1390 THE LANCET,]

Klinische Wochenschrift, 1910. 12. British Journal of Dermatology.13. THE LANCET, June 24th. 1911, p. 1691. 14. Ibid., Sept. 25th, 1911.15. British Journal of Dermatology, Jan. llth, Dr. J. H. Sequeira.16. Cabot. 17. Brit. Med. Jour., Dec. 3rd, 1910. 18. British Journalof Dermatology, November-December, 1908. 19. King’s College Hos-pital Reports, 1898, vol. v.

Clinical LectureON

COLOTOMYAND

SOME MISCONCEPTIONS OF ITS RESULTS.Delivered at Charing Cross Hospital

BY PETER DANIEL, F.R.C.S. ENG.,SURGEON TO METROPOLITAN HOSPITAL AND TO GORDON HOSPITAL FORRECTAL DISEASES; ASSISTANT SURGEON TO CHARING CROSS HOSPITAL.

GENTLEMEN,—There are few operative measures that

engender in the mind of patients, nurses, and practitioners somuch dislike as colotomy. The reason for this is notdifficult to understand; yet this is eminently a life-savingand pain-saving procedure, and its evil repute is, I am quiteconvinced, not justified. I would go further and say thatthe discomforts and disadvantages of colotomy are undulymagnified. Indeed, evils which are in no way due to theartificial anus but depend upon other factors are laid to itsaccount, and it is the sifting of these quite extraneous evilsfrom those inherent to the colotomy itself, and the placingof them where they rightly belong, which is my purposeto-day.

I do this because I know that the fear or dislike ofcolotomy leads to a great deal of unnecessarily prolongedsuffering, and even to painful and torturing deaths, for noone can deny the agony of a death by intestinal obstruction.I would say, boldly and without hesitation, that many of thedefects or disadvantages attributed to colotomy are so

attributed from erroneous conceptions of their origin, andfrom ignorance of the nature of the function of the sigmoidand rectum.Even such an apparently old subject as the anatomy of the

sigmoid and rectum, as taught even now in quite "up-to-date " books, is wrong, in view of recent research by modernmethods and advantages-I mean the gross anatomy ; whilethe character of the vermicular action of the large bowelhas hitherto been quite misunderstood, and upon this mis-conception I must strongly insist, because the normal

expulsive movements of the large bowel are so exceedinglysluggish that they could not possibly give rise to diarrhoeaeven in the absence of a sphincter : diarrhoea means

abnormal stimulation of the peristalsis, and not loss of

sphincter control.SUPPOSED DISABILITIES ARISING FROM THE OPERATION.Let us first see what the supposed disabilities consequent

on colotomy are:1. Loss of the sense of desire to defalcate—i.e., warning.2. Excessive number of actions-i.e., diarrhoea.3. Loss of control over defaecation.4. Excoriation of the skin.5. The wearing of an apparatus.6. The presence of an artificial anus on the abdomen.The latter two are inevitable, but in practice they are

really the minor of the evils, and if the former disabilitiesare reduced to a minimum the wearing of an apparatus is asmall penalty to pay for relief from pain and the peacefulprolongation of a life-a life which may be valuable anduseful.To come to actual facts, therefore, we find that it is the

inability to know when the bowel is going to act and howoften it is going to act per diem which are the two greatpractical factors, because the amount of skin excoriation islargely dependent upon these conditions.

SENSE OF WARNIIVG.Now everyone attributes the loss of warning to the fact

that in colotomy the bowel is opened above the sphinctersani. This is entirely erroneous. The sense of warning in nodegree depends upon the sphincters ani, but chiefly upon therelaxation of the lower sigmoid sphincter, which exists where

uuc jJdVi mvu aauavau waua U-10 J.UULLt. J.m&plusmn;CiaiAQ<Utt

of this coincides with the passage of the faecal mass from thesigmoid into the rectum.

It must be remembered that the rectum is normally quiteempty. Certainly the lower half (ampulla) is accepted byall authorities as being empty, normally, and that the lowerpart of the pelvic colon or sigmoid is the fascal reservoir,where the normally inspissated content of the large bowelrests until it is expelled, which in normal persons is every24 hours.

In so far as the warning preceding defsecation is concerned,therefore, its loss depends, not upon the absence of therectal sphincters, but of the loss of the sigmoid sphincter.However, there is evidence to show that sensory stimuli mustprecede the relaxation of the sigmoid sphincter-analogyalone would suggest this ; and that these sensory stimulioriginate, not only from the mucosa covering the sphincter ofthe sigmoid, but from a large extent of the sigmoid mucosa;hence the loss of the sigmoid sphincter with its mucosalcovering does not remove all the sources whence the pre-monitory sensory stimuli preceding defsecation arise.

