Abdominal section : general observations on details and after-treatment / by Alban Doran.

  • Doran, Alban H. G. (Alban Henry Griffiths), 1849-1927.
Date:
1896
Catalogue details

Licence: Public Domain Mark

Credit: Abdominal section : general observations on details and after-treatment / by Alban 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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    ABDOMINAL SECTION : « GENERAL OBSERVATIONS ON DETAILS AND AFTER-TREATMENT. BY ALBAN DORAN, F.R.C.S., Surgeon to the Samaritan Free Hospital. the humerus, the shoulder is not kept at rest for a sufficient time to allow of the acromial fragments uniting by bone, and as a consequence a false joint forms. When the blow which produced the fracture was sufficiently severe to contuse the articular cartilage of the head of the humerus, and the intervening soft parts, the changes I have just described follow. Anatomists are largely responsible for the non- recognition of these fractures, since they have chosen to regard the resulting ununited conditions as examples of non-union of an epiphysis, and, so far as I can see, upon no reliable evidence whatever. Some surgeons have readily accepted the statements of the anatomists, apparently without investigating them. They have, however, observed the frequent association of this so-called ununited epiphysis with the presence of so-called rheumatoid changes in the shoulder-joint, and have explained the cause of their association in various ways. One has gone so far as to assert that in cases of chronic rheumatoid arthritis of the shoulder-joint, a disunion of the acromial epiphysis from the rest of the bone takes place. Such a statement hardly calls for criticism, and I only mention it to indicate the frequency with which those changes which the pathologist regards as characteristic of the disease, rheumatoid arthritis of the shoulder-joint, are found associated with ununited fracture of the acromion. Can anything be more obvious and simple than the mode of development of an ununited fracture of this process of the bone, if one considers for one moment its position and muscular attachments, together with the difficulty of retaining the broken fragments at rest for any length of time, even if the fracture be recognised ? The only two examples of bony union which I have observed followed a fracture of the acromion, which was accompanied by a severe comminuted fracture of the upper end of the humerus. Owing to the pain resulting from the presence of the latter fracture, the shoulder was kept at rest sufficiently to allow of bony union. Though I might multiply such instances indefinitely, I think I have said enough to show that a severe injury to a joint is liable to be followed by the development of such pathological conditions as surgeons are still accustomed to regard as evidence of the presence of rheumatoid arthritis. Two years ago I contributed to this Journal a few notes on the feeding of patients after abdominal section.* In conclusion I observed that full attention to after-treatment is one of the best ways to attain successful results. I admitted that it is at first less interesting to contemplate than the question of antiseptics, short incision and drainage, but it is quite as important. Further experience has not led me to modify my practice in respect to diet and the management of the patient’s bowels. I believe rather more than I did in 1894 in the value of nutrient enemata as compared with starving, or early feeding by the mouth. They counteract shock, and nourish with- out causing flatulence. No irritation of the bowel need be feared if the most ordinary precautions be taken. Later on, if symptoms of obstruction or peritonitis set in, these enemata are of yet higher value. I find that, if mixed with a little lime- water, milk is not so objectionable an article of diet as I once thought it to be. A few ounces daily, after the second day, aid greatly in keeping up nutrition, especially in old women, and if not given pure or in excess, the fear of the development of scybala is not great. A dose of sulphate of soda, citrate of potash, and glycerine dissolved in water may be given two or three times daily from the fourth to the sixth day in constipated subjects, or in cases where the passage of solid motions might be dreaded for special reasons. About twenty grains of the sulphate of soda are sufficient as a rule. The citrate must not be given unless the urine is concentrated and charged with urates, or that excretion will become alkaline. After two days’ treatment with this draught, an enema will bring away a semi-liquid motion or soft solid freces without trouble. I still find the enema greatly preferable to pills * “ On the Feeding of Patients after Abdominal Section,” Vol. III., 1S93-4, p. 346.