Let us remember also that to prolong the investigation uselessly and to wait until a tumour develops is to lose the favourable time for a radical operation ; and although a clinical examination of the stomach contents and a general examination of the patient may give us strong grounds for suspicion, our diagnosis can only be rendered certain by a digital examination, which may be effected through a small incision that can, if needful, be made under local anaesthesia, though better under general anaesthesia with little, if any, risk.

At the time of the exploration it will be generally advisable to have everything ready to follow up the exploratory procedure by whatever further operation may be called for. It may be discovered that the disease is manifestly not yet malignant, and that some curative operation is necessary to bring about relief.

Or it may be found that the disease resembles malignancy both in its history and physical signs, and in the form of the tumour, which, on account of extent and adhesions, and from the presence of enlarged glands, it seems impracticable to remove with any hope of permanent success, but in which a gastroenterostomy or some allied operation may be called for in order to give relief, or maybe to effect a cure.

The following examples selected out of many such cases on which I have operated, and which were at the time of operation extremely ill, and supposed to be suffering from cancer of the stomach, are as the result of surgical treatment in good health years later.

(1) A medical man, aged thirty-one years, who was seen with Dr. B- and Dr. W-, had had dyspepsia for seventeen years; this had been more severe during the preceding twenty months. Sixteen months previously vomiting began, and from the outset large quantities were ejected, but never contained blood. There was occasional recurrence of similar attacks, which were always relieved by treatment. In December, 1897, the stomach reached to the pubes, and visible peristalsis was present. Relief followed dieting and lavage until March, 1898, after which time the pain was almost constant, and was not materially worse after food or relieved by vomiting. A loss of weight had occurred, from 10 st. to 8 st. 6h lb. There was great feebleness. Gastroenterostomy was performed on Ma}" 6th, 1898. A large irregular tumour was found at the pylorus and along the lesser curvature with extensive adhesions, but the glands, though large, were discrete. A good recovery was made and was followed by relief of all symptoms. When the patient left the home on June 7th his weight was 8 st., on August 17th, 1898, it was 9 st. 3 lb. The following is an extract from a letter from the patient, dated February 12th, 1900 : " My health continues perfect. I have not lost a day's work through illness since I recovered." He is in good health in 1906, eight years after operation.

(2) Mr. B-, aged thirty-nine years, seen December, 1901, on account of pain about two hours after food, with the passage of melasna and great loss of flesh. An indefinite tumour could be felt. On opening the abdomen on December 19th, 1901, a tumour was discovered involving the pylorus and the first and second part of the duodenum, which were thickened and infiltrated, forming a sausage-shaped tumour, very hard and nodular and adherent to the neighbouring parts, so that it was impossible to remove it. A posterior gastroenterostomy was therefore performed, the operation being concluded under the idea that the patient was suffering from cancer. As events proved this was clearly an error, for in January, 1903, he wrote to say that, although he had had two attacks of pain due to over-indulgence, he was very well and able to do his work, and that the stomach swelling had entirely disappeared.

(3) The patient, a man, aged forty-five years, gave a history of pain for two years about an hour after food, with great loss of flesh. For nine months he had vomited every day or every second day a large quantity of yeasty material, but no blood, though he was very anaemic. There were well-marked signs of dilatation of the stomach, with tenderness over the pylorus, and the presence of a tumour. Posterior gastroenterostomy was performed on June 12th, 1900. On opening the abdomen the pylorus was found to be much thickened and adherent, forming a hard, nodular tumour having the appearance and feel of cancer. Through the centre of the mass a No. 10 catheter only could be passed over a roughened, ulcerated surface. An uninterrupted recovery followed ; food was begun on the second day, and solids could be taken in the second week without pain. He rapidly gained flesh and strength, and was well in 1903. Many other similar cases could be related.

I would lay particular stress on this class of cases, for I think it serves to explain some misconceptions about cancer generally. It would be easy for one to raise a claim to having cured a number of cases of cancer of the stomach by gastroenterostomy ; but I do not for a moment believe that any of these cases were more than inflammatory tumours formed around chronic gastric ulcers; nevertheless I have no doubt that they would have proved fatal just as certainly as if they had been cancer had no operation been done. This raises an interesting point, and that is the alleged increase of cancer, for I feel sure that many cases like those related above would have been certified as deaths from cancer of the stomach had no operation been done, or no necropsy and microscopic investigation made, and I think we must take such cases into account before hastily deciding that this disease is on the increase, though other evidence seems to prove the fact.

The cases also illustrate another point: even though a tumour be present, and even though it be probably too large for removal, it may be quite worth while advocating an exploration, to be followed up by gastroenterostomy if that be practicable, in the hope that the disease may prove to be wholly or partly inflammatory, which the physiological rest secured by gastroenterostomy will either cure or materially relieve.