become complicated by engrafted cancer, which converts them into malignant and progressive diseases.

Prognosis. Cancer of the stomach is invariably a fatal disease. Life may be made more comfortable and slightly prolonged by careful management. Early and radical operation may give the patient a few months, or, possibly, one, two, or even five years. The healing art can afford only a little more comfort than unaided nature would give the hopeless patient.

Treatment.-The treatment of carcinoma of the stomach is medical and surgical. The medical treatment is only palliative, but the surgical treatment may be employed not only with a view to give temporary relief and to prolong life, but also, in the early stage, with a barely possible hope of a per

manent cure.

The medical treatment is hygienic, symptomatic, and protective. Every means should be employed to preserve the strength and weight and to diminish the excessive nitrogenous waste. Physical and mental rest are imperative, for the organism has little power for repairing its losses. Attention should be given to the skin and to the nervous system, with a view to maintaining their functions and vigor by hydrotherapy, pure air, sunshine, and pleasant surroundings. Digestive hygiene is also useful, and is briefly comprised in bodily rest before and after meals, in favoring the stomach, and in protection of the intestines.

It may well be doubted that any drug arrests or influences beneficially the growth of the neoplasm, as has been claimed for condurango, chlorate of soda (Brissaud), sulphate of anilin (Fay), and pyoktanin (Maibaum). Condurango is an excellent bitter which may often be employed with advantage, and methylene-blue in some cases seems to be of value. The methylene-blue (Merck) should be given in a capsule of three to five grains daily, and a little powdered nutmeg should be combined with it to correct its slightly irritant action on the urinary tract. Marcus Fay claims that anilin sulphate delays metastasis and cachexia, and relieves the pain better than opium. Given internally, in one to five grains a day, its absorption lasts about two hours, when the nails and lips become blue, and after several days' administration the urine becomes reddish. In full doses it produces vertigo, shivering, dyspnea, fainting, and tonic contraction of the involuntary muscles. None of these drugs, it must be confessed, is of much value, except condurango as a bitter and methylene-blue, or phenacetin, or codein, or opium and belladonna to relieve the pain.

But the medical treatment does not consist in the vain search for some specific, nor in efforts to arouse the depressed functions of the stomach. The treatment of the stomach should be protective and not excitant, irritation of all kinds only doing harm. But the maintenance of the appetite and of the motor function is well worthy of attention, and may be best accomplished by a combination of the infusion of condurango bark and hydrochloric acid with strychnin. The prescription should be ordered half an hour before meals, and is most valuable when lactic acid fermentation is present. Hydrochloric acid (but it sometimes is not well borne) may be ordered in repeated doses during the period of gastric digestion.

Pain is often distressing, and demands relief. When the pain is severe, there should be no hesitation in giving codein or morphin, hypodermically or by the mouth, after milder analgesics have failed. There is nothing to fear from a possible opium habit when the patient is already the victim of a malignant disease. Vomiting may require the usual efforts to control it. No one procedure does more good than lavage. A wet compress, covered with a rubber coil, through which hot water flows, the application being made half an hour before the meal and kept on during the period of digestion, may be beneficial.

To control fermentation and to remove the products of retention, lavage acts better than any other remedy, but it should be employed, when the disease is advanced or when there is hemorrhage, with the greatest care or not at all. This is particularly true when the neoplasm involves the body of the stomach. But in cancer of the pylorus and in infiltrating scirrhus it may be used without danger, but not more than a pint of water should be allowed to flow in before beginning to withdraw it; the danger of perforating the degenerate wall by overdistention is thus avoided. The lavage should be performed thoroughly in the morning, an hour before breakfast, and the hydrochloric acid tonic should be administered a half hour later.

The diet should be regulated so as to favor the stomach, to protect the intestines, and to maintain nutrition as long as possible. An exclusive or reducing diet in this disease is radically wrong, and the food selected should not excite or irritate the stomach, remain long in it, easily ferment, or be indigestible by the intestines. Milk seldom agrees well, except in the early stage of some cases where stagnation and fermentation are slight. In the stage of gastric retention it

only adds fuel to the flame. Consequently, finely-divided tender meats, lean fresh fish, and white of egg must usually be depended upon to furnish the nitrogenous needs of the body, but should not be given in excess with the vain hope of covering the excessive nitrogenous waste. Fat, in the form of fresh butter or a good emulsion of cod-liver oil, is valuable and digestible in moderate quantity. Meat juice and clear vegetable soups may be prescribed in order to furnish the requisite quantity of salts. Meat jellies often agree well and supplant the sweets, which must be excluded. Very thoroughly cooked whole wheat, with all the bran removed, and purées of vegetables digestible by the intestines usually agree well when the stomach is kept clean by lavage and the hydrochloric acid tonic is given. Supplementary rectal feeding should be employed early, and not held back as a last resort, when it is too late to be of much value. Alone, it exerts little influence on the progressive inanition of carcinoma.

