THE SURGICAL PROSPECT OF GASTRIC CANCER. J. H. DUNN, M.D., MINNEAPOLIS. If the surgical cure of gastric cancer is not yet admitted by all, it is from ignorance. It is a cancer more curable than that of the breast, or that of the tongue, because it is a cancer of slow evolution. Thus assert Ferrier and Hartmann in their monograph "Chirurgie de l'Estomac," Paris, 1899. A further reason for placing carcinoma ventriculi among the operable malignant diseases is that in many instances death follows, not from the malignancy of the growth, but because the local lesion causes such troubles of nutrition that life is impossible. It is now nearly twenty years since the writer observed in Billroth's clinic some of the pioneer work in this field. Two years before, i. e., in November, 1880, Billroth had performed the first successful pylorectomy for cancer. In this early period the mortality was from 50 to 70 per cent.; recurrence with few exceptions was early; and the cures, i. e., those living without evidences of recurrence after three years, were rare. In short, the results were very like those of the pioneer efforts at surgical treatment of cancer in other organs, with a particularly heavy mortality. It was probably this fearful early mortality and the difficulties of timely diagnosis, rather than any lack of faith in its rationale, that has so long retarded the popularization of the surgical treatment of gastric cancer. During these twenty years many things have transpired. Abdominal diseases have been discovered, and practically conquered so to speak; and after taking up the diseases of the other abdominal viscera pretty thoroughly surgeons are returning to the stomach much better equipped for practical solution of this difficult problem. Such a feat as total gas trectomy, first achieved in 1897, while not without interest, especially in its physiologic aspects, has added little to the solution. It is not in such extensive carcinomata that cure is to be sought surgically in the stomach or elsewhere. As unsatisfactory as the surgery of malignant disease in general and of the stomach in particular yet remains, it would seem that our point of view has been greatly changed and much improved by many lessser and indirect sidelights thrown on the subject during recent years. In the first place, both abdominal technic and differential diagnosis have been immensely improved during these decades. Gastroenterostomy, early much in vogue as a palliative operation in gastric cancer, is practically obsolete in that disease, but has won a vastly greater and more important place in ulcer, the other common gastric disorder of surgical importance. The profession is awakening to the importance of surgery in gastric and gallbladder diseases, and to the discovery, one might almost say, of gastric ulcer as an important surgical disorder. Finally, the modern views of the relation of gastric ulcer to carcinoma can scarcely fail to modify our theories and practice in reference to gastric cancer. If it is rational to operate carcinomata of the breast, uterus, rectum, tongue, etc., as we all do, it is yet more logical to look on cancer of the stomach as a surgical discase. In the latter, as in the former, it will scarcely be possible to successfully treat all cases. Certain cancers of rapid growth, especially in young subjects, defy practical surgical treatment, in whatever location. The universal experience is that real success in the cure of cancer lies in the complete and wide removal of precancerous lesions, of those in the early transitional stage, or the incipient stages of true malignant neoplasms. As soon as the lymphatic system is invaded, even in epithelioma of the lower lip, surgical cure is exceedingly rare and always uncertain. It is just in connection with this fact that recent developments give us most hope in the future of surgery of gastric carcinoma. All recent observers admit a more or less marked relation between ulcer and cancer of the stomach. Just how large a percentage of gastric ulcers soon or late undergo malignant transformation is as yet unknown. That many do is proven beyond doubt. The estimates of various observers range from 5 per cent. to approximately 100 per cent. The researches of Gustaf Fütterer, who regards ulcer as a strong factor in carcinoma, are particularly important. Dr. Christopher Graham, whose work is especially valuable as one of the few internists who have added to a large clinical experience a wide observation at the operating table, found 88 per cent. of his cancer cases gave a history of preceding ulcer extending over from one to fifteen years, showing that in a very large proportion clear indications for surgical interference existed in the precancerous stage, when radical removal would have offered quite certain prospects of permanent cure. The same observer finds that 89.5 per cent. of ulcers and 83 per cent. of cancers are located in the pyloric portion of the stomach; i. e., in that portion of the stomach lying to the right of a line dropped from the esophagus to the greater curvature. This portion is termed by W. J. Mayo the ulcer- and cancer-bearing portion of the stomach. Two fatal errors of the average practitioner have rendered the surgery of malignant disease