way described more than twenty years after the primary treatment. It is not pretended, however, that mercury will banish the disease from the blood for ever. I think it probable it might do this if, under proper precautions, its use were persevered in for a sufficient length of time, and were followed up by an appropriate course of iodide afterwards. The time over which the mercurial course is spread is unquestionably an element in the case. On inquiry, I find the patient only remained about seven or eight months under Drs. Lizars and Dunsmure, and that he had to visit the latter about five years after for mucous patches at the fundament, but did not remain long under treatment even then. When a man has an attack of ague in an Indian jungle or an American swamp, and is cured by quinine, but years afterwards at home has a recurrence of his malady, accompanied or not by an enlarged spleen, we do not exclaim that his constitution has been ruined by the previous treatment, and insist upon the patient taking some alternative but less potent drug. If not in that case, why in that of mercury and syphilis? Mercury, when properly used, is quite as beneficent a drug as any in the pharmacopoeia. Albeit, it is frequently urged that though beneficent in other forms, it is dangerous and useless in tertiary forms; and that iodide of potassium is here the therapeutic agent, par excellence. I do not wish to underrate the iodide. It is a medicine we could not dispense with in the treatment of various syphilitic affections, but it is not going beyond the facts to say that it cannot do what mercury can do in any of them; its action differing in respect of quality, quantity, and rapidity of therapeusis. Cases might be cited, and authorities quoted, ad nauseam, in proof of this; cases which would leave no door open for question as to connection betwixt cause (mercury) and effect (rapid disappearance of symptoms); and authorities too good to be lightly set aside. My own experience has been sufficient to afford abundant illustration of my thesis; and the wider it becomes the more am I convinced that when we fail in ridding the system of syphilis either we or our patients are to blame. Either we have not given mercury a sufficiently prolonged trial, or have used it not wisely, or our patients have not given us adequate opportunity. I have never seen a patient salivated for syphilis, notwithstanding; but am acquainted with men who had the disease upwards of twenty years ago and were treated with mercury, followed with iodide of potassium-the course covering upwards of two yearsand these men are now the fathers of large families, none of whom exhibit any traces of syphilis.

OBSTINATE VOMITING IN PREGNANCY.

By W. J. BROCK, M.B.ED., F.F.P.S.G.,

Assistant Physician to the Maternity Hospital, and Assistant Dispensary Physician, Royal Infirmary, Glasgow.

I AM induced to make some remarks upon this subject of obstinate vomiting in pregnancy, from the fact that within the last five years three cases of albuminuria, during gestation, have come under my observation, in all of which untoward results occurred, and in two of these obstinate vomiting was the prominent symptom. In one of the cases, the only one of which I mean to give complete details-the others being of too short duration to warrant any lengthened comment-the history and the results of treatment are of the greatest importance in their bearing upon the much debated point of etiology.

In the first place, I shall briefly allude to the theories that have been held, and that are held at present as to the causation of this often serious malady.

The celebrated Bretonneau, of Tours (Bulletin de Thérapeutique, Août, 1846), considered from analogy that these vomitings were purely sympathetic, and depended upon a deficient dilatability of the uterus in proportion to the development of the ovum.

Dr. Grailly Hewitt, at a meeting of the London Obstetrical Society, April 1871, read a paper on the subject, which gave rise to an animated discussion. Dr. Hewitt was of opinion that an analogous cause must be in operation in the slight cases as in the more serious, and he concurred with the general opinion of the time that the sickness was due to the distending effects of the increasing contents of the uterus exciting in a reflex manner the act of vomiting; but this condition alone was not sufficient without flexion of the organ. He considered, then, that the existence of flexion was the prime causal factor of the vomiting of pregnancy, and that the slight cases, where the sickness was limited to the time of rising from bed, were explained by the action of gravity-the erect position suddenly bending the uterus on itself. To use his own words, "The compression of the nerves at the seat of the flexion, a compression increased and intensified by every circumstance increasing the degree of the flexion, is, I believe, the almost universal cause of the sickness of pregnancy. The tissues of the uterus resist expansion-this is the cause assigned by Dr. Tyler Smith. Unquestionably this is the case, but if I am

correct in my view, this resistance is not enough apart from the conjoined flexion of the organ to account for more than a small number of cases." (At this meeting Dr. Tilt, Dr. Braxton Hicks, Dr. Playfair, and others, disagreed with him on the point.) Subsequently (Brit. Med. Journal, 11th August, 1880), in speaking of Copeman's treatment, he says that he considers his method successful owing to the straightening and rectifying of the uterine distortion which resulted from the operation of dilating the os.

Dr. Barnes (Lancet, January 1873, p. 551), says the vomiting is due to stretching of uterine muscular fibre under the eccentric pressure of the growing ovum and the turgescence of the uterine vessels. He also refers to the fact that in some cases, as pointed out by Sir James Simpson, the urine is albuminous, but that this may be a secondary result of the vomiting brought about by the poisonous condition of the blood, and that it would appear to be exceptional. Further, as stated by him, at the Obstetrical Society's Meeting, April 1871, he is of opinion that flexions are often present without vomiting, and that the most obstinate vomiting occurs when there is no flexion. "In fact, there was only one constant condition, that being stretching of the uterine fibre. Growth, that kept pace with the growth of the contents of the uterus did not cause vomiting, but it was caused whenever the fibre was stretched rapidly, the distending contents outrunning the accommodating growth of the uterus. When vomiting had once become excessive, another element entered into the case. The defective nutrition was attended by impoverishment of the blood, and the blood was further degraded by absorption. of noxious materials from the system; hence a double toxemia. Concurrently with this the habit of vomiting had induced a morbidly irritable state of the spinal cord, so that it readily responded to the slightest peripheral or emotional excitement. Thus, obstinate vomiting, like chorea, was maintained by an induced irritability of the nervous centres. Vomiting, in fact, now resembled convulsive neuroses."

