PERSISTENT OMPHALO-MESENTERIO 
REMAINS; 
I 
THEIR IMPORTANCE IN THE CAUSATION OF IN- 
TESTINAL DUPLICATION, CYST-FORMATION 
AND OBSTRUCTION. 
BY 
V7 
REGINALD H. FITZ, M. D., 
SHATTI'CK PROFESSOR OF PATHOLOGICAL ANATOMY IN HARVARD UNIVERSITY. 
FROM 
THE AMERICAN JOURNAL OF THE MEDICAL SCIENCES. 
July, 1884. Extracted from the 
American Journal of the Medical Sciences for July, 1884. 
PERSISTENT OMPHALO-MESENTERIC REMAINS; THEIR IMPORTANCE 
IN THE CAUSATION OF INTESTINAL DUPLICATION, CYST- 
FORMATION, AND OBSTRUCTION. 
By REGINALD H. FITZ, M.D., 
Shattuck Professor of Pathological Auatomy in Harvard University. 
The pouch-like formation of intestine occasionally seen projecting from 
the lower portion of the ileum, is universally known as Meckel’s diver- 
ticulum. Not that this distinguished anatomist was its discoverer, for 
early in the eighteenth century Ruysch1 presents 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 
publications of this investigator. Morgagni2 says, while speaking of the 
diverticulum of the ileum : “ I have also seen the same appearance more 
than once in geese, and particularly in one of such a breadth that it could 
not be taken for the remains of that duct, which has formerly belonged to 
the vitellum.” 
Meckel,8 however, while recognizing that all the better observers have 
regarded the diverticulum as a congenital malformation of early occurrence, 
nevertheless maintains that previous to his efforts “ there has been no 
attempt at explaining in what manner this fault of primitive formation 
arises.” We owe to this author not only the almost universal acceptance 
of his theory of the 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. 
Towards the end of the fourth week of the intrauterine life of the human 
foetus, the primitive intestine communicates with the umbilical vesicle by 
means of a tube, the vitelline or omphalo-mesenteric duct. During the 
1 Ruysch, Thesaurus Anatomicus, 1701, vii. fig. 283. 
2 Morgagni, The Seats and Causes of Diseases ; translated by Alexander, 17(39, ii. 141. 
3 Meckel, Reil und Autenrieth’s Archiv fur die Phy6iologie, 1809, ix» r im 2 
subsequent two weeks the abdominal plates close, shutting in a portion of 
this duct, which, as a delicate thread, unites to the navel the loop of intes- 
tine projecting into the depression at the origin of the umbilical cord. 
During the subsequent development of the intestine, that portion above 
the insertion of this thread becomes the greater part of the alimentary 
canal, while from that below this point the lowermost portion of the ileum 
and the large intestine are developed. The thread usually disappears. 
With its persistence and growth, however, there remains, more or less 
permanently attached to the navel from within, a tube, which presents the 
structure of the intestine, and which may be found patent in the adult, 
giving rise to an intestinal fistula opening at the umbilicus. The external 
free surface of this fistulous tract may project as a bulging tumour, with 
the appearance and structure of mucous membrane. An abundant new- 
formation of gland-like tissue may arise from its mucous surface, possess- 
ing the characteristics of an adenoma of the intestine. There are certain 
well-recognized variations in the seat, size, and shape of this appendage to 
the ileum to which attention may here be called. 
Since the diverticulum is present, if at all, in the earliest weeks of foetal 
life it is obvious that its position with reference to the ileo-caecal valve must 
change with the growth of the intestine. The preponderant elongation of 
the intestinal tube above the insertion of the duct is accompanied by a 
less longitudinal growth below this point, and the diverticulum is usually 
found in the vicinity of the valve. In the new-born child the distance 
between the two is about 12 inches, while in the adult the diverticulum is 
found some 3 feet above the ileo-caecal valve. The limits within which 
it may be present are thus differently stated by various authors. Roki- 
tansky1 finds its seat to be 1 to 2 feet above the caecum, while Forster2 
extends the limit to upwards of 4 feet. Klebs,3 among others, has attri- 
buted the origin of a large part of the oesophageal diverticula to congenital 
anomalies. Although other possibilities than the presence of the vitelline 
duct exist for irregularities of development in this region, the facts which 
immediately follow show that the possible presence of the duct at the 
upper part of the alimentary canal must be admitted as a cause of this 
diverticulum. For the present this view is satisfactorily disposed of by 
Zenker,4 but only from the lack of positive evidence. The possibility is 
still recognized by him that the oesophageal diverticula of pulsion may pro- 
ceed from congenital formations. 
Meckel5 states that Lobstein and Wrisberg observed a connection of the 
1 Rokitansky, Lehrbuch der Patliologischen Anatomie, 1861, 3te Auflage, iii. 182. 
2 Forster, Handbuch der Patliologischen Anatomic, 1863, 2te Auflage, ii. 97. 
3 Klebs, Handbuch der Patliologischen Anatomie, 1869, i. 163. 
4 Zenker, Ziemssen’s Handbuch der Specielleu Pathologie und Therapie, 1877, vii. 
Anhang, 61. 
5 Meckel, Beitriige zur vergleichenden Anatomie, 1808, i. 93. 3 
vitelline duct with the duodenum. Major1 describes a diverticulum which 
arose from the jejunum, and which contained valvulae conniventes for a 
short distance from its origin. One, 7 inches in length, has been found2 on 
the border-line, between the jejunum and the ileum. Fagge3 refers to a 
diverticulum, in the museum of Guy’s Hospital, which was 54 inches from 
the ctecum ; and to another which arose above the middle of the ileum. 
In his comprehensive and valuable paper on intestinal obstruction, 
Leichtenstern4 calls attention to the above cases. He says: “ The pres- 
ence of the diverticulum so high up in the intestine, a matter already 
doubted, is to be understood from the manner of development of the 
latter. If the growth of the anterior leg of the middle loop is delayed for 
any reason, the greater part of the small intestine is formed from the pos- 
terior or lower leg. In such a case the diverticulum should be found 
abnormally high.” 
A similar method of reasoning would permit the development of the 
diverticulum unusually low down, and it has been suggested by Dr. Sym- 
ington, in a connection with a case of double crccum reported by Mr. 
Lockwood,5 that the malformation in question might be regarded as a 
diverticulum. 
To these differences in the long tudinal position of the diverticulum may 
be added the striking deviations in the length of the latter. Although 
this is commonly found to be less than 4 inches, Rokitansky6 assigns a 
maximum of 10 inches. Diverticula, as usually understood, of this 
length are to be regarded as of extreme rarity. Attention has already 
been called to one of 7 inches, and Haller7 refers to a statement by 
Cocchi that he saw a diverticulum 8 inches in length. It is possible 
that this unusual length is allowed in virtue of the translation of digitus, 
which may be rendered 6 inches or 8 inches. The greatest length re- 
cognized by Rokitansky may be exceeded, however, provided it is ad- 
mitted that duplication of the bowel is due to the persistence of the 
omphalo-mesenteric duct. 
Occasional rare instances of duplication of the intestine are to be 
met with in medical literature, and are recorded as present at various 
portions of the intestinal canal. 
Meckel8 refers to the observation by Blasius of a duplication of the 
1 Major, The Lancet, 1839-40, i. 362. 
2 Aerztlicher Bericht aus dem k. k. allgemeinen Kraukenhause zu Wien, Civil 
Jahr, 1862, 221. 
3 Fagge, Guy’s Hospital Reports, 3d Series, 1869, xiv. 359. 
4 Leichteustern, Ziemssen’s Handbuch der Speciellen Patliologie und- 
1876, vii. 2, 421. 
5 Lockwood, Britisli Medical Journal, 1882, ii. 574. 
6 Rokitansky, op. cit. 182. 
7 Haller, Elementa Physiologic Corporis Huraani, 1778, vii. 97. 
8 Meckel, Tabulae Anatomico-Pathologic®, 1822. Fasc.iii. 5. 4 
oesophagus in an infant five years of age, extending from the first to the 
sixth rib. The two portions then united and were continued to the 
stomach as a single tube. 
It is stated by Habershon' that “ in a Cyclopean monster, in which the viscera 
of a double foetus existed in a single peritoneal cavity, a double oesophagus was 
found united in a single stomach, with a large convexity extending from side to 
side, and giving rise to a single duodenum, placed vertically, and receiving the 
biliary and pancreatic ducts on either side.” 
The earliest recorded case of duplication of the duodenum occurred 
in an infant who lived seven days, and is described by Calder1 as follows :— 
“The Stomach was in a good Condition, but the Pylorus was very hard, and 
felt as if it contained some other Substance which appeared on opening this in- 
ferior Orifice of the Stomach to be a glandular Piece of solid Flesh, so closely 
adhering to the Pylorus all round, that there was no separating of it, and with- 
out the least Perforation in it anywhere; so that the Passage was quite shut up. 
