Classic Articles in Colonic and Rectal Surgery MARVIN L . CORMAN, M . D . , Editor

John

Percy Lockhart-Mummery 1875-1957

J. P. L o c k h a r t - M u m m e r y was born February 14, 1875, at lslips Manor, Northolt, England, the eldest son of a distinguished dental surgeon. He was educated at Leys School and Caius College, C a m bridge. He was an o u t s t a n d i n g student, and in 1897 was appointed a n assistant demonstrator in a n a t o m y at his alma mater. From there he went to St. George's Hospital, where he w o n the T h o m p s o n gold medal. In 1900 he became a Fellow of the Royal College of Surgeons a n d subsequently received several hospital appointments. In 1903, h a v i n g developed a special interest in proctology, he was appointed assistant surgeon at St. Mark's Hospital. In 1904 he was H u n t e r i a n Professor at the Royal College of Surgeons, and in 1909 Jacksonian prize w i n n e r at the College. He contributed extensively m the literature t h r o u g h o u t his career. A m o n g his writings were six books on colorectal surgery, in addition to two collections of essays on nonmedical subjects. His work at St. Mark's Hospital attracted visitors t h r o u g h o u t the world. His m e t h o d of perineal excision was greatly admired and is the subject for this Classics presentation. His operative mortality of only 3 per cent in 200 patients a n d an overall cure rate of 50 per cent is quite remarkable, considering that the paper was written in 1926. In this paper he also presents his clinical classification of cancer of the rectum, which actually preceded Dukes' pathologic classification. L o c k h a r t - M u m m e r y was a very energetic m a n , playing golf with a h a n d i c a p of nine, and was a n avid fisherman. He was said to " h o p " u p the steps to the hospital, a n observation that is not surprising since he h a d u n d e r g o n e a leg a m p u t a t i o n , presumably for sarcoma, by Lord Lister, himself, w h e n L o c k h a r t - M u m m e r y was a student at Cambridge. His n u m e r o u s contributions included his paper on cancer and heredity, in which he described three families with familial polyposis. T h i s resulted in the establishment of the f a m o u s polyposis registry. His interest in a n y t h i n g relating to the diagnosis and treatment of cancer eventuated in his f o u n d i n g of the British Empire Cancer C a m p a i g n . He was the first secretary of the British Proctological Society, and was instrumental in establishing it as an independent section of the Royal Society of Medicine. In 1937 he was elected a Fellow of the American College of Surgeons. In 1940, after 37 years at St. Mark's Hospital, L o c k h a r t - M u m m e r y was made an Honorary C o n s u l t i n g Surgeon. In retirement he c o n t i n u e d to write, primarily on lay subjects. He died at Hove on April 24, 1957, at the age of 82. John

L o c k h a r t - M u m m e r y JP. T w o h u n d r e d cases of cancer of the rectum treated by perineal excision. Dis Colon R e c t u m 1984;27:208-219.

[Photograph

208

Percy Lockhart-Mummery c o u r t e s y o f St. M a r k ' s H o s p i t a l ]

Volume 27 Number 3

CLASSIC ARTICLES

T W O H U N D R E D CASES OF C A N C E R OF T H E R E C T U M T R E A T E D BY P E R I N E A L EXCISION. BY J. P. LOCKHART-MUMMERY, LONDON.

HISTORICAL. THE operation for the removal of rectal cancer has undergone very considerable changes during the last twenty-five years, and we may roughly divide these changes into four periods. D u r i n g the first period surgeons removed the growth by splitting up the rectum and dissecting out the growth, working from inside the rectum, or at least with one finger in the bowel. T h e operative field was necessarily soiled, and inevitably became septic. Convalescence from such an operation was long and tedious, six months being not an uncomm o n time; the results as regards continence were poor, and generally there was recurrence within a few months, although not always. This was the type of operation Herbert Allingham performed at the time when I used to assist him. The second period was that of Kraske's operation, where an incision was made over the rectum from behind, and part of the sacrum removed. The section of the rectum containing the growth was cut out, and the two ends of the bowel were sewn together again, as well as could be managed, or a sacral anus was established. Both these methods were only applicable to a few selected cases, and the results were almost invariably bad. Serious sepsis was inevitable after these operations, and the successful cases as regards recurrence were usually those where the subsequent sepsis removed extensions of the growth which the operation failed to do. The mortality was high, and the functional results as a rule were very poor. Many of the patients had a permanently incontinent sacral anus, and often a bad prolapse developed which caused a great deal of trouble. The recurrence figures after Kraske's operation were very unsatisfactory, and the great majority of those patients surviving the operation died of early recurrence. They did not all have recurrence, as I know of several who are alive to the present day. The abdomino-perineal operation which marks the next period was the first great advance in the surgery of rectal cancer, and was a decided improvement on anything that had gone before. It fulfilled two important factors which had hitherto been lacking--a free removal of the growth and surrounding tissues, and a technique which made it possible to eliminate sepsis. At first the operation was designed so as to allow the end of the colon to be brought down to the anus and more or less normal function to be restored; but it was soon found that this added serious dangers to an operation which was already very risky. It is not possible to ensure an adequate blood-

