THE TREATMENT OF CERVICAL ADENITIS BY F. M. BRIGGS, M. D. Assistant Professor of Clinical Surgery, Tufts College Medical School ; Surgeon to the Boston Dispensary Reprinted from the Boston Medical and Surgical Journal of December 3, 1896 BOSTON DAMRELL & UPHAM, PUBLISHERS No. 283 Washington Strebt 1896 THE TREATMENT OF CERVICAL ADENITIS.1 BY F. M. BRIGGS, M.D., Assistant Professor of Clinical Surgery, Tufts College Medical School; Surgeon to the Boston Dispensary. The three portions of the body where we find affections of the lymphatic glands calling for treat- ment are the neck, the groin and the axilla. What can be said of one can be applied generally to all three, but I shall confine myself to the region of the neck. Cervical adenitis is of frequent occurrence; and as, with possibly a few exceptions, it is secondary to a pre-existing condition, the first object in every case is to find the cause, if possible. For convenience of discussion I make five divisions ; and although this classification cannot be always sharply defined, I believe it to be a fairly accurate one. These divisions are: (1) The Irritative, as, for instance, due to a tonsil- litis, a tooth, pediculi, a furuncle, a carbuncle. (2) The Local Infective, as cancer or chancre in this region. (3) The General Infective, as general syphilis, leukemia, Hodgkin's disease. (4) The Tuberculous. (5) Those whose etiology is unknown. I have not attempted to include in this classification every cause of cervical adenitis, but have simply given various conditions, as illustrative of the particular class. I think, however, that every condition which may be a cause will be found to come under some one of the different heads. Class 1. The Irritative forms a considerable pro- portion of the total number; and in these cases the source of irritation is usually easily discovered upon examination. If not evident upon the outside, inspec- tion of the mouth, nose and ears should be made, and 1 Read at the meeting of the Boston Society for Medical Improve- ment, March 9, 1896. 2 made carefully. If nothing can be found to which the adenitis can be ascribed, the patient should be closely questioned' as to any trouble previously exist- ing in the parts mentioned, for it sometimes happens that after the source of irritation has disappeared the resultant glandular enlargement remains. I shall dis- cuss this question under Class 5, or those of unknown etiology, but call attention here to the importance of investigating every possible source of near-by irrita- tion, for I think that if this were done in every case, many of those which are now classed as tuberculous or scrofulous would be found to be neither. In the irritative form, treatment should be directed towards the irritating cause, for with the subsidence of the cause the glands usually take care of themselves and disappear as rapidly as they came. But they may not. The source of irritation having subsided, the glands are sometimes left behind; and if such a case be seen at this time, it must be placed in Class 5, and treated accordingly. As a general rule, however, in Class 1, treatment directed solely towards the cause cures the adenitis. Class 2. The Local Infective. We have here those due to a disease localized, for the time being, in this vicinity. Cancer of some part of the face is not unusual, aud secondary disease of the cervical glands commonly follows it. They are then cancers them- selves, and should be treated upon the same principles that the primary cancer is itself treated. If this is operable, the glands should be removed also, but nothing is gained by their removal if the original growth is inoperable. Chancre belongs in this class, for syphilis occa- sionally starts on the face. If it does, the cervical glands act precisely as do the inguinals where the initial lesion is on the penis. They enlarge as hard, painless masses. Constitutional treatment is the only one and under suitable specific treatment the glands subside. Nothing local is indicated. In Class 3 we have those cases due to constitu- tional disease, as general syphilis, leukemia and pseudo- leukemia or Hodgkin's disease. In this class the cer- 3 vical affection is only a part of a genera] glandular disturbance, but it is important to distinguish the eti- ology. As regards syphilis, in a recent case where the initial lesion occurs upon the genitals or elsewhere, but not upon the head, the cervical glands usually participate in the general lymph-adenitis, but they are rarely, if ever, found in the front. They occur on the back of the neck, running up under the scalp, as small, hard, rounded, freely movable and painless bodies. There is a late form of specific adenitis where con- siderable enlargement of the glands in the front and sides of the neck is found. In the cases that