purposes merely a case of gastric enteritis, although she did have an enlarged liver extending about three finger's breadth below the ribs. On my next visit the abdomen was distended and tympanitic and I could get but little information from palpation or percussion, and tenderness was most marked about one-half inch above McBurney's Point. She had no jaundice.

April sixteenth, 1903, was called to Taftville to see Mrs. R., a strong, vigorous, and very fleshy French woman, aged forty-two; married and mother of twelve children. For a few days she had had pain in the right side just above McBurney's Point. This had grown worse and she had had nausea and vomiting with considerable prostration.

She was sent to a Hospital where her condition was diagnosed as appendicitis, with some little hesitation, because of the location of the pain. Her right rectus was very rigid. On taking ether, the diagnosis was quickly cleared up and a large tumor continuous and attached to the liver appeared, as the anesthetic relaxed the muscles. She was operated upon and the gall-bladder opened and drained. Nine good sized stones were removed. The bladder was sutured, as in other cases. She made a good recovery and has had no trouble since. The sinus remained open about seven months, closing in November.

On December eighth, 1903, was called to North Westchester to see Mrs. O., a German woman of about forty five, married and had had several children. When I saw her she had been sick about twenty hours with symptoms of appendicitis, severe pain in right side, nausea, vomiting, slight elevation of temperature. On examination found abdomen much distended and tympanitic and very sensitive on pressure, the most sensitive spot being again just above McBurney's Point, and she also had a rigid right rectus.

The case was decided to be one of either appendicitis

or obstruction of the gall-duct. She was etherized and the enlarged gall-bladder could be easily mapped out. The abdomen was opened and the bladder emptied in the manner described above. Nineteen stones were secured. No thickening of the duct could be found. The bladder was sewed to the skin and packed. She got along in good shape and works hard and has had no trouble since. Her sinus closed in a little over three months.

Before anesthesia these two cases resembled attacks of appendicitis; the ether however, quickly cleared up the diagnosis.

In the great majority of cases the differential diagnosis is easily made, but there are cases where, unless you have watched the case from the commencement of the attack and have had opportunities for thorough examination, it will be very difficult indeed for you to state positively what causes the nausea and vomiting, the slight elevation of temperature and rapid pulse, or whether the distended tympanitic and sensitive abdomen with its rigid right rectus muscle contains and inflamed appendix or a distended gall-bladder.

CYSTS OF THE MESENTERY.

EVERETT JAMES MCKNIGHT, A.B.,M.D.,

HARTFORD,

I desire in connection with the relation of a case of cyst of the mesentery which has recently come under my observation to briefly call your attention to these unusual formations. They occur very infrequently and are rarely diagnosed as such, usually being discovered dur ing operations undertaken for some other supposed condition. During the last few years, however, this subject has been given extensive investigation, especially by Dowd of New York, and it is probable that we are now in possession of sufficient knowledge to enable us in many cases to make a correct diagnosis before operation.

Sir Spencer Wells, in the second edition of his work on abdominal tumors, says, "My last work on ovarian and uterine tumors was published in 1882. Up to that date I had not met with a case of mesenteric cyst, nor with a large mesenteric tumor; but within a month I had opened and drained a large mesenteric cyst, and had removed a large mesenteric tumor. Since that time I have not seen another."

Augagneur in 1885 found recorded only nineteen mesenteric cysts.

Greig Smith in the sixth edition of his work on abdominal surgery published in 1897, states (page 1065) that about fifty cases of operation for mesenteric cysts have been recorded. In the same year, however, (1897) Moynihan was able to gather one hundred and thirteen cases. Probably the latest statistics are those of Dowd, who in 1899 found references to one hundred and fortyfive cases.

Lawson Tait in his large experience never met with

a case.

In recent surgical works little or no mention is made of these growths.

The case to be reported is the only one which has come under my observation, either in my personal experience, or in that of those with whom I have been associated.

The first reference to these cases of any importance was probably by Portal, who in 1803, gave a complete classification of mesenteric tumors, dividing them into "scirrhous, steatomatous, petrous, cancerous and hydatid." Each pathological type was said to be accompanied by definite clinical phenomena. Portal emphasized the difficulty of making a differential diagnosis between tumors of the omentum and mesentery. Little, however, was done in the systematic study of these cysts until "antisepsis made possible the surgery of the ab domen."

Virchow (Berliner Klinische Wochenschrift, 1887, No. 14) stated in presenting before a medical society a preparation of a multilocular mesenteric cyst, that he was in possession of no satisfactory experience in reference to the origin of these formations. He assumed that they arose from degenerated mesenteric glands.

Hahn, in the same year, read an elaborate paper on this subject, before the Berlin Medical Society, (Berliner Klinische Wochenschrift, June 6, 1887) from which the writer has drawn largely in the preparation of this

paper.

On December 27, 1899, Dr. Chas. N. Dowd of New York, reported in a paper read before the New York Surgical Society, a case of multilocular cyst-adenoma in the transverse mesocolon, which contained pseudo- mucin and which was exactly like a cyst-adenoma of the ovary, suggesting its probable origin as an embryonic ovarian sequestration. This article was most exhaustive and

probably contained all of our present knowledge in relation to these growths. He was able to find references to one hundred and forty-five cases, many of which, however, were but imperfectly reported.

Although fibromata, myxomata, enchondromata and sarcomata have also been found in the mesentery, it is only necessary, clinically to consider lipomata and cysts. The former often attain great size as one reported to the Academy of Medicine, Paris, by Terillon, who successfully removed a fatty tumor weighing fifty-seven pounds by enucleation from between the layers of the mesentery.

Homans, of Boston, reports two cases of removal of large fatty tumors, which were probably of mesenteric origin.

Waldeyer and others have also reported large growths of this character.

It is probable that many of these as well as some of the larger cysts reported were retroperitoneal in origin, and by their growth and extension separated the mesenteric folds so that it was impossible to distinguish them from true mesenteric growths.

I have already referred to the classification of Cysts made by Portal in 1803. Later writers have divided them into serous cysts, chyle cysts, hydatid cysts, blood cysts and dermoid cysts.

The time which has elapsed since being asked to prepare a paper for this meeting has been so short that I have been unable to give the subject very extensive consideration.

I am convinced, however, that Dowd's classification will be found to be correct and that the chylous, sanguineous and serous cysts of the older writers will prove to be only modifications of embryonic cysts.

Dowd says,

66

It is probable that all mesenteric cysts may be included in the classifications.