209

supply to the transplanted colon, and this method has now been almost universally abandoned in favour of terminating the operation with a permanent colostomy. While the operation is a great improvement upon its preaecessors, it has certain serious drawbacks as a routine method of removing rectal cancer. The mortality of the operation, even in the hands of experienced operators, is very h i g h - - i n any large series of cases it is 30 per cent or over, and it cannot be performed on people over 60 years of age, or where there are complicating conditions--in fact, the mortality can only be kept down to at all a reasonable level by a very careful selection of cases. This is a serious drawback, since the majority of cases of rectal cancer occur at ages between 55 and 65, as will be seen by reference to the age tables; and, moreover, many of the patients have some complioti_ng disease. A mortality of anything near 30 per cent cannot be faced with equanimity, and it was in order to get a technique that would allow of satisfactory removal of the growth, and at the same time get rid of the high mortality, that I adopted the perineal operation I now perform as a routine method, and reserved the abdomino-perineal operation for cases otherwise inoperable. The abdomino-perineal operation, or some modification of it, remains the method of choice for growths too high up to allow of removal by the perineal route; but I think that the perineal operation should become the method of choice for all cases of true rectal cancer. It is obvious that the correctness or otherwise of my contention depends upon the results as regards both the mortality and, more especially, the recurrence rate after the perineal operation; and this paper, which is a description of the whole of the results of 200 consecutive cases, is published with a view to proving the correctness of this statement. A few months ago I completed my 200th case of perineal resection of the rectum for cancer, and as the cases both in private and in hospital have been as carefully traced as is possible, I think the publication of the results will be of value in showing what the actual results are in a large series of cases, and what may be expected by this operation. Cases where the growth was situated at or above the recto-sigmoidal junction are not included in this series as they have been dealt with by the abdominoperineal operation. I would particularly stress this point, as there is a distinct temptation to attempt removal of very high growths by the perineal route owing to the greater ease and safety of this operation. Attempts, however, at removal of a very high growth in the rectum by the perineal route involve the operator in serious difficulties, and discredit the operation, which was never intended to deal with such cases. The following cases are a complete sequence of 200, of which 100 were operated on in private and 100 in hospi-

210

CLASSICA R T I C L E S

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Dis. Col. & Rect.

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Fro. 59. Cancer mortality. Age rate per 100,000 population. tal. T h e p e r i o d covered by the series is a l o n g one, a n d includes the d e v e l o p m e n t of the t e c h n i q u e n o w e m p l o y e d . C o n s i d e r a b l e i m p r o v e m e n t has n a t u r a l l y taken p l a c e in the details of the o p e r a t i o n a n d s u b s e q u e n t treatment, so that the results in m a n y ways are better in the later cases. T h e recurrence figures are w o r k e d o u t o n l y o n the earlier cases, as it is o n l y in cases o p e r a t e d u p o n before o r d u r i n g the first few m o n t h s of 1921 that a sufficient time has e l a p s e d to j u d g e of the curative results of the o p e r a t i o n . In r e g a r d to these figures it m u s t be b o r n e in m i n d t h a t the c o m p a r a t i v e safety of the o p e r a t i o n has resulted in m a n y a d v a n c e d cases b e i n g o p e r a t e d o n w h i c h w o u l d n o t have been considered justifiable if a m o r e serious p r o c e d u r e was involved; a n d that for the same reason a large n u m b e r of q u i t e o l d p e r s o n s have been o p e r a t e d u p o n , n o fewer t h a n 72 p a t i e n t s b e i n g over 60 years of age, a n d these c o u l d n o t have been o p e r a t e d o n at all h a d the a b d o m i n o p e r i n e a l r o u t e been used. A g e . - - T h e f o l l o w i n g are the ages in the 200 consecutive cases o p e r a t e d on: Under 30 30-40 40-45 45-50 50-55 55-60 60-65 65-70 Over 70 3 10 10 22 36 47 42 16 14 It will be seen that the age at w h i c h the largest n u m b e r of cases o c c u r r e d is b e t w e e n 55 a n d 60, the n e x t c o m m o n est the f o l l o w i n g five years, b u t that after r e a c h i n g a m a x i m u m at 55 to 65 there is a r a p i d decline in the n u m b e r of cases as the age increases. T h e r e can be little

Ft(;. 60. Cancer of rectum removed by perineal excision, showing associated adenomata. d o u b t t h a t this decline is due to the decreased n u m b e r of p e r s o n s l i v i n g over the age of 60, a n d p a r t l y to the fact that at the h i g h e r ages a larger n u m b e r of cases are i n o p e r a b l e o n a c c o u n t of their age. T h e c h a r t ( F i g . 59) is given to s h o w the age incidence of cancer w h e n taken from a really large n u m b e r of cases. It is f r o m Dr. F r e d e r i c k H o f f m a n ' s " M o r t a l i t y of Cancer t h r o u g h o u t the W o r l d " , a n d show's, as m i g h t be expected, a steadily i n c r e a s i n g incidence of cancer w i t h i n c r e a s i n g age. My age table d e m o n s t r a t e s the value of an o p e r a t i o n w i t h a c o m p a r a t i v e l y l o w m o r t a l i t y risk, as it will be seen that n o fewer t h a n 72 p a t i e n t s o u t of 200 w o u l d have been too o l d for o p e r a t i o n by the a b d o m i n o - p e r i n e a l route. As a m a t t e r of fact, of the p a t i e n t s over 70, o n l y 2 died as the result of the o p e r a t i o n . S e x . - - O f the 200 cases, 123 were males a n d 77 females. T h i s is in the p r o p o r t i o n of 3 m a l e s to 2 females, a n d c o r r e s p o n d s very closely to the p r o p o r t i o n s h o w n in the M i n i s t r y of H e a l t h figures for 1925, w h i c h w o r k o u t at 4 males to 3 females.

