Miscellany

For thirty years Sir Arthur Hurst has been convinced that the so-called pernicious vomiting of pregnancy is always hysterical. But the condition is still insufficiently understood and, while there should be no mortality, fifty or sixty deaths are registered annually. Hurst's teaching was accepted by some leading obstetricians and in the “Midwifery” by Ten London Teachers the belief that a toxic form of the vomiting of pregnancy exists was rejected. But most modern textbooks still discuss the differential diagnosis between the toxic and the nervous form of pernicious vomiting of pregnancy. Hurst has therefore returned to the attack in the Clinical Journal. Gibberd has rewritten the chapter on hyperemesis gravidarum in the “Midwifery.” He teaches that the rare cases in which Korsakoff's syndrome of peripheral neuritis with mental symptoms develops are toxic in origin, because of the resemblance of the clinical and pathologic findings to those produced by alcohol. But Hurst points out that it has been proved that alcohol is never per se a cause of the syndrome, which is really the result of the associated vitamin B deficiency. Whitridge Williams believed that there was no clinical distinction between the nervous and the toxemic cases and that the only reliable means of diagnosis was estimating the ammonia coefficient of the urine. An increase of this pointed infallibly to toxic vomiting and was an urgent indication for prompt termination of the pregnancy, as otherwise death would occur in a few days. But Hurst points out that the high ammonia coefficient is not due to toxemia but to the starvation consequent on the vomiting. The following is an illustration: A woman aged thirty-two was admitted to Guy's Hospital and a diagnosis of pernicious vomiting of pregnancy was made, as Dr. J. H. Ryfell found that the ammonia index was 28. There was a large amount of diacetic acid in the urine. The patient vomited