clinical aspects of mesenteric adenitis

7
CLINICAL ASPECTS OF MESENTERIC ADENITIS* V. L. SCHRAGER, M.D., F.A.C.S. CHICAGO, M ESENTERIC adenit4s is an infec- tion of the mesenteric nodes, occurring most commonIy in chiI- dren, particuIarIy during seasona epi- demics of upper respiratory infections and if acute, assumes the aspects of an acute abdomen, in most instances re- sembIing appendicitis. AIthough there is a trend at the present time to subordinate cIinica1 interpretation to x-ray and Iaboratory methods as a means of diagnosis, there are many path- oIogic entities which stiI1 depend upon the acumen of the we11 trained cIinician for a diagnostic soIution. Mesenteric adeni- tis is distinctIy within the realm of cIinica1 medicine. The earIier accounts of this condition are to be found in the EngIish Iiterature. Carson’ in 1918, and Struthers in 1921, gave a comprehensive description of this entity, but do not distinguish between tubercuIous and non-tubercuIous adenitis. As a matter of fact, the EngIish writers, and some in this country, believe that tubercuIosis is the actua1 etioIogica1 factor in this disease. Maurice Richardson, in 1900, reported before the American SurgicaI Association severa cases of successfu1 remova of tubercuIar gIands from the iIeoceca1 region, the first operation being performed in 1895. J. W. EIIiot, Iikewise, removed tubercuIar gIands from the mesentery. In 1920, WiIensky3 reported 3 cases of mesenteric adenitis of non-tubercuIous origin, and three years Iater stated that “mesenteric Iymphadenitis is a syndrome which has in recent years estabIished itseIf as a definite cIinica1 entity.” In 1921, Brenneman5 caIIed attention to abdomina1 pain in chiIdren occurring during epidemics of upper respiratory ILLINOIS infections due to mesenteric adenitis. In 1929, Freeman6 stated: “As far as I am aware, my own contribution in 1923 was the first in this country deaIing with the surgica1 significance of the chronic form of the disease, aIthough Wilensky pubIished a paper in 1920 deaIing with the acute inflammatory form Iimited to the iIeoceca1 angle.” Mesenteric adenitis is discovered during abdomina1 expIorations in proportion to the curiosity of the surgeon and his knowIedge thereof. GuIecke,’ of Jena, mentions that mesenteric adenitis is pres- ent in I3 to 30 per cent of a11 Iaparatomies. Be11 writes : “When surgeons are on the Iook-out for the presence of dis- eased gIands, Iarger numbers will be demonstrated.” According to Krause,8 mesenteric nodes range between IOO and 200, whiIe other anatomists counted as many as 220. They are arranged in three groups: (I) Iocated cIose to the mesenteric attach- ment; (2) in the midmesenteric portion; and (3) in the root of the mesentery. The nodes are smaI1, pea or IentiI sized, paIe, flat, movabIe, and are usuaIIy not noticeabIe during ordinary expIorations. The majority of nodes are cIose to the iIeoceca1 sector. The Iymph flow from the intestina1 mucosa and Peyer’s patches is directed toward the mesenteric nodes and from there into the thoracic duct. The Iymphatics of the appendix drain first in the prececa1 and retroceca1 nodes, and after meeting the Iymph current from the cecum, they finaIIy empty into the iIeoceca1 nodes. EtioIogicaIIy speaking, the opinions are divided between the tubercuIous and non-tubercuIous origin, aIthough since the pubIications of WiIensky and Brenneman, * From the Department of Surgery, Northwestern University MedicaI School. 539

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Page 1: Clinical aspects of mesenteric adenitis

CLINICAL ASPECTS OF MESENTERIC ADENITIS*

V. L. SCHRAGER, M.D., F.A.C.S.

CHICAGO,

M ESENTERIC adenit4s is an infec- tion of the mesenteric nodes, occurring most commonIy in chiI-

dren, particuIarIy during seasona epi- demics of upper respiratory infections and if acute, assumes the aspects of an acute abdomen, in most instances re- sembIing appendicitis.

