Several years ago, when I practicing as a midwife and had a larger clinic in Carmel, Indiana, we had a really beautiful office, and within one of the offices, the aesthetic was a violet and royal blue. Beautiful space. As I was decorating the space, there were shelves within this office that needed a few more items and I don't like to have anything that doesn't have purpose so I searched for old medical books which were blue. To my surprise I found a SEVENTEEN volume obstetrical and gynecological reference set from the early 1900s and they were the perfect shade of blue!
I haven't had the time to peruse them yet, so today (as I am suppose to be doing something much more important) I randomly chose the Gynecological and Obstetrical Tuberculosis text and realized, in light of our current pandemic, taking a step back to a time when people were quarantined for tuberculosis seems rather fitting. What did we know in the early 1900s?
This particular text was written by Charles C Norris MD, and published by D. Appleton and Company, in 1926. Please know that in effort to make this more readable and because the entire post is focusing on my readings of this exact text, I am not going to offer proper APA citations of my entire discussion but know that throughout this post, it is in fact, the aforementioned and photographed text, I am referring.
The preface of said gem states that this text "contains exhaustive references to the various forms of tuberculosis which are of especial interest to the #gynecologist and #obstetrician. However, few monographs dealing exclusively with the subject have been written" (Norris, 1926). As I began reading, I wondered what "exhaustive references" meant a century ago? This, of course, was prior to electronic data systems so that meant awaiting printed journals. I remember doing research myself in libraries at the IU Med Center before we had sophisticated search engines, having to use the journal guides to find what I wanted to search and then walking the long aisles of journals to find the exact volume and issue I was searching. However, only half way through the book, even by today's standards, I would concur that Norris offers at least a very significant overview of the evidence available even still today.
History of Tuberculosis
Norris states that "tuberculosis was probably recognized many hundreds of years before Christ," (1926, p I). Hippocrates described phthisis which was three to four hundred years prior to Christ, and Colsus wrote of the three varieties of disease 30 years prior to Christ. Interestingly, some students "believe that the curse pronounced by Moses (about B.C. 1500) for disobedience had reference to #tuberculosis (Leviticus, 26: 16, and Deuteronomy, 28: 22) and that the laws recorded in the Talmud (Mischna, B. C. 500) indicated the recognition of tuberculosis in cattle" (Norris, 1926, p I).
Baillie was the first to recognize tuberculosis in other organs of the body in 1793 (exactly one hundred years before my home was built and exactly two hundred years before I graduated high school). Interestingly, the same person who invented the stethoscope, Laennec, also recognized the unity of scrofulous lymph nodes and phthisis. Genital tuberculosis was first recognized by Morgagni the same year, in 1793. Samuel Morton recommended open air for these patients which gave excellent therapeutic results but that wasn't until 1834, more than forty years after it was discovered to spread outside the respiratory system.
Interestingly, the author gives a historical linage of theories which were believed to have caused tuberculosis, including hydatids, deficient enervation, and something similar to typhoid. Tubercle bacillus was not discovered until 1882, or rather, it was discovered in 1865 by Villemin but he was unable to inoculate it. Koch achieved this by creating a lesions in the eye of a rabbit so with this replicable data, the history books record 1882 as the year the pathology of tuberculosis was first understood, and a public announcement was made in Berlin regarding the infectious nature of the disease.
Genital Tuberculosis
Morgagni was the first to recognize genital tuberculosis which was realized during an autopsy when a girl of only twenty was found to have died of tuberculosis peritonitis. Her uterus and adnexa (ovarian) was filled with caseous material and this was thought to be the primary location of the disease. Interestingly, the importance of this finding went fairly unappreciated until 1831 when two more cases were discovered, and then in 1853 when lesions were discovered in the urinary tract. Many were clearly missed as physicians not only didn't have any understanding of the pathology of tuberculosis, but "for so long the ovaries were not considered receptive to the infection" (Norris, 1926, p 3).
