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DIAGNOSIS OF MALIGNANT GASTRIC ULCER
925 the street, with work, dance halls, and cafes followLove at first sight was rare (13/400), and dislike at first sight was about equally common-more frequent in women than in men. " The average courtship starts with no strong feelings on either side, and after it has lasted one or two years it becomes a settled thing that the couple will marry." About 36% of men and 50% of women denied sex relations before marriage (this seems to refer only to coitus, and excludes petting which was not much in evidence) : there was a slight positive correlation between " premarital chastity " and economic status, eventual happy marriage, and family planning. When both partners had little sexual desire this was often thankfully accepted by both. As with most social surveys, this series revealed a confused background of social disorganisation, not all of it due to the war. Politics tended to be simplified into a uniform distrust and contempt for ’’ Them ’’ ; religion was no longer a numerically significant factor. The success of the average English man and woman in adjusting to life in a society which provides them with relatively little group support is all the more striking; and the authors refrain from the traditionalist jeremiad with which such results are usually greeted. The main problem, however, remains unsolved. Far fuller studies covering anthropometric, photographic, and psychological comparisons (the inventory test used here is a crude one) are needed to give us a true idea of homogamy. Freudian work would suggest that these be extended to cover parents, especially the father of the wife and the mother of the husband. are also well worth studying. The book is, as Damon Runyon would say, "more-ish"-it raises as least as many questions as it lays. Its very failings, however, point still more clearly the need for proper statistical analysis of the factors incriminated by psycho-analysts and social psychiatrists in the production of misfits. The day of the Freudian paper based on two illustrative cases is not yet over ; but the union between statistical method and psycho-analytical theory is already fertile, and should be regularised by marriage as soon as possible. was
ing.
Antipathies
DIAGNOSIS OF MALIGNANT GASTRIC ULCER DESPITE
improved
anaesthesia and
operative technique
the
prospects of radical cure of gastric carcinoma by One surgical resection remain sadly disappointing. main reason for this bad outlook is the late stage at which the disease is often diagnosed or at which the patient first comes for medical advice. This may be because the onset of the symptoms is insidious, or in some cases because the symptoms are thought to be due to a simple benign peptic ulcer. It is not always remembered that a long history of dyspepsia or of ulcer symptoms does not necessarily rule out carcinoma, or that a malignant ulcer may be of very slow growth and fora long time may closely simulate a, benign ulcer. It is, however, often precisely in those cflrcinomata which most resemble chronic peptic ulcers that surgery offers the best results, and any investigations throwing light on the distinctions between benign and malignant ulceration of the stomach deserve special study. Boudreau and his colleagueshave made a detailed study of 234 cases of gastric ulceration examined post mortem at Boston during the years 1940-49. They rightly comment on the uncertainties and differences of opinion among experts as to the value of the usual clinical criteria for the diagnosis of carcinoma. Of such criteria the age of the patient, the size of the ulcer, and the site of the ulcer in the stomach are three of the most important. As regards age, the only point of significance brought out by this investigation was that benign lesions do not decrease in later life and that they are by no means uncommon in the aged-of the 1. Boudreau, R. P., Harvey, J. P., Robbins, S. L. Ass. 1951, 147, 374.
J. Amer. med.
25 ulcers found in patients over 80 years of age, 18were benign. The size of the ulcer has been said to provide a highly significant indication of its nature : the larger the crater, the more likely it is to be malignant. Boudreau’s figures, like some others,2 do not altogether support this view ; approximately half the malignant ulcers were less than 4 cm. in size, while 10% of the benign ulcers were larger than this. The important point to note from this necropsy series is that nearly 20% of small " ulcers were inofact malignant, so that a small crater offers no guarantee of non-malignancy. Similarly the exact localisation of the ulcer is of little value in diagnosis. The general opinion that ulcers on the lesser curvature are rarely malignant, whereas prepyloric ulcers most usually are, is only half correct ; no area of the stomach is by any means immune to carcinoma. Of the malignant ulcers in this series 39% were on the lesser curvature, while of 121 prepyloric ulcers 87 were benign and 34 malignant. These figures, however, being based only on necropsy findings, do not so take into account ulcers removed surgically ; these proportions are not strictly those clinically to be expected in life. It is interesting, however, to note that of the prepyloric ulcers two-thirds were benign, and of the lesions on . the greater curvature one-half were also benign. These necropsy figures underline once more the importance of considering in all cases of gastric ulceration the possibility of malignancy and the danger of assuming too readily that an ulcer is benign merely because of the patient’s age or the size or situation of the lesion. "
LOOKING AFTER THE STUDENT congregation at Oxford on Nov. 6 the scheme university health service for undergraduates was rejected. The main argument used to defeat the proposal was that it is impossible, by a health examination, to reveal a large enough amount of preventable illness to justify an annual cost of some E6000. It was also felt that inadequate consultation had taken place between college and university authorities, and perhaps insufficient discussion within the colleges themselves. There was undoubtedly a fear that care for the health of undergraduates, which it was rightly thought should rest with the college authorities, might be taken from them and vested in some university official as yet unknown and untried. Though the two sides agreed that routine chest radiography is valuable, the opposers of the scheme preferred to rely on mass carried out by the regional while the board, hospital proposers feared that owing to expense and difficulties in personnel this service might not always be available.. They also doubted whether it would be fair to annex it solely for the university for the eight weeks of every Michaelmas term. About other medical examinations there was less agreement. It was a moot point whether the doctor’s certificate of health that some colleges demand on a student’s entry is adequate. Often the doctor does not wish to influence a candidate’s rejection, and again the certificate may be six or more months out of date. The Armv medical examination is not given to all the men students before entry and never to the women (a fifth of the student population). One opposer of the scheme wished to rely on arrangements already existing in some of the colleges ; but these are variable, particularly for students in lodgings (at least a third of the total), and may involvethe advice undergraduate in expense and delay in and treatment. The debate was pregnant with omission : no reference was made to the most important cause of long absence from work-mental illness.3 Indeed the more conservative members thought that too much attention to health
