Experiences with resection of the colon and the elimination of colostomy

EXPERIENCES WITH RESECTION OF THE COLON AND THE ELIMINATION OF COLOSTOMY * W. WAYNE BABCOCK, M.D. PHILADELPHIA,PENNSYLVANIA ESECTION of the Iarge intestine may be indicated for specific or nonspecific granuIomatous disease, for uIceration, diverticuIitis, poIyposis, other benign tumors, but especiaIIy for that very prevaIent condition, cancer. In no other interna organ with the exception of the Iarynx is cancer as curabIe by operation, and in onIy one other is it as common as in the coIon. Intrinsic cancer of the Iarynx has a nearIy IOO per cent operabiIity rate, and with an operative mortaIity of about 3 per cent, hardly 15 per cent of the growths recur after Iaryngectomy. Despite many deIays in diagnosis from 60 to 80 per cent of the cancers of the Iarge bowe1 now are operabIe when the patient is hospitaIized. The operative mortaIity for patients who have not reached the stage of compIications such as obstruction, perforation or metastasis has with the experience and the technica improvements of recent years been reduced to about IO per cent or even Iess. After radical resection about 40 per cent of the patients remain free from evidence of recurrence after five years. In contrast, hardIy 20 per cent of patients with carcinoma of the stomach reach the hospital whiIe radicaIIy operabIe, and scarceIy three out of one hundred are Iiving and free from the disease five years after the operation. Grouping the types of cancer of the uterus and adnexa treated by irradiation, operation or both, a 30 per cent surviva1 five years after initia1 treatment is very creditabIe. The better resuIts from hysterectomy for the Iess mahgnant and rarer adenocarcinoma of the corpus uteri are outweighed by reIapses after irradiation or operation for carcinoma of the cervix or ovaries. Nephrectomy for maIignancy of the kidney has an even Lower curabiIity

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* From the SurgicaI Department

rate from the predominance of tumors of the hypernephroma type over the Iess diffusibIe papiIIary cancers of the renaI pelvis. By contrast the patient with earIy cancer of the coIon has a particuIarIy hopefu1 outIook with much more to Iose from deIay in diagnosis or defect in treatment. The treatment of carcinoma of the coIon is the earIy and radica1 remova en masse of the affected segment with 7 cm. or more of norma appearing bowe1 on each side of the tumor; together with the associated mesentery, tributary Iymphatics and if possibIe any other invoIved tissues. The presence of smaI1 metastatic noduIes in the Iiver or of enlarged cancerous gIands aIong the aorta, does not, in my opinion aIways contraindicate the remova of a resectabIe primary tumor. By the remova of the origina growth the patient is IargeIy reIieved of obstructive symptoms, hemorrhage, fou1 discharge, absorption from the sIoughing tumor and invasion of adjacent parts, and usuaIIy shows a marked improvement mentaIIy and physicaIIy. Often he is abIe to resume his work for a year or more, and finaIIy passes out after a reIativeIy painIess decIine. In 252 operations for cancer of the coIon we found metastasis to the Iiver in thirtythree. In tweIve the invasion of the Iiver was far advanced or the primary Iesion irremovabIe. A paIIiative coIostomy was done in six and a simpIe expIoration in six. In the remaining twenty-one patients the primary growth was resected with three deaths (14 per cent mortaIity). A proctosigmoidectomy with perineaI anus was done in thirteen, a MikuIicz-PauI stage resection in six and a resection with end-toend anastomosis in two. Of nineteen paof TempIe University,

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tients surviving the operation most have lived over a year, four over two years, one woman now 75 years oId is. active and comfortabIe after four and one-haIf years. Carcinoma of the Iarge bowe1 may exist for two years or more without metastasis. In our series, symptoms such as coIic, meIena, change in bowe1 habit in the form of diarrhea or constipation, or physica evidence of the growth had existed for from a few months to over five years before the patient sought reIief by operation. The spread of cancer of the coIon is chieffy through the Iymphatics and porta circulation. Our experience confirms the findings of MiIes that the Iymphatic drift from cancer of the bowe1 is upward. We recaI1 no case of Iymphatic invasion cauda1 to the Iesion in the bowe1, nor in our series have we observed gross evidence of invoIvement of the inguinal Iymphatics, even from anorecta1 growths. Metastasis to the skeIeton is much Iess frequent (5 per cent) than to the Iymphatics or Iiver, but may occur earIy. Quite striking is the reIative, sIight tendency toward peritonea1 diffusion as contrasted with carcinoma of the ovaries, stomach and other organs. Even with coIonic growths of Iong duration it is usua1 to find onIy smaI1 peritonea1 noduIes in a radius of but a few centimeters on the peritonea1 Ieaffets adjacent to the tumor. In contrast is the predominant IocaI invasive tendency of the cancer. It tends to uIcerate earIy, to invade the submucosa and muscuIaris to the peritoneum, and Iater to attach to and invade adjacent structures, as the bIadder, smaI1 intestine, vagina, uterus, broad Iigament or abdomina1 waI1. Beginning in the transverse coIon we have seen attachment and IocaI invasion of the pancreas and a simuItaneous perforation and proIiferation in both the stomach and smaI1 intestine. In such cases if there is no cIinica1 evidence of metastasis we have resected the invoIved coIon with the attached invoIved uterus or invoIved portions of vagina1 waI1, bIadder, smaI1 intestine, stomach, pancreas or other removabIe tissue.

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The tendency in many cases for carcinoma of the bowe1 to remain IocaIized for many months shouId stimuIate the surgeon to undertake a very radica1 procedure even though excision has been considered impossibIe at a previous operation, and aIthough a paIIiative coIostomy has been done. FormidabIe adhesions may be found quite benign and infiItrative thickening about ureters and great vessels only inflammatory. I know of few situations of carcinoma in which a previous opinion of inoperabiIity shouId so often be discounted. On the other hand, too frequentJy we find the rareIy mistakabIe i&Itration of cartiIaginous hardness, the “frozen” peIvis, or the soft grayish materia1 of a degenerated carcinoma invading parts that are not surgicaIIy removabIe. The IocaI invasion of the growth has two important cIinica1 appIications. The base of the uIcer is commonIy thin and easiIy perforated by biopsy, or the necrosis produced by radium, fuIguration or eIectric desiccation. We have seen the secondary peritonitis and IocaIized abscess foIIowing a biopsy bIock an attempt at radical extirpation of the carcinomatous bowe1. The maIignant uIcer has such an unmistakabIe cIinica1 picture with its hard, infiItrating, ragged, raised and roIIed borders and centra1, depressed, irreguIar crater that the diagnosis can very positiveIy be made by paIpation alone. NearIy as reIiabIe is the appearance of the growth as seen through a proctoscope. I have never seen a mistake made in diagnosing an uIcerating recta1 carcinoma by palpation aIone, and therefore consider a biopsy both dangerous and unnecessary in this type. ShouId biopsy be used, onIy a portion of raised border above the IeveI of the Aoor of the uIcer shouId be removed. With projecting poIypoid or adenomatous growths a biopsy is reIativeIy safe and is desirabIe, as with benign cIinica1 features histoIogic evidence of maIignancy may be found. Likewise, except to remove smaI1 superficia1 or poIypoid adenomatous growths or to restore temporariIy a Iumen

