530 DISEASES OF THE STOMACH. 



quently a recent ulcer near the cicatrices of some that have healed. In 

 typical cases, according to Rokitansky*s classical description, there is 

 a circular hole with sharp borders in the serous coat of the atomach, 

 as if a piece had been cut out with a punch. Regarded from within, 

 the loss of substance is greater in the mucous membrane than in the 

 muscular coat, and greater in this than in the serous coat, so that the 

 ulcer is in terraces and looks like a shallow funnel. The ulcers vary 

 from J J- inch in diameter ; old ulcers attain the size of a thaler or the 

 palm of the hand. At first they are round, after they have existed 

 some time they become elliptical, or bulge out in some places, and so 

 become irregular. They spread transversely in the course of the ves- 

 sels, so that the stomach is occasionally surrounded by a girdle as it 

 were. 



Sometimes the ulcer heals before it has perforated all the coats of 

 the stomach. If the loss of substance has been .limited to the mucous 

 and submucous tissue it is replaced by granulations ; these are trans- 

 formed to shrinking cicatricial tissue ; they draw the edges of the ulcer 

 together, and a stellate cicatrix of variable size forms on the inner sur- 

 face of the stomach. If the ulcer has penetrated deeper and destroyed 

 the muscular coat also, when it heals up, the cicatricial contraction of 

 the neoplastic connective tissue will contract the peritonaeum also into 

 a stellate figure ; its inner surface may even be retracted into the form 

 of a fold in the stomach. If the ulcer were very large, its healing may 

 cause a stricture, as the diameter of the stomach will be much dimin- 

 ished by the cicatricial contraction ; this will remain as an incurable 

 obstacle to the passage of the contents of the stomach into the bowels. 



If the ulcer be located in the small curvature, as is usually the case, 

 even if all the walls of the stomach be destroyed, escape of the contents 

 into the peritoneal cavity may be temporarily or permanently prevent- 

 ed. For, while the ulceration progresses outwardly, local peritonitis 

 occurs at the affected part ; the threatened portion of serous membrane 

 becomes attached to the neighboring organs ; if it then be destroyed, 

 these organs (most frequently the pancreas, the left lobe of the liver 

 or the omentum), which are firmly attached to the edges of the ulcer, 

 fill up the resulting opening in the walls of the stomach. The destruc- 

 tion sometimes extends to the organ which covers the ulcer, but more 

 frequently a thick layer of connective tissue develops on the surface of 

 this organ, and forms the floor of the ulcer. The covering organ never 

 lies in the same plane with the inner wall or projects into the stomach. 

 But, after the muscular coat has retracted, the mucous coat becomes 

 everted at the edge of the ulcer, and comes in contact with the organ 

 in question. If, in such cases, the ulcer heal, the connective-tissue 

 layer on the organ contracts, the edges approach each other, and. 



