ence of opinion between us. In cases of pregnancy where the uterus is anteflexed, and where impaction occurs, the question arises, How far is the anteflexion responsible for the impaction? There are many cases in which anteflexion is not followed by impaction, and impaction is not a necessary sequence. The clinical facts elicited by the recital of the cases quoted (see p. 68) lead to the conclusion that in these cases of impaction and anteflexion the flexion was allimportant. And this view receives a large degree of confirmation from the result of directly treating the flexion element in such cases by mechanical elevation of the body of the uterus (see p. 77).

THE VOMITING OF PREGNANCY A REFLEX ACT.

The vomiting of pregnancy is generally assumed to be a reflex act. This implies consensuous action. of three elements :

1. The irritating agent, which is local. 2. The nerve-centre--the irritation-receiving organ-which is central. 3. The muscular contractions constituting the act of vomiting.

It is rational to suppose that, as regards Nos. 1 and 2, there may be variations from the normal condition, which may affect one or the other exclusively. Thus, we may suppose that in one case the element. No. 1 is principally at fault, while in another the element No. 2 is chiefly responsible; or, in other words, supposing the irritation (excentric) in two given cases to be equal, the vomiting occurs in one case because the central system is unduly excitable, while it fails to do so in the other case on account of the central system being in a normal, not easily excitable, condition. The opposite kind of combination is, obviously, also possible. The greatest degree of vomiting would, of course, be expected to occur in those cases in which the elements 1 and 2 are both in an exaggerated plus state; and there is not only greater excentric irritation, but an increased central excitability.

There is a class of cases in which the sickness is, perhaps, chiefly due to a general feebleness or weaken

I

ing process, one result of which is a too ready ex citability of the nervous system. Under these circumstances there exists a predisposition to vomiting, the vomiting-centre1 being too impressionable, and the consecutive links in the chain of events being(1) anæmia of organs generally (including nervecentres) from deficient nutrition; (2) pregnancy; (3) slight uterine irritation; (4) reflex vomiting.

The reflex theory of pregnancy-vomiting almost necessarily assumes that the uterus, or some part of it, is the starting-point, the element No. 1 being the locality of the excentric irritation. The reflex theory of the severe vomiting of pregnancy assumes, also, that there is no essential difference between the ordinary vomiting of pregnancy and the severe, or so-called uncontrollable, form of the affection.

Most of those who look upon the uterus as playing the part of the irritating agent, connect the irritation. with the expansion this organ undergoes during pregnancy, and the consequent action upon the uterine nerves. Some-as Dr. Barnes-attribute the irritation to undue tension of the muscular structure of the uterus; others consider that it is due to direct pressure upon the nerves, produced by compression acting, either generally or particularly, at certain situations. It appears to me that the probabilities are very strongly in favour of the idea that the nerves in the neighbourhood of the internal os uteri are the nerves which are primarily irritated, and that this is brought about by tissue-compression occurring at that situation in the way previously described, or,

1 There are good reasons, as has been pointed out by Dr. Oliver (Trans. Roy. Soc. of Edin., 1889), for the conclusion that a vomiting. centre exists, though not yet sufficiently localised.

possibly, by direct compression by the indurated tissues of the cervix on the cervical ganglion, as mentioned at p. 104. That compression is present in a great number of instances is evident on looking over the cases, in which we find note of induration, thickening, incarceration, undue flexion, &c., at or near this region of the uterus. That remedies, whether local sedatives, e.g. cocaine or solution of nitrate of silver; or mechanical treatment so acting as to liberate from compression the tissues at this situation, are very frequently effectual, can only be explained by supposing that the irritated nerves are quieted by the drug, or that the irritation is made to cease by the removal of pressure.

It is important here, again, to note that compression may be present in the cervical tissues without simultaneous displacement or incarceration, or even flexion, as in one very severe case (No. 71, p. 38), in which the patient had been so far cured of a chronic anteflexion that pregnancy occurred, but the cervix was thick and rigid, and remained so.

OTHER SYMPTOMS INDICATIVE OF UTERINE IRRITATION IN CASES OF SEVERE VOMITING OF PREGNANCY.

There are few cases of severe vomiting in which other symptoms of a very important character are absent symptoms which indicate an abnormal condition of the uterus, or of organs in close contiguity to the cervix. One of these is pain-pain felt low down in the pelvis-often of a severe character, though not always severe, yet generally present. The pain. is usually more to one side, and particularly in the region of the foramen ovale. In two recent casesNos. 87 and 100-this pain was very marked, and I carefully observed its course and history. It was found to be relieved by raising the fundus, or helping it to rise out of the pelvis, and was plainly due to the condition causing the incarceration. Another symptom is tenderness to the touch on vaginal examination. The tenderness is located, as I have observed it, on the side where the pain happens to be. It is also indicative of incarceration of the uterus, or of a condition approaching incarceration; and it may be found associated with an oedematous feel in the vaginal roof, usually more or less to one side. Another symptom often associated with the pain and tenderness is a sensation of compression or pressure. One patient had a feeling as if someone were sitting on her. It is due to incarceration, or to a condition