before injecting, I introduce through the canula a plunger, and by
pushing it in different directions through the interior of the tumor
break up the separating walls of the cysts, and thus open a way for the
better diffusion of the injecting material. The plan of Mackenzie,
destroying as it does the tumor by a slow chronic form of suppuration,
and at the same time draining away the pus as it forms, greatly lessens
the risk which might otherwise arise from diffused suppuration,
bleeding, or sloughing. At the Copenhagen Congress, Mackenzie stated
that he had by the method described treated 193 cases of goitre with
only 2 fatal cases, the latter being those of a fibro-cystic form.
In making a comparison between the relative safety of perchloride of
iron and of iodine as injections in goitre, the great superiority of
the former over the latter is well brought out in the cases collected
and analyzed by Schwalbe, 106 in number, for the cure of which iodine
was used, death following in 5 cases and diffused suppuration in 22
cases.
When all measures fail to control the growth of a goitre, and the life
of the patient is jeopardized from the effects of pressure, the case
ceases to be {982} a medical one and must be relegated to the domain of
surgery. Fortunately, the necessity for operation rarely occurs. It may
be remarked, in closing this article, that the excision of the gland
has been followed in several instances by evils greater than those for
which the operation was performed. The experiments of Zesas and Horsley
on lower animals, and the observations of Kocher after the removal of
the thyroid in man, place the question of extirpation of goitre among
the unsettled problems of surgery.
{983}
SIMPLE LYMPHANGITIS.
BY SAMUEL C. BUSEY, M.D.
ANATOMY AND PHYSIOLOGY.--The pathological relations of the absorbent
system are important, because of their direct connection with the
morbid processes and structural changes taking place in a variety of
diseases; therefore, before discussing the subject of lymphangitis, a
brief reference to the anatomy and physiology of the lymphatic system
is necessary.
The lymphatic system consists of large and capillary vessels,
interstitial spaces or juice-tracks, lacteals, follicles, and glands.
The serous cavities are also considered lymph-chambers, and the loose
cellular tissue is a vast chambered lymphatic sac communicating with
lymphatic vessels. The larger vessels are divided into two classes--the
superficial, which in the subcutaneous tissue accompany the veins,
while in the solid viscera they lie under the capsule, and in the
tubular viscera under the serous membrane; and the deep-seated vessels,
which accompany the deep-seated blood-vessels, ramify through the
interior of the organ in the solid viscera, and emerge at the hilus;
while in the tubular viscera they lie in the submucosa, and by free
anastomosis form plexuses. There is no communication between these two
sets of vessels, except in the solid viscera and in the glands which
may be common to both sets. Between the vessels of each set there is,
however, a free anastomosis, by which large-meshed plexuses are formed.
In consequence of these peculiar arrangements each set may be
separately diseased, and inflammation may spread rapidly from vessel to
vessel of the same set.
The lymph-capillaries are arranged in networks which lie in the meshes
of the plexuses of the blood-capillaries, from which they are separated
by intervening tissue-elements. Their walls consist of a single layer
of endothelium resting upon elastic tissue. In their continuity they
are sinuous, and are provided with an incomplete valvular arrangement.
The large vessels have three coats, not unlike the coats of the veins,
and are provided with numerous valves. These valves are the more
abundant in the superficial vessels, and the intervals between them
grow gradually less as they approach the glands.
The whole lymph vascular system terminates either in the right or left
thoracic duct.
The origin of the lymphatics has not been definitely settled. It has
been demonstrated that lymph circulates in the connective-tissue
interstices, and it seems to have been established that these spaces
are lymph reservoirs, discharging through lymph-capillaries. It is
admitted that the capillaries commence either in closely-meshed
networks or lacunar spaces. Plexuses of lymphatic capillaries,
corresponding with the distribution of the blood-capillaries, lie under
the endothelium of the serous membranes, and are in open communication
with the serous cavities through the stomata. The stomata vera are
either the openings of lymph-channels communicating directly with
lymph-capillaries, or discontinuities between the cells of the surface,
leading {984} into superficial lymph-sinuses. The pseudo-stomata are
the interstitial or intercellular cement substance, and represent the
communication of the lymph canalicular system with the free surface of
serous membranes.
Lymph-follicles consist of a reticulum of connective tissue, the meshes
of which are crowded with cells, thus forming patches in the submucous
or subserous tissue. Around these patches there is a plexus of
lymph-capillaries.
Lymphatic glands are round or oval bodies situated in the course of the
lymphatic and lacteal vessels. They are composed of follicular tissue,
trabeculæ, and lymph-tracts, all enclosed in a capsule. No doubt exists
in regard to a channel of communication between the afferent and
efferent vessels through a complex system of lymph-paths which
communicate more freely with the afferent than with the efferent
vessels. They are very vascular.
