TUBERCULOSIS
Tubercle bacillus--Methods of infection--Inherited and acquired
predisposition--Relationship of tuberculosis to injury--Human and
bovine tuberculosis--Action of the bacillus upon the
tissues--Tuberculous granulation tissue--Natural cure--Recrudescence
of the disease--THE TUBERCULOUS ABSCESS--Contents and wall of the
abscess--Tuberculous sinuses.
Tuberculosis occurs more frequently in some situations than in others;
it is common, for example, in lymph glands, in bones and joints, in the
peritoneum, the intestine, the kidney, prostate and testis, and in the
skin and subcutaneous cellular tissue; it is seldom met with in the
breast or in muscles, and it rarely affects the ovary, the pancreas, the
parotid, or the thyreoid.
_Tubercle bacilli_ vary widely in their virulence, and they are more
tenacious of life than the common pyogenic bacteria. In a dry state, for
example, they can retain their vitality for months; and they can also
survive immersion in water for prolonged periods. They resist the action
of the products of putrefaction for a considerable time, and are not
destroyed by digestive processes in the stomach and intestine. They may
be killed in a few minutes by boiling, or by exposure to steam under
pressure, or by immersion for less than a minute in 1 in 20 carbolic
lotion.
#Methods of Infection.#--In marked contrast to what obtains in the
infective diseases that have already been described, tuberculosis rarely
results from the _infection of a wound_. In exceptional instances,
however, this does occur, and in illustration of the fact may be cited
the case of a servant who cut her finger with a broken spittoon
containing the sputum of her consumptive master; the wound subsequently
showed evidence of tuberculous infection, which ultimately spread up
along the lymph vessels of the arm. Pathologists, too, whose hands,
before the days of rubber gloves, were frequently exposed to the contact
of tuberculous tissues and pus, were liable to suffer from a form of
tuberculosis of the skin of the finger, known as _anatomical tubercle_.
Slight wounds of the feet in children who go about barefoot in towns
sometimes become infected with tubercle. Operation wounds made with
instruments contaminated with tuberculous material have also been known
to become infected. It is highly probable that the common form of
tuberculosis of the skin known as "lupus" arises by direct infection
from without.
[Illustration: FIG. 33.--Tubercle Bacilli in caseous material
× 1000 diam. Z. Neilsen stain.]
In the vast majority of cases the tubercle bacillus gains entrance to
the body by way of the mucous surfaces, the organisms being either
inhaled or swallowed; those inhaled are mostly derived from the human
subject, those swallowed, from cattle. Bacilli, whether inhaled or
swallowed, are especially apt to lodge about the pharynx and pass to the
pharyngeal lymphoid tissue and tonsils, and by way of the lymph vessels
to the glands. The glands most frequently infected in this way are the
cervical glands, and those within the cavity of the chest--particularly
the bronchial glands at the root of the lung. From these, infection
extends at any later period in life to the bones, joints, and internal
organs.
There is reason to believe that the organisms may lie in a dormant
condition for an indefinite period in these glands, and only become
active long afterwards, when some depression of the patient's health
produces conditions which favour their growth. When the organisms become
active in this way, the tuberculous tissue undergoes softening and
disintegration, and the infective material, by bursting into an adjacent
vein, may enter the blood-stream, in which it is carried to distant
parts of the body. In this way a _general tuberculosis_ may be set up,
or localised foci of tuberculosis may develop in the tissues in which
the organisms lodge. Many tuberculous patients are to be regarded as
possessing in their bronchial glands, or elsewhere, an internal store of
bacilli, to which the disease for which advice is sought owes its
origin, and from which similar outbreaks of tuberculosis may originate
in the future.
_The alimentary mucous membrane_, especially that of the lower ileum and
cæcum, is exposed to infection by swallowed sputum and by food
materials, such as milk, containing tubercle bacilli. The organisms may
lodge in the mucous membrane and cause tuberculous ulceration, or they
may be carried through the wall of the bowel into the lacteals, along
which they pass to the mesenteric glands where they become arrested and
give rise to tuberculous disease.
#Relationship of Tuberculosis to Trauma.#--Any tissue whose vitality has
been lowered by injury or disease furnishes a favourable nidus for the
lodgment and growth of tubercle bacilli. The injury or disease, however,
is to be looked upon as determining the _localisation_ of the
tuberculous lesion rather than as an essential factor in its causation.
In a person, for example, in whose blood tubercle bacilli are
circulating and reaching every tissue and organ of the body, the
occurrence of tuberculous disease in a particular part may be determined
by the depression of the tissues resulting from an injury of that part.
