found in the blood depend upon some condition which is altogether
conjectural.
The amount of chyle voided may be somewhat diminished by restrict-
ing the patient to a vegetable diet and a small amount of liquid. In
this way the lymph-jn'essure may lie lessened, and it has been suggested
that this may result in the healing of defects in tlie walls of the vessels,
but no facts have been adduced in support of this hypothesis. The
strength must be held up by tonics. Turpentine and astringents, es])e-
cially gallic acid, have been vaunted for their supposed efficacy. It
will be suspected, however, by the whimsicality of the changes in cases
^ Chyluria (chtilns â– = chyle + "'Y'"" = urine), a discharge of chyle with the urine.
Lymphurki [lympha = lymjih -^ ovpov = urine), same as chyluria.
AFFECTIOXS OF THE LYMPHATIC GLAXDS. 485
where iki medicine has been administered, that rec<)verv or improvement
during the exhibition of these drugs is an illustration o{ jtod rather than
of propter. It will continue to be the j)art of the prudent practitioner
to pronounce a guarded prognosis in chyluria.
Affections of the Lymphatic Glands.
inflammation of lymphatic glands.'
From the list of classes of circumstances formerly invoked to account
for intlannuation of lymph-nodes the advance of science compels us to
expunge two — tlie idiopathic and tiie diathetic. As stated on a j)revious
page, it is difficult to understand how a lymphangitis can be produced
excejit through the agency of micro-organisms. The lymph-glands have
a ])erfect continuity of structure with the vessels, and we are compelled,
tlierefore, to recognize the efficiency of the microbes, which are responsi-
ble for the iuHanunation of the vessels, in the production of the same
process in the glands. If there is no idiopatliic iuHanmiation for the
channels, there is none for the nodes. We discard the diathetic causes
also, because it is so clearly demonstrated that in typical cases cited to
sustain this theory — cancer, for example — the involvement of the glands
is due to the introduction into their sinu'^es of infectious material from a
malignant mass in the region from which these organs receive their
lymph. It is not a matter of diathesis : it is one of the absorjition of a
living poison and its detention in the first convenient resting-place.
Traumatism should be considered a cause of lymphadenitis in those
cases only in which the inflammation is occasioned by violence applied
directly to the gland ; for, if the lesion is elsewhere and the node is sub-
sequentlv inflamed, the morbid process in it is secondary to the injury
and directly dependent upon the absorption of material (probably septic)
from a distant point. Thus, tiie fleld of trauma as an etiological factor
in the case is re<luced to limits which are extremely narrow. Finally,
then, it amounts to this : Almost always lymphadenitis is caused either
by extension of inflammation from a diseased tributary vessel or by in-
fection from a more or less distant focus of dissemination, the irritant
poison being conveyed to the gland tlirougii lymph-channels, which may
give passage to the toxic agent without themselves experiencing any
harm.
Lymph-nodes are exceedingly ]irone to inflammation. This may be
either acute or chronic. As the two kinds present many points of dif-
ference, it is desirable to consider them separately. In both classes there
is a tendency to inflammation of the connective tissue which surrounds
the gland (periadenitis).
Acute Inflammation of Lyjiphatic Glands. — A lymph-node
Avhich previously had never attracted the attention of the patient sud-
deidy makes its existence conspicuous by its swelling, pain, tenderness,
and heat, and often, too, by redness of the superjacent skin — in short, by
the familiar indications of inflammation. This process may invade one
or more of the neighboring glands and the adjacent tissue. In the
former case there is a multiplication of the affected area ; the latter
' Lymptrndenilh (lympha = lympli -f- aSi/v = gland) ; Adenitis (ach/v = gland).
486 SURGERY OF rilE LYMPHATIC SYSTEM.
event is aniiuuiK'ed by lui increase of the swellinj^ anil hy wilema. The
movements of" the part of the body where the disease is situated are in-
stinctively reduced to a minimum to avoid tlie sufTcrinu; whicli they
induce ; but as long as there is perfect immobility the discomfort may not
be severe, and there is generally little fever. ]\aturally, the degree of
local distress and systemic disturbance is largely dependent upon the
character of the causal irritant, the extent of the disease, and the general
condition of the patient. If the morbid action is not promptly arrested,
suppuration, to which there is a marked inclination, is almost inevitable.
