Manual of Surgery/Chapter XV

CHAPTER XV

THE LYMPH VESSELS AND GLANDS

Anatomy and Physiology--INJURIES OF LYMPH VESSELS--_Wounds of

   thoracic duct_--DISEASES OF LYMPH VESSELS--Lymphangitis:
   _Varieties_--Lymphangiectasis--Filarial
   disease--Lymphangioma--DISEASES OF LYMPH
   GLANDS--Lymphadenitis: _Septic_; _Tuberculous_;
   _Syphilitic_--Lymphadenoma--Leucocythaemia--TUMOURS.

1. Surgical Anatomy and Physiology.#--Lymph is essentially blood plasma,

which has passed through the walls of capillaries. After bathing and nourishing the tissues, it is collected by lymph vessels, which return it to the blood stream by way of the thoracic duct. These lymph vessels take origin in the lymph spaces of the tissues and in the walls of serous cavities, and they usually run alongside blood vessels--_perivascular lymph vessels_. They have a structure similar to that of veins, but are more abundantly provided with valves. Along the course of the lymph trunks are the _lymph glands_, which possess a definite capsule and are composed of a reticulated connective tissue, the spaces of which are packed with leucocytes. The glands act as filters, arresting not only inert substances, such as blood pigment circulating in the lymph, but also living elements, such as cancer cells or bacteria. As it passes through a gland the lymph is brought into intimate contact with the leucocytes, and in bacterial infections there is always a struggle between the organisms and the leucocytes, so that the glands may be looked upon as an important line of defence, retarding or preventing the passage of bacteria and their products into the general circulation. The infective agent, moreover, in order to reach the blood stream, must usually overcome the resistance of several glands.

Lymph glands are, for the most part, arranged in groups or chains, such as those in the axilla, neck, and groin. In any given situation they vary in number and size in different individuals, and fresh glands may be formed on comparatively slight stimulus, and disappear when the stimulus is withdrawn. The best-known example of this is the increase in the number of glands in the axilla which takes place during lactation; when this function ceases, many of the glands become involuted and are transformed into fat, and in the event of a subsequent lactation they are again developed. After glands have been removed by operation, new ones may be formed.

The following are the more important groups of glands, and the areas drained by them in the head and neck and in the extremities.

1. Head and Neck.#--_The anterior auricular (parotid and pre-auricular)

glands_ lie beneath the parotid fascia in front of the ear, and some are partly embedded in the substance of the parotid gland; they drain the parts about the temple, cheek, eyelids, and auricle, and are frequently the seat of tuberculous disease. _The occipital gland_, situated over the origin of the trapezius from the superior curved line, drains the top and back of the head; it is rarely infected. _The posterior auricular (mastoid) glands_ lie over the mastoid process, and drain the side of the head and auricle. These three groups pour their lymph into the superficial cervical glands. _The submaxillary_--two to six in number--lie along the lower order of the mandible from the symphysis to the angle, the posterior ones (paramandibular) being closely connected with the submaxillary salivary gland. They receive lymph from the face, lips, floor of the mouth, gums, teeth, anterior part of tongue, and the alae nasi, and from the pre-auricular glands. The lymph passes from them into the deeper cervical glands. They are frequently infected with tubercle, with epithelioma which has spread to them from the mouth, and also with pyogenic organisms. _The submental glands_ lie in or close to the median line between the anterior bellies of the digastric muscles, and receive lymph from the lips. It is rare for them to be the seat of tubercle, but in epithelioma of the lower lip and floor of the mouth they are infected at an early stage of the disease. _The supra-hyoid gland_ lies a little farther back, immediately above the hyoid bone, and receives lymph from the tongue. _The superficial cervical (external jugular) glands_, when present, lie along the external jugular vein, and receives lymph from the occipital and auricular glands and from the auricle. _The sterno-mastoid glands_--glandulae concatinatae--form a chain along the posterior edge of the sterno-mastoid muscle, some of them lying beneath the muscle. They are commonly enlarged in secondary syphilis. _The superior deep cervical (internal jugular) glands_--from six to twenty in number--form a continuous chain along the internal jugular vein, beneath the sterno-mastoid muscle. They drain the various groups of glands which lie nearer the surface, also the interior of the skull, the larynx, trachea, thyreoid, and lower part of the pharynx, and pour their lymph into the main trunks at the root of the neck. Belonging to this group is one large gland (the tonsillar gland) which lies behind the posterior belly of the digastric, and rests in the angle between the internal jugular and common facial veins. It is commonly enlarged in affections of the tonsil and posterior part of the tongue. In the same group are three or four glands which lie entirely under cover of the upper end of the sterno-mastoid muscle, and surround the accessory nerve before it perforates the muscle. The deep cervical glands are commonly infected by tubercle and also by epithelioma secondary to disease in the tongue or throat. _The inferior deep cervical (supra-clavicular) glands_ lie in the posterior triangle, above the clavicle. They receive lymph from the lowest cervical glands, from the upper part of the chest wall, and from the highest axillary glands. They are frequently infected in cancer of the breast; those on the left side also in cancer of the stomach. The removal of diseased supra-clavicular glands is not to be lightly undertaken, as difficulties are liable to ensue in connection with the thoracic duct, the pleura, or the junction of the subclavian and internal jugular veins. _The retro-pharyngeal glands_ lie on each side of the median line upon the rectus capitis anticus major muscle and in front of the pre-vertebral layer of the cervical fascia. They receive part of the lymph from the posterior wall of the pharynx, the interior of the nose and its accessory cavities, the auditory (Eustachian) tube, and the tympanum. When they are infected with pyogenic organisms or with tubercle bacilli, they may lead to the formation of one form of retro-pharyngeal abscess.

