Perforation, when it does occur, may result from sloughing or rupture of the peritoneal coat of the stomach, in the sometimes slow, sometimes rapid progress of the deepening ulcer; but it is more often caused at last, by pressure of some sort, which suddenly breaks the thinned and fragile membrane. It has frequently happened after a hearty meal; and during the acts of vomiting, and straining at stool. It has been known to take place in the effort of sneezing; under the sudden compression of the waist by a tight belt; from a rough jolt in a dog-cart.

In slower cases, and they sometimes go on for years, the symptoms, equivocal at first, become more and more significant as the disease proceeds. One leading symptom is pain, felt in a circumscribed space in the region of the stomach, and often, at the same time, or alternately in the back just below the shoulders. The pain begins immediately upon, or very soon after, the entrance of food into the stomach; especially of food or drink which is hot or stimulating. It usually continues until the digested food has left the stomach; or until vomiting puts an end to it. The pain is produced or aggravated by pressure, by exercise, by mental anxiety, mitigated by the recumbent position, and accompanied frequently by sour eructations.

Vomiting is another of the principal symptoms; later commonly in its arrival than the pain; occasional at first; afterwards very frequent. Supposing an ulcer present, this is a very dangerous symptom. It tends to starve and weaken the patient, and so to promote the progress of the ulcer: it increases also the hazard of its breaking through.

Dr. Budd holds that if profuse vomiting of blood occurs in a person between the ages of eighteen and thirty, after a long continuance of pain in the stomach, extending into the back, with tenderness on pressure over the region of the stomach, the pain and soreness being always brought on or increased by meals, with occasional sour eructations, and occasional vomiting, with no great wasting or constitutional disturbance, no evidence that the orifices of the stomach are obstructed, and no tumour to be felt, hardly a doubt can remain that the disease is simple ulcer of the stomach.

Uleer of the stomach may be distinguished from Dyspepsia in this way: in chronic gastritis there is much tenderness over the region of the stomach: the pain is increased by active exercise and by stimulating food; vomiting is usual; eructation of gas rare. In Dyspepsia, there is little or no tenderness over the stomach; the pain is not increased by exercise, and is often lessened by stimulating food; vomiting is unusual, eructation of gas common.

Treatment

When the symptoms are urgent, the patient should remain at rest, and will be better lying down than sitting up. All food which is likely to create pain; that is, all food of a stimulating nature, or which has been found upon trial to give pain, should be forbidden. Tepid Milk, alone or thickened with biscuit-powder, containing as it does all the elements of nutrition, is probably the very best kind of food. The stomach must never be distended by food; yet the strength and nourishment of the body require to be sustained. The food must therefore be taken in small quantities at a time, and often; a tablespoonful or two every hour or two, or oftener, if the stomach will bear it; in smaller quantities if the stomach will not bear as much at once. If the pain is severe, a mustard poultice may be applied to the stomach, or the back; or a stimulating liniment with Opium: such as Carbonate of Bismuth, in ten grain doses, may be taken three times a day. If blood is discharged from the stomach, ice swallowed in small quantities will sometimes give relief to the patient. And I have seen decided benefit derived in these cases, from Sulphate of Copper combined with Opium. The following may be taken:

Opodeldoc.......................................Two Ounces.

Camphorated Spirit..........................One Ounce.

Laudanum......................................Half an Ounce.

Sulphate of Copper, in fine powder,.........12 Grains.

Powdered Opium................................6 Grains.

Crumb of Bread, sufficient to make 24 pills. One to be taken three or four times a day.

If the bowels are sluggish, an injection may be given occasionally. The stomach is very frequently the seat of specific malignant disease. Cancer in the stomach is not very uncommon, but there are no particular symptoms by which it can be detected; the symptoms, when any do show themselves, being so similar to those of chronic inflammation and ulcer, that no one can positively distinguish between the two. The same precautions, care and treatment must be adopted in both cases.

The rough usage which the stomach will bear is well illustrated in the following case, contributed by Dr. Murchison to the forty-first volume of the "Medico-Chirurgical Transactions." A perverse, hysterical girl, contrived, among other extraordinary pranks, to establish an oval opening into her stomach, three inches by four in dimensions, by secretly but continuously pressing an old-fashioned copper penny piece upon her stomach. Through this wide window, as it were, the interior of the stomach could bo seen and felt, and was sometimes turned inside-out and handled, without pain, or any worse consequence than a very transitory feeling of sickness or faintness.