Classic Articles in Colonic and Rectal Surgery MARVIN L. CORMAN,
M.D., Editor
John Blair Deaver 1855-1931
John B. Deaver was born July 25, 1855, in Lancaster County, Pennsylvania, the son of a country physician. He attended Nottingham Academy near his home and matriculated in America's first medical school, the University of Pennsylvania, graduating in 1878. Following internship at the Germantown Hospital and the Philadelphia Children's Hospital, he embarked in clinical practice. Shortly thereafter he became attached to his alma mater in the Department of Anatomy, a well-recognizedstepping-stoneinto surgery. In 1886, he joined the staff of the German Hospital (now Lankenau) and developed an enormous personal practice in surgery. His Saturday afternoon operative clinics were attended by surgeons throughout the world while he performed as many as 25 operations in an afternoon. It was, in fact, at the German Hospital where he achieved his greatest recognition, although he was called to the post of professor of the practice of surgery at the University of Pennsylvania in 1911 and assumed the Chair seven years later. Deaver was considered an aggressive and radical surgeon--a great "slasher." He was among the early advocates of immediate appendectomy for acute appendicitis. He often uttered the phrase, "an inch and a half, a minute and a half, a week and a half" to mean, respectively, the length of the incision, the time it took to perform the operation, and the duration of the hospital stay. "Cut well, get well, stay well," was another of his pet phrases. He is also responsible for introducing the use of the word "pathology" to mean pathologic findings or lesion rather than the study (e.g., "What is the pathology.") While Deaver was considered a less skillful surgeon than others, his reputation was awesome. It is said even today that Deaver did more surgery in Philadelphia than any of his predecessors, and that no one again will perform a comparable number. Deaver wrote primarily on abdominal surgical conditions--ulcer, hepatobiliary disease, colon resection. His paper on lumbar versus inguinal colostomy, the subject for this Classics presentation, represents a fascinating perspective of the surgeon's philosophy in the management of rectal cancer and colorectal obstruction prior to the 20th century. Dearer is a well-recognized name to every medical student and surgical resident who has had the misfortune of hanging on to his retractor. He, in fact, did not permit his assistants to perform any aspect of the surgery. He insisted that all operations be done by his own hands. While he was accorded many honors including that of President of the American College of Surgeons, the practice of surgery was his total commitment--that, and writing five books and almost 250 articles. Dearer died September 25, 1931, at the age of 76. Dearer JB. Lumbar versus lilac colotomy. Dis Colon Rectum 1987;30:66-71.
LUMBAR VERSUS ILIAC COLOTOMY. BY J O H N B. DEARER, M . D . , PROFESSOR OF SURGERY IN TIlE PHILADELPHIA POLYCLINIC; DEMONSTRATOR OF ANATOMY AND LECTURER UPON SURGICAL ANATOMY IN THE UNIVERSITY OF PENNSYLVANIA; ATTENDING SURGEON TO THE PHILADELPHIA, GERMAN, ST. AGNES'S,AND ST. MARY'SHOSPITALS. [Read February 25. 1891.]
