PRACTICAL CONSIDERATIONS: THE STOMACH. 1631 



phrenic abscess may follow ; if the anterior wall is opened, infection of the general 

 peritoneal cavity and septic peritonitis are more likely to result. On account of the 

 course of the blood-vessels (page 1627), wounds parallel with the axes of the curva- 

 tures are attended by free bleeding, especially if near those borders of the stomach. 

 Wounds running more or less at right angles to the curvatures and removed from 

 them are much less likely to open large vessels. The vessels just beneath the sur- 

 face of the mucous membrane are numerous but smaller. Bleeding from them may 

 be controlled by separate suture of the mucosa, which is facilitated by its thickness 

 and by the looseness of the submucous cellular tissue. 



Ulcers of the stomach are found most often on the posterior wall at the pyloric 

 end and along the lesser curvature. It has been suggested that they originate in a 

 bacterial necrosis of the epithelium, which is favored by the absence of the fundus 

 or peptic glands (page 1623) at this region, and is followed by "digestion" of the 

 subjacent tissues. Allen thinks that the immense preponderance of pyloric ulcers is 

 an illustration of the "law of localization of diseased action," viz., that parts 

 enjoying the most rest are least liable to involvement by structural disease. When 

 they cause hemorrhage, it is apt to be from the branches of the coronary artery. Per- 

 foration occurs with much greater frequency in ulcers situated on the anterior wall, 

 which is the one with the greatest range of motion in varying stages of digestion 

 and degrees of distention, and also during the movements of respiration. Perfora- 

 tion from such ulcers with spontaneous cure may result in adhesions between the 

 stomach and pancreas, colon, duodenum, or gall-bladder, and may be followed by 

 fistulae communicating with those viscera. They may perforate the diaphragm and 

 cause empyema. They have opened into the pericardium and into a ventricle of 

 the heart. An ulcer may be so surrounded by adhesions that, even when on the 

 anterior wall, perforation does not cause a general peritonitis, but a localized abscess. 

 If this is, for example, in the splenic region, it will be observed that there is immo- 

 bility of the upper left quadrant of the abdomen with restriction of the respiratory 

 movements of the left thorax, both occasioned by the connection between the 

 splanchnic and the intercostal nerves through the sympathetic ganglia. The local- 

 ization of such collections of pus after perforation of the anterior wall near -the 

 cardia is favored by the ' ' costo-colic' ' fold of peritoneum extending from the dia- 

 phragm opposite the tenth and eleventh ribs to the splenic flexure of the colon 

 and forming part of the left portion of the ' ' stomach-bed. ' ' This fold, especially 

 with the patient supine, forms a " natural well," containing the spleen and a part 

 of the stomach, into which any fluid exudate or stomach contents may gravitate 

 (Box). 



Cancer of the stomach occupies by preference the pyloric region. When the 

 growth becomes palpable, but before it is tied down by adhesions to neighboring 

 organs, it often illustrates the mobility of the pyloric end of the stomach (vide 

 S2ipra), as it can be pushed even across the mid-line of the body into the splenic 

 region. 



Carcinoma, according to its situation, may extend in the course of the lym- 

 phatic vessels running along the lesser curvature in the gastro-hepatic omentum and 

 emptying into the lymph- nodes near the cceliac axis and hepatic blood-vessels, or 

 along the greater curvature and the cardia to the retro-oesophageal glands. The 

 retro-pyloric lymph-nodes may be invaded in cancer of the pylorus. Its early recog- 

 nition as a tumor obviously depends upon its anatomical site. If it occupies the 

 fundus, the cardia, the lesser curvature, or the upper and outlying portions of the 

 anterior wall, the ribs and the liver intervene and prevent palpation of the growth ; 

 and if on the posterior wall, the depth at which the tumor lies renders its palpation 

 difficult and unsatisfactory. 



Dilatation of the stomach (gas tree tasis^) may be due to simple hypertrophy of 

 the pyloric muscle, may follow stricture of the pylorus or duodenum from cicatriza- 

 tion of an ulcer, or may result from pyloric occlusion, as from carcinomatous growth 

 invading the pylorus itself, or from pressure of an extrinsic tumor, or a displaced 

 liver or right kidney. The distention is often extreme, and in some instances the 

 outline of the distended stomach can plainly be seen, the lesser curvature a couple 

 of inches below the ensiform cartilage and the greater curvature passing obliquely, 