Volume27 Number3

CLASSIC A R T I C L E S

21 1

PREDISPOSING CONDITIONS. In this series of cases, what would appear to be the most important predisposing cause of the disease, apart from age, is the presence of simple adenomata in the bowel. For the last two years these have been very carefully looked for in all cases of excision, with the result that they were found associated with cancer in all but a very few of the cases examined. It seems probable that in the few cases in which no adenomata were discovered they may have been present higher up in the bowel, since the area examined was necessarily confined to the parts removed (Fig. 60). This is borne out by the fact that in one case an adenoma was found on the mucous membrane of the colostomy. This subject has been extensively dealt with by Dr. Dukes, the pathologist at St. Mark's Hospital, in a paper read before the Proctological Section of the Royal Society of Medicine on Jan. 13, 1926. In one case (Fig. 61) there were two distinct carcinomata in the rectum within half an inch of each other. Sections cut for histological examination from the intermediate submucous tissue fail to show any signs of continuity between the two growths. In this case the presumption is that both growths had arisen simultaneously in simple adenomata previously present. Four cases (Nos. 1, 3, 18, 137) are remarkable in that another primary cancer developed in the same patient after an interval of years. One patient had his rectum removed for cancer, and eighteen years later returned with another small growth in the colon some 8 in. higher up. This also was successfully resected, and he is still alive, now twenty-one years since the original operation. Another patient developed a growth 11 in. higher up in the colon six years after a growth in the rectum had been removed by perineal resection. In neither case was there any evidence that the second growth was a recurrence of the first one. It had all the characteristics of a primary growth, and there were no glands involved nor any signs of secondary deposits. Another patient developed a duct carcinoma of the left breast three years after the removal of the rectum for cancer. T h e fourth patient also developed a duct carcinoma of the breast two years after the removal of the rectum for adenocarcinoma. This last patient died from recurrence of the breast tumour without showing any signs of secondary growths from the rectal tumour. In addition, there is the patient already mentioned who had two growths present at the sametime. Both clinical and experimental evidence seem to prove Lhat one malignant tumour inhibits the development of another primary growth in the same individual. The :ases just quoted would seem to show that the inhibitory action does not always last very long--indeed, it is ques-ionable whether the incidence of cancer in these cases, as ~hown by four having developed a second growth, is

FIG. 61. Specimen of rectum removed by operation, s h o w i n g two separate primary growths. Probably arising simultaneously in previously existing simple adenomata, several of which can be seen in the lower part of the specimen. Microscopical sections cut from the subm u c o u s layer between the t u m o u r s showed no carcinoma cells.

much less than the normal incidence would be for patients of this age who had not had a growth before; but the figures are too few to draw any definite conclusions. In several cases there was direct evidence that the cancerous growth had developed in a simple adenoma which had been present for a number of years previously. I consider an adenoma of the rectum as a definite precancerous condition, to be dealt with as such.

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CLASSICARTICLES

FI(;. 62. A complete cancer of the rectum enlarged eight times. T h e original specimen was about 1 cm. in diameter, and projected like a little button in the rectal wall.

A specimen of one very remarkable case is shown in

Fig. 62. This growth was the earliest stage of cancer of the The actual difference between the amount of tissue removed by this operation (Fig. 63) and by the abdominoperineal route is very slight. A few more of the secondary glands in the base of attachment in the mesorectum and rather more of the pelvic peritoneum can be removed by the abdominal route; but it is very doubtful if in any case recurrence can be avoided once these secondary glands have become involved. T h e few more inches of pelvic

Dis. Col. ge Rect.

March1984

Ft(;. 63. Specimen removed by perineal excision, s h o w i n g th~ a m o u n t of tissue,

colon that are resected by the abdominal route probabl) make no difference as regards recurrence, since it is n o n k n o w n that spread along the bowel itself is very unusual beyond the immediate limits of the growth. Fig. 64 show.' the parts actually removed. rectum that I have ever seen. The actual growth was a little over '~ in. in diameter, and a section of the entire growth is shown in the figure in section magnified eighl times. Histological examination of this growth shows very strong probability that it started as a simple adenoma

Volume 27

Number3

CLASSICARTICLES

21

TISSUES REMOVED BY THE PERINEAL OPERATION. These consist of the entire rectum and a few inches of the pelvic colon, together with, in one piece, the skin surrounding the anus for an inch or more, the levatores ani muscles together with the pelvic fascia reflected on to them, most of the fat in the ischiorectal space and upper pelvic space between these muscles and the rectum, and the greater part of the mesorectum and all the glands lying in immediate relationship with the bowel. These are the tissues normally removed; but when rendered necessary or advisable from the nature of the case, the posterior part of the prostate gland and vesiculae seminales can be removed, and in the female the whole of the posterior vaginal wall, and even the uterus.

THE OPERATION. A detailed account of the operation will not be given here, as it has already been described several times, and the object of this paper is to analyse the results rather than to discuss the operative technique. The operation is done in two stages, a permanent colostomy being performed either a week beforehand or at the time of the resection. Either spinal or regional anaesthesia is used, aided by gas and oxygen or twilight sleep. The patient is placed in the semi-prone position, head down, and if a male a catheter is tied into the bladder. The anus is first closed with a purse-string suture passed subcutaneously with a curved needle, and an incision is made from the base of the sacrum, passing around the anus and about 1 in. from it. The coccyx is removed by dissection, and the deep fascia divided transversely just in front of the sacrum. Both levatores ani muscles are divided close to the pelvic wall with scissors, and the rectum is then dissected off the vagina in the female, or from the urethra and prostate in the male, until the peritoneum is reached. The peritoneum is opened, and as much bowel drawn down as possible. The mesorectum is clamped off as far back as can be managed, and divided. The clamps are tied off, and, after dividing the peritoneal coat of the pelvic colon and stripping it back for a short distance, the bowel is crushed and divided with a cautery. The stump is ligatured and turned in with a purse-string suture, and the w o u n d in the peritoneum closed with catgut stitches. The wound itself is closed without dTainage in most cases. In a few a small rubber wick is inserted. The w o u n d is not dressed for forty-eight hours, and then the blades of a pair of dressing forceps are introduced between two of the stitches, and any accumulated fluid allowed to escape. If the w o u n d remains quite clean, it is allowed to heal by first intention; but if the accumulation of serum continues, a stitch is removed, a small piece of

