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General Outline Students of anatomy sometimes fail to grasp the relative importance of collecting applied data as compared to that of gaining a knowledge of the tissues, organs and general framework of the human body as outlined in texts on that subject. The physician in practice soon feels the need of greater knowledge of the various vessels, nerves and organs along the line of applied concept. As he advances in his work and studies his patients at the office and bedside, there comes a longing to know just what relation exists between the various parts of the body and the disease that he is endeavoring to diagnose. He wonders always, or should, how great an involvement is present in certain disorders where symptoms reveal specific pathological phases. In neuritis, for instance, he asks what change has taken place that has caused a normal nerve tone to be replaced by the symptoms so strikingly impressed upon the patient. He had been taught in college the general outline of the nerve tracts, their nerve root tracings and their relation to the groups of muscles. He also was taught the osseous framework and the relation of the nerves to the various bones. But in some instances he had never worked out in detail the applied part and felt that he did not understand the various stages of muscle tension as related to nerve instability and irritability. The various causes of the chemical change in the body fluids in perverted function, such as the possibility of lymph blockage through the malposition of certain bones, and the resultant organic disorders that allow a perverted blood supply to the walls or substance of an organ, and the lack of vasomotor control in some instances. As osteopathic physicians, we are more or less familiar with this follow through system, and we reason from cause to effect. We have familiarized ourselves with the general blood circulation both from an anatomical and physiological standpoint, and then the pathological. Applied anatomies have been written both from a surgical and osteopathic standpoint that deal with many phases from a very practical viewpoint. From these books we have learned much although we are yet in our infancy, so to speak, as to the real significance of applied work. As mentioned in the preface, no attempt as yet has been made to devote a book to the subject of the lymphatics in all its various phases. In dealing with the lymphatics first from an applied anatomy standpoint, we do not claim in any way to be adding any new anatomical features, but we hope to enable the student to get a mental picture of the various structures so that he will more readily grasp the significance of the causation of disorders in the body when symptoms manifest themselves. We want to emphasize, in considering the lymphatic system, the importance of any perversion of the tissues that may alter the function of any part of the body. In the various regions discussed, we hope to assist the student in clarifying the various influences that may have a bearing upon the structures affected thereby producing tissue changes to the extent of causing some bodily disturbance. The lesion theory, as propounded by Dr. A. T. Still, will be given first place in all our discussions, because we know that his reasonings were correct and can be demonstrated in any instance where there remains sufficient impulses to carry out this idea. We realize there are certain diseases so far advanced that the reflexes are lost and the nerve impulses so disturbed or feeble that it is quite impossible to restore normal functioning, but these cases are extreme, and we will consider more particularly those cases that are amenable to adjustment and restoration. In dealing with the lymphatic system, let us go about it in a manner that will first of all be broad enough in outline to realize that the body is a machine that is so correlated that if one part suffers there will be a corresponding reflex that will to some degree, at least, affect other parts or all parts. The tendency of the day is to specialize and narrow ourselves to the point of believing that any organic disturbance is a localized one, and that we must treat or deal with the affected part from a local standpoint. This must be overcome, and we must fix in our minds the fact that the circulation that bathes one part of the body one minute may be bathing a remote part a little later; that the lymphatic system is so arranged that the drainage continues to the point of emptying. The blockage at a point in the abdomen or pelvis will reflect itself upon the lymph flow possibly in the feet. We can also see how enlarged glands in the neck may cause any number of disturbances in the organs of special sense in the head. Insufficient stress has been laid upon the points of interference with the flow of lymph, and in these chapters on applied anatomy we hope to show, in some degree, the possibilities of many diseases being existent through a blockage of the lymph flow either in the nodes or vessels. Finally, we want to assist the student by demonstrating
that in any pathological condition there is invariably a relative lymphatic
disturbance, and try to show how adjustment will assist the body in clearing
up the retardation or obstruction.