1. Upper Extremity.#--_The epi-trochlear and cubital glands_ vary in

number, that most commonly present lying about an inch and a half above the medial epi-condyle, and other and smaller glands may lie along the medial (internal) bicipital groove or at the bend of the elbow. They drain the ulnar side of the hand and forearm, and pour their lymph into the axillary group. The epi-trochlear gland is sometimes enlarged in syphilis. _The axillary glands_ are arranged in groups: a central group lies embedded in the axillary fascia and fat, and is often related to an opening in it; a posterior or subscapular group lies along the line of the subscapular vessels; anterior or pectoral groups lie behind the pectoralis minor, along the medial side of the axillary vein, and an inter-pectoral group, between the two pectoral muscles. The axillary glands receive lymph from the arm, mamma, and side of the chest, and pass it on into the lowest cervical glands and the main lymph trunk. They are frequently the seat of pyogenic, tuberculous, and cancerous infection, and their complete removal is an essential part of the operation for cancer of the breast.

1. Lower Extremity.#--_The popliteal glands_ include one superficial gland

at the termination of the small saphenous vein, and several deeper ones in relation to the popliteal vessels. They receive lymph from the toes and foot, and transmit it to the inguinal glands. _The femoral glands_ lie vertically along the upper part of the great saphenous vein, and receive lymph from the leg and foot; from them the lymph passes to the deep inguinal and external iliac glands. The femoral glands often participate in pyogenic infections entering through the skin of the toes and sole of the foot. _The superficial inguinal glands_ lie along the inguinal (Poupart's) ligament, and receive lymph from the external genitals, anus, perineum, buttock, and anterior abdominal wall. The lymph passes on to the deep inguinal and external iliac glands. The superficial glands through their relations to the genitals are frequently the subject of venereal infection, and also of epithelioma when this disease affects the genitals or anus; they are rarely the seat of tuberculosis. _The deep inguinal glands_ lie on the medial side of the femoral vein, and sometimes within the femoral canal. They receive lymph from the deep lymphatics of the lower limb, and some of the efferent vessels from the femoral and superficial inguinal glands. The lymph then passes on through the femoral canal to the external iliac glands. The extension of malignant disease, whether cancer or sarcoma, can often be traced along these deeper lymphatics into the pelvis, and as the obstruction to the flow of lymph increases there is a corresponding increase in the swollen dropsical condition of the lower limb on the same side.

The glands of the _thorax_ and _abdomen_ will be considered with the surgery of these regions.

INJURIES OF LYMPH VESSELS

Lymph vessels are divided in all wounds, and the lymph that escapes from them is added to any discharge that may be present. In injuries of larger trunks the lymph may escape in considerable quantity as a colourless, watery fluid--_lymphorrhagia_; and the opening through which it escapes is known as a _lymphatic fistula_. This has been observed chiefly after extensive operation for the removal of malignant glands in the groin where there already exists a considerable degree of obstruction to the lymph stream, and in such cases the lymph, including that which has accumulated in the vessels of the limb, may escape in such abundance as to soak through large dressings and delay healing. Ultimately new lymph channels are formed, so that at the end of from four to six weeks the discharge of lymph ceases and the wound heals.

_Lymphatic Oedema._--When the lymphatic return from a limb has been seriously interfered with,--as, for example, when the axillary contents has been completely cleared out in operating for cancer of the breast,--a condition of lymphatic oedema may result, the arm becoming swollen, tight, and heavy.

