Book - Umbilicus (1916) 9
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Cullen TS. Embryology, anatomy, and diseases of the umbilicus together with diseases of the urachus. (1916) W. B. Saunders Company, Philadelphia And London.
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Chapter IX. Intestinal Cysts
Intestinal cysts developing from the omphalomesenteric duct or Meckel's diverticulum.
1. Intestinal cysts lying relatively free in the abdomen.
2. Intestinal cysts lying between the layers of the mesentery.
3. A cyst of the central portion of the omphalomesenteric duct. Symptoms of intestinal cysts.
Interesting cases of intestinal cysts were recorded by Cazin in 1862, and by Hennig in 1880, but it is to the splendid article of Roth, published in 1881, that we are indebted for the first clear and exhaustive presentation of the subject.
Fitz, in his monograph in 1884, dealt with intestinal cysts at length.
Runkel reported an interesting series of cases in 1897, and his admirable article should be read by all who desire to acquire a full knowledge of the subject. In addition to his own cases he reported the observations of Roth, Tscherning, Dittrich, Nasse, Buchwald, Kulenkampff, Huter, Rimbach, and Lohlein.
In 1906 Colmers published an article upon intestinal cysts and their treatment. He says that Raesfeld was the first to describe an enterocystoma, and that he drew attention to the fact that it developed from what we now call Meckel's diverticulum.
Roth says that these sacs are filled with fluid, and that the structure of their walls resembles more or less that of the intestinal canal. He divides intestinal cysts into two groups:
Group I . ■ — ■ Those in which the originally normally formed intestinal tract is divided into several isolated cystic sacs. The division of the intestine occurs usually as a result of a peritonitis, and according to Rokitansky, occasionally as a result of a twisting of the mesentery. In such cases the nipping-off of the bowel into isolated segments naturally severs its continuity and soon causes the death of the child.
Group II. — To the second group belong the intestinal cysts which originate from an abnormal development of the intestinal tract. The cysts are present, but we also have a permeable intestinal canal; consequently from this standpoint the life of the child is not in danger.
Roth subdivides Group II into three varieties:
A. Superfluous and cystically dilated portions of the intestine belonging to rudimentary twin pregnancies, as in Case E of Scharer-Klebs, in Klebs' Handbuch der spec. path. Anat,, i, 1013.
B. Intestinal cysts occurring in combination with abnormal deposits, and occasionally with growing organs and portions thereof. In this group he included a case of Sanger and Klopp. In this connection it may be of interest to refer to a case observed by Simmons and reported by Cazin in 1862. The patient was a wellformed female child, two years old. At autopsy a tumor was found situated at the base of the vertebral column. It consisted of fat, bones, etc., and also contained a
large quantity of intestine, part of which belonged to the ileum and part to the colon, the appendix being attached to the latter.
[Several years ago, while opening a dermoid cyst the size of a child's head at the Johns Hopkins Hospital, I found that it contained a relatively large cavity partly filled with fluid. This cavity also contained a perfectly formed loop of small bowel (Fig. 104). The tumor was opened immediately after its removal and while still
Fig. 104. — -A Well-developed Loop of Small Bowel ix a Dermoid Cyst of the Ovary. Gyn. No. 14118. Path. No. 11728. The patient was a white woman, twenty-eight years old, who had a cyst of the left ovary about 16 cm. in diameter. When the cyst was opened, a large cavity, partly filled with sebaceous-like material and hair, was found, and at one side was a well-developed loop of small bowel. This had a well-defined mesentery, and on being handled the bowel contracted, showing a definite peristalsis. August Horn at once made a sketch of this rare condition. The specimen has disappeared, and Mr. Brodel has made the drawing from Horn's original sketch.
warm. It was easy to follow the wave of contraction in the bowel, just as in the normal intestine.]
C. A simple intestinal cyst developing from the adherent normal lateral appendages of the intestine, most frequently from Meckel's diverticulum.
A full discussion of the entire subject of intestinal cysts does not come within the province of this book. We must, however, carefully consider Class C, in Roth's Group II, to which belong intestinal cysts probably arising from remnants of the omphalomesenteric duct or from Meckel's diverticulum.
THE UMBILICUS AND ITS DISEASES.