NEW METHOD OF DIAGNOSING VARIOUS DISEASES BY PALPATING LYMPHATIC GLANDS.* (*First publication of the technique of the newest thing in diagnosis -- and it is OSTEOPATHIC. Editor, Journal of the American Osteopathic Association.) (Reprint of article by author from the Journal of the American Osteopathic Association, July, 1920.) Had Dr. A. T. Still lived a few years longer I sincerely believe he would have given to the world a vast amount of information regarding the lymphatic system. I have always felt that he had in his mind some information along the line of new physiology dealing with this subject. He hinted at the reduction of obesity by lymphatic control, and often mentioned the lack of knowledge and research in relation to the lymphatics, but we could never draw any definite conclusions as to his reasonings. One day, twenty-three years ago, I ventured to ask him regarding the significance of the lymphatic system, but he passed the subject, by simply stating that he was still experimenting along that line. Recognizing that there was a field only partially worked out, I set about to determine if I could discover any hidden truth that might be of value to the osteopathic profession. My first observations were rewarded, some sixteen years ago, by a revelation that gave me grounds for further research. The idea was so new I did not feel like announcing it until I had satisfied myself that there was sufficient merit in the theory to warrant its publication. Three times during the past few years I have ventured to throw out a few suggestions. One reference to the matter pertained to swellings found in the breast and their relation to axillary disturbances; a second was the inguinal disturbance found in the right groin in cases of appendicitis; and the third, published in the May number of this JOURNAL, dealt with enlargement of the lymphatic glands from outside infections and inoculations. Allow me to state that I believe that few, if any, physicians have made it a regular part in their diagnostic work, year in and year out, to carefully examine the condition of the various lymphatic glands as a part of their examination of patients, also the following up of the state of these glands from time to time in cases where lymphatic enlargement was found. This calls for the development of a peculiar touch, as palpable glands vary so much in different systemic conditions that it is almost incredible the number of phases these nodules assume. For several years I have based, almost conclusively, my diagnosis as to the surgical or nonsurgical nature of the appendix upon the state in which I found the inguinal glands. They serve as an index to the pathological condition existing around the caccum and appendix. As stated above, I almost hesitate to announce this new method of diagnosis and suggest that you will not criticise too severely until you have gone through a period of personal findings, and have satisfied yourself as to the merit of the method. I shall not try to cover in this article all of the diseases in which lymphatics are disturbed, but simply refer to three or four disturbances, and leave it to you to think over and experiment for yourself. Going back to appendicitis, let me state that you will first have to familiarize yourself with the various conditions found in the inguinal region. It is well to always palpate carefully both groins, first with the limbs extended, and then flexed. When the limbs are extended, the glands, if present and enlarged, will present a different feeling than when the knees are bent. The subject has so many phases that I find it difficult to describe in a brief article the thoughts that will bring out the most striking features. About the first thing that you will suggest is the question. How can you differentiate when there is a pelvic congestion, such as when a right ovary or tube is involved, also, how can you distinguish if there exists an infection of a venereal nature. To say that it is easy would be foolishness, but to state that skill will follow long research would be on a par with the statement that months of practice are often necessary for the student to detect some hidden spinal lesions. We are all quite familiar with the almost set type of glandular inguinal enlargement found in gonorrhea, for instance. The nodules are usually quite enlarged and often indurat ed. They ebb and flow, so to speak, as the disease is acute and active, or subside with lack of congestion in the sexual organs. I will admit that one difficult diagnosis to make is when appendicitis is conjointly found with venereal infection. Should there be simple ovaritis or salpingitis, with no venereal infection, we usually find a disturbed lymphatic condition, accompanied with certain reflexes. Ovarian colic or cramps, or a hypersensitive hypogastric plexus will enable the examiner to determine the presence of tubal congestion. In a case of appendicitis, with apparently no complications, if pus is present and the caccal area is involved, the inguinal glands are found slightly elevated and