“=The spinal outline= characteristic of tuberculosis and of the
pretubercular stages presents the following peculiarities: The cervical
spine presents various abnormalities, usually lesions involving single
vertebræ and associated with irregular muscular tensions. The upper
thoracic spine is anterior, the ribs drooping and rather more freely
movable than normal; the vertebral articulations are less movable than
normal; the tissues in the neighborhood of the upper two or three
dorsal spines are abnormally sensitive and the muscles innervated from
these segments are contracted irregularly when the disease involves the
apices. The lower interscapular region is found sensitive and these
muscles are contracted when the lower lobes of the lung are involved,
and the location of these sensitive areas may be employed in the
localization of the lung area infected.
“In every case recorded in this clinic, lesions involving the area of
the origin of the upper and middle splanchnic nerves have been found.
The typical tuberculosis spine must include lesions of the lower dorsal
area. Probably these lesions are predisposing factors in tuberculosis,
partly because of the effects produced upon nutrition thereby, but
doubtless the lack of the normal mobility of this part of the spine
prevents the normal stimulation of the liver, the spleen, perhaps the
pancreas, thus the normal opsonic index is lost, and immunity broken.
The treatment of tubercular cases should include careful attention
to the splanchnic area, the maintenance of the normal mobility
and structural relationship of the entire spinal column, and such
stimulating movements to the ninth and tenth thoracic neighborhood as
is indicated in each individual case.”
=Pathology.=—In adults the most common site of tubercles is the lungs;
in children it is the lymphatic glands, joints and bones. No organ
is exempt; the salivary glands and pancreas are the least frequently
involved. The military tubercle is the beginning of tubercular
deposits. This may develop in any tissue where the tubercle bacillus
is found and it is only distinguished by the presence of a tubercle
bacillus, as similar conditions are produced by the aspergillus glaucus
and actinomyces.
In the development of a tubercle there is proliferation of the fixed
tissue cells, particularly those of the connective tissue and the
endothelium of the capillaries, due to the irritation of the bacillus,
producing the epithelioid cells and in some instances the giant cells,
in both of which bacilli may be found. The epithelioid cells vary in
shape. The giant cells are formed by enlargements of the epithelioid
cells and a repeated division of their nuclei or possibly by fusion
of several cells. On account of the inflammation produced by the
bacillus, there is migration of leucocytes from the adjacent vessels
and lymphoid cells. The leucocytes are largely polynuclear and are
rapidly destroyed, but later mononuclear leucocytes appear, which
are able to resist the action of the bacilli so that they are not so
readily destroyed. A reticulum of connective tissue is formed around
the various cells. The tubercles are non-vascular and when once formed
undergo caseation and sclerosis.
=Caseation= is a process of coagulation-necrosis or destructive change,
beginning at the central part of the growth, due to the action of the
bacilli. The primarily transparent tubercular tissue may become a
gray gelatinous body containing bacilli. Frequently the caseation is
followed by softening; less frequently, calcification, or it may be
surrounded by fibrous tissue.
During the time the cell destruction is going on at the center of
the tubercle, hyaline and fibrous changes may render the tissues
=sclerotic=. These changes, =caseation=, the destruction of forces,
which are dangerous to the patient, or =sclerosis=, which is a healing
process, depend upon the power of the body to produce an antitoxin to
overcome the effects of the special toxin produced by the bacilli.
There may be a widespread =tuberculous involvement=. This is the result
of fusion of the new foci of infection or of miliary tubercles. The
lungs are the usual site of infection, varying from a small area, to a
lobe or a still greater area.
The irritation of the bacilli is capable of producing =associated
inflammatory processes= in its own neighborhood. There may be an
overgrowth of interstitial tissue. In other instances, changes to
catarrhal or croupous pneumonia may occur. Suppuration is associated
with tuberculosis, especially of the lungs, and is due to a mixed
infection or the presence of pus organisms. Some authorities claim that
the tubercle bacilli alone are able to produce suppuration; it is,
however, more probable that suppuration is due to a mixed infection.
The constitutional features in tuberculosis are more dependent upon
this secondary infection, especially by the streptococci, than upon the
primary infection.