John Blair Deaver [Photograph courtesy of the University of Pennsylvania School of Medicine]
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THE subject which appeals to every surgeon whose lot is to see many cases of carcinomatous disease of the rectum, is that of colotomy. My object in writing a paper on this topic is to record the result of my experience in the two operations--lumbar and iliac, not inguinal, as it is frequently called; to advocate the establishment of an artificial anus early in the disease, when it is not feasible to remove the involved portion of the bowel; to speak of the indications for the operation; and of operative procedures other than colotomy, for malignant disease of the large intestine elsewhere than in the rectum. Having performed both lumbar and iliac colotomy, I am convinced that, in the majority of cases, the lumbar operation is preferable, as well as the most logical, for the following reasons: 1. Notwithstanding the opening of the peritoneal cavity is now a factor of comparatively little importance when deciding between what shall be an intra- or an extra-peritoneal operation, I believe that, when the same end can be accomplished without opening the peritoneum, the patient should be given the benefit of it. We must admit that an additional risk, be it ever so small, is coupled with an intraperitoneal operation. 2. Regarding simplicity. The essential element of succ e s s in any operation is a correct knowledge of the surgical anatomy of the part. The lumbar operation is as simple as the iliac, especially when the intestines are greatly distended, as they are apt to be in the advanced stages of the disease, when symptoms of obstruction are pronounced and when acute obstruction supervenes upon chronic. In opening the peritoneal cavity where the abdomen is distended, the protrusion of the small intestine through the wound complicates the operation. When the abdomen is distended, the lumbar operation is simplified by the bulging of the colon into the wound, thus making it more accessible. The advocates of the iliac operation claim that the additional advantages gained by opening the peritoneal cavity, providing the disease has not extended too far, are: to verify the diagnosis, to determine definitely the extent of the disease, to resect and re~stablish the continuity of the canal. I do not regard the diagnosis in carcinomatous disease of the rectum or the sigmoid flexure, assuming the form of a gentle growth or a stricture, with symptoms both local and general, together with the history of the case and what can be learned by an examination of the abdomen and of the rectum (if need be, assisted by anaesthesia), at all difficult. Where the sigmoid alone is involved, the additional comfort gained by a resection would not warrant the patient assuming the risk consequent upon this operation, in comparison to that of establishing an artificial anus through the loin. The advocates of the iliac operation, again, produce the following arguments in its favor, namely:
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1. The impossibility of opening the small for the large intestine. In answer to this I can say, this mistake cannot occur in the lumbar operation unless the peritoneum is opened, which should not occur to a careful surgeon, non-interference with the peritoneal cavity being the important factor in the lumbar operation. Should the surgeon be unfortunate and open the peritoneal cavity in the lumbar operation, mistaking the small for the large intestine would be a gross anatomical error. The presence of one or more epiploic appendices tells positively that it is the large intestine, these never being present as constituents of the small intestine. Again, the arrangement of the longitudinal muscular fibres of the large intestine into three separate bands, and the sacculated condition of the large intestine where both are not obscured by distention of the gut, assist in deciding the question. The small intestine may be met with so distended as to equal or exceed in size that of the circumference of the large; under such circumstances, the question of difference would be still more difficult for the surgeon not familiar with the anatomical peculiarities of both. The percentage of cases in which the descending colon does not hold its normal position to the abdominal walls posteriorly is so very small as, in my mind, not to enter into the question of deciding between the two operations. In the large number of bodies I have seen dissected in the anatomical rooms of the University of Pennsylvania, I have yet to meet with a single case of pronounced anomalous arrangement; yet, I would not be understood as disputing the fact. Mr. T. Bryant, having operated in 170 cases, in but one of which he found it necessary to prolong his incision forward to find the colon at the brim of the pelvis, is the best argument to offset that set forth by the supporters of the iliac procedure. 2. The position of the anus in the iliac operation is claimed to be a more convenient one for the patient to keep clean, as well as for the adjustment of the necessary pad which has to be constantly worn. I admit that an artificial anus in the abdominal walls anteriorly can be kept clean more conveniently by the patient than one in the loin; but the former situation, owing to the recession of the abdominal walls in certain positions assumed, allows the pad to shift. This is not the case in the loin, as the latter offers a more fixed and stationary point to retain the pad. 3. Those who prefer the iliac operation claim that, owing to the meso-sigmoid being longer than the descending meso-colon, it renders the stitching of the bowel to the edges of the wound easier; also, that there is less tendency to prolapse of the gut following this than the lumbar operation. I confess that the long sigrnoid mesocolon will permit of the bowel being drawn up much further than will the comparatively short descending meso-colon. This offers, however, no advantage over the
