Fifty lesions of gastric ulcer and 125 of gastric carcinoma were studied in freshly resected stomachs by the dissecting microscope. According to Salem's definition, the "papillae" are the architectural units of the gastric area. But in pathological conditions, the "papillae" disappear; only papilla-like architectural units are observed, the shape and arrangement of which vary in individual pathologic conditions. To those papilla-like units the author has given the name "pseudo-papillae". By the dissecting microscope three stages were clearly difined in the healing process of gastric ulcer: acute, healing and scarring. In the acute stage, pallor of the marginal mucosa was observed together with irregularity in size and shape of the "pseudo-papillae". In the healing stage, two phases were further noted : the early healing stage and the later healing stage. In the early healing stage, the pseudo-papillae were deep red in colour and membranous structure with parallel capillaries was seen to grow from those marginal "pseudo-papillae" towards the ulcer base. The author has named this the "palisade structure". In the later healing stage, regenerative “pseudo-papillae” appeared f ollowng the growth of the palisade structure. The regenerative “pseudo-papillae” were lighter red, spindle-shaped and arranged in radiating directions. The scarring stage were in like wise divided two phases: in the early scarring stage, the redness of the pseudo-papillae faded to become pink; the shape became cubic. As the scarring proceeded, the pseudo-papillae became pale pink and the shape rather globular; some degree of irregularity still remained in the shape of the pseudo-papillae. In 858 cases of gastric ulcer, healing prosess was carefully followed up by fiberscopy always with close up view of the lesions obtained. Analysis of this fiberscopic follow-up confirmed the changes of the pseudo-papillae in respective stages of healing detected by the dissecting microscope. As for gastric carcinoma, 71 cases were of an advanced type and 45 of an early type according to the difinition by the Japan Gastroenterological Endoscopy Society. Each histological type of carcinoma showed type-specific appearanse of the pseudo-papillae: In adenocarcinoma papillare, commashaped pseudopapillae, dark red in colour, were scattered. In adenocarcinoma tubulare, large and pale tightly packed pseudo-papillae were seen. In adenocarcinoma mucocellulare, irregulary shaped large deep red tightly packed pseudo-papillae, were observed, giving rise to deep red strawberry-like appearance. In adenocarcinoma muconodulare, the pseudo-papillae were large, oval and pale, partially overlapping one another. Tubular as well as papillary carcinoma formed a clear demarcation between the carcinoma involved area and the surrounding normal mucosa, while mucocellular and muconodular carcinoma were poorly demarcated. Twenty-two cases of gastric carcinoma were studied by close-up fiberscopy prior to gastrectomy. In one case for instance, close up fiberscopic view of the lesion showed irregularly shaped reddish tightly packed pseudo-papillae. Thus the endoscopic diagnosis of adenocarcinoma mucocellulare was made, coinciding with post operative dissecting microscopic diagnosis. Histology of the resected stomach confirmed this diagnosis. The present sudy shows that a close up view of the lesions through the fiberscope is in good agreement with the dissecting microscopic appearance. Thus the results of dissecting microscope study of the gastric mucosa are applicable to interpretation of endoscopic findings of gastric lesions. Not only differentiation of benign and malignant lesions, but also estimation of histological type of gastric carcinoma has become possible by fiberscopy of the stomach. Staging of healing process of gastric ulcer has become more precise. A new field has been opend for endoscopy of the stomach.

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With the advance of the fiberscope, the duodenofiberscope has become used routinely for the diagnosis of duodenal ulcers. The duodenofiberscope (Olympus JF type B) was used and 212 fiberoptic examinations were carried out in 174 patients who were clinically diagnosed as duodenal ulcers. Endoscopically, 72 of them (41%) were diagnosed as active duodenal ulcers and 36 of them (21%) were diagnosed as healing duodenal ulcers. We discussed clinical symptoms of the patients, comparisons between X-ray findings of the duodenal ulcers and serial endoscopical follow-up examinations of the active or healing duodenal ulcers. The conclusions were as follows: 1. Seventy percent of patients out of 72 who were diagnosed as active duodenal ulcers endoscopically, had epigastric pain as their chief complaints, 10 percent had melena, but 14 percent of them had no symptoms at all. On the other hand, half of the 36 patients who were diagnosed as healing ulcers endoscopically still had sympotoms, most of which were epigastric pains. 2. Compare to the X-ray examinations, more detailed inf ormations such as location, morphorogical characteristics such as active or healing, single, multiple or linear, had been obtained by the duodenofiberscope. 3. Twenty percent of patients who had duodenal ulcer endoscopically had no deformity of duodenal bulb on X-ray examinations. In the early stage of the multiple duodenal ulcer there was no deformity of the bulb noted. 4. The round or irregular shape of duodenal ulcers had tendency to repair easily. On the other hand, linear ulcers remained unchanged or recurred in a few month.

