Treatment of Scrofulous Cervical Glands by Excision. 495

ART. X X V . - - 0 n the Treatment of Scrofulous Cervical Glands'by Excision2 By J o h n FAa~z~, F.R.C.S.I. ; Surgeon to the Belfast Royal Hospital and the Belfast Hospital for Sick Children.

ExcisION of scrofulous cervical glands has been a recognised mode of treatment for many years among Continental surgeons, notably by the French school. I t has been rather sparingly adopted in this country, and other treatment of a less radical nature is usually practised.

I am glad to see, however, that of late there is a growing disposi- tion on the part of physicians to approve of, and surgeons to carry out, this most excellent method in suitable cases.

My medical colleagues, both at the Royal Hospital and the Children's Hospital, have from time to time brought under my notice, with a view to operation, certain forms of obstinate gland swellings that resisted all the recognised modes of treatment. I have up to the present time operated in about twenty-five cases, and the result in each case has been most satisfactory.

I have on more than one occasion, at this and another Society, shown the patients operated on and glands removed, and to-night I have at random secured two children on whom I operated ; one sixteen months, the other a year, ago. In each it is with difficulty that you can detect the seat of the operation wound, its only evidence being an indistinct white streak.

As illustrating my mode of operating, as well as the usual progress and termination of such cases, I will briefly record the features of interest in three or four of them ; but before doing so I may be allowed to draw your attention in a passing way to the anatomical arrangement of the cervical 'lymphatics.

Of these there are two sets--a superficial and a deep one. The first lies along the course of the external jugular vein, beneath the platysma, receiving lymphatics from the skin of the neck, part of the face and scalp, and from the auricle of the ear. The deep chain of glands lying in close contact with the large vessels is divided into a lower and an upper set. The first is situated in the supra-clavicular fossa, and communicates with the axillary and mediastinal glands as well as with those of the upper set. The latter is placed opposite the division of the common carotid, and receives lymphatics from the tonsils, nasal fossm, lower part of pharynx, tongue, palate, and larynx, from the deep muscles of the head and neck, and from within the cranium. The sub-

Read before the Ulster Medical Society, Sesalon 1883-84.

496 Treatment of Scrof~,lous Cervical Glands by Excision.

maxillary set, placed under the cervical fascia, run along the base of the j a w ; they communicate with the superficial and deep cervical sets, and receive lymphatics from the mouth and lower lip. The parotid se t - -placed some in the substance, others on the surface, of the gland--receive lymphatics from the orbit, nasal fossm and upper jaw, the upper par t of the pharynx, and f rom the frontal and parietal regions of the scalp.

This brief survey of the principal lymphatic chains in the neck may be of service when considering the local causation of morbid changes in them, as also in carrying out any operative measures for their treatment.

CASE I . - -b Iy first case was a very healthy-looking little girl, aged eleven years~ whose family history was exceptionally good. She had an oval swelling the size of a pigeon's egg, situated on the left side of the neek~ corresponding to a point a little above the centre and towards the inner side of the sterno-mastoid. I t existed for more than a year, and resisted the ordinary modes of treatment. I decided on removing the gland~ and proceeded as follows : - - I made an incision immediately over the centre of the turnout corresponding with its long axis~ and the fibres of the sterno-mastoid. Holding it between my thumb and forefinger it conveyed the feeling of being very superficial, but on dividing the upper layers of fascia instead of the gland~ the fibres of the sterno-mastoid appeared in the wound. I t then occurred to me that I had to deal with one of the upper set of the deep cervical chain. So I carefully separated Lhe fibres of the muscle~ divided the underlying layer of the deep cervical fascia freely, and exposed the gland placed in close contact with the carotid sheath. I now seized the mass with a small double-tumour hook, and~ using gentle traction~ drew it towards the surface, while with careful strokes of the scalpel I liberated it from its bed of cellular tissue, thus removing it with comparative ease and very little hmmorrhage. Two smaller glands, placed at either extremity of the large one, I removed in the same cautious manner~ after twisting a few small arteries and washing out the wound with a solution of chloride of zinc. I bestowed great care in bringing its edges into accurate apposition by numerous points of very fine silver wire suture.

A_ bit of protective~ a pad of antiseptic gauze~ and a bandage, constituted the dressing. On the third day I looked at the wound~ and found it healed by direct union. There was neither swelling nor redness nor pain. I removed a few of the sutures and dressed the wound as before. On the fifth day I removed the remaining sutures and put a pad of cotton-wool over the part. On the day following I showed the child to the members of this Society~ when the only evidence of the operation was a scarcely per- ceptible scar~ which I expect through time has become still less perceptible.

