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THESOUTHERN PRACTITIONER,

AN INDEPENDENT MONTHLY JOURNAL,

DEVOTED TO MEDICINE AND SURGERY.

SUBSCRIPTION PRICE, ONE DOLLAR PER YEAR.

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W. D. HAGGARD, M.D., Professor of Gynecology and Diseases of Children in the Medical

Department of the University of Tennessee.

REPORTED BY E. M. EVERETT, CLASS OF 1885–6.

Gentlemen: I enjoy the privilege of bringing before you this evening a pathological specimen consisting of the entire abdominal and thoracic viscera taken from a lad of fifteen years of age, who died of tabes mesenterica. The autopsy was held eight hours after death. On opening the abdominal cavity the small intestines were found crowded over to the left side, the right being fully occupied by the mesentery, which was firmly attached to the spinal column from the promontory of the sacrum to the diaphragm. The entire lymphatic system of glands of the abdominal cavity were greatly enlarged, presenting a mass of disease which had resulted in the breaking down of the glandular structures, and the formation of pus cavities, until all trace of important structures, such as the caput coli, apendix vermiformis, and the receptaculum chyli, were completely obliterated, the whole of these tissues being a conglomerate mass of disease which was so firmly adherent to the spine and the posterior and lateral walls of the abdominal cavity, that the separation necessarily destroyed the anatomical relations to such an extent that they could not be recognized. The spleen was enlarged to perhaps twice its natural size, the liver to a less extent; both were full of miliary tubercular deposits. The mucous coat of the small bowel was much congested and thickened, with frequent ulceration of Peyer's patches; the serous coat was likewise congested and studded over with miliary tubercles. In the thoracic cavity the evidences of disease were less marked. The lungs were found in a state of hypostatic congestion, the heart being normal, except considerably under size.

Gentlemen, I have now given you the history of what was revealed by the autopsy. The chief interest which attaches to the case consists in the extensive disease of the abdominal lymphatic system, which was, as I think, the outcome of an attack of typhoid fever, and the physiological deductions to be drawn therefrom may be interesting. I now ask your earnest attention to the history of this case as obtained from his parents when I was called to take charge of it some three weeks ago. The lad was about fifteen years old, had always been rather under size and delicate. Two years ago he had a severe and protracted case of typhoid fever, which left him much emaciated and profoundly anemic. He never rallied from this condition, although his appetite was good. He never complained of the slightest indisposition until about three months before I saw him. He then began to complain of pain in the abdomen, chiefly in the right inguinal region. As the boy was up and around, no special attention was paid him until the day I was called, at which time his mother had discovered an enlargement in the right side. Physical examination revealed a tumor occupying the right inguinal region as large as a goose egg, oval in shape, and exceedingly tender to the touch. The differential diagnosis now rested between typhlitis and an enlarged mesenteric gland. The excessive tenderness and resistance to pressure over the entire abdominal region precluded the possibility of a positive diagnosis, although I inclined to the opinion that the disease was tuberculous in character. He was having hectic fever, but no night sweats; his pulse was very quick and feeble; his urine was bigh-colored, and gave a decided acid reaction, and contained a good deal of mucous, as the outcome of cystitis from bladder pressure. The patient was now placed upon the use of malt, cod liver oil, and terruginous tonics, with a liberal diet. The prognosis was of course exceedingly unfavorable from the first. He continued to become more emaciated day by day, notwithstanding his appetite was good all the time. He died this morning.

Now, gentlernen, let us see what conclusions we can deduce from his clipical history and the post mortem appearances found at the autopsy. In the first place he has a history of typhoid fever two years ago. Now what are the pathological lesions found in all typical cases of this disease? Beyond all question, ulceration of Peyer's patches is the most pathognomonic lesion. These patches of Peyer, which are found in greatest abundance in the lower third of the ileum, are nothing more than the solitary glands found higher up in the intestinal tract, except they are found in groups instead of singly. I wish especially to call your attention to the fact that these glands are always situated immediately opposite the attachment of the mesentery to the gut. The intestinal canal is provided with a special apparatus whose funetion is to take up the liquefied portions of food intended for the nourishment of our bodies and carry it into the circulation. This is effected in part by the lacteal and lymphatic system of vessels, the former differing from the latter only in the fact that in addition to the transparent and colorless lymph which the lymphatics contain, they absorb a fluid rich in fat derived from the food by the process of digestion. All oleaginous matters of the food are emulsified by digestion, forming in the intestine a white, milky fluid termed chyle, which is much richer in all the elements of nutrition than any other portion of the intestinal fluids, and it is this that the lymphatic system is more especially con

and

cerned in carrying into the circulation than any thing else. Hence the largest amount of nutritive material, from which all the tissues of the body are constructed, finds its way into the circulation through the lacteal, lymphatic, and mesenteric glands, which are found in great abundance between the folds of the mesentery, and really form only a continuation of the absorbent system, which finally terminates in a sacular diverticulum of the thoracic duct known as the receptaculum chyli, which is situated opposite the second luinbar vertebra. The thoracic duct, as you may remember, after traversing the abdominal cavity, passes into the thorax and empties in the left subclavian vein. The only other channel through which the nutritive elements of food enter the circulation is by the absorption by the bloodvessels of the intestinal villi, which hang out as it were into the intestinal tract as the roots of a tree penetrate the soil, and take up in the main, that portion of food which is composed of albuminose, sugar, molecular fat, which is conveyed through the portal system to the liver, and after it traverses the capillary vessels of this organ is emptied into the vena cava. The closed follicles, or agminated glands known as Peyer's patches, bear such close relation to the lymphatics of the intestine that they are generally regarded as belonging to the same system.

Now we think we are prepared to appreciate why it was that the boy never recuperated-never gained any filesh after his spell of typhoid fever. As we have shown, the emulsified fats in the intestinal canal are mainly carried into the circulation through the absorptive process of the lymphatic system, of which the glands involved in typhoid fever form a part.* It is plain that the glands, by the pathological condition in which they are left after a severe case of typhoid feyer, are in no condition to transmit the chyle, and by reason of the close proximity of the lymphatic vessels and the lymphatic glands as well, they too partici

* Thus when the lacteal vessels and lympbatic glands are the seat of such pathological lesions as occur in typhoid fever, the general nutrition tends to be markedly impaired, owing to the interference with the transmission and due elaboration of chyle, and as they become more and more involved the entire system suffers gravely.

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