various processes, either breaking up and commingling with the blood, or undergoing a retrograde process, leading to obliteration and atrophy of the part affected, or passing into purulent or gangrenous fusion. Rokitansky also expresses it as his opinion that the capillaries may be affected in a similar way as he describes the arteries to be, by an excessive deposition of "lining membrane," only that the anomaly is here less in degree, owing to the arterial portion of the blood being expended in the process of nutrition. Among the chronic forms of disease which are attributed more particularly to the capillaries, and to which we have not had occasion to allude elsewhere, is the affection which Mr. John Bell, and English writers following him, have termed aneurism by anastomosis, or the Germans, more classically, teleangiectasis. It is also known by the simple term, erectile tumor, which is probably the best, as it implies no theory. The affection is commonly congenital, and presents itself in the shape of a cutaneous swelling of a circumscribed form and bluish-red color, liable to considerable variations of distension, according to the state of the circulation. The tumor commonly, though not always, offers a pulsation to the touch isochronous with the arterial pulse. Bell described the tumor as consisting of a congeries of vessels, between which were cavities and cells communicating with the latter; others have attributed the affection solely to a distended condition of the vessels, among whom may be mentioned Syme and Pelletan; it is, however, extremely probable that both conditions may occur, as in the analogous case of hemorrhoidal tumors; and that while one erectile tumor contains only vessels, another consists of both vessels and cellular cavities. This explanation would aid in understanding the difference in the symptoms presented by this species of tumor. 1 Teleangiectasis-literally, expansion of the remote vessels; T, distant, remote; ayy, a vessel; ixTeivw, I distend. See also page 175. CHAPTER XXV. THE LYMPHATIC SYSTEM. OUR knowledge of the diseases of the lymphatic system is not commensurate with the importance we attribute to it in the animal economy on physiological grounds. We may infer, from the close relation which it bears to the metamorphoses of the tissues, that it must be morbidly affected in all diseased conditions of individual parts, while its anatomical bearings assist in accounting for the difference which prevails between diseases specially affecting the lymphatic vessels and the veins. A morbid product, or a poison that has found its way into a vein, meets with no impediment, and, unless adhesive inflammation be set up at the point of introduction, speedily taints the whole system; the force and direction of the blood-current materially facilitate the propulsion of any foreign matter that has entered the vein. In the lymphatic vessel we have no such powerful and continuous stream, nor do the channels enlarge in the same uniform manner as in the former; on the contrary, we find the passage every now and then blocked up by a sluice, in the shape of a lymphatic gland, the obvious object of which is to submit the contents of the afferent vessel to a process of purification. By this means, further security is provided against the ultimate introduction into the blood, by the thoracic duct, of deleterious matter, which may have penetrated the lymphatics. Hasse' observes that the lymphatic vessels, being exclusively devoted to the purposes of absorption, can contain fluids of very various, and even morbid admixture, without detriment to their internal membrane, and that it is not until the fluids in question have reached the lymphatic glands that inflammatory reaction becomes established. He instances the conveyance of miasmatic and contagious matter through the lymphatic system, as in typhus, the plague, &c., where the lymphatic vessels never exhibit any morbid alteration, although the glands are found more or less disorganized. We must, however, demur both to the fact and to the conclusions drawn by Hasse; for although undoubtedly the mere presence of noxious matters, either in the blood or in the lymph, does not necessitate inflammatory reaction in the coats of the vessels, the fact of lymphatics presenting all the symptoms of inflammation between the seat of irritation and the next chain of glands is one of too frequent occurrence to establish it as a rule that the morbid manifestation only takes place in the latter. The metamorphosing and eliminating power of the lymphatic glands is one that exerts An Anatomical Description, &c., Sydenham Society's Ed. p. 2. a most important influence upon the preservation of health, and, where it is weakened, as in scrofulous individuals, we see that every species of disease makes an easy ingress, and is with difficulty expelled. This circumstance offers a satisfactory explanation for the great variation in the susceptibility of different individuals to the action of morbid agents; as we see in the undoubted exposure of several subjects to the same infectant; when, for instance, the same venereal female receives a succession of visitors, we have good grounds for assuming that each of the men came into contact with the syphilitic poison, we may find one enjoying an entire immunity from evil effects, while the other becomes the subject of secondary and tertiary symptoms. Inflammation of a lymphatic is manifested by redness, painfulness, and swelling, in its course; the coats become thickened and infiltrated, and exudation and suppuration may occur in their channels. A resolution is. the most common termination of the process. The presence of pus in the lymphatics does not necessarily demonstrate the existence of inflammation of the vessels; it may be introduced into them by abrasion or ulceration of lymphatics communicating with an abscess. Suppurative inflammation gives rise to small isolated abscesses along the course of the lymphatic vessels, forming, as it were, stations of the disease, each of which appears to serve as a fresh focus of morbid action. The inflammatory process more or less affects the surrounding cellular tissue from the commencement. With the advance of the inflammation, the lymphatics are blended with it, and suppuration and the formation of abscess involve the entire mass. A chronic inflammation of lymphatic vessels is met with in scrofulous, tubercular, and cancerous disease. Their coats are found indurated and thickened, and their channels are blocked up with the morbid blastema of the heterologous growth. The frequency with which this occurs, appears to be in a ratio to the softened condition of the deposit in the organ from which the affected lymphatics take their origin. Thus, in a case of encephaloid cancer of the stomach, in an aged female, that occurred under our own observation, the plexus of lymphatics occupying the lesser curvature of the organ were gorged to the size of crows' quills with the cancerous matter.' In the majority of instances, we meet with no such filling up of those vessels, and the subacute inflammation which coexists in their glands appears to be either the result