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drainage of marshy districts has diminished, to some extent, the fre-
quency of this disease (Buchanan), and, on the other hand, mountainous
districts are often remarkable for freedom from the disease.

Local Causes. — (1) Occupation. — Persons whose employment exposes
them to different forms of irritating inhalations are particularly liable.
In such, however, there is usually first developed a fibroid induration,
and the latter in turn is followed by pulmonary tuberculosis. The con-
tinual inhalation of an atmosphere laden with noxious particles, such as
is met with • in ill-ventilated and overcroAvded working or living apart-
ments, renders the tissues more vulnerable.

(2) Bronchial Catarrh. — An acute catarrh of the small bronchi pre-
pares the soil for tuberculous infection. Frequently, however, this is
the first step in tuberculosis, since the latter disease almost invariably
begins as a local catarrhal process, involving the smaller apical bronchi.
Here may be pointed out that gastro-intestinal catarrh (of somewhat
protracted duration — H. M. King) increases the receptivity for tuber-
culosis.

(3) Tubercular Pneumonia. — In like manner, pulmonary tuberculosis
may follow an unresolved pneumonia, but such cases are, as a rule, in-
stances of tuberculous pneumonia primarily.

(4) Hemoptysis. — According to some authors, hemoptysis is potent in
producing pulmonary tuberculosis. It is, however, certain that in most
instances in which it appears to precede phthisis, and have a causal con-
nection with it, it is in reality a symptom of existing pulmonary tuber-
culosis.

(5) Pleurisy may be, though rarely, the starting-point of phthisis.
Its predisposing effect may be attributable to compression of the lung,
thus interfering with the respiratory excursions, or to the bronchitis
which is frequently associated. Pleurisy sometimes initiates fibroid in-

18



274 INFECTIOUS DISEASES.

duration, which may then terminate in a tuberculous affection ; but the
fact is to be emphasized that a very large proportion of the cases of
apparently primary pleurisy are tuberculous in nature.

(6) Intrathoracic Tumor. — Tuberculosis is often associated with intra-
thoracic tumors, and especially with aneurysm. Fehde^ has reported
3 interesting cases of the kind.

(7) Congenital or acquired contraction of the orifice of the pulmonary
artery predisposes markedly to tuberculosis.

(8) Trauma. — Injuries to the chest-wall, with or without laceration
of the lung, are frequently followed by pulmonary tuberculosis. The
explanation of this association is to be found in the fact that trauma
increases largely the susceptibility of the parts injured by diminishing
phagocytic activity — the naturaP power of resistance. It is a familiar
observation in surgical practice that after injuries to, or operations on,
j oints, tuberculosis frequently ensues. Again, operations upon tuberculous
lesions are succeeded by general tuberculosis — often acute — in about 8
per cent, of the cases.

Tuberculosis of the Lymph-glands.

(Scrofula.)

Scrofula implies tuberculous infection, and scrofulous material inocu-
lated upon susceptible lower animals, especially guinea-pigs and rabbits,
invariably causes tuberculosis. The virus is, however, less virulent than
that derived from other sources, and this explains the slow^ progress and
often latent character of tuberculosis of the glandular system. A major
predisposing factor is age, this form of tuberculosis preponderating in
children. Hecker, from an examination of the records of the Munich
Patholoo-ical Institute, found that in 147 cases of tuberculosis among
children the lymphatics were affected in 92 per cent. ; and it is generally
conceded that in young adults tuberculous adenitis is not uncommon, and
that it is rarely met with during and after the middle period of life.
The lesions generally remain limited to the glands first infected — i. e.
the cervical, mesenteric, etc., as the case may be — and this for the
reason that the natural powers of resistance in the tissues are often able
to oppose the march of the destructive forces. Another predisposing
condition is an acute or chronic catarrh of the mucous membranes.

The cases are all divisible into tw^o groups : (1) Local tuberculous
adenitis, and (2) general tuberculous adenitis.

(1) Local Tuberculous Adenitis. — (a) Cervical. — This is the most fre-
quent form, and is especially common among children. Of 2035 per-
sons examined by Valland, enlarged cervical glands were found between
the ages of seven and nine in 96 per cent. ; between ten and twelve in
96.1 per cent. ; between thirteen and fifteen in 84 per cent. ; between
sixteen and eighteen in 69.7 per cent. ; and between nineteen and
twenty-four in 68.3 per cent. Tubercle bacilli were found in the cer-
vical lymph-glands in about 68 per cent, of adults. Negroes are found
to be more prone to the affection than whites.

