CAUSES OF THICKENED PYLORUS. 245 But it may be asked why the muscular coat is attenuated instead of being thickened, as in the case of an obstruction at one of the orifices of the heart. Hypertrophy, as we have just seen, does take place at, and immediately behind the pylorus; and the wasting of the fibres covering the body of the stomach is probably caused by the distension being occasional and sudden, instead of being gradual and constant, as in most other hollow organs. It is occasional, inasmuch as it only takes place during digestion, and sudden, as it is produced by gas evolved by the fermentation of the food. The thickening of the pylorus is most frequently found in males between thirty and fifty years of age, and especially in persons who have been addicted to the abuse of ardent spirits. The vomiting of sarcina has been observed to follow a blow or other injury to the abdomen. Generally in such cases adhesions have been formed between the stomach and some of the neighbouring organs; its position has been altered, and dilatation has taken place from the difficulty which the muscular coat had under these circumstances in propelling its contents. An injury sometimes gives rise to chronic inflammation of the stomach or upper part of the intestinal canal. I have before shown that thickening of the stomach may follow severe pressure on the epigastrium; and an instance of stricture of the upper part of the intestines came under my notice, in which the symptoms commenced shortly after a severe blow on the abdomen. The obstruction is not unfrequently caused by 1 See page 131. cancerous growths at or near the pyloric orifice. Under these circumstances there may be considerable difficulty in diagnosis, for the attention of the prac titioner is chiefly attracted by the fermentation of the contents of the stomach. Such cases may be generally distinguished by the short duration of their symptoms, by the severe pain, often of a neuralgic character, the admixture of coffee-ground materials or of blood in the matters vomited, and by the cachectic appearance which so generally attends the growth of cancer in any of the internal organs of the body. The narrowing of the pyloric opening is sometimes caused by the pressure of glandular or other tumours, as in the following example. CASE 24.-A sailor, about twenty years of age, came under treatment for enlarged glands of the axilla. He was much emaciated, but had neither cough nor expectoration, although on examination of his chest I found slight dulness under one clavicle and tubular breathing. He made no complaint of his digestion, but I subsequently found that for twelve months he had been liable to vomiting of large quantities of sour fluid, and that this took place every two or three days. I saw him on one occasion after his being attacked with violent vomiting, which was induced by food, but also took place without; the vomited matters were of a dark green colour, thick and ropy. Under the microscope they were seen to be filled with yeast cells. The vomiting gradually ceased, but his strength failed, and he sank from exhaustion. Post-mortem Examination. There was tubercular CAUSES OF DILATED STOMACH. 247 deposit in the upper part of the lung as diagnosed during life. The stomach was dilated, but not to the extent often seen in cases of diseased pylorus. The glands near the pylorus were considerably enlarged, and by their pressure narrowed the pyloric opening. The other organs of the body were in a healthy condition. The diagnosis of a case of this kind is generally difficult on account of the depth at which the tumour is situated, and from the symptoms being less distinctly marked than when the constriction is produced by thickening of the pylorus. It may be suspected that the dilatation arises from obstruction by enlarged glands when the patient presents evidence of tubercular disease, and when other circumstances likely to produce the complaint cannot be discovered. Ulceration is perhaps the most frequent cause of dilatation of the stomach. The enlargement may occur when the ulcer is still in progress, either from the deformity of the organ produced by adhesions, or from the destruction of a large portion of the muscular structure preventing the due propulsion of the food. Dilatation may take place long after the ulcer has entirely healed; the stomach being constricted or the pyloric orifice or duodenum being narrowed by the contraction of the cicatrix. The length of time at which this may occur after the ulcer has apparently healed is sometimes very remarkable. I attended a middle-aged lady affected with well-marked symptoms of ulceration of the stomach, from which she gradually recovered. She remained in good health for about ten |