356 CLINICAL APPLIED ANATOMY. 



glands along the top of the pancreas and in the gastro-splenic 

 omentum, become adherent. By an extension of the destructive 

 process the pancreas may become exposed in the floor of an ulcer 

 and eroded or inflamed or even suppurate. The same may happen 

 in the case of the spleen. Posterior ulcers rarely perforate directly 

 into the lesser sac. The roof of the stomach chamber, to which 

 ulcers of the anterior wall may adhere, is formed by part of the 

 under surface of the liver and the left cupola of the diaphragm. 

 The anterior wall of the stomach chamber, against which part of 

 the anterior surface and greater curvature of the distended stomach 

 rest, is formed by the anterior abdominal wall between the costal 

 margin on the left side and the liver on the right. Adhesions 

 may occur in this area also. Perforation of an ulcer of the 

 anterior wall of the stomach must involve the greater sac unless 

 protective adhesions have formed and the perforation occurs 

 into them. 



It is interesting to note that a part of the under surface of the 

 heart, near the apex, is only separated from the stomach by the 

 pericardial sac, the left cupola of the diaphragm, and the peri- 

 toneum ; in rare instances an ulcer of the anterior wall of the 

 stomach has been known to perforate the pericardium and even 

 the heart itself. Adhesions in the region of the pylorus have been 

 known to obstruct the bile ducts, or attach the pylorus to the gall- 

 bladder, inducing attacks of cholecystitis and colic. 



The gastric haemorrhage which results from ulceration may be 

 arterial or venous. Haemorrhage which proves fatal is nearly 

 always arterial, a large vessel being involved. The larger vascular 

 trunks in the wall of the stomach lie in the submucous tissue 

 beneath the mucous membrane. The large arteries which form 

 the vascular circle along the borders of the stomach are sometimes 

 attacked, and erosions or small aneurysms may result. The 

 arteries of the lesser curvature, particularly the coronary, may 

 suffer in this way. The pancreatico-duodenal and the right gastro- 

 epiploic arteries are, from their position, more likely to be per- 

 forated by ulcers of the pylorus or duodenum than of the stomach. 

 The splenic artery, although not directly applied to the stomach 



