Part 59

The persistent swelling of the part must be met by active rubbing or kneading, by exercise and by uniform compression by a flannel or elastic bandage.

LYMPHANGIECTASIS. DILATED LYMPHATICS.

Result of lymphangitis, of heart disease, of pulmonary arterial thrombosis, of external jugular plugging. Causes, obstruction to lymph flow, compression, increased venous blood pressure, fibrinous lymph coagula, action of sensory nerves, of lymphadenitis, anæmia. Symptoms like dropsy if in plexus, in large lymphatics, moniliform swelling, sacculation, wounds discharge lymph, hyperplasia of connective tissue, fatty deposits, lipomata. Treatment, elastic bandage, cold, astringents, iodine, punctures, ligatures, cauterizations, tonics.

The most striking cases of dilatation of the lymphatics in the lower animals are met with in horses that have suffered repeatedly and severely from the lymphangitis of plethora. Then the lower part of the shank and the pastern are enormously thickened to perhaps two or even three feet in circumference, and skin and connective tissue are the seat of a general dilatation of the lymphatic plexus and vessels with great thickening of their walls. Nocard and Barrier record cases of general dilatation of the lymphatics in dogs in connection with heart disease, also the case of a horse with old standing thrombosis of the pulmonary arteries, hypertrophy of the right heart, and dilatation of the thoracic duct to the size of the arm and of the lymphatics of the mesocolon to the diameter of half an inch to nearly an inch. Nocard records two cases in the horse, one of a reticular lymphangioma of the sheath, and the other of dilatation of the lymph vessels accompanying the saphena vein on the inside of the thigh. This formed small, soft, fluctuating, extremely irregular tumors, completely covering the vein for a space of about four inches.

In both cases the dilatations were surrounded by a thick layer of connective tissue filled with liquid. Virchow records a case of a new-born calf in which a thrombosis of the external jugular vein caused obstruction of the mouth of the thoracic duct, and a consequent extreme distension of all the splanchnic lymph vessels with a slightly sanguinolent fluid. The intestines especially were covered everywhere with broad, bead-like canals, arranged so closely together that the intervening tissue could be scarcely recognized.

The causes of lymphangiectasis appear to be generally some obstruction to the onward flow of the lymph. Any diseased condition, therefore, that causes compression of the larger lymph vessels may cause dilatation of the smaller ones leading into these. General distension may come from disease of the lungs or left heart and increased venous blood pressure, or from thrombus of the jugular, or a tumor obstructing the thoracic duct, while local engorgements may come from the pressure of tumors, or the occurrence of lymphangitis and formation of fibrinous coagula. In cases of partial obstruction of the lymph vessels the increased secretion of lymph may lead to distension and enlargement. It may be named in this connection that irritation of the sensory nerves in dogs has been shown to determine a larger production of lymph (Krause). Lymphadenitis and the obstruction of the passage of lymph through the glands is an obvious cause, and hence the disease is specially liable to appear in connection with diseases which show a predilection for the lymphatics (tuberculosis, glanders, strangles, carcinoma, etc.)

In his work on dilatation and occlusion of lymph channels Busey shows that in man the majority of cases are in hospital patients in whom blood and general health have been impoverished and reduced by unhygienic conditions. One case gave support to the theory of maternal impression, the pregnant mother having suffered from over-use of the right limb on a sewing machine, and the offspring having shown extensive lymphangiectasis in the right leg.

Symptoms consist in enlargement of the lymph vessels or plexus, and often of the glands. If of the lymph plexus it may appear like a dropsical effusion in the part, with or without saccular dilatations at intervals. If of the larger vessels, their tortuous anastomosing trunks following largely the lines of the veins are usually characteristic. If the distension is slight it is usually moniliform, as the valves are still intact, and the intervals between them stand out as bladder-like masses. If the structure is wounded or if it ulcerates there is the discharge of a straw-colored fluid, often rendered milky by the presence of fatty granules, and at times tinged with blood. There is always a tendency to the increase and condensation of the connective tissue surrounding the vessels, and fatty degeneration and the formation of lipomata are not uncommon.