There can be no doubt that excessive movement and jarring of a limb
aggravates tuberculous disease of a joint; also that an injury may light
up a focus that has been long quiescent, but we do not agree with
those--Da Costa, for example--who maintain that injury may be a
determining cause of tuberculosis. The question is not one of mere
academic interest, but one that may raise important issues in the law
courts.
#Human and Bovine Tuberculosis.#--The frequency of the bovine bacillus
in the abdominal and in the glandular and osseous tuberculous lesions of
children would appear to justify the conclusion that the disease is
transmissible from the ox to the human subject, and that the milk of
tuberculous cows is probably a common vehicle of transmission.
#Changes in the Tissues following upon the successful Lodgment of
Tubercle Bacilli.#--The action of the bacilli on the tissues results in
the formation of granulation tissue comprising characteristic tissue
elements and with a marked tendency to undergo caseation.
The recognition of the characteristic elements, with or without
caseation, is usually sufficient evidence of the tuberculous nature of
any portion of tissue examined for diagnostic purposes. The recognition
of the bacillus itself by appropriate methods of staining makes the
diagnosis a certainty; but as it is by no means easy to identify the
organism in many forms of surgical tuberculosis, it may be necessary to
have recourse to experimental inoculation of susceptible animals such as
guinea-pigs.
The changes subsequent to the formation of tuberculous granulation
tissue are liable to many variations. It must always be borne in mind
that although the bacilli have effected a lodgment and have inaugurated
disease, the relation between them and the tissues remains one of mutual
antagonism; which of them is to gain and keep the upper hand in the
conflict depends on their relative powers of resistance.
If the tissues prevail, there ensues a process of repair. In the
immediate vicinity of the area of infection young connective tissue, and
later, fibrous tissue, is formed. This may replace the tuberculous
tissue and bring about repair--a fibrous cicatrix remaining to mark the
scene of the previous contest. Scars of this nature are frequently
discovered at the apex of the lung after death in persons who have at
one time suffered from pulmonary phthisis. Under other circumstances,
the tuberculous tissue that has undergone caseation, or even
calcification, is only encapsulated by the new fibrous tissue, like a
foreign body. Although this may be regarded as a victory for the
tissues, the cure, if such it may be called, is not necessarily a
permanent one, for at any subsequent period, if the part affected is
disturbed by injury or through some other influence, the encapsulated
tubercle may again become active and get the upper hand of the tissues,
and there results a relapse or recrudescence of the disease. This
_tendency to relapse_ after apparent cure is a notable feature of
tuberculous disease as it is met with in the spine, or in the
hip-joint, and it necessitates a prolonged course of treatment to give
the best chance of a lasting cure.
If, however, at the inauguration of the tuberculous disease the bacilli
prevail, the infection tends to spread into the tissues surrounding
those originally infected, and more and more tuberculous granulation
tissue is formed. Finally the tuberculous tissue breaks down and
liquefies, resulting in the formation of a cold abscess. In their
struggle with the tissues, tubercle bacilli receive considerable support
and assistance from any pyogenic organisms that may be present. A
tuberculous infection may exhibit its aggressive qualities in a more
serious manner by sending off detachments of bacilli, which are carried
by the lymphatics to the nearest glands, or by the blood-stream to more
distant, and it may be to all, parts of the body. When the infection is
thus generalised, the condition is called _general tuberculosis_.
Considering the extraordinary frequency of localised forms of surgical
tuberculosis, general dissemination of the disease is rare.
#The clinical features# of surgical tuberculosis will be described with
the individual tissues and organs, as they vary widely according to the
situation of the lesion.
#The general treatment# consists in combating the adverse influences
that have been mentioned as increasing the liability to tuberculous
infection. Within recent years the value of the "open-air" treatment has
been widely recognised. An open-air life, even in the centre of a city,
may be followed by marked improvement, especially in the hospital class
of patient, whose home surroundings tend to favour the progress of the
disease. The purer air of places away from centres of population is
still better; and, according to the idiosyncrasies of the individual
patient, mountain air or that of the sea coast may be preferred. In view
of the possible discomforts and gastric disturbance which may attend a
sea-voyage, this should be recommended to patients suffering from
tuberculous lesions with more caution than has hitherto been exercised.
The diet must be a liberal one, and should include those articles which
are at the same time easily digested and nourishing, especially proteids
and fats; milk obtained from a reliable source and underdone
butcher-meat are among the best. When the ordinary nourishment taken is
insufficient, it may be supplemented by such articles as malt extract,
stout, and cod-liver oil. The last is specially beneficial in patients
who do not take enough fat in other forms. It is noteworthy that many
tuberculous patients show an aversion to fat.
