[65] Annals of Surgery, April, 1904.
ABSCESS OF THE MESENTERY.
Abscess formation may take place within the mesenteric structures, as an expression of acute septic infection or of a mixed infection of old tuberculous foci in the nodes. A careful case history or some peculiarity of local conditions may occasionally furnish a clue to the conditions, otherwise it will not be distinctly revealed until such operation as may be necessitated by unmistakable indications of the presence of pus or by autopsy. Inasmuch as operation can scarcely exaggerate the danger of the condition it would be best attempted when such abscess is suspected. When the meso-appendix is involved, as is often the case, the trouble may be so walled off that it is almost a purely local affair.
TUBERCULOSIS OF THE MESENTERY.
Aside from the common miliary expressions of acute tuberculosis which are seen so frequently dotted all over the bowel surfaces and the expanse of the mesenteric folds, there is a peculiar form of involvement of the mesenteric nodes, i. e., those which are especially clustered along its root. These are always involved in general tuberculous peritonitis, though but slowly in the absence of such generalized features. To the slow forms of this condition the early writers gave the name tabes mesenterica. The more limited the involvement the greater interest the lesion has for the surgeon, since it may be so limited to the nodes of a single coil as to justify extirpation. In fact, if such a focus could be easily and thoroughly removed without too much disturbance of circulation, tabes might be remedied by surgery. Not very frequently, however, do the location or the arrangement of a collection of tabetic nodes permit of their enucleation. They are usually too numerous, too large, too degenerated, too adherent, or the patient otherwise too extensively infected.
The acuter expressions of mesenteric tuberculosis may be considered as already sufficiently discussed under the caption of Tuberculous Peritonitis.
Occasionally a localized, slightly mobile tumor, especially in the ileocecal region, may cause suspicion, or may be correctly diagnosticated, by taking note of other symptoms, along with a good case history. Especially is this the case in patients known to be tuberculous. This is particularly true of the appendix and its mesentery, where a tuberculous gumma may attain considerable size before there is any active breakdown. The relation between this condition and tuberculous ulceration within the bowel will also be obvious. Moreover, it is of interest to recall that calcification of mesenteric nodes is not impossible, and that occasionally chalky tumors in this location may be thus explained.
There is also a possibility of involvement of the mesenteric nodes in constitutional syphilis and in actinomycosis.
The treatment of mesenteric tuberculosis should consist of exploration and orientation, followed by whatever procedure the condition thus revealed may require—e. g., abdominal irrigation, with or without antiseptics, extirpation, drainage, or even resection of a portion of the bowel (appendix, cecum, etc.).