186 CLINICAL FORMS OF SURGICAL TUBERCULOSIS. 



joints, and he believes that the generalization of the process was 

 favored, if not directly produced, by the operation. It is not diffi- 

 cult to conceive the modus operandi of such an occurrence. The 

 resection wound opens numerous veins in the bone, the lumina of 

 which remain patent ready for the introduction of minute frag- 

 ments of granulation tissue or bacilli, which, on entering the venous 

 circulation, are the direct cause of metastatic tuberculosis in distant 

 organs. 



Wartraann (Deutsche Zeitschrift f. Chirurgie, B. xxiv. Hefte 5, 6), 

 after giving a careful account of the results following excision of 

 tuberculous joints in the hospital practice of Feurer, has collected 

 from the practice of different operators 837 cases of excisions for 

 tuberculosis. Of this number, 225 died. Of the fatal cases, in 

 26 death followed the operation closely, and resulted from acute 

 tuberculosis, probably induced by the operation. In these cases we 

 must take it for granted that a tubercular focus during the opera- 

 tion furnished the essential fragments of granulation tissue, or free 

 bacilli which were aspirated, or forced into the openings of wounded 

 vessels, and through them into the general circulation. That fungous 

 synovitis is a genuine tuberculosis has been abundantly illustrated 

 by clinical experience, microscopical examinations, and particularly 

 the results obtained by implantation experiments in animals. I 

 will only refer to the work of Tavel (Senn : Four Months among 

 the Surgeons of Europe, 1887, Chicago, p. 154) in this connection, 

 who has been studying in a systematic manner the diagnostic value 

 of implantation of tubercular material in animals, mainly guinea- 

 pigs. Granulation tissue from tubercular joints in his experiments 

 on guinea-pigs invariably produced acute, diffuse tuberculosis, and 

 death in from five to six weeks. The course of the disease in the 

 animal is typical ; at the point of inoculation a hard nodule appears 

 first, the result of a traumatic inflammation of the tissues around 

 the graft. Next a lymphatic gland becomes enlarged in the imme- 

 diate vicinity of the . primary seat of infection, which is always 

 done in the flank, consequently the inguinal glands enlarge first. 

 Glandular infection increases rapidly ; after the whole chain of 

 lymphatic glands in the groin are involved, the axillary glands 

 become affected. At the post-mortem examination it was always 

 found that of the internal organs the spleen becomes affected first, 

 then the liver and lungs, but usually the disease is so diffuse that 

 scarcely an organ remains exempt. When the diagnosis between 

 syphilis and tuberculosis cannot be made, either clinically, or by aid 

 of the microscope, inoculation experiments always give positive and 

 reliable information. When the lesion is tubercular the animal 

 always becomes tubercular and dies. When it is syphilitic, the 

 inoculation is harmless, and the animal remains well. So far, only 



