Part 197

The morbid appearances in tabes mesenterica are not usually confined to the changes in the glands. In very many cases the evidences of disease of the peripheral glands are quite manifest, and in much the larger number of cases pulmonary phthisis and disease of the bronchial glands are present. The adjacent abdominal organs may also be involved. These consecutive morbid changes are succinctly set forth in the following notes of an autopsy taken from the records of the Children's Hospital of Washington, D.C. The subject was a negro boy aged ten, who had been taken sick a year previous to his death with a bad cold and cough, followed several months afterward by enlargement and suppuration of the cervical glands on both sides: "The body was greatly emaciated, the lips and teeth covered with sordes. Cheesy masses were scattered throughout the substance of both lungs. The right lung was firmly adherent to the thoracic walls, the left adherent at apex. The liver was enlarged and adherent to all adjacent tissues, and contained many cheesy nodules scattered throughout its substance and over the surface. The gall-bladder was distended with bile. The spleen was normal in size, very dark, and filled with cheesy masses. The pancreas contained many similar masses. The peritoneal cavity contained a quantity of muddy fluid. The peritoneum was dark in color, studded with tubercles, and ulcerated in a few places. The stomach and intestines were distended with gas; the walls of stomach thickened, the inner surface covered with a shiny mucus; in its lower wall was one large ulcer, penetrating to the peritoneal coat and measuring three-fourths of an inch in diameter. The peritoneal coat was thickly studded with nodules resembling tubercles. The small intestines were gangrenous in a few places; on the inner surface were found fourteen ulcers, varying in size from one-fourth to one and one-fourth inches in diameter, with elevated edges and red bases; two penetrated the peritoneal coat. This coat contained very many tubercles. On the mucous surface of the large intestines there were seven large ulcers, similar in appearance to those found in the small intestines. Some of Peyer's patches were ulcerated. The mesenteric glands, some as large as walnuts, were filled with cheesy material, and the mesentery was dotted over with small masses of similar matter."

In two of the reported cases of chylous effusion into the peritoneal cavity the rupture of the lacteals was caused by degeneration of the {1189} mesenteric glands; and in several other cases the rupture was produced by the presence of tumors, apparently formed by the agglomeration of numerous degenerated glands.

Several cases of fatty diarrhoea from mesenteric phthisis have been reported. Of these the most conclusive is the case of Hall. The clinical history of the case and the detection of enlarged mesenteric glands in the umbilical and hypogastric regions placed the diagnosis beyond a doubt. It was, however, verified by the discovery of several vomicæ in the lungs, and of mesenteric glands "universally enlarged and affected with strumous disease. The intestinal mucous membrane was dotted with patches of ulceration, with here and there prominent masses of strumous deposit on the surface."

SYMPTOMATOLOGY.--It is not possible to describe a definite and uniform clinical history of this disease. As a secondary complication of pulmonary phthisis and scrofulous affections the preliminary symptoms are so constantly identified with the development and progress of these maladies that, as a rule, the initial stage cannot be recognized by any special assemblage of symptoms. In any tuberculous or scrofulous child the possible implication of the mesenteric glands may be predicated upon any array of symptoms that would establish the presence of these classes of disease. And even in the absence of the rational and direct signs of such affections, in those exhibiting the physical evidences of the strumous diathesis, more especially when it is inherited, the symptoms of any trivial departure from health, such as the catching of cold, irritation of the alimentary tract, or protracted convalescence from any of the exanthematous or intestinal diseases, may constitute the initial history of tabes mesenterica. In such subjects debility and anæmia, from whatsoever cause they may apparently result--and, in fact, any manifest lowering of the standard of health, whether gradual or precipitate, and without assignable cause--may mark the beginning of the process of change in the parenchyma of the glands that will terminate in tuberculosis. The later as well as the earlier history may be completely masked by the symptomatology of other diseases belonging to the tuberculous class; and so grave, as a rule, are such primary and coexisting affections that definite recognition of this complication or localized extension of the systemic infection becomes more a matter of skilful diagnosis than of practical utility.

