An Unusual Case of Menstruation in Eighteenth-Century England

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“Mrs Wilson’s Case”, undated and unsigned, appears in the final volume of Hans Sloane’s Medical Correspondence and Cases (Sloane MS 4078, f. 372). Mrs Wilson’s troubles began the previous spring. She noticed in May that her tongue was occasionally sore when she ate, which she assumed must have been the result of a loose tooth cutting it. An obvious conclusion, with a seemingly obvious treatment: having the tooth pulled. But she waited until July before taking “a Friends Advice” to do just that.

Watercolour drawing of a Hunterian chancre situated on the dorsum of the tongue, 1892. The patient was a young woman, aged 22. Credit: St Bartholomew’s Hospital Archives & Museum, Wellcome Images.

Mrs Wilson’s tongue continued to worsen and she called in “an old experienced surgeon”, who prescribed medicinal gargles of all kinds. By August, it was clear that the gargles were not helping. Mrs. Wilson had a noticeable ulcer on her tongue. This time, the surgeon prescribed other remedies to treat internal blockages, possibly caused by a scorbutic or venereal problem. He gave her mild mercurial pills and purges.[1] He salivated her.[2] He applied a seton to the back of her neck.[3] He gave her a linctus.[4]

Nowadays, we might think these sorts of remedies were overkill in treating a mere mouth ulcer, when surely a topical treatment like Bonjela would do the trick! But the use of the term “ulcer” to describe Mrs Wilson’s problem is misleading for modern readers; in early modern usage, “ulcer” referred specifically to an open sore that seeped morbid matter. This was a much more serious problem. She had other symptoms, too, such as a pinching in her throat and pain in her ear and head. The swelling of her tongue kept increasing.

During treatment, the sore had been “ebbing and flowing”, which initially gave some hopes of a cure, but when a fungus developed over it, the surgeon “confessed it to be a discouraging case”. He consulted a second surgeon, who seemed to have more success. The fungus cleared up within a week, allowing the second surgeon to focus once more on the ulcer—at least until the fungus reappeared within a fortnight. This was treated quickly, but the fungus again returned again two weeks later, and started to spread up the tongue. This was becoming cyclical. Another fortnight passed, at which point both surgeons decided to consult Sloane.

One section of the case, marked “N.B.” to indicate its importance, explained that the salivation had “brought her Courses [menstruation] uopn her before the Time, but she has never had them since.” Indeed, the situation took an odd turn: “Some time after the salivation the Tongue voided Blood wch the old surgeon acknowledged might be the Courses flowing to the Part & bled her in the Foot.” Mrs Wilson had since been bled twice, but “the Blood continues to flow thither periodically”.

Mrs Wilson, it appeared, was menstruating through her tongue. This process, known as vicarious menstruation, has been neatly described in a blog post by Helen King: nature seeking an alternative path out of a woman’s body when her menstrual flow was suppressed. The dominant explanation for menstruation was that the body needed to purge itself of a plethora of blood, which men ordinarily excreted through sweat; plethora would continue to build up in a person’s body, leading to a variety of health problems if it was not released. Common forms of vicarious menstruation included nosebleeds, coughing up blood, or bleeding haemorrhoids.[5] These alternative flows might have been ‘natural’, but they certainly weren’t desirable; the new pathways had been created by the acidity of the stagnant, corrupted mass of blood.

So what did the eminent physician Sloane think? His response is cryptically indicated by the prescription that he scrawled on the top of the page in two lines of Latin abbreviations. He agreed with some of the first surgeon’s treatments, recommending first that Mrs Wilson be bled from the foot. This was a common method of drawing down a woman’s menstruation and re-establishing its correct path. He also aimed to treat the corrupted blood, which was causing the ulcer, by means of a cathartic electuary (a strong purge). Sloane, however, may have been a bit sceptical about the mercurial treatments, as suggested by his prescription for gold powder—a treatment to counteract mercury poisoning.

The tongue itself was an unusual location for vicarious menstruation, but certainly not impossible: any open sore offered a potential exit for retained blood. Helen King wondered in her blog post how patients suffering from vicarious menstruation might have reacted. Mrs Wilson’s case describes her physical pains, as well as the discouragement of the first surgeon, which hints at her experience. But perhaps the simple list of symptoms is evocative enough: swollen tongue, ulcer, fungal growth and periodically bleeding tongue. Enough said. It puts my teeth on edge.

