The patient rapidly lost weight in the hospital and was discharged. The further course is not known.

Hour-glass Shape of the Dilated Stomach.-Sometimes extreme constriction about the middle of the lesser curve gives an hour-glass shape to the organ. This does not necessarily indicate a true sand-glass stomach. In No. 4 the note reads: "In the left half of the epigastrium is a marked depression,

corresponding to the lesser curvature. Every few minutes waves of peristalsis cross the abdomen, during which the outline of the organ is unusually distinct, and at the lesser curvature there is an indentation which gives an hour-glass shape to the organ.' At the autopsy there was a cancerous growth at the pylorus, but the organ itself did not show any special peculiarity in form.

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One of the most remarkable cases is illustrated by the accompanying figures (14, 15, and 16), which show a greatly

distended stomach in a woman who had a very relaxed abdomen with widely separated recti. Fig. 14 shows the dilated stomach covered by the skin only, and really forming a ventral hernia. The transverse colon and its sacculations are plainly to be seen. When the waves of peristalsis passed the tumour bulged and got hard; an hour-glass contraction was visible. Then, as shown in fig. 15, the outlines became more definite and the right section of the stomach smaller. In fig. 16 the stomach is shown as a

prominent rounded mass. A brief abstract of the case is as

follows:-

No. 76. Dilatation; Hour-glass contraction. Tumour; Ventral Hernia.-S. M. (hosp. nos. 10,653 and 14,022), female, aged 39, was first admitted on Aug. 14th, 1894, complaining of abdominal pain. She had had numerous pregnancies. Her present illness had lasted for three months during which time she complained of pain in the umbilical region,

with belching of gas and nausea. She had never vomited. There had been rapid loss of weight and strength.

The

Examination showed a sallow, poorly nourished woman. abdomen was prominent, with remarkably relaxed walls, and a large easily reduced ventral hernia the size of a child's head between the recti, which were wide apart. In the left epigastrium a nodular mass was felt, which descended with inspiration. On inflation the outlines of the stomach were readily made out; the lower border extended about 4 cm. below the navel, and the lesser curvature was about midway

between the navel and ensiform cartilage. At times the stomach assumed a definite hour-glass shape. The wearing of a bandage gave her much comfort.

The previous history of this patient was unusual. The only severe symptom, pain, had been present for three months, but vomiting had never occurred. On a subsequent admission two months later the vomiting of large amounts was a prominent symptom.

On certain General Features of these Cases.-Though wasted, the patient may not present a cachectic appearance. Some of the cases have a remarkable emaciation, with redness and dryness of the skin. The lips and the mucous membranes may be of a very bright red colour, and there may be polycythemia, with a blood count of 6,000,000 red corpuscles. In a patient (seen with Dr. Hundley) who had been an active, vigorous man, aged about 56 years, and who only six weeks previously had been on a business trip, the emaciation was as extreme as seen in any case of cancer of the oesophagus. The

Fig. 17.-Showing the abdominal aorta visible to the right of the navel
with a visible gastric tumour to the left of the median line.

patient was literally "skin and bones," yet his colour was excellent. The emaciation of the abdomen was remarkable-so much so that the abdominal aorta could be seen throbbing to the right of the middle line, and the bifurcation could be seen 2.5 cm. below and to the right of the navel, and the right common iliac could be seen plainly (fig. 17).

One reason for the rapidity of the wasting is the secretion of liquid into the dilated stomach, draining the tissues, and helping to produce the remarkable exsuccous condition. The following case illustrates this general condition very well.

No. 120. Dilatation; Pyloric Tumour; Constant Secretion into Stomach; Operation; Death; Autopsy.-G. H. (hosp. no. 17,442), aged 42 years, bricklayer; admitted Sept. 30th, 1896, complaining of pain, vomiting, loss of weight and strength. For the past five years he had had stomach trouble. His habits of eating were careless, and he got his meals at irregular times. Every few weeks he had attacks of. gastric pain and vomiting, which lasted for two or three days.

Present Illness had lasted for five months, since which time he had been unable to work. But the history gradually merged into his previous stomach trouble. During these five months he had vomited every day, usually large amounts of some liquid and undigested food. He had lost 25 lbs. in weight, and had become very weak. Examination showed a much emaciated man, who looked twenty years older than his age. The abdomen was scaphoid. At times waves of peristalsis were visible passing from left to right. When they reached the right hypochondrium a distinct mass was felt. There was a large area of stomach tympany. The mass was evidently at the pylorus; it was readily felt, and was always more palpable at the end of peristalsis. Marked clapotage was obtained. On passing the tube large amounts-400 to 1100 c.c.—were always obtained from the stomach. Particles of corn were washed out which the patient had eaten nearly a month before.

Secretion into Stomach.-On two occasions the stomach was washed and emptied as thoroughly as possible. For 48 hours afterwards the patient was fed by rectum, and nourishment by the mouth was stopped. At the expiration of this time the stomach contained on the first occasion 545 c.c. of fluid, and on the second 500 c.c. Under continued washing and careful diet the stomach was much reduced in size, and the lower border, which had been midway to the pubes below the navel, was just at the navel. Peristalsis was more active now than before.

Operation was advised and consented to. It was done by Dr. Bloodgood. Gastro-enterostomy was done, and the jejunum joined to the posterior wall of the stomach. The patient did not rally well from the operation, and died in about 48 hours.

Autopsy. The stomach was dilated, and contained a small amount of grumous material; the walls were thick. At the pylorus was a mass the size of a pigeon's egg. The orifice was much contracted.

constant secretion of tissues of water so His blood examina

This case is of much interest. The fluid into the stomach had drained his that he was very thin, with dry harsh skin. tion showed hæmoglobin, 70 per cent. ; red corpuscles, 4,000,000;