accessory thyroid gland with ... lateral thyroid tumours of the neck are metastases from cancer of the thyroid ... lymph nodes, with or without abscess formation.
TUBERCULOUS
DISEASE OF THE CERVICAL
LYMPH
GLANDS'
A Clinical Study By JAMES A. ROSS, M.B.E., M.D., F.R.C.S.Ed. Assistant Surgeon,
Edinburgh Royal Infirmary, Surgeon,
Leith
Hospital
THE introduction of streptomycin and P.A.S. (P-Amino salicylic acid) in the treatment of tuberculosis has already altered our approach to the management of manifestations of the disease, previously considered essentially surgical. It is therefore likely that in the future these drugs
similar,
and
profoundly
or
alter
more our
efficacious chemotherapeutic agents may so of such cases that surgery may be very
handling
rarely required. It is felt, therefore, that a review of some 50 cases of tuberculosis of the cervical lymph glands treated by surgical operation may prove of some interest as one of the last series value for comparison with cases treated
so
treated, and
may be of some
by chemotherapy
in the future.
Clinical Features Case histories of 51 new patients in two years (1950 and I951) readily available at the Surgical Out-Patient Department of
were
Edinburgh Royal Infirmary. 35 females and 16 males ; the average age was 27 70, the youngest 12 (children under 12 not being treated at this hospital). The patients were referred to hospital because a swelling had developed in the neck, usually painless or only slightly There
were
the oldest
being
a cold, a sore throat, or an actual attack of tonsilitis* and had not subsided. The actual time the condition had been present before the patient came to hospital was six to eight weeks. In 4, there had been a swelling in the neck years before (20, 11,12 and 4 years); this had now recurred. In 3 there was a history of recurrent, multiple
painful, following
repeated operations during a number of years. A full penicillin had been given in 18 cases, sulphonamides in 2 cases, ultra-violet light therapy in 5, diathermy in I, calciferol in 2Preliminary aspiration of the swelling had been performed in 8. 35 patients, it was ascertained that tonsillectomy had been performed in 12, and not performed in 23. Of 37 questioned regarding their family history, 4 gave a history of familial tuberculosis, the history being negative in 33. On the history of a swelling in the neck of about two months duration, usually following a sore throat, and not responding to routine a treatment, a diagnosis of tuberculous cervical adenitis was made with fair degree of certainty. Chronic non-specific lymphadenitis, Hodgkin s disease, branchial cyst, lymphosarcoma, secondary carcinoma of the cervical glands from known or unknown primary sources, enter into the differential diagnosis and usually can be identified by examination and history. Certain cases, considered pre-operatively to be tuberculous
swellings course
and
of
184
TUBERCULOUS DISEASE OF CERVICAL LYMPH
lymph glands, review
were
pathological denitis, one
GLANDS
185
the time the 51 cases under be otherwise at operation, and on investigation, 2 of these proved to be non-specific lymphaone a mass of salivary tissue showing a branchial cyst; and
operated
during
on
being treated, proved
mild chronic adenitis, and
to
lymph gland
no
tissue?a low submandibular
salivary gland removed inadvertently. In one, a woman aged 67, the diagnosis of secondary carcinoma, suspected originally, was discarded as
examination of the
findings
resembled
examination showed
nose
a
and throat
broken-down
an
and the
negative,
was
caseous
anaplastic carcinoma,
mass
but
;
operative histological
and the tumour recurred
very quickly. In one patient, with a swelling in the right carotid triangle, the swelling removed was an accessory thyroid gland with hyperplastic involutionary and regressive accompaniments." In this connection the view of Warren and Feldman (1949) that most if not all lateral thyroid tumours of the neck are metastases from cancer of the "
thyroid,
must be remembered.
Classification
Cases
of
cases of tuberculosis of the cervical lymphatics Dowd (1916) has been found most useful and practical, ^owd divided his cases into three groups :? Group 1.?Disease localised to the tonsillar (jugulo-digrastic)
The classification of
given by
lymph
with or without abscess formation. 2.?Extension of the tubercular process to involve the nodes Group ?f the entire jugular chain, and also sometimes those along the trapezius
nodes,
border. Group 3.?Those
with diffuse tuberculosis. The patients show little Power of resisting tuberculosis, the neck infection quickly involves a great number of nodes, and there is usually evidence of tuberculosis lr* other parts of the body.
(1926) noted that the submaxillary and parotid group glands especially liable to tuberculous disease, and infection of these
Fraser are also
glands
can also be classed under Group 1?local infections. In the present series, the cases could be classified according as follows :?
to
^owd,
GROUP I.?Single jugulo-digrastic gland involved
.
