A CASH OF HYPEREMESIS GRAVIDARUM TER- 
MINATING IN RECOVERY AFTER AN 
INDUCED ABORTION OF TWINS. 
BY 
('[.ARY T. DERCUM, M.D., 
OF PHILADELPHIA. 
FROM 
T II K M EDICAI, NEWS 
December 9,' 1893. [Reprinted from The Medical News, December 9, 1893.] 
A CASE OF HYPEREMESIS GRAVIDARUM TER- 
MINATING IN RECOVERY AFTER AN IN- 
DUCED ABORTION OF TWINS} 
By CLARA T. DERCUM, M.D , 
OF PHILADELPHIA. 
Various and many are the theories that have been 
proposed in regard to the etiology of hyperemesis gravi- 
darum, but as a matter of convenience they may be 
divided into two classes. The first is that in which 
there are local lesions present, such as displacements 
and flexions of the uterus, erosions, lacerations, and 
various structural degenerations of the cervix uteri. 
Among this class the various lesions of the gastrointes- 
tinal tract must also be included. The other class com- 
prises those cases in which no visible or symptomatic 
local lesions exist. The simple uncomplicated cases 
that occur in women of a neurotic type are considered 
as neuroses. In the first class of cases treatment should 
be directed to the local lesions present, and their cure 
generally results in an amelioration, if notan entire ces- 
sation of this affection. In the second class, however, 
treatment, to be of any avail, must be of the most diverse 
kind, and must be chiefly directed to the hyperesthetic 
nervous system, with a view of sustaining, strengthen- 
ing, and increasing its resistance to the added strain. 
Under the burden of our modern civilization the sensi- 
tive nervous system is generally the first to suffer, and 
1 Read before the Alumnae of the Woman’s Medical College, 
May 5, 1893. 2 
consequently we have developed a state of lessened 
resistance, which perhaps may be better expressed in the 
more familiar term of neurasthenia. Under ordinary con- 
ditions the individual may not be conscious of this state 
of lowered vitality, but when pregnancy occurs in such 
a one the delicate nervous apparatus shows an abnormal 
sensibility to the physiologic change that manifests itself 
in various reflex phenomena. When in connection with 
this lessened resistance there exists a local lesion either 
of the organs of generation or of the gastro-intestinal 
tract, the effect will be all the more marked. 
In the ordinary vomiting of pregnancy the food that has 
just been taken is vomited without much effort, and there is 
an absence of nausea and ptyalism, thus showing that the 
higher nervous centers are not involved in the action ; 
it is merely a reflex act, peripheral in origin, the afferent 
impulses proceeding from the stomach; it does not 
extend beyond the vomiting and respiratory centers in 
the medulla. On the contrary, however, when nausea 
and ptyalism coexist with this act the afferent impulses 
proceed from the higher nervous centers, and the act of 
vomiting occurs independently of impulses received 
from the stomach. Therefore, as nausea and ptyalism 
are always present in any case of severe vomiting of 
pregnancy, it shows that the nervous system is mostly 
at fault, and that there is a lack of coordination between 
the higher nervous centers that manifests itself by this 
abnormal action of the alimentary canal. 
I shall not attempt to enumerate the drugs that have 
been used in this affection ; their name is legion ; it is 
enough to say that those remedies that act as sedatives 
to the nervous system, such as bromids, chloral, and 
opium, have yielded the best results. 
It is understood that if there be a local lesion present 
treatment must, if possible, be directed toward its 
removal. Varied, strange, and amusing, indeed, are 
some of the accounts of the treatment of this disease. 3 
A Frenchman reports a desperate case successfully 
cured by hypnotism ; a Russian, the cure of an equally 
serious case by injections of morphin into the fetal 
sac. 
I shall now report a case that came under my own 
observation. The patient, M. T., is an American, of 
pronounced neurotic type; her family record is not 
good, as shown by the following history. The father 
died of pulmonary tuberculosis shortly before the 
daughter’s birth ; one brother has since died of the same 
disease, and another one is at present suffering with it. 
A sister died of convulsions (cause unknown) during a 
pregnancy ; the mother is still living, and has always 
been an inveterate alcoholic. The personal history of 
this woman is as follows : 
She had always been healthy until puberty, which 
occurred at sixteen years of age; she then had a violent 
attack of chorea, for which she remained at the Ortho- 
pedic Hospital three months under the care of Dr. 
Wharton Sinkler; she was married at eighteen, and 
shortly became pregnant. Up to the eighth month of 
pregnancy vomiting and ptyalism existed to a profound 
degree. About one year after the birth of her child she 
had an attack of typhoid fever. One month after 
recovery from this disease she again became pregnant, 
and vomiting and ptyalism again made their appearance, 
but in a more aggravated form, so that at one time her 
attending physician, the late Dr. Elijah B. Shapleigh, 
considered the advisability of an abortion, but as her 
condition gradually improved the idea was abandoned. I 
saw her on the 18th of March, 1892. She stated that 
she was pregnant for the third time, and that she thought 
she had been so for about six weeks, as she had seen 
nothing of her menses since the 10th of February. 
