Surgery of Ulcerative Colitis

operation. The qualitative nature of this damage is well known. After operation patients may become more egoistic, tactless, dull, and lazy; they may be more irritable and quarrelsome; they may show lack of forethought and judgment. What is known only to those who have seen an extensive series of patients is the extent to which these undesirable changes actually occur. Exaggerated statements are sometimes made that the life of the leucotomized patient is reduced to that of a vegetable. This is not borne out by experience nor justified by the published results. Even with the standard operation the degree of impairment of personality is sometimes so slight that it can hardly be seen. In some other cases it is so severe that the latter state of the patient is worse than the first. Probabilities must be taken into account. In the psychotic patients reported on by Gillies, Hickson, and Mayer-Gross, 3% died as a result of the operation, 12% deteriorated, while 60% showed a greater or lesser degree of improvement. It seems probable that the standard operation will in course of time be superseded by one or more modifications which will reduce the likelihood of noteworthy damage to the personality. The aid of experimental science is not lacking. According to Fulton,6 whose careful work with baboons is a model of technique, the undesired intellectual impairment which may follow operation can be avoided by sparing certain pathways. When a frontal lesion involves projections from areas 9, 10, 11, and 12, the animal suffers impairment of his learning capacity but no disturbance in the emotional sphere. If the projections from the " visceral brain" only are interrupted, in the medial ventral quadrant of the frontal lobe, there are behavioural changes without loss of learning capacity. Even such a stern critic of the standard operation as Rylander7 found that two-thirds of his 14 patients submitted to an inferior lobotomy were quite free from personality changes, though their symptoms were relieved or improved. Le Beau's' work on differential resections also suggests that with improvement in operative technique the good effects of surgery will eventually be secured without the deleterious ones. The ill effects of the present methods of operating cannot but continue to be a great source of anxiety, not least to those who find it their duty on occasion to recommend surgery. That present procedures are so far from whatwe wish is no reason to give up hope of their improvement. The time will come when surgeons can act with greater knowledge and greater delicacy; and when it comes the ethical problems of operating on the brain for the relief of mental symptoms may well have faded into insignificance. SURGERY OF ULCERATIVE COLITIS Clinicians familiar with the vagaries of gastrointestinal disease are always being reminded that human alimentary function is at the mercy of the emotions. Recently we commented on the experimental investigation of the mechanisms whereby emotional stress might set in train or aggravate ulcerative colitis.1 Briefly, this work showed that the continued repression of anger, hostility, and resentment could induce colonic hyperfunction, as shown by hyperaemia, friability, increased motility, and augmented secretion of the mucolytic enzyme lysozyme, these changes sometimes progressing to submucosal petechial haemorrhages and ulceration. It may therefore seem inconsistent that in this week's issue Mr. W. B. Gabriel is able to put forward such good evidence in favour of surgical removal of the colon in the treatment of what some would regard as essentially a personality disorder. Yet there is nothing essentially illogical about this when we consider the use made of surgery in the treatment of gastro-duodenal ulceration, a condition in which psychic factors may play an equally prominent part. Properly applied, gastrectomy is one of the most satisfactory operations in the whole of surgery. It may indeed be an imperfect means of dealing with an imperfectly understood condition, but often it is the best treatment at present available. The multiplicity of medical treatments already tried and found wanting in the treatment of chronic ulcerative colitis is in itself sufficient discouragement to the physician and temptation to the surgeon to proceed with more drastic methods. Few would quarrel with Mr. Gabriel's indications for operation: stricture formation, arthropathy, pyoderma, perforation, and multiple polyposis-a precarcinomatous condition-must all demand excision. Perhaps the commonest indication, " failure of medical treatment," is open to as much variation of interpretation as in the surgery of gastro-duodenal ulceration. It is on this point that some physicians and surgeons may differ, and the advice that final decision must be made by physician and surgeon in joint consultation cannot be too strongly endorsed. In a refresher-course article in this Journal not long ago Dr. G. E. Beaumont2 put the physician's point of view with characteristic clarity. While admitting the imperfections of medical treatment, he emphasized the benefits to be gained from rest, blood transfusion, chemotherapy and antibiotics, sedation,