MESENTERIC CYSTS.

BY O. G. PFAFF, M. D., INDIANAPOLIS, IND.

Tumors of the mesentery, whether solid or cystic, are comparatively rare, and every case ought to be recorded. Surgical authors, as a rule, say very little on the subject, and some do not even refer to it. The solid growths are less frequently encountered than the cysts, and it is the latter to which I wish to call attention, and shall report a case from my records, together with the specimen, which I removed by operation.

Since 1507, when Benevieni made the first record of a speci men (discovered post-mortem), mesenteric cysts have been occasionally reported. From the reseaches of Moynihan, Treves, Dowd and others, we are enabled to refer to 147 cases, including the one here recorded.

They are found in both sexes and at all periods of life, cases reported so far varying from four to eighty years of age. The growths range in size from the small cyst discovered on the postmortem table to the enormous tumors containing gallons of fluid. It is probable that many of these tumors have been overlooked, and that others have been treated without recognition. Possibly of those large abdominal cysts, with extensive adhesions and undetermined relationships in which drainage was employed, some were mesenteric.

While most of the reported cases were discovered post-mortem, many others were treated surgically, frequently having been diagnosed by those who reported them as "ovarian tumor," "pancreatic cyst," "wandering spleen," or "floating kidney." Although these growths are not common, we must expect to encounter them occasionally, and to take this fact into account in developing the diagnosis. The surprising thing is that the mesentery is not more prolific as a cyst-bearing region, when we consider that between these

two folds of peritoneum are to be found connective tissue, fat, lymphatic vessels and glands, blood-vessels and muscular fibres; also certain remnants of embryonic life from the Müllerian and Wolffian bodies and ducts, and of the Vitelline duct.

Some elaborate classifications of mesenteric cysts have been formulated by writers on the subject, but that of Moynihan has been the most generally received, although the later researches of Dowd point to a simpler and more significant system. Moynihan describes (1) serous cysts; (2) chyle cysts; (3) hydatid cysts; (4) blood cysts; (5) dermoid cysts; (6) cystic malignant disease— cystic sarcoma. Cysts arising elsewhere and becoming mesenteric by extension are excluded.

It appears that the classification may not rest securely upon the character of the cyst wall, as shown by the microscope. This is indicated in the statement of Sutton, that small parovarian cysts. are lined with columnar epithelium, which is ciliated in some specimens, in large cysts it becomes stratified, and in very big cysts it atrophies. Therefore, it is not improbable that in certain mesenteric cysts, with fibrous walls and no epithelium, there has been a time when epithelial lining existed and that atrophy of this structure has occurred. Mesenteric cysts with epithelial lining have bene described by McDonald, Küster and others.

Dermoid cysts of the mesentery are relatively common, Mayer reporting one as large as an adult head, and Sir Spencer Wells another of similar size.

It is pointed out that segmentation from various organs is not uncommon. The well-known instances in which fragments are separated from the main structure during its development and lodging in some accessible haven, develops into an accessory of supernumerary organ, as spleen, kidney, ovary, etc., suggest the probable origin of many if not all true mesenteric cysts, not including the hydatids nor the cystic malignant growths.

Dowd explains the occurrence of blood cysts on the theory that they are simply preformed cysts into the cavities of which hemorrhage has taken place. Likewise the chylous cysts indicate that chyle has been effused into the cavities of other pre-existing cysts.

Demon reports a case in which a multilocular cyst exhibited one chamber filled with blood while another contained chylous liquid. Although the pathology of mesenteric cysts is, as yet, unsettled, it may be safely assumed that the time is not far distant when we shall have all the facts placed before us.

Dowd's conclusion is probably the best presentation of the probable facts of the matter as they appear at this time. He believes that it is altogether within the bounds of probability that a separation should take place from time to time from the Wolffian body, or the germinal epithelium at an early time in embryonic life, and that it is not strange to have such portions carried into the mesentery, or mesocolon, in the course of their development, and there form cysts.

Drs. Fehleisen and Nathan, of San Francisco, removed a large multilocular cyst from the folds of the mesentery. The walls were largely composed of muscular fibres, strongly suggesting in their size and shape the muscular arrangement of the small intestine. It was considered a teratoma, and is in apparent support of Dowd's position.

