Omentum

“ A patient in the German Ambulance in Heilbron, under Dr. Flockemann, died as a result of suppuration and hæmorrhage secondary to an injury to the colon. At the autopsy a portion of the omentum was found adherent in the wound of exit, but it had not reached the external surface. The chief interest of the observation lies in the light it throws on the mechanism of these injuries. It is impossible to conceive that a small-calibre bullet coming into direct contact with the omentum could do anything but perforate it. ”

“ In hernia with a very small orifice the omentum alone may pass through, even the small intestine proving too large for admission. In such cases it is usual to find the band of omentum adherent to the callus formed by the repair of a fractured rib. 366When the orifice is somewhat larger a portion of small intestine or of the double colon or cæcum may be engaged, while with a still larger opening the stomach, spleen, or liver may form the hernia. In cattle the reticulum is most likely to be the hernial mass, as noted in an article below. ”

“ The peritoneum, as it covers different organs or sets of organs, receives special names.
The lesser omentum consists of two layers, these split to envelope the stomach.
The greater omentum consists of four layers. Two of these layers extend from the stomach and together with two other layers of the same structure which envelope the transverse colon, form an apron for the intestines. ”

“ When, from a rupture of the peritoneum, the omentum is prolapsed, and either becomes livid or black, the part anterior to the black portion may be included in a ligature, for fear of hemorrhage, and then the part behind the ligature is to be cut off, and the extremities of the ligature allowed to hang from the under part of the sewed wound of the abdomen, in order that they may readily escape when cast off by the suppuration of the wound. ”

“ On the right side there were a few similar adhesions and a number of more delicate and probably recent ones. A mass of black, coagulated blood covered and concealed the spleen and the left margin of the greater omentum. On raising the omentum it was found that a blood mass extended through the left lumbar and iliac regions, and dipped down into the pelvis, in which there was some clotted blood and rather more than a pint of bloody fluid. [A foot-note here says: A large part of this fluid had probably transuded from the injection material of the embalmer.] ”

“ Hulme differs from both these respectable physicians, says it is owing to an inflammation of the omentum and intestines, and maintains his argument by a variety of dissections; and the celebrated Dr. John Hunter is so far of this opinion, that he thinks it is possible even for men to have a disorder like it, and says that he has known similar appearances in the omentum and intestines of men, whose abdomens have been distended by dropsy.
Dr. Hulme readily admits, that unwholesome air, and bad diet, may powerfully operate in causing the disease. ”

“ What is the meaning of polimina, omenta, palasea, or, as some call it, plasea?—of which that named omentum is a certain part enclosed by the reservoirs of the belly are kept within bounds; the plasea is an ox’s tail [5] besmeared with flour and blood; the polimina, again, are those parts which we with more decency call proles,—by the vulgar, however, they are usually termed testes. What is the meaning of fitilla, frumen, africia, gratilla, catumeum, cumspolium, cubula?—of which the first two are names of species of pottage, but differing in kind and quality ”

“ Protection of the Intestines and Omentum.—During all manipulations within the abdomen the peritoneum, intestines, and omentum should be handled most gently. Injury of the peritoneum increases the danger of shock, sepsis, and intestinal adhesions. The intestines should never be allowed to protrude through the abdominal incision unless it is necessary for the performance of the operation. Such a necessity rarely, if ever, arises in gynecological operations. All the intestines may be removed from the field of operation—the pelvis—by placing the woman in the Trendelenburg position. ”

“ In the ox the reticulum most commonly protrudes, and after that the liver, abomasum, the omentum or the small intestine. In the dog the mass is usually formed by the stomach or liver, or less frequently by the small intestine or omentum.
Causes and mode of formation. The hernia is either congenital or acquired after birth. Again, it may result from imperfect development or from a trauma. Congenital cases usually depend on an arrest of development, the foramen sinistrum fails to close and the abdominal organ passes through by the side of the œsophagus into the chest ”

“ In other cases they form on or between intestines or other viscera which are for the moment torpid and inactive, and contracting as they become organized, they bind these together and hamper their movements, and endanger the integrity of all movable viscera in the vicinity. Again they form on the omentum and threaten the integrity of the bowels by strangulation. The omentum protruding at castration becomes adherent to the inguinal ring and forms a dangerous band. ”

“ This being divided, the omentum, or cawl, appears floating on the surface of the intestines, which are likewise seen in a moist and loose state, making numerous windings through the whole cavity. The viscera next present themselves in this order: on the uppermost part of the belly, namely, under the midriff, towards the middle, but rather inclining to the right side, lies the liver, and near its concave surface is the gall-bladder; somewhat to the left is the stomach, and laterally, contiguous to it, the spleen. ”

“ Omentum. Note position of lower border, amount of fat, condition of blood-vessels, dry or moist-shining surface, adhesions (to appendix, cæcum, oviducts) , indurations, contractions (edges rolled up) , character of lymphnodes, cysts, tubercles, secondary tumors, snared-off tumors from ovary or uterus (parasitic cysts, fibroids) , encysted foreign bodies, etc., exudates on surface, fat-necrosis, accessory spleens, encysted parasites, hernia, etc. ”

