# Manual of Surgery/Chapter VIII

CHAPTER VIII
TUBERCULOSIS
Tubercle bacillus--Methods of infection--Inherited and acquired
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.
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 x 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 caecum, 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.
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.
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.
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 individual tissues and organs, as they vary widely according to the situation of the lesion.
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 Hyperaemia._--As has been explained, the induction of hyperaemia 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 vertebrae, 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 vertebrae, extend downwards within the sheath of the psoas muscle, and finally appear in the thigh.
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 toxaemia 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 septicaemia, 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.]
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.
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 anaesthetic 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.