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through an obstructing irremovabIe fungating cancer, treatment by eIectrica1 destructive or other IocaI measures shouId be strongIy condemned. Local treatment not onIy faiIs to remove invoIved Iymphatics, but histoIogic studies show the faIIacy of attempting to destroy the primary carcinoma without the fuI1 thickness of the bowe1. The treatment may reduce bleeding, deIay or temporariIy overcome intestina1 obstruction and thus give the patient a measure of reIief and much hope of cure. As with irradiation we find these patients after months of dangerous deIay drifting to the surgica1 cIinic for operative reIief. A rather Iong duration of Iife may erroneousIy be ascribed to the treatment. Patients with cancer of the coIon who escape a fata obstruction or perforation not infrequentIy Iive four or five years and some an equaIIy Iong period after metastasis has deveIoped. One of our patients with recta1 cancer who was refused operation because of extensive metastasis in the peIvic bones Iived five years and was quite comfortabIe unti1 the Iast six months of his Iife. A woman now 75 years oId, at the time we resected the coIon, January 6, 1935, had metastatic noduIes in the Iiver, yet she now considers herseIf in good heaIth for her age. As her tumors had doubtIess existed for some time before the operation it is evident that any harmIess treatment used might have been credited with the proIongation of life. Even in young patients, symptoms referabIe to the disease may apparentIy cover severa years, as in the case of a very robust and muscuIar man of 24, who for about three years had as his onIy symptom occasiona transient attacks of severe obstructive intestina1 coIic after excess in eating. FinaIIy after attending three parties and eating three Iunches in one afternoon he deveIoped compIete obstruction and at operation an advanced carcinoma of the colon was found. Irradiation by x-ray or radium has in no case of which I have persona1 knowIedge been curative. Heavy irradiation used before or after operation I consider harmfu1

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and in severa instances it has Ieft patients who otherwise wouId be we11 with distressing vesica1, intestina1 and cutaneous changes and an irradiation neuritis, which usuaIIy torments the patient as Iong as he Iives. A few patients with advanced intestina1 cancer think they have obtained a IittIe soIace from a very miId and reIatively innocuous irradiation. Spinal anesthesia has been used in nearIy a11 our resections of the coIon without mortaIity or serious compIication thanks to our very eficient assistants. AIthough 37 per cent of our patients were between 60 and 7g years of age, serious postoperative puImonary compIications, except from metastatic growths, have been infrequent. The intradura1 injection of 100 mg. of pontocaine mixed with 55 mg. of procaine is favored on account of its proIonged action. As a ruIe this is immediateIy foIIowed by IOO to 250 C.C. of a I per cent epinephrinized procaine soIution, injected IocaIIy. During the operation, if the patient is asthenic, from 500 to 1,000 C.C. of 5 per cent glucose, possibIy foIIowed by 300 C.C.of typed titrated blood, is sIowIy run into a vein. EspeciaIIy for secondary operations upon patients in very poor physica condition evipa1 and gIucose infusion, combined with IocaI anesthesia, have been very satisfactory to the operator and of great comfort to the patient. A sIow intravenous infusion of 5 per cent gIucose is started and continued during the operation. As the patient sIowIy counts, a 2.5 to 5 per cent soIution of evipa1 is injected through the rubber tube cIose to the intravenous needIe, at the rate of about I C.C. every ten or fifteen seconds. When the patient stops counting, the evipa1 is instantIy discontinued, the abdomina1 incision quickIy made and the abdomina1 waI1 and subperitonea1 Iayers freeIy inf’dtrated with a I per cent soIution of procaine containing I minim of epinephrine to each IO C.C. With a pump syringe and a 20 or 22gauge needIe, from 250 to 500 C.C. of the soIution are qui$kIy injected. With this combination IittIe additiona evipa1 may be required and an asthenic patient may doze

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through an operation lasting an hour and a haIf from a tota of onIy .6 or .8 Gm. of evipal. If the injection is made at the ankIe

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and especiaIIy indicate the desirabiIity of a direct approach by an obIique muscIespIitting incision pIaced over the Iesion.

FIG. I. Glass lamp chimney drain, attached by four wire sutures over an intestina1 anastomosis. The drain is not fastened to the skin.

the body shouId be tiIted head downward, as otherwise a dangerous accumuIation of the drug in the Iower extremity may occur before an appreciable effect is noted. If indicated, carefuIIy typed titrated bIood foIIows the gIucose infusion. It is not uncommon to find the patient in better condition at the end than at the beginning of an extensive operation, and in no case during recent years has sufficient shock occurred under either method of anesthesia to prevent the compIetion of a radica1 one-stage operation. Incision. During recent years for resection of the coIon for malignancy or inffammatory disease we have used obIique IateraI incisions of the muscIe-spIitting rectus retracting type aImost excIusiveIy. Exception is made if a scar from a previous operation Iies adjacent to the operative fieId. The excision of such a scar better enabIes the division of postoperative adhesions, the possibIe correction of an incisiona1 weakness or the avoidance of additiona1 compIications in the abdomina1 waI1. Fever, Ieucocytosis, induration of the parietes, tenderness or fixed mass suggest infection, pericoIitis, perforation or abscess

FIG. 2. Sump drain for the continuous evacuation of blood and other fluids that coIIect in the abdomen after an operation and that might Iead to a spreading peritonitis.

Through such an incision infiItrated abdomina1 waI1 may be resected, an abscess may be drained, infected bowe1 deIivered and necrotic tissue cared for with the Ieast possibIe contamination of the genera1 and with the Iowest peritonea1 cavity, percentage of hernias from a drained or contaminated wound. These incisions run paraIIe1 with the fibers of the externa1 obIique muscIe and nerves of the abdomina1 waI1 and even after drainage usuaIIy Ieave a fine Iinear scar. (Fig. 6.) Additiona room, if necessary, is obtained by dividing the anterior and, where present, the posterior sheath of the rectus, and by retracting or dividing the rectus muscIe. The IateraI extension of this type of incision gives good access to the deepIy pIaced ascending or descending coIon and faciIitates the liberation and exteriorization of the bowe1 in a MikuIicz type of resection.

