SIMPLE LYMPHANGITIS.
BY SAMUEL C. BUSEY, M.D.
ANATOMY AND PHYSIOLOGY.—The pathological relations of the absorbent system are important, because of their direct connection with the morbid processes and structural changes taking place in a variety of diseases; therefore, before discussing the subject of lymphangitis, a brief reference to the anatomy and physiology of the lymphatic system is necessary.
The lymphatic system consists of large and capillary vessels, interstitial spaces or juice-tracks, lacteals, follicles, and glands. The serous cavities are also considered lymph-chambers, and the loose cellular tissue is a vast chambered lymphatic sac communicating with lymphatic vessels. The larger vessels are divided into two classes—the superficial, which in the subcutaneous tissue accompany the veins, while in the solid viscera they lie under the capsule, and in the tubular viscera under the serous membrane; and the deep-seated vessels, which accompany the deep-seated blood-vessels, ramify through the interior of the organ in the solid viscera, and emerge at the hilus; while in the tubular viscera they lie in the submucosa, and by free anastomosis form plexuses. There is no communication between these two sets of vessels, except in the solid viscera and in the glands which may be common to both sets. Between the vessels of each set there is, however, a free anastomosis, by which large-meshed plexuses are formed. In consequence of these peculiar arrangements each set may be separately diseased, and inflammation may spread rapidly from vessel to vessel of the same set.
The lymph-capillaries are arranged in networks which lie in the meshes of the plexuses of the blood-capillaries, from which they are separated by intervening tissue-elements. Their walls consist of a single layer of endothelium resting upon elastic tissue. In their continuity they are sinuous, and are provided with an incomplete valvular arrangement.
The large vessels have three coats, not unlike the coats of the veins, and are provided with numerous valves. These valves are the more abundant in the superficial vessels, and the intervals between them grow gradually less as they approach the glands.
The whole lymph vascular system terminates either in the right or left thoracic duct.
The origin of the lymphatics has not been definitely settled. It has been demonstrated that lymph circulates in the connective-tissue interstices, and it seems to have been established that these spaces are lymph reservoirs, discharging through lymph-capillaries. It is admitted that the capillaries commence either in closely-meshed networks or lacunar spaces. Plexuses of lymphatic capillaries, corresponding with the distribution of the blood-capillaries, lie under the endothelium of the serous membranes, and are in open communication with the serous cavities through the stomata. The stomata vera are either the openings of lymph-channels communicating directly with lymph-capillaries, or discontinuities between the cells of the surface, leading into superficial lymph-sinuses. The pseudo-stomata are the interstitial or intercellular cement substance, and represent the communication of the lymph canalicular system with the free surface of serous membranes.
Lymph-follicles consist of a reticulum of connective tissue, the meshes of which are crowded with cells, thus forming patches in the submucous or subserous tissue. Around these patches there is a plexus of lymph-capillaries.
Lymphatic glands are round or oval bodies situated in the course of the lymphatic and lacteal vessels. They are composed of follicular tissue, trabeculæ, and lymph-tracts, all enclosed in a capsule. No doubt exists in regard to a channel of communication between the afferent and efferent vessels through a complex system of lymph-paths which communicate more freely with the afferent than with the efferent vessels. They are very vascular.
Every lymphatic vessel passes through one or more glands before reaching the trunks. Before penetrating the peripheric fascia of a gland these vessels divide into a number of smaller ones, which are distributed upon the surface of the cortical portion, and empty directly into the superficial lymph-sinuses. A number of vessels emerge from each gland, but they are less numerous and larger than the afferent vessels. The lymph is poured through the afferent vessels into the lymph-spaces of the cortical alveoli, and thence into the channels of the medullary substance, from which it escapes, enriched in corpuscular elements, into the efferent tubes. The current of fluid passing through such a complex structure must necessarily be retarded. This relation of the glands to the lymph-current is, moreover, especially interesting in its pathological significance. Whatever enters the lymph may, if small enough, pass through the glands and be swept along with the current, but the structure of the gland is, in a mechanical sense, a filtering apparatus, interrupting the free current of the fluid and retaining the coarser particles. The lymph in passing through the glands derives constituents not previously possessed, but, nevertheless, the retention of elements which for a time might arrest the dissemination of hurtful material may eventually convert the gland into a new source of infection. This fact is illustrated in the history of malignant growths.
