354 CLINICAL APPLIED ANATOMY. 



tenderness is to the ensiform cartilage the nearer the ulcer to 

 the cardiac orifice. (See Figs. 2023, p. 226.) 



The idea that the stomach is a flaccid bag, suspended by the 

 attachment to it of the oesophagus and the gastro-hepatic omentum, 

 is erroneous and misleading. When empty the viscus appears as 

 a contracted pyriform tube of which the cardiac end is the larger. 

 The tube is somewhat bent on itself at the junction of its cardiac 

 and pyloric segments. The long axis of the cardiac portion is 

 directed from the oesophageal opening, downwards, forwards and 

 to the right, that of the pyloric portion is directed more trans- 

 versely to the right to terminate in the duodenum. When food 

 is ingested, the more flaccid cardiac portion probably relaxes 

 quickly to receive it, whilst the relaxation of the thicker pyloric 

 segment is delayed ; finally the whole organ, with the exception 

 of its terminal inch, which may be called the pyloric canal, 

 becomes further enlarged. This explains the early onset of pain 

 after food when the ulcer is in the cardiac portion, and the delay 

 of onset when the pyloric portion is involved. The sharp angle in 

 the lesser curvature, which corresponds to the junction of the flaccid 

 cardiac and tonically contracted pyloric segments may have some 

 influence in determining the occurrence of ulcers near this part 

 of the lesser curvature. When hour-glass stomach occurs as the 

 result of ulceration, the stricture is usually rather to the pyloric 

 side of the middle of the viscus. The position of such a stricture 

 may represent the line of junction between the cardiac chamber 

 and the more contracted pyloric segment. The ulcers and cica- 

 trices which result from the swallowing of corrosive fluids also 

 tend to involve the pyloric segment of the organ. This may be 

 explained by the fact that such fluids pass quickly through the 

 cardiac portion to remain longer in contact with the pyloric 

 segment, which lies at a lower level and offers more resistance 

 to their passage. 



The stomach when distended expands away from the lesser 

 curvature, which remains more or less fixed by the attachment to 

 it of the oesophagus, the duodenum and the left pancreatico- 

 gastric fold. The right pancreatico-gastric fold, carrying the 



