Manual of Surgery Volume I Part 35

The pressure exerted on the nerves and veins of the lower extremity causes pain, congestion, and dema of the limb. Rupture may take place externally, or into the cellular tissue of the iliac fossa.

These aneurysms have to be diagnosed from pulsating sarcoma growing from the pelvic bones, and from an abscess or a ma.s.s of enlarged lymph glands overlying the artery and transmitting its pulsation.

The method of treatment that has met with most success is ligation of the common or external iliac, reached either by reflecting the peritoneum from off the iliac fossa (extra-peritoneal operation), or by going through the peritoneal cavity (trans-peritoneal operation).

#Gluteal Aneurysm.#--An aneurysm in the b.u.t.tock may arise from the superior or from the inferior gluteal artery, but by the time it forms a salient swelling it is seldom possible to recognise by external examination in which vessel it takes origin. The special symptoms to which it gives rise are pain down the limb from pressure on the sciatic nerve, and interference with the movements at the hip.

Ligation of the hypogastric (internal iliac) by the trans-peritoneal route is the most satisfactory method of treatment. Extirpation of the sac is difficult and dangerous, especially when the aneurysm has spread into the pelvis.

#Femoral Aneurysm.#--Aneurysm of the femoral artery beyond the origin of the profunda branch is usually traumatic in origin, and is more common in Scarpa's triangle than in Hunter's ca.n.a.l. Any of the methods already described is available for their treatment--the choice lying between Matas' operation and ligation of the external iliac.

Aneurysm of the _profunda femoris_ is distinguished from that of the main trunk by the fact that the pulses beyond are, in the former, unaffected, and by the normal artery being felt pulsating over or alongside the sac.

In _aneurysmal varix_, a not infrequent result of a bullet wound or a stab, the communication with the vein may involve the main trunk of the femoral artery. Should operative interference become necessary as a result of progressive increase in size of the tumour, or progressive distension of the veins of the limb, an attempt should be made to separate the vessels concerned and to close the opening in each by suture. If this is impracticable, the artery is tied above and below the communication; gangrene of the limb may supervene, and we have observed a case in which the gangrene extended up to the junction of the middle and lower thirds of the thigh, and in which recovery followed upon amputation of the thigh.

#Popliteal Aneurysm.#--This is the most common surgical aneurysm, and is not infrequently met with in both limbs. It is generally due to disease of the artery, and repeated slight strains, which are so liable to occur at the knee, play an important part in its formation. In former times it was common in post-boys, from the repeated flexion and extension of the knee in riding.

The aneurysm is usually of the sacculated variety, and may spring from the front or from the back of the vessel. It may exert pressure on the bones and ligaments of the joint, and it has been known to rupture into the articulation. The pain, stiffness, and effusion into the joint which accompany these changes often lead to an erroneous diagnosis of joint disease. The sac may press upon the popliteal artery or vein and their branches, causing congestion and dema of the leg, and lead to gangrene.

Pressure on the tibial and common peroneal nerves gives rise to severe pain, muscular cramp, and weakness of the leg.

The differential diagnosis is to be made from abscess, bursal cyst, enlarged glands, and sarcoma, especially pulsating sarcoma of one of the bones entering into the knee joint.

The choice of operation lies between ligation of the femoral artery in Hunter's ca.n.a.l, and Matas' operation of aneurysmo-arteriorrhaphy. The success which attends the Hunterian operation is evidenced by the fact that Syme performed it thirty-seven times without a single failure. If it fails, the old operation should be considered, but it is a more serious operation, and one which is more liable to be followed by gangrene of the limb. Experience shows that ligation of the vein, or even the removal of a portion of it, is not necessarily followed by gangrene. The risk of gangrene is diminished by a course of digital compression of the femoral artery, before operating on the aneurysm.

_Aneurysmal varix_ is sometimes met with in the region of the popliteal s.p.a.ce. It is characterised by the usual symptoms, and is treated by palliative measures, or by ligation of the artery above and below the point of communication.

_Aneurysm_ in the #leg and foot# is rare. It is almost always traumatic, and is treated by excision of the sac.

