FATAL NAUSEA AND VOMITING OF 
PREGNANCY, 
WITH REPORT OF CASES. 
BY 
EDWARD P. DAVIS, A.M., M.D., 
OF PHILADELPHIA. 
FROM 
THE MEDICAL NEWS, 
June 2, 1894. [Reprinted from The Medical News, June 2, 1894J 
FATAL NAUSEA AND VOMITING OF 
PREGNANCY, WITH REPORT 
OF CASES.1 
By EDWARD P. DAVIS, A.M., M.D., 
OF PHILADELPHIA, 
In 1888, Graily Hewitt, of London, an Honorary 
Fellow of this Society, contributed a paper on 
" Severe Vomiting During Pregnancy," in which he 
drew attention to anteflexion and impaction of the 
pregnant uterus as conditions encountered in these 
cases and undoubtedly concerned in their causation. 
It is my purpose to report three cases of fatal 
nausea and vomiting of pregnancy, in two of which 
conditions described by Dr. Hewitt were present, 
and in one of which a pathologic condition of 
suggestive interest and rarity was observed. I 
desire also to call attention to certain clinical signs 
of value in the prognosis in these cases as indicating 
a dangerous condition of the patient. The clinical 
histories are briefly as follows: 
Case I.-Mrs. A., a widow, had been treated for 
several months by a physician who supposed her to be 
suffering from chronic gastritis. An expert physi- 
cian who saw her in consultation had confirmed the 
diagnosis and approved the treatment. Her symp- 
1 Read before the American Gynecological Society, at its 
annual meeting, Washington, May 29 1894. 2 
toms attracted the attention of a medical student 
boarding in the 'house, who suggested to the 
family that disease of the pelvic organs might be 
present, and that a vaginal examination be made. 
I was asked to see the patient in consultation by the 
physician in charge. She was emaciated, with a 
rapid, feeble pulse, sordes beginning upon the teeth, 
her eyes sunken and glassy, her breath offensive, 
and emaciation well marked. She was vomiting 
food taken, together with mucus stained with coffee- 
ground material. 
She complained of pain in the chest beneath the 
sternum. Her intellect was clouded, although usu- 
ally her mind was clear. Vaginal examination 
revealed a uterus enlarged several times the usual 
size ; it was retroverted, the os and cervix exceed- 
ingly soft. The finger readily entered the cervical 
canal, but found the internal os closed. As the 
patient was without systematic care, she was urged 
to go at once to a hospital where trained nurses 
could attend her. Twenty-four hours after this she 
was removed to the Philadelphia Polyclinic; a 
tampon of carded wool was placed beneath the 
uterus, and the patient was carefully fed by rectal 
injections, and stimulated hypodermatically. The 
uterus was readily raised, and its altered position 
gave the patient no increased distress. Her vomit- 
ing ceased, she retained food given by the rectum, 
and also very small quantities of food taken by the 
mouth. The tampon was removed, the fundus of 
the uterus brought higher in the pelvis, and sustained 
by a packing of gauze. The patient's general con- 
dition, however, grew worse, purpuric spots appeared 
upon the body, sordes increased, low delirium 
supervened, and she died apparently from exhaus- 
tion. 
Permission for a post-mortem examination could 3 
not be obtained. As the pregnancy, if present, was 
illegitimate, nothing was said to her family regard- 
ing its existence. The size and shape of the uterus 
and its consistence were those of pregnancy ad- 
vanced several months, and a close examination of the 
history of the case supported this view. The points 
of clinical interest in the case were the coffee-ground 
vomit, and profound disorganization of the blood 
as evidenced by extensive purpuric areas. 
Case II.-This case was that of a woman, aged 
thirty years, who was first seen two years ago, and 
who complained of suffering caused by dysmenor- 
rhea, accompanied by anteflexion and prolapse of 
the uterus. She experienced relief at that time by 
the use of carded wool tampons. She passed out of 
observation, and came to my notice again in October, 
1893, stating that she had received treatment from 
another physician; that she had, she thought, 
suffered from abortion ; that she was then pregnant 
about two weeks. I afterward learned from the 
physician who treated her that granular degeneration 
of the cervix had been present, with a greatly soft- 
ened and patulous os uteri, with extreme anteflexion. 
