various : in some cases the area affected is very small, even trivial ; in
others it involves an entire limb ; there may be diminutive vesicles or
' Lymphorrhcea {lympha = lympli -(- /ifu, flow), a persistent flowing of lympli from an
injured vessel ; lymphorrhagia (lympha = lymph -j- 'pfiyvvfu, break forth), a violent lymph-
orrhcea.
^ Lymphiinriiectasis (lympha = lymph -|- a-}}e'wv = vessel -j- iKraaic = dilatation), dila-
tation of lymph-channels.
AFFECTIOXS OF THE LYMPHATIC VESSELS. 469
large cystic tumors ; the influence upon health may be insijinificant or so
serious as to destroy life ; the dilatation ma}' att'ect yessels only upon the
surface of the body, or it may implicate principally those that are deeply
situated ; some cases are readily amonalile to treatment, others are hope-
less from the l)egiuning. The enlargements which ensue from this con-
dition are in many cases hypertrophic : the tissues in which the distended
yessels lie haying constantly presented to them a far more abundant
supply of nourishment tlian is normal, the approjiriation of an excessiye
amount of pabulum is almost ineyitable, and liyperplasia results. This
increase in bulk is uniforndy an oyergrowth of true connectiye tissue —
the most easily formed of all the textures in the body — is frequently
enormous, and may produce such compression of included jiarts as to
dejiriye them of a sufficiency of nutritiyc material and cause their utter
degeneration.
The vessels may be distended so little that the \yorking capacity of
their yalyes is not impaired, in which case each tube presents the appear-
ance of a row of beads ; at a later stage the walls are so widely stretched
that the yalyes jirescnt no apprecialile impediment to the backward flow,
and the monilif irm yuriety is replaced by the cylindrical, the yessels
haying a fairly uniform diameter. Sometimes, certain yalyes holding
better than others, the interyening portion of the tube swells out and
becomes a cyst. Such a tumor may also be formed by the bulging out
of the side of a vessel where the wall is especially weak. After this
pouch has attained a considerable size the connection with the vessel
may be seyered and the cyst become iudeiiendent. When a large numljcr
of distended vessels lie in contact a continuance of their dilatation may
result in the atrophy of their contiguous walls : the thinning process
ends in the perforation of the partitions and the establishment of a com-
munication between neighboring cysts. Thus is produced the caverncius
form of lympliangiectasis. These cysts or caverns are lined with endo-
thelium autl contain lymph. Their walls are generally more resistant
than those of the commoner varieties. The inner surface may be smooth
and glistening, or rough from the presence of vascular fringes.
When the dilated yessels form a distinct and separate mass, they con-
stitute the disease called lymphangioma, which sustains the same relation
to the lymphatic system that luemangioma (or, as more commonly called,
simply angioma) does to the blood-vascular system. These tumors are
soft, feel like a bag of earth-^vorms, and may be as large as a man's fist.
They are often found in the inguinal region. A variety of lymphan-
gioma is kno^yn as lymph varix.
The minute networks of vessels near the surface may dilate, and the
bulging oi their delicate walls at points where there is least strength
produces little blebs which look like the grains of btiiled sago. These
vesicles Jire most frequent on the inner side of the thigh, the external
genitals, and the .sides of the abdomen. The ru]iturc of one of them
may give rise to a troublesome lymphorrhagia. The tubular superficial
vessels, when dilated, are cylindrical or ampullary in shape. They occur
on the inside of the thigh, tiic prepuce, the ham, jieriueum, and at the
bend of the elbow. They are soft, movable, and fluctuating. Lymph-
angitis of a dilated vessel is likely to terminate fatally in a short time.
In erysipelas we have what is perhaps the most common form of
470 SURGERY OF THE LYMPHATIC SYSTEM.
lymjiliatic occlusion. The disease is characterized by rapidly-spreading
intlanniiation of vessels and spaces in the integument and the tissue just
liencatii it, with consecjuent interru])tii)n of the flow of lyiii])h, and
hence ix'dema. If the stagnated lymph coagulates, the restoration of the
lumen is more difficult than if there is mere stasis. The re-establish-
ment of the current is probable if the attack is of only moderate
severity ; but if it is intense, and particularly if it is I'epcated again and
again, the damage may be irre])aral)le and jtcrmanent oedema ensue.
The lacteals are subject to the same disorders as the other lymphatics,
but on account of their situation and relations are not Avithin the sphere
of this article.