FIG.64. Drawingof actual specimen to show the tissues removedby perineal resection. Note the entire rectum and surrounding tissues, including levatores muscles and anal skin. (X2/3) drainage tube is introduced, and the cavity kept irrigated with weak Dakin or Milton solution. The patient is allowed out of bed on the fourteenth day, and is generally able to return home in from three weeks to a month. Operative Mortality.--In the 100 private cases there were 3 deaths, a mortality of only 3 per cent, while in the 100 hospital cases there were 14 deaths, a mortality of 14 per cent. The very marked difference between the mortality in private and hospital cases is due to several factors. T h e private cases are, of course, better nursed, as they all have special nurses who have no one else to attend to, while in the hospital the staff is more or less chronically overworked, and the same individual attention cannot be given. Probably a more important factor is that the ordi-

2 14

Dis. Col. g: Rect.

CLASSIC ARTICLES

n a r y h o s p i t a l p a t i e n t is n o t in such g o o d general condition. H o s p i t a l p a t i e n t s tend to c o m e u p for t r e a t m e n t in a m o r e a d v a n c e d state of the disease, they are n o t so well n o u r i s h e d , a n d are relatively o l d e r at the s a m e age as the result of h a r d work. A t a n y rate they do n o t seem to have the s a m e r e c u p e r a t i v e p o w e r s as the w e a l t h i e r classes. It is n o d o u b t a c o m b i n a t i o n of these factors w h i c h accounts for the difference. It is n o w m y practice to keep the h o s p i tal p a t i e n t s in bed for at least a week, a n d often l o n g e r , before o p e r a t i n g , in order to i m p r o v e their chances, a n d this seems to have c o n s i d e r a b l y i m p r o v e d the m o r t a l i t y risk. I t h i n k it is fair to c l a i m t h a t a 3 per cent operative risk is as g o o d as can be h o p e d for in a n y o p e r a t i o n for the r e m o v a l of the rectum; m o r e p a r t i c u l a r l y as the cases have been in n o sense p i c k e d ones, any cases where there seemed to be a fair p o s s i b i l i t y of safe r e m o v a l h a v i n g been s u b m i t t e d to o p e r a t i o n , irrespective of age a n d associated disease. T h u s n o fewer t h a n 72 p a t i e n t s were over 60 years of age, a n d 14 were over 70. As regards associated disease, 2 cases h a d Graves' disease, 1 h a d H o d g k i n ' s disease, 3 h a d diabetes, 3 h a d diverticulitis, 1 w o m a n of 48 h a d a n aortic aneurysm, 1 man had haemophilia. Causes of D e a t h . - - O f the three deaths w h i c h occurred in the p r i v a t e cases, two were f r o m h e a r t f a i l u r e a n d o n e f r o m c h r o n i c sepsis. T h e i r respective ages were 63, 75, a n d 54. T h e d e a t h s f r o m the h o s p i t a l cases were as follows: sepsis, 6; p u l m o n a r y e m b o l i s m , 1; h a e m o r r h a g e (one case of h a e m o p h i l i a ) , 3; shock, 1; p y e l o n e p h r i t i s , 1; d i l a t a t i o n of the s t o m a c h , 1; p n e u m o n i a , 2. I do n o t t h i n k that it is p o s s i b l e to keep the m o r t a l i t y figures for the h o s p i t a l cases as l o w as in the p r i v a t e cases, t h o u g h c o n s i d e r a b l e i m p r o v e m e n t is n o d o u b t possible. Even at the p r e s e n t time n e a r l y 80 p e r cent of all the p a t i e n t s c o m i n g u p to the h o s p i t a l for t r e a t m e n t are q u i t e i n o p e r a b l e w h e n first seen, a n d it is the very late stage at w h i c h these p a t i e n t s s u b m i t themselves for treatment, rather t h a n a n y t h i n g else, w h i c h d i m i n i s h e s their chances, as a g a i n s t the private cases, w h o are seen earlier. RECURRENCE

FIGURES.

I t h i n k I have been able to s h o w that the o p e r a t i o n risk is as l o w as can be h o p e d for f r o m a n y o p e r a t i o n for resection of the rectum; a n d the v a l u e of the m e t h o d , therefore, d e p e n d s u p o n its a b i l i t y to cure the p a t i e n t from the disease, as evidenced f r o m the recurrence rate. It is u s u a l to w o r k o u t recurrence rates o n a three-years basis; b u t I h a v e a l w a y s c o n s i d e r e d t h a t this is m u c h too s h o r t a p e r i o d , as u n o p e r a t e d cases often live as l o n g as this. A five-year basis is m u c h better, t h o u g h this, too, is n o t really l o n g e n o u g h . T h e difficulty, however, of w o r k i n g o u t figures for a n y p e r i o d l o n g e r t h a n five years is so great

March 1984

that I d o n o t t h i n k one can take a n y t h i n g b e y o n d a five-years basis. T h e f o l l o w i n g figures have been w o r k e d o u t o n the basis o f patients s u r v i v i n g the o p e r a t i o n a clear five years. T h e r e were 95 cases o p e r a t e d o n over five years ago. T h e s e w o r k o u t as f o l l o w s : - -

Cures on 5-years basis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Recurrences . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Died from other causes during the 5 years . . . . . . . . . . . . . . . . Untraced cases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Cases 45 37 6 7

