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 Intestinal Stornas
Principles, Techniques, and Management
Second Edition, Revised and Expanded

edited by
Peter A.Cataldo
University of Vermont College of Medicine
Burlington, Vermont, U.S.A.

John M. MacKeigan
Michigan State University
East Lansing
and Ferguson Clinic
Grand Rapids, Michigan. U.S.A.

MARCEL

MARCEL
DEKKER,
INC. NEWYORK BASEL
D E K K E R
The first edition was published as Intestinal Stomas: Principles, Techniques, and Manage-
ment, edited by John M. MacKeigan and Peter A. Cataldo, published by Quality Medical
Publishing, Inc., St. Louis, Missouri (1993).

Although great care has been taken to provide accurate and current information, neither the
author(s) nor the publisher, nor anyone else associated with this publication, shall be liable
for any loss, damage, or liability directly or indirectly caused or alleged to be caused by
this book. The material contained herein is not intended to provide specific advice or recom-
mendations for any specific situation.

Trademark notice: Product or corporate names may be trademarks or registered trademarks

and are used only for identification and explanation without intent to infringe.

Library of Congress Cataloging-in-Publication Data

A catalog record for this book is available from the Library of Congress.

ISBN: 0-8247-4707-0

This book is printed on acid-free paper.

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The publisher offers discounts on this book when ordered in bulk quantities. For more
information, write to Special Sales/Professional Marketing at the headquarters address
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Copyright  2004 by Marcel Dekker, Inc. All Rights Reserved.

Neither this book nor any part may be reproduced or transmitted in any form or by any
means, electronic or mechanical, including photocopying, microfilming, and recording, or
by any information storage and retrieval system, without permission in writing from the
publisher.

Current printing (last digit):

10 9 8 7 6 5 4 3 2 1

PRINTED IN THE UNITED STATES OF AMERICA

To my wife, Eileen, and to my daughters, Colleen and Anna, my advisors
and my best friends. —PAC

With appreciation to Suzie, my family, and my teachers. —JMM

Preface

Ten years have passed since the publication of the first edition of Intestinal
Stomas: Principles, Techniques, and Management. That text was envi-
sioned and created in response to a need for a comprehensive reference on
intestinal stomas. Prior to our first edition, The Atlas of Intestinal Stomas,
authored by Drs. Rupert Turnbull and Frank Weakley nearly 30 years ago,
was the only textbook dedicated to intestinal stomas and remained the au-
thoritative source. Thanks to the contributions of many intelligent and dedi-
cated surgeons, our first edition was recognized as the up-to-date source
for ostomy creation and care. Only by standing on the shoulders of the
“fathers of the field” of intestinal stomas and enterostomal therapy were we
able to create that book, and we now stand also on its shoulders to bring to
our readers a second edition.
This edition contains two entirely new chapters, “Pediatric Intestinal
Stomas” and “Technical Tips for the Difficult Stoma.” The first is a superb
compilation of stomas in children used in the treatment of Hirschsprung’s
disease, imperforate anus, necrotizing enterocolitis, and constipation. The
second new chapter, Technical Tips for the Difficult Stoma, covers solu-
tions to age-old problems of emergency stoma creation, particularly in
obese patients with inflammatory conditions leading to thickened and short-
ened intestinal mesentery.
In addition, all remaining chapters have been revised, often by a new
author in order to ensure a fresh approach. New, current references have
been added to all chapters. A new section on endoscopically assisted tre-
phine stomas has been added to the chapter “Minimally Invasive Stomas.”
New approaches to the treatment of stomal prolapse, parastomal hernias,
and peristomal pyoderma gangrenosum have also been included.
Much has changed since the completion of our first edition. We have
made every effort to ensure that the second edition addresses all these

v
vi Preface

changes and will be considered the authoritative source on intestinal

stomas.
Thank you to our dedicated contributors, without whose help this text
would not exist, and to our publisher Marcel Dekker, Inc., who coordinated
and facilitated our efforts. Special thanks to Tina Blais-Armell, without
whose dogged determination and persistence this textbook would still be a
pile of papers on the office floor. Thank you to our enterostomal therapists,
Cindy Whitehead, Randy VanAlst, and Kristin Hurt, who continue to teach
us invaluable lessons about living with ostomies, and to our students, who
teach us more than we will ever be able to teach them. Finally, we would
like to extend our deepest gratitude to our patients, who have inspired us,
learned with us, and taught us lessons that can be learned only by living
with an intestinal stoma.

Peter A. Cataldo
John M. MacKeigan
Contents

Preface iii
Contributors vii

1. History of Stomas 1
Peter A. Cataldo

2. Stoma Physiology 39
William E. Taylor and John H. Pemberton

3. Preoperative Considerations 57
Alan G. Thorson

4. Stoma Therapy 65
Ian C. Lavery and Paul Erwin-Toth

5. Quality of Life with a Stoma 91

Robin S. McLeod and Zane Cohen

6. End Sigmoid/Descending Colostomy 111

Thomas E. Cataldo

7. Diverting Stomas 121

Russell K. Pearl, Amir L. Bastawrous, and Herand Abcarian

8. Cecostomy 143
Anthony J. Senagore

9. End Ileostomy 151

Neil Hyman

vii
viii Contents

10. Continent Stomas 165

Stephen R. Gorfine

11. Ostomy Take-Down 203

Scott A. Strong

12. Methods of Urinary Diversion 215

Jeffrey A. Stern and Daniel P. Dalton

13. Laparoscopic-Assisted Colostomy 259

Martin A. Luchtefeld

14. Ileostomy and Pouch Dysfunction 267

Peter W. Marcello and Amanda M. Metcalf

15. Parastomal Hernias 277

Marc S. Rubin

16. Stomal Prolapse 307

Seth Rosen and Juan J. Nogueras

17. Management of Intestinal Fistulas 323

W. Douglas Wong, W. Donald Buie,
and Ravinder K. Annamaneni

18. Nursing Management of Cutaneous Intestinal Fistulas 355

Bonnie Sue Rolstad and W. Douglas Wong

19. Diagnosis and Treatment of Peristomal Skin Conditions 381

Najjia N. Mahmoud and Brenda S. Bradley

20. Unusual Problems in Stoma Management 397

Kerry M. Casey, Donna L. Loehner, and David J. Schoetz, Jr.

21. Technical Tips for the Difficult Stoma 411

Peter A. Cataldo

22. Pediatric Intestinal Stomas 427

Michael V. Tirabassi, David B. Tashjian, Gregory Banever,
and Stanley Konefal

Appendix A United Ostomy Association, Inc. 467

Appendix B CCFA Across the Nation 493

Index 499
Contributors

Herand Abcarian University of Illinois at Chicago, Chicago, Illinois

Ravinder K. Annamaneni Memorial Sloan-Kettering Cancer Center,

New York, New York, U.S.A.

Gregory Banever Department of Surgery, Baystate Medical Center, Spring-

field, Massachusetts, U.S.A.

Amir L. Bastawrous Cook County Hospital, Chicago, Illinois, U.S.A.

Brenda S. Bradley Thomas Jefferson University Hospital, Philadelphia,

Pennsylvania, U.S.A.

W. Donald Buie Calgary, Alberta, Canada

Kerry M. Casey Lahey Clinic, Burlington, Massachusetts, U.S.A.

Peter A. Cataldo University of Vermont College of Medicine, Burling-

ton, Vermont, U.S.A.

Thomas E. Cataldo University of Medicine and Dentistry of New Jersey,

Robert Wood Johnson Medical School, Cooper Health System, and Cooper
Colorectal Care Center, Camden, New Jersey, U.S.A.

Zane Cohen Mount Sinai Hospital, Toronto, Ontario, Canada

Daniel P. Dalton Northwestern University Medical School, Chicago, Illi-

nois, U.S.A.

Paul Erwin-Toth The Cleveland Clinic Foundation, Cleveland, Ohio,

U.S.A.
ix
x Contributors

Stephen R. Gorfine Mount Sinai School of Medicine and Mount Sinai

Hospital, New York, New York, U.S.A.

Neil Hyman University of Vermont, Burlington, Vermont, U.S.A.

Stanley Konefal Department of Surgery, Baystate Medical Center, Spring-

field, Massachusetts, U.S.A.

Ian C. Lavery The Cleveland Clinic Foundation, Cleveland, Ohio,

U.S.A.

Donna L. Loehner Lahey Clinic, Burlington, Massachusetts, U.S.A.

Martin A. Luchtefeld Michigan State University, East Lansing, Michi-

gan, U.S.A.

Najjia N. Mahmoud Hospital of the University of Pennsylvania, Phila-

delphia, Pennsylvania, U.S.A.

Peter W. Marcello Lahey Clinic, Burlington, Massachusetts, U.S.A.

Robin S. McLeod Mount Sinai Hospital, Toronto, Ontario, Canada

Amanda M. Metcalf University of Iowa, Iowa City, Iowa, U.S.A.

Juan J. Nogueras Cleveland Clinic Florida, Weston, Florida, U.S.A.

Russell K. Pearl University of Illinois, College of Medicine at Chicago

and Cook Country Hospital, Chicago, Illinois, U.S.A.

John H. Pemberton Mayo Medical School and Mayo Clinic, Rochester,

Minnesota, U.S.A.

Bonnie Sue Rolstad Fairview Home Care and Web WOC Nursing Edu-
cation Program, Minneapolis, Minnesota, U.S.A.

Seth Rosen Cleveland Clinic Florida, Weston, Florida, U.S.A.

Marc S. Rubin Harvard Medical School and The North Shore Medical
Center, Salem, Massachusetts, U.S.A.

David J. Schoetz, Jr. Lahey Clinic, Burlington, Massachusetts, U.S.A.

Anthony J. Senagore The Cleveland Clinic Foundation, Cleveland,

Ohio, U.S.A.

Jeffrey A. Stern Northwestern University Medical School, Chicago, Illi-

nois, U.S.A.
Contributors xi

Scott A. Strong The Cleveland Clinic Foundation, Cleveland, Ohio,

U.S.A.

David B. Tashjian Department of Surgery, Baystate Medical Center,

Springfield, Massachusetts, U.S.A.

William E. Taylor Mayo Graduate School of Medicine, Mayo Founda-

tion, Rochester, Minnesota, U.S.A.

Alan G. Thorson Creighton University School of Medicine and Univer-

sity of Nebraska College of Medicine, Omaha, Nebraska, U.S.A.

Michael V. Tirabassi Department of Surgery, Baystate Medical Center,

Springfield, Massachusetts, U.S.A.

W. Douglas Wong Memorial Sloan-Kettering Cancer Center, New York,

New York, U.S.A.
1
History of Stomas*

Peter A. Cataldo
University of Vermont College of Medicine,
Burlington, Vermont, U.S.A.

INTRODUCTION
Currently, there are approximately 1 million individuals with an ostomy
living in the United States, and an industry has developed solely for the
purpose of supplying ostomy products. These people live normal lives, and
some of them even compete in the National Football League and play golf
on the professional tour. However, this situation was not always the case.
Great advances in both stoma surgery and the development of ostomy man-
agement systems have made it possible for individuals with an ostomy to
lead a normally active life.
The history of stomas has its beginnings in biblical times, but the first
purposeful creation of a stoma occurred slightly more than 200 years ago.
In a relatively short time, thanks to many of the great pioneers in surgery
and enterostomal therapy, the stoma has evolved from a hastily constructed,
foul-smelling, and unsightly artificial anus covered with only moss and
leaves and held in place with a crude leather strap to an odorless, barely
noticeable, and often continent opening that may require no device whatso-
ever.

NATURE’S STOMAS

The earliest stomas were not envisioned or created by imaginative surgeons

but by the forces of nature (e.g., the result of a strangulated hernia in those
individuals fortunate enough to survive) or by ancient warriors (e.g., survi-
vors of abdominal wounds with visceral injury who occasionally lived with

*The opinions expressed in this chapter are those of the author and do not reflect
the opinions of the United States Air Force or the Department of Defense.
1
2 Cataldo

a permanent enterocutaneous fistula). One of the earliest accounts of vis-

ceral injury comes from the Old Testament, when Eglon was stabbed by
Ehud: “He [Eglon] could not draw the dagger out of his belly and dirt came
out” [1].
The first purposeful stomas were created for the treatment of abdomi-
nal trauma and bowel obstruction. A brief outline of the evolution of the
medical and surgical treatment of trauma and bowel obstruction will add
insight into the origin of abdominal stomas.
One of the earliest accounts of the treatment of traumatic abdominal
wounds is found in ancient Hindu writings. Susruta (600 B.C.) advocated
the closing of traumatic intestinal wounds with the pincers of black ants,
followed by emolument washings and reintroduction of the intestines into
the abdominal cavity [2]. In the early sixteenth century, injuries of the gut
followed one of three courses: the person died, the wound healed spontane-
ously, or an external fistula formed. The accepted surgical teaching in-
volved supportive care only. Contrary to established principles, Von Ho-
henhiem, a German surgeon, began teaching his students to repair small
intestinal wounds over silver cannulas [3]. However, he was not enthusias-
tic about this treatment. In the early sixteenth century, he was probably the
first surgeon to suggest the creation of an artificial anus for penetrating
gut injuries. However, there is no evidence that he actually performed his
procedure.
In 1757 Lorenz Heister (1683–1758) (Fig. 1), after observing the
spontaneous formation of stomas following abdominal trauma, recom-
mended exteriorization of the injured intestine. He wrote “that the lips of
the intestines so wounded, would sometimes quite unexpectedly adhere to
the wound of the abdomen; and therefore there seemed no reason why we
should not take hints from nature” [4]. In response to criticisms related to
the inconvenience of exteriorized intestine, Heister said: “It is surely far
better to part with one of the conveniences of life than to part with life
itself” [4]. This philosophy was certainly not accepted by all surgeons. In
the eighteenth century, Jean Palfin [5] and John Bell, both barber-surgeons,
emphasized closing the wound of the abdominal wall while leaving the
injured intestines alone. Exteriorization, however, grew more popular
throughout the eighteenth century. Begny, Schafer, and François de la Pey-
ronie [6] all used this technique in the treatment of abdominal wounds. In
1783 Benjamin Bell modified the exteriorization procedure by creating a
double-barreled ostomy in order to prevent stomal stenosis [7].

BOWEL OBSTRUCTION

Bowel obstruction and its treatments have been extensively reported

throughout medical history. Incarcerated hernias and intestinal tumors were
History of Stomas 3

Figure 1 Lorenz Heister. (Courtesy National Library of Medicine, Bethesda,

MD.)

in the past, as they are now, the main causes of obstruction. The first surgi-
cal treatment of bowel obstruction was prescribed by the ancient Greeks.
Praxagorus, a contemporary of Aristotle, wrote the following in 400 B.C.:
“He [unidentified] seemed to be a very bold practitioner for in this distem-
per [bowel obstruction] if the remedies did not operate, he ordered an inci-
sion to be made into the belly and even into the gut itself and the excre-
ments to be drawn out and the wound sewed up again” [8]. However, no
reports exist on the performance or results of such a procedure.
For the next 20 centuries, the treatment of bowel obstruction remained
medical and centered around purgatives and enemas. Hippocrates (a cousin
to Praxagorus) advocated a honey suppository anointed with the gall of a
bull and followed by an enema. If this method failed, rectal insufflation
with a smith’s bellows was prescribed [9]. Dolaeus recommended drinking
a concoction containing horse dung “because excrement expels excrement,”
whereas some physicians recommended rubbing the abdomen with slough
of a snake seethed in oil or wine [9]. Other experts prescribed anal insuffla-
tion of tobacco smoke in the treatment of bowel obstruction.
4 Cataldo

Ambroı̈se Paré and many of his contemporaries treated bowel obstruc-

tion with large doses of crude mercury taken by mouth in the belief that
the weight of the heavy metal would correct the blockage [3]. Application
of heat to the abdominal wall was also a popular treatment. Willis and
James covered the abdomen with calf’s omentum while Thomas Sydenham
preferred using a live puppy [9]. Even stimulation with galvanic current
was tried. Opium, a popular treatment in the seventeenth century, often
accompanied these ingenious remedies for the obstructed intestines.
As previously mentioned, physicians had observed relief of bowel ob-
struction as a consequence of spontaneous stoma formation (Fig. 2) and
had exteriorized injured intestines, thus creating stomas. However, no one
had yet proposed the purposeful creation of a stoma to relieve intestinal
obstruction.