This outline of the general features and results of the occlusion of
lymph-channels permits much more brevity than would otherwise be
possible in the presenfcition of the essential facts concerning several dis-
tinct diseases arising from such obstruction.
LYMPHANGIOJIA.
Lymphangioma is a tumor composed of dilated lymphatics. It is
usually congenital. It is generally tilled with a translucent fluid, which
is lymph slightly if at all modified. Its favorite sites ai'e the neck,
buttocks, groin, armpit, forehead, back of thigh, and the walls of the
mouth. The clinical history of the disease is not clear.
A simple lymj)hangioma is jiainless, soft, and compressible. Between
the walls of the vessels composing it is an amount of connective tissue
which varies in different cases, and in the same case at different times,
diminishing as the growth increases. The development of cysts indicates
a more advanced stage of the disease. As in the growth of these tumors
the septa between adjacent component vessels may be absorbed from
pressure, so absorption of the walls of contiguous blood-vessels may
take place, and by the establishment of a communication between the
two kinds of vessels a hremato-lymjihangioma be formed.
Lymphangioma is a benign disease, but it may be attended with
alarming debility through tlie prolonged and profuse loss of lymph
escaping from some spontaneous or artificial opening in the tumor.
Such discharge, if moderate, constitutes a lymphorrhffia ; if of large
amount, a lym])horrhagia. Though often spoken of as diseases, they
are merely phenomena \\hich may be jj resent in a number of affections
of the lymphatic system. They are less likely to occur in the cystic
than in the commoner forms. They are not necessarily serious, cases
having been credibly reported of the waste of great quantities of lymph
without impairment of health ; but, on the other hand, lymphorrhagia
may occasion a grave ansemia, called " spoliative " by Leliert, who en-
tertained the idea that in such cases the blood was impoverished more
rapidly than repair could be effected.
Cystic hygroma of the neck is a cavernous lymjihangioma. It occurs
in the upper part of the neck, immediately beneath the occiput. It is
smooth, nearly globular, a perpendicular groove dividing it into lateral
halves. The tumor may extend well into the region of the shoulders.
The system of the patient is usually enfeebled, and seems to be pecu-
liarly liable to pulmonary tuberculosis.
AFFECTIOXS OF THE LYMPHATIC VESSELS. 471
The only proper treatment for lyinphaiiuioma is I'emoval. This
should he complete, as there is danger of lyniphorrhcea if any portion
of the dilated vessels is permitted to remain.
LYMPH VAEIX.
Lymph varices are either superficial or deep. The former are either
cyliudriform or beaded. The jienis and groin are their favorite sites.
They are usually temporary, and disappear when the obstructing cause
is removed. If permanent and very annoying, they may be excised.
The deep varices present grave ditticulties. The_y occujiy inaccessible
positions in the abdomen. In advanced stages they are liable to be mis-
taken for hernife, inasmuch as they fill the inguinal canals ; indeed, it
is said that the diagnosis is rarely made correctly. The employment of
puncture as an aid in determining the character of tiiese growths has
been recommended by an illustrious surgeon, but the possibilit}- of
starting an uncontrollable lymphorrhagia should make us hesitate to
adopt this advice.
No treatment avails anything, and the prognosis is always bad.
LYMPHCEDEMA.
Any interference with the normal flow of the lymph in its channels
is liable to cause transudation through their walls into the areolar tis-
sue. The resulting condition is known as " lymj)ha?denia." The situa-
tion of tne obstruction is generally to be determined by ascertaining to
W'hat part of the lymphatic system the aifected area is the periphery.
If the obstacle is removable with safety, the rational treatment is clear.
By the compensatory enlargement of collateral ciiannels Nature once iu
a great while affords a measure of relief ^\hich surger}- cannot give.
Bandaging with elastic materials may mitigate the evil condition some-
Avhat. Often, however, the affected member becomes so monstrous a
burden that its removal must be considcicd. After ablation of a can-
cerous breast, for example, the glands in the axilla may so enlarge and
press upon the vessels as to cause prodigious increase in the size of the
corresponding liml), with severe pain and interference with the move-
ments of the joints. If the progress of the disease is slow, life may be
prolonged and comfort greatly enhanced by amputation. The tissues
in lymithredema are brawny and inflexible, and lymph flows freely from
their cut surfaces. This condition is not necessarilv a serious obstacle
to the iiealing process, as demonstrated in a case of amputation of the
thigh close to the great trochanter, in which I was obliged to use a
chain-saw in the division of the bone on account of the impossibility of
turning back the flaps sufficiently to ]icrmit tlv^ use of the ordinary in-
strumen't. The healing was rapid and perfect.
