584 AFFECTIONS OF THE INTESTINAL CANAL. 



ration, and still more, some cicatrices of healed duodenal ulcers, have 

 been overlooked at the autopsy. In one thousand post-mortem ex- 

 aminations made at the Prague institute for pathological anatomy, 

 Wittigk found perforating duodenal ulcer only twice, while in seventy 

 four cases he found either ulcers or their cicatrices. Perforating duo- 

 denal ulcers appear to be more frequent in men than in women ; just 

 the opposite of what occurs in ulcer of the stomach. It is hardly ever 

 seen during childhood ; most of the cases collected by SJrauss occurred 

 during middle age. It does not appear, from the analysis of the cases 

 known, whether certain causes, particularly burns of the skin, induce 

 this disease. 



ANATOMICAL APPEARANCES. The most frequent seat of the ulcer 

 is the upper horizontal portion of the duodenum ; in some few cases 

 it has been observed in the descending portion, and in one case in the 

 lower horizontal portion (Krauss). Lebert says that perforating 

 ulcers may occur in any portion of the intestinal canal. I myself have 

 seen an ulcer, with all the characteristics of simple perforating ulcer, 

 hi the upper third of the small intestine, in a public officer, aged fifty- 

 six years. In recent cases the edges of the ulcer are sharp and not 

 swollen, the loss of substance in the mucous membrane is more exten- 

 sive than in the muscular coat, and greater in this than in the serous. 

 Ulcers that have existed some time are surrounded by thickened edges, 

 indurated by newly-formed connective tissue. In some cases the floor 

 of the ulcer is formed by neighboring organs to which the duodenum 

 has become adherent before its complete perforation. The liver, pan- 

 creas, gall-bladder, and posterior wall of the abdomen, have been ob- 

 served as coverings of duodenal ulcers. The progress of the destruc- 

 tion from the duodenum to the adherent gall-bladder occasionally 

 causes a fistulous communication between the two. A continuation of 

 the destruction to the adherent abdominal wall may lead to perfo- 

 ration outwardly. Occasionally this, like the perforating ulcer of the 

 stomach, heals, with great retraction of the cicatricial tissue. It 

 may thus lead to stricture of the duodenum. Finally, obliteration of 

 the ductus choledochus has been observed as a result of cicatricial 

 contraction of a healing duodenal ulcer. 



SYMPTOMS AND COURSE. When speaking of round ulcers of the 

 stomach, we mentioned cases where peritonitis which was rapidly fatal, 

 or severe vomiting of blood, was the first symptom from which that 

 severe and dangerous disease could be diagnosticated. Perforating 

 ulcer of the duodenum appears to remain latent until the fatal ter- 

 mination, more frequently than similar ulcers of the stomach. At the 

 same time it should not be said that the patients have been perfectly 

 well until the appearance of these fatal symptoms ; on the contrary, it 