Below this the Duodenum was divided into two; and the Gut continued thus 
divided to about one-third of an Inch above the Jejunum. Into the largest of 
these Intestinula the biliary Duct opened.” 
Fairland3 describes and figures a specimen of duplication of the intes- 
tine found in the body of a male infant at full term, who was operated 
upon for imperforate anus. The bifurcation began an inch and a half 
below the pylorus. The small intestine was one-third of an inch in dia- 
meter, and contained semi-so id greenish meconium. 
“ It was tightly filled with this matter as far as the rudimentary caecum with 
its distinct vermiform appendix, from which continued a pipe-like portion of the 
gut terminating at the cul-de-sac forming the rectum. 
“ The second portion of the intestine was altogether larger,and more closely re- 
sembled a normal bowel; it was about thirteen inches long and one inch in dia- 
meter. Before the operation it was distended with fluid, and had been the only 
portion of the bowel patent since birth. But it terminated in a cul-de-sac and 
formed, therefore, a species of pouch from which there was no exit except by 
regurgitation.” 
It is a noteworthy fact that there are no recorded instances of duplica- 
tion of the small intestine, with the above exceptions, until the region of 
the ileo-cascal valve is reached. This omission is obviously attributable 
to the description of such malformations as examples of the abnormal 
insertion of Meckel’s diverticulum. 
Meckel4 figures a specimen of duplication of the lowermost end of the 
ileum, which is described as “ divided by a longitudinal septum before the 
bifurcation,” each portion terminating in a caecal pouch. 
The inspection of the drawing suggests, what strangely enough appears 
to have escaped Meckel’s observation, that the specimen was one of vitelline 
diverticulum with a rudimentary and imperforate colon. The explanation 
1 Habershon, Pathological and Practical Observations on Diseases of the Alimentary 
Canal, etc., 1859, 124. 
2 Calder, Medical Essays and Observations, Revised and Published by a Society in 
Edinburgh, 1733, i. 205. 
3 Fairland, The British Medical Journal, 1879, i. 851. 
* Meckel,.'Tabula; Anatomico-Pathologieae, 1822, iii. 23. 5 
of the probable origin of the longitudinal septum will be evident from what 
is to follow concerning the lateral insertion of the diverticulum. Meckel 
refers in the text explanatory of this figure to the observation of a similar 
case by Boerhaave. He, also, reproduces in the same plate a drawing 
from Fleiscbmann, to which he applies the term double caecum ; the single 
colon terminates in a blind pouch. Reference is also directed to cases 
of a similar character. 
Andral1 alludes to a case mentioned by Brugnoni, in which two colons 
sprang from a single caecum and reunited at the rectum. 
Somewhat resembling this is the congenital partial duplication of the 
colon described by Scheiber.* The caecum and ascending colon were 
widely dilated and in the normal position. Just above the ileo-caecal 
valve, the ascending colon divided into two tubes of unequal width, which, 
diverging somewhat, eventually became united into a single colon. 
Still another specimen of similar nature is described by Lockwood.3 
The case was one of intestinal obstruction in a man 57 years of age. The 
caecum lay in the right hypochondrium beneath the liver. 
“The ascending colon was double; the two tubes were upon the same plane, 
the smaller one nearer the vertebral column. Each possessed appendices epi- 
ploic*. The tube which was nearest the spine had a very small canal in its 
centre, which appeared to have a mucous lining. This canal opened above into 
the colon by means of a small aperture; below it was lost in a mass of malignant 
disease. It contained no feces. Its walls were moderately thick. The malig- 
nant mass which received the end of the diverticulum also concealed the end of 
the outer tube, which was the colon proper.” 
It is of this specimen that Dr. Symington4 suggested that one of the 
two tubes might be a diverticulum, there being no proof that they united 
below. 
The view7—that most, if not all well-authenticated instances of duplica- 
tion of the intestinal tract, at any part of its course, are the probable result 
of the persistence and growth of remains of the vitelline duct—is rendered 
highly probable from what is know'n concerning the development of the 
intestine. The thoracic and abdominal cavities are not differentiated at 
that period in foetal life when the vitelline duct is present. The seat of 
the latter high up or low down in the foetus would satisfactorily account 
for the various places of origin of the duplication in question, as it does 
for those of the diverticulum. 
It has already been made apparent that the latter may arise at any 
point between the pylorus and the caecum. Whether the duplication or 
the diverticulum is to result, depends presumably on the existence of 
1 Andral, A Treatise on Pathological Anatomy. Translated by Townsend and 
West, 1831, ii. 159. 
2 Scheiber, Oesterreichische med. Jarhbiicher, Heft 2. Jahresbericht von Vir- 
chow und Hirsch, 1875, i. 339. 
3 Lockwood, The British Medical Journal, 1882, ii. 574. 
* Lockwood’s specimen. 6 
conditions favouring or checking the growth of the intestinal walls. The 
duplication is thus to be regarded merely as an elongated diverticulum, 
and, like the latter, as will be shown later, may lie within as well as out- 
side the mesentery. 
The occurrence of duplication of the oesophagus even may be similarly 
explained. The evidence is stronger than that offered as explanatory of 
the origin of the diverticulum of the oesophagus, from the fact that the 
beginning of the duplication in Blasius’s case was lower than the usual 
seat of the diverticulum. Although in most instances of double intestine 
the cavities of the tubes are continuous only at their origin, it is obvious 
that a second communication, lower down, may become established. The 
manner in which this may take place is suggested by Grawitz1 in his con- 
sideration of a specimen of diverticulum (not of vitelline origin) of the 
ascending colon. The diverticulum, 8 inches long, consisted of a loop of 
the colon, the approximated walls of which were fused at the origin, but 
were separate lower down where the legs were distinct. The fused wall 
was perforated in two places, while the bend of the loop was closed inter- 
nally by a septum. Its origin was considered to be foetal, and the result 
of an imperforate colon forced into a loop-formation from the pressure of 
meconium from above. With the occurrence of ulceration and adhesions 
followed by perforation of the fused wall, the intestinal canal might become 
pervious. This view was favoured by the appropriate presence of cicatri- 
cial tissue and deformity. Such a restoration of the intestinal canal could 
only take place between the fifth month, when meconium is first found in 
the intestine, and the eighth day after birth, the latter date representing 
the limit of life in an infant with imperforate intestine. 
This interpretation of the origin of a second communication is applicable 
to all cases of duplication below the stomach, in that part of the intestinal 
tract where the retention of considerable quantities of meconium is possi- 
ble. The eventual fusion of the two branches of the oesophagus, as 
recorded by Blasius, may be similarly explained, from the effects of the 
retention of food ; the time of perforative communication would then take 
place during some part of the five years of life assigned to the child. The 
appearance of the drawing reproduced by Meckel and Forster is not in 
harmony with the inflammatory origin of the inferior communication, but 
neither of these observers appears to have personally examined the original 
specimen. 
Not only is the difference in the longitudinal position of the diverticulum 
of importance in connection with its subsequent history, but the fact of its 
lateral variation should also be borne in mind. All the authorities call 
attention to its usual origin from the convex border of the intestine. The 
instances are not a few, however, in which the side of the intestine, even 
the immediate vicinity of the mesenteric attachment, is the starting-point. 
1 Grawitz, Virchow's Archiv, 1876, lxviii. 506. 7 
Tn such cases the diverticulum usually has a well-marked mesentery of 
its own, which is generally described as sickle-shaped. In the Warren 
Museum of the Harvard Medical School is a specimen of this nature, 
of additional interest as presenting a branch of the mesenteric artery of 
considerable size which lies just below and within the free edge of the 
mesentery of the diverticulum. 
In the collection of the Boston Society for Medical Improvement, now 
transferred to the Harvard Medical School, is a specimen, No. 1808, 
described in the catalogue as “fcetal diverticulum.” It is a dried speci- 
men, 1~ inch long, arising from the convexity of the intestine, and for 
two-thirds its length runs parallel with the bowel, and appears to be 
covered by the same peritoneal envelope. In the same collection is still 
another, No. 1313, described1 as follows:— 
“Diverticulum: a portion of the intestine of an adult distended and dried. 
Portion from which the div. arises is largest. Div. is nearly 2 inches in length ; 
about the size of the thumb at origin; tapers to size of tip of little finger, the 
very extremity again bulges.” 
The point of interest, at present, lies in the fact that this specimen, like 
its predecessor, arises free from the mesenteric insertion, and foe half its 
length is firmly attached to the surface of the ileum, being contained within 
a common peritoneal investment. 
Klebs2 describes a diverticulum, 2 inches long, the half of which lay 
between the muscular coats of the intestine. It is evident that the case 
of double caecum recorded by Meckel3 belongs in this series. 
Roth4 describes and figures a sausage-shaped diverticulum found in the 
body of a new-born child. It was inches above the ileo-caecal valve, 
and ran for 4 inches along the convex border of the ileum within the 
mesentery. 