IN for a
radiography
ohtaining
2. Lumsden, K. Gastroenterologia. 1950, 76, 89. 3. See Parnell, R. W. Lancet, 1951, i, 731.
ing.
Antipathies
DIAGNOSIS OF MALIGNANT GASTRIC ULCER DESPITE
improved
anaesthesia and
operative technique
the
prospects of radical cure of gastric carcinoma by One surgical resection remain sadly disappointing. main reason for this bad outlook is the late stage at which the disease is often diagnosed or at which the patient first comes for medical advice. This may be because the onset of the symptoms is insidious, or in some cases because the symptoms are thought to be due to a simple benign peptic ulcer. It is not always remembered that a long history of dyspepsia or of ulcer symptoms does not necessarily rule out carcinoma, or that a malignant ulcer may be of very slow growth and fora long time may closely simulate a, benign ulcer. It is, however, often precisely in those cflrcinomata which most resemble chronic peptic ulcers that surgery offers the best results, and any investigations throwing light on the distinctions between benign and malignant ulceration of the stomach deserve special study. Boudreau and his colleagueshave made a detailed study of 234 cases of gastric ulceration examined post mortem at Boston during the years 1940-49. They rightly comment on the uncertainties and differences of opinion among experts as to the value of the usual clinical criteria for the diagnosis of carcinoma. Of such criteria the age of the patient, the size of the ulcer, and the site of the ulcer in the stomach are three of the most important. As regards age, the only point of significance brought out by this investigation was that benign lesions do not decrease in later life and that they are by no means uncommon in the aged-of the 1. Boudreau, R. P., Harvey, J. P., Robbins, S. L. Ass. 1951, 147, 374.
J. Amer. med.
25 ulcers found in patients over 80 years of age, 18were benign. The size of the ulcer has been said to provide a highly significant indication of its nature : the larger the crater, the more likely it is to be malignant. Boudreau’s figures, like some others,2 do not altogether support this view ; approximately half the malignant ulcers were less than 4 cm. in size, while 10% of the benign ulcers were larger than this. The important point to note from this necropsy series is that nearly 20% of small " ulcers were inofact malignant, so that a small crater offers no guarantee of non-malignancy. Similarly the exact localisation of the ulcer is of little value in diagnosis. The general opinion that ulcers on the lesser curvature are rarely malignant, whereas prepyloric ulcers most usually are, is only half correct ; no area of the stomach is by any means immune to carcinoma. Of the malignant ulcers in this series 39% were on the lesser curvature, while of 121 prepyloric ulcers 87 were benign and 34 malignant. These figures, however, being based only on necropsy findings, do not so take into account ulcers removed surgically ; these proportions are not strictly those clinically to be expected in life. It is interesting, however, to note that of the prepyloric ulcers two-thirds were benign, and of the lesions on . the greater curvature one-half were also benign. These necropsy figures underline once more the importance of considering in all cases of gastric ulceration the possibility of malignancy and the danger of assuming too readily that an ulcer is benign merely because of the patient’s age or the size or situation of the lesion. "
LOOKING AFTER THE STUDENT congregation at Oxford on Nov. 6 the scheme university health service for undergraduates was rejected. The main argument used to defeat the proposal was that it is impossible, by a health examination, to reveal a large enough amount of preventable illness to justify an annual cost of some E6000. It was also felt that inadequate consultation had taken place between college and university authorities, and perhaps insufficient discussion within the colleges themselves. There was undoubtedly a fear that care for the health of undergraduates, which it was rightly thought should rest with the college authorities, might be taken from them and vested in some university official as yet unknown and untried. Though the two sides agreed that routine chest radiography is valuable, the opposers of the scheme preferred to rely on mass carried out by the regional while the board, hospital proposers feared that owing to expense and difficulties in personnel this service might not always be available.. They also doubted whether it would be fair to annex it solely for the university for the eight weeks of every Michaelmas term. About other medical examinations there was less agreement. It was a moot point whether the doctor’s certificate of health that some colleges demand on a student’s entry is adequate. Often the doctor does not wish to influence a candidate’s rejection, and again the certificate may be six or more months out of date. The Armv medical examination is not given to all the men students before entry and never to the women (a fifth of the student population). One opposer of the scheme wished to rely on arrangements already existing in some of the colleges ; but these are variable, particularly for students in lodgings (at least a third of the total), and may involvethe advice undergraduate in expense and delay in and treatment. The debate was pregnant with omission : no reference was made to the most important cause of long absence from work-mental illness.3 Indeed the more conservative members thought that too much attention to health
IN for a
radiography
ohtaining
2. Lumsden, K. Gastroenterologia. 1950, 76, 89. 3. See Parnell, R. W. Lancet, 1951, i, 731.