Book - Umbilicus (1916) 8
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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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- 1 Chapter VIII. Meckel's Diverticulum
- 1.1 Intestinal Obstruction Due To Meckel's Diverticulum
- 1.2 Strangulation of Meckel's Diverticulum Caused by Volvulus of the Ileum
- 1.3 Ileus Caused by Persistence of the Omphalomesenteric Duct
- 1.4 Intestinal Obstruction due to the Tip of Meckel's Diverticulum Becoming Adherent to a Distant Point
- 1.5 Obstruction due to the Passage of Intestine Through a Hole in the Mesentery of Meckel's Diverticulum
- 1.6 Inversion of Meckel's Diverticulum into the Bowel
- 1.7 Treatment of Obstruction due to Meckel's Diverticulum
- 1.8 Literature
Chapter VIII. Meckel's Diverticulum
Hernise of the tip of Meckel's diverticulum.
A mesenteric diverticulum.
An accessory pancreas situated at the tip of the diverticulum.
Meckel's diverticulum in animals.
Intestinal obstruction due to Meckel's diverticulum.
Cases of intestinal obstruction caused by a Meckel's diverticulum adherent to the umbilicus.
Intestinal obstruction due to the tip of Meckel's diverticulum becoming adherent to a distant point.
Obstruction due to the passage of intestine through a hole in the mesentery of Meckel's diverticulum.
Inversion of Meckel's diverticulum into the bowel.
Treatment of obstruction due to Meckel's diverticulum.
Persistence of the intra-abdominal portion of the omphalomesenteric duct produces the so-called Meckel's diverticulum (Fig. 92). The subject has been so fully considered by many writers that I shall here give only a brief survey, not attempting to in any way give a full resume of the literature. Kern, in his Inaugural Dissertation, says that, according to Morgagni, this diverticulum was first observed by J. H. Lavater, who in 1671 saw a case of this character with Bienaisius in Paris.
Fitz says: "The pouch-like formation of intestine occasionally seen projecting from the lower part of the ileum is universally known as Meckel's diverticulum. Not that this distinguished anatomist was its discoverer, for early in the eighteenth century Ruysch* presented an admirable illustration of this malformation. Its frequent congenital nature was also recognized before the time of Meckel, and it seems probable that suggestions relative to its origin from the vitelline duct had been presented previous to the publication of this investigator.
"We owe to Meckel not only the almost universal acceptance of his theory of origin of the pouch in question, but are also indebted to him for calling conspicuous attention to its importance in the causation of serious disease."
In his "Darmanhang," published by Meckel in Leipzig in 1812, will be found a most careful and detailed description of the literature and of the anatomy of the diverticulum which now bears his name.
Thesaurus Anatomicus, 1701.
Fig. 92. Meckel's Diverticulum. (Schematic.) The diverticulum may pass off from the convex surface of the bowel at right angles or on a slant as here. In the latter case, if the slant be very acute, a valve-like opening may be the result. The mucosa of the small bowel and of the diverticulum is of exactly the same character. The omphalomesenteric vessels originate from the superior mesenteric vessels and pass over or under the bowel to reach the duct.
Among the many contributions to the subject there may be mentioned those of King (1843), Struthers (1854), Schroeder (1854), Cazin (1862), Fitz (1884), Lowenstein (1894), Richardson (1894), Treves (1897), Blanc (1899), and Kelly and Hurdon (1905).
Fitz says: "There are certain well-recognized variations in the seat, size, and shape of this appendage to the ileum. Since the diverticulum is present in the earliest weeks of fetal life, it is obvious that its position with reference to the ileocecal valve must change with the growth of the intestine.
"The diverticulum is usually found in the vicinity of the valve. In the newborn child the distance between the two is about 12 inches, while in the adult the diverticulum is found sometimes three feet above the ileocecal valve. The limits within which it may be present are thus differently stated by various authors. Rokitansky * found its seat to be one to two feet above the cecum, while Forster f extends the limit to upward of four feet."
Fitz says that Major J described a diverticulum which arose from the jejunum. He also refers to a diverticulum, seven inches in length, which was found on the border between the jejunum and ileum. §
Fitz also says that Faggell refers to a diverticulum which was 54 inches from the cecum and to another which rose above the middle of the ileum.
Fitz says that, although the diverticulum is commonly found to be less than 4 inches long, Rokitansky assigns to it a maximum length of 10 inches. One of the best descriptions of Meckel's diverticulum is to be found in Kelly and Hurdon's "Appendicitis and Diseases of the Vermiform Appendix" (p. 594).