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The aIIoy stee1 wire sutures with which we began to experiment in 1932 have proved of great advantage for cIosure of

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drain the septic gaII-bIadder. The device so nearIy eIiminated the mortaIity from operating for ChoIecystitis that the Iarge

FIG. 3. Sump and Iamp chimney drains with suction tubes guarding the suture Iine after a resection and anastomosis of the spIenic ffexure of the colon. Secondary intestina1 Ieakage occurred in this case but with spontaneous cIosure of the fecal fistda and recovery.

the bowe1 or abdomina1 wound. (Fig. 5.) They do not hoId or transmit infection, do not irritate, rareIy form fistuIous tracts, and therefore do not deIay the heaIing of an infected wound. Either no anesthetic or onIy a IittIe IocaI anesthetic is required for the secondary stages of a graded operation, the bowe1 being without pain fibers. For the right haIf of the coIon a direct anastomosis has in our experience given a Iower mortaIity than the MikuIicz type of operation, for both benign conditions and maIignant tumoks. ConverseIy for the Ieft half of the coIon the MikuIicz operation is considered safer than a one-stage anastomosis with a functiona bowe1. WhiIe the mortaIity from an end-to-end anastomosis in the Ieft coIon and sigmoid may be reduced by the use of “Iamp chimney” and “sump” drains, we yet fee1 that the exteriorization stage type of operation is here safer, as it is in any case in which there is pericoIitis or abscess. The “Iamp chimney” drains came into use in 1935 in our attempts to exteriorize and Iater, after adhesions had formed, to

gIass tubes were then anchored over other infected areas and aIso over insecure intestina1 anastomoses. (Fig. I .) By adding a soft rubber tube carried to the bottom of the drain, ffuid weIIing into the chimney may continuousIy be aspirated (Fig. 3.) The need for the prompt remova of septic Auids, bIood and other cuIture media, as we11as any free peritonea1 Auid which may Iead to a spreading peritonitis, is especiaIIy great after resection of the coIon. From diffIcuIties in obtaining “up hiI1” drainage, more recentIy we had the glassbIower fashion simpIe gIass “sumps” of various sizes and shapes. (Fig. 2.) These consist of an externa1 coIIecting gIass we11 or tube which has muItipIe perforations so smaI1 as to prevent herniation of bowe1 or omentum of the aduIt. The interna aspirating tube may be of gIass or rubber and is attached to a suction device, preferabIy a coIIecting bottIe connected with a motor driven suction pump, aIthough a water spigot aspirator or Wangensteen apparatus may be used. In the hospital machine shop we have had the miniature

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tor and pump assembIed as a stopper wide mouthed coIIecting bottle. (Fi g. 4.) This forms a portabIe singIe unit

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nections. It is obvious that the outer end of the coIIecting tube must remain (3pen for the free entrance of air.

FIG. 4. EIectric motor with suction pump and coIIecting bottle attached to glass sump drain for continuous aspirationof an abdominal wound.-

for nearIy any aspirating service and uses but one tube from the patient. When used for an abdomina1 resection of the coIon the suction drainage shouId be started during the operation and continued during the first twenty-four or forty-eight hours or until there is no furiher coIIection of fluid. It is especiaIIy important to remove bIood so promptIy that cIots do not form and obstruct the tubes. The aspirating tube and any other tubes (catheter, enterostomy tubes) running from the patient or any pressure port on the aspirator should be marked pIainIy or so tagged as to avoid dangerous compIications from wrong con-

Our present operative technique is as foIIows : The diagnosis of Iow-Iying growths is made by the finger and proctoscope, or, for those above the peIvis, by barium enema and Roentgen study. Evacuation and decompression of the bowe1 before operation are obtained by Iaxatives and repeated irrigations carefuIIy supervised. I have produced an acute obstruction by a Iarge dose of castor oi1. For an unreIieved obstruction a cecostomy or appendicostomy is preferred as a preIiminary iIeostomy may Iead to inanition from the heavy Ioss of water and nutriment, not.fuIIy compensabIe by diet,

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transfusions and infusions. We have seen death foIIow the deIayed cIosure of an iIeostomy apparentIy from this cause aIone.

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drain) over the Iine of union, but not to the skin, with four fine aIIoy. wire sutures. This tube is IightIy covered with a gauze dress-

FIG. 5. A, muscle-splitting, rcctus retracting incisions used in resection of the coIon. B, abdomina1 wound cIosure with anneared aIIoy stee1 wire: a, continuous sutures of 38 wire for skin; b, interrupted 35 wire sutures for suhcutaneous fat; c, d, e, interrupted Iayer sutures for aponeurosis, mu&e and peritoneum. The wire is tied in a square knot and the ends cut very short.

During the preparation the genera1 condition of the patient is studied and he is fortified by Auids and a Iow residue high caIoric diet. Selection of Operation. In removing the cecum and ascending coIon usuaIIy a onestage operation with end to end anastomosis is used. This also has given us the best resuIts in iIeitis. Cutting the iIeum obIiqueIy and properIy spacing the sutures compensates for a difference in diameter between the iIeum and coIon. The inner one or two rows of sutures may be of continuous chromic catgut or of silk, but for the outer row we prefer the fine aIIoy stee1 wire (gauge 35 to 38), the ends being cut very cIose to the square knot. Our experiments show that adhesions form even over very fine (ooooo) catgut or silk exposed on the surface of the peritoneum, but not over the aIIoy stee1 wire. As infection or necrosis aIong the suture Iines frequentIy occurs, especiaIIy after anastomoses of the coIon we think it wise to anchor a tubuIar gIass drain (Iamp chimney

ing and through it the united bowe1 is inspected daiIy for change of coIor as we11 as for offensive odor or high bacteria1 content of the fluid exudate upon the bowe1. If the exudate is free from bacteria1 contamination at the end of 48 hours the hoIding sutures are cut and the tube withdrawn. Offensive odor usuaIIy is foIIowed by Ieakage aIong the suture Iine and indicates that the tube shouId be Ieft in pIace for from five to seven days or unti1 adhesions have firmIy waIIed off the area. In severa of our patients these tubes have provided an adequate vent for intestina1 contents when Ieakage has occurred and apparentIy have been Iife-saving. The feca1 fistuIa which then deveIops usuaIIy cIoses spontaneousIy after removal of the gIass tube. No other substance with which our group has experimented, except stainless stee1, produces as Iittle irritation in the peritonea cavity, as does gIass. Buried in a dog’s abdomen a gIass tube remains free from pIastic adhesion or exudate at the end of two weeks, while a rubber tube is then

