The deformities due to rickets are so numerous as to constitute a large part of those to which special or orthopedic surgery is addressed. The mechanical and operative treatment of these cases will be referred to in their appropriate place.
CHAPTER XIV.
THE STATUS LYMPHATICUS.
Under the term status lymphaticus has been described a condition which is of interest to the surgeon, as it includes not only minor complications, and even those which are serious, which follow surgical procedure, but it also has reference to the cases of sudden death during or after operation, some of which have been attributed to the anesthetic, while others have been considered absolutely unexplainable. The condition is so easily described or defined that it should be recognized during life, but it has often been discovered only after sudden death.
The essential feature of the condition is enlargement of the lymphatic tissue and apparatus, perhaps throughout the entire body, more frequently through its internal portions. It usually occurs in children. It is accompanied by much lowering of the power of resistance, and results in sudden death from cardiac failure, as the result of causes which seem disproportionately trivial; as, for instance, such deaths as occur not merely during anesthesia, but during bathing, convalescence from the exanthemas, etc. It stands in close relation to diphtheria, perhaps because of its peculiarly depressing toxins, and probably accounts for cases of sudden demise in that disease, even when mild.
The status lymphaticus is also designated by other names, as lymphatism, lymphatic constitution, and status thymicus, the latter because of the active participation of the thymus. Enlargement of this body has been noted at autopsy, but its relation to the other features of status lymphaticus were unknown until Rokitansky, in 1842, first recognized the condition in its entirety, but confused it with the tuberculosis of the lymphatics formerly called scrofula.
The death of a son of a German professor, a few years ago, shortly after an injection of antitoxin to protect him from diphtheria, and the subsequent discovery that the boy was the victim of this condition, caused a widespread interest in and a most careful study of the problems involved. They occur in the thymus more frequently than in any other organ of the body. Normally the thymus begins its involution within a few months after birth, and this process should be completed at puberty. In the status lymphaticus this involution does not occur, but enlargement persists or increases even into adult life, varying in different cases, the weight of the thymus varying from 20 to 135 grams.
While the thymus may for some purposes be grouped among the lymphatic tissues of the body, little is known as to its function. Its juice contains leukocytes, which find their way into the general circulation, and it is supposed to have an internal secretion correlated with that of other ductless glands.
Injections into dogs of thymus extract produce a fall in the blood pressure, with acceleration of the heart, and, in fatal doses, dyspnea and collapse. While enlargement of the thymus may cause death by pressure on important structures other than the trachea, it produces a type of asthma known as thymic asthma, in which death sometimes occurs unexpectedly and rapidly by strangulation.
An examination of the thymus rarely shows anything more abnormal than the enlargement of its natural structure, with perhaps acute hyperemia, while occasionally the cut surfaces will exude a milky fluid; there will be found, in addition to these changes in the thymus, a general hyperplasia of the lymphatic system, with enlargement of the superficial and deep nodes, especially the cervical and axillary, the inguinal and those in the abdomen. The spleen enlarges and the Malpighian bodies seem to be packed with lymphoid cells. There may be enlargement of the heart and increase in the thickness of the arterial walls. This is so marked that Virchow suggested the name lymphatic chlorotic constitution. It has been suggested that the narrowing of the aortic valve in these cases is due to this lymphoid infiltration.
The relations between rickets and the status lymphaticus are so frequent and so conspicuous as to make one suspect a more than casual connection between them. Nearly all cases of lymphatism show the ordinary clinical evidences of rickets. By some such relation may be explained the benefit which accrues in rickets from the administration of the extract of thymus, as well as of the thyroid and the pituitary body.