Perhaps the most interesting consideration connected with this relation of the lymph-glands to the fluid passing through them is presented by the anatomical arrangement of the chyle-vessels and the mesenteric glands. The lacteals, commencing as the central efferent vessels of the intestinal villi, pass between the folds of the mesentery, through several tiers of mesenteric glands, and, uniting into one or more trunks, terminate in the receptaculum chyli. During digestion these vessels are full of chyle, and during the intervals of digestion they convey lymph.
The lymphatic system may be considered an appendage of the blood vascular system. By the blood the tissues are supplied with nutriment and oxygen. By both the blood and lymph the surplus and waste are conveyed away. The current of the lymph is in a reverse direction to that of the blood-supply. The lymphatic vascular system receives through its rootlets, which are distributed through the tissues, the surplus transudation from the arterial capillaries, the products of tissue-waste and transformation, and the chyle, and empties its contents into the great venous trunks near their termini. It therefore performs the double function of absorption from without and absorption from within. In other words, it introduces into the blood the material from both the food and the air which is required for the sustenance and repair of the tissues, and conveys away the unassimilated surplus, waste, and effete material.
The forces concerned in the locomotion of the lymph are numerous. Recklinghausen believes the movement of the lymph to be mainly due to the difference between the arterial and venous blood-pressure. The greater this difference the more rapid its current. The lymph canalicular system is not in vascular continuity with the blood-capillaries, and consequently the force of blood-pressure can only be communicated to the column of lymph by the passage of the plasmatic fluid into the lymphatic system by peripheral transudation and endosmosis. These are favored by the single homogeneous walls of the lymphatic plexuses and the enormous absorbing surface. These forces are essentially vis a tergo, for the difference between the arterial and venous blood-pressure is the excess of the former over the latter. To these must be added other factors, not less important or necessary, derived from the contractility of the walls of the lymphatic vessels, from the compression of the surrounding and contiguous parts, from the movements of respiration, and from the absorption of chyle. Besides these, the slowness of the movement of the lymph as compared with the rapidity of the arterial and venous blood-currents; the varying amount of pressure in the lymph vascular system, and the absence of distension in a normal condition; the entrance of the lymphatic trunks into the veins near the confluence of large branches, where the venous blood-pressure is almost inappreciable and the current is most rapid; the marked effect of active muscular movement in accelerating the flow of lymph; and the contractility of the vascular walls,—are all conditions which cannot be omitted from a consideration of the forces concerned in the locomotion of the lymph.
The supply of valves is very abundant, and they are always more numerous where pressure from surrounding and contiguous parts is most effective, though not infrequently most irregular in its operation, and consequently where isolation of small sections of the column of the fluid is most needed. The valves prevent regurgitation only so far as the superimposed column of fluid is insufficient to impair their integrity, or where there is no solution of the continuity of the vascular walls, and distension is within the limits of ordinary and normal extensibility. In cases of lymphangiectasis it is not usually necessary to look beyond the nearest neighboring and connected gland for the cause of such distension. Nature has increased the number of valves in the afferent vessels as they approach the glands, as well to modify and direct the flow as to prevent regurgitation; but if from any cause the passage of the lymph through the glands is obstructed or prevented, dilatation of the afferent vessels will ensue as a consequence. Valvular insufficiency and dilatation may exist in opposite relations to each other, either as cause or effect. The dilatation of a vessel may result from thinning or loss of contractility of its walls, caused by increased resistance to the onward movement of the fluid, and by the lesser extensibility of the intima than of the adventitia.
Lymphatic varices usually have their beginning in the vessels and extend to the plexuses, but the plexuses may be alone affected. Varicosities always extend backward from the point where the flow of the contained lymph is arrested, and may result from a repletion of each proximal intervalvular section with valvular incompetency.
The propulsive power of the heart diminishes with increased distance, due to increased friction and increasing resistance from flexures, bendings, and anastomoses, but chiefly from the increased carrying capacity of the vascular subdivisions. Hence, as the current of the lymph is in reverse relation to the capacity of the vessels, flowing, as does the venous blood, from subdivisions into trunks of diminished aggregate capacity, the velocity of the current of the lymph should be faster in the trunkal vessels than in the subdivisions. Such is the fact, though farther removed from the left heart and peripheral plasmatic circulation; and yet it is much slower in the thoracic duct than the blood-current in the venæ cavæ, which are not supplied with valves. The movement of the venous blood is in a measure due to cardiac and arterial contraction, but that force is least where the current is most rapid—in the venæ cavæ. The increased rapidity of the venous blood-current as it approaches the heart must, therefore, be derived from some other source; and it is equally manifest that the velocity of the venous blood in the terminal trunks is transmitted to the column of lymph and chyle flowing from the thoracic duct into the blood-channels.
