Part 196

Scurvy, and conditions of the blood analogous to those produced by that disease, make it almost certain that if pleurisy or pericarditis occurs while these conditions exist, it will be hemorrhagic. I am not, personally, acquainted with a single instance in which peritonitis in this condition has occurred. Copeland, however, says that hemorrhage in peritonitis has been noticed by Broussais and others. The blood is mixed {1181} with the serum and stains the surface of the false membrane, as in hemorrhagic pleurisy and pericarditis, and the disease is of an asthenic type, "occurring in the hemorrhagic diathesis." "The symptoms are inflammatory from the beginning, and rapidly pass into those indicating great depression; the pulse becomes rapid, small, and soft, death quickly supervening, with convulsions, cold and damp extremities and surface," etc.

Copeland has himself not seen a case, and regards its occurrence as very rare. Delafield states that "Friedreich describes two cases occurring in patients with ascites who had been frequently tapped. He says that both the parietal and visceral peritoneum was covered with a continuous membrane of a diffuse, yellowish-brown color, mottled with small and large extravasations of blood. The membrane was thickest over the anterior abdominal wall. It could be separated into a number of layers. These layers were composed of blood-vessels, masses of pigment, branching cells, and fibrillated basement substance. In many places the extravasated blood was coagulated in the shape of round, hard, black nodules. The new membrane could be readily stripped off from the peritoneum, and there were no adhesions between the visceral and parietal portions of the peritoneum."

The erosions of abdominal cancer sometimes open vessels of considerable size, causing large hemorrhage into this cavity and sudden death.

When aneurisms of the abdominal aorta rupture, they sometimes flood the abdominal cavity; oftener they open into the structures under the peritoneum on the left side, and make a large flat tumor extending from the point of rupture downward to the brim of the pelvis, and even beyond it.

A gentleman whose health was usually good, thirty-five years of age, felt an unwonted exhaustion and feebleness creeping over him. His countenance became pale, his pulse rapid, growing smaller and smaller. It seemed certain that there was hemorrhage somewhere, but until it was noticed that the bowels were growing tumid and hard there was nothing to guide us to its seat. Even then we were left to conjecture regarding the bleeding vessel. This sinking continued for thirty-six hours. After death it was found that a small aneurism had been formed on one of the vessels of the omentum, not larger than a small walnut, and had ruptured by a very small opening, and that it was by this small opening that life had oozed away.

Bleedings from stabs and other wounds of the bowels, from lacerations of the liver, spleen, uterus, and sometimes of the kidneys, should be mentioned in this connection; but as they, for the most part, fall into the hands of the surgeons, this is not the place to give the details regarding them.

{1182}

DISEASES OF THE ABDOMINAL GLANDS (TABES MESENTERICA).

BY SAMUEL C. BUSEY, M.D.

DEFINITION.--Tabes mesenterica may be briefly defined to be tuberculosis of the mesenteric glands. This definition may seem too limited, because it recognizes the identity of tuberculosis and scrofulosis of the lymph-glands, and excludes those hyperplastic conditions which do not certainly undergo the cheesy degeneration. It is supported, however, by the absence of any essential difference in the histological changes which take place in tuberculous and scrofulous (Wagner) lymph-glands; by the frequent simultaneous occurrence of each in the same subject; by the secondary development of tubercles during the course of scrofulous affections; and by the fact that the cheesy transformation is alike common to both these conditions of new formations. Schüppel maintains that the presence of tubercles is necessary to the production of the cheesy metamorphosis of lymph-glands, and that "scrofulous glands are always tuberculous glands." In this view Rindfleisch coincides, and expresses the belief that the inflammatory and hyperplastic changes are secondary to the formation of the tubercles. Birch-Hirschfeld asserts that cheesy degeneration of the mesenteric glands is always accompanied by tubercular formations.