For _the use of tuberculin in diagnosis_ and for _the vaccine treatment
of tuberculosis_ the reader is referred to text-books on medicine.
In addition to increasing the resisting power of the patient, it is
important to enable the fluids of the body, so altered, to come into
contact with the tuberculous focus. One of the obstacles to this is that
the focus is often surrounded by tissues or fluids which have been
almost entirely deprived of bactericidal substances. In the case of
caseated glands in the neck, for example, it is obvious that the removal
of this inert material is necessary before the tissues can be irrigated
with fluids of high bactericidal value. Again, in tuberculous ascites
the abdominal cavity is filled with a fluid practically devoid of
anti-bacterial substances, so that the bacilli are able to thrive and
work their will on the tissues. When the stagnant fluid is got rid of by
laparotomy, the parts are immediately douched with lymph charged with
protective substances, the bactericidal power of which may be many times
that of the fluid displaced.
It is probable that the beneficial influence of _counter-irritants_,
such as blisters, and exposure to the _Finsen light_ and other forms of
_rays_, is to be attributed in part to the increased flow of blood to
the infected tissues.
_Artificial Hyperæmia._--As has been explained, the induction of
hyperæmia by the method devised by Bier, constitutes one of our most
efficient means of combating bacterial infection. The treatment of
tuberculosis on this plan has been proved by experience to be a valuable
addition to our therapeutic measures, and the simplicity of its
application has led to its being widely adopted in practice. It results
in an increase in the reactive changes around the tuberculous focus, an
increase in the immigration of leucocytes, and infiltration with the
lymphocytes.
The constricting bandage should be applied at some distance above the
seat of infection; for instance, in disease of the wrist, it is put on
above the elbow, and it must not cause pain either where it is applied
or in the diseased part. The bandage is only applied for a few hours
each day, either two hours at a time or twice a day for one hour, and,
while it is on, all dressings are removed save a piece of sterile gauze
over any wound or sinus that may be present. The process of cure takes a
long time--nine or even twelve months in the case of a severe joint
affection.
In cases in which a constricting bandage is inapplicable, for example,
in cold abscesses, tuberculous glands or tendon sheaths, Klapp's suction
bell is employed. The cup is applied for five minutes at a time and then
taken off for three minutes, and this is repeated over a period of
about three-quarters of an hour. The pus is allowed to escape by a small
incision, and no packing or drain should be introduced.
It has been found that tuberculous lesions tend to undergo cure
when the infected tissues are exposed to the rays of the
sun--_heliotherapy_--therefore whenever practicable this therapeutic
measure should be had recourse to.
Since the introduction of the methods of treatment described above, and
especially by their employment at an early stage in the disease, the
number of cases of tuberculosis requiring operative interference has
greatly diminished. There are still circumstances, however, in which an
operation is required; for example, in disease of the lymph glands for
the removal of inert masses of caseous material, in disease of bone for
the removal of sequestra, or in disease of joints to improve the
function of the limb. It is to be understood, however, that operative
treatment must always be preceded by and combined with other therapeutic
measures.
TUBERCULOUS ABSCESS
The caseation of tuberculous granulation tissue and its liquefaction is
a slow and insidious process, and is unattended with the classical signs
of inflammation--hence the terms "cold" and "chronic" applied to the
tuberculous abscess.
In a cold abscess, such as that which results from tuberculous disease
of the vertebræ, the clinical appearances are those of a soft, fluid
swelling without heat, redness, pain, or fever. When toxic symptoms are
present, they are usually due to a mixed infection.
A tuberculous abscess results from the disintegration and liquefaction
of tuberculous granulation tissue which has undergone caseation. Fluid
and cells from the adjacent blood vessels exude into the cavity, and
lead to variations in the character of its contents. In some cases the
contents consist of a clear amber-coloured fluid, in which are suspended
fragments of caseated tissue; in others, of a white material like
cream-cheese. From the addition of a sufficient number of leucocytes,
the contents may resemble the pus of an ordinary abscess.
The wall of the abscess is lined with tuberculous granulation tissue,
the inner layers of which are undergoing caseation and disintegration,
and present a shreddy appearance; the outer layers consist of
tuberculous tissue which has not yet undergone caseation. The abscess
tends to increase in size by progressive liquefaction of the inner
layers, caseation of the outer layers, and the further invasion of the
surrounding tissues by tubercle bacilli. In this way a tuberculous
abscess is capable of indefinite extension and increase in size until it
reaches a free surface and ruptures externally. The direction in which
it spreads is influenced by the anatomical arrangement of the tissues,
and possibly to some extent by gravity, and the abscess may reach the
surface at a considerable distance from its seat of origin. The best
illustration of this is seen in the psoas abscess, which may originate
in the dorsal vertebræ, extend downwards within the sheath of the psoas
muscle, and finally appear in the thigh.
