In order to compare the mortality from colorectal tumours in Malta with that in other centres, the survival of patients with large bowel tumours from the cases recorded in the Tumour Registry between the years 1969 to 1972 was studied. It was only possible to follow up the patients till July 1973. The deaths occurring up to this period will be discussed in relation to the time in which they occurred and to their causes. It is immediately apparent that our patients are at an advanced stage of malignancy at the time of operation.  Aggressive surgery in these groups of individuals is not only futile but also contributes to an earlier demise. This is only too obvious when two thirds of the deaths recorded in the survey occurred within six months of surgical treatment.  The crux of the whole problem appears to be the delay between the commencement of symptoms and the surgical treatment. On this account the patients themselves may be partly to blame, minor symptoms are often ignored and not brought up for medical advice.peer-reviewe

Busuttil, Anthony

Carachi, R.

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1.0 THE EARLY MORTALITY FROM COLORECTAL TUMOURS 1'969 - 1912 R. CARACHI M.D. Senior House Officer, University Department ot PathoLogy, 'Western Infirmary, Glasgow. and A. BUSUTTIL M.D., MRC.Path. Lecturer in Pathology, University Department ot Pathology, Western Infirmary, Glasgow. En order to compare the mortality from colorectal tumours in our Islands with Histogram to show the sex incidence and the mortality that in other centres, the survival of rate in carcinoma of the colon patients with large bowel tumours from th::: No. of cases cases recorded in the Tumour Reglstry be- 15 tween the years 1.969 to 1972 was studied. It was only poss'ble to follow up the patients till July 1.973. The deaths occur-ring up to th's period will be d~scussed in relation to the time in which they occurred and to their causes. There was no slgnificant var' atio~1 in the sex of yearly mortality rate (Figures 1. and 2) for either carcinoma of the colon or the rectum. There were in all a hundr ~ d deaths in the hundred and seventy thrc3 cases surveyed; sixty seven of whom d:e.d less than six months after their tumour was diagnosed. The only information as to the cause of death was obtained from the death certi-ficates. Necropsy reports were singularly lack:ng. As expected mortality rates were highest in the seventh and eighth decades. Surprisingly, however, fourteen out of twenty four patients in the younger age group (i.e. under forty five years of age) also died within this period of the survey. The longest survival- was in patients in their early sixties for both sexes. About one third of the patients died 10 5 o 5 10 15 1969 1970 1971 1972 Figure 1 MALE FEMALE Years within a month of diagnosis (Table 1). All of these patients, with the execution of two who refused silrgery undawent a laparo-tomy, and when ind:cated, a palliative or a definitive large bowel resection was performed. Fifteen of these patients had very poor general health from the start, either because of dissemina.ted mal' g,.c'ancy, or because of associated severe card:o-respiratory insufficiency. In eleven of thes3 patients who d:ed within a month, cachexia and carcinomatosis wen~ the recorded causes of death. Five pat:ents developed clinical features of pulmonary embolism, two of myoca.rdial infarction, four of pneumonia, and two died in left ventricular failure. In the other cases who died within the month complications wh:ch included renal failure, cardiac arrest, intestinal haemorrhage and peritonitis had deve-loped. One of the conclusions which can be drawn from these figures is that the pa.tients presented in-such an advanced state of malignancy, that thev could not derive any benefit from the aggressive sur-gical intervention necessary for the' treat-ment of this tumuor. A similar observation can be made with reference to patients dying between one month and six months post-operatively. Thirty one pat1ents in this group out of the thirty five who died had either tumours staged as Grade C (Dukes' grading = metastas3s in lymph nodes) or as Grade 0 (Dukes' grading = distant metastas2s e.g. hepatic). These patients were therefore poor risk patients as well, at the time of operation, and it is no surprise that they only survived their surgery by such a short time. The causes of death in the rest of this group were carcinomatos:s in two cases, pneumonia in one case, pulmonary em-bolism from deep vein thrombosis in one 11 Histogram to show the sex incidence and the mortality rate in carcinoma of the rectum No. of cases 15 10 5 1.5 MORTALITY FEMALE 1969 1970 1971 1972 Ye,a.r§ Figure 2 case, and congestive cardiac failure in a further case. Those patients admitted with the cfnical picture of an acute intestinal ob-struct' on, and later discovered to have a carcinoma had a very bad prognosis: nine out of the ten patients who presented in this way died within six monihs. Some of them had to undergo both a defunctioning colostomy, and on- a s3parate occasion a TABLE 1 Cases 173 Mortality from C{)Ilorechl Tumours (1969-1972) Deaths 100 Deaths timed after surgery Less than a month Less than 6 months 32* 35 *Two of these patients refused surgrJry. After 6 months 30 (N.B. It was not possible to ascertain from th2 records the fme when three of the patients died). 