Scrofula and its gland diseases : an introduction to the general pathology of scrofula, with an account of the histology, diagnosis and treatment of its glandular affections

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HX64121828 RC295 .T72 Scrofula and its gla

Preface

I BELIEVE I am correct in stating that no special work on the subject of the general pathology of scrofula has appeared in the English language since the publication of the works of Benjamin Phillips, and Robert Glover in the year 1846, and no work on the subject of scrofulous gland disease since the appearance of Dr. Price's monograph in 1861. It must, at the same time, be allowed that scrofula is a disease of some importance, if on no other grounds than those of its frequent occurence and extensive distribution, and that the glandular disorders of the malady form one of the most common and most troublesome affections that come under the notice of the surgeon.

These two facts I offer as some reason for the appearance of this book at the present time.

The works of Phillips and Glover — admirable though they are — were not final as regards our knowledge of strumous processes. Since their publication immense progress has been made in pathological science, a revolution has been effected in the matter of microscopic research, and vast additions have been made to our clinical knowledge and our acquaintance with the life history of disease. In this progress and improvement scrofula has had but a somewhat niggardly share, and

Vi PREFACE.

the malady, so far as the literature of this country can show us, would appear to have been almost ignored, or dealt with only in a fragmentary manner. Among Continental surgeons and pathologists, however, the subject of scrofulosis has, of late years, received more manifest attention, with the result that the pathology of the disease has been almost reconstructed, its clinical outline more acutely denned, and a more distinct individuality given to the whole disease.

In the present volume I have made extensive use of the valuable material thus provided by the schools of Germany and France. I have endeavoured to give account of the most recent facts that have been brought forward in connection with this wide-spread affection, and the most recent theories that have been expressed as to its nature and relationships.

At the same time I must, in justice to myself, remark that the greater part of the material in this volume is the result of my own investigations into this disease. The clinical facts I have detailed are drawn from a careful examination of a very large number of scrofulous persons, and in such examination I have endeavoured to proceed free from the bias of any preconceived ideas. The opinions also that I have expressed as to the pathological bases of struma are, for the most part, founded upon my own observations ; and in the obtaining of material for such observations I have been veryfortunate. The account given of the minute changes in the glandular affections is based upon an examination of a great number of glands in various conditions, obtained from more than twenty patients, who, I think, collectively exhibited every aspect of the strumous process. Upon the matter of the treatment of scrofulous gland tumors I have bestowed much attention, and

PREFACE. V11

hope that my contributions to this branch of practical surgery will prove of some substantial value. The treatment of strumous gland affections is apt to be a little empirical, a little too exclusive, and, as a rule, very regardless of the fact that one favorite plan of treatment is not necssarily suitable for every phase and condition of a many-sided disease.

I must express my obligations to Dr. T. Smith Rovve, Mr. W. H. Thornton, and Mr. W. Knight Treves, the surgeons to the National Hospital for Scrofula at Margate (where I was for some time resident assistant), for permission to make use of the records of that Institution.

FREDERICK TREVES.

18 Gordon Square : November 1881.

Part I. The General Pathology Of Scrofula

CHAP. PAGE

I. Introductory.. . . . . . . . .it

II. Scrofula and Tubercle ...... 14

III. The Nature of Tubercle ...... 29

IV. The Inoculability of Tubercle 34

V. A Definition of Scrofula 40

VI, Scrofula and Phthisis, and the Antagonism between

Scrofulous Diseases 50

VII. Scrofula and Acute Miliary Tuberculosis. . . 62

VIII. The Etiology of Scrofula 64

IX. The Scrofulous Individual 79

Part II. Scrofulous Affections Of The External L Ympha Tic Glands

" A Scrofulous Gland " no

'.. An Outline of the Anatomy of the External Lymphatic Glands in x CONTENTS.

CHAP. PAGE

XI. The Etiology of Scrofulous Lymphatic Glands . 116

XII. The Pathology of Scrofulous Lymphatic Glands . 126

XIII. Symptoms and Diagnosis of Scrofulous Lymphatic

Glands 145

XIV. The Treatment of Scrofulous Lymphatic Glands . 159

SCROFULOUS LYMPHATIC GLANDS.

