Possibly in the same way some cases of vomiting of pregnancy are relieved where the existing intrauterine irritation is just sufficient to cause reflex gastric disturbances, and by the addition of the irritation of cervical dilatation by the physician the effect is an amelioration of the symptoms, or on the other hand by the application of cocaine to the cervix the irritation may be lessened to such a degree as to produce a similar result.

The condition of nervous irritability of the person may have considerable to do with the severity of the reflex disturbance produced. How much oftener do we see convulsions produced reflexly in infants and young children than we do in adults. We may find a woman pass through her first pregnancy with little trouble, and when reduced in strength, through lactation, become again pregnant, and in this weakened state suffer severe gastric disturbance. The most severe case of vomiting of pregnancy I have so far seen was a similar one where during the first pregnancy very little unpleasantness was experienced. The woman while nursing a fine boy became again pregnant, and so serious did her condition become from vomiting and loss of appetite that after a consultation it was considered necessary to empty the uterus in order to save her life. She rapidly regained strength and went through her third pregnancy with little inconvenience. In all probability her reflexes were so affected by her weakened state as to bring about the condition that seriously threatened her life.

The mode of onset of the irritation and the power of adaptability of the person to her changed condition have no doubt a considerable influence on the vomiting.

We find in sea sickness a reflex action where the chief factor in the causation is in all probability an increased irritation in the semicircular canals caused by the motion of the vessel. This is carried to the medulla and produces a train of reflex symptoms, the chief of which is a disturbed condition of the stomach. The more sudden the change from smooth to rough water the more certain are the symptoms of sea-sickness to be produced.

In sea-sickness also we have an example of tolerance or adaptability of the individual to its changed environment, for we find after a short time-sooner in some cases than in others— that, though the conditions causing the distress have continued, yet the symptoms of the trouble abate from an established tolerance, or the adaptability of the individual to its altered surroundings.

This may also explain why in the pregnant woman her vomiting usually ceases about the fourth or fifth month, though

the enlargement of the uterus, and consequent irritation, are rapidly increasing until the end of pregnancy.

It is said that sailors accustomed to the motion of a sailing vessel may become sea-sick on board a steamship, or vice versa, those accustomed to the steamship may become sick on a sailing vessel; acquired adaptability to one kind of motion does not protect them from the consequences of the other.

Here, again, in sea-sickness we find children are rarely affected, though we might expect the contrary from the heightened activity of their reflexes compared with that of adults, and also from the comparative ease which there is in causing children to vomit. Possibly children from their habits of constantly playing and tumbling about have become accustomed to frequent changes of position, and the motion of the vessel being somewhat similar the centres affected have acquired a greater power of adaptability to such influences.

May not some systems accommodate themselves quickly to their altered condition, and thus escape many of the unpleasant effects experienced by others?

When we find in a case of pregnancy irritation of a particular intensity acting on nerves and nerve centres particularly susceptible to such stimuli, and find such commencing suddenly in a person with little power of adaptability we cannot wonder that there may be produced a train of symptoms of serious importance, especially where the major portion of the reflex is directed towards one susceptible organ-the stomach.

Taking into account the nature of the causes producing the vomiting of pregnancy and the influences in different persons lessening or intensifying such production it may be helpful to us in endeavoring to remedy this distressing accompaniment of pregnancy when it exists.

The irritation produced in the walls of the uterus by the presence within it of a rapidly increasing body, and the stretching of muscular fibres and nerve tissue, and the increased vascularity accompanying the change cannot be obviated except to a moderate degree.

In a few cases this irritation may be beneficially increased by the additional irritation of dilatation of the cervix, but the cases suitable for this treatment are rare indeed.

Another class also small in number may be improved by applications of cocaine to the cervix, but the success in many cases is disappointing since we cannot apply the medication to the part from which the irritation arises. Medicines may be administered with a view of lessening the irritability of the

nerves and nerve centres affected, but their action also is frequently disappointing.

Oxalate of cerium and other drugs have been given with the evident intention of lessening the irritability of the nerve endings in the stomach wall, but their use has proved of little avail in the majority of cases.

The cases, where the patient feels on the verge of vomiting and a sneeze or a paroxysm of sneezing occurs and immediately dispels the impending vomiting, may give us a clue to a more rational treatment. If the patient or the physician can in any way divert the surplus energy, and have it expended in some other way than by a reversed peristaltic action of the stomach, much benefit may be derived.

In some cases the taking of food frequently may be sufficient to use up the energy as it accumulates and prevent it from exerting an intensified effect on the nervous mechanism of the stomach, for vomiting seems to result from an exalted state of stimulation.