almost futile, viz., late diagnosis and inefficient removal. The lip and face have long been the most favorable locations for the surgical cure of carcinoma, simply because the precancerous lesions are open to observation, and, as a rule, however, not without exceptions, from several months' to several years' time is given for the patient and his medical advisers to arrive at a diagnosis and to act before malignancy becomes well established. Most of these lesions are attacked before they become cancerous or at least in the incipient stage of the process, and as a result a very high percentage of cures follows, a percentage which might be still further greatly improved but for the very inefficient removals so often primarily practiced. The insignificance of the lesion leads the patient and his ordinary advisor to look on its eradication as a trivial matter which almost any one may accomplish. At the present time the primary removal too often falls into incompetent hands. After the recurrence both parties to the transaction are eager for expert services, which are then rarely of much avail. The operative treatment of advanced carcinoma of whatever region is a sorry storv. It is, perhaps, not to be totally condemned, giving as it may some solace to an unfortunate class of sufferers, but all surgeons of large experience, and a little past the stage of greatest operative enthusiasm, recognize its poverty as a life-prolonging remedy. Hence, to the writer, the prospects of the operative treatment of gastric carcinoma have been changed from one of extreme pessimism to comparative optimism by the trend of recent experience in gastric ulcer. The whole subject is still in the nebulous stage, but certain fixed points begin to stand out: First, that chronic ulcer is a surgical disease quite as much in the stomach as on the external surface of the body; that its timely cure may be expected, not only to relieve the great distress and dangers of ulcer itself, but to effect a marked prophylaxis of cancer. Second, that the exploration of suspicious gastric disorders will reveal many carcinomata, yet in their incipient stages, while the chances of successful removal are excellent. As the mortality of partial gastrectomy, under improved technic, lessens, the indications for excision of the ulcer- and cancer-bearing area as recently suggested by Mayo and Rodman, will increase. At present this radical measure is clearly indicated in three conditions: a. Carcinoma not yet disseminated beyond apparent anatomical removal. b. Chronic ulcers showing beginning malignant transformation. c. Certain extensive indurated chronic ulcers, at the primary operation if the patient's condition permits, or if not, at a secondary operation after recuperation from a preliminary gastroenterostomy. Practically, the two latter indications must be included as one, since it is not possible to always differentiate these cases before or at the operation; only subsequent microscopic investigation can be relied on in many cases. Hence the matter resolves itself into this: If the disease be clearly cancerous and radical removal practicable, it should be done. Sometimes the primary growth is found readily removable, but extensive dissemination of minute or miliary carcinosis renders excision useless and a palliative gastroenterostomy may be worth while. But this operation now has but a very small utility in gastric cancer, because in those cases in which it brings the most temporary relief gastrectomy offers more, while in those past hope by gastrectomy, the relief from gastroenterostomy is slight and of short duration. While the writer occasionally does a gastroenterostomy in inoperable carcinoma, after the abdomen is open, he never advises it in a case known to be beyond radical operation; that is, it is an operation rarely, if ever, to be chosen before the abdomen is opened. If it is apparent that the disease is cancer, and is quite clearly beyond practical hope of cure by removal, no operation is indicated. If in an old ulcer there be only suspicions of malignancy, gastrectomy is indicated, but the condition of the patient may render operation in two stages advisable. Should the mortality of such a partial gastrectomy, now probably about 15 per cent., be further reduced to approximately that of gastroenterostomy, the latter indirect operation for gastric ulcer might be largely supplanted by the, in many respects, more rational excision of the ulcer-bearing region. Reduced to 5 or 10 per cent., partial gastrectomy undoubtedly will be, but it is scarcely in the nature of things that it will ever catch up with the comparative minor gastroenterostomy, the dangers of which are also being rapidly eliminated. (Mr. Moynihan has made 75 operations for gastric ulcer with but one death.) But we have certainly reached the stage where all border-line and suspicious cases, and certain extreme ulcer cases, can afford to take the somewhat greater immediate risks for the more complete and lasting rewards. As already stated above, the two difficulties in the surgical cure of cancer are sufficiently early diagnosis and the scarcely not less important efficient technic of thorough removal. It is not the purpose of the writer at this time to touch on |