Alexis Thomson and Alexander Miles - Manual of Surgery

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_Subcutaneous rupture of the thoracic duct_ may result from a crush of
the thorax. The chyle escapes and accumulates in the cellular tissue of
the posterior mediastinum, behind the peritoneum, in the pleural cavity
(_chylo-thorax_), or in the peritoneal cavity (_chylous ascites_). There
are physical signs of fluid in one or other of these situations, but, as
a rule, the nature of the lesion is only recognised when chyle is
withdrawn by the exploring needle.

DISEASES OF LYMPH VESSELS

#Lymphangitis.#--Inflammation of peripheral lymph vessels usually
results from some primary source of pyogenic infection in the skin. This
may be a wound or a purulent blister, and the streptococcus pyogenes is
the organism most frequently present. _Septic_ lymphangitis is commonly
met with in those who, from the nature of their occupation, handle
infective material. A _gonococcal_ form has been observed in those
suffering from gonorrhoea.

The inflammation affects chiefly the walls of the vessels, and is
attended with clotting of the lymph. There is also some degree of
inflammation of the surrounding cellular tissue--_peri-lymphangitis_.
One or more abscesses may form along the course of the vessels, or a
spreading cellulitis may supervene.

The _clinical features_ resemble those of other pyogenic infections, and
there are wavy red lines running from the source of infection towards
the nearest lymph glands. These correspond to the inflamed vessels, and
are the seat of burning pain and tenderness. The associated glands are
enlarged and painful. In severe cases the symptoms merge into those of
septicaemia. When the deep lymph vessels alone are involved, the
superficial red lines are absent, but the limb becomes greatly swollen
and pits on pressure.

In cases of extensive lymphangitis, especially when there are repeated
attacks, the vessels are obliterated by the formation of new connective
tissue and a persistent solid oedema results, culminating in one form of
elephantiasis.

_Treatment._--The primary source of infection is dealt with on the usual
lines. If the lymphangitis affects an extremity, Bier's elastic bandage
is applied, and if suppuration occurs, the pus is let out through one or
more small incisions; in other parts of the body Klapp's suction bells
are employed. An autogenous vaccine may be prepared and injected. When
the condition has subsided, the limb is massaged and evenly bandaged to
promote the disappearance of oedema.

_Tuberculous Lymphangitis._--Although lymph vessels play an important
role in the spread of tuberculosis, the clinical recognition of the
disease in them is exceptional. The infection spreads upwards along the
superficial lymphatics, which become nodularly thickened; at one or more
points, larger, peri-lymphangitic nodules may form and break down into
abscesses and ulcers; the nearest group of glands become infected at an
early stage. When the disease is widely distributed throughout the
lymphatics of the limb, it becomes swollen and hard--a condition
illustrated by lupus elephantiasis.

_Syphilitic lymphangitis_ is observed in cases of primary syphilis, in
which the vessels of the dorsum of the penis can be felt as indurated
cords.

In addition to acting as channels for the conveyance of bacterial
infection, _lymph vessels frequently convey the cells of malignant
tumours_, and especially cancer, from the seat of the primary disease to
the nearest lymph glands, and they may themselves become the seat of
cancerous growth forming nodular cords. The permeation of cancer by way
of the lymphatics, described by Sampson Handley, has already been
referred to.

#Lymphangiectasis# is a dilated or varicose condition of lymph vessels.
It is met with as a congenital affection in the tongue and lips, or it
may be acquired as the result of any condition which is attended with
extensive obliteration or blocking of the main lymph trunks. An
interesting type of lymphangiectasis is that which results from the
presence of the _filaria Bancrofti_ in the vessels, and is observed
chiefly in the groin, spermatic cord, and scrotum of persons who have
lived in the tropics.

_Filarial disease in the lymphatics of the groin_ appears as a soft,
doughy swelling, varying in size from a walnut to a cocoa-nut; it may
partly disappear on pressure and when the patient lies down.

The patient gives a history of feverish attacks of the nature of
lymphangitis during which the swelling becomes painful and tender. These
attacks may show a remarkable periodicity, and each may be followed by
an increase in the size of the swelling, which may extend along the
inguinal canal into the abdomen, or down the spermatic cord into the
scrotum. On dissection, the swelling is found to be made up of dilated,
tortuous, and thickened lymph vessels in which the parent worm is
sometimes found, and of greatly enlarged lymph glands which have
undergone fibrosis, with giant-cell formation and eosinophile
aggregations. The fluid in the dilated vessels is either clear or
turbid, in the latter case resembling chyle. The affection is frequently
bilateral, and may be associated with lymph scrotum, with elephantiasis,
and with chyluria.

