CANCER OF THE STOMACH.—The treatment of this affection, owing to the advances in abdominal surgery, is rapidly passing from the domain of the physician to that of the operating surgeon. The palliative treatment by drugs, restricted dietary, lavage, &c., should only be undertaken when the decision to abandon operative procedure has been arrived at. By persevering in any form of treatment which merely has for its aim the relief of symptoms valuable time is lost and the disease passes beyond the reach of removal, whilst an early operation affords a justifiable hope that a permanent cure May or it considerable prolongation of life under comfortable conditions effected. Dancers statistics show that life is prolonged for a period of fourteen and a half months on the average by the operation of gastrectomy, and II patients out of 73 were found in good health three years and later after the operation. Spencer and Gast: conclude that with early diagnosis and operation co per cent. of all cases of cancer of the stomach may obtain an average prolongation of life of two years. An exploratory incision skilfully performed for diag nostic purposes. where no attempt is made to break down adhesions, may be regarded as devoid of risk. The disease when found by explora tion to be very circumscribed and confined to the duodenum is sometimes removed by pyloreclowy— i.e., excision of the pylorus—but this is usually unsuccessful and should always embrace the removal of a considerable portion of the stomach with all enlarged glands.
Partial gastrectomy is the recognised operation in all cases where the entire stomach is not to he removed, and is suitable for the removal of all tumours near the pylorus. It is performed after ligature of the stomach arteries and the detachment of t he gastrodiepatic and gastro-colic omen tom by cutting the stomach vertically in two from the smaller to the larger curvature after a posterior gastro-jejunostomy has been first effected with the sound cardiac end of the organ and all diseased glands removed. The cut ends of the stomach and duodenum are then closed and invaginated.
Total gastriv/uniy has been several times successful; the preliminary steps of the operation are the same, only that the entire organ is removed and the end of the divided duodenum or a portion of the jejunum is attached end to end with the lower end of the gullet.
Where the stomach on exploration is found to be diseased along with the glands on the front of the spine, or where the pancreas, liver or other organ is invaded, any attempt at a radical operation is unjustifiable. The only resource is to perform the operation of gastre-enterosionly, the variety known as posterior gastro-jcjunostomy being the most suitable in nearly all cases. The rationale of this procedure is to make an anas tomosis of the commencement of the jejunum with the stomach so as to do away with the pylorus and duodenum permit the Mod to pass directly from the gullet into the intestine withouts4-ieing retained in the stomach. It is clearly indicated in all cases of pyloric obstruction which
cannot be remedied by a radical operation.
The palliative treatment of gastric cancer consists in the exhibition of remedies for the relief of the. different symptoms as these show themselves. Appetite failure is one of the very earliest and most frequently observed features; it may be net by vegetable bitters given before eating, and by far the best of these is Strychnine given with a few minims of chlor. The dietary should be as varied as possible, owing to the intensity of the imoreNia: it should consist mainly of concentrated liquid foods 11 tin Ii will bass rapidly through the stomach, lait in the very early stage fish, chicken and eggs may be freely given. At a later stage, when symptoms of ulceration of the growth occur, the dietary must be identical with that suitable for gastric ulcer, but peptonised preparations as a rule are seldom relished, and liquid nourishment must be given in small amounts and frequently. The appetite may be somewhat improved, and the gastric discomfort lessened by the administration of digestives which hasten the absorption of the food and curtail its stay in the diseased organ. In the early stages Pepsin is valuable when given with Hydro chloric Acid, which is usually deficient; later on Papain with Sodium Bicarbonate and a trace of Morphine is highly useful when ulceration has occurred.
Symptoms of pyloric obstruction with great discomfort, organic acidity and flatulence may be often markedly relieved by lavage and the ad ministration of Creosote in the capsular form.
Vomiting may be relieved by ice, Morphia in moderate amount com bined with Bismuth and Hydrocyanic Acid, or by Creosote. Often sour buttermilk or Koumiss is retained when everything else is rejected, and occasionally a small blister over the centre of the epigastrium gives relief.
Pain must be relieved by Morphia, and Alcoholic stimulants, when these afford relief, should not be forbidden; a small quantity of good brandy or whiskey may be administered frequently in milk.
Sleeplessness, constipation and other complications are to be met by appropriate remedies. As a rule the presence of a palpable or visible tumour in the epigastrium is a clear indication that the case has passed beyond the stage at which a radical operation can be successfully attempted, but the performance of a gastro-enterostomy should always be insisted upon when the pain, vomiting and distress are severe. All these symptoms may entirely disappear after the operation, and life may be prolonged for a considerable period in comparative comfort. In deciding upon the advisability of the earlier operation the error of excluding malignancy by detecting the presence of a fair amount of hydrochloric acid in the gastric contents should be always guarded against, and the fact should be also borne in mind that a very considerable percentage of cases of the disease as insisted upon by Moynihan occur in connection with old gastric ulcer.