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encased in dense adhesions, and ukeration through the intestina1 waI1 has started. It is to be remembered that isoIating adhesions form very sIowIy about gIass drains, a very desirabIe feature when proIonged drainage of the genera1 abdomina1 cavity is necessary. The tubuIar gIass drain over the sutured bowe1 may fai1 to function when Ieakage occurs on the mesenteric surface or that opposite to the tube. If this is feared a curved suction drain shouId aIso be introduced to protect this area. Such a conceaIed Ieak may be suspected when the bowe1 and attached tube become eIevated in the wound evidentIy from pressure from beneath the bowe1; or by the pain, tympany, nausea, rising puIse and temperature, and the evidence of free gas and Iiquid in the abdomina1 cavity. The treatment is the prompt reopening of the wound and the exteriorization of the bowe1 ends to prevent further intraabdomina1 Ieakage. In many cases a proxima1 enterostomy aIs is desirabIe to reheve the associated inff ammatory iieus, and suction (sump drains) shouId be introduced through the wound, and if there is turbid or odorous fluids, aIso to dependent portions of the abdomina1 cavity. A side-to-side anastomosis is preferred by many operators for iIeocoIostomy as it convenientIy enabIes the formation of a Iarge stoma. The end of coIon and iIeum projecting proxima1 to the anastomosis should not exceed 5 cm. in Iength and should be secureIy inverted and we11 vascuIarized, as there is a tendency fsr the bIind ends, especiaIIy that of the ileum, to become distended and to Ieak or cause coIic. For severa years we have not used a side-to-side anastomosis. Resections in the transverse coIon are compIicated by the attached gastrocoIic omentum and great omentum and by the Iack of bIood suppIy when the transverse coIic artery is divided. In an obese person particuIarIy, it may be diffIcuIt to free the coIon from its fatty encasement without interrupting the circuIation. In such a patient a MikuIicz opera-

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tion may not be very practica1 even at the ffexures and we have observed that aIong the bulky foIds of retained fatty omentum,

FIG. 6. Scar from obIique muscle-splitting incision used for one-stage abdominoperinea1 resection of proctosigmoid with perinea1 anus.

infection may be carried from the open wound into the peritonea1 cavity with resuIting fataIity. As a ruIe resection of the transverse coIon except at the Aexures shouId be compIete. In the obese patient aIso an end-to-end anastomosis in the transverse coIon is particuIarIy subject to necrosis and leakage. Anastomotic resections of the descending coIon and sigmoid have a greater incidence of infection and Ieakage than those of the right coIon, and therefore a higher mortaIity unIess the feca1 current has previousIy been diverted. As a resuIt and aIso because the area is beyond the Iiquid absorbing part of the coIon it is here that the MikuIicz-PauI type of operation is especiaIIy indicated. For coIonic maIignancy the operation has been criticized and discarded as insufhcientIy radica1. We have modified the technique so that a radica1 operation may be done and the convaIescence shortened, as foIIows: (I) The cancerous bowe1, mesentery and other attached invaded tissues are Iiberated wide of the growth and exteriorized en masse. The wide remova of

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maIignant tissue, an essential part of the operation, is much more important than the peritoneaIization of denuded surfaces or the formation of a Iong spur for Iater division. (2) If the arms of the Iiberated Ioop of coIon can be apposed without tension, they may be sewed together aIong anti-tnesenteric borders. UsuaIIy the sutures cause tension and may tear out or perforate the bowe1 and I omit them. (3) A narrow sump drain is introduced to be left in for twenty-four to forty-eight hours to keep the cavity free from bIood and serum. (4) the wound is cIosed onIy with Iayer interrupted aIIoy stee1 wire sutures and Iigatures to minimize infection. With a protective dressing in pIace the exteriorized mass is immediateIy cut away between cIamps. (5) A right-angIed gIass tube with we11 rounded Iower border, and attached Penrose rubber drain is then tied in each bowe1 end--above the skin level. (6) These gIass tube vents are removed when Ieakage from necrosis occurs, usuaIIy from the fourth to the sixth day, and wet dressings of a 1 to 500 permanganate of potassium soIution are appIied and frequentIy changed to deodorize discharges. (7) After seven to ten days the necrotic bowe1 ends are trimmed, and gentIy Iiberated from the skin and subcutaneous fascia for suture. Where the arms of the Ioop of the bowe1 have been heId in apposition by the cIosure of the wound a short spur has formed. This spur is divided a centimeter at a time, the edges being united with a foIIow-up suture of interrupted 35 or 36 aIIoy wire in a fine curved needIe. By traction on the Iast two sutures introduced, the spur is eIevated and stretched, faciIitating further incision and the introduction of additiona sutures. Care is taken not to open the peritonea1 cavity. FinaIIy, the bowe1 ends are united as far as is feasibIe with inverting wire sutures. The skin and fascia are Ieft open, separated and eIevated from the sutured bowe1 by a Iight gauze packing and the wet permanganate dressing continued. The steps of the MikuIicz operation have thus been modified from such unfortunate

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experiences of myseIf or coIIeagues as: death from Ieaving an obstructive coIostomy cIamp on the bowe1 for two or more days; ischemic perforation and death from appIying a spur cIamp over the mesenteric border of the bowe1 or from using a devascuIarized Ioop; death from pressure perforation due to an indweIIing coIostomy tube and fata spreading pyoderma of the abdomina1 waI1 from faiIure adequateIy to drain the subcutaneous fat after a MikuIicz operation. In the method just described, as the spur is divided under vision and the edges united by sutures, there is Iess danger of perforation and Ieakage and much Iess necrosis than when the crushing cIamp is used. The suture method is nearIy painIess and reIieves the patient of the days of distress and sIoughing accompanying the use of the clamp. From the short Ioop used the union obtained is often more of an end-to-end anastomosis than the side-to-side junction of the Mikulicz procedure. OccasionaIIy with the wire sutures we have had the bowe1 cIosed and the patient ambuIant by the tweIfth day after operation, but usuaIIy severa steps are required. Colostomy. As nearIy a11 patients object to an abdomina1 coIostomy, I have given much attention to the preservation of a perinea1 opening. With resection of the coIon above the midsigmoid this is not diffIcuIt, and with invoIvement of the Iower sigmoid and even the rectosigmoid junction by carefuIIy Iiberating the peIvic coIon to the ffoor of the peIvis, it is at times possibIe by traction to deIiver the upper rectum through a Iower Ieft inguina1 incision with suficient room beIow the growth to appIy a cIamp cIose to the skin and remove the invoIved segment. An angIed gIass tube is at once tied in the proxima1 end of the sigmoid and the cancerous Ioop with attached mesentery excised. ShouId the cancer invoIve much of the rectum, or the patient have a thick abdomina1 waI1, an adequate excision by this method may be impossibIe, in which case the deIivery and remova of the Iiberated rectosigmoid through the perineum is the preferred

