Vomiting

VOMITING (emesis or vomitus), the involuntary, spasmodic expulsion of stomach contents through the mouth. Vomiting occurs through a series of successive and coordinated movements. After a greater or lesser period of nausea, involuntary swallowing and accelerated respiratory movements appear, often accompanied by increased salivation and tearing. Then, after a deep inhalation, the larynx rises somewhat, its opening closes due to the descent of the epiglottis, the nasal cavity is isolated by the elevation of the soft palate, the mouth opens widely, its floor and root of the tongue descend, while the tongue itself and lower jaw protrude forward, and finally the act of expulsion of stomach contents occurs. The vomiting act is mainly conditioned by the contraction of the abdominal press muscles, at which time the pylorus is tightly closed, the pars praepylorica contracts peristaltically, the fundus relaxes, the cardia opens, and the esophagus expands partly due to the relaxation of its circular muscles and partly due to the decrease in intrathoracic pressure during the preceding inhalation. Antiperistaltic movements of the stomach, which may occur during vomiting and to which primary importance was formerly attributed, play no essential role (Magendie). The vomiting act is often accompanied by enhanced peristalsis and antiperistalsis of the intestine, so that with severe vomiting, its contents may enter the stomach and be expelled outward. Usually, vomiting is accompanied by a feeling of general weakness, sweating, pallor of the face, increased pulse rate, and a drop in blood pressure, but all these quickly pass after vomiting ceases. The entire complex act of vomiting is coordinated by a special nervous apparatus consisting of a paired vomiting center and peripheral nerves connecting it with various parts of the body. The vomiting center is usually localized in the medulla oblongata in the lower part of the floor of the fourth ventricle, in the area of calami scriptorii, near the respiratory and cough centers. The sensory fibers of the vomiting reflex arc go mainly in the composition of the n. vagi (from the gastrointestinal tract, abdominal organs, dura mater), as well as in the composition of the n. glosso-pharyngei (from the root of the tongue and pharynx) and n. phrenici (from the pleura, pericardium). The motor fibers go through the n. spinales (to the muscles of the abdominal wall) and n. phrenicus (to the diaphragm). There is undoubtedly a connection between the vomiting center and the cerebral cortex (through trun-cus cortico-ponto-bulbaris), since there are cases of psychogenic vomiting, which occurs already at the sight or even only at the representation of certain repulsive things. Depending on its origin, vomiting can be: 1) central, if it is the result of direct irritation of the vomiting center itself, as for example with increased intracranial pressure, disorders of cerebral circulation, autogenous and bacterial toxemias, upon irritation of the neighboring cough center, when using certain pharmacological substances (apomorphine, lobelia, etc.) (see Emetics), and 2) peripheral, or reflex, if it occurs reflexively due to irritation of the endings of sensory nerves, as happens with diseases of the meninges and skull, with diseases and irritations of the gastrointestinal tract, organs of the abdominal and thoracic cavities, under the influence of certain pharmacological substances (e.g., emetine, etc.). The so-called artificial vomiting, caused by tickling or irritation of the root of the tongue and soft palate by inserting a finger or some other object into the mouth, also belongs here; among the ancient Romans after abundant Lucullan banquets, special long leather finger-stalls called vomiting feathers, pinna vomitoria, were used for this purpose. Artificial vomiting is used when it is desirable or necessary to remove from the stomach poisonous substances that have entered it or irritating food masses. In this case, as in many others, vomiting is a beneficial act for the body, freeing it from harmful substances, but often, especially if vomiting is frequent and persistent, it causes great harm to the body, causing a sharp weakening and exhaustion of it. Occurring in a variety of different diseases, vomiting itself gives little diagnostically, but its significance greatly increases if the connection of vomiting with other clinical phenomena, the time of its onset, the nature of the vomiting act itself, and especially the vomitus are taken into