Fig. 105. — An Intestinal Cyst. (Schematic.) Most of the intestinal cysts found have been due to partial or complete torsion of Meckel's diverticulum, which had taken place so gradually that no gangrene occurred. In rare instances both the outer and inner ends of the omphalomesenteric duct become obliterated, while the central portion remains patent. The accumulation of the secretion from the mucosa in time produces an intestinal cyst. The above is a schematic representation of a small intestinal cyst of this nature.
INTESTINAL CYSTS DEVELOPING FROM THE OMPHALOMESENTERIC DUCT OR
From a survey of the recorded cases it is perfectly clear that these cysts may be divided into two groups:
1. Intestinal cysts lying relatively free in the abdomen.
2. Intestinal cysts lying between the layers of the mesentery.
INTESTINAL CYSTS LYING RELATIVELY FREE IN THE ABDOMEN.
Tiedemann, Carwardine, Hendee, Rimbach, Roth, and Fitz have reported cases of this character. In Tiedemann's case, published in 1813, a pear-shaped cyst, 14.5 x 7 Linien* was attached to the convex surface of the bowel by a pedicle 3.5 Linien long. The cyst communicated with the bowel through the pedicle.
In Carwardine's case the tumor occupied the right upper abdomen and was twisted. Its pedicle was attached to the small bowel. The cyst was densely adherent.
In Hendee 's case the tumor consisted of two portions. One portion lay in an inguinal hernia. The tumor was attached to the convex surface of the small bowel.
In Rimbach's case the tumor was the size of a man's head, wrapped up in omentum, and attached to the small bowel by a solid co*rd.
In Roth's case the tumor measured 6.2 x 5.3 x 3.6 cm. ; it was cystic and enveloped in omentum. It sprang from the mesenteric attachment of the bowel by a twisted pedicle. The pedicle had a lumen which was patent.
It is evident that in these cases the cystic tumor had originated from a Meckel's diverticulum (Fig. 105).
The tumor tends to become adherent to the omentum and to the neighboring structures (Fig. 106). The inner surface of the cyst is lined with intestinal mucosa, which may be somewhat inflamed.
The character of the cyst contents will depend on whether or not there is a connection with the intestinal cavity. In those cases in which the cyst has been cut off before meconium
has had a chance to get into it, the contents will be glairy mucus mixed with ex foliated epithelium and sometimes with a little pus and blood.
- A Linie varied from one-twelfth to one-tenth of an inch.
Fig. 106. — An Intestinal Ctst Attached to the Umbilicus by a Pedicle but not Connected with the Bowel. (Schematic.)
On comparing the cyst with the bowel, it is found to be several centimeters in diameter. It is attached to the umbilicus by a well-developed and twisted pedicle. The omentum is plastered over its surface, and below it is adherent to the appendix and cecum. The small bowel has a tag projecting from it, possibly at the point where the omphalomesenteric duct formerly existed. The picture is a schematic representation of a condition very rarely noted.
An Intestinal Cyst Developing from a Meckel's Diverticulum. — Tiedemann,* quoted by Roth,f in examining a male fetus at term with a double-sided harelip and an accessory little finger on each hand, observed an umbilical hernia the size of a large walnut. In this lay a portion of intestine. It showed a pear-shaped, bladder-like formation, 14.5 LinienX long and 7 Linien in its transverse diameter. It had a pedicle 3.5 Linien long, and lay attached to the convex surface of the intestine by a narrow canal which admitted a probe. The bladder-like projection contained whitish-yellow fluid, and had originated through a canal communicating with the cavity of the intestine.
Volvulus of Meckel's Diverticulum. § — The patient was a child, two days old, who had intestinal obstruction and greenish vomiting. There was no fecal matter passing by the bowel and no discharge from the umbilicus. The abdomen was much distended. Rectal examination was negative. The child was watched for six hours, but nothingpassed by the bowel.
When the abdomen was opened, the small intestine was found to be very much distended and covered with lymph. The colon was not larger than a crow's quill, whitish-yellow in color, and non-sacculated. A mass could be felt to the right of the umbilicus. Here the gut was much distended, and there were so many adhesions that the bowel could not be brought out. The source of the obstruction could not be determined, but at autopsy was found to be due to an anomaly of Meckel's diverticulum.
