CAUSES AND TREATMENT MODALITIES OF HYPEREMESIS GRAVIDARUM

DURING THE LATE NINETEENTH AND EARLY TWENTIETH CENTURY IN THE

UNITED STATES AND GREAT BRITAIN

Elizabeth Ping
American Public University System
Charlestown, West Virginia 4142216
HIST500 C005 Spring 2010
Submitted to the Department of History
September 26, 2010
 CAUSES AND TREATMENT MODALITIES OF HYPEREMESIS
GRAVIDARUM DURING THE LATE NINETEENTH AND EARLY
TWENTIETH CENTURY IN THE UNITED STATES AND GREAT BRITAIN

I. Title

I propose titling the research paper “Causes and Treatment Modalities of

Hyperemesis Gravidarum during the Late Nineteenth and Early Twentieth Century in the

United States and Great Britain.”

II. Research Problem

Hyperemesis gravidarum is a condition of severe nausea and vomiting that

currently affects approximately 1 to 2 percent of pregnant women.1 Although morning

sickness is common in the early stages of pregnancy, hyperemesis represents the most

extreme form of nausea and vomiting of pregnancy. The excessive nausea and vomiting

that begins during the first weeks of pregnancy and continues until typically 20 weeks has

been deemed comparable with a state of prolonged starvation.2 Hyperemesis is generally

regarded as a life-threatening condition when a woman can no longer maintain adequate

nutrition or hydration to maintain life and has been associated with maternal and fetal

morbidity and mortality.3

The medical thought of the late nineteenth and early twentieth centuries provides

a nebulous view of the disease with no exact causative factors and with treatment

practices that vary greatly. There are many contemporary opinions of the causative

factors of hyperemesis gravidarum and treatments; however, there have been limited
1
K. Roem “Hyperemesis Gravidarum –a serious complication of pregnancy.” Nutrition &
Dietetics 59, no. 2 (June 2002): 145 (accessed September 25, 2010).
2
Marlena Fejzo, et al. “Symptoms and pregnancy outcomes associated with extreme weight loss
among women with hyperemesis gravidarum.” Journal of Women’s Health (15409996) 18, no. 12
(December 2009): 1981-1987 (Accessed September 25, 2010), 1981.
3
M. Turner, “Hyperemesis gravidarum: Providing women-centered care.” British Journal of
Midwifery 15, no. 9 (September 2007): 544, (accessed September 25, 2010).
evaluation and synthesis of past practices in current historical literature. It is important to

reflect on past attitudes and treatments for current medical practice since there is even a

reliance today on attitudes about hyperemesis that stem from the past. This can be

detrimental for women being treated under guidelines that are outdated and ultimately not

evidence based. Consequently, management of hyperemesis in the present healthcare

environment remains inconsistent, not based on best medical practice, and unsympathetic

to women with this debilitating disease.4

1.1 Questions

Using American and British gynecological and obstetrical textbooks, manuals,

and medical journals from the late nineteenth and early twentieth centuries as a

foundation of my research, I will address the theories surrounding hyperemesis

gravidarum and treatment methods. I will investigate the questions: (1)What did

physicians and midwives feel were the causative factors for hyperemesis gravidarum, and

(2) what were the common treatment modalities for hyperemesis gravidarum? Important

sub-questions that should be researched regarding hyperemesis may include: (1) How

prevalent was hyperemesis gravidarum at the turn of the nineteenth century? and

(2) What was the mortality rate for women diagnosed with hyperemesis gravidarum?

These practical questions will help enlighten the researcher about how hyperemesis

affected the lives of women during this time period and paint a clearer picture of the

importance of further exploring the gynecological history of hyperemesis.

1.2 Hypothesis and Evidence

4
. C. McParlin, R. H. Graham, and S. C. Robson, “Caring for Women with Nausea and Vomiting
in Pregnancy: New Approaches,” British Journal of Midwifery 16, no. 5 (May 2008): 280−285. CINAHL
Plus with Full Text, EBSCO host (September 20, 2010).
 My hypothesis is that the treatment modalities for hyperemesis gravidarum in the

United States and Great Britain during the late nineteenth and early twentieth centuries

are directly related to the hypothesized causative factors of the time. To test this

hypothesis, I will use American and British gynecological and obstetrical textbooks,

manuals, and medical journals from the late nineteenth and early twentieth centuries to

combine common theories of the causes of hyperemesis gravidarum and relate them to

the treatment modalities practiced.

