Tuberculosis of the Lymph Glands.
Synonyms.—Scrofula; Struma; King's Evil.
For more than two thousand years inflammation of the lymphatic glands has been recognized under the head of scrofula, and, even at the present day, there are those who, while acknowledging a very near relation, are not quite ready to admit their identity. Certain it is, that tuberculosis of the lymph glands is of a much milder and less infectious character.
It took the name King's Evil from the prevalent idea that the touch of a king was curative. That enlarged glands were far more common two centuries ago than now, may be inferred from the number touched by Charles II. During twelve years of his reign (1702-1714), he is said to have touched ninety-two thousand, one hundred and seven persons, and as the methods of travel were primitive, these thousands were in all probability in the near-by districts.
The investigations during the past twenty-five years, however, have changed all this, and the medical profession now recognizes scrofula as a form or variety of tuberculosis.
Etiology.—Anything that tends to lower the vitality of the lymph tissue is a predisposing cause. Poverty and environment are fruitful causal conditions, and tuberculosis of the lymph glands is much more common among the extreme poor than the well-to-do.
Age.—While this form may occur at any age, it is exceedingly rare after middle life, the greatest number of cases occurring among children.
Race.—The negro is peculiarly susceptible.
Catarrhal conditions of the mucous membranes render the patient far more susceptible than those otherwise affected. The germs lodge upon the mucous membranes in naso-pharyngitis, and readily find their way into the lymph channels, and are carried to the near-by glands. Tonsillitis, for the same reason, may be the forerunner of tubercular adenitis.
Eczema may furnish a rich soil for the reception of the germ, which in turn finds its way into the lymph current, and the glands receive the force of the poison.
Clinical Forms.—The various phases of this variety may be grouped under two heads: generalized tubercular lymphadenitis, and local tubercular adenitis.
Generalised Tubercular Lymphadenitis.—This form may involve the lymphatic system at large, while the viscera may escape. The cervical lymphatics are more frequently the seat of infection, though any group may be the source, and the general infection which follows might be regarded as secondary. Usually its course is chronic, though it may have an acute course.
Symptoms.—Although there is no evidence of lung trouble, the patient is going into a decline. There is loss of flesh and strength, the appetite is capricious, the tongue furred, and secretions are deranged. A fever, irregular in character, is a marked feature. Emaciation becomes marked, while the cervical and axillary glands become swollen, with a tendency to suppuration. In the general appearance there is a great resemblance to Hodgkin's disease.
Local Tubercular Adenitis.—Cervical.—This form is the most common of lymphatic lesions, either in the adult or child, and is peculiarly frequent among children of the poorer classes. Insufficient food, or, more properly speaking, improper food, together with bad air and unhygienic surroundings, as were seen but a few years ago in nearly all eleemosynary institutions, give rise to a large percentage of scrofula. Plow many of these cases were from tubercular parents could not be determined, though, if present in latent form, the poor surroundings and food early developed it.
The proof that environment was a productive cause is seen in the marked decrease of cases in the past few years, with a radical change in the care of these unfortunate waifs of humanity who are cast upon the public welfare. In fact, the records show that most of the inmates are discharged at the present day in a far healthier condition than when admitted.
In Keating's Cyclopedia of Diseases of Children, a realistic picture of the condition of things which existed under the old regime is given as follows:
"Some years ago I had a very melancholy but convincing proof of the effects of improper food in producing scrofula upon five or six hundred children in the House of Industry (Dublin), of all ages. from a year to puberty. The diet of the children consisted of coarse brown bread, stirabout, and buttermilk, generally sour, for breakfast and supper; of potatoes and esculent vegetables, either cabbage or greens, for dinner; and sour buttermilk again for their drink. They were confined in their dormitories and schoolrooms of insufficient extent for their number, there being no playground for the children; consequently, they were deprived of that exercise, so natural and necessary for the development of the frames of young animals, and which might have enabled them to digest in some degree their wretched and unwholesome diet.
"Under this cruel mismanagement, they lost all spirit for exercise or play; and on visiting the rooms in which they were incarcerated, the air of which was impure to. a degree only to be compared to jails of former times, these wretched little beings were seen squatted along the walls of their foul and noisome prisons, resembling in their listless inactivity an account I have somewhere read of savages met with in Australia, their faces bloated and pale, and their stomachs as they sat nearly touching their chins.
"Upon a closer examination of these children, it was found that, in general, the upper lip was swollen, the tongue foul, or sometimes of a bright-red color, indicative of acidity of the stomach, the breath offensive, the nostrils nearly closed by the swelling of the mucous membranes, the abdomen tumid and tense, and the skin dry and harsh; but, that which appertains most to my present subject, the cervical glands were more or less swollen and tender; and I am within bounds when I assert that nearly one-half of those unhappy children had the characteristic signs of scrofula in their necks."
This form is also very common among the colored race.
Symptoms.—The first evidence in this, as in all other forms of tuberculosis, is an enfeebled vitality, and the various symptoms that arise from an imperfect elaboration of blood. The visible local manifestation is the enlargement of one or more of. the cervical glands, usually the submaxillary. These are generally spoken of by the parent as kernels, and may remain quite small and firm for weeks, when, from cold or perhaps from some of the many unassignable causes, the vitality is still further reduced and a new activity is developed in the glands, which increase in size, varying from that of a walnut to that of an egg.