An artificial anus was made, and several ounces of meconium escaped. The cecum and ascending colon were found to be hard and small. The child died twentyfour hours later. The cyst was made up of a greatly distended Meckel's diverticulum with three twists (Fig. 107). Only a fine, impervious cord connected it with the bowel. Carwardine noted the following as the points of interest in this case: (1) An acute commencement of peritonitis before birth; (2) the occurrence of a volvulus of Meckel's diverticulum in utero during late fetal life, so that a meconium-contain
- Tiedemann: Kopflose Missgeburten, 1813, S. 66, Taf. i.
t Roth: Virchows Arch., 1881, Ixxxvi, 371. t A Linie varied from one-twelfth to one-tenth of an inch. § Carwardine, T.: Brit. Med. Jour., 1897, ii, 1637. 13
Fig. 107. — Volvulus of Meckel's Diverticulum. (Redrawn after Carwardine.) The child was two days old and had passed nothing by the bowel. There was no discharge from the umbilicus. The abdomen was markedly distended. At operation a large sac was detected and opened, but the child died twenty-four hours later. The cyst was a greatly distended Meckel's diverticulum. This had twisted three times, and an impervious cord connected it with the bowel. The lower end of the small bowel was empty and tortuous. The colon was small and sacculated. No meconium had ever reached the rectum.
THE UMBILICUS AND ITS DISEASES.
ing cyst was segmented off from the ileum, and consequently the obstruction was not relieved by an opening into the distended diverticulum; (3) the lower 12 inches of small bowel were empty and tortuous. The colon was small and non-sacculated. No meconium had ever passed into them; yet the cecum and appendix were well formed. A Solid Tumor* Probably Developing from Remnants of the Omphalomesenteric Duct.f — In an inguinal
hernia there was a small cylindric tumor. This communicated with a second mass, which lay in a chronically inflamed omentum and was connected by a cord the size of a penholder. The median portion of the last-named tumor was attached to the small intestine on its convex side, 32 cm. above the ileocecal valve. This could be traced to the submucosa of the bowel. Both tumors and the cord were completely solid, and consisted of connective tissue with numerous deposits of chalk. Colmers said that Hendee's case affords a good example of the difficulty of making an anatomic diagnosis of the remains of the omphalomesenteric duct.
An Intestinal Cyst Due to Dilatation of Meckel's Diverticulum. — In Rimbach'sJ case there was a cyst the size of a man's head. This was wrapped up in omentum and attached to the small bowel by a short, completely solid pedicle. The cyst was not lined with mucosa, but in its walls were two definite layers of muscle.
An Intestinal Cyst Developing from a Diverticulum of the Ileum and Continuing with the Bowel; Beginning Peritonitis Due to Torsion of the Pedicle. § — A boy,
- This tumor, although solid, was at first probably cystic, and is accordingly included here.
t Hendee, cited by Colmers: Arch. f. klin. Chir., 1906, lxxix, 132. % Rimbach, quoted by Colmers: Loc. cit.
§ Roth, M.: Qeber Missbildungen im Bereich des Ductus omphalomesentericus. Virchows Arch., 1881, lxxxvi, 371.
Fig. 108. — An Intestinal Cyst Developing from Meckel's Diverticulum. (After Roth.) The cyst in front and above has omentum adherent to it. From the ileum a sound has been carried into the hollow pedicle; the latter is crossed by a small mesentery.
INTESTINAL CYSTS. 179
sixteen months old, up to a month and a half before admission, had always been healthy. His stools became irregular, constipation and diarrhea alternating. About three weeks before admission the child had to remain in bed for two weeks, and for three days had marked vomiting. He died with definite signs of intestinal obstruction. At autopsy the abdomen was found distended above the umbilicus, where the intestinal loops were prominent. Below the umbilicus, in front of the mesentery, was a transverse, oval, reddish, moderately distended tumor (Fig. 108).
This tumor was 6.2 cm. in its transverse diameter, 5.3 cm. in its vertical, and 3.6 cm. in its anteroposterior diameter. It was for the most part smooth, but above and to the left it was firmly adherent. Above the anterior surface and to the right were delicate adhesions to the greater omentum. In the omentum large vessels were seen. On the under and right margin of the tumor was a pedicle 11 mm. long. This passed to the concave surface of the ileum, close to the insertion of the mesentery. The cyst was situated 66 cm. above the ileocecal valve. The pedicle consisted of two portions, one of which was conic in shape and measured 11 mm. in breadth at the ileum, whereas at the tumor it was only 4 mm. broad. Along the base the intestine had become twisted from right to left. The second portion of the pedicle, which was connected with the first, passed upward and to the left and extended to the base of the tumor. The pedicle ended in the mesentery, and was covered with peritoneum. It consisted of fatty tissue and of several vessels which passed to the wall of the tumor; in other words, this was the mesentery of the tumor. When the tumor, which was otherwise free, was turned from the left forward and to the right for 90 degrees, the torsion of the conic portion of the intestine at its crossing with the mesentery was released. The lower portion of the abdominal cavity contained a few drops of turbid yellow fluid. When the cyst was opened, air and 32 c.c. of thick, brownish-red fluid mixed with mucus and reddish flocculi escaped. The fluid consisted almost entirely of pus-cells intermingled with red blood-corpuscles and cylindric cells.
