chiefly appealed to for relief in this as in other serous
accumulations. Most physicians prefer to use the diuretics--first,
because if they will act at all, they act so quietly and produce so
little debility that whatever can be gained by them is obtained at
small cost to the system. The form of ascites that most resists
diuretics is that which originates in cirrhosis. Often a full trial of
them, with suitable changes from time to time, is of no avail, yet now
and then the kidneys yield to persuasion and act freely. The saline
diuretics and digitalis are most in favor with some. In the early part
of the present century a pill composed of squill and digitalis in
powder, and calomel, each one grain, given three times a day, was
almost universally chosen. In place of the calomel the blue mass was
often preferred. When this prescription had produced a little ptyalism
the mercurial was omitted and the squill and digitalis continued. It
has often been observed in dropsies of all kinds that diuretics act
better after a little mercurial action is set up in the system. The
diuretic that I most frequently prescribe is made of the carbonate of
potass. ounce ss and water ounce vj; to a tablespoonful of this a
tablespoonful of fresh lemon-juice is added. This is taken every two
hours, and at the same time a dessertspoonful of the infusion of
digitalis or more is taken three times a day. This is an {1179} old
prescription. Sometimes the old sal diureticus is used. This is the
acetate of potassium. It is not always kindly received by the stomach.
At Bellevue Hospital the following is much used: viz. infusion of
digitalis, ounce iv; bitartrate of potash, ounce j; simple syrup, ounce
ss; and water added to make a pint. This is taken pretty freely. But it
would require many pages to exhaust the diuretics. I will only add that
I have more confidence in the salts of potash and soda, singly or
combined, aided by digitalis and a mercurial, than in any others.
The diaphoretics that are most efficient are warm water and steam. A
foot-bath long continued and frequently repeated, the patient covered
with blankets, and the water kept at 90° or warmer, are very effectual
in producing perspiration. Bricks heated or hot water in bottles, or
potatoes heated, and enveloped in damp cloths and laid alongside of the
body and limbs, form an extemporaneous vapor-bath of considerable
efficiency. A vapor-bath can be easily extemporized in the following
way: Have a kitchen vessel furnished by the tinman with a cover which
has an inch tube fitted to this and bent so as reach the floor six feet
from the fire. The pot should have a capacity of a gallon or more, and
should be kept boiling briskly. Meantime, the patient, in his
night-dress, has a double blanket brought over his shoulders from
behind, and another from before, and fastened. Now he takes a chair
(wooden), under which the steam is delivered. The blanket from behind
is kept off his body by the back of the chair, and the front one by his
knees. The steam, shut in in this way, soon brings on a sweat, and when
it is sufficiently active the front blanket is thrown off, and the
patient wrapped in the rear one and put to bed, when the sweating can
be regulated by blankets. This is better than what is called the
alcohol sweat, for in that the patient is bathed in carbonic acid gas
as well as heat. A patient is sometimes enveloped in a hot, wet blanket
with good effect. Pilocarpine has come into use lately as a sudorific.
I have witnessed its effects many times and can testify to its
certainty as a sudorific; but it is too debilitating for common use.
Digitalis has sometimes acted with extraordinary power in this way, but
there are grave risks in administering large doses.
Among the cathartics that may be used in ascites, it has seemed to me
that the milder hydragogues are safest. One ounce of Epsom salts with a
drachm of the fluid extract of senna can be taken every second or third
day for months, if need be, with little reduction of strength, and
sometimes with an increase of it. I had charge of a young man in the
hospital in whom cirrhosis was unquestionable, and dropsy at one time
extreme, in whom the abdominal veins had made furrows that would
receive the little finger, who was wholly relieved by a drastic dose of
elaterium every second day. I saw him three years after his discharge,
and then his health was good. Notwithstanding this, I prefer the milder
medicines.
Bristowe has seen no cures from either sudorifics, diuretics, or
purgatives. I have seen one or more from each of those agents, all
cirrhotic. He "has seen cures occasionally from mercury, iodide and
bromide of potash, copaiba, and a combination of fresh squills and
crude mercury." I agree with him in his statement that
counter-irritants are useless, making exception for chronic peritonitis
and the early stage of the tubercular variety. He thinks quinia, iron,
and cod-liver oil are useful.
{1180} Paracentesis in almost every case will at length become
necessary, and the question comes whether it should be practised early
or late. If it be delayed till the oppression of the breathing makes it
imperative, the walls of the abdomen will be so stretched as to present
little resistance to the reaccumulation of the fluid, and a second
tapping will be required in fifteen to twenty-five days. A bandage is a
poor substitute for muscular contraction. If, on the other hand, the
fluid is withdrawn before the muscularity is not stretched out of the
muscles, then accumulation will be less rapid and the patient will be
spared the suffering which large accumulations cause. But tapping is
not always an innocent operation. It is sometimes followed by acute
peritonitis. By the early tapping this risk is oftener taken. Reginald
Smith suggests the use of a small canula by which only ten or twenty
ounces of the fluid can escape each hour. This mode, he thinks, removes
the danger of syncope and makes the bandage needless.
Hemorrhagic Effusion
in the peritoneum is a topic on which there is little to be said. A
primary effusion of this kind probably does not occur. In hæmatophilia,
where the mucous membrane of the nose and wounds bleed dangerously,
there is no record of spontaneous bleeding into the peritoneal cavity.
The same thing can be said of that very rare disease which has been
called bloody sweat. An unmarried lady applied to me fifteen years ago
with this disorder. The blood would ooze out at hundreds of points on
the inner face of the arm; these would run together and drop off the
arm, or the same thing would occur on the chest and in the bend of the
knee. This would continue for two or three minutes, and then cease of
itself, but to recur in one or more, rarely several, places. For years
this habit continued. There was no irregularity of the menses. I could
find no visceral disease; there was no nose-bleed. She lost strength,
but only moderately. This kind of bleeding continued for several years.
She is now approaching fifty years of age, and for the last two or
three years has had no recurrence of the bleeding. There was never
anything in this case to lead to the suspicion of peritoneal or other
serous hemorrhage. In the few similar cases on record there is the same
absence of all evidence of internal bleeding.
It has already been said that a certain amount of blood, as shown by
its corpuscles, is to be expected in cancerous ascites, and with less
uniformity in tubercular ascites, and not unfrequently in hepatic
dropsy, as well as in acute peritonitis. This may not deserve to be
called hemorrhage, on account of the moderate quantity of blood that is
effused; but aside from that which results from rupture of
blood-vessels it is about the only kind of it with which we are
familiar.
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.