CLOSURE OF ILEOSTOMY IN ULCERATIVE COLITIS* RICHARD B

CLOSURE OF ILEOSTOMY IN ULCERATIVE COLITIS*RICHARD B. CATTELL, M.D.

BOSTON, MASS.FROM THE DEPARTMENT OF SURGERY, THE LAHEY CLINIC, BOSTON, MASS.

THE SURGICAL TREATMENT of ulcerative colitis has been a recent develop-ment with sporadic cases operated upon previous to I930. During thelast decade there has been much interest and progress. The problem con-fronting surgeons at the beginning of this period was first, to determinewhat patients could be benefited or saved by surgery, and second, to convinceinternists under whose care these patients naturally fall, that surgery shouldnot be used solely as a last resort. Through the work of McKittrick, Cave,Stone, Ladd, T. E. Jones, Lahey, the author and others, it has now beeniaccepted that good results follow the employment of ileostomy, partial colec-tomy, and total colectomy, and that other operations are ineffective andshould be discontinued. The medical treatment of ulcerative colitis has beenshown to be unsatisfactory in approximately one-half of all cases. Kiefer,'in a report from the Lahey Clinic, found that patients who had been undermedical treatment and followed for five years or more gave unsatisfactoryresults in 43 per cent. Ileostomy has been necessary in many of these cases.In spite of improvement in the surgical treatment, there has been no generalacceptance of definite indications for ileostomy or uniformity in the timethat ileostomy has been elected.

This paper will present our indications for ileostomy and recommend earlyileostomy in patients with severe ulcerative colitis in order to obtain theearliest possible remission before irreversible structural changes in the colonoccur. Early ileostomy is urged so that the ileostomy may be disconnected,restoring the continuity of the intestinal tract in some patients. Therehas been a long period of trial for medical management. There has beensufficient experience with ileostomy in late cases to know what results canbe expected and in these cases ileostomy must be permanent. Early ileostomyand later closure of the ileostomy has not been given a trial in adult cases. Atthe Children's Hospital in Boston, Ladd and Gross2 have closed the ileostomyof seven children. Stone5 reported the closure of five cases in I929.

Both internists and surgeons have hesitated to advise ileostomy since sodoing, in the past, has accepted a permanent fistula of the small intestine.Those not familiar with the management of ileostomy in these cases frequentlyconsider it an intolerable situation, and one that is inconsistent with produc-tive activity. That this is not the case has now been established.3 Neverthe-less, if an ileostomy could subsequently be disconnected with safety and with-out serious recurrence of the disease, this would constitute an importantforward step. It should be emphasized, however, that an attempt to restoreintestinal continuity by anastomosis of the proximal ileum to a portion of the

*Read before the American Surgical Association, Cleveland, Ohio, April 6-8, 1942.956

Volume 115Number 6 TREATMENT OF ILEOSTOMY STOMA

large intestine involved with ulcerative colitis, either in the infective or healedstate, should be condemned. In one of Doctor Lahey's early cases in whoma satisfactory remission was obtained but rectal stricture resulted, ileostomywas taken down elsewhere, anastomosing the ileum to the sigmoid colon,against his advice. An operative death followed because of peritonitis. Eventhough obstruction is not present, the anastomosis utilizing involved colon isalmost certain to leak.

We have previously stated in a number of communications4 that once anileostomy is accepted it must always be maintained. There are additionalreasons why we previously considered an ileostomy as permanent. In ourearlier cases it was performed only in the complicated, advanced cases, usuallywith marked cicatricial changes in the colon. Furthermore, as soon as theileostomy is made an even further contraction of the colon occurs from dis-use. With clinical remission and healing of the colon as the result of ileostomy,contraction is inevitable. For this reason we do not believe there can beany appreciable change in the policy regarding ileostomy for advanced cases.As previously stated, there has been no clinical trial of disconnecting ileos-tomies in adults. For this reason we decided to take favorable cases in whichileostomy was definitely indicated, and if satisfactory response was obtained,disengage the ileostomy. After demonstrating this in favorable cases (CasesI-5), less favorable and unfavorable cases were then tried (Cases 6-9), butno anastomoses of the involved colon have been performed.

