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...
For many years at the Mayo Clinic partial gastrectomy has been the treatment of choice in 60 to 70% of cases of apparently benign gastric ulcer.1 This has been so because the 10% of patients whose ulcers prove cancerous are given the best chances of cure, the morbidity due to benign ulcer is terminated promptly, the results of surgical treatment of the benign ulcer are excellent, and the risk of surgical treatment is small (1 to 2% mortality). In the remaining 30 to 40% of cases medical treatment has been instituted, in some at the insistence of the patient and in others for various reasons with the approval of the physician. In some cases this medical treatment has been instituted at the clinic, but in most cases it has been instituted elsewhere. Such treatment has varied widely in strictness because many physicians with varying viewpoints regarding medical treatment have been responsible. METHODS OF STUDYThe records of 1,864 patients seen in the years 1940 to 1945 inclusive, in whom the clinical diagnosis of gastric ulcer was made on the basis of clinical and roentgenologic findings, were reviewed. Of these patients, 464 either refused prompt surgical treatment or chose a pre¬ liminary period of medical treatment with our consent. Excluded from the study were those cases in which sur¬ gical treatment was carried out without initial medical treatment, those in which the gastric ulcer was located in a diaphragmatic hernia, and those in which the diagnosis had been made in previous years. Trial of medical therapy under hospital conditions was instituted at the Mayo Clinic in 153 cases, but no attempt has been made to analyze separately the data from these cases. We simply wished to know what happened to the 464 cases in which medical treatment was begun either here or elsewhere.Personal interviews, records of return visits and ex¬ aminations, follow-up letters to patients, follow-up letters to attending physicians, and copies of operative, patho¬ logical, and necropsy reports and death certificates were used. Of the 464 patients, 452 (97.4% ) were traced. In 38 (8.4% ) of the 452 traced patients, we did not obtain information about the results of medical treatment, but we did find that 30 are living and 8 are dead. In the remaining 414 (91.6% ) of the traced patients, informa¬ tion about the results of medical treatment was obtained.(In 20 of these, we know only that death was not related to the ulcer.) It is the information obtained in the 414 cases that we shall present.The sex and age distribution of the 414 patients on whom adequate information about the medical treatment was obtained is given in table 1. The ratio of men to women was about 4:1. The age of the majority of the patients fell within the fourth, fifth, and sixth decades.The sex and age distribution of these patients was similar to that in other series that have been reported.2Of the 414 patients, surgical treatment was urged for and refused by 78. In these cases, medical treatment was instituted against the best judgment of the consultant. In the ...
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