their nodular surfaces under the skin readily palpable. This condition I have almost invariably found and verified by judging as to the advisability of referring the case to a surgeon on the strength of the amount of nodulation. In a test covering a period of four years, some seven years ago, I treated three hundred and ten cases, with the result that three had to be operated upon after a trial to reduce congestion. That was a small percentage. At one time I was treating eight cases that had been told to be operated upon within twenty-four or forty-eight hours. This strain was not small, as I appreciated the significance of the situation. Fortunately I was rewarded by bringing these eight cases out of danger and I followed up the acute attacks with corrective work. I relied entirely upon my diagnosis in relation to the inguinal glands. In the March number of the A.O.A. JOURNAL, 1916, there is a colored plate showing the lymphatic glands of this region. The breast region is also a most significant one, in that the axillary region is so directly concerned. Surgical operations for removal are so very common that one almost wonders where it will end. It is not uncommon to find lumps or swellings in one or both breasts. The significance of these tumors depends upon the amount of lymphatic involvement of a general nature. If you will carefully trace the channels back to the axilla in relation to the pectoral muscles, you can quite readily determine the amount of glandular involvement. If the axillary region is comparatively clear of nodules, and there seems to be no particular blocking of the connecting channels, it is usually safe to say that the lumps found in the breast are not of a malignant type, and may be reduced indirectly by corrective work. As a rule, malignancy of the breast follows axillary warning of some duration. Traumatic injuries of the breast should be attended to at once, as the tendency is toward circumscribed induration, with secondary lymphatic complications. Possibly the most patent instance of lymphatic abnormality is found in the throat. We are all familiar with the “kernels,” “lumps,” and peculiar nodular enlargements found in children as well as in adults accompanying various epidemics and tonsillar infections. In children we have a range of swollen glands, from those found preceding measles, chickenpox, etc., to those noted in scrofular and tubercular diseases. Accompanying a simple rhinitis we often note a marked disturbance, while in tonsillitis, even in the adult, there may be a most aggravated lymphatic disturbance. One more instance and we will close this abbreviated article. The final reference is to septic infection of the lymphatics of the popliteal space by absorption of material, including perspiration, dirt, and dyes from stockings, through soft corns and skin abrasions between the toes. We are all familiar with blood poison and lockjaw from plantar punctures by rusty products, with dirt and cloth carried into the wound. The resulting symptoms may include lockjaw. Examining carefully the popliteal regions, in all cases where a general examination is made, I have frequently observed enlargement of these glands when this space should be comparatively clear. Upon removing the stockings or the socks, as the case may be, I have found in a number of instances skin abrasions between the toes. Through these cracks or denuded slits perspiration, dust, or dyes are constantly being absorbed, and the resultant effect is noted upon the nodules in the space behind the knee. After instructions, and the careful healing of these tissues between the toes, I have noticed the disappearance of the nodular swellings. This last reference does not pertain to the diagnosing of a hidden trouble, as in the instance of pelvic and breast involvement, but carries out my idea that infection of a part is invariably manifested by nodular interference at the nearest gland center. Some other time I may write on other findings, especially
the determining of the degrees of tuberculosis by lymphatic enlargement,
according to the region of the body diseased, but I have given you my ideas
in part as to the possibilty of diagnosing more accurately the degree of
infection or accumulation of toxic products by lymphatic manifestations.
A LYMPHATIC EXAMINATION This is an innovation. We have been accustomed to general and special examinations, but to set out to make a lymphatic examination is a new departure. We have made a chart blank that outlines the points where the physician is most likely to find lymphatic variations and disturbances. First of all, let us consider the lymphatic system as a whole--a general circulation, yet subsidiary to that of the vascular system. We find that there is a field for applied anatomy
of the lymphatics just as of other tissues of the body. We find lymph
blockage and nodular enlargements, hyperplasia and adenitis, also in some
instances a backing up and a reverse in the flow of lymph. This has
been described in connection with the gastric lymph vessels by noted surgeons.
