(A) Frequency

According to the statistics of Brinton and Lebert, nearly 80 per cent, of all carcinomata of the stomach are accompanied by a palpable tumour. Osier and McCrae detected a tumour in 76 per cent, of their clinical cases, while in our own series a definite tumour was discovered in 69 per cent, and an ' illdefined tumour ' or a ' sense of resistance ' was recorded in 8 per cent. In the remaining 23 per cent, no evidence of a growth could be found by examination of the abdomen during life. It must, therefore, be admitted that a palpable tumour only exists in four out of every five cases of carcinoma of the stomach. As might have been expected from the anatomical relations of the stomach, the discovery of a tumour varies with the situation of the disease. Thus, in our series 81 per cent, of those which were situated in the body of the stomach were detected during life, of the pyloric growths 71 per cent., and of those located at the cardia or in the fundus only 55 per cent. It is also interesting to notice the conditions which seem to have been chiefly responsible for the non-detection of the tumour. Thus, among fifty cases in which no tumour was discovered during life-

The abdomen was distended with fluid in nineteen, or 38 per cent.

The growth was situated deeply (cardia, fundus or posterior wall) in fifteen, or 30 per cent. The tumour was very small in ten, or 20 per cent. Excessive tenderness prevented deep palpation in six, or 12 percent.

(B) Size

The tumours vary greatly in size in different cases. The smallest are those which occur in the form of annular growths, of localised indurations of the gastric wall, or of superficial ulcerations. Tumours of medium size are met with in disease of the anterior wall, of the curvatures and of the pylorus, and where there is considerable infiltration of the muscular and serous coats of the viscus; while enormous masses are often encountered when the neoplasm has extended into the omentum or has given rise to adhesions between the stomach and the intestines or the liver. Occasionally a large tumour is formed by the entire stomach, the walls of which have been greatly thickened by diffuse infiltration.

(C) Shape

This depends upon the anatomical characters of the growth. Pyloric tumours are oval, rounded, or somewhat tubular; those which affect the anterior wall or the great curvature are often globular ; while those which arise from infiltration of the omentum are usually irregular, nodular, or elongated. General infiltration of the gastric walls either gives rise to a mass which retains the normal contour of the stomach, or produces a smooth, hard, elongated swelling, the lower margin of which is more distinct than the upper.

(D) Visibility

In addition to the abdominal swelling due to a dilated and hypertrophied stomach, many of the larger growths give rise to tumours which are visible to the naked eye. This is particularly the case when the pylorus is affected and displaced downwards, where the peritoneum is implicated, and where the great curvature is the seat of the disease. Tumours situated at the upper or left extremity of the stomach may only be visible at the end of inspiration or when the viscus is distended with food or gas. A visible tumour was observed in 19 per cent, of our cases.

(E) Situation

This varies with the location of the growth in the stomach, the position of the viscus, and the presence of adhesions. In our own cases the tumour occupied the umbilical region in 37 per cent., the epigastrium in 28 per cent., the right hypochondrium in 17 per cent., the left hypochondrium in 16 per cent., and the hypogastrium in 2 per cent. The fact that the majority are found near the umbilicus is due to the downward displacement of the pylorus which accompanies gastric dilatation, and to the great tendency of all growths in this region to extend into the walls of the organ. The epigastrium is the usual site of tumours which arise from disease of the upper border of the stomach, of those formed by implication of the omentum, and of growths which are adherent to the liver. The right hypochondrium is chiefly affected when a pyloric growth is very large, or when it has involved the liver or gall-bladder. A tumour formed by disease of the fundus or of the entire stomach is commonly situated in the left hypochondrium, while the hypogastrium is affected only in those rare instances where a pyloric growth has been dragged downwards by the weight of the enlarged stomach.

(F) Tenderness

This is almost invariably present, though it varies in degree in different cases. It is most marked when the tumour is ulcerated, is of rapid growth, or has infected the peritoneum. As a rule, neoplasms of the central region of the stomach are accompanied by greater tenderness than those of the pylorus, annular strictures of the latter being often painless.

(G) Mobility

Tumours of the stomach almost always exhibit a certain degree of mobility, which varies according to their situation and external attachments.