This diverticulum projects from the convex surface of the intestine, and may be short or long; sometimes it is free, at other times attached to the umbilicus by a fibrous cord. Occasionally it extends in its continuity to the umbilicus (Fig. 93), and where it is attached to the intestine the two are often of the same diameter. The outer portion of the diverticulum may be of the same caliber and then end in a rounded extremity similar to the bottom of a test-tube ; or the duct may gradually taper off toward its extremity. The walls of the diverticulum are continuous with those of the intestine, and are .similar to them both macroscopically and microscopically.
The diverticulum may or may not have a mesentery. Where none exists, the blood supply comes from the intestine. In those cases in which a mesentery is found, it naturally is on one side, the other being perfectly smooth. The blood vessels come from the mesentery of the small bowel, pass over the ileum, and then spread out in a plexus over the diverticulum. Where the diverticulum is adherent to the umbilicus, its peritoneum may be continuous with that of the abdominal wall, and small vessels from the abdominal wall may extend over to the duct (Fig. 91).
Rokitansky: Lehrbuch der path. Anat,, 1861, 3. Aufl., 182.
t Forster: Handbuch der path. Anat., 1863, 2. Aufl., 97.
t Major: The Lancet, 1839-40, i, 362.
§ Aerztlichcr Ber. aus dem K. K. Allg. Krankenhause zu Wien, 1862, 221.
Fagge: Guy's Hospital Reports, 3. series, 1869, xiv, 359.
Fig. 93. Meckel's Diverticulum Attached to the Abdominal Wall at the Umbilicus. (After Beck.) The picture shows the inner surface of the anterior abdominal wall, to which Meckel's diverticulum has become attached, a is the small bowel; B, the inner surface of the abdominal wall; C, the umbilicus. In the lower part of the picture is seen the bladder. Passing upward from the vertex of this is the urachus. E, E, are the umbilical arteries seen on either side. Passing outward from the small bowel to the umbilicus is Meckel's diverticulum. G, G, represent the omphalomesenteric arteries; H, the omphalomesenteric vein.
If the diverticulum be free and the mesentery short, the former may be drawn down toward the bowel on one side, so that this appendage presents a curved or snout-like appearance. Lowenstein says that Riefkohl reported the cases of three children of one mother, each of whom had a Meckel's diverticulum.
The fibrous cords occasionally found extending from the tip of the diverticulum to the umbilicus are usually remnants of the omphalomesenteric vessels. These are referred to at length in Chapter XIV.
Herni se of the tip of the diverticulum have been referred to by King, Fitz, Kelly and Hurdon, and others.
Fig. 94. An Abnormally Large Meckel's Diverticulum. (After Richardson.)
The Meckel's diverticulum here is practically as large as the small bowel. It is attached directly to the umbilicus.
Fig. 95. A Meckel's Diverticulum with a lobulated extremity. (After King.) (Prep. 1818, Guy's Hospital Museum.)
Meckel's diverticulum has a diameter nearly as large as the small bowel from which it arises. The diverticulum ends in several round hernial projections.
King, in 1843, referred to a very interesting case of this character (Fig. 95). The tip of the diverticulum was free and ended in seven or eight rounded cystic dilatations.
Fitz, in the examination of the Meckel's diverticula in the Harvard Medical School (Improvement Collection, No. 1033), found a chverticulum with two rounded bulgings at its free end. These were large enough to suggest an incipient bifurcation.
Fitz quotes Hyrtl* as saying that branched diverticula are extremely rare. In making an autopsy on a hemicephalic monster, Hyrtl found a diverticulum an inch long. This toward the end was divided into five parts.
Kelly and Hurdonf show a long diverticulum with several small, cyst-like dilatations or hernia? near its tip (Fig. 96).
The opening of the diverticulum into the bowel may be large and oval or round; occasionally it is valve-like. This last condition occurs where the diverticulum leaves the bowel tangentially.
Hyrtl: Handbuch der topographischen Anatomie, 1860, i, 642.
Kelly and Hurdon: The Vermiform Appendix and its Diseases, Fig. 314, p. 598.
Cazin, in 1862, referred to a case in which Meckel's diverticulum opened into the intestine by two orifices, separated by a bridge. The superior one was surrounded by a circular valve.
A Mesenteric Diverticulum.
Although diverticula usually spring from the convexity of the bowel, in rare instances they are noted at its mesenteric attachment.
King, in 1843, referred to a specimen in Guy's Hospital Museum (Fig. 97). The diverticulum was very short. It sprang from the mesenteric border of the small bowel, and was adherent to the mesentery. This subject is considered at length in the chapter dealing with Intestinal Cysts.
Fig. 96. A Meckel's Diverticulum with Hernial Protrusions from its Surface. (After Kelly and Hurdon.)
