TUBERCULOUS ADENITIS.
Chronic inflammation of lymphatic glands may for all practical purposes be regarded as of tuberculous origin. The writer has endeavoured to show in his Cavendish Lecture for 1908 that the main source of the tubercle invasion is through the lymphatics and vessels of the intestine, the glands being ultimately reached by the main stream, and he has been able to eradicate the disease and successfully to protect the inmates of a large industrial school where tuberculous adenitis was always rife by a simple process of sterilising the milk-supply. Though protection of the intestinal route is of primary and vital importance, the physician will be s e before dealing with cervical lymphadenitis to examine the mouth for carious teeth, the middle ear for suppurative disease, and the pharynx for enlarged tonsils and adenoids. These conditions must first be remedied by surgical measures, and in a considerable percentage of cases resolution of the swollen glands may be expected. The infection under such circum stances is probably of a dual nature, and will subside upon removal of one of the infective agents. The constitutional treatment indicated in tuber culosis must be followed out. Where the cervical glands remain indolent with no tendency towards suppuration, various local procedures have been advocated.
The plan of applying a strong solution of Iodine (equal parts of the weak and strong tinctures) has still some advocates, and though now condemned by most surgeons it never can do any real harm, and in conjunction with other methods may well have a prolonged trial. The Lin. Pot. Iod. c. Sapone is not open to the objection of producing unsightly discoloration. Rest to the head and neck should as far as possible he secured. Injection into the glands of antiseptic solutions and pure Carbolic Acid should be avoided, as little benefit can follow and often suppuration results.
Vaccine treatment by minute doses of Tuberculin affords unquestion ably the best routine in all such cases, and it should be patiently employed in conjunction with the internal administration of Iodide of Iron and Cod-Liver Oil with open-air life and improved hygiene. Treatment by tuberculin has almost abolished from surgical practice that most disagree able of all operations—removal of tuberculous lymphatic glands of the neck. The writer accepts entirely Dr. Nathan Raw's view that surgical
tuberculosis is the result of infection, by the bovine bacillus, and hence Koch's Tuberculin R. (human) should he employed commencing with very small doses slowly increasing up to a maximum dose of r milligramme.
The writer has had very extensive experience of the results of excision carried out in the most skilful and thorough manner, and he has kept in touch with at least ioo cases where the operation has been faultlessly performed, and he has become convinced that the ultimate results are worse than have yet been realised by surgeons, who often lose sight of the patients after the immediately successful operation.
It cannot be denied that the danger to life occasioned by the presence of indolent tuberculous glands is a trifling one. The percentage of cases in which phthisis and bone involvement follow is very small. A somewhat parallel condition is observed in the graver condition of hip-joint disease, which is followed (when not treated by excision) by an astonishingly small percentage of lung involvement. The same holds true, but in a more remarkable degree, when the natural course of lupus is studied. 75 per cent. at least of all cases of excision of the cervical glands which the writer has watched over a period of 7 years has succumbed to pulmonary tuber culosis, and he believes that the time has come when this formidable operation should be abandoned unless under very exceptional conditions.
The only permanently successful cures which he has witnessed have occurred in cases where the tuberculous adenitis was of a very circum scribed nature, and where the disease was of very long standing. Under these conditions, combined with a high degree of unsightly deformity, there need be little hesitation in recommending a radical operation, hut where the entire glands of the neck are enlarged on both sides, and especially where there is axillary adenitis in conjunction with them, the operation should never be undertaken. Partial operations should also never be attempted; once the operation is commenced, every enlarged gland found present should be excised.