of Rhodes. Spurious works Andronicus.

The American journal of obstetrics and diseases of women and children online

. (page 101 of 109)
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The foregoing brief description is sufficient to indicate the
direct connection between the lymphatic chain of the throat
with the lungs as well as with the general circulation.

It is well known that the lymphatic stream flows sometimes
in one direction and sometimes in another. With this and the
anatomical connections in mind we can readily understand that
there is no part of the body not susceptible of infection through
the lymphatic system, and with the lymphoid tissue of the throat,
as the portal of entry.

Much has been written regarding th6 essential function of the
lymphoid glands of the throat. It is conceded by practically
all scientific investigators that there is a distinct function in-
herent in this group of lymphoid tissue. The only divergence
of opinion consists in the manner in which these structures per-
form the functions assigned to them by nature. Does the lymph-
oid tissue manufacture an antitoxin which through the lymph-
atic system gives systematic protection and immunity? Or



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980 crane: role of waldeyer's lymphatic chain.

does the protection consist entirely in a local resistance to the
invasion of infection ?

I believe the latter to be the real situation as it is supported
by clinical evidence too strong to dispute. It is with the local
barrier offered that we will confine ourselves. How does the
lymphoid tissue act, and does it have a more or less fixed period
of activity followed by a period of atrophy and inactivity? For
convenience, we will apply the term tonsil or tonsils to signify
the faucial, and adenoid, or adenoids, to signify the pharyngeal
lymphoid tissue. What is said of either applies only to a less
extent to the lingual group.

At birth the tonsils and adenoids are fully developed and
functionating. This very evidently means that nature intended
that such should be the case. What is this function? It is
very evident that in infancy and in early childhood the system
is more susceptible to infection — less resistant — than in later
life. It is during this period, before any degree of natural
immunity is developed, that some provision should be made by
nature to take care of this lack of immunity until such time as the
organism has developed sufficient resistance to infection to no
longer need this protection. This view is supported by the fact
that these glands are fully developed at birth and functionating,
that they continue to develop, reaching full development about
the sixth or eighth year when they normally begin to atrophy;
and at about the twelfth or fourteenth year of age, they no longer
exist as functionating glands. This is, of course, not true when
they have become the seat of disease. When they are found
after this age, large and of full size, it is very clear evidence that
they have been the seat of disease, and their present condition a
resultant.

What is the manner in which these lymphoid glands protect
the organism from invasion of bacteria or their toxins? This
is the disputed question. A number of theories have been
advanced; well-known investigators like Wright, Wood, Goodale,
Walsham, Williams, and others firmly believe that such a function
exists, yet differ in their explanations of the particular manner
in which it is brought about.

It has been shown that carmine injected into the tonsils
readily passes into the parenchyma of the glands while bacteria
remain within the crypts. Butter also readily passes from the
crypts into the parenchyma. It has been suggested that bacteria
in milk would more readily pass into the tonsil because of the
butter experiment.



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crane: role of waldeyer's lymphatic chain. 981

The free surfaces of the tonsils are covered with epithelium
which infolds unto the crypts. As we get deeper into the
crypts we find the layers of epithelium become fewer until
near the bottom we find only a single layer of flat cells with
here and there a space entirely unprotected by even this single
layer of epithelium.

It is thus easy to understand that any foreign matter can
easily pass from the crypts into the gland proper. Why does
the carmine red enter so readily while bacteria do so not at all
except when present in overwhelming numbers or when the
lymphoid tissue has become so altered by repeated inflammatory
changes as to no longer offer the barrier provided by normal
lymphoid tissue? That we constantly find within the crypt large
numbers of pathogenic bacteria and as often none whatever
within the tonsil proper certainly indicates that healthy lymphoid
tissue normally offers a barrier to bacterial invasion. It is not
the epithelial lining of the crypts which is responsible. We must
accept the protecting function of the lymphoid tissue found in
the throat just as we must accept this same inherent function in
lymphoid tissue formed elsewhere in the body. The fact that
some of the crypts extend to the capsular surface and come in
direct contact with the absorbing afferents of the cervical lymph
nodes opens another channel for infection. Wright has spent
a great deal of time and much hard work in attempting to
explain the protecting function of the lymphoid tissue of the
throat. It would seem from a review of his work that there is
aa inherent function which causes the lymphoid tissue to reject
certain pathogenic materials as poisons and to absorb certain
other materials as foods. The attempt to work this out in
terms of electro-dynamics has so far not been successful. How-
ever this may be, it is a fact beyond dispute that, as a result of
clinical observations and scientific investigating, the protecting
function of the lymphoid tissue of the throat has been satis-
factorily proven and is now accepted.