The fallopian tubes were identified as the most frequent site of infection within the female genital tract yet the uterus was said to be only rarely involved because the "opening from the tube to the uterus was too small." Secretions from the endometrium were tested by applying two close fitting tampons to the cervix for twenty four hours and then evaluating the secretions at the top of the tampon after removal. Tuberculosis was apparently more abundant immediately after the menses ceased and smegma bacilli (yes, the stuff in your belly button) was reported to be very similar to tubercle bacillus so that a great deal of instruction was provided to help prevent confusion between the two. The author also notes that bacteria among hay and butter were so similar to tubercle baillus that it was sometimes impossible to tell them apart (Norris, 1926).
The third chapter addressed pathology, specifically the two more popular forms found on the perineum, both ulcerative and hypertrophic. I suppose I wasn't aware of how tuberculosis presented outside the lungs, in that hypertrophic tuberculosis on the labia was often mistaken for sarcoma, carcinoma, condyloma acuminata, and true elephantiasis. Tuberculosis within the #uterus and #cervix were also discussed and admittedly, as I begin teaching another Advanced Pathophysiology course today for soon-to-be Advanced Practicing Nurses, its fascinating to realize not only were the experts in this day far more advanced in knowledge than I would have given them credit, but also, they are quite naive, even completely ignorant to important concepts we well understand today. For example, Norris reminds readers that injecting toxins into the mother was recently discovered to have potential for producing death in the fetus.
Placenta Pathology
As a nurse-midwife, I was especially excited to find this portion of the text and of course, it satisfied my intrigue as not only are there various sections throughout the book dedicated to the placenta, but also lengthy chapters are dedicated to both the placenta and congenital transmission. The author seemed rather impressed that tuberculosis seemed, most often, to alter the appearance of the placenta in no observable way, which was very much unlike the mother's genital region. If any, the area where tuberculosis seemed to create any impressionable change was near the insertion of the cord. In one case, a triangular area, measuring 5x7cm with the apex near the center of the cord and extending into the membranous surface, was found to be yellow, soft, and somewhat cheesy. There were additional reports of a "cheese-like substance" which varied in size, but were not tested for the tubercle bacilli so this may have been more frequent than understood at the time. The cord itself was generally found to be normal, but the ovaries of the very first identified patient with tuberculosis in the female organs was described with this "cheese-like substance" as well (Norris, 1926).
Congenital Infection
Congenital transmission was theorized but then dismissed as it was later thought that any transmission had to occur postnatally, aided by hereditary predisposition. At the time of this book publication however, researchers were starting to question this previous belief. The author shares that congenital exposure may occur via the sperm or the egg, or even through the environment which would contact the baby through "lymph channels." "Secondary infection and metastasis occur in the placenta in the same manner in which they affect other portions of the body. Dardeleben goes so far as to assert that they #placenta is the locus minoris resistentiae of the gravid woman" (Norris, 1926, p 46). Later in the text, the author speculates that tuberculosis may have a latent phase and part of why congenital infection was ruled out and thought to be a post-natal infection, but it had laid dormant.
The author shares that tubercle bacilli has never presented within the spermatozoon; however, it not need to for congenital infection to occur. At any point the outer surface of the cell came into contact with the bacilli within the testicle, vas deferens, prostatic fluid, urethra, external surface of the penis, vulva, vagina, cervix, uterus, or even the fallopian tube, the spermatozoon would become a germ carrier. The author shared studies in which researchers found the genitals of men infected with tuberculosis were nearly as common a cause of epididymitis as gonorrhea. A great deal of discussion was actually offered here, and less so to the impact of having an infected ovum as it was concluded that it would be exceedingly rare for an infected ovum to mature to viability (Norris, 1926).
A plethora of cases were discussed within the text, accounts of when either mother or baby became ill and the circumstances surrounding them, if they were separated and what their autopsies discovered. The terminology or conditions were sometimes hard for me to accept. Babies born with anomalies for example were called "monsters" and babies whose families were infected with tuberculosis were placed in orphanages. Of course, they were originally thought to be healthy because they didn't believe infection was possible in utero, but then they would die months later after having exposed those in the orphanage. When the author spoke about the diagnostic criteria or even treatments, details of these procedures were discussed such that when a diagnostic excision is obtained, it should be performed "under local anesthesia, and the cautery knife, heated to a dull red." This is so very precise, right?