The reddish threads proved to be hemorrhagic infiltration. The wall of the cyst was 2 mm. thick, and at every point was as well developed as that of the ileum. The inner surface was partly ulcerated, but for the most part had a lining of a soft, velvety, dark-red membrane. The latter showed, on microscopic examination, a lining of cylindric cells and Lieberkuhn's glands. Beneath the mucosa came the sub_ mucosa, then the ring muscle, and then the outer longitudinal muscle. In the subserous connective tissue were large vessels and an abundance of fat-cells, and then, covering the cyst, was peritoneum. In the lower part of the cyst, in the swollen, dark-red mucosa, was a minute opening not larger than a linseed, through which a sound could be passed into the ileum. The conic-shaped portion of the pedicle was not larger than a bean. This lay parallel with the long axis of the intestine near the mesenteric border, but on the concave side of the intestine.
From the above it is seen that the abdominal cyst corresponded to the end of the diverticulum, which still communicated with the intestine and which had a mesentery. This diverticulum showed a distinct intestinal structure. It was covered over with an inflammatory deposit and adherent omentum. The peritonitis was, without doubt, due to torsion of the pedicle.
A Cyst of Meckel's Diverticulum. — ■ Fitz,* in the Warren Museum, found the following record in the manuscript catalogue (under No. 4903) :
- Fitz, R. H.: Amer. Jour. Med. Sci., 1884, lxxxviii, 30.
180 THE UMBILICUS AND ITS DISEASES.
Diverticulum from the Small Intestine. — The specimen was obtained at autopsy from a patient dead of chronic pleurisy. There were no symptoms during life to call attention to its existence. It was given off from the small intestine about 1 meter above the ileocecal valve. It was 3 cm. in length and about 1 cm. in diameter. There was no apparent communication with the lumen of the intestine. This specimen was a cyst of the diverticulum, the origin of which was near the mesenteric attachment. Its walls consisted of a peritoneal envelope with loose subperitoneal connective tissue, both continued directly from the intestine. There was a dense middle coat, resembling in appearance the muscular layer of the intestine, although elongated nuclei were not to be made out; finally, an inner membranous lining, upon the free surface of which occasional clubshaped stunted villi were found to project. Pouch-like depressions with circular openings upon the free surface were found scattered throughout this membrane. Epithelium was not present. The middle and internal coats were in the closest proximity to the corresponding layers of the ileum.
Fitz speaks of cysts noted in the region of the duodenum, and cites a case of a cyst of the esophagus observed by Wyss. He mentions cases reported by Roth and Hennig in which there were cysts in the vicinity of the esophagus.
INTESTINAL CYSTS LYING BETWEEN THE LAYERS OF THE MESENTERY.
Cases of this character have been recorded by Buchwald, Hennig, Kulenkampff , and others. The cysts are situated in the mesentery of the bowel, usually a short distance from the ileocecal valve . They may be round or pipe-shaped. They show a peculiar tendency to form sickle-like contractions on their inner surface. The cyst is, accordingly, partially divided into separate chambers. These partial divisions may completely block off a portion of the cyst, giving rise to an isolated and walled-off secondary cyst. The cysts may or may not communicate with the lumen of the bowel. They are lined with intestinal mucosa. Where they are completely shut off from the bowel, they may be filled with clear fluid, as was noted in Hennig's case, in which the tumor reached large proportions, measuring 22 x 14 x 10 cm.
A Large Intramesenteric Enterocystoma.* — ■ The patient had a large intramesenteric double cyst. This at one point showed an epithelial lining. It communicated with the bowel.
