Alexis Thomson

“ Secondary Tumours.#--Next to tuberculosis, _secondary cancer_ is the most common disease of lymph glands. In the neck it is met with in association with epithelioma of the lip, tongue, or fauces. The glands form tumours of variable size, and are often larger than the primary growth, the characters of which they reproduce. The glands are at first movable, but soon become fixed both to each other and to their surroundings; when fixed to the mandible they form a swelling of bone-like hardness; in time they soften, liquefy, and burst through the skin, forming foul, fungating ulcers. ”

“ Excision of glands, although sometimes beneficial, seldom arrests the progress of the disease. The ease and rapidity with which large masses of glands may be shelled out is in remarkable contrast to what is observed in tuberculous disease. Surgical interference may give relief when important structures are being pressed upon--tracheotomy, for example, may be required where life is threatened by asphyxia. ”

“ A strain or other form of trauma is sometimes blamed for the onset of lymphadenitis, especially in the glands of the groin (bubo) , but it is usually possible to discover some source of pyogenic infection which is responsible for the mischief, or to obtain a history of some antecedent infection such as gonorrhoea. It is possible for gonococci to lie latent in the inguinal glands for long periods, and only give rise to lymphadenitis if the glands be subsequently subjected to injury. The glands most frequently affected are those in the neck, axilla, and groin. ”

“ The lymph passes on to the deep inguinal and external iliac glands. The superficial glands through their relations to the genitals are frequently the subject of venereal infection, and also of epithelioma when this disease affects the genitals or anus; they are rarely the seat of tuberculosis. _The deep inguinal glands_ lie on the medial side of the femoral vein, and sometimes within the femoral canal. They receive lymph from the deep lymphatics of the lower limb, and some of the efferent vessels from the femoral and superficial inguinal glands. ”

“ In the deeply placed cervical glands, especially in cases of streptococcal throat infections, the suppuration rapidly involves the surrounding cellular tissue, and the clinical features are those of an acute cellulitis and deeply seated abscess. When this is incised the necrosed glands may be found lying in the pus, and on bacteriological examination are found to be swarming with streptococci. In suppuration of the axillary glands the abscess may be quite superficial, or it may be deeply placed beneath the strong fascia and pectoral muscles, according to the group of glands involved. ”

“ Sometimes the cystic tumour becomes infected and forms an abscess--another, although less desirable, method of cure. Those situated in the neck are most liable to suppurate, probably because of pyogenic organisms being brought to them by the lymphatics taking origin in the scalp, ear, or throat.
If operative interference is called for, the cysts may be tapped and injected with iodine, or excised; the operation for removal may entail a considerable dissection amongst the deeper structures at the root of the neck, and should not be lightly undertaken ”

“ If the wound heals so that the chyle is prevented from escaping, a fluctuating swelling may form beneath the scar; in course of time it gradually disappears.
An attempt should be made to close the wound in the duct by means of a fine suture; failing this, the duct must be occluded by a ligature as if it were a bleeding artery. The tissues are then stitched over it and the skin wound accurately closed, so as to obtain primary union, firm pressure being applied by dressings and an elastic webbing bandage. Even if the main duct is obliterated, a collateral circulation is usually established. ”

“ The _cystic lymphangioma_, _lymphatic cyst_, or _congenital cystic hygroma_ is most often met with in the neck--_hydrocele of the neck_; it is situated beneath the deep fascia, and projects either in front of or behind the sterno-mastoid muscle. It may attain a large size, the overlying skin and cyst wall may be so thin as to be translucent, and it has been known to cause serious impairment of respiration through pressing on the trachea. In the axilla also the cystic tumour may attain a considerable size (Fig. 76) ”

“ The dissection is rendered easier and is attended with less risk of injury to the nerves, if the patient is placed in the sitting posture so as to empty the veins, and, instead of a knife, the conical scissors of Mayo are employed. When the glands are extensively affected on both sides of the neck, it is advisable to allow an interval to elapse rather than to operate on both sides at one sitting. ”

“ The nature of these swellings is to be recognised by their situation, by their having existed from infancy, and, if necessary, by drawing off some of the contents of the cyst through a fine needle. They are usually remarkably indolent, persisting often for a long term of years without change, and, like the haemangioma, they sometimes undergo spontaneous cicatrisation and cure. ”

“ While the disease is most common in childhood and youth, it may be met with even in advanced life; and although often associated with impaired health and unhealthy surroundings, it may affect those who are apparently robust and are in affluent circumstances.
_Diagnosis._--The chief importance lies in differentiating tuberculous disease from lympho-sarcoma and from lymphadenoma, and this is usually possible from the history and from the nature of the enlargement. ”

“ The skin incision must be sufficiently extensive to give access to the whole of the affected area, and to avoid disfigurement should, whenever possible, be made in the line of the natural creases of the skin. ”

“ In exposing the glands the common facial and other venous trunks may require to be clamped and tied. Care must be taken not to injure the important nerves, particularly the accessory, the vagus, and the phrenic. ”