CHAPTER XV

THE LYMPH VESSELS AND GLANDS

Anatomy and Physiology--INJURIES OF LYMPH VESSELS--_Wounds of thoracic duct_--DISEASES OF LYMPH VESSELS--Lymphangitis: _Varieties_--Lymphangiectasis--Filarial disease--Lymphangioma--DISEASES OF LYMPH GLANDS--Lymphadenitis: _Septic_; _Tuberculous_; _Syphilitic_--Lymphadenoma--Leucocythaemia--TUMOURS.

#Surgical Anatomy and Physiology.#--Lymph is essentially blood plasma, which has pa.s.sed through the walls of capillaries. After bathing and nouris.h.i.+ng the tissues, it is collected by lymph vessels, which return it to the blood stream by way of the thoracic duct. These lymph vessels take origin in the lymph s.p.a.ces of the tissues and in the walls of serous cavities, and they usually run alongside blood vessels--_perivascular lymph vessels_. They have a structure similar to that of veins, but are more abundantly provided with valves. Along the course of the lymph trunks are the _lymph glands_, which possess a definite capsule and are composed of a reticulated connective tissue, the s.p.a.ces of which are packed with leucocytes. The glands act as filters, arresting not only inert substances, such as blood pigment circulating in the lymph, but also living elements, such as cancer cells or bacteria. As it pa.s.ses through a gland the lymph is brought into intimate contact with the leucocytes, and in bacterial infections there is always a struggle between the organisms and the leucocytes, so that the glands may be looked upon as an important line of defence, r.e.t.a.r.ding or preventing the pa.s.sage of bacteria and their products into the general circulation. The infective agent, moreover, in order to reach the blood stream, must usually overcome the resistance of several glands.

Lymph glands are, for the most part, arranged in groups or chains, such as those in the axilla, neck, and groin. In any given situation they vary in number and size in different individuals, and fresh glands may be formed on comparatively slight stimulus, and disappear when the stimulus is withdrawn. The best-known example of this is the increase in the number of glands in the axilla which takes place during lactation; when this function ceases, many of the glands become involuted and are transformed into fat, and in the event of a subsequent lactation they are again developed. After glands have been removed by operation, new ones may be formed.

The following are the more important groups of glands, and the areas drained by them in the head and neck and in the extremities.