The foregoing reference to the anatomy and physiology of the absorbent system shows very conclusively the importance of its pathological relations. It is certainly concerned in the morbid processes of a variety of diseases. But not less important is the fact that it is the main channel for the diffusion of infections throughout the body. Disease may be conveyed by the lymph from a single focus to many and distant parts, whilst the intervening channel of communication may remain free from injury. Along the course of the current every gland may become an additional focus, intensifying the infectiveness of the noxious material and increasing the area of its diffusion. This is alike true of poisons introduced from without and of those originating in the system.
SYNONYM.—Angioleucitis.
DEFINITION.—Lymphangitis may be either simple or septic. As a rule, the disease is localized, but may, especially when induced by some septic poison, be widely diffused, implicating extensive areas of lymphatic tissue and extending to contiguous structures.
Simple lymphangitis may be either reticular or tubular. In the former the fine capillary network or plexus is involved; in the latter the trunkal vessels are inflamed. Very frequently both forms exist at the same time.
ETIOLOGY.—Simple lymphangitis may be either idiopathic or traumatic. It is, however, rarely spontaneous. External irritation, such as solar rays, pressure, and friction, may set up a superficial inflammation, though usually there is some form of injury—a wound, scratch, sprain, contusion, abrasion, prick, or sting of an insect. The graver forms are caused by neighboring inflammation, suppuration, and ulceration. The products of these morbid changes are absorbed and conveyed along the vessels. The inflammation may be continuous along the course of the vessel, or separated from the origin of the morbid product by an area of intervening healthy tissue. Absorption of the secretions and parenchymatous fluids of inflamed parts is an active and frequent agency in the causation of lymphangitis. It may also be caused by contiguous inflamed tissue and by obstruction of the current of the lymph. Lymph-thrombosis, from whatever cause produced, may excite inflammation at the locality of formation, which is usually in the immediate vicinity of a valve, or the thrombi may disintegrate or undergo puriform liquefaction, and thus extend and diffuse the inflammation.
Slight pricks, scratches, and abrasions, which in themselves are so trifling as not to attract attention, may admit irritating substances from without. This is a frequent cause among medical men, whose hands and fingers are constantly exposed to irritating and ichorous discharges.
Localized lymphangitis is frequently set up by specific kinds of irritation. The adenitis and periglandular inflammations in cases of scarlet fever and diphtheria are familiar illustrations. The indurated glands in syphilis and suppurating buboes in chancroid exhibit the different effects of the virus of these forms of disease. The lymphatics of the solid viscera are often inflamed when the organ is the seat of disease. Pelvic cellulitis, if not in itself a lymphangitis, may be the starting-point of a severe and extensive inflammation of the absorbents, occasionally involving both the superficial and deep-seated vessels along one or both thighs.
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.
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.
SYMPTOMATOLOGY.—Reticular lymphangitis is characterized by rapidly-increasing localized redness, attended with a burning, throbbing pain, and usually quickly implicates the skin and its capillaries. Oedema to a greater or less extent may soon ensue, which, when present, increases the pain. Fever may or may not be present, depending in some measure upon the extent, intensity, and cause of the inflammation and upon individual peculiarities. Erythema usually represents a reticular lymphangitis with hyperæmia of the skin and its capillaries, and erythema nodosum is the same associated with lymphatic oedema. Any trivial injury may induce this form of inflammation, such as a prick or the sting of an insect, which in extent, duration, and intensity will vary with the cause, nature of the poison introduced, location, and susceptibility of the sufferer.
Tubular lymphangitis is usually a much more serious form of the disease. When the vessels of the superficial set are involved, wavy or straight irregularly reddened lines are seen along the course of the vessels, extending from the point of beginning to a single gland or ganglion, which is usually tender and enlarged. These lines feel like hard, knotted cords. The inflammation may be limited by the first tier of glands, or it may extend to one or more distant ganglia. From the inflamed gland the disease may be conveyed along the connecting branches of the deeper set of vessels, and both sets may become involved. The inflammation may also extend through the intervening tissues from the superficial to the deeper-seated vessels. When both sets are involved, the disease assumes a graver form and the symptoms are aggravated. The pain becomes more acute, and the swelling is greatly increased and more diffused. Fever may or may not be present, and is usually moderate when the inflammation is confined to the superficial vessels, but when the deeper set is implicated it often commences with a rigor and is usually considerable. When the deeper set is alone affected the red wavy, knotted lines cannot be seen, but may, unless the oedema is great, be felt. The parts are swelled, indurated, and stiffened, due in the acute stage to increased saturation of the tissues, and in the chronic stage to hypertrophy of the connective tissue. When the oedema is great the covering integument presents a glossy, shining appearance.
