,I)ec. 1940] .HAY: SuRGERY oF AGED 531

those of Evans9 show definitely that it is possibleto produce an antiserum specific for the toxin.Based on the experience of other skin-testing

toxins it is apparent that a toxin so purified asto be practically free from bacterial antigen isessential. The toxin produced by our proceduresatisfies this requirement in that such undesirableand non-specific reactions are reduced to aminimum.

We wish to thank Professor E. G. D. Murray,Department of Bacteriology and Immunity, McGill Uni-versity, and Dr. A. Stanley Cook, for their interest andadvice throughout the course of this investigation.

REFERENCES1. STREAN, L. P.: Canad. M. Ass. J., 1940, 42: 525.2. BORDET, J. AND GENGOU, 0.: Awn. Inst. Pasteur., 1909,

23: 415.3. TEISSIER, P., REILLY, J., RIVALIER, E. AND CAMBES-

SSDAS, H.: J. Physiol. et Path. G6n., 1929, 27: 549.4. DEMNITZ, A., SCHLUTER, W. AND SCHMIDT, H.: Klin.

Wchnechr., 1936, 25: 10.5. MAUGHAN, G. B., EVELYN, K. A. AND BROWNE, J. S. L.:

J. Biol. Chemr, 1938, 126: 567.6. HARDING, V. J., NICHOLSON, T. F., GRANT, G. A.,

HERN, G. AND DOWNS, C. E.: Tra.nw. Roy. Soc. Can.,1932, 26: Sect. V., 33.

7. HARDING, V. J. AND GRANT, G. A.: J. Biol. Chem.,1931, 94: 529.

8. FLOSDORF, E. W. AND KIMBALL, A. C.: J. Immunol.,1940, 39: 287.

9. EVANS, D. G.: J. Pathol. 4- Bacteriol., 1940, 51: 49.

SURGERY OF THE AGED*

BY A. W. S. HAY, M.D., F.R.C.S.(ED.), F.R.C.S. (C.)

Demonstrator in Surgery, University of Manitoba; Assistant Surgeon, Winnipeg GeneralHospital; Assistant-Surgeon, Children's Hospital of Wtinnipeg,

Winnipeg

THE rather loose phrase "too old for opera-tion" is heard frequently coming from the

laity and occasionally from members of the pro-fession. It is a phrase which may, superficially,have some justification in the sudden and some-times unexpected casualties among old peopleafter surgery. However, the use of such aphrase drives home the necessity of emphasizingthat age is not primarily a chronological matterbut is rather the result of a summation of thedegenerative processes that may have occurredin an individual's body. No one can say, there-fore, of a man of seventy-five years, that he istoo old for operation until one has studied thatpatient not only from the standpoint of thelesion to be removed but also from the generalstandpoint. And without making such a studyone is not justified in condemning the old gentle-man to continued misery by refusing surgical aidsolely because of the added risk due to the age-factor. A 10 to 30 per cent mortality risk isvery much less to be dreaded by an old manthan months or possibly years of misery.The problem of the aged is one with which we

are going to be confronted more and more fre-quently owing to the progressive increase in theaverage duration of life as medical scienceadvances.

It is true that many surgical procedures

* Read at the Seventy-first Annual Meeting of theCanadian Medical ..Association, Section of Surgery,Toronto, June 21, 1940.

should be denied people in the advanced agegroup, i.e., plastic surgery, and surgical inter-vention to relieve minor discomforts such asbunion operations, herniotomy, for a hernia con-trollable by a truss, etc. Operations which mayjustly be advised in this group of patients fallinto three categories: (1) emergencies- (to savelife from imminent danger) ; (2) elective opera-tions which have as their object: (a) to relievesevere and recurring pain (biliary colic), (b)to overcome physical disability (large hernia);(3) malignant disease.One argument advanced in opposition to the

