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very virulent the septic products pass through the glands and generally blood poisoning ensues.

Symptoms.- In severe cases lymphangitis generally begins with a chill, or rigor, followed by high temperature and fever, and perhaps vomiting and diarrhea. Red lines, when super-lymphatics are affected, are seen running from the wound to the nearest glands, with here and there patches of redness. Usually there is pain and tenderness in the region of the swollen glands, and swelling and ædema, sometimes of the whole limb. From phlebitis it may be diagnosed by the redness being superficial and in the course of the lymphatics and not in the course of the veins, by the absence of the cord-like and knotty feeling of plugged veins, by the presence of glandular enlargement : from erysipelas by the redness having no defined margin, and generally running into lines.

The treatment consists in disinfecting any wound or abrasion by antisepsis, and placing the inflamed part at rest in an elevated position. Fresh extracts of Belladonna in glycerine or boric acid fomentations may be applied, and abscesses should be opened as soon as they appear. If any swelling is left pressure in the form of Scott's dressing or ammoniated mercury paste or plasters may be used to lessen it.

The chief causes of subacute and chronic lymphangitis are syphilis, tubercle baccilli, and in the tropics, filiariasis.

Lymphadenitis, or inflammation of the lymphatic glands, may be acute, sub-acute or chronic. Acute and sub-acute lymphadenitis is nearly always secondary to inflammation of the parts from which the afferent lymphatics proceed. In most inflammations there is some tenderness of the neighboring glands. Occasionally, however, the glands in the groin and axilla become enlarged without any discernible irritation within the area from which they receive their lymph. In such cases there is generally a history of a strain, as from lifting heavy weights, or over-exertion, as from a long walk. The explanation is probably the engorgement of the gland with lymph in the case of strain from rupture of some of the efferent lymphatics, or in case of over-exertion, by more lymph being pumped into the glands from the muscular interspaces than can escape by the efferent vessels. The inflammation, however, rarely proceeds further in the course of the lymphatics than the first series of lymphatic glands, although it often spreads to the surrounding tissues, and peri-lymphadenitis.

The changes in the inflamed gland are like those of other inflammations—the whole gland is enlarged, the vessels being dilated, anıt the lymphatic sinuses crowded with cells, micro-organisms similar to

those in the inflammatory lesion giving rise to the lymphadenitis, are discovered in the glands.

Symptoms. — The symptoms are tenderness, heat, pain, and swelling followed by redness of the skin, and ædema. The gland, at first movable, becomes fixed, and if suppuration occur, an abscess usually ensues.

Treatment consists in subduing the inflammation of the part from which the lymphatics proceed, and free incision if suppuration has occurred, or extirpation of the whole gland.

Acute lymphadenitis of the neck, without suppuration. After a period of incubation of about a week the deep cervical glands, three or four in number along the anterior border of the sterno-mastoid, form an acute swelling. The swelling begins generally on the left side, and passing to the right, reaches its maximum in two or three days, and then begins to subside. It attacks young children one after another in the same family or household, without any special inflammation of the fauces or pharynx, is attended by febrile symptoms, constipation, and sometimes albuminuria or even hematuria, but no rash. Other glands, posterior cervical, axillary, inguinal, mesenteric, and the spleen may also enlarge, but all tend to subside without suppuration, although the child remains anæmic and in poor health for a month or two. Lymphadenitis occurs in many specific forms, e. 9., at the nape of the neck in German measles. Hemorrhagic lymphadenitis is a characteristic feature of plague. Chronic lymphadenitis may be either tuberculous or syphilitic.

Tuberculous lymphadenitis is very common in children, especially in the neck. That most cases of chronic inflammation of the lymphatic glands are in their origin, course and termination, instances of local tuberculosis has been satisfactorily shown by clinical experience, microscopic examination, inoculation and cultivation experiments. The means of infection and dissemination of the tubercle bacillus is by the lymphatic circulation through some abrasions or pathological defect of the skin or mucous surface; any loss of continuity of surface may furnish the place of entrance of the microbes from without. Tuberculosis of the cervical lymphatic glands occurs most frequently by infection through the naso-pharynx, tonsils, caries, teeth, or diseased alveoli of the maxillary bones, eczematous irritation of mouth, or pediculi on the head. The disease is usually bilateral. Tuberculosis of the joints and bones seldom gives rise to glandular tuberculosis. When suppuration depends upon the presence of the tubercle bacillus, the glands slowly enlarge and become infiltrated with small round cells; while in tuberculosis foci non-vascular areas containing giant cells, lymphoid corpuscles and tubercle bacillus are found. Then enlargement may subside by the formation of sound, fibrous tissue, or the inflammatory products may cease, and suppuration occur in or around the gland. At times the caseous mass may dry up and become cretaceous or fibroid, and fatty degeneration may ensue. In relatively rare instances only does the tubercle become disseminated, leading to general tuberculosis. Thus, at first, the mass resembles lymphadenoma and is only to be distinguished by the inoculation of guinea pigs. Local dissemination of the tubercle of tuberculosis in the interior of the gland is accomplished by the assistance of the lymphatic stream, as long as the microbes remain free, and through the medium of wandering cells as they have become attached to, or have entered the protoplasm of the lymphoid corpuscles and leucocytes. The usual course of infection along the lymphatic channels is, however, in the direction of the lymph current, as the lymph stream becomes more or less impeded, or perhaps completely arrested by the inflammatory products which have accumulated in the lymph spaces. Migration of the leucocytes in an opposite direction is an explanatory reason why the lymph glands, which are not in the direct course of the lymphatic stream, become enlarged.