While the symptoms and clinical history vary greatly in different cases, there are certain resemblances which have been so frequently noticed as to acquire practical value in diagnosis. Most of the cases carefully studied have exhibited repeated attacks of severe abdominal pain, which is intensified in walking; disturbances of digestion, which are sometimes excessive; nausea is commonly but not invariably present. One peculiar and very interesting clinical feature relates to the history of the development of the tumor itself. In numerous instances it was first noticed after a fall or some unusually severe exertion.

Dr. O'Connor, of Buenos Ayres, treated a man for over two years, during which time he suffered from serious indigestion and abdominal pain. One day he alighted with some violence from a moving street car and was seized immediately with severe abdominal pain and noticed a lump below and to the right of the umbilicus. Dr. O'Connor examined him on the same day and describes the tumor as about the size of a cocoanut, well defined and tense;

fluctuation was obtained, and apparently great mobility, but this could not be thoroughly tested on account of the great soreness present. The man was operated on and the tumor found to be a cyst of the mesentery, which was treated by drainage; it contained chyle.

Dr. Rasch, of Tottenham, England, also makes a report which suggests some relationship between violent exertion and the first appearance of the tumor. A girl, twenty-one years of age, lifted a heavy trunk, and some days after was seized with severe abdominal pain; three weeks later she went to the hospital, when a large, round, elastic swelling was discovered in the middle of the abdomen, extending to the left; no diagnosis was made; operation showed cyst of the mesentery containing chyle; the treatment was drainage; a portion of the cyst wall was excised and under the microscope was found devoid of epithelial lining.

Dr. Beach, of the Massachusetts General Hospital, reports a case characterized by soreness and pain in epigastrium after eating; eructations of gas; constipation; appetite fair; four or five months later, during an attack of colic and vomiting, a movable lump was noticed in the abdomen; the tumor could be moved from just above the symphysis pubes to a position corresponding to the right kidney; diagnosis not made, but floating kidney suspected; operation demonstrated chylous cyst of the mesentery; the cyst wall showed no epithelium.

Dr. Parker Syms enucleated a mesenteric cyst, containing fourteen ounces of pure chyle, from a young man nineteen years of age. He had suffered pain in the abdomen for two years, when a well-defined, elastic, freely movable tumor was first noticed in the median line.

Suppuration of a mesenteric cyst may occur, as was illustrated in the case reported by Dr. Ludlum of Chicago. The tumor was first noticed a few days before confinement, and was not removed until two months later, when it was found that suppuration within the cyst had taken place. In one instance a mesenteric cyst filled the sac of an irreducible inguinal hernia, surely a rare complication.

The case which came into my hands through the courtesy of Dr. Minnick, of Somerset, Ind., was of intense interest to me, and to the other gentlemen who were associated with me in the diagnosis and operation. As I know of no later case I offer this as the most recent contribution to an interesting subject. I am indebted to Dr. Bernays Kennedy for the following comprehensive report:

February 24, 1904. Miss G. N., Somerset, Ind., aged fifteen years. Weight, seventy-four pounds. (No loss.) American. Born: Indiana. Previous residences: None. Single.

Family history-A sister probably has Pott's disease.

Personal history and previous illness-Chicken-pox and whooping-cough in childhood. Always well until present trouble. Appetite fair. Complains of fulness after eating, but no nausea, vomiting nor pain. Menstruation: Never menstruated. Discharge: None. Defecation: Usually regular. Constipated occasionally, followed by abdominal cramps. No symptoms of obstruction. During the past year has had frequent diarrhea, stools contained mucous. Micturition: Normal.

Present illness-Eighteen months ago, while, in good health and free of pain, patient discovered tumor about two-thirds present size in left inguinal region. The tumor was not tender and very freely movable; the patient moved it about the abdomen herself. At times she could not find the tumor herself, but the attending physician could always find it and would bring it up and out of the pelvis, after which change of position of the tumor she often experienced some relief from the pain. A few weeks after the discovery of the tumor the patient was seized with very severe abdominal cramps, beginning in the left lower quadrant and extending over the whole abdomen. These attacks were usually preceded by one or two days of gradually increasing soreness in left inguinal region, extending upward into left lumbar region. They occurred irregularly from a few days to four weeks, and lasted from a few hours to one or two days, occasionally requiring morphine for relief. The attacks of abdominal pain were not accompanied by nausea, vomiting, nor any symptoms except