account. Vomitus can be very scanty, consisting of almost transparent, slightly viscous liquid, and, conversely, very abundant, pasty, containing varying amounts of food residues of one or another degree of digestibility. The odor of vomitus is often sour, but sometimes it can be ammoniacal, putrid (in case of processes of decay in the stomach), and even fecal. The reaction of vomitus is in most cases acidic from hydrochloric acid or acids of fermentation (acetic, lactic, butyric), but it can also be neutral with large amounts of mucus neutralizing the acids, and even alkaline during the formation of ammonium compounds during the decay of protein substances stagnating in the stomach, as well as when alkaline duodenal content flows back into the stomach. Of the impurities found in vomitus, the most important are: 1. Blood, significant amounts of which characterize bloody vomiting (see Haematemesis). 2. Bile, which often enters the stomach from the duodenum, especially with intense vomiting; it gives the vomitus a bitter taste and a yellowish (from bilirubin) or greenish (from biliverdin) color; vomiting with constant presence of large amounts of bile is called bilious vomiting, vomitus biliosus, and is observed mainly in stenosis duodeni, as well as often in cholelithiasis. 3. Fecal masses give the vomitus a brownish or dark color with a specific odor; chemically, their presence is proven by the detection of hydrobilirubin in the vomitus; fecal vomits (miserere) occur in intestinal obstruction and gastrointestinal fistulas. 4. Mucus in the form of viscous, sticky masses is encountered in particularly large quantities in chronic catarrhs of the stomach and pharynx. 5. Pus in large quantities can be found in abscesses of neighboring organs that have ruptured into the stomach and in very rare phlegmonous gastritides. - Microscopically, the following can be found in vomitus: 1) sarcinae (see Cocci) and yeast fungi (see Yeasts), indicating prolonged stagnation of acidic gastric contents in gastric dilatations due to atony or benign narrowing of the pylorus; 2) thread-like bacilli of Opler-Boas, which are considered pathognomonic for stomach cancer; 3) the fungus Soor (see Thrush) in the disseminated form of the disease with this fungus in weakened and exhausted persons, mainly in children. Vomiting is most frequently observed in various diseases of the gastrointestinal tract. All acute gastritis, both alimentary and toxic, are usually accompanied by vomiting, which is one of the main symptoms and can be quite persistent and distressing. The vomitus in this case, at first quite abundant and containing food residues, later becomes scanty, containing mucus and bile, and with intoxications by cauterizing substances - an admixture of blood and even pieces of necrotized mucosa. In chronic gastritis, vomiting occurs much less frequently and is observed mainly when the stomach is overloaded with food; it usually appears in the midst of digestion and in most cases has a relieving effect; the vomitus in this case is quite abundant and contains a large amount of mucus. Morning vomiting in alcoholics (vomitus matutinus potatorum) with abundant vomitus containing residues of food eaten the previous day and a huge amount of mucus depends partly on such chronic gastritis and partly on the accompanying pharyngitis. Similar morning vomiting with the excretion of a significant amount of mucus is sometimes also observed in patients with diseases of the lungs and especially the larynx; they are accompanied by enhanced cough caused by accumulations of dried-up mucus secretions in the upper respiratory tracts overnight. The morning nature of vomiting is often observed in certain neuroses of the stomach, especially those associated with hypersecretion; they are called vomitus matutinus nervosus and usually give abundant liquid, sharply acidic vomitus, occur in the very midst of pains in the morning or late at night, and are always accompanied by significant relief. In stomach ulcers, vomiting is not always observed, but mainly when they are located in the prepyloric part; they also occur at the height of the pains and also usually have a relieving effect on them; the vomitus is quite abundant and has the appearance of a turbid liquid with a sour odor and a sharp sour taste, leaving a sour taste on the teeth, with an admixture of clots of mucus and sometimes food residues converted into a fine-crumbly mass; bloody vomiting is observed in 40% (Obraztsov). In ulcers duodeni vomiting is usually rare.