This event is evidenced by softening, both of the node and of the over-
lying integument. When a number of glands are involved simultane-
ously, the individual collections of pus may combine by destruction of
their adjacent walls and form one large abscess. The evacuation of the
pus is succeeded in most cases In- rapid healing, but sometimes there is
little effort at repair, and an ulcer is established ; or the destructive
process may invade the areolar tissue and sinuses may result. 8uch
imfortunate seipicls dejiend ujxiii a depraved condition of the system.
Other terminations of lymphadenitis are mortitic-ition, caseation, chronic
inflammation, fibrous induration, and calcification.
In most cases the disease is excited by materials brought by the lym-
phatic vessels, bacteria and the poisonous substances produced by them
being the chief offenders. Often we are unable to reach a positive con-
clusion as to the cause of tlie trouble.
The chief pathological change in this disease is the vast increase in
the number of cells in every part of the gland. This may be accounted
for in various ways : by the more than normally rapid subdivision of the
cells of the gland ; l>y the mechanical detention of leucocytes which enter
from the lymph ; by inmiigration from the blood-vessels ; but we are
imal)le to say positi\ t'ly whether it is mainly one or another, or a combi-
nation of them, which docs the work. When resolution occurs, these
superfluous elements arc disposed of in several ways : by fatty degenera-
tion, by coagulation-necrosis, by exportation in the lymph-stream, and
perhaps by other means. The channels in the gland are more or less
completely blocked by the inflammatory process, and the node thus acts
as a catch-basin not only for the lymph, but also for the injurious agents
contained in that fluid. If the occlusion is not relieved, permanent
oedema of distal parts may result.
Acute adenitis demands very different treatment from that which is
suitable for the chronic. First, the cause of the inflammation shoidd be
sought, and, if possible, removed. All authorities agree that absolute
rest is of the greatest importance and should lie insisted on. Leeches
applied close to the ])eripherv of the swelling are of service in arresting
the inflammatory action before the occurrence of suppuration. The
repeated application with a brush of equal parts of carbolic acid and
glycerin is highly recommended. If such measures do not produce the
desired effect in two or three days, more heroic means must be adopted.
Probably the most valuable is the injection of the gland with carbolic
acid. Authorities differ in their advice concerning the proper strength
of the acid for this purpose, one considering a 1 per cent, solution gen-
erally sufficient, and another employing it as strong as possible ; that is,
merely liquefied. This ^vould seem to imply that the worth of the
AFFECTIOXS OF THE LYMPHATIC GLANDS. 487
method depends more upon the drug itself tlian on its degree of dihi-
tion. There is hardly room for disagreenient as to the method to be
pursued in performing the little operation. The skin of the region
and the needle of the hypodermie instrument having been sterilized,
the point is introduced nearly througii the gland in the centre of its
long axis. It is then slowly withdrawn, the fluid being injected all
the war along until the needle is almost free from the gland. From
five to thirtv minims are to be dej)osited in tlie node, the amount needed
\'arying according to the strength of the pre])aration and the size of the
mass to be treated. A very large measure of success follows the use of
this method, but it must be used before pus forms in order to get the
desired result. The anodyne effect of the acid is pronounced ; its anti-
septic virtues will hardly lie questioned. The injection may well be
succeeded 1)V firm and cdutinuous pressure for a i'v^v days, but this is
nut advised bv all who use this treatment. \\'ln'n abscess forms the jnis
should be let out through a free incision. If there are bands or thick,
adherent pus, the cavity should be curetted carefully, swabbed out with
some antiseptic, and packed with gauze. After a few days a deep suture
mav do excellent service in expediting closure. Fistulous tracts must
be laid ojien, the pyogenic surface removed, and the cavities treated in
the manner just prescribed.
Many other plans of local therajieusis have been advocated. Aspira-
tion of the pus and irrigatit)n of the cavity with an antiseptic is one of
them, but it is less certain and much slower than proper incision.
Removal of the entire abscess is highly vaunted in some cases, but it is
pr(il)ablv rarely needed. Blisters have been much used in the past, but
siiould be discarded for less painful and more efficacious measures.