#Head and Neck.#--_The anterior auricular (parotid and pre-auricular) glands_ lie beneath the parotid fascia in front of the ear, and some are partly embedded in the substance of the parotid gland; they drain the parts about the temple, cheek, eyelids, and auricle, and are frequently the seat of tuberculous disease. _The occipital gland_, situated over the origin of the trapezius from the superior curved line, drains the top and back of the head; it is rarely infected. _The posterior auricular (mastoid) glands_ lie over the mastoid process, and drain the side of the head and auricle. These three groups pour their lymph into the superficial cervical glands. _The submaxillary_--two to six in number--lie along the lower order of the mandible from the symphysis to the angle, the posterior ones (paramandibular) being closely connected with the submaxillary salivary gland. They receive lymph from the face, lips, floor of the mouth, gums, teeth, anterior part of tongue, and the alae nasi, and from the pre-auricular glands. The lymph pa.s.ses from them into the deeper cervical glands. They are frequently infected with tubercle, with epithelioma which has spread to them from the mouth, and also with pyogenic organisms. _The submental glands_ lie in or close to the median line between the anterior bellies of the digastric muscles, and receive lymph from the lips. It is rare for them to be the seat of tubercle, but in epithelioma of the lower lip and floor of the mouth they are infected at an early stage of the disease. _The supra-hyoid gland_ lies a little farther back, immediately above the hyoid bone, and receives lymph from the tongue. _The superficial cervical (external jugular) glands_, when present, lie along the external jugular vein, and receives lymph from the occipital and auricular glands and from the auricle. _The sterno-mastoid glands_--glandulae concatinatae--form a chain along the posterior edge of the sterno-mastoid muscle, some of them lying beneath the muscle. They are commonly enlarged in secondary syphilis. _The superior deep cervical (internal jugular) glands_--from six to twenty in number--form a continuous chain along the internal jugular vein, beneath the sterno-mastoid muscle. They drain the various groups of glands which lie nearer the surface, also the interior of the skull, the larynx, trachea, thyreoid, and lower part of the pharynx, and pour their lymph into the main trunks at the root of the neck. Belonging to this group is one large gland (the tonsillar gland) which lies behind the posterior belly of the digastric, and rests in the angle between the internal jugular and common facial veins. It is commonly enlarged in affections of the tonsil and posterior part of the tongue. In the same group are three or four glands which lie entirely under cover of the upper end of the sterno-mastoid muscle, and surround the accessory nerve before it perforates the muscle. The deep cervical glands are commonly infected by tubercle and also by epithelioma secondary to disease in the tongue or throat. _The inferior deep cervical (supra-clavicular) glands_ lie in the posterior triangle, above the clavicle. They receive lymph from the lowest cervical glands, from the upper part of the chest wall, and from the highest axillary glands. They are frequently infected in cancer of the breast; those on the left side also in cancer of the stomach. The removal of diseased supra-clavicular glands is not to be lightly undertaken, as difficulties are liable to ensue in connection with the thoracic duct, the pleura, or the junction of the subclavian and internal jugular veins. _The retro-pharyngeal glands_ lie on each side of the median line upon the rectus capitis anticus major muscle and in front of the pre-vertebral layer of the cervical fascia. They receive part of the lymph from the posterior wall of the pharynx, the interior of the nose and its accessory cavities, the auditory (Eustachian) tube, and the tympanum. When they are infected with pyogenic organisms or with tubercle bacilli, they may lead to the formation of one form of retro-pharyngeal abscess.

#Upper Extremity.#--_The epi-trochlear and cubital glands_ vary in number, that most commonly present lying about an inch and a half above the medial epi-condyle, and other and smaller glands may lie along the medial (internal) bicipital groove or at the bend of the elbow. They drain the ulnar side of the hand and forearm, and pour their lymph into the axillary group. The epi-trochlear gland is sometimes enlarged in syphilis. _The axillary glands_ are arranged in groups: a central group lies embedded in the axillary fascia and fat, and is often related to an opening in it; a posterior or subscapular group lies along the line of the subscapular vessels; anterior or pectoral groups lie behind the pectoralis minor, along the medial side of the axillary vein, and an inter-pectoral group, between the two pectoral muscles. The axillary glands receive lymph from the arm, mamma, and side of the chest, and pa.s.s it on into the lowest cervical glands and the main lymph trunk.

They are frequently the seat of pyogenic, tuberculous, and cancerous infection, and their complete removal is an essential part of the operation for cancer of the breast.

#Lower Extremity.#--_The popliteal glands_ include one superficial gland at the termination of the small saphenous vein, and several deeper ones in relation to the popliteal vessels. They receive lymph from the toes and foot, and transmit it to the inguinal glands. _The femoral glands_ lie vertically along the upper part of the great saphenous vein, and receive lymph from the leg and foot; from them the lymph pa.s.ses to the deep inguinal and external iliac glands. The femoral glands often partic.i.p.ate in pyogenic infections entering through the skin of the toes and sole of the foot. _The superficial inguinal glands_ lie along the inguinal (Poupart's) ligament, and receive lymph from the external genitals, a.n.u.s, perineum, b.u.t.tock, and anterior abdominal wall. The lymph pa.s.ses on to the deep inguinal and external iliac glands. The superficial glands through their relations to the genitals are frequently the subject of venereal infection, and also of epithelioma when this disease affects the genitals or a.n.u.s; they are rarely the seat of tuberculosis. _The deep inguinal glands_ lie on the medial side of the femoral vein, and sometimes within the femoral ca.n.a.l. They receive lymph from the deep lymphatics of the lower limb, and some of the efferent vessels from the femoral and superficial inguinal glands. The lymph then pa.s.ses on through the femoral ca.n.a.l to the external iliac glands. The extension of malignant disease, whether cancer or sarcoma, can often be traced along these deeper lymphatics into the pelvis, and as the obstruction to the flow of lymph increases there is a corresponding increase in the swollen dropsical condition of the lower limb on the same side.