Wishing I Could Travel Back in Time for a Moment
Sadly there are no pictures in this text what-so-ever as the details of the pathology discovered with these cases, particularly the perineal lesions are truly as intriguing as a juicy Dr. Pimple Popper episode. If you're a fan, imagine this lesion in your office (adding the fact that we can provide antibiotics today so imaging yourself back in these days as a clinician is a completely guilt-free pleasure). "Woman, aged thirty-nine years, had cervical adenitis in childhood. Two years ago the patient sustained a fall from a horse, after which a cystic tumor gradually formed on the vulva. Nearly a year after the fall the cyst broke spontaneously. The contents were found to be sanguineous, but no pus was present in the early stages. The lesion was extremely chronic, discharged profusely, and after six months the discharge became purulent. At the same time sharp, lancinating pains occurred in the vulvar region. Menstruation became irregular, the patient lost general strength, and became emaciated. Both labia majora were much hypertrophied. A hard, reddish purple enlargement, the size of a nut, was found at the lower, left labium majus. This had two small, fistulous openings, which discharged yellowish green pus. The similar formation existed on the lower part of the right labium majus. A small piece of tissue was excised and a diagnosis of tuberculosis made. Fungous masses were found on the inner surface of the lesion and were removed" (Norris, 1926, p 120).
These chapters however, that detail hundreds of cases of gynecologic lesions are also very heartbreaking as many, many cases involved a young girl whose father either died or was infected with tuberculosis and the daughter had a tuberculosis lesion on her labia or at the vaginal orifice. It seems clear there was sexual abuse, and in some cases, all sisters had the same. A case of an exceedingly difficult childbirth was shared and then maternal death three weeks later in which autopsy revealed previously unknown tuberculosis of the vagina creating a very stiff, unrelenting vaginal canal. Can you imagine that labor and birth for this mother and child? We hear so much about the difficulties of childbirth throughout history, but I can't say that I've ever heard of obstetrical tuberculosis playing a role.
Another intriguing case of elephantiasis of the clitoris was detailed, later determined to be a tuberculosis lesion. Many of these cases were in women who had peritonitis decades prior or a previous accident or surgery, which makes it seem as if there is a crack in their health, predisposing them to tuberculosis. Some of these lesions created extensive canals within the reproductive organs, tunneling their way through deep tissues, progressing into the kidneys and beyond. Many times these lesions were described as having "vegetative growth."
It seems so odd to read that years prior these lesions were evident, and that the discharge and odor worsened over time, all without seeking counsel by a clinician. The pain they must have endured! I don't have the knowledge to understand why care would not have been sought unless potentially the community provider wasn't considered a clinician and that's where care was originally sought with natural remedies that ultimately proved unsuccessful. Midwives often cared for the entire family, as we see even on the popular television series, "Call the Midwife," and the physician is notified when cases advance. Maybe access to care was a significant issue as well?
"It is imperative that the reactive powers of the patient be strengthened as much as possible. General hygienic measures, such as regular life, outdoor living, forced feeding, particularly eggs and milk, regulation of the bowels, and perhaps the exhibition of a tonic, should be employed" (Norris, 1926, p 119).
Pregnancy and Tuberculosis
When the early literature of pregnancy in tuberculosis is reviewed, it is interesting that most conclude pregnancy as a favorable influence for cases of pulmonary tuberculosis. This was thought to be related to the fact that gestation increases the weight of the woman but then later in pregnancy, the impact is more negative and poor outcomes are seen after the pregnancy has commenced. In fact, it was so common to see pregnant women with tuberculosis and it have a beneficial impact that it was thought that tuberculosis increased sexual appetite. "Tuberculosis itself is essentially a disease due to faulty hygiene; the latter is the most common among the ignorant and poor, a class in whom fertility is notorious. Although the #fertility among the poor is probably largely the result of ignorance regarding the methods of preventing conception, the fact remains that pregnancy and tuberculosis frequently coexist" (Norris, 1926, p 244). The author also adds that approximately 33% of pregnant women die in less than one year following labor.