1.3 Implications for Research

The broad implications for research on the history of hyperemesis gravidarum are

many. By researching the history of the medical practice surrounding hyperemesis

gravidarum, we can attach a better understanding concerning how current theories of the

causes of hyperemesis were ascertained and how hyperemesis is treated in today’s

healthcare setting. Additionally, it will illuminate past stories of women who have

suffered from severe nausea and vomiting of pregnancy, and this knowledge will honor

the women who died. Lastly, perhaps treatment methods employed in the past that

seemed to improve the severe nausea and vomiting can be researched further and applied

to current plans of care.

By initiating research on theories of the causes of hyperemesis gravidarum and

treatment practices common at the turn of the twentieth century, we can discover and

expand on ideas for further research. Related research projects may include determining:

1. Whether theories of the origin of hyperemesis gravidarum were founded on

fact or on supposition and biased opinions by male obstetricians.

 2. Whether or not cervical dilation actually alleviates symptoms of nausea and

would be beneficial in a modern setting.

3. The abortion rate among women with hyperemesis in the late nineteenth

century.

4. Whether female midwives or male obstetricians were preferred among women

with hyperemesis of that period.

5. What women thought about seclusion and “tough love” concerning

psychological treatments for hyperemesis through diary reports.

6. The occurrence rate of women in subsequent generations to be diagnosed with

hyperemesis among relatives.

7. Whether there is an increase in number of behavior or medical disorders

among offspring from related generations after a woman had been diagnosed

with hyperemesis.

III. Definition of Terms

Hyperemesis gravidarum is a specialized medical term that can be confusing for

healthcare professionals of the current time. This confusion can be compounded by

outdated terminology used in the late nineteenth and early twentieth centuries. Medical

terms specific to pregnancy and symptoms of severe nausea and vomiting in this period

of history are:

Cervix − Area that connects the vagina with the uterus.

Cervical os − Opening from the vagina to the uterus.

Copeman’s Method − Insertion of one finger up to the first joint into the cervical to

slightly dilate the opening.

Ectropian − Spilling of cervical cells outside of the cervical os.

Hyperosmia − Increased sense of smell.

Hysteria − Condition resulting in a loss of voluntary control of neurosis and hysteria.

Morning sickness − Nausea and sometimes vomiting that occur during pregnancy.

Pessary – A device inserted into the vagina that helps support the uterus.

Pernicious vomiting − Another term for hyperemesis gravidarum.

Ptyalism − Hypersecretion of saliva.

Rectal enemata − Solution placed into the rectum through a tube.

Retroflexion − Inversion of the uterus.

Sim’s position − An obstetrical position where knees are drawn to chest.

There should also be a distinction made between what constitutes morning

sickness and hyperemesis gravidarum. Morning sickness is the common term for nausea

and vomiting in pregnancy and is generally considered non-pathological. Hyperemesis

gravidarum specifically refers to morning sickness characterized by weight loss greater

than 5 percent of a woman’s pregnancy weight.5

IV. Background

The first recorded description of hyperemesis was by French obstetrician Paul Du

Bois who discussed his thesis on pernicious vomiting before the French Academy of

Medicine in 1852.6 At this time, Du Bois noted 20 fatalities, and a fellow reporting

physician noted 46 out of 118 fatalities due to hyperemesis. During the end of the

nineteenth century, male obstetricians attempted to conceptualize to what morning

5
Marlena Fejzo, et al. “Symptoms and pregnancy outcomes associated with extreme weight loss
among women with hyperemesis gravidarum.” Journal of Women’s Health (15409996) 18, no. 12
(December 2009): 1981-1987 (Accessed September 25, 2010), 1981.
6
. Jacob E. Schmidt, Medical Discoveries: Who and When (Springfield, IL: Charles C. Thomas,
1959), 224.
sickness might be analogous; one physician described the nausea of pregnancy as “that

never-to-be-forgotten nausea which most who have learned to smoke have experienced.”7

Typically, historical records pertaining to hyperemesis have been divided into three

categories, each containing a myriad of treatment methods: (1) cervical abnormalities, (2)

mal-positions of the uterus, and (3) psychological origins. Finally, by 1880, the Gibbon’s

“Report on Obstetrics” identified that determining the causation of morning sickness in

any particular case was a crucial step before attempting to treat the condition.8

4.1 Abnormality of Cervix

Some physicians believed that the cervix was the root cause of hyperemesis.

