Talk:Paper - V. Meckel's diverticulum patent at the navel (1902)
MECKEL’'S DIVERTICULUM PATENT AT THE NAVEL.
By JOSHUA C. HUBBARD, MLD,
ACTING THIRD ASSISTANT VISITING SURGEON, BOSTON CITY HOSPITAL; SURGEON TO OUT-PATIENTS, CARNEY HOSPITAL; ASSISTANT SURGEON TO OUT-PATIENTS, INFANTS’ HOSPITAL.
IT is by no means rare to find at autopsy a Meckel’s diverticulum. The percentage varies, according to different writers, from one to three. It is more rare for a Meckel’s diverticulum to cause trouble; still more uncommon is it to find the diverticulum patent at the navel. As this last is a very serious condition, from which the infant seldom recovers, I consider it worth while to collect the literature of the cured cases and to add one to the list.
Meckel’s diverticulum is formed by the persistence of the vitelline or omphalomesenteric duct or yolk stalk, synonymous terms. This duct connects the yolk sac with what is to form later the small intestine, some distance above the cæcum. At first it is a duct of large calibre, but gradually it becomes smaller and smaller as the embryo grows, and normally disappears by the sixth month, though after that it may still for a while be distinguishable microscopically as a shrunken remnant in the midst of the connective-tissue cells of the cord.
The patency at birth is ordinarily not discovered till the cord falls, when a fistula is left at the navel. The umbilical cord usually is of normal appearance and size, and causes no suspicion of anything wrong. Other congenital abnormalities —harelip, palate, etc.—are at times, though apparently very rarely, present, and in adult cases of vague abdominal symptoms are considered suggestive of the presence of the diver 495 496 JOSHUA C. HUBBARD.
ticulum. The diverticulum may be so short that the ileum practically empties its contents at the navel, or it may be of considerable length.
A simple patent Meckel's diverticulum is an intestinal fistula opening at the navel. The mucous membrane lining the diverticulum is adherent to the umbilical ring. More or less of the intestinal contents may be discharged here, depend
Fic. 1. Fic. 2. Fic. 3.
FIG. 4. Fi. 5. Fic. 6.
Fics. 1 to 6 show the steps from a simple condition where the diverticulum is patent to the complicated form where the intestine is pulled out through the diverticulum.
ing on the size of the opening. If the opening is of fair size, the diverticulum may soon begin to protrude a little Two reasons for this have been given by different writers,—the pressure in the abdominal cavity and peristalsis. This makes a small tumor at the navel covered with mucous membrane, with an opening at its apex. If the opening is very small, the MECKEL'S DIVERTICULUM AT THE NAVEL. 497
tumor resembles closely an ordinary umbilical polyp. The presence of pyloric and Lieberkuhn’s glands in umbilical polyps shows that in many cases they are really due to the remains of
Fic. 7.—Prolapse of intestine between diverticulum and edge of ring.
Fic. 8.—Intussusception through Meckel’s diverticulum.
a diverticulum which has closed everywhere except at the outside. The practical point about this is in regard to the treatment. We ordinarily snip or tie off an umbilical polyp with no 498 JOSHUA C. HUBBARLD.