Specimen 7 3 22 of the Warren Museum is one of intra-mesenteric dupli- 
cation of the intestine, and is unique in presenting in a striking manner 
both these features of irregular development of the intestinal tract. 
The specimen was presented by Dr. Joseph Stedman, of Jamaica Plain, 
Mass., and came from a child eight to ten months old. Ilis recollection of 
the case, after an interval of several years, permits him to state that the 
child had been previously well, but was suffering from symptoms of intes- 
tinal obstruction, which continued for four or five days. The appearance 
of the specimen is well shown in the accompanying drawing made by Dr. 
H. P. Quincy:— 
Two more or less parallel intestinal tubes, cut transversely across in 
their continuity, are contained within a single mesentery. The bloodves- 
1 MS. Catalogue of the Anatomical Museum of the Boston Society for Medical 
Improvement. 
2 Klebs, op. cit., i. 206. 3 See note 4, page 4. 
4 Roth, Virchow’s Archiv, 1881, lxxxvi. 377. 8 
sels of the latter terminate in the wall of the outermost tube, first sup- 
plying branches to the inner tube. The diameter of the outer tube is rela- 
tively uniform throughout, while that of the inner, in general somewhat 
narrower, becomes dilated in the immediate vicinity of an opening through 
which the canals of the tubes communicate with each other. The con- 
tiguous portions of the walls of the two tubes are in close proximity to 
each other throughout the greater part of their course, and are fused near 
the common opening. 
The walls are composed of mucous, muscular, and peritoneal coats. 
The mucous membrane of the outer tube shows slightly projecting trans- 
verse folds in the vicinity of the opening, while that of the inner tube is 
relatively smooth. Villi and crypts are present in both. 
The opening between the tubes is rounded, sharply defined, one-third 
of an inch in diameter, and appears to be covered with mucous membrane. 
The canal of the inner tube is contracted in the immediate vicinity of the 
opening, and its wall at this part is thickened and fibrous. 
Although the most satisfactory explanation of the origin of this specimen 
is based upon its representing an intra-mesenteric diverticulum, its bifur- 
cated shape, and the seat of the constriction and dilatation require special 
consideration. Diverticula with knobbed ends are frequently met with, 
and the rounded ends may have secondary bulgings of their surface. In 
the Improvement Collection, No. 1033, is a diverticulum with two rounded 
bulgings at its free end, large enough to suggest an incipient bifurcation. 
Hyrtl1 says that branched diverticula are extremely rare, but he has 
seen one, an inch in length, coming from a hemicephalic monstrosity, 
which was divided into five parts. 
It is difficult to explain the dilated portion ot the inner tube, unless it 
be assumed that a communication existed between this portion of the tube 
and the intestinal canal nearer the stomach. There are no instances of 
double true diverticula. 
It is, however, conceivable that the inner tube formed a circle either 
wholly or partially within the mesentery, and ended blindly in the imme- 
diate vicinity of its origin after completing the circle. A communication 
might eventually be established between the blind end and the beginning 
of the tube by means of a perforative ulceration. 
That the latter process is not unlikely to have taken place is favoured 
by the presence of the thickened, indurated, and constricted wall at this 
part of its course. 
In the valuable and suggestive article by Roth2 on the malformations 
occurring in the region of the omphalo-mesenteric duct, attention is called 
to the origin of retention-cysts from Meckel’s diverticulum. Such cysts 
are divided into two classes, according as their cavity is continuous or dis- 
continuous with that of the intestine. The wall is composed of the various 
layers found in the intestine, and the contents are.a fluid of various colour 
1 Hyrtl, Handbuch der Topographisehen Anatomie, I860, i. 642. 
2 Loc. cit. 9 
and consistency. In both respects the condition is like that occasionally 
observed in the vermiform appendage. 
The occurrence of the first series of cysts is illustrated by the observa- 
tion of Tiedemann,1 who found in a foetus at full term a pedunculate, pear- 
Fig. 1. 
shaped cyst attached to the convexity of the intestine. It was lines 
long, and 7 lines wide. Its cavity communicated with that of the intes- 
tine by means of a canal in the pedicle large enough to admit a probe. 
The contents were a whitish-yellow fluid, containing several flocculi 
resembling clotted albumen. Roth2 contributes the description of a like 
cyst, somewhat larger, occurring in a child one year and four months old. 
It was connected with the concave surface of the ileum, near the mesen- 
teric insertion, 2G inches above the ileo-cacal valve. The pedicle having 
1 Tiedemann, Anatomie der Kopflosen Missgeburten, 1813, 66. 
2 Loc. cit., 374. 10 
become twisted a hemorrhagic infiltration and necrosis of the mucous 
membrane had occurred, also acute peritonitis. 
These are the only well-authenticated cases of extreme cystic dilatation 
of the diverticulum known to Roth. Occasional instances of globular 
forms of diverticula, with more or less constricted necks, are to be met 
with in medical literature, but none with such extreme constriction as to 
suggest the application of the term cyst. 
Even if the degree of constriction of the neck and the associated disten- 
sion of the diverticulum present the external appearance of a cyst, the 
contents are not liquid. Houston,1 for instance, describes a specimen 
where the diverticulum formed a circumscribed bag of the size of a turkey’s 
egg, the contents of which were solid, apparently hardened feces. 
There can be no question as to the exactness of the term cyst in the 
second of the series established by Roth where the cavity of the sac is dis- 
continuous with that of the intestine. The earliest observation of this 
malformation known to him is that described by Raesfeld in 1852, occur- 
ring in the body of a new-born child. The cyst was connected with the 
free surface of the intestine. 
The second indisputable observation to be found in print is that pub- 
lished by Roth. At the distal end of the intra-mesenteric diverticulum, 
already2 referred to, a cyst was seen, the size of a bean, also lying within 
the mesentery. The contents were a tough, viscid material, and the walls 
corresponded with that of the intestine. The epithelial lining was com- 
posed of cylindrical cells with and without cilia}. Other cysts, retro-peri- 
toneal and mediastinal, with a wall resembling that of the intestine, were 
found in the same infant. They were considei’ed as representing lateral 
deviations from the duodenum and oesophagus, with subsequent detach- 
ment, or separated and displaced portions of a diverticulum, or vitelline 
duct. 
Hennig3 reports the case of an abdominal cyst, in size best comparable 
to the moderately filled stomach of an adult. It occurred in a new-born 
child, and filled the anterior portion of the abdomen. The sac measured 
inches by inches by 4 inches, lay within the mesentery, and did not 
communicate with the intestine. It held 100 grammes of clear, pale red, 
somewhat viscid, slimy fluid; its walls contained intestinal glands, and was 
covered with cylindrical epithelium. In suggesting the probable origin 
of this cyst from a diverticulum, it is considered that a shrinkage of the 
mesentery of the latter may have taken place, with a consequent traction 
of the end of the diverticulum towards the root of the mesentery, and 
eventually between its layers. The communication between the intestine 
and diverticulum is regarded as subsequently obliterated. 
1 Houston, Descriptive Catalogue of the Preparations in the Museum of the Royal 
College of Surgeons in Ireland, 1834, i. 38. 
2 See note 4, p. 7. 3 Hennig, Centralblatt fiir Gynakologie, 1880, iv. 398. 11 
In the Warren Museum, specimen No. 4903 has the following record 
in the MSS. Catalogue :— 
“ Diverticulum from the small intestine. The specimen was obtained 
at the autopsy, from a patient who died 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 metre above the ileo-csecal valve. It 
is 3 cm. in length, and about 1 cm. in diameter. There is no apparent 
communication with the lumen of the intestine.” 
This specimen is a cyst of the diverticulum, the origin of which is near 
the mesenteric attachment. Its wall consists of a peritoneal envelope, 
with loose subperitoneal connective tissue, both continued directly from 
the intestine. There is 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 club-shaped, stunted villi were found to project. 
Pouch-shaped 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. 
Sanger and Klopp1 describe the presence of five cysts in the abdomen 
of an infant, the largest of the size of a child’s head. The structure of 
the wall of three of these resembled that of the intestine, and they lay 
behind the duodenum. In the wall of several of these cysts were islets of 
hepatic tissue. The cysts were regarded as constricted lateral deviations 
of the foetal intestine, arising from the duodenal portion in the region 
where the development of the liver normally takes place. It is a matter 
of easy inference, however, to regard at least one of these cysts, not con- 
taining hepatic tissue in its wall, as of diverticular origin. 
The occurrence of simple cysts of possible intestinal origin is not 
limited to the abdominal cavity. 
A cyst in the vicinity of the oesophagus is reported by Wyss.* It was 
of the size of an apple, and was seated on the posterior wall of the oeso- 
phagus inch above the cardia. The contents were a tough mucus 
in which were cells of ciliated epithelium. The wall contained muscle as 
well as fibrous tissue. There was no apparent communication between 
the cavity of the cyst and that of the oesophagus. The origin of this cyst 
was attributed to the early detachment of foetal structures, in accordance 
with the view advanced by Friedreich3 and Eberth4 concerning the origin 
of hepatic cysts with ciliated epithelium from the detachment of bile ducts. 
