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RESECTION FOR CARCINOMA OF THE SIGMOID AND SIGMOID RECTUM
1207
CORRESPONDENCE RESECTION FOR CARCINOMA OF THE SIGMOID AND SIGMOID RECTUM
To the Editor
of
SKIN TESTS FOR WHOOPING-COUGH
To the Editor
of THE LANCET SiR,—In your issue of August 17th last (p. 361) a preliminary report on a skin test for pertussis was published by Drs. Bailey, Waller, and myself. Since then I have been doing further skin tests, and using Sauer’s vaccine as an antigen. The results obtained vary with the batch, and it appears to me that the ideal and constant antigen has not yet been achieved. I hope that someone working at this subject will be able to produce a really satisfactory and constant
THE LANCET
SIR,-In your issue of Nov. 16th Dr. D. P. MacGuire describes an operation for cancer of the rectum which I feel should not be allowed to pass without criticism, especially at the present time when surgeons in this
country are striving to simplify operations of this type and reduce the mortality. The operative
procedures used in England for removal of cancerous tumours of the upper end of the rectum and lower pelvic colon are now more or less standardised, and although, no doubt, still capable of considerable improvement are a great advance on similar operation of 20 years ago. The operation as described in Dr. MacGuire’s article seems a clumsy and unnecessarily complicated procedure with nothing to recommend it. Most surgeons of the present day, myself included, prefer to do the operation in two stages, as it has been found from experience that the safety of the patient is much increased thereby and the immediate mortality lowered. This is also the opinion of many American surgeons, including those of the Mayo Clinic. The colostomy is established at the first operation and the resection performed at the second operation, after a suitable interval to allow of the colon being decompressed and the patient brought into the best possible condition. Moreover, the time which the operation takes, necessarily rather long, is considerably shortened by planning the operation in two stages. The method of first freeing the rectum from below and completing the resection from the abdomen was first described by Mr. W. B. Gabriel (THE LANCET, 1934, ii., 69) and has advantages both in saving time and making the operation easier. The combined operation, starting in the perineum, only involves one move, from the left lateral to the back position, whereas the procedure described by MacGuire involves at least two moves. In my experience there is no danger in dividing the colon at the first stage of the operation, and although I have done it a considerable number of times I have had no sepsis or peritonitis
antigen
end of the
result from it.
There
are
often adhesions which
require separating, but this slight disadvantage is being got over, and in any case is more than outweighed by the greater safety of a two-stage operation, and the much shorter time that the operation takes. I have this last week done a complete second-stage combined operation in a man in 50 minutes, including the time taken in turning the patient and changing gloves. Blood transfusion is called for only occasionally and I have never known it necessary to use more than one, while parotitis as a complication I have yet to meet with. An operation that must of necessity be performed upon an elderly patient (since cancer of the rectum is usually met with in patients between the ages of 55 and 65) must, to be successful, be as simple and as quick as is reasonably possible, and an operation which inevitably involves opening the abdomen three times (twice through one incision and once through another), and also opening the pelvis from the perineum, cannot, it seems to me, recommend itself to modern surgeons, and is not one to be copied. I am, Sir, yours faithfully,
J. P. LOCKHART-MUMMERY. Harley-street, W., Nov. 18th.
for the intracutaneous skin test. I am. Sir. vours faithfullv. DONALD PATERSON.
Devonshire-place, W., Nov. 15th. "KWASHIORKOR" To the -Editor
of
THE LANCET
SiR,-Under the above title there appears in your last issue (p. 1151) an article by Dr. Cicely
.
Williams with the sub-title " a nutritional disease of children associated with a maize diet." May I firstly enter a protest against the use of a West African native word as the title of an article. How will it be possible for anyone later looking for references to nutritional disorders to recognise one under such a designation The secondary title is equally open to criticism as it would seem that the association with a maize diet is merely incidental. There is a further objection to the name kwashiorkor ; it indicates " the disease the deposed baby gets when the next one is born." That such a sequence of events occurs is a common superstition in other parts of Africa as I first pointed out in 1922 (Harvard African Studies, vol. iii., p. 289). Among the Wa-yao of Central Africa the disease, whatever it may be, is called litango lya kututa-each successive child is said to push (ku-tuta) the previous one into its grave. In Dr. Williams’s previous article (1933) a number of statements were made in regard to the differential diagnosis between this disease and pellagra, which were calculated to give an entirely false impression of pellagra and I felt constrained to draw attention to them the following year (Arch. Dis. Childhood, 1934, ix., 115). Dr. Williams has now again repeated these misstatements in regard to pellagra, presumably based upon a failure to realise the course and symptomatology of that disease, and tends to confuse the problem at issue. To deal with the table of "Differences between Kwashiorkor and Pellagra ":1. The affected skin is " black, rugose, and soft" in K. Elsewhere Dr. Williams So it may be in typical P. states it "tends to peel off, leaving a moist, raw surface." This is often the case in P. and while branny desquamation may take place in P., in other cases large ulcerated areas may result. 2. " Extensor surfaces and points of irritation and pressure affected" in K. This of course is common in P. As I have pointed out elsewhere any form of trauma, in its wide sense, may determine the site of the pellagrous eruption. The distribution of the skin affection in K. is probably what one would expect. 3. " Skin not photosensitive" in K.-photosensitive in P. In P. the skin is not always photosensitive. In the West African children it is not proved whether or not the conditions necessary for the exhibition of photosensitivity were present or not. 4. K. " occurs in children under 5 years"—usually under 2 years. P. " rare in children, almost unknown under 2 years." This is a fallacious statement. Pellagra may
