Influence of Inflation.-Distension of the stomach with gas may alter very much the position of the tumour. Sometimes it may become more evident, as for example in No. 114, in which before inflation the tumour was about midway between the 8th left costal cartilage and the navel. After inflation it occupied a corresponding position on the right side. The tumour is most frequently moved downwards and somewhat to the right, as shown in fig. 7. It may, however, move in other directions, as upwards, as shown in fig. 8.

OF PERISTALSIS-LOCAL TUMOURS
FEATURES

ANALYSIS OF CASES-VARIETIES
WITH THE DILATED
HOUR-GLASS STOMACH
ASSOCIATED WITH DILATATION-ILLUSTRATIVE CASES.

STOMACH

THE stomach itself, when dilated, may form a readily visible tumour, and one that under some circumstances is easily palpable. This condition is very often overlooked by practitioners,

FIG.,9.-Profile view of the abdomen of No. 3, aged 65, showing the tumour formed by the dilated stomach. From a photograph taken during life.

and even in special works sufficient stress is not laid upon its importance. As an introduction to the question, the accompanying illustrations from No. 3 of this series may be studied. The two photographs taken during life show a remarkable degree of abdominal distension, and the one taken after death

shows an enormously dilated stomach in situ (figs. 9, 10, and 11). They were taken from a woman, aged sixty-five years, who was admitted to the hospital complaining of attacks of vomiting, which had persisted for nearly two years, during which time she had become gradually emaciated and very weak. She had at intervals brought up enormous quantities of fluid. On inspection the abdomen was greatly distended, particularly on the left side and in the umbilical and hypochondriac regions. It was uniform, but at intervals there were slight irregularities

and elevations; no marked waves of contraction. On palpation the abdomen was everywhere soft, except at a point to the right of and just below the navel, where there was a hard, resistant mass. At first it seemed scarcely possible that the entire abdominal distension could be due to a dilated stomach; but the reduction in size after vomiting and after lavage, the depth to which the stomach tube could pass, and the irregular waves of protrusion, left no doubt that the distension was due to an enormously dilated stomach. Dr. Osler has reported

this case briefly in his Lectures, but it is worthy of a fuller consideration.

No. 3. Enormously Dilated Stomach, Multiple Primary Carcinoma.— S. A. (hosp. no. 489), aged 65 years, female, admitted Nov. 6th, 1889, complaining of vomiting, with loss of weight and strength

FIG. 11 (Case No. 3).-Showing the position and size of the stomach.
From a photograph taken at the autopsy.

The present illness began two years before with dyspepsia and vomiting. The vomiting had continued, becoming more frequent and more severe. She had often vomited large amounts; at these times she usually brought up large quantities of gas that nearly smothered her. She had lost much weight and strength. One month ago she noticed at times a lump rise in the abdomen, and this she could see and feel move from side to side.

Examination showed a greatly distended abdomen, particularly on the left side and in the epigastric and hypochondriac regions. The surface was uniform, but at intervals there were slight irregularities and elevations. Peristalsis at times was well marked, outlining the stomach. A nodular mass was felt at the pyloric region. Under lavage and careful diet the stomach became somewhat reduced in size. The patient gradually sank, and died on Nov. 17th.

Autopsy showed an enormously dilated stomach, the fundus reaching to the middle of Poupart's ligament. A large nodular mass occupied the lesser curvature. On opening the stomach two litres of dark grumous material were found. There was a large ulcerated mass at the pylorus, which was so narrowed that only the tip of the little finger could be got into it. This mass extended 6 cm. into the stomach; its surface was ulcerated. A nodular mass was also found in the right breast, which was regarded as being also a primary growth.

In the present series there were 42 cases in which the dilated stomach itself formed a recognisable tumour either before or after inflation. The tumour, as shown so well in fig. 10, is usually asymmetrical, and the greatest prominence is in the left side of the abdomen and in the lower umbilical region. Every part of the abdomen, except the epigastric region, may be occupied by the enormously dilated organ. Usually the greatest prominence is below the navel, as is indeed well shown in the figure. When enormously distended, inspection may not show the very characteristic shape of the organ. In other cases the shape is so characteristic that the diagnosis is made at a glance. The outline of the greater curvature descends on the left side, turning at the level of the anterior superior spine of the ilium, and passing to the right at a variable distance above the pubes, sometimes not more than an inch, sometimes midway between this part and the navel. Curving upwards, it ends either in the right flank, or more frequently in the right upper quadrant of the umbilical region. In other instances it passes directly beneath the right costal margin. The lesser curvature, even more distinctly to be seen, passes vertically, parallel with the left border of the sternum, or in the parasternal line, curves to the left of the navel, and crosses the middle line in extreme dilatation, usually at or below the level of the navel.

Peristalsis is usually to be seen, but it may require very careful and prolonged inspection. Among the 42 cases in which the stomach formed a visible tumour in the abdomen, there