Alexis Thomson and Alexander Miles - Manual of Surgery

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[Illustration: FIG. 80.--Chronic Hodgkin's Disease in a boy aet. 11.]

The glands are usually larger than in tuberculosis, and they remain
longer discrete and movable; they are firm in consistence, and on
section present a granular appearance due to overgrowth of the
connective-tissue framework. In time the glandular masses may form
enormous projecting tumours, the swelling being added to by lymphatic
oedema of the overlying cellular tissue and skin.

The enlargement spreads along the chain of glands to those above the
clavicle, to those in the axilla, and to those of the opposite side
(Fig. 81). Later, the glands in the groin become enlarged, and it is
probable that the infection has spread from the neck along the
mediastinal, bronchial, retro-peritoneal, and mesenteric glands, and has
branched off to the iliac and inguinal groups.

Two clinical types are recognised, one in which the disease progresses
slowly and remains confined to the cervical glands for two or more
years; the other, in which the disease is more rapidly disseminated and
causes death in from twelve to eighteen months.

[Illustration: FIG. 81.--Lymphadenoma (Hodgkin's Disease) affecting left
side of neck and left axilla, in a woman aet. 44. Three years' duration.]

In the acute form, the health suffers, there is fever, and the glands
may vary in size with variations in the temperature; the blood presents
the characters met with in secondary anaemia. The spleen, liver, testes,
and mammae may be enlarged; the glandular swellings press on important
structures, such as the trachea, oesophagus, or great veins, and symptoms
referable to such pressure manifest themselves.

_Diagnosis._--Considerable difficulty attends the diagnosis of
lymphadenoma at an early stage. The negative results of tuberculin tests
may assist in the differentiation from tuberculous disease, but the more
certain means of excising one of the suspected glands and submitting it
to microscopical examination should be had recourse to. The sections
show proliferation of endothelial cells, the formation of numerous giant
cells quite unlike those of tuberculosis and a progressive fibrosis.
Lympho-sarcoma can usually be differentiated by the rapid assumption of
the local features of malignant disease, and in a gland removed for
examination, a predominance of small round cells with scanty protoplasm.
The enlargement associated with leucocythaemia is differentiated by the
characteristic changes in the blood.

_Treatment._--In the acute form of lymphadenoma, treatment is of little
avail. Arsenic may be given in full doses either by the mouth or by
subcutaneous injection; the intravenous administration of neo-salvarsan
may be tried. Exposure to the X-rays and to radium has been more
successful than any other form of treatment. Excision of glands,
although sometimes beneficial, seldom arrests the progress of the
disease. The ease and rapidity with which large masses of glands may be
shelled out is in remarkable contrast to what is observed in tuberculous
disease. Surgical interference may give relief when important structures
are being pressed upon--tracheotomy, for example, may be required where
life is threatened by asphyxia.

#Leucocythaemia.#--This is a disease of the blood and of the
blood-forming organs, in which there is a great increase in the number,
and an alteration of the character, of the leucocytes present in the
blood. It may simulate lymphadenoma, because, in certain forms of the
disease, the lymph glands, especially those in the neck, axilla, and
groin, are greatly enlarged.

TUMOURS OF LYMPH GLANDS

#Primary Tumours.#--_Lympho-sarcoma_, which may be regarded as a sarcoma
starting in a lymph gland, appears in the neck, axilla, or groin as a
rapidly growing tumour consisting of one enlarged gland with numerous
satellites. As the tumour increases in size, the sarcomatous tissue
erupts through the capsule of the gland, and infiltrates the surrounding
tissues, whereby it becomes fixed to these and to the skin.

[Illustration: FIG. 82.--Lympho-Sarcoma removed from Groin. It will be
observed that there is one large central parent tumour surrounded by
satellites.]

The prognosis is grave in the extreme, and the only hope is in early
excision, followed by the use of radium and X-rays. We have observed a
case of lympho-sarcoma above the clavicle, in which excision of all that
was removable, followed by the insertion of a tube of radium for ten
days, was followed by a disappearance of the disease over a period which
extended to nearly five years, when death resulted from a tumour in the
mediastinum. In a second case in which the growth was in the groin, the
patient, a young man, remained well for over two years and was then lost
sight of.