:By MR. JOHN FAGAN. 497

The large and one of the small glands on section presented in their centres caseous matter, and one or two small circumscribed abscesses.

CASE I L - - A . M., aged twenty years, was affected for about a year with a chrbnic hip arthritis, the result of an injury. His health had been considerably impaired, and for three months prior to operation he suffered from an enlarged gland, situated below the angle of the lower jaw. This commenced as a small, hard lump, which soon became painful, and increased till i t attained the size of a small hen-egg. I t was treated in the usual way, with iodine application, and cod.liver oil, &c., internally. When I saw him the mass was mobile, hard, and painless. In operating on this case I made the line of my incision in the long axis of the tumour and parallel with the ramus of the lower jaw. The gland was not so easily turned out of its cellular bed as its mobility led me to expect. The surrounding tissue was somewhat closely matted to it, and there was considerable oozing of blood into the cavity that remained; this was checked by the strong chloride of zinc solution. The wound was sutured and dressed as in the former case. On the second day after the operation I removed the dressings, as he had a rigor and hig h temperature the previous night. The wound was firmly and evenly united, but there was diffuse inflammation extending from it over the side of the face and neck. I removed most of the sutures, opened up with a probe a small part of the wound at its most dependent angle, passed in a small drainage tube, painted all the surrounding parts with the strong iodine linimen~ and put him on large doses of quinine and iron. From that time he improved; there was no discharge, except a little serous oozing from the tube. The wound remained firmly united, and a little inflammatory thickening that was about i t at first, soon disappeared.

An interesting feature in connexion with this case is that, notwith- standing the very smart inflammatory action, the new piaster material never gave way, nor did any matter form in the cavity from which the gland was removed.

On section the centre or medullary portion was seen converted into a large abscess cavity, and the cortical portion was much thickened from inflammatory infiltration.

CASE I I I . - - J . L., aged nine years, a delicate-looking, badly-nourished lad, the subject of purpura, had an enlarged gland, situated a little below and in front of the angle of the jaw. I t existed there for two years, occasionally shrinking, but it never totally disappeared.

I removed it in the usual manner, the wound healed by the first intention, the scar was scarcely perceptible.

On section the centre of the gland presented the characteristic patches of caseous matter, with a few pus loculi.

2 K

498 Treatment of Scrofulous Cervical Glands by Excisions.

Among my other cases, while there are few points of further interest, the treatment and its result, as well as the pathological condition of the glands, were somewhat similar to what I have already described. ]n the case of a young lad, where there were two enlarged glands at the angle of the jaw, one of them was partially necrosed and exposed at tile bottom of a ragged ulcer, the other joining it was deeply placed. Owing to the matted condition of the surrounding tissue, I had consider- able difficulty in removing them, and in doing so wounded the facial artery. I immediately clamped the vessel on either side of the wound with a Pean's forceps, and after dividing it between secured both ends with catgut ligatures. The case did well.

In the case of a reformatory lad, who was an exceediugly unhealthy subject and a most incorrigible patient, the removal of the glands was followed by gaping of the wound and rather profuse suppuration. After a somewhat prolonged convalescence the part healed, leaving a very perceptible scar, but not as unsightly as that which follows Nature's process of suppuration and ulceration.

I show you two strings of glands that I removed a short time ago from a lad's neck (four on each side), two of them as large as small hen-eggs. There was some suppuration, but the case has done well.

This is a case I operated on five days ago ; the union is perfect. I keep a very small drainage tube in the dependent angle to drain the cavity, from which I removed one very large and three small glands. [The patient was shown to the members.]

There are a few points connected with the operation and its after- t reatment to which I think it worth while to direct your attention : - -

1. The incision over the gland should not be made too free ; but all the underlying structures should be freely divided from angle to angle of the skin wound. When the gland is well exposed it should be seized with a small tnmour hook, and steadily but gently drawn through the wound. In the majority of the cases that are suitable for this mode of treatment this is a simple process, requir- ing only the occasional use of the knife, a stout director or the handle of the scalpel being sufficient. When all the affected glands are removed, any ragged shreds of cellular tissue that remain should be clipped away with scissors. All bleeding points should be secured, and the wound well swabbed out with a strong solution of chloride of zinc.