Accordingly, these obstetricians theorized that erosion of the cervix (also known as

ectropian) could cause pregnant women to vomit incessantly.9 Similarly, Dr. Clay,

believed that overgrowth of cervical tissues caused nausea and vomiting. Others believed

that congestion of the cervical area or maybe even inflammations of cervical tissues were

the causative agents in hyperemesis. Likewise, Dr. Cazeaux regarded pressure on the

cervix from the fundus as the force that was causing women extreme discomfort. It was

furthermore noticed that coitus exacerbated the nausea that a woman with hyperemesis

experienced.10

Treatments involving complications of the cervix include the Copeman’s method

which involved the insertion of one finger up until the first joint into the cervical os.11

This therapy seemed to alleviate some of the nausea and vomiting experienced by the
7
. Alfred Meadows and Albert Venn, A Manual of Midwifery (London: Ballantyne, Hanson, and Co.,
1882), 89−90.
8
. H. Gibbons, “Gibbons Report in Obstetrics,” Pacific medical and Surgical 24 (1880): 106.
9
George Frederick Shrady and Thomas L. Stedman, Medical Record (New York: William Wood
and Company, 1898), 448.
10
William Lusk, The Science and art of Midwifery. (New York: Appleton and Company, 1896),
116.
11
Ibid., 105.
pregnant women and was first attempted by Dr. Copeman who was trying to induce an

abortion on a woman who was near death from hyperemesis when instead of causing

premature labor, the vomiting was reduced.12 However with the success of digital cervical

dilation, and later with the development of a steel dilator, miscarriage was a risk resulting

in this procedure. James Marion Sims was a prominent physician and reported that this

method caused one of his patient’s to have a miscarriage.13 Dr. Sims also promoted the

use of ice on the cervix but only for women who presented with “urgent and rebellious”

cases. Moreover, leeches were applied to cases of congestion of the cervix. An

application of various substances was another method employed by practicing physicians

at the time, and applications of nitrate of silver were used on the cervix for granular-

appearing cervical erosions and applications of glycerin for problems relation to a

congested cervix.14 Another treatment included galvanizing the cervix with an electrode

and increasing the current until the nausea was relieved.15

4.2 Abnormalities of the Uterus

A misaligned uterus was also hypothesized by the physicians Gueniot, Rene,

Birau, Moreaux, Cazeaux, Munro, Hewitt, and Ulrich to be the factor causing

hyperemesis.16 Specifically, obstetricians speculated that a retroverted or retroflexed

uterus was the cause for pregnancy nausea because a flexing of the uterus cases irritation

of the uterus and may cause a “reflex vomiting.”17 There were also multiple treatment

modalities for abnormal positions of the uterus which include placing a woman in a knee-
12
Lusk, 116-121.
13
George Frederick Shrady and Thomas L. Stedman, Medical Record (New York: William Wood
and Company, 1898), 448.
14
Lusk., 119.
15
Ibid., 117.
16
George Frederick Shrady and Thomas L. Stedman, Medical Record (New York: William Wood
and Company, 1898), 448.
17
Ibid., 448.
to-chin position, manual moving the woman’s uterus, and using a pessary placed in the

vagina to support the uterine structures.

