A. Surgical Interference

Owing to the futility of medicinal treatment, surgical intervention has been invoked, and several bold operations have been devised, which may be resorted to in appropriate cases. These may be divided into radical and palliative procedures.

a. The radical operations include: (1) Resection of the pylorus; (2) excision of the tumor.

Billroth1 was the first to prove the possibility of excision of the carcinomatous pylorus, in 1878. Since that time, distinguished surgeons all over the world have been working in this special field of abdominal surgery, and have greatly contributed to the further development of this heroic method of treatment. The aim in total resection of the tumor is to radically cure the patient, i.e., to remove all the cancerous parts of the organ. It will be seen at a glance that the indications for this operation exist as soon as a neoplasm accessible to the knife and operable can be diagnosed. The earlier the diagnosis is made the better are the chances for radical interference. Thus far only very few cases are known in literature in which the excision of the tumor or the resection of the pylorus was followed by a real cure. The reason that these operative procedures have not been so successful as has been expected is that they are resorted to, as a rule, too late. Gastric cancer can rarely be diagnosed before it has contracted adhesions with other organs, or before metastatic deposits have formed elsewhere. Contraindications for these operations are: (1) If cancerous metastasis can be discovered in other organs 1Billroth: Wiener klin.

Wochenschr., 1891, No. 84. (liver, glands, etc.); (2) adhesions, i.e., if the tumor is not perfectly movable and found to be adherent to other organs; (3) the large size of the tumor; (4) the presence of high degrees of anaemia or cachexia; (5) very old age.

B. Palliative Operations

The palliative operations have two purposes in view:

1. To permit of a better introduction of food into the digestive tract.

2. To remove as much as possible the irritating effect of food upon the affected area.

The operations serving this object are:

1. Gastrostomy, in malignant affections of the cardiac orifice or of the oesophagus.

2. Gastroenterostomy, for malignant affections of the pylorus or its immediate neighborhood.

Gastrostomy consists in establishing an opening between the stomach and the abdominal wall, in order to introduce food by this new passage. The technique of this operation has lately been considerably improved, Witzel's 1 method accomplishing the best results. The indications for this operation exist as soon as dysphagia is well developed and the patient unable to introduce large enough quantities of liquid and semi-liquid food through his oesophagus in order to maintain his bodily weight. To wait until a time when even small quantities of liquid cannot pass through the cardia into the stomach without discomfort and pain does not appear to be advisable, for at this period the operation, as a rule, is more dangerous and affords less relief to the patient. Contraindications for this operation are the weakened condition of the system, caused either by advanced cachexia, very old age, or other conditions.

1 Witzel: Cetralbl. f. Chirurg., 1891, No. 31.

Gastroenterostomy consists in the establishment of a new communication between the stomach and the small intestine, in this way allowing the chyme to pass directly into the small intestine without previously passing through the pylorus. The indications for this operation exist as soon as the presence of malignant trouble within the organ has been diagnosed, complicated with symptoms of ischochymia, especially if a radical operation does not appear to be feasible. The sooner it is done the better. By means of it life can be considerably prolonged and made much more comfortable than is possible by any other treatment. The contraindications are the same as those given above under gastrostomy.

Exploratory laparotomy, which is often performed in this disease, seems to be permissible only in those cases in which the diagnosis, although not positive, admits of the possibility of undertaking some kind of an operation which will afford either a cure or at least some relief to the patient. To make an exploratory laparotomy merely for the sake of diagnosis does not seem to me justifiable.