Roth and Hennig5 report the occurrence of cysts in the vicinity of the 
1 Sanger und Klop’p, Archiv fur Gynakologie, 1880, xvi. 415. 
2 Wyss, Virchow’s Archiv, 1870, li. 144. 
3 Friedreich, Virchow’s Archiv, 1857, xi. 406. 
4 Eberth, Virchow’s Archiv, 1806, xxv. 478. 
5 Loc. cit. 12 
oesophagus. In each instance the wall was lined with cylindrical epithe- 
lium. In the case reported by Roth the wall had the structure of the 
intestine, with a predominant development of muscular tissue. The pos- 
sibility of the origin of these cysts from a diverticulum is to be recog- 
nized from what has already been stated with reference to the longitudinal 
differences in the place of insertion of the vitelline duct. Hennig attri- 
butes the origin of the cyst reported by him, which was between the third 
and fifth cervical vertebrae, to the persistence of a portion of the branchial 
fissure. 
Cysts with a structure resembling that of the intestine are sometimes 
to be met with in the abdominal wall, in the vicinity of the umbilicus. 
Their presence in this region suggests at once their origin from a portion 
of the vitelline duct included within the abdominal wall. The same 
statement applies to the origin of the adenomata of the navel, described 
by Kiistner.1 The evidence presented lacks the clinching fact, however, 
since the reported instances of the cysts and the growths occurred in indi- 
viduals living at the dates of observation, and there is no evidence to 
show the relation between the intestine and the posterior surface of the 
abdominal wall. 
Roser2 reports the case of a male patient, said to have had a tumour in 
the region of the navel, which had been opened. A slimy, watery dis- 
charge from the opening followed the operation, and relief from the fistula 
was desired. A sound entered a spacious cavity about 6 cm. in diameter. 
The discharge contained cylindrical epithelium. An incision through the 
skin disclosed a wall of dense fibrous tissue. When this was cut through 
there appeared a cavity lined with mucous membrane. As much of the 
latter as possible was removed, and on examination was found to contain 
Lieberkiihn’s glands. Healing, with the formation of a scar, took place 
after forty-eight days. 
A cyst of the abdominal wall an inch above the navel is reported by 
W yss.3 It was of the size of a bean, and lay between the muscle and 
peritoneum. The contents were an opaque viscid mucus, and its wall, 
composed of dense fibrous tissue, was lined with ciliated epithelium. If 
this cyst were of vitelline origin, as its situation suggests, the inclusion is 
likely to have taken place at an early period of foetal life. 
The presence of ciliated epithelium in the primitive intestine is evident 
from the investigations of Neumann and Kolliker,4 and its existence in 
intestinal cysts has already been mentioned. 
The clinical importance of these intestinal cysts obviously depends upon 
1 Kiistner, Virchow’s Archiv, 1877, lxix. 286. 
2 Roser, Archiv fur klinische Chirurgie, 1876, xx. 475. 
3 Wyss, loc cit., 143. 
4 Kolliker, Entwickelungs-geschichte des Menschen und der Hoheren Thiere, 1879, 
853. 13 
their size and situation. Large abdominal cysts may interfere with the 
birth of the child, as in Hennig’s case, and that reported by Sanger and 
Klopp. Although the actual cyst or cysts in each instance were not the 
sole cause of obstructed labour, 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. 
Sanger and Klopp also report that after prolonged labour vigorous 
traction of the half-born child was followed by the escape of large quan- 
tities of fluid. The birth of the child was then accomplished. It was 
found that the abdominal walls were ruptured through a portion weakened 
from deficient closure of the abdominal plates, and that the fluid which 
had escaped was largely of peritoneal origin. The presence of the cysts, 
however, was regarded as the chief cause of the enormously distended 
abdomen. 
Even if the child is born, the cyst may remain as a constant source of 
danger, and, as in the case reported by Both, may prove fatal by a twist- 
ing of its pedicle. The possible effect of an intra-thoracic cyst is shown 
by this observer, who found evidence of marked pressure upon the lungs 
and bronchi. The possibility that the 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 pubic symphysis. 
The vitelline duct is composed not only of layers of tissue equivalent to 
those forming the coats of the intestine, but it is also accompanied by 
bloodvessels. These are the omphalo-mesenteric or vitelline arteries and 
veins which course along its surface and ramify over the walls of the um- 
bilical vesicle. During the atrophy of the vitelline duct these vessels also 
become atrophied and eventually disappear with the disappearance of the 
former. But, as will later be shown, the progressive shrinkage and even- 
tual disappearance of the vitelline duct do not necessitate the atrophy of 
these vessels. 
In his description of the several different degrees of the more or less 
perfect continuance of the primitive connection between the intestine and 
the umbilical vesicle, Meckel1 makes the following statement:— 
“ Sometimes the umbilical vesicle continues beyond the usual time, and com- 
municates with the ileon by an open canal which the omphalo-mesenteric vessels 
attend. 
“ Sometimes only a canal exists; it varies in length, and extends from the same 
point of' the ileon to the umbilicus where it opens, and the omphalo-mesenteric 
vessels also accompany it. 
1 Meckel, Manual of General, Descriptive, and Pathological Anatomy. Translated 
from the German into French, with additions and notes, by A. J. L. Jourdan, and G. 
Breschet. Translated from the French, with notes, by A. Sidney Doane, A.M., M.D., 
1832, iii. 289. 14 
“ Finally, sometimes, a greater or less prominence exists in this place, a pro- 
longation termed the diverticulum of the ileon ; this is often accompanied by the 
omphalo-mesenteric vessels which float loosely at its extremity, or which are 
attached to the umbilicus, or to another region of the intestinal canal, so as to 
form a plexus.” 
In his article in Reil’s Archiv, previously referred to, Meckel1 states 
that in the examination of embryos older than ten weeks, he has found 
intact omphalo-mesenteric vessels in the absence of a diverticulum, and 
concludes therefrom “ that in man as well as in animals the remains of 
the vitelline canal disappear earlier from the intestine than from the vas- 
cular system.” 
The earliest observation of the existence of the omphalo-mesenteric 
vessels among the lower animals is to be found in Blasius,* whom Sclirce- 
der3 quotes. They were found by him in the dog, cat, and guinea-pig. 
Yon Siebold, who called Schrceder’s attention to this observation, also 
stated that these vessels were very frequently, if not constantly, found in 
new-born cats and dogs. Schroeder immediately verified this statement 
by the examination of two new-born puppies and a young guinea-pig. 
The latest account of the presence of these vessels crossing the abdomi- 
nal cavity of new-born carnivora as two slender cords is furnished by 
Allen,4 as follows :— 
“ The cords are attached below to the abdominal surface of the umbilicus, and 
from this they pass forwards and upwards, keeping close together at first, but 
afterwards separating. The upper end of the one passes into the mesentery of 
the ileum close to its intestinal border ; the other passes up to the meso-duodenum, 
and runs into it, close to one of the pancreatic lobes. 
“ On dissection the posterior cord is found to be connected with the mesenteric 
artery, the anterior one with the portal vein. I have found the cords in every 
specimen of new-born cat and dog examined, and frequently in these animals 
when a week or a fortnight old, and in a few cases at even a greater age 
They can be very distinctly seen in the guinea-pig, up to a week old, probably 
longer, and here also their connections and course are the same as in the kitten, 
etc. In the young rabbit there is a somewhat similar arrangement, but in it I 
have not, up to the present, succeeded in finding after birth more than one cord, 
and it, like the anterior of the two cords in the guinea-pig, is traceable up to the 
portal vein. 
“That the cords are remains of the omphalo-mesenteric system of vessels is 
shown by their connections, the one which is attached to the mesenteric artery 
being the obliterated omphalo-mesenteric artery, the cord which goes to the por- 
tal vein being the remains of the omphalo-mesenteric vein. The correctness of 
this interpretation is proved by the dissection in situ of intra-uterine specimens of 
any of these animals, e. g. the fcetal guinea-pig, the cords can then be traced out 
of the body of the foetus, through the umbilicus and into the umbilical vesicle.” 
Dr. Allen suggests,5 in explanation of the persistence of these vessels, 
that 
“ An adhesion had formed between the allantois and yolk-sac, and that when 
this adhesion was great an intercommunication was formed between the vessels 
1 Meckel, loc. cit., 444. 2 Blassius, De Anatomia Animalium, 1681. 
3 Schroeder, Ueber die Divertikel-Bildungen am Darm-Kanale, 1854, 24. 
4 Allen, The Journal of Anatomy and Physiology, 1882, xvii. 59. 
5 Loc. cit., 60. 15 
of the two sacs, and that this led to the retention of the omphalo-mesenteric 
trunks long after the cessation of the primitive function.” 