An Accessory Pancreas Situated at the Tip of the Diverticulum. — Bize, in 1904, gave an interesting account of a case in which an accessory pancreas was found at the tip of a Meckel's diverticulum (Fig. 98). He gives both macroscopic and microscopic pictures of the case, and draws attention to the fact that cystic tumors may possibly develop from such accessory pancreases.
Deve, in 1906, records a case in which Meckel's diverticulum was 7 cm. long. At its extremity was a thickening the size of a small bean. It was an accessory pancreas.
Denuce, in 1908, referred to a case reported by Albrecht. In this case Meckel's diverticulum had at its extremity a yellowish nodule the size of a pea. This nodule, on histologic examination, was found to consist of pancreatic tissue.
It will be interesting to see if, as Bize suggests, pancreatic cysts may possibly develop in the tip of the diverticulum. If such a condition were probable, one would naturally expect the literature to contain records of a few such conditions, but I have not been able to locate a cyst of Meckel's diverticulum that in any way suggested a pancreatic origin.
Meckel's Diverticulum in Animals . — Tillmanns says that the observations of Cazin have shown that true diverticula, having no connection with the abdominal wall, are regularly present in the waterhen, snipe, and swan.
Fitz quotes Morgagni as saying that he had observed the diverticulum on more than one occasion in geese.
Cazin, in his thesis on Intestinal Diverticula, published in 1862, reported an observation of Guobaux. Guobaux, on January 15, 1855, made an autopsy on a sheep. In the lower portion of the small intestine was a diverticulum 9 cm. in length, and of a caliber equal to that of the small bowel. It had the same structure as the intestine. On examining this canal he found that a Peyer patch had extended a short distance into the interior of the diverticulum. Guobaux also referred to diverticula occurring; in birds.
Fig. 97. A Short Meckel's Diverticulum Springing from the Mesenteric Attachment. (After King.) (Prep. 1819", Guy's Hospital Museum.)
Fig. 98. An Accessory Pancreas in the Tip of Meckel's Diverticulum. (After Bize.)
Meckel's diverticulum (.4) was dilated, and at its tip was a nodule the size of a small nut (B) . This nodule on histologic examination was found to consist of pancreatic tissue.
Intestinal Obstruction Due To Meckel's Diverticulum
As the reader is thoroughly familiar with obstructions of this character, and as the literature on this subject is so large, I shall not attempt to cover the subject, but shall merely give a few examples of some of the manifold ways in which a Meckel's diverticulum may occasion obstruction.
A Case of Intestinal Obstruction in which Meckel's Diverticulum was Free. — The following case gives a graphic picture of what a free Meckel's diverticulum may do. The specimen was kindly placed at my disposal by Dr. Joseph C. Bloodgood: August L., aged forty-two, came under the care of Dr. H. Jones, of Irvington, Mel., early on the morning of June 9, 1914.
Fig. 99. Meckel's Diverticulum Completely Tying off a Loop of Small Bowel. This specimen was removed by Dr. George A. Stewart at St. Agnes' Hospital, Baltimore, June 9, 1914. The arrows indicate the cut ends of the bowel. The intestinal loop is greatly distended. The pear-shaped cyst is a Meckel's diverticulum. Its extremity is perfectly free, and on its upper surface its blood-vessels stand out prominently. It ha- in some manner become tied around the gut. (For the key, see Fig. 100.)
At 1 a.m. he had nausea and vomiting, and shortly afterward abdominal pain. His bowels had moved once, but later were obstinately constipated. Twelve hours later he had tenderness all over the abdomen.
Operation (at St. Agnes' Hospital). — Fifteen hours after the symptoms developed Dr. George A. Stewart opened the abdomen and found a large loop of bowel much distended and very dark. Its mesentery appeared to be gangrenous. The bowel was so knotted at one point that no attempt was made to unravel it, and the entire area was removed. The ends were closed, and a lateral anastomosis was made. The abdomen was closed without drainage. The patient made a good recovery.
Dr. Bloodgood, in his description, says: "The specimen consists of about 18 inches of small gut, dark brown in color, and of the hardness of paper. At one end there is a peculiar knot, which was the cause of the volvulus and thrombosis (Fig. 99). From the picture it is seen that the bowel is markedly distended. The ends of the resected gut are indicated by the arrows. The cystic mass (M) is the greatly dilated Meckel's diverticulum. It is perfectly smooth, and on its upper surface are its mesenteric vessels. ' ' From the picture it is very difficult to say just how the obstruction occurred. Fig. 100, made by Max Brodel, gives the key to the situation. A loop of bowel had become twisted, Meckel's diverticulum had dropped over this, encircling it completely, and the tip had then passed through the space between its own base and the small bowel, result of the obstruction all the affected parts soon swelled up.
Early operation afforded the only hope of saving such a patient.
