i654 HUMAN ANATOMY. 



in close relation on the lower part of the right aspect with the liver and gall-bladder, 

 on the upper part of the left aspect with the head of the pancreas and foramen of 

 Winslow, and posteriorly is partly uncovered by peritoneum and rests on areolar 

 tissue and the common bile-duct. 



The general relations of the duodenum (page 1645) explain the remaining 

 lesions following duodenal ulcer, — e.g., perforations into the gall-bladder, liver, or 

 colon ; opening of the hepatic artery or the aorta, or of the superior mesenteric or 

 portal vein ; or the development of subphrenic abscess. 



As compared with the symptoms of gastric ulcer, pai?i is apt to be less on 

 account of the relative immobility of the duodenum ; vomiting after feeding is 

 later ; hemorrhage is often greater on account of the larger \'essels that may be 

 involved ; bloody stools are more common, as is jaundice from the in\'ol\'ement of 

 the bile-duct. 



In exposure of this part of the duodenum it is well to remember the suggestions 

 of Pagenstecher (quoted by Weir), — viz., that the fundus of the gall-bladder when 

 distended lies in front of the duodenum ; that by raising and drawing forward the 

 transverse colon, which lies in front of and below the horizontal portion of the duo- 

 denum, the first portion is revealed ; and that by pushing the stomach and pylorus 

 to the left and elevating the liver, access to the region of perforation may be gained. 

 In emaciated patients with contracted stomachs the duodenum may be found lying 

 above the level of the transverse colon. 



Infection through the mucous coat has already been spoken of. If of the tuber- 

 culous variety, it affects chiefly the lower part of the ileum, and tends, as is charac- 

 teristic of that disease, to follow the course of the vessels which run from their 

 entrance at the mesenteric attachment transversely around the gut. If such ulcers 

 cicatrize, they are therefore especially prone to lead to stricture of the intestine, a very 

 rare sequel of typhoid ulceration, which, affecting the same portion of the. small 

 intestine, extends in the line of the agminated lymph-nodules, — i.e., longitudinally. 

 The tuberculous ulcer sometimes produces a slow general peritonitis, rarely a local- 

 ized abscess, much more rarely an acute perforation with general septic peritonitis, 

 as the process is so slow that protective adhesions to neighboring coils of gut or to 

 the parietal peritoneum have time to form. 



Typhoid ulcers cause perforation in 6.58 per cent. (Fitz) of all cases. The large 

 majority of perforations occur in the ileum, most of them within 60 cm. (2 ft.) of 

 the ileo-csecal junction. In operation this should therefore be sought for and the 

 ileum followed upward from that point. The ulceration may so thin the intestinal 

 wall as to permit of leakage and the production of general peritonitis without actual 

 perforation ; or it may be accompanied by such an extensive exudate as to make the 

 ileum palpable, a condition which, in conjunction with localized tenderness and 

 abdominal rigidity {vide siipra), has led to many mistaken diagnoses of appendicitis 

 in cases of typhoid fever. 



Syphilitic ulccratio7i of the small intestine is rare, but is said to be most frequent 

 in the upper portions (Rieder). 



The lymphatics of the mucous and submucous coats empty into the mesenteric 

 lymph-nodules (page 1643) and convey to them various forms of infection or disease, 

 — typhoid, carcinomatous, tuberculous, etc. 



The veins emptying into the vena porta through the superior mesenteric are 

 likewise channels of infection, ulceration of the bowel sometimes resulting in abscess 

 of the liver. 



Contusion and rupture of the small intestine are favored by its exposure to 

 trauma through its close apposition to the abdominal wall, which, if relaxed, 

 offers but little protection. The interposition of the greater omentum with its con- 

 tained fat is a slight safeguard, but the movement of the coils of gut upon one 

 another and their elasticity are of much more value. 



Contusion here, as elsewhere, may be followed later by infection and ulceration. 

 Traumatic rupture is much more frequent in the jejunum and ileum than in any 

 other portions of the alimentary canal (of 219 cases, 79 per cent, were in the small 

 intestine, 11. 5 per cent, in the colon, and 9.5 per cent, in the stomach, Petry). 

 The duodenum suffers very infrequently on account of its sheltered position ; other- 