#Secondary Tumours.#--Next to tuberculosis, _secondary cancer_ is the
most common disease of lymph glands. In the neck it is met with in
association with epithelioma of the lip, tongue, or fauces. The glands
form tumours of variable size, and are often larger than the primary
growth, the characters of which they reproduce. The glands are at first
movable, but soon become fixed both to each other and to their
surroundings; when fixed to the mandible they form a swelling of
bone-like hardness; in time they soften, liquefy, and burst through the
skin, forming foul, fungating ulcers. A similar condition is met with in
the groin from epithelioma of the penis, scrotum, or vulva. In cancer of
the breast, the infection of the axillary glands is an important
complication.

In _pigmented_ or _melanotic cancers_ of the skin, the glands are early
infected and increase rapidly, so that, when the primary growth is still
of small size--as, for example, on the sole of the foot--the femoral
glands may already constitute large pigmented tumours.

[Illustration: FIG. 83.--Cancerous Glands in Neck secondary to
Epithelioma of Lip.

(Mr. G. L. Chiene's case.)]

The implication of the glands in other forms of cancer will be
considered with regional surgery.

_Secondary sarcoma_ is seldom met with in the lymph glands except when
the primary growth is a lympho-sarcoma and is situated in the tonsil,
thyreoid, or testicle.

CHAPTER XVI

THE NERVES

Anatomy--INJURIES OF NERVES: Changes in nerves after division;
Repair and its modifications; Clinical features; _Primary and
secondary suture_--SUBCUTANEOUS INJURIES OF
NERVES--DISEASES: _Neuritis_; _Tumours_--Surgery of
the individual nerves: _Brachial neuralgia_; _Sciatica_;
_Trigeminal neuralgia_.

#Anatomy.#--A nerve-trunk is made up of a variable number of bundles of
nerve fibres surrounded and supported by a framework of connective
tissue. The nerve fibres are chiefly of the medullated type, and they
run without interruption from a nerve cell or _neuron_ in the brain or
spinal medulla to their peripheral terminations in muscle, skin, and
secretory glands.

Each nerve fibre consists of a number of nerve fibrils collected into a
central bundle--the axis cylinder--which is surrounded by an envelope,
the neurolemma or sheath of Schwann. Between the neurolemma and the axis
cylinder is the medullated sheath, composed of a fatty substance known
as myelin. This medullated sheath is interrupted at the nodes of
Ranvier, and in each internode is a nucleus lying between the myelin and
the neurolemma. The axis cylinder is the essential conducting structure
of the nerve, while the neurolemma and the myelin act as insulating
agents. The axis cylinder depends for its nutrition on the central
neuron with which it is connected, and from which it originally
developed, and it degenerates if it is separated from its neuron.

The connective-tissue framework of a nerve-trunk consists of the
_perineurium_, or general sheath, which surrounds all the bundles; the
_epineurium_, surrounding individual groups of bundles; and the
_endoneurium_, a delicate connective tissue separating the individual
nerve fibres. The blood vessels and lymphatics run in these
connective-tissue sheaths.

According to Head and his co-workers, Sherren and Rivers, the afferent
fibres in the peripheral nerves can be divided into three systems:--

1. Those which subserve _deep sensibility_ and conduct the impulses
produced by pressure as well as those which enable the patient to
recognise the position of a joint on passive movement (joint-sensation),
and the kinaesthetic sense, which recognises that active contraction of
the muscle is taking place (active muscle-sensation). The fibres of this
system run with the motor nerves, and pass to muscles, tendons, and
joints. Even division of both the ulnar and the median nerves above the
wrist produces little loss of deep sensibility, unless the tendons are
also cut through. The failure to recognise this form of sensibility has
been largely responsible for the conflicting statements as to the
sensory phenomena following operations for the repair of divided nerves.

2. Those which subserve _protopathic_ sensibility--that is, are capable
of responding to painful cutaneous stimuli and to the extremes of heat
and cold. These also endow the hairs with sensibility to pain. They are
the first to regenerate after division.

3. Those which subserve _epicritic_ sensibility, the most highly
specialised, capable of appreciating light touch, _e.g._ with a wisp of
cotton wool, as a well-localised sensation, and the finer grades of
temperature, called cool and warm (72-104 F.), and of discriminating
as separate the points of a pair of compasses 2 cms. apart. These are
the last to regenerate.

A nerve also exerts a trophic influence on the tissues in which it is
distributed.

