MEDICAL SOCIETY OF LONDON

1897 The Lancet  
the necropsy. There was a slight organic narrowing of the intestine where attached to the cyst, probably due to arrest of development. The second case was that of a male child aged three and a half years, who was admitted with acute intestinal obstruction of four days' duration ; the abdomen was distended, and the patient was much exhausted by incessant vomiting. Dulness was noticed in the right lumbar region, but the tumour was obscured by distended coils of intestine. Laparotomy was
more » ... otomy was performed; and a large cyst containing thirty-two ounces of serous fluid occupied the right flank; it was situated in the free margin of the mesentery and compressed the intestine. The cyst was excised and the mesentery sutured. Death occurred from shock and as a result of the previous obstruction nine hours after operation. At the necropsy there was no peritonitis. The cyst was found to be situated seven feet above the ileo-cmeal valve. These two cases illustrate the typical symptoms of mesenteric cyst in the earlier and later stages. The first had symptoms resembling gastro-enteritis with emaciation, the second typical intestinal obstruction without definite premonitory symptoms. In the first case all the physical signs of mesenteric cyst were well marked with the exception of the presence of a band of resonance over the tumour. In the second case the tumour was entirely obscured by coils of distended intestine ; dulness on percussion was the only indication of its presence. Reference was made to the various abdominal tumours which may be mistaken for mesenteric cyst and a classification of mesenteric cysts was given, and it was pointed out that these two cases belonged to a group of lymphatic or serous cysts which were supposed to originate in the lymphatic glands of the mesentery. The cyst wall in the first case contained much unstriped muscle tissue. This was also observed in a specimen in the Museum of the Royal College of Surgeons of England. The fluid was albuminous and contained cholesterine. References were also made to more recently reported cases of mesenteric cyst possessing unusual characters. As regards treatment Mr. Eve held that drainage after attaching the cyst wall to the parietes was preferable to excision on account of its greater safety. The former was by no means an ideal operation, and its dangers and drawbacks were pointed out. The literature of the subject showed the rarity of mesenteric cysts in children.-Dr. H. D. ROLLESTON said that in the first case the microscopic appearances suggested that the cysts might have arisen from intestinal diverticula such as were occasionally present in the upper part of the large intestine. He had seen a case in which there were many small diverticular cysts at the upper part of the small intestine, and in a case recorded by a French observer there were 300 of these cysts. He thought this a better explanation than that the cysts were lymphatic retention cysts. Referring to some remarks which had been made about the position of Meckel's diverticulum Dr. Rolleston remarked that that structure did not occur in a constant position. In one case in which it had been present in an adult it was situated seventy-two inches from the cseoum.—Dr. NORMAN MOORE said that there was in the Museum of St. Bartholomew's Hospital a specimen with many small diverticular cysts along the mesenteric attachment of the jejunum. He thought that it was unlikely that a Meckel's diverticulum proper would ever become sealed off at its intestinal end.-Mr. MORGAN asked where the incision was made in operating on these cases.-Dr. R. A. GIBBONS asked for particulars of the mode of transfusion.—Mr. EVE, in reply, said that he admitted that the pathology of the cyst was not satisfactorily explained. The wall of the intestine just opposite to the cyst was quite smooth and showed no sign of any diverticulum. The incision in both cases was made in the middle line near the umbilicus. Intravenous transfusion with normal saline solution was employed. The PRESIDENT announced that at the next meeting of the society on Nov. 23rd there will be a discussion on the Prevention of Enteric Fever, which will be opened by Dr. The PRESIDENT showed two cases of Mitral Stenosis of definite Rheumatic Origin. The first was that of a girl, ten years of age, who had had recent attacks of rheumatism. She showed marked increase of cardiac dulness both to the right and to the left of the normal area. A heaving impulse was felt with the ventricular systole over the right ventricle and not over the left. A thrill was felt to the right of the apex, but it did not terminate abruptly. There was a systolic murmur at the apex, not obscuring the first sound, which was loud and had the character of a snap or tap. A short presystolic murmur was heard internal to the apex. Dr. Sansom thought that the case illustrated an early period in the pathogenesis of mitral stenosis. He regarded it as probable that rheumatic endocarditis was still in evidence and that there was some mitral regurgitation from this cause ; y but he considered that the physical signs showed mitral stenosis to be the preponderating lesion. The second case was that of a young woman, aged twenty years, of poor physique, who had had rheumatic fever three times, the first. in childhood and the last nine weeks ago. At the present. time there was some increase of the cardiac dulness to the right and the apex beat was diffuse. A slapping first. apical sound was followed by a prolonged murmur, unmodified by respiration, having its maximum to the right of the apex, fading off to the left, but was still audible at the angle of the left scapula. The aortic second sound could be heard at the apex. She had had several attacks of haemorrhage from the stomach, not due to gastric ulceration, and there were other signs that the venous circulation was impeded, and that there was as well 11 starvation of the aorta." It was to this that he attributed the nervous symptoms that the patient frequently presented,. as well as the stunted growth and the dyspepsia.-Dr. SEYMOUR TAYLOR expressed his opinion that practically all the cases of mitral stenosis in early life were of rheumatic origin or due to chorea, which he believed to be one of its manifestations. He thought that in the second case in addition to the physical signs which had already been mentioned as indicating the existence he could make out with his finger dilatation of the left auricle. He thought that the "snap" which was described was the relic of a murmur which could probably be reproduced by making the patient exert herself. He thought that dry-cupping was of the greatest service in such conditions, and sometimes wet-cupping or venesection was beneficial.-Dr. DB HAVILLAND HALL remarked that these cases often did not respond to digitalis at first. He usually began treatment by applying half-a-dozen leeches to the hepatic region and administering calomel internally. He agreed with Dr.
doi:10.1016/s0140-6736(00)46565-7 fatcat:hf34ddip7fha7osbevas6kdoie