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PARTURITION AND OBSTETRICS,
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PARTURITION ^^^
AND THB
PRINCIPLES AND PRA C TJ C E
OF
OBSTETRICS.
BY
W. TYLER SMITH, M.D., Lond,
LECTURER ON OBSTETRICS IN THB
HUNTERIAM SCHOOL OF MEDICINE.
RARi\OFTHE
urg Academy of Medicifle,
NOT TO BE REMOVED.
PHILADELPHIA:
LEA & BLANCHARD.
1849.
%>,) 6'l
r
;
" At the lime of labour, a New Principle supersedes those of ascension
and descent. Tliis gives a disposition to the uterus to exclude whatever
is contained in its cavity; and the effect produced is in proportion to
the energy of the Principle, and the power of the uterus. A perfect
intelligence of this principle, and of the mode of its operation, would
probably be op infinite use in practice, as we might be enabled to
suppress the action thereby occasioned when premature, moderate it when
too feeble, and regulate it in a variety of ways conducive to the vielfare
of our patients. On the knowledge we at present have of the manner
in which this principle operates, and the circumstances by which it is
influenced, the assistance which science and dexterity can give in cases
of ditiicuit parturition, and in preventing abortions, very much depends."
. Den MAN.
TO
MARSHALL HALL, M.D., F.R.S,,
THESE LECTURES
ARE DEDICATED
BY HIS FRIEND,
THE AUTHOR.
P 11 E PAC E.
I BEGAN to study Reflex Obstetrics in 1842, and the present
work is the result of seven years' close and earnest atten-
tion to the subject. I may say truly, that during this time,
though much occupied by other matters, it has scarcely ever
been absent from my waking thoughts.
I have no wish to deprecate criticism, but I trust I shall
not be considered merely in the light of one who applies
facts and principles already known to his own department
of practice. I believe every candid person conversant with
the current knowledge of the Reflex Function, and of
Obstetrics, when I began to write, must admit that I have
both added to reflex physiology, and made extensive applica-
tions in practice, which had eluded previous observers.
Indeed, reflex obstetrics is a new department of the reflex
function and its applications. Taking the whole range of
reflex physiology, the Cause of Labour is only second in im-
portance to the Cause of Respiration, and no one had per-
ceived that the relation of the ovarian nerves to parturition
is the same as the relation of the pneumogastric nerves to
respiration ; while, in the investigation of the causes of the
1*
10 PREFACE.
Genesial Cycles, in the Twelfth Lecture, I have entered
upon a new field, altogether distinct from the reflex motor
function.
When I published my first " Observations," reflex phy-
siology had not found even a verbal home in any work on
obstetrics, but I do not think it will be possible to say the
same of future works in this department of medicine.
Bolton-streetj March, 1849.
CONTENTS.
LECTURE I.
PAGE
Intiioductorx ... i ..•.♦.. 17
LECTURE II.
Obstetric Ideas : — 1. Development — 2. Mechanism — 3. Motor Action —
Present disunion between science and practice — Sketch of the progress
of the nervi-motor physiology of parturition . . . . .30
LECTURE IIL
The different forms of motor action observed in human parturition : —
voHtion ; emotion ; reflex action ; peristaltic action, or contraction
from the irritabihty of the uterine muscular libre . . , .46
LECTURE IV.
The nervi-motor actions of the Fallopian tubes in menstruation, coitus,
conception, and parturition — Nervi-motor actions of the vagina in the
unimpregnated and parturient states ....... 65
LECTURE V.
The nerves of the uterine system ; distributive anatomy of the nerves of
the ovaria, Fallopian tubes, uterus, vagina, and external parts of gene-
ration ; opinions of John and William Hunter — Growth of the uterine
nerves during utero-gestation .75
LECTURE VI.
Puberty — History of the ovular theory of menstruation — Analogy be-
tween menstruation, oeslruation, and the oviposition of birds, insects,
amphibia, and fishes — Nature of the catamenial secretion — Diseases
of menstruation — Sterility, amenorrhcea, dysmenorrhcea, and ovarian
convulsion — Practical applications ....... 89
12 CONTENTS.
LECTURE VII.
PAG£
The principal motor phenomena of pregnancy — Emesis, cough, tenesmus,
strangury, cramp, and the abdominal movements — Elucidation of the
real nature of the movements generally considered to belong entirely
to the foetus 104
LECTURE VIII.
Difficulties attending the inquiry into the cause of labour — Sexual exci-
tability in the frog — Cause of parturient action in oviparous fishes ; in
oviparous insects ; in birds ; in mammalia ; in the human female —
Relation between ovarian excitement, sexual excitement, and coitus —
Relation betv^^een oviposition, cestruation, menstruation, conception,
and parturition — The collective phenomena of ovi-expulsion . .118
LECTURE IX.
Abortion a branch of spinal pathology — Ex-centric causes of Abortion —
Irritation of the mammary, trifacial, vesical, ovarian, rectal, vaginal, and
uterine nerves — Centric causes of abortion — Blood-poisons — The exan-
themata, syphilis, scrofula, mercurialization, carbonic Acid, specific ute-
rine excitants — Emotion — Mechanism of abortion .... 138
LECTURE X.
The prevention of abortion — Removal of mammary, dental, vesical,
ovarian, rectal, vaginal, and uterine irritation — Uterine, placental,
and fcEtal disease — Kespiration of the foetus — Intra-uterine pathology —
Prevention of abortion from habit — Epidemic abortion; hemorrhage
in abortion ; treatment of abortion — Eradication of the abortive dia-
thesis ............ 148
LECTURE XL
Physiological Stages of Labour : — I. The Preliminary stage — II. The
stage of Dilatation — III. The stage of Propulsion — IV. The stage of
Expulsion — V, The Supplemental stage — View of the order of motor
action in parturition — Anaethesia in obstetric practice — Parturition at
the boundary between pathology and physiology — The physical pain
of parturition — Ovarian, uterine, vaginal, pelvic, perinatal, and lumbar
varieties of labour-pain — Physical pain and physical shock — Aggrega-
tion of reflex arcs in the medulla oblongata and the medulla spinalis
inferior , . . . .163
LECTURE XII.
Remarks on Periodicity — Reciprocal actions between the ovaria, uterus,
and mammae — Neural actions of a physiological kind established be-
tween the organs of reproduction — Explanation of the catamenial
periodicity — Explanation of the periodicity of gestation — Explanation
of the periodicity of lactation — The Great Gencsial Cycle— Objects of
the })criodic arrangementii- Practical applications . . . .184
CONTENTS. 13
LECTURE XIII.
PAGE
The first extra-uterine phenomena of respiration — Changes in the foetal
circulation — Arrest of the placental circulation and respiration — Estab-
lishment of Respiration in the infant — Congenital asphyxia — Motor
Phenomena and congenital asphyxia in different Animals — Opinions
of Prof. Volkmann, Drs, Marshall Hall and Edwards — Treatment
of congenital asphyxia before birth and subsequent to delivery —
Intra-uterine causes of asphyxia — Separation of the umbilical cord —
Secondary asphyxia , . . • . ... 197
LECTURE XIV.
Applications of Physiology to obstetric Pathology and Therapeutics: —
1. Disorders arising from Excess of Nervi-Motor Action — 2. Dis-
orders arising from perversion of nervi-motor action — 3. Disorders
arising from deficiency of nervi-motor action — The relation of nervi-
motor action to instrumental delivery and manual operations — A new
classification of obstetric therapeutics 212
LECTURE XV.
Causes of excessive uterine action ; ovarian irritation ; emotion ; early
rupture of the membranes ; voluntary efforts ; position of the patient;
the foetus ; state of the circulation ; digitation — Rules for manipulation
in precipitate and tardy labours — Sedatives of excessive parturient
action ; ovarian treatment ; bleeding ; nauseants ; opium ; regulation
of emotion; abdominal bandage, &c 223
LECTURE XVI.
Rupture of the uterus ; causes of this accident — Excessive motor action
of the uterus itself — Prevention of uterine rupture — Importance of
moderating excessive uterine action — Laceration of the perinseum ;
causes of this accident — Observations on the prevalent plan of sup-
porting the perinseum by manual pressure during labour . . . 235
LECTURE XVII.
Rigidity of the os uteri ; different forms of rigidity ; Treatment — En-
systed placenta ; nature and treatment of this affection — Hour-glass
contraction ; seats of contraction ; its causes and treatment — Inver-
sion of the uterus ; mechanical and motor theories ; description of this
accident; re-position of the uterus — After-pains; their causes and
treatment 248
LECTURE XVIII.
Extra-uterine reflex actions of an abnormal character, occurring before,
during, and after parturition — False or spurious labour-pains — Me-
tastatic pains — Reflex actions affecting the stomach, abdominal mus-
cles, bladder, intestines, heart, larynx, &c. — Rigors — Diuresis — Par-
tial convulsive action — Tympanitis — Reflex counter-irritation — The
sensation of the draught in the breasts — The motor actions of the
mamnne ..... . ... 261
14 CONTENTS.
LECTURE XIX. *
PASS
Natural and morbid conditions of the reflex function in the infant at the
time of birth — The influence of muscular tone — The Cotostrum —
The Meconium — Icterus Neonatorum^The acts of suction and de-
glutition— The state of the infantile mammEe — Morbus cerulseus —
Tetanus nascentium — Congenital contractions of the extremities . 271
LECTURE XX.
Puerperal Convulsion. — Opinions of contemporary authors in this countrj
respecting the cause of puerperal convulsion — Extracts from Drs. F.
H. Ramsbotham, Rigby, Burns, Robert Lee, Fleetwood Churchill,
Locock, Collins, and Merriman — Opinions of Dr. Marshall Hall —
The cerebral hypothesis ; Its errors, and the causes which have given
rise to them — Convulsion really referable to the spinal marrow and
not to the brain — Post-mortem fallacies — Causes of the cerebral phe-
nomena of convulsion — Modes in which morbid states of the cere-
brum may cause convulsion — Distinction between cause and effect in
the pathology of this disease . . . . . . . . 281
LECTURE XXL
Centric causes of puerperal convulsion — Cerebral counter-pressure —
Irritation of the spinal centre — Slates of the blood — Emotion — At-
mospheric influences — Eccentric causes of convulsion — Irritation of
the uterus — Irritation of intra-cranial excitor nerves — Irritation of the
ovaria — Irritation of the bowels — Irritation of the stomach— Irrita-
tion of the bladder, &c. — Summary of causes 294
LECTURE XXIL
Physiology of sleep — Convulsive erethismus ; sphagiasmas ; laryngis-
mus ; odaxisrnus; pharyngismus ; cardiasmus — The convulsive parox-
ysm— Relation of convulsive action to labour-pains — Relation of puer-
peral convulsion to epilepsy, puerperal mania, apoplexy, and cerebral
syncope, &c. . . . , .311
LECTURE XXIIL
Bloodletting in puerperal convulsion — Dilatation of the glottis— Appli-
cation of cold — Administration of opium — Regulation of emotion —
Treatment of sphagiasmus and cervical muscular action — Removal
of the reflex causes of convulsion — Evacuation of the stomach, bowels,
bladder, and uterus — A case, and a commentary thereon . . .331
LECTURE XXIV.
Causes of uterine inertia — States of the liquor amnii — State of the abdo-
minal muscles — Uterine displacements — Peculiar dangers of the pro-
pulsive and expulsive stages — Complication of labour with thoracic,
abdominal, and paraplegic disease — Causes of deficiency of excito-
motor action — Treatment of uterine inertia — Rest — Opiates — Evacu-
ation of the liquor amnii — Examinations — Stimulant enemata — Abdo- '
minal bandage — Position — Ergot of Rye — Galvanism — Instrumental
interference ....... 34G
CONTENTS. 15
LECTURE XXV.
The -Treatment of uterine hemorrhage : — I. By exciting reflex uterine
action; II. By direct or centric utero-spinal action ; III. By exciting
the iiterine muscular irritability; IV. By mechanical measures; V.
By astringents and refrigerants — Profound importance of the applica-
tion of physiology to practice — Proper organization of remedies . . 359
LECTURE XXVL
Hemorrhage at different periods of gestation — The principle of alterna-
tion in the application of cold or other stimuli to exciter nerves — He-
morrhage at the commencement of the early and latter months of ges-
tation— Hemorrhage in placenta prsevia — Hemorrhage occurring during
labour — Principle of the arrest of hemorrhage in placental presentation
— Hemorrhage occurring after delivery — Conclusion . . . 374
Appkhdix . 385
PARTURITION AND OBSTETRICS.
LECTURE I.
INTRODUCTORY.
Labour : the study of the act of parturition itself, and of all
that relates to the prevention or alleviation of the pangs and
dangers in which women bring forth children, and to the
preservation of their offspring, are the principal aims of the
Obstetric Art.
I propose, in the present lecture, to institute a comparison
between British and Continental obstetric medicine, for I
think I shall be able to deduce from such a comparative
examination, better than in any other way, the great funda-
mental principles upon which obstetric practice is founded
— principles to which we may refer the differences that pre-
vail in practice in this country and on the Continent, and
which will also explain some of the perturbations which have
recently crept into the British school.
The excellence of Obstetric Medicine is one of the most
emphatic expressions of that high regard and estimation in
which women are always held by civilized races. The state
of the obstetric art in any country may be taken as a measure
of the respect and value of its people for the female sex ; and
this, in turn, may be taken as a tolerably true indication of
the standard of its civilization. Schlegel, alluding to the
historical growth of nations, calls the institution of marriage
the real commencement of civilized life. It may ])e de-
clared as a truism, that obstetric science must flourish most
in countries where the marriage tie is most respected —
where women are held in the highest esteem.
2
18 MARRIAGE.
Long ago the philosophic Denman pointed out the influ-
ence which Christianity had exerted on obstetric practice,
by substituting monogamy for polygamy, and enforcing a
strict observance of the marriage tie — moral reforms which
gave increased value and consequence to every means that
science or art could devise for promoting the health and
safety of individual women. Prayers for the welfare of " all
Avomen labouring of child" have a place in our national lit-
urgy, and the interest they excite is progressive wuth every
generation, and pervades all classes of society.
But in this country respect for women and reverence for
the rites of marriage have an origin even anterior to the in-
troduction of Christianity amongst us. In the palmy days of
the Roman Empire, the stock from which w^e are mainly
sprung was celebrated for the practice of these virtues in its
heathen state. We may say, without arrogance, that we have
cherished and developed the attributes described by Tacitus
as belonging to the Teutons, in the ancient forests of Ger-
many. They held their w^omen sacred ; and of their respect
for the marriage tie, the historian wrote — " Severa illic ma-
trimonia ; nee ullam morum partem magis laudaveris."
The influences of civilization and religion, and subsequently
the spirit of chivalry, have alike combined to cultivate the
noble instincts which signalized our barbarian ancestors.
Such is the true foundation of our national midwifery. This
is tracing a high descent for the obstetric art, but not a higher
one, I believe, than is justly its due. Our ideas of social pro-
gress are intimately connected with an elevation of the cha-
racter and position of w^oman ; and it is not too much to say,
that in no country of the w^orld, in no age of its history,
has w^oman been more valued and honoured than in our
own country, and in the present times. We may look to
obstetricy for a verification of the truth of this position.
Medicine is no respecter of sex. The health of woman, in all
that relates peculiarly to the sex, has claimed the intellect
of the greatest disciples of the profession of healing — of our
Harveys, our Hunters, and our Jenners. If any comparison
of the value of human life can properly be made at all, it
may be truly said, that no life seems so valuable as that of a
woman in childbirth ; for at no other moment can the lives
of two human beings be so closely linked together. British
obstetrlf-y, then, may fairly be considered as an expression
MIDWIFE PRACTICE. 19
of our social condition — of our humanity towards women
and children ; and there is no branch of medicine which more
commends itself to the genius of the English people.
Under these combined influences of race, civilization, and
religion, modern obstetric practice has gradually advanced,
in the face of greater obstacles than have beset the elder
branches, to be acknowledged as one of the three primary
departments of medicine. It has, in process of time, tri-
umped over the objections which natural reserve placed as
barriers against male attendance, and which were, for a long
time, the main prop of the midwife — a triumph which has
well-nigh transferred the allegiance of the lying-in woman
from Lucina to Apollo. This transfer the future must com-
plete.
In private practice, in this country, the midwife is very
much out of date, belonging to a bygone, rather than to the
present age. The great mass of our obstetric practice is a
ministration of education and experience, such as no endea-
vours could impart to a body of females. Yet this venera-
ble personage has still some hold on midwifery — a hold
which 1 believe to be not less unfavourable to the safety of
mothers in parturition, than it is derogatory to the obstetric
art. The signs of her existence are occasionally seen in the
glowing report of some lying-in charity, the advertised sale
of a child's cawl, or the newspaper report of a fatal child-
birth accident.
I take an address which has been issued by the mar.agers
of the largest lying-in charity in London, the Royal Mater-
nity, from which it appears, that during the last year up-
wards of three thousand woman have been attended by mid-
wives in London, Westminster, and Southwark. Now, I
believe it to be degrading to the obstetric branch of medi-
cine thus to have it admitted, on a large scale, to be right
and fitting that parturient women should be attended by
midwives, however well instructed, or however '' honest,
skilful, and humane" they may be. To the charity I refer
to, three able and experienced obstetric physicians are at-
tached ; but it is and ever will be in the nature of things,
that under female attendance, with the very best disposition
to obtain the assistance of the physicians in difficult cases,
the lives of women must slip through their hands, when, if
an educated accoucheur had been in attendance throughout,
20 BRITISH OBSTETRICY.
such lives would have been, humanly speaking, preserved.
I think the progress of this branch of our art will hereafter
demand that the office of the midwife- be abolished alto-
gether ; and in the particular instance referred to, I think it
would be as easy to find, if necessary, three hundred edu-
cated medical attendants for the charity, as the three physi-
cians, who, I believe, undertake their duties without fee or
reward. If midwife-practice be less safe than attendance by
an educated medical practitioner, it is a very questionable
charity to supply it to poor women. There ought not to be
one attendance for the rich, another for the poor ; and it is
not so in charities relating to general medicine and surgery.
Charity should apply itself to obtain the same aid for the
really necessitous poor as the rich are able to command.
What should we say to a public institution for the spread of
inoculation after the superior efficacy of vaccination had
been tested ? I have referred to a particular charitable in-
stitution, not for the sake of invidiousness, but because I
believe it to be the first and best of its kind ; and if respect-
able and well-organized charities did not sustain a corps of
midwives, the race would soon become extinct. If they
were not legitimatized by lying-in institutions — diplomatized
as *' honest, skilful, and humane" in these reports — they
would not exist to enter into competition with the general
practitioner in the poorer walks of practice, and in poor-law
unions ; the two sexes would no longer exist in a kind of
obstetric partnership, which, while it exists, will be pointed
at, to the disadvantage of the obstetric physician and sur-
geon, and the art itself; and will be detrimental to the safety
of lying-in women. These are among the worst things that
can be said of British obstetric practice. It may tend to
their removal to hold them up to the professional eye ; but it
must be remembered that in Great Britain, attendance by
midwives is, after all, the exception, while in other countries
it is the rule. It should be the steady aim of every man en-
gaged in obstetric practice, whether as a distinct branch, or
in connection with medicine and surgery, to discourage mid-
wife-practice. This department of the profession will never
take its true rank until this reform has been efTected. Mo-
dern medicine and surgery had, like midwifery, to emerge
from embryo states ; but they emerged so long ago, that they
entertain some degree of contempt for the more modern birth
FRENCH OBSTETRICY. 21
of obstetricy. The obsolete power of conferring the degree
of Doctor of Medicine, possessed, I believe, by the Arch-
bishop of Canterbury,"is the only relic of the transfer of medi-
cine from the monk to the physician ; and the emblematic
pole is the only remnant of the passage of chirurgery from the
barber to the surgeon. We may confidently hope, that here-
after the sign of the escape of obstetricy from the midwife
will be equally obscure and insignificant, and that the v'ery
term midwifery will be rejected on account of its derivation.
Every step of scientific advancement widens the distance be-
tween the mere midwife and the educated accoucheur.
I think we may take the state of obstetricy in France as
the type of continental practice, and I do not think the Bri-
tish school need fear the most severe comparison. Almost
all observers concur in the opinion, that throughout the
Continent the ties of marriage are less severely observed than
in this country. The social organization is less favourable to
domestic union and constancy. This is reflected with
tolerable accuracy in the general condition of the obstetric
art. We must ever honour the names of Ambrose Pare, Guil-
lemeau, Mauriceau, Portal, La Motte, and others of the older
French school, as among the great fathers of modern mid-
wifery ; but I think it will be granted that contemporary
habits and manners in France are unfavourable to the general
cultivation of midwifery as a branch of the profession claim-
ing equal dignity and usefulness with medicine and surgery.
The obstetric art must, I have maintained, flourish most
where woman is held in the highest esteem. We may admit
that the French are a polite people, but they have their para-
doxes in matters of feeling, as well as in politics. Gentlemen
on the other side of the Channel most earnestly assist the fold
of a shawl, or perform slight services with the greatest gal-
lantry and devotion ; yet they consign their women, in the hour
of travail, to the care of her own sex. Such is the fashion and
custom of the time. It is well known that the sage-femme
of France is a very superior person to the old English mid-
wife, now so much out of date ; but all cannot be Boivins or
Lachapelles, and the emergencies of midwifery often call for
as stout a courage, and an action as stern and instant, as any
of the emergencies of surgery. It is not among such scenes
that the female heart and mind are fitted to excel — unless,
indeed, we can ensure a race of Amazons. The prevalence
2*
22 THE SAGE-FExMME.
of sage-femmeSj and their modes of notifying themselves to
the public, must inevitably tend to throw an air of ridicule
over the obstetric department of medicine in France. Even
in the most aristocratic quarters of Paris — the Rue and Fau-
bourg St. Honore, for instance — the ^^sonnette desage-femme,''^
or the door-bell of the midwife, may be seen with a miniature
picture of the smart midwife herself, in oil colours, over it, in
the act of presenting a fine baby to all comers. Or there may
be observed paintings of more pretension, giving the passer-
by the penetralia of the lying-in room, and containing full-
length portraits of the accoucheuse and the everlasting baby,
with an interesting view of the lady-accouchee in bed in the
back-ground ; the not over-delicate painting by Rubens, in
the gallery of the Louvre, of the delivery of Marie de Medici,
reduced to common-place — the sage-femme doing the \vork
of the angels of that celebrated artist.
I assume it as beyond contradiction, that in France, and on
the Continent of Europe generally, from various concurrent
causes, women are treated with less delicacy than in this
country ; less tender consideration is shown for their feelings,
and even their lives, than w^ith us. In France, which I have
taken throughout the present lecture as the type of the
Continent in these respects, freedom of examination has pro-
duced greater familiarity with uterine diseases than we possess,
and so far, perhaps, an important point has been gained ; but
in practical midwifery there is greater recklessness in the use
of instruments, and more love of formidable and cruel opera-
tions, than would be tolerated in England. French vivacity,
the love of striking novelty and of heroical action at any cost,
seem to find place even in their professional dealings with
women. In midwifery, France produced Sigault, to whom it
decreed an ovation for his section of the symphysis pubis, and
Lisfranc, whose chief boast was of the number of times he
had mangled the womb ; and if France had the great glory of
abolishing the actual cautery from surgery in the days of
Ambrose Pare, it must take the greater odium of introducing
the barbarous application, in modern years, of iron at a white
heat to the living body, for the treatment of uterine disease.
Even the freedom of examination to which I have alluded,
though productive of some good in a diagnostic point of view,
is carried to such an extent of indecency in the French hos-
pitals, as to make medicine the ally of immodesty and de-
ROMAN AND PROTESTANT. 23
morallzation, rather than of decency and virtue. It would be
difficult to say whether the indecent and public exposure of
their women inflicted the deeper wound on the modesty of
one sex, or the morality of the other.
But the differences between obstetric practice in this coun-
try and in France are differences induced by religion still
more than by the social status of the two countries. There
may be traced throughout the range of obstetricy a Roman-
catholic and a Protestant bias of practice. I am not here
going to draw any unfavourable picture respecting the pro-
fessors of one religion or the other ; but the truth may, I hope,
be spoken without offence. The Catholic doctrine of the
value of extreme unction as regards the mother, and the ne-
cessity of baptism to infant salvation ; the different views on
these points held by Protestants ; are visibly written in the
precepts of practical midwifery: and though other circum-
stances complicate the matter in some particulars, I think we
may fairly take France and England as the types of the two
great varieties of practice w^hich exist. In France, the safety
of the life of the child is in many cases held practically to be
of more importance than that of the mother. We may see
this in the preference evinced for the Csesarian section ; the
rash use of the long forceps ; in times past, for the Sigaultean
operation ; and in the long-cherished dislike to the induction
of premature labour, or the performance of craniotomy, under
any circumstances. In England, we see the preference given
to the mother, in the performance of craniotomy, as though
the child were already dead, in all cases wdiere the life of
the mother is imminently endangered ; and in the general
reception of the principle, that when the pelvis is greatly de-
formed, or when the health of the mother is seriously impe-
rilled from other causes during utero-gestation, premature la-
bour should be induced; we see it, loo, most forcibly, in our
dislike to the Caesarian section, and in our ancient hatred of
Sigault. To unravel the direct and collateral bearings of re-
ligious opinions on obstetric practice, in different countries,
would not only aid us in the selection of principles of action,
but it would also account for many of the anomalies which
exist — the idola of the tribe and of the market-place which
infest obstetrics.
The following division will present more strikingly the
differences between British and Continental opinions : —
24 RELIGIOUS BIAS.
Protkstant practice gives a de- Romax-catholic practice leans to
cidcd preference to the life of the the life of the infant. This is seen —
mother. This is seen —
In the partiality for craniotomy. In the favourable opinion enter-
In the induction of premature la- tained of the Csesarian operation in
hour. Ronian-cathoiic countries.
In the proposed separation of the In the high opinion in which the
placenta, in placenta prsevia. Sigaultean operation has been held.
In the dislike of the Caesarian sec- In the frequent use of the long
tion, the fc^igauitean operation, and forceps.
the frequent use of the long for- In the great dislike to craniotomy
ceps. and the induction of premature labour.
In all cases in which it may be possible to save both lives,
of course the injunctions of Protestant or of Roman doctrines
would be equally emphatic. The same beneficent dictates
would flow from each, but there can be no doubt there would
exist a latent or explicit bias in the minds of communities of
Protestants or Roman Catholics. This influence, if not exist-
ing, per se, to the mind of the accoucheur, must aflect his
practice, from the insensible bearings of the clerical and
public mind upon professional men. And many medical men,
of either church and country, who have never examined
themselves as to the bases of their opinions, would yet hold
most tenaciously to the different lines of practice.
It may be argued, against these views, that the French are
not a religious people at all. But Roman-catholic ideas were
so long dominant in France, that more generations of free-
thinking or philosophy than have elapsed since the time of
Voltaire, would be necessary to eradicate the influence of
religion from her laws and customs. That which had been
scoffingly thrown aside as matter of faith, would still remain
in many forms of hereditary prejudice ; and in midwifery, that
lament of the elder French accoucheurs for the soul of a
foetus lost during delivery, though it might excite ridicule,
would still find its representative in practice. It may be
objected, also, that the peculiarities of practice which I have
termed continental are found in America. To this I would
reply, that notwithstanding the blood-relation between the
United States and this country, American midwifery is far
more the child of France than of England.
Various causes have in late years been operating to efface
the line which separates the two schools of practice. The
editor of the late British and Foreign Medical Review^ in
the valedictory address which sums up the various merits of
PLACENTA PRiEVIA. 25
that publication, alludes especially to the copious introduction
of the treasures of foreign medical literature into its pages.
As regards medicine and surgery, this may have proved a
boon ; but in the case of midwifery, it may be fairly ques-
tioned whether familiarity with continental literature and
practice has not tended to confuse the principles which should
rule in this country. If the variations of practice could be
referred to purely scientific standards, midwifery, as well as
medicine and surgery, might become cosmopolitan ; but
midwifery must inevitably differ in different countries so
long as the present differences of religious faith exist, unless,
indeed, we should reach that happy period when the interests
of mother and offspring should never clash.
It will be useful to study the bearings of these different
principles upon disputed points of practice, and particularly
upon the newly proposed or revived plan of detaching the
placenta, and extracting it before the child, in placental pre-
sentations. I believe examination will show that this practice
is an excessive and unjustifiable application of the British
rules of practice, one which, if it were allowed to prevail,
would subjectus to more reproach, on the score of indifference
to the life of the child, than craniotomy, with all its horrors,
has ever brought upon us. For an assumed, but unproved,
advantage to the mother, it does not hesitate to sacrifice the
life of the foetus. On the other hand, the established practice
— that of turning and extraction — is one which gives a rea-
sonable prospect of safety both to the mother and the child.
The new treatment, notwithstanding all that has been said to
the contrary, is probably not more safe to the mother than
turning, while, as regards the fcetus, it is almost as fatal as
craniotomy. Statistical tables have, it is true, been adjusted,
in which turning has been conveniently termed " the old
method of practice," and under this designation, cases of
death before any treatment whatever had been applied, cases
of death in the hands of midwives, cases in which death fol-
lowed at the end of the puerperal period, from phlebitis or
fever, and other heterogeneous cases, have all been grouped
together, and laid to the account of turning in placenta
prsevia. Tables thus unfairly concocted have been compared
with picked tables, in which the placenta was uniformly de-
tached and ^expelled before the child. But you will see, that
if any fair and honest comparison is to be made, the re-
26 STATISTICS.
spective cases in which either turning was performed or the
placenta detached should alone be brought into comparison
Pure cases of turning should be placed on one side, and pure
cases of detachment on the other. It would be quite as just
to set down the cases of death before assistance had reached
the patient, or before any treatment had been adopted, to
the account of the treatment by detachment, as to the treat-
ment by turning. Properly they belong to neither class, but
they have been used most unscrupulously in the tables of
mortality from turning, to alarm practitioners about the pro-
priety of the established practice. Again : if statistical
tables are to be framed and depended on, we ought to have
tables of the mortality to the infants as well as of the safety
to the mothers from the new practice ; but such tables have
not, as far as I have known, been yet prepared. Things
to be compared should at least be comparable. Tables of
turning should not admit of being turned. In a word, ob-
stetricians can only decide for or against the newly pro-
posed method, by having the results both to the mother and
the child in veritable turning, and the results to the mother and
the ehild in an equal number of true cases of placenta prsevia,
in w^iich the placenta was actually detached artificially.
Cases have been ranked as successful cases of placenta
praevia, treated by detachment of the placenta, when there
was good reason to believe that the placenta had never been
attached at all at the os or cervix uteri, but had apparently
descended from the fundus uteri. At the present time the
advocates of the new proposition have contrived to envelop
it in great suspicion as regards the mother, while, as regards
the child, detachment is confessedly a most dangerous opera-
tion. It stands next to craniotomy. Instead of removing
the brain, it produces asphyxia, and the one is almost as fatal
as the other.
Whether accoucheurs in France and Germany will be
charmed with any thing martial in the proposed practice it
is impossible to say ; but if they decide according to the
principles of their national obstetricy, we may expect, should
it reach them for discussion, a most determined censure and
opposition. Indications of this are not altogether absent
at the present time. If the principles of continental practice
are supported, this proposal w^ill be put in the same category
as craniotomy. It will be considered as a disgraceful excess
DETACHMENT OF PLACENTA. 27
of the British principles of practice. There is one singular
circumstance which cannot fail to strike you when pointed
out : this is, that the self-same accoucheurs who, in the matter
of placenta previa, are carrying the principles of our national
practice, as I believe, to an injurious extent, are those who
attempt to violate them, on the other hand, by adopting in
other cases the foreign and antagonistic principles. The
same practitioner who one day destroys the child by the
detachment of the placenta, will, the next, endanger the life
of the mother by the Caesarian section, vacillating between
the extremes of either practice ; clearly showing to my mind
that such persons are little influenced by principles or prin-
ciple, but that they are animated by a love of startling
novelty, an affectation of heroical dealing, and a thirst for
notoriety, rather than by a desire for true and honourable fame.
It becomes us, therefore, to examine the value of the points
of difference, to know the ground upon which we stand, and
not from any mere habit of fashion to suffer a laxity to creep
in upon points where, if a nice conscience be not kept, we
raay be guilty of sacrificing lives which we were bound to
have preserved. In midwifery, it sometimes happens that
■we have two evils before us, and we must firmly fix in our
minds which of the two we must most avoid, whether the
death of the mother or the death of the child is to have our
preference — to save both is frequently impossible. And w^e
must remember that that which may be conscientious in a
Protestant country may be criminal in a Roman-catholic
community, and vice versa. I have attempted to vindicate
British midwifery, and to draw attention to the principles upon
which it rests ; and recent events have shown that some vin-
dication is necessary, unless we are prej)ared to resign its
distinguishing characteristics and practice without the sub-
stitution of any principle whatever.
In this country, the attention of the accoucheur is directed
singly and solely to the lives under his care. Life is the
sacred object of all his eflbrts. Setting aside every other
consideration, his skill is addressed to its preservation ; and
no man, thoroughly imbued with the principles of our national
practice, would dream of raising the value of the life of the
foetus to an equality with the life of the mother. Even with
this important point settled on a firm basis, cases of conscience,
such as might puzzle the nicest casuist, must often arise.