We find that many irritating drugs taken into the stomach. in small doses cause the sensation of hunger and improve the appetite, and if taken in large doses produce greater irritation ending in vomiting.

The frequent introduction of food into the stomach may, in some cases, act beneficially by using up the energy before it has accumulated to a disturbing degree. I have seen this in seasickness where food was taken and expelled, and another meal was indulged in immediately after and retained.

Our line of treatment must therefore be as varied as the number of influences causing and modifying this distressing condition, and we must take into account the peculiarities of each patient, and the accompanying conditions to be met with in each individual case if we expect our treatment to have a beneficial effect.

Selected Article.

THE BRADSHAW LECTURE ON THE TREATMENT OF ENTERIC FEVER.*-(Continued.)

BY F. FOORD CAIGER, M.D. (LOND.), F.R.C.P. (LOND.)
Medical Superintendent South-Western Fever Hospital, Stockwell.

According to Dr. Dreschfeld, the good effects of the cold bath are readily seen. The pulse becomes slower and the tension of the artery is increased; the number of the respirations diminishes, the tongue becomes moist, and the appetite improves. The nervous system is especially relieved, the delirium disappears for a time, the patient becoming much calmer and the sleep more natural; while the diarrhea, when present, if not diminished after the first two or three baths have been given, is certainly not increased. The cold bath is contraindicated when the cardiac action is weak and irregular, the pulse intermittent, or cyanosis marked; as also with intestinal hemorrhage or perforation and in the case of old persons and young children. The chief drawbacks which appear to militate against the general adoption of the cold-bath treatment are the cumbersomeness which admittedly characterizes the procedure and the increased tendency to relapse which is observed to follow its employment. The former objection, having regard to the amount of labor involved in repeatedly placing the patient in the bath and subsequently removing him, usually proves to be well nigh insurmountable in private practice. In a hospital ward the objection has less weight, but the disinclination usually evinced by the patient and the prejudices of his relatives are factors which have to be reckoned with. So true is this that Osler, while continuing the use of the bath, says that he "prays for a method which, while equally life-saving, may prove to be, to put it mildly, less disagreeable." Although a rectal temperature of 102.2 degrees was taken by Brand as the determining point for the bath, to be repeated if necessary every three hours, with an immersion of from 15 to 25 minutes or more at a tempera

*Delivered at the Royal College of Physicians of London on Nov. 15th, 1904.

ture of 68 degrees, irrespective of the onset of shivering, many of his followers have pursued a less drastic method. Some physicians, for instance, have taken 103 degrees, or even 103.5 degrees, as the determining temperature, and have removed the patient on the occurrence of definite shivering. It is generally admitted, however, that the results obtained under these conditions in practice have fallen short of those achieved by Brand. Again, the "graduated bath," as it is termed, has been widely recommended, originally, I believe, by Ziemssen. By this method the temperature of the bath which at the moment of the patient's immersion is about 90 degrees, is afterwards rapidly reduced by means of ice to 70 degrees, or slightly lower. Sir William Broadbent, who speaks well of the treatment, is inclined to prefer immersion at an initial temperature of 80 degrees, rather than 90 degrees. The graduated bath is certainly more adapted to the condition of patients whose circulation is feeble and in whom there is much respiratory distress, those, in fact, who are unable to bear the shock of sudden immersion at the lower temperature, which, on the other hand, is of such marked value as a stimulant in cases where there is considerable nervous depression. This is equally true, whether the bath be employed as a systematic measure of treatment, or whether, as is more usual in this country, it is simply used as an occcasional weapon against an unduly high temperature.

Some thirteen years ago, Dr. James Barr, of Liverpool, advocated the treatment of typhoid fever by means of the continuous tepid bath, the patient being immersed in a tank for a period of from one to three or more weeks, in fact, if necessary, during the whole course of the fever. The temperature of the water is maintained at a level of but a few degrees below the normal temperature of the body, and in proportion as the pyrexia abates the temperature of the water is raised, until at the completion of defervescence it nearly approximates to that of the patient. Dr. Barr claims for his method that it obviates the drawbacks which are incidental to Brand's, while attaining the same good results. He states that of forty cases treated by the continuous bath a fatal result occurred in only one instance. Such a record is, of course, eminently satisfactory, but relapses, as Dr. Barr, I believe, himself admits are unduly frequent. One can hardly think that the tank treatment can be a popular one with patients and the method is impracticable under ordinary conditions in private practice.

More recently, Dr. Barr has devised a method which, though