PART I.

THE GENERAL PATHOLOGY OF SCROFULA.

Chapter I. Introductory

It must be confessed that the pathology of scrofula is still very ill-defined. Our present knowledge of the disease is encumbered with the unwholesome remains of some centuries of vexed discussion. Since the earliest days of medicine vague ideas and conflicting views appear to have been bestowed upon this disease from time to time, until they have at last formed for it a kind of hereditary property that has slowly accumulated, and has been handed down to the present age with the preciseness of entail. Thus it happens that the scientific limits and outlines of the disease, called scrofula, are blurred and indistinct. Its proper position in the pathological scale is disputed and uncertain. Its relation to other morbid states is variously expressed ; and so broken up are opinions as to its nature that, unless a precise definition be given, the term " scrofula " becomes almost an untranslatable word, having a meaning only for the individual who uses it. To what varied conditions of health and to what different individuals does the term " a strumous child " apply ! How little some surgeons mean by the term, and how much is implied by its use by others ! And when we come to that nebulous person described by the term " slightly strumous," or alluded to as possessing " a touch of scrofula," a sense of utter vacuity is engendered which is almost

ii

12 INTRODUCTORY.

beyond the reach of scientific relief. No one would think of alluding to a " slightly cancerous person." Cancer exists in a patient or it exists not. It happens to be a distinct disease, and the term " slightly cancerous " would for that reason be ridiculous. Yet the " slightly strumous " are often before us, and they afford no slight indication of what clearness attaches to our present knowledge of the disease.

This lack of scientific limitation in the pathology of scrofula, and this cumbrous heritage of opposed opinions and diverse theories, appear to me to be to a great extent due to two causes, I. The difficulty of isolating scrofulous disease from the manifestations of mere ill-health, mere frailty of constitution. 2. The persistent attempt of most pathologists to find out some characteristic anatomical element, for every disease or diathesis they deal with, and not to remain satisfied until they have found such specific element. The first difficulty is purely clinical, the second has reference to pathological histology.

I. With regard to the clinical difficulty it must be remembered that there is still a wide area in medicine occupied by a class of unhealthy persons, whose morbid state is no more definitely expressed than by saying that they are delicate, of feeble constitution, of frail health. As knowledge advances this area becomes more and more limited. Indeed, it exists but as an evidence of imperfect knowledge and of indistinct notions of morbid change. This condition, known merely as the condition of delicate health, is a blank in medicine ; a state of disease without a pathology and without any scientific position. As our acquaintance with disease increases, first one portion and then another of this common and untenanted ground is absorbed, now by one affection, now by another. Some children once classed with the simply delicate are now perhaps known to be the subjects of hereditary syphilis, of ill-defined rickets, or of some hereditary conditions that have now become better known. And so long as there exists a class of individuals whose deviation from the normal state can be expressed in no clearer terms than that they are " deli-

INTRODUCTORY. 1 3

cate " and " of feeble constitution," so long must medical knowledge be considered incomplete. Scrofula has been bounded extensively by this chaotic district, and from time immemorial there has been a reciprocity between them. It is no wonder then if the limits of the disease have been ever confused and fluctuating. In less modern times any chronic state of ill-health was accredited to scrofula, and even now this tendency is not quiteextinguished. As Henle* well remarks, " Scrofula is the receptacle into which one vaguely casts all the ailment:, which afflict children under fourteen years, and of which we do not know the cause." Before hereditary syphilis was understood all its manifestations were classed as scrofulous ; rickets also was a strumous disease, as was also chronic hydrocephalus. Lugol,f still more generous, mentions favus, lice, and worms as scrofulus disorders. Carmichael ^ discovered that. scrofula and diabetes were allied ; while Hamilton § observes, " I never knew a scirrhus or a cancer take place but in a scrofulous habit."