second and third groups of operations is that thesurgical risk in elderly patients is too great.Without giving the matter much thought onemight accept such an argument, but when theproblem is studied statistically it is evident thatthe risk is not nearly so great as one mightimagine. Newton reported 100 major operationson patients generally over seventy in whom theoperative mortality was 8 per cent. It is note-worthy that in his series two of the eight deathswere largely, and probably entirely, attributableto the fact that the attending physician had per-sisted in advising against operation on theground of the patient's age. Smith, as early as1907, reported a series of cases over seventyyears with a mortality of 12.6 per cent. Horsleyhad a mortality of 20 per cent in patients overseventy requiring partial gastrectomy for car-cinoma (the shortest operating time in this series

was two hours). Bailey reported 185 operationsin elderly patients with a 7.6 per cent mor-tality. Brooks reported 68 operations in thesame age-group with a mortality of 12.3 percent. He stressed the fact that in the genito-urinary group of cases 9 of the 15 deaths fol-lowed simple suprapubic cystotomy in patientswith advanced prostatic obstruction. Theirpre-operative condition was well-nigh hopelessbecause of their neglect to seek early surgicalaid. The reason for this neglect was that theyor their family physician had been opposed tosurgical intervention except as a last resort,because of the risk from the age-factor.A second objection voiced by those who oppose

operation is that these patients, even when theydo recover, are derelicts and drag out an invalidexistence for a matter of only weeks or monthsbefore they die of some intercurrent disease.Newton's series, and to a lesser extent the pa-tients whose histories will be cited later, showthat this objection is not valid. Sixty-six of 100of Newton's patients lived for one to ten yearsafter operation. Many of them were activelyengaged in some useful or enjoyable pursuit.The subject matter of this presentation is

based partly on personal cases and partly on astudy of the records of 536 patients over seventyyears of age who were subjected to major surgi-cal procedures in the Winnipeg General Hospitalduring the years 1931-38. We are interestedprimarily to note in what way the hospital mor-tality in these cases was aifected by the age-factor, and therefore in presenting the summaryof the findings will have time only to stress thosefigures which have a bearing on that point. Inthe entire group the mortality was 16.6 per cent,which is roughly about three times as high asmight be expected among patients under seventysubjected to the same procedures.

In the group requiring emergency operationsthe mortality was not greatly higher than itmight have been in younger patients havinglesions of the same gravity. The fatal femoraland umbilical strangulated hernias had gangren-ous bowel requiring resection. Of the 8 cases ofacute appendicitis 5 had ruptured; the 2 fatalcases had peritonitis when operated on. In theacute cholecystitis group 2 of the 3 fatal caseswere almost moribund on admission; only 1 ofthe 6 cases had an emergency cholecystectomy;the remainder had drainage operations done. Itcan be stated fairly definitely, then, that themortality in this emergency group of cases is not

very much higher than it would have been at anyage in cases of similar gravity.In the operations for malignant growths the

three groups in which the mortality is appre-ciably higher because of age are the non-obstructed carcinomas of the colon, the carcino-mas of the rectum, and those of the stomach inwhich gastric resection was done. In the casessubjected to palliative procedures advanced dis-ease was probably as important a factor in thefatal outcome as was the senility of the patients.

In the group of elective operations only thecases of benign hypertrophy of the prostate re-quire comment. The total mortality in patientsover seventy was 13 per cent. They may be sub-divided as follows. In the punch operation themortality was 7.7 per cent, which is approximate-ly twice as high as the average. In the supra-pubic prostatectomies it was 24 per cent, whichis about three times what it would be in youngerpatients. In the cystotomy group it was 50 percent, which is very high, due to the presence ofheart or lung complications before operation, orto urinary infection and renal damage likewisepresent before operation. The presence of thesecomplications in the urinary tract must beblamed on procrastination and not on the sur-gery. All of this group of patients who had acystotomy only were desperate cases apart fromtheir age altogether by the time they came tooperation.Among the causes of death in the 536 cases, 4

stand out as of special importance. In 2.2 percent of the patients death was due to pneumonia,an incidence roughly ten times as great as wouldbe expected among younger patients; the in-cidence of post-operative pneumonia generally isgiven as 0.5 per cent of all cases operated on, andthe mortality from this condition as 50 per centof the cases in which it develops. In 2 per centof the patients some form of heart disease wasresponsible for the fatality, i.e., coronary throm-bosis in 5, angina pectoris in 2, and acute myo-cardial failure in two. In any group of youngerpatients, even including some cardiac casesamong its numbers, the cardiac deaths would beless than one-tenth of those recorded here.