Total.. 95

If we subtract the u n t r a c e d cases a n d those that d i e d of o t h e r causes, i.e., 14 cases, it gives us 82 cases w i t h 45 cures, or a p e r c e n t a g e of cures o n a five-years basis of 54.8. If, i n s t e a d of s u b t r a c t i n g the u n t r a c e d cases a n d 'died f r o m o t h e r causes' cases, we divide these i n t o their p r o b a b l e recurrence rate, w h i c h w o u l d be r o u g h l y 50 per cent, a n d a d d 7 cases to the cures, this w o u l d m a k e 95 cases w i t h 51 cures, or a p e r c e n t a g e of 53"6 cures. T a k i n g a three-years basis i n s t e a d of a five-years, there are 125 cases, w i t h 73 cures a n d 42 recurrences, w h i c h gives 55'5 p e r cent cures. T h e chances, therefore, of a p a t i e n t b e i n g alive five years after the o p e r a t i o n are over 50 per cent. If we n o w e x a m i n e these figures in a little m o r e d e t a i l we f i n d several i n t e r e s t i n g p o i n t s . A l l the cases were origi n a l l y d i v i d e d i n t o three classes, m a r k e d in the t a b l e - - A , B, a n d C. A: very f a v o u r a b l e cases where the g r o w t h was s m a l l a n d h a d n o t a p p a r e n t l y i n v a d e d the m u s c u l a r coat, a n d n o g l a n d s were involved. B: m e d i u m cases where there was i n v o l v e m e n t of the m u s c u l a r coat, b u t where the g r o w t h was n o t u n d u l y fixed a n d there was no extensive i n v o l v e m e n t of glands. C: very b a d cases, where the g r o w t h was large a n d fixed, or where there was evidence of extensive i n v o l v e m e n t of glands. T h e s e were b o r d e r l i n e cases w i t h a bad p r o g n o s i s . O u t of a total of 200 cases there were: 73 A cases, 96 B cases, 31 C cases. A n analysis of these three classes as regards recurrence is very interesting. T a k i n g o n l y the cases w h i c h were operated o n over five years ago, a n d l e a v i n g o u t u n t r a c e d cases a n d deaths from o t h e r causes, we find that the result is as f o l l o w s : - -

CASES

A cases B" C"

TOTAL

CURES, 5-YEARS BASIS

RECURRENCES

PERCENTAGE CURE

30 43 9

22 19 4

8 24 5

73"7 44"1 44'4

N . B . - - T h e u n t r a c e d a n d those w h o died of other causes have been subtracted f r o m the totals.

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Number3

CLASSIC ARTICLES

T h i s shows that with picked favourable cases the percentage of cures on a five-years basis is very high. T h e pity is that more cases are not operated on at this stage. T h e figures for the C cases are doubtless misleading, as they are too few; b u t they s h o w one very i m p o r t a n t point, namely, that such cases are well w o r t h o p e r a t i n g u p o n . These C cases all showed such extensive g r o w t h that recurrence seemed probable, a n d yet there were four cases w h i c h survived the five-year period, one even surviving 18 years. T h e a r g u m e n t deduced from this is that growths differ very m u c h as regards their liability to recurrence after removal. T h e r e is at present no means of estimating this liability in any individual case, n o r do we k n o w the reasons for it. A certain n u m b e r of apparently hopeless cases never get a recurrence, while some of the most hopeful ones do. It is this fact which is the strongest a r g u m e n t against extensive block resections as a routine treatment for carcinoma. While we should always remove the g r o w t h as freely as possible, compatible with reasonable safety, the facts do n o t seem to justify very extensive removal when this entails serious additional risk. T h i r t y - n i n e of the cases have been traced beyond the five-years period, a n d the following table shows w h a t h a p p e n e d to t h e m : - TABLE OF 39 CASES TRACED BEYOND 5 YEARS, SHOWING THE NUMBER OF YEARS THAT HAVE ELAPSED SINCE OPERATION. CASES

YEARS

1

..21

2 2 3

..14 ..11 . . 10

CASES

YEARS

3.

.

.

.

9

7. 8. 13 .

. . .

. . .

. . .

8 7 6

N . B . - - O u t of these 39 w h o lived b e y o n d the 5 years, 5 died between the 5th a n d 7th years from recurrence, but there are no k n o w n recurrences in any patients surviving beyond this period. DISABILITY

PRODUCED

BY OPERATION.

W h e n dealing with so serious and fatal a disease as cancer, disability after operation is a relatively u n i m p o r tant factor. It becomes important, however, w h e n comp a r i n g one m e t h o d of treatment with another. T h e disability w h i c h results from the perineal operation is entirely due to the presence of a p e r m a n e n t colost o m y o p e n i n g in place of the n o r m a l anus. T h i s is, of course, also true of the a b d o m i n o - p e r i n e a l operation.

