Chronic intestinal obstruction due to adhesion of a uterine fibroid to the mesentery / by Alban H.G. Doran.

  • Doran, Alban H. G. (Alban Henry Griffiths), 1849-1927.
Date:
1907
Catalogue details

Licence: In copyright

Credit: Chronic intestinal obstruction due to adhesion of a uterine fibroid to the mesentery / by Alban H.G. Doran. Source: Wellcome Collection.

Provider: This material has been provided by The Royal College of Surgeons of England. The original may be consulted at The Royal College of Surgeons of England.

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    if :,-.: / 3 . I The Lancet ■] A tuy^yu-^ Mattes /''r'rj'. £ct~U4„ £-Alr r MR. ALBAN DORAN: CHRONIC INTESTINAL OBSTRUCTION, BTC. [Nov. 9. 19Q7._Jj()9_ incorrectly—i.e., because there is something at fault in the machinery—but because he has acted wrongly—i.e., in a to the' dicta ,of‘;the vis major, the society way contrary piece of machinery goes on acting according to its con- struction for a long time, and it seems to us at the time to be perfect and complete; all at once it breaks down and stops • the process is a perfectly natural and correct one , the wrong action would have been if it had continued to go on under circumstances which are incompatible with pro- gression. So is it with mental processes ; we legislate for perfection, not remembering that the machinery is as yet imperfectly developed for perfection. In some cases the materials are of inferior quality and they last only for a short time, but the action is perfect in its kind as far as it goes, and when it fails, it fails in accordance with what it ought to do; in other cases there are no materials for elabora- tion, the machine cannot be raised towards the ideal; it acts in a correct and certain way but not with the perfection which we expect, and it fails because we expect what is for it impossible. In others the action of the machine seems perfect but it does not stop when it should, and in its un- checked working it offends the social system—then this action is called “criminal,” whilst all the time the con- ditions under which it was running were not perceived and ought to have been arrested, though the process was an entirely correct one and was working itself out in the only possible way. Let us, then, understand the “criminal ” process. It is not irregularity of action : it is the only possible action. We must regard the elements of the act, the factors, and the only way to be fair to the individual is to stop him when we notice something in the mechanism which is bound to work out in a way full of what the social majority deems to be danger to itself, or else to let things go on in their inevitable outworking and then, regardless of the individual, protect itself in the way which seems to it to be the best, recognising that the laws of matter are not always com- patible with the ideals of mind which are artificially set up. For some natures it is the right thing to kill, for others it is the right thing to steal—i.e,, no other result is possible. When society gets hold of people who act in this way it sup- presses them for the time being or else it eliminates them. There are too many weeds to have all exotics, but the weed is still a natural product. To recapitulate. My position is that in criminal acts the mental process introduces no fresh element. If in the insane a criminal act occurs the only fresh element is the false motive, which, however, acts in the same way as does a normal one. The constituents of the voluntary process are the same in kind as in normal minds : motive, desire, feeling, end in view, action on presentation (otherwise impulse), action upon reflection—all may occur in the same way as in normal thought processes. The only difference is not in the mechanism of the elements but in their nature; thus the motive may be a wrong one (i.e., against the accepted obligations of society) or the element of feeling may be an irregular one due to structural conditions, but we must remember that just as social systems are temporary—are themselves in a mutable condition—so are mental processes. We have not in the one the perfection of organisation, though such as it is it acts in accordance with its construction ; neither have we in the other any but a temporary adaptation, though such as it is it acts in the way we should expect it to do, and in this expectation we are rarely disappointed. The limit of time prevents more than this brief statement of what I venture to think is an Important fact to insist on and one which is not usually borne in mind—viz., the similarity of the process in criminal and legal acts. I am not dis- cussing the question of how far the motives affect responsi- bility nor how far the explosiveness of feeling may be an exculpating