INDICATIONS FOR ILEOSTOMY

In order to be able to review critically cases in which ileostomies havebeen taken down, it is necessary to outline our indications for ileostomy inulcerative colitis, since obviously if ileostomy were selected for mild cases,closure could be employed with fair frequency. In these, however, medicaltreatment is usually satisfactory. The indications for ileostomy in our clinicare as follows: (i) Acute fulminating cases, either in a first attack or withrecurrent acute attacks; (2) medical failures, including those patients whoare incapacitated; (3) massive hemorrhage; (4) subacute perforations, ab-scesses, peritonitis or fistulas; (5) obstruction; and (6) polyposis includingthose cases with possible malignancy.

SELECTION OF CASES FOR CLOSURE

We have used three means in selecting cases for closure of ileostomy:(I) We have felt that a clinical remission of symptoms should be maintainedfor an appreciable period. (2) The inflammatory process must be shown tohave healed and be inactive, as observed by sigmoidoscopic examinations.The mucosal surface may still be granular or scarred and may even bleedsomewhat on manipulation with a swab, yet any evidence of active infectioneliminates the case from closure. (3) The colon must be shown to be dis-tensible by means of a barium enema or double contrast air enema. (Figs.i and 2.) Some haustral markings should still be demonstrable, at least in

957

Annals of SurgeryJune, 1942RICHARD B. CATTELL

FIG. I.

FIG. 2.FIG. I.-Case 2: a. The full barium enema taken November IO, 1938, six weeks

after ileostomy. The sigmoid, rectosigmoid, and right colon distend readily. The re-mainder of the colon is narrowed but with suggestion of haustral markings. This ischiefly the contracture of disuse as a result of ileostomy.

b. The empty film shows excessive emptying and spasm, with some irregularity ofthe mucosa. The sigmoidoscopic examination was negative at this time. This is afavorable situation for closure of ileostomy.

FIG. 2.-Case 2: a. and b. The full and empty barium enema, taken February 23,1939, three months after closure of ileostomy. Full distensibility and flexibility aredemonstrated. The ileocecal valve is incompetent.

the film taken after evacuation of the enema. Haustral markings may beabsent in the full enema. An adequate lumen and absence of any local areasof obstruction must be demonstrated. The mucosal pattern should not showpseudopolyposis or too irregular an outline. The following case report willwell illustrate the type of serious case of ulcerative colitis in which closurehas been carried out (Case 4).

Case Report.-This patient, a man, age 25, first came to the clinic on February I9,1934, to be examined for possible heart trouble. He was found to have a small, right,

958


indirect inguinal hernia. No heart disease was found. In August, I934, he reported thathe was getting along well except that the hernia was larger. He returned to the clinicin July, I937, because of difficulty in swallowing. At this time, a complete gastro-enterologic study was carried out, and a diagnosis made of cardiospasm and nervousexhaustion. Complete examination of the blood, the Hinton test, gastric analysis, fluoro-scopy of the stomach, gallbladder test and barium enema were all negative. There wasno evidence of ulcerative colitis on roentgen examination after a barium enema.

In Janiuary, I940, the patient had severe low abdominal pain, rectal bleeding andfever. Three weeks before his admission to the hospital hemorrhoidectomy was per-formed, following which he had severe intestinal cramps and passed many liquid, bloodystools daily. He had been on a strictly limited diet, chiefly of carbohydrates, for sevenmonths. The diagnosis was ulcerative colitis, thrush, and avitaminosis. Agglutinationtests for undulant fever and dysentery were negative. The Widal reaction for typhoidand paratyphoid disease was negative. Stool cultures on repeated occasions showed alarge amount of yeast, B. coli, Staphylococcus aureus, and streptococci. An ischiorectalabscess was present, and this was drained the following day. The culture from the pusshowed Staphylococcus aureus and B. coli. He continued to pass a large amount of pusand blood by rectum. Multiple skin furuncles and ulcers of his mouth developed. Thehigh fever persisted; three blood cultures were negative. He was considered too ill toexamine by means of a barium enema. Proctoscopy showed the typical findings ofacute ulcerative colitis. Treatment with sulfathiazole did not alter his fever or symptoms.

