The surgical treatment of cancer of the stomach appears in a somewhat different light according as it is viewed from a surgical or a medical standpoint. To the surgeon the chief question is, what operation is likely to be attended by the best results or is the least dangerous under the circumstances. But to the medical attendant the subject is a much more complicated one. In the first place, while confronted by the fact that if left alone the disease will inevitably prove fatal, he is unable to assure his patient that an operation is devoid of grave risk or that a cure will result fromlit. Again, he has to bear in mind that the responsibility of recommending surgical interference, as well as the results that may be expected to accrue from it, depends almost entirely upon the accuracy of his diagnosis ; and on the one hand, if he waits until the nature of the disease can be determined beyond dispute, all hope of cure by the knife will have disappeared, while on the other, if he maintains that it exists in the absence of a tumour, it is possible that a serious operation may be undertaken without adequate cause. Lastly, he has to consider the financial and domestic concerns of his patient, and to determine whether the prospect of a prolongation of life or the relief which may be afforded to the symptoms is likely to compensate for the extra danger and expense incurred. We believe that much trouble and disappointment would be saved to both parties if the facts were always explained in a clear and straightforward manner to the patient and his friends, to whom the decision for or against operation could be safely left.
At the present time opinions seem to be divided as to the best method of dealing with a carcinoma of the pylorus, some surgeons advocating an attempt to excise the growth whenever it appears to be feasible, while others prefer merely to relieve the symptoms by the performance of gastro-enterostomy. Our own investigations lead us to believe that, unless undertaken within the first two months, an excision will seldom be attended by a complete cure, owing to the rapid infection of the gastric and retro-peritoneal glands that occurs in the majority of cases. In this connection it may be observed that a localised scirrhus which has undergone colloid degeneration appears to be the most favourable subject for operation, while a medullary growth is the most rapidly infective, and therefore the least susceptible of ablation. Unfortunately, statistics are of little value as a guide either to the mortality of pylorectomy or to its ultimate results, since the method of collecting cases from a number of different sources admits of no distinction being made as to the age of the patient, his general condition, the stage of the disease, or the relative skill and experience of the operator. In the series tabulated by Haberkant the death-rate from pylorectomy was 56.7 per cent., and in that by Wolfler 31.2 per cent.; while the figures of Carle and Fantino show a mortality of only 20 per cent. The same difficulties present themselves with regard to the results of gastro-enterostomy; for while hospital records indicate a mortality of 36-43.5 per cent., experience in private practice seems to show that when the operation is performed at an early stage of the disease the risk to life is not greater than in cases of benign stenosis of the pylorus.
Although there can be little doubt that even in the hands of the most experienced surgeons pylorectomy is a more serious operation than gastro-enterostomy, it is also certain that the expectation of life is greater after a successful excision than after the merely palliative measure. With the exception of one doubtful case (Hahn), we have been unable to find a single instance in which life was prolonged for more than two years after gastro-enterostomy for carcinoma. On the other hand, in 1896 Wolfler was able to collect fourteen cases of pylorectomy which had lived for more than two years, and four which had survived for five years ; and since that date at least fifteen others have been recorded where life has been prolonged for three years or more.