If the patient is desirous of a radical operation, two factors require consideration before it can be recommended-his general health and the physical signs of the disease.

The general state of health is best gauged by the severity of certain symptoms.

Prolonged vomiting is always attended by atrophy of the heart, which is indicated by a slow small pulse of extremely low tension. Cases which exhibit this peculiarity are liable to die from heart failure at any time, and rarely survive an operation more than forty-eight hours. The nutrition may be estimated by observing the quantity of sulphocyanide of potassium present in the saliva. A marked diminution of the salt is a sign of great enfeeblement of the powers of digestion and absorption, while its absence invariably indicates the near approach of death. Any operation undertaken under these circumstances will prove unsuccessful. Excessive cachexia usually arises from ulceration of the growth, and indicates continued loss of blood and an extensive infection of the lymphatic system. Patients who present this symptom, even though they appear well nourished, are usually beyond the hope of cure.

The chief physical signs which contra-indicate an attempt at pylorectomy are the presence of a palpable tumour, adhesions between the pylorus and the liver, and the existence of metastatic deposits.

A palpable tumour proves that the disease is already far advanced and is accompanied by a diffuse infection. Moreover, its apparent size is usually less than one half of its real dimensions, and affords no clue to the extent of the surrounding infiltration of the gastric tissues. Adhesion of the tumour to the liver is indicated by its excessive mobility with respiration, its resistance to efforts at lateral displacement, and by the impossibility of fixing the mass at the lowest point of its excursion by pressure of the hand. Even when a tumour cannot be felt, inflation of the stomach will usually show that the pylorus has not been displaced downwards by the increased weight of the organ, but remains persistently at its normal level. The principal signs of metastases are to be found in the liver, peritoneum, lymphatic glands, and skin. As a rule, an increase in the area of hepatic dulness at the back of the right chest can be determined before the edge of the liver becomes palpable. The detection of secondary tumours in its substance marks a very advanced stage of its infection, while the occurrence of jaundice points to direct pressure upon the hepatic or common bile-duct. Peritoneal carcinosis shows itself either by the presence of a tumour in the omentum or in the pouch of Douglas, or by the rapid development of ascites. Enlargement of the lymphatic glands above the left clavicle, in the left axilla, or in the right groin, indicates involvement of the thoracic duct, of the mediastina or the mesentery ; while retraction of the navel, a cord-like band in the linea alba, or nodules in the skin of the abdomen, are signs of an equally wide diffusion of the morbid growth.