[Reprinted from the Boston Medical and Surgical Journal 
of June 14, 1894.J 
STRANGULATION OF MECKEL'S DIVERTIC- 
ULUM CAUSED BY VOLVULUS OF THE 
ILEUM.1 
BY J. W. ELLIOT, M.D., BOSTON, 
Surgson to the Massachusetts General Hospital. 
The patient, a man about thirty years old, was 
brought to the accident room of the Massachusetts 
General Hospital, October 17, 1893.. He had been 
sick for four days, with vomiting, chills and abdominal 
pain. The bowels had moved twice in the previous 
forty-eight hours. The temperature was 103.6°, pulse 
160, respiration 35. 
The abdomen was distended, tympanitic and exquis- 
itely tender, especially to the right of, and below the 
umbilicus. Free fluid was evidently present in the 
peritoneal cavity. Under ether, a large hard mass 
was plainly felt in about the middle of the abdomen, 
just below and slightly to the right of the umbilicus. 
Both Dr. M. H. Richardson and I considered it a se- 
vere case of appendicitis. Dr. Richardson also kindly 
assisted me with the operation, which proved to be the 
most difficult and perplexing operation I ever saw. 
The abdomen was opened by a vertical incision two 
inches inside the anterior superior spine of the ileum. 
A quantity of turbid fluid escaped. The appendix was 
examined, and found to be normal. On exposing the 
mass near the middle of the abdomen by extending the 
incision, it looked like a large dilated and gangrenous 
knuckle of intestine, but without a mesentery. It 
sprang from the lower part of the convex surface of 
the ileum, and was tightly twisted at its point of at- 
tachment to the bowel. It extended upwards into a 
I Read at the Congress of American Physicians and Surgeons at 
Washington, May 31, 1894. 2 
dense mass of adhesions, and when dissected free was 
found to be attached to the under surface of the um- 
bilicus. It was then evident that we were dealing 
with a Meckel's diver- 
ticulum in a strangulated 
and gangrenous condi- 
tion. It was seven 
inches long, and about 
the same size as the 
ileum. During the dis- 
section, the gangrenous 
diverticulum was rupt- 
ured, allowing the es- 
cape of a quantity of 
faecal-smelling fluid into 
the peritoneal cavity. 
The diverticulum was 
removed, and the open- 
ing in the ileum was 
closed with several Lem- 
bert sutures. The ileum 
at this point was found 
twisted on itself and 
held in this abnormal 
position by adhesions. 
The gut was not wholly 
obstructed by the twist. 
On untwisting the bowel 
old adhesions were 
found extending deep 
into the mesentery so 
as to shorten it at one 
point. This contraction 
of the mesentery seemed 
to have caused the vol- 
vulus of the ileum. The diverticulum having its 
outer end fixed at the umbilicus, was twisted and 
strangulated at its base by the turning over of this 
coil of the ileum. The gangrene of the diverticulum 3 
was most intense near the ileum, the end at the um- 
bilicus being only moderately inflamed. This is ex- 
plained by the fact that the diverticulum has its blood- 
supply from the mesenteric artery of the ileum. 
The operation was severe, causing the pulse to rise 
to 180 at the end. The patient, already septic at the 
time of operation (unfortunately the cultures of the 
turbid fluid found in the abdomen were lost), died of 
septic peritonitis on the second day. 
As is well known, Meckel's diverticulum is due to 
the persistence or incomplete obliteration of the vitel- 
line duct. It is usually small, and has its principal in- 
terest in the fact that it not infrequently acts as a band 
and causes intestinal obstruction. 
Dr. R. H. Fitz,2 in a very valuable paper on this 
subject, quotes Roth 8 as calling attention to the origin 
of retention cysts from Meckel's diverticulum. " Such 
cysts are divided into two classes, according as their 
cavity is continuous or discontinuous with that of the 
intestine. The wall is composed of the various layers 
found in the intestine." Roth describes a cyst of this 
kind occurring in a child one year and four months 
old. " It was connected with the concave surface of 
the ileum, near the mesenteric insertion, twenty-six 
inches above the ileo-cmcal valve. The pedicle having 
become twisted, a haemorrhagic infiltration and necro- 
sis of the mucous membrane had occurred, also acute 
peritonitis." 
The case here reported is unique, but this case of 
Roth's resembles it in several important particulars. 
In both cases the diverticulum was strangulated by 
twisting of the pedicle, and acute peritonitis followed. 
These cases are sufficient to establish the fact 
that strangulation of Meckel's diverticulum is one 
of the causes of acute peritonitis. This fact has an 
additional interest at the present moment in that 
the diverticulum resembles the vermiform appen- 
2 American Journal of Medical Sciences, July, 1884. 
3 Virchow's Archiv, 1881, Ixxxvi, 377. 4 
dix, and the two lesions may easily be confounded, 
cMnically, as in the present case. While the diverticu- 
lum is often without a mesentery and is therefore freer 
and more likely to suffer from strangulation by twisting 
of its pedicle, yet it not infrequently has a mesentery ; 
in which case it must be liable to the same pathological 
processes (though evidently much less frequent) as the 
appendix. Such cases are not wanting. Fitz men- 
tions a case reported by Dr. Beale,4 where acute peri- 
tonitis followed perforation of a diverticulum, in the 
cavity of which were a cherry-stone, the coriaceous 
covering of several orange-pips and other substances ; 
and also a case of adherent diverticulum described by 
Houston.8 This diverticulum was filled with a hard 
matter, apparently inspissated faeces. " The omentum 
and intestines in the neighborhood were closely joined 
to the tumor by adhesions, the result of former inflam- 
matory attacks, and the woman had complained for 
many years before her death of occasional severe pain 
in the abdomen." 
The symptoms of inflammation of these two intes- 
tinal pockets are the same, as they both cause perito- 
nitis. The only points in the differential diagnosis 
which the writer is able to suggest, are that a history 
of a discharge from the umbilicus (this occurred in a 
case of intestinal obstruction due to diverticulum m the 
practice of Dr. John Homans) would suggest the pres- 
ence of a diverticulum, while a history of previous at- 
tacks of pain would be significant of either an inflamed 
appendix or diverticulum, as, according to Fitz, " In 
nearly one-half the cases of vitelline remains previous 
attacks of pain were recorded." The presence of a 
tumor or tenderness near the umbilicus should favor 
the theory of inflamed diverticulum as against the ap- 
pendix. It will be remembered that in the case here 
4 Report of Proceedings of the Pathological Society of London, 
1851-52. 
fi Descriptive Catalogue of the preparations in the Museum of the 
Royal College of Surgeens in Ireland, 1834, 1, 38. 5 
reported a distinct tumor could be felt just below and 
slightly to the right of the umbilicus. 
The only treatment to be thought of in such cases 
is prompt laparotomy and the removal of the inflamed 
or strangulated diverticulum. The special points to 
be observed in the operation are the careful stitch- 
ing of the pedicle, as it often opens directly into the 
intestinal canal; also the careful ligature of the ves- 
sels, because the diverticulum is supplied by a branch 
of the mesenteric artery, which is the persistent om- 
phalo-mesenteric artery, and may be of considerable 
size.