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observation for a number of years. Sometimes carcinoma does not develop for fifteen or more years, during which time the patient will certainly have improved enough to be able,to get about and work. We now believe that, in about one third of all instances of ulcerative colitis which come to operation and in which ileostomy is done, after six months or a year or so there should be insistence on the removal of the colon, no matter how much improvement the patient has made or how much he may feel opposed to the procedure. Since an ileostomy has already been performed, the removal of the colon and perhaps even the rectum will not alter the condition of the patient. In these cases there are not more than 3 or 4 per cent in which an internal connection is possible, and in these there is always a normal-appearing rectum. Such cases may be temporized with as far as the removal of the rectum is concerned. In ulcerative colitis, at least a third of the patients recover.There is another group, more than a third, who improve to such an extent that they lead normal lives for years. Perhaps about 10 per cent are difficult cases, in which surgical intervention is to be considered. If, after having been well for a considerable time, a patient begins to bleed or becomes worse again, malignant disease should be suspected unless proved otherwise. Increasing incidence makes one feel that malignant disease would have been obviated if colectomy had been done. I feel that the physician has a responsibility after the ileostomy, whatever the situation may be, of not depending entirely on improvements. He should insist in the vast majority of cases that a colectomy be performed.Dr. J. Arnold Bargen, Rochester, Minn. : We have discussed here one of the most serious problems in medical therapy. The complication of carcinoma in cases of ulcerative colitis is most distressing. Fortunately, this combination of lesions is relatively rare I have heard it said that the incidence of carcinoma in patients with ulcerative colitis is no higher than is that observed in the population as a whole. I cannot agree with this statement. Furthermore, it is particularly impressive that in so many of these cases the carcinoma occurs in persons before the age at which cancer usually develops. Anyone who has seen a dozen young persons between the ages of 15 and 30 die of generalized wildfire carcinomatosis must be impressed by the seriousness of this lesion, and by the fact that it occurs more frequently in patients with ulcerative colitis than in the population as a whole. In one year the vital statistics of this country indicate an incidence of 0.088 per cent carcinoma of the intestine in the population as a whole. This incidence depends on the nature of the group of patients observed and the size of the series studied, but all agree that it is much higher than in the population as a whole. The occurrence of multiple carcinomas in young persons who have had colitis for some time is an extraordinary manifestation of disease. The decision about when to operate ...

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