Iodine in any form is mischievous in acute lymphadenitis, though
esteemed by many in the chronic. So many surgeons have been in-
oculated with venerea] while operating on suppurating buboes that their
misfortune sliould be borne in mind whenever we expose ourselves to
similar dangers — a peril often incurred, as these abscesses frequently
reipiire our services.
Constitutional treatment is generally of far less moment than local.
It is to be conducted on general and familiar lines, attention being given
to the nature and severity of the disease and the state of health of the
patient.
Chroxic Ixflammatiox of Lymphatic Glands. — This variety
of lymphadenitis is commonly insidious in its approach, and may pro-
gress to such a degree that a tumor of some size has formed before its
presence has attracted the attention either of the patient or his family.
It usually is unattended with pain, and after attaining noticeable propor-
tions may remain quiescent for a long ])erio(l.
It is sometimes a termination of acute inflfMumation, though gener-
ally it originates in some other way. ]\Iost f're(|uently the sequence of
phenomena is as follows: Somewhere at the ])eripherv of a set of lymph-
vessels bacteria obtain an entrance, pass through the tube to the nearest
related gland, and establish there a low grade of inflammation by their
presence or by toxins which they form, oi- by hoih. It is not absolutely
proved that in every case the admission of micro-organisms inaugurates
the morbid jirocess ; but all the probabilities point more strongly in that
488 SURGERY OF THE LYMPHATIC SYSTEM.
direction. The iiiflaiiuiuitioii is rarely more intense than to merit heing
ealled subacnte, and is often even less vigorous. (iro.ss e.\aniinati(^n of"
tlie node does not disclose the classic phenomena of" inflannnation. An
intlannnatory proce.ss has been begun, which in a time varying from a
few months to many years is destined to destroy the gland, and, jiossi-
bly, the life of the |)ati(iit. Tlie most eliaraeteristic thing about it is a
perverted growth of the connective tissue of the gland, whieii so
encroaches uj)on the space normally occupied by the cells that they are
gradually destroyed or driven out to an extent proportionate to the
hypertrophy of the framework structure. A gland may thus become
merely a lump of connective tissue. Sometimes, however, there is great
increase in size, attended witii tlie develojiment of large ceils. The
atlection of one gland is often foliowcd or accom])anied by that of another
or many in the vicinity, and thr inflamed glands in a group have an
aptitude for coalescing into a hard, lobulated mass, which may attain a
great bulk, and by its ])resence cause not only disfigurement, but also
severe suffering and interference with the functions of vital organs.
The diseased masses are very prone to various degenerations, ])articidarly
the caseous. In this process there is destruction of the blood-vessels,
cells, and network, all being converted into cheesy material. 'J'his may
undergo no change for a very long time, or it may soften very rapidly,
and, exciting acute inflammation around itself (pcricKhnitifi), be in part
disciiarged. Tlie remainder acts like a fori'ign body and jirevents heal-
ing for a long period. Finally, granulation effects a closure, leaving a
scar which is puckered and unsightly.
This variety of lymphadenitis is most common in the poorly-nonr-
islied, and especially among those unfortunates who are begotten while
one or both parents are afflicted with tid)erculosis or with some grade of
sy])hilis whieli is not of such malignity as to give rise to the congenital
form of the disease. The general condition is discussed in a jireceding
section of this article.
Constitutional treatment is always needed. The most valuable of
the remedies required are the hygienic — imlimited fresh air, an abun-
dance of the most nourishing and easily-digested food, suitable clothing,
frecpient baths, judicious exercise, a salubrious climate. I^nhappily,
only a minute minority of such cases can possibly be provided Avith
these things. The ideal plan breaks down utterly in the presence of
penury, and only less completely in that of moderate means. Vt"e are
obliged, therefire, with medicines alone to midertake a task which is
extremely difficult when, in addition to them, there is every other desir-
able thing whieli affluence can ol)tain. Supportives and tonics are
always indicated, cod-liver oil and iron holding the places of honor.
The effects of arsenic and mercury in small doses are often very bene-
ficial, and iodine in some form has long been recognized as of great
value.
