This usually occurs in the form of an annular growth, which produces a considerable degree of stenosis. Both the stomach and the duodenum above the disease are much enlarged, and the pyloric orifice is dilated. As in the preceding varieties, the first symptoms consist of flatulence and discomfort after meals, acidity, loss of appetite, and gradual emaciation. After the lapse of a few months vomiting appears, and persists until the end. The tongue now becomes thickly coated, the thirst excessive, and there is marked cachexia and rapid loss of flesh. The bowels are obstinately confined, but the stools are seldom quite devoid of bile, and occasionally contain altered blood.
The character of the vomit constitutes one of the most important features of the disease. It always contains bile, which gives it a bright green colour, and if the patient is restricted to a semi-solid diet, the ejecta may closely resemble chopped spinach. The liquid obtained by filtration is neutral or slightly alkaline in reaction, and if warmed to the temperature of the body is usually capable of digesting fibrin, owing to the fact that it contains pancreatic juice. The sediment that remains upon the filter consists of undigested food in a state of fine subdivision, and is quite unlike the bulky masses which are vomited in cases of pyloric stenosis. From time to time attacks of intestinal obstruction supervene, attended by incessant vomiting and obstinate constipation. On these occasions from ten to fifteen pints of an alkaline bilious fluid may be vomited in the course of twenty-four hours, notwithstanding the fact that the patient has taken nothing by the mouth. The urine is greatly reduced in amount, and may even be suppressed, while that which is voided is alkaline in reaction and opaque from an excess of earthy phosphates. When boiled with nitric acid, it sometimes assumes a dark red or port-wine colour, owing to the presence of a colourless chromogen, allied to indol and indican, which has been produced by decomposition in the dilated bowel. A similar reaction is sometimes obtained in cases of melanosis, owing to the existence of melanogen in the urine; but in this instance the addition of perchloride of iron produces a brown colouration-a reaction which is absent in cases of duodenal cancer. In rare instances the chromogen is changed to indican in the body, and the urine has a distinct blue colour when voided. Rolleston noted an excess of creatinin in the case which he recorded. Symptoms of auto-intoxication are often present at this stage of the complaint, and consist of urgent dyspnoea, restlessness, palpitation, thirst, and delirium. Intense itching of the skin, like that met with in biliary and renal toxaemias, is sometimes observed, and urticarial eruptions occasionally follow the acute attacks of duodenal obstruction. Examination of the abdomen shows the stomach to be much enlarged, and a succussion splash may be obtained as far outwards as the right mammary line, or even in the lumbar region. This latter phenomenon is apt to be ascribed to dilatation of the pyloric region of the stomach, but is really due to the duodenum, which, being greatly enlarged above the stricture, forms a distended sac behind and. to the right of the pylorus. When the disease merely forms a narrow ring round the bowel, no tumour can be detected by palpation, but if the growth is accompanied by enlargement of the retro-peritoneal glands, or has infiltrated the pancreas, an ill-defined hard mass may be felt to the right of the umbilicus. Exploration of the stomach with a soft tube elicits three facts of considerable importance. In the first place, it may be observed that after the organ has been apparently emptied a fresh gush of fluid occurs when the patient coughs or inclines his body to the left side, a phenomenon which is obviously due to regurgitation of the contents of the duodenum through the incompetent pylorus. Secondly, after the stomach has been evacuated a succussion splash may still be obtained over a limited area to the right of the navel, owing to the presence of fluid in the duodenum. Finally, after the stomach has been washed out overnight, and no food taken in the meanwhile, a quantity of bilious fluid may be extracted in the morning. These three phenomena, taken in conjunction with the physical signs aforementioned, render the diagnosis of stricture of the third part of the duodenum almost a matter of certainty.