1207

CORRESPONDENCE

RESECTION FOR CARCINOMA OF THE

SIGMOID AND SIGMOID RECTUM

To the Editor of THE LANCET

SIR,-In your issue of Nov. 16th Dr. D. P. MacGuiredescribes an operation for cancer of the rectum whichI feel should not be allowed to pass without criticism,especially at the present time when surgeons in thiscountry are striving to simplify operations of this

type and reduce the mortality. The operativeprocedures used in England for removal of canceroustumours of the upper end of the rectum and lowerend of the pelvic colon are now more or less

standardised, and although, no doubt, still capable ofconsiderable improvement are a great advance onsimilar operation of 20 years ago. The operationas described in Dr. MacGuire’s article seems a clumsyand unnecessarily complicated procedure with nothingto recommend it. Most surgeons of the present day,myself included, prefer to do the operation in twostages, as it has been found from experience that thesafety of the patient is much increased thereby andthe immediate mortality lowered. This is also the

opinion of many American surgeons, including thoseof the Mayo Clinic. The colostomy is establishedat the first operation and the resection performed atthe second operation, after a suitable interval toallow of the colon being decompressed and the patientbrought into the best possible condition. Moreover,the time which the operation takes, necessarily ratherlong, is considerably shortened by planning the

operation in two stages.The method of first freeing the rectum from below

and completing the resection from the abdomen wasfirst described by Mr. W. B. Gabriel (THE LANCET,1934, ii., 69) and has advantages both in saving timeand making the operation easier. The combined

operation, starting in the perineum, only involvesone move, from the left lateral to the back position,whereas the procedure described by MacGuire involvesat least two moves. In my experience there is no

danger in dividing the colon at the first stage of theoperation, and although I have done it a considerablenumber of times I have had no sepsis or peritonitisresult from it. There are often adhesions which

require separating, but this slight disadvantage is

being got over, and in any case is more than

outweighed by the greater safety of a two-stageoperation, and the much shorter time that the opera-tion takes. I have this last week done a completesecond-stage combined operation in a man in 50

minutes, including the time taken in turning thepatient and changing gloves.Blood transfusion is called for only occasionally

and I have never known it necessary to use more thanone, while parotitis as a complication I have yet tomeet with.An operation that must of necessity be performed

upon an elderly patient (since cancer of the rectumis usually met with in patients between the ages of55 and 65) must, to be successful, be as simpleand as quick as is reasonably possible, and an

operation which inevitably involves opening theabdomen three times (twice through one incision andonce through another), and also opening the pelvisfrom the perineum, cannot, it seems to me, recommenditself to modern surgeons, and is not one to be copied.

I am, Sir, yours faithfully,J. P. LOCKHART-MUMMERY.

Harley-street, W., Nov. 18th.

SKIN TESTS FOR WHOOPING-COUGH

To the Editor of THE LANCET

SiR,—In your issue of August 17th last (p. 361)a preliminary report on a skin test for pertussis waspublished by Drs. Bailey, Waller, and myself. Sincethen I have been doing further skin tests, and usingSauer’s vaccine as an antigen. The results obtainedvary with the batch, and it appears to me that theideal and constant antigen has not yet been achieved.I hope that someone working at this subject will beable to produce a really satisfactory and constantantigen for the intracutaneous skin test.

I am. Sir. vours faithfullv.

Devonshire-place, W., Nov. 15th.DONALD PATERSON.

"KWASHIORKOR"

To the -Editor of THE LANCET

SiR,-Under the above title there appears in

your last issue (p. 1151) an article by Dr. CicelyWilliams with the sub-title " a nutritional disease ofchildren associated with a maize diet." May I

firstly enter a protest against the use of a WestAfrican native word as the title of an article. Howwill it be possible for anyone later looking for referencesto nutritional disorders to recognise one under sucha designation The secondary title is equally opento criticism as it would seem that the associationwith a maize diet is merely incidental. There is afurther objection to the name kwashiorkor ; itindicates " the disease the deposed baby gets whenthe next one is born." That such a sequence ofevents occurs is a common superstition in otherparts of Africa as I first pointed out in 1922 (HarvardAfrican Studies, vol. iii., p. 289). Among the Wa-yaoof Central Africa the disease, whatever it may be, iscalled litango lya kututa-each successive child issaid to push (ku-tuta) the previous one into its grave.

.

In Dr. Williams’s previous article (1933) a number ofstatements were made in regard to the differentialdiagnosis between this disease and pellagra, whichwere calculated to give an entirely false impressionof pellagra and I felt constrained to draw attentionto them the following year (Arch. Dis. Childhood,1934, ix., 115). Dr. Williams has now again repeatedthese misstatements in regard to pellagra, presumablybased upon a failure to realise the course and

symptomatology of that disease, and tends to confusethe problem at issue. To deal with the table of"Differences between Kwashiorkor and Pellagra ":-

1. The affected skin is " black, rugose, and soft" in K.So it may be in typical P. Elsewhere Dr. Williamsstates it "tends to peel off, leaving a moist, raw surface."This is often the case in P. and while branny desquama-tion may take place in P., in other cases large ulceratedareas may result.

2. " Extensor surfaces and points of irritation and

pressure affected" in K. This of course is common in P.As I have pointed out elsewhere any form of trauma,in its wide sense, may determine the site of the pellagrouseruption. The distribution of the skin affection in K.is probably what one would expect.

3. " Skin not photosensitive " in K.-photosensitivein P. In P. the skin is not always photosensitive. Inthe West African children it is not proved whether or notthe conditions necessary for the exhibition of photo-sensitivity were present or not.

4. K. " occurs in children under 5 years"—usually under2 years. P. " rare in children, almost unknown under2 years." This is a fallacious statement. Pellagra may