The foregoing is not offered as proof but is merely intended
as a brief reference, since to detail all the proofs would prolong
this paper beyond the required length.

When the lymphoid tissue atrophies, as it normally does, it no
longer functionates, as it is no longer needed. When it has
become the seat of disease before the atrophy has taken place,
we have certain results which will be briefly touched upon.
When this occurs the physiological functions are interfered with



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982 crane: role of waldeyer's lymphatic chain.

in whole or in part and we have instead a diseased focus to contend
with. We lose the advantages of normal functionating tissue
and have added the disadvantages and ill effects of a diseased
focus. It is then and then only that the lymphoid glands of the
throat act as portals of entry for localized, adjacent and systemic
infection. It is this phase that we wish briefly to consider.

Beginning at birth the pharyngeal lymphoid tissue may
become enlarged, and this of course means diseased. We have
quite frequently in infancy and early childhood an acute infection
of the adenoid tissue similar to an acute infection of the tonsils.
This is very often never thought of and consequently some other
reason is assigned for the patient's temperature and concurrent
symptoms. This acute infection may take place in early
infancy and as a result the lymphoid tissue here becomes infected
and thereafter remains a constant source of infection. The
infection may be of the streptococcus, staphylococcus or tuber-
cular type. Enlarged cervical glands may result, infection in
them being similar in character to that of the adenoid tissue in the
pharynx. Exclusive of the acute exanthemata this is the cause
of middle-ear infection in infancy and childhood, and even in
the acute exanthemata it is probable that the adenoid tissue
becomes infected first. This is also the cause of repeated
attacks of acute exudative inflammation in the nasal cavities.
The diseased adenoid may not be sufficiently large to cause
respiratory obstruction, and it is because it does not do so that
it is so often overlooked.

Just here it might be well to answer the question so often asked :
When is the child old enough to have his diseased or enlarged
adenoid tissue removed? The child is always old enough.
It is not a matter of age, it is a matter of removing pathologic
tissue when present and diagnosed as a source of ill health locally
or systematically. In adult life we sometimes find diseased
adenoid tissue which is an active focus for infection. The age
factor does not eliminate it.

During the past winter there have been a considerable number
of cases reported of streptococcic infection of the throat with
resulting systemic invasion:

As illustrating this class of cases, I will briefly report one.
M. C, a lawyer, about thirty-eight years of age. On March 14,
19 10, I was called to attend him because he had a sore throat.
History : Has had a sore throat for four days, high fever, ached
all over; condition growing worse. Home remedies had been
employed without avail. Has had malaria and at times what



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crane: role of waldeyer's lymphatic chain. 983

he called rheumatism; does not use alcohol except on rare
occasions.

Examination. — Temperature 103, pulse 120. Throat, marked
congestion. Swelling very marked involving both pillars, soft
palate, uvula, extending well into the hard palate, pharynx,
epiglottis, and base of tongue. Larynx not involved. No
patches nor localized areas of infection. Tonsils involved to
some extent; tongue coated; very unusual amount of mucous
secretion, patient constantly expels large quantities of ropy
mucus.

March 15. — Throat presents the same picture, slightly worse;
left stemomastoid muscle swollen and tender. Temperature
103.4. Pulse 120.

March 16. — Worse; temperature same; pulse 120; conges-
tion of entire throat more marked and mucous secretion more
abundant. Right stemomastoid swollen and tender.

March 17. — Left stemomastoid muscle subsiding. Tem-
perature 100; feels better and much less mucus secreted; less
congestion and less swelling. Entire condition seems to be
subsiding. Right stemomastoid seems still swollen and tender.