When the gland is hard, but never when softening has taken place,
good may be done by the ajiplication of ointments of iodine, iodoform,
and the iodides of lead and potassium, which, well rul)bed in, favor the
resorption of the abnormally deposited materials. Possibly, the friction
with which these unguents are ajijilied is entitled to quite as much credit
as are the drugs, ^^'hichever ointment is selected, it should be used
AFFECTIONS OF THE LYMPHATIC GLANDS. 489
daily until the .skin becomes somewhat tender, and then an interval of
rest should he allowed until tiie soreness has disappeared. The tinct-
ure of iodine, commonly prescribed in an indiscriminate and routine
manner in these affections, is probably of very little value in promoting
absorption.
If an abscess forms, it should be opened and the pus evacuated.
The incision is better when small, and may well l)e made with a cautery
knife heated to a dull red. Not only is tlic comfort of the patient pro-
moted and recovery expedited by early incision, but the resulting scar
will probal)ly l^e less noticeable than that which follows spontaneous
evacuation.
\\'ith tlie purpose c)f causing induration of the glands, thus substitut-
ing innocent cicatricial tissue for the morbid deposit, wJiich may at any
time suffer a degeneration and become a menace to health and life, the
injection into tiie centre of each of some caustic material has been prac-
tised with success. Two minims of a 10 per cent, solution of chloride
of zinc, introduced with a hypodermic syringe once a week or so, will
often bring about the wished-for change. Three minims of equal parts
of carbolic acid and glycerin are much esteemed for the same purpose.
Puncture with the tiiermo-cauterv is much preferred to injection by
some surgeons who have had large observation of l)oth methods.
This disease affects principally the lymphatic nodes of the neck, these
being more ex])osed to the invasions of bacteria, as from various surfaces
of the mouth, the nasal ])assages, and the ear, than are those of the groin
and armpit. The injurious effects of a large mass in this locality are
more pronounced than if its pressure were ajijilied to any other external
part, by as much as the organs in the neck are more essential to life.
Consequently, the question of removal by a cutting operation is con-
stantly being raised. Professional opinion is divided on this point:
surgeons of great ability and experience deprecate interference, save in
a few specially favoral)le conditions ; and others, of equal merit, enthu-
siastically advocate removal in most cases. The arguments are not
based entirely upon the necessity of removing pressure, which is not
often serious enough to kill, but much more upon the desire to get rid
of masses which we are unable to distinguish from tubercular enlarge-
ments, and which we are discovering to be, in most cases, the residence
of bacilli tuberculosis. The infection of the whole system from degen-
erated cervical glands is not ci^nmon, and yet it may occur in any single
case; and this naturally makes us wish that the glands were out, and may
lead us to operate when it would be better to leave the patient untouched
by the knife. It is a widely-recognized fact that when a mass of cervi-
cal glands is only slightly movable it is impossible to tell beforehand
how far it dips into tlic deeper regions of the neck. If only those por-
tions that can be easily reached are removed, little good may come of
the procedure, and possiljly nuich liarni may be done by it ; for there
prevails among many surgeons whose judgment is entitled to respect an
opinion, which cannot lie altogether groundless, to the effect that sui'-
gical interference with a mass of tuberculous glands which does not
extirpate them is very liable to stimulate those which remain to great
ac'tivity, so that the tumor in the neck is soon restored to its former
volume, and there is as nuu'h danger as before that the whole system
490 SUEGERY OF THE LYMPHATIC SYSTEM.
will become infected. It is unfortunate that, in the varions articles in
recent medical literature by those who argue for thorougji removal in
all cases, so little account is made of the history of the patients after
operation. Tlie writers may be entirely correct in their position, l)ut
they do not take pains to prove themselves .so by giving us information
as to the subsequent condition of health, both general and local. Until
this is done, and on a large scale, there will be room for the view that
the existence of a ma.ss of chronically-inflamed glands, even though
tuberculous and undergoing some degeneration, will not necessarily, or
even ])robably, be the starting-point for a general tnben'ulosis. Ob-
servations made long ago seemed to pro\'e it true to a large extent that
the so-called scrofidous diseases were mutually antagonistic. This clin-
ical observation loses none of its value by the growth of pathological
knowledge, M'hich has required the abandonment of time-honored theo-
ries. It is ]>robably a good rule to remiive freely moval)le masses, so
tliat neighboring glantls shall not be involved bv an extension of
inflanmiation. It is demanded that an effort should be made to remove
masses which doubtless dip deeply, if by so doing the p(>ril to the life
of the patient can be I'cmoved also. Beyond this point t\w situation is
not sufficiently illumined to enable one to speak with full knowledge.