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lumbar operation, as the length of the descending mesocolon is such as to allow the surgeon to bring the bowel up far enough to suture it to the edges of the wound of the abdominal walls, before or after it is opened, without any difficutly. In the case of a very fat subject, where the abdominal walls are flaccid, the last stages of the lumbar would be somewhat more difficult than that of the iliac operation. T h e formation of the spur, the barrier to the passage of the contents of the intestine from the upper into the lower opening, is claimed as being more pronounced after the iliac than the lumbar operation. This has not been so in my experience; on the contrary, I have been very much disappointed with the iliac operation in this respect. True, I have only performed two of the iliac operations; in both of these the patients were greatly annoyed by the collection of feces in the rectum above the seat of the trouble, and the consequent rectal tenesmus excited by the same. In my lumbar colotomies, by following the plan adopted by Mr. Bryant, namely: Having exposed the descending colon by an incision carried in the line of the normal crease situated about midway in the costo-iliac space--the structures divided being the skin, the superficial and deep fascia, the posterior border of the external oblique, the anterior border of the latissimus dorsi, the lumbar fascia with the posterior borders of the internal oblique and transversalis muscles, and the anterior border of the quadratus lumborum and the fat covering the posterior surface of the bowel, which should be separated by the fingers--it is grasped at the site of the posterior longitudinal muscular band, rotated well forward on its longitudinal axis, brought into the wound, and there fixed. Operating in the above manner, I have formed a most excellent spur, serving its purpose very satisfactorily to the patient as well as to myself. I would restrict the iliac operation to that class of cases where the upper portion of the sigmoid flexure is not involved, and where it is done first as an exploratory measure--not in a diagnostic sense, but for the purpose of determining whether resection is justifiable, when, if it be impossible, the operation is completed as an iliac colotomy. In the two iliac colotomies that I have performed, the cases not being urgent, I divided each operation into two stages; the first consisted in fixing the bowel in the w o u n d (colorraphy), and the second in opening the bowel at the end of seventy-two hours. It is not necessary to give an anaesthetic when the bowel is opened, it being almost painless. I follow this course in the lumbar operations as well, when the urgency of the cases does not demand an immediate opening. Indications for the operation: Carcinoma of the rectum, either in the form of a growth or a stricture, too high to render the removal through the perineum or back by excising the coccyx, and, perhaps, one or two of the lower
Dis. Col. 8: Rect, January 1987
segments of the sacrum, or through both the perineum and the back. Stricture of the terminal part of the sigmoid flexure and of the upper part of the rectum with symptoms of obstruction, too high to treat successfully by dilatation, divulsion, or division. Incurable cases of recto-vaginal or recto-vesical fistula. Extensive and otherwise incurable cases of ulceration of the rectum, making life a burden to the patient. Imperforate anus, where operation through the perineum and back proves of no avail. Irremovable growths of the pelvis, causing obstruction by making pressure u p o n the rectum. In this connection, I will make mention of a suprapubic cystotomy that had to be done by a colleague in one of our hospitals for retention of urine, occasioned by pressure of such a growth against the base of the bladder. Here it was only possible to pass a catheter when the patient (male) was anaesthetized. When should the operation be done? I believe the position held by most surgeons in regard to the operation of colotomy, namely, that it is only to be thought of as a last means of relief in cases of carcinoma of the rectum and sigmoid flexure, also in strictures of small calibre, otherwise incurable, is a too conservative one. We must all admit that the chief factor in the rapid growth of carcinoma involving the bowel is the irritation to which it is constantly subjected, first, by the peristaltic action of the bowel, and, secondly, by the passage of fecal matter through the involved portion; therefore, the position I maintain is, that the sooner the operation is done, there being, of course, no doubt as to the character of the trouble, the better, and for the following reasons: First, by the early establishment of an artificial anus, the patient is relieved of the severe pain caused by the contraction of the enfeebled bowel in attempting to expel its contents; to relieve this, it is necessary to administer adodynes which interfere with digestion and assimilation. Second, the