food, though there has been much acid and foul belching. Has lost greatly in flesh and strength. Three fingers width above the navel, to the left of the middle line a resistance is felt 4 cm. in length and a finger width in thickness. Stomach fasting always contains fluid contents varying in quantity from 200 c. c. to 2,000 c. c. Test breakfasts show total acidity 63 to 101, total hydrochloric acid .14 to .20 per cent. with presence of sarcinæ and yeast and absence of lactic acid and long bacilli. Exploratory laparotomy showed the presence of a tumor. Death followed five days after operation.

F. H., aet. 30, gold beater. For last six months stomach trouble with daily vomiting of sour, slimy, yellowish masses but no blood; acid belching with foul odor. No pain, a feeling of pressure on vomiting. Smaller curvature is 5 cm. below xyphoid process while the greater curvature is between the navel and symphysis. Marked splashing and peristaltic movement from left to right. A transverse tumor the thickness of a finger can be felt along the smaller curvature extending from the left arch of ribs to the middle line, movable with respiration. Examination of stomach contents shows total acidity 54 with the presence of free hydrochloric acid. Later examinations showed disappearance of hydrochloric acid and the presence of lactic acid. At operation a soft tumor involving the lesser curvature was found with metastases in the mesentery.

M. H., aet. 44, housewife. For six months had every week attacks of vomiting which in the last four weeks occurred daily. At times the vomit is of a blackish brown color. After eating, pain in the stomach, then sour belching, burning and vomiting some hours later. To the left of the navel is a flat diffuse tumor the size of a small apple, painful on palpation. Pain posteriorly to the left of the 11th and 12th dorsal vertebræ. Stomach contents showed free hydrochloric acid. Patient after repeated attacks of a coffee-ground vomit died ten weeks after first examination. Autopsy not permitted.

A. F., aet. 50, housewife. Always well until three months before first examination and since then pressure before and after eating. Burning after solid food, less after milk and soup. Acid belching, vomiting after solid food, no blood in vomit or in stool. Pressure anteriorly is uncomfortable. Loss of flesh, general appearance poor, epigastrium retracted, stomach is found almost

entirely below the navel. Just above the navel is rough, imThe fasting stomach shows liquid Total acidity 76 to 104 Free hy

movable and painful tumor. contents with food particles. drochloric acid .4 per cent. Operation showed a tumor embracing the pylorus and metastases in spleen. Gastro-enterostomy.

G. S., aet. 50, male. For six months has had gastric trouble, loss of appetite and pain which continued during the entire day and had no relation to eating. For a time condition improved under treatment. Marked loss of flesh, somewhat cyanotic. In the epigastrium a stone hard tumor is left and to the right a lesser resistance which is very painful on palpation. Test breakfast showed total acidity of 38 and the presence of free hydrochloric acid. Sugar formed in urine. Later stomach contents showed the absence of free hydrochloric acid. Autopsy seven weeks after first examination revealed a diffuse carcinoma of the stomach.

A. L., aet. 34., cigar maker. For eight years has had stomach trouble which gradually developed and grew worse. It began with pressing pains in the region of stomach some hours after eating. In the last year the pain has been more intense but relieved by vomiting which often consists of food eaten the previous day and is immediately induced by fruit, weiss bier,

etc.

When stomach is empty there is no pain. There never has been blood in vomit or stool. Patient is rapidly losing flesh. Examination of stomach contents gave total acidity 52, free hydrochloric acid present, also sarcina. Later free hydrochloric acid disappeared and lactic acid appeared. A resistance cordlike and the thickness of a finger was felt at the smaller curvature movable with respiration. Ten weeks after first examination operation showed a tumor at the pylorus which extended into the duodenum. Gastro-enterostomy performed.

W. S., aet. 47, watch-maker. For nine weeks he has had stomach trouble, poor appetite, acid belching and every two or three days sour vomiting, about two litres in quantity. Gastric contents strongly acid with presence of free hydrochloric acid. A few days later hydrochloric acid was absent and lactic acid appeared. He lost weight rapidly and after three weeks a resistance the size of a walnut movable with expiration was palpable in the epigastrium to the right of the middle line. Four weeks later operation and tumor found at pylorus.