MACRO>rELiA.' — Congenital and ac(piired occlusion of lymph-chan-
nels, with the consequent dilatation of those passages which are periph-
eral to the point of obstruction, sometimes produces results Avhich differ
materially from those previously discussed iu this article. There is no
' Macromelia (uaKpdc; = great -â– - /i^Xof = member), a form of monstrosity character-
ized by great enlargement of some member.
472
SURGERY OF THE LYMPHATIC SYSTEM.
Fig. 378.
Wacrutliulyliu.
lymphangioma (at least none conforming' to the ordinaiy rules of de-
velopment followed l)y this growth, though the deformity in question
is sometimes classed under that head), no varix, no cedema, no lymphor-
FiG. 379.
Macrudactylia.
AFFECTIOXS OF THE LYMPHATIC VESSELS.
473
rhoea ; only an onornions and disfiiiiirino- gTowtli of some niomber, as
a finger, toe, hand, foot, foi'oarni, leg, or even an entire limb, upper or
Fk;. asO.
Macropodia.
lower. The accompanying illus;trations, from photograjihs of one of
my patients, convey an excellent idea of certain phages of this class
of monstrosities. In this ease parts of both hands and the whole of
one foot and leg were involved, or, technically, there were macrodac-
tylia' and macropodia."
The etiolog-y of these cases is oljseure. Tlieir treatment must be
fashioned on general principles. If the growth interferes with function
or comfort, amputation is justified, and even demanded.
Chyloc'ELE. — A siu'gcon occasionally finds that a scrotal enlarge-
ment, diagnosticated as a common hydrocele, contains a milk-like fluid,
upon which, if it is allowed to stand, cream rises. This disease has
been called cliylocele,^ with the idea that the fluid is chyle ; galactoccle,
because it looks like milk ; and liporocele, from its oily nature. In no
reported case has the real nature of the disease been suspected bef\)re
operation.
The clinical history docs not differ from that of hydrocele. The
wall of the sac may be very thick and hard, its lining smooth, shining,
and pearly, with a granular nodule at some point enclosing the mouths
of channels whicli connnunicate with tlie spaces of the areolar tissue;
or the lymphatics of the tunica vaginalis may be over-distended from
obstruction of the normal current of lynajih resulting from gonorrha?al
inflammation of the inguinal glands. The non-translucency of the
tumor under the usual candle-test for hydrocele should lead to suspicion
of tiie character of the contained fluid ; but the failure to make a correct
' MacrodatlyUa {ftaKpdg = great -f- ioKrv/iOc, finger), excessive size of tlie fingers.
" Macropodia {fianpd; = great + Toi'f, foot), abnormal size of tlie feet.
^ Chylorde (.ffAof = juice + k'//Iv = tumor), chyle-tumor.
Galactoccle (yaXa =r milk + Ki/h] = tumor), milk-tumor.
Liporocele (X/jrof = oil + '>'/'"''/ = tumor), tumor containing oil.
474 SURGERY OF THE LYMPHATIC SYSTEiM.
diagnosis in the case need occasion no chagrin, considering the infre-
quency of the disease and tlic innocence of the error.
The origin of the con(htiiin is not (h'nionstrated. IiejiDrtcrs of cases
seem not to have thought to examine tiie blood for tilaria, and in other
respects our sources of infcjrmation are rather unsatisfactory. Prol)ably
the disease is caused by some incomplete obstacle to the uj)\\"ard current
of chyle, a portion of which, in some obscure manner, accumulates in
the vaginal tunic of the scrotum.
The treatment is precisely that for hydrocele. Injections of tincture
of iodine seem to have Ijcen preferred in the main, but probablv the ad-
vantages of liquetied carbolic acid w(_)uld be as evident in the therapeusis
of this disease as in that of the affection Avhich it so much resembles in
its clinical aspects.
FiLARIASIS.