28 MATERNAL AND FCETAL LIFE.
Hence the tender consciences of the elder obstetricians, and
their frequent meetings in grave Congress or Diet, as it were,
for deliberation, and for the division of responsibility when
any vital changes were proposed in practice. The physician
has frequently to hold the rod of Esculapius, like the brazen
serpent, between life and death ; but there is no position of
greater or equal responsibility in the entire range of the pro-
fession, than that in which the accoucheur has to choose be-
tween the life of the mother and her child, — when the mature
and the as yet glimmering torches of life are both in danger,
and the one can only be relumed by extinguishing the other,
— when to do this is the only way of escape from the sacrifice
of both.
Though, as an Englishman, I should, of course, give the
preference to our national practice, I can see some points in
which we are inferior to our continental neighbours. Either
from an improper insensibility respecting the lives of children,
or from some cruel and unjustifiable desire to punish guilty
mothers, when punishment can only fall jointly on them and
their innocent children, society in this country almost aban-
dons the unmarried pregnant woman and her illegitimate off-
spring. Our lying-in institutions generally exclude unmar-
ried women from their benefits — a most unnatural course of
action as regards the innocent children they are about to bear,
and an assumption, by human hands, of the awful severity
of the decalogue. According to the rigour of even our
criminal law, the pregnant woman with a quick child is not
executed until after her delivery ; punishment does not de-
scend upon her till her innocent offspring has been rescued
from the womb. But society does not thus suspend its
severer code for the unmarried woman about to become a
mother ; it makes an unnatural alliance between punishment
and mercy. Can it be wondered at, that in such a state of
things, infanticide should be greatly on the increase? In
France, on the contrary, either from greater indifference to
such faults on the part of women, or from a greater humanity
towards innocent children, — probably from both these
causes, — care is taken of both unmarried and married preg-
nant women. Perhaps differences of religious doctrine may
be at work more remotely here also.
Thus, I think I have shown that we may recognise two
schools or sects of obstetricians — a maternal sect and a foetal
ECLECTICISM. 29
sect. Perhaps it is beneficial to the obstetric art that there
should be these two sects in existence, the one directing its
best energies peculiarly to the preservation of the mother,
the other giving its attention preeminently to the safety of
the child. There are two lives in question in the most dan-
gerous cases, and by the dispensation which actually obtains,
each life has its partizans. Nevertheless, in the progress of
events, science and practice are not free from excesses, and
it is, above all, necessary to salutary advancement that the
protligate outbreaks of either school should be curbed. This
can only be done by reference to principles. So far as I
speak for myself, my dictum upon these weighty points
would be little worth, but if I have appealed to principles
which have been lost sight of, but which should be as lamps
to our feet, my words will not fall to the ground. The two
sects may, and probably do, exert a salutary check upon
each other, preventing, in the main, extravagance on either
side. If the eclectic spirit should have the mastery, and
each should take the wisest and best principles of the other,
rejecting their mutual defects, w^e may hope for continued
improvements in obstetricy, until the lives of both mother
and child are guarded to the utmost possible extent. The
more the obstetric art and general medicine is improved, the
more hope shall we have of approaching the time when the
lives of the mother and child shall never come into collision
— when the painful thought of sacrificing or of risking the
one for the safety of the other shall never arise to the accou-
cheur— when, if we may ever hope for such an epoch, there
could be no difference between British or Continental, Ca-
tholic or Protestant action, the efforts of both being always
exerted to save, and never to destroy. Still, during this
progress, if such be possible, we must not let even eclecti-
cism steal away our principles and springs of action. These
must be held to without bigotry, but firmly, or we shall re-
tard, rather than hasten, such a consummation.
3
30
LECTURE II.
The Scientific Ideas of Obstetricy — 1. Development — 2. Mechanism — 3. ?vfo-
tor Action — The present Disunion between Science and Practice^— iSketch
of the Progress of the Nervi-motor Physiology of Parturition up to the Pre-
sent Time.
Obstetricy, as it exists at the present time, reveals to us,
with more or less distinctness, three leading ideas, round
which many lesser ideas have ranged themselves in the ad-
vance of this department of knowledge. These primary or
leading ideas may be termed, Development, Mechanism, and
Motor action. We may trace the idea of development up to
Harvey ; that (^^ mechanism to Chamberlen and Roonhuysen ;
and the last idea — that which I have called tnotor action —
belongs preeminently in its distinct form to William Hunter.
Let us pursue the analysis of these Ideas. We may per-
ceive that of Development glimmering in the ancient axiom
— Omne vivum ex ova; but set forth with great distinctness
in the exercitations of Harvey, De generatione animalium.
In the original Latin edition of the work on generation, the
frontispiece is an engraving of Jupiter seated on a pedestal,
inscribed with the name of Harvey, holding in his hand an
egg-shaped cup or vase. The Thunderer is represented
opening the egg, and from its cavity all manner of living
things are pouring forth, — men, birds, beasts, reptiles, fishes,
and insects, are escaping to air, earth, and sea. On the
symbolical vessel is the inscription — ^^ Ex ova omnia,'^'' which
is, indeed, the epigraph of the exercitations on generation.
Tiiis great master in physiology plainly laid down the neces-
sity of following the development of the ovum from the time
of conception to the maturity of the foetus, and he himself
made many discoveries in this field of inquiry. Harvey also
conceived the existence of a general anatomy, framed by the
Creator according to one type — a conception afterwards
seized upon with such distinctness, and embodied by John
Hunter in his magnificent museum. Harvey, too, caught a
DEVELOPMENT. 31
glimpse of the progressive development of the human ovum
through conditions which are permanent in the lower ani-
mals. Besides this general view of all which relates to ordi-
nary anatomy, which follows step by step the ovum from the
point when it first becomes cognizant to the senses to the
perfect animal, and pursues, link by link, the meaner crea-
tures to those highest in organization, allying together, by
certain unities, the most distant products of animal life, a
great additional flood of light has been thrown upon deve-
lopment by the use of the microscope. To the microscope
we owe the discovery of the spermatic entozoa by Hamme
and Leuwenhoeck, and subsequently of the unimpregnated
ovule in the Graafian vesicle, by Baer. The discoveries of
Schwann and others in cell-development form another era in
structural anatomy and minute development. From the
knowledge of the mode of increase by cells, and the cell-
form of the ovule, histologists have proceeded with the study
of another phase of development — namely, the modes of in-
crease and metamorphosis peculiar to organic matter. We
may hope, at no distant period, to span the distance be-
tween the wonderful cell wdiich constitutes the minute unim-
pregnated ovule, and that vast aggregation of cells, variously
modified, which builds up the human fabric, and of which
that primary cell is the bountiful parent. Organic chemistry,
again, lends another aid to the knowledge of development,
by determining the material constitution of the animal tissues,
and the progress of this department of science gives every
promise that we shall hereafter be able to follow the assimi-
lative atom or element from its first introduction into the
animal economy to the time of its egestion, informing our-
selves of all the chemical changes it has undergone in its won-
derful passage through the arcana of life. Thus the idea of
development has now far outgrown its beginning in embry-
ology, and become the most extensive, perhaps, of any in the
anthropological sciences. Still its origin must not be for-
gotten by obstetricians.
In the next place, the evolution of the Mechanical idea
may be pursued. The germ of this idea must have existed
wherever the act of parturition was observed. It originated,
however, distinctly as such, with the first obstetric mechanists.
"When our countryman, Chamberlen, and Roonhuysen, in
Holland, invented the forceps and vectis, and it became
32 OBSTETRIC MECHANISM.
known that they and their descendants possessed a mechan-
ical mode of rendering labour, as they averred, more safe
and painless than it had previously been, and also of affording
assistance in cases of difficult labour ; every thing of a me-
chanical nature, connected with parturition, came naturally'
to be studied with the greatest interest and attention.
Thence arose the gradual improvements in obstetric instru-
ments, and in the knowledge of the modes and conditions
in which they should be applied. Thence, also, origi-
nated the study of the obstetric anatomy of the female pel-
vis, and the obstetric anatomy of the foetal head, and of
the foetus in general. Thence we derived a knowledge of
the peculiar anatomy of the separate bones, and of the com-
plete pelvis ; the articulations and soft parts ; the relation of
the parturient passage to other organs in the gravid state ;
and the perfect admeasurement of the different planes, axes,
and diameters of the pelvic canal. Thence, too, came the
study of the adaptation and organization of the foetal head,
the obstetric anatomy of the ovum, if it may be so called,
which embraces a knowledge of the different measurements
of the head of the child, and the natural provisions for its
diminution when any disparity exists between the head and
the pelvis ; and also a knowledge of the mode in which the
other parts of the child conduct themselves when the head
is not the presenting part. From the growth of the same
idea we derive a knowledge of what has been called the
mechanism of labour, which has only recently been fully
understood, consisting of an exact acquaintance with the
different presentations of the foetal head, and the various
rotatory and advancing movements and minute adaptations
of position, which occur in its passage from the pelvic brim
to the birth. The mechanical idea, which, when held in
due subordination, is of immense value in midwifery, now
pervades every department of obstetrics, and indeed it may
be imputed as a fault to the practice of even the present day,
that it is too purely a mechanical midwifery. In the height
of the mechanical era, at the time of Smellie, for instance, or
a little after, — when the phantom was invented, an accou-
cheur might have been represented as a person holding a
pair of callipers in one hand, and a forceps in the other ;
instruments were used not only in difficult, but in strictly
natural labours. At the present day, time and experience
MOTOR ACTION. 33
have effected some great changes; but still I maintain that
the improvements in obstetricy are of an empirical, rather
than of a scientific character, and the misfortune of empirical,
or merely practical, advancement in any art is, that it tends
to magnify the individual, instead of to improve the profes-
sion. If the improvements of modern times be examined, I
believe they will be found to have this fault. Now purely
empirical knowledge is not communicable to others, so that
when a man eminent for experience alone, dies, he takes
with him much of the superiority he had acquired ; whereas,
the man who makes any scientific progress, however humble,
can both inform his fellows, and bequeath his achieve-
ments to posterity.
The third idea I have spoken of, involving the Motor
actions, or physiological, as distinct from the anatomical,
mechanisms of parturition, is of far more importance to the
obstetric art than the two we have briefly considered.
Fabricius ab Aquapendente distinctly taught that the con-
tractions of the uterus, aided by the actions of the abdominal
muscles, were the chief agents in parturition, but this was con-
sidered so extravagant, that even Harvey met it with direct
opposition. For more than a century alter the time of this
anatomist, the conception of the uterus, as a muscular organ,
remained in a very crude state. Obstetricians w^re too
entirely occupied with the merely anatomical mechanisms of
the pelvis and foetus, to devote their attention to the motor
powers which over-ruled them. William Hunter was the
first to dwell prominently on the muscularity of the uterus.
It is to the chapter in his work, on the human gravid uterus,
which treats " Of the nerves," and " Of the muscular fibres
of the uterus," that we must look, as the foundation of the
true nervi-motor physiology of parturition. Though he wrote
with doubt and hesitation, and though the things of which
he wrote were surrounded by the mists of ages of ignorance
and uncertainty, and hidden by the mistakes of other anato-
mists, this part of his works is, more than any other, the
starting point from which his genius was destined to influ-
ence the progress of obstetricy. William Hunter, even, com-
mitted excesses in following anatomy, which in his accepta-
tion of the term included physiology, too far ; witness his
proposal to allow the placenta always to remain in utero until
expelled by the natural efforts — a practice which was aban-
3*
34 MOTOR ACTION.
doned, from the fatal results which followed. However, we
owe some of the happiestpeculiarities of our national practice
to the noble stand he made against mechanical principles — ■
principles which have undoubtedly injured Continental ob-
stetricy.
Denman took up the mission of William Hunter, and con-
tinued to teach a vital, or physiological, as opposed to a
mechanical midwifery. It was the greatest pride of these
distinguished obstetricians to transfer triumphs from Art to
Nature ; to repose more upon the physiological mechanisms
of parturition than upon obstetric dexterity ; and to exalt the
wisdom written upon the uterus and its endowments, above
all the skill of the hand of man. Both placed great trust in
instrumental assistance, in proper cases, but both deliberately
expressed their doubts, balancing the good and evil, and
lookingtothe prevalence of merely mechanical ideas, whether,
up to their times, it would not have been happier for the
world if instruments had never been introduced into the
practice of obstetricy. Denman even, more clearly than his
great and elder contemporary, saw the direction midwifery
was destined to take. Some passages in his writings are
almost prophetic. Looking forward to the detection of the
nature of the motor power of the uterus, and to its beneficial
influence upon practice, he wrote, '' At the time of labour, a
new principle supersedes those of ascension and descent.
This gives a disposition to the uterus to exclude whatever is
contained in its cavity, and the effect produced is in propor-
tion to the energy of the principle, and the power of the
uterus. A perfect intelligence of this principle, and of the
mode of its operation, would probably be of infinite use in
practice, as we might be enabled to suppress the action
thereby occasioned when premature, moderate it when too
violent, strengthen it when too feeble, and regulate it in a
variety of ways conducive to the welfare of our patients.
On the knowledge we at present have of the manner in which
this principle operates, and the circumstances by which it is
influenced, the assistance which science and dexterity can
give in cases of diflficult parturition and in preventing abor-
tions, very much depends."
It happens, singularly enough, that the practices and
emoluments of both William Hunter and Denman have de-
scended even to the present day. There are obstetricians
MOTOR ACTION. 35
now living who are as much the heirs of these eminent phy-
sicians as though medical practice were actually hereditary.
Buttheir representatives are the inheritors of the good fortune,
rather than of the principles or ideas, of those who are, his-
torically speaking, their forefathers. William Hunter and
Denman both acted upon the noble sentiment, that it was
better, and more conducive to the good of mankind, to teach
and improve their art than to practice it ; and thus it was
that the hand of death almost fell upon William Hunter, in
the lecture-room, among his pupils. But it must be confessed
that their descendants have failed in the most essential
qualities of their predecessors. They have acted as though
midwifery had arrived at something very like perfection, as
though all that remained to be done was to cultivate a lucra-
tive practice ; and I venture to predict that the hereditary
line w411 be broken by others possessing a better conception
of the spirit, and more able to wear the mantles, of these
eminent accoucheurs.
I look upon it, that since the death of William Hunter only
one or two great accessions have been made in physiological
midwifery, and these I take to be the more perfect establish-
ment of William Hunter's own doctrine respecting the mus-
cular structure of the uterus, by Sir Charles Bell, and the
laborious dissections of the nerves of the virgin and gravid
uterus, by Dr. Robert Lee. This latter advance settles on a
firm basis important points which were only anticipated
by William Hunter, and which must exert an influence,
not upon any especial departments of obstetrics alone, but
upon the entire art. We have now fairly before us nerve
and muscle, with which to account for many of the unex-
plained phenomena of parturition. With these elements
given, physiology can work out many an obstetric problem
before hopeless of solution. We can also bring to our aid
other and most brilliant discoveries in neurology to unravel
the mysteries of nervi-motor action which have so long per-
plexed obstetric practitioners. But I proceed more in detail
to place before you the present state of knowledge in this
department.
Up to this time, obstetric and physiological writers may
alike be appealed to as proving how scanty has been our ac-
quaintance with parturition as a motor function. It is no
exaggeration to say, that in the current works which treat of
36 MOTOR ACTION.
this subject, the opinions advanced respecting the motor
phenomena of the organs concerned in parturition, are but
little more certain and definite than those which were given
by Harvey, as the views of Fabricius, nearly two centuries
ago. The following passage, from Fabricius, quoted in the
Exercitations, sets forth both the contraction of the uterus and
the abdominal muscles. The anatomist of Padua taught the
following doctrine : —
*' The uterus being so enlarged by the bulk of the foetus
that it will admit of no further distention without danger, and
thereupon being excited to expulsion, is, by the action of
the transverse fibres, contracted upon itself, and so reduced
into a narrower compass ; and thus, whilst previously,
neither the excrements from their quantity, nor the fcjetus
from its size, could be longer retained, the uterus, being
further contracted and compressed, is still less able to con-
tain them. Hence, first the membranes, as being the weaker
parts, and more distended, give way, and the humour, which
is least resistant, first escapes to lubricate the passages.
Hereupon follows the fa?.tus, as being not only increased in
weight (by reason that it no longer swims in the humour),
and so descends, forcing the orifice of the womb ; but also
as being compressed, propelled, and expelled by the action
of the uterus itself, in which action the abdominal muscles and
the diaphragm admirably assist by theirpowerof compression."
I have already stated that Harvey himself opposed these
views of his teacher, Fabricius, maintaining that the foetus
bursts forth chiefly by its own efifbrts. To this opinion he
was misled by a false analogy, drawn from the oviparous
generation of birds and insects, in which the young animal
generally frees itself from the egg without assistance ; by
reasoning from cases of post-mortem delivery ; and by con-
sidering the remarkable case of Queen Henrietta's mare — a
beautiful animal whose vagina had been secured by iron
rings to prevent impregnation, and thus preserve her figure
and strength — but, in spite of this infibulation, she conceived
clandestinely ; and in her foaling, which took place without
the knowledge of the grooms, the vagina was lacerated by
what Harvey supposed could only have been the violence of
the foetus, but which we now know to have been the con-
tractions of the uterus itself. He was further drawn astray
by arguing physiologically from a case of labour complicated
MOTOR ACTION. 37
with convulsions, which induced him to consider the actions
of labour similar to sneezing, or any other succession of the
system. Not even a case he relates of conception, in which
there was complete prolapsus uteri, and in which abortion
took place, sufficed to convince him of the general importance
of uterine action in parturition. However, in the main
points, — the contraction of the uterus, and the action of the
abdominal muscles, — Fabricius had the truth on his side ;
and this, in the end, has prevailed even over the dictum of
his illustrious pupil.
The relation of uterine contraction to the cerebrum and
spinal cord has been examined experimentally by MM. Serres,
Brachet, and Segalas ; but their experiments, however inte-
resting, are diminished in value by the fact, that they were
performed before the promulgation of the modern views of
the action of the nervous centres. The great aim of these
able experimenters was to prove the direct influence of the
cerebro-spinal centre, as it was termed, upon the uterus.
In these experiments, the idea of a reflex spinal -action does
not, of course, obtain a place. M. Serres found that on
dividing the spinal cord in gravid animals, before the time of
parturition, death ensued at various intervals, but abortion did
not occur. He found also that when it was divided atler the
commencement of parturition, the process of parturition was
effectually arrested. Here were negative proofs that the
spinal cord influenced the uterus ; but M. Serres obtained
positive proofs by exciting abortion in animals, by irritating
the medulla in the lumbar region. The experiments of M.
Brachet were numerous, and of a similar character. For
instance, he divided the spinal cord in a guinea-pig, in which
parturition was commencing. After the section of the cord,
there were only some feeble movements in the lower part of
the abdomen, and the animal died undelivered in three days.
He repeated this experiment, and with the same result.
He then ascertained that these indistinct movements of the
abdomen depend on faint contractions of the uterus, and he
supposed his sections of the cord had not exactly hit the
origin of the nerves supplying the uterus. He devised more
careful experiments and found that on making a section of
the spinal marrow, between the twelfth and thirteenth dorsal
vertebrae, the uterine contractions were altogether suspended ;
there were no abdominal movements, and the animals died
38 MOTOR ACTION.
undelivered. To show that mere sufferlnfr had not influ-
enced these experiments, he divided the contents of the
vertebral canal in the sacral region, making, also, one in-
cision down to the spine in the dorsal, and another in the
lumbar region, but without dividing the spinal cord. Here
the uterine contractions were unaffected, and five young
guinea-pigs were produced in less than two hours. M.
Brachet also relates a case of paraplegia, from disease affecting
the lower portion of the medulla spinalis, which has been
often referred to, in which labour proceeded with extreme
inertia. M. Segalis performed experiments upon the spinal
cord, and found that when the cord was divided high up,
the uterus and urinary bladder still acted, but were paralyzed
by division of the lower portion of the cord. The above ex-
periments, taken together, prove irrefragably the relation be-
tween the spinal cord and the uterus ; but the true nature
of this connection w^as unknown. The only explanation
offered by these physiologists was, that a direct cerebro-
spinal influence emanated from the cord to the uterus ; and
this was altogether inadequate to account for the phenomena
of parturition.
The speculations of those who had not examined the mat-
ter experimentally were still more unsatisfactory. The func-
tion of parturition has always occupied a very humble and
uucertain place in physiology. You may find it dismissed in
two pages and a half of Professor Miiller's great experi-
mental work ; in a page or two of Dr. Carpenter's " Prin-
ciples of Human Physiology," and in three paragraphs of his
*' Manual ;" while in the " Cyclopaedia of Anatomy and
Physiology," the article "Parturition," recently published,
occupies just three pages, which are entirely occupied by
mere mechanism. Professor MiJller, in several parts of his
" Elements," speaks of the action of the uterus as peristaltic,
and does not, I believe, anywhere go beyond this. Dr.
Carpenter, a received authority in this country in physiology,
when he published the first edition of his work, many- years
after Dr. Marshall Hall had made the great and compre-
hensive discovery of the independent function of the
spinal marrow, was not aware of any reflex action belong-
ing to the uterus ; on the contrary, he taught that the
uterus was independent of the spinal centre. So that if we
skip two centuries, and come at once from Fabricius to our
MOTOR ACTION. 39
able countryman, we shall see but little difference between
their opinions. In this department of physiology time has
trodden very lightly, leaving but few treasures by the way.
To prove this, 1 have only to ask you to compare the passage
from the older author with the following, which contains
the whole of Dr. Carpenter's account of parturition in the
first edition of his work on human physiology: — •
" As regards the act of parturition, there would seem
reason to believe, from the evidence of paraplegia, that, of
the muscles whose operations are associated in it, the dia-
phragm, abdominal muscles, &c., are called into action, (as
in defecation) through the spinal cord, but that the contrac-
tions of the uterus itself are independent of all connection
with the nervous centres. Of the reason why the muscles,
which were up to that time inert, should then combine in
this extraordinary manner, and with such remarkable energy,
physiology can afford no certain information. There can be
little doubt, however, that the stimulus usually originates in
the uterus, or in some of the neighbouring organs, which are
incommoded by the pressure ; but it may also result from
some condition of the general system, in which the uterus
itself is but little concerned. It is an interesting fact, which
has been more than once observed, that the foetus may be
expelled from the dying body of the mother, even after the
respiratory movements have ceased. This would appear
due to the contraction of the uterine fibres alone, which,
like those of the heart and alimentary canal, retain their
irritability longer than those of the muscles supplied by the
cerebro-spinal nerves, and the power of these would be un-
opposed hy the resistance which they ordinarily have to
encounter, since the tone of all the muscles surrounding tlie
outlet would be destroyed by the cessation ot the activity of
the spinal system of nerves." — p. 153.
" At the conclusion of about nine'(solar) months from the
periotl of conception, the time of parturition arrives. The
uterus, by its own efforts, and by the assistance of the dia-
phragm and abdominal muscles, expels its contents, and the
membranes of the ovum being usually ruptured before it is
entirely discharged, the foetus comes at once into the world,
Respecting the degree in which the parturient efforts are pro»
bably dependent on nervous influence, some remaiks have
been already made. It seems by no means unlikely that the
40 MOTOR ACTION.
uterus, though not itself dependent on the spinal cord for its
power of contraction, may contain numerous afferent or ex-
citor fibres, and that these being compressed by the efforts
of its own muscular structure, may propagate to the spinal
cord the stimulus necessary for the consentaneous action of
the assistant muscles. Those who may watch a labour with
an attentive consideration of its phenomena, will find that
the " pains" usually commence in the uterus itself, and that
it is only when they become decided, that the power of other
muscles is called into operation. As to the reasons why the
period of parturition should be just nine months after con-
ception, we know nothing more than we do of similar facts in
the physical history of man — such as the periodical return
of the catamenia, the renewal of the teeth, the tendency to
sleep, &c. That it is immediately dependent on some state of
the constitution, rather than upon the condition of the uterus,
appears from the fact, that in cases of extra-uterine preg-
nancy, contractions resembling those of labour take place in
its walls." — p. 657.
Such was Dr. Carpenter's account, and I believe it to
have been the very best explanation of this function which
had at that time appeared. I ought to add, that before the
appearance of the second edition of his work, I had published
a short sketch of the reflex physiology of parturition, and Dr.
Carpenter, at once, and with the greatest candour, adopted
my views. You will observe, that besides uncertainty in
many minor points. Dr. Carpenter at first taught, that the
contraction of the uterus was independent of the spinal mar-
row; that physiology could give no explanation of the re-
markable action of the expiratory muscles in parturition ;
and that we were wholly in the dark respecting the cause of
labour.
The latest writer on the nervi-motor physiology of labour
is Dr. Todd, who introduces the subject into his article on
the "Nervous System," in the "Cyclopaedia of Anatomy
and Physiology." I may quote the following passage from
this work, as a further and convincing proof of the confusion
which prevails in this department of physiology : —
" i\s to the expulsion of the foetus in parturition, while
I am willing to admit that the physical power of the cord
excited by the sensitive nerves, at the neck of the uterus,
may exercise some influence on the contractions of the ute-
MOTOR ACTION. 41
rus, it seems to me quite evident, that the actions of this
organ are reflex only to a very slight degree. In the first
place, anatomy teaches us, that the muscular parts of the
uterus have a very trifling connexion with the spinal cord ;
the nerves distributed to it being few, and these only par-
tially derived from the spinal cord. Secondly, parturition
may take place even when the spinal cord has been diseased
or divided, so as to cut off its influence upon the inferior
half of the body. Thirdly, it has lately been ascertained,
that in women under the influence of ether, the act of par-
turition may take place with vigour, although the nervous
power have been very considerably depressed by the influ-
ence of that agent."
In a subsequent lecture, I shall have to treat, at greater
length, of the innervation of the uterus ; but I may observe
of Dr. Todd's preliminary admission, in the above passage,
that the nerves of the cervix uteri certainly do not excite
the spinal marrow by virtue of their being " sensitive
nerves," for in the healthy state the cervix is at all times
remarkably insensitive, and it often happens that it is insen-
sible to the touch when parturition is proceeding with great
energy.
To the first argument brought forward by Dr. Todd, with
a view to prove, that the contractions of the uterus are re-
flex only in " a very slight degree" — namely, the argument
drawn from anatomy — it may be fairly objected, that the
questions recently raised, respecting the nerves of the ute-
rus, are certainly not, as yet, quite decided in the negative.
Some hundreds of conscientious witnesses, many of them
distinguished anatomists, believe that they have seen, in the
dissections of Dr. Robert Lee, the muscular and other tissues
of the gravid uterus largely supplied with nerves, a consi-
derable proportion of which are derived from the spinal mar-
row. But whether the muscular nerves of the uterus are
large or small, we know that the uterus acts with excessive
energy under the influence of emotion, and if the nerves are
large enough to convey the influence of emotion to the ute-
rus, they may well be large enough to convey the physical
reflex power from the spinal marrow to this organ.
I believe Dr. Todd's " secondly," can be shown to be
very untenable. He does not cite any facts in support of
his assertion, while numerous experiments and facts may be
4
42 MOTOR ACTION.
adduced which directly contradict it. I mayrefer especially
to the experiments of MM. Serres, Brachet, and Segalas, and
to the cases of paraplegia detailed by MM. OlJivier and Bra-
chet, all of which go to prove, that injury of the upper por-
tion of the spinal marrow does not interfere with the action of
the uterus, but that this is arrested or prevented by destruc-
tion of the lower portion of the medulla.
Nor is Dr. Todd's *' thirdly" more conclusive. It is quite
true, that parturition may be completed during etherization,
but it is by no means proved, that the energy of the healthy
spinal marrow is materially or generally depressed under the
influence of ether, unless this agent be pushed to a poison-
ous extent. Dr. Todd admits that respiration is essentially
reflex, and he will not be inclined to assert, that where ether
has been resorted to in parturition, it has arrested the
respiration. This ought to happen, to make Dr. Todd's
argument consistent. In another part of his essay, Dr. Todd
mentions the fact, that agents which produce convulsions or
spasm do so by exalting the excitability or polarity of the
spinal marrow. Now, there are many cases on record, in
which spasm and convulsion have followed etherization.
Such cases support the view, that ether may act as a spinal
excitant, and they are quite as worthy of consideration as
other cases and experiments, in which spasmodic actions have
been temporarily relieved by the administration of ether.
Thus pursued, sentence by sentence. Dr. Todd's views of
the non-reflex nature of parturition may be proved unsound.
This physician endeavours to show, in its stead, that it is
to the inherent muscular contractility of the uterus, and to
the stimulus of distention, that we must refer the expulsion
of the foetus. On these subjects, Dr. Todd certainly does
not display either constructive genius or analytic power.
If, on the other hand, we turn to purely obstetric writers,
the real physiology of parturition is treated with equal or
even greater brevity, though it is undoubtedly the corner
stone, the very basis, of the Third Estate in medicine. If
we examine the most recent treatises on midwifery, though,
as I shall ^^how you, the true spinal marrow plays a part so
important in obstetricy, and though many obstetric works
have issued from the press since the date of the discovery of
the reflex function, it is remarkable that the word reflex,
in its full siofnification, is not to be found in any one of them.
MOTOR ACTION. 43
The recently-published lectures of Dr. Robert Lee, Dr. Mur-
phy, and Dr. Rigby, the large work of Dr. Ramsbotham, and
Dr. West's Reports on the progress of midwifery, may fairly
be considered as the last results of the old obstetric ideas,
yet no hint is given in either of these authors, of the reflex
nature of the major part of the phenomena of labour. In the
course of Dr. Murphy's lectures, which appeared after I had
published a sketch of the reflex physiology of parturition, the
term " Reflex Function" does once occur, but it is only in-
troduced in the most casual manner, and by way of illustra-
tion. Recently, some other obstetric writers have, in the
various medical periodicals, used this term occasionally, but
it has merely been the sounding of the word to the ear ; there
has been no investigation or comprehension of the subject.
This is the simple truth, and yet I saw it broadly stated, a
short time ago, by Dr. Snow Beck, that " In this country,
perhaps the most generally received opinion of the action of
the uterus is, that the contraction of the organ is caused by
the reflex function of the spinal cord." I can only add that
I wish such were the fact ; but there is, indeed, scarcely a
single point in the motor physiology of parturition upon
which obstetricians have been agreed. They have engaged
themselves with the consideration and study of the anatomi-
cal mechanisms, to the omission of the more important phy-
siological mechanisms of the process. Of the latter, they
have been content to give the merest outline or physiognomy
— an outline broken, and a physiognomy deformed. Hip-
pocrates compared the passage of the foetus through the pel-
vis to the escape of an olive from a bottle ; though the com-
parison has long been exploded, obstetricians in general
have still employed themselves in studying the extrication
of the olive ! I venture, without fear of contradiction, to
assert, that nothing like a correct analysis or synthesis of the
different forms of uterine motor action, no examination of the
order in which the various uterine and extra- uterine actions
of labour take place, or of the reasons why they follow each
other in a certain definite and regular order, will be found
in any of the works of British or Foreign writers on Obste-
tricy.
When I began to study this subject, valuable facts relating
to the arrest of uterine hemorrhage had already been observed
and acted upon by Mr. Simpson, of Stamford, and by Mr. W.
44 MOTOR ACTION.
F. Barlow ; an excellent paper had been read before the
London Medical Society by Dr. S. S. Alison, the object of
which was to show the reflex nature of uterine action. In
the various writings of Dr. Marshall Hall, and particularly
in his work on the *' Diseases and Derangements of the
Nervous System," many most important facts are to be found ;
and he sums up the subject by declaring, that "the whole
question of abortion and parturition, and, in a word, of
Obstetrics as a science, is one of the true spinal system."
Beyond this, I believe no one else had contributed anything
of importance to the subject; and, as I have said, the very
word Reflex, in its physiological meaning, did not exist in
any obstetric w^ork w^hatever.
Thus, then, with the exceptions just named, a few para-
graphs by physiologists, a few pages by obstetricians, — and
these latter chiefly occupied by the purely mechanical part
of labour, — make up the sum of our knowledge of the phy-
siology of parturition. How is this to be accounted for ?
It certainly is not that parturition is a less important func-
tion than digestion, or respiration, or even the circulation
of the blood, all of which have been so amply investigated.
The uterus has been compared by a distinguished living phy-
siologist to the stomach, as being the organ of nutrition and
support to the species. We may, with equal or even greater
justice, say that the uterus is to the Race w^hat the heart is to
the Individual: it is the organ of circulation to the species.
Ages are the channels in which created beings circulate; and
man passes continually from the womb of his mother onwards
to the womb of time. The succeeding generations of human
kind, following one after another, are, as it were, the pulses
of the animal Cosmos. Parturition is the systole of the
uterus, the unirapregnated state its diastole, and the living
beings which flow on in countless numbers in the stream of
life may be likened to the myriads of globules revealed by
the microscope in the circulation of the blood. In relation
to the vast scheme of existence, parturition does but assume
its just proportions, and assert its rights to the attention of
the physiologist, as the greatest epoch in generation.