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operation. In a woman of 77 with very friabIe tissues, the rectum beIow the It was cIeansed by carcinoma parted. passing antiseptic gauze through to the anus from above and a Iarge cyIindrica1 gIass drain anchored over the open end of the rectum with four aIIoy wire sutures. The proxima1 rectosigmoid was excised, with formation of a coIostomy. An uncompIicated recovery foIIowed. It is we11 recognized that resection of the obstructed coIon has a high mortaIity unless the bowe1 is fn-st decompressed by a coIostomy, iIeostomy or appendicostomy two or more weeks before the major operation. The appendix may be used provided it has a sufficient Iumen and the obstruction has not reached a critica stage. It is deIivered through a short muscIe-spIitting incision which is closed about the appendix without constricting or dividing the mesoappendix. The tip of the appendix is then amputated and a smaI1 soft rubber catheter threaded into the cecum which is graduaIIy decompressed by repeated gentIe irrigations, first with warm saIine and Iater with a 5 per cent soIution of peroxide of hydrogen. By daiIy withdrawing the catheter and substituting a we11 Iubricated one of Iarger size, we have been abIe to insert a 27’~. recta1 catheter through the appendix at the end of a week. In many middIe aged or eIderIy patients, however, the appendix is too atrophic to be used and a portion of the distended cecum or Iower iIeum is withdrawn through the muscIe-spIitting incision, a segment isolated and emptied with the aid of a non-traumatizing, curved rubber covered cIamp. Two concentric purse-string sutures of fine siIk are then introduced in the waI1 of the bowe1, within which under the protection of surrounding pads, a puncture is made, and a 14 F. soft rubber catheter introduced and tied in. In cIosing the wound about the catheter it is best to use onIy aIIoy stee1 wire sutures and Iigatures. The ends of the outer purse-string suture are brought outside the wound and tied around the catheter, after having aIso been

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used to anchor the bowe1 to the overIying edge of peritoneum. Under repeated and proIonged irrigation after the patient has been pIaced in a comfortabIe position in bed, the smaI1 catheter wiI1 usuaIIy be found adequate for the decompression of the obstructed bowe1. If the free peritoneal Auid is turbid or shows evidence of bacteria1 contamination, a Iong narrow sump drain shouId be introduced through the wound to the bottom of the peIvis and suction evacuation continued as Iong as liquid comes away. This simpIe enterostomy with a smaI1 catheter having severa openings is preferred because the introduction of a mushroom catheter is more difTicuIt, necessitates a Iarger opening, and there is risk of greater contamination in the wound. From a Iarger and therefore stiffer rubber catheter we have seen fata perforation of the bowe1 due to pressure of the tip of the catheter. In our experience the mortaIity of a forma1 coIostomy with exteriorized Ioop for iIeus from cancer of the coIon is about 15 per cent or over. Where there has been a heavy impaction of soIid feces above the obstructing carcinoma whiIe a simpIe enterostomy and persistent irrigation wiI1 reIieve the acute and dangerous symptoms, ffushing from any singIe opening may be inadequate to Iiquefy and evacuate the nearIy soIid mass. Even with a through and through flushing aIternateIy, discharging first from the rectum and then the proxima1 enterostomy, hours of effort perhaps repeated over severa days and the use of many gaIIons of water may be required before the coIon is emptied. Devine” uses the proxima1 or the dista1 part of the transverse coIon for the coIostomy, unites the intra-abdomina1 arms of the Ioop with sutures and brings the ends of the divided coIon through the recti and overIying skin by stab wounds pIaced 4 cm. apart. A month Iater the cancerous segment is excised. Realizing that it is not * Sir Hugh Devine, Operation on a defunctioned ta1 colon. Surgery, 3: 165, 1938.

dis-

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possible to sterilize the malignant area, he advocates one year’s deIay before uniting the resected boweI. FinaIIy, the coIostomy openings are enabled to cIose by introducing a bIade of a specia1 crushing cIamp through each of the openings which creates a by-pass between the arms of the loop. The special advantages of the Devine procedure are the smaI1 and we11 separated coIostomy. openings which are distant from the operative field and are in some measure controfIed by the pressure of thesurrounding rectus muscIes, the avoidance of a permanent colostomy and especiaIIy the empty, functionIess bowe1 during the operative period. Objections to the method are the difficuIties in forming the provisiona colostomy in an obese patient, the four different operations required, and the fact that fifteen or more months are required for the compIetion of the various steps. Previous operators who have used a coIostomy as a preIiminary stage to the remova of the growth whiIe they may have separated the openings and empIoyed cIeansing irrigations have, especiaIIy where the pelvic colon was involved, usuaIIy made the coIostomy a permanent one. In any such muI&stage procedure it shouId not be forgotten that each stage has its mortaIity and when the deaths from the separate operations are added, as they shouId be, the aggregate mortaIity is often higher than that from a singIe stage operation. The sterilization of a sIoughing carcinoma of the bowel by irrigation of course is not to be expected. Due to the prevaIence of cancer in the sigmoid and peIvic coIon this part is resected more frequently than any other portion of the intestine. The rectum, anus and Iower sigmoid may be removed through the perineum, but the procedure has severa objections. It wiI1 fai1, unIess combined with an abdomina1 operation, to remove invaded Iymphatics about the brim of the peIvis or disclose other serious conditions in the abdomen, whiIe in any extensive perinea1 liberation the bIood supply of the portion of the boweI brought down usuaIIy

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is so interfered with that necrosis and the fina formation of a narrow cicatricia1 and incontinent perineaI opening resuIts. The perinea1 operation has therefore faIlen into disfavor, and IargeIy has been repIaced by a combined abdominoperinea1 procedure with the formation of an abdominaI coIostomy. NevertheIess, I believe that the perinea1 operation shouId be selected for anorectal and rectal growths in patients whose genera1 condition indicates either a short expectancy of Iife or that the abdominal operation wouId be unduIy hazardous, such as from marked obesity, advanced age or serious organic disease. The perineal operation aIso seems permissibIe when the growth is smaI1, accessibIe and of the more superficia1 or Iess maIign type. In the remova of the carcinomatous bowe1 through the perineum, whiIe the posterior vagina1 waII has frequently been resected, during recent years we have not removed parts of the sacrum or rareIy even the coccyx. The mortality is Iower than that of any other resection of the Iarge bowe1, and with routine irrigations and perhaps the insertion of dilators, many of these patients Iive in reIative comfort, aIthough, as wouId be expected, the percentage of recurrences is greater than after the more radical abdominoperineal resection. As for the abdominoperinea1 proctosigmoidectomy which is the preferred procedure for cancer of the Iower sigmoid and pelvic coIon, I believe that a singIe stage operation with perinea1 anus may be as rad;caI, more aseptic, rather easier of execution and better for the patient than the conventiona muItiple or singIe stage procedures with the formation of a permanent abdominal colostomy. In generaI, surgica1 opinion contends that an operation without coIostomy is Less radical. However, in the operation we use, the Iigations are pIaced as high, the section of bowe1, mesentery and peritoneum removed is as great, and an associated panhysterectomy, or resection of the vagina, vesicIes, prostate or peIvic floor is as feasibIe as with any