of irritation propagated to them from the primary seat of the lesion, or of idiopathic disease set up in them as the purifying agents of the blood. Sir Astley Cooper reports three cases of obliteration of the thoracic duct, two of which were connected with tubercular, the third with cancerous disease. In the first, the obstruction was produced by the thickened valves, in three distinct parts, adhering to one another, the lowest still allowing of a partial transmission of fluid, the upper arresting it entirely. Serofulous matter was found deposited between the lamina of the valves. In the second there was considerable thickening and ulceration of the duct; two fungous growths occupied the channel; and in the third, which 1 Report of Pathological Society, 1847-48, p. 195. occurred in a man who had died in consequence of malignant disease of the testis and the lumbar glands, the thoracic duct was found much thickened, and filled with a pulpy mass, composed of broken, coagulable lymph. Opposite the curvature of the aorta, the vessel was lost in a swelling as large as a moderate-sized walnut, beyond which it was normal. The paper from which these cases are derived, contains various experiments upon the thoracic duct in animals, of physiological interest. One of the main conclusions arrived at by the author in reference to this point is, that the circulation in the lymphatic system may be kept up by dilatation of collateral vessels subsequent to the occurrence of obstruction in a trunk, as in the vascular system at large. A varicose condition of lymphatics is occasionally met with in atonic habits, causing them to resemble hydatid tumors. It affects parts of the system, and especially the thoracic duct is liable to dilatation; occasionally the entire system is found in this condition, and an extreme instance of this, occurring in a young man, aged nineteen, which happened in the practice of M. Amussat, is given in the works of Breschet and Carswell. Cruikshank' alludes to and delineates a similar case. Here, the lymphatics of the groins had reached a size sufficient to permit of the introduction of a straw by which air was blown into them; the iliac ganglia had entirely disappeared, and were replaced by the lymphatic vessels. A corresponding enlargement of these vessels was traced through the abdomen into the thorax; none of the other viscera presented any marked pathological changes. The depurating functions of the lymphatic glands while they render these organs safety-valves to the system, also induce in them a frequent liability to disease, which is characteristic of what is familiar to us as the lymphatic constitution. The irritation to which their affections are traceable, may proceed from some local lesions, from which it is carried to the neighboring glands by the connecting lymphatic, as in the case of a sore on the prepuce, inducing bubo, or of porrigo of the head, causing tumefaction of the cervical glands; or, it may be excited directly by the morbid condition of the blood circulating in the capillaries of the glands. Simple acute inflammation is manifested by tumefaction, softening, and a highly vascularized state of the organ, causing it, on division with the knife, to distil blood, while its color is changed from a reddish gray to a dark red or crimson tint. If suppuration has ensued, yellow spots first appear in different parts, and eventually the entire gland may be destroyed by the process, and be converted into an abscess, in which the surrounding cellular tissue is more or less implicated. The chronic form is, however, the more common; a species of plastic matter is effused interstitially, and induces gradual enlargement and induration of the gland. This condition may be perpetuated, and the resulting hypertrophy exhibits a conversion of the effused matter into the ordinary cell structure, displayed by the microscope as constituting the gland tissue. On the other hand, a reabsorption of the interstitial deposit may occur, as we have frequent opportunities of observing, as the effect 1 See Carswell, Patholog. Anat. Fasc. ix. pl. iv. fig. 4; and Breschet, Le Système Lymphatique, 1836, p. 260. of a suitable dietetic and medicinal regimen, in consequence of which the parts regain their normal size and appearance. Hypertrophy of the glands, whether simple or complicated, with the tubercular diathesis, is peculiarly prevalent in childhood, at the time when the vegetative development of the animal economy makes the greatest claim upon the organs of nutrition and metamorphosis; an atrophic condition is met with in advanced age, after the period of involution has commenced, and it is stated by Rokitansky particularly to affect the mesenteric glands as a result of typhous infiltration, in consequence of which the parenchyma of the gland is absorbed, as well as the product of the process. The inflammation of the mesenteric glands. accompanying typhous fever, is a point upon which Rokitansky lays great stress. He considers it as an integral part of ileotyphus, and states it particularly to attack the chain of lymphatic glands corresponding to the affected part of the intestine. He looks upon it as a substantive affection of the glands, allied to the morbid condition which they present in the Oriental plague. The reader will see that, in regard to the lesions of the mesenteric glands in fever, there is a wide difference of opinion between Rokitansky and Drs. Stewart and Jenner, who on very satisfactory evidence have shown that typhus and typhoid fevers are distinct forms of fever, one of the characteristic features of the latter being the intestinal ulcerations and disorganization of the mesenteric glands, while no such affections are met with in typhus. TUBERCLE. Few parts of the body are more exposed to the deposit of tuberculous matter than the lymphatic glands. It occurs in them either in a primary or secondary form, as the result of direct elimination from the blood vessels, or owing to the conveyance of tubercular matter from the organ from which the lymphatics are derived. We see it in the shape of yellowish masses, interspersed among the gland tissue; and as the morbid deposit increases, encroaching more upon, and ultimately entirely destroying all traces of, the normal tissue. The tubercular matter is observed to go through the same processes of softening and suppuration, or of induration and cretification, that we find it liable to elsewhere. Children are peculiarly prone to tubercular disease of the glandular system; but there is a considerable difference in the proclivity of different sets of glands to be affected. All authors are agreed that the bronchial are pre-eminently endowed with this tendency. The analysis of one hundred post-mortem examinations of tuberculous children, by Dr. Lombard,3 showed that the bronchial glands were affected in 87 cases. Pathological Anatomy, Sydenham Society's Edition, vol. iv. p. 390. 2 For the further details we must refer to the original papers of these authors, which are contained in the Medical Times (1851) and the Edinburgh Medical and Surgical Journal (1840). Andral, Précis d'Anatomie Pathologique, vol. i. p. 425. |