DOI: 10.7925/drs1.ucdlib_280353
title: Protrusion of omentum

description: Watercolour medical illustration depicting protrusion of omentum. It has the alternative reference number 1721 and P4A on the front. There is no Richmond Hospital Museum reference. The artist's name is in the bottom right corner 'J. Connolly fec.t' and 'Case of Jane Rice aet 45' in the bottom left. The full typescript note on the back reads 'Protrusion of the Omentum'. This illustration relates to P263/365, portfolio 6.1.
description: Users are advised that this item contains graphic images which may cause upset or distress.
description: Scope and content: The full typescript note on the back reads 'Protrusion of the Omentum – Mr Adams said – I beg leave to lay before the meeting the details of a very remarkable case of protrusion of the omentum from the cavity of the abdomen. The protrusion in this instance did not occur in any of the ordinary situations for hernia, but the omentum, uncovered by any sac, was seen (when the patient was admitted into the Richmond Hospital) to have descended from the orifice of the anus between the limbs, so far as nearly to reach the popliteal spaces. The history of the case is as follows: Jane Rice, aged 50, was admitted into the Richmond Hospital, under my care, at one o'clock on the morning of 22nd of October, 1852. The case was reported to be of that urgent nature as to require my attendance at the hospital at night. I found the woman lying on her side, and when the bedclothes were raised up and the nates exposed, a mass of the omentum, about eighteen inches in length and two inches and a half in breadth, presented itself; it had a shining, membranous surface, and was of a pinkish colour. Dr Sinclair, Assisting Physician of the Lying-In Hospital, accompanied the patient to the Richmond Hospital, and was kind enough to give me a history of the case. He stated that the woman had first been transmitted, by mistake, to the Lying-In Hospital; that he there made a special examination of the patient. He said that the finger, introduced per vaginam, reached the os uteri, which was found natural; the anterior wall of the vagina was perfect, as well as the posterior wall and recto-vaginal septum. At the orifice, however, of the vagina, there was a well-marked cicatrix, the result of laceration, which had occurred at her first confinement, about thirty years ago. Dr Sinclair further stated, that he satisfied himself that the protruded omentum had no connexion whatever with the canal of the vagina, but that it plainly proceeded from the cavity of the rectum, and passed out through the anal orifice. That on introducing the finger alongside of the protruded omentum, into the rectum, it was found that above the anus the omentum became narrower, rather pediculated, and just as high as the finger could reach, the pediculated portion could be traced to have come through an opening in the walls of the rectum, situated towards the left and posterior aspect of the gut. The edge of this aperture was abrupt, well defined, and of a semicircular form. Dr Sinclair considered it to be a portion of altered omentum protruded through an opening, which was situated (so as far as the finger could discover) to the left side of the rectum, and slightly posteriorly. He imagined that if the finger could be introduced a little higher, the opening in the rectum should be found to correspond to the lowest portion of the recto-vaginal cul de sac of the peritoneum. As to the origin of this protrusion, it was supposed by the woman herself to be the consequence of her first confinement. At this time a laceration had occurred at the orifice of the vagina. Ever since this period she had been suffering some inconvenience, caused by something which occasionally protruded, as it were "her body coming down"; but that this was merely an inconvenience, and there was nothing in it whatever to alarm her, until the evening of the day of her application to the hospital. On this evening, when she was going quickly down stairs, her foot slipped, and she made a violent effort to recover her balance, and then it was that this matter, which ordinarily came down but a little, suddenly descended to a great amount, upon which she became faint, vomited, and was immediately seized with great pain, and under these circumstances was, under an erroneous view of her case, transmitted first to the Lying-In Hospital, and subsequently to the Richmond by Dr Sinclair. The patient stated that the structure now down felt exactly similar to that which ordinarily protruded for many years, and differed only in the circumstance of the great extent of the protrusion. On reflecting on the representations of the case made by Dr Sinclair, and finding that she had no urgent symptoms just then, I merely directed that fomentations and leeches should be applied to the abdomen, which was done accordingly. On the following morning, Wednesday 22nd of October, a consultation of the surgeons of the hospital was held on the case, the result of which was, that it was deemed