GLANDULAR TUMORS OF THE NECK. J. WILLIAM WHITE, M.D., BY Professor of Clinical Surgery in the University of Pennsylvania. REPRINTED FROM THE THERAPEUTIC GAZETTE, APRIL 15, 1890. GEORGE S. DAVIS, PUBLISHER. DETROIT, MICH. I 1890. GLANDULAR TUMORS OF THE NECK. THE series of cases which I shall bring be- fore you to-day will serve to illustrate the chief varieties of glandular swellings affecting the cervical region, and for the sake of com- pleteness as well as on account of their great frequency I have included among my cases certain specific swellings not usually classed with tumors. First, a few words as to the anat- omy of the parts whose pathological changes and clinical symptoms I am about to consider. The usual convenient classification of the lymphatic glands of the neck is into the su- perficial and deep sets, the former being found between the platysma and sterno-mas- toid muscles, often following the course of the external jugular; the latter {glandule concatenate) forming an unbroken chain from the base of the skull to the clavicle, lying along the sheath of the great vessels and by the side of the oesophagus and trachea ; be- tween the carotid and the transverse verte- bral processes ; following the anterior border of the trapezius, or occupying the supra-cla- vicular fossa. These glands may enlarge so as to become a source of trouble to the patient or of interest to the surgeon from a variety 2 of causes which by way of systematizing the subject we may divide into three great classes. 1. Glandular enlargement from constitu- tional causes. 2. Glandular enlargement from constitu- tional causes plus local irritation. 3. Glandular enlargement from local irrita- tion alone. In the first group are included swellings arising from a, syphilis ; b, carcinoma; d, lymphadenoma. Of these the first is much the most frequent. Syphilis.-This patient is a typical case of this character. A young adult, with a history of suspicious exposure some ten weeks ago, observed three weeks later that a small in- durated spot appeared behind the corona glandis, which has remained indolent and pain- less, slightly elevated, and with scarcely any discharge, just as I show it to you to-day. It was followed, however, in due time by en- largement of the inguinal lymphatics, and then-almost a week ago-by involvement of the cervical chain, especially those along the edge of the trapezius. This is an unmis- takable history, and of course leads us uner- ringly to the diagnosis of syphilis. The prognosis is unqualifiedly good as to every- thing but the entire disappearance of the swellings. They never give rise to pain, never suppurate, never constitute a noticeable de- formity, but a slight degree of tumefaction usually persists in spite of well-directed con- stitutional treatment. Local treatment is of no value. A rarer condition of cervical glandular en- largement, associated with syphilis, I show you in this man who, a month ago, fell and struck his mouth, cutting his lower lip against the edge of his upper incisors. A week ago the tri- fling sore, which had nearly healed, enlarged, broadened, became covered with a grayish slough, rose above the level of the surround- ing surface of the lip, and developed a dis- tinctly hardened base. Since then the glands beneath the chin and in the submaxillary region have enlarged so that you can see them from a distance. This is undoubtedly a case of infecting chancre, and, on inquiry, we learn that this man was in the habit of smoking the pipes of some of his fellow- laborers even while he had the recent cut of the lip. The glandular swelling is therefore the characteristic syphilitic bubo, and will subside under specific treatment. [The sore disappeared promptly under the administra- tion of mercury, and the tumefaction of the glands also subsided, though more slowly.] Carcinoma.-This is the only class of these swellings that I am unable to illustrate clini- cally to-day. Primary carcinoma of the glands of the neck is extremely rare. When it does occur it is recognized by the rapid growth of the swelling, its stony hardness, its fixity, the early implication of muscles, fascia, and skin, the development of cachexia, etc. The prognosis is, of course, unfavorable, and operative treatment is not very satisfactory unless the case is seen quite early, and yet it does not follow that the unfortunate patient should be deprived of whatever benefit might result from excision. In many cases the symptoms are most distressing. Pressure on the carotid and jugular causes annoying ver- 3 tigo, disturbance of vision, etc. ; on the sym- pathetic and on the various cervical nerves, often produces severe neuralgia and some- times ptosis, irregular dilatation of the pupil, one-sided flushing of the face, etc. ; on the oesophagus and trachea, results in dysphagia, dyspnoea, or even aphasia. In such cases it is justifiable to operate, with the clear under- standing, on the part of the patient, that the procedure is palliative and the equally clear determination, on the part of the surgeon, to make the operation as thorough as possible, even if, as advised by Mr. Jessett, it is neces- sary to tie the carotid and jugular above and below the growth. Return of the neoplasm is, of course, almost certain, but it is some- times delayed for months or even years, during which there is comparative comfort and freedom from pain. Lymphadenoma.