may be diarrhoea, especially if, as often happens, tubercular ulceration of the bowels is a complication of the disease. Vomiting is a rare symptom.

The local symptoms are the only ones of any value in the detection of tabes. The belly is at first unchanged in shape, and even as the disease advances does not necessarily become more prominent. On the contrary, the abdominal wall is often retracted, and when swollen it may be soft and easily depressed, although it is apt to become tense at times from the accumulation of flatus in the bowels. The wall may also be tense when the size of the glands is very considerably increased. The degree of tension of the parietes is very important, as regards the detection of the enlargement. If the tension is very great, a moderate enlargement may escape notice, owing to the resistance of the abdominal walls, which will not allow the glands to be reached by the finger; and a tumour which can be easily felt at one visit may the next be completely concealed by the abdominal inflation, so as to be no longer detectable by the touch.

The situation of the tumour is about the umbilicus; the swelling is irregular to the feel, and hard. Its size varies, but may be as large as a foetal head. When the mass is large, it can best be detected by pressing the abdominal wall inwards towards the spinal column. When small, Sir William Jenner* recommends that the parietes should be grasped by the fingers and thumb of one hand, or between the fingers of the two hands, and pressure thus be made laterally, from the sides towards the centre, so as to seize the tumour between the fingers. By this means à swelling the size of a nut can be felt, if the wall is flaccid. The glands are sometimes slightly moveable, if the enlargement is not sufficiently great to involve the mesentery in the swelling.

There is usually more or less tenderness on pressure, but the tenderness is not necessarily a sign of inflammation of

*Lecture on Tuberculosis. Medical Times and Gazette, October, 1861.

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the diseased glands, for it is found in cases where no trace of inflammation is discoverable on a post-mortem examination.

When the glands reach a considerable size, they may press upon neighbouring parts, so as to produce secondary derangements. Thus, pressure upon the nerves may cause cramps in the legs. Compression of the large venous trunks may give rise to oedema of the lower limbs and dilatation of the abdominal veins. If this venous dilatation is very marked, the superficial veins being seen to ramify upon the abdominal wall, and to join the veins of the chest-walls, tabes should always be suspected in the absence of chronic peritonitis or enlargement of the liver.

Ascites is not necessarily a result of the tuberculisation of these glands, and is rarely produced by direct pressure unless the portal vein is compressed by enlargement of the glands occupying the hepatic notch. It may, however, be produced in a different way: thus, friction of the enlarged glands against the peritoneum lining the abdominal wall may cause inflammation of that membrane. In these cases there is some fever, with increase of abdominal tenderness, and colicky pains. The belly becomes tense from gaseous distension of the intestines; and indistinct fluctuation is often felt from adhesion of the bowels one to another, with the addition of a little serous effusion between the coils. Vomiting is not constant, and diarrhoea, if previously present, is not interfered with. The amount of ascites is in these cases not very great, and the symptoms of peritonitis generally are far from being well marked.

Adhesion may take place between an enlarged mesenteric gland and a coil of intestine: when the gland softens, perforation of the bowel may result.

The course of the disease is slow, but its duration is difficult to estimate, on account of the obscurity of the earlier symptoms. It seems to occur more frequently in boys than in girls, and is seldom found in children under three years

of age most commonly between the fifth and the tenth years. The children do not necessarily die; they sometime recover.

Diagnosis.-The diagnosis of tabes mesenterica can only be made satisfactorily by the sense of touch. If we can hold the mass between the finger and thumb, proof of its presence is indisputable, and this proof is the only one which leaves no doubt upon the mind. Enlargement of the belly is no evidence of the glandular disease, for flatulent distension is in children a common accompaniment of ill health, and in tabes the abdominal wall is more often retracted than expanded. Wasting, again, is found in almost all chronic diseases, tubercular or otherwise; and diarrhoea is a symptom by no means confined to tabes. These symptoms may be present, but they are not a result of the tubercular lesion of the glands, and either alone or combined are useless as indications of the disorder under consideration.

