Reprinted from the Occidental Medical Times, October, 1890. 
TUBERCULOSIS OF CERVICAL LYMPHATIC GLANDS, 
WITH AN ILLUSTRATIVE CASE. 
By D. W. Montgomery, M. D., Professor of Pathology and Clinician 
far- Diseases qf the Skin, Medical Department of the University of 
California, Clinician for Diseases of the Skin, San Francisco Poly- 
clinic, and 
H. M. Sherman, M. D-7 Orthopedic Surgeon to the Children's Hospital, 
and to the San Francisco Polyclinic. 
The course of the lymph stream is from the periphery towards 
the centre, and as a consequence, any deleterious matters entering 
it and floating in the current will tend to be carried to the depths 
of the body out of reach of surgical interference. If, however, 
the surgeon Gan stand in the way and prevent the poison thrown 
into the stream from passing beyond the superficial lymphatics, he 
fulfills one of the highest efforts of his calling, prophylaxis. This 
was the aim of those who proposed ligation and extirpation of the 
lymphatics in syphilis ; but the diffusibility of the poison in this 
case rendered the operation fruitless. On the other hand, there 
is every reason to think the same principle has been productive of 
much good in operations for the cure of cancer. 
The germ causing tuberculosis is not rapidly diffusible, except 
when thrown in large numbers into the blood current, and so dis- 
tributed suddenly to all parts of the body. Usually this virus first 
enters the spaces between the fibres of connective tissue, which 
are the radicles of the lymphatics ; from there it floats into the 
larger lymph channels, and so reaches the nearest lymphatic 
gland. If the lymphatic system be functionating properly, the 
germ may be passed on and finally make its exit through one of 
the emunctories without doing any more damage than a foreign 
body passing through the alimentary canal. The tubercle bacil- 
lus is a slow grower, even under very favorable conditions, and is 
hurried along in the rapid lymph stream before it has time to 
propagate and form a colony. Furthermore, it requires a suita- 
ble soil on which to grow. The lymphatic glands of children 2 
seem to be particularly vulnerable, and we find that the glands of 
the neck are very frequently the seat of disease, as evidenced by 
the old name "scrofula" (scrofa, a sow), from the thickened and 
brawnv appearance of the neck, caused by the enlargement and 
inflammation of the lymphatic glands. 
In looking for the portal through which the poison gains access 
to these glands, we naturally think of the mouth. The gums and 
anterior part of the oral cavity are subject to severe irritation dur- 
ing teething, giving rise to small ulcerations and other solutions 
of continuity of the delicate mucous membrane ; and the poste- 
rior part has on each side the soft and patulous tonsils, rich in 
lymphatics and prone to inflammation. These considerations were 
of great weight in determining the line of action in the case of a 
child who had been exposed to tubercular infection from one of 
its parents, and developed an enlarged cervical gland without any 
other known cause, such as measles or syphilis, to account for it. 
The history is as follows : 
Toward the latter part of August, 1889, May IT , aged 4 
years, developed a rounded, smooth, easily-movable tumor, about 
the size of a pigeon egg, under the left sterno-cleido-mastoid mus- 
cle. The child was fretful, but otherwise in good health, without any 
rise of pulse or temperature. There were no indications of pulmo- 
nary trouble. Her father had died of consumption the year before. 
The immediate extirpation of the gland was proposed and car- 
ried out on Sept. 19th. One striking peculiarity in these opera- 
tions is, that what appears to be quite a superficial swelling will 
be found situated much deeper than expected. After incising the 
skin, the finger had to be repeatedly inserted into the wound to 
make sure of the position of the tumor, and the gland that seemed 
so superficial was picked off the transverse processes of the cer- 
vical vertebrae. 
The gland, when removed, was reddened and soft, but not at 
all cheesy. Some of the juice and detritus squeezed and scraped 
from its cut surface, was put on slides, dried, and stained in the 
usual way for tubercle bacilli. Out of a large number of slides so 
prepared, only two or three were found to contain the bacillus, 
and then in very small numbers, but enough to fix the diagnosis. 
Transverse sections of the gland did not show the histological 
changes characteristic of tuberculosis, but only those of a diffuse, 3 
rather acute inflammatory process. Tubercular infection does not 
necessarily give rise, at so early a stage, to the formation of tuber- 
cles with their giant, endothelial, and lymphoid cells, and the 
caseous process is a still later event than the formation of tuber- 
cles. The tuberculous process gives rise at first to nodules com- 
posed of round cells, but in many instances it is impossible to 
distinguish these little aggregations of cells from the surrounding 
lymphatic tissue.1 No tubercle bacilli were found in the sections. 
It will be observed that this method of treating tuberculous 
adenitis in children, approaches in radicalness the treatment of 
malignant disease, and indeed the course of the malady justifies 
this rigor. The disease is destructive in the gland where it takes 
up its abode, leading to its structural and functional annihilation, 
and the formation of a cheesy mass. It has been asserted that 
such a mass may gradually break down into a finely granular de- 
tritus and be absorbed, and if the virus have died out beforehand, 
this must be looked upon as the most fortunate outcome possible. 
But in our opinion this happy issue is of very doubtful occurrence. 
The best we may expect is an investment of the dead and diseased 
mass with a fibrous capsule, and the deposition in it of lime salts 
causing calcification. This fortunate event rarely happens, for in 
children suppurative processes are easily set up, and indeed sup- 
puration is one means of cure here, for the whole dead infective 
mass may be extruded through a fistula. But how long will such 
a process take? And will not the child suffer in its general health 
during the process? What ugly deformed scars will be left in the 
neck? are questions full of meaning to those who adopt the ex- 
pectative line of treatment. Suppuration and the extrusion of 
the diseased mass is therefore the next best thing to encapsulation 
and calcification when Nature is left to treat the disease. 
Besides being infective in its immediate neighborhood by direct 
continuity, it must not be lost sight of that it has yet another 
characteristic ci malignancy, that is the spread of the infection 
from the gland first implicated to the next one farther down the 
lymph stream, and so on till the internal organs are reached, when 
in a pathological way, there is a vista of ugly deformities which 
few of us care to look down. So we see that although there may 
1 Zeigler, Pathological Anatomy and Histogenesis, page 173. 
bu 4 
be a happy issue to the disease without operative procedures, still 
the chances are so far against it that those surgeons who believe 
in treating tuberculosis as a malignant disease, receive, as far as 
the morbid processes in the glands of the neck are concerned, 
very positive support. 
On leaving the city, a few weeks after the operation, the child 
was quite well, and had a small linear scar on the side of the neck 
for the wound had healed kindly without accident. When last 
heard from, Aug. 5, 1890, she was not very robust, and the neck 
at the site of operation was somewhat painful when touched. No 
indications of tuberculosis, however, were present, and it is to be 
hoped that the child has escaped that danger.