.
Jugulo-digastric gland on both sides Jugulo-digastric gland with associated abscess One single gland in the side of the neck Submaxillary lymph gland Submental lymph gland
.
.
.
.
II i
...... ....
7
.....
4
.......
5
........
1
Total
29
GROUP 2.?Multiple glands in one side of the neck .16 Group 3.?(a) Multiple, bilateral (including 3 with supraclavicular glands .
.
involved
.
.
.
.
.
.
?
?
?
?
(b) With evidence of tuberculosis elsewhere (one after operation) Total
-4 .
2
186
JAMES
A.
ROSS
Treatment of
The treatment of tuberculous glands of the neck has been the subject considerable and often controversial literature for many years.
a
It may be 1.
grouped
under the
following headings
:?
Conservative, and period of observation. calciferol ; General health measures ; violet light; aspiration and repeated
vitamins ;
aspiration
ultraof
cold
abscess. 2.
Operative.
3. 4.
Streptomycin. X-ray therapy.
(1) The majority of cases of tuberculous glands in the neck have a preliminary period of conservative treatment, during which the tentative diagnosis becomes consolidated following the non-disappearance of the glands, and failure to respond to penicillin. During this time the evidence of tuberculosis X-ray of the chest and examination for elsewhere is carried out. Thompson (1936^ and
b) strongly advocated conservative treatment, cures though often occurring under the worst possible hygienic conditions, are far from being calamatous and may indeed be actually superior to those of expert surgery. He quoted a series of cases of fifty-five radical operations in which there was at some time or another a gross local recurrence in 50 cases (91 per cent.). He considered surgical excision to be unjustifiable. It has been demonstrated, however, by Opie and Aronson (1927) and others that living
and he stated that natural
tubercle bacilli continue
to
be present
as
latent foci of disease even
encapsulated by calcification. With conservative treatment alone, living tubercle bacilli are therefore left in situ, and in periods of lowered resistance are ready to re-start an active tuberculous processThis was clearly shown in several of our case histories, with recurrence years after the original swelling. Lampe, Chrest and Koch (1948) advocating treatment by roentgen therapy, based on their study of 37 cases, considered radical neck gland
when
play no part in the modern management of tuberculous adenopathy. Miller (1931) at first was much impressed by what seemed to be the therapeutic value of tuberculin, and in 1922 recom' mended its use in cases of lymphatic disease. He stated that he had
dissections should
brought up to look on the radical excision of cervical tuberculous glands as an anathema, but gradually began to realise that the result5 after months or of conservatism were very unsatisfactory and that a year or two we would find ourselves recommending operation as the most suitable way of getting rid of the disease." The authority of many surgeons, based on many years' experience) and on large numbers of cases, is in favour of operation. Stiles considered that in the vast majority of cases, tuberculous glands in the been
"
TUBERCULOUS DISEASE OF CERVICAL LYMPH
neck
GLANDS
187
(John Thomson, 1933). Fraser (1926) Dowd (1916) basing his conclusions on a in of cases which 687 study operation was performed, considered is hard to think of another form of surgical operation which gives better results. Lester (1948) stated that the treatment of choice is still are
best treated
by
excision
also advocated surgical excision.
'
complete removal in properly selected cases. Anything less than complete removal is inadequate." Hanford (1933) reporting on 131 cases of surgical excision of tuberculous lymph nodes of the neck considered excision in the early or limited stage of the disease gives as good a surgical result as operation for inguinal hernia ; rapid general improvement often follows operation. Clute (1927) reviewing 138 and Ladd (1917) 159 cases of tuberculous cervical adenitis, and Grey Turner (1922) recommend surgery as the method of choice. Barrington Ward (1937) followed up a consecutive list of 133 operations. He was able to trace 95 cases, and personally examined 89 ; of these, only one case required any further treatment. Operation is obviously the choice if the conception that tubercular cervical adenitis is a localised disease in the majority of cases. In this connection, some discussion is warranted with reference to Marfan's Law." Professor Cameron (1952) recently drew attention to this law. Marfan stated (1931) that those who had suffered from tuberculous ccrvical adenitis which had healed before adolescence, rarely developed "
Pulmonary
tuberculosis.