Treatment. Compression, by flannel or elastic bandage, from the foot upward, is the simplest and most promising treatment when the limb is affected. The local application of cold, astringents or iodine may be added. Punctures, ligatures, and cauterization have not given encouraging results. Ligature of the nutrient artery of the part, has succeeded in one or two cases, but has failed in others. Tonics are to be tried more particularly in cases due to specific debilitating diseases. Sometimes a spontaneous recovery has been noticed when the surrounding connective tissue has increased and contracted in connection with inflammation.

LYMPHORRHŒA. LYMPHORRHAGIA. DISCHARGE OF LYMPH THROUGH WOUNDS OR SORES.

Result of rupture of lymphatics. Milky, fatty lymph. Treatment, ligature, excision, cauterization, of little avail. Compression. Tonics.

Obstruction of a lymph duct may lead to rupture and the discharge of its fluid on the surface or into an internal cavity. Dr. Cayley records a case of fatal peritonitis in man from rupture of the receptaculum chyli, and the formation of lymph fistulæ has been attributed to filaria sanguinis hominis. We are aware of no corresponding case in connection with the blood parasites of the horse or dog. In the larger domestic animals the great thickness and resistance of the skin offers a barrier to the rupture of subcutaneous lymph vessels, but this no longer applies in case of a suppurating or ulcerous wound. The escaping lymph has often a milky hue from the admixture of fat, just as its escape in the kidneys causes chyluria, and in the bowel fatty stools. The escape is often very profuse and persistent, and results in marked debility. Ligature and excision of the fistulous vessel, also caustics—actual and potential, have been tried with rather poor success. Fitzer succeeded in an obstinate case by the extensive application of nitrate of silver and others by simple compression. As the victims are usually debilitated a course of tonics is usually desirable.

LYMPHADENITIS. INFLAMMATION OF THE LYMPH GLANDS.

Result of lesions of tributary tissues. Arrest in glands of microbes and other irritants. Trauma of gland. Inflammation. Symptoms, swelling, stiffness, gland tender, hot, pitting envelope, corded lymph vessels, abscess, fever. Lesions. Treatment, antiseptics, astringents, emollients, vesicants, lancing, antiseptics, antiphlogistics, antithermics. Chronic adenitis. Symptoms, enlarged glands without engorgement, if simple affects a single gland, if infectious, a group. Lesions, gland swelling, induration, shrinking, follicular distension, pigmentation, growth of lymphocytes, caseation, calcification. Treatment, antiphlogistic, antiseptic, iodine, chloride of calcium, iodide of potassium.

Apart from traumatic lesions lymphadenitis virtually implies some lesion of the tissues from which the different vessels of the glands proceed. The glands however have been referred to as filtering agents on the course of the lymph vessels and in this partial view of their functions we find abundant reason why irritants carried in the lymph stream, should be arrested with pathogenic results in the glands. A particle of pigment gaining entrance to the lymph vessels tends to be arrested among the trabeculæ of the gland, and contributes to the pigmentation so common in old animals. Cells and granules from malignant tumors, and bacteria from an infection-atrium are arrested in the glands and make these the great centres of infection-lesions.

Traumatic inflammation comes from bruises, punctures or incisions directly implicating the glands. There result swelling, tenderness and the other general signs of inflammation, and in the case of an open wound possibly lymphorrhagia.

Acute inflammation more commonly supervenes on inflammation in the area drawn upon by the afferent vessels of the gland. In inflammations generally the adjacent lymphatic glands become congested. In lymphangitis it is so in a marked degree. In external parts we can follow this by careful observations during life, in internal organs we often find the glandular enlargement after death.