March 21. — Throat clearing up; left stemomastoid practi-
cally clear of swelling and tendemess; right, much better.
Temperature 99 . 2 ; general condition very much improved and
throat and neck seem to be getting well. Complains for first
time of pain in right thigh. Examination shows some tenderness
localized about knee externally.

March 22. — Throat and neck improving continually, leg much
worse. Swelling and tendemess extend to knee. Temperature
103. Pulse 120.

March 23. — Leg condition getting worse, although he has had
treatment, local and general, with absolute rest; swelling above
and below the knee 6 inches. Temperature 103.8. Pulse
130 and irregular. Patient looks ill and septic. Diagnosis,
infection of the leg. Secondary through the throat, through
the lymph channels.

March 24. — Knee and leg much worse and patient shows
evidence of sepsis. Some mental disturbance. Temperature
103.8. Pulse 130.

March 25. — Suggested consultation, explaining that condition
of leg was not improving and that I would prefer transferring
the case to a surgeon. Dr. John Parrish was secured at once.
We thought it advisable for a surgeon to see him, and Dr. Brins-
made was called. My attendance ceased at this time.

March 28. — Dr. Brinsmade had patient removed to the Long
Island College Hospital, and on March 29, leg was opened under a
general anesthetic. Diagnosis of streptococcic infection, second-
arily to a similar infection in the throat.

Subsequent history of the case. Since first operation has had
leg opened several times; patient profoundly septic. Has had
the benefit of the best of care, and Dr. Van Cott has used his
polyvalent serum.



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984 crane: role of waldeyer's lymphatic chain.

May 4. — Saw leg while being dressed and it presented as bad
an infection as I have ever seen. Patient profoundly septic and
semiconscious.

May 25. — I learned from Dr. Brinsmade that the patient was
holding his own and he thought he would get well, inasmuch
as he had retained his ability to take plenty of nourishment.
He had been using an autogenous serum, but did not see any
special benefit from it. This had not been used until quite
late, however, after the infection was well-established and patient's
general condition very bad.

The history of this case well illustrates a class of cases which
call for early diagnosis and the institution of vaccine treatment.
The importance of taking cultures of the throat in all acute
infections cannot be too greatly emphasized. It is not fair to
the patient to depend entirely upon the clinical picture. While
it is true that an accurate diagnosis can in most instances be
made by the observer, it is well to get the habit of taking cultures
in order to avoid an occasional error. Stock vaccines may be
employed pending the preparation of a hematogenous vaccine.
With an acute infection of the foregoing description established
and proven as a fact, it is fair to assume that any form of an
acute infection of the lymphoid tissue of the throat may result
in systemic invasion and the establishment of infection in any
part of the body. When we consider the opportunity for ready
absorption through the lymphatic and venous systems we must
accept the theoretical possibilities, and when we are constantly
confronted with the clinical picture to substantiate it, what
excuse is there for skepticism?

A case has been reported of acute streptococcus tonsillitis,
followed by an acute streptococcic appendicitis, streptococcus
in pure culture of the same strain being found in tonsils and
appendix. The fact that the appendix contains a considerable
amount of lymphoid tissue strengthens the conclusion that the
infection in the appendix was secondary to the infection in the
tonsil. It matters little where the initial focus may be, the
picture is much the same. There is this difference in the throat,
we have a chain of lymphoid tissue so placed as to come in direct
contact with every form of infection contained in the air and in
the food.

The relation between acute and chronic rheuniatism and
acute and chronic tonsillitis is a matter of interest to every
practitioner of medicine. We do not know the exact nature of
what is known as rheumatism; that it is an infectious disease due
to the invasion of pathogenic bacteria or their toxins, or both, is