AIthough there is a trend at the present time to subordinate cIinica1 interpretation to x-ray and Iaboratory methods as a means of diagnosis, there are many path- oIogic entities which stiI1 depend upon the acumen of the we11 trained cIinician for a diagnostic soIution. Mesenteric adeni- tis is distinctIy within the realm of cIinica1 medicine.

The earIier accounts of this condition are to be found in the EngIish Iiterature. Carson’ in 1918, and Struthers in 1921, gave a comprehensive description of this entity, but do not distinguish between tubercuIous and non-tubercuIous adenitis. As a matter of fact, the EngIish writers, and some in this country, believe that tubercuIosis is the actua1 etioIogica1 factor in this disease.

Maurice Richardson, in 1900, reported before the American SurgicaI Association severa cases of successfu1 remova of tubercuIar gIands from the iIeoceca1 region, the first operation being performed in 1895. J. W. EIIiot, Iikewise, removed tubercuIar gIands from the mesentery. In 1920, WiIensky3 reported 3 cases of mesenteric adenitis of non-tubercuIous origin, and three years Iater stated that “mesenteric Iymphadenitis is a syndrome which has in recent years estabIished itseIf as a definite cIinica1 entity.” In

1921, Brenneman5 caIIed attention to abdomina1 pain in chiIdren occurring during epidemics of upper respiratory

ILLINOIS

infections due to mesenteric adenitis. In 1929, Freeman6 stated: “As far as I am aware, my own contribution in 1923 was the first in this country deaIing with the surgica1 significance of the chronic form of the disease, aIthough Wilensky pubIished a paper in 1920 deaIing with the acute inflammatory form Iimited to the iIeoceca1 angle.”

Mesenteric adenitis is discovered during abdomina1 expIorations in proportion to the curiosity of the surgeon and his knowIedge thereof. GuIecke,’ of Jena, mentions that mesenteric adenitis is pres- ent in I3 to 30 per cent of a11 Iaparatomies. Be11 writes : “When surgeons are on the Iook-out for the presence of dis- eased gIands, Iarger numbers will be demonstrated.”

According to Krause,8 mesenteric nodes range between IOO and 200, whiIe other anatomists counted as many as 220. They are arranged in three groups: (I) Iocated cIose to the mesenteric attach- ment; (2) in the midmesenteric portion; and (3) in the root of the mesentery. The nodes are smaI1, pea or IentiI sized, paIe, flat, movabIe, and are usuaIIy not noticeabIe during ordinary expIorations. The majority of nodes are cIose to the iIeoceca1 sector. The Iymph flow from the intestina1 mucosa and Peyer’s patches is directed toward the mesenteric nodes and from there into the thoracic duct. The Iymphatics of the appendix drain first in the prececa1 and retroceca1 nodes, and after meeting the Iymph current from the cecum, they finaIIy empty into the iIeoceca1 nodes.

EtioIogicaIIy speaking, the opinions are divided between the tubercuIous and non-tubercuIous origin, aIthough since the pubIications of WiIensky and Brenneman,

* From the Department of Surgery, Northwestern University MedicaI School.

539

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540 American Journal of Surgery Schrager-Mesenteric Adenitis MARCH, ,937

the non-specific origin of this disease is definiteIy estabIished.