I have seen, numerous similar glands have been found else- where, there has been a distinct history of a more or less remote specific infection, and the trouble has re- acted to specific treatment. From what I have seen of glandular affections I should say that enlarged glands found in the front and sides of the neck, but nowhere else, are never specific; that glands found in the back of the neck, with the characteristics above given are strongly sus- picious of a recent infection, even where nothing else is showing at the time, and that in every case of cer- vical adenitis coexisting with a general lymph-adenitis, syphilis, either recent or remote, should always be considered, and only excluded after careful investiga- tion. The importance of making the diagnosis, of course, bears upon the treatment, for if syphilis is the cause, the case calls for treatment long after all signs of adenitis have disappeared. Concerning leukemia and pseudo-leukemia, I know nothing practically ; and as, in what I have to say, I wish to keep as closely as possible within my own clinical experience, I will pass them both over with a few words. As 1 understand it, leukemia is sometimes accompanied by an affection of the lymph glands, occurring by preference in the neck. The disease is characterized by a marked increase in the white blood- corpuscles, upon which the diagnosis is based. In pseudo-leukemia enlargement of the cervical glands is an early symptom, and they may grow to an enor- 4 inous size. Their removal has apparently no influence upon the progress of the disease, and is wholly pallia- tive. Viewed from the point of direct treatment of the glands, interest centres upon the tuberculous, which I have purposely placed in a class by themselves and upon Class 5, or those whose etiology is unknown. Although I have classified them separately I shall consider them together. If, and it is by no means infrequently the case, an individual in apparently full health, with no sign of pres- ent or pre-existing disease, with a clean family history, and from whom the most rigid inquiry and examina- tion fails to reveal the slightest clue as to the cause, presents himself (or herself) with one, two or perhaps a whole chain of enlarged cervical glands, to what can we ascribe the etiology ? It is now, much too frequently, the custom to call every case of cervical adenitis, which cannot be otherwise accounted for, tuberculous; and it is the generally accepted rule that tuberculous glands should be excised. Until recently they were known as scrofulous or strumous, and were looked upon as an acute outbreak of an obscure humor handed down as an inheritance of some obscure ances- tral disease. While this latter theory was in force, surgical interference was the last, not the first treat- ment resorted to. If they disappeared spontaneously, so much the better. If they did not and pus was evident, they were either allowed to break under a poultice or were subjected to a long incision, and curetting. This method of treatment, with its disfig- uring scars, prevailed for many years. But with the demonstration of the bacillus of tuber- culosis, and with the proof that the disease can be directly inoculated by the bacillus or its products, has come a decided change as to the proper treatment to be adopted. In a chronic cervical adenitis, the opinion is, that the patient is exposed to very gieat risk of a more or less general tuberculous infection, if these glands are not removed. That each and every one of them may be a focus of disease, for the reason that, even if not tuberculous at the time, they are liable Fig. 3. Multiple glandular inflammation under right ear, with par- tial breaking down and subsequent absorption of glandular mass left after suppuration had ceased. Has ovoid cicatrix one by one-half inch, which does not show as distinctly in cut as it does on the individual. This unusual growth of scar-tissue long after recovery cannot be ex- plained. Fig. 4. Shown as being illustrative of a cervical adenitis of unknown etiology in an otherwise healthy child. Canula treatment. Poor result. This case and Fig. 3 are the only poor results in over forty cases treated by this method. When Isay poor results, I mean in com- parison with such results as are shown in Figs. 6, 7 and 9. 