We must go on to develop the dynamical Idea, the physio-
logical mechanisms of labour, of which, at present, there
exists, within the pale of obstetricy, nothing but the bare data
or formulae for their working out — namely, the muscular
MOTOR ACTION. 45
structure, and the nervous endowments of the uterine
system. The generation is but just passed away which
denied the muscular structure of the uterus ; and the very
existence of the nerves of the uterus some are still found
to deny. However, granting that the nerves and muscular
fibres have been beautifully delineated by the scalpel of the
anatomist, it remains still to study these parts in action. They
exist as a picture, but they have not been studied as actors
or performers in a drama: and there is even more difference
between anatomy (as we now understand the term) and phy-
siology, than there is between painting or sculpture, and dra-
matic representation.
4*
46
• LECTURE III.
On the Different Forms of Motor Action observed in Human Parturition : —
Volition ; — Emotion ; — Reflex Action ; — Peristaltic Action, or Contraction
from the Irritability of the Uterine Muscular Fibre.
Uterine motor action, and the action of the accessory mus-
cles concerned in parturition, with the knowledge of the
nature and laws of the forces upon which these actions de-
pend, are the Dynamics of parturition. The phenomena of
labour, and the great majority of the accidents and complica-
tions of childbirth and the puerperal period, are essentially
nervi-motor ; hence a definite knowledge of motor action in
general, and particularly of the uterus and its associated
organs, are of the first importance to the scientific accou-
cheur.
Precise and definite knowledge is required. It is not suf-
ficient to say, in general terms, that the passions of the mind
affect the pains, that voluntary efforts are improper, and that
the gravid uterus sympathizes with various parts of the body.
The motor forces, which effect the expulsion of the foetus, at
the end of gestation, must be examined, singly and collec-
tively, by way of ana4ysis and synthesis, with as nearly as
possible the same accuracy as the chemist would use in the
investigation of the simple states and combinations of the
elements recognised in chemistry. The uterus is a muscular
organ ; it is the largest, and perhaps the most important,
muscle of the female economy ; and its varied nervi-motor
actions must be studied just as we should study the actions
of the muscles of the hand, or any other muscles more evi-
dent to observation than the uterus. In the same way, too,
we must examine the extra-uterine motor actions which are
brought into play during labour for the purpose of aiding the
action of the uterus. Such an analysis will show us that the
motor organs of parturition are endowed with several kinds
of motor action, of which, as I have already said, the Reflex
is the most important. The whole subject is simple, and yet
VOLITION. 47
difficult ; the clue is distinct, but the labyrinth involved and
tortuous. I must beg, throughout, your closest attention, and
I sincerely wish I could be sure of rendering your minds as
clear and lucid upon this branch of physiology as the crystal
prism which dissects the sunbeam.
The forms of motor action which it will be necessary for
us to consider are — the Voluntary, the Emotional, the Ex-
cito-motor or Reflex, and lastly, the Peristaltic or Imme-
diate.
And first let us study the influence of Volition^ with refer-
ence to parturition.
The uterus is altogether removed from the direct influence
of Voluntary motion. The will has no direct power, either
to contract or to dilate this organ. Labour may take place
where cerebral paralysis exists, the will being entirely in
abeyance — the movements dependent on reflex action, and
peristaltic action, all remaining perfect. But though not
exciting any direct influence, volition may affect the uterus
indirectly. We see in certain cases of uterine inertia, where
the contractions of the uterus have entirely ceased, that
strong voluntary efforts are sometimes sufficient to reproduce
the labour-pains. Voluntary efforts at expiration, with the
glottis partially or entirely closed, cause the abdominal
muscles to compress the uterus mechanically, in the first
place, and this compression stimulates the uterus, and excites
it to contract, in the same way as manual irritation of the
organ through the abdominal parietes w^ould do. What in
other organs is called consensual action, may also, I believe,
be excited to some degree in the uterus. We see that violent
voluntary exertion quickens the action of the heart, and that
contracting the rectus internus muscle contracts the iris at
the same time, though both the heart and iris are quite re-
moved from the direct action of volition. In a similar
manner, during parturition, the uterus is probably affected in
a slight degree during the intense efforts at expiration, w'hich
are made during the pains.
But besides promoting the uterine contractions indirectly,
the efforts of the respiratory muscles are as much a part of
labour as the contractions of the uterus itself; and volition
increases, and in some measure increases and controls, the
reflex and emotional actions of the respiratory muscles in the
propulsive and expulsive stages of labour. The patient
48 EMOTION.
grasps the hand of an assistant, the back of a chair, or a
towel fastened to the bed-post, and by thus rendering the
thorax a fixed body, materially increases the power of the
abdominal muscles. It is at this point that volition be-
comes directly mingled with the other motor actions of
parturition.
In the next place, let us examine Emotion as a motor
power.
A very powerful influence may be exerted upon the uterus
by emotion. During labour, any sudden emotion of the mind
may increase or arrest uterine action. The different effects
of hope or despair on the commencement, progress, and ter-
mination of labour, have often been remarked upon. After
delivery, the maternal emotion excited by the sight of the
infant causes the uterus to contract in a very remarkable
manner. Emotional action, like that of volition, is psychical
in its nature ; but it acts upon the muscular system through
the medium of the spinal marrow, the great organ of physical
motion ; this is evident from the fact, that emotional move-
ments may occur in parts which are entirely paralyzed to
cerebral voluntary motion.
The most simple voluntary movements can hardly occur
"without the supervention of emotional power. It is very
difficult, by the utmost stretch of volition, to reduce ourselves
to mere automatons. We cannot raise a finger, without the
accompaniment of some emotion which either steadies the
movement, or makes it falter. In the powerful voluntary
efforts of the latter stages of parturition, a considerable
amount of emotion is induced ; the patient often fights and
rages, as it were, with her pains, and thus powerfully in-
creases or perverts the reflex and voluntary actions. Again,
reflex actions are often wisely accompanied by painful or
pleasurable sensations, and these sensations originate motions
which strengthen or otherwise alter the reflex motor actions.
In parturition, physical pain and the resultant emotions play
important parts, aiding most emphatically, when not exces-
sive, all the motor actions of dilatation or contraction which
are concerned in this function.
In normal parturition, emotion is of greater importance
than volition, as, besides the increased uterine and respiratory
action which it excites, it relaxes the glottis under circum-
stances of danger, and by removing the expiratory pressure
REFLEX UTERINE ACTION. 49
from the uterus, lessens, in a remarkable manner, the risk of
rupture or laceration. In this way the emotion arising from
the physical pain of labour is beneficial. Physical pain itself
is a great trial, but it may be doubted whether, all things
duly considered, women would be equally safe if they could
be made to pass through labour with perfect freedom from
suffering. Still, it is quite possible, in some cases, for labour'
to be performed in the total absence of all sensation and
emotion. Labour may take place during the ansethesia pro-
duced by ether, chloroform, or other narcotic agents. In-
deed, during a certain state of the mental emotions, women
have often passed through delivery in an ecstatic state, and
have appeared almost insensible to pain. I have seen several
instances of this kind. Women m.ay also be delivered in a
state of profound coma, or in sleep, or with the cerebral
influence permanently removed, as in paraplegia from dis-
ease in the middle portion of the spinal marrow ; many cases'
of this kind are on record. Volition, sensation, emotion, and
the expiratory actions, are here entirely withdrawn, and labour
is performed solely by the instrumentality of the excito-motor
power of the uterus and its peristaltic action.
We have next to consider Reflex uterine action.
The Reflex actions of the uterus are very numerous, and
it is upon these, and the numerous extra-uterine reflex actions
excited during the process, that the natural performance of
parturition essentially depends. Contraction of the uterus,
from irritation of the mammae, as in the act of suckling the
child ; contraction of this organ from the cold water douche,
applied to the vulva or the abdominal surface ; contraction
excited by irritating the rectum, as by stimulating enemata;
or of the stomach, by drinking a gulp of cold water ; of the
ovaria, by the presence of the menstrual nisus ; of the vagina,
by manual irritation, as in " taking a pain ;" of the os uteri by
irritation, as in the introduction of the hand into the uterus
— are all to be considered as so many instances of reflex
spinal action. Thus, in parturition, the uterus may be ex-
cited, in a reflex form, by irritation of the mammary incident
excitor nerves ; the pubic and abdominal branches of the
intercostals ; the rectal; the gastric division of the pneumo-
gastric ; the ovarian nerves ; and also by the nerves of the
vagina, and the os and cervix uteri.
Many of the different forms of abortion — particularly when
50 REFLEX UTERINE ACTION.
the causes are extra-uterine — strikingly illustrate the reflex
action of the uterus. A series of cases of abortion would be
one of the best expositions of reflex uterine action. Abortion
may be caused by irritation of the mammee, from the sucking
of an infant, after milk has ceased to be secreted, as in cases
in which the mother becomes pregnant during lactation ;
abortion may be excited, as a morbid reflex act, from irrita-
tion of the bladder, by a calculus ; by irritation of the tri-
facial nerve, as in cutting the dens sapientise ; by the me-
chanical irritation of coitus ; by plugging the vagina ; by
disease of the os and cervix uteri — malignant or simple in-
duration, inflammation and ulceration ; by the irritation of
the placenta attached within the uterine mouth ; by ovarian
irritation in ovarian disease ; by irritation of the rectum, as
from ascarides, and the use of irritating purgatives or enemata ;
by puncturing the membranes, and evacuating the liquor
amnii, so as to bring the head of the foetus to act as an exci-
tant to the OS uteri ; by irritation of the inner surface of the
uterus itself, in cases of blighted fcetus, where the ovum acts
as a foreign body ; by riding on horseback, or any other
violent exercise calculated, by succussion, to bring the head
of the foetus into violent contact with the os uteri ; and by
other sources of irritation to incident spinal nerves which
might be enumerated. All these are so many instances
. of uterine reflex action, the distant parts of the economy
being brought into connection with the uterus through the
medium of the spinal marrow and its special incident excitor
and reflex motor nerves. These facts are of most extensive
practical application in devising means for the prevention of
abortion.
In cases of abortion in which the irritation is applied to
the OS or cervix uteri, or the internal surface of the organ,
the immediate action depending on the irritability of the
uterus itself is called forth, in connection with true reflex
action ; but in the instances in which a distal organ is irri-
tated, there can be no doubt whatever of the purely reflex
nature of the uterine action which ensues.
In the lower animals, reflex parturient phenomena are
constantly observed ; the expulsion of the egg of the common
fowl has been caused by sprinkling a few grains of salt upon
the vulva or velabrum ; cold injections have been used empi-
rically, to excite uterine contractions duringfoaling or calving,
EXPIRATORY ACTION. 51
in the mare and cow ; and the tipula and libellula have been
observed, during the period of oviposition, to deposit eggs,
whenever they have been shaken upon rough paper, or when
the surface of the abdomen has been irritated in any way:
these insects, the silkworm moth, and others, go on with the
work of oviposition even when the abdominal have been
divided from the thoracic portions.
But besides the uterine reflex actions, there is in the Ex-
piratory actions, supervening in the course of labour, from
the irritation of the presenting part of the fcetus, another re-
markable series of reflex parturient actions, extra-uterine in
their seat, but which combine and harmonize in a remarkable
way with the reflex actions proper to the uterus. It is found
that tumours in the vagina, or the introduction of the hand
of the accoucheur, may produce the same result as the pres-
sure of tfee presenting part of the child in labour. It has
been noticed of tumours, which produce little or no motor
disturbance while they remain in the cavity of the uterus,
that no sooner do they pass from the uterus into the vagina,
than " bearing-pains," as they are termed, are produced.
In other words, the action of the expiratory muscles is ex-
cited in a reflex form by irritation of the vaginal mucous
surface.
In fully-formed labour, then, we have to study the reflex
actions of the uterus in combination with the reflex actions
of the respiratory muscles, as they are excited in parturition.
By these latter reflex actions, the cavities of the thorax and
abdomen become involved as auxiliaries to the uterus, and
their expulsory actions combine with the proper reflex ac-
tion of this organ, to effect the expulsion of its contents.
But there are also opportunities of observing the reflex ac-
tion of the uterus singly; such, for instance, as in cases of
paraplegia from disease of the middle portion of the spinal
marrow. Here the reflex expiratory efforts, the influence of
volition and emotion, are entirely withdrawn, it being quite
impossible that these actions can be brought into play when
the connections of the uterus with the medulla oblongata
and the cerebrum, the centres of the respiratory and volun-
tary actions, are severed. Labour is, in such cases, reduced
to very simple elements, being performed solely by the re-
flex action of the uterus and its peristaltic power.
In natural labour, after the process has fairly commenced,
52 COMBINED ACTIONS.
it is the ovum which furnishes the chief stimulus to the in-
cident excitor nerves, in its transit through the difTerent
portions of the parturient canal. Besides the naere enumera-
tion of the various spinal excitors, by the irritation of which
the uterus may be affected physiologically or pathologically,
we shall have to study the order and succession of the normal
reflex actions, uterine and extra-uterine, occurring in labour.
Parturition is not one reflex act, but a function, the combined
re^ilt of ndany such actions, aided by other powers ; and we
must study the preliminary phenomena, the different stages
of the process, and the final accomplishment of the function;
when we shall find that Nature has at her disposal a won-
derful succession of stimulus and action, exactly adapted to
the dilatation of the os uteri and the vagina ; the propulsion
and expulsion of the foetus ; and providing, also, for the safe
contraction of the uterus, and its return to the unimpregnated
state.
The uterus, as a motor organ, stands alone in many respects :
unlike the rectum and bladder, it is not directly influenced
by volition ; and unlike the heart, it is extremely prone to
reflex action ; it more nearly resembles the oesophagus, which
is uninfluenced by the will, but is endowed with reflex motor
and peristaltic action. It, however, differs from the oesophagus
in the great number of excitor surfaces with which the spinal
system places it in relation ; neither is there any other organ
— not even the stomach — which acts as a spinal excitor to so
great a number of organs as the uterus and its excitor nerves,
whether we consider it in the impregnated or the unimpreg-
nated states. Hence the physiological necessity for the
abundance of nerves recently discovered.
Besides the reflex action of the spinal marrow and its
system of excitor and motor nerves, there is the Direct action
of the spinal marrow, — though this does not play the impor-
tant part assigned to it by M. Serres, Brachet, and Segalas, —
in which the central organ and its motor nerves, to the ex-
clusion of the excitors, are involved. The state of the cir-
culation afi'ects all the motor organs under the control of the
spinal marrow ; and they act with increased energy when the
circulation is either plethoric or anaemic, though in the latter,
exhaustion of the nervous energy quickly ensues. Thus, there
is one puerperal convulsion of hemorrhage, when the heart
and bloodvessels have been drained of blood, and another,
PERISTALTIC ACTION. 53
of fulness of the circulation. Want and excess of blood, or
materies morbi in the circulation, act as direct stimuli to the
spinal centre, and thus the state of the circulation materially
affects the uterus during labour. There are also certain
agents of the materia medica, which, taken into the circula-
tion, affect the spinal marrow. Thus, the ergot of rye, pass-
ing into the blood, affects the uterus by a direct spinal action ;
so does strychnia, so does the inhalation of carbonic acid,
and so, I believe, does ipecacuan — the influence of which in
producing uterine contraction is very remarkable. Savine,
aloes, alcohol, and the biborate of soda, may probably be
added to the same list.
The Peristaltic or Immediate action of the uterus still re-
mains to be considered.
All muscles contract when subjected to immediate irrita-
tion, after they have been cut off from the influence of the
cerebral and spinal centres, and when they have been as far
as possible deprived of their nerves. In the case of muscles
supplied by cerebral or spinal nerves, the contraction is
limited to the spot irritated, and ceases wMth the removal of
the irritation, but in organs partly or wholly supplied by gan-
glionic nerves, as the heart, bladder, intestines, oesophagus,
&c., the motion produced is of a Peristaltic kind, spreading,
generally in a vermicular manner, to a distance from the point
of irritation, and continuing for some time after the irritation
has ceased. The uterus is eminently endowed w^ith this form
of contraction. When one point of the uterus is stimulated
through the abdominal parietes, the contraction excited ex-
tends with the utmost rapidity to the whole organ; the same
occurs when the fingers are made to irritate any point of the
internal surface of the uterus. Harvey beautifully described
this peristaltic form of action in the uterus in the doe; Wil-
liam Hunter saw it in the cat and the rabbit ; Professor Miil-
ler, in the uterus of the rat and the oviduct of the turtle; I
have seen the same thing in the uterus of the guinea-pig and
other animals. This form of motor action is the basis of the
other uterine actions. In natural labour in the human female,
it is, so to say, disguised by the reflex actions, but under cer-
tain circumstances it is able to effect, unaided, the expulsion
of the child. In paraplegia from disease of the lower spinal
marrow, where volition, emotion, and reflex actions are en-
tirely withdrawn, the immediate action of the uterus, or that
'5
54 PERISTALTIC ACTION.
depending on muscular irritability, and the ganglionic system,
is the only form of motion remaining to the uterus. Such a
case is recorded by M. Brachet, in which the uterus con-
tracted, though with extreme inertia. Patients in this state,
and animals reduced to this condition by experiment, have
been delivered by the stimulus of galvanism applied to the
uterus itself. When cut off from the spinal centre, the uterus
requires the stimulus of galvanism or some external irritation
to excite it to contraction. Cases are on record, in which
labour having commenced during life, delivery has been ef-
fected without mechanical assistance, after the death of the
mother. For instance, a case is related, in which a woman
dying during delivery w^as placed in a coffin, and the child
was found wholly expelled, between the thighs of the dead
mother, on the following day. Similar cases are on record,
both in ancient and modern authors. Dr. Robert Lee has
informed me of a remarkable, and I believe unique case, in
which the uterus was completely inverted after death. The
patient had died suddenly; and twenty-four hours afterward,
on proceeding to make an examination, the uterus w^as found
external to the vagina (it had been ruptured, which was the
cause of death), and the foetus remained in the abdominal
cavity. The solution of these extraordinary phenomenon,
though it has not hitherto been given, does not seem very
difficult. A slow reflex action of the uterus may possibly
continue long after the rhythmic respiratory movements have
ceased, as long, indeed, as the body retains its warmth. But
we know that the heart, oesophagus, and intestines, may be
excited to peristaltic action after death; violent peristaltic
action is often a part of the act of dying ; and I am of opinion
that in the human uterus, it is peristaltic action chiefly w4iich
expels the child when the mother has died during labour un-
delivered. There is, however, another source of post-mortem
muscular contraction, which 1 believe has never been referred
to in the case of the uterus — this is, the post-mortem muscu-
lar spasm. We know that in the case of an analogous organ
— the heart, the rigor mortis occurs to such an extent as to
empty the ventricles of blood, and even to simulate concen-
tric hypertrophy. The extrication of gases by decomposition
in the abdomen, the explanation usually adopted, is not suf-
ficient to account for the expulsion of the foetus after death,
and certainly not enough to explain the complete inversion
VIEWS OF WIGAND. 55
of the uterus, as in Dr. Robert Lee's case. The rigor mortis,
therefore, ought to be considered as another cause of post-
mortem delivery.
The direction taken by the peristaltic action is of consider-
able importance. Professor Muller, Michaelis, and Wigand,
teach that uterine contraction commences at the cervix, and
travels towards the fundus, returning thence towards the os
uteri. This is thought by Michaelis to prevent prolapsus of
the umbilical cord, and the descent of the arms of the foetus
before the head ; the cord and the arm, when lying low in the
uterus, being swept upwards, beyond the risk of danger, at
the commencement of every pain. Wigand considers the
direction of the contraction to be proved by the phenomena
attending a labour-pain. At first the os uteri grows tense,
the head or presenting part recedes from the touch, and the
bladder of membranes protrudes ; after this, the fundus uteri
becomes hard, and the presenting part of the child begins to
advance. I believe this view of Wigand, which has been
particularly insisted upon by Dr. Rigby, to be a close inference
from the facts which any one may observe; Professor Murphy,
however, considers it altogether incorrect, and attempts to
controvert it. This eminent accoucheur, who may be said
to have completed what has been termed the mechanism of
parturition, commenced by Sir Fielding Oulde in the school
in which Dr. Murphy was formed, believes the fundus uteri
to be the first in the order of contraction. He states, in sup-
port of his opinion, that if after delivery the hand be intro-
duced into the uterus, the organ may be fell to contract on
the withdrawal of the hand, the contraction commencing at
the fundus, and then travelling downwards. The rest of the
argument of Dr. Murphy is contained in the following pas-
sage : —
"If we desired an additional evidence to prove that the
fundus was the first to contract, and not the os uteri, we could
not have a stronger proof than that advanced by Wigand to
support a contrary opinion — viz., the head, when the con-
tractions commence, getting * even out of the reach of the
fingers whilst the os uteri is filled with the bladder of mem-
branes.' In Wigand's explanation, the influence of fluid pres-
sure seems to be altogether forgotten. The immediate effect
of contraction commencing at the fundus would be to com-
press the liquor amnii, which of necessity forces its way be-
56 PERISTALTIC ACTION.
fore the head, on to the mouth of the uterus. The fluid, in
this position, reacts against the head with the same power
that it is compressed, and therefore pushes it up until the in-
creasing contraction of the fundus forces the head down again,
so that you perceive the phenomena quoted are quite consis-
tent with the statement, that uterine contraction begins at the
fundus; in fact, it could not be otherwise, so long as the
waters remain in the uterus. But if the contraction com-
menced from below, the fluid must be driven upwards to-
wards the fundus, and that portion between the os uteri and
head pressed aside, at least in the first instance, so that the
head might be easily felt when the pain commences, although
not so afterwards ; but the reverse is the case, and you will
find, that in those cases where the liquor amnii is in large
quantity, that it is difl^cult to feel the head at all, except in
the interval of the pains."
To this it may be objected that it is Dr. Murphy who has
forgotten " the influence of fluid pressure." He imagines that
by contraction of the lower part of the uterus, the amniotic
fluid would be " driven upwards towards the fundus ;" but it
must be remembered that the uterus is a hollow muscle al-
ready accurately filled, the only outlet being at the os uteri;
and pressure exerted at any part of the uterus, cervix, or fun-
dus, can have but one immediate effect — namely, to protrude
the membranes at the os uteri, no other part of the uterus, in
fact, being able to yield. The contents of the uterus are not
compressible, so that any contraction or diminution in its ca-
pacity must be represented by some protrusion at the os uteri ;
either this or rupture of the uterus must take place. The
fluid could only pass towards the fundus uteri by displacing
the solid contents of the uterus, and protruding the head. It
is a well-known law in hydrostatics, that when fluid is sub-
jected to compression, the eflfect is equally diflfused through
the whole mass, and is felt alike in all directions. Pressure
upon the os uteri and cervix uteri, in contractions of this part,
does not aflfect that portion of fluid contained in the cervix
more than that in the fundus. Pressure applied at any part
of the uterus would as inevitably protrude, in the first in-
stance, the membranes through the open os uteri, as that
pressure on any part of a bladder of water with a hole in the
neck would expel the fluid. It would not matter whether the
pressure were exerted close to the aperture or at the fundus
PERISTALTIC ACTION. 57-
of the bladder. Thus, then, this part of the argument of Dr.
Murphy falls to the ground. The protrusion of the amniotic
bag at the commencement of a pain, is no indication that
pressure is applied either at the cervix or fundus, but simply
that pressure is somewhere applied. The direction of the
pressure must be argued from other considerations.
Neither is it correct to say, that fluid pressure coming from
the fundus would react against the head of the fcstus at the
cervix. The recession, more apparent than real, of the head
at the commencement of a pain is undoubtedly in favour of
the view of Wigand. A solid body, such as the foetus, might
be moved in a fluid medium by solid pressure applied at any
particular part; and the contraction commencing at the cervix,
the uterus comes into immediate contact with the head, and
moves it in the fluid medium, as it is moved upwards in the
ballottement; the fluid must present by just so much as the
uterine cavity had been diminished by the contraction, and
it would be only w^hen the fundus contracted, so as to come
into contact with the solid foetus, that the head would descend
and displace the waters.
If, as is most probable, the peristaltic action of the uterus
does take this course, it is not singular, for, according to the
observations of Magendie, the contents of the stomach are,
during digestion, passed through the pylorus by a peristaltic
movement, which begins at the pylorus, proceeds to the
cardia, and then sweeps back again from left to right. Muller
also describes the contraction of the heart of the frog as
commencing in the venous trunks ; then descending, in suc-
cession, to the auricles and ventricles ; and then affecting
the bulbus aortse. The peristaltic action commences at the
the auricle, travels to the apex, and then returns towards
the base of the ventricle. There seems very excellent
reasons for the commencement of the peristaltic action at
the cervix in the human subject, in the necessity which exists
for some provision against prolapsus of the cord, and arm-
presentations ; and still more, from the great probability that,
if contractions commenced at the fundus uteri, inversion of
the organ would be frequent. I am persuaded that inversio
uteri is not, as is so generally supposed, a mechanical acci-
dent, dependent on shortness of the cord, or injudicious
traction of the placenta ; but that it is really a kind of intus-
susceptio. The fundus contracts by itself, and descends into
5*
58 DILATATION.
the body of the uterus, so as to be grasped by the sides of
the organ, when it is forced downwards, and thus completely
inverted. It is worthy of note, that the fact recorded by
Dr. Murphy, relative to the descent of the uterine contrac-
tion from the fundus, on the introduction of the hand after
delivery, hardly applies to the progress of natural labour,
though it does apply very closely to the subject of inversio
uteri. The uterus may not act in the same way when empty
as when containing the foetus, and the hand of the accoucheur
is neither the natural stimulus of the organ, nor applied in
the natural way. It is very difficult, too, for the touch alone
to be certain on such a point as the direction of uterine contrac-
tion. All we can say with certainty is, that very nearly at
the same instant that the orificial circle of the uterus be-
comes tense and dilated, the fundus is felt to contract for-
cibly.. Whenever the contraction commences, it spreads
over the whole organ with great rapidity. I have often
endeavoured, by the taxis, during labour, both at the os
uteri, and through the walls of the abdomen, to trace the
direction of the uterine contractions, but have not been able
to do so satisfactorily. Where the abdominal walls have
been very lax, I have felt the organ, at each pain, erect
itself as it were, and stand out against the abdomen so firmly
as not to admit of its being moved. The peristaltic action
might be observed, perhaps, in a patient greatly emaciated,
or it would be easy to ascertain the matter, if a pain could
be watched during the Caesarian section. At present, the
evidence we possess is strongly in favour of Wigand, or at
all events, his opinions are not affected by Professor Murphy's
argument. But whatever the direction of the uterine con-
tractions, there can be no doubt of their peristaltic form ;
many of the accidents of midwifery, such as hour-glass con-
traction, inversion of the uterus, and post-mortem delivery,
can only be explained after this manner.
I have now to treat of the motor powers concerned in the
Dilatation of the os uteri durinor labour.
In addition to the divers forms of uterme contraction, there
is the Dilatation of the os and cervix uteri to be considered.
I have not treated of the muscular structure of the uterus by
which all these actions are accomplished, my present pur-
pose being with physiology rather than anatomy, and the
muscularitv of the uterus being a generally acknowledged
fact.
DILATATION. 59
But in the case of the os uteri considerable discrepancy of
opinion exists. Nothing like a complete muscular ring, such
as is found to compose the other sphincters, has been made
out in the os uteri. The cervix uteri, however, according to
Jobert and other anatomists, contains numerous semicircular
fibres arranged round it, and the sphincteric action of the
uterus is not confined to the os uteri, but extends to the
cervix also. In these two parts, taken together, there is
quite enough contractile fibre to account for all the motor
phenomena they display. The os and cervix are composed
of mixed contractile fibre and elastic contractile tissue.
United, this tissue acts as an imperfect sphincter, dilatable
partly by the mechanical force exerted by the contraction of
the rest of the organ, and the protrusion of the liquor amnii
or the foetal head ; and partly by an active sphincteric power.
In so far as it is composed of elastic tissue non-contractile in
its character, it dilates simply from mechanical distention ;
while, inasmuch as it consists of contractile fibres, it has the
power of active, positive, dilatation and contraction, as a
nervi-motor organ.
I have told you that the muscular fibres of the os and
cervix uteri are only semicircular. There is, indeed, an
obvious reason why the complete circular muscle, sought for
in vain by William Hunter and Sir Charles Bell, should not
exist in this situation. Before the commencement of labour
in primiparse, the os uteri is quite closed ; while in parturi-
tion it is dilated to such an extent as to permit the passage
of the fcEtal head — a mass whose shortest diameter is three
inches and a half, making the line of the circle necessary for
its passage nearly eleven inches. This is a dilatation far
exceeding that required in the actions of any of the recog-
nised sphincters, and we cannot but conceive that if com-
pletely circular fibres existed at the os uteri, rupture of the
circle would be inevitable. On the other hand, if there were
no contractile fibres, but merely elastic tissue, subject only
to mechanical distention, it would be impossible to account
for that sudden contraction of the os uteri which often takes
place after many hours of dilatation, immediately on the
conclusion of labour, and but for which fatal results would
be inevitable in cases of implantation of the placenta over
the OS and cervix. Thus the combination of semicircular
muscular fibres and elastic tissue is admirably adapted for
60 DILATATION.
the mixed dilatation and distention required of the os uteri
in parturition, and also for its subsequent contraction.
These observations, of course, only apply to the era of
parturition. It is not meant that during gestation the os and
cervix act as a sphincter, and so shut up the foetus in the
uterine cavity. The motor powers of the uterus, whether
of the OS or fundus, of dilatation or contraction, remain — ex-
cept, as we shall see hereafter, the peristaltic action — com-
paratively inert, until these powers are suddenly evoked fT)r
the performance of labour.
Some of the physiological proofs of the possession of dilatile
and contractile powers by the os and cervix uteri may be
enumerated, and these proofs are not less convincing than
the most certain anatomical evidence. In the first place, if
the semicircular fibres of the cervix contracted with the same
force as the fibres in the rest of the uterus, this organ could
scarcely be emptied of its contents. Doubtless the contrac-
tions of the body and fundus uteri are strong, their bearing
upon the cervix powerful, and the amniotic bag admirably
adapted for mechanical distention ; but it must be remem-
bered that the short fibres of the cervix act at a great mecha-
nical advantage, as compared with the fibres in any other
district of the uterus. Let any one who supposes the body
and the fundus may forcibly overcome a contracted state of
the OS and cervix, consider that the united powder of all the
respiratory muscles is insufficient to force the small muscles
w^iich close the glottis. The nature of the hemorrhage in
placenta prsevia, as compared with hemorrhage from the
fundus, affords a strong argument in favour of a positive
dilatation of the os uteri. In hemorrhage from the fundus,
the loss of blood is arrested during a pain, because the fun-
dus is in a state of contraction ; in hemorrhage from the os
and cervix, the flow is increased at each return of the pains,
because the cervix is in a state of dilatation. If the dilata-
tion were merely a mechanical distention, the pressure which
dilated the os uteri might be expected to arrest the hemor-
rhage at the same time.
Owins: to the mixed mechanical and muscular dilatation of
the os uteri, it generally opens slowly ; cases however occur
in which, after long continued rigidity, it dilates sosuddenly,
that even from this fact alone it is difficult to consider it a
mere mechanical distention, the resiliency of the part affecting
DILATATION. 61
its subsequent contraction. But the strongest physiological
proof of the existence of muscular power in the os and cervix
uteri, is the forcible contraction which sometimes occurs after
full dilatation — as, for instance, in cases of encysted placenta,
in which the fingers can only be introduced with the greatest
difficulty ; and again, in inversio uteri, where the speedy and
powerful contraction of the cervix is one of the elements
of the accidents most opposed to the re-position of the
organ.
Both as regards structure and function, the os and cervix
uteri are, at the time of parturition, comparable to the pylorus.
The pylorus, like the os uteri, is formed by a duplicature of
the fibrous and mucous coats. But for this duplication, the
stomach and duodenum, and the uterus and vagina, would
form two continuous tubes. If we could suppose the pylorus
projecting into the duodenum, the outward anatomical re-
semblance between the two would be perfect. In labour,
the duplicature w^hich causes the projection of the os uteri
into the vagina is not only dilated, but, as it were, unfolded,
and the uterus and the vagina become almost one smooth
continuous canal, like the stomach and duodenum when the
pylorous dilates. Another sphincter, the cardia, has the
power of dilatation to comparatively as great an extent as
the OS uteri ; the cardia of the owl, for instance, dilates to
such an extent as to admit a small bird or a mouse entire.
The enormous distention of the entire upper part of the ali-
mentary canal in serpents is well known. The uterine and
digestive systems admit also of a more general comparison.
There is analogy between the fimbria of the Fallopian tubes
and the mouth and pharynx ; between the Fallopian tubes
themselves and the oesophagus ; we may compare the circu-
lar muscles at the entrance of the Fallopian tubes into the
uterus with the cardia, the uterus itself w^ith the stomach,
and the os and cervix, as I have already said, may be com-
pared with the pyloric orifice.
The contractile and dilatile power of the os and cervix,
like that of the sphincter of the cardia, is chiefly regulated
by reflex spinal action, but it seems to be altogether removed
from the direct influence of volition. The sphincters are all
remarkable for the property of reflex dilatation as well as
reflex contraction ; of a positive dilatation excited in a reflex
form. The relations of the different sphincters to each other
62 DILATATION.
are most sins^ular and interesting. In this place, a few in-
stances of the reflex spinal connection between the different
sphincters will be sufficient, as in treating of the acts in par-
turition and rigidity of the os uteri, I shall have to speak of
the subject more fully.