The surgical treatment is palliative and prolongs life. In cancer of the cardia gastrostomy should be performed as soon as the patient is no longer able to swallow enough food to nourish the body. An attempt to dilate the obstructed cardia by means of esophageal sounds or dilators is more likely to be injurious than beneficial, on account of the swelling and inflammation excited and the danger of perforation. Little can be said in favor of the esophageal cannula. Where retention occurs above the obstruction, the constant irritation causes the neoplasm to grow more rapidly, and gastrostomy might be performed early in order to avoid this effect. But, as a rule, gastrostomy should not be performed while the body can be nourished by combined oral and rectal feeding.

The most frequent operation for cancer of the body of the stomach and of the pylorus is gastro-enterostomy. This is only a palliative operation, which improves the motor function without perceptibly increasing secretion. The operation is often followed by a remarkable improvement in nutrition, and by the subsidence of the inflammatory swelling around the neoplasm. It is the best palliative operation, and should be performed when retention renders it no longer possible to sufficiently nourish the suffering patient.

Pylorectomy is an effort to produce a radical cure, but thus far it has failed. It is the preferable operation when the neoplasm is pyloric, without adhesions, enlarged glands, or metastasis, and when the operation can be done in sound tissue wide of the zone of extension. In suitable cases a

respite is obtained until the tumor recurs, and gastro-enterostomy may be done after the recurrence, to prolong life.

The mortality of pylorectomy for cancer varies from 55 to 27 per cent. When adhesions and complications exist, the mortality is much higher (60 per cent.) than in properly operable cases (25 per cent.). The reports of Billroth's clinic from 1880 to 1894 (Hacker) give 19 deaths in 42 operations; but only 4 of the last 16 cases died. The mortality of pylorectomy done by experienced surgeons does not differ materially from that of gastro-enterostomy. The latter operation appears to give greater immediate relief; and, with very few exceptions, the patients have lived as long after it as after pylorectomy. Kocher, Czerny, and Ratimmow report cases in good health from four to eight years after pylorectomy. No radical cure has been obtained in Billroth's clinic, although one patient lived more than five years.

CHAPTER IV.

THE DISPLACEMENTS OF THE STOMACH.

TRANSPOSITION of the stomach is a very rare condition, and one which can easily be discovered on physical examination. The fundus is transposed to the right, and the pylorus lies in the left hypochondrium. The other parts of the digestive tube and its accessory glands are correspondingly changed in position. This is an anomaly of development, not a disease, and requires no further mention.

The pathological displacements of the stomach, particularly frequent in women, are very numerous in their anatomical details. But all of them are deviations from the three grand clinical types-upward displacement, lateral displacement, and total descent.

The abdominal cavity, formed in part by pliable walls, is subject to the action of atmospheric and other external pres sure, and the organs and viscera contained within it readily change their form. The stomach is attached by ligaments to the liver, spleen, diaphragm, and transverse colon, and is con tinuous with the esophagus and duodenum. Consequently, the displacements of the stomach are accompanied by changes in the form of the abdomen and in the form and relative position of neighboring organs. Its attachments, also, are ren

dered lax or are stretched, thus causing displacements of attached organs and disordering the blood- and lymph-circulation. These results often interfere with the nutrition of its coats and with its functions. The interference with nutrition by compression and by traction may be localized and circumscribed, and a strong predisposition to ulcer may thus be created. The new relations produce new points of contact and new directions of least resistance, and consequently the viscus is liable to undergo particular changes in form. The churning and evacuation of its contents must be done in unusual and unfavorable circumstances. The evacuation of the stomach may be specially difficult on account of the traction brought to bear on the beginning of the duodenum and the pyloric region, and on account of the constriction of the duodenum at its first point of firm attachment. The necessity for increased work at a mechanical disadvantage entails either compensatory hypertrophy of the muscular layer or motor insufficiency. The clinical forms of displacement are three in number-upward, lateral, and downward.

1. Upward Displacement.-The upward displacement of the stomach can occur only in the left concavity of the diaphragm. The part of the stomach to the right of the cardia can not be displaced upward, for the organs above it are solid and fixed. The upward displacement of the stomach is less frequent than the other forms of displacement, but it occurs much more frequently than is generally recognized.

Etiology. The fundus of the stomach may be situated abnormally high when the left lung is collapsed (atelectasis, sequel of left pleurisy), or the stomach may be forced upward by a large abdominal tumor. But the most frequent cause of this form of displacement is compression and arrested development of the trunk on a line which runs across the abdomen near the umbilicus and below the liver, the splenic flexure of the colon, and the spleen. The costal arch is slightly narrowed, and the lower four or five ribs are forced far inward, so as to make the smallest part of the waist nearly on a line with the iliac crests.

Clinical Description.-Upward displacement of the stomach may be a latent disease, or, at least, only insignificant subjective symptoms may result from it; but in some cases the distress occurs in paroxysms, and in others the disturbances are persistent. The symptoms vary greatly, and bear a relation to the manner in which the displacement has been produced. There may be only a slight sense of fullness in the