Among the various causes of serious obstruction of lymph-channels,
that which should be accorded the first rank is the condition known as
Ji/ariasis. Knowledge of the parasite which gives its name to this
pathological state has been only recently acquired, but the demonstration
of the connection between the presence of the worm and certain long-
known diseases has been so completely made as to put it beyond question
that the one sustains a causative relation to the other. The principal
maladies which result from tilariasis are elephantiasis Arabum, lymph-
scrotum, and chj'luria. These diseases ai-e endemic over one-half of that
portion of the world which is most densely populated, and, while they
are far from common in Ajnerica— are, indeed, of the nature of curiosi-
ties with us — they are occasionally encountered even in tlie Northern
section of our country, and it has recently been announced that tilariasis
has become actively endemic in our Southern States. AVhen one con-
templates the method by which the parasites are propagated, the offensive
and incapacitating, if not often fatal, character of the diseases which
they cause, and the possibility of a somewhat rapid dissemination of
them all over the land, the inqwrtance of a diffusion of information on
the subject becomes manifest.
It is not intended to convey the idea that tilariasis is the sole cause
of the group of diseases under consideration : doubtless anything else
which produces an obstruction in a lymph-channel as conqjletely and
permanently may occasion practically the same pathological phenomena.
But in the large majority of cases tilariasis is the prime etiological factor.
After the establishment of a filarial disease it is unlikely that any
means which are not surgical will effect much for the patient, even in
the direction of alleviation, and there are many cases in Avliich nothing
yet attempted gives relief, the removal of the cause being im]iossible.
In the prevention of the filarial diseases, however, it is probal)le that
nearly perfect results are attainable, though by methods M'hich arc not
at all surgical.
In 18(.i6, Wucherer discovered in the urine of a patient suffering
fi'om chyluria a parasite belonging to the nematoid family. In 1872,
Lewis found in the blood of an East Indian who had diarrhoea a number
of actively-moving worms, exactly those which he had independently
FILAniASIS. 475
discovered two years before, and liad come to expect in the urine in
every case of cliyliiria. Soon he detected the same parasite both in the
urine and tlie Ijhjod of a patient with chyluria ; presently lie found the
nematoid in the blood of an elephantiac, and then in the fluid drawn
from a lymph-scrotum. He named the creature filaria sanguinis hoini-
nis — the thread-like worm of the Ijlood of man. As seen in the blodd, it
is a very actively-wriggling snake-like animal, aljout the eightieth of an
inch long, and with a width not (piite equal to the diameter of a colored
corpuscle of the blood. It appears to have a delicate, transparent sheath,
which is supposed to be the chorional envelope retained and stretched,
and within which the body is alternately extended and retracted very
rapidly ; and the impression made on the observer is that the worm is
provided with a lash. The wrigoling does not seem to produce loco-
motion, but it establishes to-and-fro currents in the droji of blood on the
slide of the microscope, In' means of which the recognition of the luema-
tozoa is facilitated ; for when they are dead and motionless it is often
very diificult to distinguish them from vegetable fibres, fibrinous coagula,
and urinary casts. The alleged observation of an alimentary canal in
the filaria needs confirmation. The creature is without sex. Objectives
of high power are not needed in searching for it : a half-inch glass is
suflicient. Being found, it is best to substitute a quarter-inch objective
or a somewhat higher one. If the slide is kept at the ordinary tempera-
ture of a living-room, the M'orm may survive three days. The number
of these htematozoa in a single patient is amazing : one estimate has
jjlaced it at thirty-six million.
A most curious circumstance al)out them is the usually-observed fact
that they have a periodical daily migration. Toward evening an exami-
nation of the blood detects but a few of them, but hour by hour their
number swells until midnight, when the blood is alive with them. Fi'ora
this time they begin to disappear, until by nine o'clock in the morning
(sometimes as early as six o'clock) the most studious scrutiny fails to
find one. All through the day they elude oljservation, but near the
close of it they appear as before for their evening of mad frolic. A
change in the meal-hours of the patient effects no modification in their
behavior, though this circumstance produces, as would be anticipated, a
marked change in the times when chyle a]ipears in the urine. Experi-
ments have shown, however, that the turning of night into day in the
matter of sleep determines a complete reversal of tlieir habit, as they
then ajipear in the blood during the hours when they are usually con-
spicuous by their absence, and cannot be found at the times when they
generally swarm in countless myriads. But absence during the daytime
is not invariable, even where the usual hours of sleep are undisturbed ;
and this gives support to the theory recently advanced by Manson, who
has given special attention to their study. He claims to have differen-
tiated three varieties of filaria sanguinis hoininis: that of Lewis, which
he distinguishes by the name nocturna ; another, Avhich he calls major or
(liurnu ; and a third, christened minor or perstans. The last, he says,
has no periodicity of appearance, and is in every way smaller than the
others, which equal each other in size, but differ in their hours of exer-
cise. With no more light on the subject than we have at present it does
not seem profitable to dwell on these distinctions. It has been observed
47G SURGERY OF THE LYMPHATIC SYSTEM.
that fever interrupts the reguhirity of thi' periodical appearance of the
hajmatozon.
