THE MEDICAL DEFENCE UNION AND THE MIDWIVES' BILL
SIRS,—In your issue of Jan. 31st my old friend Mr. Jessett suggests that ileo-colostomy, in the cases of cancer of the caecum on which Mr. Rryant and I did ileostomy, would have been a better procedure, and his chief argument seems to be that the patients would then not have had faecal fistulæ. I presume he means " artificial anus," as the object of the operation is to prevent any intestinal contents .passing over the diseased surface, which, in the case of .ordinary intestinal fistulæ, is not
... al fistulæ, is not the result. But would the patients have recovered after ileo-colostomy by implantation or apposition ? '? So much depends on the local conditions met with at the time of operation and on the patient's 'general state that no hard-and-fast rule of conduct can be formulated, and in cases of cancer where any operation -except removal (which seems rarely to be indicated at the stage we see cases) can only be of a palliative nature, the -simpler the method the more appropriate it appears to me to be. Enterostomy, if done in time, is simple, of rapid execution, and effective, and in another case I would make a free opening low down in the ileum at the time of operation, so as to ensure all intestinal contents passing at once through the incision. In these cases the sufferer has but a few months to live, and an opening low down in the small intestine provides for nutritive needs, and with the use of a properly fitting obturator and oakum or wood-wool pads life is very bearable, providing pain and irritation be abolished or much diminished. I would remind my surgical brother now in arms that the fault, or rather the misfortune, in the shape of illness which befel him prevented his accepting my invitation to be present. It is probable, had he been with me, that the operation he suggests would have been done. I think it our manifest duty to give our patients the benefit of experience greater than ours in any particular branch of surgery, and I have no personal knowledge of, or care for, jealousy of so-called specialists in any domain. The onus of showing the profession that the new intestinal operations introduced by Senn, and ably continued and advocated by Mr. Jessett, are of as easy execution and as safe in result as already accepted means rests with these gentlemen, and !Until this be done cautious surgeons will rely on older plans, except in such desperate cases as that on which I operated last Thursday. Boldness is not always synonymous with wisdom, nor is carefulness the necessary autotype of surgical cowardice or timidity. So far as is in my ken, 'there are no published records of sufficient successes of these new methods in human beings, but I trust that Messrs. Senn and Jessett will soon remedy this defect. Another argument for ileostomy is that ileo-colostomy would take longer to execute, and in order to make the opening in .a healthy colon one would have to go at least three inches from the diseased part, since if the operation succeeded the liquid or semi-solid contents of the ileum would gravitate down to the cancerous part and irritate it. This, I fear, is another real objection ; but it may be urged the implanta,tion or anastomosis could be made at the transverse or descending colon, so as to avoid this backward flow. I -can only reply with the request to be shown some successes before I adopt, in ordinary cases, new proceedings. There is another objection which, in the present state of our experience, is to me a very substantial one. It is that, I believe, no one is justified in making serious experiments on human beings, and I cannot think but that all surgeons would deem a confrdre more than rash who undertook these novel proceedings without the aid of the only two men who, so far as I know, have any experience of these operations I allude to Mr. Jessett and Mr. Horsley, though I believe only the former has operated on the human subject. The technics of these operations are rather complicated until done or seen done, and the least slip in any detail will certainly most seriously endanger the life of the patient ; so that I would urge anyone contemplating them to practise repeatedly on the cadaver, and if possible to secure the aid of one or other of these gentlemen. If, now that I have had experience of one case, my services are considered worth asking for, I shall be most happy to render them. As stated in my last letter, operations and surgeons must be judged by results, and ileo-colostomy is no exception to this wholesome rule. I have recently practised what I preach, and have availed myself of Mr. Jessett's valuable aid, most willingly given, in a diflicult and complicated case of ileosigmoidostomy, and as this is the third serious operation I have had to perform on the same patient, and, moreover, as the narrative of these operations will, I am sanguine, prove of interest and instruction to surgeons, I will, with your permission, publish the case, with illustrations, in THE LANCET, whatever may be the result of the operation.