of the appendix cannot be determined massage should be made seriatim along the radii corresponding to its possible positions. Each stroke of the massage may be made after the patient exhales and while he holds the breath out, relaxing the abdominal muscles as well as possible. The method much to be preferred, however, is my method of deep palpation and massage already described. The fingers of the massaging hand should be placed six or eight inches, or as far as possible, away from McBurney's point and with as deep pressure as advisable drawn toward the point. Massage may be made more efficient by making of each radial stroke a series of interrupted strokes, removing and advancing the hand as often as deep palpation cannot be satisfactorily made. This massage is often applicable to chronic appendicitis, and if one could see cases of acute appendicitis when there is no danger of perforation and before there are much tenderness and rigidity it would probably relieve some cases in which the purulent contents of the lumen could be pressed into the cæcum, and the process could be repeated until resolution has taken place. It is a question whether one would be justified in administering an opiate to relieve pain and rigidity so that he might massage the acutely-inflamed appendix. Perhaps he would be if he could be quite sure that the tissues are not rotten. Perhaps some cases could be cured in this way if the orifice of the appendix is still patent. Now, doctor, as you have read this article, I should like to ask whether you see in it only some ideas which are not absolute in practicability, or whether you see chiefly some ideas which are of undoubted practicability, and some ideas of possible practicability. Please do not imagine that this article is claimed to be a final, summary dissertation on the treatment of the various forms of the diseases considered, and please do not blame me for not furnishing a means for the solution of calculi and concretions and for the reintegration of rotten tissues. In short, do not blame me for not having performed a miracle! The scope and adequacy of any method of treatment, whether drug, mechanical, hydrotherapeutic, surgical, psychic, or what-not, are matters of knowledge which are usually gradually ascertained over a long time by many observers. This article only touches many points which it is hoped you will help to study, and it presents many points which are of the greatest positive value in treating numerous people, particularly those who are seen during early symptoms. THE VALUE OF THE X-RAY EXAMINATION IN THE DIAGNOSIS OF GASTRIC CANCER* BY JAMES T. CASE, M.D. Battle Creek, Michigan Röntgenologist and Assistant Surgeon to the Battle Creek Sanitarium; Röntgenologist to St. Luke's Hospital, Chicago; Professor of Röntgenology, Northwestern University Medical School, Chicago WHEN a suspension of some salt opaque to the Röntgen ray is introduced into the empty stomach, the lumen of the stomach, if normal, presents a characteristic complete shadow, subject to certain normal indentations. These normal indentations are as follows: a. The splenic notch, usually present at the upper border of the greater curvature, due to the pressure of the spleen against the greater curvature. One may judge thereby as to the size of the spleen. b. The changes in shape of the stomach shadow produced by the peristaltic waves are varying but characteristic, and are easily recognized under the fluorescent screen or by a series of röntgenograms. c. The pyloric sulcus, the break between the shadow of the stomach and the shadow of the first portion of the duodenum (variously termed bulbus duodeni, duodenal bulb, stomach cap, pileus ventriculi), normally about one centimetre in width. Excluding these normal indentations in the shadow of the stomach, any defect in the shadow must be regarded as suspicious of malignancy, and its identity determined. In favorable subjects where the fluoroscopic image is clear the screen study of the contour of the gastric silhouette is very satisfactory, although the writer, for the sake of absolute safety from criticism, usually makes several röntgenograms as a matter of record, even in the cases satisfactorily studied by the screen method. In heavy patients ten or twelve röntgenograms usually suffice. On a number of occasions unsuspected gall- and kidney-stones have been discovered in this manner, and in patients too heavy for favorable fluoroscopy the serial röntgenograms have made possible the discovery of relatively early car * Read before the Chicago Medical Society, October 14, 1914. cinoma. The reason for the use of the term "relatively early" will appear later in this paper in the discussion of the possibility of negativing a diagnosis of carcinoma. In the effort to render possible an earlier diagnosis of gastric cancer than he had till then been able to make by the recognition of filling defects in the stomach shadow, Holzknecht grouped a number of radiologic and clinical signs under various heads, each one a symptom-complex." The following symptom-complex relates to gastric carcinoma: "1. Bismuth residue six hours after the Rieder meal. 2. Normal shadow of the stomach seen on the screen. 3. Achylia. Diagnosis: A small carcinoma of the pylorus." In the symptom-complex noted above the reasoning is as follows: (1) Achylia is always associated with hypermotility so long as the pylorus is free, the stomach emptying in two or three hours; (2) therefore, a residue after six hours must mean an organic obstruction, because (3) spasm of the pylorus is never associated with achylia, but with hyperacidity. The writer refers to the above symptom-complex of Holzknecht only to warn against its unreliability, for, while it is true that in a certain number of cases such reasoning might lead to the recognition of an early pyloric neoplasm, the same reasoning in many other cases will lead to ignominious failure. The writer has seen cases fitting perfectly into the above symptom-complex which at operation proved to be not malignant, but due to adhesion bands, pressure of extraventricular masses or gall-stones, and sometimes no pathology at all could be demonstrated at operation. The writer is thankful that he was able to test out this matter in a manner which did not reflect unfavorably upon himself or the surgical staff through whose courtesy the rigid check-up was possible. Thanks to a routine which requires that all patients about to be subjected to laparotomy in the surgical department of the Battle Creek Sanitarium be first submitted to a thorough bismuth-meal examination of the entire gastro-intestinal tract, the writer has been able to check at operation the Röntgen findings in hundreds of cases. For instance, in a patient operated upon for uterine fibroids, the surgeon, as a routine procedure at operation, examines and records the condition of the gall-bladder, the pylorus, |