INTRODUCTION OF COLOSTOMY

In 1710 Alexis Littré (1658–1726) suggested the creation of an abdominal

stoma for the treatment of imperforate anus after observations made during
the autopsy of a 6-day-old infant. This event was reported by Fontanel, the
historian to the Royal Academy of Sciences in Paris [10]:

Figure 2 In 1750 Margaret White developed a spontaneous colostomy as a result

of a strangulated umbilical hernia. (From Devlin HB. Colostomy. Ann R Coll Surg
Engl 52:393–395, 1973.)
History of Stomas 5

M. Littré saw in the dead body of an infant of six days a maldevelop-

ment of the rectum. The rectum was divided into two portions both
closed and connected by only a few threads of tissue about an inch
long. The upper portion of the closed bowel was filled with meconium.
The lower portion was entirely empty. M. Littré, wishing to render his
observation useful, imagined and proposed a very delicate operation in
the case where one would recognize a similar confirmation. It would
be necessary to make an incision into the belly, open the two ends of
the closed bowel, and stitch them together, or at least to bring the upper
part of the bowel to the surface of the belly wall, where it would never
close, but perform the function of an anus. Upon this slight suggestion
a clever surgeon could imagine for himself details which we suppress.
It often suffices to know in general that a thing may be possible and
not to despair of it at first sight [11].
Littré’s idea remained untested for 66 years, until Pillore, a country
surgeon from Rouen, France, performed a cecostomy for the treatment of
an obstructing rectal cancer. Pillore’s great achievement might have gone
unnoticed were it not for Jean Amussat’s inquiries. At the request of Amus-
sat, who learned of the procedure through hearsay, Pillore’s description of
the first colostomy was found in his memoirs by his son many years later.
Pillore’s eloquent account was translated by Tilson Dinnick [10]:
M. Morel, a wine merchant and posting master of Vert-Gallant in the
district of Brai, was in the course of the year 1776 taken with difficulty
in going to stool. He had first experienced some slight pain in the anal
region. These pains became a little greater, without, however, becom-
ing insupportable; but the difficulty in his motions increased to such a
degree that he became anxious and determined to come to Rouen for
consultation and the necessary remedies. He presented himself to M.
Delaroche, a capable physician, who ordered him laxatives and gentle
purgatives. These softened the bowel contents and relieved him for
some time. But finally, as his difficulties increased daily, he was ad-
vised to make use of mercury (or quicksilver) in sufficiently large doses
that by their mass would overcome the obstacle in the bowel. The
patient indeed took 2 pounds of quicksilver. It was watched for every
day but did not appear. The motions became totally suppressed and the
belly increased in size from day to day, without, however, being tender
or inflamed. In this state of affairs I was consulted. (It is now a month
since the patient had taken the mercury without having passed a single
drop of it.)
I first examined the rectum, thinking indeed it was there the ob-
struction would be found, believing it was possibly formed by the hard-
ened and incarcerated feces, as I had often seen to happen; but instead
of the species of obstruction I found the upper part of the bowel fixed
and scirrhous, forming a very large tumor which totally obstructed the
rectum. I tried to pass sounds and cannulae of all shapes and sizes,
continuing my efforts for several days, but uselessly. In this state, that
6 Cataldo

is to say, the patient having passed nothing from the bowel for over a
month, and his belly enlarging daily in spite of his most austere diet—I
proposed to him that I should make him an artificial anus. He agreed
with me and cited the case of a man in his village who for several
years had had an artificial anus which nature had provided following a
strangulated hernia. I knew of this case and also one of another woman
in from the same cause.
I was then indeed determined to perform the operation, but as the
case was a very delicate one I first asked five or six of my colleagues
to see the patient in consultation with me. No one was of my opinion
and no one agreed with me. But the patient, a man of great sense, being
present at our consultation, prayed my colleagues to show him another
means by which he might be saved. They answered that they knew
none. “Very well,” he replied, “it is indeed imperative to operate since
my illness is mortal and you know of no other means to save me.”
Encouraged by so strong an argument, I performed the operation
in the presence of my confreres, and six pension pupils who were with
me at the time. I chose the cecum as the part of the bowel most suited
to our need, as much by its situation as because it would furnish a
reservoir, and by its continual and involuntary action would hasten the
evacuation of intestinal contents. A small plate furnished with a sponge
in the shape of a large button and held by an elastic bandage was
devised in the place of a sphincter, so that the patient could at all times
voluntarily remove it when he felt the need, and, by means of a small
clyster, he could from time to time cleanse out the reservoir. My patient
and I conferred together and thought of all these things before the oper-
ation. I then operated.
I commenced with a transverse incision a little above the groin
which I deepened above and below to the depth of the cellular tissue.
I arrived at the aponeurosis of the external oblique which I incised to
the same extent a little above the fallopian ligament (Poupart’s) in or-
der to have at least a good inch of space from the integuments of the
cecum. I made a transverse opening in the muscles in peritoneum al-
most to the same extent. The base of the cecum, easy to recognize by
its appendix, presented itself—I did not have to search for it. I drew
the cecum out as far as possible and without effort; there held by an
assistant and myself, I opened it transversely and stitched it to the two
lips of the wound by means of a thread on two needles which I passed
from one side to the other. I passed them from within outward and
pulled the thread in the middle, thus obtaining two ligatures which I
tied above and below to compresses to press together the edges of the
wound. The contents of the bowel came out in abundance. For a dress-
ing I applied burnt charcoal and towels. I used no pressure in order
that the issue of fecal matter might not be interrupted. In fact, it ran
out in abundance for several days. And the belly diminished consider-
ably in size. As the quicksilver was giving us anxiety and we had not
seen a single drop of it appear, we caused the patient to be put in all
History of Stomas 7

possible positions that might give it an easy issue. There was not the
slightest sign of it, however. Fourteen or fifteen days had passed since
the operation, during which time the wound had separated and the bowel
was glued to the skin. I had taken out the stitches and all appeared to be
in the best possible state when the patient reported vague pains in differ-
ent parts of the belly. We first attributed this to gasses shut in the intes-
tines, but the patient, uneasy, always said the pains were due to the
mercury and consequently continued to take positions that might help it
to come out. On the 20th day the belly, which had been very flat, became
swollen and painful. Emollient fermentations were applied, and through
our artificial anus we threw some injections into the colon. It bled twice,
but in spite of all our efforts the symptoms quickly augmented and the
patient died on the 28th day after his operation.
I performed the autopsy in the presence of the same surgeons,
colleagues, and pupils and found as follows:
The cecum and the whole colon were healthy and in good condi-
tion. The cecum was adherent to the lips of the wounds, except in one
angle where there was a small area of suppuration in the neighboring
cellular tissue, which did not, however, communicate within. The colon
was opened to the whole of its extent, and only contained some glairy
mucous. The cancerous obstruction which was the primary illness was
8 or 9 inches long, situated at the end of the colon in the beginning of
the rectum, totally obliterating the intestinal canal. The tissues sur-
rounding the rectum were hard and fixed. At the site of the rectum was
an opening whose calloused edges announced it to be a species of
chancre from which issued fecal and purulent material. The peritoneum
in the neighborhood of the kidney was inflamed, without, however,
being separated. The peritoneum was inflamed and inherent to the folds
of the intestines. The quicksilver which the patient had taken was found
in one of the last convolutions of the jejunum, which it had dragged
down by its weight to the pelvis, behind the bladder. It was pocketed
in that portion of the bowel which contained it. This bowel presented
here and there gangrenous areas, and was inflamed, the inflammation
extending to the loins. The mercury was all recovered and had not lost
a bit of its weight. We believed that we could conclude that if the
operation has not met our expectations for success it was because of
the mercury. For it is very probable that when the intestines, which
because of their greatest dilatation had lost the power of action, became
empty of stercoral material, the peristaltic action was not sufficiently
powerful to move the mercury. Then followed inverted retrograde
movements, as announced by the nausea and colic which the patient
experienced on the 20th day of his illness. Considering the pull on the
mesentery in the intestines by the massive two pounds, one is not sur-
prised that gangrenous inflammation occurred and produced the death
of the patient.
In 1783 Dubois, a Parisian surgeon, performed an iliac colostomy on
a 3-day-old child suffering from imperforate anus. Dubois was successful
8 Cataldo

in relieving the obstruction but not in curing the patient. This child died on
the 10th day following surgery [10].
The colostomy had its true beginning with the surgery of Duret, a
naval surgeon at the Military and Marine Hospital at Brest. In 1793 Duret
performed the first successful left iliac colostomy in the treatment of imper-
forate anus in a 3-day-old infant. Tilson Dinnick [10] has provided us with
a translation of Duret’s original account:
Friday, October 18, 1793, Marie Poulaouen, midwife of Brales, deliv-
ered the wife of Michael Ledreves, a laborer, of a child. She noticed
that the infant had no anus and that the sexual parts were malformed;
judging that in the best state of affairs the child had not long to live
she advised the parents to bring the child to Brest to receive surgical
aid. On Saturday at ten in the morning the father came to my house
and I examined the child. The sexual organs were so formed that the
scrotum was divided at the raphe into two equal parts, each containing
a testicle. At first sight, one believed the child to be female. The glans
penis lay upon the perineum pierced by the urinary meatus from which
the urine issued freely. The region of the anus showed no sign of the
existence of a rectum. The skin was natural consistency in color, and
no tumor presented when the child strained. After making this examina-
tion I believed the case to merit the attention of those most skilled in
the art of healing, and with this view I called a consultation of all the
physicians and surgeons attached to the various hospitals in the city.
The consultants advised opening the skin at the spot where the rectum
should be present and searching for the bowel. The operation was not
successful. I was able to appreciate by passing a sound through the
wound into the pelvis that the lower portion of the big bowel was
absolutely missing. It was now four in the afternoon; the infant ap-
peared without resource. The vomiting, the extraordinary swelling of
the belly, and the coldness of the lower limbs seemed signs of certain
death. To my surprise, however, the next morning the child still lived.
This decided me to call a second consultation, at which I proposed as
a last resort, to prolong the life of the child, the performance of laparot-
omy and establishment of an artificial anus. To give me confidence in
this most extraordinary procedure I performed it upon the dead body
of a child of 15 days which I took from the poor house of the city. I
made an incision on the left side between the last of the false ribs and
the iliac crest about two inches long. I exposed the pole of the kidney
and a portion of the left side of the colon; this last was opened. I then
injected some water by anus. A portion of the fluid came out through
the opening of the colon and a portion escaped into the belly. I then
recognized by opening the belly that in the fetus the lateral areas of the
colon are not extra-peritoneal as in the adult, but that the colon has a
mesocolon which renders it free and floating. This circumstance caused
me to reject the operation in this region in the fear that it would give
rise to an escape of meconium into the belly. Those assembled after
witnessing this trial and after prolonging the discussion sufficiently to
History of Stomas 9

prove both its interest to humanity and to surgery, decided: (1) that
without some extraordinary intervention the death of the child was in-
evitable; (2) that the axiom of Celsius, “that it is better to employ a
doubtful remedy than to condemn the patient to certain death,” here
found its application; and finally (3) that the decisions of M. Hevin
upon laparotomy were not transgressed by this operation, as a cause
and course of the malady were, as here, recognized.
I opened the belly of the little patient in the left iliac region in
the neighborhood where the sigmoid colon was forming a tumour a
little apparent to the eye in where the meconium already imparted a
slightly deeper colour to the skin. I made an opening about an inch and
a half long which served for me to introduce the index finger into the
belly, with which I lifted and pulled out the sigmoid colon. In the fear
that it would immediately fall back into the belly I stitched it by two
waxed threads passed through the mesocolon. I then opened the colon
longitudinally. Gas and meconium came out in abundance. When the
bowel had emptied itself to a certain extent I applied a dressing. It was
simple and composed of a pierced compress. And the night between
Sunday and Monday the baby slept well, the body heat returned, the
vomiting ceased, and child took breast easily on several occasions. The
day following the operation, all who had witnessed the operation the eve-
ning before expressed themselves satisfied with the advantageous changes
they perceived. The bandages which had surrounded the child were filled
with meconium, and his voice, which had previously hardly been distin-
guishable, was now heard lustily.
On the third day, as things were going from better to better, I
charged the parents to bring the child twice daily to the hospital. Citi-
zen Massac, Chief of the Administration, and Citizen Coulon, Physi-
cian in Chief, were charged to provide the necessary dressings. On the
4th day, the stools became yellow and less in quantity, so I ordered a
washing out with simple water and 2 drops of serum of rhubarb. This
produced a good effect and gave the patient several stools.
On the 5th day, the threads which held the bowel appeared use-
less, so I removed them, as they were already producing redness and
irritation in the region of the artificial anus.
On the 6th day, about an inch of the internal coats of the bowel
appeared through the opening, giving the wound the appearance of a
chicken’s egg. I attempted to reduce the prolapse by passing a lead
cannula into the fistula, both to obstruct the further herniation and to
keep a free passage of feces, but the child’s cries made me defer this
means. The instrument has, however, since been perfected by Citizen
Morier, a clever cutler of this city. On the 7th day, the child was so
well, both at the site of operation and in exercise of his functions, that
I judged him no longer in need of care of supervision by a person of
the art.
This patient survived with an artificial anus until age 45. Duret was
unaware of Littré’s prior suggestions or Pillore’s cecostomy. Duret’s in-
10 Cataldo

sight into colostomy surgery was remarkable. He antedated Callisen in the

suggestion of lumbar colostomy. He used a mesenteric stitch to secure the
colon to the abdominal wall (90 years prior to Allingham’s famous mesen-
teric stitch). He noted and treated prolapse and used a colostomy for colonic
washouts [10].
In 1797 Professor Fine, surgeon-in-chief to the Hospital in Geneva,
performed the first transverse loop colostomy in a 63-year-old woman suf-
fering from rectal cancer [10]. Through a midline incision, he drew out an
inflamed loop of bowel, passed a stitch through its mesentery, and sewed
it to the skin. The patient’s obstruction was relieved, and she lived another 3
months. Fine believed that he had created an artificial anus from the terminal
ileum; however, autopsy revealed a successful transverse colostomy.
With the advent of colostomies, it became necessary to create a means
for the collection of feces. The first mention of such a collecting device
was reported by Daguesceau in 1795. He performed an inguinal colostomy
in a farmer who impaled himself on a cart stake while unloading wheat.
The farmer, then age 57, survived until the age of 81, and “conveniently
collected his feces in a small leather pouch” [10]. Daguesceau also per-
formed the first colostomy for the treatment of intractable perianal fistulas.
It is interesting to note that the fistulas healed and 2 years later the colos-
tomy spontaneously closed.