5 to become so at any moment, and that therefore their radical excision is called for. It must be remembered that in such cases as these we are dealing with an exposed portion of the body, a portion that is open to constant inspection, and in every case the final result, as regards the appearance of the skin, ought to have great weight in deciding as to the method of treatment to be adopted. While a considerable scar elsewhere is of little significance, any scar on the neck is of considerable importance, a fact which I have found to be fully appreciated by patients. But before the scar, the future health of the patient must be considered. A treatment which prevents a scar and which allows a phthisis to develop can scarcely be called sound, and if it is a fact that any persistently enlarged cervical gland is to be the cause of a future consumption, and if with its removal the danger ceases, then, certainly, there can be no ques- tion. Does this danger, however, exist in reality? When we consider the enormous number of cases of phthisis throughout the world, it seems incredible that this should not be distinctly proven, if it be a fact. It does not seem possible, that with the keen observa- tion of medical investigators everywhere, and with the interest taken in tracing just such points as this, that if it really were the case, we do not now have numer- ous sets of statistics, and numerous reports of individ- ual cases, proving the causal relation - but that it should stand, as it does, an hypothesis - a theoretical possibility. If I were to go to any large medical clinic in this or any other city, and ask the physician on duty to allow me to see all the cases of pulmonary tuberculosis that came to his clinic for, say, three months, I should have a small army of consumptives to demonstrate whatever particular point I might be investigating regarding the disease itself. If I were to ask to see all the cases where a cervi- cal adenitis coexisted with the phthisis, I might get a few. But if I were to ask for all the cases of pulmo- 6 nary tuberculosis where there was a distinct evidence of a pre-existing cervical adenitis, to which the pul- monary infection could be traced as its source, how many would I find ? Not one, I think. On the other hand, it is by no means uncommon to see individuals well along in life with scarred necks resulting from glandular trouble years before, who are and have been in good health, and with no sign of present or previous pulmonary or other tuberculosis. Numerous cases of cervical adenitis of unknown ori- gin disappear spontaneously in patients who were at the time, and have been, perfectly well. The subject is an obscure one. It may be explained by assuming that every lymph-adenitis is inhibitory, and is nature's method of stopping further infection ; that where infection is carried, it is by the blood, not by the lymph glands, which are everywhere acting as a check. For a period of some five years I have treated all these cases upon the theory that they are not sources of systemic infection, that the glands can be left in situ with perfect safety, and that their excision is called for only in exceptional cases. I have seen nothing as yet to change this opinion, but, on the contrary, with every year grow more positive as to its soundness. In summing up to this point, the first object of treatment of all cases of cervical adenitis is to bring about subsidence, by treatment of the cause if that is evident; by direct treatment of the gland itself, if no cause is at hand. In chronic cases, even where the cause can be clearly demonstrated, treatment must often be both general and local. As regards the use of drugs, this must depend upon the individual case : mercury, iodide of potassium for syphilis, iron for anemia, quinine, strychnia, nux vomica, calasaya, cinchona, malt, etc., or any proper combination of such drugs, as indicated. Cod-liver oil is surrounded by a time-honored halo. I question whether it has the specific action on these glands that it is supposed to have. It supplies fat to those systems where fat is lacking, and is indicated where the condition of the patient shows that fat is Fig. 5. Shown for comparison. Age eighteen. Had glandular ab- scess when a child. Treated by long incision, resulting in present dis- figuring keloidal scar. hiG. 6. Extensive suppurating adenitis of superficial and deep glands. Canula inserted at three different points. Complete recovery with one trifling mark as shown at E. The point indicated by F is a mole. I he mark left by the canula at E will be seen to be no worse than any one of the numerous freckles on the face. 7 needed. I believe one teaspoonful three times a day enough for any adult, and a smaller quantity for a child. As regards local treatment, the external use of tincture of iodine is often of great benefit, but it should be applied intermittently not continuously. It should be painted on, heavily, for three or four days, then omitted until the skin has recovered and again applied for three or four days. Even where there is no immediate apparent effect, I continue its use in this way for a long time, and have seen subsidence occur in cases which I had thought to be hopelessly chronic - whether as a result of treatment, or a coincidence, I am unable to say. Personally, however, I