THE LYMPHATICS OF THE LOWER EXTREMITY. 991 



either (a) chronic, of the nature of colicky pain due to interference with the intes- 

 tine and to gastro-intestinal disturbance, the presence of a tumor distinguishing the 

 case from one of simple gastro-enteritis ; or {d) those of acute intestinal obstruction 

 (RoUeston). 



The lumbar nodes may be enlarged from septic or malignant disease of the 

 lower extremities, the testes, the fundus of the uterus, the ovary, the kidneys and 

 adrenals, the sigmoid or rectum. The wide area thus drained by them exposes 

 them frequently to transmitted infection or disease. Their condition in the presence 

 of carcinoma affecting any of these regions or viscera has an important practical 

 bearing upon the question of operative interference, as, practically without excep- 

 tion, if they are involved only palliation can be hoped for. With an empty intes- 

 tinal tract and a thoroughly relaxed abdomen, even moderate enlargement of these 

 nodes may, in thin persons, be detected by palpation. In, persons with very mus- 

 cular or very fat abdominal walls, they cannot be felt until they have formed a con- 

 siderable mass. Their great enlargement — especially in carcinoma — often results in 

 swelling and oedema of the lower extremities on account of the obstruction to the 

 current in the inferior cava produced by the pressure of the dense indurated glands 

 which may quite encircle both that vessel and the aorta and may even interfere with 

 the circulation in the latter. 



The lumbar nodes often enlarge consecutively to enlargement of t\\e pelvic 7iodes 

 (obturator, gluteal, sciatic, internal pudic, external and internal iliacs), some of which 

 are also palpable — in thin persons — when the subject of carcinomatous infiltration. 

 The external iliac nodes, for example, lying along the anterior and inner aspect of the 

 external iliac vessels, may, when cancerous, be recognizable in this way, and may 

 be found by their tenderness — though less distinctly felt — in some septic cases. As 

 they receive the lymphatic vessels from the nodes of the groin, and the vessels 

 accompanying the deep circumflex iliac arteries, their enlargement may follow that 

 of the inguinal -nodes, or may result from septic or syphilitic or cancerous foci in the 

 supra-inguinal portion of the abdominal wall. In cancer of the testis the iliac and 

 lumbar nodes are in the closest relation to the ascending current of lymph, the 

 inguinal nodes, as a rule, being involved later, after the skin of the scrotum has 

 become infiltrated or ulcerated. In advanced cases of carcinoma of the rectum or 

 uterus, the obturator, epigastric and external iliac groups become considerably 

 affected. CEdema of the legs often results because (a) the enlarged nodes press 

 directly upon the external iliac vessels ; and {b) the lymphatics pass both over and 

 under these vessels to communicate with the obturator node and thus compress the 

 vein in a ring-like carcinomatous mass (Leaf). The pain felt in these cases is due 

 to the pressure of the affected glands upon the nerve-trunks arising from the lumbo- 

 sacral plexus. Similar pains may be felt when any of the pelvic glands are involved 

 as there is a similarly close relation between the obturator node and the obturator 

 nerve ; the gluteal, sciatic, and internal pudic nodes and the first and second sacral 

 and great sciatic nerves ; and the external iliac nodes and the anterior crural 

 nerve. The obturator group of nodes lying between the external iliac vein and the 

 obturator nerve assume surgical importance because sometimes the lowest node of 

 this group is found projecting through the crural canal. The relation of this node to 

 Gimbernat's ligament shows that when enlarged it would appear as a swelling occu- 

 pying a position similar to that of a femoral hernia (Leaf). Cases are on record 

 (White) in which an inflammation of this node has simulated a strangulated femoral 

 hernia. 



THE LYMPHATICS OF THE LOWER EXTREMITY. 



The Lymphatic Nodes. 



The Inguinal Nodes. — The principal group of nodes of the lower extremity 

 is situated in the inguinal region over Scarpa's triangle, where they form a consider- 

 able mass, placed for the most part between the layers of the fascia lata, and consist 

 of from twelve to twenty nodes united by connecting branches to form a plexus, the 

 plexus inguinalis. Though in reality forming a single group, they have been 

 divided for purposes of description into a number of subordinate groups which must 

 be recognized to have merely a conventional value. The first of these divisions is a 



