HAEMORRHAGE FROM THE STOMACH. 549 



1. The appearance of the blood ejected. Vomited blood is usually 

 dark, blackish, clotted, mixed with food ; the coagula, containing no 

 air, are heavier ; sometimes it has an acid reaction from the gastric 

 juice. On the other hand, blood coming from the lungs and bronchi 

 is usually bright-red, frothy, mixed with mucus, not coagulated at first, 

 and if a coagulum does form, it contains air-bubbles and is light ; its 

 reaction is always alkaline. But we must know that blood, which has 

 been but a short time in the stomach, and has been little affected by 

 the gastric juice, may be bright red, and, on subsequent haematemesis, 

 small portions of black blood may be thrown off. 



2. Vomiting of blood is, in most cases, preceded by cardialgic at- 

 tacks and other symptoms of ulcer or cancer of the stomach ; in the 

 much rarer cases caused by congestions and fluxions, there are symp- 

 toms of hyperaemia of all the organs in the abdomen ; haemoptysis, on 

 the other hand, is usually preceded by disturbance of the respiration, 

 and of the circulation in the thoracic viscera. 



3. Intelligent patients can generally tell whether vomiting occurred 

 first and was followed by coughing, or whether, on the other hand, 

 nausea, retching, and vomiting have been excited by the coughing. 



4. In haematemesis percussion generally shows fulness of the 

 stomach, while physical examination of the chest shows no changes 

 there. In haemoptysis there is no epigastric dulness on percussion, 

 and in the thorax we almost always hear moist rdles, if there be no 

 other sounds present. 



5. After vomiting of blood, there are almost always bloody stools 

 for a few days ; after coughing of blood, instead of these, there is just 

 as often a bloody mucous expectoration. 



We cannot tell, from the vomited matters or from the stools, 

 whether the blood vomited really comes from the stomach or whether 

 it has been swallowed. In doubtful cases we should carefully exam- 

 ine the nose and pharynx, and ask the patient if he noticed any signs 

 of nose-bleed before going to bed the previous night. A careful 

 inquiry about premonitory symptoms may clear up the matter here 

 also, particularly when we suspect intentional deception. In the 

 description of the symptoms preceding the vomiting, malingerers usu- 

 ally overdraw the picture, and this fact, with the contradictory state- 

 ments they make, often assists to expose them. 



It is generally easy to decide whether the vomited matters be 

 really blood or not, although there are cases where the physician has 

 lost his presence of mind, and mistaken stewed cherries for blood. 

 Even in the black coffee-ground masses some shrunken and misshapen 

 olood -corpuscles can almost always be recognized with the microscope, 

 and a chemical examination to prove the presence of iron in the black 