PATHOLOGY AND MORBID ANATOMY.—In lymphangitis the adventitia of the vessels and surrounding connective tissue are chiefly affected. The external coat is thickened, injected, and infiltrated with cells. The intima becomes opaque and is stripped of its endothelium. The lymph coagulates in the interior of inflamed vessels and blocks up the channel. These thrombi may become organized and permanently obliterate the lumen of the vessel, or they may liquefy or suppurate. Their products may enter the circulation and cause septicæmia or pyæmia. In a few instances the clots have undergone calcareous degeneration. In some instances coagula are found independently of any disease of the coats of the vessels. In such cases the coagulation has been caused by the entrance of some foreign material into the lymph-stream. The thickening and relaxation of the coats of the vessels lead to dilatation, and consequently to slowing of the current and stasis of lymph. From this may result the serious consequences of an extensive lymphangiectasia, which may involve either or both the superficial and deeper vessels of a large area or an entire extremity. In such cases enormous development of the adipose tissue usually takes place, not infrequently associated with rupture of the dilated radicals and exhaustive periodic discharges of lymph. In most of the cases of lymphangiectasia and lymphorrhagia the fluid, which either accumulates in the affected area or is discharged through the ruptured orifices, presents the physical characteristics and appearance of chyle, due to the quantity of fat it contains. In some cases the fluid at first discharged is serous, and gradually changes, as the flow continues, to a chylous or milk-like fluid. In these cases there is also a tendency to frequently-recurring attacks of an erysipelatous or elephantoid inflammation. This predisposition is traceable to the structural changes produced by the previous inflammation, traumatism, or thrombosis. Inflammation and lymph-thrombosis are the pathological processes which usually cause circumscribed narrowing or complete occlusion of lymph-channels; and within the area from which the narrowed or occluded vessels originate there is lymph-stasis, dilatation of trunkal vessels, and oedema of the tissues. Lymphangitis may also cause adhesion of the internal surfaces of the vessel, fibroid transformation or calcification of their coats, and suppuration.
The alterations which take place in the lymph consist chiefly of an increased proportion of fibrin, the addition of numerous cell-elements, not unlike endothelial cells, white and occasionally red blood-corpuscles, lymphoid cells, granular matter, and a varying quantity of albumen and fat, which in a measure must owe their presence to pathological processes affecting the intima and to transformation of the inflammatory products.
All forms of inflammation of the lymphatic vessels exhibit a tendency to extend to the connective tissue. Cellulitis is almost a constant accompaniment of lymphangitis. In other cases the inflammation and consequent thrombosis and obstruction of the lymph-stream produce oedema and saturation of the tissues. Hyperplasia and sclerosis of the connective tissue follow.
Adenitis is characterized by swelling, congestion, and hardness. If resolution takes place, as is usual in all forms of simple lymphangitis, the gland or ganglion will be restored to its normal condition, though not infrequently some enlargement and firmness will remain for a considerable time, which favor recurrences from very trivial causes. It often happens, however, that structural changes occur. Exudation and suppuration may take place. Suppuration begins in the centre, and sooner or later the whole gland-structure is converted into a pus-cavity. Buboes are usually associated with periglandular abscesses. In fact, the latter are very frequently present when the glands do not suppurate, but have assumed a condition of chronic or subacute inflammation, which subsides very slowly and is subject to recurring acute exacerbations from some continuous or repeated irritation. Glands may be devastated or rendered wholly or partially impermeable, thus forming permanent and irremediable obstacles to the lymph-stream. Inflamed and swollen glands are not necessarily impermeable, but the flow of the lymph through them is undoubtedly impeded. The subacute or chronically inflamed glands may become adherent to and imbedded in a mass of indurated connective tissue, and may finally undergo calcareous or caseous degeneration.