The disappearance of the vitelline duct while the vessels persist is thus 
explained :—1 
“The umbilical intestinal loop is drawn into the abdominal cavity as the rest 
of the alimentary canal grows; this movement, then, on account of the fixed 
position of the umbilical vesicle outside, causes the vitelline duct to be stretched 
so that it very probably soon ruptures, and is then speedily absorbed.” 
In the development of the vascular system of the embryo there are two 
sets of vessels, arterial and venous, which are connected with the yolk sac. 
The original function of both obviously ceases with the establishment of 
the placental circulation. According to Kolliker,2 the two primitive om- 
phalo-mesenteric arteries which proceed from the aorta to the umbilical 
vesicle are soon reduced to one. In the foetus of five weeks, this right 
artery alone remains. The mesenteric artery arises from this, at first as 
a small branch, but later becomes the main trunk, with the progressive 
atrophy of that portion between the intestine and the umbilical vesicle. 
In like manner two veins are found at the outset, but eventually are 
reduced to one. This, the left omphalo-mesenteric vein, eventually re- 
ceives a small mesenteric branch from the intestines. With the disap- 
pearance of the peripheral portion and the growth of that nearer the heart, 
the differentiation into the portal and mesenteric veins becomes estab- 
lished. 
Although the occasional persistence of the vitelline vessels was apparent 
to Meckel and his predecessors, as well as to others like Schroeder, who 
followed in the consideration of the remains of the omphalo-mesenteric 
apparatus—renewed attention has been of late years called to this feature. 
Hyrtl,3 in recognition of the fact, refers to an observation by Osiander 
in 1801, who stated that he found a very fine thread, probably an artery, 
running from the mesentery to the “side of the peritoneum, where the 
umbilical artery was lacking.” 
Ahlfeld4 showed to the Leipsic Obstetrical Society a preparation from 
a foetus, consisting of a delicate vessel filled with blood, which could be 
followed from the umbilical vesicle through the entire umbilical cord, and 
across the abdominal cavity to the mesentery. 
Huge5 reports the discovery, in the body of a new-born child, of a cord, 
the thickness of a linen thread for 2 ctm. and then of hair-like thinness 
for ctm., which ran between the mesentery of the small intestine and 
the tissue around the right umbilical artery, just before its entrance into 
the abdominal wall. He further describes the projection of a delicate 
1 Loc. cit., 61. 2 Kolliker, op. cit. 919-921. 
3 Hyrtl, Die Blutgefasse der Menschlichen Nachgeburt, 1870, 6. 
4 Ahlfeld, Archiv fur Gynakologie, 1875, viii. 363. 
5 Ruge, Zeitechrift liir Geburtsliiilfe und Gynakologie, 1877, i. 7. 16 
thread-like process with a knobbed end from the mesentery near the in- 
testine, and a short distance above the caecum. The statement is then 
made by him that floating threads with rounded ends may often be found 
in the mesentery, or near the navel, which are to be attributed to omphalo- 
mesenteric vessels, or the duct. Immediately after my attention was 
directed to this point, on examination of the body of a man who died from 
chronic tuberculosis at the Massachusetts General Hospital, there were 
found two tuft-like projections from the upper surface of the mesentery, each 
a half-inch long and about a half-inch apart. They were about two inches 
distant from that portion of the ileum lying some three feet above the ileo- 
caecal valve. The peritoneum covering them was normal in appearance, 
and the mesentery elsewhere was free from all abnormal changes. The 
peritoneum in the vicinity of the navel was examined, but with negative 
results. Since then repeated examinations have been made with refei’ence 
to what might be regarded as vitelline remains, but with indifferent success. 
One of the most remarkable instances of a persistent omphalo-mesen- 
teric vessel must be sought for among the earlier observers. The recent 
discoveries have been made in the bodies of foetuses and new-born chil- 
dren. Spangenberg,1 however, found in the body of a young man twenty 
years of age, what he regarded as an open omphalo-mesenteric vessel. 
“It could be followed to within a half inch of the navel, where it became a 
delicate ligament and was lost in the umbilical ring. It descended from the 
navel, between the epigastric veins, on the posterior surface of the peritoneum, 
to which it was united by fibrous tissue, to nearly midway between the umbilicus 
and pubes. Then, leaving the wall of the abdomen as a thin round cord, and 
crossing its cavity between the coils of small intestine, it passed beneath the lat- 
ter towards the spine, rather to the left, and emptied into a bifurcation of the 
main trunk of the superior mesenteric vein. The vessel was wholly free 
throughout its entire course, nowhere adhering to the intestine, and was envel- 
oped in a fibrous sheath. It was open to within two inches of the navel, and a 
small quantity of thin blood from the mesenteric vein was admitted as far as its 
middle. Its coats for three inches from its origin from the mesentery were 
collapsed like those of any other vein ; but from this point onwards it was of 
denser structure, and very smooth externally. It had no branches and its texture 
resembled in all respects that of the umbilical vein ; which latter was found open 
through half its course. The appearance of the navel as seen from without did 
not vary from that of other normally formed umbilical depressions.” 
The existence of the omphalo-mesenteric vessels, their relation to the 
omphalo-mesenteric duct, and their occasional persistence entire or in part 
were well known to Meckel. Their transformation into fibrous cords was 
likewise familiar to this author. He says,2 
“ Quite recently I found them in a child of three months arising, as usual, 
from the superior mesenteric artery and vein, running along the entire length of 
the diverticulum and converted at its end into a solid thread, several inches long 
and hanging free.” 
1 Spangenberg, Deutsches Archiv fur die Physiologie, 1819, v. 88. 
2 Meckel, Archiv iiir die Physiologie, 1809, ix. 439. 17 
lie refers to similar threads being found by Otto, Sandifort, and Van 
Doeveren, and adds:—1 
“In one of the last two eases this thread was adherent to the mesentery, in 
the other to the colon, thus forming a large loop, which might give rise to the 
most dangerous results.” 
This suggestion is evidently based upon a familiarity with the works 
of Sandifort and Van Doeveren. The former,2 in his description of an ap- 
pendix arising from the ileum, states that its end was united to the upper 
part of the mesentery by a narrow strong thread. He further adds that 
this formation might have given rise to much disturbance if its infant pos- 
sessor had lived, especially since a similar band had been found in the 
bodies of men suffering from ileus. In his catalogue of Van Doeveren’s 
anatomical collection he incorporates the latter’s description of a fatal case 
of intestinal strangulation from a diverticulum and its appendage, prob- 
ably the first on record. He states3 that the specimen is one of a sacci- 
form diverticulum, with a blind extremity, from which proceeded an 
exceedingly tough cord resembling in structure the round ligament of 
the liver. This crossed the large intestine, ascending on the right beyond 
the ileo-cmcal valve, and became firmly attached to the left side of the 
caecum somewhat posteriorly. It served as a noose to constrict the in- 
testine between the diverticulum and the colon, producing most of the 
symptoms of intestinal obstruction and death within forty-eight hours. 
Meckel,4 in his classification of the causes of internal herniae, mentions 
the partial adhesions between parts which should be separated. These 
may be produced “ at the summit of a diverticulum of the ileon, especially 
by the filament which still exists there, and which is formed by the rem- 
nant of the omplmlo-mesenteric vessels.” This statement is supported by 
a reference to the above case of Van Doeveren and to another, that of 
Monroe, which had occurred in the mean time. 
That the latter is not an apt illustration will appear from Monroe’s 
account. He gives5 the drawing of a specimen coming from a patient in 
whom “a process grew from the ileum, which passed around, and so 
greatly compressed a portion of the small intestines as to prove the cause 
of death.” 
A round cord is figured which unites the above-mentioned process, a 
diverticulum, to the mesentery; the strangulation, however, was the result 
of a knot formed by the diverticulum about a loop of intestine. 
Conspicuous attention having been called to the importance of Meckel’s 
1 Meckel, Reil’s Archiv, op. cit. 441. 
2 Sandifort, Observationes Anatomico-Pathologicae, 1777, 124. 
3 Sandifort, Museum Anatomicum, 1793, i. Series iii. 121. 
4 Meckel, Manual, etc., op. cit. iii. 486. 
5 Monroe, The Morbid Anatomy of the Human Gullet, Stomach, and Intestine, 
1811, 538. 18 
diverticulum in the production of intestinal obstruction later observers 
were not slow in adding to the literature of the subject. Escliricht1 re- 
ports a fatal case of strangulation in an old woman, in whom 
“ The actual diverticulum was about three inches long and a half inch wide at 
its origin, but became gradually narrowed at its inferior third, and transformed 
into a solid band about three inches long, which curved backwards towards the 
mesentery and was inserted not far from the place corresponding with the origin 
of the diverticulum 
“ The narrower cord entering the mesentery was evidently merely an apparent 
continuation of the diverticulum, and I was speedily convinced that it could be 
only an obliterated omphalo-mesenteric vessel, especially in consequence of the 
place of its insertion 
“ The case is thus one declared as possible by Meckel in his Pathological Anat- 
omy, while describing that reported by Sandifort, where incarceration may occur 
without the attachment of the diverticulum to the umbilicus, where a congenital 
loop is formed by the origin of the cord at the mesentery and its insertion at the 
end of the diverticulum.” 