Etiology. — I have stated before that tubercle bacilli are sometimes

^ " Lungentuberculose mit Brusthohlengeschwulste," Inaug. Diss., Leipzig, 1894.



TUBERCULOSIS OF THE LYMPH-GLANDS 275

found on the nasal mucous membrane of healthy persons. The pres-
ence of an acute or chronic catarrh of the nasopharynx may now
lower the resistance of the tissue-cells, so that the bacilli may gain
access to the lymph-current, and through the latter to the neighboring
glands, setting up tubercular adenitis. Though often the seat of tuber-
cular invasion, the cervical lymph-glands do not furnish a highly favor-
able soil for the growth and development of the bacilli, and hence the
tendency toward latency.

The tonsils, owing to their free communication with the atmosphere,
in which there is a wide diffusion of tubercle bacilli, may be primarily
infected. But here also, as in the case of other glandular structures,
there is a tendency for the affection to become encapsulated, for the
reason that the tissue-soil after a prolonged contest generally gains the
ascendency over the invading bacilli. The latter may, however, under
certain favorable conditions, break down the barriers opposed by nature
and effect a lodgement elsewhere, or even become widely diffused
through the economy. Thus Kinckmaun in 64 autopsies found 25 cases
of tuberculosis, in 12 of which the tonsils were affected.

A third mode of infection of the cervical lymph-glands is through
the medium of slight injuries and abrasions of the skin or certain forms
of skin-eruptions (eczema, etc.). These serve as doors of entrance for
the bacilli, which find their way into the neighboring lymph-glands
through the lymph-channels. Compared with infection from Avithin,
this mode is most probably much less frequent.

Symptoms. — The main feature is a visible enlargement of the af-
fected cervical glands, chiefly the submaxillary. At first the glands
are too small to be even palpated ; later, they can be felt as small, firm
tumors underneath the skin. By and by they appear as visible protuber-
ances, ranging in size from that of an English walnut to that of a hen's
egg or even larger. The sMri over the enlarged gland is freely movable,
as a rule ; less frequently it becomes adherent — an indication of suppu-
ration. When an abscess forms and is allowed to open spontaneously,
there remains a chronic discharging sinus. Suppuration is attended
with fever, anemia, and emaciation. In well-marked cases the separate
tumors coalesce, forming large and irregular masses. The affection is
usually bilateral, though almost invariably it is more marked on one
side than on the other.

Not infrequently, in addition to the enlargement of the submaxillary,
post-cervical, and supraclavicular glands, there is also involvement of
the axillary, as was the case in a fatal instance in my own practice.
The patient was a male child, eight years of age, who developed pul-
monary tuberculosis. It may reasonably be assumed that the bronchial
glands also become implicated, and may excite lung tuberculosis.

The diagnosis is based upon the history and the associated evidences
(keratitis, conjunctivitis, eczema of the scalp or face, nasopharyngeal or
bronchial catarrh, etc.), coupled with the ghindular enlargement. Bacilli
have occasionally been found in the purulent discharge from abscesses.
Otis applies the tuberculin-test, and obtains positive reactions in 62 to
69 per cent.

The course of this affection is exceedingly slow, often extending
over a number of years. Many cases, however, recover after timely



276 INFECTIOUS DISEASES.

surgical intervention. On the other hand, neglected cases are a menace
to the life of a patient, since they may be followed by diffusion of the
bacilli, with the development of a fatal form of disease.

(5) Bronchial. — Tuberculosis of the bronchial glands may be primary,
or secondary to infection of the lungs, and it is commonly preceded by or
associated with bronchial catarrh. Avhich is its chief predisposing cause.
The primary form is met with frequently in young children, the medias-
tinal lymph-glands being affected uniformly in 127 cases at the Xew
York Foundling Hospital (Xorthrup).

The bronchial and tracheal glands are the receptacles for all foreign
substances, including the tubercle bacilli that are not dealt with by the
broncho-pulmonary phagocytes. After infection with tubercle bacilli
the lymph-glands become swollen, tumefied, and are the seat of caseous
change ; later they may undergo calcification or proceed to abscess-for-
mation. The latter may rupture either into the lungs, into the trachea
or the bronchi, or into a pulmonary blood-vessel.

Symptoms. — If a fistulous communication be established with the air-
passages, cough and expectoration of purulent material, blood, and
caseous matter containing bacilli will be noted.

