SURGERY will obviously demand the most careful consideration, and technique may require modification in the case of those who are termed " bad surgical risks," and when the anatomico-pathological arrangements revealed on abdominal section are also complicated and complex, pre-conceived notions of surgical carpentry may need readjustment: therein lies surgical judgment.This address, however, in no way purports to concern itself with the causal agencies operative in determining a patient a " bad surgical risk" ; these have been dealt with at length in a recent communication [1], and it must suffice merely to mention here that certain general considerations discussed therein should merit at least a passing thought, when intestinal surgery of unusual gravity is envisaged.In this former paper it was upon the patient rather than on the operation that attention was focused; in these pages the anatomico-pathological condition and its operative surgery command most attention.
(A) A NEOPLASM OF THE LARGE INTESTINE MAY PRESENT ITSELF IN COMPLICATED CLINICAL GUISEThe complication may, in point of fact, prove to be the means of first attracting attention to a malady hitherto unsuspected or too light-heartedly considered; in any case, the complication will probably necessitate modification of the customnary surgical treatment of the primary pathological state. But the notice of the clinician may also be indirectly drawn to the existence of a malignant neoplasm of the colon by reason of surgical incursion insistently demanded for some other condition of the abdomen.(a) On scores of occasions surgical interference for disease of the gall-bladder, even for such gross disease as suppurative calculous cholecystitis, has resulted in the discovery of an additional lesion in the form of an unsuspected carcinoma of the large intestine.Nowadays the term " exploratory laparotomy " has, I think, almost disappeared from operation-lists proudly displayed on hospital notice-boards, and the procedurJ itself is, I trust, almost entirely relegated to " the dark backward and abysm of timd." Far more care is now displayed in the days preceding an operation to establish an accurate diagnosis by means of radiology, biochemistry, &c., and everything is also done to make "the patient safe for surgery"; it is, therefore, only the emergency operation for an acute abdominal condition that reveals the unsuspected colonic FEB,-SURG. 2 *