Lymphangitis sometimes extends by contiguity of tissue to the synovial membrane of joints, most frequently the knee-joint. So likewise may synovitis and other joint affections set up a lymphangitis. In either case the tendency to suppuration is imminent.
DIAGNOSIS.—The diagnosis of the forms of simple lymphangitis is very easy. The red, wavy, corded, and irregularly-knotted lines following the course of lymphatic vessels readily distinguish it from phlebitis. These lines lead to a gland, which soon also becomes tender and swollen. Oedema soon takes place. An inflamed lymphatic vessel is much smaller and more tender to the touch than an inflamed vein, and usually lies between the injured locality and an inflamed gland. Fever is more constantly present and higher than in phlebitis.
Reticular lymphangitis is usually a circumscribed inflammation, with more or less oedema, located in the region of a lymphatic network. It invades the integumental structures. It is not necessary to distinguish it from an erythema, for the latter can scarcely ever be present without implication of the lymphatic radicles. Tubular lymphangitis and lymphangiectasia, which are so frequently associated conditions and attended with oedema, present objective appearances very similar to those present in oedema from phlebectasis. Phlebectasis is excluded by the absence of pain, of dilatation of the superficial vein, and of changed color, and of a single hard cord along the course of the varicose vein; by the non-appearance of oedema in the neighborhood of the ankle and on the dorsum of the foot during the earlier stages of the disease, and its gradual extension upward. The infiltration in phlebectasis results from increased transudation in consequence of increased blood-pressure in the venous radicles, and their dilatation, or from interrupted venous circulation. The accumulated fluid is consequently watery, poor in solid constituents, and the resulting swelling presents all the characteristics of ordinary oedema. Absorption may be normal or perhaps increased, and with rest of the limb the intumescence will probably diminish or disappear. In consequence of the poverty of the transuded fluid the changes in nutrition are very slow, and the enlargement partakes more of the nature of an anasarca than of an hypertrophy; and, finally, phlebectasis is usually connected with some constitutional affection or distant local disease, and attacks the most distal parts, where the circulation is least supported by the muscles. Lymphangiectasis is most often found in circumscribed localities where the networks of lymph-capillaries are most numerously distributed. The swelling is more diffused, and is not in the form of single hard cords. It is more resistant, and the color of the surface is unchanged. It usually extends downward, and is not so much influenced by continued rest and posture. The accumulated fluid results from diminished absorption or interrupted lymph-circulation, and consists of the normal pre-existing parenchymatous fluids, the nutritive juices continually conveyed thither, and the fluids consumed by the functions of the parts saturated with organic débris. It is, however, more abundantly supplied with organic elements from both progressive and retrogressive metamorphosis. It also contains more albumen and fibrinous substances than the accumulated fluid in phlebectasis and ordinary oedema. The swelling or enlargement is formed of more consistent, coagulable, and partly organizable material, possesses greater consistence, and is nearly compact to the touch, which increases as the fluid undergoes the changes due to its retention in the parts. The development is peculiar, and not altogether unlike phlegmasia. The pus-formations which sometimes ensue partake of the nature of cold abscesses, and are located in the connective tissue. The pus-formations in phlebectasis usually begin in the venous thrombi within the dilated and enlarged veins, are associated with acute symptoms, and result, usually, in purulent absorption.
In view of later anatomical and pathological researches, it must be admitted that phlegmasia dolens is occasionally a lymphangitis, having its origin in inflammation of the vessels or areolar tissue. Some pathologists have advanced the theory that, as seen in lying-in women, it is a parametritis commencing in the cellular tissue in the immediate vicinity of the womb and extending to remoter parts. The writer saw recently, in consultation with J. Taber Johnson, a case of puerperal pelvic cellulitis associated with a firm, resistant, diffuse, painful, and tender swelling involving the inner aspect of both thighs, and extending from the groin on each side downward below the middle third of the thigh. The pelvic inflammation appeared first in the left iliac fossa, and was associated with the swelling before described on the thigh. This subsided, and was immediately followed by a similar condition in the right iliac fossa, accompanied by a precisely similar intumescence on the right thigh. At no time could any enlarged, hard, or corded veins be discovered. The swellings presented the usual objective and tactile characteristics of those inflammatory affections so frequently supervening within areas abundantly supplied with lymph networks, in communication with the original lymphangitis and lymph-thrombosis. In this case the swellings were located in a region specially rich in lymph capillary networks. With the subsidence of the pelvic cellulitis the thigh intumescence on either side gradually disappeared.