Secondary infection of the lung may occur in this manner. When
rupture takes place into a vessel systemic infection promptly follows.
Tubercular adenitis involving mediastinal lymph-glands may also lead
to infection of the pericardium and then proceed to tuberculous peri-
carditis.

(c) Mesenteric [Tahes Mesenterica). — This may be primary or sec-
ondarv. the latter beino; verv common and a secondary infection to
intestinal tuberculosis.

The former is rare, however, and the intestinal catarrh with which
it is associated is doubtless tuberculous in the vast majority of cases.
The mode of infection has already been pointed out. The lesions pre-
sented are similar to those met with in tuberculous bronchial glands.

The sympAorns are not always distinctive, and may be entirely nega-
tive during the life of the patient ; hence the condition is often incident-
ally discovered during the post-mortem examination. The local symp-
toms when marked are due in the main to an associated peritonitis. The
abdomen is painful and more or less swollen. Peritoneal effusion is
present, and sometimes sufficient in amount to be detected by the cus-
tomary physical signs. Large and small nodules may sometimes be felt.
Jjiarrhea is a marked and obstinate feature and is usually due to tubercu-
lous intestinal ulcers. Fever of an intermittent type is almost constantly
present, causing emaciation, and the objective changes (pallor of skin,
mucous membranes) due to anemia become pronounced. This form of
tuberculosis may persist as a local condition, but there is danger of
extension to other organs (pleura, lungs). On the other hand, in the
adult pulmonary tuberculosis may be followed by involvement of the
mesenteric glands without involvement of the intestines, and in such in-
stances there occurs an extension by contiguity along the course of the
lymphatics that pass through the diaphragm, and finally, in adults, pri-
mary tuberculous new growths may be met with in the mesenteric glands.

JJiacpiosis. — A probable diagnosis can usually be made if careful at-
tention be paid conjointly to the symptoms, physical signs, and course



. ACUTE TUBERCULOSIS. 277

of the affection. The detection in a child of a tumor which may be
moderately hard, doughy, or even fluctuating will aid materially in the
diagnosis, and will also afford evidence of tuberculous disease in other
organs.

(2) General Tuberculous Adenitis. — This term implies tuberculous dis-
ease of the lymph-glands throughout the body, with little if any involve-
ment of other organs ; this is a rare condition. The affection may begin
as a local tuberculous lymphadenitis, nearly all of the rest of the glands
of the body becoming secondarily implicated. The primary seat of the
trouble is perhaps most frequently the cervical lymph-glands, though in
one instance observed by myself the mesenteric glands first became
affected, the case terminating in pleuro-pulmonary tuberculosis.

Symptoms and Diagnosis. — There is protracted fever., the temper-
ature beino- of the remittent or intermittent type. Wasting and debility
are progressive until the patient presents a decidedly puny aspect,
while the lymph-glands that are accessible to inspection and palpa-
tion are more or less enlarged and manifest a marked tendency to sup-
puration. The affection is usually chronic^ though very exception-
ally it may exhibit an acute course. One of the chief dangers over-
hanging the sufferer in this affection is that, owing to liberation of the
bacilli, the meninges or the lungs may become tuberculous ; these cases
may also terminate unfavorably from asthenia. Cases in which the
glands are but little enlarged, while the general features axe moxkedi,
are puzzling. On the other hand, when the superficial lymph-glands
are greatly enlarged the affection may bear a striking resemblance to
Hodgkin's disease.

Acute Tuberculosis.

This form of tuberculosis is characterized anatomically by the rapid
development of miliary tubercles in many and widely-separated parts of
the body. In some instances the new growths are pretty evenly distrib-
uted through all the organs of the body, manifesting the clinical symp-
toms of an acute general infection. In other instances there is a tend-
ency to centralization of tuberculous growths, as, for example, in the
lungs (pulmonary variety) or in the meninges of the brain and spinal
cord (meningeal variety).

Pathology. — The fact is to be emphasized that somewhere in the
body there is an old tuberculous focus. Apart from this primary lesion,
the anatomic changes consist in the widely disseminated miliary tuber-
cles. Their most frequent seats are the lungs, liver, and spleen ; less
frequently, the marrow of the bones, the heart, the choroid, and the
meninges. In some of the organs, particularly the meninges, lungs,
etc., the tubercles may be readily perceived by the naked eye, Avhile in
others they frequently cannot be detected without the aid of the micro-
scope. It must not be forgotten that in some of the more protracted
cases the nodular tubercles may grow into foci of considerable size,
ranging from that of a lentil to that of a pea.