The author however shares personal opinion that tuberculosis is not advantageous to pregnancy, potentially because "the general routine of life incident to the pregnancy, and the lessened amount of fresh air and lack of exercise indulged in by pregnant women may to some extent also be causative factors in some cases" (Norris, 1926, p 250). The death of the child was not thought to be congenital infection but rather, "a hypersusceptibility to infection," and even the "unhygienic environment and often motherless condition to which these children are exposed" (Norris, 1926, p 252). "Children of tuberculous mothers are constitutional weaklings" and 68% of children to tuberculous mothers die (Norris, 1926, p 252). "Many of the infants of tuberculous mothers are bottle fed even during the mother's life, and the mortality among such children in naturally high" (Norris, 1926, p 253).
"A number of authorities argue that, since no one can tell which apparently favorable cases will do well and which will do badly, the correct treatment of all cases of early pregnancy is, therefore, to empty the uterus, and thus be on the safe side. However, the reverse is also true, although, unfortunately, in a much smaller percentage of cases" (Norris, 1962, p 256). Birth complications are said to have been increased in those with tuberculosis with essentially all requiring forceps, versions, or some other form of operative delivery. #Lactation was certainly considered unfavorable influence on the course of the disease, but "among the extremely ignorant" it was the lesser of the two evils. Concealment of tuberculosis by a personal entering into marital relations was grounds for annulment of the marriage.
Treatment of Pregnancy and Tuberculosis
Interestingly the test states, "as a matter of fact, the physician is frequently no consulted regarding the advisability of either marriage or conception, and often sees the case for the first time after pregnancy has taken place. This is especially true of the ignorant classes, and even the intelligent are as yet not sufficiently educated upon this point. If pregnancy has taken place, the most important point to be decided is, shall the uterus be emptied, and if so, what are the indications for performing the abortion" (Norris, 1926, p 263). There were a few pages devoted to #abortions before and after the fifth month of pregnancy which the author admitted to having a preference for no matter when the lesions were identified, but I did not read these pages as my heart could not bear it. In spite of being in favor of abortion, the author does admit, "As a general principle, it may be stated that when the pregnancy has advanced beyond the fifth month, little benefit will be derived by the patient from the induction of abortion, since in any event the most dangerous period for the pregnant tuberculous woman will not be avoided" (Norris, 1926, p 274).
An Incidence We Can't Comprehend
When discussing incidence, the author shares, "Tuberculosis is the most frequent serious infectious disease that attacks mankind. It has been estimated that from 9 to 12 percent of all deaths are due to tuberculosis. In Germany, during one year, the mortality statistics show that diphtheria, pertussis, scarlatina, rubeola, and typhoid fever were accountable for 116,705 deaths, whereas during a similar period tuberculosis was responsible for 123,904 deaths" (Norris, 1926, p 55). It's interesting that this infectious disease is not much of a threat today and this was accomplished without implementation of a vaccine.
"Tuberculosis of the female genital tract and peritoneum is of frequent occurrence and is usually secondary to tuberculosis elsewhere in the body" (Norris, 1926, preface). Certainly most who are familiar with tuberculosis today recognize it as an infectious process of the respiratory system, but I wonder if many appreciate that this disease could occur elsewhere in the body and was an area of concern for the gynecologist? Seven percent of all pelvic inflammatory disease was related to tuberculosis of this time. Eight percent of adnexitis was related to tuberculosis. Today, it just isn't incredibly concerning. Many clinicians have never seen a client with active disease, and I making the assumption that most lay people today believe tuberculosis is an older disease that doesn't even occur today.
Fascinating read and so much more I could have shared. Leave your thoughts and comments below, and stay tuned for sixteen more from this volume and a number of other #antiquebooks I can't wait to read. The perspective is invaluable. Humbling.