Cameron
considered that
clinically
this
observation holds true. The lymph glands bear the brunt of primary tuberculous infection in childhood, and recovery seems to lead to a high degree of acquired resistance against tuberculous disease. Other observations have confirmed this view. Wang (1917) in 2000 patients ^ith pulmonary tuberculosis found only 3*2 per cent, had scars in the neck. Wilkinson (1940) noted that patients treated for cervical or abdominal tuberuculous adenitis did not develop tuberculosis elsewhere, and Wilkinson and Cureton (1943) found in 1038 cases of pulmonary tuberculosis only 3 per cent, showed evidence of healed tuberculous glands. At their sanatorium, no patient treated for glandular tuberre-admission for a fresh tuberculous lesion other than though many of them had passed the age of adolescence.
culosis required *n
the
glands
Similar findings
less
calcareous
were
glands
f?r other conditions,
recorded in the
by Osier (Christian, 1947). Symptomabdomen, incidental to X-ray examination
are very common in Scotland. In one series of the of the abdomen reviewed by X-rays present writer (Ross, 1948), 608 were found to show calcerous glands (12-16 per cent.) ; in this series there were 89 cases with renal tuberculosis, and of these 11 showed
5ooo
calcereous glands, practically
the
percentage (12*36 per cent.) those without visceral tubercle. Williams (1921) in a fifty years' experience observed that those who suffered from cervical gland lesion to suppuration did not develop pulmonary tuberculosis. (1936^) found remote extension from the tuberculous cervical glands so infrequently as to regard its occurrence as quite same
as in
leading Thompson
vol. lx. no. 4
m 3
188
JAMES
A. ROSS
exceptional. On the other hand, Dunlop (1930) did not find the association of gross glandular disease and pulmonary tuberculosis was by any means as rare as is commonly supposed ; of 68 cases of pulmonary tuberculosis, 13 had gross glandular disease. The present series (51) is too small upon which to pronounce fixed opinions. In only one case did the active disease progress beyond the glands, and in another an X-ray of the chest showed opacity of the right cardiophrenic angle and calcification of the right hilar region, but 2 cases seen recently, not included in the present review, both showed active disease elsewhere in the body besides in the cervical glands. The lymphoid tissue, fulfilling its normal function as a filter, arrests the infection in a high percentage of cases ; but with gross infections, and in debilitated persons, the infection progresses
beyond
Marfan's law, though a valuable generalisation, and in most cases as regards prognosis, must not therefore be reassuring as absolute, and it is liable to exceptions. regarded A careful clinical examination, and an X-ray of the chest is essential in all cases. Records of the general examination are unfortunately the filter.
in the present series. In 14 X-ray findings recorded, 12 were negative one showed pleural thickening of the right costophrenic angle, and one showed opacity of the right cardiophrenic angle " and calcification of the right hilar region, probably a calcified
imperfect ;
complex." It is generally
stated that supraclavicular gland involvement means that the disease is not local, but has spread up from the thorax ; Grey Turner (1922) found carbon pigment in some of his cases, confirming If these glands are troublesome, and form discharging sinuses, be removed. In this series, the position of the gland was should they not considered an unduly important point in assessing operability, this.
and the
cases
post-operative
of
supraclavicular gland
involvement made
uneventful
recoveries.
Frankau, Pugh and Windeyer (1938), summing up, consider opera-
be advisable (1) for single glands or small groups of glands not subside under prolonged and adequate general treatment or in which signs of caseation or periadenitis develop. (2) For glands in which caseation has occurred. (3) For collar-stud abscesses. They consider operation inadvisable apart from the evacuation of caseous material, (1) in massive infections and (2) in diffuse involvement of tion
to
which do
many small glands. Aird (1949) considers that excision should be performed only for well-localised chronic infection limited to a single gland group free
and stationary over a period of at least a year. This an ideal which does not often occur, as constitutes periadenitis picture is an almost invariable accompaniment of tuberculous glands, and cold abscess formation, with possible discharge through the skin and secondary infection may well occur long before a year is out. " The In the present series, all the patients were operated on. the of of of the only satisfactory type operation, irrespective stage
from
periadenitis
TUBERCULOUS DISEASE OF CERVICAL LYMPH
GLANDS
189
"
a complete removal of the affected glands (Quarry Wood, The 1950). present writer was privileged to watch this operation performed by Sir John Fraser many times. Dissection of the affected glands was carried out in 40 cases. Careful dissection of the affected glands is the correct treatment; but the presence of a cold abscess, and the marked periadenitis associated with Jt, may render dissection especially difficult. It is in these cases that
disease,
is
there is a temptation offered to the inexperienced to incise, remove the obvious pus, and scrape the wall of the cavity. This is inadequate, " as Dowd If the incision of an abscess (1916) pointed out so clearly. ?r
the removal of
a
very poor operative ?f all the
enlarged lymph
nodes in the
'
'
operation we shall have operation means the removal neck, we shall have very good
node is called results ; if the term
simple
an
the tubercular detruitus, the so-called pus of Hamilton Bailey no bar to thorough operation." cervical of tubercular abscesses, (1932) in describing the treatment stressed the importance, after opening a subcutaneous abscess, of
operative results the cold abscess is .
