- Email: [email protected]
GASTRIC CANCER
926
In A
England
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THE
English medical congress is a notably sedate event at which quiet conversations between friends are interrupted from time to time by a formal address whose content is as familiar to listeners as to the speaker. Elsewhere they manage these things better. For example, an advance bulletin heralding a congress in the New Year " and in the New World promises’that the social program will be intense." Now in Britain the only concession to sociability is a congress dinner (30s., excluding wines) and, with luck, a reception by the mayor. Not so at next month’s meeting. " Among the events is the ... Fiesta, in which the participants of both sexes will be attired in typical regional costumes ; they should therefore not forget to include this costume in their baggage." This plainly sets a sticky problem for the distinguished British representative. If only he were Austrian, or Dutch, or Danish, it would be easy. Perhaps by claiming a grandmother north of the Highland line he could appear in some non-committal tartan without fear of reprisal. If not he will, I suppose, be driven back to the battered bowler and frayed umbrella which seems to have become the native costume of middle-class males in our region. *
*
*
An old friend, who asks me to dinner when I am well and promptly puts me into one of his hospital beds when I fall ill, is shortly to retire, having reached the age limit for a professor of medicine. He has to deliver a valedictory address to his students, and his subject is to be : " What to Say to the Moribund." Some doctors, he says, have a rule-of-thumb solution for this most delicate of problems : not a word, not a gesture to indicate the approach of death. Such doctors will have nothing to do with the mysteries beyond the veil. The professor himself has as many solutions as he has moribund patients, with this one rule applied to all-to do as he would be done by. One of his patients was an old cancerdoctor with a tumour in the lower abdomen. phobe " Is it that, Professor? " he asked. " Yes, I am afraid it is," came the answer, and the word cancer was never mentioned. It is curious, the professor notes, how seldom hospital patients themselves broach the subject of impending death. Is it that the relation of hospital doctor to hospital patient is seldom tete-a-tete and
leisurely ? Looking back,
I can remember only one occasion, 40 years ago, when I blurted out a death sentence. It was
murder with a bludgeon. The patient was a middle-aged chemist recently admitted to a private sanatorium whose one and only doctor was about to take a holiday. The doctor said to me as I took over : " So-and-so is a ’ gonner.’ It is your duty to tell him so." There was still plenty of fight in him when I began. When I had finished a minute later he was down and out. A knockout blow in the ring could hardly have been more instantaneously effective. Once I was the recipient instead of the donor of a death sentence. The exceedingly able doctor in charge, of me felt obliged to tell me my days were numbered. He did so with infinite tact and well-graduated circumlocution. I smiled to myself, for the point to which he guided me so skilfully was one I had reached long before on my own account. Now he is dead and I am alive and kicking. All of which suggests that silence is golden. *
Letters to the Editor
Now
*
*
Patients always say they have never closed an eyeall night; their nurses always swear that they have put in the regulation eight hours. The psychiatrist adjudicates according to-well, perhaps according to the laws of chance more than anything else, with some attention to the dictum that if the patient says he has not slept well then at least he has not slept well enough. A night in a tilted armchair in a transatlantic plane is instructive. All night, it seems, one is not sleeping ; one hears the engines all the time; one even looks at one’s watch like the.patients who report the hourly striking of the clockand suddenly and inexplicably it is Gander, and one has certainly not been awake for eight or nine hours: It seems that an interrupted sleep or a light sleep, either of which allows some perception of the surroundings, gives the impression of sleeplessness.
GASTRIC CANCER
SIR,-A whole corpus of statistical legend has gradually grown up around the subject of gastric cancer. There is little or no evidence in support and strong evidence against, but, as the history of medicine shows, facts can be almost powerless against the imaginative appeal of the attractive story. Mr. Shorter (Dec. 6) gives all the main myths with an excellent bibliography in a single paragraph. He tells us that though the total incidence of all forms of cancer is much the same in different communities, gastric cancer has important variations. " The racial incidence varies from 20 % of all cancers in Great Britain to about 10 % in America " ; the preponderance of males is much greater in America ; " the highest incidence is " between the ages of 40 and 60 " ; gastric cancer is " much commoner in the poor than in the rich." It is impossible to impugn so many statements in a single letter, but the following table is one of many which could be constructed from official figures to show how similar the incidence of gastric cancer is in comparable populations ; and if Mr. Shorter cares to browse
carefully into available death returns, he will see how unwise he has been to rely on the authors whom he cites. The 1939 English and 1940 U.S.A. figures have been chosen as the latest available information undisturbed by war from the particular countries Mr. Shorter has mentioned. more
Gastric
male mortality per 100,000 L .5.. England and HTulcs (1939) (1940)
cancer :
lge-grouj3 25-35 35-45 45-55 55-65
65-75 75-
....
