THE PREVENTION OF SURGICAL TUBERCULOSIS. WILLIAM KEILLER, F. R. C. S. (ED.), M. D., The forms of tuberculosis which most frequently come under the care of the surgeon are tuberculosis of the lymphatic glands of the neck, of the bones, joints, kidneys, and peritoneum. More rarely he has to deal with the tubercular testicle, prostate, vesicula seminales, or uterus and its adnexa. The anatomical relations of these organs suggests strongly that the channels by which invasion takes place must be the lymphatics directly in the case of the lymph glands; while bacilli could scarcely be conveyed to kidneys, bones, joints or testicles except through the blood vessels. The bladder, prostate, and seminal vesicles are usually infected secondarily to kidney or testicle, and disease of these organs may be left out of consideration in the study of the prevention of surgical tuberculosis. In discussing this question, I shall regard bovine tuberculosis as capable of producing true tuberculosis in man. It is to be regretted that Prof. Koch's magnificent work has again been shadowed by a premature announcement; but his statement that bovine tuberculosis cannot be transmitted to man has only stimulated other investigators to bring forward fresh proof that he is in error. Ravenel's experiments on guinea pigs and swine, his reported cases of tuberculosis of the skin due to bovine infection; Sim's Woodhead's magnificent work, and cases of veterinarians other than Ravenel's cases who have been infected with tuberculosis while making post-mortem examinations of tuberculous cattle, all prove the identity of bovine and human tuberculosis. Newsholme, in his annual report of 1900 for Brighton, England (a health resort for tuberculous patients), says: "After making the fullest allowance for errors in diagnosis, the following remarkable and suggestive facts are noteworthy: (a) The death rate from tabes mesenterica has remained stationary, while that from other forms of tuberculous disease has greatly declined. (b) The chief incidence of death from tabes mesenterica is among infants in the first two years of life, these being the years in which uncooked milk forms the chief item of the child's food. The same fact may be expressed in another form, thus: While only 3.6 per cent. of the deaths from tuberculosis of the lungs occur in children under five years of age, 78.2 per cent of the deaths from tuberculosis of the bowels occur at these ages. It is impossible to dissever these statistics from the firm belief that while tuberculosis of the lungs is usually due to direct inhalation of infective dust, tuberculosis of the bowels is frequently caused by the drinking of the milk from tuberculous cows." In a large proportion of cases of tabes mesenterica, or tuberculosis of the mesenteric lymph glands in children, the intestinal mucosa is not attacked by the bacilli, proving conclusively that these organisms may reach the lymph stream, and therefore the blood stream, from the intestine without any local manifestation of the disease. So too it seems proven that bacilli may pass through the lymph glands and thus reach the blood stream without causing any lesion of the glands. Even in the most extensive pulmonary tuberculosis, one seldom finds apparent tubercular lesions of the bronchial glands, at least in adults, though occasional calcareous nodules are found in them; yet large numbers of bacilli must pass through these glands in all cases of pulmonary consumption. In many cases, too, apparently normal bronchial lymph glands have been found to contain virulent bacilli, and that too in the absence of any pulmonary lesion. Thus many bacilli may reach the circulation through the pulmonary mucosa without producing any local lesion. It is reasonable, therefore, to conclude that the digestive and respiratory tracts are great portals through which tubercle bacilli may invade the blood stream. Whether they are destroyed or find a nidus in some organ or organs and there develop, will depend on the number and virulence of the bacilli, and the resistance of the host. In thinking of tuberculosis of the cervical lymphatic glands, one observes that the jugular glands are most often affected, and the relation of these glands to the extensive ring of lymphoid tis sue which surrounds the naso-pharynx and fauces is strongly suggestive that the tonsils must play an important rôle as a possible source of infection in tubercular, and probably other germ diseases. The abundant adenoid crypts on the dorsum of the tongue forming the lingual tonsil, the deep excavation in the faucial tonsils, the extensive lymphoid tissue of the naso-pharynx, the liability of the faucial and naso-pharyngeal tonsils to repeated attacks of inflammation especially in young people, and the frequency of swelling and tenderness of the glands at the angles of the mandible as a complication of these attacks, are facts which draw attention very forcibly to the pharyngeal ring of lymphoid follicles as a probable portal through which tubercular invasion may take place. The rôle of staphylococci, streptococci, pneumococci, and other virulent organisms in the commoner inflammations of the nose and throat, can only be fully appreciated by the habit of making cultures from these ordinary cases as they are met with in office practice. Tubercle bacilli are very frequently found in the tonsils, though tonsillar tuberculosis is not very common. Altogether it seems more than probable that the tonsils are frequently the source of cervical tuberculous lymphadenitis. One other consideration must be kept in mind when one considers tuberculosis