Ileostomy was performed February 7, 1940, without abdominal exploration. Animmediate decompression of the ileum was effected. The patient received a blood trans-fusion on that day, on March ii, and on March _i6.: Pain developed in the right lowerquadrant, followed by the production of an abscess, and later a pelvic abscess developed,which ruptured spontaneously into the bowel. On May 29, a roentgenogram of hiscolon showed little change in the bowel except in the rectal region. After another bloodtransfusion he was discharged from the hospital in greatly improved condition on JulyI9, four and one-half months after admission.

The patient was reexamined on October I9, 1940, at which time there was a sinusaround the ileostomy. On proctoscopic examination there seemed to be adequate sphinctercontrol; the mucosa was entirely normal. There was no discharging pus. A bariumenema showed good flexibility. The mucosal pattern was found to be within normallimits throughout (Fig. 3).

On October 3I, the ileostomy was resected, draining a small chronic abscess of theabdominal wall, and a side-to-side anastomosis of the terminal ileum was performed.Sulfanilamide powder was placed in the wound and the peritoneal cavity. The colonappeared to be within normal limits. There were congenital polyps of the distal smallintestine.

On December 20, 1940, after a barium and air enema, roentgenologic examinationwas negative (Fig. 4). On November I0, I941, more than a year after operation, thepatient weighed I76/2 pounds, was well, and had no bleeding. Rectal and proctoscopicexaminations gave negative results. He had one formed stool a day. The abdominalwound was firmly healed.

In January, I942, while working in an airplane factory, the patient was badly burnedabout the face, hands, and shoulders in an explosion, but he made a good recovery.

March 25, 1942, he had recovered without recurrence of the ulcerative colitis.

CLINICAL DATA

We have closed the ileostomy in nine patients. The first patient was aboy I i years of age whose ileostomy was closed in 1935 (Case i ). He had amild recurrence the third week after closure but has been quite well since, fora period of over six years. Our second case was a man, age 38 (Case 2),

959

Annals of SuirgeryJ u n e , 1 9 4 2RICHARD B. CATTELL

FIG. 3-

a

&L

FIG. 4.FIG. 3.-Case 4: a and b. The full and empty barium enema, taken October I5,

1940, eight months after ileostomy. The findings suggest complete healing, with thecontracture of disuse due to ileostomy. The proctoscopic examination was negative atthis time.

FIG. 4.-Case 4: a and b. The full and empty barium enema taken December 20,I940, approximately two months after closure of ileostom-y. Except for a more rapidemptying time and spasm, the findings approach those of a normal colon.

with a very acute, fulminating form of ulcerative colitis as a first attack. Hisileostomy was closed in November, I938. He was well for two years andthree months, and then had a moderate recurrence at the time of an acuteupper respiratory infection. Since that period when he had medical treat-ment he has been well. During I939, I940, and I94I, seven additional caseshave been closed. During this period of three years, 50 ileostomies wereperformed, with five deaths, an operative mortality of io per cent. In thegroup of 45 patients who survived the operation of ileostomy, seven havebeen closed, or I5.5 per cent of those surviving operation and I4 per centof all ileostomies during this period. Twelve patients still have their ileostomy

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and are being carried along under medical observation. Some of these arebeing followed with the expectation that their ileostomies may be closed.

In our group of nine patients, there was one child of I I, who was theyoungest of the group; the oldest was 56. The ages of the remainder wereI9, 20, 2I, 26, 31, 38, and 44. The ages of these patients agree with thegeneral age-group of patients suffering with ulcerative colitis, those of ayoung adult group. Seven patients were men and two were women. I thinkwithout question that the large group of males is partly due to insistence ontheir part that the closure be done so that they could return to work witlhoutileostomy, since the sex distribution of our cases of ulcerative colitis isabout even.

