the history and the intensity of the gastric symptoms enabled us to reach a diagnosis. Thrombosis.-Thrombi were present in the left femoral vein in 2 cases, one of which came to autopsy. Post mortem they were found in 3 cases. An opinion of Trousseau in regard to thrombosis may be quoted:"Should you, when in doubt as to the nature of an affection of the stomach. . . . observe a vein becoming inflamed in the arm or leg, you may dispel your doubt and pronounce in a positive manner that there is cancer." The marantic condition produced is probably the cause of the thrombosis. The most remarkable case of general thrombosis was presented by No. 64; the history is given among the latent cases. As shown in the annexed figure (fig. 1) there were thrombi in some fourteen or fifteen veins. CHAPTER VI. STUDY OF THE TUMOUR. GENERAL CONSIDERATIONS-INSPECTION OF THE ABDOMEN- -MOBILITY OF GASTRIC TUMOURS--RESPIRATORY, COMMUNICATED, INTRINSIC AND MECHANICAL-ILLUSTRATIVE CASES-INFLUENCE OF INFLATION. So important are the many features presented by a tumour in this disease that we shall consider them in some detail. Incidence. In 115 cases (about 76 per cent.) a tumour was recognised during life. Position.-Epigastric region, 48; umbilical, 25; left hypochondrium, 18; right hypochondrium, 17; descended from beneath the left costal margin, 7. Into the systematic details of the methods of examining the stomach we do not propose to enter; but there are two points to which particular attention may be called-viz. the value of inspection, and mobility in gastric tumours. Inspection. The value of a very careful visual study of the abdomen in cases of cancer of the stomach is illustrated by the fact that in 88 cases important information was gained in this manner. In 62 cases a definite mass was visible; in 14 there was prominence or fulness; in 12 peristalsis only was the prominent feature on inspection (in 10 of these 12 no tumour was visible, but was felt on palpation; in the remaining 2 the tumour was only found at autopsy). To inspect the abdomen it is necessary that the light should be good, and that the patient should be sufficiently exposed. One day at the Montreal General Hospital a consultation of members of the staff was held upon a doubtful case. Several physicians had examined the patient without finding anything. When the turn came of the late Dr. George Ross, he tucked up the patient's shirt, which heretofore had not been above the costal margin, and after looking for a few moments, he requested the patient to draw a deep breath, when a tumour became visible quite plainly below the left costal margin. In reality this is not a very infrequent experience. In the epigastric and umbilical regions of a healthy person nothing is seen beyond the normal respiratory movements and the communicated pulsation of the abdominal aorta, sometimes the pulsation of the heart in the left costo-xiphoid angle. On the other hand, when the abdominal walls are very thin, either as a result of a general wasting, or a local atrophy from repeated stretchings of the abdomen in pregnancy, the outlines of the viscera themselves may be visible. In a patient with extreme enteroptosis, not only may the thin edge of the left lobe of the liver be seen moving up and down with the respiratory movements, but the notches of the organ may be plainly visible. Occasionally the shadowy outline of the pylorus may itself be seen descending a little to the left of the middle line. the case of Miss A., aged 28, weighing 93 lb., the abdomen was very relaxed, and the pylorus was readily palpable, and presented distinct contractions at intervals, through which one could feel and hear the gas bubbling. Its shadowy outline was plainly to be seen. At intervals the coils of the small intestine were visible, and the transverse colon, with its sacculations. In Even the outlines of the abdominal aorta, with its bifurcation, may be seen. Of this we have a photograph in an instance of extreme emaciation in anorexia nervosa, and we shall also refer to it as visible in a case of cancer of the pylorus. Tumours of the abdominal wall itself are by no means uncommon-small lipomata or fibro-lipomata in the epigastric and umbilical regions. Still more frequent in the linea alba, often situated exactly in the position of tumours at the pylorus, are the pro-peritoneal herniæ, consisting either of a small nodule of fat, or a bit of omentum, or, in larger ones, a portion of the gut itself. These rarely offer any difficulty, as they are felt to be more superficial, and on inspection it is noticed that they do not descend with inspiration. Abscess in the recti muscles may cause a prominent swelling, but this is easily distinguished from an intra-abdominal tumour. Mobility of Tumours of the Stomach.-Under this we may consider somewhat fully the changes in position and shape which a tumour of the stomach may undergo. The question is one to which we have paid very particular attention during the past few years, and we can warmly commend the study as one particularly helpful in diagnosis, and we urge this the more strongly, since in recent monographs on diseases of the stomach the point has not been dwelt upon with the fulness it deserves. I. Movement with Respiration.-In 52 of the cases the tumour was seen to move visibly with respiration; in 69 cases the tumour moved with respiration either on inspection or palpation. Of the 69 cases in which this movement was determined, 13 came to autopsy. Of these 9 showed the presence of adhesions between the tumour and adjacent parts; 4 had no adhesions. FIG. 2 (Case No. 51).—a, position of the tumour in expiration; b, in inspiration. In a large proportion of all the cases in which a tumour of the stomach is visible it follows to some extent the respiratory excursion. The movement may be visible only as a well-defined shadowy outline in the epigastric region. In other instances a prominent nodular mass appears beneath the costal margin on deep inspiration. Much depends on the method of inspection, and on the proper degree of illumination. A good side light, or light from behind the observer, is all-important. The extent of respiratory excursion is variable. It may not be more than an inch, but in extreme cases it may be as much as five or six inches, as shown in fig. 2. from No. 51. II. Communicated movement from the Aorta. Of the 88 cases with visible movement, 21 showed also communicated pulsation from the aorta. Usually in the left half of the epigastric region and in its lower part, this may be the special feature to attract the attention of the observer. More than once it had been mistaken for the pulsation of an aneurism. Occasionally FIG. 3. From a photograph, showing undulatory waves of peristalsis. the impulse is remarkably defined and punctuate, more frequently it is diffuse and occupies a larger area to the left of the middle line than in the " throbbing " aorta. III. Intrinsic movements of the Stomach.-Thirty-six cases showed vermicular movements of the stomach wall or of localised portions of it. In a majority of the cases there was peristalsis, causing wave-like protrusion of the abdominal wall, as shown so |