TUBERCULOUS ADENITIS tuberculous adenitis in children will agree

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TUBERCULOUS ADENITIS tuberculous adenitis in children will agree Powered By Docstoc
					    THE RESPONSIBILITY OF THE TONSIL IN
          TUBERCULOUS ADENITIS.
                  BY FRANK S. MATHEWS, M.D.,
                                 OF NEW YORK,
  Associate Surgeon to St. Mary's Hospital for Children; Assistant Surgeon to the
                   General Memorial an4 St. Francis Hospitals.
    To attempt to prove that the gland at the angle of the jaw
may be infected with tuberculosis by way of the tonsil with
which it is in such immediate anatomical and physiological
relation would seem a demonstration of the obvious. No one
is likely to dispute it, but when we ask whether the tonsil is
the uniform, the occasional, or a rare source of cervical ade-
nitis, we may expect widely different opinions.
     For its frequent etiological relationship we have the fol-
lowing: Pathological conditions are frequent in children in
both tonsils and lymph-nodes. When the tonsil is inflamed
from any cause the tonsillar nodes at the angle of the jaw are
the first to enlarge. One familiar with the early stages of
tuberculous adenitis in children will agree that in at least
go per cent. of cases the first nodes to enlarge are these same
tonsillar nodes. Lymphatic anastomosis being very free, this
does not rule out the possibility of infection of these nodes
from a back tooth, the pharynx or the nasopharyngeal ade-
noids. Later in life infection of both tonsil and lymph-nodes
is less common. Wood, of Philadelphia, says on the basis of
personal observations, that the tonsils of consumptives show
evidence of tuberculosis in the vast majority of cases, though
the rest of mouth, nose, and pharynx does not. Dr. A. M.
Shrady, with a very long experience at the Seton Hospital for
Tuberculosis says it is a rare occurrence for consumptives to
develop clinical tuberculosis of the tonsil aird that they usually
die without clinical signs of infection of neck nodes. On the
other hand the infrequency of clinical tonsillar tuberculosis and
hitherto the almost uniform failure to demonstrate it micro-
scopically have made some question the etiological importance
-    27                                                                   753 C5C)
754                    FRANK S. MATHEWS.
of the 'tonsil in cervical tuberculosis. Other avenues of in-
fection are by no means wanting, such as gums, nose, and
pharynx, and even the skin of the face, lips, and scalp. In
the past ten years we have seen probably 25 cases of tubercu-
lous femoral adenitis result from scratches on the foot. One
child under six months of age had a tuberculous inguinal bubo
following a scratch with a diaper pin at the base of the penis.
These cases are mentioned simply to show that almost any
part of the body's surface may admit the bacillus. The writer
submits the results of the examination of sixty-five whole
tonsils recently removed. These. can be considered in three
groups:
    i. Fifty-seven tonsils removed for a variety of reasons
from children and embracing all types of tonsils. In none
of these patients was there reason to suspect tuberculosis in
the neck or other part of the body. None showed tuberculosis
on microscopic examination in the tonsil, i.e., there was no acci-
dental discovery of tubercle in a tonsil where it was not sus-
pected. This confirms the experience of others. Hodenpyl
examined several hundred tonsils without finding any tuber-
culous. Hurd quotes Wright as having examined 6o unse-
lected specimens without finding tubercle. Judd, of Rochester,
says that at the Mayo's Clinic only one or two tuberculous
tonsils have been found among some hundreds of tonsils sec-
tioned. In conversation one frequently hears it said as a piece
of common knowledge that tonsils removed for all causes are
found tuberculous in 5 to IO per cent. of cases. I am unable
to find who said it first and feel certain that it does not approxi-
mate the truth. With the uniform result of examinations
by Hodenpyl, Wright, the Rochester Clinic and myself we
feel safe in asserting that one is not likely to find the tonsil
harboring the tubercle bacillus without other manifestations
of tuberculosis in the body.
    2. Five tonsils showing well-defined tuberculous lesions
and all taken from children with recent tuberculous cervical
adenitis.
   CASE I.-A small collection of nodes at angle of left side of
jaw, largest hickory-nut sized. Left tonsil small. In it, several
          THE TONSIL IN TUBERCULOUS ADENITIS.                  755
 discrete scattered tubercles, few giant cells, just a suspicion of
central necrosis. A couple of tubercles located in the capsule of
the tonsil.
     CASE II.-Boy at Sea Breeze Hospital for Tuberculosis.
Adenitis has not been operated on. Has widely distributed
enlarged nodes in both sides of neck. Tonsils are peppered with
discrete miliary tubercles both near mouth surface and capsule.
No giant cells or necrosis.
    CASE III.-Age three years. A collar of enlarged nodes in
both sides of neck. Seem recent. Von Pirquet positive. Ton-
sil quite small. Small area in one tonsil shows giant cells with
peripheral nuclei and poorly defined epithelioid tubercles. After
removal of tonsils the glandular enlargement partly subsided and
child removed from hospital without operation upon the neck.