2. The second cause for the unstable position of scrofula in general pathology depends upon an ancient impression that every disease or diathesis must have some specific anatomical feature associated with it. The outcome of this impression has brought into the field the subject of tuberculosis. Since tubercle was first described its fortunes and those of scrofula have been linked together. In all its changes, in all its losses, in all the false positions into which it has been thrust first by one pathologist and then by another scrofula has had a share. Scrofula at one time posed as a tubercular process, tubercle at another has been described as a scrofulous process. Once more, the two conditions have been quite distinct and have even been antagonistic ; and lastly, they have been identical and with no

f ' ' Researches and Observations on the Causes of Scrofulous Diseases." Translated by W. H. Ranking. London, 1844.

\ "On the Nature of Scrofula," by Richard Carmichael. London, 1810, p. 21.

§'• Observations'on Scrofulous Affections," by R. Hamilton, M. D. London, 1791, p." 65.

line of separation between them. The very term " tubercle " has experienced a violent series of fluctuations. It has been applied first to one appearance and then to another ; its limits have been terribly curtailed ; vaunted specific features have one by one been removed from it, until it must be owned that the tubercle of today is but a poor and bald affair as compared with the tubercle of the time of Laennec.

The forced association of scrofula, therefore, with this vague pathological element, the very Proteus of pathology, can in some way account for the uncertain position the disease has occupied from time to time, and for the somewhat indefinite outlines it still retains. At the same time it must be owned that much good has been done by the extensive investigations that have been pursued on the subject of tubercle, although the,y have tended a little too much towards an attempt to demonstrate a specific element for a certain class of disease. Thus it happens that few additions to our knowledge of the histology of so-called tubercular affections have been made that have not been seriously burdened by theoretical matter. New facts have been immediately hampered with some new theory or some old dogma, and the results of pure investigation have often been lessened in value by speculation and conjecture. These difficulties, clinical and pathological, while they can perhaps explain the vagueness that still marks the scrofulous process, may indicate the direction it would be well to pursue in any subsequent inquiries.

Chapter II. Scrofula And Tubercle

Inasmuch as scrofula is so closely bound up with the subject of tuberculosis, the first point to be considered in discussing the pathology of the former disease is the nature of tubercle and its relations to the scrofulous

SCROFULA AND TUBERCLE. I 5

process. It is obvious that no definition of scrofula can be attempted until this relationship has been clearly set forth.

The term " tubercle " was originally applied to a certain nakecj eye appearance, to little distinct specks or spots of diseased tissue that were conspicuous as nodules or tubercles. When first used the term " tubercles " had no more clinical significance than has the term "nodular;" and it is remarkable to note how in time a clinical meaning of the most emphatic character attached itself to the term, and has since clung to it. So close is this connection that it is almost impossible to separate certain anatomical appearances from certain clinical conditions ; and no matter to what structural change the word tubercle is, or has been, applied, there still lurks behind it a subtle suggestion of a distinct clinical state, known as the tubercular condition. The term was for a time applied to many states of tissue, that although anatomically different, yet possessed the common feature of being nodular in outline. A better restriction of the word was arrived at when it was set forth that some of these nodules were grey and clear, while others were yellow and opaque. Thus arose a division of tubercle into the grey and the yellow varieties. The yellow, or so-called crude, tubercles were for the most part caseous masses, or at least masses advanced in that decay ; and they had soon to be eliminated from the domain of tubercle when it was shown that caseation was by no means limited to what was known as the tubercular process. With regard to the other tubercles, the grey variety, it was found that such nodules when met with in the lung were often made up solely of little masses of alveolar epithelium, the results of a lobular catarrh. All such nodules, therefore, had to be eliminated, and still finer distinctions laid down as characteristic of tubercle. The term was then restricted to such grey semi-transparent bodies as were not merely masses of catarrhal exudation, and that, while retaining the size of a millet seed, were hard and firm. These tubercles, it was noted, in time became opaque in the centre and then wholly caseous, and had l6 SCROFULA AND TUBERCLE.