In the act of swallowing the cardia dilates, and the glottis
closes accurately, to prevent the entrance of particles into the
larynx ; in vomiting, the cardia is also open, and the glottis
closed. In defecation, the dilatation of the sphincter ani
causes the sphincter vesicse to dilate. In dilatation of the
constrictor vaginaB, both the sphincter ani and sphincter
vesicae dilate, andthere is simultaneousrelaxationof the glottis.
The play of reflex action among the sphincters is altogether,
in health or disease, a most interesting topic. Singular to
say. Dr. Todd, overlooking numerous facts to the contrary,
denies the reflex action of the sphincteric muscles. It is our
duty, not only to endeavour to set forth the truth clearly,
but to anticipate objections. It may, perhaps, be argued,
that the consentaneous action of the diflferent sphincters takes
place simply from mechanical pressure ; that the same pres-
sure which evacuates the rectum empties the bladder. The
answer is simple — in vomiting, for instance, an immense
pressure is exerted on the open cardia, yet the glottis is
firmly closed.
For the performance of all the acts of ingestion and eges-
tion, the thorax, abdominal cavity, and pelvis, may be looked
on as forming one cylindrical cavity, supplied with a number
of stops, which close and open with admirable accuracy un-
der the control of the nervi-motor apparatus, presiding over
the various acts of ingestion and retention, egestion and ex-
clusion. This is, in fact, one great function of the true spinal
marrow, and its excitor and motor nerves. The materials
for ingestion and egestion, by their physical qualities alone,
independently of sensation, supply, when brought into con-
tact with the ingestive and egestive tubes, the necessary
stimulus to the excitor spinal nerves, whereupon all the ne-
cessary motor phenomena, both of contraction and dilatation
occur with the nicest regularity, and the most perfect apti-
tude for the functions to be performed.
Such are the various forms of motor action belonging to
the uterus, and brought into play at the time of parturition.
Volition may be said to affect the process only indirectly.
POST-MORTEM DELIVERY. 63
Emotion lias a direct influence, but it is accessory rather than
essential to its performance. Reflex action is the ^reat phy-
siological power, which being absent, the function of partu-
rition could not be properly performed. Peristaltic or Imme-
diate action is the basic or radical element upon which the
other causes of motor action operate. Here, as in other in-
stances, *' Knowledge is power ;" to know the various sources
and modes of motor action is almost equivalent to the ability
to guide and control their impulses.
Delivery may be effected under a variety of circumstances,
and we may consider every new condition in which there is
a departure from the natural method as in reality an experi-
ment offered by Nature, and of use in the illustration of normal
parturition. Delivery may take place in cerebral paralysis,
in which volition only isw^ithdrawn — the influence of emotion,
all the reflex motor actions, and the peristaltic action of the
uterus, remaining. It may occur in profound coma, w^here
volition and emotion are both withdrawn, all the reflex
and the peristaltic actions being present. It may also be
effected in paraplegia, from disease in the middle portions of
the spinal marrow, in which volition, emotion, and the respi-
ratory reflex actions, are cut off; the reflex actions of the
uterus itself, and the peristaltic action of the organ,
only remaining. It will hardly take place except in rare
instances, but it may be excited, as by electricity, even in
cases of paraplegia from disease affecting the lower seg-
ments of the spinal marrow, where volition, emotion, and the
reflex actions, uterine and extra-uterine, are removed, and
where peristaltic action exists alone. It may even, as we
have seen, take place at the moment of death, or some hours
after dissolution, when it may be excited by the spasm of
death itself; by reflex actions continued after death; by the
rigor mortis — this peculiar condition affecting the uterus in
common with the heart and other muscles ; by the peristaltic
action continued after death ; or by all these actions com-
bined. But putting aside everything save the post-mortem
spasm, it is no more w^onderful for the uterus to contract and
expel its contents after death, than it is for the heart to con-
tract to such a degree as to empty its cavity ; for the oeso-
phagus of a rabbit to swallow food ; for the oesophagus and
cardia of the human subject to expel flatus, as I have seen hap-
pen ; or for the intestines to contract violently after death —
64 SUMMARY.
facts, all of which have been repeatedly observed. The ex-
cessive action of the uterus before death probably increases
its tendency to contract after death. It has been observed,
that after death from Asiatic cholera and fevers attended by
spasmodic actions, the post-mortem contractility of the mus-
cles is rem.arkably increased.
These different conditions under which the expulsion of
the foetus may take place in health, disease, or even after dis-
solution, afford in themselves a very admirable analysis and
synthesis of the various motor powers by which natural par-
turition is performed. So far, however, from being used in
this manner, such facts have hitherto only been made a
source of confusion, and the occurrence of delivery in hemi-
plegia, paraplegia, and after death, has been thought to
afford positive and conclusive proof that the uterus is in
natural parturition altogether independent of the nervous
centres.
65
LECTURE IV.
Nervi-.VTotor Actions of the Falloftian 'I'ubcs in Menstruation, Coitus, Con-
ception, and J'arturition — N'orvi-Motor Actions of the Vagina in the
Uiiimpregnatcd and I'arturient .States.
Impregnation, uterine ovij-)Osition, or ihe conduction of the
ovule from tlie ovarian to the uterus, and, finally, par-
turition, are all effected by means of certain motor princi-
ples of the female economy. You will find the study of the
motor phenomena of those functions tends very much to
their mutual elucidation, for, strictly considered, they are
only so many different yet allied actions of one and the same
motor apparatus. I shall show you plainly, as we proceed,
how the intimate but hitherto unperceived relations which
exist between menstruation, impregnation, and gestation,
may be made of the greatest use in detecting the nature
of the more mysterious phenomena of parturition. The
Ovaria, Fallopian tubes. Uterus, and Vagina,. form in the
aggregate the sexual canal, the machinery in and by means
of which this entire series of functions are performed ; and
we shall fall very short of understanding them, unless we
study, separately and collectively, all the motor actions of
the dilferent parts of this apparatus, in all the functions of
the generative system. In deciphering the j)hysiology of
parturition, it is as necessary to study the nervi-motor en-
dowments of the vagina and Fallopian tubes, as those of the
uterus itself; as important to examine menstruation and
conception, as to investigate the act of labour. In the pre-
ceding lecture, I have directed your attention to the nervi-
moior actions of the uterus, but the motor actions of the
vagina and Fallopian tubes still remain to be studied. Taken
together with the uterus-, they may be consideret] the develop-
ment of the simple tubular oviduct of the lower animals;
and, in many points cf view, we may look on these parts as
forming one continuous canal for the reception and transmis-
sion of the ovule from the ovary to the uterus, and the ex-
6
66 FALLOPIAN TUBES.
pulsion of the ovum from the uterus at childbirth. The Fallo-
pian tubes are the organs of oviposition ; the uterus and
vagina are the organs of gestation and parturition. The
vagina is, moreover, the primary organ for the ingestion of
semen. Let me first speak of the Fallopian tubes, the ovi-
positors of the human female and of mammalia in general.
The Fallopian tubes, like the intestinal canal, possesses
two sets of muscular fibres — a circular and a longitudinal ;
and their action is also Peristaltic in form. In fleshy sub-
jects the muscular fibres of these tubes are readily made out,
but in others, they are sometimes difficult to trace. In cases
of tubarian pregnancy, the muscular structure becomes very
evident, and increases with the growth of the ovum, till it
reaches a very considerable thickness. Both before and
at^ter conception, they have been seen in the rabbit, by
Cruickshank and other anatomists, firmly embracing the
ovaria, and in a state of strong vermicular action. By this
action the impregnated ovule, when detached, from the
ovarium, is conveyed into the cavity of the uterus. The
Fallopian tubes have also been seen clinging to the ovaria,
in the lower animals, during the period of cestruation, where
no congress wuth the male had been effected. In women
who had died during menstruation, the same thing was ob-
served by M. Gendrin. The Fallopian tubes were found
firmly applied to the ovaria. Here, the office of the tube
must be to conduct the unimpregnated ovule from the ovary
to the uterus. M. Gendrin insists on dilatation and injection
of the Fallopian tubes, and the application of their dilated
extremities to the ovaria, as constant and special conditions
of menstruation.
Besides the strictly motor phenomena of the Fallopian
tubes, these tubes become so turgid under stimuli, as almost
to deserve to rank with the Erectile organs. In the experi-
ments of Cruikshank upon rabbits, the fimbriae were black
from excess of blood ; and in a preparation in the museum
of St. George's Hospital, this injected and erectile state of
the tubes is shown in great perfection.
It is also probable that in simple coVtus the same action of
the Fallopian tubes occurs ; that at the instant of the orgasm,
they erect themselves, and contract upon the ovaria. The
human female is considered passive both by Professor MiJller
and Dr. Carpenter; but the sexual orgasm of the female
PHYSIOLOGY OF COITUS. 67
was fully recognised by John Hunter, as a passage from one
of his papers on the Animal CEconomy will show; — " There
is," he says, " one part common to both the male and female
organs of generation, in all the animals which have the sexes
distinct : in the one, it is called the penis, in the other, the
clitoris. Its specific use in both is to continue, by its sensi-
bility, the action excited in coftion, till the paroxysm alters
the sensation." This paroxysm in the female may be at-
tended by an action of the Fallopian tubes similar in kind
to that affecting the ejaculatores muscles and the bulb of the
urethra. At all events, it is extremely probable that during
coYtus contractions of the tubes upon the ovaria take place.
It is true that no sensations are referred to the tubes them-
selves during coitus ; but neither are the vesiculse serainales
sensitive during the contractions of these organs in the male.
Some of the older anatomists — Whytt and other — implicitly
believed in this contraction of the Fallopian tubes during
coi'tus.
The physiology of Coitus is a subject very little under-
stood, some eminent names denying, as we have seen, any
orgasm to the female, while others imagine that this orgasm
is necessary to conception. But neither of these positions
are really correct. Sensation and emotion are super-imposed
upon conception, doubtless for wise and provident purposes ;
but they are bestowed rather as incitements to fecundity, than
as conditions absolutely essential to the propagation of the
species. Strip the function of reproduction of all that is sen-
sational and emotional, take away the psychical, leaving only
the physical, and still propagation is not necessarily arrested.
This is irrefragably proved by the fact, that fecundity re-
mains, notwithstanding the annihilation of sensation, and
the emolutions dependent upon local excitement, by para-
plegia. These points are of evident importance in the com-
prehension and treatment of sterility. Impotence and ster-
ility are both of them disorders to which the human female
is liable. I would limit the term impotence in women, to
failure in the production of the sexual orgasm ; sterility, to
failure either in the maturation of the ovule, impregnation,
or the process of oviposition. Paradoxical as it may seem,
a woman may be fertile, but yet impotent ; or she may be
impotent, and yet conceive and bring forth children.
Women to whom the term " frigida" is applicable, but who
68 FALLOPIAN TUBES.
have become mothers, are referred to by Heberden. These
facts are well conveyed in the followini^ passasje from this
eminent physician : — " Duo mariti mihi narrarunt uxores
suas in venerera fuisse frigidas, omni ejus cupiditate et voliip-
tate carentes ; ScTpe tamen gravidas factas esse et recte
peperisse." Such a state of things, which may be a source
of great marital unhappiness and disappointment, is not un-
common, particularly in women of chaste minds, who have
not entered upon married life till after the season of youth.
Of course, this frigidity may be either positive or relative ; it
may depend altogether upon the female, or the imperfection
may be on the side of the male. Harvey explicitly notices
the fact, that many women in the married state habitually
conceive in the absence of all sexual sensation. Permea-
bility, and unerring motor action of the Fallopian tubes,
are conditions positively essential to healthy impregnation
and conception ; and to this portion of the sexual canal we
must look for the cause of sterility in a considerable propor-
tion of cases. Occlusion, displacement, or inactivity of these
tubes must inevitably lead to sterility or extra-uterine preg-
nancy.
The form of action of the Fallopian tubes has been shown
to be peristaltic, but it comes to be a question whether those
tubes can be excited to Reflex action. Now, they contract,
and apply themselves to the ovaria before they have received
the ovule ; and there is no direct nervous communication
between the ovaria and the Fallopian tubes sufficient to ac-
count for any direct excitation of the tubes by the ovaria.
Like every other action of a similar kind with which we are
acquainted, the action of the Fallopian tubes is doubtless
reflex and spinal, and the ovaria must be the chief excitors
of their reflex actions. This is the case in oestruation, men-
struation, and conception ; but if the fimbrise embrace the
ovaria in coYtus, it is probable that the nerves of the vagina
are also excitors of this reflex action. In the whole range
of reflex action, or, indeed, of physiology, there is nothing
more extraordinary than the reflex action of the Fallopian
tubes from ovarian excitation. There seems a positive in-
stinct, a powder of selection, in the exactitude with which
their fimbriated extremities find out and embrace the ovaries,
but for which, extra-uterine foetation, with its great dangers,
would be very frequent. In this internal embrace, the most
FALLOPIAN TUBES. 69
perfect adaptation occurs, in the total absence of sensation
and volition. Many minds have felt a difficulty in receiving
the doctrine of the independent and insentient action of the
true spinal marrow, and its excilor and motor nerves,
because of the extraordinary adaptation and appearance of
design sometimes observed after decapitation or decerebra-
ti.on, being fain to consider such adaptation a proof of the
presence of design and will, in the spinal marrow itself.
Here, in the case of the Fallopian tubes, there can be no
suspicion of volition, and yet the motions of these muscular
tubes are so unerring in their power of embracing the
ovaria, and of not seizing the intestines or the abdominal
parietes, as quite to equal any of those actions which have
been supposed to be emotional or voluntary in decapitated
animals.
Thus, then, the motor endowments of the Fallopian tubes
are, like those of the oesophagus, both peristaltic and reflex.
I have referred to the erection of the Fallopian tubes. This
erection is insentient. Women are not conscious of the
erection and embrace of the ovaria during menstruation, nor,
indeed, during coitus. In menstruation particularly, this
erection is not preceded or attended by sensation, so that
here it cannot, as in the case of the male, be partly emo-
tional ; it must, like the erection of the penis in paraplegia,
be reflex. This erection of the Fallopian tul^s is probably
of great use in directing the tubes and their fimbriae towards
the ovaria. A study of the anatomical relation of the tubes
to the uterus, ovaria, and broad ligaments, strengthens this
probability. Still, notwithstanding the aiding power of an
erectile state of the tube itself, the accurate grasp of the ovary
at the precise point by the loose and floating morsus diaboli,
is not the less wonderful.
Many years ago. Dr. Marshall Hall, after describing erec-
tion and emissio seminis as reflex in their nature, observed,
*' That the grasp of the Fallopian tubes is excited on the same
principle is extremely probable ;" and again he remarked,
" Of all the facts in physiology and pathology, the nature of
conception and the causes of sterility are, perhaps, the most
obscure. Excito-raotor in its nature, conception involves
the ingestion of the semen, and the grasping of the ovum."
I quote these passages for their own importance, and for the
sake of bringing them to bear on an objection which has
6*
70 FALLOPIAN TUBES.
recently been urged against them. I refer again to the
article on the nervous system in the Cyclopaedia of Anatomy,
to which I have alluded in former lectures : Dr. Todd, the
author, rejects the reflex action of the .tubes in coitus and
conception. He says, — "In conception, or what Dr. Hall
calls the ingestion of semen, I am at a loss to conceive what
reflex act can occur. The grasping of the ovary by the
extremity of the Fallopian tube is more likely to be an act
of emotion, due to the general sexual excitement, than a
reflex phenomenon, excited by the stimulus of coition." I
submit that the answer to Dr. Todd's own explanation of
these phenomena is clear and decisive. Conception may
take place in coma, insensibility, the cataleptic trance, or
even in women perfectly paraplegic. In none of these cases
can the grasp of the ovaria by the Fallopian tubes be referred
to the emotional excitement of coitus. It is quite possible
for women to conceive under other circumstances, not only
without sexual excitement, but where feelings of an opposite
character are present, as in cases of rape or violence. Be-
sides, the Fallopian tubes, as we have seen, grasp the ovaria
on other occasions than coitus, as in menstruation, &c.
There must therefore be some other source of motor action
in these tubes besides emotion and sexual excitement. Of
the really reflex nature of this action it is impossible to doubt
unless a grea4 body of convincing facts relating to the sub-
ject are entirely overlooked. But to overturn Dr. Todd's
hypothesis, one fact is sufficient, — namely, the grasp of the
Fallopian tubes and conception in women sufllering from
paraplegia, where the act of coitus is altogether devoid of
sexual sensation and excitement, and where emotion is cut
off from the organs concerned. In expressing myself thus,
I do not mean to deny that emotion may, during coitus, con-
tribute to the contractions of the Fallopian tubes, but what I
"would insist on is this ; we must separate coitus from
conception : and the facts I have cited prove that there
must be another and a more general cause exciting these
tubes to action, quite independently of sensation and emo-
tion.
At the point of the junction of the Fallopian tubes with
the uterus, the internal "area of the tubes is considerably
diminished ; there is a condensation of the muscular fibre in
this situation, and on the internal surface of the fully-deve-
ACTION OF THE FALLOPIAN TUBES IN PARTURITION. 71
Io])ed gravid uterus, two large circular muscles, described by
Ruysch, are visible — Fallopian sphincters, as they might be
termed. I have already drawn an analogy between the
cardia and the uterine extremities of the Fallopian tubes, as
the superior orifices of the uterus and stouiach respectively.
The anatomical structure of the two organs is similar, and
though it would be difficult to determine the point with
certainty, it is not improbable that sphincteric contraction
and dilatation may occur at the utero-Fallopian apertures
during the ingestion of the ovule into the uterus. During the
passage of the ovule, the simple dilatation of the Fallopian
tube is very marked. I dwell on these points, for my wish
is to make the ingestion of the ovule as clear to you as
deglutition, or any other ingestive act.
The condition of the Fallopian tubes during Parturition is
an interesting subject of inquiry. The relative position of the
uterus, the broad ligaments, the tubes and the ovaria, are
considerably altered by the development of the uterus during
gestation ; but still the fimbriae remain within reach of the
ovarium ; and it is very probable, that during parturition,
the tubes are active, arid applied to the ovaria in the
same manner as in menstruation and conception. You
will see hereafter, from evidence derived from the pheno-
mena of parturition in the lower animals, that it is very
difficult to reject this view of the action of the tubes in par-
turition.
There is one peculiarity in the action of the Fallopian
tubes which is of considerable importance. In simple coitus,
any contraction which occurs is probably of a transient
nature ; there is the temporary stimulus and the temporary
action; but in menstruation, oestruation, and conception, the
contraction is persistent, remaining for a considerable period :
the stimulus and the action are both continued. This per-
sistence distinguishes it from ordin-ary reliex action in the
human economy, and allies it in its nature to the contraction
of the fore limbs of the male frog, and the extension of the
fore limbs of the female frog, during their prolonged coitus
and oviposition, which continues for several weeks. At the
first glance, this may seem a far-reaching analogy : but you
will see, as I proceed, that I shall be quite able to justify it.
The tendency to this persistent contraction is periodic. In
the unimpregnated human female, the stimulus returns every
lunar month ; in the frog, only once a year.
72 THE VAGINA.
The Fallopian tubes, then, are organs of periodic func-
tion during a certain portion of female life. They are the
ovipositors of mammiferous animals during the fertile eras.
In the human female, during infancy and childhood, until
the development of these tubes, they remain, together with
the other parts of the generative system at puberty, quiet
and inactive. But after puberty, roused, like so many other
portions of the female economy, they are probably brought
into energetic action during coitus, menstruation, conception,
and parturition ; but most certainly during menstruation and
conception, the action being transient in coitus, and persistent
in menstruation and conception. In menstruation, concep-
tion, and parturition, the ovarian nerves are the excitors of
the reflex and insentient contractions of the tubes ; but if
they erect themselves and contract upon the ovaria during
coitus, the nerves distributed to the erectile tissue of the
vagina must act as additional excitor nerves. For the pre-
sent I must dismiss this part of our subject : when I come to
speak of the cause of labour I shall have to refer to the
functions of the Fallopian tubes again. I hope I may ob-
serve, without justly incurring the charge of egotism, that
although many of the points now brought under your notice
have been referred to and dwelt upon before, still they have
not hitherto been grouped together in a consistent and logi-
cal manner, so as to bring out their real physiological mean-
ing.
I have next to speak of the motor actions of the Vagina.
The chief outlets of the mucous cavities, except the vagina,
are guarded at the orifices by sphincters. The constrictor
vaginse, at the entrance of this canal, represents the sphincters
found in other situations. It is a thin, small muscle, not per-
fectly orbicular. A perfect sphincter in such a situation
would indeed be out of place, owing to the immense dilatation
required of the vagina in childbirth. An ordinary sphincter,
if it existed, must far exceed the sphincter ani in size. When
labour comes to be treated of, it will be seen how a sphinc-
teric muscle in this situation is compensated for, and how well
the actual arrangement contributes to the safe expulsion of the
foetus. The cellulo-fibrous sheath immediately surrounding
the mucous membrane of the vagina is an extension of the
fibrous tissue of the uterus itself. I have already said that
the OS uteri is formed, like the pylorus, by a re-duplica-
tion of the raucous and contractile tunics, only this mode of
THE VAGINA. 73
formntlon is more exaggerated in the os uteri than in the
gastric sphincter. In labour, the process of dilatation
causes the almost entire obliteration of the os uteri, and the
uterus and vagina become, as it were, one uninterrupted canal.
The vagina, and particularly the upper portion, enlarges in
size during the latter months of pregnancy. A real growth
of the fibrous or muscular sheath, similar to the growth of
the muscular tissue of the uterus, with which it is continuous,
takes place, though in a less degree. We know that during
the early months there is some contraction, but in the later
months an enlargement, and even protrusion, of the vagina ;
and during labour, not only is the diameter increased, but the
length of the vaginal canal becomes greater. This could
hardly exist without an actual increase of size.
In the unimpregnated state, a slight. Voluntary power mciy
be exerted over the constrictor vaginee, and apparently over
the muscular sheath, particularly at its lower portion. Women
have some voluntary power of expelling matters from the
vagina — as, for instance, the menstrual secretion, particularly
where coagula are passed, by a slight, voluntary contraction
of this organ, aided by the action of the abdominal muscles.
The vagina, in the unimpregnated state, has also a Reflex
action. This is evident when the canal is distended by a
polypus, or a tumour of any kind; in some cases it is very
marked. On the introduction of the speculum, the vagina
grasps the instrument very firmly, and without any exertion
of the will.
There is no sign of the presence of Peristaltic action in
the vagina. We may observe, that it is in the distal and
most simple portion of the human oviduct that the peristaltic
form of action is most marked — namely, in the Fallopian
tubes, but as we approach the outlet, the peristaltic action
becomes less marked, while the influence of volition and sen-
sation appear, as if by way of compensation.
The Dilatation o{ {he. vagina is an important function of this
organ: it occurs at its upper portion, before the fcetal head
has passed through the vagina, and it is therefore not simply
a dilatation by distention; the undoubted presence, too, of
contractile fibres in the vagina, renders the idea of a simple
relaxation impossible. The dilatation must be of the same
mixed kind as that of the os and cervix uteri. It is one part
of the concatenation of events by which delivery is accom-
plished. At the same time that active contractions are going
74 THE VAGINA.
on at the fundus and body of the uterus, a positive muscular
dilatation is taking place in the passages through which the
fcetus has to be expelled. When the propulsive stage of
labour has commenced, and the expiratory muscles are acting
forcibly, the dilatation of the vagina is increased by the
effects of mechanical pressure. To this point I shall have to
revert hereafter. The dilatation commences at the os uteri,
and gradually proceeds downwards to the vagina, but in its
whole course it distinctly precedes the mechanical pressure
of the child upon the parts. Even the the perinseum is in
some deQ:ree dilated before it comes to be distended.
Such is the nature of the succession of stimuli to action
provided in parturition, that the Contraction of the vagina in
labour does not commence until after the full point of dilata-
tion has been reached. When this is the case, and the foetus
has fairly engaged the vagina, the whole parturient canal be-
comes contractile, and the cervix uteri and vagina act power-
fully upon their contents. The contraction of the vagina may
be felt by the attendant. It is this, aided by the action of the
abdominal muscles, but chiefly the former, which delivers the
breech and inferior extremities in natural presentations. After
delivery, the contraction of the os uteri is often sufficiently
obvious, and the placenta, when forced into the vagina by
the last throes of the uterus, may be expelled from the va-
gina by vaginal contractions alone. This contraction of the
cervix uteri and vagina is extraordinary when we consider
that it only occurs after an amount of dilatation and disten-
tion sufficiently to paralyze many other muscular organs. In
this particular it somewhat resembles the bladder, to which,
though it is paralyzed by excessive distention, a certain dila-
tation is necessary before the muscular fibres can act with
advantag:e.
But I may observe, that however important the vagma
may be considered in parturition, it is still more remarkable
as the organ for the reception of the semen, and for the sen-
sitive and excitor properties of its internal surface. As an
organ of sensation, particularly at its outlet, it produces the
orgasm of coitus, the most intense of all the sensations; and
as an excitor surface, it brings a greater number of involun-
tary and reflex actions into operation than any other portion
of the parturient canal.
In the next Lecture I shall treat of the Nerves of the Ute-
rine System.
75
LECTURE V.
The Nerves of the Uterine System — Distributive and Derivative Anatomy of
the IS'erves of the Ovaria, Fallojiiaii 'I'ubcs, Uterus, Vagina, and External
parts of Generation — Opinions of John and William Hunter — Growth of the
Uterine iNerves during Utero-gestation.
Sympathies and Synergies innumerable between the uterus
and other organs, as well as the scalpel of the anatonnist, pro-
claims the existence of uterine nerves, both in the impregnated
and unimpregnated states. The nerves of the uterine system
can best be studied as a distinct group, and for this purpose
they form a class almost as well marked as the respiratory
nerves. This group will include the nerves of the ovaria,
Fallopian tubes, uterus, vagina, and the external parts of
generation.
I. The nerves of the Ovaria. — The ovarian nerves are de-
rived from the renal ajid spermatic plexuses. In some recent
dissections of Dr. Robert Lee, these nerves are demonstrated
in considerable quantity. These nerves exhibit numerous
ganglia upon the surface, and subsequent to their entry into
the substance of the ovaria. They pass to the ovaria in com-
pany with the spermatic artery, and pervade the whole organ.
Fibres from the spermatic plexus and ganglia pass to the fun-
dus uteri, and communicate with the nerves coming from the
OS and cervix uteri.
■ IL The nerves of the Fallopian tubes. — These tubes are sup-
plied with nerves from the hypogastric ganglion. A nerve is
described as passing on each side of the uterus, from the upper
and anterior surface of this ganglion at the neck of the uterus,
to the broad ligament and the Fallopian tubes. Dr. Snow
Beck describes additional branches to the Fallopian tubes from
the nerves accompanying the internal iliac artery.
in. The nerves of the Uterus. — The uterus is principally
supplied with nerves by the hypogastric and sacral nerves,
and by branches from the spermatic plexus. Below the
bifurcation of the aorta, the aortic plexus divides into the
two hypogastric nerves. Dr. Lee describes the hypogastric
76 DERIVATIVE ANATOMY.
nerve as forming, in its descent to the cervix uteri, the
hypogastric plexus. This plexus, when it reaches the cer-
vix, terminates in a large ganglion, which Dr. Lee has
called the hypogastric ganglion. The hypogastric ganglion
is, in the unimpregnated state, on the authority of the same
anatomist, from half an inch to three-quarters of an inch in
diameter, and is made up of numerous lesser ganglia with
their rami of communication. Into the outer and lower sur-
face of the hypogastric ganglion, numerous branches enter
from the third, and sometimes from the second and fourth
sacral nerves. This ganglion, thus composed and reinforced,
is considered by Dr. Lee as the centre from which each
lateral half of the uterus is supplied ; from the hypogastric
ganglia nerves pass in various directions to the os, cervix,
body, and fundus, and are distributed extensively to the
muscular structure and the internal surface of the uterus.
In the course of their ramifications over and in the substance
of the uterus, numerous ganglionic enlargements occur. In
the virgin uterus. Dr. Lee has specially directed attention to
a beautiful ganglion in front of the hypogastric ganglion,
extensively connected with the surrounding nerves, which
he has called the Lawrentian ganglion, in honour of Mr.
Lawrence ; and in the gravid organ, Dr. Lee has described
numerous suh-peritoiioeal ganglia and plexuses on the anterior
and posterior surfaces of the organ. These ganglia and
plexuses maintain extensive communications with each other
and with the hypogastric ganglion below, and the spermatic
plexuses and ganglia above. The nerves of the virgin
uterus are sinuous or undulating in their course, and are
invariably accompanied to their terminations by small
arteries.
IV. The verves of the Vagina. — The vagina is supplied by
branches from the hypogastric ganglion and from the spinal
sacral nerves, a very large supply of nervous fibres being
distributed to the erectile tissue of the ostium vagina?.
V. llie nerves of the External Parts of Generation. — The
vulva and perina^um are chiefly supplied by filaments of the
genito-crural nerve, branches of the anterial sacral nerves,
and the perinatal branches of the pudic nerve.
But besides the distributive anatomy of the nerves of the
Uterine System, their derivative ?in-Aiomy is highly important,
particularly in a physiological point of view.
In the first place, the chain of thoracic and abdominal
DERIVATIVE ANATOMY. 77
ganglia of the sympathetic communicate with both the sensi-
tive and motor roots of the spinal nerves, and in this way
cerebral and spinal fibres become mingled with the fibres of
the sympathetic, and fibres from the sympathetic communi-
cate with the spinal roots. The splanchnic nerves are chiefly
formed by these intercommunicating [ibres, from the spinal
roots to the ganglia of the sympathetic. The great splanchnic
nerve arises from the sixth, seventh, eighth, ninth, and tenth
thoracic ganglia ; and according to Dr. Beck, from the
superior thoracic ganglia also. The lesser splanchnic arises
from the tenth and eleventh thoracic ganglia. The great
splanchnic enters the semilunar ganglion, and it is by the
two semilunar ganglia, and their communicating filaments
and lesser ganglia, that the solar plexus is chiefly formed.
Into the solar plexus some of the terminal filaments of the
pneumogastric and phrenic nerves also enter. These fibrillae
from the phrenic and pneumogastric may terminate in the
liver and the kidney, or they may pass through the superior
plexuses of the abdomen, to reach the inferior abdominal
and even the pelvic plexuses. The renal plexus is formed
by branches from the solar plexuses and the termination of
the lesser splanchnic nerves : the renal plexus also receives
fibres from the vagus ; and the spermatic plexus is a sub-
plexus of the renal. From the spermatic plexus the ovaria
and part of the fundus uteri are supplied. The inferior aortic
plexus is the last of the series of abdominal plexuses, and it
is connected by a chain of ganglia and plexuses with the
solar and renal plexuses, and with the latter lumbar ganglia.
From the inferior aortic plexus the hypogastric nerve de-
scends, forming the hypogastric plexus and the hypogastric
ganglion ; with this ganglion branches of the sacral nerves
unite ; and from this nervous estuary the uterus is finally
supplied. If we adopt the view, that the plexuses of the
abdomen, like the external plexuses, are mechanical adap-
tations for mixing nervous fibres from different sources, and
apply it to the uterine nerves, it becomes a possibility, and,
I may say, a probability, that the uterine nerves are more
variously derived than any other nerves of the body. They
may be derived from different points of the great nervous
tract between the origin of the pneumogastric nerve, in the
medulla oblongata, and the origin of the sacral nerves, in the
Cauda equina. There is no actual impediment to the ap-
7
7S HISTORY OF THE UTERINE NERVES.
proacli of nervous fibres to the uterus, from the medulla ob-
longata through the medium of the vagus; from the cervical
portion of the spinal marrow by the phrenic ; from the
thoracic by the splanchnic nerves ; and from the dorsal by the
compound lumbar branches of the sympathetic, and from the
sacral nerves, which latter come directly from the spinal
chord. Taking all these facts into consideration, there is
no need of continuing to maintain, as some physiologists
have done, that the thoracic and abdominal cord of ganglia
are centres of reflex actions independently of the spinal
marrow. This view was suggested by the obscure reflex
actions which are said to occur when a large portion of the
spinal marrow^ has been destroyed. The circuitous paths by
Avhich the abdominal and pelvic viscera may be placed, in
some degree, in relation with the upper part of the spinal
marrow, after the portions of the spinal centre from which
they derive their more direct supply of spinal fibres has been
destroyed, is a sufficient explanation of such phenomena if
they really exist.
The nervous lines I have been enumerating are quite suf-
ficient to account for the communications between the uterus,
and the brain and spinal marrow. The communications be-
tween the numerous ganglionic centres and the uterus are
still more obvious, and there is little question but that the
great mass of the uterine nerves is composed of ganglionic
fibres. This is nothing more than might be expected when
we consider the immense increase of nutrition over which
these nerves have to preside during the whole period of
utero-gestation — an increase quite as remarkable as the ac-
cession of nervi-motor power at the time of parturition. I
have dwelt at length, in former lectures, on the relation of
the nervous fibres derived respectively from the brain,
spinal marrow, and the ganglia of the sympathetic, to the
vohintary, emotional, reflex, and peristaltic motor actions of
parturition.
