The principles and practice of modern surgery

by Roswell Park

Syphilis of the lymph nodes has already been considered, as well as the frequency, nay, the certainty, with which the lymphatics become involved in this disease. So true is this that any general lymphatic involvement which cannot be accounted for in some other manner is usually attributable to syphilis. The condition of the lymphatics may be considered a fair index as to the success and effect of antisyphilitic treatment, for if, under such treatment, these enlargements subside completely it may be regarded as eminently successful. On the other hand, it is not felt by many that it is safe to discontinue treatment in the presence of these enlargements. Syphilitic enlargements may, moreover, undergo secondary infection, either acute or chronic, i. e., may suppurate or become tuberculous. In gonorrheal bubo the pus which the lymph-node abscesses contain will often be found almost a pure culture of the gonococcus, thus illustrating the specificity of this kind of infection.

The extent to which the lymphatics are involved in cases of cancer will often be the guide for the surgeon in advising removal or the reverse. The principal advance in the modern operative surgery of cancer has come through a better working knowledge of the area of lymph distribution of given regions. All cancerous lymph nodes which can be reached should be extirpated. If others can be discovered which are beyond reach it raises a doubt whether the operation should be performed. At all events, in these cases it should be represented as a temporary rather than an absolutely curative resort, not only because this is true, but because the surgeon may need to protect himself against charges which may be made later by disappointed patients.

The advisability of removing diseased lymph nodes is often a matter for serious discussion. There is little to justify their removal when the exciting cause cannot also be taken with them. It is a mistake to operate on nodes in the neck and leave diseased teeth through which the infection may be spread. So, too, it is a mistake to operate on nodes which may prove to be syphilitic. In many instances, then, it is best to apply the therapeutic test. In cancerous disease it can rarely be advisable to remove lymph nodes alone except for purely temporary purposes, as to check hemorrhage, remove breaking-down material, or something of the kind. In the neck, groin, or axilla the operation is not to be lightly undertaken, for it is made extremely difficult by adhesion of the surrounding structures. The surgeon should be prepared then for careful dissection, which should be made with a not too sharp knife, and he should be ready to sew up a rent in the jugular vein or tie it, as it and its large branches are frequently so displaced and obscured as to be injured, even by the most careful operator.

HODGKIN’S DISEASE.

This is one of many names applied to a condition whose most conspicuous characteristics are a progressive anemia, with enlargement of lymph nodes, as well as usually of the spleen, with secondary or metastatic growths in the viscera, bone-marrow, and elsewhere. That its etiology hitherto has been considered obscure and that its clinical characteristics vary in different cases may be shown by a partial list of the names by which it has been previously known: lymphadenoma, malignant lymphoma, infective lymphoma, progressive glandular hypertrophy, lymphosarcoma, and pseudoleukocythemia. To the writer’s mind, if the disease is to be known by any other name rather than that of the one who first described it, it might be called malignant lymphomatosis, as its tendency is downward, in which sense it is malignant in an almost hopeless degree.

The changes which occur in the blood are at first in the direction of simple anemia, followed by marked reduction in the number of red cells, with poverty of hemoglobin and increase in the number of leukocytes. In the anemia of extreme cases the red cells may be reduced 1,000,000 per Cm., while the leukocytes, especially the polynuclear forms, may be numbered by the hundreds of thousands. In one case recently under my observation the leukocytes amounted to about 300,000 when treatment was begun. (See chapter on the [Blood].) It is a disease of early rather than of later life, and occurs more often in males than in females. The most pronounced objective changes occur in the lymph nodes, which enlarge steadily, the swellings thus formed being hard or soft according to the rapidity of the disease. The swellings thus formed will appear conspicuously in the neck and will be noted also in the axilla and the groin. Careful examination will show that every lymph node in the body which is accessible is involved in the course of the disease. Sometimes the tumors become so large as to cause serious pressure, and when in the neck perhaps to require tracheotomy to prevent suffocation. [Fig. 192] illustrates a case under the writer’s observation, in which he had to resort to this emergency measure. The microscopic picture of this enlargement is that of hyperplasia of the tissues composing the lymph nodes, while the lymphoid cells are multiplied in number.[30]

[30] Pathologists have long suspected that Hodgkin’s disease and sarcoma have, at least, certain features in common if they are not more or less actually associated in character. Yamasaki has recently reported several cases of typical Hodgkin’s disease without any suspicion of tuberculosis, in which there were unmistakable sarcomatous formations in various parts of the body, especially in the viscera, and he believes, as do others, that the affection which begins as Hodgkin’s disease may later assume the characteristics of a general sarcomatosis.

Fig. 192

Hodgkin’s disease.