INGUINAL VS. LUMBAR COLOSTOMY

By the 1800s the colostomy became an acceptable surgical solution to re-

fractory intestinal obstruction. At that time debate centered on the technique
of construction, and two distinct schools emerged, those favoring inguinal
colostomy and those preferring lumbar colostomy [12].
As mentioned earlier, lumbar colostomy was first suggested by Duret.
Callisen, however, a professor of surgery at Copenhagen, is often cited as the
first to perform a lumbar colostomy [13]. He performed a lumbar colostomy
on the corpse of an infant who had died of imperforate anus. During the
procedure he inadvertently entered the peritoneal cavity, yet was able to com-
plete the lumbar colostomy through a second incision. Because of the diffi-
culties he encountered, Callisen never became an advocate of the procedure.
Jean Zulema Amussat (1796–1856) (Fig. 3) can be considered the
father of the lumbar colostomy. He began his medical career as a “medic”
in the French army during the Napoleonic wars and became a studied anato-
mist as the result of many dissections performed on Russian corpses [14].
Amussat published manuscripts on hemorrhoidectomy, surgery for uterine
fibroids, and experimental intestinal anastomosis. He is most famous, how-
ever, for his description of the lumbar colostomy.
After being called in consultation to see a 48-year-old woman with
bowel obstruction, Amussat and his colleagues suggested enemas, uterine
History of Stomas 11

Figure 3 Jean Zulema Amussat. (Courtesy of National Library of Medicine,

Bethesda, MD.)

pessary, rectal sounds, aloe suppositories, and even galvanic current. When
none of these standard remedies cured the intestinal obstruction, they rec-
ommended the creation of an artificial anus. Amussat, after hearing of Cal-
lisen’s approach [13], planned a lumbar operation and performed the proce-
dure on a cadaver. The following day the patient underwent surgery.
Amussat [12] described the procedure in the following way:
The patient was placed on her abdomen leaning toward the right side,
and two pillows were placed side by side under her abdomen. By this
exposure the left side of the lumbar region was well exposed. There
appeared, at this point, a round protuberance, indicating the point where
the incision should be made.
The skin incision was made two fingers above the iliac crest. I
continued the incision deeper in a transverse fashion. An artery was
twisted and after having incised the aponeurosis as well as after having
gone through a considerable area of fat, I clearly recognized the intes-
tine, which was very distended and outside the peritoneal cavity. Being
at the point of perforating the bowel with the trocar, I thought that
perhaps it could be decompressed, and then I decided to place two
sutures into the bowel approximately one thumb’s distance apart. The
intestine was held by these two sutures by one of my assistants. I then
punctured the point between the two sutures. Gas and fecal matter es-
caped through the trocar and cannula. Immediately after I passed a
hernial probe adjacent to this cannula which permitted me to enlarge
the opening I had created with the trocar. This allowed a copious
amount of gas to escape as well as more fecal material.
12 Cataldo

Two irrigations of the artificial anus were performed—one in the

direction toward the lower part of the bowel and the other toward the
upper bowel, which again resulted in more fecal material appearing.
The quantity was so large that 3 buckets were quickly filled. The evac-
uation, as well as the gas which had previously distended the abdomen
and created so much discomfort, caused the patient to state how much
better she felt. The intestinal opening was then brought forward and
anteriorly sutured to the skin in 4 points by everting the mucosa. The
first suture was made of an ordinary curved needle. And the others
were made with acupuncture needles which I usually employ, and were
hardly felt at all. The posterior angle of the wound was reconstructed
with sutures.
The patient stoically withstood the operation. Immediately after-
wards she was returned to her bed and a simple dressing of oiled cloth
was applied. During the day the patient felt a great deal of relief. How-
ever, she slept very little that night.
The patient did well postoperatively and was discharged 39 days after
surgery. At that time she was having one bowel movement every 24 hr. It
is interesting that her lumbar colostomy was described as “continent” by
Amussat.
Amussat collected and reported on 29 cases of artificial anus between
1776 (Pillore’s cecostomy) and 1839 (his own first case) [10]. Of the 29
cases, 20 patients died. Twenty-one operations were performed for imperfo-
rate anus, and there were only four survivors. (All four survivors were from
Brest, the seaport town where Duret performed the first successful colos-
tomy.) Of the eight adult cases, there were only five survivors. All 29 pa-
tients had been operated on via the abdominal route. Amussat attributed the
high mortality to peritonitis; therefore he considered the lumbar route to be
the preferred approach for the creation of an artificial anus.
In 1820 Daniel Pring, a surgeon from Bath, performed a left iliac
colostomy in the treatment of an obstructing rectal cancer, which made him
the first English surgeon to successfully create an artificial anus. (Freer
performed a similar procedure in 1815, but the patient died on postoperative
day 9.) In his memoirs Pring made these comments concerning the artificial
anus [10]:
(1) The operation prolongs life in cancer of the rectum. (2) It is always
acceptable in imperforate anus. (3) It would be useful in simple stric-
tures of the bowel. (4) Peritonitis is a danger. (5) It is imperative to
always open distended bowel. (6) Cecostomy is advocated for obstruc-
tion in the transverse colon. (7) The opening can be controlled to act
once in 24 hours. (8) Prolapse can be prevented and the opening pro-
tected by means of a truss and a pad.
After Amussat’s success with the lumbar approach, the debate be-
tween abdominal and retroperitoneal creation of an artificial anus swung in
favor of the retroperitoneal route. The fear of peritonitis expressed by
History of Stomas 13

Amussat influenced many surgeons. Additional advantages attributed to the

lumbar colostomy included the absence of a spur (then considered a disad-
vantage), less tendency to prolapse due to greater parietal fixation, a ten-
dency toward constipation rather than incontinence, dependent drainage in
the supine position, and absence of an offensive artificial anus on the ab-
dominal wall. Until 1852 the debate continued based on personal prefer-
ences, not scientific evidence. However, in 1852 Caesar Hawkins, president
of the Royal College of Surgeons in England, reported on a series of 44
patients treated surgically for intestinal obstruction [13]. Seventeen patients
underwent transperitoneal colostomy, and 27 patients were operated on via
the lumbar approach. The outcome was similar for both groups, and Hawk-
ins concluded that neither approach was clearly better. With the advent of
general anesthesia and improved surgical techniques, the abdominal ap-
proach gradually replaced the lumbar operation. However, in 1912 Paul of
Liverpool emphasized that the lumbar colostomy was still a valued proce-
dure. In his text Personal Experiences with the Large Bowel, Paul [15]
advocated the right lumbar approach for obstructions beyond the cecum,
because this approach would not complicate a subsequent abdominal proce-
dure, and for inflammatory conditions of the colon. He recommended left
lumbar colostomy for old or weakened patients with rectal obstructions,
noting that it was safer than the transperitoneal route.
An interesting addition to the history of colostomy came from New
Zealand. In 1876 de Lautour reported the case of a 37-year-old man with a
carcinoma of the rectum so painful that he was afraid to have a bowel
movement [9]. The patient, completely unaware of any previous achieve-
ments in colorectal surgery, placed his hand over his left groin and im-
plored the surgeon to create an opening in his side through which his
bowels might pass. Abiding by his patient’s wishes, de Lautour created a
left-sided colostomy, which successfully relieved the patient’s pain.
In 1880 de Lautour presented to the Royal College of Surgeons Mu-
seum in London a specimen of a lumbar colostomy found in the loin of a
sheep [9]. The case was remarkable not only for its occurrence but also for
its method of creation. The colostomy had been made by the kea parrot
(Nestor notabilis). Apparently this type of parrot feeds on sheep, most com-
monly dead ones but occasionally live ones. The birds hunt in pairs and
tear through the wool of the sheep until they reach the meat on the sheep’s
sacral area. Most often this action results in the death of the sheep. How-
ever, in several instances it has resulted in a lumbar colostomy, as in the
case of de Lautour’s sheep.

END COLOSTOMY
Until this point in time, only loop stomas had been created, but they were
prone to prolapse and often did not completely divert the fecal stream. In
14 Cataldo

1881 Schitzinger [10], and in 1844 O.W. Madelung [16] described a proce-
dure of creating a proximal “single-barreled” stoma while returning the dis-
tal closed loop to the abdominal cavity. F.T. Paul [17] also advocated com-
plete transection of the bowel in order to adequately defunctionalize the
distal colorectum (Fig. 4). In conjunction with this procedure, he described
the placement of a glass tube into the proximal colon to remove the intesti-
nal contents from the wound and to prevent subsequent wound infection.
These efforts represent the beginnings of the end colostomy.

COLONIC RESECTION AND ANASTOMOSIS

(MIKULICZ PROCEDURE)
In most cases (i.e., imperforate anus or obstructing rectal carcinoma) a
stoma is required for the remainder of the patient’s life. However, in many
cases only a temporary colostomy is needed, and the natural question is:
How can the natural passage of feces per anum be resumed? The Mikulicz
technique of intestinal anastomosis, described by Johann von Mikulicz-
Radecki in 1903, solved that very problem [18].
However, the idea had been alluded to by Schmalkalden [19] in 1798,
over 100 years prior to Mikulicz. In his doctoral thesis, Schmalkalden de-

Figure 4 Double-barreled colostomy with attached glass tubing to remove feces

from the surgical wound, as described by F. T. Paul of Liverpool. (From Devlin
HB. Colostomy. Ann R Coll Surg Engl 52:393–395, 1973.)
History of Stomas 15

scribed a 23-year-old man left with a double-barreled ostomy from a gan-

grenous inguinal hernia. Schmalkalden reported passage of a suture be-
tween the proximal and the distal intestinal ends and placement of a linen
tent. He noted that this procedure eventually eliminated the ostomy spur
and allowed the patient to pass feces normally per anum.
A brilliant paper entitled “Memoir on a New Method of Treating Ac-
cidental Anus,” written by Baron Guillaume Dupuytren [20] in 1828, de-
tailed the formation of a fecal fistula following a strangulated groin hernia.
Dupuytren accurately described the proximal and distal intestinal ends ap-
pearing in the wound in the shape of a double-barreled gun, an analogy he
ascribed to Sir Astley Cooper, and the intestinal spur. He also understood
the importance of removing the obstruction between the proximal and distal
limbs while creating a fibrous bond between the two limbs to prevent fecal
peritonitis. After learning of the achievements of Schmalkalden [19] with
the linen tent, Dupuytren performed a similar procedure in 1813 on a 36-
year-old man with a fecal fistula resulting from a strangulated inguinal her-
nia. Eventually the patient passed feces via the normal route. However,
during Dupuytren’s attempts to cure the residual fistula (by dividing the
deepest portion of the spur), the patient developed peritonitis and died. Du-
puytren studied the effects of this procedure on dogs and realized that adhe-
sive inflammation caused by the sutures prevented the escape of feces and
prevented fatal peritonitis. Unhappy with the outcome with the linen tent,
Dupuytren [20] experimented further and suggested a device called an en-
terotome. The enterotome contained a “male” and “female” limb, each hav-
ing serrated edges. The male limb was fitted into a groove in the female
limb, and both limbs were closed over the intestinal spur. The clamp was
slowly tightened, which eventually resulted in the elimination of the intesti-
nal spur.
Dupuytren studied the effects of his enterotome on animals and found
well-formed fibrous adhesions between the proximal and the distal limbs
in 2–3 days, long before the spur was divided (6–8 days). In 1815 Dupuy-
tren first used this device in the treatment of a 26-year-old man with a
strangulated hernia. The enterotome was induced into the double-barreled
stoma and closed without producing any pain. Pressure was gradually in-
creased. The patient passed some stool normally on day 6, and the clamp
loosened and came away on day 8. Examination of the enterotome revealed
two complete intestinal walls. The fecal fistula persisted, but eventually it
closed with the help of silver nitrate, pressure dressings, and finally sutures.
Dupuytren [20] noted that he thought his method had received “the
sanction of experience.” He collected and reported on a series of 41 intesti-
nal anastomoses performed with the help of his enterotome, 21 performed
by him and 20 done by others. Of the 41 patients, 38 survived, and in 29
cases the fecal fistula had healed completely in 2 to 6 months. Of the re-
maining 9 patients, Dupuytren [20] said:
16 Cataldo

It remains to find in all cases a means of producing the cicatrization in

a useless opening. . . . I declare that without hesitation the discovery of
a sure method of promptly achieving in all cases the healing of this
disgusting malady would constitute one of the greatest steps of which
the healing art was capable.
Soon after Dupuytren presented his work but before it was published,
his pleas were answered. Because of the new developments in intestinal
anastomosis, he added the following footnote to his paper just prior to pub-
lication. It concerns the methods of intestinal suture described by Lembert
and Jobert: “Both of them [methods] seem to be perfect and, if I accord the
preference to that of M. Lembert, I should fail not to say that he has been
preceded by M. Jobert” [20].
Technical advances in the creation of ostomies continued throughout
the nineteenth century, and “resection with exterioration” became the fa-
vored method of colonic resection. At this time, despite the work of An-
toine Jobert de Lamballe and Antoine Lembert, primary intestinal anasto-
mosis was considered too risky and therefore was not widely practiced.
Paul, Morrison, Schede, Gussenbauer, Madyl, and von Volkmann all con-
tributed to technical advances [21]. However, Mikulicz-Radecki was pri-
marily responsible for the wide acceptance of resection with exteriorization
in the surgical community.
Although Mikulicz popularized intestinal resection and the procedure
that now bears his name, the first colonic resection was performed many
years earlier. At Guys Hospital in London in 1832, Thomas Bryant [22]
performed the first elective colonic resection followed by a double-barreled
colostomy for a stricture of the descending colon.
Johann von Mikulicz-Radecki (1850–1905) (Fig. 5) was born in Cer-
nowicz, Austria [23]. He earned his doctorate in medicine in Vienna and
soon became assistant to C. A. Theodor Billroth. Mikulicz’s titles included
professor of surgery at Krakow, Konigsburg, and Berslaw. He died at the
age of 55 of carcinoma of the stomach [24].
Mikulicz [18] presented his technique of intestinal resection and anas-
tomosis in a now famous article entitled “Surgical Experiences with Intesti-
nal Carcinoma,” first read before the Thirty-First Congress of the German
Society of Surgery in 1903. He not only detailed his technique of intestinal
resection but also included his personal experience in over 100 cases. Mi-
kulicz eloquently described the presenting symptoms, anatomic distribution,
microscopic pathology, surgical treatment, complications, and survival rate
of 106 patients with intestinal (mainly colonic) carcinoma.
Mikulicz understood and explained the danger of primary anastomosis
in the face of acute and chronic obstruction and in the malnourished, chron-
ically ill patient. He appreciated the increased difficulty in colonic (vs.
small intestinal) anastomosis: “The lessened strength of the wall of the
large gut, the poor blood supply, the sluggish peristalsis as a result of which
History of Stomas 17

Figure 5 Johann von Mikulicz-Radecki. (Courtesy National Library of Medi-

cine, Bethesda, MD.)

the firm feces stagnate at the site of suture, give far less assurance to the
primary union than in the small intestine” [18].
Mikulicz realized, as did his contemporaries, the pathophysiological
and often fatal consequences of intestinal spillage, peritonitis, and sepsis;
yet he showed unusual insight [18].
We can almost say as a rule a slight amount of bacterial invasion is
overcome by the peritoneum; the effect produced is the circumscribed
peritonitis observed in all stomach and intestinal operations. The capac-
ity to overcome successfully an insignificant peritoneal infection of
such a nature depends, in the first place, on the resistance of the entire
organism.
He also appreciated the increased risk of bacterial seeding in the immuno-
comprised patients [18]:
The patient [with intestinal cancer] is found in a state of chronic intoxi-
cation by which he is doubtless less resistant to intestinal bacilli. . . . I
do not doubt that the frequent pneumonias following this operation in
part at least are to be attributed to a bacterial infection of the perito-
neum which is locally overcome but which leads to pneumonia by way
of small pulmonary emboli.
Because of the aforementioned problems, Mikulicz considered pri-
mary anastomosis to be too risky in the treatment of intestinal carcinoma.
He reviewed his peers’ experience with primary suture and compared it to
that of his two-stage procedure, citing a reduction in mortality from more
18 Cataldo

than 50% to 12.5%. He described three main advantages of the two-stage

resection: (1) the proximal dilated bowel is decompressed and the patient
is detoxified, (2) the intestinal anastomoses are performed on normal intes-
tine, and (3) the risk of peritonitis is minimized.
Mikulicz [18] described his technique in the following way:
The intestinal tumor along with the diseased lymph glands in the corre-
sponding portion of the mesentery are freed from all attachments as in
the single stage resection, so the tumor is finally connected only with
the gut leading to and from it. The mesentery must be loosened suffi-
ciently to allow the section of bowel which is to be resected to be laid
out on the surface of the abdomen without tension. When this is done
the abdominal wall is closed off so that only the cleft necessary for
passage of the afferent and efferent segments of the gut is left open;
this cleft must not be so narrow that the afferent section is compressed.
A series of serosal sutures is placed at the point where the parietal
peritoneum comes into contact with the protruding portion of the
bowel, these sutures also closing off the peritoneal cavity at this point.
The outer skin is sutured carefully to the protruding bowel (with tam-
ponades). Next a line of sutures as well as the surface of the contact
between the exposed gut and the skin wound are thickly spread with
zinc paste and over this a sterile dressing is placed. Over the bandage
comes a large piece of waterproof material with a slit just large enough
to allow the protruding gut to be drawn through. Thus the tumor which
is to be resected is finally separated from the abdominal cavity not
only by the secured abdominal wall but also by the protective dressing.
Formally, I removed the tumor only after the passing of 12 to 48 hours,
but now I usually do it at once. A thick glass tube is fastened into the
discharging segment of gut and a thick rubber tube fastened to the glass
one so that the intestinal contents flow off.
The wound in the abdominal wall in this procedure heals, as far
as it is sutured, by primary intention. After 2 to 3 weeks, by means of
my spur-crusher, I transform the artificial anus resulting from the re-
moval of the tumor first into a fecal fistula and then later make a clo-
sure by suture.
The advantages of this procedure are evident. The main operation
is shorter than by the single stage method, the peritoneal infection dur-
ing the operation is absolutely avoided, and one can thus attempt it
much earlier on a patient debilitated by disease. A further advantage is
that the operation can be performed in cases of wide extension of the
tumor or in deep locations as for example in the lower part of the
sigmoid flexure, where it would be too dangerous to unite the intestines
because of too forceful tension on the loops of gut. The method is not
only less dangerous but also more easily performed. Of course, the
procedure also has its drawbacks. The duration of the treatment is
longer and the patient operated must bear with the unpleasantness of
an artificial anus for a long time. But I think these disadvantages are
History of Stomas 19