It will be unnecessary for me to enter minutely into the
various })oints of the controversy respecting the nerves of
the uterus. The nerves of the unimpregnated uterus were
first actuallv described by William Hunter, in his work on
the Gravid Uterus. He described the hypogostric nerve as
passing to the uterus, spreading out in branches like the
portio dura, or the sticks of a fan, and communicating freely
HISTORY OF THE UTKRINE NERVES. 79
over the whole side of the uterus and vagina. Next, Tiede-
mann published two plates of the nerves of the uterus, in a
subject who died six days after delivery. In one of his
plates the fundus uteri is pulled forwards, and a very mode-
rate supply of simple nervous filaments, without any appear-
ance of plexus or ganglion, is represented as coming from
the hypogastric plexus. The other plate is a lateral view of
the middle and inferior portions of the uterus, with the com-
mencement of the vagina ; it represents the hypogastric
plexus as supplying very moderately the sides of this part of
the uterus, but there is in this plate no appearance whatever
of gangliform enlargements on the branches supplying the
uterus itself, though there are ganglia visible on that portion
of the " plexus gangliosus" supplying the vagina. Other
anatomists, as Lobstein, Osiander, and Longet, have either
denied the existence of uterine nerves, or they have limited
this organ to a very scanty supply.
Dr. Lee was the first to demonstrate, by actual dissections,
the extent of the uterine nerves, the existence of num.erous
ganglia and plexiform arrangementsuponthe uterus, the nature
of the ganglia at the neck, and the distribution of the nerves
to the muscular structure and the internal surface of the organ.
It is well known that Dr. Beck has, by the dissection of
a gravid uterus, and of an unimpregnated uterus taken from
the body of a woman who had borne children, arrived at
conclusions widely difTerent from those of Dr. Lee. As
I believe in the truth of Dr. Lee's dissections, I shall not
refer to those which have been placed in opposition to
them, further than to point out the chief points of difTer-
ence. In the first place. Dr. Beck believes that the nerves
of the impregnated uterus are not by any means so large
or so numerous as they appear to be in Dr. Lee's dissections.
He considers that the nervous arraagement at the neck of
the uterus should be called the pelvic plexus, instead of the
hypogastric ganglion, and that the sacral nerves do not enter
into that portion of this plexus supplying the uterus, but that
they are distributed to the vagina and other })arts. Dr.
Beck further believes that there is no increase in the size
of the nerves of the uterus during pregnancy. Briefly stated,
I believe, these are the chief difierences between the dis-
sections of Dr. Lee and Dr. Beck. Dr. Beck may be con-
sidered as the representative of a class who believe that the
so ANATOMICAL AND PHYSIOLOGICAL PROOFS.
nervous supply of the uterus is very diminutive indeed,
having no relation, as regards size, with the importance of
the functions it is called upon to perform.
'I'he opposition to the views of Dr. Lee not only has an
anatomical but a physiological bearing. It is sought to
prove that uterine action is in great measure or entirely, in-
dependent of the nervous system ; or that, at the most, its
motor functions are limited to the ganglia of the sympathetic.
Even Dr. Lee himself leans to the opinion, that the sensibility
and contractility of the uterus are in a great degree derived
immediately from the ganglia and other nervous structures of
the organ: still Dr. Lee can hardly be said to have broken
ground in physiology at all; his attention has been so purely
limited to dissection and anatomy.
But the plainest facts of physiology, as well as the analogies
and facts of anatomy, demand more extensive nervous endow-
ments for the uterus as the principle organ of generation in
the female. No one doubts that the uterus is susceptible of
pain ; this is one proof of a nervous connection between the
uterus and the brain as the organ of sensation. No one doubts
that an emotion of the mind may excite the uterus to power-
fjl contractions; this is another proof of nervous connection
between the brain and the uterus. No one denies that, dur-
ing pregnancy, the uterus affects synergetically the most dis-
tant organs, producing the changes in the mammefi and the
gastric disturbances, which are so universal ; these facts are
only explicable by the existence of nervous communications
between the uterus on the one hand, and the stomach and
mamma on the other. There is no other route than that
afforded by the nervous system. No one denies, either, that,
after parturition, the breast or the stomach may excite the
uterus to action: these facts further prove a reciprocal
influence/rom the stomach and breasts to the uterus. Such
facts are, in their sphere, as convincing as though the eye could
see a great concourse of nerves running between these organs.
A physiological fact is worth quite as much as an anatomical
fibre. These communications can only take place through the
medium of nerves, and whether there be one channel or many ;
whether the chief place be given to the spinal fibrillar of the
sympathetic, or to the proper nerves of the spinal chord, the
necessity for uterine nerves is equally inexorable. There
must be nerves, and there must be nerves sufficient for the
OPINIONS OF WILLIAM AND JOHN HUNTER. 81
functions to be performed. Anatomical facts can never give
the lie to the facts of physiology.
The next question respecting the nerves of the uterus,
one which has been hotly discussed for some years past, and
which may almost be called the "still vexed Bermoothes"
of the anatomical world, is this: Do the uterine nerves en-
large pari passu with the other tissues of the gravid organ
during gestation?
This question, as it is disputed at the present day, descends
to us from the times of the Hunters. William Hunter's
words upon this subject are these : " I cannot take upon me
to say what change happens to the system of uterine nerves,
but I suspect them to be enlarged in proportion as the vessels."
It does not appear that William Hunter ever dissected the
nerves of the impregnated uterus himself, or that he ever
saw the nerves of the gravid organ dissected out. I have in
vain searched his splendid series of engravings for any repre-
sentation of these nerves, either in the gravid or ungravid
states.
John Hunter, in this, as in many other points which occu-
pied the attention of these distinguished anatomists, adopted
an opinion directly opposite to that of his elder brother. In
his Treatise on the Blood he wrote as follows : — " The uterus
in the time of pregnancy increases in substance and size,
probably fifty times beyond what it naturally is, and this
increase is made up of living animal matter, which is capable
of motion within itself. I think we may suppose its action
more than double, for the action of every individual part of
this viscus at this period is much increased, even beyond its
increase of size, and yet we find that the nerves of this part
are not in the smallest degree increased, and that the nerves
and brain have nothing to do with the actions of a part,
while the vessels, whose uses are evident, increase in pro-
portion to the increased size : if the same had taken place
with the nerves, we might have reasoned from analogy."
Thus you perceive the opinion of John Hunter respecting the
growth of the uterine nerves during pregnancy was even
more decidedly negative than that of his brother William
was positive. I may here observe, that the idea respecting
the capacity of action within itself attributed to the uterus,
\vas also entertained by Harvey, This may be seen by the
following sentence from his sixty-eighth Exercitalion, which
T
82 DR. LEE'S DISSECTIONS. -
treats of the condition of the uterus of the deer in October,
the month after conception. "The uterus at this time being
examined immediately after death, the cornua are often seen
to move in an undulatinc^ ma-nner, similar to the motion of
the tortoise (appearing like the under surface of the snail or
slug when it creeps), just as if the uterus were an animal
within an animal, and exercising its own movement." I
quote these passages, because there are anatomists even in
the present day who have not outgrown the views they em-
body. I might refer to contemporary authors, who still con-
der the uterus independent of the nervous centres, as being
animnl in aimnali. There can be little doubt that the posi-
tive dictum of John Hunter has done much to retard our
knowledge of this subject.
Dr. Lee strenuously contends for the actual growth of the
nerves during pregnancy, and there is no point on which he
has met with greater opposition, many anatomists still be-
lieving, with John Hunter, that though the other tissues in-
crease in a manifold degree, the nerves remain stationary.
Dr. Lee bases his opinions upon the evidence supplied by his
numerous dissections. The nerves of the virgin uterus, and
of the gravid organ, at the full term of gestation, are, in Dr.
Lee's dissections, of very different sizes; the other tissues,
the growth of which is so evident, do not appear to have in-
creased more remarkably than the nervous structures. These
dissections are very numerous; Dr. Lee has now dissected the
human virgin uterus six times, and the gravid organ of fifteen
subjects. He has, moreover, dissected the gravid uterus of
the mare, cow, and other animals, and has invariably found
a large supply of nerves in these dissections. Dr. Lee fur-
ther teaches, that after parturition the nerves of the uterus
diminish in size very rapidly as the uterus returns to the con-
dition natural to the unimpregnated state. He has made a
series of dissections of the nerves of the heart, which go to
confirm his dissections of the nerves of the uterus. His pre-
parations demonstrate, that the nerves of the right side of the
heart are smaller that the nerves of the left, and what is more
to the [)urpnse, that the nerves of an hypertrophied heart are
considerably larger than the nerves of this organ in its normal
state. These dissections are not hidden in a corner ; any one
may examine them for himself, either at Dr. Lee's residence,
or at the museum of St. George's Hospital ; and perhaps no
TEMPORARY GROWTH OF NERVES. 83
dissections that ever were made have been so scrutinized by
anatomists of ditTerent countries ; it is truly a matter of
wonder, that in a question so purely a3sthetic, so entirely open
to the senses, the slightest difFerenee of opinion shoidd exist.
I believe I may say, with perfect truth, that those who have
been boldest in their disbelief of Dr. Lee's anatomy have
been the most chary of personal investigation : they have
tested these nerves by their preconceived ideas, rather than
with their own eyes and hands.
Probably the increase of the nerves of the uterine system
after conception is only one fact of many of a similar kind.
To determine the question, all the instances of periodic in-
crease and diminution, distinct from ordinary growth — all the
epicycles upon the larger cycles of increase and nutrition,
should be examined. Precise observations, following in the
track of Dr. Lee, must be made of the condition of the nerves
of the virgin uterus, of the uterus of the girl, of the gravid
organ after puberty, of the uterus of the multiparous woman
in the unimpregnated state, and of the uterus after the child-
bearing period has passed. The nerves of the generative
system in the young pullet and in the mature hen during the
period of oviposition should be dissected. In the same way
the mammary nerves of the virgin, the nursing mother, and
the nerves of the breast after the period of lactation, should
be compared ; or these nerves could be examined still more
etfectually by dissections of the lower animals, where the in-
crease in size and the isolation of the mammary glands are
more obvious than in the human female. The male sexual
organs also offer opportunities of setting at rest the question
respecting the growth of nerves in organs of periodic increase ;
the nerves of the testis and penis of the youth before and alter
puberty should be compared ; the nerves of the penis and
testes of the bull and the stallion, and the nerves of the penis
and those leading to the excised testes in the ox and gelding,
are also fitted for observation. Then there are animals in
which the increase in the testes is temporary, as the sparrow,
the frog, or the toad, in each of which a great increase or
diminution of the glands takes place in comparatively short
periods. There are also other instances fitted for anatomical
observation ; the growth of the horns of the stag ; the
whiskers of the fera3, which are supplied with nerves ; the
fore-limbs of the frog ; the tail of the salamander ; the de-
f4 ANATOMICAL COMPARISONS.
ciduous teeth in tlieir growth and decay, and the increase of
the permanent teeth. All these taken together, would, after
due investigation, afford a body of evidence independently
of the uterine nerves, which would establish or overthrow
the opinions of Dr. Lee beyond all question Nothing of
this kind has, liowever, been done by his opponents ; the
microscope, and the two dissections of Dr. Beck, are the
only weapons used against Dr. Lee, and these dissections
were not made in the usual manner — the neurilemma, which
is one of their component parts, being removed from the
nerves. Meanwhile the chief evidence is in Dr. Lee's
favour. Those who maintain that the nerves of the uterus
do not increase in size during gestation, must show, not only
that there is no such increase in the gravid, as compared with
the virgin uterus, but they are bound to show, that the
nerves relatively diminish in breadth during pregnancy ; for
when we consider the extent and superficies of the fully-
developed gravid organ, it must be evident to the meanest
capacity, that if the nerves of the virgin uterus, remaining
stationary as regards size, are merely stretched upon, drawm
out, or unfolded, over and in, the enormously increased
gravid organ, they ought proportionately to appear as much
diminished as the growing tissues of the uterus are increased
in size. The length of the virgin uterus is two inches; of
the gravid, at the end of the gestation, twelve inches. The
weight of the virgin uterus is one ounce ; that of the fully-
developed gravid organ, twenty-four ounces. The dispro-
portion in size between the fcetus and the adult man is not
nearly so great as the disproportion between the virgin and
the paturient uterus. If we could conceive the nerves of
the fcetus stretched out or unwound in the space of nine
months, so as to accommodate the skeleton of the adult, we
should have but an imperfect idea of the mechanical maras-
mus of the uterine nerves at parturition, which we are called
upcn to believe, if the nerves do not actually grow during
gestation. In truth, the argumentum ad absurdum applies
with great force to those who dispute the growth of the
uterine nerves in pregnancy.
The questions naturally suggest themselves — How does
this increase in the nervous structures, described by Dr. Lee,
take place ? Is there an increase in the number of fibrillffi,
or are the original nervous fibres only increased in size ?
DR. LEE'S CLAIMS. 85
Is the process of growth active in the ganglionic or in the
cerebral and spinal fibres, or in the fibres of all these systems ?
Now it is not prob'able that the number of fibres increase,
more especially of those fibres which are in relation with the
brain and spinal marrow. The growth of the uterine nervous
structures must not be compared with the original formation
of the nervous system in the foetus, — for the virgin uterus
already possesses its nerves, — but it must rather be compared
with the growth of the nervous system from infancy to man-
hood. We can hardly imagine such a thing as the insertion
of new fibres into the spinal chord, establishing new relations
with the rest of the brain, spinal chord, and nerves, in an
adult animal. We are obliged to suppose the growth to be
one of increase in the length and calibre of the fibres already
existing, and this may be very well illustrated by reference
to the growth of an animal which arrives at maturity during
the first year of its existence. Take the cock, for example.
At the time of hatching we must believe the nervous system
perfect as regards the number of its fibres, because the move-
ments of the chick are as perfect and facile a few days after
birth as they are in the full-grown bird, yet there is a great
difference between the size and extent of the nervous system
of the young chick of one spring, and the gallant chantecleer
of the next. The change in the nervous system can only,
according to our present knowledge, arise from an increase
in the length and thickness of the nervous fibres, and there
is nothing more extraordinary, in the development of the
uterine nervous structures, than there is in the harmonious
growth of the entire nervous system in animals which reach
maturity within a year from the period of birth.
I believe, then, Dr. Lee may fairly claim the merit of
showing the extent of the nervous endowments of the gravid
uterus, and there can be no doubt that he was the first to
attempt, by numerous dissections, to grapple with the problem
respecting the growth of the nerves of the uterus during
gestation — a problem which a very great number of anato-
mists, in every part of the world, believe him to have solved.
Taken together, these points form a very complete anatomi-
cal discovery, the more to be prized because Dr. Lee came
after so many other observers, who had touched upon this
subject without coming to any satisfactory decision, and
further, because he has laboured in direct opposition to some
of the most celebrated anatomists of the present century.
86 DK. LEE'S CLAIMS.
The opponents of Dr- Lee confidently appeal to the micro-
scope to prove the justice of their rejection of his labours,
but the fact of such an appeal would seem a prejudice
against him, and a willingness to deny the fidelity of his dis-
sections. The microscope is used to ascertain the intimate
physical appearances of nervous and other tissues, but
hardly, on ordinary occasions, to distinguish grossly as
between nerve, muscle, and cellular tissue. It must be
borne in mind, that the nerves of the body generally were
dissected and held to be nerves upon other evidence than
such as that furnished by the microscope long before this
valuable instrument was invented. If, in the case of the
uterine nerves, we deny that the tracing of the scalf^el or
dissecting needle, continuity with other nervous structures,
and careful ocular examination — ibr the debatable structures
are quite large enough to be inspected by sight and touch, — ■
if, I say, these are not sufficient to help us to a decision in
the case of the uterine nerves, neurological anatomy should
begin again, and we ought to question the reality of every
nerve in the body; for they hold their title to be considered
nerves only on evidence which, if applied to the uterine
nerves, answers directly in the affirmative. What should
we say of a proposal to apply the microscope to the de-
scendens noni and the digastricus, or to distinguish the
muscular fibres of the stomach from the branches of the
pneumogastric ; yet the nervous and fibrous tissues of the
gravid uterus are as palpably presented to the eye as those
of the stomach ? Possibly — I say, possibly, though I cannot
persuade myself that such is the case — Dr. Lee may in his
anatomical enthusiasm overrate the quantity of the uterine
nerves ; he may not estimate sufficiently the amount of cel-
lular tissue still remaining in his dissections. In some of
his dissections he does not pretend that he has cleared the
nerves of their neurilemma, or completely removed the cel-
lular tissue ; and every one accustomed to minute dissection
knows that it is next to impossible to do this without remov-
ing nervous matter. To my mind the question of the nerves
of the uterus does not depend for its answer upon dissec-
tions of such marvellous delicacy. These nerves a;e s>een
with the greatest certainty in some of the most unfinished
dissections of Dr. Lee, just as we sometimes see the design
of an artist more forcibly in the original sketch than in tlie
DR l.EK'S CLAIMS. 87
elaborate picture. In many of bis preparations — particularly
those which are injected — the sih'er-tbreaded filaments of
nerves are seen shining ihrough the cloudy cellular tissue, in
a manner which the nicest art could not hope to imitate ;
and 1 fear in this case the microscope will prove to have
been a screen, behind which some anatomists have placed
themselves, not that they may see, but rather that they may-
escape the li2;ht. It will be right to refer to the evidence
offered by Dr. Lee, as well as to that demanded by those
who question his views. He himself considers continuity of
structure with other acknowledged nerves, as the hypogastric,
sacral, and spermatic nerves ; the similarity of the nerves of
the uterus to the nerves of other viscera, as the stomach and
heart ; and the circumstance, that each minute nerve, as dis-
played in injected preparations, is accompanied by a small
artery ; as atibrding good and sufficient proof that the struc-
tures he has dissected and portrayed in many drawings and
plates are bona fide nerves, ganglia, and plexuses.
But those who seek to reduce Dr. Lee's merits to the very
lowest point, ought to accord him considerable praise. There
is a sense in which his labours ought to command at least
their respect. One of the most eminent writers of recent
times has observed, — "That man is not the discoverer of any
art who first says the thing; but he who says it so long, and
so loud, and so clearly, that he compels mankind to hear him
— the man who is so deeply impressed with the importance
of the discovery that he will take no denial, but, at the risk
of fortune and fame, pushes through all opposition, and is
determined that what he thinks he has discovered shall not
perish for want of a fair trial." Tested by this standard, Dr.
Lee's title to the discovery of the uterine nerves is undispu-
table; but ibr him this f'epartment of anatomy would have
slumbered on, as it had done all through the great anatomical
ages; we should have had nothing be^yond the meagre plates
of Tiedemann ; and though the physiology of the subject
might have progressed, it would still have lacked the clear
warrant of anatomy. To Dr. Lee alone belongs the merit of
liaving compelled the attention of anatomists to the uterine
nerves ; this, even those who dispute that his laborious dis-
sections, during eight years, have added a single fibrilla,
must, willingly or unwillingly, allow. But I do not make
these concluding remarks to qualify my own most sincere be-
lief that he has given us the real anatomy of the uterine
88 DR. LEE'S CLAIMS.
nerves, and that he has proved the growth of this system of
nerves durinjy utero-^estation.
The nerves of the urinary bhidder and the rectum are de-
rived from the same sources as the nerves of the uterine
system. We may compare the nerves of the genito-urinary
organs, and of the outlet of the intestinal canal, to the par
vagum, which is distributed to the respiratory apparatus, the
heart, and the upper portions of the digestive tube; only that
the inferior vagus is more diffused in its origins and termina-
lions. Probably, also, there is in the lower medullary bulb,
from which the cauda equina arises, an analogue of the me-
dulla oblongata; the lower medullary bulb having the same
relation to the support of the species, as the upper has to the
support of the individual.
89
LECTURE VI.
Puberty — History of the Ovular or Ovarian theory of Menstruation — Analogy
between Menstruation, Q^struation, and the Oviposition of Birds, Insects,
Amphibia, and Fishes — Nature of the Catamenial Secretion — Diseases of
Menstruation — Sterility, Amennorrhoea, Dysmennorrhoea, and Ovarian Con-
vulsion.
At the time of puberty the dev^elopment of the ovaria takes
place, exercising an extraordinary power over the entire
female economy. The ovaria become centres, from whence
synergetic influences radiate to every part of the system.
New emotions arise in the mind ; affection, pudency, and
desire, for the first time agitate the heart of the virgin. The
whole mechanism of expression is informed and beautified
with a new spirit; the eyes, hair, lips, voice, gestures, and
carriage, are all transformed ; awkwardness and disproportion
are often metamorphosed into dignity and grace. The ovaria
modify the processes of nutrition, and excite that harmonious
and plastic power, more cunning than the creative hand of the
statuary, which moulds the beauty of womanhood out of the
limbs of the girl. The ovaria it is, too, which lit the breasts
to give suck, the womb to bear, and causes the bones of the
pelvis to enlarge at puberty, for the purposes of parturition.
It is, however, to the more imiTiediate function of the ovaria
— namely, menstruation, that I must now beg your atten-
tion.
The modern Theory of Menstruation, which makes it de-
pendent on the periodical excitement of the ovaria, and the
esca])e of mature ovules from the Graafian vesicles, the secre-
tion of the catamenial fluid being secondary to the ovarian
phenomena, may be considered as definitely proved. The
fundamental analogy between menstruation in the human
female, and the oestruation of mammalia, and the oviposition
of oviparous animals, has also been satisfactorily shown ; but
I believe a comprehensive generalization of all the facts, and
their application to the theory of reproduction, still remains
8
90 OVULAR THEORY OF MENSTRUATION.
to be made. I know of no better mode of placing the theory
of menstruation before you, than by tracing briefly the differ-
ent steps by which we have arrived at our present know-
ledge of this most interesting subject.
The vesicles of the ovary had been observed by Fallopius
and others as early as the middle of the sixteenth century,
and probably even before that period. In 1651, Harvey
published his great work on the generation of animals, but
it was chiefly composed at Oxford during his stay there,
between the years 1642 and 1646. The fifth Exercitation
contains an extraordinary comparison between menstruation
and unimpregnated oviposition, which I shall here quote, and
which I shall subsequently have to comment upon. It wuU
be seen, from this passage, that our great physiologist not
only saw " the same significance" in oviposition anJ men-
struation, but that he drew a vivid picture of the disorders of
celibacy in all animals.
"j\Tany birds, consequently, the more salacious they are,
the more fruitful are they ; and occasionally, when abundantly
fed, or from some other cause, they will even lay eggs with-
out the access of the male. It rarely happens, however, that
the eggs so produced are either perfected or laid; the birds
are commonly soon seized with serious disorders, and at
length die. The common fowl, nevertheless, not only con-
ceives eggs, but lays them, quite perfect in appearance, too ;
but they are always wind eggs, and incapable of producing
a chick. In like manner many insects — among the number,
silkworms and butterflies — conceive eggs, and lay them, with-
out the access of the male; but they are still adventitious
and barren. Fishes also do the same.
" // is of the same significance in these animals^ when they
conceive eggs^ as it is in young women when their uterus grows
Lot^ their menses flow, and their bosoms swell — in a word,
when they become marriageable ; who, if they continue too
long unwedded, are seized with serious symptoms — hysterics,
furor uterinus, &c., or fall into a cachectic state, and di§tera-
peratures of various kinds. All animals, indeed, grow savage
when in heat, and unless they are suffered to enjoy one
another, become changed in disposition. In like manner
women occasionally become insane through ungratified desire,
and to such a height does the malady reach in some, that
they are believed to be poisoned, or moonstruck, or possessed
OVULAR THEORY OF MENSTRUATION. 91
by a devil. And this would certainly occur more frequently
than it does, without the influence of good nurture, respect
for character, and the modesty which is innate in the sex,
which all tend to tranquillize the inordinate passions of the
minil."
De Graaf had seen the human ovum descending through
the Fallopian tube as early as 1668. In the Philosophical
Transactions for 1672, there is an account of the inquiries of
Kerkringius, a continental physician, in which the Graafian
vesicles of the virgin ovarium are called eggs, and are de-
scribed as similar to the eggs laid by birds, without commerce
with the male. In this paper he says, *' Femina3 desjiciunt
hsec ova imprimis tempore menstruorum, vel in irse vehemen-
tia." Kerkringius had seen the impregnated ovum in the
uterus, and he believed it was nothing more than the Graafian
vesicle, or egg of the ovary, enlarged by impregnation. He
gives the figure of an ovum, of the size of a black cherry,
which he had taken from the body of a woman who had died
three or four days ''post tiuxum menstruum." Suspecting
that, in this case, conception had taken place subsequently
to menstruation, he says he took the husband aside, to ask
him, '* Num a tempore fluxus menstruorum uxorem cogno-
visset ?" The answer was in the affirmative, and it strength-
ened his hypothesis. Kerkringius is far, however, from lay-
ing down the escape of his hypothetical ova as the law of
menstruation : his positive errors consist in his supposing that
the vesicles of the bigness of a pea found in the virgin ova-
rium were veritable ova, and that the impregnated ovum
found in the uterus was merely an ovarian vesicle enlarged
by impregnation ; he further erred in imagining that anger
played any part in the process of oviposition. The hypothesis
of Kerkringius appears to have soon fallen into abeyance.
The more accurate knowledge of the ovarian vesicles promul-
gated about this time by De Graaf, must have surrounded it
with doubt. It WMS so very evident that the ovarian vesicles
could not, on account of their size, pass through the Fallopian
tubes entire, and the real ova were then entirely unknown.
Menstruation, therefore, continued to be considered strictly
as a function of the uterus, without any special reference to
the ovaria.
In the year 1797, Cruickshank, William Hunter's favourite
pupil, examined the body of a woman w^ho had died during
92 OVULAR THEORY OF MENSTRUATION.
menstruation, and he observed that the peritoneal coat of the
ovarium was ruptured. He says of this case, " I have also
in my possession the uterus and ovaria of a young woman
who died with the menses upon her. The external mem-
branes of the ovary were burst at one place, from whence I
suspect an ovum escaped, descended through the tube to
the uterus, and was washed off by the menstrual blood."
This observation of Cruickshank appears to have been a
solitary one. It was, however, a great advance upon any-
thing which had been observed before, but no deduction or
explanation respecting the essential nature of menstruation
appears to have been suggested by it to his mind.
The Ovular theory of menstruation was next revived, or
rather originated, by Dr. John Power, who made it the sub-
ject of one of his Essays on the Female Economy, published
in 1821. By an intuitive sagacity, based on many original
observations of his own, and on the facts and opinions of his
predecessors, he arrived at the conclusion, then stated dis-
tinctly for the first time, that at every menstrual period an
ovule reaches maturity in the ovarium, and is discharged
from it during the flow of the catamenia. He taught that
the catamenial secretion was excited in the uterus by the
condition of the ovaria, and that the menstrual fluid was an
imperfect attempt at the formation of the decidua ; the
ovarian stimulus, when the ovule is unimpregnated, not being
sufficient in ordinary cases to excite the deposition of fibrin,
but stopping short at the menstruous secretion. He, how-
ever, drew attention to the fact, that in certain cases of dys-
menorrhoea the ovarian stimulus is greater than usual, and
that then the false membrane of dysmenorrhoea maybe formed.
He looked on the uterine phenomena of the menstrual func-
tion as an abortive attempt at the formation of a deciduous
membrane, preparatory to the reception of the abortive ovule.
So far, there is little to add to the theory of menstruation at
the present time. I should mention to you that Dr. Power
does not seem to have been aware of the observation of
Cruickshank or Kerkringius. His essay contains the most
striking evidence of an original genius. It must, however,
be said, that the ova of Dr. Power were almost as hypothe-
tical as those of Kerkringius ; he knew of no ova except the
vesicles of Kerkringius and De Graaf, and he drew a wrong
analogy in comparing the formation and expulsion of the
OVULAR THEORY OF MENSTRUATION. 93
membraneous secretion in dysraenorrhoea, to the extrusion of
the unimpregnated egg of the pullet ; and while he recog-
nised the analogy between the uterus, as the nidus of the
human ovum, and the nest of the bird, he appears to liave
failed to see any apology between the oestruation and men-
struation. With these drawbacks, which are not very im-
portant, considering the state of physiology twenty-five years
ago, the classical essay of Dr. Power is quite on a par with
the last word of science, and it affords a very remarkable
and beautiful instance of the advance of theory before fact,
as we shall immediately see. His mind saw the inevitable
necessity for the existence of ova, and he wTote as though
he had actually observed them.
In 1831, Dr. Robert Lee examined a woman who had died
during, orshortly after, menstruation, and,likeCruickshank,he
found the peritoneal coat oftheovary perforated overthe site of a
Graafian vesicle. Other opportunities of dissection followed,
and four similarcasesw^ere published by Dr. Lee in 1833. Dr.
Lee not having seen ova in the Graafian vesicles, refused to
admit the existence of hypothetical ova. Cognizant of no
ovum except that which had been found in the uterus and
Fallopian tubes after impregnation, and the escape of which
from the Graafian vesicles seemed, on account of their size,
an impossibility, he repudiated the theory of Dr. Power, and
pronounced that menstruation depended on some unknown
change in the Graafian vesicle. Dr. Lee refused to go a
step beyond his own facts. At the time he was perfectly
right ; but the progress of knowledge soon converted Dr.
Power's hypothesis into an intelligible and tested theory ;
and in this process Dr. Lee's observation were of the greatest
assistance. They were, in fact, the anatomical part of the
discovery.
In 1827, the missing link in the chain had been detected
by the discovery, by Baer, of the minute ovule wnthin the
Graafian vesicle ; and if Dr. Lee had only succeeded in
seeing the ovule of Baer, his knowledge of menstruation,
after his dissections, would have been complete. As it was,
he did not interpret their true meaning. Baer's discovery,
which converted the Graafian vesicle into an ovisac, sup-
plied, with the original dissections of Dr. Lee, the complete
verification of Dr. Power's views. Other observers — MM.
Negrier Gendrin, (whose observations were most important),
8*
94 OVULAR THEORY OF MENSTRUATION.
Raciborski, Mr. Mayo, Dr. Girdwood, and others, followed
with testimony to the truth of the escape of an ovule from
the Graafian vesicle at each catamenial period. Dr. Gird-
•wood has endeavoured to show that in young women who
have died after menstruating a few times only, the number
of menstruations correspond with the number of cicatrices on
the surface of the ovaria ; following Mr. Mayo, he points
out that the puckered condition of the ovaria in elderly
females are referable to the numerous cicatrices of the whole
menstrual era. There are circumstances which militate
against the numerical opinion of Dr. Girdwood — namely,
that there may be the rupture of two or more vesicles at a
menstrual period, and it is possible for a menstrual period
to pass over without the rupture of a single vesicle. Dr.
Girdwood further contends for the analogy between men-
struation and ffistruation, adducing some interesting facts on
this point, drawn from the observation of the menstrual and
CEStrual secretions, and from instances in which he believes
that the duration of gestation in animals is a multiple of the
oestrual, just as pregnancy is a multiple of the menstrual
period. Many valuable observations had been previously
made by Dr. Laycock respecting the periodicity of oestruation
in the lower animals, all of which corroborate the analogy
between the functions of menstruation and oestruation. Pro-
fessor Bischoff has brought direct experiment to bear on
the subject, and has shown most positively, that at the
cestrual period of animals, ovisacs are commonly ruptured,
and the escape of ova occur, whether the male be admitted
or not.
Lastly, certain aberrations of the ovular theory of men-
struation have been observed by Dr. Ritchie, of Glasgow.
He ascertained, from the dissection of numerous females
who had died at all periods of life, and under all circum-
stances, that ovisacs are occasionally ruptured, and ovules
expelled, in childhood, and at other times than the menstrual
periods, in women during the childbearing era ; and that in
some cases the ovarian excitement accompanying menstrua-
tion does not proceed so far as the rupture of the peritonaeal
coat, and the shedding of an ovule. Still, these are excep-
tional cases; in the great majority of instances there is
ovarian excitement, and the escape of one or more ovules,
durintr the flow of the catamenia. The conclusion I should
OVULAR THEORY OF MENSTRUATION. 95
draw from Dr. Ritchie's papers is, that in certain cases the
ovarian action of menstruation is incomplete ; that though
it excites the catamenia it is insufficient to cast off* an ovule.
The ovules shed in the intervals between the catameninl
periods, without any uterine discharge, are probably either
immature, like those of childhood, or they may escape from
the ovaria without a sufficient degree of ovarian excitement
to set up the catamenia, being in this respect the antithesis
of those other cases in which there is the uterine secretion
without the extrusion of ova from the ovarium. In perfect
menstruation, both ovarian excitement and the escape of an
ovule concur; but the ovarian excitement is absolutely
indispensable.
We may now retrace our steps, in order to follow more
rapidly the facts which prove the Ovular or Ovarian Theory
of Menstruation. De Graaf had seen the ovum in the Fal-
lopian tubes as early as 1668, and they continued to be ob-
served there, and in the uterus, by other anatomists ; but
the difficult point was, to learn from whence the ovum orig-
inated. Harvey, as the result of his examinations of the
King's deer, had positively asserted that it did not come
from the ovary. Kerkringius subsequently broached the
ovular hypothesis of menstruation, but in a very incomplete
form. The earliest fact pointing out the mode of escape of
the unimpregnated ovule from the ovarium was observed
by Cruickshank. The first decisive group of facts was
observed by Dr. Lee. Meantime, the future theory of men-
struation had been fairly constructed by Dr. Power, and the
discovery of the ovule within the Graafian vesicle, or ovisac,
following upon this, rendered both the facts and the theory
complete. When the theory of menstruation had been thus
established, the nature of conception was evident ; the rela-
tion of menstruation to fecundity, and the common occur-
rence of impregnation immediately after the menstrual period,
were easily comprehended. There is no doubt that at the
latter part of each menstrual period, and immediately after
its conclusion, when the ovule is ready for impregnation,
there is an actual increase of the sexual emotion in women,
though this is greatly disguised by natural modesty and
reserve.