Symptoms consist in swelling and perhaps stiffness in the region of the gland. Manipulation shows tenderness and heat, the gland being felt abnormally large, round, or oval, tense, loose from the skin but having a distinct envelope of soft pitting exudate which tends to increase in a downward direction. There may or may not be a corded feeling of the afferent lymphatic trunks. As the pasty swelling increases, it extends into surrounding parts, binds the gland to the skin and adjacent structures, and may even conceal the gland in the excess of its investing engorgement. This is especially frequent in strangles. As the process advances softening may take place in the centre and extend toward the circumference, and this may burst like an ordinary abscess. In some cases the softening is very limited and tardy, and the pus may be pent up and inspissated, or it may appear to be entirely reabsorbed while the gland is in process of induration. Fever which may run high during the process of suppuration, moderates when that has been accomplished.

In the case of glands too deeply situated to be clearly felt the occurrence of purulent fluctuation in their vicinity suggests abscess of the glands, an important induction as the maturation and healing are usually slow in the gland tissue.

Lesions. At the outset the glands are visibly enlarged, softened, and of a dark red hue, with spots of a brighter red. The changes, mainly in the medullary layer, consist in a great proliferation of spheroidal cells in the follicles and also of polyhedral cells in the lymph sinuses. The endothelial cells are swollen, the blood vessels gorged, and extravasations of blood into the follicles and sinuses are frequent. Abscess or fibroid hyperplasia with induration may follow. Much depends on the particular infection (tuberculosis, glanders, carcinoma, etc.) as the special product of each disease will be found in the affected gland.

Treatment is in the main as advised for lymphangitis and will vary with each specific causative disease. Locally antiseptics, astringents, deobstruents, emollients, and vesicants will be requisite in different cases. As soon as pus can be distinctly diagnosed it should as a rule be evacuated, and the cavity treated antiseptically. General treatment may at first be antiphlogistic and febrifuge, but must usually embrace tonics and stimulants in the end.

=Chronic Adenitis= may be a sequel of the acute, or it may arise independently. In the latter case it is usually the result of some other disease (tuberculosis, glanders, carcinoma, sarcoma melanosis inveterate disease of the skin, chronic fistula, abscess, or mucous inflammation).

The symptoms are those of enlarged glands with no material surrounding engorgement. In the infections of tuberculosis and glanders it shows a tendency to affect the whole group, whereas in simple abscess or in suppuration of the nasal sinuses it may implicate one gland only, the remainder appearing normal.

Lesions. The gland often becomes indurated and even shrunken, the connective tissue elements undergoing a steady increase at the expense of the follicles and lymphoid cells. This is a common condition of tuberculous glands (perl-knoten, grapes) of cattle, but may result from the entrance of pigment or other cause of mild irritation. In other cases pigment entering from without or developed from blood in the congested gland, finds permanent lodgment in its tissue and may give it a gray mottled or quite black aspect. In still other cases, there is a great increase of the round lymphoid and larger polyhedral cells, many of which degenerate becoming strongly refracting, stain feebly, or not at all, and pass into a cheesy degeneration. This is a common condition in tuberculosis and glanders, and the caseous centres beginning as multiple miliary centres may coalesce to form masses of six or twelve inches in their greatest diameter as in bovine tuberculosis. In other cases the caseating mass becomes the seat of calcareous deposit and the necrotic and caseated gland becomes in part calcified. Other degenerative changes such as atrophy, amyloid, and hyaline are met with but have received little attention.

Treatment will be subordinated to the primary cause. If that is a simple local inflammation or irritation its removal will entail a speedy improvement in the gland, and, in the absence of too extensive structural change, a speedy recovery. The infectious cases on the other hand are likely to prove as inveterate as the disease on which they depend. In case the enlargement or congestion of the gland persists after the removal of its primary cause local deobstruents especially the preparations of iodine are usually effective. Tincture of iodine with soap, iodide of lead, and mercurial ointment have been severally used with advantage. Injection of a weak solution of iodine into the gland will at times succeed. The internal use of chloride of calcium or iodide of potassium will often hasten recovery.

INDEX.

Abomasum, position of in ox, 156.

Abscess in adynamic inflammation, 71.