concern. However, it is well to look at them carefully hereafter, as the result of opening a diverticulum might be disastrous in the extreme. Lowenstein cut off what appeared to be a simple polyp. The removal of the polyp was followed immediately by a prolapse of intestine at the navel. Barth has said that a more careful examination of these apparently ordinary polyps will show an opening in many more than we expect. If the opening at the navel through which the prolapse comes is of sufficient size, the protrusion continues to increase and the intestine to be drawn nearer and nearer to the abdominal wall. Finally, the posterior wall of the protruding bit of intestine projects as a spur, exactly as occurs occasionally in an artificial anus. Guthrie reports a fatal case where this spur was so firmly wedged into the umbilical ring that no fæces could pass below into the lower intestine, which became atrophied. Until the appearance of the spur, there has been but one opening in the middle of the tumor; now, however, as the spur forces its way out, it divides this and forms two openings, one leading into the afferent piece of intestine and the other into the efferent. The spur may be so large that it pulls the intestine out through the ring. It becomes flattened and hides the openings which lie just under its overhanging edge. Further complications may occur from a knuckle of intestine prolapsing at one side between the diverticulum and the edge of the ring. When this occurs in a case where there is already a large protrusion of intestine, it makes a very complicated situation. Barth reports such a case. Golding-Bird reports even a more complicated one, where an intussusception had formed through the diverticulum. This necessarily makes three openings in the tumor,—two for the diverticulum formed by the intussusception dividing the original one, and one in the middle for the opening of the intussuscepted gut. Diagnosis.—The essentials for a diagnosis are a fistula at the navel discharging fæcal matter with the mucous membrane firmly attached to the umbilical ring. The history is of importance in distinguishing an open Meckel’s. diverticulum from a fistula at the navel as the result of an abscess at that MECKEL'S DIVERTICULUM AT THE NAVEL. 499
point. It is to be distinguished from an umbilical hernia so large that it was caught in the ligature about the cord and was left as a fistula by the falling of the cord. Barth says that the diagnosis between these two is easy, though I think it might at times be difficult. An umbilical hernia caught in this way discharges all the fæces onto the abdominal wall, while an uncomplicated diverticulum ordinarily does not. The umbilical hernia also protrudes on coughing or straining, which a diverticulum is said not to do. At first, of course, the hernia is not attached to the umbilical ring, and its outside is covered by serous and not mucous membrane. If a child survives such a condition, the diagnosis later offers many diffculties, as the hernia then becomes adherent to the edges of the ring, and its surfaces covered so thickly with granulations that it is difficult to distinguish a serous from a mucous membrane. A patent diverticulum must also be differentiated from an open urachus. The direction taken by the probe in passing into the fistula and the character of the discharge are the distinguishing points. It may require a microscopic examination of the material which the eye of a catheter can pick up in the fistula to determine whether fæces are present or not, and of course on this hangs the diagnosis.
Treatment.—As soon as the diagnosis is made, compression should be applied, that an uncomplicated diverticulum may not begin to prolapse, and thus prevent, if possible, the chain of complications already mentioned. The treatment varies, of course, with the size of the fistula. Spontaneous cure is said to be rare. Barth gives in his article three cases which were cured by comparatively simple means. Marshall closed the fistula after freshening the edges, and then removed the tumor by the galvanocautery. (Chanderlux cut off the tumor with scissors, and the wound healed without disturbance. Wernher cured temporarily his case by compression and cauterization. When the fistula is of any size, these procedures are inexact and may be dangerous, as shown by Lowenstein’s case, already mentioned, where an intestinal prolapse followed the removal of what seemed a simple polyp, and the cicatrix 500 JOSHUA C. HUBBARD.
obtained by them is not so firm that a recurrence may not occur. To get a perfect view of the diverticulum and any complicating protrusions of intestine, a laparotomy is necessary. The case can then be dealt with rationally, the complications recognized and treated and the diverticulum removed, the opening into the intestine closed, and the edges of the abdominal ring freshened and sutured with a space for a wick or not, according to the judgment of the operator. This is a serious operation, and may be attended with profound shock.
Prognosis.—The prognosis depends on the severity of the case and the vigor, rather than the age, of the child. In the complicated cases it is most grave. Operation in these cases, however, seems to offer the only chance for cure. The mortality is large. In 1806, Kern could find but four cases (Broca, Gevaert, Stierlin, Shepherd) cured by laparotomy. By an examination of the literature since then, I have found four more cases, which, with the one I have to add, make nine cures in all.
I will simply mention the cases collected by Kern: Broca operated on a child six months old; Gevaert on one two and a half years old; Stierlin on one at two months, and Shepherd at three months.
To these I can add four cases from the published literature.
(1) Broca (Prolapsus Ombil., Bureau). Male, six months. At umbilicus a small red tumor with central orifice, into which a probe can be passed for some distance. Mucous membrane around the orifice directly continuous with skin of umbilicus. Operation. Diverticulum resected. Abdominal wall closed. Recovery.
