after the setting in of the peritonitis, the occurrence of which is a peculiar feature of the case.

Vomiting was a symptom from the first. This was more characteristic of the disease than either of the others mentioned, especially considering the nature of the matter ejected. Persistent vomiting is suggestive of cancer but not diagnostic. Cases are mentioned of thickening about the pyloric orifice causing it, and so also does sarcina ventriculi, pregnancy sometimes, ulcer, &c. But I suppose that in cases of regular vomiting lasting several months, cancer should be first thought of. The coffee ground matter too, is, if thrown off for a long time, characteristic. In gastric ulcer blood is vomited in abundance, if at all, and not in this particular form.

The pallor exhibited in the case is indication of the cancerous cachexia-so to it is of anaemia. There was nothing peculiar about it-nothing of the yellowish tinge spoken of as that of this cachexia.

The marked weakness-which was one of the three prominent symptoms from the first-has nothing in it peculiar to cancer.

It was this weakness, with the pallor and the heart murmur, which was at first thought to be anæmie, which led to the thought of lencocythemia. But examination detected no enlargement of the spleen or liver or of the lymphatic glands, and no increase in the number of the white blood-cells was found by the microscope.

Taken together, the pallor, the continued vomiting of coffee colored fluid, and the tired feeling or weakness may be looked on as sufficient upon which to base a diagnosis of cancer of the stomach, even in the absence of any marked pain or of the tumor in the epigastrium, usually spoken of as the most constant symptoms of cancer of the stomach.

The PRESIDENT called attention to the fact that while in this case there was no tumor discernable, there was a more than ordinary communication of the pulsation of the heart to be felt over the epigastrium. This could be caused only by hard tissue, not by a stomach filled with gas or fluid. of the stomach may exist without upon the location of the deposit.

As to the length of time cancer being fatal, this depended much It might last for a considerable

time without causing serious disturbance if the curvatures are not affected.

Dr. VAN DERVEER gave a number of cases illustrating various points of the disease, which he has kindly written up for insertion. Mr. C., married, aged 71, temperate habits, states that for the past 20 years he has had occasional sharp pains in the region of the stomach, and that at times he would vomit his food, yet he considered himself in good health, and could generally attend to his business, that of a carpenter. Saw him first, January 10, 1874. Has been in decided ill health for the past year, failing in flesh and strength, suffering severe pain in the stomach, and most of the time vomiting his food. For the past month his stomach will not retain anything, and only during that time has he been confined strictly to his house. He appears very much emaciated, and

extremely pale and cachectic.

In the epigastric region can define a hard tumor the size of a goose egg, painful to the touch, producing, when handled, a sensation of extreme weakness and desire to vomit.

Some ædema of the feet, lungs and other organs appear healthy; urine examined and found normal. Ordered small doses morphine be given with a bitter tonic, also sub-nit. bis. and pepsine.

The latter acted well, but could not bear the tonic and anodyne. There was no improvement in his case-none was expecteddeath occurring on January 19, 1874.

Autopsy 24 hours afterwards, decided emaciation. No general anasarca, slight swelling of the feet. Head not examined. Lungs and heart in a healthy condition, very slight pleuritic adhesions, and slight atheromatous change on inner coat of the large arteries.

The coats of the stomach from the cardiac to the pyloric openings were thickened in some places as much as two inches, the deposit scirrhus in character. The cavity of the stomach was almost completely obliterated, and yet the passage through its orifices continued open. It could not hold more than an ounce of fluid. In some places the mass had softened and presented points of ulceration.

The great omentum was filled with hardened masses from a pin head to that of a cherry. Spleen small. Capsule shrunken, ad

hered decidedly to great end of stomach. Other abdominal organs healthy. Slight effusion of serum in peritoneal cavity.

Scrotum on examination presents double hydrocele, and on a more careful examination each testicle is the seat of a cancerous deposit, the one in the right quite large.

Mr. L., married, aged 62, good habits, always in excellent health, except one severe attack of cystitis ten years ago, from which after a six month's illness made a good recovery. Came to my office December, 1872, presenting a decided case of jaundice, for which he desires treatment. Gave him Pil. Hydrarg Quinine, Dil. NitroMur. Acid and Ext. Tarax alternately until the 12th of January, 1873, without any improvement in his case; is failing in strength and emaciating in flesh. Very little vomiting. Has continued at his work up to the present time. A careful examination reveals decided tenderness over the liver, but cannot make out any tumor in the epigastric region.

April 21st, 1873. To-day, by desire of Mr. L.'s family, am requested to see him with his medical attendant, Dr. H.