In 1 per cent of the patients a pulmonary em-bolus was the cause of death. This is a rate tentimes as high as the average incidence, and isdirectly related to the age-factor, because of thefrequent presence in t-his group of patients ofvascular degeneration, myocardial damage, ten-dency to dehydration pre- and post-operatively,

532 THE CANADIAI.Z MMICAL ASSOCIATION JOURI.ZAL [Dee. 1940

Dec. 1940] HAY: SURGERY OF AGED 533

SUMMARY OF CASESMAJOR SURGERY-ALL PATIENTS 70 OR OVER

WINNIPEG GENERAL HOSPITAL1931-38 INCLUSIVE

TABLE I.

Number Deaths Mortality percentage

536 89 16.6

EMERGENCY OPERATIONS

Patients Deaths Percentage

Strangulated hernia:Inguinal ................ 21 2. 10Femoral ................ 5 2 40Umbilical ............... 2 1 50Ventral ................ 2 1 50

Acute appendicitis ......... 8 2 25Small bowel obstruction.. 9 5 55Acute cholecystitis ..... 6 3 50Colon obstruction (benign). . 1 1 100

Total ................ 54 17 31

TABLE II.OPERATIONS FOR MALIGNANT GROWTHS

Patients Deaths Percentage

Prostate carcinoma........ 48 8 16Colon carcinoma .......... 23 12 52

Obstructed......... 12 7 58Non-obstructed ..... . 11 5 45

Rectum carcinoma.17 4 23Palliative ..... 11 2 18Radical. 6 2 33X

Breast carcinoma .......... 17 0Pancreas; head carcinoma,

one-stage operations orexploration only......... 10 3 30

Stomach carcinoma.9 3 33Palliative or exploration 5 2 40Gastric resection ... .. . 4 1 25

Common bile duct carci-noma ................... 2 2 100

Gall bladder carcinoma.... 1 1 100Hypernephroma ........... 1 0

Total ................ 128 33 25.8

TABLE III.ELECTIVE OPERATIONS

Patients Deaths Percentage

Inguinal hernia ... . 31 0 0Chronic cholecystitis....... 18 1 5.5Amputation .............. 14 2 14Duodenal ulcer ............ 9 1 11Vesical calculus ........... 8 1 12Renal calculus ............ 2 0 0Ventral hernia ............ 7 1 14Pelvic operation ........... 7 0 0Toxic adenoma ............ 7 0 0Graves disease ............ 1 0 0Femoral hernia ............ 1 0 0Benign prostatic hyper-

trophy ................. 249 33 13

Total ................ 354 39 11

and the difficulty of keeping these old peoplefrom becoming immobile in the post-operativeperiod. In 0.6 per cent the patient's death wasdue to cerebral accidents, again a much higherincidence than in a group of younger patients.

It is not the purpose of this paper to advocatepromiscuous surgery in elderly patients. Nor isit my object to suggest that surgery can beundertaken light-heartedly in patients in thisage-group. "A surgeon can sometimes parry thescythe of death but has no power over the sandin the hour glass." It may, however, be per-missible to emphasize that the age-factor is only

TABLE IV.CAUSES OF DEATH IN ELDERLY PATIENTS

Sepsis .................................Uremia ...............................Pneumonia.............................Shock .................................Intestinal obstruction .................Heart failure..........................Hemorrhage ...........................Cachexia (Extensive Ca.)................Embolus.............................Cerebral accident......................Liver failure..........................Diabetes mellitus......................Acute pancreatitis .............;..

201612121198S

53211

one of a group of conditions influencing surgicalrisk and must be viewed in proper perspective.The other factors are listed here.