(2) Broca (Prolapsus Ombil., Bureau). Male, ten months. At centre of umbilicus small red tumor composed of mucous membrane of everted diverticulum. At summit an orifice. Operation. Resection of diverticulum. Lateräl suture of intestinal wall. Suture of abdominal wall. Recovery.
(3) Neurath (Wiener klinische Wochenschrift, 1896, No. 49). At centre of umbilicus red cone covered with mucous memMECKEL'S DIVERTICULUM AT THE NAVEL. 5oI
brane. Fistula in summit, into which probe passes eight centimetres. Tumor increased in size by crying or pressure. Never any fæcal discharge. Operation when three weeks old. Resection of diverticulum six centimetres long. Recovery.
(4) Briddon (ANNALS OF SURGERY, 1898, Vol. xxviii). When ten days old, baby began to pass fæces through unclosed umbilicus. After a few days all fæces discharged in this way. When three weeks old, admitted to hospital. At umbilicus an ovoid maroon-colored mass, size and shape of large hen’s egg. On surface reduplications of valvulæ conniventes. Peristalsis visible. At apex an opening connecting with the lumen of the gut. About an inch in length close to the base of this larger mass and communicating with it a smaller one directed obliquely downward and to left. About size and shape of adult little finger. At its apex, also, an aperture communicating with the lumen of the gut operation showed that the prolapse was formed of the ileum projected through a diverticulum arising from that portion of the gut about a foot from its termination in the cæcum. Diverticulum about an inch in length. Neck of prolapse divided and artificial anus made. At a second operation this was closed and the diverticulum excised. Recovery.
The following came last May to the Out-patient Department of the Infants’ Hospital, where I saw it.
No. 29,752. ©. P. D. female, one month old. When baby was born, had a red mass projecting from navel about size of cord. When cord came off this was left. Bleeds all the time. Black discharge with bad odor. The case was referred to the House for operation, and Ï am indebted to Dr. John Dane for the following notes on the case.
Physical Examination.—Well developed and nourished except for malformation about umbilicus. Tumor one inch long and one-half inch wide protrudes from umbilical ring. Base constricted and gangrenous from attempts of parents to tie tumor off. One-half inch of apex covered by inflamed mucous membrane, which bleeds from many small areas all over surface. Centre occupied by a firm canal, which admits probe two inches. No discharge of fæces seen.
Operation.—Dr. John Dane. Ether. Vertical incision three 502 JOSHUA C. HUBBARD.
inches long in median line passing to left of umbilicus. Stump at umbilicus protected by moist gauze fastened to edges of wound. Some bleeding in abdominal wall requiring forceps pressure. Peritoneum opened and mesentery at once protruded. A diverticulum two millimetres long, one inch in circumference at base, three-eighths millimetre at apex found arising from free border of loop of small intestine and passing out through umbilical ring. Position of loop not ascertained. Loop drawn through abdominal wound. Peritoneal cavity walled off with gauze. Heavy clamp applied just inside umbilical ring. Intestine held on either side of diverticulum by digital pressure. Prolongation cut one-half millimetre from gut. Edges inverted and approximated by two rows Lembert sutures of fine silk. Umbilicus removed by a second vertical cut close to its base on right side. Skin and peritoneum rapidly sutured with interrupted silkworm gut. Gauze drain. Dry dressing. Considerable shock. Recovery.
Barth: Deutsche Zeitschrift für Chirurgie, xxvi, 1887. Minots: Embryology.
Guthrie: Archives Pædiatrics, ii, 1896.
-Golding-Bird: Clinical Society Transactions, London, xxix. Kern: Beiträge zur klinischen Chirurgie, Tübingen, xix, 1897. Sauer: Deutsche Zeitschrift für Chirurgie, 1896-07.
Briddon: ANNALS oF SURGERY, Vol. xxviii, 1898.
Neurath: Wiener klinische Wochenschrift, No. 49, 1896. Bureau: Thèse, Prolapsus Ombilical, Paris, 1898.