In no respect is this more true than in local tuberculous infections, or in others which have become tuberculous through the process of mixed or secondary infection.
Tuberculosis of the cervical lymphatics is then one of the results of previous mild or severe infections. They constitute the so-called “scrofulous glands” or swellings of writers of the past generation. There may be seen repeated within these structures those processes which in the lungs cause at one point softening, at another caseation, and at another sclerosis. An acute suppurative process may also be going on, or there may be found, in broken-down cavities, that pyoid material which is often seen in cold abscesses, and to which elsewhere in this work is given the name archepyon, indicating that it was originally of a truly purulent type, which it has lost in course of time.
Fig. 494
Cluster of tuberculous lymph nodes removed by dissection, and showing the usual and various changes. (Lexer.)
Tuberculosis of the cervical lymph nodes may be a limited and almost single expression of disease, or one involving both sides of the neck, and to a degree that may produce large and disfiguring swellings. It is nearly always a secondary infection, the original lesion being found upon the surface of the skin, more frequently in the middle ear, the pharynx, the tonsils, the nose, the teeth, or other parts within the mouth. The first measure in every instance should be to trace this source of the infection, since to leave it uncared for is to invite a continuance of the disease. The course of events often is an acute exanthem, a chronic tonsillitis, a mildly septic involvement of the lymph nodes, followed later by tuberculous invasion through a port of entry opened by the previous process ([Fig. 494]).
Most of the acute septic infections of these lymphatics will be followed by local abscess and by one of the extensive phlegmonous manifestations described above. This usually means an acute abscess formation, which should lead to early incision and speedy recovery. It is the more chronic and less suppurative types which cause serious trouble. They occur more frequently in the young. There is a distinct form, however, occurring in the aged, which is called senile tuberculosis. Its pathology nowise differs from that of the type occurring in the young, although it has a different clinical expression.
When the lymph nodes are but recently involved they are simply so encapsulated as to be easily shelled out from their beds; but when degenerating and slowly suppurating they become so firmly embedded in the surrounding tissues by dense infiltration that their extirpation is exceedingly difficult. This condition has been spoken of as peri-adenitis, a bad term, because nowhere in this work are lymph nodes spoken of as “glands.” Not infrequently the operator will find large masses affixed to the carotid sheath, or surrounding the vessel and nerve trunks, so that it is almost impossible to separate them. During the dissection the internal jugular may be torn, or one of its branches severed at its base, while an important nerve trunk may be so lost in the mass that it is almost impossible to distinguish it, and it may not escape injury.
Treatment.
—Search should be first made for the source of the infection, since to attack the consequences of the disease and to leave the cause untouched would be a mistake. If it be a chronic nasopharyngeal catarrh it will require considerable local treatment. If an enlarged tonsil this should be removed. If due to dental caries, or ulceration in connection with faulty dentition, or to pyorrhea alveolaris, the patient should be sent to the dentist; if the trouble be in the middle ear, to the aurist; if the infection come from the skin, as in various ulcerating skin diseases, again appropriate external measures should be adopted. When the patient is otherwise in good condition and freed from liability of further infection, then the question of surgical intervention is to be decided. Decision will rest somewhat upon the general condition of the patient and the extent of the lesions. A consumptive patient, for instance, is not a good subject for surgery, and it may be held that the lymphatics will be benefited by such change of climate as is indicated for his tuberculous lungs. A puny or anemic subject is not a favorable one for an extensive surgical operation, such as the removal of a large mass of those nodes often necessitates. It may be deemed advisable to delay while the patient is temporarily sent to the mountains, or is placed upon treatment, including arsenic as an alterative, and the best restorative tonics. Some cases not favorable for operation are benefited by x-ray treatment. This should be judiciously administered, in such manner as not to produce a dermatitis nor increase the infiltration in the tissues of the neck. It is to be advised rather in cases considered inoperable than in those favorable for operation.