2 15

This disability is not a serious o n e - - i n fact, n o t nearly so serious as m i g h t well be imagined. Patients are able to live comfortable a n d useful lives, a n d after the first few m o n t h s it is remarkable h o w little inconvenience the colostomy causes. T h e best way, perhaps, to estimate the disability is in reference to the w a g e - e a r n i n g capacity of hospital patients. We find that this is not diminished except in the case of very heavy labour involving strenuous exertion. T h e vast majority of patients were f o u n d to be still in the same e m p l o y m e n t as formerly. T h u s , o u t of 20 cases apparently cured by operation, 6 were w o m e n , 5 of w h o m did their housework, and 1 was a stationer's assistant. T h e r e were 14 men, of w h o m 10 were in full w o r k in the f o l l o w i n g o c c u p a t i o n s : p r i n t e r ' s cutter, fish-curer, schoolmaster, packer, tailor, pilot, messenger, waiter, platelayer, a n d odd-job man. T h r e e were living in retirement, being over 65 years of age; a n d one, w h o used to be a farm labourer, n o longer works. CONCLUSIONS. These figures show that w h e n the operation is performed u n d e r the most favourable conditions the mortality is only 3 per cent, a n d that the percentage of cures o n a five-years basis is 50 per cent; while where specially favourable, picked cases alone are dealt with, the p r o p o r t i o n of cures o n a five-years basis reaches the very h i g h figure of 73 per cent. T h i s compares most favourably with cancer of the breast or any other organ. It is only by the collection of a large n u m b e r of cases and publication of the results that we can arrive at any satisfactory j u d g e m e n t of the merits of any operation. T h a t n o statistics of this character are entirely satisfactory m u s t be admitted, for they do n o t show the w h o l e truth. T h e proper way in w h i c h such statistics s h o u l d be worked o u t is to take, say 500 consecutive cases of cancer presenti n g themselves for treatment, a n d show the n u m b e r of cases operated u p o n , the operative mortality, a n d the percentage of cures, based o n the original 500 cases. Such tables, if they could be worked o u t (as a matter of fact they cannot, as a large n u m b e r of inoperable cases do not reach the surgeon at all), w o u l d f o r m a useful guide as to the relative merits of different operative procedures. Unfortunately, they w o u l d show such a relatively low percentage of cures o u t of the total that they w o u l d be depressing reading. It is to earlier diagnosis that we m u s t look for any material i m p r o v e m e n t in our cancer cures from operation.

216

CLASSIC ARTICLES

TABLE

A = Very favourable.

SHOWING

B = M e d i u m cases.

RESULTS

AND

SUBSEQUENT

C = B o r d e r - l i n e cases.

Dis. Col. ~ Rect. March 1984

HISTORY

OF THE 200 CASES.

D = Death from operation.

R = Recovery from operation.

PRIVATE CASES.

Case

Y e a r of Operation

Sex a n d Age

T y p e of C a s e and Result

1

1905

M.

37

C.

R.

2 3

1912 1913

M. F.

60 68

A. A.

R. R.

4 5 6

1915 " 1916

M. M. M. F. M. M. M. M. M. M. F. M. M. M. M.

60 62 52 75 63 52 43 66 67 52 63 68 68 57 53

C. C. A. A. C. A. A. B. B. B. B. B. A. A. A.

B. R. R. R. R. B. R. R. R. R. R. R. R. R. R.

57 55 40

A. B. C.

R. R. R.

7

"

8

"

9 10 11 12 13 14 15 16 17 18

" " 1917 " " " " " " "

19 20

" 1918

21

"

M. M. F.

22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50

"

F.

62

A.

R.

" " " " " " 1919 " " " " " 1920 " " " " " " 1921 " " " " "

F. M. F. F. F. F. F. M. M. M. M. M. F. F. F. F. F. M. F. M. M. F. M. M. F. M. M. M. F. M. M.

58 50 50 36 70 56 44 56 72 51 64 54 54 52 42 60 43 51 63 72 61 54 61 52 53 62 69 60 58 51 47

B. B. B. B. B. A. B. B. B. B. B. B. C. B. A. B. A. C. B. A. B. B. A. A. A. A. A. A. A. C. B.

R. R. R. R. R. R. R. R. R. R. R. R. R. R. R. R. R. R. R. R. R. R. R. R. C. R. R. R. R. R. R.

" "

1921

51

"

52

1922

53

"

L e n g t h of S u r v i v a l a n d R e m a r k s 21 years: i n 1923 a n e w g r o w t h o c c u r r e d i n u p p e r p a r t of r e c t u m ; : the s e c o n d g r o w t h w a s excised 14 y e a r s 8 years: 4 years a f t e r h a d d u c t c a n c e r of breast, w h i c h w a s r e m o v e d ; d i e d in 1921 of a p o p l e x y 7 years: d i e d of h e a r t disease i n 1922 5 years: died of c e r e b r a l disease 2 years: died of r e c u r r e n c e 6 m o n t h s : d i e d of p l e u r i s y 2 years: r e c u r r e n c e i n liver 9 m o n t h s : d i e d of r e c u r r e n c e 9 years 9 years 2 years: died of p n e u m o n i a 2 years: r e c u r r e n c e 2B years: r e c u r r e n c e i n pelvis 6 months: probably recurrence Alive 5 years, u n t r a c e d later 8 years 7 years: d i e d of a s e c o n d p r i m a r y g r o w t h in c o l o n w h i c h r e c u r r e d after removal 8 years 8 years 6 years: r e c u r r e n c e i n v a g i n a 2 years: r e c u r r e n c e Alive 3 years later, b u t h a d r e c u r r e n c e Alive 4 years later, b u t h a d r e c u r r e n c e Alive 3 years, b u t r e c u r r e n c e i n c o l o n 1 y e a r later, r e c u r r e n c e in v a g i n a 1 year: d i e d f r o m c o m a ; n o l o c a l r e c u r r e n c e 7 years ( h a d G r a v e s ' disease f o r 20 years) 2 years: r e c u r r e n c e in l u m b a r g l a n d s 7 years 6~ years 6~ years: d i e d of r e c u r r e n c e 6 years ( h a d H o d g k i n ' s disease at t i m e of o p e r a t i o n ) 6 years 4 years: d i e d of r e c u r r e n c e 6 years 1 year: r e c u r r e n c e 6 years 6 years 1 year: r e c u r r e n c e in l u m b a r s p i n e 4 years: r e c u r r e n c e i n liver 5 years 5 years 2 years: r e c u r r e n c e 5 years 4 years 4 years 2 years: r e c u r r e n c e 4 years: d i e d of 'seizure': n o r e c u r r e n c e 4 years: d i e d of r e c u r r e n c e 3 years: died of r e c u r r e n c e ( h a d G r a v e s ' disease) F e w m o n t h s later l o c a l r e c u r r e n c e , d i e d after X - r a y b u r n 3 years: alive in 4 t h y e a r b u t h a s r e c u r r e n c e

Volume 27 Number 3

217

CLASSIC ARTICLES

TABLE S H O W I N G R E S U L T S A N D SUBSEQUENT H I S T O R Y OF T H E 200 CASES. ( C o n t i n u e d ) A = Very favourable.