Dr. Henry Bennett says (Lancet, January 1875), "According to the experience of my entire obstetrical career, extreme irritable sickness, during pregnancy, is generally occasioned by the accidental existence of inflammatory mischief of the uterus, or of actual chronic inflammation of the body or of the neck of that organ."

Dr. W. M. Turner (West India Quarterly Magazine, August 1861), in an interesting paper on the subject states, "The ultimate and prime cause of this vomiting is, in my opinion,

the pressure exercised on the blood-vessels by the gravid uterus. Irregularity of the circulation is thus induced. We find oedema of the lower extremities proving this fact. Why should not the opposite part of the body suffer likewise from the same cause. The brain, for instance, must be improperly emptied and badly irrigated. Its function is disorderedhence the derangement of stomach through sympathetic media. This seems to me to be natural, at least, for by it can be explained all causes of morning sickness and all absence of it. Pressure on the blood-vessels I consider then the prime cause of vomiting in pregnancy. We know that the womb, by pressure on the vena cava descendens, does create an oedema of the lower extremities; also, we have neuralgia produced by the pressure of the same organ on the nerves, sacral plexus, &c." "It is very natural that the sickness should be so decided in the morning, for the recumbent position is eminently favourable to bringing about the pressure as mentioned. The feeling of nausea passes away as the patient stirs about, and as the circulation becomes improved and more general."

I shall give one instance more of the diversity of opinion existing on the subject under discussion, and in this case shall quote a guarded, but somewhat vague exposition of the reason for the occurrence of vomiting.

Dr. Inman (Brit. Med. Journal, Mar. 24, 1860,) says"Uterine sympathy does not hold so prominent a place as the formation of a new being, for other affections of the uterus never do produce these constant symptoms." The symptoms, he holds, do not occur in perfectly healthy and strong women, in country air. He ascribes the phenomena to "that most recondite of all subjects, vital power. It leads us to speculate upon the condition of such power in a woman who is beginning to impart some of her life to a new being.'

I believe that in the above summary I have included all the typical views of writers upon this subject.

I have perused the reports of cases recorded by some 50 European practitioners, and, strange to say, whether or no the urine has been examined by them, scarcely a case is mentioned of its having been subjected to the test for albumen. Professor Gustave Braune, Vienna, in discussing the subject of vomiting (Zeitsch. der K. K. Gesel. der Aerzte in Wien., Nos. 39 and 48, 1863) does, indeed, mention that Frerichs directed attention to the coincidence of vomiting with albuminuria and uræmia. Sir James Simpson noticed that obstinate vomiting is sometimes connected with albuminuria in the pregnant state, and

Dr. Paul Henry Stokoe, A.B., Peckham (1875), remarks that by far the most severe and protracted attacks of vomiting he had witnessed ensued from over stimulation, the sufferers losing self-control, and finding it impossible, in their intolerable drought, to refrain from incessantly imbibing huge quantities of any handy thirst quencher; and he further adds, by way of caution, that the above mentioned condition is sometimes associated with albuminous urine, even in the earlier inonths of pregnancy. In an account of Dr. Copeman's third case, where he found dilating of the os succeed, it is stated that the operation was effected on the 6th April, 1875, when the patient was at the eighth month, and was found to have albuminuria.

With some such exceptions, the cases are detailed without any reference to the condition of the urine. This is even so in a list of five very severe cases, of which three were fatal, recorded in the Medical Times of 1st August, 1863.

One of the objects in making this communication to the Journal is to impress upon all who have the misfortune to encounter a case of obstinate vomiting the importance of testing the urine, for from the rapidity with which the albumen sometimes came and went in the case about to be described, I judge that practitioners, from only one or two examinations in a case, may be apt to conclude that no albumen is present.

Before entering into the particulars of the principal case, allusion may be made to the other two which, although probably less interesting, are of sufficient consequence to be mentioned in connection with it.

I. Mrs. P., aged about 35, first came under my notice five years ago. She was then pregnant, and complained much of sickness throughout the whole period of gestation. I omitted to make any examination of the urine, and therefore cannot say whether albumen was present at this time. She stated that vomiting was always very severe and trying with her while carrying her children. Her confinement was normal. She again became pregnant about eight months after delivery and vomiting was very severe. The urine at this time was tested, and found albuminous. Sickness was relieved to some extent by various remedies, and she carried her child to full term; but at the time of its delivery she complained of haziness of vision and confusion of ideas. She made a good recovery, and I frequently afterwards examined the urine, and found it free of albumen. She again became pregnant in September, 1881, and complained, as before, of great sickness, No. 3.

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Vol. XIX.