FACTORS AFFECTING THE OPERATIVE RISKAge. Race. Heredity. Sex. Bodily conformation:

fat, thin. Previous habits and modes of life: dissipation,overwork, worry. Occupation: labourer or sedentary.Antecedent or intercurrent disease should be especiallyscrutinized in elderly people, e.g.: cardiovascular-renaldisease, bronchitis, tuberculosis, prostatism. Psychologyof patient: this is especially important in elderly people.The will to get better or not may turn the scale one wayor another in an old patient. Condition requiring opera-tion. Type of operation proposed.

It is essential, when attempting to assess therisk of operation, that account be taken of thedegenerative changes that occur with advancingage. A painstaking search should be conductedfor lurking deficiencies in the reserve capacity ofthe respiratory, cardiovascular and urinary sys-tems. Cough or catarrh, even if minimal, shouldcall for a special review of the sinuses, pharynxand lungs, including radiographs. The amountof physical effort voluntarily undertaken by thepatient in an average day may give a good clueto the reserve of the cardiovascular system. Amost important test in old people is the exercisetest for cardiac reserve. Failure of the pulse toreturn to normal in two minutes after exercise

HAY: SURGERY op AGED 533Dee. 1940]

53 H AAINMDCLASCAINJUNL[e.14

may be the earliest objective evidence of a dimin-ished cardiac reserve. A normal blood pressurereading in an old patient known to have had aprevious hypertension is an ominous finding, andshould necessitate a thorough study of the cardio-vascular system. Repeated urinalyses should pre-cede any major surgical procedure in elderlypatients. If the specific gravity of the urine isconsistently low, and certainly if albumin orcasts are found, a renal function test or a bloodurea estimation should be done.

It is evident that to conduct such a painstak-ing study as an office procedure in these oldpatients, especially where repeated radiographicexaminations are required, is not likely to besatisfactory. Hospitalization saves them muchexertion and thus conserves their waning physi-cal resources. Further, adequate pre-operativetreatment calls for much longer hospital carethan is necessary in younger persons, probablynot less than three days and up to two weeks ormore, depending on the patient's general condi-tion, the presence or absence of anaemia, pyloricobstruction, partial obstruction of the colon, andprostatic obstruction.

There is no need here to go into details of pre-and post-operative care. Dehydration is commonin old people, and should be dealt with in thepre-operative period, due precautions beingtaken to avoid overloading the circulation withintravenous fluid. The twenty-four hour urinaryoutput (provided the specific gravity goes up to1.015 or 1.020) is the best guide to the adequacyof the intake. The output should be from 1,000to 1,500 c.c. We believe there is a definite place,especially in old people, for the prophylactic useof vaccines, with a 'view to preventing post-operative infections. In carcinoma of the colonwhere post-operative peritonitis constitutes amajor hazard pre-operative peritoneal vaccina-tion has proved to have considerable value.While admitting that the subject is controversial,and aware that some authorities who formerlyadvocated the use of pre-operative peritonealvaccination have now discarded it, we believe itto be an added factor of safety. No proof thatit is not so has been adduced. None of the fortycolon cases in which we have employed pre-operative peritoneal vaccination has developedperitonitis.The choice of anesthetic is important, since

the incidence of post-operative pulmonary com-plications is seven times as great in patients over

sixty-five as in those of middle age. Althoughthe lesion to be operated on and the general con-dition of the patient are much more importantthan the anesthesia in determining the incidenceof post-operative pulmonary trouble, it is gen-erally agreed that the least harmful anestheticprocedure is local block or' infiltration, supple-mented where necessary by ethylene or cyclo-propane and oxygen.During the actual operation speed without

haste, gentleness in handling tissue, and theavoidance of tension are cardinal rules of sur-gery which apply even more forcibly 'in oldpatients than in any other. The vascular supplyof their tissue is often definitely impaired, thelymphatic pathways partly obliterated, and theregenerative powers minimal. It follows, there-fore, that healing takes place slowly and suturelines may readily give way under very littlestress; or infection, minimal in quantity, may beof serious import. It should be emphasized thatvery painful time-consuming or multi-stageoperations should not be advised in old people.However, in the case of such a lethal disease ascarcinoma of the stomach or rectum, if theoperation is undertaken, even a two-hour periodmay be necessary to see it through. In Horsley'sseries of partial gastrectomies in elderly patientssome operations required as long as two and ahalf hours for their completion.