[1] Mercury was used to treat venereal and scorbutic problems, which were thought to result from a hot, poisonous humour.

[2] A treatment that aimed to drain bad humours of the body through a continuous flow of saliva.

[3] A small surgical hole in the skin, kept open to allow drainage of bad humours.

[4] A cough medicine, presumably in this case an expectorant one to expel the phlegm in the lungs.

[5] On menstruating men, see my Wonders and Marvels post. On a periodically bleeding leg ulcer, see Sara Read’s post.

 

The Old Bailey Online: A Digital Inspiration

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Birthday Cake! Credit: Wellcome Library, London.

The Proceedings of the Old Bailey Online, 1674-1913 and I sort of grew up together. When OBP was first released ten years ago this weekend, I had recently finished my Ph.D. and started out my teaching career at the University of Saskatchewan. OBP was the cool big kid down the street whom I wanted to be like, but was always too shy to introduce myself. I saw immediately the possibilities of the new resource for teaching, with so many interesting criminal cases now available to use for lectures or assignments. It wasn’t until a couple years into the project, however, that I began to understand what OBP might mean for my own research. After all, I wasn’t working on the history of crime.

What I was working on, though, was a voluminous correspondence. Depending on what you include, there are forty-one volumes of letters written to Sloane, with an estimated seven-thousand letters. It was only by using the OBP for teaching that I began to realise that what I had in front of me was a dataset.

I had done my Ph.D. at the University of Essex, famed for its Data Archive and long-term work on various historical census projects: data was always in the air. I learned a lot about the digital potential for history from talking to the many people working on these projects, but their work always seemed to be “other” to the sort of work I do. My data, I thought, was too complex to reduce to a database. I’d tried out an Access database to keep track of my research on recipe books and that hadn’t worked very well. The Sloane letters, I was sure, would be even more complicated to reduce to fields since I wanted to analyse sufferers’ narratives about ill health, not count instances of particular health problems. While I counted myself as computer literate, I also didn’t see myself as particularly ‘techie’, as someone who might be able to build, or to imagine, something better than Access. My real problem, then, was a lack of creativity and appropriate tools.

OBP changed my way of thinking about digital history. The historians behind the site were not necessarily ones I’d have associated with that old-style computing or quantitative history. Their dataset was in many ways very like mine: both include stories about individuals. Although a user could mine the dataset for statistics, it was also possible just to search a mountain of material for a single interesting story. The data could be used in a variety of ways, according to the imagination of the user. As the project grew in size, with more information and images being added, I realised that a project does not have to be finished to be useful—and, anyway, the concept of “finished” itself is moveable in the digital world, determined according to a series of stages. The most recent addition is OBP’s connection to other digital projects. Linked data will prove to be an even more powerful tool. OBP has consistently demonstrated what good digital methodology should look like, with clear statements on how the data was entered and tagged.  

Hello Old Bailey Online, I’d like to introduce myself as a long-time lurker now that a decade has passed. Thanks to you I have been able to think differently about the potential of the Sloane letters. Your legacy for me has been the ability to imagine new tools and new questions for my own research.

Eighteenth-Century Pain and the Modern Problem of Measuring Pain

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The offending machine. A Saskatchewan example. Image credit: Daryl Mitchell, Wikimedia Commons.

I read the news about the recent study using fMRI to measure physical and emotional pain intensity right after a visit to the physiotherapist for help with my migraines. (I’ve been a migraineur since the age of eleven when a Tilt-a-Whirl ride gave me a case of whiplash.) Although there is not always a close relationship between life events and scholarly work, my migraines have shaped my interest in patients’ illness narratives. It is as both scholar and sufferer that I am troubled by the fMRI study’s implications.