The glands of the _thorax_ and _abdomen_ will be considered with the surgery of these regions.

INJURIES OF LYMPH VESSELS

Lymph vessels are divided in all wounds, and the lymph that escapes from them is added to any discharge that may be present. In injuries of larger trunks the lymph may escape in considerable quant.i.ty as a colourless, watery fluid--_lymphorrhagia_; and the opening through which it escapes is known as a _lymphatic fistula_. This has been observed chiefly after extensive operation for the removal of malignant glands in the groin where there already exists a considerable degree of obstruction to the lymph stream, and in such cases the lymph, including that which has acc.u.mulated in the vessels of the limb, may escape in such abundance as to soak through large dressings and delay healing.

Ultimately new lymph channels are formed, so that at the end of from four to six weeks the discharge of lymph ceases and the wound heals.

_Lymphatic dema._--When the lymphatic return from a limb has been seriously interfered with,--as, for example, when the axillary contents has been completely cleared out in operating for cancer of the breast,--a condition of lymphatic dema may result, the arm becoming swollen, tight, and heavy.

Various degrees of the conditions are met with; in the severe forms, there is pain, as well as incapacity of the limb. As in ordinary dema, the condition is relieved by elevation of the limb, but not nearly to the same degree; in time the tissues become so hard and tense as scarcely to pit on pressure; this is in part due to the formation of new connective tissue and hypertrophy of the skin; in advanced cases there is a gradual transition into one form of elephantiasis.

Handley has devised a method of treatment--_lymphangioplasty_--the object of which is to drain the lymph by embedding a number of silk threads in the subcutaneous cellular tissue.

#Wounds of the Thoracic Duct.#--The thoracic duct usually opens at the angle formed by the junction of the left internal jugular and subclavian veins, but it may open into either of these vessels by one or by several channels, or the duct may be double throughout its course. There is a smaller duct on the right side--the right lymphatic duct. The duct or ducts may be displaced by a tumour or a ma.s.s of enlarged glands, and may be accidentally wounded in dissections at the root of the neck; jets of milky fluid--chyle--may at once escape from it. The jets are rhythmical and coincide with expiration. The injury may, however, not be observed at the time of operation, but later through the dressings being soaked with chyle--_chylorrha_. If the wound involves the only existing main duct and all the chyle escapes, the patient suffers from intense thirst, emaciation, and weakness, and may die of inanition; but if, as is usually the case, only one of several collateral channels is implicated, the loss of chyle may be of little moment, as the discharge usually ceases. If the wound heals so that the chyle is prevented from escaping, a fluctuating swelling may form beneath the scar; in course of time it gradually disappears.

An attempt should be made to close the wound in the duct by means of a fine suture; failing this, the duct must be occluded by a ligature as if it were a bleeding artery. The tissues are then st.i.tched over it and the skin wound accurately closed, so as to obtain primary union, firm pressure being applied by dressings and an elastic webbing bandage. Even if the main duct is obliterated, a collateral circulation is usually established. A wound of the right lymphatic duct is of less importance.

_Subcutaneous rupture of the thoracic duct_ may result from a crush of the thorax. The chyle escapes and acc.u.mulates in the cellular tissue of the posterior mediastinum, behind the peritoneum, in the pleural cavity (_chylo-thorax_), or in the peritoneal cavity (_chylous ascites_). There are physical signs of fluid in one or other of these situations, but, as a rule, the nature of the lesion is only recognised when chyle is withdrawn by the exploring needle.

DISEASES OF LYMPH VESSELS

#Lymphangitis.#--Inflammation of peripheral lymph vessels usually results from some primary source of pyogenic infection in the skin. This may be a wound or a purulent blister, and the streptococcus pyogenes is the organism most frequently present. _Septic_ lymphangitis is commonly met with in those who, from the nature of their occupation, handle infective material. A _gonococcal_ form has been observed in those suffering from gonorrha.