Fig. 100. A Diverticulum Tying off a Loop of Small Bowel. This indicates the manner in which the obstruction occurred (ef. Fig. 99) . Meckel's diverticulum has dropped over a loop of bowel which has been partly twisted. After passing under the loop it curves upward and passes through the space between the base of the diverticulum and the adjacent small bowel. With the consequent distention of the constricted bowel, complete obstruction has resulted.
CASES OF INTESTINAL OBSTRUCTION CAUSED BY A MECKEL'S DIVERTICULUM ADHERENT TO THE UMBILICUS.
As a Intestinal obstruction is more likely to occur when the diverticulum extends to and is fixed to the umbilicus, or when it is attached to the umbilicus by a fibrous cord.
Strangulation of Meckel's Diverticulum Caused by Volvulus of the Ileum
Elliot's patient was a man, aged thirty, who was admitted to the Massachusetts General Hospital. He had been sick for four days. He gave a history of vomiting, chills, and abdominal pain. On admission his temperature was 103.6° F. ; pulse, 160. The abdomen was distended and exceedingly tender, especially to the right of and below the umbilicus ; there was free fluid in the abdominal cavity.
Elliot, J. W.: Trans. Amer. Surg. Assoc, 1894, xii, 217.
Operation. — When the abdomen was opened, there was an escape of turbid fluid. The appendix was normal. The mass encountered looked like a large, dilated, and gangrenous knuckle of intestine, but without a mesentery. It sprang from the lower part of the convex surface of the ileum and was tightly twisted at its point of attachment to the bowel. (See Fig. 101.) It extended upward into a dense mass of adhesions, and was found to be attached to the under surface of the umbilicus. It was a strangulated and gangrenous Meckel's diverticulum, 7 inches long, and about the same size as the ileum. During dissection it ruptured. The ileum at this point was found to be twisted on itself and held in position by adhesions. The gut was not wholly obstructed by the twist. The diverticulum, having its outer end fixed at the umbilicus, was twisted and strangulated at its base by the turning over of this coil of ileum. The gangrene of the diverticulum was most intense near the ileum, the end at the umbilicus being only moderately inflamed. The patient died on the second day.
Fatal Intestinal Obstruction Due to Remains of the Omphalomesenteric Duct.* — Mrs. M. C, aged twenty-four, admitted to St. Francis' Hospital, Pittsburgh, June 6, 1906. The patient had always been healthy until the onset of the present illness. Three days previous to admission she was seized with sudden severe pain in the abdomen. This was followed by vomiting. There was a slight elevation of temperature; the pulse was rapid.
The diagnosis of intestinal obstruction was made, and immediate operation advised. When the abdomen was opened, a gangrenous loop of ileum was found. This was twisted twice about a narrow band which was attached at one end to the umbilical site; at the other end, to the convex surface of the ileum, about six inches from the cecum. A resection of the bowel was made, but the patient died three days later of peritonitis.
Examination of the section of the band which was removed showed clearly that it was the obliterated remnant of the vitelline duct.
Muggins, R. R. : Personal communication.
Fig. 101. Strangulation op Meckel's Diverticulum Causing Volvulus op the Ileum. (Redrawn after Elliot.)
The specimen was from a man aged thirty who had signs of intestinal obstruction. The abdomen contained turbid fluid. In the incision a mass presented which looked like a large, dilated gangrenous loop of intestine, but had no mesentery. It sprang from the lower part of the convex surface of the ileum, and was slightly twisted at its point of attachment to the bowel. It extended upward into a dense mass of adhesions, and was found to be attached to the under surface of the umbilicus. It was a strangulated and gangrenous Meckel's diverticulum. It was about seven inches long, and had about the same diameter as the ileum. The small bowel at thia point was twisted on itself and held in position by adhesions. The gut was partially obstructed at the twist. The patient died on the second day after operation.
Ileus Caused by Persistence of the Omphalomesenteric Duct
The patient, a man nearly twenty years of age, had always been strong and hearty. He was suddenly seized with vomiting and pain in the umbilical region. The vomiting was frequent, and two days later assumed a fecal character. The abdomen, particularly in the lower half, was much distended.
Operation. — When the abdomen was opened, a part of the bowel was found distended; the rest was contracted. One loop of bowel was green and gangrenous. The gangrene had been caused by a half-turn made by a cord the size of the little finger passing from the umbilicus. This cord was inserted in the gangrenous loop. It was an omphalomesenteric duct. The gangrenous loop of small bowel was 1.1 meters long, and reached to within 7 cm. of the ileocecal valve. A resection was made but the patient died almost immediately.