The theory of menstruation was very much ridiculed when
first propounded by Dr. Power. Its author was treated as a
96 OVULAR THEORY OF MENSTRUATION.
visionary, and I have heard he acquired among accoucheurs
the name of "Menstruation-Power." His little book was
severely scourged by the critics of that time ; but the event
is another proof, that whenever ideas of sterling worth are
put forth, the world, even if it do not at once appreciate
their value, is sure to find them *' after many days." Dr.
Power himself seems to have been little careful about the
result ; he never appears to have discussed the matter, or
even resorted to experiments; but to have calmly thrown his
ingot of gold into the stream of time, there to be refined,
instead of casting it into the burning fiery furnace of contro-
versy, for that more rapid assay which original minds some-
times covet. Very recently, 1 paid a visit to him, at his
residence at Westminster, and I am proud to say he was
much interested in my own researches in the physiology of
Parturition. I found him amusing himself with painting and
composition. He showed me some geological landscapes, if
I may so term them, from his pencil, the still-life and figures
of which w^ere composed from the study of geological strata
and fossil remains ; icthyosauri, plesiosauri, and other mon-
sters basked, or pursued their prey, in scenes belonging to a
primeval world. I mention this to show the original turn of
the mind to which we owe the true theory of menstruation.
It is little to the credit of our profession or of science that he
has never received any reward whatever for his beautiful
discovery. Indeed, until recently, it was not known whether
he was alive or dead. He has neither courted nor received
the distinctions and honours of learned societies, British or
foreign : born of a family in whom medicine may be almost
said to be hereditary, and of which, until very lately, three
generations of physicians were living, he has still no other
title or distinction save the M.D. of his professional diploma.
But it will be necessary not only to study menstruation by
itself, but to assign it its true place in the physiology of re-
production. Dr. Laycock, Dr. Gird wood, and Professor
Bischoff have already established the analogy between men-
struation and cestruation. As far as the ovaria are concerned,
this analogy is perfect, the only ditTerences are in the nature
of the uterine and vaginal secretions, and the absence or
control of the sexual rage which characterizes the mammalia
in general. With respect to the oviparous and ovoviviparous
animals, the analogy is not, at first sight, so perfect, Harvey,
OVULAR THEORY OF MENSTRUATION. 97
on more than one occasion, compares the uterus to the nest
of birds ; and Dr. Llewellen, his first translator, gives, in
the not inharmonious verses prefixed to the translation, and
in which he sets forth the theme of his original, the follow-
ing line. It embodies an important physiological truth : —
•' To conceive is but to lay within."
Harvey himself, in a passage I have already quoted, made
a comparison between menstruation in the virgin, and the in-
fecund oviposilion of birds, insects, and fishes ; and though
there is an immense difference between his vague idea and
the development of the subject as it may now be studied,
still this glimpse of the true analogy was a fruitful germ, a
genuine mother-thought. Harvey foresaw a connection be-
tween these apparently remote phenomena ; and this pre-
science of his magnificent genius, fertile as the subject to
which it was devoted, has always seemed to me as remark-
able as Sir Isaac Newton's prophecy of the burning of water
or the diamond.
Dr. Power adduced, in his essay, analogies between the
development of ova in the ovaria, at menstruation, without
impregnation ; and the maturation of ova in the hen or
pullet, and in amphibia and fishes, without the influence of
the male ; he even instituted a comparison between the
human ovarium, in menstruation, and the seed-pod or ova-
rium of plants. As I have already mentioned. Dr. Power's
comparison of the membraneous formation of dysmenorrhcEa
with the egg of the unimpregnated pullet was incorrect. The
menstrual fluid, of which the membraneous secretion is an
excess, is comparable, not to the entire egg^ but to its outer
shell. The catameniai fluid is, most probably, I may say
certainly, intended as an envelope for the ovule escaping
from the ovarium, but unless impregnation takes place, no
relation ever occurs between the uterus and the ovule.
There is a dislocation, so to speak, between the outer mem-
branes of the human ovule, in menstruation ; and if, in
menstruation, the ovoid membrane is formed, it is entirely
disconnected from the proper ovulum. The ovoid mem-
brane of dysmenorrhea, and the ovule proper, are discharged
separately. In birds, on the contrary, whether impregnation
take place or not, the external covering of carbonate of lime,
instead of coagulable lymph, is deposited. The function of
98 OVULAR THEORY OF MENSTRUATION.
the human uterus is, in the bird, performed in part by the
uterine cavity, in part by the nest. The preparation of the
human uterus for the impregnated ovum is the analogue both
of nidification and the secretion of the shell of the esftr of
the bird. With this difierence, then, relating to the external
envelope, menstruation is closely analogous to the unimpreg-
nated oviposition of the bird, while conception is analogous
to the deposition of the impregnated egg.
Menstruation is, in fact, the unimpregnated oviposition,
while conception is the impregnated oviposition, of the
human subject. The analogy between menstruation and the
oviposition of those amphibia and fishes which are impreg-
nated out of the body, is very close ; in them, as in the
human subject, the ovarian excitement and the extrusion of
ova are periodic, and may occur without the intervention of
the male. I shall have to dwell on these analoorous functions
more at length, when I come to treat of the Cause of Labour.
Menstruation is an ovarian rather than an uterine function,
and it may be considered as the first act of human parturition
— it is the parturition of the Ovule, instead of the parturition
of the Ovum; find it represents, with the exception I have
already dwelt upon, the whole of parturition in birds, and in
many fishes and amphibia. The mechanism by which the
ovule is conveyed from the ovarium to the uterus I have
explained in former lectures — namely, the reflex and peris-
taltic action of the Fallopian tubes. To the manner in
which the tubal portion of the paturient canal is excited to
act in a reflex form, by the ovarium, and in a peristaltic
form, by the ovule, I would direct your special attention and
memory.
In treating of menstruation, I have attempted to keep
your minds fixed on the ovaria as the theatre of the essential
phenomena of this function, and because their actions have
an intimate relation to parturition. The secretion from the
internal surface of the uterus is purely secondary. I do not
believe that there is a sinsfle fact on record to show that the
catamenia is secreted from the uterus in the absence of the
ovaria. Cases in which this has been supposed to happen
are probably not truly menstrual, but similar to the hiemor-
rhoidal discharges in the male, which are sometimes periodic.
But there are recorded instances in which all the pain and
excitement of menstruation have occurred regularly in women
OVULAR THEORY OF MENSTRUATION. 99
in whom the ovaria hav'e been present, and in whom cica-
trices have been found upon the ovaria, but with the uterus
entirely wanting. I firmly adhere to the opinion of Dr.
Power, that the cataraenial secretion or exudation is an abor-
tive attempt to place the uterus in a position to receive and
attach the ovum to its cavity. When Dr. Power wrote, the
nature of the menstrual secretion was not understood, its
i(ientity wnth the blood was disputed, and especially it was
said that this fluid contained no coagulable matter. But
some recent observations of Mr. Whitehead, of Manchester,
are very interesting upon this point. He has found that
when the menstrual secretion is received directly from the os
uteri, through the opening of a pessary or by means of a
speculum, it always contains coagulable matter, and coagu-
lates like ordinary blood ; and he has further ascertained that
its coagulability is lost during its passage through the vagina,
the cause being in the acidity of the vaginal secretion. Mr.
Whitehead has invariably found the uterine secretion alka-
line, and the vaginal secretion strongly acid, and he traces a
final cause for this acidity in the prevention of coagulation
in the uterine secretion. If, he argues, the menstrual blood
coagulated, there would be difficulty in its expulsion, and it
w^ould remain to decompose within the uterus and vagina.
The menstrual blood is probably secreted from the internal
surface of the Fallopian tubes as well as the uterus. Y^u
know how commonly it is said that the generative canal,
unlike all the other mucous canals, opens directly into a
serous cavity. This is only true of the Fallopian tubes
while they remain inactive. When the peritonaeum has
been perforated, and the fimbriae of the tubes are closely
applied over the ovaria in the sugescent embraces of men-
struation and conception, and probably, also, of parturition
and coitus, the channel from the ostium vaginae to the internal
structure of the ovarium is as direct and unbroken as that of
the ureter into the kidney : the generative mucous canal be-
comes quite independent of the peritonaeal cavity.
Gregory has beautifully said, " Hsec Naturae lex, hoc con-
silium ; ut singuli pereant homines, gens, humana floreat."
This is exemplified in the phenomena of menstruation, con-
ception, and parturition. The identical processes which
frequently lead to disease and death in the individual are
resorted to by Nature for the separation of the ovule and the
100 PRACTICAL APPLICATIONS.
ovum from the parent system, in the perpetuation of the
species. In pathology, how often do we see death caused
by the exudation of fibrin in the trachea, or by perforation
of the intestine, or by sphacelus, from obliteration of the
vessels of a part. In the transmission of the race, we see an
increased action perforate the peritonaeum, for the escape
of the ovule ; we see coagulable lymph thrown out in the
Fallopian tubes and the uterus, to effect the adhesion, and
for the support, of the ovum during utero-gestation ; and
lastly, on the conclusion of pregnancy and parturition, com-
pression of the uterine vessels on the maternal side, and a
diversion of the circulation on the side of the foetus, cut off
the supply of blood to the placenta, when it is forthwith
expelled as dead matter. So nearly are death and life
connected !
Having convinced ourselves that the ovaria are the organs
primarily concerned in menstruation — that the catamenia are
the efTect, and not the essential part of this function — we
shall be short-sighted, if we do not at once refer many of
the disorders of menstruation, not to the uterus, but to the
ovaria. I know of few applications of the modern physio-
logy of menstruation to practical medicine. One of the
most important is the plan of treatment recommended by
Professor Naegele in sterility. He prescribes, that in certain
cases coitus should take place during the presence of the
catamenia. In many other cases the ovular theory of men-
struation suggests that the greatest attention should be paid
to women affected with sterility immediately after the cessa-
tion of each catamenial flow. In the middle of the interval
between the periods, there is little chance of impregnation
taking place. The same kind of knowledge is of use, by
way of caution, to women who menstruate during lactation,
in whom there is a great aptitude to conceive ; pregnancy,
under such circumstances, would be injurious to the health
of the foetus, the child at the breast, and the mother herself,
and therefore should be avoided, if possible. Another ap-
plication of this theory has been in the more satisfactory
determination of the duration of pregnancy, and the expla-
nation of those cases in which pregnancy is prolonged beyond
the tenth catamenial period.
Amenorrhcca and amenorrhoeal sterility are clearly affec-
tions, not of the uterus, but of the ovaria. When we give
PRACTICAL APPLICATIONS. 101
emmenagopjues empirically, with a view merely to excite the
menstrual flow, we place medicine far in the rear of physio-
logy. The essential cause of amenorrhoea is in the absence
of the periodic ovarian excitement, and the maturation of
ova. We can only cure amenorrhoea by bringing the ovaria
into that condition which admits of their periodic excitement
and the extrusion of ova, and this we must do either by
local or general stimuli, or both. Jf in a case of amenorrhoea
we paint the inner surface of the uterus with nitrate of silver,
as some have recommended ; or inject a solution of ammo-
nia, and so produce the uterine secretion, we do not cure the
amenorrhoea, unless, indeed, these agents affect the ovaria at
the same time ; we, in fact, only remove a symptom; for the
amenorrhoea, the absence of the menstrual flow, is a symptom^
and not the whole disease. We want a new term, which
shall include both the ovarian and uterine conditions of this
disorder.
In dysmenorrhoea, or painful menstruation, the greater
portion of the pain consists, I am convinced, of ovarialgia;
the deep lumbar pain is decidedly ovarian, and not uterine.
Many women suffer so much lumbar pain at each menstrual
period, that it resembles, and, indeed, almost amounts to, a
monthly attack of ovaritis. Almost all women in the better
classes suffer so much pain and disturbance from menstrua-
ting, that we may almost venture to say menstruation, like par-
turition, lies in debatable ground, between physiology and
pathology ; but of this more hereafter. Part of the pain of
dysmenorrhoea, then, is ovarian, and that which is uterine is
often symptomatic of ovarian disorder. In dysmenorrhoea,
there is doubtless a pathological state of the uterus induced;
but there would be no uterine excitement without the pre-
vious excitement of the ovaria. On the other hand, there
are patients in whom the uterus is wanting, from congenital
deficiency, who suffer all the ovarian pain of dysmenorrhoea.
Uterine disturbance must be considered as a secondary con-
dition— an aggravated symptom of ovarian excitement in
painful menstruation. Of one part of the uterine pain of
dysmenorrhoea, I have a word to say — I mean, that which
^vomen call the bearing-down pain, and of which they com-
plain so much from the pubes downwards to the knees. This
bearing-down I believe to be a tenesmus of the os and cervix
uteri ; it is most frequent and severe in women who have
9
102 PRACTICAL APPLICATIONS.
borne children, and in whom the os and cervix have been
developed. I have before directed your attention to the
points of similarity between the healthy actions of the various
sphincteric muscles ; you will find the pathological analogies
equally interesting. The tenesmus uteri is analogous to the
tenesmus of the bowel, or the tenesmus of the bladder.
These spasmodic affections of the outlets of the sexual,
urinary, and intestinal canals, are comparable with many other
spasmodic symptoms. Thus, the globus hystericus, or pha-
ryngismus, is a contraction of the pharynx, and the laryn-
gismus affecting the larynx, and the form of cardialgia
dependent on contraction of the cardia, are analogous affec-
tions of the respiratory and digestive tubes. Of course,
where there is disease of the os and cervix, the tenesmus
uteri will be more distressing than usual, and will often
require the chief part of our treatment, yet the ovarian
excitement in the background must not be forgotten. I am
decidedly opposed to the view that dysmenorrhoea is caused,
in the majority of cases, by chronic inflammation of the os
and cervix uteri. The relation between dysmenorrhcea
and inflammation of the os uteri is generally one of coinci-
dence, not of causation, nay, it is often a symptom induced
by ovarian irritation, a symptom requiring palliation, but the
relief of which by no means constitutes the whole of our
treatment. Let any one who believes in the merely uterine
theory of dysmenorrhoea, closely examine the nature and seat
of the pain; he will speedily be obliged to recognise the
paramount influence of the ovaria. Of course, wherever
there is inflammatory action of the os and cervix, the inflam-
mation will be rekindled at every menstrual period, and
constitute a variety of painful menstruation ; what lam con-
tending against is, the too exclusive attention of the practi-
tioner to this superficial form of dysmenorrhoea.
But the most serious disorders of menstruation are the
hysteric and epileptic convulsions, which are sometimes
excited by the ovarian irritation. The first attack of epilepsy
frequently invades women at the coming on of a catamenial
period ; young girls are liable to convulsive attacks on the
first appearance of the catamenia ; and in confirmdil epilep-
tics the fits are always most violent and prolonged during
the accession of the periods. Ovarian irritation is, I am
persuaded, Vie most important of all the causes of epilepsy in
PRACTICAL APPLICATIONS. 103
the female. Ovarian irritation is also a fruitful source of
hysteric convulsion, and there is no other state of the
economy in which the fits of hysteria and epilepsy run so
much one into the other, and where the diagnosis requires to
be made with equal care. In these cases it is not so much
the uterine as the ovarian excitement which is the cause of
the convulsion. It often happens that the fits of epilepsy
occur before the commencement of the uterine secretion,
Avhen there is little uterine disturbance, and that they cease
immediately on its appearance, the secretion from the uterus
effectively depleting the neighbouring ovaria.
The influence of the ovaria upon the intellect and the
emotions are as remarkable in diseased as in healthy states.
At each catamenial period the temper is disturbed in women
of irritable constitution — in some women almost to madness.
Indeed, the ovaria appear to be an exciting cause of insanity
in unmarried females, in the puerperal state, and at the cata-
menial climacteric. At the catamenial climacteric a revolu-
tion of the emotions commences, which requires especial
study. General hypereesthesia and hyper-emotion exist at
this epoch, of the most distressing character, both to the
patient and her friends. Not the least singular feature of
mental disturbance from ovarian irritation is the sudden ap-
pearance and subsidence of the disorder. The most violent
mania may appear almost without premonition, and disap-
pear as abruptly. But I can only allude to these subjects,
and to the influence of the ovaria in chlorosis, anaemia,
hysteria, and various other affections peculiar to the sex.
In all such affections the treatment must be, not merely
that which removes uterine disorder, but that which relieves
undue ovarian excitement and irritation, both in the intervals
between the periods, and during the periods themselves. In
the pathology as well as in the physiology of menstruation
the first place must be given to the ovaria. Their pathological
synergies are quite as decided as those of a physiological
kind.
104
LECTURE VII.
The Principal Motor Phenomena of Pregnancy — Emesis, Cough, Tenesmus,
Strangury, Crarnp, and Abilominal Movements — Elucidation of the Keal
Nature of the Movements Generally Considered to Belong to the Foetus.
Emesis occurring in the earlier months of pregnancy is so
generally a reflex affection, that I scarcely need insist upon
it. The morning sickness depends sometimes on the influ-
ence of the impregnated uterus on the brain, and the sensa-
tions of giddiness and nausea ; sometimes on the vitiated
gastric secretions, the state of the uterus exerting a marked
influence on the secreting surface of the stomach ; but it is
usually excited as a reflex act by the irritation of the uterine
nerves. In ordinary cases, women sufler only temporary
inconvenience from morning sickness, and there is a general
belief that it conduces to safe and easy parturition. It is
very probable that the nausea and sickness favour the rapid
enlargement and growth of the uterus, the dilatation with
hypertrophy, if it may be so called, which affects this organ.
The sickness is most severe in the early months, when the
mechanical irritation is pelvic, and diminishes or ceases
when the irritation is abdominal, and the disposition to in-
crease fully established. When the disorder is severe, the
indications of treatment are, to diminish the cerebral giddi-
ness by caution in assuming the upright position in the
morning ; to improve the secretions of the stomach and
upper portion of the intestinal canal by a gentle emetic oc-
casionally, of warm water, chamomile infusion, or the sul-
phate of zinc ; and to allay uterine irritation by warm water
enemata, the daily use of an opiate liniment to the breasts,
the application of a few leeches to the vulva, or wearing a
pad dipped in spirit lotion upon the external parts. 'I'o the
epigastrium we may apply a liniment of opium or morphia,
ice, leeches, or a small blister, in order to allay irritation of
the stomach. As in these cases we cannot remove the cause
REFLEX ACTIONS OF PREGNANCY. 105
of the sickness until the time of parturition, the vomiting
may become so incessant, that it shall be necessary to induce
premature labour, whether the infant be viable or not, to save
the mother from death by marasmus. Only a short time
since the medical journals contained the particulars of the
death of a pregnant woman from the exhaustion of irremedia-
ble vomiting, in whose case no attempt was made to induce
premature delivery. This was on the Continent: in our
own country such a case would cover any practitioner with
deserved censure.
The irritation of the uterine system in pregnancy excites
distressing cough in some cases. The uterine cause remain-
ing, we can only palliate the uterine and pulmonary* dis-
order. It is curious, that in cases of consumption the ute-
rine disturbance often acts as a derivative, and soothes the
cough ; and I have known an asthmatic patient whose only
freedom from the fits of asthma occurred during her preg-
nancies.
The rectum and bladder are also excited to action by the
uterus, particularly at the commencement and termination of
pregnancy. The tenesmus and strangury are partly caused by
mechanical pressure on the rectum and cervix vesicae, and are
in part reflex acts excited by irritation of the uterine nerves,
To relieve these symptoms, local depletions, if they are suffi-
ciently severe, and washing out the rectum with enemata of
warm water, are advisable. A w^arm enema is both an in-
ternal warm bath, and cleanses the intestines of sordes and
faecal matter ; it may be rendered still more efficacious in
allaying pain, by the addition of ten or fifteen drops of lau-
danum.
Cramp, particularly of the lower extremities, is a very
common and troublesome attendant on pregnancy, and some-
times it exists, to a distressing degree, during or after labour
itself. This aflfection is generally considered to depend on
pressure upon the sacral nerves; a little reflection will, how-
ever, show us that this is not its true cause, but that it ought
to be classed with the morbid reflex actions. Long con-
tinued pressure, applied in the course of nerves, may produce
numbness or entire loss of sensation, or it may weaken the
motor power, but it does not cause muscular spasm. That
cramp is caused by the pressure of the gravid uterus is
improbable, because it is most frequent during the night-time,
9*
106 CRAMP OF PREGNANCY.
and in the recumbent position, when this pressure is least
exerted; and still more so, because it sometimes afTects the
upper extremities, where pressure of any kind is out of the
question. The cramp of pregnancy is like the cramp of
cholera from irritation of the bowels, or of paralysis from
intestinal accumulations, only milder in its form. In preg-
nancy, the cause may be either in the uterus or the intestinal
canal. To comprehend the subject thoroughly, every form of
cramp or painful spasmodic action ought to be associated and
studied together. They are all allied in their nature, from
the simple spasm of one or two muscles, in temporary cramp
up to the almost universal spasms of tetanus. Internal or
external irritation of excitor nerves are the general causes
of this painful afifection. Visceral irritation of some kind
or other^is the cause of the cramp of pregnancy, paralysis,
cholera, spasmodic tic, and certain tropical fevers; while
external irritation is the cause of local trismus and the cramp
of the swimmer. In the cramp of the drowning persons,
which is a tetanoid affection, suddenly induced, the external
impression of cold is the cause of the general spasmodic seiz-
ure which neutralizes the voluntary elTorts; and renders the
strongest swimmer helpless. There are some persons who
cannot dip a limb into hot or cold water, or enter a warm or
cold bath, or even enter a cold bed, without being seized
with cramp.
I have often mentioned to you that there is an harmonious
and reciprocal action of contraction and dilatation between
the sphincters, of considerable importance in Parturition and
Obstetricy. I have referred particularly to the reflex dilata-
tions of the glottis and cardia, and the sphincteric muscles
of the bladder, rectum, and vagina. Mr. Vincent, in his ex-
cellent Observations on Surgical Practice, recently published
— a work rich in original thought — shows, in a clear and'
admirable manner, that the same reflexion, or reciprocity of
action, goes on in the muscles of voluntary motion, and is
capable of a practical application to the relief of cramp and
the reduction of dislocations. I cannot do better than quote
so much of his remarks as apply to cramp. 'Mf cramp occur
in one muscle, as in the extensor of a joint, and the ilexor of
the same joint be put into strong action, the cramp ceases
immediately. If the extensor pollicis proprius of the foot (a
very common muscle for the occurrence of cramp) be the one
CRAMP OF PREGNANCY. 107
affected, it is only to put into action strongly the flexor pol-
licis longus, by pressing the toe against some substance, \vhen
all cramp at once ceases. These two muscles are associated
by reciprocity of action, and as the one motion is strongly
called forth, the other gives way to the minimum of action,
and thus the cramp is removed by the law of consentaneity
existing between all muscles of one joint. The biceps flexor
cruris is also a muscle very liable to cramp; by bending the
leg on the thigh, and rotating the tibia inwards by means of
the inner hamstrings, the foot being pressed against some re-
sistance, at once the cramp goes. Rubbing a cramped mus-
cle rather adtls to the suffering, and the approximating the
attachments, or what is called relaxing the muscle, has no
effect at all." In pregnancy the muscles most frequently
affected with cramp are the gastrocnemius, or the extensor
proprius pollicis, and relief may be obtained in the manner
mentioned by Mr. Vincent, or by bending the foot upward
by the action of the tibialis anticus. This mode of relieving
cramp, often instinctively had recourse to, requires a strong
effort of the will, and some courage, as at the instant of giv-
ing way the suffering is momentarily increased. The radical
relief, or prevention of the cramp of pregnancy, lies in the
removal of irritating matters from the rectum antl large intes-
tine by mild enemata, and by subduing uterine irritation as
rauch as possible.
During pregnancy certain movements are felt in the abdo-
men by the mother, and they may also be perceived by
the accoucheur during the latter months. These move-
ments are almost universally and entirely attrif)uted to the
foetus; there is hardly a point relating to utero-gestation upon
which greater unanimity prevails. Scarcely any difficult case
of labour occurs in which the presence or absence of these
movements do not influence the practitioner. Operations
involving the chances of safety to the mother are frequently
made to depend upon the presence or absence of this pre-
sumed sign of the life of the fcEtus.
This state of things often leads to the most serious mis-
chances in practice. I could put my finger upon many
recent cases which prove this. In one case, delivery was
waited for with much anxiety, and every preparation was
made to perform the Caesarian operation, when the patient
was delivered of a putrid child, which had been dead in utero
108 ABDOMINAL MOVEMENTS.
a considerable time. In another and more lamentable case,
a young woman was accused of illicit pregnancy. This sign
and other circumstances concurring, she herself believed in
the existence of pregnancy, and her shame and disgrace
hastened her death. An autopsy proved that no pregnancy
had ever existed; there had been no movements save those
natural to the abdomen. A multitude of instances mi<iht be
cited to prove how entirely fallacious is this test of preg-
nancy.
If the abdominal movements in the latter months of preg-
nancy are very carefully observed, two tolerably distinct kinds
of motion may be made out. The one is a movement travers-
ing irregularly over the abdomen, and conveying the sense
of hardness either in ridges or in eminences underneath the
hand. These movements are often felt at several points of
the uterus simultaneously, and are accompanied by pain.
When the hardness is most apparent the patient will say that
the child kicks and hurts her. These movements will in
some cases continue for hours together, particularly at night.
When very violent, they give the idea of a blow or a succes-
sion of blows, if the hand be laid upon the abdomen. The
other kind of movement is distinct from that I have been de-
scribing; it conveys to the hand a sudden shock or impulse,
like that obtained by repercussion in ascites, only stronger.
The abdomen gives, as it were, a sudden shudder ; it is like
the quick and temporary movement of a young infant touched
in its sleep. The first and most frequent of these movements
I believe to be purely uterine ; the second, fcetal, and to be
felt only in undoubted pregnancy.
I proceed to state to you my reasons for believing that the
general opinion upon this subject is an error, and that the chief
part of these abdominal movements do not depend upon
the foetus, but are true peristaltic movements of the uterus
itself.
These movements are often distinctly felt by the mother at
the period of quickening, about the sixteenth week, and sub-
sequently. They may in ordinary cases be felt externally
after the bejrinninf]: of the fifth or sixth month.
At these dates the foetus is very small, for it is during the
latter months that the chief increase takes place ; and the
anterior and posterior extremities are smaller in proportion
than the rest of the body.
UTERINE MOVEMENTS. 109
Professor Naegele the younger, teaches that the movement
of the limbs of the foetus may be heard by the stethoscope,
before the sound or the foetal heart is audible — namely,
before the expiration of the fourth month. These sounds are
vaunted as of very great importance as a new and infallible
sign of pregnancy. I need hardly say that I consider such
precocious movements fabulous so far as the fetus itself is
concerned, and as being really referable to the uterus. I
believe, also, that the early period at which the abdominal
movements may be felt by the mother herself, or during an
examination, affords strong evidence that they do not belong
to the ovum. In the domestic animals, the dog or cat for
instance, the abdominal movements of pregnancy may be
v^'atched with the greatestease ; and when the mother is killed,
and the abdomen opened, or the young animals removed in
the membranes, they are undoubtedly seen to move. It is
straightway concluded, that the embryos were the cause of
the movements observed externally. Nothing can be more
erroneous. I shall show you, by-and-by, when I come to
treat of congenital asphyxia, that these movements of the
embryo after the death of the mother, or after removal from
the uterine cavity, are in reality the movements of dying by
asphyxia, and consequently not to be compared to any move-
ments occurring in normal gestation. Such are the facts ;
yet the supposed identity between these really different move-
ments has been a fertile source of confusion among obste-
tricians. The chick, it is true, during the concluding days
of incubation, manifests signs of uneasiness and motion, but
no comparison between the chick and the foetus is admissible
on this point, because of the respiration which goes on before
the escape from the egg, and the consequent maturity of the
chick at the time of hatching.
Let any one examine a patient in whom these movements
are active in the latter months of pregnancy ; he will find
them both voluble and in considerable force. It seems as
though the head of the child appeared suddenly at one part
of the abdomen, and then as suddenly at another and most
distant point ; the limbs move about apparently from one
end of the uterus to the other faster than the most experienced
touch can follow them. Often it seems impossible to account
for all the heads and limbs which seem to appear, on the
supposition of a single fojtus, and the mother is confident of
119 UTERINE MOVEMENTS.
the presence of twins at least. The movements are some-
times of considerable force. If the hand be placed on the
abdomen, it appears as if struck from within, as distinctly as
the hand placed upon the chest is struck by the impulse of
the heart in hypertrophy of this organ. I have known a case
in which the abdomen w^as so prominent that a book could
be placed upon it, and the book would be repeatedly struck
off" by the violent abdominal movements. Expectant mothers
among the common people frequently talk of the child as
turning somersaults in the womb. If all these movements
were foetal, there must and w'ould, I consider, very often
happen mischief to the cord, partial separation of the placenta,
frequent and mal-presentations, and other accidents.
The Emotions of the mother exert a considerable influence
over these movements. I was some time ago in attendance
on a lady in whom they were excessive, so much so as to
disturb and alarm the mother, filling her with dread of pre-
mature delivery ; but a violent storm of thunder and light-
ning occurring in the night-time, they suddenly ceased. I
mentioned this fact to an eminent obstetric physician, a
friend of mine, the next day, and he informed me that in the
same night he was called to a patient, in whom the alarm
caused by the thunder-storm had excited such violent move-
ments, that premature labour seemed to be imminent.
During violent mental emotions on the part of the parent, the
foetus in utero has been supposed to be even affected with con-
vulsions. I believe these phenomena, and such occurrences
as those I have described, are much more easily explained
by supposing it to be the uterus itself which causes the ab-
dominal movements.
A very common plan is to place the cold hand, or the hand
just taken out of cold water, upon the abdomen, with a view
to excite the movements of the foetus, for the purpose of
diagnosis in suspected pregnancy. It is imagined that the
foetus is affected by the temperature of the external hand.
When we consider, however, that the integuments and abdo-
minal muscles, the uterus, the membranes, and the liquor
amnii, all intervene betwixt the cold hand and foetus, it is
rather to much to suppose that any direct thermometric in-
fluence can be exerted on the embryo by such means. A
Reflex contraction of the uterus itself, from the application
of cold to the abdomen, is readily comprehended ; and no
UTERINE MOVEMENTS. HI
sound physiologist would think of giving any other solution
to such movements, if the experiment were performed either
during or soon after parturition. Why, then, accept such a
different explanation of the movements of pregnancy?
If we carefully consider tlie condition of the child, we shall
see that it is such as to render the profuse movements which
are attributed to it quite incredible.
These movements are often felt, both by the medical at-
tendant and the parent, at a time when subsequent events
prove the child to have been dead ; they have been felt by
experienced accoucheurs, and living children diagnosticated
in cases where the uterus has been distended by hydatids,
a large collection of catamenial fluid, or by other causes.
On the other hand, they have not been felt, and from this
and other signs the child has been believed to be dead, and
yet the child has been born alive and healthy.
We may frequently observe, after birth, even in cases in
which there has been much abdominal movement, that the
legs of the fcetus are across, and have indented each other ;
or the arms may be marked by contact with each other, or
with the body ; or there mav be the distinct mark of the
hand against the side of the head. These indentations are
such as could only have been made by the long continuance
of the foetus in exactly the same position. Such facts are
quite incompatible with frequent movements of the foetus.
There is no relation whatever between the size and strength
of the foetus at birth and the amount of these movements
during gestation ; it often happens, that wilh a very small
and stunted foetus there has been almost perpetual abdominal
movement ; while with large and active children it may be
very inconsiderable in amount. If the movements were
foetal, we should expect them to bear some proportion to the
size of the foetus at birth.
Again, what motor power is there which could possibly
excite such, in some cases, almost perpetual motion of the
foetus. Volition, cerebral voluntary motion, is out of the
question before respiration has taken place, and before the
brain has been roused by arterial blood. Emotion is equally
wanting. The rellex actions must be faint and obscure, for
with the exception of the liquor amnii, the parietes of the
uterus, and the contents of the fcetal intestine, the embryo is
cautiously removed from all excitors of reflex action. The
112 NERVI-MOTOR CONDITION OF THE FCETUS.
fluid medium in which the embryo swims, and its equable
temperature, render external excitation very diflicult, while
the internal excitor surfaces are all in a state of the greatest
possible repose.
The state of the fcRtus In utero is peculiar ; as regards the
absence of volition it resembles deep sleep or cerebral para-
lysis, and it is comparable in some degree to the state of
hybernation in animals, in which a very low degree of respi-
ration and oxygenation of the blood is kept up. In all these
states, the muscles, which are subject to voluntary regulation,
contract from the principle which has been called muscular
tone ; the sphincters are all closed, and the flexor muscles,
as the stronger, acquire a mastery over the extensors, so as
to contract the limbs. The muscles of the foetus are, I have
no doubt, subject to this form of contraction, its final cause
being to keep the foetus in an ovoid shape, adapted to its
retention within the uterus, and to its expulsion through the
parturient passages at the time of birth. The hidden Phidias
of the womb not only moulds each fibre*and particle in the
inward laboratory, but arranges the limbs according to the
fashion best suited to their preservation during the embryo
state, and their delivery at the appointed time of labour.