TABLE I

Dura-tion of

Age Dura- Medical Condi- Ile-and tion of Treat- Date of tion of Date of ostomy

Case Sex Colitis ment Indication Ileostomy Colon Closure Present ResultI II 5 mos. I mo. Med. failure II/ 7/34 Favor- 8/13/35 9 mos. Well (mild recurrence 3

M. able wks. after closure)2 38 5 mos. 7 days Mel. failure 8/23/38 Favor- II/22/38 3 mos. Well (mild recurrence

M. able February, 1941)3 21 2 mos. 5 days Hemorrhage 1/26/39 Favor- 6/2I/39 5 mos. Very well

F. able4 3I 3 wks. 7 days Acute fulmi- 2/ 7/40 Favor- I0/3I/40 8 mos. Well

M. nating, ableabscesses,fistula

5 56 5 wks. I8 days Med. failure 5/17/40 Favor- II/26/40 6 mos. Well (recurrence,M. able October, I941)

6 44 4 mos. 36 days Abscess, 12/ 2/40 Unfav- 5/i6/41 5 mos. Improved but severalM. fistula orable stools daily

7 20 3 yrs. 21 mos. Mel. failare I/IO/3( Unfav- 5/26/4I 28 mos. Failure from obstruction,F. orable malnutrition; new ile-

ostomy 3/24/428 I9 3 mos. I mo. Generalized 4/ 9/40 Unfav- I0,/28/41 I8 mos.- Improvedbutmanystools

M. peritonitis orable daily9 26 6 yrs. 3 mos. Reg. ileitis, 9/1I/40 Unfav- IT/ 8/41 I4 mos. Failure from colitis; new

M. recurrent orable ileostomy 2/9/42acute

Only one of our nine patients had had ulcerative colitis for under onemonth. This was an acute case that had had ulcerative colitis for three weeksand been under treatment for seven days. Many patients with the acute,fulminating form die from their disease even though ileostomy is acceptedearly. Six of the patients had had their disease one to six months. Theyrepresent a group of serious cases and yet have not had their disease so longthat the colon had been unalterably changed. One patient had had ulcerativecolitis for three years and was a definite failure after closure, as was thepatient who had had ulcerative colitis for six years.A consideration of the indications for ileostomy in this group of nine

patients is of interest. Referring to our group of indications for ileostomywe find that ileostomy was elected for the following reasons: (i) Acute,fulminating, one; (2) medical failure, four; (3) hemorrhage, one; (4) infec-tion, two; (5) obstruction, one; and (6) polyposis or malignancy, none.

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RICHARD B. CATTELL Annals of Surgery

In addition to determining the duration of the ulcerative colitis, it isimportant in this group of cases to know the duration of the medical treatment,which was as follows: One to seven days, three; one to four weeks, three;one to three months, two; 2I months, one. The latter case was a failure.

As we first considered the possibility of closure of ileostomy, we felt t.hata long period of time should elapse before considering closure. These patientshad their ileostomy from three to 28 months, the latter one being a failure.Four patients had ileostomy for six months or less; two patients had ileostomyfor six to I2 months, while one each had their ileostomy for 14 months,i8 months and 28 months. The patients having ileostomy for I4 monthsand 28 months were failures, while the one having it for i8 months wasunimproved -after closure.

, < . :.^ },f, . - _ -f: ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

FIG. 5.-Case 8: a. The full barium enema taken i8 months after ileostomy. Thereis foreshortening of the colon with both flexures drawn downward, with little flexibilityor distensibility. The mucosal outline is irregular.

b. The empty film shows rapid emptying of the distal half of the colon with re-tention of barium in the proximal colon. This is an unfavorable case for closure.

RESULTS

There was no operative mortality in this group. The fact that restorationof their intestinal tract was accomplished by anastomosing normal ileum andnot any part of the bowel involved with ulcerative colitis is, we believe, respon-sible for the fact that these cases were closed without complications ormortality.

The results of ileostomy in this group of seriously ill patients were good.In other words, clinical remission was obtained or the symptoms for whichileostomy was elected, were relieved in all nine patients. However, whenthe ileostomies were disconnected, the results were by no means as satisfac-tory. Two patients have had complete relief of their disease. One of these-was a patient who was operated upon for hemorrhage (Case 3), anid the otherwas a patient who had pelvic 'peritonitis from a subacute perforation (Case4). Three patients had a mild recurrence on one occasion and with further

962


FIG. 6.

i:

FIG 7.FIG. 6.-Case 9: a and b. The full and empty barium enema taken July 1s 1940,

after a modified Mikulicz resection of the ileum and a portion of the right colon forregional ileitis. There is no evidence of ulcerative colitis at this time.