.
.
Watson Cheyne seeker for the opening in the deep fascia which leads to the underlying gland. Simple aspiration, or " " incision of the cold abscess clears the shop-window but leaves the
seeking
with
a
In the present series, sufficient per se?all these cases required operation later. The gland will continue to produce tuberculous pus till its core has finally discharged on the surface or become calcareous ; in this process the skin may become infected
factory" the underlying gland preliminary aspiration in 8 cases
untouched.
was not
the discharging openings. Hamilton Bailey (1945) also described how a cold abscess may track down a considerable way from the producing gland, but both must be dealt with if a cure is to be obtained. In 10 of the present series, incision of the overlying abscess, demonstration of the communication, and curetting out of the underlying gland, was the procedure adopted. In one case, simple incision and drainage was quite ineffective, a careful dissection of the glandular rnass underneath being required at a later date. around
Post-Operative Progress
and
Results
The critics of operative treatment stress the frequency of the presence in the neck after operation (Thompson) either due to ^adequate removal or to recurrence of the ^disease ; the unsightly nature of operation scars, and the frequency of nerve damage, are also ?f
glands
Mentioned. ?f these
A
post-operative
survey therefore is essential in any review
cases.
In the present series, an immediate post-operative survey, and a fourteen months (on an average) after operation was made. One patient, a girl aged 12, did not improve, though the operation
follow-up
^ound healed satisfactorily.
showed
involvement of both
Nineteen days after operation and enlargment of the hilar
lungs
X-rays glands.
JAMES
190
Ten months after
operation
she
A. ROSS
tuberculous arthritis of the sanatorium. Operation may have
developed
and was admitted to a caused an exacerbation of the disease and produced the dissemination to the other organs, but it is more probable that if X-rays had been taken before operation (as should have been done) the involvement of the lung and the enlarged hilar shadows would have been seen.
right knee,
Four developed further glandular masses requiring a second operation, of these being the inefficiently treated case noted above. Four had small glands palpable after operation, gradually regressing without treatment. Three had a discharge from the wound for about two one
months ; one of these cleared up spontaneously, the other 2 also cleared up, with streptomycin. Two had paresis of the lower lip, due to injury of the cervical branch of the facial nerve ; one had hypoglossal nerve paresis ; one, accessory nerve ; 2 great auricular nerve, and one, supraclavicular nerve paresis. With the exception of the accessory nerve, the paresis had disappeared or were disappearing. Apart from
slight hypertrophy,
not
amounting
to
keloid in
one
case, all the scars
healed well. Other Treatments
series, streptomycin was given in only two cases with after operation, and it was effective. There is no discharge persistent doubt that the administration of streptomycin combined with P-aminosalicylic acid (P.A.S.) and similar chemotherapeutic agents will be increasingly employed in the future. It may well be that when this line of therapy has become perfected, surgery will take only a very secondary place. In the present
X-ray Therapy
Lampe, Chrest and Koch (1949) treated 37 cases of cervical tuberculous adenities with complete regression of the diseased nodes and healing of sinuses in 84 per cent, of the cases ; in about 20 per centof these a second course of irradiation was necessary to achieve this result. Hanford (1927) reviewed 141 patients treated by small doses of filtered roentgen ray and considered that this treatment given at intervals of less than three weeks appears to shorten the course of the disease and to favour resolution or marked improvement in all stages
to (except cold abscesses) in a sufficiently large percentage of cases justify the conclusion that the roentgen ray is useful in the treatment of tuberculous glands of the neck.
