The curved intestinal needles I use for all visceral suturing I have also employed since 1884, and with slight modification in size and thickness they have done me very good service. I never use a needle-holder.
No useful purpose can be served by comparing the results of gastrectomy with those of gastroenterostomy for cancer, since the latter operation in malignant disease is reserved for late cases that have passed the stage when gastrectomy would have been a justifiable operation ; nor do I consider that an estimate of the true value of gastrectomy can be attained by a consideration of the earlier cases operated on before the technique had been perfected.
Up to the end of 1905 Kocher had performed 110 partial resections of the stomach with a mortality of 24 per cent., but of the cases, fifty-eight in number, operated on since 1898, the mortality wTas only 15 per cent., a percentage closely corresponding to that of the brothers Mayo, who up to the end of last year had performed 100 gastrectomies with a mortality of 14 per cent.
In my own practice since 1896, the mortality for partial gastrectomy lias been 14 per cent., and Maydl's statistics give a 16 per cent, mortality.
We may thus conclude that the immediate risks of partial gastrectomy, as calculated from a considerable series of cases, are between 14 and 16 per cent.
Of the twenty-seven cases of total gastrectomy collected from all sources by Mr. H. J. Paterson (1), ten died, a mortality of 36 per cent.
Of the twenty cases of sub-total gastrectomy, six died, a mortality of 30 per cent.
The remote results are equally interesting and not less important, not only from the point of freedom from recurrence, but also as to the effect on the general health and comfort of the patient after the removal of the whole or part of the stomach. I have had under my notice for over six years a case of subtotal gastrectomy, and from observations on this case it would seem as if the wdiole of the functions of the stomach could be replaced.
It would at first sight appear that as a reservoir the stomach could not be replaced, but the fact that a meal of moderate size can be taken shows that the upper end of the duodenum, or the lower end of the oesophagus, or both, become dilated and serve that purpose, though, perhaps, to a limited extent. The mechanical functions of the stomach can be vicariously performed by the mouth and by a careful selection of diet. The digestive functions of the stomach can be taken up by the pancreatic and the intestinal secretions, and the absorption which normally occurs in the stomach can as easily take place in the intestine.
Pachon and Carvalho (2) have shown that dogs may gain in weight and remain in perfect health after removal of the entire stomach, and further observations on patients after complete gastrectomy, as in Schlatter's case, show that perfect health is compatible with absence of the stomach.
Of the twenty-seven total gastrectomies (1), it is interesting to note that ten are living and well 8, 7, 5, 4 3/4, 4, 3 1/2, 2, and If years, and two others at less periods after operation, while others survived 3 3/4 years, If years, 13 months, 9 months, and 7 months respectively.
With regard to the sub-total gastrectomies, of the fourteen patients who recovered from operation one was well 7 1/2 years, one 6 3/4 years, and one 5^ years after operation, while of the others, one survived operation for 11 years and died of heart trouble without recurrence, one 5 years, two 2 1/2 years, two If years, and one 1 1/2 years respectively.
The immediate results of partial gastrectomy have been mentioned above, and the final history has been obtained by Mr. H. J. Paterson in fifty-five of those that recovered. Of the fifty-five patients, thirty-five have died since the operation, one died from recurrence 7 years and two 5 years later; but it is interesting to note that all the other patients in whom recurrence ensued died within 3 1/2 years, so that if a patient remains free from recurrence for four or more years there would seem to be a strong probability of cure. Eight of the patients who died, lived over 3 years after operation, and the average duration of life in cases where recurrence took place was just over 2 years. Of the patients who are apparently cured, one is alive and well 14 years, one 7 1/2 years, two 6 years, one 5 years, two 4 years, five over 3 years, and three over 2 years subsequent to operation, and one was living 4 1/2 years after operation, but recurrence was feared. Thus nearly 14 per cent, of the patients who recovered from operation would seem to be cured or to have a reasonable prospect of remaining free from recurrence.
After a careful analysis of all the cases operated on I cannot help feeling that far too gloomy a view is taken of cancer of the stomach, for if the disease be caught early and a wide excision peformed, care being taken to remove the lymphatic area of the stomach with the glands along the lesser curvature, results even better than those I have just mentioned will be obtained. Our great hope of success, I venture to state at the risk of being accused of reiteration, lies in early and complete removal.