Running through much of the pain scholarship is the assumption that it cannot be adequately represented by language or truly understood by others.[1] Chronic pain’s invisibility makes it difficult even for people close to a sufferer to sympathise. There has been a recent shift to trying to understand pain holistically, with the development of pain clinics where sufferers can receive treatment from a variety of health practitioners and the focus is on mind-body integration. But scientific studies of pain still often come down to one question: can you tell how much pain a patient is experiencing, either in relation to his own pain, or that of others? To this end, many have tried to find ways of measuring pain.[2]

The news is all abuzz, with headlines such as “Study shows pain is all in your head, and you can see it”. Like many previous studies, the latest attempts to provide, as Maggie Fox at NBC News puts it, an “objective way to measure pain”. Researchers applied heat-based pain to volunteers, then measured the changes within the brain using fMRI. They were able to identify a person’s relative pain, such as when one burn feels worse than another, as well as the influence of painkillers. The results of this study have the potential to be very useful when treating patients who are unable to talk or unconscious.

But there is an unsettling aspect to the study—or at least to the way in which it is being reported—in that it tries to distinguish between a real, objective pain and the experienced pain. According to the lead researcher Tor Dessart Wager quoted in the above article, the tests reveal that people really do feel pain differently: “Let’s say I give you a 48-degrees stimulus and you go ‘This is okay; I can handle it’ and I might say ‘Oh, this really hurts’… My brain is going to respond more strongly than yours. We are using this to track what people say they feel.” In other words, some people are wimps and some are stoic—and patients cannot be trusted to report the truth.

An unhelpful distinction at best: it misses out the psycho-social experience of pain of why one person might feel the pain more keenly. Age, ethnicity, status and sex all play an important role not just in a sufferer’s experience of pain, but in how others perceive what the experience should be and the trustworthiness of a sufferer’s account of pain.

It is also a potentially dangerous distinction, reinforcing as it does the idea that pain needs to be measured objectively and that technology provides the answers. The problem, as Daniel Goldberg tweeted yesterday, is that:

A report in Scientific American explains the study’s implications for chronic sufferers. The fMRI was also used to measure coping tactics for the heat-induced pain, such as mindfulness, meditation, imagination or religious belief, revealing that such methods reduce pain. Pssssst… about that: we’ve known this for a while. These sorts of methods were used long before we had effective painkillers and are frequently used by modern chronic illness sufferers.

Will measuring pain ‘objectively’ really benefit the sufferer? The use of technology for chronic pain provides a mere (if very expensive) bandaid and, to make matters worse, undermines one of the most important elements in a successful doctor-patient relationship: trust. Sometimes looking at a historical case can pinpoint the modern problems.

Lady Sondes just before her marriage. Miniature of Lady Katherine Tufton by Peter Cross, 1707. Image Credit: Victoria and Albert Museum, London.

Catherine Watson, Lady Sondes, wrote to Sloane several times between 1722 and 1734 about an unspecified illness.[3] Although she was in her late 30s, she had a litany of complaints that made her feel as “old and decayed” as someone aged fifty or sixty. Her pains ranged from headaches, gnawing leg pains, and “fullness” in her head to a stiff lip, constant fear, memory loss and “rising nerves”. She described the ways her daily life was affected. Besides being constantly distracted by pain, she worried about her legs giving out from under her or losing her memory so she would be unable to do the household accounts. These were problems for a woman who prided herself on running a large household successfully. Her descriptions were circular and repetitive, even boring, but reflected her ongoing experience: the physical pains, often not severe, nagged constantly at her throughout the day, and the fear and anxiety of what the pain might mean was all-encompassing.

Her symptoms did eventually pass, allowing her to once again go “about Busiynesse”, but the treatment had been difficult. Lady Sondes began to consult Sloane by letter when she disagreed with her regular physician’s diagnosis of hysteria. While Dr. Colby considered her ailment to be hysteria, Lady Sondes did not feel that she could trust her full story to him. Hysteria was associated with overly delicate women and a mixture of imagined problems alongside real ones, suggesting that such a diganosis may have predisposed Colby to disregard her accounts of pain. She wrote instead to Sloane who treated her “with great kindness and care”. It was not until Colby rediagnosed her as having a blood condition that she began to trust him again. A large part of Lady Sondes’ healing came from the ability to express her narrative. Sloane was not physically present; the greatest therapy he could have provided was reading her letters and answering her specific, stated concerns.