“ Matted or diseased omentum must be tied off and removed. Should peritonitis supervene after the operation on account of bacillary infection, the bowels should be quickly made to act by repeated doses of Epsom salts in hot water. ”

“ If the sac contains bowel and omentum, it is safer to open it over the omentum than over the bowel. When a small opening is made, an escape of the contained fluid takes place, and then the sac should be slit up as far as its neck by a probe-pointed bistoury, guided by the finger, introduced to protect the bowel, whenever the opening is sufficiently large. The forefinger must now be cautiously insinuated into the neck of the sac, the nail being directed to the bowel, the pulp to the crescentic margin of Gimbernat's ligament, and any constriction very cautiously divided. ”

“ After the appearance of these symptoms, a more or less firmly adherent but limited perityphlitic abscess, and a less intense although well developed peritonitis in this region, were assumed; the latter, notwithstanding the painful meteorism, was not necessarily diffuse in the strict sense of the term; the omentum often protects the upper abdominal cavity from infection, as was proven in this case at the autopsy. ”

“ Whilst the stomach is in a [59] state of repletion its vessels are more apparent on its exterior surface than during its vacuity; its mucous surface at this time has no higher degree of redness, but it has sometimes appeared to me to be less red than when the viscus was empty. (2) The omentum, being less extended during the plenitude of the stomach, presents nearly the same number of apparent vessels, equal in length, but more folded upon themselves than during the vacuity of that organ [C] . If they are then less [60] loaded with blood the difference is scarcely perceptible. ”

“ Thus I have had a case of strangulated inguinal hernia in which it was necessary to take away half a pound of thickened omentum, heal without any deep-seated suppuration or any tenderness of the sac or any fever; and amputations, including one immediately below the knee, have remained absolutely free from constitutional symptoms. ”

“ In rare cases the small intestines, omentum or liver protrude (Youatt, Lafosse) . The protruding organ is liable to be constricted and strangulated sooner or later by increase in its bulk in connection with its vermicular movements, the accumulation of its contents or the extrication of gas in its lumen, or by the gradual contraction of the orifice in process of healing. Then there may be dark red venous congestion, blood extravasation and effusion, friability and even rupture of the intestinal walls, and adhesions to the wound or the lungs. ”

“ Just as the membrane extends further to the left than required by its visceral connection with the stomach, so the downward growth exceeds the demand made by the rotation of the attached border (greater curvature) caudad and to the left. The mesogastrium, forming, as it now does, the great omentum, enlarges in descending toward the transverse colon (Fig. 177) . The bag thus formed can be distended with air in a fœtus of from 8 to 9 cm. vertex-coccygeal measure, as shown in the figure. ”

“ Normal condition of the scrosa above the omentum: the appendix surrounded by adhesions embedded in fecal pus? gangrenous toward its terminal portion, and showing perforation; fecal calculus in the pus; appendix movable toward the cecum."
[Just what may be expected in all cases! Nature is always busy reinforcing weak points, but the modern physician and surgeon is too wily and artful for her; she can't always anticipate his moves, hence she can't always fortify successfully.] ”

“ Their true significance and their influence on the adult anatomical arrangement of the abdomen is, however, only appreciated when the changes in the arrangement of the peritoneal membrane which they involve, are taken into account.
The dorsal mesogastrium changes more than any other portion of the peritoneum in the course of development. It not only becomes displaced and altered in direction by the rotation of the stomach, but in addition it grows so extensively that it finally hangs down like an apron over the entire mass of small intestines, forming the great omentum. ”

“ When it is established the septum primum grows down and meets the endocardial cushions, and so the ostium primum is obliterated. The septum secundum grows down on the right of the septum primum and is never complete; it grows round and largely overlaps the foramen ovale and its edges form the annulus ovalis, so that, in the later months of foetal life, the foramen ovale is a valvular opening, the floor of which is formed by the septum primum and the margins by the septum secundum. ”

“ The body is a sac, branched in the adult, but simple in the young; its continuous cavity is everywhere lined with choanocytes, its wall is traversed by inhalant pores, and its cavity opens to the exterior at the distal end by an osculum. The simple sac-like young is the well-known Olynthus of Haeckel—the starting-point from which all sponges seem to have set out. Two processes are involved in the passage from the young to the adult, namely, multiplication of oscula and branching of the original Olynthus tube or sac. ”

“ To make an opening in a slight barrier is not one of her methods. She could do it if she wished; for to gnaw through the ceiling of the cell on hatching and then through the general door of the nest is a more difficult job. She possesses in her mandibles a tool powerful enough for the purpose; but she is not aware that a splendid gallery lies beyond the obstacle. How did the Odynerus learn, if she did not know from the beginning, what the Osmia, with her greater experience of the reed, does not know? ”