Vomiting in gastric ectasias differs by abundant vomit masses containing remnants of food eaten long ago (sometimes several days prior), with a rancid-sour smell of fermenting or a putrid smell of decomposing gastric contents, sometimes of a foamy appearance; after them, significant improvement usually follows. In stomach cancer, vomiting may be absent for quite some time and appears more often in cancers located in the pyloric part, especially when they are decomposing or due to the development of catarrhal changes in the stomach, and eventually may become regular; the character of the vomit masses in this case often resembles that in ectasias, and sometimes they contain mostly altered blood.-Esophageal vomiting (vomitus oesophagealis) usually gives little altered food with a large amount of mucus, absence of HCl, and sometimes a putrid smell; it occurs in diverticula and dilation of the esophagus above the site of narrowing or compression. In acute intestinal diseases (enteritis, colitis, sigmoiditis), vomiting is not often observed and, if it occurs, it is usually at the very beginning of the disease. It occurs much more frequently in acute and subacute appendicitis, and it is most constant in ileus, with both the time of its onset and its character depending on the location of the obstruction: vomit masses, initially containing food remnants and an admixture of bile, gradually take on an increasingly fecal character. It is just as constant a symptom and one of the first in acute peritonitis, becoming very frequent and distressing, although in most cases it is accompanied by almost no nausea; vomit masses, initially colorless with food remnants, then become yellowish, greenish, dirty-olive, brown, and finally black. A similar picture, resembling perforative peritonitis or ileus, with single or repeated vomiting, occurs in embolism and thrombosis of mesenteric vessels. Vomiting may be accompanied by abdominal aortalgias of sclerotic and toxic origin (nicotine, alcohol, lead). In some cases, vomiting may be associated with the presence of hernias - inguinal, femoral, umbilical, and especially epigastric, as well as it can be caused by the presence in the intestine of one or another type of worms, which is particularly often observed in children. Vomiting often accompanies a number of diseases of the abdominal organs. Acute and chronic pancreatitis, acute necrosis of the pancreas are usually accompanied by vomiting. Diseases of the liver and especially the bile ducts also often accompany vomiting, sometimes even of a bilious nature, and in cholelithiasis, gallstones occasionally may be expelled in the vomit masses. From diseases of the kidneys and urinary tract, vomiting occurs in pyelitis and especially in nephrolithiasis during colic, as well as in nephritis in the pre-uremic and uremic periods. Uremic vomiting is usually very persistent and distressing, accompanied by prolonged and painful nausea; vomit masses are usually scanty, often have an ammonia smell and an alkaline reaction due to the presence of ammonium urate in them, and sometimes bile is mixed with them. Sometimes vomiting may occur even in diseases of the sexual organs - in women in oophoritis, salpingitis, metritis, perimetritis, and in men in prostatitis, inflammation of the seminal vesicles. Among diseases of the chest cavity, those of the pleura, especially the diaphragmatic, diseases of the pericardium, and sometimes acute endocarditis are most often accompanied by vomiting; vomiting is often observed with insufficient cardiac activity with signs of stagnation. Sometimes vomiting is the final act of severe coughing attacks in lesions of the larynx, trachea, tracheobronchial glands.-Vomiting has great diagnostic significance in a number of infectious diseases. It is very characteristic in cholera, where it appears soon after the onset of the disease and gives vomit masses that resemble rice water in appearance. Vomiting, usually single, often appearing at the beginning of some exanthematous diseases, mainly scarlet fever, typhus, smallpox, sometimes erysipelas, is particularly noteworthy. No less characteristic is vomiting at the beginning of lobar pneumonia and very often in cerebrospinal meningitis. Sometimes vomiting may occur in other infections - paratyphoid, relapsing fever, diphtheria, influenza, in sepsis, especially in rapidly and severely progressing forms, in malaria, and in severe cases it may have a bilious nature. In typhoid fever, vomiting is most often encountered in children. In whooping cough, vomiting often accompanies coughing attacks. Vomiting is a very constant symptom in a number of diseases of the nervous system, especially the brain. In the latter case, it is called cerebral vomiting and differs (though not always) in that it usually occurs quite easily, without distressing preceding phenomena and mainly without nausea, often on an empty stomach or when moving from a horizontal to a vertical position. It is observed in encephalitis, meningitis, tumors and other processes associated with increased intracranial pressure, especially with localization of the lesion in the posterior cranial fossa; then in concussion of the brain, hemorrhages into the brain and its membranes, in cerebral anemia and other circulatory disorders in the brain. This also includes the intense and prolonged vomiting in seasickness, as well as vomiting, which often occurs in migraine. In Meniere's disease, vomiting is one of its very frequent symptoms. From