This definition is therefore adopted as the expression of the result of the most recent investigations. It must, nevertheless, be admitted that a few equally competent observers deny the identity of the tuberculous and scrofulous new formations in lymph-glands. It must also be conceded that occasionally hyperplastic processes in the lymph-glands undergo the cheesy metamorphosis independent of tubercular development.

SYNONYMS.--The differences of opinion, especially among the older authors, in regard to the nature of this disease are very distinctly indicated in the varying significance of the numerous synonyms, of which the following list is only a part: Atrophia mesenterica; Atrophia infantum (Hoffmann); Febris hectica infantum (Sydenham); Scrofula mesenterica (Sauvages); Paralysma mesentericum (Good); Physconia mesenterica (Baumes); Mesenteritis chronica (Stewart); Mesenteric fever, Hectic fever, Marasmus (Underwood); Carreau, Entero-mésentérite of the French; Darrsucht der Kinder and Gekröschwindsucht of the Germans; Tubercles of the mesentery; Tuberculous disease of the abdomen; Phthisis mesenterica; Tabes glandularis; Tabes scrofulosa; Macies infantum; Pædatrophia; and Rachialgia mesenterica.

{1183} Some of these synonyms indicate the theoretical and unsupported opinions of their authors, and others refer merely to a symptom. The name carreau refers to a hardness of the abdomen; physconia, to the presence of a non-fluctuating and non-sonorous abdominal tumor; and that of entero-mésentérite presupposes a secondary origin from a primary enteritis. Good classes it among his numerous varieties of mesenteric turgescence, but characterizes this special form as a scrofulous turgescence always associated with the strumous diathesis. The terms tabes and atrophy originated when the nomenclature of disease was derived from symptoms, and not from pathology.

HISTORY AND PATHOLOGY.--The history of tabes mesenterica is coeval with that of scrofula and pulmonary consumption. The ancient authors recognized the existence of a chronic disease of the mesenteric glands, characterized by enlargement and induration, followed by destruction of the gland-parenchyma, which was associated with digestive disturbances, emaciation, hectic fever, and usually terminated in death. At first, the degenerative process was regarded as suppurative. But as the study of scrofula progressed, and frequent observations were made of the occurrence of disease of the external lymphatics and of the mesenteric glands in the same subject, disputes arose as to the identity of the two affections. These controversies led to the general acceptance of the belief that the scrofulous degeneration of lymph-glands and the process of destruction in tabes mesenterica were identical. Consentaneous with these investigations, and for a long time subsequent, even down to a very late period, which is, perhaps, not yet concluded, the relation of scrofulous disease of the lymph-glands to pulmonary consumption was discussed and studied with great assiduity. As the knowledge concerning these diseases advanced, and the results of investigations were accepted, the doctrine of the identity of the morbid processes in scrofulous disease of the external glands and mesenteric phthisis became firmly established. The history of scrofulosis and tuberculosis cannot be separated. The connection and identification of the two processes have been subjects of constant discussion from the discovery of tubercle to the present time. Occasionally, the dividing-line seemed definitely fixed. Then would follow the general acceptance of the doctrine of identity. With the discovery of miliary tubercle a determined reaction took place against this view, and for a while many regarded scrofulosis merely as a form or stage of tuberculosis. As the conclusions in regard to these questions changed, so did the opinions concerning the true nature of tabes mesenterica change, until, finally, the investigations of Rindfleisch, Schüppel, and others seem to have established the tuberculous nature of the disease. Many authors of a comparatively recent date have applied the term tuberculosis to this condition, not because they knew or believed the development of true tubercle was a constant or essential characteristic, but because they regarded the words scrofulosis and tuberculosis as synonymous.

Notwithstanding the obscurity in which, for so long a time, the pathology of this disease was involved, certain facts well known to the earliest writers have been confirmed by continuous observation down to the present. Its secondary character has been so uniformly recognized that some of the older authors based its origin upon the absorption and conveyance along the lymphatic vessels to the glands of some peccant material originating {1184} in a primary focus of disease. The constant coexistence with scrofulous affections and pulmonary consumption had long ago established the direct and primary relation of these diseases to tabes mesenterica, and authors of recent date, though not so generally holding the opinion that it is always an intercurrent complication of these maladies, yet maintain its secondary development. Even Schüppel, whose investigations and conclusions lead in the direction of an idiopathic origin, admits that the only primary element is the tuberculosis, which finds its cause in some peripheral irritation.