greatly outweighed by the advantages of greater safety and increased

ease of performance.
Mikulicz recommended his two-stage technique for all resections and
anastomoses of the large bowel and for the small bowel when ileus (ob-
struction) was present. For resections of the small intestine without obstruc-
tion, he advocated primary anastomosis. For cecal resections in healthy pa-
tients, Mikulicz recommended primary anastomosis with simple resections;
for patients in ill health or with large tumors requiring extensive dissection,
he recommended a two-stage procedure.
Of the 106 patients who comprised his report, Mikulicz performed a
two-stage resection in 16 cases. Two patients died, one from marasmus 7
weeks following surgery and one from injury to the descending colon, which
was infiltrated with cancer and accidentally torn down during the proce-
dure. No patients died as a result of anastomotic leakage. It is interesting
that also included in Mikulicz’s report were 21 patients who underwent
resection and primary anastomosis nine of whom died (mortality, 42.9%).
Mikulicz’s “Surgical Experiences with Intestinal Carcinoma” received
much attention because Mikulicz was a well-respected surgeon and an elo-
quent speaker. Following his presentation, the two-stage resection with ex-
teriorization, a procedure that still bears his name, became the preferred
technique for the treatment of carcinomas of the intestine. Mikulicz never
acknowledged the contributions of Schmalkalden, Bryant, or Dupuytren to
this procedure.
While Mikulicz was refining the two-stage resection, several other
inventive surgeons were contributing technical advances of their own. Ray-
bard of Lyon, in a report in the memoirs of the Paris Academy for Surgery
in 1844, described the successful resection of an “orange-sized” tumor of
the sigmoid colon with primary intestinal anastomosis by means of a “fur-
rier’s suture” in 1833 [25]. However, the specimen was disposed of, and
an autopsy was not performed after the patient’s death 10 months later. The
Paris commission found the report insufficient and lacking in precision.
In 1879 Martini of Hamburg may have been the first surgeon to per-
form what was later to become the Hartmann procedure [25]. After remov-
ing a large tumor in the sigmoid colon, he was unable to approximate the
intestinal ends. Instead he closed the distal end and returned it to the ab-
dominal cavity while creating an end colostomy with the proximal colon.
As previously mentioned, Schitzinger and Madelung advocated com-
plete transection of the bowel with reintroduction of the closed distal end
into the peritoneal cavity, even when a simple colostomy without resection
was being performed. This idea was not widely accepted. In general, sur-
geons had two main concerns: (1) the fate of the undrained distal loop
returned to the abdominal cavity, and (2) the possibility that the proximal
loop would be inadvertently closed, thus creating an intestinal obstruction.
20 Cataldo

Polloson championed this procedure, however, and after his presentation at

the German Surgical Society, its popularity grew. As explained by Made-
lung, the advantages of complete fecal diversion included the following
[25]: (1) no feces came in contact with the obstructing region, and therefore
the patient experienced less irritation; (2) feces could no longer reflux from
the distal end into the stoma; and (3) the accumulation of feces in the distal
segment was avoided.
Polloson suggested, although he never received credit for, another im-
portant use for the completely diverting colostomy. He was first to rec-
ommend its use prior to transanal resection for rectal tumors in order to
prevent the dreaded complication of pelvic sepsis, a use that is still occa-
sionally employed today.
In 1886 Sonnenburg developed a method of avoiding the undrained
distal loop. Operating through a lower midline incision, he implanted the
closed lower loop just below the incision so that if infection and perfora-
tion did occur, a harmless intestinal fistula would develop [25]. In fact,
Sonnenburg observed this occurrence in one of his patients who was thus
treated.

COLOSTOMY SPUR

Sir Charles Ballance first used a rubber tube passed under the loop of bowel
to lengthen the colostomy spur and to completely divert the fecal stream
[9]. After using this method, however, he thought that it caused obstruction
of the proximal loop and led to the death of his patient, and therefore he
abandoned this technique.
Madyl is credited with being the true father of the colostomy rod. He
described the use of a rigid rod covered with iodoform gauze. The rod was
passed beneath the loop colostomy and left to rest on the abdominal wall,
thereby preventing retraction of the bowel. The proximal and distal loops
were further approximated by two sutures, one anterior and one posterior,
in order to ensure proper spur formation and complete diversion of the fecal
stream.
Bryant in England and Kelsey of New York described similar meth-
ods of creating a colostomy spur [9,25]. A harelip pin was passed through
the skin and peritoneum, through the intestinal mesentery at the junction of
its middle and lower two thirds and back through the peritoneum and skin
on the opposite side (Fig. 6). This technique produced a protuberant stoma
with a large spur that completely diverted the fecal stream.
Allingham considered Madyl’s technique to be too dangerous, and
subsequently developed “Allingham’s mesocolic suture,” a mattress suture
placed through the mesentery to secure the bowel and create an adequate
History of Stomas 21

Figure 6 Bryan and Kelsy independently described the use of harelip pin (inset)
to support a loop stoma. (From Corman JM, Odenheimer DB. Securing the loop—
Historic review of the methods used for creating a loop colostomy. Dis Colon
Rectum 34:1014–1021, 1991. Copyright American Society of Colon and Rectal
Surgeons, Inc.)

spur. To this suture application, Paul of Liverpool added his glass tube,
which diverted feces away from the wound and thereby prevented infection.
While these modifications were being introduced and confusion sur-
rounded the proper method of creating the colostomy spur, Reeves pub-
lished “Sigmoidostomy Simplified” in the British Medical Journal [25]. He
stated that an adequate colostomy spur could be created by passing a vul-
canite rod through the mesentery of the exteriorized intestine and that su-
tures were generally unnecessary. Reeves thought that the bowel should be
left unopened for 3–4 days and that the rod should be left in place for
approximately 1 week. Reeves believed that many of the other modifica-
tions were unnecessary and considered simplicity to be always advanta-
geous, as illustrated by the following quote: “The simplification of opera-
tive procedures should in the interest of the patients be the aim of the
surgeon, and experience abundantly proves that the simpler the operation
is the better are its results” [25].

RECTAL RESECTION

While stoma surgery progressed, other important advances were occurring

in the surgical world. Rectal excision was particularly important in the de-
velopment of intestinal stomas. In 1793 Faget performed the first rectal
22 Cataldo

resection for extensive ischiorectal suppuration [26]. In 1826 Lisfranc re-

ported the first rectal extirpation for cancer, and 5 years later he reported a
personal series of nine cases (six of which were successful) [27].
Early excisions were performed through the anal canal or the peri-
neum but exposure was limited and only lesions confined to the lower half
of the rectum were amenable to excision. In 1873 Verneuil, at the sugges-
tion of Amussat, excised the coccyx to extend the limits of resection [28].
This approach was also adopted by Kocher [29]. However, it was Paul
Kraske who popularized the transsacral approach. After witnessing the re-
moval of a sacral sarcoma Kraske realized that the lower sacrum could be
removed with minimum morbidity and that its removal provided excellent
exposure to the upper rectum. Following Kraske’s presentation to the Four-
teenth Congress of German Surgeons in Berlin, transsacral excisions of the
rectum flourished [30]. Other approaches also were attempted. A.T. Norton
[31], in 1889, described a transvaginal resection with the reestablishment
of continuity and postoperative continence.
H. T. Byford [32] replaced the excised rectum with a vaginal segment
in which both the proximal and distal ends were sutured to the vagina and
the vaginal introitus was closed. L. L. McArthur [33], after resecting recur-
rent rectal cancer, was unable to attach the rectum to the anus; therefore he
sutured it to the upper vagina and claimed that his patient (with a surgically
created rectovaginal fistula) had good postoperative continence.
In 1883 Vincent Czerny performed the first combined procedure for
rectal cancer. Unable to complete a transsacral resection of a high rectal
lesion, Czerny turned the patient and completed the procedure transabdomi-
nally [34]. Unfortunately, the patient died.
As mentioned earlier, Polloson advocated a diverting colostomy prior
to transanal rectal excision to prevent sepsis. Quénu, Hartmann, Juillard,
Bishop, and Jaboulay also favored this approach. Ball and Edwards rec-
ommended preliminary colostomies on selected patients, but Kraske and
Czerny thought that such colostomies were unnecessary except in unusual
cases. Although pelvic sepsis was a concern in the early postoperative pe-
riod, tumor recurrence was a major worry of surgeons. Allingham reported
a 100% recurrence in 18 personal cases, whereas Cripps reported only a
38% survival in 85 cases. Vogel reviewed 1500 cases of rectal cancer
treated by 12 prominent surgeons prior to 1900 and found an astonishing
recurrence rate of 80%.
Charles Mayo and Sir Ernest Miles (Fig. 7) had similar experiences
and believed recurrence was caused by the failure to resect perirectal lym-
phatics. Charles Mayo [35] in 1904 and Miles [36] in 1908 described their
techniques of abdominoperineal resection. In the early period the periopera-
tive mortality was high (20%), but the long-term survival was much im-
proved. Colostomy had found a secure place in the management of rectal
cancer.
History of Stomas 23

Figure 7 Sir Ernest Miles. (Courtesy Marvin L. Corman, M.D.)

HARTMANN PROCEDURE
During the nineteenth century the colostomy was extensively used in the
treatment of rectal cancer. First, it was important for its palliative role in
treating obstructing rectal lesions; second, for its protective role prior to
transanal rectal excisions; and finally, for its curative role in association
with abdominoperineal resections. However, colostomy is often used in the
treatment of other diseases of the colon and rectum. In 1907 Mayo et al.
[37] first described the use of the right transverse colostomy to “defunc-
tion” the sigmoid colon in the treatment of diverticulitis. The colostomy
was often permanent, but it was occasionally closed after the acute episode
has subsided. In the 1930s a three-stage approach, consisting of (1) divert-
ing transverse colostomy and drainage, (2) sigmoid resection with anasto-
mosis, and (3) closure of transverse colostomy, was independently de-
scribed by Mayo [38] and by Rankin and Brown [39]. These procedures,
however, are rarely, if ever, used today, having been replaced by the Hart-
mann procedure in the surgical treatment of complicated diverticular
disease.
Henri Hartmann (1860–1952) (Fig. 8) was born in France and was
graduated from the University of Paris medical school in 1887. He became
the professor of surgery at Hotel Dieu in Paris in 1909 [40]. During his
medical career Hartmann performed over 30,000 operative procedures, and
on his retirement he turned over to his successor his personally kept records
for each patient. Sometime between 1909 and 1923, he devised what is
24 Cataldo

Figure 8 Henri Hartmann. (Courtesy Marvin L. Corman, M.D.)

now called the Hartmann operation. The details of this procedure were pub-
lished in his text Chirurgie du Rectum in 1931 [41]. Hartmann described
resection of the sigmoid colon and upper rectum, oversewing of the distal
rectal stump, and creation of an end descending colostomy. However, he
advocated this procedure for the treatment of carcinoma of the sigmoid
colon. He even mentioned reanastomosis as a second procedure but thought
it a very difficult undertaking. It is unknown whether Hartmann ever per-
formed his procedure in the treatment of diverticulitis. It is believed that
sometime in the 1930s an unknown surgeon first performed this two-stage
resection and anastomosis for diverticulitis. Possibly, that surgeon was the
first to call it the Hartmann procedure [40]. Albeit through a circuitous
route, sigmoid resection with creation of a descending colostomy has be-
come the most popular procedure for the treatment of complicated divertic-
ulitis and is known as the Hartmann procedure.

CECOSTOMY AND APPENDICOSTOMY

In the late 1800s colostomy was first employed in the treatment of ulcera-
tive colitis. Ulcerative colitis was first described by Sir Samuel Wilks [42]
in 1875. In 1895 Keetley [43] of London described appendicostomy, and
in 1902 Weir [44] of New York described appendicostomy with colonic
irrigation in the treatment of severe ulcerative colitis. In 1895 Hale White
reported the use of cecostomy and colonic irrigation with boric acid for
severe “membranous colitis” [45]:
History of Stomas 25

It has been suggested that in a very intractable case it might be justifi-

able to open the colon high up and by allowing the feces for some time
to pass out through the artificial anus to give it a rest and at the same
time to flush it from the artificial anus to the natural anus with boric
acid lotion.
Bolton in 1901, Braun in 1913, and Cattell of the Lahey Clinic in 1935 all
used cecostomy and colonic irrigation in the treatment of severe ulcerative
colitis.
Cecostomy and appendicostomy also were described in the treatment
of chronic constipation. Keetley, a true champion of appendicostomy, Mur-
ray, and Sir William Bennett advocated appendicostomy in the treatment
of intractable constipation.

ATTEMPTS AT CONTINENT COLOSTOMY

Shortly following the acceptance of abdominal colostomy, surgeons began
to focus their attention on the establishment of a continent stoma. Cromar
[25] classified the early attempts into three main categories: (1) obturation,
(2) external pressure, and (3) sphincterization.

Obturation
In 1901 Payer created a skin flap to cover the colostomy outlet. Apparently
he met with little success, and his technique never gained any popularity.

External Pressure
In 1889 Witzel directed a colostomy through the subcutaneous tissue over
the crest of the ileum. With use of an external bandage, he compressed the
colon to maintain continence. Lenkinheld and Borchardt used this meth-
od with success but found the external bandage unnecessary. Roux cut a
V-shaped defect in the symphysis pubis and brought the sigmoid colostomy
between it and the rectus muscle to maintain continence. Bailey, Tuttle,
Braun, Andrea, and Burrows all used modifications of a subcutaneous tun-
nel combined with external pressure to maintain colostomy continence.
Goldschmidt and many other surgeons maintained continence by means of
a colostomy clip held in place with a tubular skin graft. Lambert created
anus en trompe, a 10-cm spout covered with skin grafts that was com-
pressed against the abdominal wall by means of an adhesive strap. This
technique was later modified by Hayem and Briscoe.

Sphincterization
In 1888 Maydl, the creator of the colostomy rod, and Hartmann advocated
a muscle-splitting incision similar to McBurney’s to create an artificial co-
26 Cataldo

lostomy sphincter. Gersuny and Lilenthal both brought the colostomy

through the rectus muscle and twisted the proximal end 180 to 360 degrees
and claimed perfect continence within 1 month of the procedure. Bernays
attempted a “sphincteropoiesis” by placating the circular muscle fibers of
the terminal sigmoid colon without much success. Ryall attempted to create
a sphincter by using fibers of the rectus muscle, again without success.
Failure of both of these methods was attributed to the lack of autonomic
nerve supply. In 1932 Spivack attempted to create an artificial sphincter
with a reversed ileocecal valve. None of these methods met with any long-
term success, and therefore all have been abandoned.

LOOP STOMAS
In 1888 Maydl first suggested the use of an external appliance to support a
loop stoma and to facilitate creation of a spur. Since that time, hundreds of
modifications have been used, but all are based on Maydl’s idea. Maydl
[46] described the use of an Indian rubber rod or goose quill passed through
the mesentery and left to rest on the skin. Reeves used a vulcanite rod for
the same purpose. In 1900 Hartmann [47] advocated rolled iodoform gauze
passed through the colonic mesentery. He also covered the peristomal skin
with iodoform gauze. These two maneuvers prevented stomal retraction
while protecting the peristomal skin. Greig Smith devised a glass rod for
stomal support, to which Makins added a piece of rubber tubing to prevent
slippage. Mouat further modified the glass rod by adding a metal cap to
prevent dislodgment and called it a “colostomy fixation pin” [25].
In the 1960s the glass rod was replaced by rubber tubing sewn to
the abdominal skin, which facilitated the placement of an ostomy pouch.
Wangensteen [48] developed a colostomy support device consisting of two
glass rods connected to a belt with rubber tubing. With this device, the two
ends of the bowel were pulled apart in order to better divert the fecal
stream. Plastic devices created by Greene [49] and Aries [50] and in the
1970s by Hollister, Inc. (Libertyville, IL) involved the development of a
butterfly-shaped stoma bridge, which is most commonly used today.