The inflammation affects chiefly the walls of the vessels, and is attended with clotting of the lymph. There is also some degree of inflammation of the surrounding cellular tissue--_peri-lymphangitis_.

One or more abscesses may form along the course of the vessels, or a spreading cellulitis may supervene.

The _clinical features_ resemble those of other pyogenic infections, and there are wavy red lines running from the source of infection towards the nearest lymph glands. These correspond to the inflamed vessels, and are the seat of burning pain and tenderness. The a.s.sociated glands are enlarged and painful. In severe cases the symptoms merge into those of septicaemia. When the deep lymph vessels alone are involved, the superficial red lines are absent, but the limb becomes greatly swollen and pits on pressure.

In cases of extensive lymphangitis, especially when there are repeated attacks, the vessels are obliterated by the formation of new connective tissue and a persistent solid dema results, culminating in one form of elephantiasis.

_Treatment._--The primary source of infection is dealt with on the usual lines. If the lymphangitis affects an extremity, Bier's elastic bandage is applied, and if suppuration occurs, the pus is let out through one or more small incisions; in other parts of the body Klapp's suction bells are employed. An autogenous vaccine may be prepared and injected. When the condition has subsided, the limb is ma.s.saged and evenly bandaged to promote the disappearance of dema.

_Tuberculous Lymphangitis._--Although lymph vessels play an important role in the spread of tuberculosis, the clinical recognition of the disease in them is exceptional. The infection spreads upwards along the superficial lymphatics, which become nodularly thickened; at one or more points, larger, peri-lymphangitic nodules may form and break down into abscesses and ulcers; the nearest group of glands become infected at an early stage. When the disease is widely distributed throughout the lymphatics of the limb, it becomes swollen and hard--a condition ill.u.s.trated by lupus elephantiasis.

_Syphilitic lymphangitis_ is observed in cases of primary syphilis, in which the vessels of the dorsum of the p.e.n.i.s can be felt as indurated cords.

In addition to acting as channels for the conveyance of bacterial infection, _lymph vessels frequently convey the cells of malignant tumours_, and especially cancer, from the seat of the primary disease to the nearest lymph glands, and they may themselves become the seat of cancerous growth forming nodular cords. The permeation of cancer by way of the lymphatics, described by Sampson Handley, has already been referred to.

#Lymphangiectasis# is a dilated or varicose condition of lymph vessels.

It is met with as a congenital affection in the tongue and lips, or it may be acquired as the result of any condition which is attended with extensive obliteration or blocking of the main lymph trunks. An interesting type of lymphangiectasis is that which results from the presence of the _filaria Bancrofti_ in the vessels, and is observed chiefly in the groin, spermatic cord, and s.c.r.o.t.u.m of persons who have lived in the tropics.

_Filarial disease in the lymphatics of the groin_ appears as a soft, doughy swelling, varying in size from a walnut to a cocoa-nut; it may partly disappear on pressure and when the patient lies down.

The patient gives a history of feverish attacks of the nature of lymphangitis during which the swelling becomes painful and tender. These attacks may show a remarkable periodicity, and each may be followed by an increase in the size of the swelling, which may extend along the inguinal ca.n.a.l into the abdomen, or down the spermatic cord into the s.c.r.o.t.u.m. On dissection, the swelling is found to be made up of dilated, tortuous, and thickened lymph vessels in which the parent worm is sometimes found, and of greatly enlarged lymph glands which have undergone fibrosis, with giant-cell formation and eosinophile aggregations. The fluid in the dilated vessels is either clear or turbid, in the latter case resembling chyle. The affection is frequently bilateral, and may be a.s.sociated with lymph s.c.r.o.t.u.m, with elephantiasis, and with chyluria.

The _diagnosis_ is to be made from such other swellings in the groin as hernia, lipoma, or cystic pouching of the great saphenous vein. It is confirmed by finding the recently dead or dying worms in the inflamed lymph glands.