EARLY AND LATE CASES OF GASTRIC ULCER

WILLIAM FITCH CHENEY
1908 Journal of the American Medical Association  
quent, and because it is often impossible to tell with certainty by local examination whether an ovarian tumor is malignant or not. Neither extreme youth nor old age are in themselves contraindicalions to the removal of ovarian tumors. Old women usually stand this operation remarkably well, while in little girls malignant disease of the ovary is by no means uncommon. The ovarian tumor is usually unilateral, and whenever possible the other ovary should be' left. The indication for oophorectomy
more » ... for oophorectomy in inflammatory troubles depends solely on the pathologic condition of. the ovaries, not on the patient's symptoms. The focus of infection is the tube in most cases. The oophoritis then begins at the outside of the ovary and oftentimes completely clears up on removal of the offending tube. The "indications for oophorectomy in inflammatory diseases of the pelvic organs are, therefore, about as follows : When the tube and ovary are so bound together by adhesions that removal of the tube alone is technically impossible, the ovary must also be removed. If both ovaries are in this condition, efforts should be made to leave at least a part of one ovary to keep up the internal secretion. The ovary should also be removed in operations for inflammatory disease when it is so extensively inflamed that a restoration to normal is apparently impossible. As a commentary to this last indication I would add that I believe that the more operations one does the less likely one is to remove ovaries through this indication. In hysterectomy for myoma it is sometimes necessary to remove one or both ovaries on account of dense adhesions between the ovary and the growth. As a rule, one or both ovaries can and should be left. Removal of normal ovaries on account of chronic pain "in the ovarian region," or double oophorectomy in order to relieve dysmenorrhea is not indicated. HYSTERECTOMY. As in oophorectomy, the more major operations one does the less inclined one is to do hysterectomy. The same general principles hold good here as in the preceding considerations. Removal of the normal uterus, because the woman has some vague "female trouble" which does not yield to treatment, is never justifiable. Clear, well-defined indications are always necessary to justify hysterectomy. Such indications are given for the most part in malignant disease of the uterus or ovaries, myomata, pelvic inflammatory disease in which the uterus is generally involved or in which the process is tuberculous in character, some cases of complete prolapse and a few cases of intractable uterine hemorrhage arising from microscopic changes in the endometrium or uterine musculature. CONCLUSIONS. I will not carry this discussion of special operative , procedures farther. It has been seen that there are certain considerations common to the discussion of all of them. I wish, in conclusion, to deduce from these common factors a few simple principles, the strict observance of which is of vital importance in the successful practice of elective surgery. Before it can be said that any given operation is necessary or advisable three conditions must be satisfied beyond reasonable doubt: First, we must be satisfied that the symptoms of which the patient complains are caused by the lesion toward which the operation is directed. Second, we must have a reasonable assurance that these symptoms will be relieved entirely or greatly benefited by the operation which is proposed. Finally, we must be reasonably certain that the probable danger from the operation itself, when compared with the severity of the lesion and the expectation of relief, is small enough to justify the patient in taking the operative risk. These postulates seem absurdly simple and self-evident. They are, of course, the fundamental principles of all therapeutics. But in elective surgery, more than in any other department of medicine, we are prone to lose sight of them or to minimize their importance. In just so much as we disregard them in the same proportion will the results of our surgical work fall below the high plane of excellence. If we should carefully consider them before every proposed operation of elective surgery I am sure that, while we might not do as many operations as we may be doing now, on the other hand, the end results of the operations which we would do would be much more brilliant than at present. Two conclusions have impressed themselves on me regarding gastric ulcer: 1, Heretofore the condition has not been diagnosed early enough; 2, it has not received sufficiently rigorous treatment after the diagnosis has been made. NEED OF EARLY DIAGNOSIS. Early diagnosis is of immense value as an aid to cure, certainly as much so as in gastric cancer, possibly as much so as in pulmonary tuberculosis. It has been too much the custom in the past to consider no case gastric ulcer unless certain definite evidence was present, such as vomiting of blood, blood in the stools, violent attacks of gastralgia and lancinating pain through the abdomen from epigastrium to back. These signs are classical and are usually accepted as convincing, hut diagnosis ought to be made and treatment instituted before this stage has been reached. My own conviction is that many cases of chronic dyspepsia, characterized for weeks or months by flatulence, waterbrash, burning and distress after food, where the epigastrium shows tenderness and the test meal shows hyperacidity, are in reality gastric ulcer, even when the feces show no occult blood. Such cases can not positively be diagnosed as ulcer any more than incipient tuberculosis can positively be diagnosed before bacilli are found in the sputum; yet they deserve routine treatment on suspicion, in one instance as truly as in the other. If these dyspeptic cases are allowed to go on indefinitely without treatment or with only haphazard treatment, serious symptoms are likely sooner "or later to appear that make the diagnosis clear but that render the results of treatment much more dubious. I would not urge the ulcer cure at once in every case of acid dyspepsia, but if one month's treatment by ordinary methods, with the patient up and about, does not cause a marked decrease of the trouble I have
doi:10.1001/jama.1908.25310320010001b fatcat:tfuisqwtjne6xgjrb2a4ildiem