Fatal Intestinal Obstruction in Consequence of a Twist in the Mesentery and the Falling of Some Folds of Intestine over a True Diverticulum. f — The patient, a strong, robust boy, was seized with a violent pain in the abdomen after drinking a cup of hot coffee. He had no movement of the bowels for six days. General peritonitis developed, and he died on the ninth day.
Autopsy. — On section, general peritonitis was found. The mesentery of some loops of the small bowel was twisted on itself. The intestines were deeply injected and quite black. Loops of intestine had fallen over a diverticulum, which extended from the small gut to the linea alba, about one inch below the umbilicus. The diverticulum was 5 inches long and 34 inches distant from the cecum.
Strangulation of Intestine by Diverticulum Ilei.| — Eliza W., aged ten, was admitted with symptoms of strangulated bowel. Peritonitis developed, and she died in a few hours. The symptoms had begun ten days before death, with an attack of sickness attributed to the eating of some indigestible fruit.
Autopsy. — On section, an acute peritonitis was found. When the abdominal wall was lifted up, a band was seen passing from the umbilicus to the lower part of the ileum, to which it was attached. The portion of the gut above was much distended; the part below was contracted. The constricting band was found to be a diverticulum of the ileum which had become obliterated at the umbilicus. At its origin it was of the same caliber as the contracted portion of the ileum below it.
"The only practical consideration arising from such a case is to remember that, in an exploratory operation in a case of obstruction, a cord passing to the umbilicus is very likely to be a diverticulum of intestine."
Wilks says that, in the Guy's Hospital Museum, there are four specimens of this malformation causing obstruction of the intestine. In one case the patient had reached forty-three years of age. In another, a child, the patient had previously undergone a successful plastic operation for a fecal discharge from the umbilicus.
Jordan, Max: Ueber Ileus verursacht clurch den persistirenden Ductus omphalo-mesaraicus. Berlin, klin. Wochenschr., 1896, xxxiii, 25. t Ward, Nathaniel: Trans. Path. Soc. London, 1856, vii, 205. % Wilks, Samuel: Trans. Path. Soc. London, 1865, xvi, 126.
Intestinal Obstruction due to the Tip of Meckel's Diverticulum Becoming Adherent to a Distant Point
The following case reported by Sheen is a very good example of this group of cases :
Fatal Intestinal Obstruction Due to Meckel's Diverticulum.* — Case 2 . — A. L. W., male, aged forty-one. Admitted to the Cardiff Infirmary, November 7, 1899.
" History. — Loss of flesh for one year. Present illness began with an attack of abdominal pain after supper nine days ago. Since then absolute constipation and constant vomiting, which has been fecal for the last six days. Has had two enemata without effect. Abdominal pain and latterly hiccough have been constant.
"Present Condition. — The man looks very ill, with cold extremities; pulse, 72, feeble; temperature, 97° F. Has vomited a little brown fluid matter, smelling fecal. Abdomen moderately distended, flanks and hypochondriac region somewhat flattened; some dulness above pubes; remainder resonant, peculiar hollow, highpitched note over position of sigmoid flexure ; no visible peristalsis ; splashing sounds on manipulation; rectal examination negative; pain referred to umbilicus.
' ' The patient was given ether immediately, and the abdomen opened in the left iliac region. The colon was found empty; some distended coils of small intestine presented themselves, and the hand could feel something like a band on the right side, and apparently near the pelvic brim. The closure of the wound was commenced with a view to opening in the middle line, when, somewhat suddenly, the patient, whose condition was extremely serious throughout, collapsed and died. The trachea was opened, and various measures resorted to to restore animation, but without effect.
"Postmortem (Twelve Hours After Death). — Abdomen only opened through a crucial incision. No peritonitis. Small intestine distended and injected. Without disturbance, the seat of obstruction was at once seen in the form of a diverticulum of the bowel passing downward and outward from the median line, at a point about opposite to the third lumbar vertebra, toward the pelvic brim. On examination the diverticulum, which was devoid of a mesentery, was found to be about four inches long, bulbous at its commencement, then narrowing suddenly, but patent to its extremity. It sprang from the posterior aspect of the ileum, about two feet above the ileocecal valve, curved forward and inward round the bowel from which it came, and passed downward and inward, to be attached by its apex to the small intestine again, about five inches from the ileocecal valve. The obstruction of the ileum took place at the point of attachment of the apex of the diverticulum, which attachment was made by a few short, firm adhesions. The bowel was very near perforation at this point. The gut was also pressed upon somewhat at two points above the actual seat of obstruction: (1) Where the diverticulum wrapped itself around the ileum at its point of origin; (2) where a loop of bowel passed under the diverticulum. It was evident that the more distended the bowel became, the more would the diverticulum pull upon and kink its point of attachment."