ILEOSTOMY

Although the history of colostomy dates back to the early 1700s, the ileos-
tomy is a much more recent event. The first reported creation of an ileos-
tomy was by Baum [51] in Germany in 1879. Baum performed a diverting
ileostomy in the treatment of an obstructing right colon cancer. Eight weeks
following the first surgery, he resected a tumor and performed an ileocolos-
tomy. Unfortunately, the patient died on postoperative day 9, after an anas-
History of Stomas 27

tomotic leak. In 1883 Mayd [52] of Vienna, the inventor of the colostomy
rod, performed the first successful ileostomy in combination with colonic
resection. Six years later, J.M.T. Finney described the flush-loop ileostomy
for the treatment of small bowel obstruction in association with appendiceal
abscess [53]. Severe skin irritation resulted, and the procedure never gained
any popularity.
The widespread use of ileostomy was a result of the work of John
Young Brown (1865–1919) (Fig. 9), a St. Louis surgeon. In 1912 Brown
[54] reported his experience with 10 patients. All 10 patients underwent
ileostomy after failure of colonic irrigation following either a cecostomy or
appendicostomy. These patients suffered from colon cancer, bowel obstruc-
tion, tuberculous colitis, amebic dysentery, and ulcerative colitis. Brown
brought the end ileostomy through the lower pole of a midline laparotomy
incision. This stoma protruded 2–3 in. beyond the abdominal wall and was
emptied by means of a catheter sewn in place (Fig. 10). Eventually the
catheter was removed, and, as a result of serositis caused by the ileal efflu-
ent, the mucosa everted to reach the abdominal wall. Brown was the first
to advocate diversion of the fecal stream in the treatment of ulcerative coli-
tis, and his technique was used for the next 40 years. However, ileostomy
still remained a procedure of last resort, and most ileostomy patients were
almost chronic invalids. In 1932 the mortality of ileostomy for the treatment
of ulcerative colitis at the Mayo Clinic was an astounding 32% [55].
Minor improvements occurred in the 1930s and 1940s. Rankin [56]
of the Mayo Clinic described creating an ileostomy in a separate wound in

Figure 9 John Young Brown. (From Royster HA, ed. Trans South Surg Assoc
32:526, 1919.)
28 Cataldo

Figure 10 Brown ileostomy. (From Brown JY. The value of complete physio-
logical rest of the large bowel in the treatment of certain ulcerative and obstructive
lesions of this organ. Surg Gynecol Obstet 16:613, 1913. By permission of Surgery,
Gynecology, and Obstetrics.)

the right lower quadrant. The use of skin grafting around the stoma to pre-
vent serositis gained some brief popularity [57] (Fig. 11). However, sub-
sequent stenosis of the grafted skin led to ileostomy obstruction and dys-
function, and therefore the idea was abandoned. No significant advances
occurred until the 1950s, when Crile and Turnbull [58] of the Cleveland
Clinic described ileostomy dysfunction and Bryan Brooke of the University
of Birmingham in London described the now famous Brooke ileostomy [59].
In a 1952 paper entitled “Management of the Ileostomy and Its Com-
plications,” Brooke (Fig. 12) described the ileostomy that remains in use
today. One sentence, “A more simple device is to evaginate the ileal end at
the time of operation and suture the mucosa to the skin; no complications
have occurred from this” [59], accompanied by a single illustration, changed
the ileostomy from a chronically inflamed and ulcerative stoma, frequently
associated with dysfunction, to the functional “rosebud” we know today. In
his article Brooke described the classic technique of primary eversion and
maturation of the ileostomy, which eliminated ileoserositis and stomal
dysfunction.
However, Crile and Turnbull were the first to fully understand and
describe ileostomy dysfunction. Ileostomy dysfunction consisted of partial
stomal obstruction manifest by watery diarrhea, abdominal pain and disten-
tion, and dehydration. They attributed this obstruction to serositis of the
“naked” ileal serosa now exposed to ileal effluent [58]. The serositis led
History of Stomas 29

Figure 11 Skin-grafted ileostomy as described by Lester Dragstedt. (From Drag-

stedt LR, Dack GM, Kirsner JB. Chronic ulcerative colitis: A Summary of evidence
implicating Bacterium neocrophorum as an etiologic agent. Ann Surg 114:655,
1941.)

Figure 12 Bryan N. Brooke. (Courtesy W. C. McGarity, M.D.)

30 Cataldo

to a rigid stoma without peristalsis, which caused a functional intestinal

obstruction and resolved only when the ileostomy had matured. Maturation,
as described by Crile and Turnbull, was the natural process of eversion of
the ileal mucosa to reach the abdominal wall. For the treatment of ileos-
tomy dysfunction, they recommended catheter drainage of the ileostomy as
having good results.
Unaware of Brooke’s work in London, Crile in 1952 suggested “mu-
cosal grafted ileostomy” to prevent ileostomy dysfunction. He described
removing the distal 3–4 cm of serosa and muscle from the ileostomy and
folding over and suturing the redundant mucosa to the abdominal skin in
order to “mature” the ileostomy at the time of surgery [58]. Through the
work of Brooke, Turnbull, and Crile, we now have an easily matured ileos-
tomy rarely associated with dysfunction.

CONTINENT STOMAS

Even when functioning well, the Brooke ileostomy drained constantly and
required the full-time use of a pouch. Many patients were disturbed by this
feature, which led Nils Kock (Fig. 13) to begin work on a continent ileos-
tomy. In 1969 Kock [59] described the creation of an ileal reservoir drained
by a tiny stoma brought through the rectus muscle. This method, however,
did not lead to complete continence. Therefore in 1972 he added a nipple
value of intussuscepted ileum. Dozois et al. [60], at the Mayo Clinic, fol-

Figure 13 Nils G. Kock. (Courtesy W. C. McGarity, M.D.)

History of Stomas 31

lowed a series of patients and found that most were fully continent, their
stomas requiring only intermittent catheter drainage. Initially, valve spillage
rates were high, but they were later reduced to less than 20%.
More recently, Barnett has developed a new continent ileostomy. A
reservoir of ileum similar to the Kock pouch is created; to this is added a
collar of functioning ileum. This collar functions similarly to a Nissen
wrap, generating higher pressures (and therefore preventing leakage) when
the intestine is distended with fluid. Early results with this method were
encouraging. However, since the advent of J, S, and W pouches combined
with ileoanal anastomosis, continent ileostomies are rarely required.
In 1974, Drs. Feustel and Henning in Germany developed a “colos-
tomy plug,” the Erlangen magnetic ring. This involved implanting a mag-
netic ring subcutaneously around the stoma neck. Following recovery from
surgery a magnetic plug was inserted into the stoma opening, thereby main-
taining continence. Removing the plug led to convenient stoma emptying.
Unfortunately, complications with this system outweighed benefits, and it
was therefore abandoned.

ENTEROSTOMAL THERAPY
In the 1950s Brooke in England and Turnbull and Crile at the Cleveland
Clinic changed the ileostomy from a procedure of last resort to a well-
tolerated solution for the treatment of ulcerative colitis. As the Brooke
ileostomy gained popularity, the number of patients with long-term ileosto-
mies increased dramatically. These patients required specialized care that
needed to be continued long after hospital discharge. Because of this need,
the field of enterostomal therapy developed. Rupert Turnbull had a special
interest in intestinal stomas and realized the need for trained professionals
dedicated to stoma care.
In 1954 Turnbull operated on a young mother of three, Normal Gill
(Fig. 14), for ulcerative colitis, leaving her with a permanent ileostomy
[61]. Since Gill’s mother had a colostomy, Gill was well aware of the
problems of living with a stoma. During her own recovery period she be-
came interested in helping other ostomy patients. When Gill returned to her
home in Akron, Ohio, she began to volunteer her services to individuals
with stomas in her local area. In 1958 Turnbull hired Gill as an ostomy
technician. Together they later coined the term enterostomal therapist. As
the word spread, other hospitals became interested in sending personnel for
specialized training with Turnbull and Gill.
In 1961 Turnbull opened the first school of enterostomal therapy be-
cause of increasing demand for trained enterostomal therapists. Only people
with stomas were accepted as students, but many were also trained nurses.
Joy Richey, a registered nurse from California, was the first graduate of the
32 Cataldo

Figure 14 Rupert Turnbull and Norma Gill. (Courtesy W. C. McGarity, M.D.)

school in 1961. Similar schools opened in Grand Rapids, Michigan (Fergu-

son-Droste-Ferguson Hospital) and in Harrisburg, Pennsylvania.
At the United Ostomy Association (UOA) national meeting in Phoe-
nix, Arizona, in 1968, the American Association of Enterostomal Therapists
(AAET) was born. The first national meeting of the AAET was held at the
Cleveland Clinic in 1969. Edith Lenneberg, who had had an ileostomy and
was instrumental in the development of the UOA, was elected president,
and Norma Gill was named as secretary. In 1969 the name of the organiza-
tion was changed to the North American Association of Enterostomal Ther-
apists (NAAET) and in 1971 to the International Association of Enterosto-
mal Therapists (IAET).
In 1976, Annelise Eidner, a nurse working in the proctology depart-
ment at the University Hospital Erlangen, Germany, attended the Enterosto-
mal Therapists Nursing Education Program (ETNEP) at the Rupert Turn-
bull School of Enterostomal Therapy. She attended at the suggestion of
Dr. Thorlolph Hager, who had just returned from training visit with Dr.
Turnbull.
The training of nurse Eidner led to the origin of an enterostomal ther-
apy program in Germany, the first in Europe. Patients throughout Germany
were referred for combined specialized proctological and stomal care. In
addition, advanced ostomy management systems became available in Ger-
many for the first time.
In 1977 Anneliesse Eidner and Dr. Hager established 2-week courses
in enterostomal therapy. Participants attended from all over Europe, as this
was the first time specialized enteral stomal therapy training was available
in continental Europe.
History of Stomas 33

In 1978 a more extensive 8-week course began at the Heinrich-Heine

University of Düsseldorf, led by Professor Kievelitz and ET nurse Nortrud
Schienzilorz. This eventually lead to the founding of the first enteral stomal
therapy association in Germany, the German Association of Enterostomal
Therapists.*

OSTOMY MANAGEMENT SYSTEMS

Although spontaneous stomas had occurred for centuries, the first mention
of an ostomy pouching device was not until 1795. In France, Dageusceau
created an inguinal colostomy in a 57-year-old farmer who had impaled
himself on the stake of a wheat cart. For the following 24 years, the farmer
“collected his feces in a small leather pouch” [10]. In 1824 Martland of
Blackburn, England, created an ostomy device from a self-adjusting truss
containing a tin box in the center for the collection of feces [62]. However,
the advances in stoma surgery were not accompanied by advances in stoma
management. As late as the early twentieth century, patients were using
Model-T inner tubes, tunafish cans, and bread bags with talcum powder,
cornstarch, or aluminum gel to prevent leakage. Vanilla and peppermint
extracts, mouthwash, perfume, parsley, and bicarbonate of soda were used
to diminish odors [61].
Despite the fact that colostomy irrigation had been reported in the
early 1800s, it did not gain popularity until the 1920s. In 1924 Dudley
Smith, a California surgeon, and John Greer, who worked for a surgical
supply company, developed the Colostogator [63]. This device, which con-
sisted of a metal cup held around the colostomy by means of a belt, was
the first commercially available irrigation system. Attached to the cup was
a long rubber sleeve that ran into a bucket placed at the patient’s feet. The
colostomy was irrigated by a rubber catheter placed through a hole in the
sleeve. With this device patients were able to irrigate once every 24 hr,
between which they wore a “simple belt of plastic webbing . . . [with] sev-
eral pieces of absorbent paper” [61]. The John R. Greer Company also
developed a device for people who did not wish to irrigate. It consisted of
a canvas bag lined with several thicknesses of toilet paper and a single
sheet of oiled paper attached to a stoma ring in a belt.
In 1944 Henry Koenig of Chicago, who had undergone an ileostomy,
was encouraged by his surgeon to create a pouching device. The revolution-
ary result was a rubber bag attached to a circular faceplate that was fixed

*Personal communication: Alexander Fleischmann, RN, ET and Klaus Matzel,

MD, Ph.D., Surgical Department, University Hospital Erlangen, Germany.
34 Cataldo

to the skin with rubber-based cement (Fig. 15). This instrument was the
first pouching device that could be drained while still in place. Eventually,
Koenig recruited H.W. Rutzen, who had also had an ileostomy, to market
his invention. The H.W. Rutzen & Son Co. remains in business today.
Another person who had an ostomy, Murle Perry, at the urging of his
surgeon, developed a line of stoma management devices. The Perry Model
51, which was introduced in 1951, consisted of a plastic pouch with absor-
bent papers combined with a close-fitting rubber gasket designed to keep
irritating stoma output away from the surrounding skin [61].
Despite these advances, skin irritation continued to be a significant
problem, particularly for ileostomy patients. Just as had happened with Al-
exander Graham Bell and the telephone many years earlier, an accidental
discovery led to a great advance in stoma surgery by Rupert Turnbull.

Figure 15 Rutzen bag, 1944. (Courtesy H. W. Rutzen & Sons, Inc., Chicago,
IL.)
History of Stomas 35

In 1952, he [Turnbull] was cleaning out the desk of his former chief,
Tom Jones, and accidentally knocked over a small canister of Jones
dental powder into spilled coffee on the desk. The karaya immediately
absorbed the coffee and stuck to Turnbull’s wet hand. He thought the
powder might also absorb ileostomy effluent and protect the skin from
excoriating effects of the liquid stool. [61]
Thus the use of karaya was introduced. Karaya powder (and later wafers)
was a major advance in peristomal skin care.
Another dental product was found to be useful in stoma care. In 1964
Squibb (Princeton, NJ) developed Orahesive paste and powder for use as a
paste and dental fixative. E.S.R. Hughes, an Australian surgeon, realized
the usefulness of this product in stoma care and conveyed his experiences
to Turnbull, a close personal friend. The result was the Stomahesive wafer,
introduced in 1972, a product that was particularly useful for patients with
watery ileal effluent (which diluted the karaya) or those with an allergy to
karaya. Recently, stoma adhesive wafers have been combined with a flange
apparatus (Sur-Fit; ConvaTec, Princeton, NJ) to create a two-piece ostomy
management system. This system allows for easy stoma access since the
pouches can be removed and the faceplate can be left intact. In addition,
the pouches can be washed and reused.

CONCLUSION

Over the past 200 years intestinal stomas have developed from “last
chance,” lifesaving efforts to well-planned, technically refined artificial
anuses. Colostomies can be “trained” to function once every 24 to 48 hr.
Ileostomies and urostomies can be made “continent” if the patient so de-
sires. Although stomas formerly were foul-smelling and offensive, today
they are rarely noticeable, even to the patient’s closest contacts.
These advances in stoma management are the result of an increased
understanding of intestinal physiology, refinements in surgical techniques,
advances in ostomy management products, and the development of enteros-
tomal therapy. It is hoped that the overview of these developments provided
by this chapter will add perspective to the information found in the follow-
ing chapters.

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Another random document with
no related content on Scribd:
 Iltapimeässä ilmaantui taas Ranta-Jussikin Palomäkeen. Jussi
pysytteli useimmiten ulkosalla, tallissa ja navetan puolella, sillä
emäntä ei kärsinyt häntä, kun tiesi Jussinkin aina vähän väliä olevan
salakuljetushommissa.

Mutta Santeri näkyi nyt olevan omassa huoneessaan, ja Jussi hiipi

sinne.

Mitä lie ollut papereita ja laskuja tarkastamassa, mutta syvissä

mietteissä hän oli. Jussin tultua hän kokosi kaikki yhteen pinkkaan ja
pisti pöytälaatikkoon.

Ja nyt hän alkoi selittää Jussille, mitä oli miettinyt ja miten nyt
alettaisiin vetää tullimiehiä nenästä.

Käkisaaren kautta, Rantalan ladon ohi, piti ajaa. Sitä tietä eivät
tullimiehet nyt, kun markkinain aika lähestyi, joutaneet öisin
vartioimaan. Sitten noustaisiin maihin Lehmikankaalle, josta
Kortesuolle kääntyvää tietä pitkin ajettaisiin Lampan ladoille asti.
Kuormat purettaisiin sinne. Joonas saisi heinähäkissä toimittaa osan
kotiin, mutta suurempi osa olisikin vietävä markkinoille.

Mutta jottei syntyisi mitään suurempaa rähinää tai liikettä, oli

Santeri päättänyt olla ottamatta ketään vierasta poikki viemään…
yksin vain oriilla ajaisi… Siitä olisi sitäpaitsi se hyöty, ettei tarvitsisi
apureille maksaa palkkaa, sillä ne olivat vaativia semmoisissa
hommissa… Vain Jussin kanssa kahden ja Iso-Liisa kolmantena.
Jussin tulisi oleskella Rantalan ladossa Käkisaaressa. Siellä hänen oli
pidettävä silmät auki, ja kun alkaisi kuulua, että Santeri jo oli
tulossa, silloin piti kaksi kertaa helistää suurta, rautapeltistä
lehmänkelloa. Se olisi merkkinä, että sopi tulla…
 »Mutta jopa sinä hoksaat!» ihmetteli Jussi, kun kuuli Santerin
tuumat.

