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.
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.[1] 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."
[Footnote 1: _Guy's Hospital Reports_, vol. i., 3d Series, 1855, p.
371.]
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.