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other operation. Moreover that the colostomy may not have been essentia1 for a radicaI excision at the origina operation is indicated by our abiIity to transfer such an opening from the abdomina1 waI1 to the perineum at a Iatter time. The single stage operation with perinea1 outIet is done without crushing, dividing or opening the bowe1 unti1 after the wounds have been sutured and dressings in pIace and therefore, shouId be more aseptic than one performed with an abdomina1 coIostomy. In either case in the Iiberation of the cancer an inadvertent opening of friabIe bowe1 or an invasion of a septic focus may occur. That the patient prefers the perinea1 opening even without sphincter contro1 is the testimony of those we have operated upon, as we11 as those who have had an abdomina1 coIostomy transferred to the perineum. From about I IO such operations we have Iearned that a perinea1 sigmoidostomy has a convenience, an infrequent soiIing and discharge of gas, and an expuIsive power from the abdominal muscIes unequaIed by an abdomina1 coIostomy. With reguIated emptying of the coIon, over one-haIf of the patients with the perinea1 opening can dispense with a protective pad and 85 per cent have infrequent soiling. With a few modifications the technique we now use foIIows the pIan described in Ig32.* A muscIe-spIitting, rectus retracting incision paraIIe1 with and about 3 cm. above the Ieft inguina1 Iigament is preferred. A hand is introduced through the incision and the abdomen expIored from the liver and periaortic gIands to the peIvic floor. The peritonea1 Ieaffets of the sigmoid and rectum are divided wide of the growth, the ureters identified by their trombone movements and the Ieft superior hemorrhoida and inferior mesenteric arteries doubIy Iigated and divided near their points of origin. The peritonea1 incision is continued around the brim of the peIvis *Babcock, W. W. The operative treatment of carcinoma of the rectosigmoid with methods for the eIimination of colostomy. Surg., Gynec. CY Obst., 55: 627, 632. 1932.

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and back of the bladder or cervix and the bowe1, Iymphatics and fat are separated by the hand from the sacrum and IateraI peIvic waIIs to the peIvic floor. The middIe and inferior hemorrhoida vesseIs are divided we11 IateraI to the bowe1. The uterus and adnexa are freed with the bowe1 if invaded. If the vagina, prostate or vesicIes are adherent to the growth, their separation is Ieft for the perinea1 stage. At a point we11 above any evidence of maIignancy, the mesosigmoid is divided to the bowel. If at this IeveI the sigmoid is stiI1 viabIe as shown by puIsating or continuousIy bIeeding vesseIs, a foIded gauze tape I meter Iong is tied about the bowe1 and the ends packed against the floor of the peIvis. If the sigmoid is ischemic, the tape, which indicates the IeveI for the artificia1 anus, is tied about the Iowest segment of puIsating bowe1. Up to this time a11 effort has been devoted to the compIete remova of maIignant tissue. The next important step is to Iiberate 12 cm. (5 inches) of viabIe sigmoid or descending coIon to reach from the posterior border of the peIvis to the perinea1 skin. To obtain this it may be necessary to divide the IateraI pkritonea1 Ieaffet of the descending coIon and other restraining bands. The Iiberated bowe1 is pIaced in the peIvis, the omentum puIIed over the smaI1 intestine and the incision is cIosed in Iayers with interrupted 32 and 30 stee1 wire for the deep Iayers and interrupted continuous 35 and 38 wire for the skin. A sump drain is used onIy when there is contamination or unusua1 oozing. The rectum which had been irrigated and, just before beginning the operation, IightIy packed with gauze wet with 3% per cent tincture of iodine or tincture of mercuric chIoride is now occIuded by a purse-string suture about the anus. Through an incision from the posterior border of the anus aIong the right side of the coccyx, the peIvis is entered and with the wound we11 retracted, the tape and attached Iiberated bowe1 and adnexa are withdrawn, taking care not to make

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traction upon the friabIe cancerous mass. A perforated curved gIass tube drain with smaI1 perforations is inse’rted aIong the

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the anaI ring posteriorIy and then to pIace the sigmoid in the mucous-Iined ana groove. For fear of perforation the sigmoid

FIG. 7. One-stage abdominoperineaI proctosigmoidectomy with perinea1 anus. A, the diseased loop of bowe1 has been liberated from above, then delivered through a median post-anal incision and removed. B, the perineum, peIvic Aoor and rectosigmoid have been removed after I&ration from below. c, for an invading anterior proctosigmoid cancer the pelvic coIon and infiltrated portion of the prostate have been deIivered through an anterior perineal incision and removed. The sigmoid has been brought through the remaining anus which has been spIit anteriorIy to reIieve tension. D, the peIvic coIon and sigmoid have been delivered and removed as in A, but the rectum has been amputated just above the sphincters, and the withdrawn sigmoid Iaid in the gutter formed by splitting the anus posteriorly. A gIass peIvic drain is in place. a, anus; b, rectum; c, perforated glass drain; d, sigmoid; e, anterior perineal incision for anterior inhhrating cancers of the rectum;J, defect from excising pelvic Aoor by a wide eIIiptica1 incision; b, posterior split anus; i, recta1 tube tied in sigmoid; j, posterior perforated glass tube drain extending aIong sacra1 curve.

hoIIow of the sacrum, dressings are appIied and the bowe1 then cut away. A recta1 tube is tied in the sigmoid end; a short gIass tube with attached Penrose drain in the recta1 end. The purse-string suture is then removed from the anus. The gIass drain is withdrawn after twenty-four to forty-eight hours. On the seventh to tenth postoperative day the partitions between the sigmoid, rectum and anus are divided and the edges sutured, converting the three openings into one. A desirabIe variation at the concIusion of the operation is to divide the asepticized rectum just above the sphincters and aIso

is not sutured to the skin or anus. Several patients have been out of bed by the tenth and have Ieft the hospita1 by the fourteenth day after the operation. We aIso have used this operation for diverticuIitis where the sphincters have been damaged. If the carcinoma has penetrated the anterior recta1 waI1, an anterior perinea1 incision curving forward between the ischia1 tuberosities may be used, and the rectosigmoid deIivered with any resected attached portions of vagina or of prostate or vesicIes. (Fig. 7.) In this case the sigmoid is divided by cautery between cIamps and puIIed through the diIated and anterior

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divided anaI ring. If the perinea1 floor is invoIved the invaded portion is freeIy excised and removed with the attached