....
....
....
....
....
2-1 23 10-7 11 42-8 43 111 108 217 199 297 210 ....
....
....
....
These figures demonstrate how readily huge differences in the apparent incidence of gastric cancer can arise if The incidence statistics are handled light-heartedly. over the age of 65 (where diagnosis and death certification is most unreliable) is high compared with the incidence in the younger age-groups where full investigation and operation are probable. Unless care is taken to allow for the exact age and sex distribution of the populations compared, and to consider the effect of varying investigation and autopsy facilities in the older age-groups, the undoubted similarities will be obscured by the dubious differences. Exact figures also show how rarely gastric cancer is the cause of indigestion and how impractical it is to push investigation to the point of diagnostic
laparotomy. London, W.I.
-
DENYS JENNINGS.
CLINICAL IMPRESSIONS OF MALARIA AND LIVER DAMAGE
SIR,-The paper by Professor Maegraith, Dr. Andrews, and Dr. Gall in your issue of Nov. 29 encourages me to . describe a group of cases -Isaw in Siam while a prisonerof-war. Two of us were medical officers to a party of 400 men working on the Mergin road from May to August, 1945. Of these, 100 died ; and about half of these died in an unusual manner. Their illness began with a continuous fever of about 102 °F. After five days they began to hiccup and became deeply jaundiced. After another four days they went into coma. This was not the irritable coma with hypertonia of cerebral malaria but a deep .coma with stertorous breathing suggestive of hepatic failure ; after every few respirations they would hiccup. After three days in coma they died. At the onset there was complete anorexia. Vomiting was present but was not severe. There was no haematuria or tendencv to general hemorrhage. The urine was scanty and coloured by bile pigment-not haemoglobin. There was some enlargement of the liver and spleen, but of no great degree. At first we thought this .was a leptospiral infection, but later some men were evacuated to the hospital camp at Nakon Paton and died in this’ manner. We heard that the blood slide from all of them showed Plasmodium falciparum. It is my feeling that these cases were due-
In A
England
R1/,nninn )tmM<’MA-M’/
hll PPrrrrr.fpt,4,r. r!nT1"p’wl1n’nrlp.nf.Q
THE
English medical congress is a notably sedate event at which quiet conversations between friends are interrupted from time to time by a formal address whose content is as familiar to listeners as to the speaker. Elsewhere they manage these things better. For example, an advance bulletin heralding a congress in the New Year " and in the New World promises’that the social program will be intense." Now in Britain the only concession to sociability is a congress dinner (30s., excluding wines) and, with luck, a reception by the mayor. Not so at next month’s meeting. " Among the events is the ... Fiesta, in which the participants of both sexes will be attired in typical regional costumes ; they should therefore not forget to include this costume in their baggage." This plainly sets a sticky problem for the distinguished British representative. If only he were Austrian, or Dutch, or Danish, it would be easy. Perhaps by claiming a grandmother north of the Highland line he could appear in some non-committal tartan without fear of reprisal. If not he will, I suppose, be driven back to the battered bowler and frayed umbrella which seems to have become the native costume of middle-class males in our region. *
*
*
An old friend, who asks me to dinner when I am well and promptly puts me into one of his hospital beds when I fall ill, is shortly to retire, having reached the age limit for a professor of medicine. He has to deliver a valedictory address to his students, and his subject is to be : " What to Say to the Moribund." Some doctors, he says, have a rule-of-thumb solution for this most delicate of problems : not a word, not a gesture to indicate the approach of death. Such doctors will have nothing to do with the mysteries beyond the veil. The professor himself has as many solutions as he has moribund patients, with this one rule applied to all-to do as he would be done by. One of his patients was an old cancerdoctor with a tumour in the lower abdomen. phobe " Is it that, Professor? " he asked. " Yes, I am afraid it is," came the answer, and the word cancer was never mentioned. It is curious, the professor notes, how seldom hospital patients themselves broach the subject of impending death. Is it that the relation of hospital doctor to hospital patient is seldom tete-a-tete and
leisurely ? Looking back,
I can remember only one occasion, 40 years ago, when I blurted out a death sentence. It was
murder with a bludgeon. The patient was a middle-aged chemist recently admitted to a private sanatorium whose one and only doctor was about to take a holiday. The doctor said to me as I took over : " So-and-so is a ’ gonner.’ It is your duty to tell him so." There was still plenty of fight in him when I began. When I had finished a minute later he was down and out. A knockout blow in the ring could hardly have been more instantaneously effective. Once I was the recipient instead of the donor of a death sentence. The exceedingly able doctor in charge, of me felt obliged to tell me my days were numbered. He did so with infinite tact and well-graduated circumlocution. I smiled to myself, for the point to which he guided me so skilfully was one I had reached long before on my own account. Now he is dead and I am alive and kicking. All of which suggests that silence is golden. *
Letters to the Editor
Now
*
*
Patients always say they have never closed an eyeall night; their nurses always swear that they have put in the regulation eight hours. The psychiatrist adjudicates according to-well, perhaps according to the laws of chance more than anything else, with some attention to the dictum that if the patient says he has not slept well then at least he has not slept well enough. A night in a tilted armchair in a transatlantic plane is instructive. All night, it seems, one is not sleeping ; one hears the engines all the time; one even looks at one’s watch like the.patients who report the hourly striking of the clockand suddenly and inexplicably it is Gander, and one has certainly not been awake for eight or nine hours: It seems that an interrupted sleep or a light sleep, either of which allows some perception of the surroundings, gives the impression of sleeplessness.