There is usually a greater development on one side than on the other. A low form of inflammation sets in, and deposits take place in the adjacent tissues, which become swollen and hard. The inflammation now becomes more or less acute, the part is reddened, painful, hot, tender on pressure, and the swelling increases rapidly. Continuing in this way for a longer or shorter time, suppuration commences, and the deposit is gradually changed to pus, which in time makes its way to the surface and is discharged.
This occupies a variable period of time, sometimes passing through all its stages in eight or ten days, and at others occupying as many weeks. In some cases the inflammation is acute and the pain severe, but in others it progresses without much redness, heat, or pain. The pus forms slowly in many cases, and there is but little tendency to its discharge, while in others weeks pass, the part still continuing hard; and at last, when our patience is nearly exhausted, suppuration occurs rapidly.
Sometimes the pus is well formed and healthy, and, when discharged, the part heals rapidly; at other times it is watery, of a greenish-brown color, or clear, with more or less flocculent material mixed with it. Occasionally the abscess exhibits no tendency to point, but the pus burrows in the tissues for a long time, unless it is opened. In other cases, when the pus is discharged, the abscess does not heal, but continues to discharge a dirty flocculent pus; and if we examine it, we will find the walls ragged and often a chain of lymphatic glands dissected out and lying at the bottom.
The constitutional disturbance varies greatly. Sometimes there is quite a brisk febrile action when inflammation first comes up, with loss of appetite, arrest of secretion, and much prostration. In these cases suppuration is frequently marked with a chill or rigor, and occasionally attended by hectic fever and night-sweats. The fever may be very irregular, assuming either a remittent or intermittent type.
In other cases the only systemic disturbance is the gradual loss of flesh and strength, derangement of the secretions, a pallid or waxen appearance, with progressive emaciation. With the enlargement of the cervical glands the post-cervical, supraclavic-ular, and the maxillary may also become involved.
Tracheo-Bronchial.—This form is usually preceded by a catarrhal condition of the bronchial tubes, and may be primary or secondary to pulmonary infection; the primary form being especially common in children, Northrup recording affection of the lymph glands in every one of his one hundred and twenty-seven cases examined in the New York Foundling Hospital.
These glands are the catch-basins for the various debris which have escaped the destructive action of bronchial and pulmonary phagocytes; consequently, they become frequently infected, and undergo changes similar to those of the cervical glands; namely, become swollen, tumefied, and finally caseate or calcify.
In the advanced stage there is a tendency to form abscesses, which may rupture into the lung, bronchi, or trachea. These glands may assume quite a large size, though they rarely ever produce pressure sufficient to impair respiration.
Symptoms.—The general symptoms are those of impaired or enfeebled vital force. There is a progressive decrease in flesh and strength, and the general condition is well described as "going into a decline." If perforation of the lung, bronchi, or trachea has taken place, there will be cough, with expectoration of a cheesy purulent or bloody material. When secondary infection of lung takes place, the symptoms are those of phthisis.
Mesenteric.—Tabes Mesenterica.—This form is usually met with in children, and is rare after the age of twenty-one. It may be primary, when it is frequently associated with intestinal catarrh; or secondary to tuberculosis of the intestines. The glands of the mesentery enlarging, caseate, though rarely followed by calcification or suppuration.
Symptoms.—The symptoms are those of malnutrition. In children it is usually preceded by diarrhea and gradually increasing prostration. The appetite is usually good, sometimes ravenous, but the patient receives no apparent benefit. The bowels are sometimes tumid, hot, and tender; at others very much shrunken; the evacuations, consisting of a thin mucus, greenish in color, and frequently resembling the washings of meat.
The countenance is contracted and pinched, the eyes set far back in the head, and the skin peculiarly dry, wrinkled, and sallow, giving the child a prematurely aged appearance. He is restless, irritable, and fretful, and presents many of the symptoms of cholera infantum.
In the adult there may or may not be diarrhea, frequently there is diarrhea alternated with constipation, and sometimes severe pain. There is a marked marasmus, increasing day by day; though the appetite may be good and the digestion seemingly well performed. The patient has an anxious expression of countenance; a sallow, wrinkled skin, contracted abdomen, and is uneasy, restless, and irritable.
In the latter stages diarrhea sometimes sets in, and carries the patient off quickly, or disease of the brain or lungs comes on to assist the tabes. In both cases the enlarged glands may escape detection, owing to the distention of the abdomen, due to the associated peritonitis, though where the abdominal walls are flabby the enlarged glands may readily be felt.
Diagnosis.—The diagnosis is not easily made in the early stage of the disease. As it assumes a chronic form, however, the child becomes thin, puny, and emaciated, despite the fact that the appetite has not failed and sufficient food has been taken to nourish the patient. These symptoms, together with the persistent diarrhea, associated with more or less peritoneal involvement, and the enlargement of the mesenteric glands, which can be readily felt through the abdominal wall, render the diagnosis comparatively easy.