Iso-Liisa olisi miehenvaatteissa Ruotsin puolella, hiihtäen

Lehmikankaan, maantien ja Kortesuon tienhaaran väliä edestakaisin.
Jos tullimiehet silloin sattuisivat sinne päin, jolloin kello soi (sillä Iso-
Liisa kuulisi kyllä kellonsoiton Lehmikankaalle yhtä hyvin kuin
Santerikin suomenpuoliselle rannalle), tulisi Liisan hiihtää vastaan,
jotta Santeri tietäisi kääntyä takaisin.

»Hyvin on mietitty!» vakuutti Jussi. »Kovin hyvin!»

Kaikki oli jo valmiin?. Liisakin oli jo mennyt paikoilleen Ruotsin

puolelle. Nyt saisi Jussi lähteä.

He menivät ulos, ja Santeri antoi tallista Jussille rautapeltisen

lehmänkellon, joka kesäisin kuului kaukaisista kiveliöistä asti. Jussi
köytti kellon vyölleen, kun ensin oli täyttänyt sen heinillä, ettei se
kalisisi, ja niin hän lähti hiihtämään Käkisaarta kohden.

Santeri aikoi lähteä tuntia myöhemmin.

Joen jäällä oli keli melkoisen hyvä, vaikka olikin pakkanen. Jussin
sukset luistivat aika vauhtia, eikä hän juuri vaivannut mieltään
raskailla ajatuksilla. Mutta olipa hänellekin sen jälkeen, kun Oinas-
Matin oli täytynyt paeta Amerikkaan ja hän oli kuullut, kuinka raskas
rangaistus tullikavalluksesta oli, monesti johtunut mieleen, että
voisihan hänen sattua käymään huonosti. Ja huolena oli ollut sekin,
että hän kävi Santerin neuvosta tullimiehille valehtelemassa.

Kummaa oli, että Santeri niin rohkeasti uskalsi, vaikka oli kuullut,
kuinka oli monen muun käynyt… Ja Lamppa toinen hyvä! Kyllä kai
Lamppa jo tiesi, että linnaa saisi Viikluntin patruunakin…

Mutta Santeri oli niin viisas ja varovainen, ettei ihan ensi hädässä
joutuisi tullimiesten käsiin. Hitto vie, jos tullimiehet tietäisivät, kuinka
heitä oli puijattu monena talvena!

Hyvä oli Santeri ollut häntäkin kohtaan.

Reilusti maksoi palkan, ja ryypyt olivat valmiina… Nytkin pisti

pullon poveen, ettei kylmä hätyyttäisi… Rentoa ja mukavaa oli ollut
hänenkin, Jussin, elämä näinä vuosina. Ei ollut tosin iso perhekään,
yksi ainoa poika, alulla toistakymmentä, akka jo aikaa kuollut. Mutta
sittenkin oli ennen pitänyt halonhakkuulla henkeänsä elättää, eikä
liiennyt koskaan kahviin tai viinaan talven aikana yhtään penniä.
Mutta nyt liikeni. Kahvipannu oli aina lämpimänä ja silavaa leivän
höysteenä joka päivä…

Semmoisissa mietteissä Jussi hiihteli, ja saaren nenään päästyään

hän kuunteli siinä ja jatkoi sitten hiihtämistään, kunnes joutui
Rantalan ladolle.

Hän kätki suksensa ja sauvansa ladon alle ja kiipesi sisään. Siellä

hiljaa istuessa kuului ääniä sekä Ruotsin että Suomen puolelta.
Selvästi kuului nytkin, että joku ajoi Suomen puolen maantietä kovaa
kyytiä, kulkusen helistessä, niin että vaarat lauloivat, ja Ruotsin
puolelta kuului postiljooni torveensa puhaltelevan kylää
lähestyessään.

Jussi irroitti lehmänkellon vyöltään ja kuunteli tarkkaan, kömpi

taas ladosta ulos ja vaani kinoksen nokassa sen edessä. Ei kuulunut
hiihtämistä mistään päin… Iso-Liisakin luultavasti oleskeli lähempänä
maantietä ja Lehmikangasta…
 Mutta tunnin kuluttua Jussi kuuli reenjalasten ratinaa ja ruomain
kitinää Suomen puolelta päin… Hän arvasi, että Santeri oli jo tulossa,
ja siksi hän helisti kahdesti kelloa, niin että itsekin säpsähti.

Ei viipynyt kuin vähän aikaa, kun jo hevonen kuului lähestyvän

nopeaa juoksua lahdelle päin, ja kohta sitten Santeri vilahti ohitse
oriillaan kuin lentävällä linnulla ja nähdessään Jussin ladon luona
hihkaisi… ei muuta joutanut.

Vain silmänräpäyksen ajan hevonen oli näkyvissä. Sitten se katosi

saarelle ja uudestaan jäälle Lehmikangasta kohden. Jussi kuuli vain,
että oriilla oli tulinen vauhti, että reki hyppeli perässä, vaikka paino
oli raskas.

Jussi kiipesi takaisin latoon, ja nyt hän kaivoi povestaan esille

pullon ja otti ryypyn.

Mutta pitkää aikaa hänen ei tarvinnut odottaa, ennenkuin kuuli

hevosen tulevan takaisin Ruotsin puolelta. Tavattoman nopeasti oli
Santeri ehtinyt käydä Kortesuolla! Mutta ihmekös, kun ajaa niin
vimmatusti ja Joonas on siellä vastaanottamassa!

Ladon luona Santeri pysähdytti hevosensa ja virkkoi Jussille

nopeasti:

»Pidä silmät ja korvat auki! Minä käyn vielä toisen kerran!»

Ja samassa hän tempasi ohjista, niin että ori karkasi hurjaan

juoksuun.

Jussi jäi vartioimaan. Nyt hän käveli ympäri latoa ja nousi joskus
kinoksen nokkaan kuuntelemaan. Pakkanen oli kova, ja tähdet
valaisivat yötä. Ei mistään päin näkynyt tulia, eikä korva enää
eroittanut matkamiestenkään ääniä tieltä. Kylmä ei lainkaan
ahdistanut Jussia. Hänellä olikin jalassa hyvät lapinkengät ja yllä
monta villapaitaa ja puseroa; turkki tosin oli lyhyt ja sen villa
kulunut.

Jo kuului Santeri tulevan toista kertaa ja vimmattua vauhtia nytkin.

Jussi helisti kelloaan, kuten ennenkin.

Santerilla oli nyt korkea kuorma, korkeampi kuin ensi kerralla, niin
että hän näytti itse istuvan kuin katon harjalla. Ja ori porhalsi niin,
että vain vilahdukselta ehtivät nähdä.

»Hei!» huusi Santeri ladon kohdalla.

»Hei!» vastasi Jussi ladon edestä.

Ja niin kuorma katosi taas näkyvistä kuin Sirkan Mikko

vallesmannia piiloon.

Kumma, että Santeri pysyikään noin korkean kuorman päällä, kun

ori lennätti tuommoista vauhtia! ihmetteli Jussi.

Mutta nyt hän kiipesi taas latoon ja otti kaksi ryyppyä, molemmat
pitkänlaisia. Hän koetti arvata, mikä aika yöstä jo oli kulumassa,
tarkasteli taivaan tähtiä ja päätteli, että aamupuoli yötä jo oli. Tuskin
Santeri enää kolinatta kertaa ehtisi, jos uskaltaisikin Ja voivathan
tullimiehet aamupuolella olla liikkeellä…

Niin hän mietiskeli ja siinä toivossa, ettei Santeri enää kolmatta

kertaa yrittäisi, hän joi pullonsa tyhjäksi ja hyräili huvikseen.
 Santeri ei viipynyt tälläkään kertaa kauan. Mutta nyt hän tuntui
ajavan pikkuhölkkää, ja kun hän tuli lähemmäksi, huomasi Jussi, että
reessä istui kaksi henkeä.

Ladon kohdalla Santeri pysähdytti ja käski Jussin suksineen tulla

rekeen.

Iso-Liisa istui mahdottoman pitkävillainen naapukka päässä ja

turkki yllään Santerin vieressä reslan perässä.

»Istu sinä kuskipukille!» käski Santeri Jussia.

Jussi pisti suksensa reslaan ja hyppäsi seville.

»Hyvinkö kävi?» kysyi Jussi.

»Ollreit», vastasi Santeri ja tarjosi pullosta ensin Jussille, sitten

Liisalle. »Ja tulevana yönä taas!» sanoi hän sitten molemmille.

»Niinpä tietenkin», vastasi siihen Jussi. Hän alkoi jo humaltua.

Pikku hölkkää he sitten ajoivat Suomen puolelle ja saapuivat

perille juuri kun taloissa sytytettiin ensimmäiset aamutulet.

*****

Koko viikon, joka yö, jatkoivat Santeri, Ranta-Jussi ja Iso-Liisa

samaa hommaa. Onni oli suosinut heitä ihan tavattomasti.
Tullimiehet eivät olleet kertaakaan tavanneet heitä eivätkä mitään
hoksanneet, vaikka eräänä yönä oli ollut paha vaara: Jussi oli
maistellut liikaa ja rämpytellyt kelloaan niin, että Ruotsin puolellakin
oli arveltu saaressa olevan poroja, koska kello noin kalisee… Muita
eläimiä siellä ei voinutkaan olla pakkas-iltana.
 Ja niin he saivat kuljettaa poikki kaikki Lampan tavarat, jotka olivat
Palomäessä. Tosin ei niitä ollut saatu Lampalle kotiin, vaan melkein
kaikki olivat vielä Kortesuolla heinälatoihin kätkettyinä.

Santeri oli osannut valita otollisen ajan tullikavallukseen. Hän tiesi,

että tullimiehet nyt Kainuun markkinain aikana vartioivat markkinoille
meneviä, ja senvuoksi hän rohkenikin liikkua. Ja hullusti olikin käynyt
monen markkinamiehen. Outoja ja tyhmiä kun olivat, eivät he
osanneet välttää eivätkä ajaa semmoisia teitä, joilla ei olisi ollut
tullihurttia. Ylempänä jokivarrella oli otettu kiinni kaksi hyvää hevosta
ja Makon kylän kohdalla yksi. Saalkreeni ja Fynke olivat eräältä
iiläiseltä ottaneet hevosen takavarikkoon Lampan kartanolla, kun
tyhmä mies oli siinä kaupannut hevosiaan ja tullimiehet sattuivat
kuulemaan.

Mutta monta pääsi menemään tullia maksamatta, ja kun kerran

oltiin Kainuussa, niin siellä kyllä tultiin miehissä toimeen. Suomalaiset
myyjät hankkivat jonkun taatun ruotsalaisen kauppaamaan
hevosiaan ikäänkuin omiansa. Ja hyvin kaupat kävivät.

Santeri oli saanut tietää, että myös Miukin Matti ja Alaniemen

isäntä jo olivat myyneet hevosensa, eikä heilläkään ollut tullimiehistä
tullut haittaa.

Hurinaa ja ajamista oli koko markkinain aika Tornionjoen

varrellakin, ja ihmisiä oli paljon liikkeellä.

Lampassa oli tulinen kiire. Mutta aina joka päivä oli siinä pihalla ja
ympäristöllä joku tullimiehistäkin vaanimassa.

Ja lisäksi olivat epäluulot nyt kohdistuneet heinähäkkiin. Joka

kerta, kun Joonas tuli heiniä noutamasta, sysivät tullimiehet
rautakrassilla heinähäkkiin poikki ja pitkin, mutta onneksi ei niillä
kerroilla sattunut mitään olemaan, kun Joonas ei silloin palannutkaan
Kortesuolta, vaan vainioladolta.

Mutta erään kerran, — silloin Santeri oli jo kavaltanut kaikki

tavarat Kortesuon latoihin ja markkinakiire oli parhaillaan, — Joonas
uskalsi mennä Kortesuolle, ja kun oli tarve ja patruuna hätäili, pani
hän häkkiinsä kaksi ruisjauhosäkkiä ja ajoi sitten kartanoon.
Tullimiehiäkään ei ollut silloin näkynyt koko päivänä, mutta sattuivat
juuri tulemaan toisesta kujasta, kun Joonas toisesta ajoi kuormineen
pihaan.

Fynke meni heti sysimään häkkiä…

Patruuna katseli konttorin ikkunasta, hätäili, kirosi ja silmäsi

ympärilleen, ikäänkuin apua hakien.

Jopa tuli Jönssonkin tunnustelemaan, Saalkreeni ei ollut mukana.

Joonas yritti ajaa tallin eteen, mutta tullimiehet komensivat

purkamaan kuorman.

Silloin patruuna riensi portaille ja huusi, että heidän piti antaa

rengin olla rauhassa.

Mutta tullimiehet purkivat heinät maahan ja niin ilmestyi kaksi

sadan kilon jauhosäkkiä häkin pohjalta.

Tämä oli tapahtunut pari tuntia ennen kuin Santeri saapui

Lampalle. Nyt oli patruuna juuri kertomassa Santerille, kuinka
ohraisesti oli käynyt ja mitä oli viety, vaikkei rakkareilla ollut mitään
todistusta, että jauhot oli tuotu Suomen puolelta.
 Santeri kuunteli ääneti loppuun asti ja kysyi sitten:

»Omistitteko säkit ja sanoitte, että ne ovat teidän?»

»Joonas oli sanonut, ettei hän tiedä, kenen ne säkit ovat, mutta
minulta ei ole kysyttykään.»

»Sepä oli hyvä… Vahinko ei ole suuren suuri eikä teitä voi
sakottaakaan, kun ette ole tunnustanut jauhoja omiksenne.»

»Höhöhöhö… Joonas saa vastata koko asiasta», sanoi patruuna

päästäen rehevän naurun.

Samassa tulivat tullimiehet konttoriin.

Patruuna kirosi ruotsiksi, mutta Santeri istui vakavana paikallaan.

Ensi kertaa pitkästä ajasta tullimiehet nyt kävivät Lampan
konttorissa.

He tahtoivat tietää, olivatko äsken takavarikkoon otetut jauhot

patruunan.

»Minun ne eivät ole, minä en tiedä koko asiasta… Iso-Joonas niistä

vastaa», kivahti patruuna.

»Mutta ne on tullitta tuotu yli rajan», sanoi Saalkreeni, joka johti

puhetta.

»Jaa, minä en tiedä mitään, eikä minulla ole niiden kanssa mitään
tekemistä…»

»Siitä tulee kysymys!» sanoi Saalkreeni.

 Patruuna käveli tuimana edestakaisin ja silmäili rumasti
tullimiehiin.

»Mistä te tiedätte, että ne jauhosäkit on Suomesta tuotu?» kysyi

hän.

»Me arvaamme!» vastasi Saalkreeni.

Silloin patruuna suuttui ja karjaisi: »Ulos minun huoneestani… ja

hyvin pian!»

Tullimiehet lähtivät, mutta ehtivät lisätä, että vielä tavattaisiin.

Patruuna ja Santeri jäivät kahden kesken miettimään asiaa. Monta

tuntia he istuivat ja puhelivat.

*****

Santeri oli patruunalle sanonut, että nyt piti koettaa saada

tullimiesten huomio kääntymään toisaalle, sillä he voivat alkaa
vainuta, että tavaraa oli tuotu enempikin. Joonaan piti käydä
heinässä, mutta Käkisaaressa, jossa Lampalla myöskin oli niitty. Sillä
selvää oli, että he nyt alkaisivat jotakin arvella, eikä ollut
yrittämistäkään ensi päivinä uudestaan käydä Kortesuolla. Ja
Joonaan tuli kulkea tikkatietä, jotta ilmeisesti näkyi tulevan Suomen
puolelta.

Joonas oli liikkeellä joka päivä; väliin oli kuormana halkoja, koska
patruunalla oli Suomenkin puolella maatila, ja väliin taas
heinähäkkejä. Santeri hommasi kaikki, ja jotta asia saisi suuremman
merkityksen, hiihteli Santeri aina vähää ennen Lampalle, muka
vartioimaan, ennenkun Joonas tuli joen poikki.
 Joka kuorman tullimiehet penkoivat, mutta turhaan.

He eivät silti lakanneet vakoilemasta loitompaa. Kaikki lähitienoon

heinäladot ja riihet he tarkastivat. Sillä heille oli selvinnyt, että
jossakin Santerilla kaiketi oli varasto, josta Joonas oli jauhosäkit
kuljettanut.

Mutta sitä he eivät löytäneet, kun eivät arvanneet hiihtää

Kortesuolle.