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Many authors reported that visualization of cholangiogram was more difficult than that of pancreatogram in EPCG. and also emphasized that the failure of the contrast medium to enter the common bile duct in these cases may be due to organic stenosis or technical reasons. In our series, cholangiograms were obtained in 12 (42.8%) out of 28 cases such as papillitis without stones (8 cases), cholelithiasis ( 7 cases) choledocholithiasis (9 cases) and postcholecystectomy Syndrome (4 cases), which satisfy the major criteria (1-4) but in 18 (75.0 %) out of 24 other cases of cholelithiasis, choledocholithiasis, chronic pancreatitis and postcholecystectomy syndrome which did not have major criteria. In 7 out of eighteen cases where the canulation was succesf ul, the contrast medium did not enter the common bile duct on the first atemput, but entered the common bile duct after the intra venous administration of anti-cholinergic agents or anti catechol-o-metyl transf erase. We consider that the diagnosis of functional stenosis in terminal portion of the common bile duct be made in cases where opacification was only succesful after administering anti-cholinergic agents or anti COMT.

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The pathogenesis of gastric ulcer has not been obscure yet, although several factors such as acidity, pepsin activity, local circulation, gastric mucin or hormones may be considered to contribute. The present paper deals with two cases with unusual giant ulcers of "trench" shape complicated with high ACTH level in serum. Case 1. A 72-year-old male was admitted to Osaka University Hospital with complaints of jaundice of four day duration, anorexia and epigastric discomfort over the preceding two months. He had been suffered from diabetes mellitus since these three years. At six hospital day melena was occurred. Urgent gastrofiberscopy was performed on nineth hospital day and two "trench" ulcers (wide and belt-shaped ulcers) from cardia to angle of the stomach, running in parallel onthe lesser curvature and posterior wall, were observed. Gastric bleeding continued and on 20 th hospital day a partial resection of the stomach and choledochojejunostomy were performed. Resected stomach showed two ulcers, one sized 6.0×2.8cm, the other 10.0×4.0 cm. Both ulcers were Ul-2 in depth. The patients died on 50th hospital day. At autopsy, oat cell carcinoma was found in the upper lobe of the right lung, and the choledochus was obstructed by metastatic tumor of the head of the pancreas. Diffuse and nodular hyperplasia of the adrenals were also seen. ACTH level in the serum of the patient was much higher than that of normal controls.Case 2. A 57-year-old male developed an episode of sudden substernal pain a week prior to admission and was diagnosed as having myocardial infarction and diabetes mellitus by his family physician. Two days before admission he complained of epigastric pain. Gastrofiberscopy was performed on 14th hospital day and two"trench" ulcers similar to those of case 1 were found. Moreover, an another deep ulcer was found at cardia. After three months the ulcers became linear red scar with convergence of mucosal folds and white scar after nine months. The level of ACTH in the serum was also high. These two cases had similarity in the shape of ulcers ("trench" shape) and in the location (the lesser curvature and the posterior wall from cardia to angle of the stomach), and therefore it might be suggested that same factors acted on the production of ulcer. Both cases had diabetes mellitus, and thinking of the presence of chronic hypoxemia due to lung cancer in case 1 and of myocardial infarction in case 2, it seems likely that the disturbance of the circulation in whole body and the local disturbance of the circulation in the stomach are very important factors. The administration of anti-inflammatory drugs and hormonal factors may, also, be responsible for these "trench" ulcers.

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The great progress in gastrofiberscopy has brought us a broadening of its application to both diagnosis and treatment. We have performed 33-polypectomies in 32 cases, utilizing radio frequency electric current under visual control with gastrofiberscope. We discussed the safety of this method and perfect retrieve of the resected polyps. Out of the 3 electrodes, i.e., the one with blunt tip, the one with goblet-shaped forceps and the coagulation electrode with loopwire, that were all invented by us, the last one is superior to the others in its quality. The adhesion method by suction with GIF-D has improved the ratio of the retrieve of the polyps. We have experienced a case that awakened us to the new significance of biopsy in toto by endoscopic polypectomy. In this case, the biopsy before polypectomy showed atypical cells of group III but histological examination after endoscopic polypectomy revealed local nestle of adenocarcinoma papillotubulare.

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