FIG. 8. Transfer Iiberated and bowel with a placed against

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an abdomina1 incision. This proved to be a satisfactory and not diffIcuIt procedure. The perinea1 opening enabIes the earIy

of abdominaI colostomy to perineum. a cap of gauze and rubber has been foIded gauze tape. B, the liberated the floor of the peIvis for withdrawa

proctosigmoid. A retention catheter is inserted in the bIadder before and not removed for severa days after the operation. I have Iost two patients from a hemorrhagic and necrotic cystitis foIIowing postoperative over-distention of the bIadder. In a11 cases posterior dependent drainage with curved perforated gIass tubes carried through the perineum aIong the hoIIow of the sacrum shouId be used. Adequate drainage is the best prophyIactic against spreading peritonitis in these cases. At first from using gIass drainage tubes with an open end we had three patients in whom Ioops of smaI1 intestine entered and stranguIated in the tube, with necrosis and secondary fistuIa in the perineum. The erosive discharge from these fistuIas makes them very dangerous, as Iarge bIood vesseIs in the peIvis may be opened with fata hemorrhage, as occurred in one case. Our experience has indicated that attempts to cIose such an intestinal opening through the perineum made matters worse and we wouId advise that the perforated Ioop be promptIy Iiberated and cIosed through

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has been tied over the end of the bowel and traction tape through the perineum.

detection of a peIvic recurrence by paIpation. In six patients a recurrent noduIe was thus detected and excised at a reIativeIy earIy stage. Three of these patients are now Iiving without paIpabIe recurrence, from two to over four years after the Iast operation. Without the diagnostic advantage of the perinea1 opkning, such recurrences may reach an inoperabIe stage before recognition. As with an abdomina1 coIostomy, the comfort of the patient with the perinea1 opening depends IargeIy upon determining and utilizing the storage function of the coIon. If the patient reguIarIy empties the coIon just before its capacity has been reached, he wiI1 as a ruIe then have freedom from evacuation for from twenty-four to seventy-two hours, apparentIy much Ionger than with a coIostomy. Most patients obtain the best resuIts from a physioIogic saIine or tap water enema taken in the morning or evening every twenty-four to seventy-two hours. For the seventy-two hour scheduIe a Iow residue diet the day after the enema foIIowed by a fuI1 diet the

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day preceding the enema often works weI1. About 20 per cent of patients prefer a smaI1 dose of a quickIy acting saIine such as one or two teaspoonfuIs of sodium suIfate taken in a IittIe coId water immediateIy on arising. Soon after breakfast, which incIudes a cup of hot coffee, the coIon empties, after which constipation foIIows for the two or three days it is found feasibIe to wait before repeating the Iaxative. MineraI oi1 or Iaxatives of deIayed or proIonged action shouId not be used. The perinea1 orifice shouId be of adequate size. A narrow or strictured outIet prevents the rapid and compIete emptying of the coIon, and consequentIy smaI1, frequent and annoying discharges from overflow resuIt. This shouId be overcome by diIatation, the patient daiIy inserting test tubes or other dilators. Protrusion of the mucosa of the sigmoid may cause an unpIeasant IocaI moistness, easiIy corrected without anesthesia by Iinear gaIvanocauterization or the injection of a few minims of a 5 per cent soIution of quinine and urethane. A perinea1 hernia apparentIy is Iess common than the hernia often seen about an abdomina coIostomy. In two cases, however, we have operated for such a perinea1 protrusion. IIeus is an important postoperative compIication of resections of the proctosigmoid. Where a peIvic diaphragm has been formed the smaI1 intestine may herniate between the stitches or by tension the mobihzed peritoneum may so anguIate the termina1 iIeum as to cause obstruction. In either case the abdomen shouId be opened and the obstructed Ioop reIeased. In the one-stage operation we have described, no peIvic diaphragm is formed and a Ioop of smaI1 intestine may adhere in the denuded peIvis and anguIate. Like the ileus which occurs in the immediate postoperative period after operations for inflammatory conditions of the abdomen or peIvis or for Iarge hernias we consider the best treatment to be a simpIe iieostomy. The most distended coi1 is IocaIized by physica signs (distention and tympany)

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exposed by a short muscIe-spIitting incision and a No. 14 catheter with severa perforations, tied in the Ioop. When the tension is reIeased the obstruction usuaIIy disappears. If, on the other hand, the abdomen is freeIy opened and expIored with separation of recent adhesions, these commonIy soon readhere with return of the obstruction. Recent adhesions as a ruIe are too soft to produce necrosis of the stranguIated Ioop. Quite different are the dense, we11 organized fibrous cords or bands, which produce an acute obstruction months or years after the abdominal operation which Ied to their deveIopment. The obstruction then often foIIows overeating or the use of Iaxatives and the great danger is from pressure necrosis, perforation and peritonitis. Very recentIy a man, five years after a one-stage abdominoperinea1 proctosigmoidectomy with perinea1 anus, deveIoped obstructive symptoms the night after heavy eating at a picnic. Three days Iater an emergency iIeostomy was done and after an additiona thirty-six hours, as this had not given relief, the abdomen was expIored. Necrotic bowe1 which ruptured on deIivery was found under a rigid fibrous cord in the peIvis. Such an experience is not very usua1, and I wouId formuIate a ruIe that an earIy postoperative iIeus usuaIIy is best treated by a prompt enterostomy without separation of adhesions, whiIe a Iate postoperative iIeus indicates an immediate expIoration and remova of the cause. Elimination of the Abdominal Colostomy. An abdomina1 coIostomy was transpIanted to the perineum in seven patients. In four the coIostomy had been a part of an abdominoperinea1 proctosigmoidectomy for cancer, in one patient eIeven years, in another four years before. In the third patient the cancer had perforated the vagina and invaded the uterus and we had combined a panhysterectomy and resection of much of the vagina with an abdominoperinea1 proctosigmoidectomy and coIostomy, seven months before. The

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fourth patient had an en masse resection of uterus, appendages, upper vagina, rectosigmoid and 4 or 5 cm. of one ureter eIeven

FIG. 9. Cancer of the rectoslgmoid and attached double-barretIed coIostomy of the sigmoid withdrawn in one stage through a post-anal incision after closing the abdominal wound. A, cancer. B, coIostomy openings covered with gauze and rubber dam. c, traction tape fastened to B. The bowe1 was adherent and two previous attempts at remova through the abdomen had been abandoned. The patient strongly objected to the abdominal colostomy.