Various degrees of the conditions are met with; in the severe forms, there is pain, as well as incapacity of the limb. As in ordinary oedema, the condition is relieved by elevation of the limb, but not nearly to the same degree; in time the tissues become so hard and tense as scarcely to pit on pressure; this is in part due to the formation of new connective tissue and hypertrophy of the skin; in advanced cases there is a gradual transition into one form of elephantiasis.

Handley has devised a method of treatment--_lymphangioplasty_--the object of which is to drain the lymph by embedding a number of silk threads in the subcutaneous cellular tissue.

1. Wounds of the Thoracic Duct.#--The thoracic duct usually opens at the

angle formed by the junction of the left internal jugular and subclavian veins, but it may open into either of these vessels by one or by several channels, or the duct may be double throughout its course. There is a smaller duct on the right side--the right lymphatic duct. The duct or ducts may be displaced by a tumour or a mass of enlarged glands, and may be accidentally wounded in dissections at the root of the neck; jets of milky fluid--chyle--may at once escape from it. The jets are rhythmical and coincide with expiration. The injury may, however, not be observed at the time of operation, but later through the dressings being soaked with chyle--_chylorrhoea_. If the wound involves the only existing main duct and all the chyle escapes, the patient suffers from intense thirst, emaciation, and weakness, and may die of inanition; but if, as is usually the case, only one of several collateral channels is implicated, the loss of chyle may be of little moment, as the discharge usually ceases. If the wound heals so that the chyle is prevented from escaping, a fluctuating swelling may form beneath the scar; in course of time it gradually disappears.

An attempt should be made to close the wound in the duct by means of a fine suture; failing this, the duct must be occluded by a ligature as if it were a bleeding artery. The tissues are then stitched over it and the skin wound accurately closed, so as to obtain primary union, firm pressure being applied by dressings and an elastic webbing bandage. Even if the main duct is obliterated, a collateral circulation is usually established. A wound of the right lymphatic duct is of less importance.

_Subcutaneous rupture of the thoracic duct_ may result from a crush of the thorax. The chyle escapes and accumulates in the cellular tissue of the posterior mediastinum, behind the peritoneum, in the pleural cavity (_chylo-thorax_), or in the peritoneal cavity (_chylous ascites_). There are physical signs of fluid in one or other of these situations, but, as a rule, the nature of the lesion is only recognised when chyle is withdrawn by the exploring needle.

DISEASES OF LYMPH VESSELS

1. Lymphangitis.#--Inflammation of peripheral lymph vessels usually

results from some primary source of pyogenic infection in the skin. This may be a wound or a purulent blister, and the streptococcus pyogenes is the organism most frequently present. _Septic_ lymphangitis is commonly met with in those who, from the nature of their occupation, handle infective material. A _gonococcal_ form has been observed in those suffering from gonorrhoea.

The inflammation affects chiefly the walls of the vessels, and is attended with clotting of the lymph. There is also some degree of inflammation of the surrounding cellular tissue--_peri-lymphangitis_. One or more abscesses may form along the course of the vessels, or a spreading cellulitis may supervene.

The _clinical features_ resemble those of other pyogenic infections, and there are wavy red lines running from the source of infection towards the nearest lymph glands. These correspond to the inflamed vessels, and are the seat of burning pain and tenderness. The associated glands are enlarged and painful. In severe cases the symptoms merge into those of septicaemia. When the deep lymph vessels alone are involved, the superficial red lines are absent, but the limb becomes greatly swollen and pits on pressure.

In cases of extensive lymphangitis, especially when there are repeated attacks, the vessels are obliterated by the formation of new connective tissue and a persistent solid oedema results, culminating in one form of elephantiasis.

_Treatment._--The primary source of infection is dealt with on the usual lines. If the lymphangitis affects an extremity, Bier's elastic bandage is applied, and if suppuration occurs, the pus is let out through one or more small incisions; in other parts of the body Klapp's suction bells are employed. An autogenous vaccine may be prepared and injected. When the condition has subsided, the limb is massaged and evenly bandaged to promote the disappearance of oedema.

_Tuberculous Lymphangitis._--Although lymph vessels play an important role in the spread of tuberculosis, the clinical recognition of the disease in them is exceptional. The infection spreads upwards along the superficial lymphatics, which become nodularly thickened; at one or more points, larger, peri-lymphangitic nodules may form and break down into abscesses and ulcers; the nearest group of glands become infected at an early stage. When the disease is widely distributed throughout the lymphatics of the limb, it becomes swollen and hard--a condition illustrated by lupus elephantiasis.

_Syphilitic lymphangitis_ is observed in cases of primary syphilis, in which the vessels of the dorsum of the penis can be felt as indurated cords.

