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Delay in healing of the perineal wound is a major cause of disability in patients after excision of the rectum. The outcome of primary suture in 76 patients treated at St Mark's Hospital between 1967 and 1976 was correlated with a number of factors describing the patients, their preparation for surgery and details of surgical technique and management. The perineal wound healed by first intention in 33 patients. The remaining 43 patients regarded as failures included 7 with delayed breakdown after initial healing. The results showed that women fared better than men. Excision of the rectum following colectomy and ileostomy was associated with failure of the perineal wound to heal in 9 out of 10 patients. Treatments with peroperative ampicillin and topical antibacterial agents were both correlated significantly with success. Preoperative sepsis and operative contamination were followed by perineal sepsis and wound breakdown on 16 out of 21 occasions. Discriminant analysis showed that topical and peroperative antibacterial treatments, sex, preoperative sepsis and finally ACTH were the most important variables in descending order of importance. The prediction of success and failure by this procedure was 72.4 per cent correct.

Twenty-one women with slow-transit constipation have been treated by bowel resection. All had a normal barium enema, but an increased colonic transit time. Pathological examination of the resected colons showed no evidence of aganglionosis. Some of the patients were treated by segmental colonic resection, anorectal myectomy, anal stretch or internal sphincterectomy but were not helped. Colectomy with ileorectal or caecorectal anastomosis gave the best results; on balance, ileorectal anastomosis seems preferable. Of sixteen patients who underwent colectomy, ten subsequently had normal bowel function and four were markedly improved. The spontaneous bowel frequency in this group rose from 0·3 ± 0·1 (s.e.m.) to 21·7 ± 8·3 weekly (P < 0·001).

Four cases of non-Hirschsprung megacolon in adults are presented. The histology of the myenteric plexus suggests that this may be an anomaly of development.

Between 1971 and 1978 at St Mark's Hospital and St Bartholomew's Hospital, 8 patients were seen with a psoas abscess complicating Crohn's disease. All patients had a long history of disease and the diagnosis was usually obvious on clinical grounds. The abscess was drained in all patients and 5 required drainage on more than one occasion. The underlying Crohn's disease was treated surgically in all patients. Seven patients are now well, although 2 have required further excisional surgery; 1 patient died 2– years after the first drainage of the psoas abscess.

A retrospective study was made to compare the results of restorative surgery with those of total rectal excision in the treatment of patients with a poorly differentiated adenocarcinoma of the middle third of the rectum (between 8 and 12 cm from the anal verge). Of 1163 patients presenting between 1963 and 1975, 42 with poorly differentiated tumours at this level were followed up after treatment by a radical (i.e. curative) operation. Twenty-eight underwent total rectal excision and 14 anterior resection. Examination of the preoperative biopsy correctly established the histological grade in 17 (40 per cent) of 42 cases. Pathological examination of the resected specimens showed a slightly higher proportion of Dukes' C2 tumours and those with venous invasion removed by total rectal excision, but the extent of local spread among tumours removed by either operation was similar. There was no operative mortality. Ten out of 28 patients treated by total rectal excision (36 per cent) and 6 out of 14 treated by anterior resection (43 per cent) were alive at 5 years. One patient developed a histologically proved local recurrence after anterior resection; no other proved local recurrence was recorded. It would appear, therefore, that where radical surgery is possible, anterior resection offers as good a prospect of cure as total rectal excision for poorly differentiated tumours of the mid-rectum.

Hirschprung's disease (aganglionosis) in the adult is a rare condition but needs to be considered as a diagnosis in any case of intractable constipation. A series of 35 cases of probable aganglionosis seen at St Mark's Hospital since 1954 is reviewed. Diagnosis is discussed and operative management evaluated.