from the standpoint of prophylaxis, namely, the amount of local and general resistance to the disease, the influences which diminish resistance and the means to increase it. It seems to be established beyond doubt that certain individuals afford a more favorable soil for the growth of the bacilli than others, and that this suitability of soil is hereditary. Further, any lowering of the general tone, as by overwork, worry, continued confinement indoors in a vitiated atmosphere, insufficient or improper food, and the depreciated health attending convalescence from other diseases, especially pneumonia, typhoid, smallpox, measles, will render susceptible those normally resistant. As regards local resistance, while tubercle bacilli can apparently penetrate normal mucous membrane, it seems probable that catarrhal conditions of the respiratory or digestive mucosa favor their entrance. Further, such conditions induce secondary inflammatory disturbances of the corresponding lymph nodes, and lym phatic glands which have been subject to frequent inflammation, as the cervical glands in children suffering from frequent sore throat or carious teeth, are deemed more liable to tubercular invasion than healthy glands. The influence of sprains and other joint traumata in predisposing to bone and joint tuberculosis is at best. problematical. Keeping these points before us, let us now consider prophylaxis. No bacilli, no tuberculosis; hence every tubercular patient is a menace to the community, and especially to his own family. I need not again insist on early diagnosis, straightforward dealing by the physician with every consumptive patient, and the constant insistance on the necessity of efficient measures to destroy all tubercular sputum. Again, if the people could only be taught how houses are infected by tubercular tenants, registration and thorough house disinfection would soon be required by law. Above all things, educate the people. And here let me say that one of the most unsanitary things ever invented is fibre floor matting in every form. Nothing can possibly be worse than floor matting that can not be taken up and beaten clean, out of doors. A house in which a tubercular patient lives should have no form of floor covering that can not be taken up and cleaned out of doors daily, or at least weekly, and for the sweeping of rugs the rotary floor sweeper that makes no dust is infinitely safer than any form of broom. No matter how careful one is of sputum, it should be remembered every time a phthisical patient coughs he sends a shower of tubercle laden spray over everything in his neighborhood. A phthisical servant is an ever present menace to a household. Next in importance to destruction of sputum is regulation of the milk supply. No city dairy whose cows are not tested by the tuberculin test can be trusted to supply uninfected milk. In Europe, from 6 per cent to 80 per cent. of dairy cows tested in different cities proved tubercular. In America, Jersey and Guernsey are especially subject to tuberculosis. Cross bred cows are more resist Certain pastures and dairies are undoubtedly infected. It follows that those who own their own cows should have them tested for tuberculosis before accepting them as a suitable source of the family milk supply, especially where there are children; and where the cows can not be controlled, the milk for the children should be pasteurized at 60 deg. centigrade in a closed vessel, a temperature which kills tubercle bacilli in twenty minutes and does not lessen the digestibility of the milk. Prophylaxis in the individual is above all things necessary where there is a history of hereditary tendency to tuberculosis. It is especially necessary in children and young people. First of all comes general hygiene. Provided the patient react properly and does not get chilly after it, systematic cold bathing, summer and winter, by its tonic action on the vasomotor system, is perhaps the most effective means of increasing the resistance to common colds which we possess. It is equally suitable for both sexes. The morning bath should be followed by five or ten minutes carefully regulated calisthenic exercises so directed as to fully inflate the chest and exercise every joint and muscle in the body. This should be taken in the bedroom immediately before or after the bath, and elaborate apparatus is unnecessary. Good food, unlimited fresh air, regular open-air exercise, abundant sunshine, are all invaluable. The bedroom, and especially the nursery, should be the best, sunniest, airiest rooms in the house. We spend eight or nine hours daily in our bedrooms, at least one-third of our whole lives, only a short time in the other rooms. Night and day, winter and summer, fresh air and sunshine are necessary in these rooms, and bedroom windows should be open summer and winter. In winter sleep in double flannels if you like, but sleep with your windows open; and no matter how furniture and carpets suffer, sunshine should be admitted freely to every living room. Next to general hygiene, attention should be given to nose, throat and teeth. My old surgical teacher used to say the mouth was the dirtiest place in the body. Americans, as a nation, are careful of their teeth; those of suspected tubercular tendencies should be doubly so. Teeth, tonsils, naso-pharynx, are all liable to infection, causing repeated inflammation of cervical lymph glands. Systematic cleansing of the teeth at night is really much more important than in the morning. There is no reason why the quiescence of eight hours sleep should give the germs eight hours clear head |