diseases of the spinal cord, vomiting may occur in myelitis, multiple sclerosis, but especially often in tabes dorsalis, where it accompanies gastric crises and is sometimes very long and distressing with scanty vomit masses; in some cases, bile and even blood may be mixed with them. Vomiting, often occurring in functional disorders of the nervous system, is called nervous vomiting (vomitus nervosus) (see Stomach, neuroses); this includes juvenile vomiting in weak, overworked adolescents, periodic crisis-like vomiting in nervous individuals, and finally hysterical vomiting (vomitus hystericus), which can have a very varied character and is distinguished by its long duration and persistence; often hysterical vomiting occurs immediately after eating completely unchanged food, mixed with saliva and mucus, and sometimes blood and even fecal masses may be present in the vomit masses; it usually has little effect on the general condition of the patients. Occasionally, vomiting may be observed in severe cases of Basedow's disease and Addison's disease, as well as in pernicious anemia.-In some cases, vomiting occurs in shock, both traumatic and operative, as well as in severe and extensive burns, and its appearance usually serves as a bad sign. Vomiting is often observed with the use of general anesthesia, especially chloroform. Vomiting is very often a symptom of pregnancy. In some cases, vomiting takes on a very persistent, prolonged (sometimes even for several weeks), intense character and then it is called intractable (hyperemesis). Such intractable vomiting may be observed in severe forms of many infectious diseases, as for example smallpox, typhoid and typhus, cerebrospinal meningitis, sepsis, as well as in acute poisonings, in uremia in terminal stages, in gastric crises and hysteria, sometimes in cardiac patients with large circulatory disorders, in migraine and finally it is most often encountered in pregnant women. Since vomiting is only a symptom and moreover of many and various diseases, no special treatment for it is undertaken. It disappears along with other symptoms as the disease itself is eliminated. However, in many cases where vomiting is especially persistent and distressing and heavily affects the general condition of the patient, it is necessary to resort to one or another measures to stop it or at least limit it. Such measures include cold on the stomach area, the patient's restful position, and various antiemetic agents (see Antiemetica). In gastric ectasias, systematic stomach lavage brings great relief. Uremic vomiting is sometimes significantly alleviated by bloodletting followed by the administration of a 10% glucose solution and even without it. Vomiting in severe forms of infectious diseases with severe intoxication is sometimes alleviated by the administration of large amounts of physiological NaCl solution. Great importance is attached to the care of the patient during the act of vomiting, especially in severely ill and unconscious patients, as vomit masses may be aspirated and cause undesirable complications. If possible, it is best to place the patient in a sitting position or semi-recumbent lateral position with the head tilted down, and a basin or tray should be placed under the mouth for the expelled vomit masses. It is very important to support the patient's head at this time, as such fixation facilitates the evacuation of stomach contents.

If, however, the patient during V. must remain in a lying position, then it is necessary to turn his head to the side and hold it in this position during the entire act of vomiting. For collecting the vomit masses, a basin is placed under the corner of the mouth or a towel folded several times is laid underneath. After vomiting is completed, the patient should be given to rinse his mouth with water, and in weak patients, the oral cavity should be cleaned with a wet swab.

A. Molchanov. Vomiting of pregnancy (emesis gravidarum), a disease affecting exclusively pregnant women and thus representing, as it were, a reaction of the organism to the introduction of the embryo into it; it is expressed in frequent attacks of nausea and vomiting. Slight nausea accompanies the beginning of most pregnancies and is considered a more or less physiological phenomenon. Sometimes, however, it takes on a more pronounced character and already passes into vomiting, which in turn can range from single, small vomits, mainly in the morning (vomitus matutinus gravidarum), which disturb the pregnant woman little and do not prevent her from her daily work, to the threatening picture of severe continuous vomiting (hyperemesis gravidarum gravida), leading to rapid exhaustion and death of the pregnant woman. When vomiting crosses the boundaries of physiology and begins to cause suffering to the pregnant woman, we speak of intractable vomiting. Intractable vomiting of pregnancy was known even in deep antiquity, first described as a separate disease by Paul of Aegina, but was exhaustively presented in 1852 by Dubois. - According to the severity of the suffering, vomiting of pregnancy is divided (Selitsky) into three main groups: 1) emesis gravidarum (vomiting of pregnancy) - frequent, mild vomits, causing some suffering to the woman, but still allowing her to continue her usual work; the weight of the pregnant woman is not sharply affected by emesis gravidarum; 2) hyperemesis gravidarum (intractable vomiting of pregnancy of moderate degree) - distressing vomiting almost after every