This variety closely resembles that which ensues from simple ulcer, and is generally evidenced by the vomiting of six to eighteen ounces or more of blood. This copious bleeding is usually brought about by the destruction of a medium-sized vessel in the submucous or subserous tissue of the stomach, but occasionally it arises from sloughing of a vascular growth, or from ulceration of an artery of some neighbouring viscus. It is most frequent when the orifices or the lesser curvature are the seat of disease, and is hardly ever encountered in growths which produce extreme stenosis of the pylorus. Brinton estimated that this form of haematemesis occurred in 7 per cent, of all cases of gastric cancer, but our own statistics indicate a frequency of 10.8 per cent. The colour of the vomit varies according to the rapidity of the effusion and the length of time the blood has remained in the stomach, sudden haemorrhage and immediate vomiting being evidenced by the rejection of bright clotted blood, while a more tardy expulsion renders it darker in colour and more fluid in consistence. In many cases the haematemesis occurs without premonition, but in others it is preceded by a sense of heat or fulness at the epigastrium, palpitation, a peculiar taste in the mouth, nausea, faintness, dyspnoea, or even convulsions.
The symptoms vary according to the severity of the haemorrhage and the condition of the patient. If the loss of blood is strictly moderate in amount and the general nutrition good, the patient exhibits the usual signs of loss of blood. The face becomes pallid, the skin cold and clammy, and there is great restlessness and a desire for air. The pulse increases in frequency but diminishes in volume, and there is usually complaint of weakness, faintness, or vertigo. Occasionally palpitation, dimness of vision, noises in the ears, or a sense of emptiness and sinking at the epigastrium, are notable features of the attack. Dryness of the mouth and thirst are invariably present. During the continuance of the haemorrhage the pulse is quick, small, and compressible, and in bad cases may cease to be felt at the wrist, while the temperature of the body is markedly depressed.
As soon as the bleeding has ceased a certain amount of reaction sets in, and the pulse increases in volume, though it still continues to exhibit the compressible and jerky character of an incompletely filled artery. The temperature also recovers itself, and may even rise one or two degrees above the normal, but the febrile reaction is much less noticeable than in cases of simple ulceration. During this period the cheeks become slightly flushed, the eyes sunken and surrounded by dark lines, the lips dry and cracked, and sordes may collect about the teeth. Owing in great measure to the prohibition of solid food, the tongue is dry and coated with a grey or brown fur, while the palate and throat are apt to be attacked by thrush. Thirst is always a prominent symptom, but all desire for food is absent. Among the minor symptoms, throbbing in the head, noises in the ears, palpitation, insomnia, and uncontrollable restlessness are the chief subjects of complaint.
As a rule the gastric symptoms remain temporarily in abeyance, and even when severe pain has preceded the haematemesis it almost invariably subsides for the time. The bowels are confined, and it may not be until they have been opened once or twice that a black appearance of the stool proves that some blood has found its way into the intestines. In other cases the first evacuation is found to contain blood, and several liquid tarry motions are passed in rapid succession. The amount voided in this manner is usually in inverse proportion to the quantity vomited.
When the haemorrhage occurs at a late stage of the disease, the symptoms are often modified by the low vitality of the patient. Thus, in many instances vomiting is absent, and an attack of syncope or collapse, followed by intense prostration, constitutes the only indication of the loss of blood. In others the first attack is followed by continuous vomiting of coffeeground material, or small quantities of bright blood continue to be rejected at intervals. Not infrequently the bleeding is followed within a few days by intense pain after food, which prevents the administration of nourishment and leads to rapid loss of strength. Lastly, the haemorrhage may induce a semicomatose condition, from which the patient never rallies, or it is followed by pneumonia, profuse diarrhoea, or suppuration of the parotid gland, which rapidly destroys life. It is very rare for moderate haematemesis to recur at distant intervals.