In disease the stomach may be contracted or dilated, and is often the seat of ulcer and carcinoma.

Contracted stomach occurs either as a normal or pathological condition; it has already been alluded to on page 401. The contraction of the middle, producing the hour-glass shape, results from cicatrices and adhesions due to gastric ulcer. In cases of oesophageal stricture the contraction may be marked. It then embraces mainly the right third of the organ and the affected portion resembles the adjoining duodenum. Abstention from food in the course of an illness may also cause a contracted condition which one should be prepared to encounter in case of operation. A normal contracted condition of the right end of the stomach, often of a more or less hour-glass shape, is frequently encountered in autopsies when death has been caused by disease of other organs (Fig. 417).

Dilation results from functional diseases as well as obstructive affections, such as ulcer or carcinoma, involving the pylorus. Distention causes the pylorus to pass from the midline 2.5 to 7.5 cm. (1 to 3 in.) to the right. The organ becomes more horizontal and descends so that its lower border sinks below the umbilicus - its extreme normal level. Sometimes the greater curvature alone is lowered, while in others the gastrohepatic omentum is stretched and the pylorus as well as the greater curvature descends. This is called gastroptosis. The amount of distention is recognized by percussion, as pointed out on page 402, or by administering bismuth and examining by the Rontgen rays.

Ulcer occurs most frequently along the lesser curvature; then the posterior wall, the region of the pylorus, the anterior wall, cardiac end, fundus, and greater curvature, in the order of frequency. The ulceration may open an artery, producing hemorrhage, or there may be adhesions to neighboring organs, resulting in the formation of abscess, or direct communication with the greater or lesser peritoneal cavity may be produced. Healing of ulcers near the pylorus may cause stenosis resulting in distention. Hemorrhage may occur from the vessels of the stomach walls or the vessels along the lesser curvature, the splenic or hepatic arteries or even the portal vein. One reason why the arteries along the curvatures are not still more frequently affected is because thev often lie a short distance away from and not in immediate contact with the stomach walls. Adhesions to surrounding organs are least liable to form when the perforation is on the anterior wall. Then the larger peritoneal cavity is infected and a general peritonitis quickly ensues. A perforation on the posterior wall involves the lesser cavity of the peritoneum, and the infection must travel first through the foramen of Winslow before a general peritonitis develops. Abscesses may form between the under surface of the liver and the stomach, and they have been known to penetrate the pleura, pericardium, and transverse colon.

Carcinoma

This is located in about 60 per cent. near the pylorus, in 15 per cent. in the lesser curvature, in 10 per cent. at the cardiac end, and in the remaining

Fig. 417.   Showing the right end of the stomach normally contracted to near the size of the duodenum. From an actual specimen.

Fig. 417. - Showing the right end of the stomach normally contracted to near the size of the duodenum. From an actual specimen.

15 per cent. in other portions of the organ. Cuneo has shown that extension occurs in the lymphatic nodes along the lesser curvature, in those of the greater curvature along the right third of the stomach adjacent to the pylorus, and in the nodes around the pylorus and head of the pancreas. It has been noticed that there is no tendency to extension to the region of the duodenum. It will thus be seen that a line drawn from the junction of the right and middle thirds of the greater curvature to the cardiac extremity would have nearly all the nodes to the right. It is this portion which is removed in pylorectomy and partial gastrectomy; owing to the extension of the disease up the lymphatics of the oesophagus, enlarged nodes may sometimes be present in the left supraclavicular fossa or even in the left axilla.

The tumor is visually felt in or near the median line, a variable distance above the umbilicus; it may drag the pylorus lower down than normal. If the stomach is distended the tumor may be carried 5 to 7.5 cm. (2 to 3 in.) to the right of the median line. If, as is not uncommon, the disease infiltrates the walls of the stomach, the tumor can be felt passing to the left side, disappearing under the costal margin.

Adhesions and ulceration are common. They are so marked that peritonitis from acute perforation is moderately rare. The adjacent organs are matted together and purulent collections are liable to occur. The ulceration may open into adjacent organs, as the colon. The colon may be adherent to the stomach and the large omentum contracted into a roll. The adhesions and pressure from the growth often interfere with the biliary ducts, and jaundice ensues; interference with the portal vein and vena cava causes ascites, and thrombosis of the veins sometimes occurs. In this disease, as in gastric ulcer, adhesions are least liable to form on the anterior wall, and here perforation requiring operation is most likely.