factor. I just ask the indulgence of my medical confrrrcs in insisting upon a point which by some may be considered self-evident, but which perhaps may be deemed worthy of categorical statement and of official reception or rejection. Harley-street, W. CHRONIC INTESTINAL OBSTRUCTION DUE TO ADHESION OF A UTERINE FIBROID TO THE MESENTERY. By ALBAN II. G. DORAN, F.R.C.S. Eng., SURGEON TO THE SAMARITAN FREE HOSPITAL, LONDON. /S Ji°YA\£0LLEGE of Physicians of Ireland — Kovaf Cniwl7 TmnR- the President ™d Fellows of the T)r Phnri ? u Physlclans of Ireland held on Nov. 1st ‘.Itoi’oS2geat“e WM a licentiate in A patient with a small, empty umbilical sac and a lobulated uterine fibroid tumour suffered for a year from symptoms of obstruction the source of which could not be determined. When the abdominal cavity was opened the symptoms were found to be due to an adhesion of one lobe of the tumour to the mesentery, forming an arch under which coils of small intestine became incarcerated. The tumour was also remarkable for its relations to the left broad ligament. Such were the features of interest about the case which I will now relate in detail. A woman, aged 50 years, came under the care of Mr. E. B. Leslie Moore of Harlesden in the summer of 1906 for an attack of severe abdominal pain, tenderness, distension, and vomiting. She had been married for 25 years and had borne two children. Her last pregnancy ended when she was 31 years of age. There was a small umbilical hernia which apparently consisted of nothing more than an empty sac. The bowels could be freely opened and the symptoms subsided and disappeared after the patient had kept in bed for a few days. The attacks, however, repeatedly recurred at intervals of from two to four weeks. Mr. Moore, on examining her at the end of June, 1907, detected an abdominal tumour which was clearly a lobulated uterine fibroid. She was admitted into my wards in the Samaritan Free Hospital on July 8th. On admission the patient was stout and pale. There was a large varicose ulcer on the inner side of the lower third of the left leg. The urine was scanty ; it contained pale-red urates and a distinct trace of albumin ; its specific gravity was 1020. The patient was not allowed to get up for a few days ; by the end of that space of time the daily excretion of urine exceeded 30 fluid ounces and the albumin had disappeared. The abdomen was extremely distended, measuring 41 inches in girth at the umbilical level, yet it was not tense. The integuments were pale and the subcutaneous veins were not dilated. There was a small protrusion at the umbilicus not one inch in diameter. The integuments were red ; the neck of the sac admitted the tip of the forefinger and was apparently free irom any adherent omentum. The sac seemed quite empty. The abdomen was tender to the touch and a bilobed mass, not freely move- able, occupied the hypogastrium. On binanual palpation the uterus was found to be continuous with the mass which did not extend downwards below the brim >f the pelvis. The periods were irregular, appearing withii less than three weeks’ interval; the show was more free than before the illness, but there had never been any ittacks of severe hcemorrhage. The significance of the attacks of pain, tenderness, distension, and vomiting renamed uncertain. There was no obstruction to the passage oi flatus and ffeces. The patient lived in dread of a recurrence if the symptoms. I operated on July 16th. The tumoui was bulky and solid and could not be delivered unti the abdominal incision had been prolonged into the henial sac. Then I found that the right lobe was completely eparate from the left and that its uppermost part adhered psteriorly to about four inches of mesentery, close to intestne. That portion of intestine was in no way obstructed, bt under the arch formed by the adhesion were severe coils distinctly incarcerated. They were drawn out without any diffi- culty. The cause of the symptoms of ofetruction was now evident. There was no other adhesion, parietal, omental, or visceral. The vessels running from thi mesentery to the tumour at the point of adhesion were larg and the adhesion itself was nearly one inch broad in the mddle. I dissected up a thin layer of the serous coat and siojacent capsule of the tumour around the adhesion and seourd it with sutures ; the fibroid was then severed from the mesntery without any loss of blood. The right Fallopian tube aid ovary lay quite free from the tumour which had pushed tieni down into the pelvis. The right ovarian vessels were ligaured and divided ; the right round ligament was moderately aypertropmed an“ required to be ligatured on both sides bJf°re div v’on- ' Doyen’s clamp was applied to the right broad whioh was then divided. The left lobe, or, ©ore ' '