the internal jugular chain behind the posterior | line with the thymus and the thyroid, and is not belly of the digastric. This is the principal a pure lymphoid structure. It begins to demeeting place of the neck lymphatics. A not velop about the fourth month of embryonic life, inconsiderable number of the lymph vessels go and matures about puberty. It probably has directly from the posterior pharyngeal wall to some protective function in the early years of the deep glands of the neck and the jugular life as the experimental work performed by region. The adenoid area drains into the poster- G. H. Wright and many others has shown. The ior wall of the pharynx, which is the chief col- argument that because no deleterious results lecting point of the lymphatics of the pharynx follow enucleation, the tonsil is of no value, and both from the roof of the pharynx, and from the should be removed in every case, is not a good posterior and side walls, and from the Eustach- one, since its period of greatest functional activian tube. The lymphatics of the larynx drain ity is before puberty. Tubercular adenitis is into the glands arranged along the internal usually a localized tubercular affection most jugular chain, the substerno mastoid glands frequent in childhood from the sixth to the being the principal terminus. The lymphatic fifteenth year, although it may occur in early glands of the lung form a rich network joining infancy, and seems to have some relationship to together up to the point of entrance of the lung diseased tonsils, adenoids and general pharynwhere they become superficial. They pass geal disturbance. It has repeatedly been demthrough several pulmonary lymph glands forming by their union broncho mediastinal trunks. These course along the trachea to the lower portion of the neck, and finally open at the venous confluence or into the thoracic duct on the left, and on the right directly into the subclavian, or at the junction of the jugular and subclavian.

onstrated by Wood and others that tubercle bacilli can be made to invade and pass through the faucial tonsil without producing tuberculosis of the tonsil itself. The same is probably true of other portions of the lymphoid area whose anatomy we have been considering. When we come to estimate the number of cases of tonThe tonsil itself develops as an ingrowth of sils which of themselves are actually diseased, endothelium from the second bronchial pouch. we find the number varying from one or two According to Gordon Wilson, in origin it is in per cent. up to ten, according to the experience

of the individual observer. Tubercle bacilli have since. She is a strong and robust woman, and been extremely hard to demonstrate in the ton- never had any cough. She married, the adesil, hence the question of the presence or ab- noids were removed from her child, and then sence of tubercular disease has had to depend this child developed adenitis with broken down principally upon histologic findings. A suffi- glands, but without signs of any general tubercient number of observations have been made to culosis. The glands were removed, and later demonstrate that tubercular adenitis is not the tonsils also, with the result that the child is necessarily accompanied by a tubercular tonsil, now in perfect health, more than a year having but seems to have its source with the tonsils as elapsed since the last operation. I do not think the port of entrance of the trouble even though there was any direct heredity in this instance, they themselves may not have been diseased. In but in each case the infection occurred through one instance I removed the adenoids in a the faucial tonsils. Certain it is that after regirl of twelve, some years later she had a severe moval of the faucial tonsil in many children attack of cervical adenitis, with broken down previously suffering, to a greater or less degree, glands, which on removal, were found to be tu- from enlarged cervical glands, these glands disbercular. The tonsils were removed at this time, appear and are no longer palpable to the finger. and the individual has been perfectly well ever In a recent review clinic, held to determine the

final results, in a series of cases operated on for the back of the mouth where it is very subject tonsils and adenoids, something over 100 in to infection and to pressure during the act of number, it was found that the cervical lymph eating and swallowing, is probably the greatest glands, were, as a rule, felt not at all, or to only offender. As the tonsil is such a possible portal a slight degree. Many of these children did of infection, and as its removal seems to be folhave enlarged lymph glands at the time of lowed by no deleterious effects upon the organoperation. Although it is impossible to deter- ism, and as it is very likely to be a source of enmine in the individual case whether the tonsil trance for the infection of rheumatism, I should is the source of the adenitis or whether its re- advise its removal in all cases of cervical ademoval will cause a disappearance of the en- nitis, and in all children whose parents give a larged glands, I am inclined as the result of my history of having had cervical adenitis. At the own experience and that of others, to recom- same time, one cannot say with positiveness that mend that in all cases of cervical adenitis the the removal of the tonsil will either cure or pretonsil be removed as the first procedure. If the vent cervical adenitis. Here, as in other deglands are broken down, and an operation up- partments of medicine, each case must be judged on them has to be performed, then the tonsil on its own merits. One can always reassure should be removed at the same time. That the the parents of such children that in all probabilremoval of the tonsil removes all source of pos- ity the cervical adenitis is not an accompanisible danger of infection of the cervical ment of a general pulmonary tubercular prolymph glands is not claimed, since claimed, since ana- cess, since the lymph glands of the lung drain tomical studies already referred to have directly into the blood stream, the drainage shown that the entire area of the middle ear, from the two areas having no direct meetingEustachian tube, superior, posterior and lateral place, unless near the point of final entrance pharyngeal wall, the tonsils, base of the tongue, and posterior nares all have their lymphatic drainage area into the cervical lymph glands. The tonsil, however, being large, and situated in

into the general blood stream. It, of course, cannot be denied that there is some possibility of general infection from the entrance into the general blood stream of bacilli from the infected

signed the application blank on which he made this note,

"Tuberculous cervical adenitis; operation not advisable. Signs of tuberculosis present at right apex."