Intestinal Cyst and an Esophageal Cyst in a Newborn I n f a n t . f — In this case the labor was a very difficult one, and the child died before delivery. A hook was introduced into the chest and then a perforation was found advisable. Pressure on the abdomen caused a discharge of about 3000 c.c. of clear fluid from the child. The mother made a good recovery. The length of the child's body was 45 cm. In the abdomen was a sac which had not been injured, and reminded one of a partially filled stomach of a grown person. Passing to it were numerous large blood-vessels, which behind and in front of it went to the ileum.
The ileum lay peripherally to the sac, near the point where it passed over into
- Buchwald: (Colmers, Loc. cit.).
t Hennig, C: Cystis intestinalis, Cystis citra cesophagum bei einem Neugeborenen. Centralbl. f. Gyn., 1880, iv, 39S.
INTESTINAL CYSTS. 181
the cecum. There was no communication between the ileum and the sac. The sac was 22 cm. long, 14 cm. broad, and 10 cm. thick. It contained about 100 c.c. of almost clear, slightly reddish, somewhat sticky fluid, which was suggestive of intestinal fluid. The large bowel was empty and much contracted. (We have purposely omitted a description of the esophageal cyst.)
Microscopic examination showed that the intestinal cyst was lined with cylindric epithelium; in its walls intestinal glands were demonstrable. The sac was a large intestinal cyst which lay in the mesentery. This specimen was examined by Weigert.
An Intestinal Cyst; Death From Intestinal Obstruction.* — The patient, a poorly developed boy three years old, had died with signs of intestinal obstruction. At autopsy a cyst was found in the mesentery of the small bowel, 40 cm. from the ileocecal valve. It was the size of a man's fist, had very thin walls, and was almost translucent. It had several sickle-like constrictions, partially dividing it into semi-spheroid sacs. There was no communication with the bowel. The cyst was filled with very thin, chocolate-colored fluid. Kulenkampff refers to Roth's article. In this case no microscopic examination was made.
In the following case, recorded by Roth,f there was not only a cyst attached to the bowel, but also one in the mesentery and another in the thorax :
A Congenital Intestinal Cyst Separated From a Diverticulum Situated in the Mesentery; In Addition, Intestinal Cysts of the Abdominal and Thoracic Cavities; Compression of the Air-passages.- — ■ The specimen and the history came from Roth's colleague, J. J. Bischoff. Elsie B., aged nineteen years, was delivered easily. Immediately after there was an escape of 3000 c.c. of amniotic fluid. The child, a male, was small. Movement of its extremities was noted, and an attempt to breathe was detected. The abdomen was markedly distended. Notwithstanding artificial respiration, the child died in ten minutes. The body was 42 cm. long. There was marked edema of the umbilical cord; on the left side was a hydrocele. When the greatly enlarged abdomen was opened, a large, thin-walled cystic tumor with numerous vessels covering it was found beneath the liver. This tumor covered the stomach and the duodenum. A few loops of small bowel lay over the tumor; others lay to the left, and through the walls of the latter a small quantity of meconium could be seen.
A more careful examination of the tumor showed that it consisted of two parts : the one on the left and in front was the size of a hen's egg (Fig. 109, 6); the other (&') was only a third as large. The latter lay in the cecal region, and the cecum was pushed over to the median fine. The stomach was in the normal position, and contained a little tenacious, yellowish mucus. The spleen, adrenals, kidneys, and bladder showed nothing unusual. The thymus gland was the size of a hazel-nut. The lungs were atelectatic. The pleurae showed ecchymotic spots. The foramen ovale was the size of a pea. Near the right lung, and covered by it, was
- Kulenkampff, D.: Ein Fall von Enterokystom. Tod durch Darraverschlingung. Centralbl. f. Chir., 1883, x, 679.
f Roth, M.: Ueber Missbildungen im Bereich des Ductus omphalomesentericus. Virchows Arch., 1881, lxxxvi, 371.
THE UMBILICUS AND ITS DISEASES.
a fluctuating tumor which sprang from the vertebral column and was covered by the costal pleurae. The esophagus passed obliquely above the left half of the tumor, and was easily dissected from it (Fig. 109, c).
Fig. 109. — Intestinal Cysts in the Abdominal Cavity. (After Roth.) The heart, lungs, and liver have been removed. The ascending colon has been thrown to the left, and the pedicle of the cysts (b and b') has been freed. On the upper surface of the cyst (b) are several lymph-glands. The spleen, stomach, duodenum, and the right kidney are visible; also remnants of the diaphragm. To the left of the cyst (c), which lay in the thoracic cavity, are the esophagus and the doubly cut aorta.
