180 CLINICAL FORMS OF SURGICAL TUBERCULOSIS. 



fifty-one years of age, who had given birth to two children, their 

 father being the subject of advanced tuberculosis, and both of 

 whom died of tuberculosis. She had been in perfect health until 

 her forty-ninth year, when she was attacked simultaneously with 

 pulmonary and glandular tuberculosis. In 128 of the reported cases 

 the glands were extirpated, some of the operations being quite seri- 

 ous; in 16 cases the internal jugular vein had to be tied. In 91 of 

 the operations the wound healed by primary union, and in 25 the 

 healing was retarded by suppuration. Erysipelas complicated the 

 result five times. In one of these cases a large part of the tubercu- 

 lous mass was left, and it was noticed that the erysipelas had no 

 effect on the tubercular process. Only in 49 of the cases operated 

 on could the final result be obtained. Taking three and a half 

 years as the time when the patient could be considered exempt from 

 a recurrence of the disease, it was ascertained that in 24 per cent, 

 no relapse followed the operation ; a local relapse was observed in 

 14 per cent., and reappearance of the disease distant from the seat 

 of operation in 4 per cent. 



As lymphatic tuberculosis, in most instances, signifies the entrance 

 of bacilli through a loss of continuity of the skin or of the mucous 

 membrane, or through the socket of a carious tooth, localization 

 occurring in one of the nearest glands to the portio invasionis, it 

 must be looked upon as a local process, and amenable to timely 

 surgical treatment by the removal of all of the infected tissues. 

 The capsule of the lymphatic glands furnishes an efficient barrier 

 against infection of the para-glandular tissue for a long time, and 

 perforation only takes place after the disease has made considerable 

 progress, and has been followed by extensive caseation, and espe- 

 cially by suppuration. Early operations are as necessary in the 

 treatment of tubercular adenitis as in the treatment of malignant 

 tumors, and holds out more encouragement so far as a permanent 

 cure is concerned. By a thorough removal of the primary focus 

 of infection, successive infiltration of proximal glands and miliary 

 tuberculosis are prevented almost to a certainty if the operation is 

 performed before the para-glandular tissues are affected. If the 

 operation is done at such a favorable time, it is not attended by any 

 great difficulties, as the glands can be readily enucleated, and as 

 suppuration has not taken place the wound usually heals by primary 

 union. If, however, the tubercular inflammation has involved 

 many glands, and has extended to the connective tissue surround- 

 ing the glands, the operation becomes one of the most formidable 

 in surgery on account of the close proximity of important vessels 

 which are often imbedded in the mass. Under such circumstances 

 a complete removal is often impossible and early local recidivation 

 is inevitable, owing to imperfect removal of the infected area. 