diarrhoea, so frequently a c o m m o n symptom in these cases, does not occur. Third, the danger of total obstruction, one of the causes of death in unrelieved cases, is prevented. And, lastly, the opportunity afforded of subjecting the affected bowel to frequent antiseptic irrigation, by which the progress of the disease is very materially stayed. I am convinced that in the case of lumbar colotomy I here report, showing a drawing of the artificial anus, by frequently washing out the lower bowel with a one-half-per-cent solution of creolin (preventing the collection of the excretions of the growth, which cannot be done thoroughly until an opening is established with the bowel above the seat of the growth), as has been done conscientiously by my resident surgeon, Dr. C. D. H a m m a n , the patient's comfort has been gready added to; also, that the progress of the growth since the opera-
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don has been but little, if any. T h u s far, I have spoken simply of left l u m b a r and left iliac colotomy. O w i n g to the modern advancement made in intestinal surgery, right l u m b a r and right inguinal colotomy are operations, I hope, of the past. I trust, at this time, no surgeon who is abreast with the times would think of either of the two last-mentioned operative procedures, but would open the abdomen of his patient, remove the g r o w t h - - i f possible, by resection--and re&tablish the continuity of the canal, either by lateral implantation, or better, lateral apposition by perforated decalcified bone plates or rubber rings. Where it is not possible to remove the growth in the cases last referred to, sooner than establish an artificial anus, make a lateral anastomosis. In carcinomatous disease of the upper portion of the rectum, colotomy offers the only operative means of relief. In carcinomatous disease of the sigmoid flexure, or of the descending colon, too high for colotomy, lateral anastomosis by ileo- or colo-rectostomy may be feasible, but here I give preference to lumbar colotomy; elsewhere I prefer anastomosis. James R., hostler, aged thirty-eight years. Admitted to the G e r m a n Hospital July 26, 1890. Family history negative. Has had p a i n on defecation, and discharge of bloodstained matter. On examination, an ulcerating mass was found high u p in the rectum, involving the entire calibre of the gut. August 16. Left lumbar colorraphy performed. 17th. Considerable tympanites. 18th. Gut opened; immediate relief from tympany. W o u n d was dressed twice daily. Primary union. Patient discharged September 6th. T h e patient was able to regulate the movement of the bowels at the end of two weeks. H e improved markedly in health and strength. December 17. Patient has been doing light work as a hostler for six or eight weeks. His bowel is washed out twice a week with a one-half-per-cent, solution of creolin.
FIG 1. Showing the artificial anus. The two openings drawn apart so as to bring out the spur. again at a later date, opening the caecum in the right lilac region; the patient had her evacuations satisfactorily for a number of months through this orifice. I have seen a surgeon embarrassed in the lumbar operation by a large cyst of the kidney, which presented in the wound, and had to be evacuated before the bowel could be found. As to the greater convenience of the patient when the artificial anus is in front, I do not feel that we can as yet judge, from the small number of recorded cases of this kind. My own experience has been almost entirely with the lumbar operation, and has
DISCUSSION. DR. JOHN H. PACKARD:I would call attention to one important point as to the distinguishing between large and small intestine, which I do not think was mentioned by Dr. Deaver. It is that the small intestine moves with the respiration, while the large bowel does not. Opening of the peritoneum is, of course, to be avoided, if possible. Yet, when it does occur, it is not a matter of very serious consequence. I have had it happen in my hands in a case where the bowel was contracted, and could not be found; I simply caught up the wounded part and tied a catgut ligature tightly round it, and never heard from it again. In this case I operated
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FIG. 2. Pad.
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FIG.3. Showing pad adjusted.
been very favorable. In one case, operated upon three years ago, the woman is still living, and able to do something toward supporting herself. As to operations on fat subjects, it does not seem to me that there would be less difficulty in drawing out the bowel in the iliac region than in the lumbar. Dr. Deaver did not, I believe, mention the extent of the opening to be made in the intestine. If this is too large, there is apt to be, not only incontinence of feces, but also an eversion of the mucous membrane, which becomes very tender, and discharges an irritating secretion. It is true, the orifice tends to contract, but if it becomes too small, it can always be enlarged. I would ask why, in the iliac operation, it is considered proper to wait seventy-two hours before opening the bowel? The serous surfaces become glued together in a much shorter time; and should the intestine become distended, the adhesions formed might be pulled apart. I agree with Dr. Deaver in the opinion that there are cases in which the operation should be done early. Patients with malignant disease of the rectum are sometimes allowed to go on suffering, when they could be relieved by surgical interference. So much comfort is given by lumbar colotomy that I have operated on a man who was in extremis, to save him pain, just as