The operation for removal cif the glands is generally not difficult
where they are freely movable. In other cases it may be formidable
and heavily tax the resources of the surgeon. The incisions should be
long enough to permit the freest possible inspection of the parts con-
cerned. When the glands are reached the knife would better be laid
aside and the remainder of the work done with the fingers, perhaps
assisted by blunt instruments. It is often impracticable to remove the
tumor in a mass ; indeed, there is no good reason for attempting it if
the piecemeal method is more expeditious. In operating on the neck
the principal danger is that the great vessels will be injured. The
internal jugular is not infrequently wounded. If it is merely punctured,
a side ligature may sufficiently jn'otect from hemorrhage. It has re-
peatedly been cut off unwittingl3^ Being pushed into an abnormal
position by the bulging growth behind it, and stretched by the pulling
to which the tumor is subjected, it is emptied of its blood, and may
easily be mistaken for a band or strijj of fascia. The vein, the carotid
ai'terv, and the pneumogastric have all been cut in the same jjatient,
and that, too, by a surgeon of great experience and skill, M'ho tells of
the case in a report of one thousand ojierations for the removal of en-
larged lymphatics of the neck, with only fi\'e deaths.
HoDGKiN's Disease and Associated Conditions.
The nomenclature of medicine is far from perfect : at many points
it is obscui-e and misleading ; but nowhere does it disjjlay a more painful
degree of confusion than in relation to the disease which is the subject
of this section. The trouble lias arisen doubtless, in great part, from
the imperfect state of information in the premises, and in some degree,
ajjparently, from the reporting of cases insufficiently observed, but,
nevertheless, confidently described as belonging under this head, or,
if not conforming exactly to the type, claimed as specimens of a peculiar
HODGKIN'S DISEASE AND ASSOCIATED COXDITIOyS 491
and hitherto unmentioiied variety so distinct as to be wortliy of a new
and distinguishing name. The time will eome — perhaps before many
years — when the whole lot of existing titles will be discarded and a new
appellation, based upon demonstrable knowledge, will be adopted to
designate the disease. The title chosen for this section is thought to
possess the negative merit of conveying no erroneous idea of the disease
to which it refers, and the positive one of prolonging the memory of a
learned and observant jjhysician who many years ago called the atten-
tion of the profession to the affection now to be described.
Once in a while a patient — more frequently a male and young-
presents himself for advice on account of the enlargement of glands
near the surface, and more commonly in the neck than elsewhere.
Examination sliows that the growth is not jiainful or tender ; that the
glands are discrete and not adherent to the skin ; that there is no appa-
rent tendency to suppuration or caseation ; that the spleen is somewhat
enlarged ; and that the general health is beginning to suffer in the direc-
tion of astlienia. The ]wtient looks slightly antemie, and the microscope
reveals a little diminution of tiie normal number of colored corjniscles
of the blood, wiiile that of the colorless cells is not aifectod. Tuber-
culosis and cancer are easily excluded, and the existence of sarcoma is
rendered impi'obable.
The patient is kept under close observation, and the disease is found
to progress in the following manner: The glandular enlargement in-
creases, slowly or rajiidly ; if the former, the tumor is jirobably hard — if
the latter, it is likely to be soft. Other clusters of lymph-nodes take
on the same action, the axillary and inguinal probal)ly preceding those
in other parts. There is still no suffering, except that of debility,
unless, as is not improbable, there is some fever. The number of leu-
cocytes in tlie blood remains normal, but there is a marked and increas-
ing scantiness of tlie colored corpuscles — perhaps no more than a third,
or even a quarter, as many as there should be. The pallor of the sur-
face is pronounced ; the spleen gets larger and larger ; and the movement
of the disease is steadily toward the impoverishment of the blood and
growth of the lymphatic glands. There is noticeable depression of
spirits.
In the course of a year, or jierhaps two, liad has gone to worse, until
every lymph-node in the bodv, deep and sujicrficial, is enormously en-
larged, and the spleen, too, has grown, but has not kept pace with the
glands. There is no formation of abscess or cheesy deposit, or breaking
down of any kind, but the separate tumors in the various groups have
fused together, and between the diff(n-ent colonies the lymphoid tissue,
too scanty to be noticed in health, has attained consideralde proportions