meal, accompanied by a noticeable drop in the patient's weight and making her unable to work; 3) hyperemesis gravidarum gravida (severe, fatal, intractable vomiting of pregnancy) - almost continuous convulsive vomiting, not only when eating or drinking water, but also without such stimuli (at night); it is accompanied by a sharp drop in diuresis, the appearance of protein and pathological impurities in the urine, a sharp exhaustion of the pregnant woman, and can lead to a fatal outcome (38%, Selitsky). The frequency of vomiting of pregnancy is inversely proportional to its severity. "Physiological" vomiting accompanies almost half of all pregnancies, and according to some authors, even more. Emesis gravidarum occurs less frequently, hyperemesis gravidarum gravida - very rarely. The statistics of various authors give too wide a range of fluctuations in the frequency of intractable vomiting of pregnancy. This obviously depends on different understandings of the term intractable vomiting. Hyperemesis gravidarum gravida is already measured not in percentages, but in tenths and hundredths of a percent. Hyperemesis gravidarum affects mainly young age - 20-30 years; after 35 years, it occurs relatively rarely. The disease affects primigravidas or those who have had a history of abortion, but not childbirth, in the vast majority of cases. Intractable vomiting of pregnancy does not confer immunity; on the contrary, recurrences of intractable vomiting of pregnancy are often noted with each subsequent pregnancy. Among multiparas, those who had vomiting of pregnancy in previous pregnancies are mainly affected. Intractable vomiting rarely appears for the first time in a multipara. The disease begins to manifest in the first months of pregnancy, most often from the first day of expected but absent menstruation, continues, gradually increasing, until 3-4 months, then begins to subside and disappears by 20 weeks, but sometimes it lasts until childbirth. In very rare cases, hyperemesis gravidarum begins in the second half of pregnancy, then we are dealing with so-called late vomiting of pregnancy (Sudakov). Clinical picture. At first, there is slight vomiting in the morning; the patient does not pay much attention to it at first, considering it a physiological phenomenon. Appetite decreases, and more abundant salivation is noted (>50%). Then vomiting gradually becomes more frequent, appearing almost after every meal, and begins to seriously disturb the patient. At the same time, appetite decreases, for a time manifesting only toward certain dishes, and toward certain types of food, idiosyncrasy may develop. Increased thirst appears. As vomiting attacks become more frequent, it occurs independently not only of food intake but also of drinking. Finally, vomiting continues almost without interruption, the slightest raising of the head from the pillow causes new and new convulsive vomiting attacks. At the beginning of the disease, vomit consists of recently eaten food in various stages of gastric digestion or of secretions of the gastric mucosa (morning vomiting). As vomiting attacks become more frequent, bile enters the stomach from the duodenum, and the vomit contains a large admixture of bile. In individual cases, antiperistalsis of the intestine, caused by intractable vomiting, can give the vomiting a fecal character. Frequent vomiting attacks sharply change the blood pressure in the vessels of the stomach walls and esophagus. This leads to trauma of the mucosa and can cause an admixture of blood in the vomit. Vomiting is usually accompanied by belching. The patient's weight drops sharply, and the pregnant woman sometimes reaches extreme degrees of cachexia. Jaundiced discoloration of the sclera and skin appears. Body temperature in mild and moderate degrees of intractable vomiting is normal, sometimes even slightly lowered, but as threatening symptoms increase, it becomes subfebrile. Pulse is frequent and arrhythmic, pulse wave drops are observed, its filling decreases. Dryness, and sometimes cracks, appear on the lips. Intractable vomiting, even quite severe, can pass by itself, but in most cases requires immediate therapy, since if left to herself, the patient can die from increasing weakness, complete exhaustion, and coma. In severe cases, damage to the nervous system, degeneration of peripheral nerves, and mental disorders are observed; cases of Korsakov's psychosis have been described. One of the frequent (about 10%) accompanying symptoms in intractable vomiting is salivation (ptyalismus, salivatio), which can sometimes precede vomiting, and sometimes appears simultaneously. This salivation dehydrates the already exhausted woman (in individual cases, up to 1 liter of saliva is lost per day!). An even more severe, but rather rare complication of intractable vomiting of pregnancy is "intractable diarrhea," which can occur independently, regardless of vomiting. Laboratory examinations. Urine. The amount of urine, despite abundant drinking, sharply decreases, reaching 100.0-150.0 cm³ per day, its color becomes saturated, surface tension decreases, specific gravity increases (sometimes to 1.040 or more). Cylinders, protein, ammonia, urobilin, acetone, and acetoacetic acid appear. The presence of the latter is explained by incomplete breakdown of fats due to carbohydrate starvation. Urobilinuria is particularly sharply expressed in prolonged cases of intractable vomiting of pregnancy. The amount of nitrogen decreases mainly due to urea, whose