Sheen, William: Some Surgical Aspects of Meckel's Diverticulum. Bristol Medico-Chir. Jour., 1901. xix, :ni).
Obstruction due to the Passage of Intestine Through a Hole in the Mesentery of Meckel's Diverticulum
I have not found the record of a similar case in the literature. The mesentery of the diverticulum, as a rule, is very slender and narrow, and even if a hole existed, the bowel would tend to pass not through but over it.
Umbilical Polyp; Intestinal Obstruction Due to Hernia through the Mesentery of Meckel's Diverticulum. Death.* — "E. T. L., male, aged one year, nine months, admitted to the Cardiff Infirmary April 22, 1897.
"History. — Swelling at the navel since birth. The confinement was not attended by a doctor. The swelling has always been the same size. About a halfpint of glairy fluid comes from it in twenty-four hours, staining and stiffening the linen. The general health has always been good.
" Present Condition. — A healthy, well-nourished child. Attached to the center of the navel is a bright-red, bluntly lobulated, pedunculated tumor the size of a grape, with skin reaching only to its margin. The surface resembles intestinal mucous membrane and exudes a viscid fluid of alkaline reaction. In the center is a channel one inch deep. Through the parietes a cord the thickness of a cedar pencil can be felt passing backward for about 13^2 inches. Urination and defecation are normal.
"After admission the fluid was collected as far as possible in a small glass vase strapped to the child's abdomen. The total amount in twenty-four hours was 10 to 15 c.c. ; on two occasions, 22 c.c. ; sometimes there were only 5 c.c, but then some was lost. It was a colorless, viscid fluid, and could be poured from vessel to vessel like a thin jelly; it was alkaline in reaction and contained a little albumin. It had no digestive action on fibrin or starch. So far as our examination went, therefore, it resembled succus entericus. On July 31st the tumor was removed with scissors and the base cauterized, the procedure being quite a slight one. The child vomited continuously after the anesthetic. On August 3d a simple enema was given, and the bowels moved twice; on the following days the child was fretful and became thinner; the milk was peptonized, but the vomiting continued, the vomitus consisting of undigested milk; the abdomen was distended and tender. The child grew worse. On August 7th a blood-streaked motion is stated to have been passed after an enema, but it was not saved by the nurse. Nutrient enemata were given toward the end, but the child died at 5 p. m. on August 7th, one week after operation. The cause of death was thought to be peritonitis.
"August 8th, Postmortem. — No peritonitis. Death was found to be due to intestinal strangulation. The parts involved were removed for separate examination. In the specimen removed were the lower part of the small intestine, cecum, appendix, and a small piece of ascending colon. Connected with the small intestine was a Meckel's diverticulum, patent to within an inch of the umbilicus, to which it was attached by a solid cord (Fig. 102). The skin around the umbilicus was removed by an elliptic incision.
" On dissection the following points were made out : (1) The bowel is strangulated by being herniated through a hole (A) in the mesentery of the diverticulum ilei. (2) The constricted bowel is 25 inches in length. (3 J Practically all the bowel between the origin of the diverticulum and the ileocecal valve is strangulated. (4) The strength of the constricting cord of mesentery is largely due to a vessel traversing it. (5) The bowel is twisted within the ring and near perforation at its proximal end. (6) The diverticulum is bulbous in shape, and its lumen is much narrowed where it joins the intestine.
Sheen, W.: Op. cit.
Fig. 102 shows the condition, the strangulated loop represented as being turned out of the constricting ring (A). The polypus is shown. The position of
the appendix was interesting. It lay against the diverticulum, with its apex pointing toward the liver.
" Microscopic examination of the polypus showed a connective-tissue basis, with a layer of intestinal glands — exactly like Lieberkiihn's follicles. In places the intestinal glands were proliferating, so as to produce a mass resembling an ordinary intestinal adenoma.
"Clinically disappointing, this case is of great interest pathologically. The writer has been able to find no other record of a case of strangulation through the mesentery of a Meckel's diverticulum."
Fig. 102. Fatal Intestinal Obstruction Due to the Passage of the Bowel through a Hole in the Mesentery of a Meckel's Diverticulum. (After Sheen.) Attached to the umbilical depression was a bright red, bluntly lobulated, pedunculated tumor the size of a grape. Its surface was covered with mucosa. In the center was a channel one inch deep, and through the abdominal walls a cord the size of a lead-pencil could be felt extending backward into the abdomen. The child developed intestinal obstruction and died. At autopsy 25 inches of small bowel were found to have passed through the hole (A) in the mesentery of Meckel's diverticulum. Practically all the bowel between the diverticulum and the ileocecal valve had become strangulated. The strength of the constricting cord of mesentery was due largely to a vessel traversing it. Meckel's diverticulum was bulbous in shape and much narrowed where it joined the small bowel.