There is an ebb and flow, so to speak, in the lymph stream. To illustrate this point we will note that when there is mesenteric blockage or pelvic lymph nodular adenitis a corresponding disturbance is found in the lymph areas of the popliteal space; also a slight edematous condition in the ankles, usually on the outer side just in front of the external mallcolus. Again, we note where there is a puffiness above the clavicles, on one side or both, a corresponding blockage of the lymph stream exists either at the emptying point of the thoracic duct and right lymphatic duct, or we will find an over-burdened thoracic duct from too much tension or too great an accumularion of lymph. The system is constantly trying to clear itsself and the clearing house is partly made up of the lymphatic system. Again we note a puffiness around the eyes. There is a cause for it. If we trace the lymph stream, we will soon discover that there is a blockage in the cervical nodes, or possibly the submaxillary, or nodes in the parotid region. There may be lesions causing tensed muscles that prevent a free drainage. In all of the lymph nodes and vessels in the throat and neck there is a possibility of blockage. There is also a possibility of lymph obstruction through the enlargement of the salivary glands or a subluxation of the mandible or hyoid bone. The puffiness of the eyes may be due to over-burdened kidneys, and an enlarged liver. Disorders of the spleen may also cause it when the system is loaded with toxic products and elimination is faulty. We may look then for a lymph stream blockage and puffy areas in certain regions. Thus we see it is well to examine for areas of lymph obstruction where there are evidences of edema. Now that we have this viewpoint in mind, let us proceed to make our lymphatic examination. With the blank before us, we will start always at the emptying points of the lymph tubes or ducts. On both sides these ducts empty into the subclavian veins. If the drainage is fairly perfect there will be no puffiness above the clavicles. If there is a blockage or over-loading, we will observe edema. Let us take the presence of edema on the left side and work out our examination and diagnosis. The second point we will note will be the axillary region (No. 5). Note any nodular enlargement or adenitis, and if present trace out the cause. See if there has been a recent scratch or abrasion of the skin on arm, forearm or hand. If there has been, note the presence or absence of pus or even a blister. Also note the vasomotor tone in the entire arm. Cold hands affect the lymph stream. Should there be signs of a recent vaccination or serum injection, determine the amount of axillary adenitis that existed at the time. Next, palpate over the mammary region and note enlargement of nodes and extent of induration if present. Connect up the arm and pectoral regions, lymphatically speaking, and determine which area was first affected and to what extent. Note carefully what quadrant of the breast is nodulated, and whether they are deep seated nodes or superficial. Go over the thoracic vertebrae and costal areas, and determine the number and significance of lesions. Adjustment of vertebral and costal lesions may clarify the nodular enlargement if no abrasions or recent vaccine or serum injections have taken place. We will go back to the neck now and palpate for superficial and deep nodular enlargements (No. 6). Note presence or absence of goitre, and determine if there have been recent symptoms of laryngitis or pharyngitis. The presence of muscle tension and venous stasis will be of value in tracing the lymph blockage. Corresponding bony and muscular lesions may be found, and lymph nodes enlarged to the extent of irritating the nerve cords in the neck. If there exists any congestion of tissues due to tonsillitis, abscessed teeth or sinus infection, note the effect on the cervical lymph nodes. Determine, if possible, the amount of lymph suspended and retained in the vessels and nodes at all points above the hyoid region (No. 7). After testing and palpating the various nodes and edematous areas, including the tonsillar and faucial areas, try and determine the relation of this blockage to that found in the terminal area, back of and above the clavicles. Again, we note the lack of drainage, if present, from the bronchomediastinal trunks. Following bronchitis or a pleuritic infection, there may be a difficult drainage that will reflect itself upon the tissues above the clavicles. How often in throat and bronchial troubles we note not only cervical nodular enlargement, but that peculiar puffiness above the clavicles which is so hard to reduce unless we reason out just why this blockage