-This patient is a young girl whose appearance will at once attract your attention. She is pale almost to blood- lessness, with dilated pupils and an expres- sion of profound weakness. You can see that she has on both sides of her neck rounded tumors, and, on palpation, these are found to be made up of elastic, mobile, painless glands, rounded, soft or fluctuating, and without evi- dence of inflammatory action. A further examination reveals similar enlargements in both axillae and in the right groin, a marked increase in the size of the spleen, and it is reported to me that there is a notable increase in the proportion of white corpuscles in the blood. The disease is evidently lymphade- noma (or Hodgkins's disease) together with leucocythsemia. The prognosis is unfavor- 4 5 able. Operation is contraindicated. The treatment should be tonic and hygienic. Sea air, arsenic, iron (especially the iodide), cod- liver oil, etc., are the usual remedies, and they are usually disappointing. The second group of glandular tumors in- cludes those in which there is an underlying constitutional condition with a certain degree of local irritation superadded. These are decidedly the most important from the surgi- cal stand-point, as affording the largest field for operation with the best prospect of per- manent good results. The word " scrofu- lous" would describe the growths belonging in this class, but that word demands some little definition. At the present time it is very generally ac- cepted that scrofula and tubercle are patho- logically, or at least etiologically, identical, for the reasons that the same characteristic products are found in both affections ; that such products, taken from so-called scrofulous glands and inoculated on other animals, pro- duce tuberculosis ; and, finally, because the bacillus of tubercle is frequently present in scrofulous diseases and has all the properties of the same bacillus when associated with genuine tubercle. The acceptance of this theory should have great weight in deciding the course of the practical surgeon in his management of cases of this character. There can be little doubt that glands affected with this form of tubercular inflam- mation are liable to become foci of infection, not only for other glands immediately con- nected with them, but for the general system. While, of course, there is the greatest possible 6 difference between the progress of a case of acute tuberculosis and that of scrofulous gland disease (which may be regarded as the two clinical extremes of the tubercular diath- esis), yet so long as we do not know the exact relation which one bears to the other, but do know that their etiology and their pathological anatomy are identical, and that either one may give rise to the other, we certainly have a clear indication for opera- tive interference in those cases which resist other forms of treatment. A case of this character will probably have the following characteristics: The patient will be comparatively young, very often be- tween the ages of three and fifteen ; there will be a family history of scrofula or con- sumption ; some source of local irritation will be discovered, such as a carious tooth, a sup- purative otitis, enlarged tonsils, post-nasal catarrh, eczema of the scalp, or some similar irritating cause ; the patient has the so-called scrofulous physiognomy, is dull and stupid in appearance ; the glands themselves are more solid and less elastic than in lymphadenoma ; they are more fixed and more tender than are the glands in that disease, and have a less wide-spread distribution ; they are espe- cially apt to undergo the change known as caseation, the cheesy degenerated product either remaining harmless or, like any other foreign body, setting up suppuration and causing the formation of an abscess. The treatment of such conditions may be considered, following the excellent classifica- tion of Mr. Frederick Treves (whose writings upon this subject, together with those of his brother, the surgeon to the Royal Hospital for Scrofula, at Margate, are without excep- tion the most authoritative in recent times), by clothing the patient carefully with wool; sending him to some sea-side or mountain resort, preferably the former ; the administra- tion of tonics, such as arsenic, iron, quinine, and cod-liver oil; the removal of the local irritation, whatever it may have been, which gave rise primarily to the glandular inflam- mation ; the employment of rest by use of a stiff collar or stock ; the inunction of some resolvent ointments, such as the ointment of iodide of lead, etc. Under this combined treatment many scrofulous enlargements will entirely disappear ; and I show you here two cases in which glands that a few weeks ago constituted a mass as large as a small apple have now become imperceptible to sight, and barely to be found by touch. But in hospital practice particularly, and in patients whom you do not see in the early stages of the growth, this treatment cannot be satisfactorily carried out. Poor people cannot take or send their children to the sea- shore or to watering places in the mountains, and they are very apt indeed to neglect the most essential of the methods of local treat- ment, namely, that of rest for the head and neck. Such was the history of the three cases which I now show you, and which only pre- sented themselves at this clinic after the glandular mass had attained a size varying from that of a cocoanut to that of a child's head. They have been operated upon by me as you know, at the different ward classes and with the assistance of members of your class. 