In addition to acting as channels for the conveyance of bacterial infection, _lymph vessels frequently convey the cells of malignant tumours_, and especially cancer, from the seat of the primary disease to the nearest lymph glands, and they may themselves become the seat of cancerous growth forming nodular cords. The permeation of cancer by way of the lymphatics, described by Sampson Handley, has already been referred to.

1. Lymphangiectasis# is a dilated or varicose condition of lymph vessels.

It is met with as a congenital affection in the tongue and lips, or it may be acquired as the result of any condition which is attended with extensive obliteration or blocking of the main lymph trunks. An interesting type of lymphangiectasis is that which results from the presence of the _filaria Bancrofti_ in the vessels, and is observed chiefly in the groin, spermatic cord, and scrotum of persons who have lived in the tropics.

_Filarial disease in the lymphatics of the groin_ appears as a soft, doughy swelling, varying in size from a walnut to a cocoa-nut; it may partly disappear on pressure and when the patient lies down.

The patient gives a history of feverish attacks of the nature of lymphangitis during which the swelling becomes painful and tender. These attacks may show a remarkable periodicity, and each may be followed by an increase in the size of the swelling, which may extend along the inguinal canal into the abdomen, or down the spermatic cord into the scrotum. On dissection, the swelling is found to be made up of dilated, tortuous, and thickened lymph vessels in which the parent worm is sometimes found, and of greatly enlarged lymph glands which have undergone fibrosis, with giant-cell formation and eosinophile aggregations. The fluid in the dilated vessels is either clear or turbid, in the latter case resembling chyle. The affection is frequently bilateral, and may be associated with lymph scrotum, with elephantiasis, and with chyluria.

The _diagnosis_ is to be made from such other swellings in the groin as hernia, lipoma, or cystic pouching of the great saphenous vein. It is confirmed by finding the recently dead or dying worms in the inflamed lymph glands.

_Treatment._--When the disease is limited to the groin or scrotum, excision may bring about a permanent cure, but it may result in the formation of lymphatic sinuses and only afford temporary relief.

1. Lymphangioma.#--A lymphangioma is a swelling composed of a series of

cavities and channels filled with lymph and freely communicating with one another. The cavities result either from the new formation of lymph spaces or vessels, or from the dilatation of those which already exist; their walls are composed of fibro-areolar tissue lined by endothelium and strengthened by non-striped muscle. They are rarely provided with a definite capsule, and frequently send prolongations of their substance between and into muscles and other structures in their vicinity. They are of congenital origin and usually make their appearance at or shortly after birth. When the tumour is made up of a meshwork of caverns and channels, it is called a _cavernous lymphangioma_; when it is composed of one or more cysts, it is called a _cystic lymphangioma_. It is probable that the cysts are derived from the caverns by breaking down and absorption of the intervening septa, as transition forms between the cavernous and cystic varieties are sometimes met with.

The _cavernous lymphangioma_ appears as an ill-defined, soft swelling, presenting many of the characters of a subcutaneous haemangioma, but it is not capable of being emptied by pressure, it does not become tense when the blood pressure is raised, as in crying, and if the tumour is punctured, it yields lymph instead of blood. It also resembles a lipoma, especially the congenital variety which grows from the periosteum, and the differential diagnosis between these is rarely completed until the swelling is punctured or explored by operation. If treatment is called for, it is carried out on the same lines as for haemangioma, by means of electrolysis, igni-puncture, or excision. Complete excision is rarely possible because of the want of definition and encapsulation, but it is not necessary for cure, as the parts that remain undergo cicatrisation.

[Illustration: FIG. 76.--Congenital Cystic Tumour or Hygroma of Axilla.

(From a photograph lent by Dr. Lediard.)]

The _cystic lymphangioma_, _lymphatic cyst_, or _congenital cystic hygroma_ is most often met with in the neck--_hydrocele of the neck_; it is situated beneath the deep fascia, and projects either in front of or behind the sterno-mastoid muscle. It may attain a large size, the overlying skin and cyst wall may be so thin as to be translucent, and it has been known to cause serious impairment of respiration through pressing on the trachea. In the axilla also the cystic tumour may attain a considerable size (Fig. 76); less frequent situations are the groin, and the floor of the mouth, where it constitutes one form of ranula.

The nature of these swellings is to be recognised by their situation, by their having existed from infancy, and, if necessary, by drawing off some of the contents of the cyst through a fine needle. They are usually remarkably indolent, persisting often for a long term of years without change, and, like the haemangioma, they sometimes undergo spontaneous cicatrisation and cure. Sometimes the cystic tumour becomes infected and forms an abscess--another, although less desirable, method of cure. Those situated in the neck are most liable to suppurate, probably because of pyogenic organisms being brought to them by the lymphatics taking origin in the scalp, ear, or throat.