Struthersg in 1921, reported 4 cases of mesenteric adenitis, 3 of which were tubercuIous. He firmIy beIieved that the infection was either pure tubercuIosis, or that in some instances it was a mixed infection. The proneness of young chiIdren to tubercuIosis expIains the frequent in- vasion of the mesenteric nodes, which hea in most instances, but are subject to occasiona ffares on account of mixed infections. The incidence of mesenteric tubercuIosis varies greatIy according to many writers. Cornet, beIieves that tuber- cuIar nodes are found in every chiId during expIoratory operations. StiII found enIarged mesenteric nodes in 5g per cent of a11 post- mortems in chiIdren. OsIer and McCrae, anaIyzing the postmortem of Bovaird from the Mt. Sinai HospitaI of New York, put the incidence of tubercuIosis at Iess than I per cent. Braithwaite, who hoIds tubercuIosis responsibIe for a11 cases of mesenteric adenitis, admits that the statis- tics vary in different IocaIities and in various countries. The partisans of the tubercuIous etioIogy trace the origin of the infection to infected cow’s miIk and consider a11 infections to be of the bovine type. Freeman found tubercuIosis present in. severa of his cases of mesenteric adenitis, both histoIogicaIIy and by anima1 inocuIations, and concIudes: “I am in- cIined to beIieve, hbwever, that if a sufficient number of gIands have been tested, a Iarge majority wouId have been found to be tubercuIous.” The inabiIity of the Iaboratory to find tubercIe baciIIi is expIained by the fact that organisms are either too few in number, or that they are dead. The cases reported by WiIensky, Brenneman, and my own cases have no reIationship to tubercuIosis. There are a great many other etioIogica1 factors in mesenteric adenitis, and aIthough not a11 of equa1 importance, I shaI1 enumerate them for the sake of compIeteness: neurotic types of chiIdren; Iymphatic constitution (Heuser) ; habitua1 constipation (Pribram) ;

chronic constipation (Carson) ; rickets (EI- man) ; inff uenza (Pribram, CoImer, EdeI- man, Schmieden) ; throat i n f e c t i o n s (Brenneman) ; appendicitis (Pribram) ; in- testina1 parasites (Heuser, Pribram, Gulecke, Briining) ; Hodgkin’s disease (Symmers). In a case of Wagner’s,lO a bIow to the right abdomen caused an inffammation of the cecum with marked mesenteric adenitis. IntestinaI parasites were present in several instances. Accord- ing to Briining, l1 the inffammatory changes in the cecum and the associated adenitis were due to ascarides. Heuser,13 of BaseI, beIieves that severa types of parasites, such as oxyuris, ascaris, and trichocephaIus are responsibIe for adenitis. In one of my recent cases, this etioIogy was present. A boy, ten years oId suffered for about one year with paroxysms of abdomina1 pains associated with nausea and vomiting, yet the picture did not conform to any of the known abdomina1 compIexes. E$L- pIoration reveaIed the presence of chronic appendicitis and mesenteric adenitis. The pathoIogic report read : “ Chronic appendi- citis, mesenteric adenitis, and numerous pinworms.” AI1 symptoms disappeared promptIy after the operation.

AIthough we have recorded the various etioIogica1 factors, we are mainIy concerned with onIy two : upper respiratory infe’ctions and appendicitis. The reIationship between upper respiratory infections and abdomina1 pain in chiIdren has been cIearIy and force- fuIIy brought to the attention of the profes- sion in this country by Brenneman. He stated that during certain epidemics of upper respiratory infections, abdomina1 pain is present in nearIy 25 per cent of a11 cases. Curiously enough, most of the chiIdren with throat infections wiI1 com- pIain IittIe or nothing of their throats, but invariabIy point to the umbiIicus and when questioned, they answer, “The pain is in my stomach.” AbdominaI pain in the course of epidemics of throat infections may even attack several members of the same famiIy. The height of the season is from December to May, the highest peak

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New SERIES VOL. XXXV. No. 3 Schrager-Mesenteric Adenitis American Journal of Surgery j4 1

being in February. According to Brenne- iIy. GuIecke, at the German Congress of man, the abdominal pain in chiIdren “is Surgery in 1924, denies the existence of perhaps the most frequent abdomina1 pain primary mesenteric adenitis and insists that that comes to the doctor’s attention in it is always secondary. Pribram’” thinks children beyond the period of infancy.” that mesenteric adenitis is aIways second- Brenneman, considering the two possible ary to some intestinal lesion and not infre- avenues of infection, by way of the blood quentIy secondary to pathorogic changes in stream or by direct transmission, favors the the appendix. The intestine and the appen- Iatter. The absence of generahzed adeno- dix may be grossIv norma at the time that pathy speaks against the former. He is mesenteric adenitis is apprehended, never- inclined to beheve that there is a seIective theless, it suggests that the origina lesions Iocahzation of the infection in the colon or have healed and that the mesenteric small intestine, even though the organisms response persisted. Pribram states that have either been kiIIed or attenuated by aIthough the appendix may have been the the influence of the gastric juice. The starting point of mesenteric adenitis, the mesenteric nodes are secondariIy invoIved, removal of the appendix may have no very much Iike the invoIvement of cervi- influence upon the retrogression of the ca1 and retropharyngea1 nodes in throat enIarged nodes, if the appendectomy is infections. performed late.