Ktiology. — This has been, in the main, given in connection with the
general etiology of tuberculosis {vide supra), though a few special points
remain to be adduced. The acute forms of tuberculosis are decidedly



278 INFECTIOUS DISEASES.

more frequent during infancy and childhood than during adult life, and
with few exceptions the cases are secondary to a local tuberculous form
in one or more lymph-glands (tracheal, bronchial, mesenteric) or in the
lungs. More rarely a pre-existing tuberculous focus in the kidneys,
the bones, or the skin may give rise to the affection, as may the occur-
rence of certain other acute infectious diseases — such as measles, whoop-
ing-cough, and influenza, in children, and typhoid fever and lobar pneu-
monia, especially with delayed resolution, in adults.

Modes of Infection. — Most frequently there is established a fistulous
connection between the local tuberculous focus and a vein, especially the
pulmonary vein. Under these circumstances there may be large num-
bers of bacilli discharged into the blood-stream ; but oftener only small
numbers of bacilli enter and subsequently multiply, inducing general
infection (Ribbert and Wild^). A second mode of infection, though de-
cidedly more rare than the above, is the rupture of a tuberculous focus
into the thoracic duct, in which case the tuberculous material passes
almost directly into the subclavian vein. In these cases, according to
Ponfick, the disease is less rapid in its course.

Clinical History. — That miliary tubercles may exist in many
organs of the body (liver, heart, etc.) without giving rise to symptoms
is a noteworthy fact. Cohnheim and Manz have discovered miliary tu-
berculosis of the choroid when the condition was only detectable with
the aid of the ophthalmoscope.

The following forms of the disease may be distinguished :

General Miliary Tuberculosis.
(a) TYPHOID form.

The symptoms are those of a general infection of the body, there
being in most cases a period of incubation, during which the patient
complains of malaise, headache, chilliness, feverishness, and increasing
debility. Rarely, the onset is comparatively sudden. The reaction of
the nervous system against the poison, which is now scattered to all
parts of the body, is shown by such symptoms as the fever, which rapidly
increases, a rapid, feeble pulse, and mental dulness or delirium. The
tongue becomes dry, and sometimes also brown. The respirations are
accelerated, and there is more or less cyanosis, with which symptom is
associated a peculiar and characteristic pallor of countenance. Coinci-
dently with the febrile exacerbations the cheeks may wear a circum-
scribed blush. Among the rarer -early symptoms is epistaxis. The
patient soon becomes profoundly prostrated or experiences a feeling of
anxiety : if, as sometimes happens, the course is protracted, tveakness,
ayiemia, and especially emaciation, are well marked and assume diag-
nostic importance. These cases sometimes pass into the pulmonary or
the meningeal form, the patients often succumbing speedily to such
localized developments.

Fever. — The temperature usually pursues a high range, although

there are a few cases in which the entire course is afebrile. Again, it

occurs not infrequently that the temperature is normal or nearly so for

a short period. The usual temperature-curve ranges at first between

' Deutsche medicinische Wochenschrift, Dec. 30, 1897.



ACUTE TUBERCULOSIS. 279

102° and 104° F, (38.8°-40° C), and then continues to rise, with the
development of the serious general condition in a way exactly similar
to that observed in typhoid fever. In many instances the fever is
irregularly remitting, at least at intervals, if not so constantly. Thus,
periods of irregular fever may alternate with others of continued, and
later deeply remittent or distinctly intermittent, fever.

Nervous Symptoms. — In most cases the nervous symptoms are not
prominent. In a smaller number headache, vertigo, delirium, and often
stupor, become marked at an early stage and may persist. They are due
to the general infection.

Oirculatory System. — The pulse is small, and its rate is out of pro-
portion to the fever, varying from 100 to 140 or higher. It may be-
come irregular, particularly if the meninges be involved.

Respiratory System. — The breath is somewhat hurried and labored ;
there is a cough, but it is not annoying as a rule; and there is a slight
expectoration, which is not characteristic. If there be present simul-
taneously in the lungs an old tuberculous focus, the expectoration may
be more profuse and typical. The bacilli are also absent from the spu-
tum unless an old tuberculous lesion exist in the lungs.

The physical signs are those of a moderate, diffuse bronchitis, though
local signs of consolidation or pleurisy may develop late in the course
of the affection. On the other hand, such signs may be evidences of an
old tuberculous affection.