Every lymphatic vessel passes through one or more glands before
reaching the trunks. Before penetrating the peripheric fascia of a
gland these vessels divide into a number of smaller ones, which are
distributed upon the surface of the cortical portion, and empty
directly into the superficial lymph-sinuses. A number of vessels emerge
from each gland, but they are less numerous and larger than the
afferent vessels. The lymph is poured through the afferent vessels into
the lymph-spaces of the cortical alveoli, and thence into the channels
of the medullary substance, from which it escapes, enriched in
corpuscular elements, into the efferent tubes. The current of fluid
passing through such a complex structure must necessarily be retarded.
This relation of the glands to the lymph-current is, moreover,
especially interesting in its pathological significance. Whatever
enters the lymph may, if small enough, pass through the glands and be
swept along with the current, but the structure of the gland is, in a
mechanical sense, a filtering apparatus, interrupting the free current
of the fluid and retaining the coarser particles. The lymph in passing
through the glands derives constituents not previously possessed, but,
nevertheless, the retention of elements which for a time might arrest
the dissemination of hurtful material may eventually convert the gland
into a new source of infection. This fact is illustrated in the history
of malignant growths.
Perhaps the most interesting consideration connected with this relation
of the lymph-glands to the fluid passing through them is presented by
the anatomical arrangement of the chyle-vessels and the mesenteric
glands. The lacteals, commencing as the central efferent vessels of the
intestinal villi, pass between the folds of the mesentery, through
several tiers of mesenteric glands, and, uniting into one or more
trunks, terminate in the receptaculum chyli. During digestion these
vessels are full of chyle, and during the intervals of digestion they
convey lymph.
The lymphatic system may be considered an appendage of the blood
vascular system. By the blood the tissues are supplied with nutriment
and oxygen. By both the blood and lymph the surplus and waste are
conveyed away. The current of the lymph is in a reverse direction to
that of the blood-supply. The lymphatic vascular system receives
through its rootlets, which are distributed through the tissues, the
surplus transudation from the arterial capillaries, the products of
tissue-waste and transformation, and the chyle, and empties its
contents into the great venous trunks near their termini. It therefore
performs the double function of absorption from without and absorption
from within. In other words, it introduces into the blood the material
from both the food and the air which is required for the sustenance and
repair of the tissues, and conveys away the unassimilated surplus,
waste, and effete material.
The forces concerned in the locomotion of the lymph are numerous.
Recklinghausen believes the movement of the lymph to be mainly due to
the difference between the arterial and venous blood-pressure. The
greater this {985} difference the more rapid its current. The lymph
canalicular system is not in vascular continuity with the
blood-capillaries, and consequently the force of blood-pressure can
only be communicated to the column of lymph by the passage of the
plasmatic fluid into the lymphatic system by peripheral transudation
and endosmosis. These are favored by the single homogeneous walls of
the lymphatic plexuses and the enormous absorbing surface. These forces
are essentially vis a tergo, for the difference between the arterial
and venous blood-pressure is the excess of the former over the latter.
To these must be added other factors, not less important or necessary,
derived from the contractility of the walls of the lymphatic vessels,
from the compression of the surrounding and contiguous parts, from the
movements of respiration, and from the absorption of chyle. Besides
these, the slowness of the movement of the lymph as compared with the
rapidity of the arterial and venous blood-currents; the varying amount
of pressure in the lymph vascular system, and the absence of distension
in a normal condition; the entrance of the lymphatic trunks into the
veins near the confluence of large branches, where the venous
blood-pressure is almost inappreciable and the current is most rapid;
the marked effect of active muscular movement in accelerating the flow
of lymph; and the contractility of the vascular walls,--are all
conditions which cannot be omitted from a consideration of the forces
concerned in the locomotion of the lymph.
The supply of valves is very abundant, and they are always more
numerous where pressure from surrounding and contiguous parts is most
effective, though not infrequently most irregular in its operation, and
consequently where isolation of small sections of the column of the
fluid is most needed. The valves prevent regurgitation only so far as
the superimposed column of fluid is insufficient to impair their
integrity, or where there is no solution of the continuity of the
vascular walls, and distension is within the limits of ordinary and
normal extensibility. In cases of lymphangiectasis it is not usually
necessary to look beyond the nearest neighboring and connected gland
for the cause of such distension. Nature has increased the number of
valves in the afferent vessels as they approach the glands, as well to
modify and direct the flow as to prevent regurgitation; but if from any
cause the passage of the lymph through the glands is obstructed or
prevented, dilatation of the afferent vessels will ensue as a
consequence. Valvular insufficiency and dilatation may exist in
opposite relations to each other, either as cause or effect. The
dilatation of a vessel may result from thinning or loss of
contractility of its walls, caused by increased resistance to the
onward movement of the fluid, and by the lesser extensibility of the
intima than of the adventitia.