Abti3 summarizes the matter by saying: “Even as the cervica1 gIands are invoIved secondary to throat infections, so there is good evidence that indicates that the abdomina1 Iymph glands are also involved, and that the Iatter secondariIy produce in- testina1 irritation with pain and vomiting.”

GoIdb erg and Nathanson’” report 16 cases of mesenteric adenitis from the Surgi- cal Service of the MichaeI Reese HospitaI, I I of which gave a history of upper respira- tory infection. Influenza is regarded by many cIinicians as an important etioIogica1 factor and may either precede or may be associated with mesenteric adenitis. Mesen- teric nodes have been found to be invoIved in influenza by EdeIman, Schmiedem and others. Striimpel, in 1918, described the intestina1 type of influenza. During the influenza epidemic in 1918 in Germany, Schmiedem noticed the association of a subacute type of abdomina1 symptoms which was recognized as an abdomina1 reaction to a systemic infection and, as such, these cases were not operated.

On the other hand, WiIenskv and HahnI state that mesenteric adenitis‘is practicaIIy never present in appendicitis, since cases of adenitis showed no gross changes in the appendix, and therefore, there is no etio- Iogic relationship between the two. In my own cases, the appendix, to al1 appearance was normaI, except those cases which were very acute and in which the entire smaI1 intestine, cecum and appendix, showed inflammatory changes. Heuser, of BaseI, likewise, found IittIe or no changes in the appendix in these cases.

The roIe of a pathoIogica1 appendix as a cause of mesenteric adenitis has both partisans and opponents. Mtihsam15 be- Iieves that mesenteric adenitis is a primary Iesion, and that if the appendix shows pathoIogic changes, it is invoIved secondar-

There are diffrcuIties which arise from the etioIogic relationship between the naso- pharyngeal infections and appendicea1 pathoIogy on the one hand, and upper respiratory infections which invoIve onIy the mesenteric nodes, without affecting the appendix itseIf. The fact that organisms from infected tonsiIs metastasize in the appendix seem to be fairIy we11 established. Kirshenmannl’ is perhaps a bit dogmatic when he says: “Appendicitis is a compiica- tion of tonsillitis in the same sense as is rheumatic fever and endocarditis,” and con- ciudes : “Appendicitis in children is a com- pIication of upper respiratory infections.” When, then, do mycotic agents from naso- pharyngea1 infections invade the appendix and when do they attack the mesenteric

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542 American Journal of Surgery Schrager-Mesenteric Adenitis MARCH, 1937