excretion, both absolute and in percentage terms relative to other nitrogenous compounds, sharply decreases, sometimes below 50%; the ammonium index, accompanied by ketonuria, is also a result of starvation, and for determining the excess formation of acids in the blood, the percentage of ammonia is not as important as its absolute amount excreted per day (Wesselow, Wyatt). In the most severe cases, tyrosine and leucine are found. Blood. As a rule, an increase in acidosis, the presence of amino acids, indoxyl, acetone, acetic and β-oxymethyl acids are noted. According to Bockelmann, in vomiting of pregnancy, more than 100 mg% of acetone bodies are found in the blood (normally 42.8 in pregnant and 29.8 in non-pregnant women). The amount of urea and total residual nitrogen decreases. An increase in bilirubin in the blood is directly proportional to the severity of the disease and in severe cases of intractable vomiting reaches 25.0-50.0 mg%. Hemoglobinemia is noted, sometimes reaching severe degrees. The number of white blood cells increases, and red blood cells decrease, so the ratio between leukocytes and erythrocytes sharply changes. Blood pressure in intractable vomiting of pregnancy is low, in contrast to high pressure in eclampsia. Examination of the reticuloendothelial system shows a decrease in its functional capacity, and first of all, the liver's reticuloendothelial system. The liver's ability to retain sugar is decreased: oral administration of levulose gives hyperglycemia, and the curve has a "hepatic type" in the form of a high plateau, i.e., after 2 hours it not only has not returned to normal, but in some cases continues to rise. The difference between the height of the rise and the initial figure reaches 0.1 and in severe cases up to 0.2 (normally 0.04-0.06). Intravenous injections of phenoltetrachlorphthalein show a sharp slowing down of the dye excretion. The Kongroft index (KI) in vomiting of pregnancy reaches 75-90% compared to 54-75% in normal pregnancy and an even smaller figure in non-pregnant women. In the vomit, a decrease in acidity and an increase in gastric mucous secretion are noted, an admixture of bile, and, as a result of mucosal trauma, a small admixture of blood. Examination of gastric contents after an Ewald test breakfast using a thick probe also shows a sharp decrease in acidity (pH from 2.0 to 4.3 instead of normal pH = 1.8 in non-pregnant and pH = 1.45 in normal pregnancy).

The pathological-anatomical picture (Lindemann, 1892; Schickele, Solovyov, Selitsky) resembles that of eclampsia. Degenerative fatty changes of the liver, kidneys, and heart are noted. The kidney lesions sometimes reach the stage of parenchymal degeneration, while in the liver they extend to necrosis of liver cells, with necrosis mainly beginning in the center of the lobules, in contrast to the peripheral necrosis in eclampsia. In individual cases, significant reduction of the liver and spleen, edema of the brain, hemorrhages into the medulla oblongata, stomach, bladder, and under the skin have been found. Cases of degeneration of peripheral nerve trunks in the form of marked fatty decomposition of the myelin sheath (staining by Scharlach-Rot) have been described. This has led some authors to classify intractable vomiting of pregnancy as a toxemia, on a par with eclampsia. Siegert and Kronig (Fr. Siegert, Kronig) consider these changes identical to those in the edema of starving individuals, seeing in them, thus, a consequence of exhaustion of the organism. Stefko found lesions of the adrenal glands at autopsies and therefore considers their insufficiency the primary cause of V. In the liver and kidneys of the fetus, marked changes extending to necrosis have also been found. No parallelism is noted between the severity of the clinical picture and the degree of changes found at autopsy. Despite significant functional disorders of the reticulo-endothelial system, the pathological-anatomical changes in it are slight (Benda). The etiology of intractable V. remains unclear to this day. There are dozens of theories, of which the most widely accepted are: 1. The theory of pregnancy toxemia (Selitsky, Seitz, Bouffe de St. Blaise). V., in the words of Pinard, is 'the cry of a poisoned organism for mercy,' therefore continuous intractable V. is a consequence of the constant entry of a toxin into the organism. Such a toxin, poisoning the entire female organism, are the products of the implanted embryo, with most authors attributing the main role in this poisoning to the placenta. The state of acidosis found in every pregnancy and increasing in pregnancy V. was also considered by many authors a cause of intoxication, although acidosis by itself does not cause V. Interesting is the hypothesis of Polonsky and Kamenetsky, who see the cause of pregnancy V. in the dysfunction of the gastric filter, which should remove excess acids from the organism. They found in patients with pregnancy V. instead of an increase (as in normal pregnant women) a sharp decrease in the acidity of gastric contents, which intensifies the 'periodic contractions of the stomach' (Boldyrev) and leads to V. The proponents of the pregnancy toxemia theory substantiate their viewpoint with the above laboratory research and pathological-anatomical data, as well as with the fact that artificial interruption of pregnancy (removal of the source of the toxin-the egg) almost always immediately stops intractable V. 2. Nervous theories. Their proponents see the cause of intractable V. of pregnancy in a reflex from the stretching peritoneum covering the growing, especially retroflexed uterus, in irritation of the autonomic nervous system, particularly the n. vagi and the vomiting center. 