4.3 Hysteria

There were physicians who believed that hyperemesis is caused by psychological

instead of biological causes. The belief that a woman’s mental state is directly related to

the female organs was a common belief and even termed an “indisputable fact.”18 The

most famous case of suspected hyperemesis gravidarum during the mid-eighteenth

century is the English author, Charlotte Bronte, who is thought to have died from this

disease during the fourth month of her first pregnancy because she was considered

predisposed to hysteria and nervous tendencies.19 Kaltenbach was the first physician who

theorized that hyperemesis is caused by a woman’s psychological state in 1890 because

he believed that some women were cured of their nausea simply by the suggestion that

the treatment would alleviate vomiting.20 Kaltenbach promoted isolation from friends and

household duties and lying to women that different treatments would cure nausea when in

actuality the treatment was merely being used as a placebo and to try to ameliorate the

psychological state of the woman through suggestion.21 If other measures had failed to

relieve the nausea and vomiting and the woman was near death, artificial abortion was

attempted.22

18
William Anderson, Hysterical and Nervous Affections of Women (London, Harveian Society, 1853),
9.
19
Pitkin. RM. “Historical Perspective: Charlotte Bronte and hyperemesis gravidarum.”
ACOG Clinical Review 13, no. 6 (November 2008): 13-16.

20
George Shattuck and Agernon Coolidge eds., The Boston Medical and Surgical Journal. 125
(1891): 45.
21
Ibid., 46.
22
Edward Reynolds, Practical Midwifery: A Handbook of Treatment (New York: William
Wood & Company, 1892), 27.
 V. Research Methods

My research methods will consist of comparing and contrasting primary and

secondary sources. Specifically, I will use American and British gynecological and

obstetrical textbooks, manuals, and medical journals from the late nineteenth and early

twentieth centuries as a foundation of my research. These references are readily available

on Internet search engines. Specifically, I will use CINAHL to assist in locating current

articles on hyperemesis that reference older sources; these modern documents will make

up the majority of the secondary sources utilized. After gathering my research materials, I

will draw upon these sources to look for patterns in treatment plans and to identify the

different theories of hyperemesis gravidarum as a disease process of pregnancy. From

there, I will match the believed origin of disease with the plan of care of that time period.

VI. Research Limitations

As with any research, there are deficits in the reliability of the information that

can be gathered. The validity of research can be compromised when the historian has

biased viewpoints. With this in mind, there are several important limiting factors

impeding the research process when studying hyperemesis at the turn of the twentieth

century. These factors include a gap in the historical record from traditional midwives

who were providing most of the maternity care in the United States, the use of

incongruent or extinct medical terminology, and personal bias regarding psychological

associations with causes and treatments for hyperemesis.

6.1 Insufficient Documentation from Midwives

Although there is an abundance of information in the form of textbooks and

manuals regarding the theories of hyperemesis and common treatment modalities from
the late nineteenth and early twentieth centuries by obstetricians, there is a scarcity of

written information from traditional midwives. The lack of documented cases and

treatments may be related to the illiteracy rates of women and their granny (African-

American) and immigrant midwives.23 Additionally, midwives practiced without

collaboration with other midwives. This was true also for European immigrant midwives

because they received their training through apprenticeships and mentors instead of a

formal institutionalized setting and usually did not participate in scholarly research

themselves.

It is important that the historical record regarding midwifery’s attitudes and

treatments for hyperemesis is incomplete because the majority of women during this time

period were cared for by midwives and not obstetricians. In fact, it is estimated that

before 1910, midwives were the primary caregivers for more than 50 percent of women.24

Treatment practices by midwives are almost entirely unpublished. This leads to the

important realization that the practices surrounding hyperemesis during the late

nineteenth and early twentieth centuries were written by obstetricians who were

overwhelmingly male.25 Therefore, history is devoid of the female perspective on a

disorder that occurs only with pregnancy. Since biased attitudes toward women were

prevalent during this era, this same prejudice may be found within some of the accounts

of treatment approaches.26

23
. Judith Pence Rooks, Midwifery and Childbirth in America (Philadelphia: Temple University
Press, 1997), 18.
24
. Barbara Ehrenreich and Deirdre English, Witches, Midwives, and Nurses: A History of Women
Healers (New York: The Feminist Press, 1993), 33–34.

25
. G. J. Barker-Benfield, The Horrors of the Half-Known Life: Male Attitudes Toward Women
and Sexuality in Nineteenth-Century America (New York: Routledge, 2000), 70.
26
. Helen Varney, Jan Kriebs, and Carolyn Gegor, Varney’s Midwifery (Sudbury, MA: Jones and
Bartlett Publishers, 2004), 7.
6.2 Antiquated Medical Terms

Another apparent limitation is the scarcity of modern-day interpretations of past

treatment approaches for nausea and vomiting of pregnancy. Therefore, the majority of

research material must come directly from contemporary physicians and midwives.