A case of marked importance in the recognition of the relation between 
omphalo-mesenteric remains and strangulation of the intestine is reported 
by Falk.2 He found in a man, 20 years of age, a diverticulum, inches 
long, 2 feet above the ileo-cmcal valve; a solid pseudo-membranous 
ligament, inch long, ran from its apex to the abdominal wall, an 
inch from the umbilicus. A band united the diverticulum and the me- 
sentery, and this appeared to have caused intestinal obstruction. 
Falk states that diverticula of themselves arfe not of much importance in 
producing functional disturbance of the intestine. 
“But where the umbilical vessels are still adherent, and hang off as threads 
in the abdominal cavity, they may become agglutinated to the organs of the ab- 
domen, and thus cause volvulus.” 
The relation of the omphalo-mesenteric vessels or their remains to 
strangulation was well appreciated by Schroeder.3 He recognizes the oc- 
currence of a band stretching across from the navel to the diverticulum, 
or to the mesentery in the absence of a diverticulum. In both instances 
he regards the band as the persistent or obliterated omphalo-mesenteric 
vessel, and states that 
“The insertion in the mesentery is so peculiar, whether it be found in 
the embryo, infant, or the adult, the observer is obliged to give up the idea 
of its inflammatory origin, and feels himself almost compelled to recognize the 
cord as a part of the development of the intestine, particularly as the persistent, 
more or less completely obsolete, omphalo-mesenteric vessels.” 
Although recognizing the primitive nature of the cord-like termination 
of the diverticulum, he accounts for its attachment to other parts of the 
abdomen than the vicinity of the navel, on the ground of a detachment 
1 Escliricht, Muller’s Archiv ur Anatomie, Physiologie, uud wissenschaftliche 
Medicin, 1834, 222. 
2 Falk, De Ileo e Diverticulis, Adiecta Morbi Historia, 1835,18. 
3 Sclirceder, op. cit., 21 ff. 19 
in intra- or extra-uterine life, and a subsequent adhesion to some part of 
the peritoneum. 
From the time of Schroeder’s publication to the appearance of Leich- 
tenstern’s article on Intestinal Obstruction in Ziemssen’s Cyclopaedia, the 
relation of the omphalo-mesenteric remains to intestinal obstruction be- 
came somewhat obscured. Rokitansky1 asserted that strangulation of the 
intestine may result when the free end of a diverticulum is adherent, or 
when the terminal ligament, the obliterated omphalo-mesenteric vessels, 
becomes adherent to some other part than the umbilicus. 
In the consideration of fibrous bands as a cause of intestinal obstruction, 
Forster2 says that these are usually the result of peritonitis. The band, 
however, may be a Meckel's diverticulum adherent to the navel or else- 
where, or a thread representing the remains of the omphalo-mesenteric 
duct. Klebs3 treats the matter somewhat more superficially, especially with 
reference to the nature of the cord which may unite the end of the 
diverticulum to the navel, mesentery, or cmcum. He admits that the 
cord, being fastened at both ends, may lead to incarceration of the intestines. 
Wilks and Moxon,4 in speaking of malformation of the intestine, say :— 
“The diverticulum may extend through the umbilicus of the foetus, and so be 
divided when the cord is cut; it may then be attached or not to the umbilical 
opening. Under these circumstances a plastic operation may close the bowel, 
but afterwards strangulation by the band thus formed has been known to occur.” 
In the consideration of incarceration it is stated5 that “ in some cases 
this diverticulum appears as a solid cord, representing, as it were, the 
vessels that once accompanied the vitelline duct, but sometimes such 
cords are too high for the vitelline duct.” 
Jones and Sieveking6 are still less explicit in referring to the relation 
between the omphalo-mesenteric remains and strangulation of the bowel. 
The adherence of the inflamed peritoneal coat of the diverticulum to 
neighboring organs is spoken of by Birch-IIirschfeld.7 “ In this in- 
stance, and also when the diverticulum is connected with the navel by a 
solid cord, it may be the cause of intestinal strangulation.” 
In one of the most recent comprehensive works on Pathological Anat- 
omy, that of Ziegler,8 there is no mention at all of the importance of 
omphalo-mesenteric remains as a cause of intestinal obstruction. This 
author speaks of the etiological importance of new-formed membranes, 
and thread-like adhesions of pathological origin ; but leaves it as a matter 
1 Rokitansky, op. cit., iii. 182. 
2 Forster, op. cit., ii. 110. 3 Klebs, op. cit., i. 206. 
4 Wilks and Moxon, Lectures on Pathological Anatomy, 1875, 396. 
5 Op. cit. 399. 
6 Jones and Sieveking, Manual of Pathological Anatomy. Payne’s ed., 1875, 577. 
7 Birch-Hirschfeld, Lehrbuch der Pathologischen Anatomie, 1877, 853. 
8 Ziegler, Lehrbuch der Allgemeinen und Specielleu Pathologischen Anatomie, 2te 
Auflage, 1883, ii. 1, 315. 20 
of pure inference, that the cord, which in rare instances unites Meckel’s 
diverticulum to the umbilicus, is of any importance whatsoever. 
This omission is all the more striking as forcible attention has been 
recently called to the importance of the structures in question in connec- 
tion with intestinal obstruction. 
Leichtenstern,1 in his monograph, includes a brief consideration of the 
facts already presented in this paper relative to the persistence of the 
omphalo-mesenteric remains and their pathological importance as a cause 
of intestinal strangulation. He refers particularly to the lack of know- 
ledge of the congenital nature of the abdominal ligament so frequently 
regarded as the result of peritonitis, and emphasizes the various condi- 
tions whose importance has attracted so little prominence during the twenty 
years or more since the publication of Schrceder’s paper. Attention is 
called to the observation of Falk, corroborated by the examination of the 
specimen from another case, which illustrates the attachment of the liga- 
ment at three points, the mesentery, the end of the diverticulum, and the 
umbilicus. The umbilical portion may become atrophied, while that be- 
tween the intestine and mesentery persists, thus forming a bridge capable 
of strangulating the loop of intestine wdiicli may pass beneath. 
The criticism which naturally occurs in the consideration of Leichten- 
stern’s contribution is that he, also, may attach too much importance to 
the effects of peritonitis. He states2 that “the end of the diverticulum is 
usually free or adherent to the mesentery, the small intestine, cmcum, 
pelvic organs, and anterior wrall of the abdomen along the linea alba, or 
beneath the navel.” Later, while speaking of the possible detachment of 
the omphalo-mesenteric cord from the navel, he says that:— 
“The free end of the cord, under favouring conditions, may again become 
implanted at various parts of the abdomen, and thus give rise to ligaments, 
which, proceeding from the ileum, one to three feet above the ileo-csecal valve, 
are inserted in the mesentery, the small intestine, or pelvic organs.’’ 
When, however, the detachment takes place at the intestinal end the 
free portion may likewise become implanted, “ and thus give rise to 
cords extending from (or beneath) the umbilicus to various parts of the 
abdomen.” 
Although the thought readily arises that, in consequence of inflamma- 
tory processes, the diverticulum may become adherent to various parts of 
the abdomen, there is very little evidence in its favour. The suggestion 
is obviously based upon the numerous recorded instances, the resemblance 
borne by the diverticulum to the vermiform process, and the well-knowrn 
frequency of inflammatory adhesions between the latter and adjacent parts. 
The recorded instances are all open to the objection so frequently 
referred to, that their determination often indicates no familiarity with 
developmental conditions. 
1 Leichtenstern, op. cit., 421. 
2 Loc. cit., 422 ff. 21 
In the "Warren Museum, specimen No. 49G of the Improvement Collec- 
tion has the following record :—1 
“ Strangulation of the intestine by means of a diverticulum, this last arising 
from the lower end of the ileum, adheres by its blind extremity to the mesentery, 
and through the ring thus formed a portion of the intestine had passed and be- 
come strangulated. The patient died at the Marine Hospital. Chelsea, with all 
the symptoms of bilious colic, having frequently had similar attacks. Dr. S. D. 
