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A comparison was made of the mortality rates for various surgical operations, by age groups and by time periods. The age groups were: under 60, 60-69, 70-79, and 80 or over. The three time periods were: 1951-1955, 1956-1967, and 1967-1977. Only slight improvement was noted in these mortality rates despite the fact that during the 1951-1977 period many improvements were made in anesthesia, surgical techniques, antibiotic therapy, intensive-care units, and presumably the better understanding of disease. Further improvements will depend almost exclusively upon studying the basic problems of old age, chiefly atherosclerosis with its effects on the heart, blood vessels, brain, respiratory system and urinary tract. Unless this is done, there is no prospect of great improvement in operative results, and no basis for believing that the operative risk in the aged is the same as in the young. Unless the physiologic reserves of the aged can be improved, the surgical mortality rates likely will remain static.

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The growing importance of geriatrics is well exemplified by the increasing number of operative procedures performed upon elderly patients at the State University of Iowa Hospitals. Figure 1 illustrates the number of aged patients admitted to the surgical services, the number of operative procedures performed on these patients and the operative mortality during the three years 1950 through 1952. During this period, 7,499 surgical procedures at which an anesthesiologist was in attendance were performed upon 5,588 patients 60 years of age or older, with 339 deaths (4.5 per cent mortality). A growing consciousness on the part of the hospital staff as to the feasibility and importance of performing indicated surgical procedures in older patients is suggested by these figures. It will be noted that the mortality rate during this three-year period has remained essentially stationary, although the surgical indications have been steadily extended to include more patients with advanced lesions requiring more formidable procedures.The surgeon must frequently decide whether or not an operation of considerable magnitude should be undertaken on the elderly patient. This problem is not posed by the emergency which demands that the indicated surgical therapy be instituted if the patient is to be salvaged. The elderly patient with adenocarcinoma of the rectum poses the type of problem to which we have reference. Can abdomino-perineal resection be justified in the patient of advanced age, or should only palliative procedures be considered if complications intervene? The established position of abdomino-perineal resection as the treatment of choice for this lesion must be weighed against the possible prohibitive morbidities and mortalities associated with aging. This paper deals with the morbidities and mortalities which occurred in elderly patients (60 years of age and older) upon whom abdomino-perineal resections were performed. PATIENTS AND PROCEDURESThe patients included in this study were operated upon during the years 1947 through 1951. In Figure 2 it will be noted that the patients have been divided into four age groups. The diagnosis in each instance was adenocarcinoma of the rectum or rectosigmoid. Lesions were arbitrarily placed within one of two groups. Those lesions included in the "without-extension" group were confined to the bowel macroscopically and microscopically; those in the "with-extension" group were shown to have spread to nodes, prostate or uterus, but were judged grossly resectable. The data suggest that there was no relationship between age and the extent of the lesion.A Miles type of abdomino-perineal resection was performed. In some instances resection of the vagina, uterus or a portion of the prostate was necessary in order 450

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