Clinical evidence, derived from the sensations of patientswho have colotomies, clearly shows that most of the success-ful cases have very definite warning of the impending actionof their colotomies ; while others learn by certain sensationspeculiar to each, and which are not normal warnings, whentheir bowel is going to act. Hence, even though the acutestwarning of the impending action of the bowel is supersededby the performance of a colotomy, all warning is not cut off,or if it is I aurae " develop which efficiently replace the warn-ing. Consequently, we cannot maintain that one of thegreat disabilities of colotomy is the inability to know whenthe bowel is going to act.

HOW OFTEN IS THE COLOT01IY GOING TO ACT

(DIARRHOEA) ?This is the great difficulty with colotomy, and it is usually

entirely attributed to the loss of the sphincters ani.Ca.?se of Diarrhaea.

First, consider what this means. In effect this explana-tion of diarrhoea in colotomy says the fseces run away fromthe bowel because the colostomy opening has not a sphincter,like the normal anus, wherewith to restrain the fasces. Thisis an entirely wrong explanation. The chief reason the

patient has diarrhoea, or even why he has more than oneaction, or at most two actions, of the bowel per diem, is thatthe mucosa of his colon is chronically inflamed-i.e., thepatient has always some degree of colitis. The best proofof this assertion is the result of treatment. Cure the colitisor remove its cause and the diarrhoea ceases, yet is the

patient still minus a sphincter. So it was not the absence ofthe sphincter which formerly permitted the diarrhoea.

Is this assertion reasonable ? You have only to follow thereasoning to its logical conclusion to see that it is so. Inthe person whose sphincteric apparatus is intact-sigmoidand anus-the presence of colitis in a late stage will resultin diarrhoea, and sphincteric action is absolutely in-

competent to prevent it-i.e., the diarrhoea occurs in spiteof the presence of normal sphincters.

Understand clearly what I mean. A normal personempties the sigmoid once daily. The faecal mass lies in the

sigmoid stationary, not because it is retained there by asphincter, most certainly not by the anal sphincters or thelevator ani, but because the t’is a tergo-i. e., the propulsionforwards of the contents of the transverse and descendingcolon-is very slow and gradual, so that until a sufficientmass of faeces has had time to accumulate in the sigmoid theperistaltic action of the latter remains in abeyance. Hence,for example, the presence in the sigmoid of the debris of thepreceding day’s breakfast alone is insufficient to excite theperistalsis of the sigmoid, and it is not until the debris ofthe preceding evening meal has arrived in the sigmoid thatthe total bulk is sufficient to start peristalsis.The best stimulant to bowel action is distension. When

the d&eacute;bris of 24 hours food has collected in the sigmoid thedistension it produces suffices to start the process of defoeca-tion, the sigmoid sphincter relaxes, peristaltic action isexcited, and the fsecal mass is driven into the rectum, whenthe desire to empty the bowel becomes imperative and

voluntary action is called into play, either to expel the massor to retain it. This voluntary retention is partly exertedthrough the sphincters ani and the levator ani.

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What happens, however, if the mucosa is inflamed or themuscular coats unduly excited ? The debris of each meal asit arrives at the sigmoid is not retained at all or only for ashort time, but on the contrary is hurried into the rectum andexpelled-in short, diarrhoea results, and in spite of normalsphincters. In fact, we find that the sphincters are chieflyexpulsive agencies, being essential for the cleanly completionof defalcation.Apply this reasoning to the patient’s case when he has

a colotomy. If the surface of the colon is healthy-i.e.,free from colitis-the debris of the food will graduallycollect and remain in the sigmoid until suffi 3ient bulk hasaccumulated to excite the normal peristaltic action, when anevacuation occurs. This bulk of stool usually represents inthe normal patient the food debris of the preceding 24 hours ;hence a second action should not be necessary, or possibleeven, for another 24 hours.On the contrary, if the mucosa is catarrhal, the undue

stimulation excited partly by the excess of mucus, partly bythe excess of flatus which is almost always associated withcatarrh, and by the muscular stimulation produced by thetoxins present, all these stimuli result in excessive peristalticactivity of the bowel wall; hence inability of the sigmoidto retain the debris of more than one meal (or even less thanone meal) which is expelled from the bowel as soon as itarrives instead of lying in the sigmoid until the debris of the24 hours has collected, when a normal stood would result.So we see that diarrhoea in colotomy is not due to the absenceof a sphincter. It would, indeed, be a mighty sphincterwhich could for long retain the stool in the presence ofcatarrh-i.e., colitis. That the colotomy is unjustly blamedas the cause of diarrhoea is therefore patent.