a tendency to fuse together and form larger masses. The name of miliary tubercle was given to them, and in the disease known as acute miliary tuberculosis they were considered to be met with in perfection. In time, however, certain tissue changes were noted, which were regarded as tubercular, but which were not associated with the appearance of these distinct grey masses. In the place of such masses certain microscopic nodules alone were detected that were found to possess a fairly simple structure ; and as it was observed that certain of the grey miliary tubercles, visible to the naked eye, were simply made up of a collection of these microscopic nodules, the latter were distinguished by the term submiliary tubercle. It must be owned that for a long while the microscopic features of tubercle were very indefinite and confused, and it was not until this finer restriction of the word was adopted that anything like uniformity was obtaintd in histological descriptions. These little microscopic nodules were found to be of common occurrence, and capable of undergoing the final degenerative process, without having first formed themselves into the larger masses known as miliary tubercles. It is to these microscopic nodules only that the bare term "tubercle" is, in its strictest sense, now applied. Thus it will be seen that the anatomical ground on which tubercle rests has been from time to time curtailed, and that the large basis it originally possessed has been cut down at last to a very minute point. This submiliary mass, this ultimate tubercle has been described by many observers, and has received many names ; but although the terms used differ, and although some descriptions are a trifle modified from the rest, yet there is so much general accord that pathologists of the present day appear to be at least agreed as to what tubercle looks like, even if they disagree as to what it is. It must be understood that tubercle in its simplest sense refers to the most typical stage of a certain tissue change, and that to the process that preceeds its appearance, as well as to that that follows, the term tubercular can be applied.

Histology of Tubercle. — This simple submiliary tubercle has been described under many names, as " primitive or elementary tubercle" by Koster, as "tubercular follicle" by Charcot, as "reticular tubercle" by E. Wagner. All these terms may be regarded as synonymous. The structure of such a tubercle is this :

It is composed of a mass having a fairly rounded outline, and made up principally of cells. These cells are so arranged as to form in typical specimens three zones. The central part is occupied by one or more giant cells, round this is a zone of many so-called epithelioid cells, and beyond this is a third zone of simple embryonic cells or leucocytes. All these cell elements are supported by a fine reticulum, which is generally concentrically arranged at the periphery, and towards the centre is observed to be continuous with the processes that commonly come off from the giant cells. The affected district is non-vascular. Such is a typical tubercle. Modifications of structure are, however, permitted. The giant cell may occupy the periphery, or may be entirely absent, in which case the appearance is supposed to be maintained by the character of the cells in the mass, their obvious changes, and their general arrangement. The giant cell, although not specific of tubercle, is usually present, and if any differentiation is adopted with regard to terms, the term "follicular or reticular tubercle " would apply to the perfectly developed mass, the terms " elementary or primitive tubercle " to those nodues that show less perfect evolution, and possess perhaps no giant cell.* As to the structural origin of tubercle it will be easily understood that great diversity of opinion exists. Some hold that it is developed from connective tissue, and is a connective tissue growth ;f others, that it is essentially a lymphoid or adenoid structure.;}; Some observers — and among them Cornil and Ranvier§ — refer its origin to

* For a brief but excellent account of the grades of tubercle, see Art. by Dr. Grancher in "L'Union Medicale," vol.' xxxi 18S1, p. 873.

f See exposition of this view, by Dr. D. J. Hamilton. " Practitioner," August 188 1.

% "On the Artificial Production of Tubercle," by Dr. Wilson Fox. London, 1868, p. 25,

§ " Manuel d'Histologie pathologique. Paris 1881, vol. i. p. 236. 2 the vessels of the part, and state that a coagulum forms in the blood capillary, the endothelium of whose wall vigorously proliferates, so that on section the coagulum is seen to form the mass of a giant cell, and the proliferated endothelium its many nuclei. If the vessels be larger changes take place in its walls, and the various zones of the tubercle are then considered to correspond to the various tunics of the artery.* Others, again, regard the giant cell as a protoplasmic mass, and consider that it indicates a return of the tissue to a more embryonic state.f Those who hold this view -believe that all gradations can be observed between the epithelioid cells and the leucocytes on the one hand, and the giant cells on the other. Lastly, among other views may be noted one that applies only to the lung, and is to the effect that these giant cells are formed by the fusion of the epithelial cells of the lung alveoli.;}: These — although but a few of the theories that have been advanced — are perhaps the most representative, and will be more fully discussed in the chapter on the Pathology of Scrofulous Glands.