Inversion of Meckel's Diverticulum into the Bowel
The following case, recorded by Ktittner, is a very rare one. The diverticulum had turned inside out, just as when one inverts the finger of a glove. It projected into the bowel and had caused obstruction and subsequent intestinal perforation.
Ileus Due to Intussusception of Meckel's Diverticulum.* — This case was observed by Bruns. A woman, forty-nine years of age, had always been well up to eight weeks previously, when she suddenly showed signs of intestinal obstruction. There was fecal vomiting for five days. The patient then improved, but did not get perfectly well. Three days before her admission the symptoms returned and rapidly grew worse. At operation the peritoneum was found to be markedly injected. The intestines were covered with fibrin and were lightly adherent, and in the pelvis was a thin, odorless fluid. Part of the small intestine was dilated, and the rest collapsed. No obstruction could be found, and there was no evidence of perforation. The fluid was wiped out, and an anastomosis made between the dilated and collapsed bowel. A drain was left in the lower angle of the wound. The patient died three days later.
Kuttner, H.: Ileus dureh Intussusception eines MeckeFschen Divertikels. Beitrage zur klin. Chir., 1898, xxi, 289.
Autopsy. — The peritonitis had progressed. About 90 cm. from the beginning of the jejunum was an area of thickening 4 cm. long. Here there was a polyp-like structure 7 cm. long, having at its base a breadth of a thumb. It was a Meckel's diverticulum that had turned inside out and projected into the bowel (Fig. 103). The intestinal lumen at this point was somewhat narrowed. The portion of the bowel at the point of the insertion of the diverticulum had also become drawn into the lumen. Near the base of the diverticulum was a gangrenous spot and a small perforation.
Kiittner then gives the report of seven other cas.es which he had collected from the literature. These were those of Maroni, Ewald, St. Bartholomew's Hospital, Adams, and three recorded by Heller.
Treatment of Obstruction due to Meckel's Diverticulum
Fitz, who devoted to this subject a most thorough and exhaustive study in 1884, arrives at the following conclusions:
- Bands and cords as a cause of acute intestinal obstruction are second in importance to intussusception alone.
- Their seat, structure, and relation are such as frequently to admit their origin from obliterated or patent omphalomesenteric vessels, either alone or in connection with Meckel's diverticulum, and oppose their origin from peritonitis.
- Recorded cases of intestinal strangulation from Meckel's diverticulum, in most instances, at least, belong in the above series.
- In the region where these congenital causes are most frequently met with, an occasional* cause of intestinal strangulation, viz., the vermiform appendage, is also found.
- It would seem, therefore, that, in the operation of abdominal section for the relief of acute intestinal obstruction not due to intussusception, and in the absence of local symptoms calling for the preferable exploration of other parts of the abdominal cavity, the lower right quadrant should be selected as the seat of the incision. The vicinity of the navel and the lower three feet of the ileum should then receive the earliest attention. If a band is discovered, it is most likely to be a persistent vitelline duct, Meckel's diverticulum, or an omphalomesenteric vessel, either patent or obliterated, or both these structures in continuity. The section of the band may thus necessitate opening the intestinal canal or a blood-vessel of large size. Each of these alternatives is to be guarded against, and the removal of the entire band is to be sought for, lest subsequent adherence prove a fresh source of strangulation."
"The chief practical conclusion thus reached in this article is essentially the same as that of Nelaton.* This surgeon advised that the incision through the abdominal wall for the relief of intestinal obstruction should be made a little above Poupart's ligament, preferably in the right side. The knuckle of intestine first presenting was to be united to the edges of the wound and incised, an intestinal fistula being thus established. His recommendation was based upon the applicability of this operation — enterotomy — to all cases of intestinal obstruction, since it is usually impossible to make a differential diagnosis of the cause of ileus. The place was selected because a loop of small intestine above the seat of obstruction is likely to be found in this part of the abdomen, and it is also likely to be so far from the stomach that a sufficiency of intestine for digestive purposes will be left intact.
Fig. 103. Inversion of Meckel's Diverticulum into the Lumen of the Bowel. (Redrawn after Kiittner.)
The patient was a woman aged forty-nine. In this case Meckel's diverticulum was virtually turned inside out, and is seen lying in the bowel. The condition produced obstruction and death.
If Reginald Fitz were living today and rewriting this paragraph he would, remembering his epoch-making studies on appendicitis, replace "occasional" by the word "frequent."
- The due appreciation of the relative f requency of congenital causes of intestinal obstruction acting in the region recommended by Nelaton as the place of operation adds force to his arguments. The operation of enterotomy in the best favored position is still available, provided the above causes of obstruction are not found."
