it is administered, and the delay of a therapeutic test may be enough to transform a resectable growth into an inoperable one. Gastrectomy is always preceded by exploration, and exploration should not be deferred indefinitely. In gastric cancer there always comes a day when for the last time resection is possible and another day when for the first time it is impossible, but it is not given to either the physician or the surgeon to know when those days will come.In this connection, another word of warning should be issued. Two patients in the Charity Hospital series entered the hospital complaining of the same symptoms for which shortly before they had been submitted to appendectomy through McBurney incisions and which were proved to be caused by cancer of the stomach. Ochsner 2i has personally observed 6 such cases. One way of improving the results of gastric carcinoma would seem to be to make the diagnosis of chronic appendicitis with very great caution in the so-called cancer years, and never to perform an appendectomy at this time of life through a McBurney incision.3. Any improvement in the results of gastric cancer rest first with the patient. Until he presents himself to the physician no treatment is possible. Once he has sought medical advice, however, the responsibility becomes the physician's, who must turn him over to the surgeon without delay. In other words, as Hunt25 expresses it (he is a surgeon who advocates gastrec¬ tomy to the limit of possible indications), the patient's hope of salvation lies not in the surgeon but in the medical man whom he first consults. Cooper20 has recently demonstrated statistically the correctness of this observation, and my own series proves it, too.The idea is not new. Welch,14 writing in 1885, called attention to it then. He was speaking of gastrectomy, of which his opinion was necessarily low, since it was based on 27 fatalities in 37 cases, when he said "It is therefore but a feeble glimmer of hope which is now admitted to the hitherto relentlessly fatal forecast of this disease. . . . These results are certainly not calculated to awaken much enthusiasm for the opera¬ tion." It is highly significant that, feeling as he did, he should have continued : "The opinion entertained by the physician as to the propriety of surgical inter¬ ference in gastric cancer is not ... a matter of indif¬ ference, for cases of gastric cancer come first into the hands of the physician, and generally only by his recom¬ mendation into those of the surgeon."In short, in what Mayo said in 1900,1 in what Welch " wrote in 1885, lies the clue to such improve¬ ment in the results of cancer of the stomach as we are likely to achieve in the present state of our knowledge. The basic problem, when once the patient presents himself to the physician, is how soon the physician turns him over to the surgeon, how soon the surgeon operates, on suspicion if he cannot positively eliminate the posŝ ibility of gastric carcinoma. I do not in any way desire to detract from the heavy responsibilities which are c...
INTERMITTENT obstructive jaundice due to the formation of tumor of the bile ducts is comparatively rare. Marshall, in I930, found that only four cases of benign tumor and forty-nine cases of primary carcinoma of the extrahepatic bile ducts had been seen in The Mayo Clinic in the last twenty years. Rolleston and McNee, in 1929, recorded II2 cases of carcinoma of the ducts exclusive of the growths in the ampulla, and of only ten cases of benign tumors. Of these tumors the benign, although much more rarc than the malignant, lend themselves to surgical cure and afford the patient assurance that recurrence or metastasis will not occur. A twofold interest is found in these cases of intermittent obstructive jaundice due to a benign tumor of the extrahepatic bile ducts, of which the following is an example.REPORT OF CASE.-A woman, aged fifty-five years, registered at the clinic September 30, I930, complaining of pruritus and jaundice of two and a half weeks' duration. At the age of thirty years a series of typical attacks of colic of the gall-bladder began; they were not associated with jaundice. Ten years before admission cholecystectomy and appendectomy had been performed elsewhere. A biliary fistula persisted. Two temporary closures of the fistula were followed by jaundice; the final closure occurred eighteen weeks after operation and the patient remained well for five years. Five years afterward deep jaundice developed, which was essentially painless and was associated with anorexia and pruritus. The jaundice disappeared after five weeks, to reappear one and a half years later and to last five or six weeks. This second attack of jaundice as well as the third, which occurred a year before admission, was accompanied by severe prostration, loss of strength and weight, chilly sensations, and slight fever. The last attack began at night in the right upper quadrant two and a half weeks before admission with discomfort which awakened the patient from sleep. Vomiting relieved the distress. Jaundice and pruritus appeared two days later. The appetite remained fair and the digestion good. The stools became clay-.colored and the urine dark.The patient was 5 feet, 2 inches tall and weighed I26 pounds. She had lost 20 pounds in the last five years, but appeared to be well nourished. She was markedly jaundiced and her skin had been diffusedly excoriated by scratching. Nodules were not found along the course of the nerves suggestive of von Recklinghausen's disease. The liver was slightly enlarged and firm. The specific gravity of the urine was I.02i; it was acid in reaction, did not contain sugar, but a moderate amount of bile, and an occasional erythrocyte and leucocyte in the high-power field. The test of urobilin was positive. The percentage of hlemoglobin was 8o; erythrocytes numbered 3,950,000 and the leucocytes 7,Ioo. The coagulation time by the Lee and White method was 6
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