338 SURGERY 



ing illustration of what surgery has achieved. It has reduced the 

 mortality of an operation in cancer of the stomach from 60 % to 

 10 %, and in a limited number to zero, and with every prospect 

 in the near future of even a mortality of less than 10 % in a large 

 series of cases. 



The third reason why surgery has not invaded this field lies in 

 the fact that the diagnosis cannot be made by medical means in 

 time to effect a cure. Exploratory incision to find out is recom- 

 mended by Mayo, and by this means an early operation can be 

 performed that will be attended by small mortality as regards the 

 operation itself, and a large percentage of cures as regards the dis- 

 ease itself. Cancer of the stomach, as a rule, is situated near the 

 pylorus, just below the lesser curvature. Moynihan states that from 

 this focus it spreads widely through the submucosa, and rapidly 

 toward the cardia, and slowly toward the pylorus. Until very 

 recently no surgery has been done upon the stomach for cancer, 

 for the reason that it was considered a hopeless disease. Murphy 

 collected 189 cases in which radical operation was done, with 26 

 deaths. Of these, 17 patients survived three years, or about 8 % 

 of cures. This is a gain in the right direction, since all patients die 

 without operation. This 8 % of cures was reduced to 5 % by a re- 

 turn of the disease after three years. Mikulicz in 100 cases had an 

 average duration of life of 15 months. The patients had relief from 

 suffering at least 15 months, and there did not follow that terrible 

 suffering so characteristic of the inoperable cases of cancer of the 

 stomach. The reason that the results are not better in cancer of 

 the stomach is owing to delay in operation, and when that obstacle 

 is overcome the results will be brilliant, compared with the gravity 

 of the disease. Time permits of adhesions, and when the opera- 

 tion is resorted to before adhesions form, the mortality is very 

 much lessened. Thus Haberkaut had a mortality of 72 % in cases 

 with adhesions, and only 27 % without adhesions. Gastrectomy 

 was done, as reported by Murphy, in Kappeler's clinic, with 26 % 

 mortality, Kronlein with 28 % mortality, Kocher 29 %, Roux 33 %, 

 and Mikulicz 37 % mortality. Murphy has called attention to the 

 prophylactic treatment of cancer. He believes in the removal of 

 conditions which seem to be essential in the majority of cases to 

 the development of the disease. Mikulicz has shoAvn that 4 % 

 to 5% of the human race suffer from gastric ulcer, and that a fifth 

 die as a result of the gastric ulcer. The other factor which largely 

 influences the growth of cancer is the pyloric stenosis when the 

 stomach cannot empty itself. The suggestion, therefore, is the 

 removal of gastric ulcers by excision, and the relief of the pyloric 

 obstruction by gastroenterostomy, and these prophylactic opera- 

 tions when performed early are attended with a comparatively 