These suggestions, made by Nelaton in 1857, and by Fitz in 1884, are in thorough accord with the surgical views of to-day. Thirty years have elasped since Fitz wrote his article. To-day the cases are, fortunately, often recognized early. The surgeon will make a right rectus incision, which can be extended upward or downward and the obstruction relieved or the cause removed, as the case may be. In addition to this, due consideration must be given to the question whether the partly paralyzed bowel can expel its contents even after the obstruction has been removed. If there is any doubt on this point, it is the duty of the surgeon to bring up a loop of bowel above the point where obstruction has existed, attach it to the abdominal wall, and open it a few hours later.
In the late cases, when the patient is too weak for any prolonged operation looking to the relief of the obstruction, a loop of the distended bowel should be brought up into the incision and an enterostomy made with the hope that in a few days the patient will be strong enough to withstand the more radical procedure.
Xelaton: I/Union medicale, 1857, xi, Xos. 89, 91, 93.
Literature Consulted On Meckel's Diverticulum.
Beck, B.: Ueber das angeborne Divertikel des Rrummdarms. Illustr. Med. Zeitung, Munchen,
1852, ii, 294. Bize: Etude anatomo-clinique des pancreas accessoires situes a l'extremite d'un diverticule intestinal. Revue d'orthopedie, 1904, xv, 149. Blanc, H. : Contribution a la pathologie du diverticule de Meckel. These de Paris, 1899, No. 393. Cazin, Henry: Etude anatomique et pathologique sur les diverticules de l'intestin. These de
Paris, 1862, No. 138. Denuce: Fistules pseudo-pyloriques congenitales de l'ombilic. Revue d'orthopedie, 190S, xix, 1. Deve, F.: Des teratomes "enteroides." A l'occasion d'un cas de "tumeur entero'ide pancrcati forme." La Normandie med., 1906, xxi, 169. Elliot, J. W.: Strangulation of Meckel'-S Diverticulum Caused by Volvulus of the Ileum. Trans.
Amer. Surg. Assoc, 1894, xii, 217. Fitz, R. H.: Persistenl Omphalomesenteric Remains: their Importance in the Causation of In tesl inal Duplication, Cyst-formation, and Obstruction. Amer. Jour. Med. Sci., 1884, lxxxviii,
30. Huggins, R. R.: Personal communication. Jordan, Max: Ueber Ileus verursacht durch den persistirenden Ductus ornphalo-mesaraicus.
Berlin. klin. Wochenschr., 1896, xxxiii. 25. Kelly and Hurdon: The Vermiform Appendix and its Diseases. W. B. Saunders Co., 1905.
Kern, T. : Leber die Divertikel des Darmkanals. Inaug. Diss., Tubingen, 1874. King, T. W.: A Feculent Discharge at the Umbilicus from Communication with the Diverticulum Ilei. Guy's Hospital Reports, 1843, i, 2. series, 467. Ki'ittner, H.: Ileus durch Intussusception eines Meckel'schen Divertikels. Beitrage zur khn.
Chir., 189S, xxi, 289. Lowenstein: Der Darmprolaps bei Persistenz des Ductus omphalo-mesentericus, mit Mittheilung
eines operativ geheilten Falles. Langenbeck's Arch. f. khn. Chir., 1894-95, xlix, 541. Meckel, Johann Friedrich: Handbuch der pathologischen Anatomie, 1812, i, 553. Richardson, W. G.: A Case of Abnormally Large Meckel's Diverticulum found Postmortem.
Quart, Med. Jour., 1894-95, iii, 267. Schroeder, G. : Ueber die Divert ikel-Bildungen am Darm-Kanale. Inaug. Diss., Augsburg, 1854. Sheen, W.: Some Surgical Aspects of Meckel's Diverticulum. Bristol Medico-Chir. Jour., 1901,
jrix, 310. Struthers, John: Anatomical and Physiological Observations, Edinburgh, Part I, 1854, 137. Tillmanns, H. : Ueber angeborenen Prolaps von Magenschleimhaut durch den Nabelring (Ectopia
Ventriculi) und iiber sonstige Geschwulste und Fisteln des Nabels. Deutsche Zeitschr. f.
Chir., 1882-83, xviii, 161. Treves, Frederick: Allbutt's System of Medicine, 1897, iii, 802. Ward, X.: Fatal Intestinal Obstruction in Consequence of a Twist in the Mesentery and the
Falling of Some Folds of Intestine over a true Diverticulum. Trans. Path. Soc. London,
1856, vii, 205. Wilks, Samuel: Strangulation of Intestine by Diverticulum Ilei. Trans. Path. Soc. London,
1865, xvi, 126.
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