1909.] 



Pathology of Gastric Ulcer. 



245 



covered with glands of the duct epithelium type. So that the delay occurring 

 in cases of motor insufficiency is merely an exaggeration of the delay which 

 may occur in exceptional cases normally. That it is a true delay is obvious, 

 because the different conditions found exactly correspond to the various 

 stages in the normal healing of an ulcer. 



Cause of the Delay in Healing. — For the normal regeneration of the mucous 

 membrane to take place it is necessary (1) that the epithelial cells should be 

 uninjured and free to grow over the base of the ulcer ; and (2) that the base 

 of the ulcer should consist of healthy granulation tissue containing an 

 abundance of cells, so that the ovei'-growing epithelial cells can be properly 

 nourished, and so that the tissue over which the cells grow can supply a 

 suitable stroma for the growth of the glands from the surface epithelium. If 

 either of these conditions be not fulfilled the healing must be delayed. 



It will, 1 think, be generally admitted that the epithelial cells are more 

 resistant to the action of the gastric juice than the tissue forming the base of 

 the ulcer, and the great resistance displayed by these cells is seen in the 

 promptitude with which they cover the surface, and by the fact that they can 

 resist the action of HCl of 0*7 to 0-9 per cent, strengtli (4). Of course, the 

 incurving of the mucous membrane at the edges of the ulcer must offer a 

 formidable resistance to the growth of the cells, both by the abnormal direction 

 in which the cells have to grow, and the pressure exerted on the base of the 

 ulcer by the incurved mucous membrane. Still, this is by no means an 

 insuperable obstacle, as the cells are readily able to grow round the angle in 

 a single layer and, when free from the pressure, to sprout out into glands in 

 the centre of the ulcer. So that one is rather compelled to look for any 

 conditions which may be present in the base of the ulcer which can prevent 

 the epithelium growing over it or are able to modify its growth. If the base 

 of the ulcer be necrotic, as may occur as the result of bacterial invasion or 

 digestion by the gastric juice, it is obvious that the growth of the epithelium 

 over it would be at once arrested ; and, on the other hand, if the base be 

 irritated and dense fibrous tissue rapidly formed, it is equally obvious that the 

 epithelium would be modified in its growth, both by deficient blood supply 

 and the failure of the fibrous tissue to form a suitable stroma for the process 

 of glandular formation. In the three cases described in the normal healing of 

 ulcer, I have mentioned that in one the exuberant granulations had become 

 necrotic and had stopped the growth of the epithelium ; that in another the 

 base was formed of dense fibrous tissue and the overlying glands formed of 

 duct epithelium only ; and that in the third the glands were completely 

 regenerated and the underlying tissue more loose and cellular in character. 

 In the cases of pyloric stenosis the same principle is observed. In 