Chronic pain, with its messy emotional bits and day-to-day dullness, is encompassed within an entire life, not just a few moments spent inside a machine while clutching something uncomfortable. A crucial component of effective therapy is the trust between doctor and patient, allowing the patient to create a narrative, to be heard and to be understood. If a physician is primed to distrust a patient’s account, whether through a diagnosis or reliance on technology, the healing process will be thwarted. Sure we can measure pain, but when it comes to chronic pain, it’s not really the question we should be asking.

[1] This comes from Elaine Scarry’s influential book, The Body in Pain: The Making and Unmaking of the World (Oxford: Oxford University Press, 1985).

[2] For example, the famous McGill Pain Questionnaire. See R. Melzack, “The McGill Pain Questionnaire: Major Properties and Scoring Methods”, Pain 1, 3 (1975): 277-299.

[3] I discuss this case and others from Sloane’s letters in my article, “ ‘An Account of an Unaccountable Distemper’: The Experience of Pain in Early Eighteenth-Century England and France”, Eighteenth-Century Studies 41, 4 (2008): 459-480.

Hans Sloane and the Pit

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Headlines today: “‘Black Death pit’ unearthed by Crossrail project“. It’s all very exciting when London starts to dig deep under its surface, with various plague pits, Bronze Age transport networks and more being unearthed. I can’t help thinking, sometimes, that it’s only a matter of time before we have a Quatermass and the Pit situation!

In the eighteenth century, building on a plague pit was a matter of national concern. On 16 March 1723, The British Journal (iss. XXVI) reported that Richard Mead and Sloane had been consulted on the matter of Lord Craven wanting to build over the Pest-House Fields. As I’ve discussed before, Sloane–who was no less than a court physician and President of the Royal College of Physicians–and Mead had advised the government about preventing an outbreak in London during the Marseilles plague of 1720-22.

Human bones and skulls in a brick-built pit. Credit: Wellcome Library, London.

During the plague of 1665, William, 1st Earl of Craven, stayed in London as a member of a commission to prevent the plague’s spread. The commission recommended isolating the sick by setting up pest houses and burying the dead in plague pits. A few years after the outbreak (1671), Lord Craven purchased land near Lancaster Gate, with a Pest House Field for the use of nearby parishes: St. Paul, St. Clement Danes, St. Martin-in-the-Fields and St. James.By 1700, however, London was growing rapidly and, without a recent outbreak of the plague, the unused land was increasingly seen as a problem. In any case, with so many people around, it could no longer serve as a place of isolation if an epidemic did break out.[1]

The answer to Lord Craven’s question in 1723 was “no”. The physicians had apparently

determin’d, that the Digging them [the land] up might be of dangerous Consequence, there having been many hundred distemper’d Bodies buried there in the Plague Time.

With the memory of the Marseilles plague still fresh in people’s minds, this was probably not the best time for Lord Craven to ask! The fact that the plague experts Sloane and Mead were called in for a consultation suggests that the disposal of Lord Craven’s land was a matter of national importance. If meddling with the land could cause a plague outbreak, threatening the health of people and the economy, it should not be done.

Eleven years later, the family had greater success in determining the use of their land. Although the government did not consult Sloane and Mead this time, their decisions still erred on the side of caution. The government specified that only a hospital could be built on the site.

By the 1820s, the family had divided and leased the land, but a curious clause was written into the leases: the leasees were required to turn over the land for use during a plague outbreak. The definition of ‘plague’ was a bit ambiguous: did this refer only to plague or to any infectious disease? This became a pressing matter during the 1833 cholera epidemic, but fortunately for the tenants, the lease remained limited to plague. With plague deemed unlikely ever to happen again, a wealthy neighbourhood soon spread across the area.

Then and now, London is frequently faced with the problem of its multitude of inconvenient corpses. The ghost of the plague that haunted eighteenth-century London’s plague pits still peeks its head out every so often, but we can greet it with curiosity instead of fear.[2]

[1.] A short history of the Craven Estate can be read here: http://www.corringham.eu/cravenestate.html.

[2.] UPDATED 16 MARCH 2013: Some of us, anyhow. A slightly strange article in The Telegraph has taken the angle of trying to scare readers about the possible dangers posed by old plague pits. Darin Hayton has also picked up on some media hyperbole and commenter anxiety about the discovery, which he discusses in his post “A Dozen Medieval Plague Victims?”