Lymphangitis

“ But I am inclined to believe that the vast majority of cases of elephantiasis in the Tropics is of peripheral origin, and is due to a lymphangitis arising peripherally, caused by the introduction of a specific micro-organism, and resulting in the gradual narrowing and obstruction of the peripheral lymph vessels. Radcliffe Crocker points out that in a temperate climate erysipelas, either as a severe or diffuse cellulitis or from repeated attacks, is one of the most common causes of lymphatic obstruction. ”

“ 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 illustrated by lupus elephantiasis.
Syphilitic lymphangitis is observed in cases of primary syphilis, in which the vessels of the dorsum of the penis can be felt as indurated cords. ”

“ The general plan of treatment of acute simple lymphangitis is antiphlogistic, by the employment of remedies to reduce inflammation and promote resolution. The danger of suppuration should not be overlooked or underestimated. A single suppurating focus may widely diffuse disease and impair the entire organism. ”

“ But the grade of such lymphangitis is as varied as the particular germ or combination of germs present in the wound, and the susceptibility of the animal attacked, and there will be high, moderate or no fever, according to the severity of the case, and in some cases purely local trouble and in others general infection with purulent or septic localization in distant parts. There is always danger of extension to a neighboring joint with destructive results. ”

“ A simpler form is where a bruise by the harness causes a hard, thick, slough, embracing the entire thickness of the skin, from which the firm corded lymphatics extend in different directions. After the slow process of detachment, the local lymphangitis usually subsides under simple cooling or antiseptic treatment. ”

“ Acute inflammation more commonly supervenes on inflammation in the area drawn upon by the afferent vessels of the gland. In inflammations generally the adjacent lymphatic glands become congested. In lymphangitis it is so in a marked degree. In external parts we can follow this by careful observations during life, in internal organs we often find the glandular enlargement after death. ”

“ Infection can be transmitted by mediate or immediate contagion. The eruption usually appears on the limbs, but it may occur on the body or on the head and neck. The symptoms closely resemble those of cutaneous glanders or farcy, from which this disease may readily be distinguished by microscopic examination of the pus discharged from the sores, or by testing the horse with mallein. Glanders and epizootic lymphangitis may coexist in the same animal. It is a scheduled disease, and treatment should not be attempted. ”

“ Lymphangitis may also find its cause in excessive exercise of function, paralysis of vessels, mechanical obstruction to the lymph-stream, lodgment of particles of cancerous or tuberculous matter in the vessels, compression from cicatrices, indurated connective tissue, tumors, diseased glands, stasis in large veins, and regurgitant heart affections. ”

“ Bahr notes the influence of adult filariae in producing an increase in connective tissue in glands and considers such glands as less resistant to bacterial infection.
Manson has an idea that some factor may cause the female to give off immature embryos, which being oval, and of considerable width, may block the lymphatics.
It has often been claimed that various cocci were the exciting factors in the lymphangitis associated with filariasis. Recently Dutcher has reported the isolation of an organism resembling B. subtilis as the cause of filarial lymphangitis (Bacillus lymphangiticus) . ”

“ The lesions of interstitial mammitis are similar to those of ordinary lymphangitis, the condition originating near the teat and gradually extending to the layers of connective tissue between the acini, mammæ, etc.
In the parenchymatous form the inflammation may remain partial, and be localised in particular tracts of glandular tissue. The secreting epithelium, when infected, exhibits cloudy swelling, becomes loosened, and disappears ”

“ At a later stage, when the animal has become weak, microorganisms are present in much greater variety. Nocard found in lung abscesses the bacillus of epizootic lymphangitis. It seems that the development of various lesions in the thoracic cavity may be due to auto-infection, i.e., to the penetration from the intestine of germs which, after passing through the circulation, establish themselves at some point in the lung. ”

“ It must always be remembered that they are part of an anastomosis necessary to life. Should they be very troublesome and incapacitate for work, they may be removed. In operating, strict aseptic methods must be practised, as septic lymphangitis readily occurs, and has frequently proved fatal after operations in such cases. Excision is not always satisfactory, as it may be followed by lymphorrhagia at the seat of the wound, by excessive dilatation of some other part of the implicated lymphatic area, by chyluria, or by elephantiasis in one or both legs. ”

“ Treatment: laxatives, diuretics, exercise, elastic bandage, friction, astringents, iodine.
Chronic thickening of the skin is most commonly seen in horses as a sequel of lymphangitis in the hind limb, the engorgment of the lymph plexus and thickening of its walls being associated with a general productive inflammation and thickening of the derma until the fetlock may be thirty inches or more in diameter. It may follow eczema, grease or chronic glanders. ”

“ The course of the symptoms offers a certain analogy to that of septic engorgements and interstitial mammitis or mammary lymphangitis. As a rule only one gland is infected, but generally symptoms at once appear, indicating an extremely dangerous condition, viz., peracute mammitis. The patient suddenly becomes dull and entirely loses appetite, rumination ceases and respiration is short and jerky, although the bodily temperature does not always rise to any marked extent. ”

“ Horses and cattle in certain countries (Japan, Sweden, Finland, France, Guadaloupe) are subject to a chronic lymphangitis resembling cutaneous glanders, but associated with the development of bacilli or fungi in the nodular, caseating swellings in the skin, subcutem, in mucosæ and in internal organs.
Nocard describes the affection in the horse as characterized by skin nodules (buttons, boils) , which burst and discharge a thick, grumous, or thin, oily, yellowish or bloody pus. The surrounding lymph plexus swells up into corded lines, with at intervals nodules or abscesses. ”

