PERFORATING DUODENAL ULCER. 585 



seems that slight dyspepsia, a feeling of fulness after eating, and sen- 

 sitiveness to pressure in the upper part of the abdomen, have preceded 

 the perforation or the vomiting of blood for a few days ; but these 

 symptoms have remained unnoticed, or have not led to the diagnosis. 

 In another series of cases, the symptoms were as nearly as possible 

 those common to perforating ulcers of the stomach. The cases that 

 have been published do not by any means prove that cardialgia and 

 vomiting occur later in perforating ulcer of the duodenum than in the 

 same disease of the stomach, and only in a few cases did it appear 

 that the pains were seated rather farther to the right side. In the 

 same way the analysis of published cases shows that duodenal ulcer 

 does not induce icterus more frequently, so that this symptom does not 

 aid in the diagnosis between gastric and duodenal ulcers. The rare 

 occurrence of icterus appears to prove that perforating ulcer of the 

 duodenum is not accompanied by extensive catarrh any more fre- 

 quently than ulcer of the stomach is. If the catarrh did occur, nutri- 

 tion would be sooner affected from ulcer of the stomach, and obstruc- 

 tion of the gall-ducts with resorption of bile (icterus), from ulcer of 

 the duodenum. The sudden occurrence of peritonitis after slight dis- 

 turbance of digestion gives us no more certainty, in the diagnosis be- 

 tween a perforating ulcer of the duodenum and one of the stomach, 

 than does the following group of symptoms, viz., feeling of pressure 

 and fulness after eating, sensitiveness in the epigastrium, cardialgia and 

 vomiting. Perforating ulcer of the stomach being far the more fre- 

 quent, the probabilities are in its favor. Finally, a number of cases are 

 reported, where duodenal ulcers ran their course with periodical attacks 

 of pain, and where, from the pain being in the right hypochondrium, 

 from their occurrence several hours after meals, and the accompanying 

 symptoms of dyspepsia and acidity, and occasionally from decided 

 enlargement of the stomach, the diagnosis of duodenal ulcer could be 

 made with great probability. But even in such cases we cannot 

 always be certain there is not a cancerous or a simple stricture of the 

 pylorus. At the present time, I am treating two patients who, besides 

 having a dull pressure in the right hypochondrium, complain of an in- 

 sufferable feeling of fulness after eating, also of a belching sometimes of 

 gases without smell or taste, sometimes of sour and rancid substances. 

 One of these patients never vomits, the other rarely ; but both appear 

 convinced that there must be an obstruction to the exit of food from 

 the stomach, both insist that the food escapes from the stomach more 

 readily when they remain upright for a few hours after eating ; and, in 

 spite of then* emaciation and debility, they persist in sitting up for 

 several hours after their meals. No tumor can be found in the hypo- 

 chondrium ; the prominence in the epigastrium can be perceived after 