give the benefit of the doubt to the iodine. Contractile collodion applied thickly sometimes causes subsidence. It is indicated only where one or two glands are involved, and where they are com- paratively soft. Injection of carbolic acid into the gland tissue is recommended, but as I have never tried the method can give no opinion as to its merits. It would not be an overestimate to state that in fully 90 per cent, of all these cases, we can expect one of two results, namely, subsidence or pus. Supposing, however, that in any given case subsi- dence does not occur, and no abscess results, but the indolent masses stay enlarged with little or no change, it is very difficult to decide as to what to advise regarding treatment. Should such glands be excised? I am strongly opposed to their removal until there is positively no further chance of a cure by absorption, that is to say, when the long-continued chronic inflam- matory process has caused a true tissue change. But just when this time can be said to have been reached, is in my experience a very difficult point to decide. I make it a rule (it is, of course, an arbitrary one) that no such gland should be removed until it has re- mained unchanged for twelve months. I emphasize " unchanged " for if during that time, it has gone par- tially down, then enlarged again, etc., I consider that there is still chance for absorption. Excision of cervical glands is not a satisfactory 8 operation, for if only a few glands are to be removed at the time, others are liable to enlarge and call for one or more future operations, and if a whole chain, both superficial and deep, is involved, the removal is no slight matter, either at the time or afterwards. Fig. 1. Sketch of large cervical abscess, showing the canula as it was when inserted (1) and as it is when within the abscess cavity (2). In conclusion, there is left to be considered a very frequent result of cervical adenitis, namely, cervical abscess. Having already written twice at some length regarding the treatment of cervical abscess with refer- ence to the avoidance of scar, I shall only briefly recapitulate here what I have already said and refer any one interested in the subject to my previous arti- cles for a more extended discussion.2 2 The Avoidance of Scar in the Treatment of Cervical Abscess, •With Three Cases, Boston Medical and Surgical Journal, June 12, 1893. A Self-Retaining Drainage Canula for preventing a Scar in Cervical Abscess, loc. cit., May 2,1895. 9 Since my last report made in May, 1895, in which I gave a table of 13 cases, I have added to the list numerous other cases that I have treated; but as the results have been, with one exception, uniformly good, and similar in every way to the results already re- corded, I have no further notes to add. Out of some 40 cases treated, I have had but two scarred necks. " r Fig. 2. Figure 1 (enlarged). This sketch shows in detail the introduction of the canula, the way in which it dilates the im- mediate tissues, retains itself, and drains the abscess cavity. The almost invariable rule is either no scar, or a mark so slight as to be merely a blemish. My method is what I have named the canula treat- ment, and is as simple as it is satisfactory. My re- sults are obtained by using a little self-retaining drain- age canula8 invented by me some two years ago. A glance at the accompanying cuts will show just what 8 These canulas are manufactured by Leach & Greene, Park Square, Boston. 10 this canula is and what it effects. The skin cut is barely three-eighths of an inch in length, just long enough to admit the canula (see Fig. 1), which upon being inserted, is pushed in until its joint is reached, as shown at 1. The canula is then reversed by clos- ing its outer arms, when, as will be seen, as shown at 2, it is retained within the cavity, dilating the tissues in the vicinity of the cut and giving good drainage through a minimum cut. I show this on an enlarged scale in Fig. 2. It should be left in place from twenty-four to sev- enty-two hours, but usually two days are sufficient. The shorter the time it is left in, the better the result; and I think it wiser to err in removing the canula too soon, rather than to leave it in too long, for it can be easily re-inserted at any time, should further drainage be needed. Syringing and curetting are not needed. Nothing should enter the abscess except the knife which opens it and the canula which drains it. In the average case, healing follows in from five to seven days ; but if the gland is only partially destroyed when pus is evident, the case may take many weeks. In these cases a persistent sinus is left, calling for treatment. It is here where injections and curetting are called for. I dilate these sinuses with olive-pointed bougies, scrape with a small