The researches of Stoffel on the minute anatomy of the larger nerves,
and the disposition in them of the bundles of nerve fibres supplying
different groups of muscles, have opened up what promises to be a
fruitful field of clinical investigation and therapeutics. He has shown
that in the larger nerve-trunks the nerve bundles for special groups of
muscles are not, as was formerly supposed, arranged irregularly and
fortuitously, but that on the contrary the nerve fibres to a particular
group of muscles have a typical and practically constant position within
the nerve.

In the large nerve-trunks of the limbs he has worked out the exact
position of the bundles for the various groups of muscles, so that in a
cross section of a particular nerve the component bundles can be
labelled as confidently and accurately as can be the cortical areas in
the brain. In the living subject, by using a fine needle-like electrode
and a very weak galvanic current, he has been able to differentiate the
nerve bundles for the various groups of muscles. In several cases of
spastic paralysis he succeeded in picking out in the nerve-trunk of the
affected limb the nerve bundles supplying the spastic muscles, and, by
resecting portions of them, in relieving the spasm. In a case of spastic
contracture of the pronator muscles of the forearm, for example, an
incision is made along the line of the median nerve above the bend of
the elbow. At the lateral side of the median nerve, where it lies in
contact with the biceps muscle, is situated a well-defined and easily
isolated bundle of fibres which supplies the pronator teres, the flexor
carpi radialis, and the palmaris longus muscles. On incising the sheath
of the nerve this bundle can be readily dissected up and its identity
confirmed by stimulating it with a very weak galvanic current. An inch
or more of the bundle is then resected.

INJURIES OF NERVES

Nerves are liable to be cut or torn across, bruised, compressed,
stretched, or torn away from their connections with the spinal medulla.

#Complete Division of a Mixed Nerve.#--Complete division is a common
result of accidental wounds, especially above the wrist, where the
ulnar, median, and radial nerves are frequently cut across, and in
gun-shot injuries.

_Changes in Structure and Function._--The mere interruption of the
continuity of a nerve results in degeneration of its fibres, the myelin
being broken up into droplets and absorbed, while the axis cylinders
swell up, disintegrate, and finally disappear. Both the conducting and
the insulating elements are thus lost. The degeneration in the central
end of the divided nerve is usually limited to the immediate proximity
of the lesion, and does not even involve all the nerve fibres. In the
distal end, it extends throughout the entire peripheral distribution of
the nerve, and appears to be due to the cutting off of the fibres from
their trophic nerve cells in the spinal medulla. Immediate suturing of
the ends does not affect the degeneration of the distal segment. The
peripheral end undergoes complete degeneration in from six weeks to two
months.

The physiological effects of complete division are that the muscles
supplied by the nerve are immediately paralysed, the area to which it
furnishes the sole cutaneous supply becomes insensitive, and the other
structures, including tendons, bones, and joints, lose sensation, and
begin to atrophy from loss of the trophic influence.

#Nerves divided in Amputation.#--In the case of nerves divided in an
amputation, there is an active, although necessarily abortive, attempt
at regeneration, which results in the formation of bulbous swellings at
the cut ends of the nerves. When there has been suppuration, and
especially if the nerves have been cut so as to be exposed in the wound,
these bulbous swellings may attain an abnormal size, and are then known
as "amputation" or "stump neuromas" (Fig. 84).

When the nerves in a stump have not been cut sufficiently short, they
may become involved in the cicatrix, and it may be necessary, on account
of pain, to free them from their adhesions, and to resect enough of the
terminal portions to prevent them again becoming adherent. When this is
difficult, a portion may be resected from each of the nerve-trunks at a
higher level; and if this fails to give relief, a fresh amputation may
be performed. When there is agonising pain dependent upon an ascending
neuritis, it may be necessary to resect the corresponding posterior
nerve roots within the vertebral canal.

[Illustration: FIG. 84.--Stump Neuromas of Sciatic Nerve, excised forty
years after the original amputation by Mr. A. G. Miller.]

#Other Injuries of Nerves.#--_Contusion_ of a nerve-trunk is attended
with extravasation of blood into the connective-tissue sheaths, and is
followed by degeneration of the contused nerve fibres. Function is
usually restored, the conducting paths being re-established by the
formation of new nerve fibres.

When a nerve is _torn across_ or badly _crushed_--as, for example, by a
fractured bone--the changes are similar to those in a divided nerve, and
the ultimate result depends on the amount of separation between the ends
and the possibility of the young axis cylinders bridging the gap.