3. Psychogenic theory. Its proponents (Kaltenbach, Ahlfeld, Muller, Platov, Zdravomyslov) believe that the cause of the irritation of the n. vagi may not only be toxic or mechanical but also psychic, since the visceral branches of the n. vagi and n. sympathici are in close dependence on mental representations. They assert that in each individual case a psychogenic impulse can be found. Physiological V. of pregnancy begins to take on a pathological character mainly in those women in whom the given pregnancy causes one or another mental conflict. With a strong desire to have a child, intractable V. occurs mainly in recurrent cases, i.e., in those women who suffered from it in first pregnancies when the mentioned conflict existed. The same theory is supported by the fact that first of all, all therapeutic agents for intractable V. of pregnancy act worse in extramarital pregnancy (Kronig), and secondly, the disease occurs mainly in young and non-parturient women, because in parturient women normal family relations are more common, reducing the possibility of the mentioned mental conflict. Seitz, criticizing the psychogenic theory, points out that such vomiting also occurs in animals (cats, dogs). 4. Endocrine theories. Proponents of the endocrine theory see the etiology of V. of pregnancy in dysfunction of one or another endocrine gland. Some authors see it in insufficiency of the parathyroid glands and tetany, others-in dysfunction of the thyroid gland; Sergent and Lian, Stefko-in insufficiency of the adrenal glands; Comte-in dysfunction of the pituitary gland; Hofbauer-in decreased function of the ovary, Dickson, on the contrary-in increased work of the ovary; some (Speidel)-in insufficient work of the corpus luteum and finally a whole series of authors see the etiology in carbohydrate starvation due to insufficiency of insulin in the organism. Thus, as we see, there is not a single endocrine gland that has not been considered a cause of this disease. The common shortcoming of all these theories can be considered that authors focus their attention on changes in one particular gland, whereas probably the equilibrium in the entire secretory system is disturbed. The possibility of such a combined disturbance of the equilibrium of the endocrine system is not denied even by proponents of other theories; the differences lie only in whether these changes are the primary cause of the suffering or a consequence of starvation or poisoning of the mother by products of the fetus. Treatment of intractable V. of pregnancy is extremely varied. Proponents of the toxemia theory propose injections of horse serum (R. Freund, Selitsky), serum of pregnant women, blood transfusions, auto-hemotherapy, and finally infusions of Ringer's, Fischer's, and Locke's solutions. Authors who see the cause of intractable vomiting of pregnancy in the absorption of poison from the intestine use irrigation of the gastro-intestinal tract with a gastric tube. McDonald uses a duodenal tube, introducing through it 1 liter of 4-6% Sol. Natrii sulfurici. Paddock leaves this tube in place for 8-26 days and through it feeds the patient. Proponents of nervous theories give either various anesthetic agents (cocaine, anesthesin, orexin) with the aim of lowering the increased excitability of nerve endings or narcotic (luminal, sulfonal, veronal with phenacetin, chloral hydrate, brom, mainly in enemas) with the aim of lowering the excitability of nerve centers, as well as correct the position of the uterus to reduce the reflex from the peritoneum. This can also include the application of d'Arsonval currents, galvanization and X-ray of the stomach (Frenkel). Authors adhering to the psychogenic theory treat with psychotherapeutic means, of which hypnosis and psychoanalysis should be placed in the first place. Proponents of endocrine etiology prescribe various endocrine preparations with the aim of lowering, in their opinion, the existing hyperfunction of one or another gland or to compensate for its insufficiency. Ovarin, ovoglandol, mammmin, extracts from the corpus luteum, adrenaline, thyreoidin, spermin are prescribed. This should also include the widely used treatment with intravenous infusions of insulin with glucose. Among dietary advice, the necessity to eliminate or sharply restrict the introduction of meat, to introduce large amounts of liquid, mainly milk, in small portions but frequently, stands in the first place. If food is completely retained, the use of nutrient enemas is necessary. In conclusion, all agree on the necessity for the success of therapy to isolate the patient from the home environment. Having reviewed all possible types of therapy, it must be noted that many agents are direct antagonists of others and yet give, according to reports of physicians who used them, a therapeutic effect. Obviously, the application of all these means has one common aspect playing a decisive role, namely trust in the physician, and therefore in the method used by him, i.e., the element of suggestion. In case of threatening symptoms (appearance of jaundice, pathological impurities in urine, rapid loss of weight and general severe condition of the patient), only 'therapy of despair' remains-interruption of pregnancy, which saves the patient if done NOT TOO LATE.'