The _diagnosis_ is to be made from such other swellings in the groin as
hernia, lipoma, or cystic pouching of the great saphenous vein. It is
confirmed by finding the recently dead or dying worms in the inflamed
lymph glands.

_Treatment._--When the disease is limited to the groin or scrotum,
excision may bring about a permanent cure, but it may result in the
formation of lymphatic sinuses and only afford temporary relief.

#Lymphangioma.#--A lymphangioma is a swelling composed of a series of
cavities and channels filled with lymph and freely communicating with
one another. The cavities result either from the new formation of lymph
spaces or vessels, or from the dilatation of those which already exist;
their walls are composed of fibro-areolar tissue lined by endothelium
and strengthened by non-striped muscle. They are rarely provided with a
definite capsule, and frequently send prolongations of their substance
between and into muscles and other structures in their vicinity. They
are of congenital origin and usually make their appearance at or shortly
after birth. When the tumour is made up of a meshwork of caverns and
channels, it is called a _cavernous lymphangioma_; when it is composed
of one or more cysts, it is called a _cystic lymphangioma_. It is
probable that the cysts are derived from the caverns by breaking down
and absorption of the intervening septa, as transition forms between the
cavernous and cystic varieties are sometimes met with.

The _cavernous lymphangioma_ appears as an ill-defined, soft swelling,
presenting many of the characters of a subcutaneous haemangioma, but it
is not capable of being emptied by pressure, it does not become tense
when the blood pressure is raised, as in crying, and if the tumour is
punctured, it yields lymph instead of blood. It also resembles a lipoma,
especially the congenital variety which grows from the periosteum, and
the differential diagnosis between these is rarely completed until the
swelling is punctured or explored by operation. If treatment is called
for, it is carried out on the same lines as for haemangioma, by means of
electrolysis, igni-puncture, or excision. Complete excision is rarely
possible because of the want of definition and encapsulation, but it is
not necessary for cure, as the parts that remain undergo cicatrisation.

[Illustration: FIG. 76.--Congenital Cystic Tumour or Hygroma of Axilla.

(From a photograph lent by Dr. Lediard.)]

The _cystic lymphangioma_, _lymphatic cyst_, or _congenital cystic
hygroma_ is most often met with in the neck--_hydrocele of the neck_; it
is situated beneath the deep fascia, and projects either in front of or
behind the sterno-mastoid muscle. It may attain a large size, the
overlying skin and cyst wall may be so thin as to be translucent, and it
has been known to cause serious impairment of respiration through
pressing on the trachea. In the axilla also the cystic tumour may attain
a considerable size (Fig. 76); less frequent situations are the groin,
and the floor of the mouth, where it constitutes one form of ranula.

The nature of these swellings is to be recognised by their situation, by
their having existed from infancy, and, if necessary, by drawing off
some of the contents of the cyst through a fine needle. They are usually
remarkably indolent, persisting often for a long term of years without
change, and, like the haemangioma, they sometimes undergo spontaneous
cicatrisation and cure. Sometimes the cystic tumour becomes infected and
forms an abscess--another, although less desirable, method of cure.
Those situated in the neck are most liable to suppurate, probably
because of pyogenic organisms being brought to them by the lymphatics
taking origin in the scalp, ear, or throat.

If operative interference is called for, the cysts may be tapped and
injected with iodine, or excised; the operation for removal may entail a
considerable dissection amongst the deeper structures at the root of the
neck, and should not be lightly undertaken; parts left behind may be
induced to cicatrise by inserting a tube of radium and leaving it for a
few days.

Lymphangiomas are met with in the abdomen in the form of _omental
cysts_.

DISEASES OF LYMPH GLANDS

#Lymphadenitis.#--Inflammation of lymph glands results from the advent
of an irritant, usually bacterial or toxic, brought to the glands by the
afferent lymph vessels. These vessels may share in the inflammation and
be the seat of lymphangitis, or they may show no evidence of the passage
of the noxa. It is exceptional for the irritant to reach the gland
through the blood-stream.