The flexion of the limbs of the foetus in utero is not merelv a
passive, but an active state ; for even after birth, volition is
a long time in acquiring the power of extending the limbs
with precision. This is particularly the case with the lower
extremities, to which the chief amount of foetal movement is
referred. Both before and after birth, the lower limbs are
more contracted than the upper. There is a difference in
the state of the circulation in the upper and lower extremi-
ties, the arms being supplied with blood more decidedly
arterialized than the legs. This is probably a cause of the
different condition of the muscles. Intimately connected
with this state of the muscular systeni in utero, we have the
various descriptions of congenital talipes or podiismus, and
the other objects of orthopcedic surgery. These deformities
are caused by excessive contraction of certain muscles, or
relative contraction of these muscles from paralysis, or from
feeble contraction in the muscles which should oppose them.
Many cases may depend on excess of the tonic contraction
of the muscles in utero. The preponderance of podrismus
over cheirismus is remarkable ; its connection with the cir-
NERVI-MOTOR CONDITION OF THE F(ETUS. 113
CLilation and the normal contraction of the extremities cannot
fail to strike the thoughtful observer. But the wh-ole subject
is one which deserves to be pursued separately, and as the
disorder is congenital, its correct pathology must be based
upon the study of the nervi-motor condition of the fcetus.
We may derive another series of evidences from what
takes place in the anencephalic or amyelencephalic foetus.
These are facts which show that the abdominal movements
or supposed motions of the foetus take place just as much in
the foetus born without brain or spianl marrow, as in the
perfect embryo. In September last I had an opportunity, by
the kindness of Mr. Bluett, of St. John's Wood, of seeing
a remarkable case of anencephalic birth, which occurred to
a woman who had been delivered of a similar monster at a
former labour. The brain was absent, but the supposed
movements of the child had been distinctly felt during preg-
nancy. The mother in this case had borne numerous chil-
dren, so that she could have perceived any difference in the
movements, but she declared that there was no difference
whatever. Here, then, could have been no cerebral or
voluntary movements of the child, for there was none even
after biith, the infant lying perfectly still, unless when ex-
cited to motion or convulsion by external stimulus. But
there is a case placed on record by M. Lallemand, in which
there was neither brain, spinal marrow, nor even the origins
of any of the nerves, and yet the supposed movements of
the foetus were present! M. Lallemand says of this remark-
able case, that the mother had dated the time of her quick-
ening from the appearance of the supposed movements of
the fffilus, and she had caused them to be felt by others,
only a short time before her delivery. As it was not her
first pregnancy, these facts are the more important. M.
Lallemand's words are —
" EUe jugeait qu'elle etait au huitieme mois de sa gros-
sesse par I'epoque ou elle avait commence a seniir Us mouve-
mens du fcetus. Deux jours avant d'accoucher elle faisait
observer qu'elle les sentait encore distinctement, mais qu'ils
eiaient moins forts que dans les grossesses precedentes."
In this case, then, both brain and spinal marrow, the two
great sources of voluntary and reflex motor action, were
absent. If we suppose the movements felt by the mother to
have been foetal, we are reduced to the necessity of believing
114 GENERAL CONSIDERATIOx\S.
the ganglionic nerves to be sources of motor power in the
limbs, a position which few w^oulcl be found to uphold. I
argue this question so much at length, because it is of real
importance, and the difficulty of ascertaining the truth by
manual examination is almost insuperable, unless we call
reasoning and experimental observation to our aid.
There is another point w-ell worthy of consideration. Dr.
Marshall Hall has established, beyond all question, the law
of the inverse proportion between respiration and muscular
irritability in animals. In the human foetus, the placental
respiration, so to speak, is extremely low, and the irritability
of the muscular fibre extremely high. Under such circum-
stances a great amount of excitation and motor action would
exhaust and destroy the foetus. I have already dwelt on the
care with which the foetus is protected from stimulus, and it
is very certan that the foetus would be speedily destroyed if
it were subject to the constant motor action so often wit-
nessed, for several months together, in pregnant women.
If we return our consideration from the embryo to the
uterus, we are met by further evidence and reason for believ-
ing that it is to this organ, and not to the foetus, that the abdo-
minal motions are to be referred. The undulating, wave-like
motion, proper to peristaltic action, can sometimes be seen
upon the surface of the abdomen, and this can belong to no
other organ save the uterus. It may be seen better than it
can be felt by the accoucher, as the hand cannot, like the
eye, follow the movement as it passes from one side of the
abdomen to the other, or from the epigastrium towards the
pubis. The most distinguished obstetricians have felt, I
repeat to you, what they have believed to be the movements
of the child in cases where no child existed. In enlarge-
ment of the uterus from hydatids, or from retention of the
catamenial secretion, they have been certain, according to
the received ideas, that they have felt a living child move;
it is most extraordinary that such facts should not have long
ago led observers to seek for some other and more general
cause of the abdominal movements of pregnancy than the
limbs of the foetus.
According to the prevailing ideas, we are called on to be-
lieve that the uterus, during the forty weeks in which it is
developed into the largest muscle of the animal economy,
remains during the whole period inert, and without contrac-
GENERAL CONSIDERATIONS. 115
tion. Such a state of things would at once isolate the uterus
from the rest of the muscular system. It is improbable.
It may be replied that there is an obvious reason why the
uterus should remain quiet until the term of pregnancy has
expired, inasmuch as its contents are not intended to be ex-
pelled until the expiration of that time. But this reasoning
will not hold good ; the peristaltic actions of the intestine,
of the stomach and the bladder, are perfectly distinct from
the acts of expulsion of these organs ; the vermicular move-
ment to which they are constantly liable by no means effects
of itself the evacuation of their several contents.
If we consider the evidence respecting the actual percep-
tion and recognition of the limbs and different parts of the
child by the taxis, we shall find it worth absolutely nothing ;
it has already been said that men skilled in diagnosis have
declared that they had felt the child in cases where preg-
nancy had never existed. In cases where the child had been
pronounced dead, from the cessation of abdominal move-
ment, it has been born alive ; and in other cases in which
they have continued vigorously to the extreme term of ges-
tation, a premature and putrid child has been born, which
must have been dead in utero for a considerable time.
When mothers or accoucheurs have been positive about
the existence of a foetus in utero ^ on the evidence of sup-
posed fcetal movements, and the event has proved that there
was no fcetus at all, or that it had long been dead, the way
of escape from a false opinion has been to refer the move-
ments to the abdominal muscles, or to the colon. Sometimes
the peristaltic movements of the intestines have been mis-
taken for the movements of pregnancy : at others, the motions
have depended upon the developed uterus containing a dead
child, or hydatids, or retained catamenia. That pseudo-
prophetess, Joanna Southcott, in particular, was accused of
simulating the movements of pregnancy by the abdominal
muscles. But this celebrated virgin was very obese, and I
do not believe such simulation possible under the circum-
stances, if at all. The movements must have been those of
the stomach and intestines.
Altogether, the facts I have gradually collected on this
subject are conclusive to my mind as to the impossibility
that the child can be the author of all, or even the majority,
of the abdominal movements of utero-gestation, and as to
116 QUICKENING.
the certainty that these movements really depend upon Peris-
taltic action of the uterus. The general fact, that when the
child is dead, the abdominal tumour subsides, and the ab-
dominal movements cease, admit of quite another explana-
tion. The truth is, that the abdominal movements cease
after the death of the ovum, because the circulation between
the uterus and placenta ceases, the temperature of the fcetus
falls, and the whole intra-uterine mass becomes a foreign
body, exciting the uterus to uniform contraction, instead of
the peristaltic actions of healthy pregnancy.
I have been thus careful in tracing the nature of the ab-
dominal movements, in order that accoucheurs may estimate
them at only their just value when pregnancy is suspected,
and on occasions when the life or death of the child is an
important element in deciding upon obstetric operations in-
volving the safety of the mother and the child. If my
opinions are correct, and I confidently believe them to be so,
these movements ought never, as they have often done, to
decide in future upon questions of life or death. We must
ascertain the condition of the foetus by auscultation, and not
trust either to our own manipulations, or to the sensations of
the mother.
Obstetricians are divided in opinion as to the real cause of
the sensations observed by the mother at the time of Quicken-
ing, as it is called. Some believe the sensations of quicken-
ing depend on the appearance of the fundus uteri above the
pubis; others refer them to the first movements of the fcetus;
I have little doubt that they really depend upon the first
peristaltic actions of the uterus, and that the date of quicken-
ing marks the time when the contractile tissue of the uterus
is so far developed as to admit of these contractions. This
term quickening, which it would be impossible to abolish too
soon, is a relic of theo-physiology, absurd and groundless in
itself, but upon which laws have been based that remain to
the present day, to the disgrace of our jurisprudence. The
imaginary quickening, marks the period when our ancestors
believed the foetus to become endued with life and soul.
Women, therefore, who were quick with child, and convicted
of capital crimes, were respited until after delivery. We
now know that such a special commencement of human and
immortal life has no foundation, and modern laws make it a
punishable crime to procure abortion, and destroy the ovum
QUICKENING. 117
at any time ; but the ancient laws which sanction the execu-
tion of a pregnant woman, and her child with her, before the
period of quickening, with their attendant absurdity of a jury
of matrons, still survive. The law is therefore in this anoma-
lous position : in one case, it punishes as a crime the destruc-
tion of the ovum in the early months; in the other, the Law
itself ruthlessly commits this crime.
10*
lis
LECTURE VIII.
Difficulties attending the Inquiry into the Cause of Labour — Sexual Excita-
bility in the Frog — Cause of Parturient Action in Oviparous Fishes; in
Oviparous Insects; in Birds; in Mammalia; in the Human Female — Re-
lation between Ovarian Excitement, Sexual Excitement, and Coitus — Re-
lation between Oviposition, ^struation, Menstruation, Conception, and
Parturition — The Collective Phenomena of Ovi-Expulsion — Objections to
the Discovery — Obstetric Results.
Reflex physiology plays so important a part in the actions
of the uterus during parturition, that it can excite no surprise
if I assert that it is intimately concerned with the cause ©f
the coming on of labour at the end of the 280 days which
complete the term of natural pregnancy.
In 1842, while studying the more obvious reflex actions of
parturition, the cause of the first contraction of the uterus met
me as a barrier beyond which it seemed impossible to pass.
The pious exclamation of Avicenna, " At the appointed
time, labour comes on by the command of God," expresses
his idea of the profoundness of the mystery, and his hope-
lessness of its solution. The words of the Arabian physi-
cian agree with the candid admission of a modern writer. Dr.
Carpenter, that " we know nothing" of the reason why the
period of parturition should be just forty weeks after concep-
tion. And, though hypotheses have been numberless, no
intermediate author has given anything like a reasonable so-
lution of the mystery in which this subject has always been
involved. I began by steadily considering the first motor
phenomenon of labour — namely, the equable contraction of
the uterus which occurs before the actual pains of labour
commence; endeavouring to understand the nature of this
contraction, and why the uterus should acquire the special
tendency to contract at this time in preference to any other.
At first, I confess, I could see no excitor cause; I could only
suppose that the premonitory contraction must depend on
the irritability of the muscular tissue of the uterus itself.
THEORY OF OVI-EXPULSION. 119
I further believed this' irritability to be excited by the foetus,
acting after its full development, as a foreign body. But [
soon found the insufficiency of such an explanation; and as
all the other functions of egestion in the animal economy,
and many of the particular actions of labour, are reflex in
their nature, I felt impelled to look for some special excitor
cause which should be adequate to set up the various reflex
and other motor actions of parturition. The contractions of
the uterus, which take place at the conclusion of the term of
gestation in extra-uterine pregnancy, even when the ovum
has been attached to the abdominal parietes, rendered it im-
possible that the cause of labour should be found in any reci-
procal action between the foetus and the parturient canal.
The facts, often observed, that natural gestation is alw^ays a
multiple of the catamenial period, and that abortions gener-
ally occur at what would, in the unimpregnated states, have
been catamenial periods, led me by degrees to inquire whether
the exciting cause of labour might not be detected in the
ovaria. I gradually accumulated facts and observations to
a sufficient extent to make me believe I had now obtained
the clue to the discovery of the true Cause of Labour, and I
determined to prosecute the subject, by examining the rela-
tion of ovarian excitement to the parturient processes in the
different classes of animals. 1 must appeal to what follows
to prove whether I have completed the task I thus proposed
to myself; and whether I have been able, as I believe I have,
to unfold the correct theory of Parturition, or Ovi-Expulsion,
throughout the animal kingdom.
At the time of parturition, there is the tendency of the
uterus to contract on the application of stimuli to be con-
sidered ; besides this tendency ov aptitude, there are the par-
ticular actions really excited by the stimulus of the foetus,
and other incidental stimuli. In any successful inquiry into
the cause of labour, it must be necessary, at the threshold,
to ascertain the cause of this first tendency to uterine con-
traction, after the organ has lain so nearly dormant during the
whole time of utero-gestation. What, then, is the cause of
this increased tendency to motor action; of the increased ex-
citability, in other words, of the excito-motor arcs which pre-
side over the parturient actions of the uterine system ? This
is the really important question. Let me attempt the an-
swer.
120 OVARIAN EXCITEMENT IN AMPHIBIA.
Very early in the present inquiry, I saw that the cause of
labour in the human female must also be the cause of all
the parturient phenomena of the animal kingdom; and this
set me to observe and deduce from the parturient actions
of the lower animals, in order to explain those of the human
subject. There are many animals I might choose as a base
from whence to extend this research upwards, but I will select
the frog, a creature which has been quaintly termed " Na-
ture's gift to the physiologist." It is certainly more nearly
related than any other animal to the most important discov-
eries in physiology, and it is admirably suited to the matter
before us. In the male frog, then (for we may consider both
male and female), the growth of the testes, in the winter and
early spring months, alters the innervation of the animal in
many important respects. In the autumn, all the limbs are
flexible, the frog leaps and swims with the greatest alacrity;
it exerts the most perfect voluntary control over all its loco-
motive organs. But as the growth of the testes proceeds,
there may be observed, the development of the dark tuber-
cles upon the thumbs of the anterior extremities, and the in-
crease in the size of the muscles of the fore-limbs. There is
now no longer perfect voluntary control of these muscles, but
the two arms are closely flexed over the breast, in the manner
often described by physiologists. This contraction of the
arms occurs whether the animal be alone, or whether it em-
braces the female, or any other foreign body. The contrac-
traction of the arras is of a persistent and even tetanoid kind,
continuing for many weeks, so long, indeed, as the testes re-
main in a state of increase and activity. Besides these phe-
nomena, which are referrable solely to the testes, the whole
of the surfaces of the body is excitable to an intense degree.
The most excitor parts of the body are the tubercles ; but when
these are cut away, irritation of the inner surface of the fore-
arms, and of the entire anterior surface, will still excite
increased rigidity and contraction of the anterior limbs.
The evident intention of these excito-motor phenomena is
to enable the male to embrace the female during the pro-
longed descent of the ova through the oviduct, and the
process of oviposition, which, taken together, last several
weeks.
In the female frog, during the enlarged and active state of
the ovaria, the muscles of the fore-limbs increase in size, the.
OVARIAN EXCITEMENT IN AMPHIBIA. 121
tubercles being absent ; but instead of he'mg Jlexed, as in the
the male, they are c^-Ze^riec/, though in the same rigid tetanoid
manner, as if for the purpose of supporting the weight of the
male, and the raising the throat of the female herself out of the
water ; the natural site for the deposition of ova being near
the edge of shallow waters. These motor actions are per-
fectly involuntary both in the male and the female, continuing
after division of the cervical spinal marrow ; indeed, they im-
pede the voluntary movements, as the fore-limbs are quite
useless in progression, from the amount of involuntary con-
traction which affects them. The wisdom of this arrange-
ment is as evident as the mingled voluntary and reflex ac-
tion in the flight of the bird ; no merely voluntary move-
ments could support these creatures in the proper position
during their lengthened coYtus and oviposition. At the
time of oviposition, in the latter end of March, or the begin-
ning of April, frogs assemble in numbers on the banks of
streams and shallow pools, when their w^hite throats, tinged
with red or yellow, give them, at a little distance, almost
the appearance of water flowers. Their movements are so
impeded by the circumstances 1 have named, that they may
be collected in almost any quantity.
The motor condition, and the coitus and oviposition of the
toad, are very similar to the frog. During the great part of
the sexual congress in both, the ova are traversing the ovi-
duct ; when the ova have reached the external aperture,
and oviposition has commenced, the ova are expelled with
great rapidity, being fecundated by the male after, or rather
during, the moment of expulsion. The ova of the frog are
deposited in masses ; and the gelatinous matter in which they
are involved swells by immersion in the water into hexagonal
shapes, so that the arrangement of a mass of ova from the
frog is almost as regular as the hexagons of the bee : in the
toad, the ova are arranged in strings, the gelatinous matter
being the medium of connection, and when taken out of the
water, the black ova hang together like the beads of a
rosary.
I need hardly insist on the dependence of the motor phe-
nomena of the fore-limbs of frogs on the development of the
ovaria and testes. They all disappear with the shrinking of
these organs in the summer, and they reappear with their
enlargement in the winter and spring ; they would not ap-
pear at all if the ovaria and testes were wanting.
122 OVARIAN EXCITEMENT IN AMPHIBIA.
These facts, then, which any one may observe in the repro-
duction of these animals, prove that the activity of the
ovaria and testes produces a long-continued and involuntary
contraction of certain muscles ; and further, that they increase
the excitability of the nervi-motor apparatus devoted to the
function of reproduction. The latter is the fact I wish more
particularly to use in the explanation of the higher forms of
parturition.
You will remember that, in a former lecture, I begged your
close attention to the persistent grasp of the ovaria by the
Fallopian tubes, during the menstrual period, and that I
referred to an analogy between the action of these tubes in
menstruation, — the oviposition of the human female, — and
the action of the fore-limbs of the frog in the oviposition of
this meaner creature. I pointed out to you that during men-
struation and oestruation in the mammalia, the tubes were in
a state of persistent contraction, and that there was also an
increased tendency to reflex contractions in these organs.
You cannot now fail, as I think, to see the analogy most
clearly. I believe, further, that at the time of parturition in
mammalia, the uterus and the uterine nervous system are
excited by the ovaria ; that it is ovarian excitement which
induces both the permanent contraction of the uterus imme-
diately before the coming on of labour, and the tendericy to
those reflex, emotional, and peristaltic actions, by which
parturition is completed. In menstruation, a small synergic
and reflex arc is described between the ovaria and the Fal-
lopian tubes ; in parturition, a larger arc is in operation,
extending from the ovaria to the uterus. According to my
researches, the excitability of the uterine nervous system at
parturition, upon the presence of which the due performance
of this function depends, is caused by ovarian excitement.
At the time of ordinary menstruation, the ovarian irritation
which excites the contraction and rigidity of the Fallopian
tubes is manifest. Throughout utero-gestation the ovarian
excitement returns in a slight degree at each periodic date ;
but at the eleventh period after conception (reckoning the
last catamenial period inclusively), the ovarian excitement
returns in full force, and, as a consequence, the uterine exci-
tability, and the uterine actions of labour begin.
But it is incumbent upon me that I should show you more
in detail the connection between ovarian excitement and
parturient motor action. In animals in which the separate
OVARIAN EXCITEMENT IN FISHES. 123
female organs of reproduction exist in their most simple
form, as where the ovarium is a mere lamina, without any
special duct, throwing off ova from its surface to be impreg-
nated out of the body by the male, the ovarian excitement,
the sexual passion, and the parturient actions, all proceed
together ; they are, in truth, one act, the ovarian excite-
ment being the essential part of the process. Ascending in
the animal scale, the function of reproduction becomes more
divided. The separation of ova and the performance of the
sexual function become in some measure distinct from each
other ; and the parturient actions become more complicated,
consisting of a series of processes. Still the ovarian excite-
ment remains in the higher animals, as the fundamental con-
dition which produces all the other and apparently inde-
pendent acts.
Thus, in oviparous fishes, where the ova are fecundated
externally, while the female is depositing the ova, she is
pursued by the male, the time of oviposition being the only
period of sexual congress. In the salmon, for instance, one
or two male fish will sport round the female, pressing against
her sides, and fecundating the ova with milt, after their
escape. In the frog and the toad, as I have already said,
ovarian excitement, the sexual congress, and oviposition, all
proceed together. The male embraces the female firmly, in
the way I have described, fecundating the ova as they
escape from the mouth of the oviduct. It is very interesting,
too, to \vatch the process of oviposition in the salamander.
Both varieties, the smooth and warty, proceed in the same
manner, and their habits have been most minutely and care-
fully observed by Rusconi and by Mr. Higginbottom, of Not-
tingham ; to the latter I am much indebted for sending me
some living gravid specimens, when 1 did not know that
they might be obtained in great plenty near London. In
the w^ater-newt, the gravid state or the development of ova
occurs W'ithout the intervention of the male, and it is in the
spring months, when the abdomen is distended with ova,
that congress and oviposition take place. During the period
of oviposition the male occasionally approaches the female,
and after playing about her a short time, she remains sta-
tionary in the water, when the male, turning on his side,
makes a sudden movement with his tail, like the- lash of a
^vhip, towards the female ; at the same moment ejaculation
124 OVARIAN EXCITEMENT IN INSECTS.
takes place, and the ova are fecundated within the body of
the female. After this, she seeks out a blade of grass, and
deposits her egg upon it, carefully curling down the tip, so
as to enclose and protect it. In the male salamander, the
tail and the dorsal fringe are so developed during the sexual
epoch, as to fit them for the lashing movement upon which
the impregnation of the female depends. The lash is evi-
dently an involuntary and reflex movement, occurring as a
part of the sexual orgasm at the moment of ejaculation.
Among insects, the silkworm oflers a forcible example of
the connection between sexual and ovarian excitement and
the phenomena of oviposition. Let us take up the con-
sideration of this curious and interesting insect at the time
when the caterpillar is preparing for its change into the
chrysalis.
The silkworm involving itself in its cocoon has often been
compared by poets with the burial of the dead ; physiology
may find in it an image of life, and we may consider the
cocoon as the analogue of the nest of the bird, or of the
uterus of mammalia. In the higher animals, the ovum
undergoes development in its natural receptacle within the
body ; in the bird, the process of nidification prepares a
receptacle for receiving and developing the ovum externally
to the body of the parent ; but in the silkworm, after a cer-
tain period of independent, but still embryo life, the insect
itself prepares the nidus or womb-like cell, in which to
undergo its final transformation. Wrapped in this sphere,
the metamorphosis slowly takes place. After the change
from caterpillar to chrysalis, the chrysalis remains its allotted
time in the cocoon, until, incited by the sexual passion, it
wakens from torpor, and bursting the inner shell encasing its
limbs, eats through the silken covering. Immediately on its
escape, it rushes to the sexual congress, stamping its feet,
and criq-criq-ing with its wings before the female ia the most
gallant and spirited manner, if we consider the size of the
insect. The contact continues for several hours, and is
attended with a constant and involuntary flapping action of
the wings. Immediately on the withdrawal of the male,
oviposition commences, and proceeds with great rapidity,
the female often depositing upwards of a hundred eggs in
the course of a few hours after her impiegnation. U the
females emerge from the cocoons before the males, they
OVARIAN EXCITEMENT IN BIRDS. 125
begin to deposit unimprefrnated eggs, but slowly ; if the
males appear while the process of oviposition is going on,
they approach the females in the ordinary manner, and after
the congress is finished, oviposition is resumed, proceeding
now much more rapidly than it did before impregnation.
Thus the ovarian and sexual excitement are at once the cause
of the birth of the parent insect from its cocoon, and of the
oviposition which sends forth a new generation of ova.
Impregnation and oviposition being completed, the insect
dies away, in this climate, in a few days, as if these were
the only essential functions of its perfect state. In the
history of the ephemerides, the birth of the parent insect
and the process of oviposition must be still more nearly con-
nected.
In birds, the relation of ovarian and sexual excitement to
oviposition is equally apparent. Our own Harvey, to whom
I am proud of referring so often, compared the nest of the
bird to the uterus, an J he adverted to the fact, which to
him was inexplicable, that the cock immediately bestows
his favours upon the hen after her leaving the nest. The
common hen, after laying, seems to call the cock by her
noise, and he will prefer the parturient hen to any of the
rest of his dames at this moment. The crowing of the cock
is undoubtedly a sexual manifestation, and hens will some-
times drop their eggs out of the nest, excited by the crowing
of their mate. But I wish to dw^ell more particularly upon
one fact — namely, that the favourite time for congress is
immediately after the parturition of the hen. I have already
mentioned my opinion of the analogy between the secretion
of the shell of the egg, in birds, and the catamenial secretion.
An important part of the uterine secretion of the bird is the
pigmentary matter deposited on the large end of the egg of
almost all birds, just before or during the time of oviposition.
'J'he beautiful spots and colours which decorate the eggs of
birds in such infinite variety, are, viewed as a secretion,
probably connected with salacity in the female bird, like
the oestrual secretion of the mammalia ; the coloured spots
upon the eggs themselves doubtless excite her maternal cares
and attentions, just as the plumage and song of the male
excite the sexual emotions. After the completion of laying,
and the suspension of the ovarian function, the sexual emo-
tion disappears, and its place is taken by the maternal emotion.
II
126 OVARIAN EXCITEMENT IN MAMMALIA.
There can be little doubt but that, besides the beauty of their
colour, the smoothness and warmth of the eggs, and subse-
quently of the young birds, impart pleasurable sensations to
the inferior surface of the mother, and are a great aid or
provocative to the instinct of incubation and maternal care.
It is singular that in birds, and almost all the lower animals,
it is the back which is the sexual surface of the female, while
in the human subject the contrary obtains.
I now proceed to the mammalia, and we shall find the
same phenomena grouped together with an unmistakable
meaning. In many of the low^er mammalia we may witness
the processes of oviposition or oestruation, parturition, con-
gress, and conception, all going on as nearly as })ossible at
the same time. In the guinea-pig, for instance, immediately
that the young are dropped, the female admits the male, con-
ception takes place, and a new" utero-gestation commences,
dating from the very hour of parturition. There is, in these
animals, oestruation and ovulation going on in the ovaria
•while ])arturition is taking place from the uterus ; and during
or immediately after the expulsion of the young, the sexual
heat develops itself. The same phenomena are present in
all the mammalia, in a greater or less degree. In those
animals of which we know the order of the oestrual periods,
as the rabbit, the horse, and cow, the duration of pregnancy
is a multiple of an oestrual period. Doubtless this law is as
extensive.as periodic oestruation itself. Not only is gestation
a multiple of the oestrual period, but the time of parturition
is positively an oestrual period. The maturation of ova,
which has ceased during utero-gestation, is resumed, and
the sexual instinct is predominant, just as though the uterus
did not contain the product of a former ovulation and con-
ception. The presence of heat, or oestruation, in parturient
animals, did not escape the observation of Harvey, though
the fact has never hitherto been utilized in pliysiology.
Speaking of the return of the human uterus to the unim-
pregnated size after delivery, he says, —
'* In other animals the process is shorter and simpler ; in
them the parts concerned recover their ordinary bulk and
consistence in one or two days. In fact, some, as the hare
and rabbit, admit the buck, and again become fecundated,
an hour after kindlino-. In like manner I have stated that
the hen admits the cock immediately on laying."
HUMAN PARTURITION. 127
These and other kindred facts are sufficient to prove that,
among the lower animals, the mother may be suckling one
group of progeny while she carries another within her, which
were conceived at the time of the birth of the first : nay, in
the marsupialia there may be two series of embryos in pro-
cess of devek)pment at the same time, the one hanging at the
mammary glands in the marsupial pouch, the other concep-
tion remaining in utero.
Lastly, let us consider Human Parturition with reference
to these ideas.
The duration of human pregnancy is well known to be a
multiple of a catamenial period. It has been also observed,
that in the rare cases, w4iere the duration of pregnancy ex-
ceeds the ten menstrual periods, the function of parturition
is deferred to the following period, so as to make pregnancy
reach to eleven periods inclusive. This fact came out most
clearly in the obstetric evidence on the Gardner peerage
case, and will prove of very great importance in cases of
supposed criminality in wedlock, or in establishing the
legitimacy of posthumous children. On the other hand, it
is well known, that when utero-gestation is brought to a
premature termination, it is at what w^ould have been a
menstrual period that abortion usually takes place. There
is, in fact, in all women, a tendency to abortion at the times
represented by the catamenial periods. In placenta prsevia,
the hemorrhage occurring in the later months of pregnancy
generally happens at the periodic dates. Hemorrhage
sometimes occurs for two or three periods in succession be-
fore parturition in these cases, with perfect immunity in the
intervals. The occurrence of uterine pains at the termina-
tion of the natural time of gestation in cases of extra-uterine
fcetation, points very decidedly to the operation of some
extra-uterine source of excitement. - After abortion, and
very speedily, too, in some cases, — it is known that there is
a remarkable aptitude to conceive ; and during the catame-
nial climacteric, when the ovaria are irregularly excited, there
is frequently an increased tendency both to conception and
to abortion. These accumulated facts are sufficient to estab-
lish the influence of the ovaria and of the ovarian function
on the uterine phenomena of gestation and parturition. But
to complete the evidence, we must inquire what proofs there
are that the sexual excitement which attends exaltation of
128 OVARIAN EXCITExMENT IN HUMAN PARTURITION.
the ovarian irritability in the lower animals, is present in the
human subject. An attentive observer will not fail to per-
ceive the existence of this excitement, though in a rudimen-
tary degree. I have insisted, in a former lecture, that there
is an actual increase of the sexual emotion during, or imme-
diately after, the catamenial periods. There are also distinct
traces of sexual excitement in some cases of parturition.
That they are not always present does not tell against my
argument, because the reasons why they are not so present
are, as we shall presently see, very evident. My own ob-
servation convinces me of the truth of the position, and I
have obtained from some of the most distinguished obstetri-
cians of the present day the admission, that sexual excitement
is sometimes apparent during or after labour in a very high
degree ; indeed, cases of this kind may pass into erotomania
after parturition ; and cases of puerperal mania sometimes
present this form of excitement as the most remarkable con-
comitant of the disease. We should be bound to speak the
truth in any case ; but it w^ould be most offensive to all the
best feelings of our nature to suppose sexual excitement
present during ordinary cases of labour, and it would cer-
tainly interfere very much with the confidence now placed
in the obstetric practitioner. But no such suspicion need be
entertained. Happily, human emotions are very much under
moral control, and in women, almost universally, the utmost
retiredness is preserved in everything which relates to child-
bearing and the puerperal state. Provident Nature has,
moreover, specially exempted women from the dominion of
all passion save that of maternity at the time of childbirth.
I believe this exemption and moral superiority arises, in a
very great degree, from the physical suffering of parturition.
The natural throes deliver woman-kind from those emotions
natural to the inferior animals. Here it is that we see more
clearly than under any other circumstances, the morality of
pai7i^ and I cannot but consider women would dearly pur-
chase relief from the bitter pangs of travail at the expense
of descendinof to the condition of the brutes of the fiehl.
The pains of natural labour are hard to bear, though of late
the^' have been most cruelly exaggerated by interested par-
ties, but they ennoble the sufferer morally, and after the trial
has passed, there comes the cry of her infant as a happy
crown to the maternal martyrdom. I believe it to be right,
ANALOGY BETWEEN PARTURITION AND MENSTRUATION. 129
and conducive to the safety both of the mother and her child,
that women should, with all the alleviations we can offer,
short of interfering with a physiological process and de-
throning reason, endure the sorrow and the joy of travail.
With our present knowledge, they can, as I sincerely believe,
only escape the suflering at the risk of greater evils. On a
former occasion I pointed out, that in women, to whom
ether-vapour had been administered during parturition, the
sexual orgasm had been substituted for their natural pains —
an exchange which women of modesty would far more shrink
from, than the liveliest agony. Under chloroform, too, I
have been informed of instances in which the lying-in room
has been defiled by the most painful and obscene conversa-
tion. There appears, therefore, apart from considerations of
safety, to be a moral objection to the use of anaesthetic agents
in natural labour — an objection which should unite against
them all men who desire to uphold the respectability of the
obstetric department; for, most assuredly, the present kind of
attendance could not continue if the facts were understood
by parents and husbands, or by w^omen themselves. The
metamorphosis of the rites of Lucina into the orgies of
Venus would be no real boon to woman, and it would pro-
bably degrade obstetricy into mere mid-w^ife practice.
However, passing by for the present the question of the
propriety of inducing artificial anaesthesia or intoxication in
labour, the facts revealed by the use of ether and chloroform,
taken in connection with others, prove that though hidden or
quenched by reason, morality, and, above all, by pain, there
still exists in human parturition ovarian irritation, and at least
the traces of sexual excitement. The phenomena of human
parturition are a confirmation rather than an exception to the
law of the existence of ovarian and sexual stimulus during
Ovi-Expulsion.
Let me now proceed with the argument, that parturition
does not merely occur at what w^ould otherwise be a menstrual
period, but that parturition is essentially a menstrual period.