nodes? It is very IikeIy that certain strains of organisms may concentrate upon the cecum, Peyer’s patches or the Iymphoid foIIicIes of the appendix and that mesenteric adenitis is a subsequent event. It is aIso possibIe that by a process of seIective affinity, some organisms, particuIarIy dur- ing the severe first attack, may invade the mesenteric nodes onIy. The diagnostic con- fusion between appendicitis and mesenteric adenitis may be readily understood, since one may be the sequence of the other or be invoIved interchangeabIy. As stated before, norma nodes are not visibIe during ordinary expIorations, as they are paIe and smaI1 and are covered by the yeIIow and thick mesenteric Ieaves. If pathoIogic, however, the nodes appear as reddish, IenticuIar enIargements, which project beyond the mesenteric surface, varying in size from a pea to an aImond. The enIarge- ment is not uniform in a11 groups, some being larger than others. If the nodes of the iIeoceca1 sector are the Iargest, it suggests that the infective irritant originated in the iIeoceca1 structures. The inflamed nodes are freeIy movabIe, they are not covered with fibrinous exudate, and the adjacent peri- toneum is not inflamed. Hedinger, who examined Heuser’s materia1, describes the nodes as having a thin capsuIe with a sIight Iymphocytic infiItration; narrow sinuses in some instances, and enlarged in others. In their Iumen are found norma ceIIs of the reticuIum, often numerous desquamated sinus endotheIia and a few Ieucocytes. The Iymph foIIicIes are marked with germ centers, indicating a picture of chronic hyperpIasia. Doerr, from the Hygenic Institute of BaseI, found practicaIIy no organisms in inffamed nodes. He never found pus cocci and found Bacterium coIi onIy twice in 25 cases. Guinea-pig inocuIa- tions and antiformin search for tubercIe baciIIi gave invariably negative resuIts. StaphyIococcus and Streptococcus hemo- Iyticus have been isoIated occasionaIIy from mesenteric nodes, which proved to be morphoIogicaIIy identica1 with the organ- isms obtained from the throat of the same

patients. Mesenteric nodes from 15 cases were submitted to the Iaboratory and with- out exception a11 reports read: “Acute non- specific hyperpIasia.” SimiIar Iaboratory reports are quoted by WiIensky and Hahn.

It must be borne in mind, however, that early tubercuIosis of the Iymph nodes exhibits the histoIogic picture of Iymphatic hyperpIasia and cannot be distinguished from it. On the other hand, in tubercuIosis of the Iymph nodes, caseated or catcified nodes frequentIy wiII be found besides the mere hyperpIastic ones.

WiIensky and Hahn cIassify mesenteric adenitis in four groups: (I) simpIe mesen- te.ric adenitis; (2) suppurative mesenteric Iymphadenitis; (3) tubercuIous mesenteric Iymphadenitis; and (4) termina1 stage of mesenteric Iymphadenitis.

WhiIe one must admit that mesenteric adenitis does not offer a cIear cut cIinica1 picture which one can easiIy recognize, nevertheIess, it has definite aspects by which one can at Ieast suspect it.

Patients af%cted with this condition are usuaIIy chiIdren between the ages of five and eIeven years. They are often paIe, thin, and on routine examination one invariabIy finds Iarge tonsiIs, adenoids and paIpabIe cervica1 Iymph nodes. Many chiIdren give a history of “stomach troubIe,” which may date back to the period of earIy infancy. Some chiIdren compIain of headache, drowsiness and some refuse their breakfast. AbdominaI pain is the most conspicuous symptom in this syndrome. Its onset may be sudden and of short duration, disappear- ing as rapidIy as it occurred, a fact observed by Carson. AI1 grades of pain, from the very miId to the most severe may be present, so that some chiIdren scream. The pain is most commonIy Iocated in the right iIiac fossa, it is invariabIy referred to the umbiIicus, and in exceptiona cases may be situated in the epigastrium, or even in the left iiiac fossa. Steinberg described two points of tenderness, one at McBurney’s point, suggesting appendicitis, the other to the Ieft and a IittIe above the umbiIicus opposite the second lumbar vertebra. Sub-

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jective pain is usuaIIy greater than the Iocahzed tenderness, which is the reverse in appendicitis. Nausea is usuaIIy present and is not necessariIy foIIowed by vomiting, which is Iess constant. Leucocytosis is usuaIIy higher than in appendicitis, and in severe toxemia associated with upper respiratory infection it may mount to 20,000 or 25,000. If associated with inffu- enza, the Ieucocyte count may be beIow the norma count. The temperature is usuaIIy high and reaches 102~ to 103’ within a comparativeIy short time after the onset, which is not the case in appendicitis. Obviously, the greater the genera1 toxemia, the higher the temperature. ChiIdren with high temperature frequentIy have convuI- sions, whereas aduIts have chiIIs. The attacks of abdomina1 pain may come on acuteIy and abruptIy or may recur miIdIy and become chronic.