Hanford noted that the first recorded use of the roentgen ray in glandular tuberculosis was about the year 1900 as described by Dawson Turner (1902) medical head of the electrical department of the Royal Infirmary, Edinburgh, the credit of initiation of this treatment lying
with Dr Hope Fowler. Though X-ray therapy was therefore initiated in Edinburgh it has not assumed the pre-eminent place in the treatment of glandular tuberculosis, and no case was treated by it in the series. Professor McWhirter (1952) has summed up the present Edin-
present
TUBERCULOUS DISEASE OF CERVICAL LYMPH GLANDS
burgh view as follows
191
"
: We have treated very few cases of tuberculosis of cervical lymph glands by X-ray therapy. I agree the Americans treat some cases, and on the Continent X-ray therapy is fairly extensively used. Good results are obtained in the early stages of the ordinary type of infection, but the treatment is much less effective once
the gland capsule has ruptured or the tuberculous process has broken down and liquefied. The results have been good in the non-caseating
type of involvement, and we have treated one or two patients with large glandular masses extending the whole length of the neck, and usually patients where operation has been tried and has failed, these cases do very well."
Tuberculin Tuberculin has had a vogue in the treatment of tuberculous cervical both in the main treatment and as an adjunct to other methods. (1936) used it and Miller (1922) favoured its use at first,
glands,
Thompson but
later influenced
by
the ill
of conservative treatment, turned Pugh and Windeyer (1938) wrote of
success
to
operative surgery. Frankau, tuberculin, "No good word to say; at one time its use was strongly advocated in various dosages, but the only effect obtainable from its Use is a rapid breaking down of the affected glands." Tuberculin ^as not used at all in the
present review.
heliotherapy in 200 cases of gland tuberculosis was reviewed by Hyde and Grosso (1921) and ultra-violet light has also been advocated. Our impression is that ultra-violet light tends to accelerate the caseous process in the glands with the production of cold abscesses ; and this form of therapy in consequence is no longer The beneficial effect of
Used here. Pathological Reports
of
Operative Findings
on the tissue removed at operation was Active tuberculous lymphadenitis was described cases. in recorded 32 lr* 16 caseous ; lymphadenitis with abscess formation in 9 ; active cellulitis in 2 ; fibrocaseous tuberculous lymphtuberculous sPreading " adenitis in 3 ; caseation and calcification in one, and proliferative " tuberculous lymphadenitis in one. The sections, in fact, show the
The
pathological reports
stages of tuberculous process, Eraser and Hamilton Bailey.
so
clearly
described in the
writings
of
Conclusions Persistent
tonsillitis
looked
or
on as
Cases
glandular swelling in the neck, following on coryza, pharyngitis, and not responding to penicillin, must be
suspect tuberculous cervical adenitis.
require
e*ceptions
be present
do as
classification
to be assessed
accurately before operation, because law, and pulmonary tuberculosis may
to Marfan's well as the cervical glandular disease. Dowd's simple is most helpful in assessment. Preliminary X-ray of the occur
?
JAMES
192
A.
ROSS
chest is required in all cases ; if neglected, and pulmonary tuberculosis is detected shortly after operation, it may be considered that operation has opened up pathways for the bacilli to other organs, a suggestion difficult to disprove in the circumstances. Operative treatment up to the present date would appear to be the method of choice in the case of these cases. Operation must be adequate, "
"
important factor being the removal of the factory lymph glands. The risk of damaging certain nerves (cervical branch of facial ; hypoglossal ; accessory; great auricular; supraclavicular) must be accepted, but this hazard should not deter the surgeon from operatingIn the present series, 7 had nerve lesions (14 per cent.), 3 of these having recovered spontaneously within fourteen months. Of the remaining 4> 3 were superficial nerves of minor significance, and one, the accessory nerve, damaged during dissection in dense scar tissue following previous operations. The result of the operation must be judged by the patient's relief from clinical signs and symptoms, and in this operative treatment for tuberculous cervical glands is undoubtedly successful. Temporary and minor complications may occur?induration around the scar, small glands palpable after operation, slight discharge from the wound, none of these requiring further treatment. Keloid may develop in the scar ; it was not encountered in this series. In the present 51 cases, 4 required further dissection-removal for glandular enlargement following operation (8 per cent.) ; and in one, general tuberculosis developed. Forty-six therefore could be judged to have made a good recovery?90 per cent. ; a figure similar to Hanford s (1933), 87 per cent, and Ladd's (1917) 90 per cent. This figure com' a pares favourably with that of Thompson, who quoted a series with recurrence rate of 91 per cent., but is not as good as Barrington-Ward s, who only had one case in 89 requiring further treatment. Streptomycin was employed successfully in 2 cases with post' operative discharge. Combined with P-aminosalicylic acid (P.A.S-) the
it should prove of great benefit in the treatment of future cases. no doubt that, as in other forms of tuberculosis, there is
is
There
a
great
future for
chemotherapy. X-ray therapy was not employed used in this country, though used in
in the present series. It is little centres in America and ?n
some
the Continent. It would appear to offer some benefit in certain selected groups of cases?in the non-caseating type of involvement, in patient5 with large glandular masses extending the whole length of the neck> and those
patients
where
operation
has been tried
unsuccessfully.
