A system of practical medicine. By American authors. Vol. 2

by Unknown

Recently attention has been called to the probable transmission of the disease through the milk of diseased cows, but further investigation and 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 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 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."

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.