RATIONS GUIDE: FOOD REQUIREMENTS OF CHILDREN
SIR,-Mr. P. Lockhart-Mummery's contribution to this subject in your issue of March 10th calls for comment. His assertion that "a temporary colotomy is a rare condition in civilian practice" is far from being correct. The general recognition on the part of surgeons that obstruction in the large intestine is best dealt with by a proximal colostomy, to be followed in suitable cases, after an interval, by resection of the offending segment of the bowel, and, later still, by closure of the
... re of the artificial anus, has produced many such operations. Moreover, the established value of the three-fold operation in cases of obstruction has led many surgeons to adopt the procedure as a routine practice in dealing with cancerous growths of the colon where obstruction is not a feature of the case. My chiet object, however, in writing this letter is to call attention to a method of closing colostomy openings which I have adopted in upwards of 30 consecutive cases without a single fatality and with uniform success. The method was fully described by the late Greig Smith in his work on " Abdominal Surgery," vol. ii., p. 727. The aim of the operation is to close the artificial anus without opening the general peritoneal cavity, and this is managed by detaching from the parietes, all round the anus, sutficient peritoneum to permit of delivery of the gut through a parietal incision without separating it from its adhesions to the peritoneum. The opening is temporarily closed by a gauze plug. Incisions, each ly inches in length, are made above and below it through the skin and abdominal muscles down to the parietal peritoneum. They begin immediately outside the junction of the skin and mucous membrane, and may be either vertical or oblique. A finger is introduced and the muscles are gently raised from the underlying peritoneum on either side of the incisions. It is best to begin the separation at the end of the incision farthest from the anus because there are no adhesions here. Next the skin all around is divided with a scalpel one-eighth of an inch from its circumference ; then with scissors the muscles are separated, taking care not to puncture the underlying peritoneum. When this has been done the colostomy opening and the adjacent colon can be lifted out of the wound to almost any desired extent. Gauze is packed in the wound all around the protruding anus and its muco-cutaneous margin is cut off. The refreshed edges of the anus are now united transversely to the long axis of the bowel by a suture of fine catgut, which should take a firm grip of both the musculo-peritoneal and mucous coats. The gauze packing and the surgeon's gloves are changed, and the area thoroughly cleansed with a stream of warm saline solution. A superimposed suture of fine silk is passed through the peritoneal and muscular coats, so as to bury the catgut suture. The loop of bowel is then pushed inside the abdominal wall, and the peritoneal wound closed by closely placed through-and-through silkworm-gut sutures. A small rubber drain-tube is placed in the centre of the wound and the usual dressings applied. The drain-tube is removed at the end of 48 hours, and in the vast majority of cases primary union results. Very occasionally a small fsecal fistula appears at the end of a week, but in every such case closure follows after a short interval. Every now and then the parietal peritoneum has been punctured, but in no case has this made any difference. Inasmuch as there is nearly always a bridge of healthy bowel wall, varying from onethird to two-thirds of its circumference, on the mesenteric side. there is not the slightest risk of a stricture forming at the site of operation Greig Smith's operation is applicable to the vast majority of colostomy openings, including faecal fistula: from gangrenous umbilical hernia and those following operations for gangrenous appendicitis. In view of its safety and the uniform success following its adoption, I may be pardoned for expressing the conviction that enterotomes and similar contrivances should be relegated to surgical instrument museums. Two of my most recent cases were soldiers who had been shot in the abdomen. They were operated on a few hours later by Captain J. Frazer, who in both cases, after suturing multiple wounds of the intestines, established an artificial anus in the transverse colon. In both the colostomy opening concerned quite one-half of the circumference of the colon. Both healed without suppuration. Mr. Paul Bernard Roth in your issue for to-day describes what he calls a simpler method of closing colostomy openings." Admitting its ingeniousness, one is bound to recognise that it involves the resection of a segment of the colon within the peritoneal cavity. This procedure, owing to the relatively septic condition of the mucous membrane and the poor blood-supply as compared with the small intestine is, when every precaution has been taken, one involving a very definite risk to life, and with Greig Smith's operation as an alternative I do not hesitate to say that, in my opinion, it is quite unjustifiable. Just a word as to after-treatment. Mr. Lockhart-Mummery recommends that the bowels should be made to act daily after the operation. Surely this is bad advice. Here, more than elsewhere, one of the essentials to good healing is rest. Care should be taken to have the bowels well emptied before operation, but thereafter for a few days the less peristalsis the better. As a matter of fact I never give an aperient in these cases until the end of the first week.