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Condition of Bonel in Colotomy Patients.We generally find that colotomy is performed in a bowel

already the seat of colitis, either above a malignant growthor a stricture, or infective ulceration of the rectum ; often thetwo latter conditions are part of a process diffused throughoutthe bowel, and one often most intractable to treatment, anda colotomy may or may not be proper treatment.Above a cancerous growth the bowel is always catarrhal,

and for some time after the performance of a colotomy somedegree of diarrhoea will result in these cases, until, indeed,the catarrhal condition subsides as a result of the relief ofthe chronic intestinal obstruction. When this is attainedthe bowel will act once, or at most twice, daily. If, however,the catarrhal condition of the bowel is maintained by anycause then the diarrhoea persists, and will persist, till thecause of the catarrh is removed, and for a short time longer.

Oral Sepsis.The obstruction, and hence the catarrh, produced solely

bv the growth being relieved by the colotomy, is there

usually a cessation of the diarrhoea ? I regret to say No,because in most cases there is an additional source ofcatarrh present. It is to this additional cause of catarrh orcolitis that most of the inconvenience or evil attributed tothe colotomy must be oharged ; certainly not to the absenceof a sphincter. What is the commonest cause of this&deg; &deg; residual " colitis ? In my opinion it is by far most oftendue to oral sepsis. So with a not inconsiderable experienceof colotomy, I wish to empbasise strongly the propositionthat the comfort of a patient with a colotomy is directlyproportionate to the presence or absence of oral or nasal

accessory sinus sepsis.Site of Colotomy.

Granted, therefore, that this corollary is correct, it followsthat the many ingenious methods of endeavouring to manu-facture a sphincter "to prevent diarrhoea " are not only un-necessary but are bound to fail to effect this object-noteven nature’s sphincters can prevent diarrhoea. Butinasmuch as it is impossible by any method of performingcolotomy known to me to retain the whole of the f&aelig;calreservoir, the sigmoid, the operation, by reducing thestorage capacity of the bowel, inevitably interferes to someextent with the normal capacity to hold the accumulation ofthe 24 hours’ food debris, which means that the one normaldaily evacuation will be interfered with. The nearer therectum the colotomy opening is placed the less do we reducethe storage capacity, and vice versa. Hence the selection ofthe transverse colon as the site of a colotomy is absolutelyindefensible, while the historical method of selecting theproximal end of the sigmoid is also incorrect; the question of

prolapse apart, the ideal site for a colotomy is the junction ofsigmoid and rectum.

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Regulation of Diet.It is because we do reduce the storage capacity of the

colon that throughout I have reiterated that a successful

colotomy, even in the favourable cases-namely, those freefrom oral sepsis-may act twice daily. This, however,depends largely upon the quantity and debris-producingqualities of the food partaken, and is to this extent underthe patient’s control.

If we have so reduced the capacity of the sigmoid thatinstead of being able to hold the debris of all the four mealstaken daily it is only able to retain that of three meals, itnecessarily follows that when this amount of debris collectsit is evacuated as a stool, while the debris of the last mealof one day is added to that of the following day, and so on.Irregularity of the bowel must result ; but if the nature ofthe food can be so adapted that the amount of debris pro-duced per diem is so reduced as to enable the diminishedsigmoid to hold the debris of all four meals, then the onedaily evacuation of the bowel is not interfered with.

CONCLUSIONS IN FAVOUR OF COLOTOMY.

We thus see that-(1) There is ample warning of an impending stool ;(2) If there is no oral or accessory sinus sepsis there is no

diarrhoea ;(3) While regulating the diet permits of control of

defaecation ;(4) Skin excoriation is very greatly reduced, but as this is

also dependent upon the mucus exuded from the exposedmucosa it is not entirely done away with.

REMOVAL OF SOURCES OF PUS.Before doing a colotomy, therefore, all sources of pus

likely to be swallowed must be thoroughly dealt with, and Imean thoroughly, not in the half-hearted manner so oftenadopted, and inevitably bound to result in disappointment.This will prove the most important of the accessory steps tothe operation of colotomy, and should be carried out as soonas it is decided a colotomy is to be done, and must not be leftuntil the time the colotomy is done, unless of course thelatter is performed urgently, when, if possible, the mouth ornose should also be attended to-i.e., at the same time.