Vomiting, nausea, and ptyalism had been present for 
about four weeks, and these derangements had so 
steadily increased in severity that not even water could 4 
be retained on the stomach. The mere sight of water 
was sufficient to cause a flow of saliva, and then the effort 
made to swallow it would bring on an attack of vomit- 
ing. This flow of saliva was so profuse that, without 
exaggeration, in a few hours a quart could be collected 
by allowing it to dribble into a basin. Calomel, cerium 
oxalate, bismuth subnitrate, wine of ipecacuanha, co- 
cain hydrochlorate, soda-water, champagne, blisters and 
sinapisms to the epigastrium ; morphin and atropin, 
hypodermatically ; bromids and chloral by the rectum, 
were successively tried, without producing any effect 
whatever; the vomiting and ptyalism continued inces- 
santly, both by night and by day, and independently of 
either food or drink. On the morning of the 22d rectal 
feeding was begun, peptonized milk being used for the 
purpose; the woman’s pulse now rose to 120, and the 
prostration was extreme. Her physical appearance was 
most abject; she lay in a profound stupor, only arousing 
to perform the almost incessant act of vomiting, and 
during the intervals of the vomiting the saliva dribbling 
from her mouth over everything. She had marked 
Cheyne-Stokes respiration, and it was impossible to 
rouse her. 
Dr. Eleanor C. Jones and Dr. F. X. Dercum saw the 
woman with me on the morning of the 23d. The ad- 
visability of performing an abortion was discussed, but 
we decided to wait a little while before resorting to such 
an extreme measure. The following plan of treatment 
was instituted : Opium, bromids, and chloral by the 
bowel were ordered, to act as sedatives to the nervous 
system ; rectal feeding with peptonized milk, liquid 
peptones, and whiskey; hypodermatic medication of 
atropin, strychnin, and digitalis to support her strength. 
Two days in succession the cervix was dilated with rapid 
dilators, and iodin was applied to the canal and to the 
vault of the vagina. High rectal injections were also 
given, in order to move the bowels thoroughly, so as to 5 
be sure that the vomiting (as the matter ejected 
sometimes had a characteristic fecal odor) was not due 
to obstruction of the bowel. The food and medi- 
cines given by the rectum were retained and the patient 
soon began to show some signs of improvement, as she 
vomited only from about fifteen to twenty times in the 
twenty-four hours. Dr. Joseph Price saw the patient 
with me on the 26th ; he approved of the treatment pur- 
sued, and as her condition was slightly better advised 
that an abortion be deferred. On the 28th she refused 
further medication by the hypodermatic method, and the 
medicines that had been so administered were continued 
by the bowel, the dosage being doubled. The patien 
ceased vomiting suddenly on April 1st, after partaking 
of a lamb chop; she was, however, still partially 
nourished, as well as medicated, by the bowel. She 
gradually improved, and by April 6th all medicine and 
food were taken by the mouth and were retained. 
I was again summoned to see her on April 25th, vom- 
iting, ptyalism, and nausea having recommenced on the 
23d. The same treatment was again resorted to, but 
this time without any result. She rapidly grew worse, 
and her condition again became alarming; then the 
same stuporous state as formerly developed, with occa- 
sional intervals of violent delirium ; at times her suffer- 
ing seemed unbearable, and as she threatened to commit 
suicide she was closely watched. Active interference was 
postponed from day to day with the hope that this con- 
dition would cease as suddenly as before. 
On May 8th, after a consultation with Dr. Joseph 
Price, an abortion was performed. For this purpose 
two rubber catheters were introduced to the fundus 
and allowed to remain, the vagina being packed 
with wool to keep them in place. On the 10th, twins 
—a boy and a girl—in separate sacs, and from ten 
to twelve weeks old, were delivered ; the placental 
tissue was adherent; and on the nth, without ether- 6 
izing her (for she was in a very precarious state), it 
was detached with the aid of a curet. The uterus was 
thoroughly washed out with a solution of mercuric 
chlorid i : 4000. Although the vomiting, nausea, and 
ptyalism ceased immediately after the expulsion of the 
contents of the uterus, there was now such extreme 
prostration and emaciation as to make recovery exceed- 
ingly doubtful. Respiration was 50, the pulse 180, the 
temperature 102°. The treatment was now chiefly directed 
toward improving the strength, stimulants being freely 
ordered for the purpose. The woman continued in this 
condition, with but slight variation in respiration, pulse, 
and temperature until May 16th, when she had a severe 
chill, her temperature rising to 104°. She complained 
of intense pain during urination and defecation, and a 
physical examination revealed a mass about the size of 
a hen’s egg in the right broad ligament. Large doses of 
quinin were given her, and cantharidal blisters were 
applied to the iliac regions, with large douches of hot 
water for the vagina. An ice-bag was placed over the 
precordial region, as the heart’s action was violent and 
rapid ; this soon made an impression upon this compli- 
cation. For several weeks following the abortion the 
patient had various delusions, and at times was so 
violent that it was difficult to restrain her and impossible 
to keep her in bed; but as time passed and she regained 
strength these gradually disappeared. She made a com- 
plete recovery in almost two months. 
It seems remarkable in this case that after vomiting had 
once ceased and apparent recovery had taken place vomit- 
ing should have again recurred. I know that it is a phy- 
siologic law that the child goes on developing at the ex- 
pense of the mother, no matter what her physical condi- 
tion may be ; but nevertheless I would offer this explana- 
tion, that in the absence of all nourishment for several 
weeks the fetuses developed very slowly, and therefore 
for a little while the cause of these nervous manifesta- 7 
tions remained in abeyance, but as the nutrition of the 
mother improved and their development went on in a 
more vigorous manner the same conditions presented 
themselves. I am also of the opinion that if there had 
been but a single pregnancy it would have gone to full 
term as previously, but the reflex irritation, produced by 
the more rapidly developing uterus under the conditions 
mentioned, being so much greater, the nervous system 
could not resist it. At the seventh week of pregnancy 
the uterus was so much larger than one would expect at 
that period that she was told that she must be mistaken 
in regard to the time, i. e., was further advanced than she 
thought, but she assured us positively that she was right, 
and of course the possibility of a twin pregnancy never 
occurred to us. The Medical News. 
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