Dis. Col, & Rect. January 1987
I would in some cases perform tracheotomy to relieve urgent dyspnoea. In cases of imperforate anus or rectum the question between the iliac and lumbar operations is important. I think that here the former is the better; the peritoneal surfaces in a child will adhere with great rapidity, and the bowel is very accessible. We are in this procedure close to the seat of trouble, if further measures are to be adopted for restoring the natural channel of the anus. It seems to me that it might sometimes be an advantage to bring the inner wall of bowel out to the wound, in the lumbar operation, so as to close off the lower portion of the gut altogether, and prevent any portion of fecal matter from passing down so as to come in contact with the diseased surfaces. Let me ask, in conclusion, whether there is upon record any instance in which a portion of the lower bowel, affected with malignant disease, has been resected with good result, with such success as might lead me to recommend a like operation in the case of a friend, or to consent to its performance upon himself. DR. JOSEPH HOFFMAN: I have now a case of cancer of the rectum in a woman, sixty-five years of age, where I have refused to do colotomy, because the disease is in such a condition that life cannot be prolonged over a few weeks. From what I have seen of these operations, I look upon them more as curiosities than as accomplishing much good. I do not believe that the prolongation of life for three or four months in the presence of suffering, simply because it is possible, is always a justifiable procedure. I have in mind one case which I attended after colotomy was performed where the woman went on from bad to worse, finally begging me to give her something to end her misery. If the operation had not been.clone she would probably have died a much easier death. As an adjunct to the treatment of diseases of the lower bowel, amenable to treatment, the value of colotomy is not disputed. The shutting off of the lower portion of the intestine is referred to by Treves as a procedure which, to a great extent, prevents the bulging of the intestine after the operation is performed. DR. H. R. WHARTON: I think that often the inguinal operation is simpler than the lumbar. The incision that I have employed is one recommended by Mr. Ball, an Irish surgeon; it is made in the line of the linea semilunaris, and is two to three inches in length. As regards prolapse of the bowel, I think that there is little difference in the two operations. I have seen marked prolapse after the inguinal operation. T o prevent this it has been proposed to drag the bowel well down, and remove the redundant portion at the time that it is secured. In regard to the best operation in imperforate anus or rectum, experience has shown that the lumbar operation is difficult, and that it is uncertain on account of the tendency, in young children, of the descending colon to be displaced. In a number of instances the operation has had to be abandoned on this account. Inguinal colotomy is the better operation in these cases.
As regards the time at which the gut should be opened. If the symptoms are urgent, the surgeon should open the bowel at the time of the operation; if the symptoms are not urgent, he should allow twelve to thirty-six hours to elapse before opening the
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bowel. The accumulation of feces below the opening is, in many cases, a troublesome feature. In inguinal colotomy the collection can be cleared away through the artificial anus, and this is one of the advantages of the inguinal operation. DR. DEAVER: While under the present methods of surgery there is not much risk from opening the peritoneum, yet we should avoid it where possible, From what has been said in regard to the inguinal operation in cases of imperforate anus, I think that it will be better in these cases. In regard to the property of the operation, I have only to say that good men have done the operation for years, and I am inclined to follow their example. What should be done to Dr. Hoffman's case is lumbar colotomy. The diarrhoea, pain, and hemorrhage in cancer o[ the rectum is such as to make the sympathetic surgeon shrink. In the formation of a spur, I have adopted Bryant's plan,
which consists in rotating the descending colon well forward, so that the posterior wall projects to the extent of half an inch. This offers a sufficient barrier to the passage of feces.
Acknowl~gment The Section Editor acknowledges Dr. Clyde F. Barker, Professorand Chairman, Department of Surgery, University of Pennsylvania School of Medicine, for his help in the preparation of this manuscript.
Bibliography Dearer JB. Lumbar versus iliac colotomy. J Phila Co Med Soc 1881;12:97-106. Biography--Ashhurst ATC. Obituary. Tr Am Surg Assn 1931;49: 503-6. Pfeiffer DB. Memoir of John B. Dearer, M.D. Tr Col Phys Phila 1932;54:87-9.
Erratum Due to a publishing error, the figures in the Classic Articles in Colonic and Rectal Surgery section in the November issue of Diseases of the Colon and Rectum were incorrectly attributed to the College of Physicians of Philadelphia. The portrait of Dr. Allis is courtesy of the College of Physicians; the figures are from the original printing of the article by Dr. Allis (Am J Obstet Dis Women Children 1902:60-66).
