Carcinoma of the Stomach

MANY renowned surgeons have directed attention to the subject of gastric carcinoma since Billroth performed the first successful partial gastrectonmy for this lesion in 1881 (Billroth, 1881) and Schlatter accomplished the first total gastrectomy in 1897. Although advances have been made in the diagnosis and treatment of gastric cancer since the work of these pioneers, I am sure we would all agree that even our most competent efforts of today leave nmuch to be desired. It is natural that the names of surgeons are prominent in the literature relating to gastric malignant disease, since no patient, to my knowledge, has ever been cured of gastric carcinoma exccpt by surgical removal of the growth. Although a review of past work is always of interest, no historical account will be given at this time, as I would prefer to discuss some current controversial phases and to report on experiences which my associates and I have had in the recognition and management of patients who have gastric cancer. Etiologic factors that might be responsible for development of various types of malignant lesions have been the object of many detailed and specific studies. Certain general data also stimulate thought and might possibly provide clues regarding etiology if they could be properly studied and evaluated. For example, there has been much comment during recent years about the increased incidence of pulmonary cancer. Equally intriguing is the great difference in relative incidence of gastric carcinoma in various countries. Interesting also, and possibly presenting easier investigative possibilities, is the difference noted in relative incidence of gastric carcinoma in various parts of the same country (Haenszel, 1958). The age-adjusted death rate froIm cancer of the stomach is highest in Japan, Finland, and Chile. In fact, it was found that during the years 1951 to 1954 it was between two to three tinmes higher in these countries than it was in Ireland, England, or the United States. An undoubtedlv significant but unexplained fact is that age-adjusted death rates for cancer of the stomach have decreased significantlv in some countries but not in others (Moore, 1962; Segi, 1960) (see figure). This decrease started in the United States thirty or more years ago and has been rather pronounced. In contrast, the same change has not occurred in Northern Ireland or England (Segi, 1960). Many theories have been advanced to explain the geographic and national differences in the relative 128