6’75 THE BRITISH JOURNAL OF SURGERY

malignant growth of the right thumb. The thmnb was amputated in May, 10% and the wound healed well.

The specimen (Fig. 485), which is now in the Museum of the Royal College of Surgeons (No. 1871.5), shows a large raised fungating growth on the inner side of the right thumb. The microscopical craminat ion provcd thc condition to be a typical squamous-celled carcinoma (Fig . 486).

This case is of interest bccause i t is perhaps the first case of cancer in a radiuin worker, and because the patient was seen oEf and on ever since he first noticed pigmentation in his fingers. When the carcinoma did develop, it grcw very rapidly.

It is interesting to note that Mrs. G . , who helped her husband in some of his radium work, and oftcn sat and talked to him in his laboratory, died of carcinoma of the bladder. She was admitted to hospital and partial cystec- toniy war pcrformcd, but the growth recurred and proved fatal.

The nail is fissured and striated.

REFERENCE. 1 lV.\i<i.:rxx-, C. 1’. G., Hril. .TOUT. Surg., 1924, s i i , 137.

FOREIGN BODIES IN THE ILEAL (MECHEL S) DIVERTICULUM, WITH FORMATION OF‘ A PEDUNCULATED CYST

WHICH STRANGULATED A LOOP OF SMALL INTESTINE. BY HUGH MILLER, EDISBURGIL

A MALI: patictit, age 35 years, was admitted to Edinburgh Royal Infirmary a t 1 a.m. on May ‘7, 1026, with the following history :-

HrsToni-.-He was a ship-brcaker by trade and accustomed to arduous work. Since thc end of 1023 he had suffered from attacks of abdominal pain and discomfort, and had experienced ‘dragging pains in the stomach’, especi- ally while stooping a t his work. On the afternoon before admission, when hc was lifting sonic heavy material from the ground, he felt severe pain in the ~uinbilical and epigastric regions of the abdomen. The pain was agonizing for n few minutes and thcn passed away, but similar attacks came en at inter\-als, becoming more severe and more frequent. He reached home in a collapsed condition one and a half hours later. Soon after, vomiting occurred, and this was repeated several times. The bowels did not move. He was seen by a doctor and removed to hospital at midnight.

oh- EXAMINATIOX:.--T~~ patient appeared a strong, well-built man. He was obviously suffering with severe spasms of pain which passed across the abdomen, but were worst about the umbilicus. On palpating the abdomen, tenderness was found to be present in the left cpigastrium, umbilical region, and right iliac fossa, and there was slight rigidity on pressure of both rectus muscles. The pulse-rate was 80 per minute, respirations were 24 per minute, and the temperature 99”.

He stated that he was living under healthy conditions as regards housing,

He was vomiting bile-stained material.

EARS OR OBSCURE CASES 679

work. and food. His appetite was good and he was particularly fond of sweets and fruit, especially tomatoes, oranges, grapes, and raisins, sometimes hax-ing sis to ten oranges in a day.

~1.4c:n-osrs.-The condition was diagnosed as being acute intestinal ob~trurtion, the cause being obscure, and immediate operation was decided up011.

O ~ ~ ~ ~ ~ a ~ r o ~ . - C ~ l i o t o n i y was performed, the abdomen being opened by an incision through the right rectus sheath in its lower part. There was clear free h i d within the abdominal cavity, and distended loops of small intestine Irere at once seen. Then there presented a firm, lobulated cystic mass the siw of a duck’s egg. On trying to pull this out a t the wound, it was found that the mass was attached by a pedicle 3& in. long. The pedicle passed cloirii to the left side of, and then behind, a loop of small intestine and its nic\entery, which were thus being strangulated. The condition found is rcpreseiiteci in Pig . 457. When the loop of small intestine had been pulled iip the base of the pedicle was exposed. The structure was then seen to be 21 diverticulum of bowel coming off the aiitimesenteric bolder of the ileum, j ~ s t distal to the strangulated loop and two feet prosiinal to the ileocaecal \-al\*c. The loop was very congested, cspccially at its- constricted neck, but WIS qiiite viable ; thc small intestine prosimal to it was distendcd, while t h t 011 the distal side was narrow and dlapsed. When the diverticulum was I‘rectl its pedicle retracted to 2 in. in length. Pressing the terminal cystic swelling could not force its contents iiloiig thc diverticulum into the ileum. The di\-erticulum was clamped near it.5 coinnieiicement and removed, the 0l)ciiiiig in the ileum being closed by two layers of sutures running in the transverse asis of the bowel.

The patient inade ail uneventful recover!;, and left hospit.al, cured, thrce jvecks later.

PaTrroLocu.-wheii removed the diverticulum had the appearance shown in Pig. 458. There were two distinct parts. The proximal part, or pedicle, was similar in structure to the ileum. As one passed a finger along the lumen a partition was felt stretching entirely across it at the level of a slight constriction which showed on the peri-

FIG. 487.-Diagrain to show the way in which the loop of intmtine was strangulated by the pedicle of the diverticulum.

toneal surface. sented itself at the operation. the surface, arid no evidence of acute inflammation was present.