SOME POINTS IN THE OPERATION.As regards the actual operation there are two chief points

to be considered: (1) That the whole of the faeces must bepassed through the colotomy, hence the spur must be

effective ; (2) that prolapse of the bowel in the future mustnot take place.

Effectiveness of Spur.In order to be certain that the spur is effective in the

operation usually performed, the mesenteric border of thesigmoid must be at or near the level of the skin. It con-

sequently follows that the whole diameter of the gut liesabove the skin, and the surest way of ensuring this is to passa glass rod though the mesentery to sustain the bowel. Thisis the most effective way of making a spur ; it is also muchless painful than any form of stitch (the through-and-throughsuture is really painful) and it is the least septic also. The

glass rod is 42 in. long, *in. in diameter, and over the twoends are passed in. to 1 in. of rubber tubing to prevent itsaccidentally slipping out of the mesentery. One of therubber sleeves is slipped off when the glass rod is finallyremoved on the seventh to tenth day.

Prolapse.With regard to future prolapse, it has always been taught

that the way to prevent the proximal part of the colon fromintussuscepting through the colotomy opening is to pulldown the colon until it is I I taut "-i.e., until there iq noslack part of colon between the place where the colo tomyopening is to be made in the bowel and the descending colonwhere it is bomnd down to the left kidney. This advice is

quite correct, but unfortunately the method removes almostall the sigmoid reservoir and interferes with the desirablestate of one daily action of the bowel.The best method of performing colotomy, therefore, is not

so easy to decide ; and when it is to be a permanent thing, asin cancer of the rectum, it is still further complicated by themethod now in vogue of attempting the removal of " all thelymphatic watershed, including a great deal of the sigmoid

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and ;most of the meso-sigmoid," a proceeding which, in myopinion, neither the anatomy of the part nor clinical evidencejustifies.With regard to prolapse, it is my experience that theconstant expulsive effort due to diarrhoea is the most im-portant predisposing factor to this painful and disagreeablecomplication. Another is the " drawing " effect of even thebest made colotomy receptacles, due, I think, chiefly to thewant of an air vent, the introduction of which tends to

leaking. The more the sigmoid retains its normal functionof a reservoir the less the probability of prolapse, and, as Ihave indicated, we can prevent diarrhcea, hence we can

practically remove the most important factor conducing toprolapse.

Prevention of Possible Nipping of Intestine.In conclusion, I would like to warn you that in performing

the operation of colotomy by the so-called "gridiron" "

method-i.e., the separation of the flat abdominal musclesin the direction of their fibres as we do in appendicectomy-itis wise after making the incision in the tendinous part of theexternal oblique in the direction of its fibres to notch the

aponeurosis at right angles to the fibres, as I have known atleast two deaths follow the operation of colotomy, fromnipping of the wall of the intestine by the strong tendinousedge of the external oblique of such a severe degree as tolead to a linear band of necrosis of the bowel wall-i.e.,there was no effective obstruction to the contents of thebowel, which could be and were expelled by mild laxativesor by passing a tube into the bowel, but death was due tothe intense togaemia which we now know is associated witheven a linear necrosis of the bowel wall and the virtualobstruction which is produced, but which in a colotomy onecould mechanically overcome. To all intents and purposesstrangulation by a band occurs.

THE DIFFERENTIAL DIAGNOSIS OFSYPHILIS AND PARASYPHILIS

OF THE NERVOUSSYSTEM.1

BY F. W. MOTT, M.D.LOND., F.R.S., F.R C P. LOND,DIRECTOR OF THE PATHOLOGICAL LABORATORY OF THE LONDON

COUNTY ASYLUMS; PHYSICIAN TO CHARINGCROSS HOSPITAL.

FOURNIER was the first to express the opinion that tabesdorsalis is a post-syphilitic disease, and Erb in Germany andGowers in this country have done more than any other neuro-logists to support this doctrine of Fournier. Esmarch andJessen, and later Kjelberg, were the first to call attention tothe fact that general paralysis occurred especially in personswho had suffered with syphilis, but it was Fournier whoreally put forward the doctrine that general paralysis was,like tabes, a consequence of syphilis, and that the twodiseases were so similar in their etiology that they mightprobably be regarded as one disease affecting different partsof the nervous system. The inoculation of a number of

general paralytics with no history or signs of syphilis withthe virus of a hard chancre without any signs of infectionresulting led Krafft-Ebing to postulate the’,dictum "generalparalysis is the product of syphilisation and civilisation." When I was appointed pathologist to the London County

Asylums I found no mention of syphilis as a cause of thisdisease and comparatively little of other mental conditions inthe annual reports. This struck me forcibly, for as a neuro-logist I had been greatly impressed in my hospital experiencewith the fact that of all the causes of organic disease of thenervous system syphilis easily occupied the first place. I foundthat careful inquiry in cases of general paralysis revealed thefact of antecedent syphilis much more than had been sus-pected ; still, the obvious syphilitic residua of scars of gummataand other tertiary manifestations in the body were relativelyinfrequent. I found that cases of syphilitic brain disease withdementia were called general paralysis, also cases of Korsakoffalcoholic psychosis ; but etiologically and pathologically,especially in the light of recent research, these are quitedifferent diseases and can usually be differentiated clinically.