imprudent to interfere surgically with it. There was now no sickness of the stomach, and the inflamed action of the peritoneum and intestines was trifling. We felt convinced, indeed, that the omentum was in a state of strangulation; at the same time we felt, that if the structure were divided we should not then be without fears that there might be a difficulty experienced in replacing the protruded part; or, supposing this last effected, we foresaw that it was by no means impossible that some of the intestines might force their way out through the aperture; or if, supposing the operation performed, and that none of these circumstances occurred, still an opening should remain through which the air would penetrate, and be followed by the passage of the ordinary contents of the rectum into the cavity of the peritoneum, which, it is needless to say, must be necessarily fatal. It was considered, therefore, more prudent to leave the case to nature and to palliative measures, than to have recourse to any surgical operation. We considered it probable that the ligature (placed as it were by nature) on the omentum, at the very point of its protrusion from the peritoneal cavity, would effectually strangulate and cause the death of the omentum, and thus would the patient be rid of the protruded part, the vitality of which we believed had already suffered much from exposure for many hours. The patient lay in bed on her side, and the protruded part was smeared with the linimentum calcis composition; it was directed that leeches should be applied to the epigastric region should acute abdominal pains be complained of. From day to day the patient appeared to suffer less uneasiness; she lay upon her side, and the protruded part gradually withered, and on the seventh day sloughed off. The finger introduced into the rectum discovered that this intestine was now empty. The edges of the ring through which the omentum had protruded could now be felt as before; but the foramen, as far as could be discovered by touch, seemed stopped up. All her uneasiness had disappeared, and did not return so long as she remained in bed; but she still found, on getting up and walking about, the same tendency to protrusion, as it were, "her body coming down", existed as before, and she feels instinctively the necessity of being very cautious in all her movements. It is now six weeks since the occurrence of the rectal protrusion for which she was admitted into the Richmond Hospital; she was yesterday discharged, as she felt anxious to return to her home; she declared that she felt herself quite as well as she has done for the last twenty years. Observations – In endeavouring to account for the protrusion, we must conclude that a perforation through all the tunics of the anterior and left wall of the rectum, at a point about four inches above the opening of the anus, and in the immediate vicinity of the recto-vaginal cul de sac of the peritoneum, must have occurred; and by this opening the cavity if the rectum, and that of the sac of the peritoneum, were put in direct communication with each other. The engagement of the lower extremity of the omentum into this opening of communication must be looked upon as a happy interposition, thus closing up the aperture and prevent fatal consequences; but the question arises, how did the perforation of the rectum, and direct communication between the cavity of the intestines and that of the peritoneal cavity, occur? In the preceding history of the case, the circumstance of the woman's having suffered much in her first confinement is much dwelt upon, but what has been the mechanism? It is not proved that this severe labour had anything to do with what subsequently occurred, namely, the protrusion of the omentum. It is true that the external orifice of the vagina had been ruptured, and that the laceration extended through a portion of the peritoneum towards the anus during the labour referred to; but there was no evidence that the upper part of the vagina, near the recto-vaginal cul de sac of the peritoneum, had ever suffered injury during labour, indeed, if it had, a protrusion into the cavity of the vagina should have occurred, instead of that observed in this case. Happily, we have not had any means of ascertaining anatomically the precise nature of the lesion which existed in the coats of the rectum, nor do we know whether the laceration we presume to have occurred had originated in the serous or mucous coat of the intestine. The situation of the perforation we know to be about four inches above its anal opening, and we can infer that the perforation into the cavity of the peritoneum through which the omentum passed must correspond exactly to the lowest point of the recto-vaginal cul de sac of this membrane. This case appears to me to be a novel one, and well worthy of being recorded. The two drawings, and the portion of sloughed omentum, have been preserved in the collection of the Richmond Hospital Museum.-March 12, 1853'.
description: Numbering/sequence: Original reference number: 1721.