But in those cases where disease of the respiratory organs and of the bronchial glands can be excluded the general symptomatology becomes of paramount importance. And in view of the value of prophylactic measures which may be employed to arrest, limit, or delay the localized tuberculosis of these glands, the precursory symptoms may be of special significance. This condition may be characterized by languor and dulness or marked debility and anæmia, with loss of color, attended with flatulence, stomachal disturbance, frequent eructations consisting mainly of mucus, a sense of uneasiness in the abdomen after the ingestion of food, a variable appetite, sometimes voracious and occasionally depraved. Sometimes a dislike for fatty foods is a prominent symptom. The tongue may be coated, the breath is usually foul, and some have said the body emits an acid odor. If these symptoms occur in a child of the {1190} scrofulous diathesis, or be directly or remotely associated with a previous gastro-intestinal disease, or occur or persist during the convalescence of some of the acute affections of infancy and childhood which stand in etiological relation to this disease, they may justify a reasonable presumption of commencing change in the mesenteric glands. This presumption will be strengthened by emaciation, a more marked disturbance of the digestive function, attended with fetid and occasionally whitish stools, a tumid belly, and deep, lancinating abdominal pains of short duration, recurring at long intervals and neither relieved nor aggravated by pressure or an evacuation. Some have attributed special importance to a chalky appearance and loss of consistency of the stools, indicating the suspension of absorption by the lacteals. There may also be slight evening fever. Later, the enlargement of the belly increases, the emaciation becomes more marked and rapid, the appetite more variable, sometimes very voracious, the alvine discharges more fetid or less consistent, sometimes putty-like, and generally irregular or constipated. The febrile exacerbations are more decided, and sometimes chills may occur at irregular intervals. When, in addition to these symptoms, either during the earlier or later stages, the enlargement of the glands can be detected, the clinical picture is complete. In consequence of the tympanitic distension of the abdomen, which usually increases with the progress of the disease, it is impossible in a majority of cases to detect the glandular enlargement; especially is this true when the affected glands are separate; but, as frequently happens during the last stage, when large tumors are formed by the coalescence of a number of diseased glands the diagnosis may be easily determined. In the absence of the discovery of enlarged glands the diagnosis cannot be considered positive. They are usually most readily found in the region of the umbilicus, and may in some cases, even when the tension of the abdomen is very great, be detected by grasping the abdomen with the hand and compressing it between the fingers and thumb so that the enlarged glands will be brought in close contiguity to the walls and be felt immediately under the fingers. If a tumor should be present and the peritoneal cavity be free from fluid, its locality may be recognized by a sense of resistance and circumscribed area of diminished resonance, and then definitely outlined by palpation. Underwood says: "Indigestion, costiveness or purging, irregular appetite, flushed cheeks or a total loss of color, impaired strength and spirits, remitting fever, and a hard and tumid belly, with emaciated limbs, are amongst the more common symptoms, attending at one period or other, of this disease."

When the diagnosis has been made out, it is not impossible to determine the stage of the disease. The progressive intensity of the symptoms, with rapid emaciation as a rule, bears a definite relation to the progress of the morbid changes taking place in the glands. It must, however, be borne in mind that children have died of tabes mesenterica who had enjoyed excellent health up to the moment of death, and the autopsy disclosed the condition of the glands, which had not been suspected during life. In the case previously cited, in which the autopsy exhibited such grave lesions of the stomach, liver, spleen, pancreas, and intestinal mucous membrane, the clinical phenomena were at no time commensurate with the gravity of the morbid changes.