Beyond this was- the distended mass which had first pre- It was smooth and red-blue in colour on

There was

680 THE BRITISH JOURNAL O F SURGERY

no sign of a mesentery, or of

FIG. 18R.-Tlie diverticulum removed, its two parts.

A microscopic examination of a picce of the cyst was made by Dr. Jamcs Davidson, of thc Pathology Department, Univcrsity of Edinburgh, t o whom I am indebted for this report :-

" The tissuc cxamined shows mucous-secreting glands and epithelium resembling that of the small intestine, but on the whole the wall is thinner than that of the normal gut. Chronic inflammatory reaction is prescnt. Thcre is no pan- creatic tissue or any evidencc of nia1ignanc.y ".

The foreign bodies were found to be seeds and other little pieces of vegetable debris -namely: 117 tomato seeds, 29 grape seeds, 10 odd shreds of husks, 1 orange pip.

a terminal band or adhesion between the mass and any other structure. The contents felt of fluid con- sistency.

The specimen was cut open longitudinally ; the cystic space was found to contain clear, colourless fluid like thin mucus, and very numerous small dark- coloured foreign bodies. A sketch of the diverticulum laid open is shown in Fig. 4.59. The main cyst was irregular in shape, and com- municated by a small opening with anothcr space also packed with foreign bodies. The dia- phragm closing the cyst off from the patent part had ~ U C O I I S

membrane lining both of its sur- faces. The wall of the cyst consisted of much thinned-out

s~iowing intestinal wall with a few small fatty collections on its peritoneal surfacc.

Fxc. 489.--Sliowing the divcrt,icnIum laid open and exposing its accumulation of forcign bodies.

RARB OR OBSCURE CASES 681

CONCLUSION. I h n i :L roiisicieration of tlic history a l i c i the pathological findings in

6his ~ H S C tlic €ollowiiig appears to bc the likely sequence of events. The paticiit from birth had a Meckel’s diverticulum-a short intestinal processus fro111 tlic ileum, due to iion-oblitcratioii of the fatal vitelline duct in its prosinial part. This, commuuicnting with thc ilcuni, rcceired intestinal coiitciits horn it. Oiic of the folds (plica c k w h i s ) of mucous membrane I)c.c*:inic cnlarged and foiiiicd ti valm 1)arti:tlly shutting oft tlic distal portion of thc diverticulum, and in this part seeds, etc.. wcrc licld up. As the result o f irritation and subsequcnt inll:miniatio~i tlic frce ed&v of the plictr gradually :itt,achcd itself to the wall of tlic di\-crticmlurn opposite it, until the distal prtioii was complctcly scparatetl from the rest. This portion then became clistcnded with secretion from tlic glands in the mucous membranc to the sizc and shapc in which it was found. Thc weight of the distended sac caused t hc proximal part of thc di\-ei-tic~ulmi~ to become stretched into the form of :i 1)cdivlc, and hy iiirniis of it,, dragging on the ileum and mesentery rcsultcd. This would account for thc discomfort and ‘ dragging pains in the stomach ’ which the paticiit Iiud c!oniplniiied of (luring the last few years. Thc sudden otisct of his aciitc symptoms was ~)rodrtcccl by the peduiiculated nitiss being swiuig ro~uid hchiid a loop of sniall iiitestine and then falling over it to thc riglit, so as to ‘snare’ it, thiw giving rise to acute obstruction.

The diverticulum which I havc described presents soiiie unusual features. lhreigu bodies are frequently clisco\-erecl in Meckel’s diverticula, but this case is remarkable on account of thc largc nimibcr of roreign bodies (fruit seeds), ;liid also thc inanner in which they wcrc scgrcgated. Cysts, too, are some- tiincs presciit in connection with Meckel’s divcrticula. These are considered to 1)c cwibr:r/uiric in origin, hcing dcriwd froiti iiidimentary portions of the \-itcllinc duct ; but the cyst in my case W R S an acquired onc, p d u c e d by tlic tcriiiiid part of the divcrticuluiu becoming shut off during life. I do not t.liiiik siich a variety has been prcrioiisly described. The way in which stritngiilittioii of thc bowel ocmrred is also of intcrcst. A coninion fwtor in causing this is a reinnulit of the \-itellitie duct fmming a fibrous bnid hctwccn thc distal cnd of the di.c~crtic!ulum and tlic abdominal wall. Xo such band was prcwxt, I~owc\w, mid the strniipiltitioii was brought :ihoiit I)y thc pwiiliar ii:tturc of the divcrt,iciilruni itselC, in the maiiner sho\vii.

I wish to csl)rrss my indehtediicss to Mr. Georgc Cliiciic. l?.lW.S., in whose wards thc pntirnt was treated. Sor helpful advice in wri tiiig this case, aiid for permission to publish thc notcs.