In the earlier times, as now, tuberculosis of the mesenteric glands has been observed during every period of life from birth to advanced old age, but then, as at the present time, the greater number of cases were known to occur during infancy and childhood. But few cases have been observed during the earlier months of life or before weaning. Between the ages of two and eight years is the period of greatest frequency. Though rarer during the later years of childhood, the older the child the more rapid its progress to a fatal termination. Nursing infants are not exempt, but those nursed by healthy mothers are much less liable than the wet-nursed. Among hand-fed infants it is not an uncommon disease, but it is much more common among the farmed-out children. While, as has been stated, the greatest number of cases occur in those between two and eight years of age, statistics show that the liability to it increases from the age of two and a half years up to the eighth, and, according to some authors, up to the tenth year. At the latter age there is a remarkable diminution in the number of cases. This fact is probably due to the greater prevalence of the acute diseases of the respiratory organs and of the exanthematous diseases among children during this period of life. Some have attributed it to the more rapid development and increased functional activity of the mesenteric glands. This circumstance might afford a plausible explanation for the apparent sudden increase in frequency after the completion of the second year because of the independent subsistence of children at that age, and the additional duties imposed upon the alimentary tract and its dependencies; still, if this were so, the period of greatest frequency ought to begin at an earlier age and more nearly correspond with the time of weaning. It is, however, a fact that tubercularization of the mesenteric glands is more frequently associated with chronic intestinal inflammation in those over one year than in those under that age. This fact, together with the greater liability of artificially-fed infants, would seem to connect, at least in such cases, its secondary origin with some primary irritation of the intestinal canal.

Authors are not yet agreed in regard to the relative frequency of this disease in boys and girls, though opinions predominate in favor of the greater number among the males. The statistics of Rilliet and Barthez and Schmalz show a decidedly greater prevalence among boys.

The comparative frequency of tuberculosis of the mesenteric glands cannot be determined. Louis found disease of the mesenteric glands in one-fourth of the autopsies of persons dying of phthisis; in 100 adults dying of the same disease Lombard found tuberculosis of these glands in 10; and in the bodies of 100 tuberculous children he found the glands tuberculous in 34 cases. In the Hôpital des Enfants Maladies tubercles were found in the mesentery of one-half of the children dying of {1185} tuberculous affections. In the bodies of children dying of tuberculous disease in the Children's Hospital of Washington tuberculous degeneration of the mesenteric glands has been found in two-thirds of the cases, and without a single exception in those dying of rickets. Authors differ also, and the statistics are equally unreliable, in regard to the relative frequency of tubercularization of the bronchial and mesenteric glands. The general opinion seems to be in favor of the greater frequency in the bronchial glands. In a majority of cases both sets of glands are found diseased.

The geographical distribution of tabes mesenterica is as universal as that of scrofula and pulmonary phthisis. No country or climate is exempt, yet there is no locality in which it is endemic. It has been observed among all civilized nations, in the cold regions as well as in the tropical countries. Wherever scrofulous and phthisical diseases are known, there also are found cases of tabes mesenterica. Livingstone has stated that scrofula is unknown in some regions in Central Africa, and other travellers have made similar statements in regard to some Indian tribes. The statistics of the Children's Hospital of Washington show a far greater frequency among the African race than among the whites. It belongs to no class or condition of life, but occurs more frequently among the children of the squalid than among the children of the affluent and well-to-do.

