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Lymphatic glandular enlargements of the neck may be divided into groups for descriptive purposes. First group Non-tubercular cervical adenitis: Etiology (from focal infection of nasopharynx, mouth and face, jaws teeth, middle ear, mastoid, salivary glands, etc.). Clinically. This type may or may not have an elevation of temperature and polymorphonuclear leucocytosis, depending largely upon virulence of organism and extent of involvement. However, if there is a constant increase of temperature and an increase of the polynuclears, it is significant of this variety of cervical adenitis. Particularly is this prone to occur if there is a rapid increase in size of this type, for they then undergo necrosis and suppuration. This train of circumstances is not characteristic of the tubercular type and is useful as a differential diagnostic point. If these glands do not progress to suppuration they rarely attain a very large size and though occasionally isolated nodes are observed (the size of a bean) over a long period of time, the tendency is for them to be transitory. In other words, those which do not develop to a larger size (say the size of a walnut) rarely suppurate and soon return to their normal size. Second Group. Tubercular cervical adenitis or “scrofulous neck swellings” are the next most common. The proportion of these two groups are the next most common. The proportion of these two groups are approximately five of the first group (considering those which go on to suppuration) to one of the second group. The Etiology. The mode of infection is very similar to that of group 1, but the tubercle bacilli being the organism present. The structures of the mouth, nasopharynx and larynx being the primary foci from which the lymph nodes are involved secondarily. Chief among these are tuberculosis of tonsils and adenoids and a great many cases, no doubt, are directly infected through mucous membrane upon which is left no clinical trace of tuberculosis. Wright’s description of this latter process seems to be quite logical. It has been demonstrated experimentally and observed clinically. The mucous membrane absorbs, the lymphoid tissue harbors, and the lymph channels carry the tubercle bacilli. Clinically. The tubercular nodes as a rule have a tendency to attain a larger size than those in group 1, and do not undergo suppuration as quickly. To illustrate, take two nodes of the same size (the size of a walnut) one in each class. The one in class 1 will develop to its size and suppurate in days, while the one in group 2 will take weeks before it will attain the size of a walnut and abscess formation occur. The temperature, if elevated at all, is more apt to be the characteristic evening rise and morning fall, the increase in white blood cells, due to lymphocytosis rather than multiplicaation of polynuclear leucocytes. Von Pirquet’s test for tuberculosis in young children may also be of help in differential diagnosis, particularly if it is negative. The above points or rules are of course, not infallible; they vary with the individual case, stage of involvement and complicatons, but as a whole they are characteristic of the majority of uncomplicated cases of tubercular cervical adenitis. It is not the purpose to discuss here the probable outcome of tubercular cervical adenitis with and without various modes of treatment, but because of the prevalency and importance of this malady, it is deserving of a little further mention. There is a possibility of the local tubercular process in the neck becoming disseminated, most frequent of which, of course, is the pulmonary involvement. The very probable local disfigurement as a result of cold abscess formation fistula, etc., which is much more prone to occur under any other line of treatment than complete excision. The complete excision should be done as soon as the diagnosis is made, and an early diagnosis is important. Third Group. Lymphatic enlargements as a result of old syphilitic infection. The posterior cervical nodes are most commonly involved of the neck lymphatics. They rarely attain a very large size unless mixed infection is present, and syphilis of cervical nodes is usually associated with the same type of enlargements of lymphatics in axilla, inguinal region and above the elbow. They rarely suppurate and are present for a long period of time. The blood Wasserman examination, of course, is of value here in making a diagnosis. Fourth Group. Hodgkin’s disease or Pseudoleukemia. This fortunately is not very frequent and unfortunately most always fatal. It does not respond to the Von Pirquet’s test, and rarely suppurates. Clinically, it can be divided into two stages. In the first stage there are no signs except a mass of nodes which are in most cases in the neck and the general health seems to be surprisingly good. In the second stage, groups of nodes may be involved almost anywhere, axilla, mediastinum, inguinal region, etc., steadily increasing in size, this accompanied with an anemia which becomes progressively worse. Various forms of treatment have been advocated, chief among which are X-ray, radium and surgery. In the first stage, surgery seems to offer the best means of delaying the steady progress of the disease. After generalization or second stage, the most that is warranted by way of operation is removal of a node for diagnosis and further surgery to do what is possible for mechanical interference with respiration or deglutition, such as a tracheotomy or excision of cervical nodes if the difficulty is due to the neck glands and not those in the mediastinum. Fifth Group. Cystic lymphangioma is very rare and often attains a very large size, may be stationary in size for some time, and then suddenly begins to increase; most common in youth and early adult life. Lymphosarcoma is another rare condition and is more frequently diagnosed by microscopic section than clinically. NOTE: Other cysts and tumors of the neck such as bronchial, parotid and thyroglossal cysts, hygroma colli, tumors of the carotid body, enlargements of the thyroid and aneurism must be considered at times in a differential diagnosis. All the above cases, both surgical and non-surgical, should have osteopathic care, particularly directed to bony lesions and improving constitutional condition. That variety of cervical adenitis which is non-specific and non-suppurating, in addition, should be cared for along the lines advised by Dr. Deason. Briefly summing up the therapeutic indications for
all the above cases, is to treat conservatively with recognized osteopathic
care, instituting surgery when indicated and then post-operative osteopathic
work to accomplish the maximum normalization possible.