Since 90 per cent of the chest complicationsafter operation begin as atelectasis it follows thatpost-operative care of the lungs should empha-size the importance of ensuring complete ventila-tion of the lungs. Chilling and undue handlingof the patient are avoided by having his warmedbed brought into the theatre to transport himback to the ward. Sedatives such as morphine,heroin, and barbiturates are minimized post-operatively because of their depressing effect onthe cough reflex. Repeated changes of postureare insisted on. Voluntary deep breathing ordeep breathing induced by inhalations of carbondioxide also plays some part in lessening thedanger of post-operative atelectasis and its moredangerous sequela pneumonia, lung abscess, organgrene. To be of value in the prevention ofatelectasis, carbon dioxide must be used fre-quently during the first twenty-four hours, say,two or three times an hour. It must be supple-mented also by encouraging the patient volun-tarily to move about and to cough up thebronchial secretions. The value of sulfapyridine

534 THE CANADIAN MMICAL A$SOCIATION JOURNAL [Doe. 1940

Dec 190 HA:SREY FAE3

in the treatment of lung infections when they dooccur is too well known to require any emphasishere.

There is another important reason for insistingon muscular activity during the post-operativeperiod, that is, the great danger of thrombosisand embolism. The frequency of post-operativepulmonary embolism roughly parallels the ageof the patient. It is scarcely seen at all in pa-tients under twenty; from twenty to sixty theincidence of embolism is 0.1 per cent. In ourseries of cases it is 1 per cent, or ten times thegeneral incidence. This incidence of embolismmight possibly have been reduced by the use ofheparin.

Faecal impaction occurs frequently in oldpeople and needs to be kept in mind. An occa-sional digital rectal examination, especially ifthere appears to be any sluggishness of bowelaction will often save these people a great dealof local and general distress.The psychology of the elderly demands special

emphasis. It is essential that an atmosphere ofoptimism and encouragement surround him. Hiswhims, as far as possible, should be humoured.Any non-essential restriction in physical activityand in food are extremely irksome to him andshould be avoided. Life-long habits, such assmoking or the use of alcohol, should not beforcibly broken without the most valid reason.The patient who is apathetic and resigned, andwho is unwilling before operation to make anyeffort to help himself should definitely be refusedany but the simplest of operative procedures.Pain is usually tolerated surprisingly well, afortunate fact which minimizes the necessity ofsedatives. Codeine affords a good means of con-trolling pain and the bromides act efficiently asa hypnotic. Opinions as to the optimum timefor getting old people out of bed vary from theextreme position of advocating almost immediateactivity to the other extreme of prolonged bedcare. As in most other matters the intermediatecourse is probably the wiser one. In all thosecases where early activity can be undertakenwithout danger of undoing the work of theoperator the old patient should be encouraged toget about, with suitable precautions, earlier thana younger patient.

People of advanced years are often tided alongwith palliative measures when surgical reliefcould be given with reasonable safety. Not in-frequently some urgent complication arises

which makes operation imperative. If the resultis disastrous it is blamed on the patient's ad-vanced age, when in reality it should often beblamed on undue procrastination. Several timesa year we see patients with inoperable malignantdisease who have been denied treatment in theearly stages simply because they happen to beover seventy. It should be emphasized again andagain that people may be chronologically wellover seventy and yet physically much younger.This fact should be recognized and the patienttreated accordingly.A few pertinent case reports are now recorded.

CASE 1Mrs. P., aged 77. This patient had been seen

previously several times in the last ten years for variousrelatively minor complaints, but on each occasion verymarked arteriosclerosis had been noted, and at timesevidence of mental deterioration, with however, longintervals of normal mentality in between. She had ahyp -rtension along with this arteriosclerosis but noevidence of myocardial or renal failure.

