Fig. 20
Tuberculosis of cervical lymph nodes.
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, 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 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.
Fig. 21