There was a marked swelling over the left temporal vein, and numerous ecchymoses wore encountered in the dura. The pia mater was edematous, and the vessels
> > J&& »
were engorged and tortuous. The ventricles were dilated and contained bloody fluid.
In the abdominal cavity, in addition to the above-mentioned tumors (Fig. 109, b and b'), there was still another which lay between the layers of the mesentery and close to the lower portion of the ileum. This was a sausage-shaped cyst (Fig. 110, a), which lay close to the concave wall of a loop of the ileum. The mesenteric vessels passed on the top of, over, and beneath the tumor to the intestinal canal, and from these vessels numerous small branches went into the cyst. This mass itself resembled a sausage and was somewhat club-shaped. Its upper end was directed toward the jejunum, and it had a knob-like end, 13 mm. broad. Here the tumor had a greater diameter than the small intestine. The smaller, lower end terminated in an extremity having a diameter of over 5 mm.
When the ileum was opened, it was seen that the lower end of the mesenteric tumor projected into the intestine and then opened into it through a roundish aperture (Fig. 110, x). The opening followed the direction of a very acute angle. In the picture the edges of the opening have been spread with a glass rod, and in this way the original prominence has been much exaggerated. The opening was situated at a point 14.5 cm. above the ileocecal valve. The length of the club-shaped tumor was 10 cm. A sound introduced into the intramesenteric diverticulum encountered several ring-like narrowings through which only a bristle could be passed. The swollen end of the diverticulum (Fig. 110, a) did not admit the
sound. On being opened, it was seen that in this portion was a cyst the size of a bean that had been completely cut off from the remaining portion of the diverticulum. The diverticulum contained no yellowish material, but in the lower portion was mucus. The small cyst contained thick masses which, on microscopic examination, showed numerous glistening round-cells without nuclei.
The walls of the diverticulum were similar to those of the intestinal canal, and the inner surface was lined with a single row of cylindric goblet-cells with Lieberkuhn's glands beneath. The small cyst was different in structure. The outer coats were similar to those of other portions of the diverticulum. The septum between the cyst and the diverticulum did not contain longitudinal muscle in the subserous layers. The mucosa was very thin. The upper surface was partly flat. Lieberkiihn's glands were entirely wanting. The inner surface was lined with ciliated epithelium.
The abdominal cyst, which consisted of two apparently separate sacs (Fig. 109,
Fig. 110. — An Intramesenteric Ctst. (After Roth.) The specimen shows the lower portion of the ileum, with the mesentery, vermiform appendix, and ascending colon. The anterior fold of the mesentery has been removed. The branching of the superior mesenteric vein and the larger portion of the diverticulum lie on the concave side of the intestine and have been dissected free. a is the outer cyst, which has been but incompletely developed from the diverticulum, x indicates the ostium, which has been made visible through the splitting open of the intestine.
184 THE UMBILICUS AND ITS DISEASES.
b and 6'), anteriorly, above, and below was covered with a glistening peritoneum, and occupied a large portion of the middle of the right abdominal cavity. Both sacs were easily moved on one another in various directions. Only in the region of the pancreas and on the lower portion of the duodenum were they fixed. On dissection it was found that there was a short pedicle, 1 cm. long, between the anterior round and the lower sausage-like mass. The pedicle was 2 mm. broad, and had a canal 0.5 mm. in diameter, which joined the two cavities. There was no open connection between the intestinal canal and the cysts. The whole tumor, on its posterior and left side, was attached by a rather firm connective tissue to the superior mesenteric artery from its point of origin beneath the pancreas. There was no direct connection with the vertebral column.
The superior mesenteric artery was 1.6 mm. thick, and formed in its middle course three ring-shaped anastomoses. It gave off from its right side, 9 mm. below the art. colica dextra, the art. ileo-colica, which was 1 mm. in diameter. The largest branch of this supplied the cyst (6). Eleven millimeters further on, it gave off a branch which supplied the small cyst (&')•
On the upper surface of the cyst these vessels formed an extensive network which, on the one side, anastomosed with the arteriae intestinales, and on the other side with the arteria colica dextra. The veins had relations similar to those of the arteries. There were numerous nerves and also veins over the surface of the cyst (6) .
Lymph-glands were also present under the serosa.