Lymphatic varices usually have their beginning in the vessels and
extend to the plexuses, but the plexuses may be alone affected.
Varicosities always extend backward from the point where the flow of
the contained lymph is arrested, and may result from a repletion of
each proximal intervalvular section with valvular incompetency.
The propulsive power of the heart diminishes with increased distance,
due to increased friction and increasing resistance from flexures,
bendings, and anastomoses, but chiefly from the increased carrying
capacity of the vascular subdivisions. Hence, as the current of the
lymph is in reverse relation to the capacity of the vessels, flowing,
as does the venous blood, from subdivisions into trunks of diminished
aggregate capacity, the velocity of the current of the lymph should be
faster in the trunkal vessels than in the subdivisions. Such is the
fact, though farther removed from the left heart and peripheral
plasmatic circulation; and yet it is much slower in the thoracic duct
than the blood-current in the venæ cavæ, which are not supplied with
valves. The movement of the venous blood is in a measure due to cardiac
and arterial contraction, but that force is least where the current is
most rapid--in the {986} venæ cavæ. The increased rapidity of the
venous blood-current as it approaches the heart must, therefore, be
derived from some other source; and it is equally manifest that the
velocity of the venous blood in the terminal trunks is transmitted to
the column of lymph and chyle flowing from the thoracic duct into the
blood-channels.
The foregoing reference to the anatomy and physiology of the absorbent
system shows very conclusively the importance of its pathological
relations. It is certainly concerned in the morbid processes of a
variety of diseases. But not less important is the fact that it is the
main channel for the diffusion of infections throughout the body.
Disease may be conveyed by the lymph from a single focus to many and
distant parts, whilst the intervening channel of communication may
remain free from injury. Along the course of the current every gland
may become an additional focus, intensifying the infectiveness of the
noxious material and increasing the area of its diffusion. This is
alike true of poisons introduced from without and of those originating
in the system.
SYNONYM.--Angioleucitis.
DEFINITION.--Lymphangitis may be either simple or septic. As a rule,
the disease is localized, but may, especially when induced by some
septic poison, be widely diffused, implicating extensive areas of
lymphatic tissue and extending to contiguous structures.
Simple lymphangitis may be either reticular or tubular. In the former
the fine capillary network or plexus is involved; in the latter the
trunkal vessels are inflamed. Very frequently both forms exist at the
same time.
ETIOLOGY.--Simple lymphangitis may be either idiopathic or traumatic.
It is, however, rarely spontaneous. External irritation, such as solar
rays, pressure, and friction, may set up a superficial inflammation,
though usually there is some form of injury--a wound, scratch, sprain,
contusion, abrasion, prick, or sting of an insect. The graver forms are
caused by neighboring inflammation, suppuration, and ulceration. The
products of these morbid changes are absorbed and conveyed along the
vessels. The inflammation may be continuous along the course of the
vessel, or separated from the origin of the morbid product by an area
of intervening healthy tissue. Absorption of the secretions and
parenchymatous fluids of inflamed parts is an active and frequent
agency in the causation of lymphangitis. It may also be caused by
contiguous inflamed tissue and by obstruction of the current of the
lymph. Lymph-thrombosis, from whatever cause produced, may excite
inflammation at the locality of formation, which is usually in the
immediate vicinity of a valve, or the thrombi may disintegrate or
undergo puriform liquefaction, and thus extend and diffuse the
inflammation.
Slight pricks, scratches, and abrasions, which in themselves are so
trifling as not to attract attention, may admit irritating substances
from without. This is a frequent cause among medical men, whose hands
and fingers are constantly exposed to irritating and ichorous
discharges.
Localized lymphangitis is frequently set up by specific kinds of
irritation. The adenitis and periglandular inflammations in cases of
scarlet fever and diphtheria are familiar illustrations. The indurated
glands in syphilis and suppurating buboes in chancroid exhibit the
different effects of the virus of these forms of disease. The
lymphatics of the solid viscera are often inflamed when the organ is
the seat of disease. Pelvic cellulitis, if not in itself a
lymphangitis, may be the starting-point of a severe and extensive
inflammation of the absorbents, occasionally involving both the
superficial and deep-seated vessels along one or both thighs.
Age and constitution are recognized factors. Lymphangitis is more
frequent in the young, and is much more easily excited in the strumous
and persons in a low state of health. Unhygienic conditions predispose
to its development.
{987} Lymphangitis may also find its cause in excessive exercise of
function, paralysis of vessels, mechanical obstruction to the
lymph-stream, lodgment of particles of cancerous or tuberculous matter
in the vessels, compression from cicatrices, indurated connective
tissue, tumors, diseased glands, stasis in large veins, and regurgitant
heart affections.
