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Within the past eighteen months four cases of fatal hyperemesis gravidarum have come under my observation. Having felt so helpless in treating these cases effectually, I am impressed that the subject is one requiring further research and more careful consideration on the part of the medical profession. Having carefully been over all available literature appertaining to this subject, the fatality of a certain class is forcibly emphasized after they have assumed an aspect significant of an advanced condition.

Before attempting to treat successfully the vomiting of pregnancy, necessarily it is imperative that such cases should be classified.

In treating and observing these cases the consciousness that something was occurring in the human anatomy concerning which I was totally ignorant was unmistakable. The inclination was to ascribe the deaths to an intestinal toxemia, due, as ventured in a previous report, to a total inactivity of the functions of the digestive organs; for in three cases, for several days before death, the stomach retained liquid nourishment; and when this organ becomes retentive one is justified in hoping the danger is passed.

Only in one case was an autopsy obtained. The patient was extremely emaciated, and the liver a pale yellow, almost white, and easily pitted under pressure. The gross

appearance of the organ was not followed up by a microscopical examination, but enough was seen to suggest the conclusion that the case was probably one of acute atrophy of the liver; and on a similar hypothesis it is assumed the two other cases presented the same pathological picture.

The classification that appears most practical is the one given by Dr. J. W. Williams, of Baltimore, and which is as follows:

1. Reflex vomiting of pregnancy.

2. Neurotic vomiting of pregnancy. 3. Toxemic vomiting of pregnancy.

Under the head of reflex vomiting may be included as causative factors, malpositions of the uterus, especially retroflexions and ovarian tumors. The removal of the cause necessarily eliminates the condition.

The neurotic origin of many cases was suggested by Auquelin in 1865, but Kaltenback presented the subject before the Berlin Obstetrical Society, in 1890, in such a distinct and forcible manner that it has been given marked consideration. This class only should be seriously considered, after excluding the reflex and toxemic varieties, the latter by a careful examination of the urine.

The third, or toxemic type, is of the utmost importance, because, under that subdivision fatal hyperemesis gravidarum finds its logical place.

For a better comprehension of the condition as it exists, it is well, perhaps, to quote the opinions of some well known writers on obstetrics. With this end in view, abstracts from a paper by Dr. William S. Stone, of New York, on "Toxemia of Pregnancy," may help to solve the problem.

Winckle says: "In five per cent. of the cases vomiting is of no consequence, while in two-thirds of the cases it

occurs after eating. In thirty-five years he has never had to perform an abortion on account of it."

Lusk declares that "it is usually the part of prudence to do nothing for the ordinary morning sickness or continuous nausea, unless the general nutrition of the patient is disturbed." For some cases he suggests Stenfort's advice, to "let the wife go on a visit to her mother." (This furnishes a serviceable hint in the way of practice.) When the vomiting is uncontrollable, a resort to abortion may be necessary. "Remember," he says, "vomiting stops.

after the third month."

Barnes remarks: "It appears to us that incoercible vomiting induces or aggravates organic changes in the liver and kidneys. We have seen it is the first symptom of acute yellow atrophy of the liver.”

The American Text-book of Obstetrics avows that "the progress of our knowledge of the pathology of pregnancy gives good reason for the belief that nausea and vomiting are not physiological, but pathological, accompaniments of pregnancy.”

Jewett defines the vomiting as "pernicious when it is so severe and persistent as to seriously jeopardize the woman's life, and when it will not yield to the usual remedies."

As Dr. Stone remarks: "The general conclusion drawn from the various text-books is that pernicious vomiting of pregnancy is a condition whose pathology is unknown."

Dr. J. Shortridge Williams, Professor of Obstetrics at the Johns Hopkins University, has recently written a widely published and able paper on the "Pernicious Vomiting of Pregnancy." Therein he states that "“at present we are absolutely ignorant of the nature of the toxic substance, or substances, concerned; though it would seem, with our present knowledge, that there is a disturbance in

the metabolism, and directly connected with pregnancy, though whether derived from the mother or fetus, or both, is unknown. All we can say is, that in some cases of pernicious vomiting we have to deal with a toxemia, which gives rise to serious lesions of the liver; and, later, in the kidneys. That the latter are secondary in character is indicated by the fact that the urine does not contain albumin until shortly before death.

Dirmoser, Vienna, has made a careful examination of the urine in twenty cases. He believes that hyperemesis gravidarum is due to a toxemia from the intestines. The growing ovum causes a reflex irritation of the vagus and sympathetic nerves, which disturb the secretions of the alimentary canal, so that the by-products of the albuminous substances are absorbed. In favor of this theory is offered:

Ist. The presence of a number of proteid bodies in the urine.

2d. Experimentation shows that injections from the contents of the small intestines soon produce death.

There is no fixed time as to when the pernicious vomiting may occur. The cases under observation happened in the early months; in fact, before the end of the fourth month. According to Maurice Gerst, "forty-two per cent. of all women vomit during pregnancy."

This emesis is more frequent in primiparae, and, as a rule, increases in severity until the third month. The average duration covers that period; and in seventy-two per cent. has ceased by the fourth month.

Autopsies on fatal cases of hyperemesis gravidarum show identically the same result: Changes in the abdominal viscera simulating acute yellow atrophy of the liver.

For practical purposes the following report of an autopsy, held on one who had succumbed to pernicious

vomiting of pregnancy, is tendered in full from the writings of Dr. William S. Stone, of New York:

"Abdomen: No signs of peritonitis.

"Liver: Markedly retracted from anterior abdominal wall, appeared much smaller than normal; did not reach free border of the ribs surface wrinkled..

"Color: Light-yellow; easily pitted under finger pressure; fatty appearance.

"Microscopical Examination: The cells have undergone fatty degeneration, etc.

"Stomach and Intestines: Black coffee-ground fluid in intestines, which gave Hemin test.

"Mucosa: Normal.

"Spleen: Color dark, normal size; capsule smooth; cut surface showed congestion, etc.

"Pancreas: Macroscopial examination, normal.

"Microscopic examination showed mild cloudiness of parenchyma.

"Kidneys: Normal size; consistency, fim; color, light yellow; capsules, smooth; stripped easily; surface, smooth; cortex somewhat thickened, color yellow. Microscope showed intense fatty degeneration of parenchyma, especially of convuluted tubules. No evidence of any chronic nephritis.

"Uterus and Appendages: Normal."

Now as to the clinical manifestation of the condition presented to us in actual practice: The first case, a primipara, aged twenty-six, four months pregnant, was seen with Dr. Ralph M. Thomson, of Savannah. She began vomiting soon after conception, and continued without any abatement. The patient was confined to bed, listless, with rapid pulse and occasional delirium. At my suggestion it was considered advisable to remove her to the Park View Sanitarium, in order that she might be under

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