Townsend.*’ 
The following details may be added to the above description : The di- 
verticulum is inches long, and arises from the convex border of the 
ileum. It is for the most part flattened, two-thirds of an inch wide at its 
origin, then tapers gradually, till at its extreme end it becomes dilated 
sufficiently to admit the tip of the little finger. Beneath the peritoneum 
at the distal end is a circumscribed quantity of fat tissue as large as a 
raisin. This end of the diverticulum gives no evidence of a preexisting 
peritonitis, but is continued directly to the upper surface of the mesentery 
by means of a gradually tapering cord, one inch in length, and varying in 
its width from one-quarter to one-eighth of an inch. The last measure- 
ment is present at the junction of the cord with the mesentery an inch and 
one-eighth from the attachment of the latter to the intestine. The cord 
is composed of peritoneum, fat tissue, and fibrous tissue, and its continu- 
ance upwards toward the root of the mesentery, but wholly within the 
structure of the latter, is suggested by a circumscribed, broad, linear ele- 
vation of the peritoneal envelope of the mesentery. A branch of the 
mesenteric artery was dissected out from its origin near the root of the 
mesentery, and was found to lie beneath and cause the linear elevation 
just described. It then entered the tapering cord, uniting the diverticu- 
lum and the mesentery. Its course through the cord to the diverticulum 
was followed out, and its patency demonstrated by the introduction of a 
fine probe. 
Specimen No. 4831 of the museum collection has the following state- 
ment :—2 
“ Diverticulum 4 in. long; arose from ileum, 3 feet above coecal valve, 
and adherent at its blind extremity to the mesentery. Through the ring 
thus formed convolutions of the small intestine had passed and become 
strangulated ; of a claret colour, and adherent slightly to omentum and 
parietes. There was about a pint of bloody serum in peritoneal cavity. 
Man, aet. 28, sick 56 hours; attack sudden; pain and tenderness of abdo- 
men and increasing tympanites on second day. Vomited only once after 
an opium pill. No dejection; bowels free the day before the attack ; 
simple enema the first day, but no cathartic given. Treatment by opiates 
and stimulants. Symptoms of peritonitis and obstruction in 1877. Dr. 
Henry J. Barnes.” 
1 A Descriptive Catalogue of the Anatomical Museum of the Boston Society fo 
Medical Improvement, 1847,142. 
2 MS. Catalogue. 22 
This diverticulum arises from near the mesenteric attachment, and for 
the greater part of its length has a diameter of one-half an inch. Its distal 
end is dilated to the size of an English walnut, and is intimately connected 
with the mesentery, without evidences of peritonitis, two inches from the 
intestinal insertion of the latter. The mesenteric peritoneum is apparently 
continued directly over the diverticulum, at the distal end of which a con- 
siderable quantity of subperitoneal fat is present. The mesenteric artery 
is followed downwards, from near the root of the mesentery, toward the 
attachment of the diverticulum. A half inch from the latter a branch is 
given off, readily admitting a capillary bougie for two-thirds of an inch. 
In dissecting out this artery it was followed directly into the subperitoneal 
fat of the divei'ticulum where it became too small to trace further. 
The direct passage to the diverticulum of a branch of the mesenteric 
artery, which, in virtue of its size, position, and relation, is to be regarded 
as a persistent omphalo-mesenteric artery, thus furnishes positive evidence 
against the theory of an inflammatory origin of the connection between 
the diverticulum and the mesentery. Negative evidence is afforded, not 
only by the customary absence from the diverticulum of the appearances 
of peritonitis, but also by the comparative immunity of the diverticulum 
from inflammatory disturbances. 
Among the numerous specimens of diverticula in the Warren Museum, 
there is but one, No. 2296, which is the seat of a chronic process. Its 
record is as follows :— 
“ A portion of intestine inverted, with a diverticulum. The latter is 
inches in length, was situated five feet and a half from the cascal valve, 
and shows upon its inner surface three large tubercular ulcers.” 
Dr. Beale1 records an instance of acute peritonitis following perforation 
of a diverticulum, in the cavity of which were “ a cherry stone, the coria- 
ceous covering of several orange-pips, and two masses of very irregular 
form and tough consistence, resembling in texture the concretions that 
are often found in the intestines of horses.” Adhesions were present in 
this case, but the report does not indicate with precision their nature or 
seat. 
An adherent diverticulum is described by Houston,2 in a manner in- 
dicative of the origin. The diverticulum was filled with hard, brittle 
matter, apparently inspissated feces. The omentum and intestines in the 
neighbourhood were closely joined to the tumour by adhesions the result 
of a former inflammatory attack, and the woman had complained for 
many years before her death of occasional very severe pains in the ab- 
domen. 
Mention may also be made of the occurrence of typhoid ulcers in the 
1 Beale, Report of the Proceedings of the Pathological Society of London, 1851-52, 
366. 
2 Op. cit. i. 38. 23 
diverticulum. Dr. Galton1 describes sucli a case in which perforation oc- 
curred terminating fatally. 
These few instances of circumscribed peritonitis of the diverticulum, or 
causes capable of producing it, with the addition of a rare instance of its 
adherence to the wall of a hernial sac, are the result of a somewhat exten- 
sive research into the literature of the subject. A personal experience of 
more than thirteen years, in connection with the post-mortem examina- 
tions at the Massachusetts General Hospital, does not enable me to recall 
a single instance of adhesive peritonitis in connection with a diverticulum. 
Although by no means denying the possibility of the inflammatory adher- 
ence to various parts of the abdominal wall or its contents of the end of 
the diverticulum, or of the obliterated omphalo-mesenteric vessel at its 
end, such an event must be regarded as extremely rare. On the contrary, 
it is highly probable that most of the cases reported as adherent diver- 
ticula owe their condition to the persistence of open or closed omphalo- 
mesenteric vessels, continued from the diverticulum as a cord or band. 
This may unite the diverticulum to the abdominal wall near the navel, 
to the mesentery, or to the intestine, according to the seat and extent 
of the atrophy of the vitelline vessels. 
As the frequent existence of inflammatory adhesions between the 
diverticulum and neighbouring parts may be disputed, so may the inflam- 
matory adherence of persistent or obliterated omphalo-mesenteric vessels 
be doubted. Leichtenstern deserves credit for redirecting attention to the 
almost forgotten, exact, and congenital nature of many of the strangulat- 
ing bands and cords attributed to the remains of a pre-existing peritonitis. 
At the same time it seems unnecessary to admit to any considerable extent 
their detachment and subsequent adherence. The absence of evidences 
of peritonitis, and an appreciation of the possible points of union from 
variations in the development of these vessels, will remove much obscurity 
concerning the origin of the apparent adhesions. 
The practical importance of bearing in mind the congenital nature of 
certain of the causes of acute intestinal obstruction cannot be too earnestly 
insisted upon. Unfortunately the statistics which are available for the 
determination of the comparative frequency of the various causes of ob- 
struction are necessarily derived from cases whose record is not sufficiently 
detailed for our present purpose. At the same time they present a rela- 
tive value, and the figures are interesting if not important. Haven,2 
Duchaussoy,3 Brinton,4 and Leichtenstern3 have already published com- 
prehensive tables of the causes of intestinal obstruction, and an attempt 
is here made to compare their results. It is obvious that each succes- 
1 Galton, Transactions of the Pathological Society of London, 1872, xxiii. 103. 
2 Haven, American Journal of the Medical Sciences, 1855; reprint. 
s Duchaussoy, Memoirs de l’Academie Imperiale de Medecine, 1860, xxiv. 97. 
4 Brinton, Intestinal Obstruction, 1867, 88. 5 Leichtenstern, op. cit., 528. 24 
Acute Intestinal Obstruction. 
Haven 
Puchaussoy 
Brinton 
Leichtenstern . 
103 
347 
481 
1134 
Number of cases 
included. 
GO Ot CO CO*? 
CO CO co 0 
Intussusception. 
P- c. 
24 
19 
17 
9 
Bands and adhesions. 
p. c. 
11 
6 
10 
6 
Twists, knots, and 
displacements. 
p. c. 
6 
6 
7 
6 
Diverticulum. 
*3 
CO C* • • 
Vermiform appendix. 
4* l 05 CO * 
Pressure from tumours, 
abscesses, or organs. 
CO • 
Oi • 
o 
Diaphragmatic hernia. 
• 
CO • 
ca 
»d 
co • 
Mesenteric hernia. 
CC^ 
c* W 
Omental hernia. 
<1 
»d 
05 * 
O 
Other internal hernias. 
Approximate relative frequency of the more prominent causes. 
sive writer has probably included all the cases of his predecessors, although 
his method of tabulating varies materially. In consequence of this 
diversity of arrangement, considerable, even wide, differences in the result 
arise. This is particularly true with reference to the frequency of obstruc- 
tion from bands and adhesions. It is from this series that it is important 
to eliminate in the future those which may be due to congenital causes, as 
obliterated or patent omphalo-mesenteric vessels, and those which are the 
result of inflammatory conditions, dislocated organs, or pedunculate 
tumours. 