1 A paper read before the Medical Society of London on Nov.13th,1911.

A number of causes were asserted to be the agencies capableof inducing general paralysis, and while not denying thatalcoholism, sexual excesses, inherited neuropathic and psycho-pathic predisposition, worry and excessive mental strain-infact, all those causes which may lead to neurasthenia, are im-portant exciting factors, yet it is my conviction that syphilisis the essential cause.

It seemed to me that the proof would be afforded if I couldcollect a sufficient number of cases of juvenile generalparalysis in which most of these exciting factors are absentand show that they were the subjects of congenital syphilis.From the numerous inmates in the London County AsylumsI was soon able to collect a large number of cases of generalparalysis occurring at puberty or early adolescence, and todemonstrate that clinically and pathologically they in noessential respect differed from cases occurring in adults thesubjects of acquired syphilis.Again later, I was able to collect 70 cases of tabo-paralysis

and compare the same with 70 cases of tabes dorsalis, and Ifound among these that the parasyphilitic affection maybegin with spinal svmptoms or optic atrophy and terminatein general paralysis ; or general paralytics may simul-taneously with, or s-accesively to, the onset of thecerebral symptoms develop tabes dorsalis, and I came

to the conclusion from a research extending over

three years that there is one tabes or wasting diseaseof the central nervous system from an etiological and

pathological standpoint. One of the strongest argumentsclinically in favour of this view is the fact that the ArgyllRobertson pupil is for all practical purposes only met with inthese post-syphilitic diseases of thenervous system. Re-searches in connexion with the examination of the blood and

cerebro-spinal fluid, which will be referred to later, confirmthis view.According to some authorities-Bosc, Lesser, Hirschl,

Nageotte, and others-general paralysis and tabes are

quaternary syphilis ; the former authority asserts, and withsome degree of correctness, that there is a general similarityeven in the lesions of general paralysis and tabes to othersyphilitic lesions-viz., there is an endothelial and connectivetissue hyperplasia with a tendency to fibrous and sclerousformation. But there is more than this, there is a primaryneuronic decay which cannot be accounted for, solely by thechanges in the supporting, enclosing, and nutrifying tissuesthe same as can be done in syphilitic lesions.The view I take of the pathology of parasyphilitic affec-

tions is that in certain acquired or congenital syphiliticindividuals the durability of the neurones is greatly curtailed,so that they decay and die prematurely, thereby giving riseto a series of symptoms which may be associated either withirritation of definite nerve structures-e.g., lightning pains,visceral crises, mania and epileptiform convulsions-or withneural destruction, e.g., ataxy, par&aelig;sthesia, ansesthesia,paresis, and dementia. The irritative phenomena may bethe sign of increased neural irritability due to degenerationof neurones prior to their death and loss of function. I do

not, however, affirm that the lymphatic and vascular changesplay an unimportant part in the process of decay and death ofthe neurones-especially in general paralysis. Now it maybe asked, What is the evidence to show how this neuralirritation and destruction are brought about ? ‘!

It is a fact that the cases of syphilitic disease of thenervous system diminish in number and gravity with eachsucceeding year following infection, although it must beadmitted there is no essential difference in the histologicalchanges met with in early and late syphilis of the nervoussystem. It is, however, comparatively very rare for para-syphilitic affections to occur within four or five years ofthe primary infection, and the average time is at leastten years after the appearance of the primary sore.

Seeing that the great bulk of persons are affected in

youth or early manhood, so the curve of incidenceof onset of syphilitic affections of the nervous systemreaches its maximum somewhere between 25 and 30,whereas the curve of the incidence of onset of generalparalysis and tabes reaches its maximum between 35 and40. Whereas, on the one hand, syphilis of the nervous systemproduces more or less sudden obtrusive symptoms indicativeof gross lesions due to meningeal irritation and vascularocclusion of a random kaleidoscopic character, with remissionsand exacerbations causing new and variable paralytic andirritative phenomena, on the other hand, parasyphilitic