SENIOR SURGEON TO, AND LECTURER ON SURGERY AT, THE HOSPITAL. GENTLEMEN,-The subject to which I wish to draw your attention to-day only a few years ago was considered to be entirely outside the province of surgery. Many of our medical colleagues appear to think that it is so still. Yet it is absolutely beyond contradiction that the only proceeding known at the present day which holds out the least hope of curing a patient suffering from this complaint is a surgical operation. Medicine does not

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... fer the slightest, and does not pretend to; it merely treats the symptoms and lets the disease alone. And I have no hesitation in expressing my conviction that the time is not far distant when the public, who are much better informed as to the progress of surgery and surgical treatment than is usually believed, will insist on a surgical consultation being held at the earliest opportunity in every case in which there is the least suspicion of the existence of this complaint. One of our greatest living authorities on diseases of the stomach the other day went so far as to say that the repugnance of the patient to operative measures is very often merely the outcome of the repugnance and lack of initiative in the physician. Cancer of the stomach at its onset is a local complaint. If operated upon sufficiently early it can be removed completely and the patient cured. If left it involves the glands in a definite order and spreads into neighbouring structures, such as the pancreas, but for cancer it is for a long time free from the presence of metastatic growths which either make their appearance late or not at all. The stomach, unless it has been allowed to become tied down by adhesions, is easily accessible in all its parts, with the exception of the cardiac orifice, and stands sutures singularly well. Shock, unless the patient is exhausted by advanced disease and prolonged starvation, need never give rise to anxiety. Peritonitis is a thing of the past. Primary union with restoration of function can be relied upon if only the favourable time has not been allowed to pass by. Our task is to make a diagnosis while the growth is still local, before it has involved the glands or the neighbouring organs, while the cancer is still in that stage in which removal can be effected without too great a degree of risk. When the diagnosis is obvious, when the glands in the neck are involved and there is a fixed tumour in the abdormn, when the patient has already lost two or three stones in weight and there is a cachectic look upon his face, it is too late. The only chance has been lost and nothing can bring it back again. Unhappily, in London at least, patients suffering from cancer of the stomach are usually allowed to reach this stage in a wen-developed form before the condition is realised. In the North it appears to be different. Cancer of the stomach is met with in circumstances so different that cases may be divided into two distinct classes. It may either begin, apparently de novo, in a perfectly healthy stomach, in a perfectly healthy man who has never had more than the most transient indigestion ; or it may develop at the site of some old chronic ulcer which has been the cause of more or less suffering for years past. It is still undecided what proportion these two classes bear to each other. Some years ago Hauser estimated that at least 4 per cent. of cakes of chronic ulcer ended in cancer, but this is manifestly a very low estimate. Looking at it from the opposite point of view, Sapesbko found that out of 100 cases of carcinoma of the stomach all but ten had originated in this way. Jedlicka, from the statistics of Maydl's clinic, ' considers that this mode of origin is much the more frequent of the two. Certainly carcinoma and chronic ulcer are both most common in the same regions of the stomach ; : and with the well-known tendency for carcinoma in other parts of the body to originate from the neighbourhood of scars, especially of scars that are constantly being irritated, it seems only natural that this mode of origin should be the common one. Our own post-mortem statistics are of no value with regard to this point, for nearly always by the time a patient has died from cancer of the stomach all trace of any antecedent uleer has long since disappeared The only certain informaiion we shall ever have must be derived from a long series of early operations carefully recorded, but all probability is in favour of the proportion being a very high one, even if it falls short of 90 per cent. Now, gentlemen, I have not brought any museum specimens to show you to-day, for the very good reason that none of them illustrate the point to which I wish to direct your attention. Museum specimens are of especial value in showing us what should not be allowed to occur. They illustrate the last stage of the disease, the stage that is incompatible with the further prolongation of life, when no one would dream of such a thing as operation. What I wish to deal with to-day is the very earliest, the stage in which there is yet hope not only of relief but of cure, and naturally specimens that illustrate this are only to be obtained by the rarest chance. But I have brought the clinical histories of several patients who have been recently under my care and these I propose to discuss with you now. For the present I am only concerned with those cases in which there is either no history of ulcer of the stomach at all or in which, if there has been an ulcer at some distant time, it has long since ceased to cause any symptoms. All those cases in which there is evidence either of long-standing ulceration or of the deformity and contraction which it so often leaves behind it I shall put aside. Whether cancer is beginning to develop in them or not ought not to make the least difference in the line of treatment. In all alike cure is impossible without an operation and even the smallest measure of relief improbable. Delay only makes the condition worse-very quickly if cancer is present, more slowly if it is not, until at last in either case the time comes when nothing can be done and the specimen is mounted in a museum as a warning. Looking back upon these histories the first thing to attract the patient's attention was nearly always either an alteration in the appetite or pain. In several vomiting occurred as an early symptom ; one patient persibtcd that he had never been troubled in any way until he had a sudden attack of hasmatemesis ; and one or two, though they were aware that something was not right, never complained until they had become alarmed by suddenly discovering the existence of a tumour ; but in nearly every case careful inquiry elicited the fact that either some alteration in appetite or pain, or both together, preceded everything else. The alteration in appetite took various forms. In most there was a distaste for meat and all rich articles of diet. In borne the distaste was general. There was con pete loss of appetite ; no wish or desire for food, even a loathing of it, though previously the appetite had been normal. I have not met with any instances in which the appetite was increased though such are said to be by no means uncommon. Exercise, ccld, and change of air made little or no difference. There was no definite evidence of gastritis though most suffered from flatulence and one or two used to vomit a little mucus ; there were simply no wish to eat and an utter distaste for food. Then, very soon, loss of strength and energy followed and in those who kept a record loss of weight as well. In several who were under my care the loss of energy was not only physical but mental. They became listless and apathetic, taking no interest even in their own symptoms, tired of everything. I am bound to add that in most the change was bo quiet that it was only by looking back that it could be appieciated and this, no doubt, is one reason why it is so seldom recorded, but I do not think it easy to over-rate the importance ' f it when it does occur. Distaste for food, and particularly for albuminous food, occurring suddenly without any dc finite reason in a middle-1ged person who is apparently healthy and who has never given occasion for gastritis is a very disquieting syn.ptom. Pain, varying in severity, may occur at the same time as loss of appetite or not until later. It is rarely absent iltogether, though it may be no more than a sense of oppression and discomfort. As a rule it is continuous and though, as in simple gastric ulcer, it is worse after meals, it lever quite disappears and vomiting does not give much :elief. The usual situation for it is m the epigastrium and M