This constitutes the immediate cause of death in about 3 per cent, of all cases of gastric carcinoma, and is most common when perforation occurs on the anterior surface of the organ, near the pylorus. The fact that the accident does not usually ensue until a late period of the disease, when the patient is suffering from profound exhaustion, renders its attendant symptoms less conspicuous than those which usually accompany perforation of the stomach. In those rare instances, however, where an attack of acute general peritonitis is the first indication of the disease, its onset is equally abrupt and its symptoms quite as characteristic as in cases of simple ulcer (Watson, Ellis).

Perforation may occur suddenly and without warning, or it may be preceded for some days by an increase of pain, excessive vomiting, or by profuse haematemesis, the two latter symptoms being particularly frequent when the morbid growth has been destroyed by sloughing. In other cases excessive distension of the stomach, violent vomiting, or straining at stool appears to be the immediate cause of the rupture. As a rule, pain in the abdomen is the most conspicuous of the early symptoms ; but if great debility exists, or the gastric complaint has been accompanied throughout by considerable suffering, its significance is liable to escape attention (Given). In debilitated or insane subjects, and also in those where the peritoneum has been implicated by the malignant disease, the abdominal pain is often slight, or even entirely absent. Vomiting is also an inconstant symptom, and when it exists does not materially differ from that which was previously present. The most important indication of perforation is the general appearance of the patient. In every instance, whether pain and vomiting exist or not, a rapid access of weakness may be observed, and within a few hours the face assumes an expression that is highly suggestive of acute peritonitis. The cheeks seem to shrink, the eyes recede into their sockets, the nose becomes pinched, and the skin exhibits a bluish or dusky hue. At the same time the temperature of the body is markedly depressed, the extremities become cold, the pulse is small, quick, and feeble, and the surface of the body is often bedewed with a cold sweat. Examination of the abdomen usually reveals a moderate degree of distension, with some rigidity of the walls and general tenderness; but complete flaccidity of the tissues and an entire absence of pain are quite compatible with suppurative peritonitis. Obscuration of the hepatic dulness from the presence of free gas in the abdominal cavity is rarely to be observed, owing to the frequent existence of adhesions or ascites. Retention of urine is sometimes an important sign, and should diarrhoea have previously existed the sudden onset of constipation seldom fails to attract attention. Life is rarely prolonged for more than forty-eight hours.