{1191} DIAGNOSIS.--In the absence of the proof of the presence of enlarged glands or of a tumor the diagnosis cannot be positively determined. The enlargement and tympanitic distension of the abdomen do not necessarily establish the existence of glandular disease, for they are present in a great many conditions of ill-health in children. Nor is the coexistence of a tumid belly, emaciation, and fever sufficient, for they are found in other tuberculous and in gastro-intestinal diseases. The discovery of enlarged discrete glands by palpation, as before described, in connection with such disturbances of nutrition as have been set forth, constitute the strongest presumption in favor of tabes mesenterica. The presence of enlarged glands unaccompanied by the ordinary symptoms of the tuberculous or scrofulous processes is inconclusive, because the glandular hypertrophy may be a simple hyperplasia, entirely independent of any tendency to retrogressive metamorphosis. There is usually some tenderness on pressure, but this may be present in any disease of the abdominal viscera. When the glands are of sufficient size, they may, by pressure, produce secondary derangements. Cramps in the legs may be caused by pressure on nerves. Oedema of the legs and dilatation of the superficial abdominal veins may result from compression of venous trunks. "If," says Eustace Smith, "these veins are seen to ramify on the abdominal surface and to join the veins on the thoracic walls, tabes may be suspected in the absence of chronic peritonitis and enlargement of the liver." Ascites may be present, but is not a necessary result of disease of the glands.

When a tumor has been discovered by palpation, it is necessary to determine its glandular nature. If situated about the umbilicus, in front of the spinal column, if irregular, hard, and feeling like a congeries of irregularly-rounded nodules, the evidence is very decided in favor of its glandular origin. But care must be taken to exclude tumors formed by fecal accumulations and masses attached to the omentum. Omental tumors are usually more movable, better defined, more superficial, and regular in form. Cancerous masses sometimes simulate glandular tumors. The general history of the case and the age of the patient are usually sufficient to make a diagnosis by exclusion. Rilliet and Barthez distinguished a cancerous pancreas by the presence of vomiting, jaundice, and abdominal pains.

The writer has many times based a conjectural diagnosis--which was verified by a post-mortem examination--upon the presence of a tumid abdomen, increasing emaciation, with the history of a protracted gastro-intestinal catarrh, and an irregular febrile curve characterized by frequent subnormal temperatures. He has also observed a number of cases of protracted diarrhoea in children, accompanied with extreme emaciation, notwithstanding the appetite was good, sometimes even voracious, and the food taken was ample, nutritious, and easily digested, in which the stools, varying from two to three, or twice as many, daily, were whitish, leaden, or slate-colored, sometimes semi-fluid, at other times containing lumps or masses of putty consistence, presenting to the naked eye a greasy appearance and to the touch a fatty feel, and at the autopsy has found only thinness and transparency of the coat of the small intestines and degenerated mesenteric glands.

PROGNOSIS.--The prognosis is decidedly unfavorable. So far as is known to the writer, there is but one recorded case of recovery in which the {1192} diagnosis was indisputable and the fact of a cure was established by an autopsy. This was the case reported by Carswell, before referred to. The older and some of the modern authors have claimed many recoveries, but it must be manifest to every student of pathological anatomy that the mistaken diagnoses must have been nearly if not quite as numerous as the cases of cure. The writer has not witnessed a single case of recovery, but he has observed very many cured cases of disease which exhibited all the subjective and objective symptoms of tuberculosis of the mesenteric glands, save and except those by which its existence can alone be definitely and positively established. The case of Carswell demonstrates a remote possibility of cure by the cretaceous metamorphosis of the degenerated glands in a subject exhibiting the scrofulous diathesis. In view of this isolated observation, one cannot refuse to accept a similar possibility in cases in which the disease may be localized and confined to a few of the glands. In such cases, if recognized previous to the formation of cheesy foci, the possibility of staying, limiting, and perhaps occasionally curing, the disease should not be regarded as absolutely hopeless; yet the opportunities of examining the glands in the first stage of change has so rarely occurred that no one is authorized to assert that the hyperplasia is the true picture of the condition in which those in the advanced stage had its beginning; nor has any one claimed to have witnessed the progressive stages of resolution taking place in such glands.