#Clinical Features.#--The insidious development of the tuberculous
abscess is one of its characteristic features. The swelling may attain a
considerable size without the patient being aware of its existence, and,
as a matter of fact, it is often discovered accidentally. The absence of
toxæmia is to be associated with the incapacity of the wall of the
abscess to permit of absorption; this is shown also by the fact that
when even a large quantity of iodoform is inserted into the cavity of
the abscess, there are no symptoms of poisoning. The abscess varies in
size from a small cherry to a cavity containing several pints of pus.
Its shape also varies; it is usually that of a flattened sphere, but it
may present pockets or burrows running in various directions. Sometimes
it is hour-glass or dumb-bell shaped, as is well illustrated in the
region of the groin in disease of the spine or pelvis, where there may
be a large sac occupying the venter ilii, and a smaller one in the
thigh, the two communicating by a narrow channel under Poupart's
ligament. By pressing with the fingers the pus may be displaced from one
compartment to the other. The usual course of events is that the abscess
progresses slowly, and finally reaches a free surface--generally the
skin. As it does so there may be some pain, redness, and local elevation
of temperature. Fluctuation becomes evident and superficial, and the
skin becomes livid and finally gives way. If the case is left to nature,
the discharge of pus continues, and the track opening on the skin
remains as a _sinus_. The persistence of suppuration is due to the
presence in the wall of the abscess and of the sinus, of tuberculous
granulation tissue, which, so long as it remains, continues to furnish
discharge, and so prevents healing. Sooner or later pyogenic organisms
gain access to the sinus, and through it to the wall of the abscess.
They tend further to depress the resisting power of the tissues, and
thereby aggravate and perpetuate the tuberculous disease. This
superadded infection with pyogenic organisms exposes the patient to the
further risks of septic intoxication, especially in the form of hectic
fever and septicæmia, and increases the liability to general
tuberculosis, and to waxy degeneration of the internal organs. The mixed
infection is chiefly responsible for the pyrexia, sweating, and
emaciation which the laity associate with consumptive disease. A
tuberculous abscess may in one or other of these ways be a cause of
death.
_Residual abscess_ is the name given to an abscess that makes its
appearance months, or even years, after the apparent cure of tuberculous
disease--as, for example, in the hip-joint or spine. It is called
residual because it has its origin in the remains of the original
disease.
[Illustration: FIG. 34.--Tuberculous Abscess in right lumbar region in a
woman aged thirty.]
#Diagnosis.#--A cold abscess is to be diagnosed from a syphilitic gumma,
a cyst, and from lipoma and other soft tumours. The differential
diagnosis of these affections will be considered later; it is often made
easier by recognising the presence of a lesion that is likely to cause a
cold abscess, such as tuberculous disease of the spine or of the
sacro-iliac joint. When it is about to burst externally, it may be
difficult to distinguish a tuberculous abscess from one due to infection
with pyogenic organisms. Even when the abscess is opened, the
appearances of the pus may not supply the desired information, and it
may be necessary to submit it to bacteriological examination. When the
pus is found to be sterile, it is usually safe to assume that the
condition is tuberculous, as in other forms of suppuration the causative
organisms can usually be recognised. Experimental inoculation will
establish a definite diagnosis, but it implies a delay of two to three
weeks.
#Treatment.#--The tuberculous abscess may recede and disappear under
general treatment. Many surgeons advise that so long as the abscess is
quiescent it should be left alone. All agree, however, that if it shows
a tendency to spread, to increase in size, or to approach the skin or a
mucous membrane, something should be done to avoid the danger of its
bursting and becoming infected with pyogenic organisms. Simple
evacuation of the abscess by a hollow needle may suffice, or bismuth or
iodoform may be introduced after withdrawal of the contents.