If, as has been said, the superficial veins are distinctly seen to ramify on the abdominal wall, and to join similar veins on the thoracic parietes, tabes should be suspected, but nothing more than suspicion is allowed by such evidence. Any interference with the portal circulation will produce the same result, and when the abdominal wall is tense it is difficult to exclude hepatic disease.

Even when by direct exploration the existence of a tumour in the belly has been ascertained, we have still to satisfy ourselves that the tumour is formed by enlarged mesenteric glands. The disease may be simulated by fæcal accumulation in the colon, or by tubercular masses attached to the omentum.

Fæcal accumulations are distinguished by the absence of tenderness; by the situation of the tumour, which usually occupies the transverse or descending colon instead of the umbilical region; and by the shape of the mass, which is elongated, the long axis being in the direction of the long axis of the bowel in which it is contained. In doubtful

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cases, a positive opinion should be reserved until the effect upon the swelling of a good injection has been tried. For a child of four years old, an enema * of a pint or more of soap and water, or thin gruel, containing half an ounce of oil of turpentine and four ounces of olive oil, should be thrown up the bowel by a good syringe. The injection should be retained for a few minutes by firm pressure upon the anus, and then be allowed to escape. If the tumour is due to fæcal accumulation, a quantity of pale, brittle lumps. will be discharged with the returning fluid, and the swelling previously noticed in the belly will be found to have disappeared. If tuberculized glands are the cause of the tumour, the evacuation of gas and fæcal matter will only make the presence of the enlargement more manifest, by removing the tension of the abdominal wall, and allowing of more efficient exploration of the cavity of the belly. In these cases an enema of sufficient quantity to distend the bowel is of more value than any number of aperients. It is well, also, to remember that fæcal accumulation having once occurred, there is great liability to a second collection of the same kind, therefore for some time afterwards a careful watch should be kept over the condition of the bowels.

Between tubercular masses attached to the omentum and tubercular mesenteric glands the distinction is often very difficult, particularly if the seat of the tumour happens to be the umbilical region. When their seat is the omentum the masses are more superficial, are less nodular, and have better defined edges than is the case where the glands themselves are diseased. They are usually also more freely moveable.

In a case mentioned by MM. Rilliet and Barthez,† a cancerous pancreas offered some resemblance to the tumour of tabes mesenterica, but was distinguished, amongst other

* Jenner on Tuberculosis, Medical Times and Gazette, October, 1861, † Maladies des Enfants, vol. iii., p. 817.

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signs, by the presence of vomiting, jaundice, and abdominal pains.

Anatomical characters of enlarged tubercular glands.-The formation of tubercle usually begins in the centre of the gland, and from this point the morbid change spreads gradually towards the circumference. Occasionally, however, several distinct points of tubercle are seen at different parts of the same gland; these may increase in size, and approach one another until the whole gland is converted into tubercular matter. The colour of the diseased gland is usually yellow, but sometimes a grey point is seen in the centre, surrounded on every side by the yellow mass.

The glands are not all equally affected. Some remain perfectly healthy while others are diseased; some which are diseased remain small, while others undergo considerable enlargement.

The alteration in these glands consists, according to Virchow,* in a great increase of their cell elements with not unfrequently hypertrophy of the connective tissue. The cells become large, round, tough, transparent, finely granular, and contain one or two large nuclei. They have a great tendency to undergo degeneration by fatty change. A gland so altered is seen at first as a large spongy-feeling body; its colour is reddish, passing, where the fat change is much advanced, into a dirty, opaque-white colour. there is much hypertrophy of the connective tissue the gland becomes very hard. After a time the whole gland becomes thick, tough, anæmic-looking, and dry, quickly transforming into a yellow, opaque, cheesy mass.

The capsular vessels become much enlarged, and the capsule itself thicker and divisible into two layers.

After a time the glands soften; the softening process usually begins at the centre, although isolated points at the circumference may first undergo this change. These, on

* See Gulstonian Lectures on the Nature and Affinities of Tubercle, by Reginald Southey, M.D. Oxon. London, 1867.