He has sought help from many physicians, but his disease has been gradual and certain in its advance. Is very weak, and a mere skeleton in appearance, presents the same deep jaundiced condition as when I last saw him. It is difficult to define the borders of the liver; a hardened mass is felt over the region of the stomach; of late has vomited everything. Urine is found, on examination, loaded with bile, in quantity scant.

Death ensued April 25th, 1873, from starvation.

Autopsy 18 hours after death. Muscles rigid what little is left of them. Encephalon not examined. Organs of Thorax healthy. The pyloric end, and including about one-third of the stomach, was found to be the place of deposit of a cancerous mass as large as a good sized orange flattened. The pyloric orifice of the stomach was closed from the inflammation and ulceration present. The cancerous mass also enclosed a portion of the pancreas, all the vessels going to and from the liver, and a portion of the duodenum. The liver was about half its natural size, and filled with nodules of cancerous growth. Gall bladder shrunken, having in it about a Spleen very small but healthy. Omentum

drachm of bile.

studded with hardened masses of various sizes. Kidneys healthy. No traces of inflammation about the bladder. Testicles not examined.

Mr. W., aged 65, has suffered for the past fifteen years from hydrocele left side scrotum. Been tapped many many times. For the past year the testicle has become quite hard, much enlarged and paining him constantly. His general condition has been good, but now, from want of sleep and the intense pain he suffers, is failing in strength, and is very desirous of being relieved. Is willing to undergo any operation if he can only get relief from the pain. Has a large scrotal hernia on the same side. In consultation with his attending physician, October 12, 1873, we decided to remove the testicle, which was done. The rupture gave us some trouble, but notwithstanding the patient made a good recovery in three weeks. The testicle is as large as a goose egg; the tunica vaginalis is very much thickened, but the inner part of the mass is found to be on microscopical examination encepaloid in character. The structure is so changed that it is impossible to define any portion of the testicle proper. The patient at the present time remains in good health. No symptoms of disease returning.

About second week in April, 1873, W. M. came to the office for treatment; symptom, inability to swallow. On examination with œsophageal tube could detect a decided stricture about four inches down, through which only the smallest size will pass. Looks pale, has lost in flesh, and is weak. Esophageal bougies were passed twice a week, of various sizes, until at one time I could pass the largest size, with marked relief, up to June 10, 1873, when, on withdrawing the largest one, he complained of some pain, and raised a trifle of blood, while on the instrument there were several pieces of a fleshy-looking substance. This substance under the microscope exhibited small cells, and spindle shaped cells with nnclei. After this did not pass the bougie but two or three times On telling the old gentleman that we believed his case was one of cancer of the throat, he became very much disheartened, and used to come and almost beg to have us pass the bougie-if only for temporary help, he would say. Was confined to his house for two months previous to his death; not able to swallow much of any

4

thing. Suffered much pain, not acute,-more a distress. No family history obtained. His habits had not been good for a greater part of his life. For the past ten years had been a steady drinker of alcohol in some form.

Post-mortem showed ulceration nearly through the anterior and lateral walls of the esophagus about its middle. The stomach was healthy, containing a small quantity of dark, gumous look. ing fluid. Microscopical examination showed the diseased tissue to be encephaloid.

August 17, 1873, was called to attend Mrs. A., aged 44, married, mother of four children; usually in good health; had lost the left eye from disease two years ago. Family history good; not well nourished; is over anxious to help provide a home for herself and family, and denies herself much in good diet. Is somewhat jaundiced; bowels constipated; tongue much coated; is failing in strength, yet does her own housework. Menstrual periods regular; feels very much like vomiting at times; urine natural; is losing in flesh; does not sleep well; has much pain in right side. On examination a distinct enlargement of the right lobe of the liver can be felt, extending downwards and inwards towards the umbilicus; is very hard to the touch, and percussion gives acute sickening pain. No disease of any other organ can be detected. Ordered good tonics, nourishment, rest, and sufficient anodyne to relieve pain.

Nov. 1st. Mrs. A. has remained in about the same condition, except that she now occasionally vomits her food. The enlargement has extended down toward the inguinal region and on a level

with the navel.

Feb. 1st. Patient has just passed a natural menstrual period, but is now not able to leave her bed; is much emaciated; skin of a dark jaundiced hue; can retain but little food in her stomach; suffers great pain; enlargement much increased, and of a stony hardness and very sensitive; bowels move about once in four days; feces of a light clay color; passes urine quite freely, and in appearance like dark, red wine. A tumor about the size of a butternut can be felt in the left breast, also one much larger surrounding the sternal end of the left clavicle. These tumors feel very hard,