If the viscera are congested and there is fluid in the peritonea1 cavity, the case may exhibit the picture of peritonitis rather than appendicitis. This is particuIarIy true if one or more nodes break down, sup- purate and infect the peritonea1 cavity, as happened in 3 of WiIensky’s cases.

In one case the abdomina1 compIex resembled appendicitis, aIthough the pa- tient was extremeIy toxic and acuteIy iI1. In the course of routine examination, I was impressed by the deep injection of the nasopharynx and by a marked congestion of the ear drums. ExpIoratory Iaparotomy reveaIed extensive mesenteric adenitis and generaIized peritonitis, the appendix beingmereIy a part of the genera1 inffammatorv orocess. This showed that the chiId suffered from a peritonea1 invoIve- ment as a reaction to a systemic infection. The pathoIogy of the ear drum shouId have served as a warning to the real nature of the case. I have since examined the ear drums in these cases and if deep redness is present, I am incIined to dis- regard the abdomina1 compIex and treat the case conservativeIy.

_Mesenteric adenitis may resembIe and mimic many abdomina1 conditions in

chiIdren. The usua1 diagnostic probIem is whether or not the chiId has appendicitis. RandIe Short, of EngIand, states: “ In my experience, more mistakes in the diagnosis of acute appendicitis arise from this simiIarity than from any other cause.” The association of the abdomina1 pain with an upper respiratory infection raises doubt in the mind of chnicians and, occasionaIIy, they may miss an acute appendicitis that happened to be asso- ciated with a severe coId. Brenneman cited severa cases in which an acute appendicitis was masked by the acute toxemia of an upper respiratory infection and warns the diagnostician by saying: “One must not dwel1 in a fooI’s paradise.” WhiIe the differentiation between appendi- citis ‘and mesenteric adenitis has intrigued and bafhed the diagnostician, a finer anaIy- sis and interpretation of facts may serve to cIarify the situation. I shaI1 limit myseIf to three points in differentia1 diagnosis, which I beheve wiI1 serve as a guide.

I. MurphyI gives the foIIowing cardina1 symptoms m appendicitis . . . “pain, nausea, and vomiting within a few hours of the time of the onset, Iocahzed pain, eIevation of temperature. . . . The symp- toms occur in the above order, and when that order varies, I aIways question the diagnosis.” In mesenteric adenitis, the order and the sequence of events are apt to be distorted, and, therefore, do not conform to Murphy’s cIinica1 ruIe, as temperature often precedes the abdomi- na1 pain.

2. As Iong as the pathoIogic process is confined to the waIIs of the appendix, the patient has no constitutiona mani- festations, and does not Iook or fee1 sick. Taking a streptococcic sore throat as a cIinica1 index of acute iIIness, no case of appendicitis, in which the pathoIogy is stiI1 Iimited to its waIIs, ever Iooks as toxic as a streptococcic sore throat. In mesenteric adenitis, the patient is apt to fee1 and Iook III, which is the greatest singIe hint that we may be deaIing with an acute mesenteric adenitis.

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544 American Journal of Surgery Schrager-Mesenteric Adenitis MARCH, 193,

3. The symptoms of appendicitis are usuaIIy modest in their expression and p&e, temperature and leucocytosis run paraIIe1 to each other. The gradation in quaIity of these three symptoms is aIso paraIIe1 to the eIement of time. In mesen- teric adenitis, there is no strict paraIIeIism and the time eIement varies, e.g., a patient may have a high temperature six to eight hours from the onset, with a Ieucocyte count above 20,000 ceIIs, which rareIy occurs in such a short time in appendicitis. With these points as a guiding ruIe, one may come cIoser to the diagnosis.

Mesenteric adenitis must be differen- tiated from other intra- or extra-abdomina1 conditions. It must be differentiated from intussception, MeckeI’s diverticulitis, ab- domina1 grippe, pyelitis in the feinaIe, and typhoid. OccasionaIIy, pneumonia and pericarditis, refer the pain to the abdomen. Rapid descent of the testicIe in maIe chi,Idren may give rise to stormy symptoms, referred to the abdomen. I mereIy mentioned these conditions casuaIIy and omitted the detaiIed differentiation, since appendicitis is the chief concern in most cases.