In addition to the usual discomfort of early preg- 
nancy, the patient suffered from intense nausea and 
vomiting. She had always been of nervous temper- 
ament and lacking in self-control. She complained 
that, in addition to vomiting, she suffered severely 
from straining and retching. She was informed 
that her condition required very careful attention, 
and various remedies were given her; her diet was 
regulated, and peptonized milk, broths, and other 
suitable food were systematically given. She grew, 
however, steadily worse. As she was in a boarding- 
house, she was urged to hire a trained nurse, and to 
remain in bed or to change her quarters to a 
hospital where skilled nursing could be obtained. 4 
Her progressive increase in substernal pain and her 
persistent straining and retching seemed grounds 
for grave anxiety. She refused a vaginal examina- 
tion, and did not appreciate the danger of her con- 
dition. She declined to accept my advice, and 
sought treatment from Dr. Elizabeth Greenbank, to 
whom I am indebted for notes of the case until I 
saw the patient in consultation before her death. 
Dr. Greenbank records that the patient's temper- 
ature was subnormal, her pulse remaining below 
i oo, her condition exceedingly variable, substernal 
pain, occurring in the early evening, being espe- 
cially severe. The patient finally allowed Dr. 
Greenbank to make a vaginal examination, when 
marked anteflexion with prolapse of the uterus were 
found. This examination greatly increased the 
patient's distress. She finally secured a house of 
her own, and accepted a trained nurse. Her pulse 
gradually increased in frequency, and at the end of 
the thirteenth week of pregnancy rose above 100. 
At the end of the fourteenth week of pregnancy, 
I saw the patient in consultation with Dr. Anna 
Broomall; her pulse was 120, her temperature nor- 
mal, her tongue slightly coated; she was but little 
emaciated. The uterus was anteflexed, the fundus 
low, the lower segment impacted in the pelvis. 
Under partial anesthesia, the uterus was raised and 
the vagina tamponed. Coffee-ground vomit was 
present, although in slight amount; substernal 
distress, however, continued and was excessive. On 
the day following the replacing of the uterus, the 
patient's symptoms were aggravated. On the second 
day following the first consultation, the tampon was 
changed, and the uterus was found considerably 
higher in the pelvis. On the third day, another 
consultation with Dr. Broomall was held, and I urged 
that the cervix be dilated, and gave an unfavorable 5 
prognosis. Dr. Broomall urged that the stomach 
be washed out at the same time. Under chloroform, 
the internal os was found to be rigid, thickened, and 
tightly closed. The finger could not enter the 
uterus, and the bladed dilator was used until the 
finger could be inserted. This dilatation was in- 
creased by the use of the solid metal bougies until 
the index finger entered easily. The stomach was 
thoroughly douched with dilute saline solution. 
Following this dilatation, the patient's vomiting 
ceased, her substernal distress ceased entirely, and 
she spent the best night for two weeks. Her pulse 
was 130, her temperature 990. In the afternoon, 
her temperature rose to ioi°. At 6 p.M., a chill 
occurred, with temperature 102.6°. This was followed 
by syncope from which the patient slowly rallied. 
Pain and hemorrhage supervened, and I saw the 
patient at n p.m. She was excessively weak, but 
conscious, and complaining of labor-pains only. 
Her vomiting and substernal distress had entirely 
ceased. At her urgent request and that of her 
husband, it was decided to terminate the abortion 
at once. She recognized the hopelessness of her 
condition, but begged to be relieved of the pain of 
abortion and excessive weakness. She was accord- 
ingly stimulated by hypodermatic injections, and 
under chloroform the fetus was quickly removed, 
and the uterus thoroughly curetted with the blunt 
douche-curet. It was then packed with iodoform- 
gauze, and carried well up into the pelvis. There 
was no hemorrhage during the emptying of the 
uterus; the patient rallied from the anesthetic, 
became conscious, but died in syncope shortly after- 
ward. 
The post-mortem examination was made by Dr. W. 
M. L. Coplin, in the presence of Dr. Broomall and 
myself, sixteen hours after death. The color of the 6 
body was yellow; the conjunctivae were clear ; the 
mucous membrane reddish. Slight subcutaneous 
edema was universally present. Rigor mortis was well 
marked, except on the abdominal walls, which were 
flaccid. The body was not entirely cold, although 
surrounded by ice. An incision was made from the 
tip of the sternum to the pubes. The subcutaneous 
fat was abundant, firm, and bright-yellow. The 
extra-peritoneal fat was also abundant. The omen- 
tum was fat, containing fatty masses along the colon. 
The fundus uteri was one inch below the umbilicus. 
