. The Canada lancet and practitioner. y pursue a symptomless course, and there may be per-fect health until the disastrous rupture into the peritonealcavity takes place, and even then the diagnosis may be a rule, however, there are very definite indications whichlead us to a correct conclusion. A history of indigestion cannearly always be obtained, either of recent date and compara-tively mild, or prolonged and intermittent. The dyspepsia isassociated with pain after food and with vomiting, which often *Read before the Canadian Medical Association, Halifax, August, 1905. 188 DOMINIO
. The Canada lancet and practitioner. y pursue a symptomless course, and there may be per-fect health until the disastrous rupture into the peritonealcavity takes place, and even then the diagnosis may be a rule, however, there are very definite indications whichlead us to a correct conclusion. A history of indigestion cannearly always be obtained, either of recent date and compara-tively mild, or prolonged and intermittent. The dyspepsia isassociated with pain after food and with vomiting, which often *Read before the Canadian Medical Association, Halifax, August, 1905. 188 DOMINION MEDICAL MONTHLY gives-relief. The more classic evidences of gastric ulcer, hema-temesis and melena, are usually lacking. Perforation mayoccur at any time, and under any circumstance, and is favoredby muscular strain. Sudden intense pain, referred to theumbilical region, gives warning of the perforation. The patientbecomes faint and collapsed, has to lie down, and generallyvomits. As a rule the passage of flatus ceases, and symptoms. Diagram of stomach to show sites of perforation : A., Cardiac ;B., Fundus; C, Middle; D., Pyloric Portion; E., Pylorus. The figuresrefer to the cases 2, 7, 15, 16 on the posterijr,aspect of the stomach. simulating those of obstruction may arise. Occasionally thereis a movement of the bowels. The initial condition of shock varies in degree and prolonga-tion. Generalized abdominal pain is felt; the abdomen•becomes board-like and rigid, no longer participating in therespiratory wave. The most useful indication of danger is DOMINION MEDICAL MONTHLY 189 found in the shabby, rapidly quickening, pulse. Respiration in-creases and the temperature has a tendency to rise. On pal-pitation the abdominal wall is hyperesthetic, and marked localtenderness is evinced in the epigastric region and above thepubis. There may be diminished liver dullness. Rectal exam-ination sometimes reveals tenderness, but there is rarely bulgingin the Pouch of Douglas. The
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