In January, 1939, she developed an attack of fairlysevere right lower quadrant pain. The physical findingswere minimal, with a normal temperature, tenderness inthe region of the right kidney, and slight tenderness inthe right lower quadrant. The urine showed an occa-sional red blood cell and an occasional pus cell. A plainx-ray plate of kidneys, ureter and bladder revealed asmall shadow in the line of the right ureter which aurologist, on considering the case as a whole thought wasmost likely a ureteric calculus. The patient was advisedto strain the urine and watch for the calculus and waswell for a month or six weeks. No stone had beenpassed.

After a lapse of six weeks she developed a similarattack of pain about two o'clock in the morning. Be-cause of the previous history and because the presentattack was essentially the same as the former one, shewas given sedatives sufficient to tide her along untilmorning. When I examined her again in the morning itseemed very probable that the attack might be appendi-citis. However, it was especially essential in view ofthe patient's age that we should make sure no stone waspresent in the right ureter. Unfortunately, eight hourshad to elapse before a catheter could be passed up thleright ureter. When the absence of a stone was demon-strated an appendectomy was done through a McBurneyincision under gas and local anwsthesia. Even in thislength of time a small perforation had developed at thetip of the appendix. The peritoneal cavity was drained,the patient developed a post-operative bronchopneu-monia, later an acute pyelonephritis, and finally, aboutthree weeks after operation, a pelvic abscess, which wasdrained through the rectum. An immediate vasomotorcollapse occurred which required emergency shock treat-ment. The application of a tight binder to the abdomenseemed to be an important factor in the restoration ofintra-abdominal pressure to what it had been before theabscess was evacuated. Further progress to completerecovery was uneventful.

CASE 2Mr. A.O., aged 75. This patient's actual age was

75 years but he looked not more than 60. He was activephysically, did some gardening and a good deal of walk-ing; hence anything that necessitated a restriction ofphysical activity was exceedingly irksome to him. Dur-ing this past ten years he had had four herniotomies, twoon the left, and two on the right. The second hernio-tomy on the left side held, but the repair on the right

HAY: SURGERY OF AGm 535DeC. 1940]

53 TH CAAINMDCLASCAINJUNL[e.14

side gave way each time. The patient had an old chronicbronchitis which probably was a factor in the failure tosecure a permanently satisfactory result.

I first saw him in December, 1938, at which time hewas in hospital having just recovered from an attack ofacute bronchitis with, possibly, a mild bronchopneumonia.At that time it was suggested that since he was in hos-pital his hernia might be repaired. HIowever, we advisedthat nothing be done about the hernia until summer timewhen he would be relatively free from cough. Accord-ingly he continued with a course which, however, wasquite unsatisfactory as a permanent measure, the reasonbeing that if he walked any distance or attempted to liftanything the hernia not infrequently would push out,giving him a good deal of colicky pain, and could onlybe reduced by lying down wherever he might happen tobe and manipulating it back in. On several occasionshe had had to lie down in the street in order to get hishernia reduced.

In June, 1939, he returned for operation, at whichtime a careful study was made of his chest, heart, kid-nevs, etc., and also of the local condition of the hernia.It was a recurrent direct right inguinal hernia, w.ithquite a large but rather vague ring, and there seemed nodoubt that a fascial repair would be the ideal procedurefrom every standpoint, except that of the patient's age.Preparations were made for fascial grafts if this hadto be done, but it was hoped that an adequate amount oftissue could be obtained to make that unnecessary.However, when the structures were exposed it was foundto be impossible to demonstrate a conjoined tendon orthe external oblique aponeurosis; they had aU been re-placed by rather weak scar tissue and there was sucha large gap that the upper edge of the opening could notbe brought down to the inguinal ligament without veryconsiderable tension. Accordingly, a fascial graft wasused and it was woven back and forth to create a sortof lattice work filling in the defect. -The patient madean uneventful recovery from the operation, and the re-sult has been entirely satisfactory.