“ Age and constitution are recognized factors. Lymphangitis is more frequent in the young, and is much more easily excited in the strumous and persons in a low state of health. Unhygienic conditions predispose to its development. ”

“ Thus in Barbadoes, where there is no malaria, a condition in which there occurs a high fever of sudden onset with rigors and associated erysipelatous redness of leg or scrotum, accompanied by lymphangitis and painful lymphatic glands, has given a suggestion of a malarial paroxysm. The tense inflamed area, after several days, shows an exudation of lymph and the redness disappears, but with some resulting thickening of the affected tissues. Such attacks may terminate with profuse sweating. ”

“ Swelling is very painful and when the affected legs are palpated, pain is manifested by flinching. The inguinal lymph glands are often swollen but in some cases they are not affected in any perceptible degree. In the average case suppuration does not occur and when conditions are favorable, resolution is complete within ten days. The extent of the involvement and the intensity of the affection vary materially in different cases and a chronic lymphangitis may succeed the acute attacks and finally in some instances, elephantiasis results. ”

“ Law [3] refers to this ailment as "Acute Lymphangitis of Plethora in Horse." When one takes into consideration that these cases so frequently occur in heavy draft animals that are not worked regularly, that the pelvic limbs are the ones involved, and that the disorder often runs a short course (recovery often taking place within two or three days, with no treatment given other than a purge, circulatory stimulants and walking exercise) it is plausible to ascribe the condition to idiopathic factors. ”

“ It would seem that the greater frequency of inguinal buboes is because a greater area of skin drains into these glands. There may be multiple buboes and it must not be forgotten that the lymphatic glands of any region may become enlarged. There may also be lymphangitis. Only one gland of a group may be involved or the whole group may show enlargement. Very characteristic for plague buboes is the oedema of the periglandular tissues, which is largely responsible for the great size of some of these buboes ”

“ Those of them that are at all serious are rare, and can generally be traced to fortuitous circumstances.
Inflammatory complications are usually due to undue traumatism at the time of the inoculation, to injury of the pock, or to the previous existence of a cutaneous disease or of some dyscrasia. Dermatitis is the most common. It is usually a mere erythema, but in some instances lymphangitis, lymphadenitis, phlegmonous inflammation, with diffuse suppuration, may result. From injury of the pock ulceration and gangrene may take place, and septic absorption may follow in their train. ”

“ They are tender and more or less painful, and are usually accompanied with a sense of burning. Lymphangitis is at times observed. At the end of two or three weeks the affection has usually run its course. ”

“ The cause is always the absorption of some toxic or infective material from the periphery. This may take place in several of the acute infectious diseases, notably in scarlet fever, mumps, diphtheria and German measles, or may be the result of poisoned wounds. The lymphatic glands are also affected in constitutional diseases such as syphilis. Simple lymphadenitis usually subsides of its own accord, but if toxins are produced in the inflamed area the enlargement is obvious and painful, while if pyogenic organisms are absorbed the inflammation progresses to suppuration. ”

“ A strain or other form of trauma is sometimes blamed for the onset of lymphadenitis, especially in the glands of the groin (bubo) , but it is usually possible to discover some source of pyogenic infection which is responsible for the mischief, or to obtain a history of some antecedent infection such as gonorrhoea. It is possible for gonococci to lie latent in the inguinal glands for long periods, and only give rise to lymphadenitis if the glands be subsequently subjected to injury. The glands most frequently affected are those in the neck, axilla, and groin. ”

“ For my own part, I am of opinion that the small-pox is a disease of the lymphatic system only, and my opinion seems to be confirmed by the impossibility of communicating [Pg 76] the infection by inoculating with the blood. Be this as it may, it is indisputably true, that the crude lymph is sufficient to give the infection, and that there is no necessity to draw blood at the time of incision. Add to this, the frequent tumour of the lymphatic glands in the axilla soon after the operation. ”

“ But when I come to examine the distribution of the lymphatics in the different situations in which elephantiasis occurs, I find a difficulty, from a mechanical point of view alone, of explaining how the obstruction which is necessary to produce a complete lymph stasis can occur. Looking again at the illustration of the superficial lymphatics of the leg, at what point in the limb can a single worm be situated so that the lymph-stream would carry the ova so as to obstruct the whole of the superficial inguinal glands? ”

“ Lymph nodes are also a part of our immune system and produce white blood cells to help control invading organisms. When the lymph is overloaded with waste products the ducts and nodes swell, and until the source of the local irritation is removed, are incapable of handling further debris. If left in this condition for years they become so hard they feel like rocks under the skin. Lumps in the armpits or the groin are prime sites for the future development of a cancer. Fasting, massage, and poultices will often soften overloaded lymph nodes and coax them back into operation. ”

“ Under this condition of an increased excitement in the peritoneal or other serous membrane, coagulable lymph is discharged into its cellular tissue, and a thickening of it takes place; until at length the operation of paracentesis, which in the early stage of the disease was attended with only inconsiderable inconvenience, becomes an adequate cause of a still higher inflammation, which terminates perhaps in suppuration; and, in the post mortem examination the serous fluid is found so mixed with coagulable lymph, and purulent matter, as to give a whey or milk-like appearance to the mass. ”

“ Where infective wounds of muscles of locomotion occur, the course and gravity of the affection are directly influenced by the proximity of the injury to lymph plexuses. For instance, injuries causing an infectious inflammatory involvement of the adductors of the thigh may result in a generalization of the infection by way of the inguinal lymph glands.
Large open wounds that extend deep into muscles, render inactive such structures, and even where division is not complete, the pain occasioned causes the subject to favor the part in every way possible. ”