Surgical tuberculosis appears often as a sequel of the exanthemas. In the lymphatics, periosteum, bones, and joint cavities, and in and about the eye and ear, manifestations of suppurative disease are often found. It is believed that these sequels are likely to appear when the eruption has been incomplete. Hyperplastic thickening of periosteum and neuralgic pains of the affected parts occur without suppuration, hence the rheumatic character which Bonnet and others have wrongly ascribed to these manifestations.
While the absence of pus takes these out of the category of pyogenic infections, it nevertheless leaves them still as surgical complications which have often to be dealt with by mechanical measures, such as orthopedic apparatus, etc.; while more or less formidable operations, as for relief of ankylosis, have to be performed. Postscarlatinal arthralgia may be explained as a local ischemia; so may acute swelling or chronic thickening. But pus is an expression of infection, and cannot be otherwise regarded. Retropharyngeal abscesses and a peculiar necrosis of the alveolar process of the jaws, described by Salter, are among the various serious surgical complications of scarlatina. Epiphyseal separations and purulent destruction of ribs have also been noted.
TYPHOID FEVER.
Although in elaborate treatises, as by Liebermeister and Murchison, there is no mention of bone and joint complications as sequels of typhoid, they have, nevertheless, been recognized by surgeons. Post-typhoid hip dislocations have been reported by several German surgeons. Boyer observed spontaneous dislocation of both thighs after what he called “essential fever,” and the general topic of spontaneous luxations subsequent to typhoid has been frequently discussed.
Those affections of joints formerly considered rheumatic occur much less often after typhoid than after dysentery. Nevertheless, post-typhoidal arthralgia and myodynia have been recognized by several French writers. Some with affected joints, supposed to be rheumatic, have later been discovered to be suffering from genuine typhoid fever, and it has been afterward recognized that the joint lesion was a bizarre expression of the typhoid poisoning. The works on general practice call attention to the frequent complications of the pleural and pericardial serous membranes in this disease. They say little, however, about the implications of the articular serous membranes, though one is as easy to explain as the other. Post-typhoidal polyarticular serous arthritis has been described by more than one writer. Multiple joint abscesses have been rarely seen. Pus has been known to collect not only in the joints, but also in the tendon sheaths and bursæ. The lymph nodes are also frequently affected, and cervical, axillary, and inguinal abscesses are not rare. Post-typhoidal pyarthrosis, as leading to spontaneous luxation, has had a medicolegal interest, for luxation has been known to occur while raising or lifting a patient, the question of violence being subsequently brought into court. When the joint disease assumes the mono-articular form it is likely to terminate in suppuration; when polyarticular, pyarthrosis is less common. In the pus from many of these abscesses typhoid bacilli may be recognized, but by no means in all. The writer has found them in a case of abscess in the abdominal wall occurring during convalescence from typhoid in a young woman. A non-suppurative but painful form of periostitis is occasionally observed. I have never seen more exquisite tenderness nor expressions of suffering than I met in a case of this kind in a boy in whom the bones of both lower extremities, of the pelvis, and the lower spine were involved. The slightest jar upon the floor would make him exclaim with pain, and to minister to his ordinary wants was a distressing task. He eventually recovered without any pus formation. Deep suppuration in bones occasionally occurs, and even necrosis with separation of sequestra.
Thrombosis and thrombophlebitis are also well-known sequels of typhoid, which may lead to unpleasant complications. Typhoid fever appears to bear a peculiar relation to the growth of bones, as it has been noticed that during its course, or during convalescence, they show an extraordinarily rapid growth in length, even to the extent of 1 Mm. a day. This is probably caused by the irritation of the typhoid toxin upon the osteogenic tissue, since hyperemic areas have been found in the bone-marrow of those dying of the disease, and bone pains are a frequent accompaniment of the disease. Typhoid bacilli have the power of remaining latent in the tissues for a long time after cessation of active symptoms, and have been found alive and capable of active growth seven months after cessation of the fever. Remembering the multiple ulcers of the lymphoid tissue which characterize the intestinal lesions of typhoid, it is difficult to explain pyogenic or other septic infection by absorption through these open ports of entry; and the typhoid bacilli themselves, entering the circulation through these paths, may be carried to all parts of the body, and have been found in the pia.
A large amount of interest has attached to the so-called “surgery of typhoid fever,” which, however, has been permitted to include only abdominal section for perforation of intestinal ulcers. The mortality due to this accident is nearly 70 per cent.—i. e., is formidable. It occurs generally during the third week. It is usually preceded by leukocytosis, and is followed by profound shock. Operation offers almost the only hope. It has been successful in about one out of five cases. (See [Surgery of the Intestines].)
Post-typhoidal infections of the biliary and pancreatic ducts, with their resulting complications, play a conspicuous part in the etiology of biliary obstruction. They are regarded as among the most common causes of acute and chronic or latent disease in these passages.
DIPHTHERIA.
This also belongs to the diseases frequently complicated by lesions, aside from those of laryngeal obstruction calling for surgical relief. Abscess occurs so frequently as to scarcely call for comment. Here, as in the cases of scarlatina, the location of the throat lesions and the absorbing powers of the lymphadenoid tissue so completely involved will readily account for all septic or pyogenic manifestations at a distance. Multiple abscesses have been found in the liver, the spleen, and lungs, in and around bones, betokening thereby a pyemic manifestation. Infectious nephritis is also common.