It results, from a comparison of the above statistics, that next in import- 
ance to intussusception as the cause of acute intestinal obstructions are bands 
and adhesions. In a valuable paper published by Fagge,6and based upon 
the examination of the records of 4000 autopsies at Guy’s Hospital, from 
1854 to 18G8, it appears there were 54 cases of intestinal obstruction, 
the chronic as well as the acute varieties being included. Among these 
were 7 of intussusception, G of volvulus, and 5 each from a diverticulum 
and from bands. The importance of the bands and adhesions is all the 
more evident when it is appreciated that in the table above presented 
this group should include many recorded instances of omental if not 
1 Brinton gives 43 per cent, of intussusception in his table of 600 cases of intestinal 
obstruction by this lesion, bands, adhesions, diverticula, or peritoneum external to the 
bowel, strictures (including a few tumours) involving the intestinal wall, and torsion 
of the bowel on its axis. Op. cit. 38. 
2 Ruptured mesentery. 
3 Other peritoneal and omental lesions. 4 Omental incarceration. 
5 This percentage includes cases of mesenteric incarceration and compression, incar- 
ceration in abnormal openings of organs, in rings from adhesions, as well as internal 
hernise. 
6 Fagge, Guy’s Hospital Reports, 3d series, 1869, xiv. 272. 25 
mesenteric strangulation, as well as of incarceration in rings from adhe- 
sions between organs. It is not intended to suggest that, in most of the 
cases of obstruction from bands and adhesions, the latter are the result of 
developmental conditions. It is obvious, however, from what has already 
been stated, that persistent vitelline vessels, closed or open, may be found 
as cords or bands between the umbilical region of the anterior abdominal 
wall and the intestine or mesentery, or both ; that they may be con- 
nected with these parts near the stomach, as well as at the lower portion 
of the ileum. Furthermore, a band or cord of similar origin may connect 
a diverticulum with the intestine or with the mesentery. Finally, the 
band may be attached at both ends to the mesentery, and yet be of like 
congenital origin. 
In this connection, the figures given by Brinton1 relative to the insertion 
of bands are of interest. This author states that “ their attachment is 
generally (75 per cent.) to mesentery or omentum (as 4 to 1) . . . . 
often (34 per cent.) by one end to the free margin (or some other part) 
of the bowel . . . Rarely (1 case in 5) are they fixed to the large intes- 
tine ; and it is still more (thrice as) infrequent for them to unite two 
points of bowel.” 
Duchaussoy2 states, that of 48 cases of strangulation from bands and 
adhesions, the right side of the abdomen was the seat in 30 cases ; and in 
most instances between the umbilicus and the right iliac fossa. It is in this 
part of the abdomen of all others in which the persistent omphalo-mesen- 
teric remains are found, since it is here that the lowermost portion of the 
ileum is situated. The suggestion is thus readily entertained, that of 
these cases collected by Duchaussoy, several if not many of the bands 
were of congenital origin, and the examination of the original articles 
as well as of' his abstracts makes such a suggestion more than justified. 
The above consideration seems to warrant the following conclusions :— 
1. Bands and cords as a cause of acute intestinal obstruction are second 
in importance to intussusception alone. 
2. Their seat, structure, and relation are such as frequently admit their 
origin from obliterated or patent omphalo-mesenteric vessels, either alone 
or in connection with Meckel’s diverticulum, and oppose their origin from 
peritonitis. 
3. Recorded cases of intestinal strangulation from Meckel’s diverticu- 
lum, in most instances at least, belong in the above series. 
4. 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. 
5. It would seem, therefore, that in the operation of abdominal section for 
the relief of acute intestinal obstruction not due to intussusception and in 
1 Brinton, op. cit., 69. 
2 Op. cit., 318. 26 
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, i. e., Meckel’s diverticulum, or an omphalo-mesenteric 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.1 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 recommenda- 
tion 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 causes of ileus. The place was selected since 
a loop of 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. 
The due appreciation of the relative frequency of congenital causes of 
intestinal obstruction in the region recommended by Nelaton as the place 
of operation adds force to his arguments. The operation of enterotomy 
in the best favoured position is still at hand, provided the above causes of 
obstruction are not found. 
The notes of the following case, kindly given me by Dr. John Homans, 
of Boston, in whose practice it occurred, illustrate several of the points 
treated of in this paper. 
A man, 21 years of age, met with a severe fall Feb. 8, 1884. He had 
always been healthy with the exception of a congenital umbilical sinus, 
which was vaguely supposed to communicate with the intestine. His 
mother was confident that portions of food (seeds and the like), after 
being swallowed, had escaped at times from the sinus, and that the latter 
had been closed since October, 1882. For the past three months he has 
not been obliged to wear a protecting pad. 
Four days after the fall he was seen by Dr. John O. Dow, of Reading, 
Mass., who found him suffering from absolute intestinal obstruction, 
tympanites, tenderness, and pain. Three days later, a week after the 
accident, frequent vomiting of an offensive, so-called fecal, matter took 
place. Dr. Homans was summoned in consultation after another interval 
of three days, and found the patient vomiting every few minutes an 
i N6laton, L’Union Medicate, 1857, xi. Nos. 89, 91, 93. 27 
exceedingly offensive brown fluid. The abdomen was distended, tympa- 
nitic, and tender. The eyes were bright, and the countenance intelligent. 
Pulse feeble, about 130. 
A dark-coloured urine was drawn from tbe bladder, and a director intro- 
duced into the sinus. A little fecal matter seemed to escape. The open- 
ing was enlarged laterally, especially to the left, sufficiently to admit the 
finger. The incision may have been an inch and a half long, and the 
finger entered the peritoneal cavity. No obstruction was felt near the 
umbilicus within reach of the finger. A loop of intestine was seized, 
sewn to the skin, and an opening, about a half inch in length, was made 
through its wall. No fecal or intestinal contents escaped till after the 
junction was completed, when an offensive, brownish, ffuid material and 
gas were freely discharged. 
The patient remained under the care of Dr. Dow, who from time to 
time reported his condition to Dr. Homans. 
On the day following the operation the temperature was 100.4° ; the 
pulse 108. The vomiting had ceased, and there was some relish for food. 
Occasional twinges of pain in the right groin were complained of. There 
was but little abdominal distension, and Dr. Dow was able to detect a 
circumscribed enlargement in the vicinity of tbe ileo-caecal valve. Two 
days later the temperature was normal; pulse 108. The swelling and 
tenderness in the groin were much diminished, and there were no twinges 
of pain. Solid food was desired. On the next day, Feb. 22, the tem- 
perature was 90.2° ; the pulse 120. Restlessness, distress in the back, 
and ringing in the ears were the prominent symptoms, and were attri- 
buted to insufficient nourishment. Injections of beef-tea were given, and 
were followed by marked relief, the pulse falling to 108, and the tempera- 
ture rising to the normal. His strength gradually failed, however, not- 
withstanding food was given by the mouth and rectum. The temperature 
became persistently lower, and tbe pulse weaker with increasing frequency. 
His death took place Feb. 25, one week after the operation. On the day 
preceding a passage from the bowels occurred, although Dr. Dow was of 
the opinion that the contents of the stomach never passed beyond the 
intestinal fistula. 
An autopsy was made twenty-six hours after death by Dr. G. E. Put- 
ney, of Reading, who has furnished the following interesting report:— 
He found the body considerably emaciated and the abdomen flat. A 
probe inserted into the congenital opening passed downwards, forwards, 
and to the right, at an angle of 40° with the median line. 
The parietal peritoneum was glistening, of a dark, reddish-slate colour. 
Its bloodvessels were prominent, especially around the umbilicus, within 
a radius of four inches. There was no lymph. The small intestine was 
of a very dark, drab-red colour. The large intestine moderately injected 
and the colon about two-thirds the normal size. The artificial opening 
into the intestine was fifty-two inches below the pylorus. Its edges were 
thickened, ragged, and sloughing, and had failed to unite with those of 
the abdominal wound. 
A diverticulum four inches long and a half inch in diameter arose from 
the ileum four feet above the ileo-caecal valve, and extended to the 
umbilicus. The ileum below its origin was three-fourths of an inch in 
diameter. The tissues of the diverticulum appeared normal with the 
exception of the muscular coat of the distal three-fourths of an inch, 
which was thrice the normal thickness. A tendinous cord the size of a 28 
darning needle and four inches long proceeded from the mesentery along 
the diverticulum, and became lost in the tissue surrounding the umbilical 
opening. In its course along the diverticulum it appeared as if ensheathed. 
The contents of the small intestine resembled a dark pea soup; those 
of the large intestine were pultaceous, resembling yeast. There was no 
evidence of an existing constriction at the time of the autopsy. 
There seems to be no reasonable doubt that the above case is one of 
intestinal obstruction from persistent omphalo-mesenteric remains. The 
band is of exceptional interest as composed throughout of both vascular 
and intestinal portions, although evidence of patency of the former is not 
recorded. The autopsy gives no evidence of the manner in which the 
obstruction occurred, but it is known that a coil of intestine may become 
looped or knotted over a cord or band. It may also become twisted, and 
be prevented from unwinding by the pressure of the distended intestine. 
The operation was effectual in relieving the obstruction, presumably by 
removing the pressure caused by the distended intestine, and thus per- 
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