12 large bowel resection. At the time of the first laparotomy, a cons~derable numb::r were found to have either perforated or 'leaked' at the s'te of the tumour, or Dro-ximal to it, with per~tonitis. Because of this, closure of the colostomy and colectomy at a later date were oftm technicallv d:fficult. This m::ty explain in part the poorer sur-vival rate in thEse cases. Local recurrence of the tumour w:th obstruction of the intestinal tract together with further vascular dissemination of the tumour were said to account for the vast majority of deaths occurring in the late post-operaLve period. The surv~val rates over the four years of the survey are shown in Table 2. TABLE 2 Survival Rates for Colon and Rectum Maximal Years Follow up Colon Rectum 1969 4 yrs. 24% 30% 1970 3 yrs. 21% 67% 1971 2 yrs. 40% 55% 1972 1 yr 47% 63% An attempt has been made to tabulate the cI:ude five. year survival rates (Table 3) publishsd from other centres in order to correlate these figures with our own. The maximaf follow UD available of the patients in this survey is four years; it has been shown however that the majority of pa1J'ents who develop metastases do so within three years of operation. (Royal Marsden Clinical Statistical Report 1972). Discussion Our survival figures for carcinoma of the rectum are marginally better than those for colonic cancer. However on the whole the mortal'ity figures in the present series are high compared to the other se:r:~es listed (Table 3). If is immediately apparent that our patients are at an advanced stage of malignancy at the time of operation. A~u;trossive surgery in those grouDs of in-dividuals is not only futile but also con-tributes to an earlier dem:se. This is only too obvious when two thirds of the deaths recorded in the survey occurred within six months of surgical treatment. In th;s context better pre-operative preparation of poor risk pat'ents may have to be weighed agahlst delay in surgery. Correct'on of anaemia and of gross electrolytic imbalance may be required. Closer selection uf patients for the more radical SurgiC8J ap-proaches may have to be considered. The amenities offered by an intensive therapy unit may also mifgate the early post-operative mortality. Other forms of therapy may have to be considered in order to diminish tumour cell mass and allow for possible palliative surgery cases. In fact Morson (1969) claims that "anaplastic inoperable rectal cancers" can be made resectable by pre-operative irradl'ation. The five year sur-vival for the pre~operatively irradiated carcinoma rectum cases in a survey was forty per cent against twenty seven point five: per cent for those treated by surgery alone (Brady et al1974). Post-operative irra-diation has also been found to prevent pelvic recurrences in pat~ents with low rectal carcinomas in whom local spre'ad is extensive (Morson 1969). Chemotherapy for advanced colorect-al tumours with either hepa,tic and/or pulmonary metastases as worth cons'der-aVon. The most effective chemotherapeu-tic a~ent in this respect is five fluorouracil (5 F.b.) (Ansfield, 1962; Leone 1974). Fol-lowing administration by either the intra-venous route or the oral route, an object-ive response as assessed by radiography and isotope scint'scanning of the liver and lung was observed in at least twenty five per cent of the cases (Leone 1974). In another study (Lahiri 1971) five fluor-ouracil was administered as an oral dose of fifteen milligrams per kilogram body weight per day for six days and thereafter as a single dose weekly: eleven of the fourteen patients treated responded, and in three of these there was a complete d; sappearance of the tumour on the sC':ntiscan. Selective intraarterial per-fmion of thp. livp.r has also been shown to be more effective (Burrows et AI 1967), Recent advancps in hopatic surgery have made partial hepatectomies for local-13 TABLE 3 Comparison of crude five-year Survival Rates in several large selies Series Birmingham Slaney et al, (1971) Royal Marsden Hospital (1972) (cl:nical state report) (in press) St. Marks Hospital Morgan (1965) New York Cornell McSherry et al, (1969) Cleaveland