exists, and drain the lymph vessels. In this brief chapter we must necessarily point out only a few of the cardinal points. A thorough examination including all applied anatomy findings would fill a book. We will recall our anatomy teaching regarding the collection of lymph on the two sides. This will explain the suggestion just made that more often we find edema in the left supraclavicular region. The epigastric region we will next discuss briefly (No. 4). The liver, from a lymphatic standpoint, is more significant than the spleen. The tendency of the liver to enlarge and become torpid and sluggish makes lymph drainage uncertain. Part of the liver’s drainage is above, and eventually empties into the right lymphatic duct or indirectly into the thoracic duct in part. The principal lymph vessels drain into the thoracic duct along with the drainage of the stomach. If the patient is thin, you will observe on palpation a peculiar enlargement of the receptaculum chyli when the knees are flexed. Sometimes you can palpate the larger nodes and you can press the abdominal aorta so readily against the receptaculum chyli that you can cause the pulse beat to fluctuate. I have palpated the receptaculum chyli when it could almost be picked up with the finger tips in a thin person when there was a heavy mesenteric blockage. Splanchnoptosis and venous stasis combined with ovarian congestion or appendicitis, will soon prove to you the great amount of blockage that takes place in the receptaculum chyli and thoracic duct. In pelvic congestion the nodes are markedly enlarged, as you will determine by special local examinations, vaginal and rectal. The inguinal glands (No. 3) will reflect not only pelvic congestion but appendicitis. The lymph blockage of the mesenteric glands and in the receptaculum chyli will reflect itself upon the inguinal glands by a blockage of lymph. Lastly, we will go briefly over the lower extremities. Palpate over the popliteal space (No. 2) with patient on the back, and then with patient standing. You will find a new viewpoint when you make this double test. Look for varicose veins, even small ones; also palpate
the calf muscles deeply between thumb and fingers and determine presence
or absence of stasis. Recently I noticed a lymph disturbance in inquinal
region due to a bruise on the thigh; also a popliteal lymph enlargement
due to a soft corn. Go over the ankles (No. 1) and look for any swelling
that would indicate a lymph blockage higher up. Again, note vasomotor
tone in blood vessels and observe the effect upon the lymph nodes in popliteal
and inguinal regions.
Summary 1. For every congested tissue there is a corresponding
lymph disturbance.
In school we used to spend a few days on the subject of lymphatics. Five years from now, or less, students will receive daily instruction on this subject. It will be embodied in texts on applied anatomy, and each organ and area will be considered from a lymphatic standpoint. Under the discussion of every diseased organ or tissue a few paragraphs will be included referring to lymph drainage. We have devoted much time in the past to a study of the vascular system in all its details, but have neglected to a great extent the tracing of lymph flow and in accounting for edematous areas that indexed the amount of venous stasis and lymph blockage that existed. We have paid so little attention to the lymph stream that we have not gone beyond a few findings in two or three regions, usually the cervical, axillary and inguinal. Let us spend a few minutes going over the principal findings that should be included in every examination, and at every treatment. In the first place, wherever there is venous stasis there is bound to be lymphatic disturbance. We will take the mesenteric region first. We recall the innervation and vasomotor control of the vessels in this area. With the osseous lesions that may cause an interference with peristaltic action, secretion and vasomotor control, we are familiar. If there is ptosis and stasis we must naturally expect lymph blockage. The receptaculum chyli that drains this region is readily blocked when the above conditions exist. We cannot expect to correct these changes in blood and lymph streams unless we first of all correct the ptosis. Organs that have sagged cause pressure on vessels and lymph channels. Neither can we expect to free lymph drainage unless there is a normal thoracic duct passage. If there exists a puffiness back and above the clavicle on left side we must see that the edema is reduced before we attempt drainage at a point in the region of the receptaculum chyli. This will necessitate correction of lesions from the cervical area down to the pelvis. It would be