V. Zdravomyslov.. Vomiting in children occurs much more frequently than in adults, being an element of a number of diseases, and sometimes representing the main symptom of suffering. The younger the child, the more frequently vomiting is observed, and in children of the first months of life it takes on a special form of spitting up, which differs from vomiting in that it occurs relatively easily in a healthy child without preliminary nausea, without tension of the abdominal press, without pallor of the face and without any unpleasant sensations for the child. The mechanism of spitting up consists only in contractions of the stomach with an open cardia and occurs under the influence of a reflex passing through the open Opkhovsky local ganglia located in the wall of the stomach in the area of the cardia and pylorus. According to Cannon, periodic regurgitations are observed on an x-ray in a cat after a significant amount of contrast mass in the form of rice broth with bismuth is poured into its stomach, and the liquid enters the esophagus and flows back into the stomach until the acidity of the stomach contents increases. Cannon considers this phenomenon physiological. Such regurgitations occur especially easily in small kittens and can be recorded by the corresponding curve (Speransky). Spitting up in children ceases with age; after 6 months it is observed extremely rarely, since the nervous regulation of stomach contractions, which apparently has the greatest significance, reaches a certain norm by this time. According to many authors, the ease of spitting up and vomiting in young children is facilitated by a number of anat.-physiol. conditions present in the child: the vertical position of the stomach, its cylindrical shape with poorly developed fundus, weak development of the cardia muscles, the relatively large liver, which acts mechanically on the stomach with changes in position, and finally the excitability of the nervous apparatus of the stomach and the vomiting center itself. However, most of these indications are merely assumptions and require proof. If we exclude acute forms of vomiting in the cases indicated above, then the clinical forms in which we encounter spitting up and vomiting in young children are divided into the following groups: a) Simple spitting up, often occurring especially with disordered breast feeding, with overfeeding, and less frequently with underfeeding of children in the first months of life. This spitting up is considered to a certain extent physiological ('spitting up children-healthy children'); by half a year it usually disappears, b) Habitual vomiting, which is observed in children with aerophagia who, with each new swallow, also swallow the air present in the pharyngeal cavity. This depends on the absence in them of the reflex act called 'swallowing breathing', which consists in the fact that at the beginning of any swallowing act we make a weak but distinct inspiratory movement produced by weak contraction of the diaphragm. This movement removes air from the pharyngeal cavity and protects the stomach from distension, which happens in a number of children who have not yet developed this reflex movement. Then, the air escaping forcefully from the stomach in the form of belching carries food along with it.^:-Further, there are children with atonia with weak gastric musculature as a manifestation of general atonia. Slight pressure on the abdomen, swaddling such children or lifting them after feeding causes them to spit up; sometimes milk flows easily from their mouth even without any external influences.- Finally, the third group consists of neuropaths. Here, in turn, it is necessary to distinguish: 1) Vomiting from cardiospasm, when unchanged milk, without any signs of stomach contents, is thrown back shortly after feeding (see. Cardiospasm). 2) Persistent vomiting occurs in pylorospasm (see), often leading to hypertrophy of the pylorus and stenosis of its opening. 3) Finally, true nervous vomiting is observed in children with other manifestations of neuropathy: anorexia, great excitability, crying, caprices, superficial sleep, etc., where vomiting is a habitual reflex that even arises psychogenically. This should also partially include children with manifestations of rumination (see Chewing). In older children, this nervous vomiting continues to exist, remaining even later in the form of easily occurring vomiting during excitement (especially in women), when riding with one's back to the direction of movement, etc. In addition, in children 4 years of age and older, the so-called acetone vomiting is observed, which also occurs in children with nervous heredity but complicated by metabolic disorders. After dietary errors or under the influence of infections, and sometimes without any discernible cause, persistent, intractable vomiting often occurs periodically, sometimes with bile, for 3-5 days. Rapid exhaustion of the body occurs with a decrease in the amount of urine, which contains protein-acetone, acetoacetic acid, indigo, cylinders. The exhaled air also smells of acetone. In rare cases, the condition progresses to a comatose state. The fight against vomiting in these cases is quite unsuccessful, but during periods free from these attacks, one should care to change the child's metabolism, establishing a regime that prevents the development of acidosis, appropriate nutrition, introducing calcium, and also strengthening the nervous system. G. Speransky.