I need scarcely repeat my previous remarks as to the necessity for care and patience when engaged in the examination of suspected abdominal tumours. The patient should be placed in different positions, and the colon should, if necessary, be previously emptied by a purgative or an enema.

In some cases ascites, produced by secondary disease of the liver, deprives us of all chance of finding a tumour. In others, especially in the earlier periods of the disease, the epigastrium seems full both to the eye and hand, but no distinct evidence as to the cause of the fulness can be obtained by examination. Under such circumstances, palpation and percussion should be frequently and carefully repeated, until we can satisfy ourselves as to the exact nature of the complaint.

We might anticipate that in a disease so beset with difficulty in its diagnosis at an early stage, the examination of the matters vomited by the patient would be of value. There is no doubt that such is the case, and in all probability future researches will increase our knowledge upon this point.

In the earlier stages, before ulceration has begun, there is often a regurgitation of a sour liquid; sometimes a glairy or ropy mucus is rejected, whilst in other cases it is bitter, as if from an admixture of bile. Fluids presenting similar characters are often vomited in chronic gastritis and in simple ulcer, so that from these alone no definite opinion can be formed.

When cancerous ulceration has taken place, there is almost always an admixture of blood in the matters vomited. As previously stated, profuse hæmorrhage

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is comparatively rare, but the fluid rejected from the stomach generally contains flakes of blood, is of a black colour, or resembles coffee-grounds. Slight bleedings also may occur in simple ulceration, but they are not so constant as in cancer. When, therefore, we find the matters vomited by a patient continuously mixed with blood, we have good reason to suspect malignant ulceration.

There are certain circumstances which act as predisposing causes of cancer of the stomach, and these are well worthy of attention.

We have before seen that simple ulcerations of the stomach are more frequent in the female than in the male in the proportion of two to one; but the male is more subject, on the contrary, to malignant disease of this organ.

Non-malignant ulcers, as before stated, may occur at any period of life, but cancer of the stomach rarely commences before the degenerative processes of middle age come into operation. Out of one hundred and fifty-nine cases analysed by Lebert, only one was below thirty; seven took place between thirty and thirty-five; five between thirty-five and forty; and all the rest at subsequent ages.

In simple ulceration the disease is often of very slow progress, and the general health may be but little affected, even in cases of some years' duration. In cancer the symptoms rapidly increase in severity, and in the majority of instances death takes place within a year from the commencement of the complaint. Out of thirty cases given by Lebert, two died within three months; seven within six months; and eighteen within one year.

In the earlier stages of gastric cancer the real nature of the disease is often overlooked. There may be neither pain nor vomiting, and yet the fatal malady may be progressing. We have already seen that in the majority of cases of dyspepsia occurring in middle life some symptoms of indigestion have been before experienced, or its approach has been slow and gradual; but of those attacked by cancer there has generally been no previous affection of the stomach, and the symptoms, when once they have made their appearance, rapidly and steadily increase in severity.

If the patient, in addition to the dyspepsia, present a very rapid loss of strength and flesh, we have reason for suspecting that malignant disease is present. In ordinary indigestion, feebleness and emaciation are the results of the affection of the stomach, but in cancer they often precede the dyspepsia, or at any rate are out of proportion to its duration and severity.

In the later stages, the chief difficulty in diagnosis is to distinguish the simple from the malignant ulcer. If the patient be a female under thirty-five years of age, and the disease has lasted for some time without any great diminution of flesh or strength, the presumption is in favour of her being affected with chronic ulcer; but if, on the other hand, the patient be between forty and fifty, if the symptoms rapidly increase in severity and are not relieved by treatment, if the general health be seriously affected, and if the vomited matters have the characters of those furnished by a cancerous sore, we have every reason for believing that malignant disease is present. In any case, a most careful examination should be made, both of the abdomen and of the matters vomited.

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If there be discovered in the epigastrium a tumour of an irregular shape and hard uneven surface, cancer is present; or, if without the existence of a distinct tumour, there should be a general fulness of the epigastrium, and the fluid rejected from the stomach frequently contain flakes of blood, or be of a coffeeground colour, we must arrive at the same conclusion. On the other hand, if we can find no swelling, and the pain be chiefly confined to the period when digestion is going on, and if the vomited fluid contain casts of the gastric tubes, or particles of any of the neighbouring organs, we may reasonably hope that the disease is not of a malignant character.

The treatment of cancer of the stomach can be only palliative, but we have the power, nevertheless, of greatly relieving the sufferings of the patient.

The diet should be similar to that recommended for non-malignant ulceration. It should be given frequently and in small quantities. Liquids are to be preferred, such as milk or animal broths, or they may be thickened with farinaceous substances. Stimulants are generally required, and of these brandy agrees best. It should be well diluted or mixed with ice, in case the vomiting is troublesome.

Digestion may be much assisted by means of pepsin and dilute mineral acids. Preparations of iron, such as the carbonate, are often of great value, both in improving the general health, and probably also, by acting as a sedative to the mucous membrane.

As the two most prominent symptoms are pain and vomiting, these usually require especial attention. The pain is best relieved by preparations of

opium, which must be given in considerable doses. When it assumes a neuralgic character, small blisters or applications of belladonna are useful. The injection of morphia beneath the skin is by far the best method of giving relief in such cases. It should be frequently repeated, and its employment may be often entrusted to the patient or his friends. Other sedatives, such as conium, belladonna, and hyoscyamus, have been greatly recommended, but according to my experience they are much inferior to opium.

The treatment of the vomiting depends entirely upon the pathological condition from which it arises. If the matters rejected be clear, watery, or acid, the use of lime water and other alkaline remedies is indicated. If they consist of mucus, astringents, such as bismuth, oxide of silver, kino or tannic acid may be given with or without opium, as the circumstances of the case require. When signs of decomposition are present, creasote or charcoal will be found useful. If the symptoms indicate dilatation of the stomach, the treatment must be directed to the relief of this condition.