The cretaceous transformation is an accepted though remote possibility, and absorption by means of gradual softening of the cheesy masses is perhaps a reasonable hypothesis. But even if either of these processes was an occasional termination of the disease, it could only lessen its gravity and prolong life, with an incomplete recovery, in those few cases in which the tuberculous or scrofulous changes were confined to a less number of glands than was necessary to maintain the nutrition of the body. For while there is no serious obstacle to the flow of chyle through the glands in the condition of simple hyperplasia, it is completely obstructed in those transformed into cheesy masses or purulent collections. The channels through the glands must sooner or later be obliterated by the presence of the abundant cell-proliferation which characterizes the initial stage of change in this disease. For if the compression is sufficient to cut off the supply of blood, it must prove equally destructive to the complex system of lymph-paths. To the impermeability of the glands must the emaciation and exhaustion which mark the course of the disease, to a greater or less degree according to the number of glands involved, be due.

If the investigations of Schüppel should be verified, and the primary tubercle-formations be accepted as the initial stage of change, the prognosis will be less favorable, but a distinct line of demarcation may be established between two classes of cases in each of which cheesy transformation may occur, but in one the tubercle-formations may be primary, and in the other secondary. In the latter class the prognosis may be more favorable, because treatment may be effective if commenced prior to the beginning of the retrogressive metamorphosis.

COURSE, DURATION, AND COMPLICATIONS.--When tabes is a complication of pulmonary or bronchial phthisis, or when either of the latter {1193} diseases appears as an intercurrent affection during the course of a primary localized tuberculosis of these glands, the glandular degeneration runs a more rapid course. When it appears as an extension of external scrofulous affections or finds its cause in gastro-intestinal irritation, its course is usually less rapid. The number of glands involved greatly influences its duration. The mechanical impediment to nutrition offered by a large number of impermeable glands promotes rapid emaciation and exhaustion. The condition of the mucous coat of the alimentary tract offers many considerations that affect its course and duration. Follicular enteritis hastens, and tuberculous ulceration of the mucous membrane speedily brings, the case to a fatal termination.

Some of the older authors refer to the frequent complication of rickets with tabes mesenterica, and the writer in numerous post-mortem examinations of the bodies of children dying of rickets has invariably found cheesy mesenteric glands. In view of the fact that rickets is constantly associated with disturbance of the alimentary tract, it should not be a surprise to find the glands in such close contiguity to, and having vascular communication with, the diseased mucous surface in a condition of hyperplasia. Simple hypertrophy is probably a common complication in cases which terminate by recovery, but there must be some element of cause, other than inflammation of the mucous membrane of the intestines, that determines the retrogressive metamorphosis. Several of the older authors have classed rickets in the category of strumous diseases, and it may be that in the fatal cases tuberculosis of the mesenteric glands is a local expression of this diathesis.

TREATMENT.--The treatment consists, for the most part, in methods of prevention and palliation. The tendency to disease of the lymphatic glands in scrofulous children is so constant that it is important to remove all sources of irritation and to combat all influences likely to hasten or promote the localization of the constitutional condition. All chronic discharges and diseases of the skin and mucous membrane, the continuance of which might produce glandular complications, should be cured as speedily as possible, slight colds should receive prompt attention, and catarrhal inflammations of the respiratory organs should be arrested as quickly as the resources of science will permit. The alimentary tract demands constant and careful observation. Trivial disorders should not be neglected: the causes should be ascertained and removed. Digestion and nutrition should be maintained at a healthy standard. The hygiene of person, dwelling, and sleeping apartments merits constant and intelligent supervision.

As stated above, tabes of the mesenteric glands is so frequently secondary to other diseases of a scrofulous nature that the danger lies in the failure to arrest or cure such affections. It is unfortunately too true that some of them are often beyond the resources of medical skill, but in many cases the initial manifestations of the strumous diathesis are either entirely neglected or inappropriately treated. In many such cases the final and fatal complication of mesenteric phthisis could be prevented. The treatment of these affections belongs properly to the subjects of tuberculosis and scrofula, to be found in other parts of this System of Medicine.