C. F., aet. 57, carpenter. Eleven months ago had a severe hemorrhage from the stomach which confined him to bed for several months. Then gastric distress, pressure, vomiting and loss of appetite. Test breakfast showed a large quantity of hydrochloric acid and sarcinæ. Abdomen sensitive but no resistance palpable. Progressive emaciation with cachexia and eight months later in the epigastrium a hard resistance about the size of a dollar was palpable. Total acidity 35, combined hydrochloric acid 28. Autopsy which occurred soon after showed a large tumor at the pylorus. On opening the stomach there was an ulceration the size of the palm of the hand at the pylorus. This ulceration had a hard infiltrated border which microscopically proved to be carcinoma. C. G., aet. 30, waiter. For three years stomach trouble shown by pressure after eating, vomiting at times before and at times after eating and sour belching. Appetite good but great loss of flesh. Examination of stomach contents showed total acidity 40, free hydrochloric acid 24, sarcinæ. Just above the navel a finger-thick transverse tumor was felt not movable with respiration. Later examination showed an acidity from 74 to 102 with free hydrochloric acid strongly marked. Exitus after gastroenterostomy showed pyloric carcinoma on the base of the old ulcer.

H. H., aet. 47, plaster worker. Has always had a weak stomach. Four years ago began to have belching of gas, pain and pressure in the region of the stomach with great hunger. Has attacks of vomiting which always occur some time after eating. Improvement followed treatment. About nine months ago the old condition reappeared with continuous pain and attacks of vomiting every three or four days. He is now much reduced in flesh and cachetic on the left side below the navel peristaltic movements. At the level of the navel a tumor, hard, painful and movable to the right and left. Examination of stomach contents showed marked acidity with the presence of free hydrochloric acid, An operation seven days later revealed a large carcinoma of the plyorus with cancerous degeneration of the mesentary.

F. L., aet. 50, housekeeper. Always well until four months ago when she began gradually to have recurring pains short in duration in the region of the stomach and belching of gas having

a disagreeable odor. At times after eating she had attacks of vomiting and in the vomit food eaten days before was found. No hæmatemesis. Has lost greatly in weight and is markedly cachetcic. At the level of the navel a transverse, rough, hard, painful tumor is palpable 5-6 cm. long, freely movable and not affected by respiration. Marked splashing two fingers width below the navel. Repeated examinations of gastric contents showed acidity with presence of free hydrochloric acid, many sarcina and remnants of food. Gastro-enterostomy eleven days after first examination revealed a large tumor the size of the fist at the pylorus.

F. B., aet. 53, housewife. For ten years has had stomach trouble; one-half hour after eating pain and pressure. Vomits two to three times daily, often food eaten the previous day. Has lost in weight. Stomach reaches a hand's width beneath the navel. Four cm. above the navel and to the right is a transverse tumor about 5 cm. long which moves downward on inspiration. Repeated examination of stomach conterts shows them to be acid with the presence of free hydrochloric acid and sarcinæ. Gastroenterostomy five days later reveals a tumor which extends from the lesser curvature and completely embraces the pylorus. Stomach movable in all directions. Small mesenteric glands enlarged.

F. T., aet. 74, widow. Always healthy until two months ago when she began to lose greatly in weight. She vomits after two or three hours all liquids, while solids are better retained. The vomit has at times the appearance of coffee grounds. Suffers from pyrosis and heart-burn, but not pain. Tumor palpable.

Gastric contents show remnants of food eaten the previous day, free hydrochloric acid, lactic acid and many sarcina. Patient came to the clinic on two occasions only.

G. B., aet. 60, waiter. For over a year has had stomach trouble. Pressure after eating and loss of appetite. For the last three weeks has had daily attacks of vomiting, often of food from preceding days. Vomit is often of a greenish black color as is also the stool. In epigastrium a round, hard tumor. Total acidity in different examinations 32 to 56 and free hydrochloric acid 6 to 12. Many sarcina. Lactic acid absent. Patient has lost fifty-one pounds in last three months.

E. B., aet. 50, merchant. For five years has had pressure in the

stomach and tendency to vomiting which has in the last three years increased. For the last four weeks frequent vomiting of food and sour belching. Patient has lost sixty pounds in weight, is anæmic, and the cervical and subclavicular glands are enlarged. Just above the umbilicus and extending from the middle line to the right is a distinctly movable tumor which is moderately sensitive. Gastric contents show the presence of free hydrochloric acid with carcinæ and the absence of lactic acid and yeast.

H. V. M., aet. 62, government official. For several years has been troubled with heart-burn, especially at night. About a year ago had after a rich dinner sudden vomiting. Appetite has been gradually failing with weakness and loss of flesh. Has recently had feeling of pressure and fullness after eating and once vomited food which was eaten three days previously, also belches foul smelling gases. A large round tumor palpable in epigastrium and movable to the right and left. Repeated examinations of gastric contents show marked acidity with the presence of free hydrochloric acid and many sarcinæ, no lactic acid. Patient shows great loss of strength and marked cachexia.

WESTFIELD, N. J., June 5, 1900.

To the ANNALS:-Although "A Americanos para todo” (“To the Americans for everything!") implies something like disgust in Havana, and is an expression that is largely current, it is the more common thing for those who are very ill to seek the American medical men. I might say, in passing, that I think