7 8 In such cases operation must be thorough and unsparing, and these are typical examples of the difficulties and dangers which surround these extensive dissections of the neck. In each case it was necessary to lay bare both the anterior and posterior cervical triangles, to dissect the sterno-cleido mastoid free for its entire length, and, in one, to divide it in the middle and turn it upward and down- ward. In all of them the growth required to be dissected carefully from the great vessels, particularly from the internal jugular vein, which is chiefly endangered in these cases. In all of them also the growth extended into the supra-clavicular fossa and had to be sepa- rated from the immediate neighborhood of the subclavian vessels and the brachial plexus. The phrenic was exposed lying on the scale- nus anticus in two of the cases, and in all of them the dissection had to be carried down by the side of the trachea even to the oesophagus and the transverse processes of the vertebrae. The cardinal secret of success in these operations is to keep on the tumor,- that is, to cut with the knife, or to scratch with a grooved director, through the bands of connective tissue which hold the gland down to the neighboring parts, doing this cutting and scratching directly upon the glands them- selves at safe limits from the edge nearest to important structures. By doing this patiently it is remarkable what enormous growths of this kind may be safely removed. These cases are convalescent and in none has there been the least alarming symptom since the operation. The highest temperature reached was 100.5° and in each case union by first intention took place through the entire length of the skin wound. Free provision for drain- age is made by the use of large rubber drain- age-tubes for the first twenty-four or forty- eight hours, at the end of which time they are withdrawn wholly or partially and are re- placed by strands of catgut. The wound is brought together with sutures of silver wire or silk-worm gut, and is covered with cyanide gauze, and all the hollows of the neck from the chin to the clavicle are filled with bi- chloride cotton, which is held in place by a bandage in the shape of a double figure-of- eight of the head and neck, and neck and axilla. It is rare that more than two or, at the most, three dressings are necessary, and the wound is usually healed completely in about ten days, but such good results can only be obtained if, after the operation, the head and neck of the patient are immobilized by the employment of sand-bags placed on either side of the head as the patient lies supine, and heavy enough to prevent rotation of the head on the spine. The third and last group of cases in- cludes those in which the cause is simply local irritation without the admixture of constitutional infection of any sort. I am enabled to illustrate this form of glandular swelling by this young man, whose swollen and protruding under lip is in striking con- trast with that of the patient with labial chancre, whom you saw a few moments ago. He gives us a history of herpetic ulceration followed by a diffuse general inflammation of the cellular tissue of the lip, running into 9 10 suppuration and to the formation of the labial abscess which I now evacuate. As a result of this local inflammatory process there has been a similar process set up in the cer- vical glands, especially in the submaxillary region and its vicinity. We find an illy-de- fined, tender, hot, hard, red, brawny swelling with a focus of softening already, although the whole trouble is of but one week's dura- tion. Emptying of the small glandular ab- scess with the cure of the original source of trouble will probably cause the disappearance of all the symptoms in a few days. In resume let me reiterate the chief charac- teristics of these different forms of glandular tumors of the neck : i. Lymphatic enlargements, situated in the neck and dependent on constitutional causes, may arise from syphilis, carcinoma, and lym- phadenoma. When from syphilis, they affect by prefer- ence the posterior chain of glands, are small, freely movable, painless, bilateral, and yield readily to specific treatment. If carcinomatous, they form a very hard, rapidly-growing mass, infiltrating surround- ing parts, becoming fixed to everything be- neath it, involving the skin, causing serious pressure symptoms, and followed by the de- velopment of cachexia. Operative treatment is useful, though only palliative. If lymphadenomatous, they are rounded, regular, movable, painless, elastic or fluctu- ating, do not affect the skin, and are associated with anaemia, leucocythaemia, and with en- largement of other and widely removed lym- phatics and of the spleen. The treatment. 11 should be tonic and supporting. Operative interference is useless. 2. Scrofulous adenitis is essentially a tuber- cular inflammation of glands, occurring usu- ally in young persons with a scrofulous or phthisical family history, and with some form of local irritation superadded, which must be sought for in the mouth or pharynx or about the face or head. The glands are all charac- terized by a tendency to caseation, with or without suppuration, and form indolent masses, less defined, more fixed, and more tender than in lymphadenoma. The treat- ment in recent cases should be first hygienic and tonic with fixation of the head, and, if possible, with cure of the proximate cause. If this fails, or without attempting it in old cases, excision should be resorted to. 3. Simple adenitis results from some source of local irritation, and constitutes an acute, tender, inflamed, poorly-defined swelling, run- ning a rapid course to either suppuration or resolution. Treatment should consist in re- moval of the cause and in the application of resolvent lotions or ointments, or, later, in the free evacuation of pus.