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crane: role of waldeyer's lymphatic chain. 986

now accepted by most men. That it is a streptococcus infection
is believed by many, although the particular strain of streptoco-
cus has not been determined. It may very well be that what
we call rheumatism is not always the same kind of infection.
There may be a number of bacteria which may be responsible
for the great variety of symptoms which go to make up the vary-
ing clinical picture of rheumatism, acute or chronic. Note the
symptoms of acute tonsillitis of the streptococcus type and we
have oftentimes symptoms similating some of the manifestations
of acute rheumatism. So many cases of acute rheumatism
accompanying or following acute tonsillitis have been reported
that the inference seems plain. We see patients who have
never had any manifestations of acute rheumatism become vic-
tims of acute tonsillitis and soon after develop the clinical picture
of acute rheumatism, and thereafter have repeated attacks
associated with tonsillitis. That we see the symptoms of rheu-
matism subside and never afterward return following the removal
of the septic foci in the tonsils is also well known. We find
practitioners have for years used drugs in the treatment of acute
tonsillitis which they used also in treating rheumatism. The
same holds true for chronic forms of rheumatism. We have
diseased tonsils acting as a constant focus for the absorption of
toxins. Now and again we have an exacerbation of the local
focus followed by an exacerbation in the rheumatism. The
foregoing is not offered as scientific proof of the causal relation-
ship between rheumatism and a diseased condition of the
lymphoid tissue found in the throat. It is a clinical picture,
however, which is certainly more than suggestive.

We frequently see children with a well-developed chorea
improve very markedly and in some cases get entirely well of
their chorea following the removal of enlarged and diseased
tonsils and adenoid. This has. been true in cases where all other
methods of treatment have apparently failed. Whether this is
due to the removal of a diseased focus of infection acting as an
etiological factor in the chorea or whether it is due to the im-
provement in the general nutrition and health of the patient
following the operative procedure, is in the light of our present
knowledge an open question. The relation between chorea
and rheumatism, or at least the association of these two con-
ditions, together with the endocarditis accompanying both,
presents another link in the chain of clinical proof of the close
connection . between these apparently allied conditions. It is



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986 crane: role of waldeyer's lymphatic chain.

suggested that much may be done in the near future along
bacterial lines to prove or disprove a clinical picture of a common
occurrence, as well as provide more suitable vaccine treatment.

The question of the relation of tuberculosis of the lymphoid tissue
found in the throat to pulmonary tuberculosis or to tuberculosis
elsewhere in the body, offers considerable opportunity for study.
To establish this relation it is necessary to prove tubercular
lesiop in the tonsils or that tubercle bacilli may enter through
the tonsil without causing a localized area of tuberculosis.

In the course of investigation of a very considerable number
of tonsils, they have been found to be the site of tubercular
lesions. Tubercular and giant cells have been found in the
tonsil tissue. That the tubercle bacilli may pass through the
tonsil tissue without causing local tubercular lesion is overlooked.
With a tubercular focus in the tonsils it is very evident that we
have very frequently to do with a similar infection in the cervical
glands into which the tonsils drain.

It has been a very common experience to remove tubercular
glands of the neck without finding the tonsils to present on gross
appearance any tubercular lesions. It has been found that the
tonsils which on gross appearance did not present tubercular
lesions did present such lesions under the microscope.

It is a common experience to find large cervical lymph nodes
which have been diagnosed as tubercular subside and completely
disappear subsequent to complete removal of the diseased ton-
sils. We find an exacerbation of the tonsillar infection is fre-
quently accompanied by an exacerbation of the cervical adenitis.
That a tubercular aflfection of the cervical lymph nodes may
extend to the parietal pleura, through the lymphatic connec-
tion already mentioned, or to the mediastinal glands and thence
to the parietal and visceral pulmonary glands is to my mind not
only possible, but probable.

About two months ago at The Brooklyn Hospital we began to
examine the tonsil and adenoid tissue removed from patients
operated upon. Up to the present time, we have in the course
of examination tonsillar and adenoid tissue from about 150 cases.
It was hoped that we might be able to make a preliminary report
at this time, but the work has proven to be so time consuming
that the report will have to be postponed until a later date.

We may not be able to present anything new, but we hope to be
able to do so. If as a result of our investigations 'and examina-
tions we succeed only in corroborating or controverting the



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SILL: DIPHTHERIA IN CHILDREN. 987

conclusions of others, the time will have been well spent. The

object of these examinations will be to determine the character

of tissue changes, the presence or absence of specific bacteria

or specific lesions in the tonsils. This field offers a wide scope and

we expect to enlarge the work as different lines of thought suggest

themselves.

