The greatest difficulty in diagnosis is presented by cancers which do not obstruct the orifices of the stomach. Many of these cancers run an almost latent course so far as the gastric symptoms are concerned, and in case they produce no recognizable tumor and are unattended with hemorrhage, the difficulties in their diagnosis are almost insurmountable.
In general, a diagnosis of the particular form of cancer which is present cannot be made, nor is such a diagnosis of any practical value. In very exceptional cases such a diagnosis might be made by the examination of secondary subcutaneous cancers96 or of fragments found in the fluids obtained from the stomach.
96 As for example, in Finlay's case, already referred to (p. [567]). It is not safe to trust implicitly in this criterion, as the subcutaneous tumors may be of a different nature from the tumor of the stomach, as in an interesting case observed by Leube (op. cit., p. 125).
Although the diagnosis of gastric cancer can generally be made before the death of the patient, unfortunately a positive diagnosis in the early stages of the disease is usually impossible. Should resection of cancer of the stomach become a legitimate operation in surgery, it will be of the utmost importance to make the diagnosis in an early stage of the disease. Only those cases are suitable for resection in which there are no secondary deposits, the general health of the patient is in fair condition, and extensive adhesions have not been formed. It was to be hoped that the ingenious instrument devised by Mikulicz for exploring the interior of the stomach by electrical illumination would prove a valuable aid in diagnosis. The gastroscope in its present construction, however, has proved of little value.97 It is, moreover, difficult to manipulate, and is not free from danger to the patient. We may be permitted, however, to hope for improvement in this direction.
97 Mikulicz has observed with the gastroscope in a case of pyloric cancer immobility of the pylorus and absence of rugæ in the mucous membrane of the pyloric region (Wiener med. Wochenschr., 1883, No. 24). It does not seem probable that there can be anything peculiar to cancer in these appearances.
In cases in which there is reasonable suspicion of the existence of gastric cancer, and in which there is proper ground to contemplate resection of the tumor, it is justifiable to make an exploratory incision into the abdomen. It can then be decided whether or not cancer exists, and whether the case is suitable for operation. When this incision is made with all of the precautions known to modern surgery, it is attended with little or no danger,98 and it should not be made except by surgeons who are practically familiar with these precautions.
98 Of 20 exploratory incisions for tumor of the stomach performed by Billroth, not one had ended fatally (Deutsche med. Wochenschrift, 1882, ii.).
PROGNOSIS.—There is no proof that cancer of the stomach has ever ended in recovery. It may be admitted that partial cicatrization of gastric cancer may occur. We have, however, no sufficient reason to believe that cancer of the stomach has ever been completely destroyed by any process of nature or by any medicinal treatment.
A successful resection of a cancer of the pylorus by Billroth in January, 1881, made a great sensation in the medical world. Since that time the operation has been performed successfully ten times, and with fatal issue twenty-seven times. A radical cure has not, however, been effected, although life has been prolonged for a year and a half after the operation.99 The possibility of permanent cure of gastric cancer by extirpation must be admitted. Enthusiasm over this possibility, however, is seriously lessened by the fact that a radical cure is not to be expected unless the operation is undertaken when the tumor is of small size, has produced no distant metastases, is free from many adhesions, and the patient is not greatly prostrated. In view of the difficulty of diagnosis in the early stages it is not likely that these favorable conditions can be fulfilled except in the rarest instances. Metastases may already exist when the tumor is small and before it has given rise to any symptoms.100 Pylorectomy, moreover, will probably be successful in the hands of only comparatively few surgeons. It is therefore but a feeble glimmer of hope which is now admitted to the hitherto relentlessly fatal forecast of this disease.
99 Several of the patients are still living (1884), but, so far as I can learn, no patient has survived the operation more than a year and a half.