Fig. 77.—Tuberculous Cervical Gland with abscess formation in subcutaneous cellular tissue, in a boy æt. 10.
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.
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.
Fig. 78.—Mass of Tuberculous Glands removed from Axilla (cf. [Fig. 79]).