Thus the large abdominal cyst was retroperitoneal in the right portion of the mesentery, and had pushed the mesentery in a pouch-like manner before it. It was supplied by two branches of the superior mesenteric artery. The portion (6) contained 34 c.c. of tenacious, somewhat flocculent fluid. The fluid gave a reaction for mucin. The inner surface of the cyst was smooth. The thickness of the wall varied: near the vertebral column it reached a maximum of 1.5 to 2 mm. On microscopic examination all the layers of the intestinal wall could be identified. The mucosa, however, was very thin, and only where the inner surface was rough were there villus-like elevations. The inner surface was lined with cylindric epithelium, but the mucosa was hardly sufficiently developed to form glands. The portion (&') corresponded in the main with (6) and only differed in that the walls were thinner and there were more folds. The surface was lined with cylindric cells and goblet-cells, and here and there in the depth were real gland-like spaces. The sac contained 7.5 c.c. of fluid. Lining the canal between the two sacs were cylindric cells. In all three portions there was a lack of perfect development of the mucosa, whereas the muscular layers were hypertrophied.
The cyst in the mediastinum (Fig. 109, c) extended from the third to the tenth dorsal vertebra. It was 5.5 cm. long, 3.7 cm. in its transverse diameter, and 4 cm. in thickness. It had thick walls, was opaque, distended, and elastic. The tumor was firmly connected with the vertebral column. From above downward it was only slightly movable; from side to side, somewhat more so. It lay to the right of the esophagus.
The tumor, as shown in the hardened specimen, had produced much pressure on the thoracic organs. The left lung, just behind and below the hilum, presented a fiat surface. The right lung had a deep groove, 4.3 cm. long and 1.5 cm. broad, which extended over the entire lower lobe.
The cyst contained 12 c.c. of tenacious, mucilaginous fluid, in which cylindric
INTESTINAL CYSTS. 185
cells and goblet-cells were found. It was divided into three chambers, which were entirely separated from one another. The walls showed an intestinal structure, but with more marked development of the muscular layers, while the mucosa was everywhere thin and in most places devoid of folds or glands. Here and there, however, were irregular folds between which small glands opened.
In summing up the findings Roth says: "In the first place, the intramesenteric position of the diverticulum is perhaps unique. Usually the diverticulum springs from the convex surface of the intestinal canal; not infrequently, however, it is situated near the mesenteric attachment. Interest is also attached to the small intestinal cyst, which is separated from the diverticulum at the matrix; it has the same longitudinal muscular layers and the same serosa." He refers to the cyst as a diverticulum.
Roth said he knew of only one similar case in the literature, that of Raesfeld, in which the entire diverticulum had been transformed into a cyst, but in that case the cyst was seated on the free circumference of the intestinal tract.
A CYST OF THE CENTRAL PORTION OF THE OMPHALOMESENTERIC DUCT.
Most of the schematic pictures illustrating the various points at which remnants of the omphalomesenteric duct may be found represent cysts developing midway between the intestine and the umbilicus (Fig. 105, p. 176). Theoretically, one might expect to find them in such a position, but the following case, recorded by Schaad,* is the only example of such a condition that I have found in the literature.
An Abdominal Cyst Originating From a Remnant of the Omphalomesenteric Duct. — The patient was a married woman, thirty-two years of age. Nothing is known of the appearance of the umbilicus at birth. She gave a history of two normal labors. At the last labor a tumor was noted below the umbilicus. This patient was supposed to have had a severe inflammation of the bowels seven years previously.
Several fingerbreadths below the umbilicus one could feel an elastic tumor which was sharply outlined and was the size of a child's head. This could be pushed in all directions.
Operation. — A cyst the size of a five-franc piece was found about two fingerbreadths below the umbilicus, and attached to the abdominal wall in the median line. It had been separated from the peritoneum and drawn out of the abdomen. Omental adhesions were tied off and cut. The cyst was adherent to the appendix. The left ovary was hard and atrophic; the right ovary was normal. The patient made a good recovery.
The cyst was oval in form, 7.5 cm. long, 6 cm. broad, and 4.5 cm. in thickness. Its walls varied from 2 to 4 mm. in thickness. Its inner surface resembled mucosa and was light yellow in color, with dark spots. On the right side of the cyst was a secondary cyst, which communicated with the larger one by an opening the size of a pin-head. The inner surface of the cyst was smooth, and its walls were in places 0.5 mm. thick.