ETIOLOGY.--Predisposing Causes.--Modern as well as the older authors have very generally accepted the conclusion that a constitutional tendency or liability to this disease is its most frequent and potential etiological factor. This predisposition may be either inherited or acquired. The ancients called it the strumous, and the more recent writers the scrofulous or tuberculous, diathesis. Lugol maintained that this diathesis is begotten of old and syphilitic fathers, and others state that children of parents nearly related and of those broken down by disease and excesses may inherit it. That it is transmitted by scrofulous and phthisical parents no one can doubt, but as yet it cannot be defined to be anything more than a peculiarity of the constitution which may exhibit abnormal reactions against irritating influences. The scrofulous habit is believed to be indicated by physical appearances which represent two extremes. The erethic form is characterized by a feeble and delicate frame; deficient muscular development; transparent, smooth, and florid skin; light hair and blue eyes, large pupils; precocious intellect and sanguine temperament; the torpid form, by a large head; large and tumid upper lip; soft and flaccid flesh, bloated appearance; short and thick neck; muscular incapacity, tumid abdomen, and sluggish intellect. Some of these features are more frequently symptoms of the actual disease than of the existence of a predisposition to it, and, except so far as they may refer to a primary scrofulous or pulmonary disease, cannot be accepted as indicative of the presence of a constitutional tendency to tuberculosis of the mesenteric glands. A tumid abdomen, rapid emaciation, and anæmia are far more valuable signs of the disease of these glands.

Bad air and bad food are also important predisposing causes. They are conditions to which the children of the poor, especially in large cities, are constantly exposed. Insufficient protection from climatic influences, neglect of person, and unhygienic surroundings must be classed in the same category. It is claimed that vitiated air, unwholesome habitation, {1186} insufficient or improper food, squalor and filth may cause the constitutional tendency, as they will certainly precipitate the development of the disease in those predisposed to it.

Exciting Causes.--The border-line between the predisposing and exciting causes cannot be positively fixed. The presence of tuberculosis or of some form of scrofulous disease in some other part of the body so constantly precedes the development of tuberculosis of the mesenteric glands, even in those who have not exhibited the characteristic phenomena of the scrofulous diathesis, that such affections must be regarded as exciting as well as predisposing causes. No one can doubt the frequent infection of the mesenteric glands in cases of pulmonary tuberculosis. The probability of systemic infection from a single focus is universally admitted. These facts and circumstances do not exclude the possibility of localized tuberculosis of the mesenteric glands. Whether such exclusively local development of tubercles ever occurs independent of the scrofulous diathesis cannot be determined, but that the disease does find its exciting cause in inflammatory conditions of the intestinal mucous membrane cannot be doubted. Schüppel, who asserts the primary development of the tubercle-formation in lymphatic glands, does not claim an idiopathic origin, but admits the necessity of a primary peripheral irritation in direct connection with the affected gland. The intimate connection between diseases of the intestinal mucous membrane and of the mesenteric glands is established beyond a doubt. Vogel and Steiner assert that tabes mesenterica is a common result of enteritis folliculosa. A primary inflammatory process may not contain any element which could be classed as tubercle, yet it may excite secondary tuberculosis of the glands. Whether such a result only occurs in those who may have acquired or inherited the predisposition is yet undecided. In many of the cases of tabes mesenterica tuberculous ulcers are found in the intestines, but it cannot be claimed that such ulcers are always the primary foci of tuberculous development. If primary, it is not difficult to understand how the virus may be transmitted to the glands.

It has been claimed that certain articles of food will produce the disease. Potatoes and rye bread in large quantities and a coarse vegetable diet have been mentioned among the exciting causes. Deficiency in the quantity of food is a much more frequent cause than inferiority in quality, yet there can be no doubt that any and every article of diet that will set up catarrhal inflammation of the intestinal mucous membrane may become a cause. Irritation of the mucous membrane of the alimentary tract, induced by coarse, stimulating, or imperfectly-digested food, or by the improper and frequent use of purgative medicines, may give rise to disease of the glands; and, even though the irritation may in itself be trivial, its long continuance or frequent renewal may prove sufficient, especially in those in whom the predisposition is present. Malarial and exanthematous diseases have also been considered exciting causes, and among the latter class measles and scarlet fever, because of the inflamed condition of the intestinal mucous membrane which they leave, are the most frequent. Difficult dentition and whooping cough must also be classed in this category.