CASE 3Mr. S.J.S., aged 70. This patient was seen in con-

sultation in the General Hospital in January, 1937. Hegave a history of duodenal ulcer for 20 years. He hadhad prolonged courses of medical treatment, but for thelast three weeks before his admission to the hospital hehad been unable to retain food for any great length oftime, he had lost very considerable weight, he sufferedfrom continuous upper abdominal fulness and distress,and for five days he had been unable to have a bowelmovement. Physical examination and, later, radiographicexamination demonstrated a complete pyloric obstruction.The patient also had some prostatic symptoms and hadinspissated impacted feces in the rectum and sigmoid.By means of medical measures, continued suction, intra-venous therapy, enemas, etc., it was possible to reducethe distension of his stomach and to clear out his bowelwith a definite, but not marked improvement, in his gen-eral condition. His blood picture was normal.

After two weeks ' preparation the patient wasoperated on under local and gas anesthesia, and aposterior gastro-enterostomy was done. It was obviousthat the lesion in the duodenum producing the obstruc-tion was benign. The patient made an uneventful re-covery from the operation, has since gained 40 poundsin weight, and a year ago underwent a transurethral re-section of the prostate for urinary obstruction.

CASE 4Mr. J.P., aged 70. This patient had had a neoplasm

removed from his right lower lip two years ago by hisfamily doctor. A month later he noticed a recurrence.He concealed this recurrence, however, until February,1939; at that time when he reported for examination theright lower lip presented a raised, ulcerated tumour, ex-tending around the commissure into the upper lip andinto the right cheek, the size of the involved area being

41A x 3 cm., the tumour being 1½2 cm. thick. Therewere no glands in the neck. Physical examination other-wise was negative. The patient was actively engagedin fairly heavy physical work.

Radiation treatment was out of the question becausethe tumour was of a low grade, namely grade 1, alsobecause of its size. Accordingly, the only method ofremoval available was by surgical excision with an at-tempt at plastic closure.

The operation was done on February 28, 1939, undertrigeminal nerve block anesthesia. A circle of lip andcheek about 5 cm. in diameter was removed and a smallflap turned down from the right cheek in what seemedlike a vain attempt at filling the huge defect left by theremoval of this large tumour. By mobilizing what wasleft of the lower lip, and also mobilizing the cheek some-

what, it was possible finally to close the large defect withsutures that were under quite considerable tension. Afterabout ten days the sutures having all been removed, therewas some infection and a slight breakdown of the woundwith the formation of two fistule in the cheek. In thecourse of the next two weeks the infection was graduallytaken care of and the fistulae healed, leaving the patientwith a mouth of useful size and a comparatively unde-formed face.

CASE 5

Mr. W.J.B., aged 73. In March, 1938, this patientreported with a large fungating tumour in the rightlower lip, which had been present two years. The lesionwas 3 cm. in diameter. It was reported epidermoid car-cinoma, grade 3. The size of the lesion made it unsuit-able for radiation treatment, and therefore a plasticoperation was performed after wide removal of thetumour. The operation was done under trigeminal nerveblock ancesthesia.

The patient made a good recovery but within amonth definite enlargement in the lymph nodes in theright submaxillary area and the right submental trianglehad appeared. A course of x-ray therapy was given tothese glands with some improvement, but without com-plete regression. Accordingly, a month later they wereexposed under local ancesthesia and heavily irradiated bythe implantation of gold seeds. Since that date thepatient has reported regularly and has shown no signsof further recurrence of his disease.

CASE 6Mr. J.McN., aged 83. This feeble old man was

admitted to hospital with retention of urine and a severebladder infection as a result of self-catheterization.Aside from this disturbance, which was the result of anenlarged prostate, his general condition was good. Hehad bilateral inguinal hernie which had been controlledfor years by trusses. Suitable treatment cleared up theurinary infection, but before he could have a prostaticresection a coughing spell pushed a loop of bowel intohis left inguinal canal where it became incarcerated andobstructed. All attempts at reduction of the herniafailed. Operation was therefore decided upon.

Under local anasthesia the sac was opened and thecontents reduced without being seen. It was then foundthat a sliding sigmoid was down in the neck of the largesac; this had to be mobilized and reduced into the ab-domen. The inguinal canal was firmly closed and thepatient made a slow recovery. C02, liberal fluids, fre-quent changes of posture, and active movements of hislower extremities were all regarded as important featuresof his post-operative treatment.