FIo. 7.-Case 9: a and b. The full and empty enema taken October 5, I941, 13months after ileostomy. There is marked contraction, foreshortening, irregular mucosaloutline, and rapid emptying. This is an unfavorable case for closure and required asecond ileostomy.

medical treatment have remained well (Cases I, 2 and 5). We considerthese five patients to have a satisfactory result. Two patients have con-tinuing bowel symptoms without recurrence of fever, but are able to work(Cases 6 and 8). Both of these patients should be considered to be unim-proved so far as ileostomy closure goes. Probably ileostomy was responsiblefor obtaining their clinical remission, but because of cicatricial changes inthe colon (Fig. 5), they have mild, obstructive symptoms or have frequentbowel movements daily. Two patients had complete failures and have had

963

RICHARDB. CATTELL ~~~~~~Annals of SurgeryRICHARD B. CATTELL J u n e, 1 9 4 2

a new ileostomy performed. One of these had had the disease for three years,and the ileostomy was kept open for 28 months (Case 7). The other patienthad had trouble for six years, and the ileostomy was kept open for I4 months(Case 9). One failed because of definite obstruction and malnutrition, with-out evidence of active infection, while the other failed because of definiterecurrence of ulcerative colitis.A consideration of these cases demonstrates clearly that the best results

can be anticipated in those patients in whom ileostomy has been done rela-tively early, since the favorable results in this group of nine patients wereclearly in a group of cases in which early ileostomy was decided upon. Apatient, recently operated upon, demonstrates this quite well. She had beenobserved for a period of two years, during which time she has had two longperiods of medical treatment in the hospital. The barium enema at the timeof the initial treatment (Fig. 8 a) shows an enlarged, dilated colon, with asmooth outline. After evacuation of the enema, spasm and contraction wereseen in the distal half of the colon, with satisfactory haustral markings in theproximal two-thirds of the colon (Fig. 8 b). Two years later, when she hadvery unsatisfactory results from medical treatment, the barium enema showedmarked contraction and foreshortening of the colon, with both splenic andhepatic flexures drawn downward. There were no haustral markings eitherbefore or after the enema and the mucosal pattern was definitely irregular(Fig. 9 a and b). Since we did not elect ileostomy two years ago, we havelost any chance of restoring continuity in this patient. Ileostomy was per-formed March 24, 1942. There will be further contraction to produce thetypical "lead-pipe colon" in this patient within three to six months afterileostomy. If she still continues to have symptoms, total colectomy will benecessary. The clinical story and roentgenograms in this patient demonstrateclearly our reasons for recommenidilng early ileostomy in serious cases ofulcerative colitis.

Any patient who is not doinig well on medical treatmenit, continuing tolose weight, run fever, and witlh excessive stools, should have ileostomy.Patients with the acute, fulmiiinating form of the disease who do not respondto medical management withinl the first five to seven days should have ileos-tomy. In the acute, fulminiating cases ileostomy should be done in all ofthem whether it is the first attack or a recurrent acute attack, unless theyhave a rapid response to treatment. In our group of nine patients, closureof ileostomy was possible in patients who were done as recommended. Webelieve in spite of a limited experience that definite evidence has been pre-sented to show that closure of ileostomy can be done in specially selectedcases where ileostomy has been done reasonably early. Approximately 25per cent of all cases of ulcerative colitis will require surgical treatment.Closure seems possible in approximately IO per cent of operated cases. Ifthe indications for ileostomy are extended and if ileostomy is decided uponearlier, this figure may be increased.

964

TREATMENT OF ILEOSTOMY STOMA

FIG. 8.

...

i @_l.... ........ <.X.- l S b ^- .....

* . _ ..

... :.. ze | = .....

.'.C.'<....>.jl. ... . . _ .

.:...;..i I

FIG. 9.

FIG. 8.-a. The full enema of the colon of a young woman with a severe, first,acute attack of ulcerative colitis. The outline of the mucosa is smooth, with a sugges-tion of haustral markings. There is no contraction.

b. With the empty film there is excessive emptying of the distal half, with reten-tion of barium in the proximal half of the colon. This is the ideal roentgenogramfinding for early ileostomy with a chance of subsequent closure.

FIG. 9.-a and b. After recurring, acute attacks and several periods of medicaltrial utilizing all conservative means, the colon is now foreshortened and contracted,with a smooth outline. Ileostomy was necessary because of medical failure. There isnow no prospect of subsequent closure.

