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these fungi along with growing grain. The path of infection is usually
by the mouth, while accident seems to determine whether the
infection shall manifest itself mainly in the intestinal canal or the
respiratory tract. In animals there is less tendency to suppuration
than in man, the infection in man being usually a mixed one. The
name lumpy jaw, so generally given to the affection, is indicative of
the most conspicuous lesion in cattle, for the organism, having once
invaded the gum, for instance, passes quickly to the bone, or, having
involved the tongue, is not slow to infect the lymphatics of that
region. In consequence we have tumors, often of inordinate size,
which may involve the bones or the soft parts and cause great
disfigurement, along with necrosis, leading eventually to the death of
the animal. These tumors are essentially granulation tumors due to
the presence of a specific irritant—the actinomycis—which acts here
as do the tubercle bacillus, the lepra bacillus, etc., in other infectious
granulomata.
In man the disease is generally accompanied by abscess
formation, the pus containing the distinctive yellow gritty particles
which are found in no other disease. The strong resemblance
between the lymphoid cells of this form of granuloma and the
embryonal cells of sarcoma has permitted the perpetuation of
confusion between these two neoplasms.
Large abscesses form as the result of the coalescence of small
ones, and by the time the disease is recognized extensive
destruction and loss of substance may have taken place. In man it is
not alone about the mouth that the disease is noted, although
primary lesion here is by no means infrequent. It leads to affections
similar to that already spoken of in cattle, with a progressive
infiltration and breaking down, including actual necrosis of bone, etc.
The pus will escape at various points, and may give to the surface
an appearance as of many craters with a central cause. When the
disease has involved the lung, either directly or indirectly, the fungi
and the calcareous particles may be found in the sputum. Should
there be suspicion of this involvement, the sputum should always be
examined. Even in the heart substance tumors of this same
character have been found. The first case noted in man had
undergone extensive vertebral caries. Intestinal infection is possible,
 Fig. 19 in which case multiple
lesions will form in the
intestinal walls, which
may contract
adhesions to the
abdominal parietes
and discharge
externally through
them. The appendix
has been found
involved in such
lesions. Infection of
the skin has also
been described,
though this occurs
more rarely.
Diagnosis.—
Actinom
ycotic lesions have
been mistaken for
cancer, sarcoma,
tuberculosis, syphilis,
Actinomycosis in man. (Lexer.) etc. In man it will
always be
characterized by more or less suppuration, and in the purulent
discharge from the infected focus the yellow calcareous particles
should enable recognition of this disease at once.
Prognosis.—As long as the focus is accessible it is a purely local
matter, and prognosis is as favorable as in local
tuberculosis; but, inasmuch as in many cases infection has
proceeded to a point where the surgeon cannot safely follow it,
prognosis must be guarded. Actinomycosis is free from acute
manifestations, for the main part free from pain, pursues a chronic
course, and is characterized, as are the other slow infections, by
progressive emaciation, prostration, etc. As it is essentially a chronic
condition, time is afforded for careful study in doubtful cases, for
microscopic examination, etc.
 Treatment.—This must consist of extirpation of all infected tissues
and areas. If this can be done thoroughly there is a
prospect of positive cure. Free incision, wide dissection, the use of
the actual cautery, etc., are always called for in these cases. If it
involves the tongue alone, there is an excellent prospect; if but a
portion of the jaw is involved, a complete excision of one-half or
more may be followed by excellent results. If, however, the lung,
liver, vertebrae, or other vital and inaccessible parts are involved,
surgical measures may afford amelioration, but can hardly be
expected to cure.
Iodine, alone or in combination, has been found efficacious in the
therapy of actinomycosis. In diluted solutions used locally, or as
potassium iodide given internally or injected into tumors, it doubtless
has a beneficial effect during the period of its administration. Recent
reports and experiences show that great value attaches to the use,
as suggested by Bevan, of copper sulphate in the treatment of
actinomycosis, its use having been suggested by the fact that copper
is used to destroy rusts (fungi) on grain. One-half grain (3 Cg.) may
be given internally three times a day, while the sinuses are irrigated
with a 1 per cent. solution. I have seen apparently complete cure of
an aggravated case follow its use. Incidentally it may be stated that
Bevan advises its use also in cases of blastomycosis.

MADURA FOOT.
While madura foot is not a disease from which domestic animals
suffer, its general characteristics make it a proper subject for brief
consideration. It is essentially a disease of the tropics and
subtropics, and is often seen in some of our new possessions.
It commences as a painless swelling upon either aspect of the
foot, in which hard nodules form, which later soften, ulcerate, and
discharge puruloid material containing granules in which the
microscope reveals mycelia of the peculiar fungus that produces the
disease. In some cases these particles are black, in others colorless.
The disease is of slow progress, and the lower limbs become weak,
atrophied, and finally useless Death results from exhaustion or some
terminal infection.
 The principal lesion is the slowly growing gumma or granuloma,
whose presence is unmistakable. This is due to the presence of a
fungus, called by Vincent the streptothrix maduræ. Thus in its
pathology the disease much resembles actinomycosis. The
habitually bare feet of most of the inhabitants of the tropics and the
habitat of the fungus explain the site of the primary lesion.
Treatment.—The only treatment is extirpation of the growth—i. e.,
amputation.
 PLATE VI

Tuberculosis of Testicle.
Miliary Tubercle with Caseation and Giant Cells. (Gaylord and Aschoff.)
a, seminal tubules; b, giant cells; c, caseated tubercles.
 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.
 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.
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,
 Fig. 20 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
Tuberculosis of cervical lymph nodes. 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.
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