In the subacute or chronic type, mesen- teric adenitis must be differentiated from Moro’s “nave1 coIic.” The condition was first described by Wertheimer in 1866 who caIIed it “mesenteric neurosis.” It was mentioned Iater by Hutchinson and finaIIy cIearIy described by Moro20 in 1913. This condition is characterized by intermittent coIicky pain referred to the umbiIicus, recurring paroxysmaIIy over a period of many months, especiaIIy after eating, when peristaIsis is apt to be more active. ChiIdren thus affected are of the neuropathic type and in a state of vago- tonia. Newman and Cohen21 expIained the abdominal pains on the ground of entero- spasms. It is obvious that this picture sug- gests mesenteric adenitis for which an attempt at differentiation shouId be made.

There are two other conditions, Iess known, with which mesenteric adenitis may be confused:

I. Infectious mononucIeosis, in which paroxysma abdomina1 pain associated with Ieucocytosis and a predominance of mono- nucIear ceIIs may be present;

2. PainfuI fat in McBurney’s zone in the FroeIich type of chiIdren, with paroxysma abdomina1 pains.

A subacute or chronic type of intestina1 or peritonea1 tubercuIosis in chiIdren may give symptoms which cIoseIy resembIes mesenteric adenitis, especiaIIy if the mes- enteric nodes participate in the tubercu- Ious process.

The treatment of mesenteric adenitis depends upon the reasonabIe certainity of the diagnosis. If one is in doubt at the bed- side, and if the patient does not appear acuteIy iI1, one shouId expIore even at the risk of a wrong diagnosis. This attitude must be extended even to the cases which occur in the course of an acute coId, pro- vided the patient does not Iook acutely iI1. One shouId give appendicitis the benefit of the doubt and expIore when reasonabIe doubt exists. The patient, however, who Iooks seriousIy and acuteIy iI1, even though he has an abdomina1 compIex which sug- gests appendicitis, particuIarIy in the pres- ence of frank nasopharyngea1 and ear drum phenomena, is best Ieft aIone. The opera- tive trauma and the chemica1 toxemia of the anesthetic add decidedIy to the gravity of the situation and many chiIdren thus ex- pIored die who, otherwise might have Iived.

If we side with Pribram and others who beIieve that the appendix is the primary cause of adenitis, there is ampIe justifica- tion in doing an appendectomy in the moderateIy iI patients. Many cases who suffered from vague abdomina1 symptoms over a period of many months or years and who at operation had extensive mesen- teric adenitis with a seemingIy norma ap- pendix, recovered and remained we11 after an appendectomy. If we are incIined to accept the tubercuIous origin of mesenteric adenitis, there is justification in the expIora- tion, patients getting we& as do other tubercuIous processes foIIowing mere ex- pIoration. BeII22 in the summary of his

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NEW SERIES Var.. XXXV, No. 3 Schrager-Mesenteric Adenitis Arnerlcarl J<,urnnl 01 Surge: 343

articIe says, “All cases of mesenteric suspected by a thorough anaIysis and a Iymphadenitis should be treated as tuber- finer interpretation of the order and quality cuIous unti1 proved otherwise.” of symptoms which differ from appendicitis.