Localized tuberculosis of the mesenteric glands is so often, either {1194} directly or indirectly, connected with catarrhal inflammations of the gastro-intestinal mucous membrane that the cure of these affections cannot be too strongly insisted upon as an effective method of prevention. This is especially true with children exhibiting the physical signs of the strumous diathesis. When it is inherited from a diseased mother, it may be necessary to resort to artificial feeding before the proper time for weaning has been reached. In such cases no uniform rule can be arbitrarily followed. The condition of both mother and child must be considered, and cases will occur which will demand the exercise of the most cautious discretion and diligent observation.

When the disease has become established but little can be accomplished. In such cases the treatment refers to the palliation of symptoms and the maintenance of nutrition. Pain, when present, must be relieved--if necessary by anodynes, either given internally or applied in the form of cataplasms. Most often it is due to the coexisting disease of the intestinal mucous membrane or to the ingestion of unsuitable foods. The diet should be regulated and limited to nutritious and easily-digested articles. Sometimes, even in cases of advanced degeneration of the glands, great benefit may be temporarily obtained by attention to the diet. Diarrhoea should be controlled, but when dependent upon tuberculous ulcerations of the intestinal mucous membrane but little can be done toward delaying the fatal termination. When a large number of glands are affected, it will be necessary to limit the diet to such nutrient fluids as may be absorbed from the stomach.

The medical treatment is confined to a few remedies. Faulty nutrition is the predominant factor, and the drugs employed should be directed to the improvement of the assimilative functions. The lacto-phosphate of iron in the form of syrup, or the phosphates in the form of the compound syrup, sometimes prove valuable tonics. The lacto-phosphate may be given in combination with cod-liver oil. This latter, either internally or by inunction, is the most valuable and universally applicable of all remedies. The mistake is very frequently made of giving too large quantities. Few children can digest as much as a drachm administered three times a day. In Washington it is usually given in the form of the phosphatic emulsion, and has proved in the service of the Children's Hospital a valuable and effective remedy in the nutritional disorders of children. Of the chalybeates, the syrup of the iodide of iron is by far the most valuable; this may be given alone or in combination with cod-liver oil. It is specially indicated when anæmia is a marked characteristic. Some recent reports favor the employment of pancreatized foods. The ointment of the iodide of lead has been highly extolled as a local application to the belly. The nature of the disease should be constantly borne in mind, and all depressing agencies should be sedulously avoided.

{1195}

INDEX TO VOLUME II.

Abdomen, enlargement of, in rachitis, 153 state of, in ascites, 1176 in cancerous peritonitis, 1169 in cirrhosis of liver, 994 in cholera morbus, 722 in chronic peritonitis, 1162 in dysentery, 796, 804 in enteralgia, 661 in intestinal catarrh, 679, 706, 707 in tabes mesenterica, 1190 in tape-worm, 940 tetanic spasm of, in dilatation of stomach, 595 tenderness of, in tubercular peritonitis, 1165, 1166

Abdominal bandage, use of, in dilatation of stomach, 609 belt, use of, in constipation, 654 distension, in acute peritonitis, 1141 glands, disease of, 1182 swelling, in intestinal indigestion, 627 tenderness, in intussusception, 848 veins, abnormal anastomoses of, in thrombosis and embolism of portal vein, 1096 prominence of, in ascites, 1177

Abortions, frequent, significance, in diagnosis of hereditary syphilis, 310

Abortive treatment of acute gout, 134

Abscess in acute pancreatitis, 1118 in local peritonitis, 1159, 1160 of joints in gout, 116 of liver, 1002 discharge of, into neighboring organs, 1007 influence on causation of acute peritonitis, 1138 in dysentery, 801 of rectum, a cause of fistula in ano, 897 of tonsils, 383 peri-anal and peri-rectal, 703, 895

Abscesses, number, in suppurative hepatitis, 1006 peritoneal, in perforation of simple ulcer of stomach, 499 seat of, in acute peritonitis, 1136 in typhlitis and perityphlitis, 817

Acanthocephali, the, 949