STOMACH AND INTESTINE. 



417 



The mucous membrane in the neighbour- 

 hood of the ulcer is sometimes a little swollen': 

 and the immediate margin of the excavation 

 is often indurated and raised above the level 

 of the adjacent mucous surface. But it offers 

 no other appearances worth mentioning as 

 indicative of inflammatory reaction in the con- 

 tiguous tissues. 



The mode in which the ulcer penetrates 

 the various tissues is somewhat characteristic. 

 The smooth, sharp and vertical edge by 

 which it passes through the mucous mem- 

 brane, and reaches the submucous tissue, is 

 here exchanged for a less regular one ; which 

 forms a circle of smaller diameter than the 

 opening in the mucous coat. In like manner, 

 when the ulcer has gradually eaten its way 

 through the muscular coat, it reaches the 

 peritoneal coat, at a point which about occu- 

 pies the centre of this smaller circle. Hence, 

 the whole depth of the ulcer forms a cone ; the 

 base of which is at the free or internal surface 

 of the stomach, while its apex occupies the 

 peritoneum. The latter membrane is scarcely 

 ever destroyed by mere ulceration, except in 

 those instances in which it has previously been 

 strengthened and defended by an exsudation 

 of lymph. Where this has not been deposited, 

 the peritoneum becomes converted into a 

 yellow slough ; the rupture or detachment of 

 which gives rise to perforation of the sto- 

 mach, and allows its contents to escape into 

 the abdominal cavity. 



The process by which the gastric ulcer ori- 

 ginates is at present unknown. Rokitansky 

 thinks it probably begins as a haemorrhagic 

 erosion, or a circumscribed slough ; and that 

 it gradually extends by its basis throwing off 

 a succession of laminated sloughs, or exfolia- 

 tions. Some such process he has indeed 

 observed in a few instances. On the other 

 hand, if we may venture to regard that ulcer 

 of the duodenum which sometimes occurs in 

 severe burns, as analogous to the gastric 

 ulcer, we should probably find reason for con- 

 cluding, that the ulcerative process may some- 

 times occur, without being preceded by hae- 

 morrhage, sloughing, or any appreciable ex- 

 sudation, in the situation of the affected 

 part.* 



The cicatrization of such ulcers may take 

 place at almost any stage of their course. The 

 precise details of its occurrence vary with the 

 amount of destruction which has preceded it. 

 Where the destructive process has been 

 limited to the mucous membrane, there is 

 little more than a condensation and thicken- 

 ing of the subjacent areolar tissue ; which ul- 

 timately forms a scar that has a shape similar 

 to the ulcer. But where the muscular coat 

 has been partially destroyed, its remaining la- 

 mina, and the subjacent peritoneum, are gene- 



* See Pathological Transactions, vol. i. p. 258, 

 for an instance brought forward by Mr. Prescott 

 Hewett ; where one of these ulcers seemed to be 

 commencing as " a slight depression in the surface 

 of the mucous membrane, which in their neigh- 

 bourhood presented some traces of increased 

 vascularity." 



Supp. * 



rally more or less folded or crumpled up, so as 

 to bring the margins of the ulcer nearer to 

 each other. Hence the resulting cicatrix has 

 a much more irregular form ; and often con- 

 tracts into a kind of thickened cord, with 

 radiating extremities, which seriously affects 

 the shape and diameter of the whole organ. 

 The amount of contraction thus im pressed 

 upon the stomach varies, other things being 

 equal, with the size and shape of the ulcer. 



The extension of the ulcerative process 

 would always end in perforation, were it not 

 this event is, in most instances, to some extent 

 guarded against by the occurrence of adhe- 

 sion. From what has been already stated, it 

 is evidently very doubtful whether the ulcer 

 originates in an inflammatory state. And 

 in many cases, it certainly seems devoid of 

 all the ordinary appearances of inflammation 

 during its progress. But it is often accom- 

 panied, not only by swelling and induration 

 of its mucous margin, but bj r exsudation and 

 hardening at its base, and by adhesive inflam- 

 mation of the neighbouring tissues. Thus the 

 peritoneal coat at the bottom of the ulcer 

 becomes inflamed, and pours out upon its 

 free surface a stratum of coagulable lymph ; 

 by means of which the stomach may become 

 united to any adjacent viscus. In this man- 

 ner the liver above the organ, or the pan- 

 creas behind it, may become attached to the 

 outer surface of the stomach, at a point cor- 

 responding to the situation of the ulcer in 

 its interior. But the more mobile diaphragm 

 and anterior wall of the belly are less fre- 

 quently the seat of such adhesions. 



The adhesion does not, however, replace 

 the loss of substance in the gastric coats. 

 And hence, in many of these cases (just as 

 in adherent wounds of the stomach, attended 

 with much loss of its parietes) the mucous 

 membrane around the edges of the ulcer becomes 

 prolapsed and protruded into it ; and thus 

 comes into contact with the surface of the 

 adhesion at its base. The substance of the 

 adhesion itself may either ultimately become 

 converted into a cicatrix : or it may be gra- 

 dually drawn out by the constant traction 

 which the stomach exercises so as to form a 

 hollow funnel-shaped tube, that is lined by a 

 smooth surface having the appearance of a 

 serous membrane. 



The efficiency of the adhesion, as a means 

 of protection against perforation, varies with 

 its situation, and still more with its structure. 

 Where it is a mere thickening of a delicate 

 fibrous network by inflammatory lymph, as 

 is generally the case when it occupies the 

 omentum, it is of little avail in this respect. 

 While where the exsudation possesses a fibro- 

 cartilaginous character, such as is often seen 

 in the adhesions which unite the stomach 

 with the liver, it forms a much more efficient 

 protection against such an event. 



But in many instances, a continuance or 

 renewal of the ulcerative process attacks and 

 destroys the new tissue itself: and either 

 penetrates the viscus (pancreas, liver, or spleen) 



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