SUMMARY AND CONCLUSIONS

The present status of the surgical treatment of ulcerative colitis is re-

viewed, and the surgical indications for ileostomy are presented.Closure of ileostomy has been carried out in nine patients, with satis-

factory results in five. Two continue to have symptoms sufficient to make965

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RICHARD B. CATTELL Annals of Surgery

them unsatisfactory, and two were complete failures, and a second ileostomywas required. There were no operative deaths.

Early ileostomy for patients with serious ulcerative colitis is recom-nmended when medical treatment fails, in order to obtain the earliest possibleremission before irreversible structural changes in the colon occur. It is inthis grouip that later closure of the ileostomy can be considered.

BIBLIOGRAPHY

'Kiefer, E. D.: Clinical Results in the Medical Treatment of Chronic Ulcerative Colitis.Am. Jour. Diges. Dis., 3, 56-59, I936.

2 Ladd, W. E., and Gross, Robert: Personal communication.3 Cattell, R. B.: Management of Ileostomy and Colostomy. Proc. Inter-State Postgrad.

Med. Assem. North America, pp. 67-7I, I940.4 Cattell, R. B.: Chronic Ulcerative Colitis and Its Surgical Management. Proc. Inter-

State Postgrad. Med. Assem. North America, 1938.Idem.: The Surgical Treatment of Ulcerative Colitis. Lahey Clin. Bull., I, 2-I0,

September, I939.5 Stone, H. B., Chronic Ulcerative Colitis. Penn. Med. Jour., January, I929.

DISCUSSION.-DR. HENRY W. CAVE (New York): To condemn an individual,particularly the young, to permanent ileostomy is a serious decision. We all recognizethat the mortality after ileostomy is approximately 20 per cent; due to the fact thatboth the physician and the gastro-enterologist, knowing the disease to be a cyclicallyrecurring one with phases of convalescence and quiescence, hope for a remission. Thusthey wait and wait, until the call for emergency surgery in desperately ill patients issent out; after hemorrhage, septic fever, dehydration, and total lack of any type of re-sistance to infection have taken their toll.

Doctor Cattell, no doubt realizing the profound morbidity of this disease, and thediscomfiture of an abdominal fecal fistula is convincing, I feel, in his presentation thatearly ileostomy is justified; and that in selected cases the ileal stoma can be taken downand fecal continuity restored.

We must be cautious in advising early ileostomy only when it is beyond questionthat the patient is suffering from a true ulcerative colitis, as we know it, and not fromamoebic or bacillary dysentery, or milder form of colitis which is amenable to medicalmanagement.

To obtain "the earliest possible remission before irreversible changes have takenplace" in severe ulcerative colitis, the earlier the ileostomy the greater the chance of com-plete permanent restoration of the fecal stream.

Doctor Cattell has been fortunate in having turned over to him six of the ninepatients (whom he closed later) with the disease existing for a period not longer thansix months. I have had no such luck. All of the 45 patients to whom I have givenan ileostomy, except three (who had massive hemorrhages, and who were of the acute,fulminating group, and who died after ileostomy), had irreversible changes before Ihad been given the opportunity of diverting the fecal flow. I believe that he is right,without question, when he states "that an attempt to restore intestinal continuity byanastomosis of the proximal ileum to a portion of the large intestine involved withulcerative colitis, either in the infective, infectious or healed stage, should be condemned."Also, I am in complete agreement with his "policy regarding permanent irrevocableileostomy for advanced cases."

I am not in accord with all of Doctor Cattell's indications for ileostomy in ulcera-tive colitis-particularly in reference to massive hemorrhage. We have had a 50 per centmortality where we have given ileostomy to patients in the acute, fulminating stage,accompanied by massive hemorrhage. It is my opinion, that the mortality can belowered considerably, if, by the use of papaverin hydrochloride, belladonna and repeatedtransfusions, they can be carried through this desperate stage of hemorrhage and convertedinto a more chronic form.