Clinic Turnbull et al, (1969) New York St. Luke's Kuehner et al, (1970) San Francisco California Galante (1967) Nat!onal Cancer Institute Axtell et al, (1972) U. Iowa Hospital Liechty et al, (1968) U. Minnesota Gilbertsen et al, (1971) Temple U. & Natl. Cancer Inst. Shimkin et al, (1964) New Orleans Charity Hosp:tal Falterman et al, (1974) New Orleans Charity Hosp:tal Falterman et aI. (1974) ized liver me>iastases a possibility (Foster 1970). Such heroic surgical measures are obviously only possible in carefully selected patients and high-powered centres gelared to the prolonged and in-tensive post-operative ca,re of such pat:ents. There is scope for ilmprovement in the years to come ,in the local manage~ ment of large bowel cancers. The crux of the whole problem appears to be the delay be,tween the commencement of symptoms and the surgical treatment. On this account the patients themselves may; 'be partly to b~ame, minor symptoms are often ignored and not brought up for Number of cases 12,494 477 (rectal tumours only) 1,625 896 (colonic tumours only) 329 975 44,227 2,251 1,884 3,127 2,010 (all pts. with a histological diagnosis) 923 (curative resections) Crude five year survivaL rates CoLon/Rectum 41% 55-60% 50% 46.5% 46.9% 49.4% 43.5% 32-45% 31.5% 30.7% 28% 24% 47% medical adv':ce. Education a'med at cor-recting this may be in order. General practifoners' delay in investigating minor bowel complaints in the middle aged or elderly pate'ints may also have to be con-sidered. The med:cal treatment of con-stipation or alteration in bowel habits should only take second place to endos-copy and radiological investigation. Acknowledgement We would like to acknowledge the help of Professor V.G. Grlffiths and Dr. Sultana for allowing us to collect these cases from the tumour reg:stry in Malta. 14 References ANSFIELD, R.J., SCHROEDNER, J.M. and CURRERI, A.R. (1962). J.A.M.A. 181:295. BRADY, L.W., ANTONIADES, J., PRASA VINI-CHAI, S., TORPIE, R.J., ASBELL, S.O. and GLASSBURN, J.R. (1974). Cancer 34 : 960. BURROWS, J.H., TALLEY.. R.W., DRAKE, E.H. (1967). Cancer 20 : 1886. FOSTER, J.H. (1970). Cancer 26 : 493. GALANTE, M., DUNPHY, J.E. and FLETCHER, W.S. (1967). Ann. Surg. 165 : 732. GILBERSTEN, V.A. (1971). Cancer 27 : 143. KUEHNER, C.R., Nay, H.R., WEST, J.P. (1970). Surg. Gynecol. Obstet. 131 : 63. LAHIRI, S.R., BOILEAU, G. and HALL, T.C. (1971). Cancer 28 : 902. LEONE, L.A. (1974). Cancer 34 : 972. LIECHTY, R.D., ZIFFREN, S.E., MILLER, F.E., DENBESTEN, D.C.L. (1968). Dis. Colon Rectum 11 : 201. McSHERRY, C.K., Corn ell, G.N. and GLENN, F. (1969). Ann. Surg. 169 : 502. MORGAN, N.C. (1965). Annals of Royal College of Surgeons of England 36 : 73. MORSON, B.C. (1969). British Journal of Hospit3.l Medicine Nov. ROYAL MARSDEN HOSPITAL (1972). Clinical StClltistical report (in press). SHIMKIN, M.B., CUTLER, S.J. (196). Dis. Colon Rectum 7 : 502. SLANEY, G., WATERHOlISE, J.A., POWELL, J. (1971). British Society of Gastroenterology 730. TURNBULL, R.B., KYLE, K, WATSON, F.R., SPRATT, J. (1969). Annals of Surgery Sept. 420. RELICS OF PHRENOLOGY IN MALTA PAUL CASSAR S.B.St.J., M.D., B.Sc., D.P.M., F.R.Hist.S. Hon. Fellow of the R,oyal Unlive1rsity of Malta Introduction Since the days of the classical Greek philosophers, it was speculated that the mind was made up of such mental or moral "faculties" or linnate powers as sensation, imagination, reason and memory. In medieval times these 'facul-ties' were thought to be 10caUsed in the hollow ventricles of the brain. In 1792 Franz Joseph Gall (1758-1828) elabo'rated the conce'p-t of "faculties" in his work which he publ'shed with J.C. Spurzheim in 1810-1819 (Gall, 1810-19). He suggest-ed that there was a larger number of "faculties" than those propounded by ancient philosophers and that the seats of these "facuWes" were, not in the ven-tl'icles, but in the cortex. In fact, accord-ing to him, each trait of character cor-responded to an "organ" in the cerebral cortex. The size of these "organs" varied in accordance with the extent of develop-ment of the trait or "faculty" it subserved. He furthermore inferred thwt the hemi-spheres of the brain were duplicate bodies performing the same functions "like the two eyes" or the two nostrils. Hi,s next assumption was that the skull was an exact cast of the underly:ng cortex and that, therefore, prominent '''organs'' in the cortex produced a corres-ponding prominence or bump on the out-side of the' cranium. As some of the "organs" were thought to be situated on that part of the undersurface of the brain 

The early mortality from colorectal tumours 1969 - 1972

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The early mortality from colorectal tumours 1969 - 1972

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