months before the transpIantation. The fifth patient had vertica1 very adherent abdomina1 scars from two previous attempts to remove a cancerous rectosigmoid. On account of adhesions the growth had been considered irremovabIe and a doubIebarreIIed sigmoid coIostomy was done. Without disconnecting the openings in the sigmoid, adhesions were divided and the recta-sigmoid and coIostomy Iiberated from above and then deIivered through the perineum with the formation of a perinea1 anus. (Fig. 9.) AI1 five patients had satis-

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factory recoveries. The advantages of the perinea1 opening were very evident, such as abihty to go without a pad or other pro-

FIG. IO. Hernia and intestinal prolapse from coIostomy eIeven years after MiIes operation for carcinoma of the rectosigmoid. The redundant bowe1 and scar were excised, the hernia repaired, and perinea1 anus formed.

tection, evacuations occurring every two to four days instead of severa times daiIy, convenience for irrigation, diminished Aatus, and more effective expuIsive action of the abdomina1 muscIes. The remaining two patients were cachectic men. One, aged 60 had been treated for over a year by injections. A sigmoid coIostomy for an obstructing anorecta1 carcinoma was done twenty-four days before an abdominoperinea1 resection with transpIantation of the coIostomy to the perineum. Despite preoperative evacuant measures the coIon contained much impacted feca1 materia1. The advanced adherent carcinoma ruptured in deIivery. The patient died of a postoperative peritonitis. The seventh patient, aged 70, had a recto-

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sigmoid carcinoma. On account of his great debiIity a two-stage operation was tried, a doubIe-barreIIed sigmoid coIostomy being done at the first stage, and a proctosigmoidectomy with deIivery of the bowe1 and of the coIostomy through the perineum at the second stage fifteen days Iater. The patient died Iater from a necrotic metastatic carcinoma of the lung. These experiences have confirmed our impression that it is easier and safer to do a proctosigmoidectomy in one instead of severa stages, that any preIiminary coIostomy shouId not be in the fieId of the radica1 operation, and that whiIe a permanent paIIiative coIostomy for cancer of the rectosigmoid may properIy be pIaced in the sigmoid, a temporary coIostomy for intestina1 obstruction shouId be in the cecum or proximal coIon. It aIso was evident that it is safer to reoperate in the fieId of an oId rather than a recent coIostomy. With chronic obstruction in the termina1 bowe1 a buIky feca1 impaction may extend back to the cecum and be very difScuIt to remove by retrograde irrigation through a sigmoidostomy. In transferring a coIostomy to the perineum, if there is a doubIebarreIIed opening, it is usuaIIy better to isoIate and Iigate the ends of the bowe1 as one, covering the openings with a singIe protection of gauze and rubber drain, secureIy Iigated in pIace rather than to divide the bowe1. Technique of Transferring an Abdominal Colostomy to the Perineum. The coIostomy opening is pIugged with antiseptic gauze and cIosed with sutures, and when Iiberated, the end of the bowe1 is covered by a cap of gauze and rubber dam secureIy tied on with a Iong tape. (Fig. 8.) The sigmoid segment and if necessary the descending coIon are then suffIcientIy mobiIized from peritonea1 and other attachments to sIide at Ieast 12 cm. (5 inches) below the posterior peIvic brim. The soft tissues in the midIine cIose to the sacrum are divided and then tunneIed to the peIvic floor unti1 a channe1 is formed through which the sigmoid may easiIy be drawn. The tape is packed in this tunne1, the end of sigmoid

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Iaid over the opening and abdomina1 wound cIosed. With care not to injure the urethra or bIadder the perineal scar is opened from beIow and the tape and attached sigmoid puIIed through. A gIass tube drain is introduced at the side of the coccyx or through the incision back of the sigmoid. A recta1 tube is fastened in the sigmoid to prevent soiIing during the first few days after the operation. The gIass drain is usuaIIy removed in from twentyfour to forty-eight hours. Operability and Mortality. UnfortunateIy, universa1 standards have not been adopted as to the operabiIity of persons having cancer of Iarge intestine. PersonaIIy I have attempted a radica1 operation in any case in which it offered a chance of proIonging the patient’s Iife or rendering it more comfortabIe even though it couId not be curative. Thus of about 265 patients seen during more recent years, operation was done in 252, which incIuded remova of the cancerous segment in 212, an operabiIity rate of 84 per cent, if we incIude patients not curabIe but reIievabIe. In about 40 per cent of the patients symptoms indicative of cancer had been present over one year and in 21 per cent from two to even five years before the operation. At the time of operation 37 per cent of the patients were over 6o years of age, and I I per cent between 70 and 7g years. As has been indicated, metastases were not uncommon in those considered to be radicaIIy operabIe. With such an exorabIy distressing and fata disease as cancer the patient has IittIe to Iose, except pain, if given the benefit of every surgica1 doubt. An enIarged Iymph node in the fieId of the cancer is frequentIy found free from maIignancy in the Iaboratory. OccasionaIIy ominous physica signs, as fixation, the intense anemia of a ceca1 cancer, or a report from previous operation that the growth was adherent and irremovable, wiI1 be found due to a benign cause or to a maIignancy that can be extirpated. MortaIity and our concepts of operabiIity are cIoseIy reIated. Of the 252 patients forty-six, or 18 per cent, died after

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operation whiIe in the hospita1. The highest mortaIity occurred in cases with perforation and resuhing peritonitis, abscess or fistula: fifteen cases with nine deaths (60 per cent). Next was the mortaIity from direct anastomosis, nine deaths in twentysix cases, almost entireIy from resections of the functiona Ieft coIon. WhiIe the mortaIity has been reduced by the recent use of better drainage, and whiIe the operation is beIieved to be safer than a MikuIicz resection for the right coIon, it has now been IargeIy abandoned for the Ieft side of the coIon unIess the feca1 current has previousIy been diverted. CoIostomy-an operation under other circumstances of very Iow mortaIity-had a mortality of 30 per cent in the twentythree advanced cases in which it was used as a paIIiative measure. The operation renders these patients disgusting to themseIves and to their friends, who do not care to take, them from the hospita1 and often Ieave them unti1 they succumb to the

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progress of the disease. Our present tendency is to do very few so-caIIed paIIiative coIostomies. In the face of obstruction we depend upon a Iow residue diet, irrigations, and duodena1 suction. For the patient whose advanced disease Ieaves him but few remaining days we think it better to Iet him die obstructed than to inflict the nuisance of a coIostomy upon him and his attendants. The operative mortaIity is much reduced if we eliminate those shown by autopsy or otherwise to have been hopeIessIy diseased by metastasis or those that we have Iearned by experience were inadequateIy drained at the time of operation. Then the mortaIity in our series from abdominoperinea1 proctosigmoidectomy with perinea1 anus drops from 20 per cent to under 6 per cent, from perineal proctectomy from I I per cent to under 4 per cent, and from the MikuIicz-PauI operation, from 15 per cent to about 5 per cent.