To me, it is of especial interest to learn of Doctor Cattell's criteria for selection ofcases for closure of ileostomy. The first, a clinical remission of symptoms followingileostomy; and that accompanying medical treatment should be maintained for an ap-preciable period. By this appreciable period, I assume he means from six to eight months

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Volume 115 TREATMENT OF ILEOSTOMY STOMANumber 6

or even longer, and I should like to ask Doctor Cattell if he has used either sulfalylguanidineor sulfasucidine in irrigating out the colon or has given orally the other sulflylonamidesduring this waiting period. Secondly, that the inflammatory process must be shownto have healed and to be inactive, as observed by sigmoidoscopic examination. I havefound it difficult to determine accurately how inactive the process is by the use of thesigmoidoscope. So many patients seem to be in the quiescent stage and yet the slightestirritation from the insertion of the sigmoidoscope will produce bleeding, and a granularmucosal surface will exist indefinitely. Thirdly, the distensibility of the colon by meansof a barium enema or double contrast air enema; and also that the haustral markingsshould be demonstrable, "at least in the film taken after evacuation of the enema." Tome, the presence of haustral markings in the entire colon after evacuation of the enemawould indicate a reasonably favorable and successful closure. Needless to say, as he hasstated "that if the mucosal pattern shows a pseudopolyposis or a too regular outline,closure would be out of the question." He states that one of the series of nine patientswho had the disease for three years was a definite failure after closure and, also, he statesthat another patient, ill for six years, proved a failure after closure. It seems to me thatthese two failures should have been expected.

The duration of the medical management before operation was short, "one toseven days, three; one to four weeks, three; one to three months, two; 2I months, one."Ninety per cent of the patients in my own series have been treated for a much longerperiod. There was no operative mortality in this group of nine that he closed. May Iask what type of ileostomy was carried out? Was it divided or end-ileostomy, or wasit a loop-ileostomy? It would seem to me that, particularly in the acute, fulminatingtype, of which he had one, and of the massive hemorrhage type, of which he had one,that loop-ileostomy would be less hazardous.

In all nine of the patients, ileostomy showed a clinical remission of the disease "butwhen the ileostomy was disconnected the results were by no means as satisfactory." Twoof the patients were complete failures and had to have new ileostomies performed. Evenwith these failures, I believe that to have had five of the nine patients with satisfactoryresults justified the procedure of early ileostomy and subsequent closure of the opening.

I wish to congratulate Doctor Cattell in his fine presentation, for I am sure it is astep forward in the treatment of this devastating disease. Ileostomy, at its best, is as-suredly undesirable; and any method, program or maneuver that can eliminate it, is tobe commended.

DR. WILLIAM E. LADD (Boston, Mass.): I am a little bit in the position thatDoctor Oughterson put Doctor Harvey in yesterday, because Doctor Gross is lookingup our data at the Children's Hospital on ulcerative colitis, but I have not been permittedto see them yet, so I do not have all the data at hand.

I think we have not felt justified in undertaking an ileostomy quite as early asDoctor Cattell has. In children it is, I think, fairly difficult to group the cases intothe ones that may possibly recover as the result of prolonged medical treatment and thecases that will never recover as a result of prolonged medical treatment. So we have notfelt quite justified in performing ileostomy as early as some of Doctor Cattell's cases.However, I think we have established them perhaps earlier than some others have.

We have had seven cases which we have closed after leaving the ileostomy function-ing for quite a long period of time, I think a good deal longer period of time thanDoctor Cattell has used. I do not think we have closed any prior to the ileostomy havingfunctioned for at least two years. I think that these seven cases that have been closedhave all remained well. I know that in one case I closed I 2 years ago, I had a letterfrom the patient two or three weeks ago, saying that she was perfectly well and askingwhether we thought it was advisable for her to get married, having had her previoushistory. I advised her to get married, and I presume she has.

There is one unfortunate case which we had, that I think perhaps is quite as im-portant as the clinical observation on the cases that we have closed. This case was aboy of about six, who had an ileostomy, which had been open for about two years.I had examined him by the sigmoidoscope, and I thought he was a suitable case forclosure, and I had made an appointment for him to come into the hospital to have itundertaken. In the interim, he developed a volvulus from which he died. We had apostmortem examination, and a very careful examination of the colon showed it tobe completely healed. It seems to me that this is really a very important piece of data.

