When the antiseptic and aseptic era arrived the glandular tumors were doomed to the knife. Surgeons quite generally, including the author, made "thorough" extirpation through incisions along the sterno mastoid or, according to Kocher, through incisions extending from the mastoid to the cornu of the hyoid bone. By avoiding the blood-vessels and working with blunt instruments it is possible to dig out the glands the same way as a potato is dug out of the ground. The small and nu merous glands around the blood-vessels gave the surgeon much concern. Long incisions were not exactly things of beauty, especially when heal ing was interfered with by the bursting of suppurating glands, in which cases we got both long scars and fistulae. Dollinger tried to improve the cosmetic effect by making his incision at the border of the scalp, but as this made the technic very difficult he found only few imitators.
These patients who had undergone a "radical" operation were apt to return the following winter or spring with "new" glandular tumors, and very few could be persuaded to undergo another "radical" operation, whilst the large majority were satisfied to have the cheesy glands scraped out and to have the pus let out.
The foregoing was the typical treatment of tuberculous lymph nodes up to a few years ago; these cases were the bugbear of the sur geons in children's hospitals. We have recently learned to improve upon this method (Bier). The author no longer operates on tubercular glands in children and considers total extirpation an unphysiologic procedure. The treatment should first of all be general, against the scrofulosis. It is unnecessary to treat irrelevant parts of a disease when recurrences are sure to occur.
The single glands are sucked into cups and arc thus made highly hyperemic. We apply the cups for five minutes and have them off for the next five minutes. This is done several times daily. After school the children come to the out-patient's department and remain for the treatment for one hour. At home heat is applied (Fig. 116).
Time is not of great importance in children. Some of the glands disappear under the hyperTudc treatment, but most of them suppurate; as soon as fluctuation is present we make a small incision before the skin has time to become necrotic in order to avoid ugly sears.
The contents are aspirated through the opening in one or more sittings, and the application of heat is continued.
No packing is necessary, but a drainage tube may be inserted in deep abscesses. Should a portion of the gland remain or fistuhe form we treat these also with cups and heat. The hygienic conditions should be im proved if possible,—fresh air, plenty of sunlight, floating hospital, etc.; but never place these children in hospital wards.
The advantages of this treatment consist in the improved results, but not in shortening the time of treatment. Small and scarcely notice able scars and the possibility of managing these cases in the policlinic, thus relieving the hospital wards of this class of unpromising cases, are advantages gained by these methods. Up to 1904, 100 out of a total of 500 operations annually in the author's service were for the removal and scraping out of glands. In the last four years out of a total of 3000 operations not more than three were for the removal of glands.
With this treatment we imitate Nature and adapt our measures to the general condition and function of the glands. It is surely better for the child than total extirpation, which is still advocated in some recent publications.
We do not want to be misunderstood, for occasionally a refractory indurated gland in an older child may have to be removed. But then this should be done under strict cosmetic rules and without opening the gland if possible; any scraping or curetting most be avoided, because it simply offers a chance to spread the disease anew.
We have not seen any beneficial results from the medicinal treat ment, iodine, and ointments of all kinds. At most they may aid in intel ligent genera] treatment.