Ja vaikka he yrittivät parastaan, onnistui Santerin sittenkin Rämä-

Heikin avustamana viedä useita kuormia Kortesuon ladoista
Ylikainuuseen. Sillä aikaa kun tullimiehet penkoivat Lampan pihalla
Joonaksen kuormia, kiirehti Santeri suksilla Kortesuolle. Sinne oli sitä
ennen Rämä-Heikki mennyt hevosella. Mutta pienissä erissä täytyi
yrittää, sillä tullimiehet tutkivat kuormia Ruotsinkin puolella.

Kerran olivat Jafetin kylän tullimiehet olleet Kortesuon

tienhaarassa, kun Rämä-Heikki Lehmikankaan kautta yritti
Kortesuolle, mutta ehti onneksi kääntää hevosen Lampalle päin.
Tullimiehet tunsivat Palomäen oriin ja Rämä-Heikin ja arvasivat, ettei
Heikki ollut huvin vuoksi liikkeellä.
VI

Kului pari viikkoa. Ylikainuun markkinoilta oli palattu ja koko

markkinahumu tauonnut.

Rajan yli kulkeminen oli vähentynyt niin, että Palomäen—Lampan

tikkatie oli pyryjen perästä päivän kaksi melkein ummessa.

Eräänä pyryisenä aamuna ajaa huristi Iso-Joonas Lampan

juoksijatammalla Palomäkeen. Santeri oli ehtinyt nousta vuoteelta ja
aikoi juuri mennä talliin, kun Joonas saapui pihaan.

Nyt oli piru irti!

Tullimiehet olivat osanneet Kortesuolle ja ottaneet kaikki

takavarikkoon! Koko yön he olivat siellä puuhanneet, ja nyt olivat
kaikki tavarat tullimiesten hallussa!

Varhain tänä aamuna, kun patruuna vielä oli vuoteessa, he olivat

käyneet ilmoittamassa, että Lampan ladoista Kortesuolta oli otettu
niin ja niin paljon tavaraa. Tunnustiko patruuna ne omikseen?

Patruuna oli kironnut kuin ukkonen ja Joonaan mukana lähettänyt

tullimiehille terveiset, että heidän piti kiireesti korjata luunsa hänen
kartanoltaan…

Mutta sitten hän oli heti käskenyt valjastaa hevosen ja lähteä

Palomäkeen Santeria noutamaan.

Niin kertoi Joonas, nenänpää valkeana.

Kirjavaksi meni Santerinkin naama, ja silmiin tuli pirullinen ilme.

Samassa hän laski suustaan pitkän kirouksen.

Hän kävi pirtissä, sieppasi pikkuturkin ylleen, ja he lähtivät

yhdessä täyttä juoksua ajamaan Lampalle.

*****

Vasta illalla Santeri palasi Lampaita tavallista kiihtyneempänä.

Oliko tehty takavarikko häneen niin vaikuttanut vai oliko hän
maistellut väkeviä liiemmälti? Kiirettä hänellä oli, ja hän hommasi
kuin tuli olisi jalkain alla. Kävi kylälläkin ja tuli yksin takaisin.

Kerran emäntä yritti häntä puhutella, mutta ei saanut yhtään

oikeaa vastausta.

Illempänä Santeri katosi kotoaan. Ei ottanut hevosta eikä

suksiakaan.

Mutta kun hän oli kävellyt maantielle asti, odotti häntä siinä kaksi
hevosta, joilla oli tyhjät reslat perässä ja mies kummassakin lakki
silmillä istumassa. Santeri hyppäsi ensimmäiseen rekeen, ja he
läksivät ajamaan täyttä juoksua alaspäin.

Kun he pääsivät kylän päähän, liittyi heihin kolme hevosta erään

mökin pihalta ja niin he jatkoivat matkaa peräkkäin, mies kussakin
reslassa, paitsi ensimmäisessä kaksi, Santeri toisena.

Kun oli ehditty kylän ohitse, pysähdyttiin taipaleella, ja Santeri

tarjosi kaikille pitkät ryypyt ja maistoi itsekin vastoin tapaansa
runsaanlaisesti.

Ja taas he lähtivät ajamaan, nyt nopeampaa vauhtia.

Santerilla oli rohkea tuuma, johon hän oli saanut avukseen

vankkoja miehiä. Kaikki hänen kumppaninsa olivat tullikavaltajia;
silloin tällöin he tulivat avustamaan sekä Santeria että muitakin,
jotka harjoittivat tätä ammattia runsaammin. Mutta tämmöiseen
retkeen ei heistä vielä moni ollut ottanut osaa, sillä nyt olikin
erinomaista tekeillä.

Tullimiehet olivat näet samana iltana aikeissa lähteä viemään

takavarikkoon ottamiaan tavaroita, joita oli viisi hevoskuormaa,
Haaparannan tullikamariin. Santeri oli ottanut siitä selon ja tiesi, että
Saalkreeni ja Jönsson lähtisivät kahden kuljettamaan.

Ja näin hän oli miettinyt:

Hän hankkii entisiä apureitaan mukaan, ja he ajavat ensin Suomen

puolta ja sitten Kolukankaan kohdalla poikki Ruotsin puolelle
Järvirannalle. Siinä on pitkä, taloton ja metsäinen taival. Siinä he
odottavat, ja kun tullimiehet tulevat, ryöstetään heiltä kaikki kuormat
ja ajetaan takaisin Suomen puolelle.

Niin hän oli miettinyt ja laskenut, että tullimiehet, jos levähtävätkin

Jafetin kestikievarissa hetkisen, puolen yön jälkeen ovat Järvirannan
taipaleella. Siksi ajaksi piti sinne ehtiä. Heitä oli kuusi miestä tässä
joukossa, ja kaksi hiihti Ruotsin puolta, nimittäin Rämä-Heikki ja Iso-
Joonas. Heidän tehtäväkseen oli Santeri määrännyt hiihtää
tullimiesten perässä niin kaukana ja varovasti, etteivät Saalkreeni ja
Jönsson saisi heistä vihiä. Mutta Järvirannan taipaleella heidän tuli
hiihtää hyvin likellä, ihan perässä, ollakseen apuna kuormia
ryöstämässä, kun hän, Santeri, miehineen tulisi vastaan.

Santeri selitti miehilleen, kuinka piti menetellä. Tullimiehet

otettaisiin kiinni, ja toiset pidättäisivät heitä kinoksessa sillä aikaa,
kun toiset nostaisivat tavaroita omiin resloihin. Tullimiesten hevoset
ajettaisiin menemään tyhjin rein eteenpäin, ja vasta sitten, kun omat
kuormat olisivat reilassa ja toiset jo menossa, laskettaisiin tullimiehet
irti… ja kaikin sitten he ajaisivat jäälle ja Kalliosaaren luo Suomen
puolelle. Kalliosaaren törmän alle purettaisiin kuormat ja palattaisiin
heinäteitä Käkisaaren kautta.

Santerin suunnitelmaa pitivät kaikki miehet viisaana ja parhaana.

Ja rohkeasti he aikoivat yrittää ja, jos niin tarvittaisiin, vähän
kepittääkin tullimiehiä, sillä kaikilla oli entistä kaunaa heitä kohtaan.

Isolan Antti ja Taavolan Kalle, jotka olivat vankimpia joukossa,

ehdottivat, että he ottaisivat toinen Saalkreenin, toinen Jönssonin
hoitaakseen. Toiset hommatkoot, että kuormat vaihtuvat omiin
resloihin.

Ja niin keskustellen he ajelivat eteenpäin ja ryyppäsivät väliin, sillä

Santeri oli toimittanut runsaasti eväitä mukaan.

Yö oli pimeä ja taivas pilvessä.

Ei ainoatakaan ihmistä näkynyt Kolukankaan kylässä liikkeellä, kun

siitä läpi ajettiin Ruotsin puolelle.
 Pian he saapuivat Järvirannalle, ja kun oli noustu maantielle ja
päästy talottomalle taipaleelle, annettiin hevosten kävellä. Hetkisen
kuljettuaan he pysähdyttivät hevoset, kuuntelivat ja ottivat hyviä
ryyppyjä.

Santeri neuvoi ja rohkaisi miehiään. Kaikkien piti olla hiljaa, ja

ääntä päästämättä piti kaiken tapahtua, sillä tässä oli pääasiana se,
ettei heistä ketään tunnettaisi. Lyödä ei saanut, ellei ihan ollut
pakko, mutta sitä piti välttää, ettei hengenlähtöpaikalle osuisi.

Heillä oli reissään sylen pituisia aisankappaleita, joita he aikoivat

käyttää aseinaan. Kaikki olivat jo ryypänneet sen verran, että olivat
rohkeimmillaan, parhaassa nousuviinassa. Juuri kun taas pullo kulki
miehestä mieheen, alkoi tien mutkan takaa kuulua aisatiu'un ääntä…

He menivät kukin rekeensä, Santeri ja Taavolan Kalle istuen

ensimmäisessä reessä ja ajaen vähän edellä toisista.

Oli pimeä, mutta Santeri tunsi Saalkreenin, joka istui ensiksi

vastaantulevan hevosen reessä kuorman päällä… He ajoivat sen ja
vielä toisenkin hevosen ohitse, jolla ei ollut ajajaa.

Silloin Santeri hyppäsi seisaalle ja kiljaisi. Se oli merkki toisille.

Takaapäin alkoi kuulua kauheaa kiroilemista, seassa

revolverinlaukauskin… ja edestäpäin julman äreä miehen ääni…

Taavolan Kalle riensi sinne, missä Iso-Joonas ja Rämä-Heikki

tappelivat
Jönssonin kanssa… Santeri tuli perässä, mutta kun Iso-Joonas ja
Rämä-Heikki alkoivat nostella jauhosäkkejä reistä toisiin, pääsi
Jönsson irti Taavolan Kallelta ja tarttui Santeriin kiinni avonaisesta
turkinrinnuksesta, nykäisten Santerin kuin kuivan rievun kinokseen.

Sillä aikaa sai Taavolan Kalle reestä aisankappaleen ja iski sillä

Jönssonin päätä kohti, mutta toinen ehti väistää ja isku putosi
raskaasti reenperää vasten. Santeri ehti kinoksesta pystyyn ja
karjaisi:

»Lyökää lujemmin, pojat!»

Mutta silloin oli Taavolan Kalle jo saanut Jönssonin alleen

tiepuoleen, ja Joonas ja Rämä-Heikki nostelivat kuin riivatut säkkejä,
keskenään supattaen.

Takaapäin kuului silloin hätäinen ääni:

»Ajakaa menemään! Ihmisiä tulee!»

Santeri ja Taavolan Kalle hyppäsivät oman hevosensa rekeen,

johon ei ollut ehditty panna kuin yksi tupakkakuli. Kannaksille ehti
vielä Iso-Joonaskin, läähättäen kuin ajettu poro.

Santeri iski hevosta selkään, ja virma juoksija karkasi heti täyteen

laukkaan.

Rämä-Heikki ehti saada kiinni jälkimmäisen reslan perästä, kun

yksi tullimiesten hevosista oli kääntynyt poikkipuolin tielle, niin että
toisten täytyi ajaa tiensyrjää pitkin.

Jönsson oli päässyt jaloilleen ja ehti iskeä kannaksilla seisovaa

Rämä-Heikkiä olkapäähän maasta sieppaamallaan aisankappaleella.
 Pimeä oli, eikä yksikään uskaltanut huutaa tai kovaa puhua.
Hurjaa menoa kavaltajat ajoivat eteenpäin, eikä kukaan oikeastaan
vielä tiennyt, kuinka oli käynyt. Jälkimmäisillä hevosilla oli täydet
kuormat, mutta tiepuolessa oli ollut monta jauhosäkkiä kinoksessa
sillä kohdalla, jossa tullimiesten hevonen oli esteenä.

Kun Järvirannan taival loppui ja kylä alkoi, oli siinä joella tie, jota
heinämiehet kulkivat. Siitä oli ollut puhe ajaa jäälle.

Perässä tulevat kuulivat jo hevosten laukkaavan myötälettä joelle

päin, ja kaikki kääntyivät samaa jälkeä perässä.

Juuri tienhaarassa tuli heitä vastaan kaksi rahdista palaavaa

miestä, jotka näkivät kaksi jälkimmäistä hevosta laukkaamassa
heinätietä pitkin rantaan. Viimeisen reen kannaksilla seisoi mies
koukussa, molemmin käsin pitäen reslan perästä kiinni.

Vasta kun oli päästy poikki Käkisaaren, pysähdyttivät Santeri ja

Taavalan Kalle hevosensa ja odottivat toisia. Ensiksi tarkastettiin
kuormat, mitä oli saatu ja mitä oli täytynyt jättää.

Ja nyt alkoi kukin kertoa, mitä oli ehtinyt toimittaa. Saalkreenia oli
huitaistu selkään, niin että hän kaatui silmilleen kinokseen; vain
kerran hän oli ehtinyt ampua, luoti oli mennyt metsään. Neljästä
kuormasta oli tavarat saatu, viides oli jäänyt.

Yhteen rykelmään kokoontuneina seisoivat kavaltajat, joita nyt,

kun Rämä-Heikki ja Iso-Joonas olivat lisänä, oli kahdeksan miestä ja
viisi hevosta, ja kahakasta selvitti kukin töitään ja tavaroitaan. Ja
musta, kiiltävä pullo kierteli miehestä mieheen, ja kun se tyhjeni,
kiskoi Santeri uuden auki.
 Kahdet ryypyt otettuaan he istuivat taas resloihin ja ajoivat
Käkisaaren laitaa pitkin korkearantaisen Kalliosaaren luo. Sinne,
korkean törmän alle, jonka yläpuolella kasvoi laajoiksi levinneitä
pajupensaita, kaivettiin kinokseen kuoppia, joihin tavarat aluksi
kätkettiin.

Sillä niin oli Santeri ennakolta päättänyt.

Mutta miehet alkoivat olla humalassa jokainen, ja Rämä-Heikki

kiljaisikin jo pari kertaa ja noitui, että sukset jäivät häneltä
taistelutantereelle. Liian paljon oli Santerikin tällä kertaa maistanut.
Kieli sammalsi, eikä hän kyennyt pitämään miehiä oikein kurissa. Kun
he nostelivat säkkejä, suistuivat he tavantakaa lumeen, nauroivat ja
kirosivat.

Isolta-Joonaalta oli kahakassa hukkunut lakki ja Santerilta

molemmat kintaat.

Vihdoin he pääsivät lähtemään. Ajettiin heinätietä myöten joen

rantaa pitkin ja vasta lähellä Palomäkeä noustiin maantielle, jolloin
toiset hajaantuivat kukin omalle suunnalleen.

Silloin alkoi jo näkyä aamun sarastusta.

Joonas seurasi Santeria Palomäkeen ja hoiperteli siitä vielä poikki

väylän avopäin Lampalle.

Santeri hiipi hiljaa omaan huoneeseensa ja retkahti vaatteet yllään

sänkyynsä, johon heti nukkui.

*****
 Hän heräsi siihen, että pihaan ajettiin parilla hevosella, ja tiu'ut ja
kulkuset soivat niin, että nurkat helisivät.

Hän hyppäsi kuin orava vuoteeltaan ja riensi ikkunaan, joka oli

pihan puolella… Oli jo iso päivä.

Hän säpsähti, mutta tointui merkillisen pian unen ja kohmelon

vallasta. Ensiksi hän näki Saalkreenin ja Jönssonin, jotka virkamerkit
rinnoillaan nousivat jälkimmäisen reestä. Toisessa reessä olivat olleet
vallesmanni ja poliisi, jotka jo seisoivat pihalla.

Santeri pyyhkäisi hiuksiaan, hieraisi silmiään ja meni pirttiin. Hän

arvasi, mitä varten tulijat olivat liikkeellä, ja omituinen säpsähdys,
jonkalaista hän ei ollut ennen tuntenut, kävi hänen hermostonsa
läpi.

Hän koetti tyyntyä, eikä hänen kasvoistaan nähnytkään

minkäälaista mielenliikutusta. Se pelko, että hänet tai heidät kaikki
oli tunnettu, ahdisti kuitenkin niin, että hän liikkeissään näytti
hermostuneelta.

Vallesmanni selitti Santerille, mikä heillä oli asiana.

Tullimiehet, vallesmanni ja Santeri olivat menneet talon saliin

isännän pyynnöstä. Vallesmannin puhuessa Santeri seisoi
näennäisesti tyynenä, vaikka Saalkreenin ja Jönssonin vihaiset
katseet tähtäsivät häntä kuin ahmaa puussa.

»En ole kuullut koko asiaa», vastasi Santeri hyvin kuivalla äänellä.

Vallesmanni kivahti:

»Tiedätkö, että tämä on raskas rikos, josta sinua syytetään?»