The peritoneum and intestines were normal; no 
evidence of septic paresis was present. Both tubes 
and ovaries showed no gross evidence of disease. 
The uterus was slightly edematous to pressure. The 
spleen was vascular, not enlarged or especially soft- 
ened. Both kidneys were flabby in consistence, and 
the cortex stained bright-yellow. The liver was 
normal in shape, the gall-bladder normal, the liver- 
substance of normal consistence and bile-stained. 
The uterus, tubes, and ovaries were removed. 
Longitudinal section of the entire uterus was made 
through the anterior wall. The uterus was dis- 
tended with gauze, and was dark purplish-red in 
color, its sinuses filled with soft currant-jelly masses, 
not clotted. On the posterior wall, on a line ex- 
tending between the orifices of the Fallopian tubes, 
a transverse line resembling scar-tissue could be seen. 
The internal os had been dilated, but was exces- 
sively resistant, resembling gristle. The placenta 
had been attached over the fundus and the orifice 
of the left tube; a small portion of the placenta 
remained adherent. No other portions of the ovum 
or appendages remained in the uterus. The uterus 
had evidently been curetted and practically emp- 
tied. No evidence of injury to the organ from 
dilatation or curetting could be detected. On 7 
the anterior and posterior walls of the cervix 
were areas of fibrous tissue, excessively firm, re- 
sembling that extending transversely across the 
posterior surface. In dilating the uterus these 
tissues had expanded more laterally than antero- 
posteriorly, although careful examination failed to 
reveal evidence of injury to them. 
The stomach was long, narrow, filled one-half 
with fluid; areas of thrombosis were visible along 
its greater curvature. The stomach was ligated and 
removed unopened. The diaphragm was punctured, 
and an effort was made to remove the heart by in- 
serting the hand into the chest. The heart was 
excessively friable. The valvular apertures admitted 
two fingers; no evidence of atheroma was present. 
The heart-substance was dark-red, very flabby, and 
tore easily. The pleurte were smooth, non-adherent, 
and tough. The lungs were collapsed and contained 
air in portions; the substance was normal. One 
lung was removed and examined. The pancreas 
was apparently normal. 
Especially noteworthy was the condition of the 
blood, which was fluid, dark currant-jelly in color, 
and without clots. No ante-mortem clot was found 
in the sinuses of the uterus. Also remarkable was 
the flabby condition of the heart, kidneys, spleen, 
and uterus, and the stained appearance of the par- 
enchyma of all the viscera ; this staining was with a 
dark currant-jelly fluid. 
The patient died a cardiac death. 
A close examination of the uterus revealed an 
exceedingly interesting condition of the cervix; 
this part of the womb was composed of dense con- 
nective tissue arranged in whorls; amid this tissue 
were found two cysts, one an inch and a quarter in 
diameter, the other half its size. These cysts con- 8 
tained thick, transparent, yellow, gelatinous sub- 
stance, which on microscopic examination was 
found rich in small, ovoid cells without nuclei, the 
protoplasm in a granular condition. These were 
undoubtedly retention-cysts from retained secretion 
of mucous follicles. No bacteria were found in the 
cervix, although it is quite possible that parasitic 
growths were present. Microscopic examination of 
the liver showed the parenchyma in a state of granu- 
lar degeneration. A very interesting phenomenon 
shown in microscopic sections of the kidneys is the 
presence of hyaline casts in situ, which are freely dis- 
tributed throughout these organs. The illustrations 
appended, showing the cervix and cyst, and the 
walls of the cysts, are the work of Dr. David Bevan, 
Instructor in Microscopy in the Jefferson Medical 
College. The various tissues in the case were 
examined in the pathological laboratory of Drs. 
Coplin and Bevan. 
Referring to the notes of the patient's condition 
during the last two weeks of her life, we find that 
albumin and hyaline casts were found in consider- 
able quantities. 
In reviewing the history and pathology of this 
case, I desire to call attention, first, to the condi- 
tions present in the pelvis: marked anteflexion of 
uterus, the neck of which was composed of dense 
connective tissue; the presence of retention-cysts 
in its cervix, the impaction of the uterus against 
the symphysis, and the excessive tenderness of the 
pelvic tissues were certainly irritant cause enough 
for reflex vomiting. The hematin-staining of the 
patient's tissues, the fatty degeneration of the vari- 9 
Eig. x. 