GASTRIC CANCER
SIR,-A whole corpus of statistical legend has gradually grown up around the subject of gastric cancer. There is little or no evidence in support and strong evidence against, but, as the history of medicine shows, facts can be almost powerless against the imaginative appeal of the attractive story. Mr. Shorter (Dec. 6) gives all the main myths with an excellent bibliography in a single paragraph. He tells us that though the total incidence of all forms of cancer is much the same in different communities, gastric cancer has important variations. " The racial incidence varies from 20 % of all cancers in Great Britain to about 10 % in America " ; the preponderance of males is much greater in America ; " the highest incidence is " between the ages of 40 and 60 " ; gastric cancer is " much commoner in the poor than in the rich." It is impossible to impugn so many statements in a single letter, but the following table is one of many which could be constructed from official figures to show how similar the incidence of gastric cancer is in comparable populations ; and if Mr. Shorter cares to browse
carefully into available death returns, he will see how unwise he has been to rely on the authors whom he cites. The 1939 English and 1940 U.S.A. figures have been chosen as the latest available information undisturbed by war from the particular countries Mr. Shorter has mentioned. more
Gastric
male mortality per 100,000 L .5.. England and HTulcs (1939) (1940)
cancer :
lge-grouj3 25-35 35-45 45-55 55-65
65-75 75-
....
....
....
....
....
....
2-1 23 10-7 11 42-8 43 111 108 217 199 297 210 ....
....
....
....
These figures demonstrate how readily huge differences in the apparent incidence of gastric cancer can arise if The incidence statistics are handled light-heartedly. over the age of 65 (where diagnosis and death certification is most unreliable) is high compared with the incidence in the younger age-groups where full investigation and operation are probable. Unless care is taken to allow for the exact age and sex distribution of the populations compared, and to consider the effect of varying investigation and autopsy facilities in the older age-groups, the undoubted similarities will be obscured by the dubious differences. Exact figures also show how rarely gastric cancer is the cause of indigestion and how impractical it is to push investigation to the point of diagnostic
laparotomy. London, W.I.
-
DENYS JENNINGS.
CLINICAL IMPRESSIONS OF MALARIA AND LIVER DAMAGE
SIR,-The paper by Professor Maegraith, Dr. Andrews, and Dr. Gall in your issue of Nov. 29 encourages me to . describe a group of cases -Isaw in Siam while a prisonerof-war. Two of us were medical officers to a party of 400 men working on the Mergin road from May to August, 1945. Of these, 100 died ; and about half of these died in an unusual manner. Their illness began with a continuous fever of about 102 °F. After five days they began to hiccup and became deeply jaundiced. After another four days they went into coma. This was not the irritable coma with hypertonia of cerebral malaria but a deep .coma with stertorous breathing suggestive of hepatic failure ; after every few respirations they would hiccup. After three days in coma they died. At the onset there was complete anorexia. Vomiting was present but was not severe. There was no haematuria or tendencv to general hemorrhage. The urine was scanty and coloured by bile pigment-not haemoglobin. There was some enlargement of the liver and spleen, but of no great degree. At first we thought this .was a leptospiral infection, but later some men were evacuated to the hospital camp at Nakon Paton and died in this’ manner. We heard that the blood slide from all of them showed Plasmodium falciparum. It is my feeling that these cases were due-