Recently attention has been called to the probable transmission of the disease through the milk of diseased cows, but further investigation and {1187} more reliable data are necessary to establish this connection. Klebs has deduced the conclusion from recent experiments that the use of the milk of cows in advanced phthisis will always produce tuberculosis, which begins as an intestinal catarrh and extends to the mesenteric glands.

Some of the older authors believed that the cure of some chronic diseases of the skin and mucous membranes and the suppression of chronic discharges might induce tuberculosis of the mesenteric glands; but these conditions are now known to be most frequently the initial manifestations of the scrofulous diathesis, and the mesenteric complications are far more likely to occur when these primary foci are neglected and the patient is left to suffer the unabated progress of the disease.

MORBID ANATOMY.--It is not usual to find all the glands of the mesentery affected at once, nor of those affected all in the same stage of disease. Newly-affected glands may be found alongside of others in an advanced condition. In the first stage the glands are enlarged, but rarely exceeding the size of a filbert; they are firm, but not inelastic. This change consists in hyperplasia of the gland-constituents. Microscopic examination shows abundant cell-proliferation, but the cells are badly constructed and prone to undergo retrogressive metamorphosis. The cells accumulate in clusters without any intercellular substance, and compress the lymph-sinuses and blood-vessels.

The second stage is characterized by the commencement of the cheesy degeneration. The glands enlarge and coalesce in clusters, sometimes forming large masses of hardened and inelastic glands. On section they exhibit in the beginning foci of cheesy material imbedded in the gland-parenchyma. In the further progress of the change the whole gland is transformed into a homogeneous yellowish substance. In this condition there are found on microscopic examination globular corpuscles, nuclei, shrivelled cells, sometimes giant-cells, and most frequently tubercles. The tubercles are usually found in the follicular substance. Birch-Hirschfield says the cheesy formations in secondary tuberculous mesenteric glands are only found in discrete foci, and the tubercles occur in the follicular substance imbedded in relatively normal tissue. The cheesy transformation is, according to Virchow, a necrobiosis of the hyperplastic gland-elements, but Schüppel insists that it is the result of tubercular development. After a time the cheesy masses soften, and the glands are converted into sacs containing a purulent fluid mixed with débris. In this condition they are most frequently coalesced in bunches, sometimes forming large tumors. The intervening walls may break down and the whole bunch be transformed into one large sac filled with purulent fluid and débris. Occasionally these masses of agglutinated glands become adherent to the abdominal parietes or to the intestines. Rupture of their walls may occur, and the contents may be emptied into either the peritoneal cavity or the intestines. When communication with the intestines takes place, it is usually through an ulcer on the mucous surface. It is probable that the cheesy substance may sometimes be absorbed, as Virchow thinks, by gradual softening proceeding from the surface toward the centre.

It is believed that these degenerated glands sometimes undergo the cretaceous transformation. Such an instance has been reported by Carswell: "The patient, who when a child had been affected with tabes {1188} mesenterica and also with swellings of the cervical glands, some of which ulcerated, died at the age of twenty-one years of inflammation of the uterus seven days after delivery. Several of the mesenteric glands contained a dry cheesy matter mixed with a chalky-looking substance; others were composed of a cretaceous substance; and a tumor as large as a hen's egg, included within the folds of the peritoneum, and which appeared to be the remains of a large agglomerated mass of glands, was filled with a substance resembling a mixture of putty and dried mortar, moistened with a small quantity of serosity. In the neck, and immediately behind an old cicatrix in the skin, there were two glands containing, in several points of their substance, small masses of hard cretaceous matter." Calcareous concretions have been observed by Andral and others in the mesenteric glands in cases of chronic pulmonary disease; and Soemmering records several observations of a tartar-like substance found in devastated mesenteric glands in cases of rickets.