The large cyst contained about 200 c.c. of a chocolate-colored, tenacious fluid, with an abundance of cholesterin detritus and fat-droplets. The smaller cyst had
- Schaad, T.: Ueber die Exstirpation einer Cyste des Dotterganges. Corr.-Bl. f. Schweizer
Aerzte, 1886, xvi, 345.
186 THE UMBILICUS AND ITS DISEASES.
similar but thicker contents. The wall of the large cyst consisted of connective tissue and of a large quantity of smooth muscle arranged in bundles, which ran in all directions. The inner surface was lined with high cylindric epithelium. Glands also opened on the surface. The epithelium and glands were in places missing.
The small cyst was lined with granulation tissue, in which were found giantcells, some containing 20 to 30 nuclei, arranged at the margin or irregularly scattered in the center. [This rinding reminds one of foreign-body giant-cells.]
Schaad says there is no doubt that the cyst represented a remnant of the omphalomesenteric duct. A portion of the duct had remained open and caused a retention cyst.
SYMPTOMS OF INTESTINAL CYSTS.
Some of the children were born dead. Carwardine's patient lived two days, Roth's patient lived a year and four months, and Kulenkampff's patient, three years. In each of these cases the death was apparently due to intestinal obstruction.
Schaad's patient, a woman of thirty-two, recovered. In this case the tumor apparently had no connection with either the bowel or the mesentery. It was removed.
Fitz says: "The clinical importance of these intestinal cysts obviously depends upon their size arid situation. Large abdominal cysts may interfere with the birth of the child, as in Hennig's case and in that reported by Sanger and Klopp. Although the actual cyst or cysts in each instance were not the sole cause of obstructed labor, for an associated ascites was present, they were an important element.
"In Hennig's case, puncture of the abdominal cavity was necessary before the child could be delivered, and some three liters of a relatively clear fluid escaped. The cyst was not injured. Even if the child is born, the cyst may remain as a constant source of danger, and, as in the case reported by Roth, may prove fatal by a twisting of its pedicle. The possible effect of an intrathoracic cyst is shown by this observer, who found evidence of marked pressure upon the lungs and bronchi. The possibility that cysts of the abdominal wall may become of considerable size is suggested by the history of the urachus cysts sometimes found between the muscle and peritoneum and extending from the navel to the symphysis pubes."
TREATMENT. If these cysts were recognized early and before the obstruction was marked, it would, of course, be possible to remove those arising from the free margins of the bowel. Where the cyst is located in the mesentery, the danger of injuring the blood-supply of the intestine would naturally materially increase the risk.
LITERATURE CONSULTED ON INTESTINAL CYSTS.
Buchwald: (Colmers, Loc. cib.).
Carwardine, T.: Volvulus of Meckel's Diverticulum. Brit. Med. Jour., 1897, ii, 1637.
Cazin, H.: Etude anatomiquc et pathologique sur les diverticules de l'intestin. These de Paris,
1862, No. 138. Colmers, F.: Die Enterokystome und ihre chirurgische Bedeutung. Arch. f. klin. Chir., 1906,
INTESTINAL CYSTS. 187
Dittrich: (Runkel, Op. cit.)
Fitz, R. H.: Persistent Omphalomesenteric Remains; their Importance in the Causation of Intestinal Duplication, Cyst Formation, and Obstruction. Amer. Jour. Med. Sci., 1884, lxxxviii, 30.
Hendee: (Colmers, Loc. cit.)
Hennig, C: Cystis intestinalis, Cystis citra oesophagum bei einem Neugeborenen. Centralbl. f. Gyn., 1S80, iv, 398.
Huter: (Runkel, Op. cit.)
Kulenkampff, D.: Ein Fall von Enterokystom. Tod durch Darmverschlingung. Centralbl. f . Chir., 1883, x, 679.
Lohlein: (Runkel, Op. cit.)
Nasse: (Runkel, Loc. cit.)
Rimbach: (Colmers, Loc. cit.)
Roth, M.: Ueber Missbildungen im Bereich des Ductus Omphalomesentericus. Virchows Arch., 1881, Lxxxvi, 371.
Runkel, A.: Ueber cystische Dottergangsgeschwulste. Inaug. Diss., Marburg, 1897.
Tiedemann: (Roth, Loc. cit.)
Tscherning: (Runkel, Op. cit.)
Schaad, L. : Ueber die Exstirpation einer Cyste des Dotterganges. Corr.-Bl. f. Schweizer Aerzte, 1886, xvi, 345.
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