SYMPTOMATOLOGY.--Reticular lymphangitis is characterized by
rapidly-increasing localized redness, attended with a burning,
throbbing pain, and usually quickly implicates the skin and its
capillaries. Oedema to a greater or less extent may soon ensue, which,
when present, increases the pain. Fever may or may not be present,
depending in some measure upon the extent, intensity, and cause of the
inflammation and upon individual peculiarities. Erythema usually
represents a reticular lymphangitis with hyperæmia of the skin and its
capillaries, and erythema nodosum is the same associated with lymphatic
oedema. Any trivial injury may induce this form of inflammation, such
as a prick or the sting of an insect, which in extent, duration, and
intensity will vary with the cause, nature of the poison introduced,
location, and susceptibility of the sufferer.
Tubular lymphangitis is usually a much more serious form of the
disease. When the vessels of the superficial set are involved, wavy or
straight irregularly reddened lines are seen along the course of the
vessels, extending from the point of beginning to a single gland or
ganglion, which is usually tender and enlarged. These lines feel like
hard, knotted cords. The inflammation may be limited by the first tier
of glands, or it may extend to one or more distant ganglia. From the
inflamed gland the disease may be conveyed along the connecting
branches of the deeper set of vessels, and both sets may become
involved. The inflammation may also extend through the intervening
tissues from the superficial to the deeper-seated vessels. When both
sets are involved, the disease assumes a graver form and the symptoms
are aggravated. The pain becomes more acute, and the swelling is
greatly increased and more diffused. Fever may or may not be present,
and is usually moderate when the inflammation is confined to the
superficial vessels, but when the deeper set is implicated it often
commences with a rigor and is usually considerable. When the deeper set
is alone affected the red wavy, knotted lines cannot be seen, but may,
unless the oedema is great, be felt. The parts are swelled, indurated,
and stiffened, due in the acute stage to increased saturation of the
tissues, and in the chronic stage to hypertrophy of the connective
tissue. When the oedema is great the covering integument presents a
glossy, shining appearance.
PATHOLOGY AND MORBID ANATOMY.--In lymphangitis the adventitia of the
vessels and surrounding connective tissue are chiefly affected. The
external coat is thickened, injected, and infiltrated with cells. The
intima becomes opaque and is stripped of its endothelium. The lymph
coagulates in the interior of inflamed vessels and blocks up the
channel. These thrombi may become organized and permanently obliterate
the lumen of the vessel, or they may liquefy or suppurate. Their
products may enter the circulation and cause septicæmia or pyæmia. In a
few instances the clots have undergone calcareous degeneration. In some
instances coagula are found independently of any disease of the coats
of the vessels. In such cases the coagulation has been caused by the
entrance of some foreign material into the lymph-stream. The thickening
and relaxation of the coats of the vessels lead to dilatation, and
consequently to slowing of the current and stasis of lymph. From this
may result the serious consequences of an extensive lymphangiectasia,
which may involve either or both the superficial and deeper vessels of
a large area or an entire extremity. In such cases enormous development
of the adipose tissue usually takes place, not infrequently associated
with rupture of the dilated radicals and exhaustive periodic discharges
of lymph. In most of the {988} cases of lymphangiectasia and
lymphorrhagia the fluid, which either accumulates in the affected area
or is discharged through the ruptured orifices, presents the physical
characteristics and appearance of chyle, due to the quantity of fat it
contains. In some cases the fluid at first discharged is serous, and
gradually changes, as the flow continues, to a chylous or milk-like
fluid. In these cases there is also a tendency to frequently-recurring
attacks of an erysipelatous or elephantoid inflammation. This
predisposition is traceable to the structural changes produced by the
previous inflammation, traumatism, or thrombosis. Inflammation and
lymph-thrombosis are the pathological processes which usually cause
circumscribed narrowing or complete occlusion of lymph-channels; and
within the area from which the narrowed or occluded vessels originate
there is lymph-stasis, dilatation of trunkal vessels, and oedema of the
tissues. Lymphangitis may also cause adhesion of the internal surfaces
of the vessel, fibroid transformation or calcification of their coats,
and suppuration.
The alterations which take place in the lymph consist chiefly of an
increased proportion of fibrin, the addition of numerous cell-elements,
not unlike endothelial cells, white and occasionally red
blood-corpuscles, lymphoid cells, granular matter, and a varying
quantity of albumen and fat, which in a measure must owe their presence
to pathological processes affecting the intima and to transformation of
the inflammatory products.
All forms of inflammation of the lymphatic vessels exhibit a tendency
to extend to the connective tissue. Cellulitis is almost a constant
accompaniment of lymphangitis. In other cases the inflammation and
consequent thrombosis and obstruction of the lymph-stream produce
oedema and saturation of the tissues. Hyperplasia and sclerosis of the
connective tissue follow.