    CASE IV.-Already reported in ANNALS OF SURGERY, April,
I910, P. 577. The enlargement of neck nodes followed a ton-
sillotomy. Discrete typical miliary tubercles found in tonsillar
stumps.
    CASE V.-Child, age eight years. A few soft glands at angle
of jaw found to be tuberculous. The tonsil on the same side
as the nodes showed many typical miliary tubercles. The en-
largement of nodes was recent.

    3. Cases with tuberculous glands in neck but zwrithout tube.-
culosis in tonsil.
    CASE VI.-Child, age three. Glands in right side of neck of
one month duration. Von Pirquet positive. The largest node
is the tonsillar one, but the first one to enlarge was in front of
the submaxillary salivary gland and it was the only gland at oper-
ation which had gone to the stage of suppuration. Tonsils,
small, appear normal and no tuberculous lesions found in them.
In this case it would seem likely from location of swelling that
infection took place through lip, gum, or floor of the mouth.
    CASE VII.-Child. Tonsillar nodes enlarged. Also a large
soft node in the substance of the parotid gland just in front of
external auditory canal. Von Pirquet positive. Nodes proved
tuberculous. Tonsil without tuberculosis. The clinical evidence
would suggest that this was a case of scalp infection as the most
advanced tuberculous lesion was in a node well up in the parotid
gland.
756                   FRANK S. MATHEWS.
    CASE VIII.-Two good-sized tonsils not found to be tuber-
culous. Von Pirquet positive. A collection of nodes in right
tonsillar group of several months' standing proved to be tuber-
culous. In this case clinical evidence suggested tonsillar origin.
     As illustrating the probability with which we can infer the
point of infection from the location of the first involved node,
 we may mention the following case: A child, aged four, had
tuberculous nodes on the right side in the tonsillar and sub-
 maxillary region. A submaxillary node was suppurating.
There was a red spot on the upper gum, at the insertion of
the second incisor tooth, about one-fourth inch in diameter.
This little piece of gum was removed at the same time as the
nodes and showed typical tuberculous lesions. This is the
only case in which we have demonstrated a tuberculous gingi-
vitis as the starting point for tuberculous adenitis. In this
case the tonsils appeared normal and were not removed.
    There is an impression that the tubercle bacillus may pene-
trate the tonsil without producing any manifestations of its
presence and be carried through it to the neck nodes. So far
as I know, the only basis for the belief is one experiment by
Wood of Philadelphia on a pig. He rubbed tubercle bacilli
on the tonsil, killed the pig later and identified bacilli in the
cervical glands only-not in the tonsil.
    To sum up, 57 tonsils of patients not clinically tuberculous
show no tuberculous lesions. Of 8 patients with cervical
adenitis the tonsils are tuberculous in five. In two there is
evidence of other than tonsillar origin for the infection. In
one the adenitis was of long standing and may have been extra-
tonsillar in origin or slight tonsillar lesions may have escaped
observation.
    These results closely parallel those of Hurd. In an ex-
amination of ii tonsils from patients with tuberculous nodes
he found tuberculosis in the tonsil 8 times. In an examina-
tion of I3 tonsils of persons with slightly enlarged neck nodes,
not believed from clinical evidence to be tuberculous, only one
tonsil showed tubercle. In cases then where there is clinical
evidence that the tonsil is responsible for a tuberculous adenitis,
         THE TONSIL IN TUBERCULOUS ADENITIS.                757
both Hurd and myself have as a rule found tuberculous lesions
in the tonsil.
          CHARACTER OF TONSILLAR TUBERCULOSIS.
     Hurd has said that tuberculosis is to be found in the small
buried tonsils, not the large soft elevated ones. We may put
it in another way and say tuberculosis does not greatly enlarge
the tonsil. In none of our five have the tonsils been consider-
ably enlarged. The lesions as seen by the microscope have
shown considerable variation in type. For instance, giant cells
are in some few, in others abundant. In general we may say
that the lesions are scattered rather than confluent, ulceration
was never present and there was never more than a suggestion
of central necrosis. In other words, we see the early or cellu-
lar type of lesion rather than the late fibrous and necrotic.
The tubercles have been found both superficial and deep-
in one case even in the capsule.
     With a recognition of the frequency of tonsillar infection
we shall probably more frequently remove the tonsil in cases
of cervical adenitis than has been done in the past with the idea
of avoiding reinfection of neck nodes. That we have been
able to cure so large a per cent. of gland cases without remov-
ing the tonsil is simply another illustration, if one be needed,
that we do not cure surgical tuberculosis by removing every
single bacillus and lesion but by reducing the load of infection
with which the body must contend.
     If the tonsils and nodes are both to be removed, it would
not seem wise to attempt both at one sitting. Which shall be
done first will probably have to be decided on the merits of
each case. We have seen the nodes largely subside on removal
of the tonsils alone; in other cases the extensive involvement
of -uch nodes makes their removal much more important than
that of the tonsil.
     The material for this paper has mainly come from St.
 Mary's Hospital for Children. The pathological work has
 been done at the Laboratory of Surgical Pathology of Colum-
 bia University through the kindness of Dr. W. C. Clarke.