If operative interference is called for, the cysts may be tapped and injected with iodine, or excised; the operation for removal may entail a considerable dissection amongst the deeper structures at the root of the neck, and should not be lightly undertaken; parts left behind may be induced to cicatrise by inserting a tube of radium and leaving it for a few days.

Lymphangiomas are met with in the abdomen in the form of _omental cysts_.

DISEASES OF LYMPH GLANDS

1. Lymphadenitis.#--Inflammation of lymph glands results from the advent

of an irritant, usually bacterial or toxic, brought to the glands by the afferent lymph vessels. These vessels may share in the inflammation and be the seat of lymphangitis, or they may show no evidence of the passage of the noxa. It is exceptional for the irritant to reach the gland through the blood-stream.

A strain or other form of trauma is sometimes blamed for the onset of lymphadenitis, especially in the glands of the groin (bubo), but it is usually possible to discover some source of pyogenic infection which is responsible for the mischief, or to obtain a history of some antecedent infection such as gonorrhoea. It is possible for gonococci to lie latent in the inguinal glands for long periods, and only give rise to lymphadenitis if the glands be subsequently subjected to injury. The glands most frequently affected are those in the neck, axilla, and groin.

The characters of the lymphadenitis vary with the nature of the irritant. Sometimes it is mild and evanescent, as in the glandular enlargement in the neck which attends tonsillitis and other forms of sore throat. Sometimes it is more persistent, as in the enlargement that is associated with adenoids, hypertrophied tonsils, carious teeth, eczema of the scalp, and otorrhoea; and it is possible that this indolent enlargement predisposes to tuberculous infection. A similar enlargement is met with in the axilla in cases of chronic interstitial mastitis, and in the groin as a result of chronic irritation about the external genitals, such as balanitis.

Sometimes the lymphadenitis is of an acute character, and the tendency is towards the formation of an abscess. This is illustrated in the axillary glands as a result of infected wounds of the fingers; in the femoral glands in infected wounds or purulent blisters on the foot; in the inguinal glands in gonorrhoea and soft sore; and in the cervical glands in the severer forms of sore throat associated with diphtheria and scarlet fever. The most acute suppurations result from infection with streptococci.

Superficial glands, when inflamed and suppurating, become enlarged, tender, fixed, and matted to one another. In the glands of the groin the suppurative process is often remarkably sluggish; purulent foci form in the interior of individual glands, and some time may elapse before the pus erupts through their respective capsules. In the deeply placed cervical glands, especially in cases of streptococcal throat infections, the suppuration rapidly involves the surrounding cellular tissue, and the clinical features are those of an acute cellulitis and deeply seated abscess. When this is incised the necrosed glands may be found lying in the pus, and on bacteriological examination are found to be swarming with streptococci. In suppuration of the axillary glands the abscess may be quite superficial, or it may be deeply placed beneath the strong fascia and pectoral muscles, according to the group of glands involved.

The _diagnosis_ of septic lymphadenitis is usually easy. The indolent enlargements are not always to be distinguished, however, from commencing tuberculous disease, except by the use of the tuberculin test, and by the fact that they usually disappear on removing the peripheral source of irritation.

_Treatment._--The first indication is to discover and deal with the source of infection, and in the indolent forms of lymphadenitis this will usually be followed by recovery. In the acute forms following on pyogenic infection, the best results are obtained from the hyperaemic treatment carried out by means of suction bells. If suppuration is not thereby prevented, or if it has already taken place, each separate collection of pus is punctured with a narrow-bladed knife and the use of the suction bell is persevered with. If there is a large periglandular abscess, as is often the case, in the neck and axilla, the opening may require to be made by Hilton's method, and it may be necessary to insert a drainage-tube.

[Illustration: FIG. 77.--Tuberculous Cervical Gland with abscess formation in subcutaneous cellular tissue, in a boy aet. 10.]

1. Tuberculous Disease of Glands.#--This is a disease of great frequency

and importance. The tubercle bacilli usually gain access to the gland through the afferent lymph vessels, which convey them from some lesion of the surface within the area drained by them. Tuberculous infection may supervene in glands that are already enlarged as a result of chronic septic irritation. While any of the glands in the body may be affected, the disease is most often met with in the cervical groups which derive their lymph from the mouth, nose, throat, and ear.

