2. Vomiting

Vomiting in gastric ulcer occurs in nearly the same proportion of cases as pain. As a rule, it is absent during the first period of the disease, and appears somewhat later than the pain. Sometimes, however, both these symptoms occur simultaneously. The vomiting, most frequently met with in cases of ulcer, appears an hour or two after meals, at the time when the pain has reached its acme. As a rule, the vomiting relieves the pain. Sometimes the vomiting occurs less frequently, for instance once a day or still more seldom. The vomited matter ordi-narily consists of a watery fluid mixed with particles of food. Occasionally, however, the latter are absent and the ejected matter then consists, as a rule, of clear gastric juice which, in many cases of ulcer, is secreted in too abundant a quantity. In such instances the vomiting may occur independently of the meals, and thus may take place either in the middle of the night or early in the morning on arising.

There are also cases in which vomiting takes place very soon after meals, or where, instead of the vomiting, there is regurgitation of food. The regurgitation may also occur two to three hours after a meal (the fluid brought up consisting of very acid gastric chyme or juice) and is very often accompanied by pyrosis. Again there are cases in which instead of the vomiting we have spells of nausea. Vomiting of very large quantities of chyme, although met with in gastric ulcer, is most characteristic of cases of ulcer complicated with stenosis of the pylorus, and will be discussed later on when dealing with that affection.

3. Hemorrhage

Hemorrhage is a symptom of the greatest importance in gastric ulcer. Since the process of ulceration implies a solution of continuity in the coats of the vessels of the stomach, there is nothing more natural than an effusion of blood. As a rule, however, the opening of the vessels is very soon obliterated by the formation of a coagulum. For this reason hemorrhages occurring from the very small vessels are not of much import, and pass unnoticed by the physician or the patient. It is only when a larger vessel is corroded and a considerable quantity of blood enters the stomach that grave symptoms appear. In a typical case of such a hemorrhage the patient experiences a sensation of fulness soon after a meal, combined with anxiety. Some time afterward he feels nauseous, restless. Suddenly vomiting of a large quantity of blood occurs, having either a clear red, brownish, or black color, possibly mixed with food (haematemesis). The patient, as a rule, feels faint, his face becomes pale, his extremities grow more or less cold, and if the hemorrhage goes on uninterruptedly, death is likely to occur in consequence of the profuse loss of blood. Under such circumstances the patient soon becomes unconscious, convulsions supervene, and life is gradually extinguished.

If hemorrhage of a large vessel has taken place, it may even happen that the patient dies before any vomiting has occurred. In such instances the cause of death, if there have been no previous symptoms of ulcer, usually remains unknown until the autopsy, when the stomach may be found filled with liquid or coagulated blood. In most cases, however, gastric hemorrhage is not lethal. The blood, instead of being vomited, may pass into the intestines, and be evacuated with the stools, which then assume a blackish, tarry color (melaena). Very often both hsematemesis and melaena take place.

Blood vomiting (hseinatemesis), if present, is the most certain sign of ulcer, and its occurrence alone is sufficient to warrant a positive diagnosis of this affection. In almost one-third of his cases of ulcer, Anderson 1 found this symptom present. There is no doubt that hemorrhages in gastric ulcer appear more frequently than we are able to recognize their existence. Very often in small hemorrhages the blood will pass through the digestive canal unnoticed, the reason being that small quantities of blood mixed with alimentary residues may be changed in such a way as to be unrecognizable. Even if blood be present in the stools in larger amounts, it will sometimes pass unnoticed because the patient does not pay attention to their color, especially nowadays when every one goes to the water-closet, and is not in the habit of inspecting his passages. Not long ago I had the opportunity twice of detecting blood in the stomach of patients who apparently never had any hemorrhages. In one of them, at the examination with the tube one hour after the test breakfast, I obtained quite a quantity of blood having a black coffee-ground color (under the microscope red blood corpuscles were present). The second patient was a lady presenting symptoms of gastric ulcer.

While in the clinic, I noticed that she looked unusually pale; she also complained of feeling somewhat faint. As she had partaken of a test breakfast, I administered the stomach bucket, which came up filled with a fluid of coffee-ground color, also containing red blood corpuscles.

1Anderson: British MedicalJournal, May 10th, 1890.