NERVOUS VOMITING may occur as an idiopathic condition, without primary gastric disorder or obvious reflex cause, then dependent upon a neuropathic con dition; or it may have origin in a ire fleeted disturbance, such as in disease of the brain (meningitis, tumor, etc.); dis ease of the spinal cord (tabes, causing gastric crises); disease of the kidneys (vomiting of or that due to stone in the kidney), etc. The vomiting occur ring in the early months of pregnancy is a well-recognized form of reflected gas tric disturbance. Nervous vomiting is especially characterized by its occurrence independent of irritation of the stomach by food, and in one in whom previously the gastric functions may have been prac tically normal; by its precipitate onset, as in cerebral disease, without marked or any preliminary nausea.
Certain forms of nervous vomiting are described occurring in neuropaths, and not dependent upon obvious reflex cause, such as the periodical vomiting of Ley den and vomiting occurring in pro foundly neurasthenic subjects. Nervous vomiting is common in hysteria. In the periodical vomiting (of Leyden), a some what rare affection, periodical attacks of violent vomiting occur at regular inter vals and in an otherwise healthy subject. The duration of an attack is from one to fourteen days. It is attended with pros tration and resembles in its general char acter the gastric crisis of tabes.
An important feature of idiopathic nervous vomiting, and especially of that form occurring in hysterical subjects, is that, although it may persist over a very long period, the bodily nutrition does not especially suffer. Commonly in these subjects but a portion of the gastric con tents is ejected during the act of emesis.
The treatment of a seizure of nervous vomiting is similar to that of the vomit ing of gastric ulcer. In the interval the underlying neurosis must receive careful attention.
CARDIOSPASM—Cramp of the inferior extremity of the pylorus and of the car diac extremity of the stomach—occurs as a symptom of neurasthenia, hysteria, etc., and, as with pylorospasm, it is often symptomatic of certain nervous affections of the stomach, such as increased secre tory activity, and increased sensibility of the mucous membrane (hypermsthesia). Cardiospasm is observed in two forms: as a paroxysmal, transitory affection, last ing from a few hours to a day or two, and as a chronic ailment which may extend over a long period. The acute seizure resembles an attack of gastralgia save that the situation. of the pain is in the region of the cardiac orifice, and thence extends into the back. There is attend ing gaseous distension of the stomach and dvspha[_ria. In the chronic affection dys phagia is more or less constant, and may become habitual as time passes, coinci dent with dilatation of the lower end of the oesophagus. From this last a diver
ticulum ultimately results, much as is the case in organic stricture. The pa tient complains that the food does not enter the stomach. Regurgitation of un changed food soon after its ingestion is then common. There is then absence of the second deglutition-murmur, normally heard immediately below the xiphoid ap pendix in a few seconds (2 to 10) after swallowing solids or liquids. From the chronic form of cardiospasm organic, malignant, and non-malignant stricture of the cardia must be separated. The treatment of cardiospasm is that of the underlying neurosis. In addition the sys tematic careful passage of a soft oesopha geal boogie or the stomach-tube must be practiced. Thoracic aneurism must first be excluded.
PYLOROSPASM—spasm of the pyloric orifice of the stomach—is of less frequent occurrence than cardiospasm. Its exist ence has been questioned, but the writer has seen a number of undoubted in stances. It occurs in neurotic, debili tated subjects, and is commonly asso ciated with hyperchlorhydria, hypems thesia, and with simple atony or with dilatation of the stomach. Ulcer may be an exciting cause. In a case of un doubted pylorospasm recently under ob servation the symptoms, briefly, were: attacks of paroxysmal pain occurring a trifle below the right of the costal mar gin, at the junction of the eighth and ninth ribs, shooting thence through into the back and across the abdomen. Un easiness and pain in the pyloric region lasting a half-hour or more would pre cede the paroxysmal pain. The attacks were induced by eating when overfa tigued, and occurred nearly always be tween 12 and 3 in the morning. The patient was of spare build and of nervous temperament. Ile was neurasthenic, overworked, and was greatly given to worry. The attacks usually were of from one to two hours' duration. Vomiting only occurred if self-induced and then cut the attack short. Lavage with hot soda solution always had a similar, but more prompt, effect. The stomach-con tents obtained by the tube during a seiz ure usually amounted to a litre (acute atony) and the acidity was high, equaling 0.3 to 0.35 free HCl (hyperchlorhydria with hyperseerction).
The treatment of pylorospasm is, as with the foregoing, attention to the underlying neurosis, and, coincidently, treatment of the associated gastric affec tion. In cases associated with hyper chlorhydria and with hypersecretion, the local employment of silver, alumnol, and of bismuth, as detailed in the treatment of ulcer and of simple hyperchlorhydria, has been of extreme value iu the writer's hands. The case mentioned was cared by this means.