_The appearance of the glands on section_ varies with the stage of the disease. In the early stages the gland is enlarged, it may be to many times its natural size, is normal in appearance and consistence, and as there is no peri-adenitis it is easily shelled out from its surroundings. On microscopical examination, however, there is evidence of infection in the shape of bacilli and of characteristic giant and epithelioid cells. At a later stage, the gland tissue is studded with minute yellow foci which tend to enlarge and in time to become confluent, so that the whole gland is ultimately converted into a caseous mass. This caseous material is surrounded by the thickened capsule which, as a result of peri-adenitis, tends to become adherent to and fused with surrounding structures, and particularly with layers of fascia and with the walls of veins. The caseated tissue often remains unchanged for long periods; it may become calcified, but more frequently it breaks down and liquefies.

1. Tuberculous disease in the cervical glands# is a common accompaniment

or sequel of adenoids, enlarged tonsils, carious teeth, pharyngitis, middle-ear disease, and conjunctivitis. These lesions afford the bacilli a chance of entry into the lymph vessels, in which they are carried to the glands, where they give rise to disease.

The enlargement may affect only one gland, usually below the angle of the mandible, and remain confined to it, the gland reaching the size of a hazel-nut, and being ovoid, firm, and painless. More commonly the disease affects several glands, on one or on both sides of the neck. When the disease commences in the pre-auricular or submaxillary glands, it tends to spread to those along the carotid sheath: when the posterior auricular and occipital glands are first involved, the spread is to those along the posterior border of the sterno-mastoid. In many cases all the chains in front of, beneath, and behind this muscle are involved, the enlarged glands extending from the mastoid to the clavicle. They are at first discrete and movable, and may even vary in size from time to time; but with the addition of peri-adenitis they become fixed and matted together, forming lobulated or nodular masses (Fig. 78). They become adherent not only to one another, but also to the structures in their vicinity,--and notably to the internal jugular vein,--a point of importance in regard to their removal by operation.

At any stage the disease may be arrested and the glands remain for long periods without further change. It is possible that the tuberculous tissue may undergo cicatrisation. More commonly suppuration ensues, and a cold abscess forms, but if there is a mixed infection, the pyogenic factor being usually derived from the throat, it may take on active features.

[Illustration: FIG. 78.--Mass of Tuberculous Glands removed from Axilla (cf. Fig. 79).]

The transition from the solid to the liquefied stage is attended with pain and tenderness in the gland, which at the same time becomes fixed and globular, and finally fluctuation can be elicited.

If left to itself, the softened tubercle erupts through the capsule of the gland and infects the cellular tissue. The cervical fascia is perforated and a cold abscess, often much larger than the gland from which it took origin, forms between the fascia and the overlying skin. The further stages--reddening, undermining of skin and external rupture, with the formation of ulcers and sinuses--have been described with tuberculous abscess. The ulcers and sinuses persist indefinitely, or they heal and then break out again; sometimes the skin becomes infected, and a condition like lupus spreads over a considerable area. Spontaneous healing finally takes place after the caseous tubercle has been extruded; the resulting scars are extremely unsightly, being puckered or bridled, or hypertrophied like keloid.

While the disease is most common in childhood and youth, it may be met with even in advanced life; and although often associated with impaired health and unhealthy surroundings, it may affect those who are apparently robust and are in affluent circumstances.

_Diagnosis._--The chief importance lies in differentiating tuberculous disease from lympho-sarcoma and from lymphadenoma, and this is usually possible from the history and from the nature of the enlargement. Signs of liquefaction and suppuration support the diagnosis of tubercle. If any doubt remains, one of the glands should be removed and submitted to microscopical examination. Other forms of sarcoma, and the enlargement of an accessory thyreoid, are less likely to be confused with tuberculous glands. Calcified tuberculous glands give definite shadows with the X-rays.

Enlargement of the cervical glands from secondary cancer may simulate tuberculosis, but is differentiated by its association with cancer in the mouth or throat, and by the characteristic, stone-like induration of epithelioma.

The cold abscess which results from tuberculous glands is to be distinguished from that due to disease in the cervical spine, retro-pharyngeal abscess, as well as from congenital and other cystic swellings in the neck.

_Prognosis._--Next to lupus, glandular disease is of all tuberculous lesions the least dangerous to life; but while it is the rule to recover from tuberculous disease of glands with or without an operation, it is unfortunately quite common for such persons to become the subjects of tuberculosis in other parts of the body at any subsequent period of life.

_Treatment._--There is considerable difference of opinion regarding the treatment of glandular tuberculosis. Some authorities, impressed with the undoubted possibility of natural cure, are satisfied with promoting this by measures directed towards improving the general health, by the prolonged administration of tuberculin, and by repeated exposures to the X-rays and to sunlight. Others again, influenced by the risk of extension of the disease and by the destruction of tissue and disfigurement caused by breaking down of the tuberculous tissue and mixed infection, advocate the removal of the glands by operation.