2. Regarding drainage of the wound, I have had good results with and without i t ; still, on the whole, I think it better and safer to drain either with horsehair or very fine tubes. This is

By MR. JOHt~ FAGAm 499

especially requisite in cases where the wound is large, and where there has been oozing of blood and difficulty of enucleating the gland.

3. As regards suturing the wound, the finest silver wire should be used. I t should not be passed too deeply through the lips of the wound, which should be most accurately adjusted, and the sutures should be removed not later than the third day, and sooner if the slightest inflammatory blush should appear at their points of exit from the skin. The marks that follow the suppurating tracks of the sutures are far more disfiguring than the scar from the incision.

4. As regards maintaining the parts at rest while union is taking place, this is most essential for obvious reasons. The most effectual way of securing this is, I find, by means of a night-cap with a pair of strings attached to either side ; these are brought down and fastened in front to a thoracic binder, and drawn sufficiently tight to bring the head well forward on the chest. Such a form of restraint is especially necessary in the case of children, who will only remain at rest on compulsion.

5. Should inflammation attack the wound the tension should be at once relieved by removing some, if not all, of the sutures ; and if there has been no drainage, a probe should be passed into its cavity at the most dependent angle, and a small tube inserted.

I have now explained to you a certain well-defined mode of treatment, as carried out by me in a considerable number of cases, and I have shown you the results of such treatment. To some it may appear very satisfactory, while to others it may seem an unnecessarily heroic method, subjecting, as it does, the patient to a certain amount of deformity no matter how successfully carried out, and not altogether devoid of risk to the life of the patient.

While deferring a reply on this head, I may be allowed to examine cursorily some interesting features in this broad subject that just now occur to me, as in some way bearing on the mode of treatment advocated in this paper.

In the whole range of medicine and surgery I question if there is a subjzct concerning which there is more diversity of opinion, regarding both its nature and treatment, than there is about what we term scrofula or struma. The various and conflicting views held at different periods by equally eminent inquirers concerning the nature of this condition; the innumerable nostrums displacing one another in rapid succession--their virtue often consisting in their novelty--is a striking proof of the unstable nature of the basis on which the pathology and therapeutics of this disease rest.

500 Treatment of S~rofulous Cervical Glands by Excision.

From a purely surgical standpoint I would define the term struma or scrofula as an inflammatory process attacking the tissues of a lowly vitalised organism, and manifesting itself by a slow and silent destructive action.

The exciting causes that are likely to give rise to this condition in the lymphatic glands arc many and obscure :--Traumatism, direct or indirect, through the lymphatics; all sources of irrita- tion, internal as well as external--for instance, bad teeth, sore throat, bronchitis, enteritis, skin affections, exposure to cold, &c. That the glands of the neck are more frequently than any other the sub- ject of this condition will appear evident from the fact that there is a very intimate connexion between them and the large amount of 13nnphoid tissue in the mouth and pharynx, which in most delicate subjects is highly susceptible to the slightest variation in tempera- ture or the contact of septic matter.

While we know that in almost all cases there are two factors-- viz., the hereditary and acquired---in producing the strumous con- dition, you may ask which plays the more important part ?

Mr. Savory, in his remarks on the subject of scrofula, answers this question more fully and satisfactorily than any other author. He says the causes of disease are conveniently and naturally divided into predisposing and exciting, and the development of disease depends on the extent to which these causes act in combination. For example, by way of illustration merely, let it be assumed that any given disease cannot be produced unless the sum of the causes reach a certain figure, say 100. :Now, so long as this number can be attained by the causes conjointly, it matters not what their relative share in it may be. The predisposing cause may equal 70, the exciting cause 30, or vice versd. From this it follows, as is well known, that when the predisposition to disease is strongly marked, the most trivial exciting cause may suffice to develop i t - - it may be 99 to 1. On the other hand, if the exciting cause or causes be sufficiently intense and prolonged, the disease may be produced where there is only the faintest predisposition.

Let us illustrate this by an example :--Take a child of parents in the better class of life, surrounded by all the necessaries for its wellbeing, and although there may be a strong hereditary tendency, the exciting causes being almost nil, the sum total is not sufficient to develop the scrofulous condition; but suppose that child by some misfortune is reduced to the state that we find the wretched children of the poor in our large cities, the victim of bad air, bad

By MR. JOHN FAGAN. 5(|1

food, uncleanliness, insufficient clothing, and particularly in this rough, changeable climate of ours, you will soon see the disease manifesting itself in its most severe form.