The course of the disease is characteristic. One gland becomes enlarged, and from this center the infection invades successively gland after gland, until the whole chain of lymphatics has been involved. Another feature in extensive tuberculosis of the glands of the neck is that the superficial and deep glands are affected alike at the same time, the infection from one set of vessels to the other being accomplished through the medium of communicating branches. As long as the infection has not extended along the entire length of the chain of lymphatic glands, the patient is protected against miliary tuberculosis, but as soon as the virus has passed all the lymphatic filters it enters the general circulation, and diffuse miliary tuberculosis follows as the result.

Pathological Histology and Morbid Anatomy.- As soon as a sufficient number of bacilli have entered the parenchyma of a lymphatic gland, a karyokinetic process is set up, which involves the parenchyma cells, the cells of the reticulum, and the endothelial cells. The proliferating tissue cells produce epitheloid and giant cells, while the lymphoid elements are either the normal lymphoid corpuscles which have remained unaffected by the inflammatory process of leucocytes; as the number of bacilli present is not great, the process is very slow and the inflammatory product undergoes very gradually the characteristic degenerative changes. The entrance of new bacilli from the

infection centers is prevented by the obstruction in the lymph spaces caused by the accumulation within them of the products of inflammation, which arrests the lymphatic circulation in the afferent vessels of the gland through which the bacilli first entered. The bacilli found in the tubercular glands are, therefore, derived from the multiplication of the bacilli which originally entered the gland from the first primary infection center. The cells that first undergo coagulationnecrosis are those in the center of each gland, or the nodule in the center of the gland. As the product of coagulation-necrosis does not furnish the necessary nutritive material for the growth of the bacillus the microbes gradually disappear in the center of the nodule, while they can still be formed within and between the cells in the surrounding granulation tissue. Cell necrosis is followed by caseation and by this time nearly all of the bacilli have disappeared. The numerous nodules which appear often almost instantaneously in the interior of the same gland becomes confluent and in the course of time the entire parenchyma of the gland is destroyed, while the intact capsule of the organ still furnishes a wall of protection against infection for the surrounding tissue. A single tubercular gland is seldom larger than a walnut, and the large masses found together in the neck and other regions are composed of several glands so closely packed together as to give the appearance of a single gland. When the capsule becomes infected, the same processes are initiated here as in the parenchyma .of a single gland; the connective tissue is transformed into granula

tion tissue, which undergoes coagulation necrosis, and caseation in the .same manner as the fixed tissue-cells of the parenchyma; and finally, after perforation of the capsule has taken place, the inflammation extends to the paraglandular tissues, resulting in tubercular periadenitis. The cheesy material may dry and shrink and become inclosed by a capsule of dense connective tissue, resulting in calcification, or it may undergo liquefaction. If secondary infection with microbes takes place, an acute suppurative inflammation takes place of a chronic process, and almost without exception results in a rapidly-spreading suppurative peri-adenitis. The connective tissue surrounding the gland becomes swollen and ædematous and large abscesses form, which, on being incised, give exit to pus which resembles the pus of an ordinary phlegmonous inflammation, resulting in cheesy glands, which can be readily extirpated by the finger. If, however, the abscess is simply incised, and the radical operation postponed for weeks or months, the removal of such plants is an exceedingly difficult task, as the capsule of the gland will be intimately adherent to the surrounding tissue.

Symptoms. – Enlargement without pain-at first glands are distinct and movable, but later often coalesce and become adherent to the surrounding parts. After a time they soften and break down, the skin becomes adherent and red, and gives way, and a curdy crust and pus is exuded. After the abscess has opened a portion of the broken down gland may be seen in the floor of the ulcer, the edges of which are bluish pink and undermined. The ulcers are slow and when finally healed leave characteristic raised, puckered, pinkish-white scars. Signs of tubercles are frequently present.

Treatment.- Remove all source of irritation, and if the patient is tuberculous, treat as such. Tuberculous glands that do not subside under general treatment should be removed. If an abscess has already formed it should be opened early to minimize scarring. If an indolent ulcer or sinus remain, curette it and cut away its rough edges and dress with full aseptic and antiseptic precautions.

Other diseases, such as lymphadenitis, elephantiasis, lymphorrhea, lympho-adenocele, lymphadenoma and lympho-sarcoma may be only mentioned, as time and space will not approve of a full discussion of each in this short article.


By W. H. Ketchum. “It is natural for men to indulge in the illusions of hope. We are apt to shut our eyes against a painful truth, and listen to the song of that siren until it has transformed us into, beasts. Is this the part of wise men engaged in a great and arduous struggle for truth?”.

They who in the light of the twentieth century are willing to be guided by that variable and uncertain light, the lamp of experiment, will be led in as many different directions as its rays are thrown. The old school and its teachings may be likened to the Paris fashions for ladies' gowns, and are almost as changeable. They go by fads and isms continually, first it is anti-this and anti-that, and then serums, and then something else. They are looking for specifics, they say, and at the same time declaring that medicine is not a true science and never will be.

Such is only an example of the very rapid progress about which we hear and read so much now-a-days. We are frank to admit that rapid strides have been made along certain lines, especially pathology and diagnosis, but the majority of these discoveries have been made upon the cadaver, and but very slight change can be noted in the teaching of therapeutics to-day from that of thirty years ago. Such

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