A strain or other form of trauma is sometimes blamed for the onset of
lymphadenitis, especially in the glands of the groin (bubo), but it is
usually possible to discover some source of pyogenic infection which is
responsible for the mischief, or to obtain a history of some antecedent
infection such as gonorrhoea. It is possible for gonococci to lie latent
in the inguinal glands for long periods, and only give rise to
lymphadenitis if the glands be subsequently subjected to injury. The
glands most frequently affected are those in the neck, axilla, and
groin.

The characters of the lymphadenitis vary with the nature of the
irritant. Sometimes it is mild and evanescent, as in the glandular
enlargement in the neck which attends tonsillitis and other forms of
sore throat. Sometimes it is more persistent, as in the enlargement
that is associated with adenoids, hypertrophied tonsils, carious teeth,
eczema of the scalp, and otorrhoea; and it is possible that this indolent
enlargement predisposes to tuberculous infection. A similar enlargement
is met with in the axilla in cases of chronic interstitial mastitis, and
in the groin as a result of chronic irritation about the external
genitals, such as balanitis.

Sometimes the lymphadenitis is of an acute character, and the tendency
is towards the formation of an abscess. This is illustrated in the
axillary glands as a result of infected wounds of the fingers; in the
femoral glands in infected wounds or purulent blisters on the foot; in
the inguinal glands in gonorrhoea and soft sore; and in the cervical
glands in the severer forms of sore throat associated with diphtheria
and scarlet fever. The most acute suppurations result from infection
with streptococci.

Superficial glands, when inflamed and suppurating, become enlarged,
tender, fixed, and matted to one another. In the glands of the groin the
suppurative process is often remarkably sluggish; purulent foci form in
the interior of individual glands, and some time may elapse before the
pus erupts through their respective capsules. In the deeply placed
cervical glands, especially in cases of streptococcal throat infections,
the suppuration rapidly involves the surrounding cellular tissue, and
the clinical features are those of an acute cellulitis and deeply seated
abscess. When this is incised the necrosed glands may be found lying in
the pus, and on bacteriological examination are found to be swarming
with streptococci. In suppuration of the axillary glands the abscess may
be quite superficial, or it may be deeply placed beneath the strong
fascia and pectoral muscles, according to the group of glands involved.

The _diagnosis_ of septic lymphadenitis is usually easy. The indolent
enlargements are not always to be distinguished, however, from
commencing tuberculous disease, except by the use of the tuberculin
test, and by the fact that they usually disappear on removing the
peripheral source of irritation.

_Treatment._--The first indication is to discover and deal with the
source of infection, and in the indolent forms of lymphadenitis this
will usually be followed by recovery. In the acute forms following on
pyogenic infection, the best results are obtained from the hyperaemic
treatment carried out by means of suction bells. If suppuration is not
thereby prevented, or if it has already taken place, each separate
collection of pus is punctured with a narrow-bladed knife and the use of
the suction bell is persevered with. If there is a large periglandular
abscess, as is often the case, in the neck and axilla, the opening may
require to be made by Hilton's method, and it may be necessary to insert
a drainage-tube.

[Illustration: FIG. 77.--Tuberculous Cervical Gland with abscess
formation in subcutaneous cellular tissue, in a boy aet. 10.]

#Tuberculous Disease of Glands.#--This is a disease of great frequency
and importance. The tubercle bacilli usually gain access to the gland
through the afferent lymph vessels, which convey them from some lesion
of the surface within the area drained by them. Tuberculous infection
may supervene in glands that are already enlarged as a result of chronic
septic irritation. While any of the glands in the body may be affected,
the disease is most often met with in the cervical groups which derive
their lymph from the mouth, nose, throat, and ear.

_The appearance of the glands on section_ varies with the stage of the
disease. In the early stages the gland is enlarged, it may be to many
times its natural size, is normal in appearance and consistence, and as
there is no peri-adenitis it is easily shelled out from its
surroundings. On microscopical examination, however, there is evidence
of infection in the shape of bacilli and of characteristic giant and
epithelioid cells. At a later stage, the gland tissue is studded with
minute yellow foci which tend to enlarge and in time to become
confluent, so that the whole gland is ultimately converted into a
caseous mass. This caseous material is surrounded by the thickened
capsule which, as a result of peri-adenitis, tends to become adherent to
and fused with surrounding structures, and particularly with layers of
fascia and with the walls of veins. The caseated tissue often remains
unchanged for long periods; it may become calcified, but more frequently
it breaks down and liquefies.