The conditions vary widely in different cases, and the treatment should be adapted to the individual requirements. If the disease remains confined to the glands originally infected and there are no signs of breaking down, "expectant measures" may be persevered with.

[Illustration: FIG. 79.--Tuberculous Axillary Glands (cf. Fig. 78).]

If, on the other hand, the disease exhibits aggressive tendencies, the question of operation should be considered. The undesirable results of the breaking down and liquefaction of the diseased gland may be avoided by the timely withdrawal of the fluid contents through a hollow needle.

_The excision of tuberculous glands_ is often a difficult operation, because of the number and deep situation of the glands to be removed, and of the adhesions to surrounding structures. The skin incision must be sufficiently extensive to give access to the whole of the affected area, and to avoid disfigurement should, whenever possible, be made in the line of the natural creases of the skin. In exposing the glands the common facial and other venous trunks may require to be clamped and tied. Care must be taken not to injure the important nerves, particularly the accessory, the vagus, and the phrenic. The inframaxillary branches of the facial, the hypoglossal and its descending branches, and the motor branches of the deep cervical plexus, are also liable to be injured. The dissection is rendered easier and is attended with less risk of injury to the nerves, if the patient is placed in the sitting posture so as to empty the veins, and, instead of a knife, the conical scissors of Mayo are employed. When the glands are extensively affected on both sides of the neck, it is advisable to allow an interval to elapse rather than to operate on both sides at one sitting. (_Op. Surg._, p. 189.)

If the tonsils are enlarged they should not be removed at the same time, as, by so doing, there is a risk of pyogenic infection from the throat being carried to the wound in the neck, but they should be removed, after an interval, to prevent relapse of disease in the glands.

_When the skin is broken_ and caseous tuberculous tissue is exposed, healing is promoted by cutting away diseased skin, removing the granulation tissue with the spoon, scraping sinuses, and packing the cavity with iodoform worsted and treating it by the open method and secondary suture if necessary. Exposure to the sunshine on the seashore and to the X-rays is often beneficial in these cases.

1. Tuberculous disease in the axillary glands# may be a result of

extension from those in the neck, from the mamma, ribs, or sternum, or more rarely from the upper extremity. We have seen it from an infected wound of a finger. In some cases no source of infection is discoverable. The individual glands attain a considerable size, and they fuse together to form a large tumour which fills up the axillary space. The disease progresses more rapidly than it does in the cervical glands, and almost always goes on to suppuration with the formation of sinuses. Conservative measures need not be considered, as the only satisfactory treatment is excision, and that without delay.

1. Tuberculous disease in the glands of the groin# is comparatively rare.

We have chiefly observed it in the femoral glands as a result of inoculation tubercle on the toes or sole of the foot. The affected glands nearly always break down and suppurate, and after destroying the overlying skin give rise to fungating ulcers. The treatment consists in excising the glands and the affected skin. The dissection may be attended with troublesome haemorrhage from the numerous veins that converge towards the femoral trunk.

Tuberculous disease in the _mesenteric_ and _bronchial glands_ is described with the surgery of regions.

1. Syphilitic Disease of Glands.#--Enlargement of lymph glands is a

prominent feature of acquired syphilis, especially in the form of the indolent or bullet-bubo which accompanies the primary lesion, and the general enlargement of glands that occurs in secondary syphilis. Gummatous disease in glands is extremely rare; the affected gland rapidly enlarges to the size of a walnut, and may then persist for a long period without further change; if it breaks down, the overlying skin is destroyed and the caseated tissue of the gumma exposed.

1. Lymphadenoma.#--_Hodgkin's Disease_ (Pseudo-leukaemia of German

authors).--This is a rare disease, the origin of which is as yet unknown, but analogy would suggest that it is due to infection with a slowly growing micro-organism. It is chiefly met with in young subjects, and is characterised by a painless enlargement of a particular group of glands, most commonly those in the cervical region (Fig. 80).

[Illustration: FIG. 80.--Chronic Hodgkin's Disease in a boy aet. 11.]

The glands are usually larger than in tuberculosis, and they remain longer discrete and movable; they are firm in consistence, and on section present a granular appearance due to overgrowth of the connective-tissue framework. In time the glandular masses may form enormous projecting tumours, the swelling being added to by lymphatic oedema of the overlying cellular tissue and skin.

The enlargement spreads along the chain of glands to those above the clavicle, to those in the axilla, and to those of the opposite side (Fig. 81). Later, the glands in the groin become enlarged, and it is probable that the infection has spread from the neck along the mediastinal, bronchial, retro-peritoneal, and mesenteric glands, and has branched off to the iliac and inguinal groups.