Such being tubercle, the first question to be asked is this — Does this tubercle present any specific anatomical element ? It assuredly does not. Lebert§ some years ago endeavored to establish the specific character of certain cells in tubercle, the so-called " tubercle corpuscles," but his conclusions were soon found to be erroneous ; and indeed these " corpuscles" were none other than shrivelled cells, not distinguishable from shrivelled pus corpuscles. Schuppel,| again, in more recent times endeavored to maintain the specific character of the giant cell, and urged that this structure was peculiar to tubercle, and indeed diagnostic of it. This argument

* M. Kiener. "Discussion before La Societe Medicale des hopitaux. L'Union Medicale," vol. xxxi. 1881, p. 316.

f See on this point " Epeer. Untersuch. uber die Herkunft der Tuberkelelemente," etc. Wurburg, 1875, by E. Ziegler.

X Dr. E. Klein. " The Anatomy of the Lymphatic System — The Lung." London, 1875, p. 76.

8 " Physiologie Pathologique. Paris, 1845.

has, however, been overthrown, and it is now known that giant cells are to be met with under the most varied circumstances and in conditions that could in no way be termed tubercular. Thus they have been found in simple chronically inflamed connective tissue, in chronic ulcers, in gummata, in erosions of the os uteri,* and in many other parts and tissues. Although giant cells cannot be regarded as special to tubercle, yet it must be owned that they are not commonly met with unassociated with that product. The anatomical individuality of tubercle therefore depends upon no especiai factor or element, but must rest upon the general conformation of the mass, the grouping of its parts, the relation it holds to the tissues around, and above all to its history, its tendencies, its peculiar progress. The most remarkable features of the nodule are perhaps its early non-vascularity, its tendency to caseation, its aptitude for spreading locally and, under certain conditions, generally, and its action when inoculated experimentally in animals. Other points in the history of tubercle will be considered subsequently.

Scrofula and Tubercle. — The ground is now prepared for a discussion of the relations between scrofula and tubercle. As a preliminary step some definite meaning must, for the purpose of this discussion, be attached to the terms " scrofulous " and " tuberculous." It is obvious that at the present stage of the enquiry those terms cannot be used in an anatomical sense, and must therefore be applied temporarily to certain clinical conditions. For the present purpose then the terms " tuberculosis " and " tuberculous " will be considered as applying to such diseases as acute miliary tuberculosis, tubercular peritonitis, tubercular meningitis, and the term " scrofulous " to those diseases commonly known by that name, as, for example, glandular enlargements, certain chronic bone and joint affections, cold abscess, certain ulcers and eruptions of the skin and mucuous membranes.

It would be well to omit phthisis from either cate-

gory, as it will be separately discussed by-and bye. Is tubercle- — as just described — met with in scrofulous affections ? To this question an affirmative answer must most certainly be given. In scrofulous lymphatic glands the most perfect and most typical tubercle is to be met with; in the synovial membrane, and in the bone' in cases of so-called strumous joint disease perfect tubercle has been discovered. Dr. Lannelongue has lately shown the origin of cold abscess from tubercular deposit, and demonstrated the progress of such abscesses by extension of the so-called tuberculous process. Tubercle also is to be found in the floor of scrofulous ulcers, in lupus, in certain affections of the mucous membrane, and in other parts. If this be the case there would appear to be no difficulty in establishing the fact that scrofula is what is termed anatomically a tubercular process. But this proposition is not so simple as it seems, and much of the difficulty that surrounds it is due to the severe and definite clinical meaning that attaches to the term proposed. In the first place, these tubercles are not met with in all scrofulous affections. In the superficial skin eruptions, in some of the more common affections of the mucous membranes, and in many typically scrofulous glands, no tubercle is to be met with. And, again, the presence of tubercle has not been demonstrated in all cases of disease of bone and joint observed in the scrofulous. Thus it happens that some pathologists would limit the term " scrofulous " to those affections only that present no tubercle,' and reserve for the rest the term "tuberculous." It is chiefly with regard to the lymphatic glands that this division of disease has been urged, and by no one more vigorously than by Cornil.* But it must be remembered that there are grades and degrees in the tubercular process, just as there are varieties and degrees of inflammatory action. In some cases the tubercular action — if I may be allowed the term — does not proceed so far as the formation of tubercle, just as all inflammations do not

* Jotirnal de V anatomie ~et de la pkysiohgie (Charles Robin). Paris, 1878, No. 3.

always proceed to the formation of pus. At any point in the tubercle-producing process the action may end and caseation set in.