Vertical section of uterus, showing cyst in posterior wall 
of cervix. 
ous portions of the body so extensively present, and 
the great softening of the heart-muscle, point to 
fatal anemia. This fatty degeneration was largely 
responsible for the fact that the patient seemed but 10 
Fig. 2. 
Dense connective tissue in cyst-wall. 
little emaciated, and this appearance of nutrition 
was urged by one of the physicians in the case in 
support of a favorable prognosis. 11 
Case III.-Mrs. X. was a primigravida, the wife 
of a clergyman. She was seen in consultation by 
me at the request of Dr. Loux, of Philadelphia, who 
had been called in attendance a few days previously. 
During the first weeks of her pregnancy she had 
been subjected to homeopathic medication, which 
consisted largely of the administration of water in 
teaspoonful doses, and also comforting assurances 
regarding the future. On examination the patient 
was not excessively emaciated. Her pulse varied 
from too to 120; her temperature was not above 
990 ; she complained of very little abdominal dis- 
tress, but at night suffered from substernal pain, 
nausea, and vomiting. Vaginal examination re- 
vealed the uterus anteflexed and low in the pelvis, 
but not impacted. The physician in attendance 
had faithfully endeavored to feed the patient in 
various ways, had given sedatives, and also stimu- 
lants hypodermatically, but without avail. It was 
his opinion that prompt emptying of the uterus was 
indicated. The vomitus had been streaked with 
coffee-ground material for two days. After examin- 
ing the patient, I agreed with Dr. Loux, that inas- 
much as the uterus was not impacted, but sharply 
anteflexed, we would gain little by simply elevating 
it in the pelvis. I urged that the cervix be dilated, 
and that if this was not followed by immediate im- 
provement, that the uterus be curetted and packed 
with gauze as soon as possible. This advice was 
conveyed to the husband, who was distinctly in- 
formed that his wife was in a very critical condition. 
He asked for delay until the following day to com- 
municate with her relatives. Immediately after the 
consultation, members of his congregation persuaded 
him that the gloomy prognosis was entirely unjusti- 
fied, and strongly urged employment of a different 
physician. The second physician called in consulta- 12 
tion at once supported the view of the parishioners, 
and assured the husband that rest and feeding and 
waiting were all that were necessary, quoting the 
familiar obstetric teaching, that "cases of nausea 
and vomiting of pregnancy often improved sud- 
denly and radically, and that the practice of abor- 
tion is rarely indicated." I did not see the patient 
again, but am informed by Dr. Loux that the patient 
went steadily from bad to worse, dying from exhaus- 
tion a short time after I saw her. In her case I based 
an unfavorable prognosis upon the substernal pain, 
coffee-ground vomit, the length of time during which 
she had been in an anemic condition, and her general 
aspect, which closely resembled, though in less de- 
gree, that of the cases already described. 
In summarizing these cases, their significance to 
my mind lies in the fatal condition of anemia which 
was present. The literature of pernicious anemia in 
pregnant and puerperal patients affords abundant 
illustrations of serious impairment of the blood, 
sometimes accompanied by ulcer of the stomach 
(Leube and Fleisch, Virchow's Archiv, Ixxxiii 
1124). Atrophy of the gastric mucous membrane, 
often associated with hypertrophied polypoid villi, 
is not infrequently seen in pernicious anemia, in 
cases in which pain and coffee-ground vomit are 
familiar symptoms. The condition of the heart 
may be partially responsible for the substernal pain 
in these cases, while changes in the marrow of the 
bones of the thorax are thought by some to produce 
it (myelogenic leukemia). It is also a recognized 
fact that, in anemia, pain may be reflected to the 
central ganglia of the trunk, so that the substernal 
distress of which these patients complain may be 13 
properly considered as a reflex from a uterus in a 
pathologic condition. 
In conclusion, I desire to advance the following 
propositions, of which the cases reported are illus- 
trations : Nausea and vomiting of pregnancy are 
dangerous in proportion, as they induce pernicious 
anemia. Such a condition of danger is to be recog- 
nized by studying these cases in the light thrown 
upon them by the pathology of anemia. While it 
is possible that sudden and radical improvement may 
occur in cases in which a functional neurosis is the 
predominant factor, only when pernicious anemia 
is once established is delay dangerous, no matter at 
what period of pregnancy the patient is seen. While 
it is true that raising and sustaining an impacted 
uterus will relieve many milder examples of this 
affection, cases in which danger threatens should be 
met by prompt dilatation and emptying of the 
pregnant uterus, which are to be effected by modern 
surgical methods. The Medical News. 
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