Digestive System. — As before noted, there are anorexia and a dry
tongue (symptoms due to the systemic infection), while vomiting may
occur at the outset and excessive thirst is common. The spleen usually
becomes enlarged, though only to a moderate extent.

Ocular Symptoms. — The important symptom presented by the eye is
the presence of choroid tubercles, which may be determined by a care-
ful ophthalmoscopic examination. Their absence does not militate
against the diagnosis of general miliary tuberculosis, since they may
be too few to be detected, or possibly absent altogether. Their demon-
stration is always exceedingly difficult, and only possible with the
skilled ophthalmologist.

Diagnosis. — This form of tuberculosis is often with difficulty dis-
criminated from typhoid fever, but in the following table I have endeav-
ored to contrast points of dissimilarity :

Acute General Miliary Tuberculosis. Typhoid Fever.

Family history of tuberculosis, or pres- Coexistent with an epidemic or following

ence of an old focus. previous cases of typhoid.

Evolution of the disease not characteris- Evolution of the disease is character-
tic, istic.

Epistaxis rare. Epistaxis a common early symptom.

Fever-curve of decidedly irregular type. Temperature-curve of the continued

Pulse rapid, out of proportion to fever. Pulse often dicrotic : slow in proportion

to fever.
Respirations rapid and labored. Respiration moderately increased.

Face dusky, with peculiar pallor. No duskiness of face.

Abdominal symptoms are not suggestive. Abdominal symptoms (stools, enlarged

spleen, tympanites, etc.) suggestive.
No characteristic eruption. The eruption (appearing in successive

crops) is pathognomonic.



280 INFECTIOUS DISEASES.

Acute General Miliary Tuberculosis. Typhoid Fever.

Widal reaction absent. Present.

Knee-jerk may be absent. Knee-jerk never wanting.

Leukocytosis may be present. Leukocytosis absent unless complicated

by a suppurative process. .
Choroid tubercles may be detected. Choroid tubercles absent.

Tubercle bacilli rarely demonstrable in Cultures from punctured spleen may show
the blood. typhoid-bacilli (dangerous procedure).

They may be found in the stools.
Hemorrhage from bowels exceptional. Hemorrhage from the bowels common.

Perforative peritonitis absent.^ Perforative peritonitis often present.

The tuberculin test may prove an aid to diagnosis in cases pursuing
an apyrexial course.

(5) PULMONARY FORM.

Though all gradations between the typhoid and the pulmonary types
occur, the latter should be recognized and briefly described. It may
develop suddenly, the ushering-in symptom being sometimes a chill,
though more frequently there is a premo7iitory period, during which
the general health fails materially. Some acute illness, as measles or
whooping-cough, in which there has been marked catarrhal bronchitis,
often constitutes the point of departure for this variety.

The respiratory symptoms are early prominent, and later preponder-
ate in the clinical picture. From the start there is dyspnea, and this
gradually increases until the respirations become rapid (40 to 60 per
minute). When dyspnea becomes pronounced the face assumes a char-
acteristic cyanotic pallor. The cough at first is moderately severe, but
it soon becomes troublesome, being frequent and attended with a slight
expectoration, which, however, is non-characteristic.

The physical signs are those of broncho-pneumonia, and the latter
may or may not be preceded by the signs of generalized bronchitis.
With the onset of consolidation there appear spots that yield either
dulness or a tympanitic resonance on percussion, and broncho-vesicular
breathing with numerous subcrepitant rales on auscultation.

The general symptoms are marked from the beginning. The fever
is high— from 103° to 105° F. (39.4°-40.5° C.) or often higher. The
pulse ranges from 100 to 140, is small, feeble, and sometimes irregular,
and it may be more rapid still during the advanced stage of the affec-
tion (see Fig. 23). Cerebral symptoms rarely appear.

The course, as a rule, is more prolonged than that of general miliary
tuberculosis, except in children, in whom it often runs an exceedingly
acute course. As the end approaches the signs of suffocation are gradu-
ally intensified, and finally lead to a fatal termination.

Diagnosis. — The diagnosis is difiicuit ; but a family history of
tuberculosis, a knoAvledge of the pre-existence of a tuberculous focus or
of an antecedent predisposing affection, will aid in its recognition.
Tubercle bacilli are perhaps not demonstrable in the sputum unless an



Online LibraryJames Meschter AndersA text-book of the practice of medicine → online text (page 36 of 175)