_Involvement of Nerves in Scar Tissue._--Pressure or traction may be
exerted upon a nerve by contracting scar tissue, or a process of
neuritis or perineuritis may be induced.

When terminal filaments are involved in a scar, it is best to dissect
out the scar, and along with it the ends of the nerves pressed upon.
When a nerve-trunk, such as the sciatic, is involved in cicatricial
tissue, the nerve must be exposed and freed from its surroundings
(_neurolysis_), and then stretched so as to tear any adhesions that may
be present above or below the part exposed. It may be advisable to
displace the liberated nerve from its original position so as to
minimise the risk of its incorporation in the scar of the original wound
or in that resulting from the operation--for example, the radial nerve
may be buried in the substance of the triceps, or it may be surrounded
by a segment of vein or portion of fat-bearing fascia.

_Injuries of nerves resulting from_ #gun-shot wounds# include: (1) those
in which the nerve is directly damaged by the bullet, and (2) those in
which the nerve-trunk is involved secondarily either by scar tissue in
its vicinity or by callus following fracture of an adjacent bone. The
primary injuries include contusion, partial or complete division, and
perforation of the nerve-trunk. One of the most constant symptoms is the
early occurrence of severe neuralgic pain, and this is usually
associated with marked hyperaesthesia.

#Regeneration.#--_Process of Repair when the Ends are in Contact._--_If
the wound is aseptic_, and the ends of the divided nerve are sutured or
remain in contact, they become united, and the conducting paths are
re-established by a regeneration of nerve fibres. There is a difference
of opinion as to the method of regeneration. The Wallerian doctrine is
that the axis cylinders in the central end grow downwards, and enter the
nerve sheaths of the distal portion, and continue growing until they
reach the peripheral terminations in muscle and skin, and in course of
time acquire a myelin sheath; the cells of the neurolemma multiply and
form long chains in both ends of the nerve, and are believed to provide
for the nourishment and support of the actively lengthening axis
cylinders. Another view is that the formation of new axis cylinders is
not confined to the central end, but that it goes on also in the
peripheral segment, in which, however, the new axis cylinders do not
attain maturity until continuity with the central end has been
re-established.

_If the wound becomes infected_ and suppuration occurs, the young nerve
fibres are destroyed and efficient regeneration is prevented; the
formation of scar tissue also may constitute a permanent obstacle to new
nerve fibres bridging the gap.

_When the ends are not in contact_, reunion of the divided nerve fibres
does not take place whether the wound is infected or not. At the
proximal end there forms a bulbous swelling, which becomes adherent to
the scar tissue. It consists of branching axis cylinders running in all
directions, these having failed to reach the distal end because of the
extent of the gap. The peripheral end is completely degenerated, and is
represented by a fibrous cord, the cut end of which is often slightly
swollen or bulbous, and is also incorporated with the scar tissue of
the wound.

#Clinical Features.#--The symptoms resulting from division and non-union
of a nerve-trunk necessarily vary with the functions of the affected
nerve. The following description refers to a mixed sensori-motor trunk,
such as the median or radial (musculo-spiral) nerve.

_Sensory Phenomena._--Superficial touch is tested by means of a wisp of
cotton wool stroked gently across the skin; the capacity of
discriminating two points as separate, by a pair of blunt-pointed
compasses; the sensation of pressure, by means of a pencil or other
blunt object; of pain, by pricking or scratching with a needle; and of
sensibility to heat and cold, by test-tubes containing water at
different temperatures. While these tests are being carried out, the
patient's eyes are screened off.

After division of a nerve containing sensory fibres, there is an area of
absolute cutaneous insensibility to touch (anaesthesia), to pain
(analgesia), and to all degrees of temperature--_loss of protopathic
sensibility_; surrounded by an area in which there is loss of sensation
to light touch, inability to recognise minor differences of temperature
(72-104 F.), and to appreciate as separate impressions the contact of
the two points of a compass--_loss of epicritic sensibility_ (Head and
Sherren) (Figs. 91, 92).

