local measures_, _physiological rest_ should be placed first, and can be achieved in some places better than in others. The various forms of apparatus resorted to by orthopedists are simply mechanical measures in furtherance of this purpose. Some surgeons have faith in _iodoform_, used locally in solution or suspension in some menstruum like glycerin, oil, etc. The benefit which has been claimed in some cases is not duplicated in the experience of all surgeons; nevertheless, it has undoubtedly been of service. A recent and most promising method of treating tuberculous disease of the extremities has been suggested by Bier, and consists in the establishment of a _permanent hyperemia_ by the application of a rubber tourniquet on the proximal side of the lesion. (See chapter on the Joints.)

It would appear that the access of more blood which is thus permitted is inimical, presumably by the presence of the oxygen which it brings, to the development of the disease germ. The method depends for its rationale upon the fact that the congested lung does not become tuberculous. Lannelongue has suggested what he calls the _sclerogenic treatment_ of tuberculous lesions, by injection of a very dilute solution of zinc chloride, which serves as an irritant and produces a tissue sclerosis that serves the purpose of a prophylactic membrane, while at the same time the solution is fatal to those germs with which it comes in contact. This treatment is painful and has not proved acceptable.

The astute surgeon, who gains the confidence of his patients and retains it, will not hesitate to remove by a suitable operation the tuberculous focus which he feels confident that he can reach and extirpate. The resulting tissue defects may be in many instances atoned for by plastic operations. At other times this procedure means _excision of some joint_, which leaves usually a much better functionating member than would the disease if permitted to go on to spontaneous recovery--_i. e._, ankylosis--and at the same time removes a focus of disease which is a menace if left to the future welfare of the patient. It may mean at other times _amputation_, but the artificial limbmaker now supplies a member vastly more useful than a natural one crippled by this infectious disease. In a general way, then, time may be saved and recovery ensured by early and judicious operation, while later in the course of this protean malady it may be absolutely necessitated in the endeavor to save life.

After operations where clean extirpation and reunion of the parts with primary healing is impossible a local dressing of balsam of Peru containing 10 per cent. of guaiacol is recommended. Gauze saturated with this dressing and packed into the cavity best accomplishes the purposes of a surgical dressing for such cases.

The superficial and ulcerative (skin) lesions due to tuberculosis often yield very readily to exposure to the Röntgen rays and the ultraviolet rays. Recrudescences appear not infrequently, and the treatment should be administered at intervals long after the apparent subsidence of the lesion.

Deep pain of tuberculous lesions, especially in bone, is often relieved by _ignipuncture_, meaning thereby a perforation into the depth even of the bone-marrow by the actual cautery (Paquelin’s), which may be thrust directly through the skin or which may be used after exposing the bone by incision. The use of the actual cautery is indicated in eradicating and destroying tuberculous tissue when a neat dissection or extirpation is impossible.

=Tuberculin.=--Finally the treatment of tuberculosis cannot be dismissed without a reference to the glycerin extract made from a filtered culture of the tubercle bacillus, containing the peculiar toxalbumin first prepared by Koch, forever associated with his name, and first given to the world in 1890, when its announcement created a furore and aroused hopes that have never been completely realized. Yet in spite of disappointments which have often followed its use, it is a remedy of great value when judiciously used in selected cases. The diagnostic value of the material should also not be forgotten, as by its use one may possibly decide in doubtful cases as between tuberculous or some other disease. The best preparation for use today is that made by Koch’s new process, by which the possibility of the presence of microörganisms is eliminated. It contains those constituents of the bacilli which are insoluble in glycerin, and which have distinct immunizing power. On the market it is known as _tuberculin rest_, indicated simply as T. R. The initial dose is ¹⁄₅₀₀ Mg., to be increased with each injection. Its effect, _e. g._, on lupus, is very marked.

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