Furthermore, due to limited technology and diagnostic tools, it is difficult to determine

whether a woman actually had hyperemesis; differential diagnoses such as cholecystitis,

pyelonephritis, thyroid disorders, diabetes mellitus, and brain tumors cannot be separated

from the diagnosis of hyperemesis.27 Consequently, statistics regarding the number of

women during the period diagnosed with hyperemesis may not be reflective of the

disease. Furthermore, antiquated terminology from a century ago makes it difficult to

determine whether a term demonstrates a device or idea that correlates to today’s

definitions.

6.3 Personal Bias

It is not uncommon for a person who vomits uncontrollably and is ignored by

medical professionals to feel loneliness and depression. This was my own experience

after being emotionally and physically drained by hyperemesis during three pregnancies.

Accordingly, an additional limitation includes a personal emotional attachment to the

subject which focuses on finding causes of hyperemesis that are not solely dependent on

psychological factors. That is to say, I have the personal opinion that hyperemesis is not

caused by a psychiatric condition; therefore, I may be unintentionally biased against

theories stating that hyperemesis derives from hysteria, behavior disorders, and other

27
. T. S. Carpenter, “Is it Morning Sickness—or Something Worse?” RN 66, no. 10 (2003): 34−38
(September 24, 2010).
similar speculations. Therefore, it will be important during my research to remain neutral

to the different theories of nausea and vomiting during pregnancy.

 Annotated Bibliography

Anderson, William. Hysterical and Nervous Affections of Women. London, 1853.

This nineteenth century book, Hysterical and Nervous Affections of Women, explains that
morning sickness is a form of hysteria as are other forms of female conditions such as
leucorrhea, amenorrhea, dysmenorrhea, and menorrhagia. This text is important because it is
an early depiction of how the uterus has been attributed to causing hysteria.

Barker-Benfield, G. The Horrors of the Half-Known Life: Male Attitudes Toward Women
and Sexuality in Nineteenth-Century America. New York: Routledge, 2000.

This is a modern book that describes how men have viewed women during the nineteenth
century. It is important for research on hyperemesis because it describes how most
obstetricians were male and not female. Therefore, pregnant women were not being taken
care of by the same sex.

Carpenter, T. S. “Is it morning sickness – or something worse?” RN 66.10 (2003): 34-38.

(accessed September 24, 2010).

This is a journal article that describes the determining factors of whether or not morning
sickness has reached such an extreme that ordinary measures are considered no longer
appropriate. This source is important for the research paper because it describes the
importance of ruling out other causes of vomiting for pregnant women who vomit frequently.

Ehrenreich, Barabara and Deirdre English. Witches, Midwives, and Nurses: A History of
Women Healers. New York: The Feminist Press, 1993.

This is a modern book that describes important roles that women have played over time in
society. The book is important because it describes how at the turn of the nineteenth century,
50 percent of women were still being taken care of by midwives.

Gibbons, H. “Gibbons Report in Obstetrics,” Pacific medical and Surgical 24 (1880).

This journal article from the late nineteenth century discusses treatment modalities for
hyperemesis. The source is important for the research paper because it identifies Copeman’s
method which is the insertion of a finger into the cervical os.

Fejzo, M., B. Poursharif, L. Korst, S. Munch., K. MacGibbon., R. Romero, and T. Goodwin.

“Symptoms and pregnancy outcomes associated with extreme weight loss
among women with hyperemesis gravidarum.” Journal of Women’s Health
(15409996) 18, no. 12 (December 2009): 1981-1987 (Accessed September 25, 2010).

This modern journal article describes hyperemesis gravidarum as a state of continued

starvation. It is important to the research project because it describes the definition of
hyperemesis as a weight loss of approximately five percent pre-pregnancy weight because of
excessive nausea and vomiting.

Lusk, William. The Science and art of Midwifery. New York: Appleton and Company:
1896.

The Science and art of Midwifery is a nineteenth century textbook that has a chapter that
describes treatments for morning sickness. Treatments include cocaine applications to the
cervix, use of electrical equipment on the cervix, and pessaries to correct uterine alignment.
This text is interesting because it mentions that women with hyperemesis may experience
“hyperosmia” or the complaint of smelling unpleasing odors. The book also describes the
mortality rate of the disease as being 49 out of 121 cases.