#Tuberculous disease in the cervical glands# is a common accompaniment
or sequel of adenoids, enlarged tonsils, carious teeth, pharyngitis,
middle-ear disease, and conjunctivitis. These lesions afford the bacilli
a chance of entry into the lymph vessels, in which they are carried to
the glands, where they give rise to disease.

The enlargement may affect only one gland, usually below the angle of
the mandible, and remain confined to it, the gland reaching the size of
a hazel-nut, and being ovoid, firm, and painless. More commonly the
disease affects several glands, on one or on both sides of the neck.
When the disease commences in the pre-auricular or submaxillary glands,
it tends to spread to those along the carotid sheath: when the posterior
auricular and occipital glands are first involved, the spread is to
those along the posterior border of the sterno-mastoid. In many cases
all the chains in front of, beneath, and behind this muscle are
involved, the enlarged glands extending from the mastoid to the
clavicle. They are at first discrete and movable, and may even vary in
size from time to time; but with the addition of peri-adenitis they
become fixed and matted together, forming lobulated or nodular masses
(Fig. 78). They become adherent not only to one another, but also to the
structures in their vicinity,--and notably to the internal jugular
vein,--a point of importance in regard to their removal by operation.

At any stage the disease may be arrested and the glands remain for long
periods without further change. It is possible that the tuberculous
tissue may undergo cicatrisation. More commonly suppuration ensues, and
a cold abscess forms, but if there is a mixed infection, the pyogenic
factor being usually derived from the throat, it may take on active
features.

[Illustration: FIG. 78.--Mass of Tuberculous Glands removed from Axilla
(cf. Fig. 79).]

The transition from the solid to the liquefied stage is attended with
pain and tenderness in the gland, which at the same time becomes fixed
and globular, and finally fluctuation can be elicited.

If left to itself, the softened tubercle erupts through the capsule of
the gland and infects the cellular tissue. The cervical fascia is
perforated and a cold abscess, often much larger than the gland from
which it took origin, forms between the fascia and the overlying skin.
The further stages--reddening, undermining of skin and external rupture,
with the formation of ulcers and sinuses--have been described with
tuberculous abscess. The ulcers and sinuses persist indefinitely, or
they heal and then break out again; sometimes the skin becomes infected,
and a condition like lupus spreads over a considerable area. Spontaneous
healing finally takes place after the caseous tubercle has been
extruded; the resulting scars are extremely unsightly, being puckered or
bridled, or hypertrophied like keloid.

While the disease is most common in childhood and youth, it may be met
with even in advanced life; and although often associated with impaired
health and unhealthy surroundings, it may affect those who are
apparently robust and are in affluent circumstances.

_Diagnosis._--The chief importance lies in differentiating tuberculous
disease from lympho-sarcoma and from lymphadenoma, and this is usually
possible from the history and from the nature of the enlargement. Signs
of liquefaction and suppuration support the diagnosis of tubercle. If
any doubt remains, one of the glands should be removed and submitted to
microscopical examination. Other forms of sarcoma, and the enlargement
of an accessory thyreoid, are less likely to be confused with
tuberculous glands. Calcified tuberculous glands give definite shadows
with the X-rays.

Enlargement of the cervical glands from secondary cancer may simulate
tuberculosis, but is differentiated by its association with cancer in
the mouth or throat, and by the characteristic, stone-like induration of
epithelioma.

The cold abscess which results from tuberculous glands is to be
distinguished from that due to disease in the cervical spine,
retro-pharyngeal abscess, as well as from congenital and other cystic
swellings in the neck.

_Prognosis._--Next to lupus, glandular disease is of all tuberculous
lesions the least dangerous to life; but while it is the rule to recover
from tuberculous disease of glands with or without an operation, it is
unfortunately quite common for such persons to become the subjects of
tuberculosis in other parts of the body at any subsequent period of
life.

