As has been remarked, when the hemorrhage is scanty all the blood may escape by the bowel. Sometimes, although much less frequently, blood effused in large quantity is entirely evacuated with the stools. After hæmatemesis more or less blood is discharged by the bowel, sometimes for several days after the vomiting of blood has ceased. Blood which has traversed the whole length of the intestinal canal acquires a tarry consistence and a black or brownish color in consequence of the production of dark-brown hæmatin by the action of the digestive juices upon the hæmoglobin, and in consequence of the formation of black sulphide of iron by the union of hydrogen sulphide in the lower part of the intestine with the iron of the hæmatin. The passage of these black viscid stools is called melæna. Inasmuch as we cannot presume gastric hemorrhage to be absent simply because no blood has been vomited, it is evidently important to examine the stools for blood when the diagnosis of gastric ulcer is obscure, and also in cases of gastric ulcer where there are symptoms of internal hemorrhage not accounted for by blood vomited. It should be remembered that certain drugs, particularly iron and bismuth, may blacken the feces.
In very exceptional cases of gastric ulcer the effusion of a large volume of blood causes sudden death before any of the blood has been vomited. The autopsy shows the stomach and more or less of the small intestine distended with coagulated blood.
Hemorrhage from gastric ulcer is usually made manifest by the vomiting of blood. The quantity of the vomited blood varies from mere traces to several pounds. The color and the consistence of the blood depend upon the quantity effused and the length of time that the blood has remained in the stomach. Blood which has been acted upon by the gastric juice is coagulated, has a grumous consistence, and acquires by the formation of hæmatin out of hæmoglobin a dark-brown color, often compared to that of coffee-grounds. Blood effused in small quantity is usually vomited only with the food, and has usually the coffee-grounds appearance. The patient's condition is not appreciably influenced by this slight loss of blood. A little blood expelled after repeated acts of vomiting has no diagnostic importance. Vomiting usually occurs soon after a large gastric hemorrhage. It is the mechanical distension of the stomach rather than any irritating quality of the blood which causes the vomiting. Blood which is rejected immediately after a large gastric hemorrhage is alkaline, fluid, and of an arterial (rarely of a venous) hue. Often, however, even with large hemorrhages, the blood remains sufficiently long in the stomach to be partly coagulated and to be darkened in color. Ulcer more frequently than any other disease of the stomach causes the vomiting of unaltered blood in large quantity. But this kind of hæmatemesis is not peculiar to simple ulcer. It may occur in other diseases, such as gastric cancer, and coffee-ground vomiting may be associated with ulcer.
Copious hæmatemesis in cases of gastric ulcer appears usually without premonition, or it may be preceded for a day or two by increased pain. Its occurrence is somewhat more common during the digestion of food than in the intervals, but there have been cases of ulcer where the bleeding was favored by an empty stomach and was checked by the distension of the organ with food. The free use of stimulants and violent physical or mental exertion may excite hemorrhage. With the onset of the hemorrhage the patient experiences a sense of warmth and of oppression at the epigastrium, followed by faintness, nausea, and the vomiting of a large quantity of blood. An attack of syncope often causes, at least temporarily, cessation of the hemorrhage. But the thrombus which closes the eroded vessel may easily be washed away, so that the hemorrhage often recurs and continues at intervals for several days, thereby greatly increasing the danger to the patient. Thus, the tendency is for the hemorrhage from gastric ulcer to appear in phases or periods occupying several days.
A single hemorrhage is rarely so profuse as to cause immediate death. More frequently the patient dies after successive hemorrhages. In the majority of cases the hemorrhage is not immediately dangerous to life, but is followed by symptoms of anæmia, more or less profound according to the strength of the patient and the amount of blood lost. Prostration and pallor follow the larger hemorrhages. Dizziness, ringing in the ears, and dimness of vision appear when the patient attempts to leave the recumbent posture. Thirst is often a marked symptom. The pulse is feeble and more frequent than normal. There is often a moderate elevation of temperature (anæmic fever) after profuse hemorrhage. The urine is pale, abundant, and sometimes contains albumen (Quincke). After a few days anæmic cardiac murmurs can often be heard. Under favorable circumstances these symptoms of anæmia disappear in the course of a few weeks.
The other symptoms of ulcer, particularly the pain, are sometimes notably relieved, and may even disappear, after an abundant hemorrhage. They usually, however, return sooner or later. After a variable interval one attack of hæmatemesis is likely to be followed by others. There is much diversity in different cases as regards the frequency of these attacks and the character of the symptoms in the intervals. In a few cases recovery follows a single attack of gastric hemorrhage; in other cases the hemorrhage recurs frequently after intervals of only a few days, weeks, or months; in still other cases hemorrhage recurs only after long intervals, perhaps of years, although other symptoms of ulcer continue. Sometimes the disappearance of symptoms indicates only an apparent cure, and later the patient dies suddenly while in apparent health by a profuse gastric hemorrhage. In the rare cases of this last variety Cruveilhier has found sometimes that the ulcer has cicatrized except just over the eroded blood-vessel.
The sources of the hemorrhage in gastric ulcer will be described in connection with the morbid anatomy.
The symptoms of gastric indigestion are commonly, although not constantly, present in gastric ulcer. They may constitute the sole symptoms, in which case the diagnosis of the lesion is impossible. The most important local symptoms of gastric dyspepsia are diminution, less frequently perversion or increase, of the appetite; increased thirst; during digestion, and sometimes independent of digestion, a feeling of discomfort merely or of painful oppression, or even of sharp pain, in the epigastrium; nausea; vomiting of undigested food, of mucus, and of bile; regurgitation of thin fluids; often acid, sometimes neutral or alkaline, flatulence, with belching of gas, and constipation. In many cases of gastric ulcer the appetite is not disturbed, but the patient refrains from eating on account of the pain caused by taking food. Among the so-called sympathetic symptoms of dyspepsia are headache, dizziness, depression of spirits, oppression in the chest, and irregularity of the heart's action. Dyspepsia contributes its share to the production of the anæmia and of the loss of flesh and strength which are present in some degree in most cases of chronic gastric ulcer.
In many cases of acute perforating ulcer, as well as in some cases of chronic ulcer, the symptoms are either absent or they are but slightly marked. It has been demonstrated that in many cases of gastric ulcer the resorptive power of the mucous membrane of the stomach is unimpaired.44
44 This is shown by the experiments of Pentzoldt and Faber, who determined the length of time which elapsed between swallowing gelatin capsules containing iodide of potassium and the appearance of the iodide in the saliva (Berl. klin. Wochenschr., No. 21, 1882). Quetsch observed rapid absorption from the stomach in two cases of gastric ulcer (ibid., 1884, No. 23). It is believed that also the duration of the digestive process in the stomach is often within normal limits in cases of gastric ulcer, although exact experiments upon this point, as they require the use of the stomach-pump, have not been made in this disease (Leube).