Soon after tlie discovery of tliese minute «ornis it \\as rendered
almost certain that they were the embryos of an unknown parent, to
which, ratlier than to the offs])rinir, should ])e ascribed the hai-ni done in
eonnectidn with tiieir residence in the human body ; and proljabilitv pave
phu'c to proof in ISTG, when Jjanci'oft of Australia found and descril)e(l
the prolific parent of this multitudinous progeny. In his honor it has
been dubbed Flliiria Bancrofti. It has a hair-like, smooth body, about
three and a half inches long and one-ninetieth of an inch thick ; its
mouth is circular and has no j)a]iillfe ; its neck is one-third as thick as its
body. Its slender alimentary canal runs from the clul)-like head nearlv
to the blunt tail. The vagina, m liicli opens near the head, is short and
terminates in a bieornous womb, which occupies the remainder of the
body and is crammed with embryos. The parent worms may display
great longevity, if W'e judge from the number of years that the urine has
been known to be constantly chylous. The jiossibility of the renewal of
filarial disease by the repeated introduction of maturing jKirasites is to be
entertained in this connection, tiiough it seems unlikely that a successive
series of them should occupy substantially the same position in the lym-
phatic system for a considerable number of years. The two sexes proba-
bly live together, and always in a lymphatic vessel of some size. Their
progeny, which are viviparous, are carried in the lymph-stream through
the thoracic duct, and thus enter the blood-vascular system. The cha-
racter of the disease lirought on by filariasis is determined by the vessel
selected by the parents for their residence and liy the integrity of the
lymphatic glands.
The method by ^\•hich filariasis is propagated is of much practical
interest. The nnhapjiy host of the lymphatic worm is stung by a female
mosquito, Avhich, in filling her stomach with his blood, ingests a large
number of filaria embryos. She then betakes herself to some pool, where
she can quietly digest her meal and lay her eggs. A large proportion of
the jiarasites are digested with the blood, but about one-tenth of them
escape this process. It is said that a certain mosquito which can digest
canine filarise cannot thus affect the himian variety. However this may
be, a ])art of the creatures are spared destruction in the body of the
insect ; and when the latter, having fulfilled her re])roductive duty to her
species, dies and falls into the water, the filariie which have had the for-
tune to survive, having developed considerably during their four or five
days of sojourn in the alimentary canal of the culex, are liberated into a
medium which is peculiarly adapted to promote their further advance-
ment. They grow to the length of half an inch, and then, being swal-
li>\\('d in the water drunk by some human l>eing, are led by instinct to
the lymphatic system, whither they arrive, presumably, by boring their
way through the intervening structures. A worm, having reached the
thoracic duct or some other large lymph-vessel, sets up ulceration or
inflanunatory thickening, by this means producing stenosis of the channel.
The lymph is dammed up on the distal side of the obstruction ; the vessel
dilates ; its valves become useless ; its walls either burst from internal
pressiu'e or, what is more jirobable, experience a compensatory hyj)er-
trophy ; the region from which the channel has previously collected
FILAEIASIS. 477
lymph is saturated and swollen witli the constantly accumulating fluid,
and the tissues undergo changes of a characteristic nature.
Xotliing ill detail is positively known of tlie life-history of the hel-
minth from its entrance into the human body until its full development.
Several parent worms have been found in a single case, but in others it
is nearly certain that one individual, or, at most, one couple, has inaugu-
rated all of the trouble in a filarial disease of great severity. As already
remarked, there are many cases of occlusion of lymph-channels not due
to parasitic plugging, but it is imaginable that some of the cases wliich
do not seem to be filarial are so in reality. For instance, an unmated
male or an uniiupreguated female might cause occlusion, setting up the
local disease about itself, as just described, and bringing on elephantiasis ;
but in such a case there would be no embryos in the blood.
Several theories have been broached to account for the periodicity in
the appearance of the emlnyo tilariiie. It is conjectured that the mother
has a dailv jiarturition, in which some millions of offspring are started