stomach; and either the nerve-fibres may be found to present their ordinary microscopical appearance, or be entirely destroyed. It is this destruction of nerve fibres which sometimes leads to a cessation of pain, and of the extreme irritability of the stomach.

4. The symptoms are modified by the vascularity of the growth. When the pancreas is diseased, or the glands at the lesser curvature are infiltrated, or the posterior part of the left lobe of the liver affected so as to press upon the aorta or other large vessels, pulsation may be communicated, and the disease simulate aneurism; but when the growth in the stomach is very vascular, pulsation may be felt in it from this cause alone. This pulsation is less affected by position than the instances just referred to of glands pressing upon the aorta. If both sides of the stomach be affected by a vascular growth, the intervention of fluid by varying the position of the patient, modifies the pulsation to some extent.

In the diagnosis of cancer of the stomach, there are several conditions so closely resembling this malady, that we are in danger of forming an erroneous opinion as to the nature of the disease. 1, ulceration; 2, aneurism; 3, disease of the glands of the lesser curvature; 4, disease of the liver; 5, abscess at the pancreas; 6, cancerous disease of the pancreas; 7, similar disease of the omentum; 8, affections of the transverse colon; 9, local peritonitis; 10, fibroid disease of the pylorus.

The symptoms of cancer closely resemble those of

chronic ulcer of the stomach. Both are preceded by a period of dyspeptic suffering, during which the diagnosis is exceedingly obscure. The expression of countenance in both is indicative of distress, but in chronic ulcer there is pallor; in cancer, cachectic sallowness. Vomiting of blood is more frequently observed in ulceration than in cancer, but in the closing stages of cancerous disease, the rejection of coffee-ground substance is of frequent occurrence. The pain of chronic ulceration is often very intense, even more so than in cancer; but it is of a gnawing character in the former, more acute and lancinating in the latter. Again, the vomiting is often more severe in ulceration, than in cancer. The tumour of cancer is generally much larger and more perceptible than the thickening around an ulcer. The emaciation in both may be gradual, progressive, and extreme; but the termination in ulcer is more frequently by hæmorrhage or perforation, whilst in cancer, it generally arises from the typhoid exhaustion consequent on the degeneration or sloughing of the growth, the absorption of decomposing material into the blood, or the extension of disease to adjoining structures. Both diseases may occur at the same age, but it is more common to find chronic ulceration at an earlier period than cancer. In my own experience of cases, the average age of cases of ulceration of the stomach is 37, of cancer 52. From 40 to 60 years is the age at which we are most likely to have cancerous disease of other organs,

and the law holds good with the stomach. The age will in some measure assist us in the diagnosis even at the later stages, but still more in the earlier; for the varied forms of dyspepsia, gastrodynia, pyrosis, &c., are very frequent at a period long antecedent to the age at which cancer generally manifests itself; dyspepsia being exceedingly common among young females, whilst cancer is almost unknown.

In aneurismal disease in the gastric region, the stomach itself often suffers remarkably little. Digestion may be sound, the food being taken and absorbed in a healthy manner. The pain of aneurism is of a different kind, and is uninfluenced by the diet. It is generally a dull constant pain in the back, but with severe and even intense paroxysms at night. The pulsation is uniform, not changed by position. A bruit, if audible at all, be systolic, or almost diastolic.

may

In diseased glands at the lesser curvature of the stomach, the tumour may be marked, but the pain and vomiting are less distinctive, than in disease of the stomach itself; the latter often becomes involved, however, before the close.

In disease of the liver also the position is some guide to us, so also the absence of severe gastric symptoms; but when the left lobe of the liver is diseased, and pressure exerted upon the stomach, the correct diagnosis is very difficult, jaundice being often absent in hepatic

cancer.

In inflammation and abscess at the pancreas, a tumour may form at the epigastric region, with severe pain, vomiting from pressure, a haggard countenance, and compressible pulse. The symptoms are more sudden than in ordinary gastric cancer, but this will not always save us from mistake, for we remember an instance of cancer in a sailor, who was said to be quite well; in whom sudden pain came on at the scrobiculus cordis of so severe a character that he fell down on deck, and soon afterwards a large tumour of a cancerous kind was found.

Cancerous diseases of the pancreas, although behind the stomach, and accompanied with cachexia, leave the stomach free to perform its function. Fatty evacuations have been recorded by some, but such a sign is certainly not always present.

Diseases of the omentum would only produce any doubt, when adhesion to the stomach has taken place, and when there is pressure from the size of the growth.

Cancerous disease of the transverse colon is sometimes a source of obscurity in diagnosis; for adhesions with the greater curvature of the stomach having formed, the disease often extends into the stomach so as to cause extravasation of gas or fœces; and the pain in cancer of the colon comes on at a much later period after food; discharge of blood from the bowels is also occasionally present.

Local peritonitis induces peritoneal adhesion and external hardness; and when local extravasation has fol

lowed so as to form a fœcal abscess, the emaciation is progressive, the hectic is severe, pain is sometimes excessive; and in the certainty of fatal issue, the disease approaches the character of the worst forms of cancer; but we do not find the malignant cachexia. The pain is more superficial, and digestion is less directly disturbed than in gastric disease.

Fibroid disease of the pylorus is regarded by some as of a cancerous nature; still it has neither the patholo gical character nor the physical history of that disease. As with cancer, there is progressive emaciation, with cachexia, and too often a steady downward course; but the duration is longer, the tumour less distinct, hæmorrhage is less frequently, if ever observed, and the disease is more amenable to treatment. The constant ejection of food at the close of the digestive process, from the obstructive disease of the pylorus, and the presence of sarcinæ of Goodsir, have led many to form a more unfavourable diagnosis, than the case has warranted. The statistical tables of Dr. Brinton in reference to

the

age of the patient affected with gastric cancer, and the position of the disease, are of great interest. The pyloric extremity is the part most frequently affected, and the disease extends upon the posterior or upon the anterior surface. Next in frequency is the lesser curvature; then the oesophageal extremity and the cardia; and lastly the middle of the stomach. When the greater curvature alone is affected, the mischief has