It is fully appreciated that the paper has not covered the

subject stated by the title, but it has been my object to introduce

some thoughts in the hope that they will stimulate active

investigation.
119 Halsey Street, Brooklyn, N. Y.



DIPHTHERIA IN CHILDREN.

A STUDY BASED ON TREATMENT OF EIGHT HUNDRED CASES.*

BY

E. MATHER SILL, M. D.,

Attendins Physician at the Good Samaritan Dispensanr, Children's Department. Lecturer
on Diseases of Children at the New York Polyclinic Medical School and Hospital.

Diphtheria is one of the most insidious and treacherous
diseases we have to deal with, and on account of the great
divergence of its clinical manifestations, even those with the
widest experience cannot expect to diagnose every case by
clinical means alone; in fact, it is possible so to do only in the
more typical cases. On the other hand, in many cases which on
culture growth show bacteria morphologically identical with the
Klebs-Loeffler bacillus, the clinical aspects alone would not indi-
cate or even lead us to suspect diphtheria. It is from my studies
along this line that I have been prompted to write this paper.

The cases I here report were all verified by bacteriological
culture growth. My figures cover a period of eight years, the
cases being endemic, they also show diphtheria was most preva-
lent in this series during February, March, April, and June, the
most cases occurring in March and fewest in January. It seems
reasonable to believe that children are more susceptible during
the spring months on account of the prevalence of catarrhal affec-
tions at that time of the year and also from the fact that they
are less resistant on account of a lowered vitality at that season.

I here report the frequency of diphtheria of the nose, throat,
and larynx at the different ages.

Of 757 cases under ten years of age, there were 521 phar-
yngeal, of which 24 were one year and younger; 116 from one

* Read before the Medical Society of the County of New York, March 28, 1910.



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sill: diphthema in children.

to three years; 76 from three to five years; and 265 from five
to ten years.

There were 166 nasal cases, the youngest being five weeks
old; 22 were one year and mider, 69. from one to three years,
32 from three to five years; and 43 from five to ten years.

There were 70 laryngeal cases: 7 one year and under; 35 from
one to three years; 9 from three to five years; and 19 from five
to ten years.

There was one case of diphtheria of the eyelid in a child five
years of age, and one case where diphtheria bacilli were found
in the discharge from the ear.

Thus it will be seen that the order of frequency is pharyngeal,
nasal, laryngeal.

Pharyngeal diphtheria in this series was the most frequent
at all ages, more cases occurring, however, between the ages of
five and ten years. More cases of nasal diphtheria occurred be-
tween the first and third years, but comparatively and absolutely
the most cases of laryngeal diphtheria occurred between the
first and third years.

One hundred different cases of sore throat and nasal dis-
charge were examined, clinically, bacteriologically by culture
growth, and also by direct smears on slides from the throats.

Of these there were thirteen cases of clinical pharyngeal
diphtheria, all of which on culture growth were reported positive
Klebs-Loefifler from the Board of Health; the direct smears on
slides showed four to be streptococcic, four staphylococcic, one
diplococcic, two diphtheritic, one large diplococci (this case
was diagnosed as scarlet fever and proved to be such later) .

There were eight cases of nasal discharge, which were suspi-
cious, culture growth showed one to be positive Klebs-Loeffler,
and seven negative Klebs-Loefjler by the Department of Health.
Direct smears on slides showed five to be streptococcic infection,
one diplococcus, and two diphtheria. There were three cases
of laryngeal diphtheria, and all three gave positive Klebs-
Loeffler culture reports from Board of Health. One slide showed
diphtheria and two streptococci.

There were 76 cases of clinical tonsillitis, and of these culture
growth showed 67 to be cases with germs other than the diph-
theria bacilli; 9, however, showed Klebs-Loeffler bacilli and were
therefore considered to be cases of diphtheria.

We were able to diagnose three of these cases by direct smear
on slides as cases of diphtheria, the same as the culture growth.



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Online Libraryof Rhodes. Spurious works AndronicusThe American journal of obstetrics and diseases of women and children → online text (page 101 of 109)