_Evacuation of the Abscess and Injection of Iodoform._--The iodoform is
employed in the form of a 10 per cent. solution in ether or the same
proportion suspended in glycerin. Either form becomes sterile soon after
it is prepared. Its curative effects would appear to depend upon the
liberation of iodine, which restrains the activity of the bacilli, and
upon its capacity for irritating the tissues and so inducing a
protective leucocytosis, and also of stimulating the formation of scar
tissue. An anæsthetic is rarely called for, except in children. The
abscess is first evacuated by means of a large trocar and cannula
introduced obliquely through the overlying soft parts, avoiding any part
where the skin is thin or red. If the cannula becomes blocked with
caseous material, it may be cleared with a probe, or a small quantity of
saline solution is forced in by the syringe. The iodoform is injected by
means of a glass-barrelled syringe, which is firmly screwed on to the
cannula. The amount injected varies with the size of the abscess and the
age of the patient; it may be said to range from two or three drams in
the case of children to several ounces in large abscesses in adults. The
cannula is withdrawn, the puncture is closed by a Michel's clip, and a
dressing applied so as to exert a certain amount of compression. If the
abscess fills up again, the procedure should be repeated; in doing so,
the contents show the coloration due to liberated iodine. When the
contents are semi-solid, and cannot be withdrawn even through a large
cannula, an incision must be made, and, after the cavity has been
emptied, the iodoform is introduced through a short rubber tube attached
to the syringe. Experience has shown that even large abscesses, such as
those associated with spinal disease, may be cured by iodoform
injection, and this even when rupture of the abscess on the skin surface
has appeared to be imminent.
Another method of treatment which is less popular now than it used to
be, and which is chiefly applicable in abscesses of moderate size, is by
_incision of the abscess and removal of the tuberculous tissue in its
wall_ with the sharp spoon. An incision is made which will give free
access to the interior of the abscess, so that outlying pockets or
recesses may not be overlooked. After removal of the pus, the wall of
the abscess is scraped with the Volkmann spoon or with Barker's flushing
spoon, to get rid of the tuberculous tissue with which it is lined. In
using the spoon, care must be taken that its sharp edge does not
perforate the wall of a vein or other important structure. Any debris
which may adhere to the walls is removed by rubbing with dry gauze. The
oozing of blood is arrested by packing the cavity for a few minutes with
gauze. After the packing is removed, iodoform powder is rubbed into the
raw surface. The soft parts divided by the incision are sutured in
layers so as to ensure primary union. If, on the other hand, there is
fear of a mixed infection, especially in abscesses near the rectum or
anus, it is safer to treat it by the open method, packing the cavity
with iodoform worsted or bismuth gauze, which is renewed at intervals of
a week or ten days as the cavity heals from the bottom.
Another method is to incise the abscess, cleanse the cavity with gauze,
irrigate with Carrel-Dakin solution and pack with gauze smeared with the
dilute non-toxic B.I.P.P. (bismuth and iodoform 2 parts, vaseline 12
parts, hard paraffin, sufficient to give the consistence of butter). The
wound is closed with "bipped" silk sutures; one of these--the "waiting
suture"--is left loose to permit of withdrawal of the gauze after
forty-eight hours; the waiting suture is then tied, and delayed primary
union is thus effected.
When the skin over the abscess is red, thin, and about to give way, as
is frequently the case when the abscess is situated in the subcutaneous
cellular tissue, any skin which is undermined and infected with tubercle
should be removed with the scissors at the same time that the abscess is
dealt with.
In abscesses treated by the open method, when the cavity has become
lined with healthy granulations, it may be closed by secondary suture,
or, if the granulating surface is flush with the skin, healing may be
hastened by skin-grafting.
If the tuberculous abscess has burst and left a _sinus_, this is apt to
persist because of the presence of tuberculous tissue in its wall, and
of superadded pyogenic infection, or because it serves as an avenue for
the escape of discharge from a focus of tubercle in a bone or a lymph
gland.
[Illustration: FIG. 35.--Tuberculous Sinus injected through its opening
in the forearm with bismuth paste.
(Mr. Pirie Watson's case--Radiogram by Dr. Hope Fowler.)]
The treatment varies with the conditions present, and must include
measures directed to the lesion from which the sinus has originated. The
extent and direction of any given sinus may be demonstrated by the use
of the probe, or, more accurately, by injecting the sinus with a paste
consisting of white vaseline containing 10 to 30 per cent. of bismuth
subcarbonate, and following its track with the X-rays (Fig. 35).
It was found by Beck of Chicago that the injection of bismuth paste is
frequently followed by healing of the sinus, and that, if one injection
fails to bring about a cure, repeating the injection every second day
may be successful. Some caution must be observed in this treatment, as
symptoms of poisoning have been observed to follow its use. If they
manifest themselves, an injection of warm olive oil should be given; the
oil, left in for twelve hours or so, forms an emulsion with the bismuth,
which can be withdrawn by aspiration. Iodoform suspended in glycerin may
be employed in a similar manner. When these and other non-operative
measures fail, and the whole track of the sinus is accessible, it should
be laid open, scraped, and packed with bismuth or iodoform gauze until
it heals from the bottom.
The _tuberculous ulcer_ is described in the chapter on ulcers.