Subsequent to his recovery from the herniotomy hehad a suprapubic cystotomy from which he has recovered.

SUMMARY1. An individual's chronological age must not

be accepted as a criterion of his prospect of sur-viving a surgical operation.

536 THE CANADIAN' MEDICAL ASSOCIATION JOURNAL [Dec. 1940

Dee. 1940] ROSS: PAINFUL FEET 537

2. Age is only one factor in estimating surgicalrisk.

3. Intravenous therapy must be cautiouslyadministered in old people. Hard arteries, de-generated heart muscle, and liability to pul-monary oedenia are the reasons for this caution.

4. Vaccines, pre-operatively, have a definitevalue in lessening chest complications and peri-tonitis.

5. Sedatives and hypnotics must be individual-ly, not routinely, administered to old people be-fore operation.

6. A relatively prolonged pre-operative periodof preparation is generally advisable before anymajor operation is undertaken in old people.

7. Finally, surgery in old people, when essen-tial to save life, to remove physical disability,and to cure malignant disease, not only can, butshould, be undertaken. The risk is not undulygreat if modern methods of pre-operative prepa-ration, operative technique, and post-operativecare are employed.

A complete list of references can be obtained byapplying to the author.

TREATMENT OF PAINFUL FEET*

BY C. C. Ross, M.D., F.R.C.S.(EDIN.)

London, Ont.

PROPOSE to discuss some of the conditionsgiving rise to pain in the feet. No considera-

tion will be given to the anatomy of the region,nor to such conditions as fractures, infections,ulcers, etc., all of which are familiar to you.

There are, however, a number of othercauses of painful feet which many practitionersdo not attempt to treat. As a result many pa-tients consult chiropodists, so-called foot spe-cialists, and irregular practitioners. We, in theprofession, ought to be able to give relief tothese patients better than these others to whomthey frequently apply for treatment.

CORNS AND CALLOSITIES

Let us consider first that common affliction,corns, and with it the allied condition of cal-losities. Both develop as a result of pressureand friction. If the pressure is over a smallarea a corn develops, if over a wide area acallosity is produced. They are caused almostalways by poorly fitting shoes, but they areoften associated with static or other deformitiesof the feet. The pressure has been of necessitypresent for a long time, and, frequently, whenthe patient is seen the shoes are not responsible,although their predecessors have been. Thepain produced is due to a traumatic inflamma-tion of the underlying tissues, or frequently toassociated mild infection.

Corns, broadly.speaking, are of two types-hard or soft. The former are seen most fre-

* Read at the Seventy-first Annual Meeting of theCanadian Medical Association, Section of Surgery,Toronto, June 19, 1940.

quently on the outer and upper aspects of thelittle toe, the latter between the toes in theclefts where the skin is moist, and here slightinfection is usually present.The treatment consists of: (1) correcting if

possible any deformity of the feet; (2) Recom-mending suitable shoes; (3) application of acorn paint. I use the following:

Glacial acetic acid . ...........dram 1Salicylic acid . . ..........grs. 50Cannabis indica ............ grs. 15Flexile collodion ............ to make oz. 1

This should be applied twice daily, and forsome time after the corn appears to have dis-appeared.

In very severe cases surgical removal may benecessary, and in an occasional patient whenthe corn is large and situated on the fifth toe,amputation may be the best treatment.

FLAT FEET

Next, let us consider flat feet. There areseveral varieties. To begin with, the flatteningmay be of the longitudinal arch or of the trans-verse arch at the heads of the metatarsal bones.In addition, there is the so-called spastic type.In this the foot is everted as well as flattenedand the peroneal muscles are in spasm. Like-wise there are three degrees of flatness. Firstly,when the arch is depressed only on weight bear-ing; secondly, when the arch is depressed with-out weight-bearing but can be replaced manual-ly; and, thirdly, when the foot is fixed and canonly be brought into more or less normal positionby mechanical wrenching.