Now I think there may be some of you who are not familiar with the fact that this967

RICHARD B. CATTELL Annals of SurgeryRICHARDB.CATTELL ~~~~~~~June 1 94 2

disease occurs in very early life at times. We have had three cases in the first six monthsof life. Of these, one had an ileostomy which was closed, and I think that was aboutthree years ago. That child is quite all right. One has had an ileostomy, and on fre-quent examinations we have not felt justified in closing it, as there is still evidence ofthe disease persisting in the colon. The third was kept on our medical ward and wasnot correctly diagnosed by our medical colleagues, and died. The postmortem examina-tion showed a typical ulcerative colitis, with perforation, and death from peritonitis.

DR. FRANK K. BOLAND (Atlanta, Ga.): I would not rise again, except for thereference which was made to what I said about ulcerative colitis in the Negro.

It is true that the colored race had very few cases of this condition. As a matterof fact, I have seen only two or three in a long period of time. But I am familiar withtwo cases of ulcerative colitis which apparently were cured by one of the sulfonamidedrugs, called by our friend, Doctor Gage, "sulfa-cure-all drugs." That seems to be agood name. I did not think that was so important, but when I heard from one ofthe most eminent colon surgeons in our country that the use of these drugs had almosteliminated the necessity for operation, I felt that something new was here, and that isthe reason it was mentioned in the paper.

I would like to say, in this connection, a word about these drugs. I think thereare two things which should be considered in evaluating a drug or any procedure, andthat is not only the number of cases in which you have used it but also the length oftime which has elapsed since the procedure came into use.

For instance, you all recall how enthusiastic we were in World War I about theuse of the Carrel-Dakin treatment. We thought that was fine, and it did seem to befine. But I heard some gentlemen recently, who had treated and seen some of the patientsat San Francisco who had come from Pearl Harbor, tell the valuable, wonderful resultsof sulfathiazole treatment of wounds. Several of them seemed to think: "We will nothave to use that Carrel-Dakin treatment any longer." I hope they will not be sayingthat 20 years from now about the wonderful drugs we seem to have to-day.

Our President is very fond of telling a story to drive home a point, and I have alittle story I think illustrates the error of drawing conclusions from too small a seriesof cases. In the days of typhoid fever, when we had perforations and hemorrhage, ayoung physician had in the ward an Irishman who was in a very low state of typhoidfever, and it seemed that he was going to die. As you remember, the patient with typhoidfever was not fed anything in those days. This Irishman was very hungry. Seeing abig plate of cabbage on the table between him and another patient, he reached over andtook it and ate all the cabbage. The young doctor knew his patient was gone, butstrange to say, the patient immediately got well.

A little later the same young physician had a Swede in the ward with typhoidfever, and he reached about the same condition the Irishman had been in. Rememberingthe luck he had had with the Irishman's eating cabbage, he gave this Swede some cab-bage, and the Swede immediately died.

Then the young doctor wrote a paper on the use of cabbage in the treatment oftyphoid fever, and his conclusions were that cabbage in typhoid in an Irishman was awonderful thing, but in a Swede it was not worth a damn.

DR. RICHARD B. CATTELL (closing): I appreciate the discussion, including DoctorBoland's reply. I think I might comment on it first and say that I think his cautionwith regard to any interpretation of results in a small series of cases, such as this, certainlymust be approached with great prudence.

Dr. Cave raised the question with regard to hemorrhage and how serious these casesare. We feel that only ileostomy offers any possible prospect of surgical help in these cases.We have employed actual irrigations with sulfonamides in only a few. We have usedsulfanylguanidine and other sulfonamides by mouth, and our results, chiefly done underDoctor Kiefer's direction, have not been as satisfactory as many that have been reported.

With regard to the other question of Doctor Cave, as to the type of ileostomy,we have established a divided ileostomy in all of these cases.

In the text of my paper you will find the reference to Doctor Ladd's and DoctorGross's series of closures in seven children. I was familiar with this work, and I think thatit was largely instrumental in encouraging us to try this in adults. I think Doctor Ladd'sresults are better than our own. I believe that one of the reasons why the percentageof our number of recurrences is high is because we tried it in bad as well as in good cases.

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CLOSURE OF ILEOSTOMY IN ULCERATIVE COLITIS* RICHARD B