TUBEECULOSIS. 449 



Now the discovery of miliary nodules upon all the ramifications 

 of the afferent vessels makes it clear that tuberculosis belongs to 

 this category ; hence too, we see why it extends across, and not 

 along the bowel. 



§ 388. As regards the further consequences of tuberculous 

 ulceration of the bowels, I need only say that hsemorrhage and 

 perforation may occur, just as in abdominal typhus. The tuber- 

 culous infiltration of the vascular wall on the one hand, and of 

 the serous membrane on the other, and the necrobiotic detach- 

 ment of the infiltrated part, necessarily lead to perforation, now 

 into the blood- channel, now into the peritoneal sac. In either 

 case, however, this accident presupposes the absence of those 

 natural safeguards which usually ward off any such extreme 

 issues ; in the former instance, timely coagulation of the blood 

 in the endangered vessel, in the latter, timely adhesion of the 

 serous coat to some other part of the peritoneal surface. I have 

 seen a case in which five tuberculous ulcers of the ileum had 

 perforated, not however into the peritoneal sac, but into other 

 divisions of the bowel, which had previously become adherent 

 opposite the seat of ulceration. This, of course, put a stop to 

 all peristalsis, the products of digestion circulating without any 

 order through numerous false passages in the abdominal cavity, 

 inasmuch as the fistulous communications were in some cases 

 wider than the calibre of the intestinal tube itself. 



§ 389. Passing now to tuberculosis of the laeyngeal and 

 BRONCHIAL mucous membranes, we enter on a debatable 

 ground, where it becomes extremely difficult to ascertain how 

 much of the morbid process is really tuberculous. Virchow 

 does not scruple to assert that " tuberculous " ulcers of the 

 larynx actually originate from miliary tubercles ; he assigns 

 their production, and extension both in breadth and depth, to 

 a process identical with that which we learnt to know in con- 

 nexion with tuberculous ulceration of the mucous lining of the 

 urogenital tract. Other observers, as e.g. Ri/hle, utterly deny the 

 presence or participation of miliary granulations in the process ; 

 indeed Virchoiv is at the pains to explain, that miliary nodules 

 are so rarely to be detected in these " tuberculous " ulcers, 

 because they are here especially frail and perishable: this 

 explanation is equivalent to an admission that they are very 

 seldom to be seen. 



39 