Many scrofulous glands caseate without developing any tubercle, but in the process that precedes such caseation one recognizes a state that is at least preliminary to the formation of the nodule, a pre-tubercular state as it may be termed. Tubercle is the most finished structural change of a certain process, and such dipfriodc d'ttat may never be reached in a vast number of strumous disorders. Now it appears unreasonable to make a conspicuous division between these two grades of gland affection — the gland that shows tubercle and the gland that just falls short of that product. They are both essentially tubercular, and terms should not be applied to their morbid conditions that would indicate more than differences in degree. But those who assert the distinction of scrofula from tuberculosis term those glands that show perfect tubercle tuberculous, and those that present only the immature structure scrofulous. This use of terms would not be objectionable had it only an anatomical basis, and did not a very rigorous clinical meaning associate itself with these two adjectives. Cornil, and those who follow his teaching, do not limit themselves to structural differences, but lay down clear clinical distinctions between the scrofulous and the tubercular gland. As regards at least the external glands — and it is with these that we are now most concerned — I must assert that these clinical distinctions are not clearly marked and can hardly be maintained. I own that there are affections of internal glands (those of the mesentery, for example) that present perfect tubercle, and yet follow a course so distinctive and often so detrimental that they are clinically removed from the category of what is commonly known as scrofula. Such glands, however, differ from the simply scrofulous — to use that term in its usual sense — only in degree, and the evils that attend their development depends mainly upon the cause and locality of the disease.

It will be said that all this is merely a matter of terms, It is so ; but certain circumstances conspire to make it also a matter of importance. The term " tubercular" is used in a double sense. It is applied to an anatomical condition — to any disease presenting perfect tubercle — and it is also applied to certain clinical states. Unfortunately these two conditions do not quite coincide and the presence of tubercle does not, of necessity, imply that grave state of health associated with the word " tuberculosis." Tubercle has to a great degree been discussed in connection with acute miliary tuberculosis and certain lethal lung affectioms ; and from ancient custom or ancient bias it has somehow become associated with all the grave clinical import of these diseases. This is much to be regretted, and constitutes a bias of evil consequence. In a little patch of lupus on the face perfect tubercle may be found. Is a patient so affected to be called tuberculous in the usual clinical sense ? Is he likely to die of some acute and sudden tubercular mischief? Is he not, on the contrary, as likely to attain old age as is the majority of other persons ? One can quite understand from a case such as this the vigor with which the application of the term tuberculous to such a disease would be combated. Perfect tubercle is met with in lymphatic glands, but such glands after a time may eliminate the disease and a cure result followed by no bad consequence. Leaving even scrofulous affections, one finds tubercle in other diseases quite remote from any clinical association with tuberculosis. Koster has described miliary tubercle in osteo-myelitis, in chronic pericarditis, in the primary syphilitic sore, in elephantiasis of the labia, and in other conditions. To apply the clinical term " tuberculous " to such cases would simply be ridiculous. This injurious use of the term proceeds, I imagine, to a great degree from the general attempt to associate every diathesis and disease with some specific anatomical element. The logic has been as follows : Tubercles are found in acute miliary tuberculosis and other fatal diseases ; these diseases are called tuberculous, therefore every other disease that presents tubercle must also be tuberculous.

As M. Ferrand * well observes, " tubercle does not constitute a disease any more than does suppuration." It is the exclusive indication of no one malady and the outcome of no one special state of defective health. Although one recognizes the fact that tubercle appears in scrofula, yet one is positively loth to term scrofula a tuberculous disease ; and I would almost go so far as to say that it would be well not to call it a tuberculous disease, until the bias associated with the latter term has been removed, until that term is accepted in a more generous and rational sense, and until it ceases to attempt to force an alliance between an anatomical appearance and a clinical state.