. Diseases of the stomach : including dietetic and medicinal treatment . therigid protective spinal column within the confines of the lesser jieri-toneal .sac, and is in close relation with the pancreas, duodenum, andliver. Owing to these relations, ulcers on the posterior wall are moreapt to contract protecting adhesions and arc therefore not so liableto perforate. From ulcer of the anterior wall of the duodenum fatal perforationoften , owing to the absence of any solid viscus that can act asa secondary basis for the ulcer, but when ulceration occurs on theposterior wall, perforation i
. Diseases of the stomach : including dietetic and medicinal treatment . therigid protective spinal column within the confines of the lesser jieri-toneal .sac, and is in close relation with the pancreas, duodenum, andliver. Owing to these relations, ulcers on the posterior wall are moreapt to contract protecting adhesions and arc therefore not so liableto perforate. From ulcer of the anterior wall of the duodenum fatal perforationoften , owing to the absence of any solid viscus that can act asa secondary basis for the ulcer, but when ulceration occurs on theposterior wall, perforation is often prevented by the pancreas which lieimmediatcl\ behind it. ^Vcr< it not for the presence of the i)ancreas rOMPIJCATIOSS OF ULCER 159 at this exact p(jint it is probable that a much greater number of duodenalulcers would perforate. Recurring perforations in the same individual are not uncommon;in the literature of the year instances of successive operations werereported by Cuff/ Willis,^ and Schmitzler.^ Perforation may be acute, subacute, or chnjnic. Fig, 20. Perforated gastric ulcer. The stomach is adherent to the pancreas which forms the base of theulcer. X, ulcer; P, pancreas; .S, wall of stomach. (From the Pathological Mu-seum of the Presby-terian Hospital, New York.) Acute Perforation.—In the acute form the perforation is unprotectedby adhesions, so that the gastric or duodenal contents escape rapidlyand freely into the peritoneal cavity. Following perforation of a gastriculcer, an acute diffuse peritonitis is at once set up, the infectionspreading rapidly to all parts of the abdominal cavity. The contentsof the duodenum, on the other hand, are relatively sterile, whichaccounts for the fact that while the number of the duodenal perfora-tions is large, the death rate is comparatively low. Not only is theduodenum more often empty at the time of the perforation than isthe stomach, but a protective spasm of the pylorus is induced at thetime of the accident, prevent
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