SUMMARY
Fifty-one
cases
of tuberculous disease of the cervical
reviewed. The assessment of cases, and the discussed.
lymph
glands
are
significance
of Marfan's law
lS
TUBERCULOUS DISEASE OF CERVICAL LYMPH
Differential
diagnosis,
described. and
and
different methods
GLANDS
of treatment
of operative treatment, particularly of glandular swelling, are noted in a short
Complications recurrence
nerve
193 are
injury,
follow-up.
I am
grateful to Mr H. W. Porter, Mr J. Hunter Annan and Mr A. McEwen permission to include their cases in this review. I am also grateful to Mr J- N. J. Hartley, Curator of the museum of the Royal College of Surgeons, Edinburgh, preparing the histological slides. I must also thank Sister Dewar for her care of the patients, and Miss McNeill for her help in recording the details of this paper. Smith
for
REFERENCES
^IRD,
I.
(1949),
Ltd.,
^Ailey,
companion
in Surgical Studies,
Edinburgh,
E. & S.
Livingstone
183.
p.
H.
A
(1932),
Brit. Med. Journ., 1,
xi.
j^lLEY, H. (1945). Brit. Journ. Surg., 53. ^ArrINGton-Ward, Sir L. (1937), Lancet, 980. 33,
1,
Cameron,
C. (1952), Edin. Med. Journ., 59, 143. H. M. (1927), Ami. Surg., 86, 666. C. N. (1916), Journ. Amer. Med. Assoc., 67, 499. D. M. (1930), Edin. Med. Journ., 37, 202. C., Pugh, G., and Windeyer, B. W. (1938), Proc.
^Lijte, ^OWd, ^UNlop, ^Rankau, 1?
Roy.
Soc. Med., 31,
I03'
RASer, J. (1926), Surgery of Childhood,
Vol. 2, London, Edward Arnold & Co.,
p. 628.
(1927), Arch. I^Anford, J. M. M.
Surg., 15, 377. Clin. N. A?ner., 13, 301. C. L., and GROSSO, H. (1921), Amer. Rev. Tuberc., 5, 159. W. A. (1917), Surg. Gynec. Obstet., 24, 467. I., Chrest, C. P., and Koch, D. A. (1949), Amer. Journ. Med. Sci., 217, 632. C. W. (1948), Surg. Gynec. Obst., 87, 719.
^Anford, J.
(1933), Surg.
^yDE, ^Add, Wipe,
Jester,
^CWhirter,
R.
(1952).
(Personal communication.)
Amer. Med. Assoc., 79, 350. J^LLER, R. H. (1922), Journ. Ann.
Filler,
Surg., 94, 539. (1931), and AR0NS0N, J. D. (1927), Arch. Path, and Lab. Med., 4, I. W. (1947), The Principles and Practice of Medicine, 16th ed., H. A. Christian, New York and London, D. Appleton-Century Co., p. 297. J. A. (1948), Brit. Journ. Urol., 20, 109. B. C. (1936), Lancet, 1, 946. B. C. (1936), Brit. Med. Journ., 2, 584. **OMSON, J. (1933), The Clinical Study and Treatme?it of Sick Children, 5th ed., Leonard Findlay, Edinburgh, Oliver & Boyd, p. 960. ^RNER, Dawson (1902), A Manual of Practical Medical Electricity, the Roentgen and Finsen Light, 3rd ed., Edinburgh and New York, Wm. Wood & Co., R. H.
plE, L.,
^Sler,
Joss, ^Hompson,
^Hompson, Rays
f,
P- 376. G. Grey (1922), Brit. Med. Journ., 1, 352. S. L. (1917), Journ. Amer. Med. Assoc., 68, 1963. s., and Feldman, J. D. (1949). Surg. Gynec. Obstet., 88, 31. M. C. (1940), Brit. Med. Journ., 2, 660. M. C., and Cureton, R. J. R. (1943), Lancet, 2, 662.
URNer,
^Ang, }VArReN)
^Lkinson, ^Lkinson, .^Lliams, W.
(1921), Brit. Med. Journ., 1, 158. Ood, w. Quarry (1950), Miles and Learmonth's Operative Surgery, 3rd ed., London, Oxford University Press, p. 80.