useless to correct cervical and thoracic lesions if a sacrum was tilted sufficiently to cause an unbalanced spine. We must also work to restore normal impulse to the mesenteric vessels in order that venous stasis will disappear. Normal relations will come about only by correction of all lesions causing ptosis and misplacement. A sagged stomach dragging over the thoracic duct and receptaculum chyli will interfere with lymph drainage. Venous stasis must be cleared up by securing first of all a normal liver condition. Any lesions affecting the various functions of the liver will check the clearing of the veins and lymph vessels. It is in this region that we find the many tumors, benign and malignant. The lymphatics are involved, the nodes enlarged, and lymph vessels obstructed. If you want to see this object lesson make a few post mortems in cancer of stomach or associated parts and observe the lymph blockage. While venous stasis is relatively important, yet we believe lymph blockage the more significant in foreign growths and in congestion. While venous stasis may precede lymph blockage, yet it is the lymph disturbance that spells disaster to the tissues. In the final analysis the veins are much less important in relation to a pathological phase than are the lymph vessels and nodes. It is easier to re-establish venous drainage than lymph drainage. The nodes once enlarged and indurated are not easily reduced. True, the lymph vessels have valves more numerous than the veins, but they also have a lesser calibre and the lymph flow is constantly checked by the flow through the nodes. While some nodes have vasomotor nerve fibres, the blood vessels are much better supplied with these fibers. Thus we have to contend in lymph blockage first, with a venous stasis that must be cleared, then a lymph drainage that must include a reduction of the nodes when enlarged, and a free lymph flow at the terminals of the lymph ducts. The blood vessels that supply the nodes may have vasomotor nerves, but we must depend in freeing the lymph stream upon indirect vasomotor control through the nerves to the vascular system. The vasomotors to the nodes are not constant. Again, in order to clear the lymph stream in the mesenteric region, we must consider the possibility of an unusual lymph flow from the pelvic region. If this exists there will be found an additional tax upon the receptaculum chyli from the lymph below, and this additional burden upon the thoracic duct in cases of pelvic disturbance will make mesenteric drainage more difficult. Normally, the receptaculum chyli and afferent ducts are sufficiently taxed, but abdominal and pelvic venous stasis will overtax the lymph stream in every instance. This will reflect itself upon the lymph drainage of the various organs in this region and only the insurance of a normal venous and lymph flow will clear the area and remove the tax upon the lymphatics of the receptaculum chyli. The majority of ailments of the human body have their beginning in the epigastric region. A sluggish, inactive liver may start a stasis and lymph blockage that will reflect itself upon not only the immediate organs and tissues but, by blockage, prevent pelvic drainage of the lymphatics. We will then note a little puffiness in the ankles, a similar condition back of the knees in the popliteal spaces, and unless we free the ducts and chyli nodes, the edema will persist. It is easy to block drainage below the second lumbar segment. An obstructed alimentary tract will produce lymph blockage very nicely. A lessened vasomotor tone will also block the lymph vessels and nodes when venous stasis is present. There must be tone and there is only one way to get tone, and clear the congestion, and that is by good technique and specific corrective work. You will recall the peculiar vasomoto control in the mesenteric region. The second relay, so to speak, to give extra impulse to the mesenteric vessels. This will call for lesion findings, and corrections higher up than is usually found in other organic disturbances. It is well to re-read anatomies occasionally and keep in mind the nerve centers that control the vasomotors. It is through these nerves that we make headway in clearing stasis and secondary lymph blockage. In this brief chapter we can discuss only one region, but we have tried to emphasize a fact that may be applied to any lymph area, namely, that a venous stasis will invariably cause a lymph blockage. We have not included in this chapter conditions where lymph obstruction maya be primary, such as direct poisoning of the system through introduction of vaccines, serums, or ptomaine substances. This phase of the subject must be dealt with from a different angle. |