_Motor Phenomena._--There is immediate and complete loss of voluntary
power in the muscles supplied by the divided nerve. The muscles rapidly
waste, and within from three to five days, they cease to react to the
faradic current. When tested with the galvanic current, it is found that
a stronger current must be used to call forth contraction than in a
healthy muscle, and the contraction appears first at the closing of the
circuit when the anode is used as the testing electrode. The loss of
excitability to the interrupted current, and the specific alteration in
the type of contraction with the constant current, is known as the
_reaction of degeneration_. After a few weeks all electric excitability
is lost. The paralysed muscles undergo fatty degeneration, which attains
its maximum three or four months after the division of the nerve.
Further changes may take place, and result in the transformation of the
muscle into fibrous tissue, which by undergoing shortening may cause
deformity known as _paralytic contracture_.

_Vaso-motor Phenomena._--In the majority of cases there is an initial
rise in the temperature of the part (2 to 3 F.), with redness and
increased vascularity. This is followed by a fall in the local
temperature, which may amount to 8 or 10 F., the parts becoming pale
and cold. Sometimes the hyperaemia resulting from vaso-motor paralysis is
more persistent, and is associated with swelling of the parts from
oedema--the so-called _angio-neurotic oedema_. The vascularity varies with
external influences, and in cold weather the parts present a bluish
appearance.

_Trophic Phenomena._--Owing to the disappearance of the subcutaneous
fat, the skin is smooth and thin, and may be abnormally dry. The hair is
harsh, dry, and easily shed. The nails become brittle and furrowed, or
thick and curved, and the ends of the fingers become club-shaped. Skin
eruptions, especially in the form of blisters, occur, or there may be
actual ulcers of the skin, especially in winter. In aggravated cases the
tips of the fingers disappear from progressive ulceration, and in the
sole of the foot a perforating ulcer may develop. Arthropathies are
occasionally met with, the joints becoming the seat of a painless
effusion or hydrops, which is followed by fibrous thickening of the
capsular and other ligaments, and terminates in stiffness and fibrous
ankylosis. In this way the fingers are seriously crippled and deformed.

#Treatment of Divided Nerves.#--The treatment consists in approximating
the divided ends of the nerve and placing them under the most favourable
conditions for repair, and this should be done at the earliest possible
opportunity. (_Op. Surg._, pp. 45, 46.)

#Primary Suture.#--The reunion of a recently divided nerve is spoken of
as primary suture, and for its success asepsis is essential. As the
suturing of the ends of the nerve is extremely painful, an anaesthetic is
required.

When the wound is healed and while waiting for the restoration of
function, measures are employed to maintain the nutrition of the damaged
nerve and of the parts supplied by it. The limb is exercised, massaged,
and douched, and protected from cold and other injurious influences. The
nutrition of the paralysed muscles is further improved by electricity.
The galvanic current is employed, using at first a mild current of not
more than 5 milliamperes for about ten minutes, the current being made
to flow downwards in the course of the nerve, with the positive
electrode applied to the spine, and the negative over the affected nerve
near its termination. It is an advantage to have a metronome in the
circuit whereby the current is opened and closed automatically at
intervals, so as to cause contraction of the muscles.

_The results_ of primary suture, when it has been performed under
favourable conditions, are usually satisfactory. In a series of cases
investigated by Head and Sherren, the period between the operation and
the first return of sensation averaged 65 days. According to Purves
Stewart protopathic sensation commences to appear in about six weeks and
is completely restored in six months; electric sensation and motor power
reappear together in about six months, and restoration is complete in a
year. When sensation returns, the area of insensibility to pain steadily
diminishes and disappears; sensibility to extremes of temperature
appears soon after; and last of all, after a considerable interval,
there is simultaneous return of appreciation of light touch, moderate
degrees of temperature, and the points of a compass.

A clinical means of estimating how regeneration in a divided nerve is
progressing has been described by Tinel. He found that a tingling
sensation, similar to that experienced in the foot, when it is
recovering from the "sleeping" condition induced by prolonged pressure
on the sciatic nerve from sitting on a hard bench, can be elicited on
percussing over _growing_ axis cylinders. Tapping over the proximal end
of a _newly divided nerve_, _e.g._ the common peroneal behind the head
of the fibula, produces no tingling, but when in about three weeks
axis cylinders begin to grow in the proximal end-bulb, local tingling is
induced by tapping there. The downward growth of the axis cylinders can
be traced by tapping over the distal segment of the nerve, the tingling
sensation being elicited as far down as the young axis cylinders have
reached. When the regeneration of the axis cylinders is complete,
tapping no longer causes tingling. It usually takes about one hundred
days for this stage to be reached.