Briefly the history of the case was as follows:

[I have to acknowledge in the preparation of this article my special indebtedness to the volThe glands of the left cervical region began to ume on the "Lymphatics" of Poirier, Cuneo, enlarge four years ago. Those of the right side and Delamere, and to the articles entitled "Der two years later. Recently she noticed considerLymphgefâssapparat des Kopfes und des Hal- able loss of strength and her weight was fourses," by Professor August Most, published in teen pounds below normal. Vol. I "Handbuch der speziellen Chirurgie des Ohres und der oberen Luftwege," edited by Katz, Preysing and Blumenfeld, from which article the illustrations here presented have been redrawn.]

II.

Physical examination showed that the anterior, posterior and sub-maxillary groups of glands were all involved. The swelling was so extensive that the neck had lost all its natural con

tour.

While at the hospital a small gland was exeised for examination and a pathologist reported that it was tuberculous.

There was slight consolidation of the right apex, without signs of active disease.

TREATMENT OF TUBERCULOUS CERVICAL ADENITIS. BY HENRY D. CHADWICK, M.D., WESTFIELD, MASS. For the first week following her admission, Superintendent, Westfield State Sanatorium. her temperature varied from 100 to 103, and IN March, 1910, a young woman 23 years of then gradually declined until it reached normal age, was transferred from the Massachusetts in about six weeks. During this time there had General Hospital to the Westfield State Sanator- been little decrease in the size of the enlarged ium. One of the assistant resident physicians glands. After her temperature had been normal

for about a month tuberculin treatment was commenced. The initial amount given was one millionth of a milligram. The dosage was cautiously increased up to a maximum of ten milligrams. The swollen glands steadily reduced in size during the treatment.

She was discharged as a patient in November, 1910. At that time her neck had a normal appearance and only a few of what had been the largest glands could be felt. Her general condition was very good, and she was given work as a ward maid. We continued the tuberculin several months longer, while she was thus employed.

The results in this case were so good that all subsequent patients, as they were admitted, were given tuberculin treatment if they had enlarged glands and their pulmonary disease was not so active as to contraindicate its use. I have had but a comparatively few adults with tuberculous adenitis who were suitable cases for this treatment. Each one has responded satisfactorily to tuberculin, except one out-patient. This woman came for treatment twice a week and continued her usual occupation. Although she came faithfully for the injections until a dose of ten milligrams was reached, there was no apparent decrease in the size of the glands. I am of the opinion that had this patient been under sanatorium conditions while being treated, a satisfactory result might have been obtained.

As a routine part of their treatment, we put these patients on bacillen emulsion, if they do not have more than a degree of temperature, or other signs of active pulmonary disease.

The initial dose is one millioneth of a milligram, and the course of treatment extends over a period of about six months, until we reach ten milligrams. This maximum could be reached in a shorter time, but I feel that a small dose given over a longer period is more effective, and can be given in this way without causing reactions.

The result of treatment in these children is very satisfactory. The cervical glands decrease perceptibly in size, and the area of dullness over the hilus becomes smaller and less pronounced.

The longer the tuberculous disease has existed in a gland the slower will be the effect of treatment.

Resolution must necessarily be limited if fibroid changes have taken place. Suppuration has not occurred in any case where it did not exist prior to treatment.

One young girl having multiple tuberculous ulcerations of the skin and numerous involved glands showed marked improvement as soon as we began to administer tuberculin. She is still under treatment with every indication that the ulcers will heal and that the enlarged glands will disappear.

prompt resolution.

In a few instances where patients have deOne other patient had cervical adenitis so ex- have invariably found that instituting tuberveloped adenitis while in the sanatorium, we tensively that it made operation inadvisable. She culin treatment will prevent further swelling had been referred to the sanatorium from the and cause that which has occurred to undergo out-patient department of the Massachusetts. General Hospital. This girl had been at the sanatorium two different periods for a few months each, and left against advice each time. Tuberculin was given regularly while at the sanatorium, and continued at irregular intervals at the out-patient department of the hospital. In this case much good has been accomplished, but probably some of the larger fibroid glands will later need to be excised.

This experience leads me to the conclusion that surgical interference is only necessary to remove such glands as have become caseous, or fibroid. Extensive dissections are unnecessary in these cases, as the small recently diseased glands that are left will disappear under the influence of tuberculin treatment.

IV.

TUBERCULOUS

ADENITIS.

CERVICAL

BY JOHN B. HAWES, 2D, M.D., BOSTON.

Another young woman had a marked enlargement of the right posterior cervical group. Some of the glands had become caseous, broken down, THE TREATMENT OF and there was a discharging sinus. Four months' treatment with tuberculin was without apparent effect. The enlarged glands were then excised, and the tuberculin continued. The I WISH it understood that I am making no wound healed by first intention. After her dis- special plea for tuberculin in the treatment of charge as a patient, she worked at the sanator- tuberculous adenitis. I believe that tuberculin ium for two years as a domestic. Her health does a certain amount of good in certain cases. was excellent, although at one time a swelling With proper handling it does no harm. appeared near the sight of the old scar, which, wish it understood that I am likewise not opafter resuming tuberculin medication, soon dis-posed to proper surgery. I feel very strongly appeared.

Many of the children admitted at Westfield have tuberculous cervical glands. Not many are noticeably large, but they can be readily felt on examination. Almost invariably these children also have enlarged bronchial glands, as evidenced by impaired resonance between the scapulae.

that if we could multiply over this country men of the skill and experience in this line of Judd of Rochester, Dowd of New York, and Stone and Porter of this city, we might not need any tuberculin. What I want to emphasize strongly, however, is that surgery in many hands cannot do all we ask of it when dealing with