Tubular lymphangitis is readily distinguished from erysipelas by the presence of the knotted and corded lymphatic vessels. Reticular lymphangitis is characterized by fine, closely-arranged red lines limited to a circumscribed area, and is usually associated with and starts from some injury. In erysipelas the redness is uniform. It does not follow the course of the lymphatic vessels, nor extend from a wound in the direction of and to a gland or ganglion of glands. The fever is usually higher and of longer duration. The inflamed surface is marked by the appearance of blebs.
PROGNOSIS.—Simple lymphangitis is usually unattended with danger unless complicated with suppurating arthritis. The disease, as a rule, runs a rapid course to recovery. It is more favorable the nearer the inflammation lies to the surface.
TREATMENT.—The treatment is both constitutional and local. The first indication is to remove the cause. The wound should be cleansed and disinfected. For this purpose solutions of carbolic or acetic acid may be employed, or it may be cauterized with caustic potash or chloride of zinc. The fever should be controlled by the employment of antipyretics. One or more full doses of the sulphate or hydrochlorate of quinia, administered at shorter or longer intervals according to the quantity given at each dose and the intensity of the fever, may be sufficient. Antipyrin is a very valuable remedy. It will reduce the fever more speedily and decidedly than the salts of quinia. If the fever is reduced and kept under control by the judicious administration of this remedy in moderate doses, the tendency of the inflammation to extend is very greatly diminished, and may be arrested. Its antipyretic effect is, however, less durable than that of the salts of quinia, but is unattended with the cerebral disturbances usually associated with the employment of quinia salts. The bowels should be kept solvent by the use of saline cathartics. The diet should be restricted during the pyrexial stage. After the acute stage has passed, tonics and improved diet may become necessary; especially will this be the case in those previously debilitated. In healthy, robust subjects it is not probable, under proper and prompt treatment, that the disease will continue long enough to endanger convalescence by serious exhaustion. When needed, iron, cod-liver oil, and the salts of quinia may be resorted to. But, after all, a good appetite and a sufficient supply of nutritious and easily-digested foods constitute the best and most available tonics. Rest of the affected part is very important, and the posture should be such as to remove pressure and relieve tension.
In the beginning of the acute stage cold applications may be employed, but, as a rule, the local treatment should be confined to the assiduous application of hot soothing and emollient fomentations, to which opium or belladonna may be added. By these means the tension of the swollen and inflamed parts, and consequently the pain, are assuaged. It is rarely necessary to employ internally any anodyne to relieve the pain; but in occasional cases, occurring in persons keenly susceptible to pain, an opiate or some less powerful anodyne may be administered. Some advise the local abstraction of blood by leeching, but it is admissible only when the pain is very acute and confined to a limited and defined area. After the subsidence of the fever and acute inflammatory stage the remaining oedema and indurations may be treated with the local application of the tincture of iodine, inunction with mercurial ointment, bandaging, massage, and rest.
For the oedematous condition, which is sometimes very persistent, pressure is the most available and potential remedy. This should be secured by systematic bandaging either with a flannel or an elastic bandage. In such cases passive movement and massage or kneading of the part constitute an important and valuable auxiliary to pressure.
To allay itching, which is sometimes almost intolerable even after the acute inflammation has subsided, the part may be painted with a solution of nitrate of silver or collodion. If these fail, an alcoholic solution of benzoic acid, twenty grains to the ounce, may be employed.
If suppuration takes place, the abscess should be promptly and effectually incised. It should be thoroughly evacuated and dressed antiseptically. When this occurs a more or less tonic and supporting treatment is necessary. Iron, cod-liver oil, quinia, and stimulants may be, according to circumstances, administered. The devastating effects of suppurating cavities should be controlled by the liberal use of the appropriate remedies to arrest exhaustion and to rebuild waste.
In occasional instances the initial stage, consentaneous with the receipt of the injury, such as the sting of an insect, is marked by violent shock and threatening collapse. The writer has witnessed two such cases occurring in robust, healthy men stung by honey-bees on the forearm, where great exhaustion and alarming collapse, with violent retching, profuse diarrhoea, and agonizing pain, were accompanied by rapidly-developed inflammation and swelling at the locality of the puncture. In such cases the free administration of alcoholic stimulants seems imperatively demanded.
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. A single and apparently trivial inflammation of lymphatic tissue may be the initial stage of a fatal pyæmia or septicæmia.