McParlin, C, R. H. Graham, and S. C. Robson. “Caring for women with nausea and
vomiting in pregnancy: new approaches.” British Journal of Midwifery 16, no. 5
(May 2008): 280-285. CINAHL Plus with Full Text, EBSCO host (accessed
September 20, 2010).

This current British journal discusses treatment concerns for women with
hyperemesis gravidarum and promotes hyperemesis to be treated within the spheres of
biological, social, and psychological realms. It is important for the research because it
supports the idea that modern women are still not receiving adequate and sympathetic
support when diagnosed with hyperemesis.

Pitkin. R. M. “Historical Perspective: Charlotte Bronte and hyperemesis gravidarum.”

ACOG Clinical Review 13, no. 6 (November 2008): 13-16.

This is a modern journal article from the American Congress of Obstetricians and
Gynecologists discussing hyperemesis from a historical perspective. Specifically, the article
talks about a famous case of suspected hyperemesis gravidarum in Charlotte Bronte who is
thought to have died from this disease during the fourth month of her first pregnancy during
the mid-eighteenth century.

Reynolds, Edward. Practical Midwifery: A Handbook of Treatment. New York: William

Wood & Company, 1892.

Practical Midwifery: A handbook to Treatment is a nineteenth century gynecological text for

students that implies that there may be multiple causes of morning sickness that may
originate from digestive disturbances and even abnormal uterine conditions. This is deduced
from the myriad of treatments suggested that are divided into three categories which are “diet
and general care,” local and other organic diseases,” and “erosions of the vaginal surface of
the cervix.” The book is interesting because it labels what is now termed hyperemesis
gravidarum as the “uncontrollable form.” Furthermore, the book describes the mixture of the
“rectal enemata” or of forced oral feedings as being milk, raw eggs, beef juice, raw oysters,
and defibrinated blood. Practical Midwifery is unique because it mentions that erosions of
the cervix (ectropian), prolapse of the uterus, and retroversion of the uterus are plausible
causative agents in nausea and vomiting in pregnancy and gives treatment ideas for each
condition. Another notable aspect of the book includes its sensitivity toward how the option
for artificial abortion should be considered in terms of the mother’s health and religious
views when the nausea and vomiting are so excessive that the mother would die if no relief
was found. Since this book gives such a diverse view of hyperemesis, it may be one of the
most valuable resources of the research paper.

Roem, K. “Hyperemesis Gravidarum –a serious complication of pregnancy.” Nutrition &

Dietetics 59, no. 2 (June 2002) (accessed September 25, 2010).

This is a modern case study concerning a women who lost her twins due to hyperemesis. The
source is important for the research paper because it identifies the prevalence rate of
hyperemesis among women.

Rooks, Pence Judith. Midwifery and Childbirth in America. Philadelphia: Temple University
Press, 1997.

This book describes the history of nurse midwifery in the United States. This source is
important for the research paper because it describes how many midwives compared with
physicians took care of patients during this time period.

Shattuck, George and Agernon Coolidge eds., The Boston Medical and Surgical Journal. 125
(1891): 45.

This late nineteenth century journal describes the psychological causes of hyperemesis as
related by the physician Kaltenbach. This text is important to the research paper because it
represents a physician who believed that all disorders of women are related to female
hysteria.

Turner, M. “Hyperemesis gravidarum: Providing women-centered care.” British Journal of

Midwifery 15, no. 9 (September 2007) (accessed September 25, 2010).

This modern journal article describes the role that nurse midwives play in providing
supportive care to women with hyperemesis. The source is important to the research paper
because it describes the fact that hyperemesis is associated with mortality and morbidity.

Varney, Helen, Jan Kriebs, and Carolyn Gegor, Varney’s Midwifery Sudbury: Jones and
Bartlett Publishers, 2004.

This is a modern Midwifery textbook that describes some of the history of midwifery. This
source is important to the research paper because it describes how males viewed females as
inferior. Therefore, male viewpoints on hyperemesis may be slightly biased because male
obstetricians held women in disregard.