B = M e d i u m cases.

C = Border-line cases.

D = Death from operation.

R = Recovery from operation.

PRIVATE CASES.

Case

Year of

Sex a n d

T y p e of Case

Operation

Age

a n d Result

L e n g t h of S u r v i v a l a n d R e m a r k s

54 55

" "

F. F.

46 39

A. C.

R. R.

4 years 2 years: r e c u r r e n c e

56 57

" "

M. M.

63 38

C. A.

D. R.

Sepsis 3 years: died 4th year, r e c u r r e n c e in liver

58 59 60

" " "

M. F. F.

46 47 75

A. B. C.

R. R. D.

4 years 3 years: r e c u r r e n c e ' H e a r t f a i l u r e ' 3 weeks after o p e r a t i o n

61 62 63 64 65

" 1923 " " "

M. M. M. F. M.

56 45 64 54 64

B. B. A. B. A.

R. R. R. D. R.

3 years 2 years: r e c u r r e n c e 3 years 'Heart failure' 3 years

66 67

" "

F. M.

63 59

A. A.

R. R.

3 years Died 1 year later of r e c u r r e n c e ( h a d diabetes a n d diverticulitis)

68 69 70

" " "

F. F. F.

60 70 68

A. B. C.

R. R. R.

3 years 3 years: diabetes 1 year: r e c u r r e n c e

71 72 73 74 75 76 77

" " " " " " "

F. M. F. F. M. M. F.

63 69 60 50 56 72 58

B. B. A. A. A. B. B.

R. R. R. R. R. R. R.

3 years 1 year: r e c u r r e n c e in liver Alive to date Alive to date Alive to date Alive to date Alive to date

78 79

1924 "

M. M.

73 62

B. B.

R. R.

Alive to date Alive to date

80 81 82 83 84 85 86

" " " " " " "

M. F. F. M. M. M. M.

65 59 71 64 59 64 67

B. B. B. B. B. B. B.

R. R. R. R. R. R. R.

Alive Alive Alive Alive Alive Alive Alive

to to to to to to to

date date date date date date date

87 88 89 90 91 92 93 94 95 96 97 98 99 100

" " " 1925 " " " " " " " " " "

F. F. M. F. F. M. F. F. M. F. M. F. F. M.

61 56 56 62 58 55 58 52 73 75 65 71 58 72

A. A. A. A. B. A. A. A. A. B. C. C. C. A.

R. R. R. R. R. R. R. R. R. R. R. R. R. R.

Alive Alive Alive Alive Alive Alive Alive Alive Alive Alive Alive Alive Alive Alive

to to to to to to to to to to to to to to

date date date date date date date date date date date date date date

H O S P I T A L CASES 101 102 103 104 105 106 107 108

1910 1911 1912 1913 " " 1914 1915

M. M. M. F. M. M. M. M.

56 59 61 59 58 62 53 49

B. A. C. B. B. A. B. B.

R. R. R. R. R. R. R. R.

Untraced 14 years 1 year: r e c u r r e n c e Died of r e c u r r e n c e Untraced Untraced 6 years: r e c u r r e n c e 11 years

2 18

Dis. Col. ~:Rect. March 1984

CLASSIC ARTICLES

T A B L E S H O W I N G R E S U L T S A N D S U B S E Q U E N T H I S T O R Y OF T H E 200 CASES. ( C o n t i n u e d ) A = Very f a v o u r a b l e .

B -----M e d i u m cases.

C = B o r d e r - l i n e cases.

D = Death from operation.

R = Recovery from operation.

PRIVATE CASES.

Case

Year of Operation

Sex a n d Age

T y p e of Case a n d Result

109 110 111

" " "

M. M. F.

61 50 43

B. B. B.

R. R. R.

1 year: died of t u b e r c u l o s i s 11 years 2~Ayears: r e c u r r e n c e

112 113 114 115 116

" 1916 " " "

F. F. M. M. M.

45 62 68 35 54

B. A. B. C. B.

D. R. D. D. R.

Shock 10 years Sepsis Haemorrhage (haemophiliac) 1 year: r e c u r r e n c e

117 118 119 120 121 122 123 124

" " " " " 1917 " "

M. F. M. M. M. M. F. F.

46 53 52 48 48 64 34 62

B. A. B. B. A. B. A. C.

R. R. R. R. R. D. R. D.

2 years: r e c u r r e n c e in liver 10 years 10 years 1 year: r e c u r r e n c e 9 years Sepsis 4 weeks after o p e r a t i o n Alive 5 years later, b u t h a d r e c u r r e n c e Sepsis

125 126 127 128 129 130

" " " " " 1918

M. M. M. M. F. M.

35 58 59 50 43 45

A. A. A. A. A. B.

R. R. R. R. R. R.

3 years: u n t r a c e d later 8 years 8 years Untraced 3 years: r e c u r r e n c e 6 years: r e c u r r e n c e in liver

131 132 133 134

" " " "

M. F. M. M.

57 48 47 47

B. B. B. A.

R. R. R. R.

2 years: died of r e c u r r e n c e 8 years Died of r e c u r r e n c e in 3rd year 2 years: died of cerebral h a e m o r r h a g e : n o r e c u r r e n c e

135 136 137 138

" " " "

