CARCINOMA OF THE STOMACH. 543 



a circumscribed, nodular tumor, we find a regular, more or less exten- 

 sive prominence and resistance of the epigastrium. Percussion of the 

 tumor, caused by cancer of the stomach, almost always gives a not 

 quite clear and decidedly tympanitic sound. 



In cancerous stricture of the pylorus, besides showing the presence 

 of a tumor, physical examination may prove a dilatation of the stomach, 

 whose symptoms we described while speaking of simple stricture of 

 the pylorus ; if, on the other hand, the stomach be contracted, and, as 

 often happens, the bowels be empty, the lower margin of the ribs be- 

 comes very prominent, while the belly is sunken, so that we can dis- 

 tinctly feel the vertebral column and the pulsating aorta. The symp- 

 toms of cancer of the stomach are modified by the development of 

 cancer in other organs, particularly in the liver. Occasionally, also, 

 cancer of the lymphatic glands of the stomach spreads to the retro- 

 peritoneal glands, to those of the mediastinum, thence to those of the 

 neck, so that a hard swelling of the supra-clavicular glands may be of 

 diagnostic importance in cases of cancer of the stomach (I have seen 

 such cases). The symptoms of alveolar cancer are often modified by 

 the occurrence of ascites. 



During the course of cancer of the stomach the symptoms gener- 

 ally increase regularly ; more rarely, the patient improves for a time, 

 pain and vomiting cease for a while, and even the appetite returns. 

 These remissions do not usually continue long ; the difficulties increase 

 again, the appetite is entirely lost ; constipation, which has existed 

 from the first, can hardly be overcome ; emaciation makes giant strides. 

 If the cancer be medullary, the disease usually runs its course in a few 

 months, while scirrhus, and particularly alveolar cancer, may run on 

 for years. 



The only termination of cancer of the stomach is in death. In 

 those cases where cure of cancer has been claimed from the clinical 

 course of a disease of the stomach, there may have been a mistake in 

 diagnosis. Those observations, where autopsy is said to have revealed 

 the cicatrix of a cancerous ulcer, also are not perfectly trustworthy ; 

 for if fresh cancerous growths are found in the vicinity of the cicatrix, 

 the disease has not truly disappeared ; but if this support be wanting, 

 the cicatrix from a cancer cannot be certainly distinguished from that 

 of a simple ulcer. In most cases, death occurs with the symptoms of 

 exhaustion. As there is no accompanying fever, the last stage of the 

 disease is usually much protracted, and patients may live for days, 

 while we hourly expect their death. In these cases the tongue usually 

 becomes red, inclined to dryness, and covered with aphthous deposits. 

 Besides this painful affection, there is not unfrequently a painful tense 

 oedema of one of the legs shortly before death. This symptom d- 