The hereditary or predisposing causes among the children of the poor may be almost nil, but the exciting are so many and so forcible that of themselves they often give rise to the scrofulous condition.

The general treatment of this affection in its earliest manifesta- tion, more especially when due to hereditary causes, falls within the province of the physician. But there are some conditions of gland enlargement in which timely surgical interference would be of the greatest possible good. In a healthy subject when a gland enlarges and grows painful, if the tension be not soon relieved the probabilities are that it will go on to suppuration. The timely relief of tension is a principle I strongly adhere to in dealing with all forms of inflammation, especially when the affected tissues are bound down by a dense, resisting medium. I f we consider for a moment the anatomical characters of a lymphatic gland, we shall at once see the necessity there is for attention to this point. When its structure becomes inflamed multiple punctures of the dense, fibrous capsule should be made to relieve the congested gland sub- stance and allow the inflammatory products free exit into the surrounding cellular tissue. I t can be practised by means of a fine tenotome passed subcutaneously at some distance from the gland.

I find time will not permit me to discuss the merits of many other useful surgical methods of treating strumous gland disease; and while admitting the thermo-cautery, Volkmann's spoon, and appro- priate caustics to be good in certain forms of the disease, I hold strongly to the opinion that when disease is limited within a well- defined area, and the tissue involved is steadily, however slowly, deteriorating, that its total extirpation is the only rational and effectual mode of dealing with it, and this principle is, I maintain, equally applicable whether the structure implicated be gland, bone, or joint, provided anatomical considerations allow of such operative interference.

Let it not be understood that, while making this somewhat strong statement, I am an advocate for the wholesale use of the knife for treating diseased structures. Such a practice I believe to be as mischievous as that where its use is never recommended. But the judicious physician or surgeon who, when he sees diseased structure persistently deteriorating, and not alone so, but endan- gering the vitality of that in its neighbourhood, recommends its

502 Two Cases of Intestinal Obstruction.

timely removal, is a far greater benefactor to his patients than he who temporises in the hope that Mature, with the aid of his nos- trums, will bring about a cure.

Anyone who has seen my cases must, I think, admit that the method of treatment I have adopted is the best for those chronic cases that resist all other recognised remedies. Its superiority over the temporising plan will appear strikingly manifest if we compare a patient restored to health after the rapid riddance of the diseased mass, and showing scarcely any mark, with another graphically described by Dr. Clifford Allbutt as "dragging on a chequered and tedious course, drifting, perhaps, from doctor to doctor, consuming volumes of cod-liver oil and medicines, breaking up life and prospects by prolonged exile from home, pestered by filthy discharges, or poisoned by decay which is not discharged, disfigured by sinuses, sluggish streaks and lumps of fibrous increase, seamy scars, and indurated gland-remnants. Such patients, thanks to the marvellous pertinacity of life, do generally fight their way into complete or partial recovery, but at the price of permanent dis- figurement ; at the price of tell-tale corrugations in the neck; at the price, perhaps, of a deferred pulmonary phthisis, set up by absorption of the partially voided caseous products."

You will admit that this is not an overdrawn picture, and you will agree with me that scrofula, as it now is, is an oTprobrium medicince.

ART. XXVI.--Two Cases of Intestinal Obstruction2 By KENDAL FRANKS, MD., Univ. Dub. ; Ex-Sch. Trin. Coll. Dub. ; Fellow of the Royal College of Surgeons, Ireland; Fellow of the Academy of Medicine of Ireland; Surgeon to the Adelaide Hospital; Surgeon to the Throat and Ear Hospital.

L - - I N T U S S U S C E P T I O N F I V E INCHES IN LENGTH AT ILEO-C~ECAL

V A L V E - - IRREDUCIBLE BY E N E M A T A - - ABDOMINAL SEC-

T I O N - R E D U C T I O N - D E A T H FROM EXHAUSTION.

I I , - - T W I S T OF THE INTESTINE AT SIGMOID FLEXURE OF THE

COLON--REDUCT IO N BY INTERNAL MANIPULATION THROUGH

RECTUM--RECOVERY.

IN the following paper I desire to bring under the notice of the Academy two cases of intestinal obstruction, which, though differing as to the pathological condition to which the obstruction was due,

Presented to the Medical Section of the Academy of Medicine in Ireland, Friday, May 16, 1884.