_Treatment._--There is considerable difference of opinion regarding the
treatment of glandular tuberculosis. Some authorities, impressed with
the undoubted possibility of natural cure, are satisfied with promoting
this by measures directed towards improving the general health, by the
prolonged administration of tuberculin, and by repeated exposures to the
X-rays and to sunlight. Others again, influenced by the risk of
extension of the disease and by the destruction of tissue and
disfigurement caused by breaking down of the tuberculous tissue and
mixed infection, advocate the removal of the glands by operation.

The conditions vary widely in different cases, and the treatment should
be adapted to the individual requirements. If the disease remains
confined to the glands originally infected and there are no signs of
breaking down, "expectant measures" may be persevered with.

[Illustration: FIG. 79.--Tuberculous Axillary Glands (cf. Fig. 78).]

If, on the other hand, the disease exhibits aggressive tendencies, the
question of operation should be considered. The undesirable results of
the breaking down and liquefaction of the diseased gland may be avoided
by the timely withdrawal of the fluid contents through a hollow needle.

_The excision of tuberculous glands_ is often a difficult operation,
because of the number and deep situation of the glands to be removed,
and of the adhesions to surrounding structures. The skin incision must
be sufficiently extensive to give access to the whole of the affected
area, and to avoid disfigurement should, whenever possible, be made in
the line of the natural creases of the skin. In exposing the glands the
common facial and other venous trunks may require to be clamped and
tied. Care must be taken not to injure the important nerves,
particularly the accessory, the vagus, and the phrenic. The
inframaxillary branches of the facial, the hypoglossal and its
descending branches, and the motor branches of the deep cervical plexus,
are also liable to be injured. The dissection is rendered easier and is
attended with less risk of injury to the nerves, if the patient is
placed in the sitting posture so as to empty the veins, and, instead of
a knife, the conical scissors of Mayo are employed. When the glands are
extensively affected on both sides of the neck, it is advisable to allow
an interval to elapse rather than to operate on both sides at one
sitting. (_Op. Surg._, p. 189.)

If the tonsils are enlarged they should not be removed at the same time,
as, by so doing, there is a risk of pyogenic infection from the throat
being carried to the wound in the neck, but they should be removed,
after an interval, to prevent relapse of disease in the glands.

_When the skin is broken_ and caseous tuberculous tissue is exposed,
healing is promoted by cutting away diseased skin, removing the
granulation tissue with the spoon, scraping sinuses, and packing the
cavity with iodoform worsted and treating it by the open method and
secondary suture if necessary. Exposure to the sunshine on the seashore
and to the X-rays is often beneficial in these cases.

#Tuberculous disease in the axillary glands# may be a result of
extension from those in the neck, from the mamma, ribs, or sternum, or
more rarely from the upper extremity. We have seen it from an infected
wound of a finger. In some cases no source of infection is discoverable.
The individual glands attain a considerable size, and they fuse together
to form a large tumour which fills up the axillary space. The disease
progresses more rapidly than it does in the cervical glands, and almost
always goes on to suppuration with the formation of sinuses.
Conservative measures need not be considered, as the only satisfactory
treatment is excision, and that without delay.

#Tuberculous disease in the glands of the groin# is comparatively rare.
We have chiefly observed it in the femoral glands as a result of
inoculation tubercle on the toes or sole of the foot. The affected
glands nearly always break down and suppurate, and after destroying the
overlying skin give rise to fungating ulcers. The treatment consists in
excising the glands and the affected skin. The dissection may be
attended with troublesome haemorrhage from the numerous veins that
converge towards the femoral trunk.

Tuberculous disease in the _mesenteric_ and _bronchial glands_ is
described with the surgery of regions.

#Syphilitic Disease of Glands.#--Enlargement of lymph glands is a
prominent feature of acquired syphilis, especially in the form of the
indolent or bullet-bubo which accompanies the primary lesion, and the
general enlargement of glands that occurs in secondary syphilis.
Gummatous disease in glands is extremely rare; the affected gland
rapidly enlarges to the size of a walnut, and may then persist for a
long period without further change; if it breaks down, the overlying
skin is destroyed and the caseated tissue of the gumma exposed.

#Lymphadenoma.#--_Hodgkin's Disease_ (Pseudo-leukaemia of German
authors).--This is a rare disease, the origin of which is as yet
unknown, but analogy would suggest that it is due to infection with a
slowly growing micro-organism. It is chiefly met with in young subjects,
and is characterised by a painless enlargement of a particular group of
glands, most commonly those in the cervical region (Fig. 80).