CORRESPONDENCE RESECTION FOR CARCINOMA OF THE SIGMOID AND SIGMOID RECTUM
To the Editor
of
SKIN TESTS FOR WHOOPING-COUGH
To the Editor
of THE LANCET SiR,—In your issue of August 17th last (p. 361) a preliminary report on a skin test for pertussis was published by Drs. Bailey, Waller, and myself. Since then I have been doing further skin tests, and using Sauer’s vaccine as an antigen. The results obtained vary with the batch, and it appears to me that the ideal and constant antigen has not yet been achieved. I hope that someone working at this subject will be able to produce a really satisfactory and constant
THE LANCET
SIR,-In your issue of Nov. 16th Dr. D. P. MacGuire describes an operation for cancer of the rectum which I feel should not be allowed to pass without criticism, especially at the present time when surgeons in this
country are striving to simplify operations of this type and reduce the mortality. The operative
procedures used in England for removal of cancerous tumours of the upper end of the rectum and lower pelvic colon are now more or less standardised, and although, no doubt, still capable of considerable improvement are a great advance on similar operation of 20 years ago. The operation as described in Dr. MacGuire’s article seems a clumsy and unnecessarily complicated procedure with nothing to recommend it. Most surgeons of the present day, myself included, prefer to do the operation in two stages, as it has been found from experience that the safety of the patient is much increased thereby and the immediate mortality lowered. This is also the opinion of many American surgeons, including those of the Mayo Clinic. The colostomy is established at the first operation and the resection performed at the second operation, after a suitable interval to allow of the colon being decompressed and the patient brought into the best possible condition. Moreover, the time which the operation takes, necessarily rather long, is considerably shortened by planning the operation in two stages. The method of first freeing the rectum from below and completing the resection from the abdomen was first described by Mr. W. B. Gabriel (THE LANCET, 1934, ii., 69) and has advantages both in saving time and making the operation easier. The combined operation, starting in the perineum, only involves one move, from the left lateral to the back position, whereas the procedure described by MacGuire involves at least two moves. In my experience there is no danger in dividing the colon at the first stage of the operation, and although I have done it a considerable number of times I have had no sepsis or peritonitis
antigen
end of the
result from it.
There
are
often adhesions which
require separating, but this slight disadvantage is being got over, and in any case is more than outweighed by the greater safety of a two-stage operation, and the much shorter time that the operation takes. I have this last week done a complete second-stage combined operation in a man in 50 minutes, including the time taken in turning the patient and changing gloves. Blood transfusion is called for only occasionally and I have never known it necessary to use more than one, while parotitis as a complication I have yet to meet with. An operation that must of necessity be performed upon an elderly patient (since cancer of the rectum is usually met with in patients between the ages of 55 and 65) must, to be successful, be as simple and as quick as is reasonably possible, and an operation which inevitably involves opening the abdomen three times (twice through one incision and once through another), and also opening the pelvis from the perineum, cannot, it seems to me, recommend itself to modern surgeons, and is not one to be copied. I am, Sir, yours faithfully,
J. P. LOCKHART-MUMMERY. Harley-street, W., Nov. 18th.
for the intracutaneous skin test. I am. Sir. vours faithfullv. DONALD PATERSON.
Devonshire-place, W., Nov. 15th. "KWASHIORKOR" To the -Editor
of
THE LANCET
SiR,-Under the above title there appears in your last issue (p. 1151) an article by Dr. Cicely
.
Williams with the sub-title " a nutritional disease of children associated with a maize diet." May I firstly enter a protest against the use of a West African native word as the title of an article. How will it be possible for anyone later looking for references to nutritional disorders to recognise one under such a designation The secondary title is equally open to criticism as it would seem that the association with a maize diet is merely incidental. There is a further objection to the name kwashiorkor ; it indicates " the disease the deposed baby gets when the next one is born." That such a sequence of events occurs is a common superstition in other parts of Africa as I first pointed out in 1922 (Harvard African Studies, vol. iii., p. 289). Among the Wa-yao of Central Africa the disease, whatever it may be, is called litango lya kututa-each successive child is said to push (ku-tuta) the previous one into its grave. In Dr. Williams’s previous article (1933) a number of statements were made in regard to the differential diagnosis between this disease and pellagra, which were calculated to give an entirely false impression of pellagra and I felt constrained to draw attention to them the following year (Arch. Dis. Childhood, 1934, ix., 115). Dr. Williams has now again repeated these misstatements in regard to pellagra, presumably based upon a failure to realise the course and symptomatology of that disease, and tends to confuse the problem at issue. To deal with the table of "Differences between Kwashiorkor and Pellagra ":1. The affected skin is " black, rugose, and soft" in K. Elsewhere Dr. Williams So it may be in typical P. states it "tends to peel off, leaving a moist, raw surface." This is often the case in P. and while branny desquamation may take place in P., in other cases large ulcerated areas may result. 2. " Extensor surfaces and points of irritation and pressure affected" in K. This of course is common in P. As I have pointed out elsewhere any form of trauma, in its wide sense, may determine the site of the pellagrous eruption. The distribution of the skin affection in K. is probably what one would expect. 3. " Skin not photosensitive" in K.-photosensitive in P. In P. the skin is not always photosensitive. In the West African children it is not proved whether or not the conditions necessary for the exhibition of photosensitivity were present or not. 4. K. " occurs in children under 5 years"—usually under 2 years. P. " rare in children, almost unknown under 2 years." This is a fallacious statement. Pellagra may