178 CLINICAL FORMS OF SURGICAL TUBERCULOSIS. 



which it can be constantly found, while it is absent in the central 

 mass, or, at least, only an isolated rod can be found here and there 

 on patient, careful search. In all probability the death of the 

 granulation tissue which precedes caseation is caused by the action 

 of the ptomaines of the bacilli of tuberculosis, which by their toxic 

 properties destroy the protoplasm and arrest further cell-growth in 

 that portion of the gland as well as reproduction of the micro- 

 organisms. When a true suppuration takes place in a tubercular 

 lymphatic gland, it does so in consequence of a secondary infection 

 with pyogenic microorganisms. A spontaneous and permanent cure 

 is not infrequently effected by the substitution of an acute suppura- 

 tive process in place of the primary specific chronic inflammation, 

 which destroys the entire soil of the bacillus of tuberculosis, and, 

 at the same time, effects complete elimination of the pus-microbes 

 and the bacilli through the discharges of the abscess. The capsule 

 of the gland furnishes an efficient protection wall to the para- 

 glandular tissues against tubercular infection often for months and 

 years, but when perforation has once taken place the disease attacks 

 the surrounding tissues irrespective of their anatomical structure. 

 When a tubercular gland becomes the seat of an acute suppuration, 

 the suppurative inflammation appears in the form of a para-adenitis 

 with suppuration between the gland and the surrounding tissues, 

 which often terminates in extensive separation of the gland from 

 the adjacent tissues. While tuberculosis of the lymphatic glands 

 often stands in a direct causative relationship to, and precedes gen- 

 eral, diffuse, and pulmonary tuberculosis, it is seldom observed as 

 a secondary affection in the course of tuberculous affections of other 

 organs. Tuberculosis of the lymphatic glands is an affection usually 

 noted for its chronicity, often remaining stationary for many years. 

 I have repeatedly seen patients forty to fifty years of age who 

 during childhood had suffered from enlarged cervical glands, which 

 eventually diminished in size, but did not disappear, which, after 

 years, again became the seat of an active tubercular process. In 

 exceptional cases this affection pursues an acute course. Delafield 

 reports an exceedingly interesting case of this kind (Medical Record, 

 vol. i. p. 425, 1885). The disease commenced with an enlargement 

 of one of the cervical glands near the angle of the lower jaw with 

 a temperature of 40 C. (104 F.) and rapid extension to the 

 proximal glands as far as the clavicle. Symptoms of pulmonary 

 complication were not present. Rapid emaciation and marked 

 anaemia supervened, followed after six weeks by swelling of axillary 

 and inguinal glands. Ophthalmic examination revealed the same 

 conditions of retina and papilla as in leukemia or Bright' s disease. 

 A few days after the beginning of the disease profuse diarrhoea 

 and reduction to nearly normal temperature occurred. The diag- 



