In proportion to the distance of the diseased part from the body centres the prognosis becomes more favorable. When an entire limb is involved the matter is very serious; when in the face or abdomen, still more so, the fear being of septic phlebitis and a fatal termination by a more or less typical pyemic process.
Treatment.
—All exciting causes, including sloughing tissues, foreign bodies, pus, etc., should be thoroughly removed. Pus, when present, should be evacuated, and when its presence is suspected suitable exploration should be made. Tension should always be relieved by incision. In cases where breaking down has already begun, continuous immersion in hot water is beneficial. Nothing, however, will take the place of removal of pus or necrotic tissue, and this should be first attended to or proved to be unnecessary. In an open and sloughing wound nothing is as satisfactory as brewers’ yeast; next to this is hot water. Over an unbroken area which is simply edematous and pits on pressure, may be applied the ichthyol-mercurial ointment (10 per cent. ichthyol, 40 per cent. mercurial ointment) or the Credé silver ointment. This should not be rubbed in, but smeared freely over the surface, and then covered with oiled silk, twice daily, in acute cases. The surgeon should satisfy himself as to the presence or absence of pus; even when only suspected it is advisable to make incision early, as tissue and possibly life may thus be saved. Constitutional treatment should not be neglected. It will consist in improving elimination, maintaining nutrition, and overcoming the acute toxemia due to absorption, the toxins being best antidoted by alcohol in some palatable form, strychnine and quinine being serviceable, but not so valuable. (See chapter on [Septic Infections].)
Chronic Lymphangitis.
—Chronic lymphangitis is seen in connection with the slower infections, tuberculosis—syphilis, filariasis, etc. Here the lymph vessels are not involved so much as the lymph nodes. Chronic lymphangitis does not occur without a toxic or infectious process behind it.
LYMPH NODES.
For the surgeon’s purpose, at least, he may assume that lymph nodes are never enlarged except in the presence of toxemic or infectious processes. The role which they play as filters of the fluid returning through the lymph vessels subjects them to daily possibilities of contamination. They may be acutely infected and actually break down by a phlegmonous process, or their lesions may be very slow, chronic, and intractable. The lymph nodes, like the leukocytes, are among our best friends; they serve as guardians at the various portals of the system, excluding, sometimes at the risk of their own existence, various deleterious elements.
The term “lymph gland” should be expunged from medical terminology, the node having, so far as known, no secretion nor any title to be considered a gland. This would mean abandonment also of the expression “lymphadenitis,” and so the writer would prefer to use the expressions lymphitis, lymphangitis, etc., which at least do not imply a wrong conception of the process. The morbid activity which the lymph nodes present will be an expression of the general virulence of the whole process which has produced it. To a tender enlargement, in acute cases, there will succeed rapid swelling, with pain and soreness commensurate with the density of the surrounding tissues and the degree of tension thus produced. The result is essentially an abscess, or multiple abscess, which necessitates prompt treatment by free incision, evacuation, and drainage, as does any other abscess. It is as often necessary to use a curette as a knife, and when so-called specific features are present, as in chancroidal bubo, a strong antiseptic should also be used. Under these conditions the collection of lymph nodes in the axilla or in the groin may become involved in multiple abscess, and it is then good practice to make a complete cleaning out of these regions. The ultimate effect of such extirpation is beneficial, and the patient does not seem to suffer from the loss of the involved lymph nodes; indeed, it is probable that new ones form to replace those which are destroyed.
The chronic affections of the lymphatics which come under the surgeon’s care are expressions of tuberculosis, syphilis, gonorrhea, cancer, or of some of the other less frequent surgical diseases. In every one of these instances the disease has assumed constitutional proportions, and the lymph-node involvement will be general. The ultimate fate of these affected nodes will differ with the different diseases; in tuberculosis they sometimes suppurate by secondary infection, and they frequently caseate, or remain enlarged for indefinite periods, often throughout life. Around them will be found an area of infiltration which produces firm adhesions and frequently makes their extirpation very difficult. The lymph vessels which connect the various nodes will also be involved in a similar process, which adds to the difficulty of operation. In many cases these involved nodes can be felt where they cannot be attacked—for example, in tabes mesenterica. If, under suitable climatic and constitutional conditions, it be possible to favorably affect other tuberculous conditions, these expressions of the disease may also subside or at least cease to trouble.[29]
[29] At date of going to press I do not feel justified in lauding too highly the work done by numerous workers with the opsonins. Justice to what has been done with and claimed for them demands, however, their extensive trial, and suspension of any judgment not as yet favorable.