M. M. F. F.

60 54 48 57

A. A. C. C.

R. R. R. R.

7 years 3 years: r e c u r r e n c e in liver 5 years: died of c a n c e r of breast 1 year: r e c u r r e n c e

139 140 141 142 143 144 145 146 147 148 149 150 151 152 153 154 155 156 157 158 159 160 161 162 163 164 165

" " " 1919 " " " " " " " " " " 1920 " " " " 1921 " " " 1921 " 1922 "

M. M. M. M. M. F. F. M. M. F. F. M. F. F. M. F. M. M. M. M. F. M. F. F. M. M. M.

50 62 57 66 50 26 60 46 29 56 59 54 63 48 66 61 52 59 63 57 43 55 59 53 28 56 58

A. A. A. A. A. A. B. A. A. B. B. B. C. B. B. B. C. B. B. B. B. B. B. B. C. B. B.

R. R. R. R. R. R. R. R. R. R. R. R. D. D. R. R. R. R. R. D. R. D. R. R. R. R. D.

2 years: r e c u r r e n c e U n t r a c e d since 1920 7 years 7 years 1 year: r e c u r r e n c e Untraced R e c u r r e n c e 2 years later in v a g i n a , died 4 years later 7 years 1 year: r e c u r r e n c e 9 months: recurrence 18 enonths: r e c u r r e n c e 2 years: r e c u r r e n c e A s c e n d i n g p y e l o n e p h r i t i s after cystitis Sepsis 6 years 1 year: r e c u r r e n c e (had diverticulitis) 6 years 6 years 1~ years: r e c u r r e n c e Sepsis 2 years: r e c u r r e n c e in liver Sepsis 4 years 2 years: r e c u r r e n c e in liver 2 years: r e c u r r e n c e 3 years, u n t r a c e d later Bronchopneumonia

L e n g t h of S u r v i v a l a n d R e m a r k s

Volume 27 Numlaer3

219

CLASSIC ARTICLES

TABLE S H O W I N G R E S U L T S AND SUBSEQUENT H I S T O R Y OF THE 200 CASES. ( C o n t i n u e d ) A = Very favourable.

B = M e d i u m cases.

C = B o r d e r - l i n e cases.

D = Death from operation.

R = Recovery I r o m o p e r a t i o n .

PRIVATE CASES.

Case

Year of Operation

166 167 168 169 170 171 172 173 174 175 176 177 178 179 180 181 182 183 184 185 186 187 188 189 190 191 192 193 194 195 196 197 198 199 200

" " " " " " " " " " " " " " " " " 1924 " " " " 1925 " " " " " " " " " " 1926 "

Sex a n d Age F. M. F. F. F, M. M. F. F. F. F. F. M. M. M. F. M. F. F. M. F. M. F. M. M. M. M. M. M. M. M. M. M. M. M.

48 59 53 38 64 66 54 72 74 66 59 56 60 61 53 66 65 56 53 63 60 40 65 51 63 64 58 55 73 60 62 51 51 63 63

T y p e of Case and Result C. B. B. B. C. A. B. C. B. B. B. B. A. A. C. B. A. B. A. B. C. C. B. A. B.. B. A. B. C. A. A. C. A. A. B.

R. D. R. R. R. R. R. D. R. R. R. R. R. R. R. R. R. R. R. R. D. R. R. R. R. R. R. R. D. R. R. R. R. R. R.

L e n g t h of Survival a n d R e m a r k s 4 years (had a o r t i c a n e u r y s m ) Pulmonary embolism 4 years 4 years 2 years: recurrence i n g r o i n ( h a d d i v e r t i c u l i t i s ) 3 years 1~ years: recurrence i n liver Pneumonia 1 year: recurrence i n liver 3 years 3 years 3 years Alive to date Alive to date Alive to date H a d diverticulitis: alive to date Alive to date Alive to date Alive to date Alive to date Haemorrhage Alive to date Alive to date Alive to date Alive to date Alive to date Alive to date Alive to date D i l a t a t i o n of s t o m a c h Alive to date Alive to date Alive to date Alive to date Alive to date Alive to date

REFERENCES

HOFFMAN,F. L., The Mortality of Cancer throughout the World, 1915. LOCKHART-MtJMMrRY. P., " C a n c e r a n d H e r e d i t y " , Lancet, 1925, Feb. 28, 427. D u ~ : s , C., " R e l a t i o n of S i m p l e to M a l i g n a n t T u m o u r s of the L a r g e Intestine", Proc. Roy. Soc. Med. (Proctol. Sub-Sect.)., 1926, Jan. DUKES, C., " R e l a t i o n of S i m p l e to M a l i g n a n t T u m o u r s of the L a r g e Intestine", Brit. Jour. Surg., 1926, xiii, April.

Acknowledgments The Editor is grateful to Professor J. C. Goligher, Leeds, England, for suggesting this article, and to Mr. Ian P. Todd, London, England, for procuring the photo-

graph of Mr. Lockhart-Mummery. Finally, the Editor is most grateful to Miss Elizabeth McChristie, research associate, Reeves Medical Library, Santa Barbara Cottage Hospital, Santa Barbara, California.

Bibliography L o c k h a r t - M u m m e r y . T w o h u n d r e d cases of cancer of the r e c t u m treated by p e r i n e a l excision. Br J Surg 1926-1927;14(53):110-24. B i o g r a p h y - - M o r s o n BC. S o m e p r o m i n e n t personalities in the history of St. M a r k ' s H o s p i t a l . Dis C o l o n R e c t u m 1962;5:173-83. Obituary. John Percy Lockhart-Mummery. Lancet 1957;272:938-9. O b i t u a r y . J P L o c k h a r t - M u m m e r y . Br M e d J 1957;1: 1066-7.