Two clinical types are recognised, one in which the disease progresses slowly and remains confined to the cervical glands for two or more years; the other, in which the disease is more rapidly disseminated and causes death in from twelve to eighteen months.

[Illustration: FIG. 81.--Lymphadenoma (Hodgkin's Disease) affecting left side of neck and left axilla, in a woman aet. 44. Three years' duration.]

In the acute form, the health suffers, there is fever, and the glands may vary in size with variations in the temperature; the blood presents the characters met with in secondary anaemia. The spleen, liver, testes, and mammae may be enlarged; the glandular swellings press on important structures, such as the trachea, oesophagus, or great veins, and symptoms referable to such pressure manifest themselves.

_Diagnosis._--Considerable difficulty attends the diagnosis of lymphadenoma at an early stage. The negative results of tuberculin tests may assist in the differentiation from tuberculous disease, but the more certain means of excising one of the suspected glands and submitting it to microscopical examination should be had recourse to. The sections show proliferation of endothelial cells, the formation of numerous giant cells quite unlike those of tuberculosis and a progressive fibrosis. Lympho-sarcoma can usually be differentiated by the rapid assumption of the local features of malignant disease, and in a gland removed for examination, a predominance of small round cells with scanty protoplasm. The enlargement associated with leucocythaemia is differentiated by the characteristic changes in the blood.

_Treatment._--In the acute form of lymphadenoma, treatment is of little avail. Arsenic may be given in full doses either by the mouth or by subcutaneous injection; the intravenous administration of neo-salvarsan may be tried. Exposure to the X-rays and to radium has been more successful than any other form of treatment. Excision of glands, although sometimes beneficial, seldom arrests the progress of the disease. The ease and rapidity with which large masses of glands may be shelled out is in remarkable contrast to what is observed in tuberculous disease. Surgical interference may give relief when important structures are being pressed upon--tracheotomy, for example, may be required where life is threatened by asphyxia.

1. Leucocythaemia.#--This is a disease of the blood and of the

blood-forming organs, in which there is a great increase in the number, and an alteration of the character, of the leucocytes present in the blood. It may simulate lymphadenoma, because, in certain forms of the disease, the lymph glands, especially those in the neck, axilla, and groin, are greatly enlarged.

TUMOURS OF LYMPH GLANDS

1. Primary Tumours.#--_Lympho-sarcoma_, which may be regarded as a sarcoma

starting in a lymph gland, appears in the neck, axilla, or groin as a rapidly growing tumour consisting of one enlarged gland with numerous satellites. As the tumour increases in size, the sarcomatous tissue erupts through the capsule of the gland, and infiltrates the surrounding tissues, whereby it becomes fixed to these and to the skin.

[Illustration: FIG. 82.--Lympho-Sarcoma removed from Groin. It will be observed that there is one large central parent tumour surrounded by satellites.]

The prognosis is grave in the extreme, and the only hope is in early excision, followed by the use of radium and X-rays. We have observed a case of lympho-sarcoma above the clavicle, in which excision of all that was removable, followed by the insertion of a tube of radium for ten days, was followed by a disappearance of the disease over a period which extended to nearly five years, when death resulted from a tumour in the mediastinum. In a second case in which the growth was in the groin, the patient, a young man, remained well for over two years and was then lost sight of.

1. Secondary Tumours.#--Next to tuberculosis, _secondary cancer_ is the

most common disease of lymph glands. In the neck it is met with in association with epithelioma of the lip, tongue, or fauces. The glands form tumours of variable size, and are often larger than the primary growth, the characters of which they reproduce. The glands are at first movable, but soon become fixed both to each other and to their surroundings; when fixed to the mandible they form a swelling of bone-like hardness; in time they soften, liquefy, and burst through the skin, forming foul, fungating ulcers. A similar condition is met with in the groin from epithelioma of the penis, scrotum, or vulva. In cancer of the breast, the infection of the axillary glands is an important complication.

In _pigmented_ or _melanotic cancers_ of the skin, the glands are early infected and increase rapidly, so that, when the primary growth is still of small size--as, for example, on the sole of the foot--the femoral glands may already constitute large pigmented tumours.

[Illustration: FIG. 83.--Cancerous Glands in Neck secondary to Epithelioma of Lip.

(Mr. G. L. Chiene's case.)]

The implication of the glands in other forms of cancer will be considered with regional surgery.

_Secondary sarcoma_ is seldom met with in the lymph glands except when the primary growth is a lympho-sarcoma and is situated in the tonsil, thyreoid, or testicle.