The workings of the lymphatics of the chest are hidden from us, except as they are manifested to us through disease. The lymphatics of the lung take their origin from the pulmonary lobes, while others take their origin in the fine connective tissue network. The lymphatics of the visceral pleura join with those draining from the lobes of the lung surface, and form the superficial collecting trunks terminating in glands at the root of the lung. The deep trunk is made up of the lymphatics from the deeper lobes and those of the bronchi; the latter, having free communication with the surface of the organ, terminate in the peribronchial lymphatics, which, accompanied by the bronchi and vessels, terminate in the hilum. The lymphatics of the pleura offer an interesting study in drainage, the pleura being a closed serous cavity, the inner surface being lined with endothelium, the costal and parietal portions being in close contact. It is lubricated by serous secretions and is well supplied with blood vessels and lymph. The lymphatics are formed in two series, one beneath the endothelium, the other in the cellular portion adjoining the pleura, both having free communication. As previously indicated, the visceral portion joins the lymph draining from the lobe surface and forms the superficial collecting trunk which terminates in the hilum of the lung. The costal portion of the parietal layer is well drained by the deep intercostal lymphatics, and these terminate in the mammary glands and vessels. The communication of the deep with the superficial intercostal lymphatics and the free communication of the latter with the lymphatics of the chest explains the involvement of the axillary lymphatics in thoracic disease. The lymphatics of the pleural and parietal surfaces of the diaphragm communicate freely. Infection passing from one serous sac to the other can be explained in this manner. Poirier, in his works on lymphatics, explains the frequency of pleurisy as a sequel to abscess and infection of the liver as due to the fact the lymphatic vessels from the liver pass directly to, and drain into, the sub-pleural lymphatics of the diaphragm. PLATE XLVII. Lymph Nodes in relation to Larynx, Trachea and Bronchi. The uppermost node is the pre-tracheal. This new X-ray effect to illustrate the transparency of the various tissues will be carried out from time to time. Note the nodes on the bronchioles and the possibility of infection traversing the entire laryngeal, tracheal and bronchial regions. Treatment for drainage and circulation of the Thorax. In cases of pneumonia and allied conditions, there is one master treatment which accomplishes amazing results. This, I term the “make and break” movement. With one hand on the heads of the ribs posteriorly and the other on the ribs anteriorly, spring the ribs rhythmically in a line with their angle, alternating the pressure from hand to hand. To promote vaso-dilatation, sit down beside the patient with the hands at the 2nd and 3rd dorsal vertebrae. Exert pressure enough to almost raise the patient from the bed yet not quite do so. Alternately relax and inhibit for 10 to 15 minutes, repeating as the case necessitates. Then, standing at the head of the bed, grasp the neck as low down as possible so as to get straight traction on the 2nd dorsal. Make and break for dilatation of the lung arterioles. Direct pressure movements downward and backward of the sternum and upper seven ribs on each side, the patient lying on his back, are very efficacious in stimulating the lymphatics. |