It is suggested that a reasonabIy Iarge in- 3. ExpIoration is both excusable and cision should be made to permit a thorough indicated when the abdomina1 pain is asso- pathologica survey. Pribram and the ciated with mild or no constitutiona Mayo’s oppose the buttonhoIe incision on reaction. the ground that it prevents a detaiIed Operation is contraindicated when the pathoIogica1 inventory. If the diagnosis can patient is acuteIy iI and the nasopharyn- be definiteIy estabIished, there is no partic- gea1 mucosa and the ear drums are deepIy uIar risk in waiting. ShouId there be an injected. eIement of doubt, earIy intervention is Appendectomy either cures or heIps in more desirabIe. Pribram condemns the the retrogression of pathologic nodes. tendency to postpone operation for appen- In most cases, the hyperemia induced by dicitis after forty-eight hours have eIapsed expIoration exerts a beneficia1 effect upon from the time of the onset. WhiIe it is true the enIarged nodes. that the acute appendix may recede after 4. Biopsy is aIways a scientific asset, and that time if Ieft aIone, it does not prevent there is no contraindication to its perform- the invasion of the mesenteric Iymph ante, except in suppurating nodes. nodes which may remain active once estabIished, even after the appendix is removed. AIthough I am partia1 to drainage in the presence of pus, I beheve that these cases fare better if they are not drained, especiaIIy if the process shouId, after aI1, be tuberculous, as cIaimed by some. The question of remova of a node for the pur- pose of biopsy is by no means settIed. Speese23 cites the case of a patient who died, presumabIy because of an infection which ensued after the remova of a node. He cIaims that streptococci may be spread in the peritoneum by such a procedure. Brownz4 shares the view of Speese. I have had no reason to regret the remova of nodes for biopsy. I consider the procedure simpIe and safe and it can be done with- out traumatizing the node.

REFERENCES

2.

CARSON, H. W. Lancet, I : 869, 1918.

STRUTHERS, J. W. Edinburgh Med. Jour., 27: 22,

3. 4.

5.

1921. WILENSKY, A. 0. Med. Rec., N. Y., 112: 768, Ig2o. WILENSKY, A. 0. Ann. Surg., 83: 812, 1923. BRENNEMAN, J. Am. Jour. Dis. Child., 22: 493

6. (Nov.) 1921.

7. 8.

9.

IO.

FREEMAN, L. Surg., Gyn. and Obst., 37: 149, 1923; Ann. Surg., go: 618, Igzg.

GULECKE, N. Zentralbl. j. Cbir, 5 I : 1296, 1924.

KRAUSE, W. (Quoted by Heusser.) Bruns’ Beitr. e. klin. Cbir., 85: 130, 1923.

STRUTHERS, J. W. (Quoted by Heusser.) Bruns’ Beitr. z. khn. Cbir., 85: 130, 1923.

WAGNER, J. Internat. Jour. Med. and Surg., 38: 113 (March) 1925.

II. 12.

BROWNING, F. Arch. j. klin. Cbir., 145: 257, 1927. HEUSSER, H. Bruns’ Beitr. z. klin. Cbir., 85: 130,

‘923.

13. 14.

ABT, I. Pediatrics, VoI. III, p. 568. GOLDBERG, S. L. and NATHANSON, I. T. Acute

mesenteric Iymphadenitis. Am. Jour. Surg., 25: 35-40 (July) 1934.

SUMMARY

I. Mesenteric adenitis is, in most cases, a non-specific inff ammatory infection of the mesenteric nodes from a nearby or distant focus of infection, occurring most com- monly in chiIdren during seasona epidemics of upper respiratory infections, and strongIy suggests appendicitis.

2. The symptom compIex of mesenteric adenitis is not pathognomonic, yet can be

15. M~~HSAM, E. Deutscb. med. Wcbnscbr., 52: 1646,

16.

17.

I 926. PRIBRAhf, B. 0. Arch. J. klin. Cbir., 140: 589, Ig26. WILENSKY, A. 0. and HAHN, L. J. Ann. Surg., 83:

812, 1926. 18. KIRSHENMAN, J. J. Appendicitis in children. Am.

19. 20. 21.

22.

23.

24. BROWN, H. P. Surg. Clin. N. Amer., g: 1195, Ig2g.

Jour. Surg., 16: 318-322 (May) 1932. MURPHY, J. B. Am. Jour. Med. SC.. 128: 187. 100~. MORO, c. Miincben. med. W’cbnscbr:, 60: 2827, 1913. NEW~TAN, H. and COHEN, P. Arch. Pediat., 45: 383

(JuIy), 1928. BELL, L. P. Surg. Gynec. and Obst., 45: 465, 1927. SPEESE, J. Pennsylvania Med. Jour., 32: 225-228

(Jan.) Ig2g.