 »Niin tuntuu olevan, mutta syytön minä olen», vastasi Santeri.
Jonkinlaista hermostumista hänessä sittenkin voitiin huomata.

»Se näytetään toteen, että sinä olet ollut joukossa ryöstöä

tehdessä», sanoi Saalkreeni yhteisesti Santerille ja nimismiehelle.

»Kotonani olen ollut», väitti Santeri.

Tullimiesten pyynnöstä kuulusteltiin todistajina talon palvelijoita,

renki Uptan Kreusia ja piika Josefina Alasenpäätä sekä mäkitupalaisia
Juho Malmia ja Liisa Vuojokea, jotka viimeksimainitut poliisi oli
käynyt heidän kotoaan kutsumassa.

Kaikki tulivat saapuville.

Vallesmanni piti pöytäkirjaa, ja poliisi istui ovensuussa.

Saalkreeni ja Jönsson istuivat nimismiehen kahden puolen, ja

Santeri seisoi poliisin vieressä. Emäntäkin tuli kuuntelemaan.

Ensiksi kuulusteltiin renki Uptan Kreusia, sitten toisia siinä

järjestyksessä kuin tullimiehet olivat todistajia ilmoittaneet. Ja he
kertoivat:

Uptan Kreusi: Pääasiaan ei tiennyt mitään. Illalla isäntä oli ollut

kotona, kun hän pani maata, ja samoin nyt aamulla. Hevoset olivat
olleet koko yön tallissa eikä niitä ollut yön aikana liikuteltu, koska
tallinavain oli ollut hänen huostassaan. Muuta ei tiennyt.

Josejina Alasenpää: Ei tiennyt mitään. Isäntä oli ollut maatapano-

aikana kotona.
 Juho Malmi (Ranta-Jussi): Ei tiennyt mitään. Ei ollut viikkoon
käynyt koko talossa eikä ollut takavarikostakaan kuullut mitään.

Liisa Vuojoki (Iso-Liisa): Ei tiennyt, oliko isäntä ollut kotona vai ei,
sillä hän ei ollut talossa käynyt edellisenä päivänä.

Muita todistajia tullimiehet eivät sanoneet tällä kertaa olevan,

mutta vaativat jo kuitenkin, että Santeri vangittaisiin. Sanoivat
tuovansa todistuksia Ruotsin puolelta.

Saalkreeni tosin vielä muisti Rämä-Heikin, mutta vallesmanni

selitti, ettei Heikki kelvannut todistajaksi, sillä hänellä ei ollut
kansalaisluottamusta ennenkuin vasta kolmen vuoden päästä.

Mutta tullimiesten vaatimukseen ei vallesmanni ainakaan vielä

voinut suostua, sillä eihän ollut mitään todistusta, että Santeri
Palomäki oli ryöstössä osallisena.

»Siihen kyllä saadaan todistuksia», vakuuttivat sekä Saalkreeni

että
Jönsson.

»Se on sitten eri asia», sanoi nimismies ja rupesi kokoomaan

papereitaan.

Ja niin päättyi poliisitutkinto, joka oli ensimmäinen Palomäen

talossa ja josta asia sitten kehittyi.

*****

Santeri sulkeutui koko päiväksi kamariinsa mietiskelemään.

 Vielä ei ollut mitään hätää. Hänen tietääkseen ei heiltä ollut
kukaan tuntenut eikä Kolukankaallakaan kukaan nähnyt, kun he
ajoivat Ruotsin puolelle. Ne miehet, jotka olivat tulleet
keskeyttämään ryöstöä, olivat kaiketi olleet ruotsalaisia, eivätkä
tietenkään heitä tunteneet. Samoin ei ollut heidän tuloaankaan
nähty.

Mistä siis todistukset tulisivat?

Mutta rauhaa hän ei kuitenkaan saanut, ja aina johtui mieleen

joku seikka, josta he voisivat päästä alkuun.

Jönsson oli sanonut varmasti tunteneensa joukossa Santerin,

mutta muita ei ollut tuntenut! Siinä oli paha pykälä. Ja nyt Santeri
lisäksi muisti huutaneensa: lyökää lujemmin, pojat!… Olisiko sitä
sattunut kukaan vieras kuulemaan?

Koko päivän hän mietti ja otti pari hyvää ryyppyä vahvistuakseen.

Kului päiviä.

Santerin oli tehnyt mieli käydä Lampalla, ja monta kertaa oli

Lamppa lähettänyt kutsun, mutta hän päätti vielä olla lähtemättä.
Sillä huhuja alkoi kuulua monenlaisia ja monelta haaralta. Ranta-
Jussi ja Iso-Liisa kuljettivat kaikki kuulemansa Santerille. Ruotsin
puolelta olivat tullimiehet vihdoin saaneet todistuksia, ei kuitenkaan
Santeria, vaan Taavolan Kallea vastaan.

Ja jonkun päivän päästä kerrottiin, että tullimiehet olivat löytäneet

ryöstetyt tavarat Kalliosaaren törmän alta ja vieneet pois. Sitäpaitsi
oli liikkeellä huhu, että Kettu-Heikki oli ollut Kalliosaaressa
heinäladon suojassa samana yönä, jona kavaltajat sinne kätkivät
ryöstämiänsä tavaroita. Hän oli kuullut heidän rähinänsä, mutta
muita ei ollut tuntenut äänestä kuin Taavolan Kallen. Ja huhu tiesi
lisätä, että tullimiehet olivat myöskin Kettu-Heikiltä saaneet tietoja.

Sellaisia sanomia Jussi ja Liisa toivat Santerille. Joka päivä tuli

lisää ja aina pahempia. Ja kummallisinta oli, että ne kohdistuivat
Taavolan Kalleen. Muita ei ollut tunnettu.

— Jos Taavolan Kalle joutuu kiinni, — mietti Santeri, — niin pian

siihen sekaantuvat muutkin. Kalle ei ole mikään luotettava mies ja
saattaa, kun näkee itselleen huonosti käyvän, ilmiantaa toisetkin.
Hänet pitäisi saada pois tieltä….

Ja eräänä päivänä toi Iso-Liisa uutisen, että Taavolan Kalle joutuu

kiinni. Liisa oli puhutellut Kallea, joka oli ollut kovasti huolissaan.

»Vai niin. Kumma, kun ei korjaa luitaan pois!» sanoi Santeri Liisan
puheisiin.

»Kyllä uskon, että korjaisi, jos joku avustaisi matkaan.»

Muutamien päivien perästä etsittiin Taavolan Kallea, mutta häntä

ei näkynyt, ei kuulunut. Mökkinsä, vaimonsa, lapsensa ja elukkansa
hän oli jättänyt, itse kadoten. Vaimo kertoi hänen menneen käymään
kaupungissa, mutta häntä ei kuulunut sieltä takaisin.

Asiaa ei jätetty vieläkään.

Kevätpuolella löytyivät kinoksesta ryöstöpaikalta Santerin kintaat,

joissa oli selvästi musteella kirjoitettu nimi Santeri Palomäki, ja siitä
alkoivat huhut taas viritä. Sitäpaitsi oli toinenkin huhu samaan
aikaan lähtenyt liikkeelle. Kolukankaalla oli Varpulan isäntä nähnyt,
että viisi hevosta samana yönä, jona ryöstö tehtiin, ajoi heidän
pihansa läpi jäälle ja siitä Ruotsin puolelle, Järvirantaa kohden.
Ensimmäisessä reessä olijat oli isäntä tuntenut Palomäen Santeriksi
ja Taavolan Kalleksi.

Nämä tiedot toi Ranta-Jussi Santerille. Jussi oli käynyt Lampalla, ja

Lampan puodissa oli siitä puhuttu. Patruunaa Jussi ei ollut nähnyt,
mutta Joonas oli kertonut hänen itsekseen kiroilevan ja välistä
kävelevän öilläkin. Joonastakin hän oli potkinut ja lyönyt korvalle
sinä päivänä, jona tuli tieto, että tullimiehet olivat löytäneet tavarat
Kalliosaaren törmältä.

Syviin mietteisiin jäi Santeri, kun Jussi oli kertonut kaikki

kuulemansa.

»Mutta niin kuuluivat arvelevan Lampan puodissa, ettei sitä

Palomäen
Santeria saada syylliseksi, vaikka onkin löydetty kintaat», koetti
Jussi lohduttaa nähdessään, että Santeri oli synkissä ajatuksissa.

Mutta siihen Santeri ei vastannut mitään.

Hän koetti puuhailla talossaan niinkuin ennenkin, mutta ei pysynyt

kauan yhdessä työssä, ennenkuin siirtyi toiseen ja siitä meni
kamariinsa mietiskelemään. Emäntänsä kanssa hän vältti jäämästä
kahden kesken ja kulki kylällä useammin kuin hänellä ennen oli
tapana ollut.

Hän oli huomaavinaan kaikkien ihmisten ja varsinkin

kotikyläläisten katseissa ikäänkuin salaista iloa ja toivoa, että hänet
pantaisiin kiinni…
 Sillä sen hän tiesi, että hänellä oli paljon kadehtijoita, jotka olisivat
suoneet hänelle pahinta. Ja se häntä kiukutti… Pääsisivät hänen
vahingostaan iloitsemaan, kun saisivat nähdä hänet, kylän
rikkaimman isännän, raudoissa…

Kerran hän tapasi kylällä poliisin ja alkoi tälle kertoa, että häntä
ahdistettiin viattomasti. Hän voisi näyttää toteen, että hän oli
ryöstöyönä ollut koko ajan kotona…

Poliisi oli vain arvellut, että tämä oli paha asia, jos siitä kiinni
joutuisi.

Mutta sittenkin Santeri vielä uskoi, ettei mitään sellaista todistusta

ollut olemassa, joka näyttäisi hänen syyllisyytensä. Ja viimeisenä
toivona oli, että jos todellakin alkaisi näyttää vaaralliselta ja huhut
yhä varmistuisivat, silloin hänellä olisi tie valmis… hän karkaisi
Amerikkaan. Sillä linnaan hän ei lähtisi…

Ja hän varusteli runsaasti rahaa lompakkoonsa, jota aina piti

pöytänsä laatikossa siltä varalta, että tulisi hyvinkin kiire.

Kerran hän oli kauan aikaa kahden kesken Ranta-Jussin kanssa

kamarissa. Jussi oli juuri palannut kuulustelumatkalta Ruotsin
puolelta ja tiesi kertoa, että siellä oli pidetty poliisitutkinto ja siinä oli
päässyt todistamaan Jönssonkin, joka oli sanonut varmasti
tunteneensa Santerin. Muuan rahtimies lisäksi oli kertonut
tunteneensa Santerin ja Taavolan Kallen Järvirannan taipaleella
vähää ennen ryöstöä.

»Se on pitkä vale!» sanoi siihen Santeri.

 Mutta näiden kuulemiensa johdosta arveli Jussi omana
mielipiteenään, että Santerin pitäisi olla varuillaan… Ja jos hän, Jussi,
nyt olisi Santerin sijassa, niin matkalle lähtisi…

Santeri ei väittänyt tätä vastaan, vaikkei toisaalta myöntänyt

Jussin puhetta oikeaksikaan.

Siitä illasta alkaen hän kuitenkin aina makasi vaatteet yllään ja

valveilla melkein koko yön. Reki oli myös valmiina pihalla ja oriilla
valjaat selässä…

Hän pelkäsi nyt todenteolla, mutta ei saanut päätetyksi, lähteäkö

karkuun vai eikö…

Niin kului joku päivä.

Mutta eräänä yönä, kun Santeri oli nukahtanut vuoteelleen, hän

kuuli kolkutusta ovelta ja ääniä pihalta.

Kun hän sytytti tulen ja aukaisi oven, näki hän vallesmannin ja

poliisin astuvan sisälle. Hän pysyi kuitenkin tyynenä ja kysyi, mitä
olisi asiaa.

Vallesmanni selitti tulleen ilmi niin raskauttavia asianhaaroja, että

hänen nyt oli pakko vangita Santeri, mahdollisen karkaamisen
varalta näin rajamaalla.

»Vai niin», sanoi Santeri kylmällä äänellä, mutta levollisesti.

»Tehkää tehtävänne! Tässä minä olen!»

Eikä hän puhunut sen enempää, kun häntä lähdettiin viemään

vanginkuljettajan luo.
VII

Aavistamatta tuli Lampalle tieto, että Santeri oli pantu kiinni ja

lähetetty linnaan välikäräjiä odottamaan.

Jo samana päivänä oli siitä tuotu sana Lampalle, ja koska se myös

tiedettiin muualla.

Uutisen kuultuaan Lamppa kirosi ja käveli koko päivän eikä

kärsinyt ketään puheillaan; toisena päivänä hän joi ja pauhasi Tiltalle
ja potki Joonasta, mutta kolmantena päivänä hän oli sairas ja synkkä
ja kulki itkien konttorissaan. Sillä kaiken muun lisäksi hän sai
haasteen viinanmyynnistä ja monivuotisesta tullipetoksesta.

Eräänä iltana piti Joonaan lähteä käskemään Ranta-Jussia hänen

puheilleen.

Silloin oli kevät ja hangen aika, tikkatiekin pohotti jo

likaisenmustalta, ja kinosten harjat olivat pudonneet matalammiksi.

Keväthankea pitkin Joonas palasi iltahämyssä Jussin kanssa.

Patruuna puhutteli Jussia ystävällisesti, ikäänkuin olisi saanut

taloonsa sukulaisen. Viimeksi hän oli nähnyt Jussin syysmunakan
aikana.

Mitä nyt -kuului Suomen puolelle?

Jussin piti selittää juurta jaksain kaikki mitä tiesi. Patruuna käveli
edestakaisin poltellen sikaaria ja kysellen. Jussi istui konttorin
pöydän päässä ja teki selvää kaikista tullikavallusasioista ja tästä
viimeisestä ryöstöstä, josta patruunalle koitui niin suuri vahinko ja
Santeri oli pantu kiinni.

»Kumma mies se Santeri, kun ei minua uskonut», puheli Jussi

alakuloisella äänellä. »Minä kehotin lähtemään varalta pois… mutta
hän ei uskonut, että saataisiin todistajia. Mutta kun se Jönssonkin
pääsi todistamaan, vaikka luultiin, ettei pääse, niin kummako sitten
oli…»

»Joo, mutta kun ne tulevat käräjille, niin eivät tiedä puoltakaan.

Irti lasketaan Santeri… Odotappa, jahka välikäräjät tulevat», tuumi
patruuna vielä toivoen.

Jussi näytti epäilevän.

»Ei sitä miestä niinkään tuomita siitä, mitä yksi ja toinen on ollut
näkevinään», vahvisti patruuna omaa uskoaan.

»Kumma mies kuitenkin… Muita osasi toimittaa meren taakse, kun

ymmärsi hädän tulevan, mutta itse ei älynnyt lähteä», sanoi siihen
Jussi, äänessä epäilys.

Patruuna ei ollut kuullutkaan mitä jälestäpäin oli tullut ilmi, ei

tiennyt, mitä Kolukankaan isäntä oli poliisitutkinnossa todistanut,
eikä sitäkään, että Santerin kintaat olivat löytyneet tappelupaikalta.
Mutta nyt sen Jussilta kuultuaan hän oli hyvän aikaa ääneti ja sanoi
viimein:

»Jaa, mutta…»

Mutta siihen hän ei tiennytkään jatkaa. Käveli vain edestakaisin ja

veti sikaarista savuja.

»Olisipa ollut se Rämä-Heikki joutilaampi mies linnaan kuin

Santeri», sanoi hän sitten.

»Olisi kyllä joutanut, eikä papinkirja olisi siitä paljoa huonommaksi

mennyt», myönsi Jussikin.

Patruuna vetäisi kuin vihapäissään sikaaria ja jatkoi:

»Sillä muutoin tästä ei tule mitään. Eiväthän ne enää uskalla tänne

tulla tyhjinäkään Suomen puolelta. Pelkäävät mokomia rakkareita…
Mutta sen minä sanon, että… Jo se oli sentään onneton juttu, että
noin piti käydä…»

»Santerikin oli ollut sinä yönä vähän liiemmältä ryypyissä… siinäkin

Kalliosaaren luona olivat niin huutaneet ja mellastaneet…»

»Niin, ja nyt tavarat kuitenkin joutuivat tullimiesten käsiin…»

»Niin kävi…»

»Olisi pitänyt toimittaa ne tänne heti seuraavana päivänä!»

»Niinpä tietenkin. Mutta kuka silloin uskalsi lähteä?»

»Sepä se… kuka uskalsi lähteä!»