curette and inject with any one of the various stimulating or irritating solutions, accord- ing to the apparent condition of the lining wall of the sinus. These cases are extremely tedious, but the final result is good, as will be seen by examination of the accompanying cuts. Fig. 3 is the first and Fig. 4 the second of the poor results that I have referred to. Fig. 3 is Case 11 of the table in my report of May 2, 1895, when I gave the following description of the case.4 " Case 11 is still under treatment. This was a mass of partly broken-down glands under the right ear. A canula was inserted February 28th, and was pulled out on the dressing, by the patient herself, the following day. It was pulled out with the inner arms open, and the cut was torn 4 Boston Medical and Surgical Journal, May 2, 1895, p. 436. Fig. 8. Case 3 before treatment. A multiple in- volving the front of the neck. Drained by one canula inserted at D. Fig. 9. Same case two months later. 11 to three-eighths of an inch. There was very little subse- quent suppuration, and the glands instead of showing ab- scess formation have been slowly disappearing. There is a sinus about one inch in depth. It may be that in this case a radical operation will be necessary later on, and that the glands will have to be cut out; but before doing this I shall give the patient at least eight weeks more. I think, however, that the adenitis will disappear spontaneously, or that further suppuration will occur, and allow of the insertion of another canula. At present, absorption is evidently going on. The swelling has diminished fully one-half in size, and the patient is in good physical condi- tion. The final result will be reported in any event." The final result is here reported. In this case absorption went on, and the glandular masses disappeared entirely, leaving a small round cicatrix. For some reason, which cannot be ex- plained, this cicatrix grew in size, and ended by leav- ing an ovoid scar one inch long by half an inch broad, slightly depressed, but not discolored. I saw the patient in October, 1895, and she thought it seemed to be growing smaller, but I could see no change. Why this scar should have grown after all inflam- mation had subsided and all glandular enlargement had disappeared, is beyond explanation ; but it exem- plifies the tendency, long since observed, to the forma- tion of scar after abscess of the neck. This tendency is again shown in Fig. 5. This girl, eighteen years of age, had a glandular abscess when seven years old. It was cut by a long incision, and the present network of keloid is the result. Fig. 4 is shown as being a fairly typical case of cervical adenitis in a child. It has not done well, and there is quite a scar; for what reason I cannot ex- plain. But as this case and Case 3 are the only two poor results that I have had in some 40 cases, they should not militate against the method, for with 95 per cent, of good results in all varieties of cases an occasional poor result has no weight. Figs. 6, 7, 8 and 9 are shown as being good results in extremely difficult cases. Fig. 6 is Case 1 of the table which I published with my last paper. There is nothing showing, al- 12 though it was an extensive suppurating adenitis, needing three canulas at different points. E is one of these points, and is a slightly depressed, small cicatrix. F is a mole. The points where the two other canulas were inserted are not visible. Fig. 7 was the first case treated by me upon this principle, and it was this case that led me to develop the canula, for I had great difficulty in keeping the points A, B and C open, and in draining properly. No case of the kind could be more severe, extensive or destructive than was this one. Apparently every gland on the left side of the neck, both superficial and deep, inflamed and broke down. He was left with large branching sinuses running from the ear to the clavicle. The cut shows his present appearance, with only three trifling marks. He is and has been in fine con- dition physically. Figs. 8 and 9 are reproduced from my last paper, and show Case 3 before and after treatment. Fig. 10 is shown for comparison. I could show many other cases similar to those here demonstrated, but the extreme difficulty of per- suading patients to have their photographs taken for publication compels me to limit my illustrations to those as shown by accompanying cuts. Fig. 7. Suppurating adenitis of apparently the whole chain of glands, both superficial and deep, extending from the mastoid process to the clavicle. Treated four years ago. Has three small scars, one back of the ear, the others in a line directly below this one. Fig. 10. Shown for comparison. Child, age three. Glandular ab- scess twelve months ago. Broke under poultice. Has never healed Has present appearance.