This I have taught you before, and these same words I pub-
lished years ago. The sanguineous appearance called the
*' show," which indicates the coming on of labour, is gener-
ally considered to be the result of the laceration of certain
hypothetical vessels at the os uteri. I say, hypothetical, for
they have never been seen. But I assure you there is no
11*
130 ANALOGY BETWEEN THE LOCHIA AND CATAMENIA.
evidence of the reality of this explanation. The pure facts
are, that M'hen labour is about to be ushered in, the firm
mucous plug, which has closed up the os uteri during the
latter months of pregnancy, is loosened, and escapes from the
vagina. This mucous discharge is tinged with blood. The
patient herself will tell you, if you inquire, that this appear-
ance is very much like the onset of a catameniai period.
She, in fact, detects the coming on of labour by precisely the
same signs as she would detect the reappearance of the men-
strual secretion after ordinary amenorrhcea. The " show" and
the easting off of the mucous I believe to be the result of a
secretion, not the mere product of ruptured bloodvessels.
The sanguineo-mucous appearance is often preserved through-
out the whole process of parturition, just as much as we might
expect an uterine secretion to be, considering that the mouth
of the uterus is almost entirely blocked up by the advancing
foetus. It is, as we might expect, most abundant at the first
dilatation of the os uteri, and when the dilatation is com-
pleted.
The sensations of quickening, which, as I have stated in a
former lecture, appear to me to depend on the first move-
ments of the uterus, generally occur at the twelfth, sixteenth,
or twentieth w^eek ; most commonly at the sixteenth week.
This, it will be seen at once, is at the date, respectively, of
the third, fourth, or fifth, periodic nisus after conception.
One fact not unusually observed at the time of conception,
bears more particularly upon the present subject — namely,
that quickening is often attended by a slight sanguineous show
or discharge. It is certainly most extraordinary that the
catameniai discharge, and the sanguineous shows of quicken-
ing and labour, should not long ago have been allied together
as kindred phenomena. I cannot but fully believe the show
of quickening, like that of parturition, to be catameniai in its
nature.
After the completion of labour, the condition of the uterus
must be considered under a double aspect: we must consider
the state of that portion from which the placenta has been
detached, and the state of the rest of the internal surface of
the organ. At the time of the separation of the placenta,
blood escapes in considerable quantity ; subsequently, the
contractions of the uterus prevent any escape of blood from
this situation, and the placental site resembles, as was observed
ANALOGY BETWEEN THE LOCHIA AND CATAMENIA. 131
by Cruveilhier and others before him, a new-made wound.
During the first few days after delivery, the rest of the ute-
rine surface secretes the lochia. 1 have examined the internal
surface of the uterus after death, and I have seen the whole
of the internal surface of the uterus dyed with the sanguine-
ous secretion. This would not be the case if it were pro-
duced by one circumscribed spot in the uterus; and it must
be remembered, that the site of the placenta is considerably
diminished in size when the uterus is contracted. The gen-
eral time during which the lochia are tinged with blood is
about the same as the flow of the catamenia. I consider the
lochia to be only different from the catamenia by the admix-
ture of the discharges from the placental site. Hitherto the
nature of the lochia! discharge has been hidden by exclusive
attention to the placental separation. This has seemed to
give a sufficient explanation of the post-partum phenomena,
and none other has been looked for ; but it is by no means
adequate to account for the lochia] flow which occurs in just
the same manner after abortion, in the early months of preg-
nancy. I might adduce other reasons for believing that the
lochia and catamenia are, with the difference just mentioned,
identical. I have observed, in cases of abortion occurrino"
at what would have been a catarnenial period, that menstrua-
tion has appeared at the end of a lunar month from the abor-
tion, as if it were dating itself from a simple menstruation.
One series of facts, relating to the lochia and catamenia, made
a particular impression on my mind. I attended in close
succession three ladies ; one of these was delivered of a still-
born child ; the other hired a wet-nurse from the birth; and
the third always menstruated regularly during lactation.
Here were three different circumstances under which men-
struation occurred after parturition. In all these cases I ob-
served that the catamenia appeared regularly just one month
after delivery! Since that time I have often observed other
cases of the same kind. Another singular fact I may mention.
Some obstetric writers mention, with surprise, that those
women who have suffered from dysmenorrhcea, before preg-
nancy, suffer severely iVom after-pains, even with their first
children. This point is referred to in the valuable work just
published by Drs. M'Clintock and Hardy, of Dublin. I
scarcely need say how easy the explanation becomes, when
we recognise the real analogies between menstruation and
132 ANALOGIES OF OVI-EXPULSION.
parturition, between the lochial and the catamenial discharges.
During labour itself there is every indication that much of
the physical pain of childbirth is attributable to the ovarian
nerves.
I may now pass in review before you the entire subject of
Ovi-Expulsion — a term I have adopted as well suited to ex-
press all the parturient actions of the different classes of ani-
mals, and here I may state that I make the claim of having
discovered their nature and their true cause.
The simplest form in which the separate sexual organs of
both sexes appear is that of a mere lamina, as in some fishes,
and here the organ of the male and female are essentially alike.
This fundamental form is a point from which two diverging
lines proceed ; at the extreme end of one of these lines, we
have the generative organs of the human male ; at the ad-
vanced point of the other, those of the human female. From
the simple lamina, we ascend, by tube, duct, gland, and
stroma, to the human testis and ovarium, with their various
anatomical accessories. In the same way in physiology, from
the simple elimination of the sexual product on the surface
of the laminar testis or ovarium of the fish, one line of analogy
stretches out to emissio seminis; the other, to the perfect
act of parturition, in the human subject.
Our present business is to trace the differences and ana-
logies between the acts of generative egestion in the female,
advancing from the lower to the higher forms of this func-
tion. It will be found that, in the higher forms of ovi-expul-
sion, and even in human generation and parturition, the
characteristics of the more primitive forms of parturition or
ovi-expulsion are preserved. The different parts of the gene-
rative canal in the human female — the ovarium. Fallopian
tube, uterus, and vagina — only combine to perform, in a
more elaborate manner, the same function as that belong-
ing to the lamina, or the simple duct. There is one type
in thr physiology of the generative canal in the female of
all oviparous, ovo- viviparous, and viviparous animals, which
type is, the periodical return of the sexual passion and the
acts of generation. In many insects, fishes, amphibia, and
mammalia, the periodic return is annual ; in others, and es-
pecially those brought under the influence of civilization, the
return is at shorter intervals ; in the human female it is
lunar. In the lower animals the sexual passion is closely
ANALOGIES OF OVI-EXPULSION- 133
allied to the periods of ovulation, and it exists at no other
times ; and in all animals there is a distinct trace of ihis
alliance visible in the increase of the sexual appetite with the
maturation and dehiscence of ovules. There is a strict ana-
logy between all the acts of all the female generative organs
— namely, coitus, oestruation, menstruation, conception, and
parturition. Coitus and the sexual orgasm are merely incite-
ments to the fruitful performance of the other acts of gene-
ration. The rest — oestruation, oviposition, menstruation, con-
ception, and parturition — are only so many varieties of fertile
or unfertile ovi-expulsion, and are convertible one into the
other. There are three forms of ovi-expulsion — the first,
that in which the ovule is expelled unimpregnated, as in the
oviparous fishes ; the second, in which the ovule is expelled
in the impregnated state, as in the ease of the trition ; the
third, in which the ovule is both impregnated and partially
or entirely developed before its extrusion, as in ovo-vivi-
parous and viviparous animals. To one or other of these
heads all the acts of ovi-expulsion may be referred. In
some animals, all these forms of ovi-expulsion may be ob-
served ; in others, one or more can be distinguished. Thus
the unimpregnated oviposition of fishes is similar to the ovi-
position of the virgin pullet ; it is also analogous to oestrua-
tion w^ithout congress in the lower mammalia, and to men-
struation without impregnation in the human female. The
impregnated oviposition of the salamander and of the bird ;
the act of conception in the mammalia and in the human
female, are essentially the same, only that the sexual pro-
duct, the fertilized ovule, is differently deposited in each ;
in the one the blade of grass, in the other the nest, and in
the rest the uterus is the receptacle, according to the dif-
ferent organization of the sexual canal in the different ani-
mals. Ovarian excitement is essentially the cause of all the
acts of ovi-expulsion of the female generative organs. This
obstetric dogma I would especially insist upon. The great
body of facts and observations I have marshalled before you
in the present lecture demonstrate most unequivocally to my
mind, that in all animals which deposit ova for fecundation
out of the body, the ovaria supply the stimulus to the motor
actions necessary to their expulsion ; next, that in those
which expel impregnated ova, after they have remained a
short time in the generative receptacle, it is a return of the
134 OVARIO-EXCITOR PHENOMENON.
same kind of ovarian excitement which conveyed the ovule
from the ovarium to the receptacle that ultimately causes its
expulsion ; and lastly, that when the ovum is expelled as a
mature embryo it is still ovarian excitement, at the return of
an ovarian period, which brings about its delivery from the
uterus. Under this point of view, the dehiscence of an
ovule from the most simple ovarium is analogous to the
complex function of human parturition. Unimpregnated
oviposition is, as we have seen, performed by all animals
without the access of the male, though oviposition is per-
formed more energetically and regularly from the stimulus
of coitus, even when impregnation does not take place.
CoYtus and conception, then, are accessories to oviposition,
wdiich is the fundamental generative act of the female.
Menstruation and cestruation, and the descent of unimpreg-
nated ovules through the Fallopian tubes, in mammalia,
represent the whole process of parturition in the frog or the
salmon. Conception and the deposition of the impregnated
ovule in the human uterus represents the whole function of
fertile parturition in the bird. In the parturition of vivi-
parous animals, the conduction of the ovum from the uterus
to delivery, is only another stage of the same process which
conveyed the impregnated ovule from the ovarium to the
uterus. In the dehiscence of ovules from the simplest
ovarium , the nervous endowments of the organ are in an excited
state, and promote the process of ovulation ; in the con-
duction of ovules, whether impregnated or unimpregnated,
from the ovarium through the oviduct, whether it be the
simple oviduct of the amphibia or the compound oviduct of
the mammalia, the nervi-motor actions necessary to the pro-
cess are excited by the nerves of the ovaria ; and when the
lower part of the generative canal is finally roused to action
at the time of parturition, for the expulsion of the developed
ovum, it is still the ovarian excitement, which, acting in the
modes I have endeavoured to explain, rouses the utero-vaginal
portions of the canal to energetic action.
Where the ovarium is anatomically severed from the rest
of the sexual apparatus, as in the mammalia and the human
female, the ovarium is connected with the rest of the par-
turient canal by a series of reflex arcs. By means of the
spinal excitor nerves of the ovaria, that portion of the spinal
centre which presides over the actions of the uterus is, at the
LAW OF OVI-KXPULSION. 135
end of utero-gestation, thrown into a state of excitability or
polarity somewhat resembling the general spinal excitability
of tetanus. It is curious that at this time, besides the ovarian
excitement of the catamenial period, which ushers in par-
turition, there is, upon the surface of the ovarium, the
cicatrix (corpus luteum) left by the ovarian phenomena of
conception, but which speedily disappears after delivery.
'I'he uterine nervi-motor system being thrown into such a
state of persistent excitability that the uterus firmly contracts
equably upon its contents, the fcetus itself, hitherto defended
by the liquor amnii, becomes an ordinary excitor, and the
reflex actions of labour are gradually established. The
e(]uable contraction of the uterus preceding labour is, in
effect, just as though the membranes had been punctured in
the operation of inducing premature delivery, and the head
of the foetus brought to exert pressure upon the os and cervix
uteri.
Thus far I have attempted to trace the law which governs
the distribution of the unimpregnated egg or ovule, and the
impregnated ovum, in all animals ; and I believe I have
proved that ovarian excitement is the law of parturition
IN ALL ITS FORMS OF ovi-EXPULsioN. Having attempted this,
it may seem sufficiently obvious, but, at least, no one had
done it before me. When Columbus wished to typify the
simplicity of original discovery, he is well known to have
proposed to his companions that they should try to set an
egg upright upon the table, and, on their relinquishing the
attempt, he set it up himself by crushing the point. Placing
the egg of fact upright may seem, when the way has been
shown, as easy as the setting up of the egg of figure ; but,
in this respect, however humble the attempt may be, it is
only similar to other interpretations of Nature.
Let me now attempt to anticipate some of the objections
which may be urged to the Law of Ovi-expulsion which I
have endeavoured to estal)lish, and which includes the dis-
covery of the Cause of Labour in the human subject; for I
can hardly hope to have made the matter so clear that no
objection may be urged. Probably some may say that I
do not advance beyond the teaching of Flarvey, Professor
Naegele, Dr. Rigby, and M. Berthold, all of whom have
insisted on the fact that the duration of })regnancy is a mul-
tiple of a menstrual period, and some of whom have believed
]36 CERTAIN OBJECTIONS ANTICIPATED.
that it is the return of the menstrual nisus, or effort, which
produces labour. No one has stated the fact that pregnancy
is a multiple of the catamenial period more distinctly than
the illustrious author of the " Exercitations," and 1 cannot
do better than quote his words : —
" Prudent matrons, calculating after this rule, as long as
they note the day of the month in which the catamenia
usually appear, are rarely out of their reckoning ; but after
ten lunar months have elapsed, fall in labour, and reap the
fruit of their womb the very day on which the catamenia
would have appeared had impregnation not taken place."'
This, it will be seen at a glance, is merely the clear ex-
pres-sion of a numerical fact, one which must have struck the
earliest observers. It does not stand in connection with any
reasoning or induction, and it still left men to frame a thou-
sand vain theories as to the cause of the action of the uterus
at this particular epoch.
The greatest advance beyond the simply numerical idea
with which I am acquainted, is contained in the writings of
Dr. Rigby. This physician states, that fourteen years ago he
surmised that " the reason why labour usually terminates
pregnancy at the fortieth week, is from the recurrence of a
menstrual period at a time during pregnancy, when the uterus,
from its distention and weight of its contents, is no longer
able to bear that increase of irritability which accompanies
these periods without being excited to throw off the ovum."
This view of the subject is insisted on by Dr. Rigby in his
** System of Midwifery," published four years ago; but by
catamenial excitement he expresses merely the uterine excite-
ment of the periods, without any reference to its ovarian cause.
He does not even recognise the analogy between menstruation
and oestruation ; and indeed he expressly objects to any com-
parison between the duration of human and comparative preg-
nancy in the concluding paragraph of his chapter on this sub-
ject. Dr. Rigby there observes, that" the valuable facts col-
lected by M. Tessier respecting the variable duration of preg-
nancy in animals, which have been quoted by some authors
in proof of the partus serotinus, are scarcely ap[)licable to this
question in the human subject: the absence of menstruation,
and the difTerent structure of the uterus, prevent our making
any close comparison." So far from this being the case, I
contend that a comparison between human and comparative
OBSTETRIC RESULTS. 137
parturition, and all the other forms of parturient action, is
essentially and absolutely necessary to a comprehension of
this branch of human physiology. Dr. Rigby's words convey
precisely the same meaning as those of Denman when he
urged, as an objection to the old surmise, which made labour
depend upon " the effort to menstruate," that "it would not
be judging according to any philosophical rule to attribute
as the immediate cause of parturition, at any certain time,
a circumstance peculiar to any individual class of animals."
The same author (Denman) remarks, "How far the dis-
covery of the particular cause of the birth of a child might
lead to the improvement of practice it is impossible to deter-
mine." One improvement I may suggest as very obvious.
It will enforce and dignify the Excito-Motor Idea. Mecha-
nical principles must take their proper and subordinate posi-
tion, and the instauration of the excito-motor principle by the
discovery of the cause of labour, must cause it to pervade
the whole obstetric art, giving this hitherto humble depart-
ment, as I believe, a truer and sounder basis than either
medicine or surgery can at present boast. I do not wish to
underrate or discredit mere mechanism, but I do say that the
ditfusion of a knowledge of the motor phenomena of labour,
from the first muscular contraction to the last, must render it
difficult for any one to agree with a living authority of consid-
erable note, when he says, that the mechanism of labour is
"the basis upon which the principles of practical midwifery
should be founded." The prosecution of the motor idea, in
the front of which the discovery of the cause of labour must
stand, cannot fail to be thus productive of immense good.
This will be evident, if we consider that uterine inertia, pre-
cipitate labour, ruptures and lacerations, sterility, the various
forms of hemorrhage, inversio uteri, abortion, puerperal con-
vulsions, and many other grave accidents of pregnancy and
parturition, are all essentially nervi-motor in their pathology
and treatment. I have here no further remark to make, ex-
cept that the discovery of the cause of labour is one of the
fruits of the discovery of the spinal system.
12
138
LECTURE IX.
Abortion a branch of Spinal Pathology — Ex-centric Causes of Abortion —
Irritation of the Mammary, Trifacial, Vesical, Ovarian, Rectal, Vaginal, and
Uterine JNerves — Centric Causes of Abortion — Blood-Puisons — The Exan-
themata, Syphilis, Scrofula, Mercurialization, Carbonic Acid, Specific Ute-
rine Excitants — Emotion — Mechanism of Abortion.
Irritation of the extremities of Excitor Nerves, and irrita-
tion of the Spinal Centre, are the two Classes of Causes,
which must be studied in all their forms and varieties, in
order to obtain a knowledge of the true nature of Abortion.
In this subject we deal only with surface-pathology, unless
we recognise the paramount influence of the nervous system.
EX-CENTRIC CAUSES OF ABORTION.
1. Irritation of the Marmnary nervesm^y produce abortion.
This cause is seen in operation in cases of undue lactation,
complicated with a second pregnancy. Cases occur in which
during prolonged lactation, two or three conceptions and
abortions follow each other, the latter being caused by the
irritation of constant suckling. The question naturally sug-
gests itself, — whether it is not the constitutional debility,
rather than the local irritation, which induces abortion in
these cases ; and there can be no doubt that this, like many
other anaemic conditions, may help to produce the accident.
There is, however, over and above this, mammary irritation
as a distinct cause. I have observed cases in which, owing
to the synergic action betw^een the uterus and the breasts, the
secretion of milk had been almost entirely arrested by con-
ception— the infant being chiefly supported by feeding. The
child would still suck most vigorously, in its attempts to obtain
milk, until the uterus was excited to the expulsion of the
ovum; and after the abortion has occurred, the secretion
of milk returns abundantly. Such cases are very diflferent
from those in which the breasts are dried up from debility.
MAMMARY AND DENTAL IRRITATION. 139
If the synergic relations between the mamrase and the uterus
required any more obvious proof, I might refer to cases on
record in which actual metritis has been caused by the appli-
cation of sinapisms to the breasts in amenorrhcea. It is im-
portant to recognise mammary irritation as a cause of abortion
in the early months, because it may be mistaken for a co-
pious menstruation ; and the woman, misled by the subsequent
profusion of milk, may allow of its recurrence, and so suffer
considerable constitutional injury. It is curious that irritation
of the stomach, between which and the uterus there is such
a distinct relation, should not produce abortion. After par-
turition, the slightest gastric irritation will excite contractions
of the uterus; but during pregnancy, gastric irritation, and
sickness, even to death, may occur without disturbing the
foetus in liter 0 ; on the contrary, sickness seems positively
favourable to the continuance of utero-geslation. The syner-
gies between the lungs and the uterus are equally remarkable.
The uterine phenomena of utero-gestation retard the progress
of pulmonary disease, but if the most extensive disease of the
lungs exist, it does not excite abortion. An amount of pul-
monary disease sutlficient to cause death a few days after de-
livery may be present, without any interruption to the natural
duration of pregnancy.
2. Irritation of the Trifacial nerve seems, in rare cases, to
excite abortion. It happens w^hen no cause can be recognised
but the appearance of the dens sapientiae, and this phase of
dentition is known to produce considerable local and consti-
tutional disturbance. General convulsions may, in fact, be
excited from this source, either in the male or female subject.
The reflexion of irritation from the trifacial upon the uterine
nerves, in young pregnant women, is no more remarkable
than the strangury excited by teething in the infant. Ex-
traction of decayed teeth during pregna^ncy is another cause of
abortion in which the trifacial is concerned. There is a well-
known synergy between the uterine system and the teeth
during pregnancy, leading to toothache and caries; and there
is also a tendency to reflex action in the direction from the
teeth to the uterus. These facts and their rationale require
to be borne in mind in the management of pregnancy.
3. Irritation of the Vesical nerves is, in rare instances, a
cause of abortion, as w^hen patients conceive who are the
subjects of chronic vesical irritation, or when there is stone
140 CAUSES OF ABORTION.
in the bladder. The uterus itself reflects irritation upon
the bladder during pregnancy, so as to exaggerate the effects
of any primary vesical irritation which may exist.
4. Irritation of the Ovarian nerves is a very frequent and
important cause of abortioii. ft is a well-recognised fact,
and one upon which I have often had occasion to dwell,
that the majority of cases of abortion occur at wdiat would
have been menstrual periods. In such cases it is the ovarian
nisus, and the attendant irritation of the ovarian nerves,
either alone or combined with other causes, which excite
the uterus to expel the ovum. The ovarian excitor nerves
act in such cases just in the same way as they act in bringing
on natural labour at the completion of the full term of preg-
nancy. Almost all women can perceive the menstrual periods
as they pass through utero-gestation, particularly at the first
three or four periodic dates. Those who have suffered from
menorrhagia or dysmenorrhcea, or in whom organic ovarian
disease has existed before conception, recognise the men-
strual nisus most clearly, and it is precisely in these subjects
that abortion is most likely to happen. Abortion in the
early months is common during the grand catamenial cli-
macteric ; it constitutes, in fact, one of the chief dangers of
this epoch. In all cases of abortion caused by irritation of
the ovarian excitor nerves, the most common time for the
occurrence of the accident is at the second, third, or fourth
periods, but it may happen at any one of the periods. In
cases where the abortion depends upon irritation of other
excitor nerves, or upon erythismus of the spinal centre, the
periodic ovarian irritation often determines the time of the
accident.
5. Irritation of the Rectal nerves is a common cause of
abortion. This variety of abortion is obvious when the
accident occurs from hemorrhoids, or from operations for
their removal ; the presence of ascarifles in the rectum ;
from the employment of irritating purgatives, particularly
aloes, in excess, or the use of irritant enemata, or from the
cccurrence of severe diarrhoea or dysentery during preg-
nancy : obstinate and long-continued constipation, or any
other great irritation of the lower bowel and its excitor
nerves, may also occasion abortion.
6. Irritation of the Vaghial nerve sometimes excites abor-
tion. Plugging the vagina is one of the means resorted to
CAUSES OF ABORTION. 141
for the artificial induction of premature expulsion ; the me-
chanical irritation of coitus will sometimes produce abortion,
and this cause must be divided between the os uteri and the
vagina. In cases of threatened abortion with hemorrhage,
the danger of the accident is sometimes increased by the
plugging of the vagina resorted to in order to arrest the loss
of blood. This fact should always be borne in mind when
the plug is resorted to in hemorrhage of any kind occurring
during utero-gestation. It is possible that in arresting the
hemorrhage we may ourselves cause abortion.
7. Irritation of the Uterine nerves is, beyond doubt, the
most important of all the causes of abortion. Abortion may
occur without any other apparent disorder of the ovum or
the uterus, except an absence in the uterus of the proper
disposition to growth or development. The uterus will
grow to a certain size, and then an arrest of development
appears to take place, which ends in the expulsion of the
ovum. In other cases, the foetus dies, and becomes a foreign
body, directly irritating the uterus to throw off its contents.
This cause of labour involves the whole subject of intra-
uterine pathology, and all disordered conditions of the foetus,
membranes, and placenta. The separation of the membranes
from the walls of the uterus, and the effusion of blood, or
disease of the placenta, are important causes of abortion.
Puncturing the membranes, and bringing the foetus in direct
contact with the parietes of the uterus by the evacuation of
the liquor amnii, will excite abortion in the same manner.
In the abortion excited by violent horse or carriage exercise,
the accident depends on the mechanical irritation of the os
and cervix by the foetal head, in consequence of the succus-
sion. In principle, the abortion caused by equestrian or
carriage exercise is precisely the same as the oviposition
excited in the tipula or libellula, by .shaking these insects
upon rough paper. Irritation of the os uteri by coitus ; the
use of the plug ; vascular irritation and inflammation ; and
ulceration of tlie os and cervix, will, it continued, excite re-
flex actions of the uterus, terminating in the loss of the
ovum. The uterine versions are also causes of abortion.
Another uterine source of abortion is the implantation of the
placenta over the os and cervix uteri. The presence of the
placenta in this abnormal situation excites the uterus from
within, in the same manner as the plug from without ; hence
12*
u
142 INSULATION OF THE UTERINE SYSTEM.
the frequency with which placenta-prcevia cases terminate in
premature delivery. When speaking of ov^arian irritation
as a cause of abortion, I mentioned that this danger was
chiefly incurred during the early months of pregnancy. In
placenta prsevia, on the contrary, owing to the greater de-
velopment of the placenta, and the anatomical changes
occurring in the os and cervix uteri as pregnancy advances,
the danger of abortion increases with the advance of preg-
nancy. Different tumours, malignant or non-malignant,
attached to the os and cervix, or to the parietes of the
uterus, when they excite abortion, act after the same manner.
To the long list of uterine irritations issuing in abortion, I
may add injuries of the uterus itself from external violence,
and inflammatory disease of the uterine tissues.
All these causes, it should be observed, whether vaginal,
mammary, vesical, rectal, facial, or uterine, are purely ex-
cito-motor in their operation. The irritation is applied to the
excitor nerves, and reflected through the spinal marrow upon
the motor nerves and the uterus. It often occurs that two or
more causes are in operation at the same time. The reflex
contractions of the uterus which constitute abortion are not
excited, as in the case of respiration or vomiting, immedi-
ately on the application of stimuli. If cold water be thrown
upon the breast, the movements of inspiration — if the fauces
are irritated, the movements of vomiting — are instantly pro-
duced. But it is not thus in the case of the uterus. ThouQ;h
this organ is so distinctly under the control of the spinal mar-
row during and immediately after labour, so distinctly, in-
deed, that merely asperging the abdominal surface with cold
water soon after delivery produces instantaneous uterine
contractions, yet during pregnancy, no reflex actions suf-
ficient to cause abortion follow immediately upon the appli-
cation of the ordinary stimuli of excitor-raotor action. It
requires that the nervous arcs in relation with the uterus
should be irritated for a considerable time, and an excitable
or charged state of the uterine nervous system is then pro-
duced, during which reflex actions are readily excited by
slight causes.
The nervous arcs presiding over parturition are, to a cer-
tain extent, isolated from the rest of the spinal system. If it
were not so, and if the uterus immediately obeyed an excitor
stimulus, like the stomach, or the respiratory muscles, abor-
ABORTION A SPASMODIC DISEASE. 143
tion would be the rule, normal parturition the exception.
There are certain facts which show this independence of the
nervi-motor apparatus of ovi-expulsion in a remarkable man-
ner. I may mention one fact and one experiment, both of
which I owe to Dr. Marshall Hall. Dupuytren relates the
case of a woman who became the subject of traumatic teta-
nus during her pregnancy, but who, nevertheless, recovering
from the tetanus, passed on to the end of utero-gestation
without aborting. A frog taken during the time the oviduct
was full of ova, was rendered tetanic by strychnia for a
considerable time : the ova were not expelled during the
presence of the tetanoid symptoms, but several days after-
wards, when they had entirely disappeared, oviposition took
place in the ordinary way. It is well known how difficult
it is to induce uterine contractions with the ergot of rye before
the time of parturition, though this agent has a special action
upon the nervi-motor actions of the uterus. All these facts
prove the independence and seclusion of the nervi-motor
apparatus of ovi-expulsion, until the appearance of the ex-
citing causes of labour. When this epoch has arrived, or
when the excitability of the uterine nervous system is roused,
as in cases of abortion, the ready answer of the uterus to
stimuli is as remarkable as was its previous indifference.
All the excito-motor causes of abortion are, in. fact, imita-
tions of the ovario-excitor cause of natural parturition at the
end of utero-gestation, only, in many cases, instead of the
ovarian nerves being; the inducers of the uterine nervous ex-
citability which terminates in premature expulsion, it is the
mammary, vaginal, rectal, &c. In the instances where ovarian
irritation is the cause of abortion, the cause of abortion is
precisely the same, and acts in the same manner, as the cause
of natural labour, the only difference being that of time. I
have said that oftentimes more than one cause of abortion
is in operation ; thus uterine irritation may produce the
irritability or excitability of the uterine nervous system, but
before this irritability has actually produced expulsion, irrita-
tion of the rectum may step in and complete the abortion.
One point I would insist on most emphatically — namely,
that in cases of vesical irritation, or rectal irritation, we can-
not correctly talk of the extension of nervous irritation from
these organs to the utetus, by structural contiguity and con-
tinuity, or because they are supplied by nerves from the same
144 ABORTION A SPASMODIC DISEASE.
source. Vascular phenomena may so extend from one organ
lo another in the same vicinity, but nervi-motor phenomena
never can do so. There are abundant vascular anastomoses
to account for such extensions of vascular phenomena, but
there are no anastomoses of the nervous fibrils. However
close the irritation may be to the motor organ, all the motor
action which does not depend upon irritation of the muscular
fibre, or upon sensation or emotion, is reflex in its form.
The uterine contractions of abortion caused by irritation of
the rectum and bladder — nay,, even of the uterus itself — is
as truly reflex and spinal as the uterine contractions excited
by trifacial, gastric, or mammary irritation. I insist on this
point, because I frequently observe relaters of cases speaking
of motor sympathies between the bladder, uterus, and rectum,
as though there were some short cut between these organs,
whereas there is no motor connection or route whatever,
except it be through the spinal centre, and by way of the
excitor and motor nerves. In all, there is the excitor nerve,
the spinal centre, and the reflex motor nerve concerned ; at
one end of the nervous arc there is the physical irritation, at
the other, the motor contraction. As in other cases of excito-
raotor action, sensation may be present, but it is by no means
essential. Physical irritation of the excitor surfaces, short of
sensation or pain, may produce the entire phenomena of
abortion. This is one of the facts which renders the due
recognition of all the excito-motor causes of abortion so
essential to the prevention and treatment of this accident.
We may look on abortion as, in some points of view, com-
parable WMth spasmodic asthma, or any other excito-motor
disease. From some irritating cause, an excitable condition
of the excito-motor arcs presiding over parturition is induced,
just as in the case of asthma, where it is the respiratory
nervous arcs w^hich are rendered excitable. This state of
excitability once induced, slight causes of irritation, which
in healthy subjects would produce no disturbance whatever,
are sufficient to produce in the one case, spasmodic respira-
tion ; in the other, morbid or spasmodic parturition. Besides
the ordinary periodicity of abortion — namely, the tendency to
premature expulsion at the catamenial dates, there is another
remarkable periodicity observable in abortion, in the tendency
to the occurrence of miscarriage in successive pregnancies at
a particular time. It often happens that we may see in these
CENTRIC CAUSES OF ABORTION. 145
cases the obvious physical cause of abortion developed at the
Sjiecial times ; but in others there seems to be a habit, or pre-
disposition, the nature of which we cannot so well understand.
CENTRIC CAUSES OF ABORTION.
But besides the causes of abortion involved in physical
irritation of spinal excitor nerves, there are other causes in
which the circulation of the blood, and the Spinal Centre^
are chiefly concerned. I'here are certain erythematic con-
ditions of the system in which abortion is very prone to
occur. These are, the exanthemata, particularly small-pox
and syphilis, in each of which a special poison is introduced
into the blood ; the pyretic state of the system, which obtains
at the commencement of the non-specific fevers, and simple
inflammations of the viscera is attended with similar danger ;
the scrofulous diathesis, too, has been considered as prolific
of abortion as the syphilitic ; but, I believe, with far less
justice. The inhalation of carbonic acid rapidly excites
abortion, and during accidental or intentional poisoning by
this gas the ovum is often found expelled. During the cele-
brated razzia, Algeria, in which a great number of Arab
women were suflfocated in the caverns of Dahra, those of
them who were pregnant were found to have aborted.
Military histories oflfer examples of the same kind in other
countries- I believe the retention of noxious elements in
the blood, in the albuminuria of pregnancy, to be a cause of
abortion as well as of puerperal convulsions. There are also
certain specific agents, as the essential oil of savin and the ergot
of rye, which, if persisted in, are adequate to cause abortion ;
and lastly, all the agents recognised in toxicology may cause
abortion, as well as the destruction of the parent, when ad-
ministered during pregnancy. In all these instances the
blood is the medium by which the exciting agent is con-
veyed to the spinal centre. They are precisely similar to
the artificial abortion which may be excited in the lower
animals by direct mechanical irritation of the spinal
marrow.
Another important cause of abortion, acting through the
spinal centre, is Emotion. This cause, unlike those causes
which reach the spinal centre by the blood, is \)WYt\y psychical
in its nature. The influence of emotion in exciting the uterus
146 MECHANISM OF ABORTION.
to evacuate its contents is as undoubted as the influence of
emotion upon the stoniach or upon the rectal and vaginal
sphincters. But just as in the case of uterine excito-motor
action, ordinary emotion does not affect the uterus instanta-
neously. Time is generally required for its effects to develop
themselves into uterine excitability. The ra{)idity with
which emotion affects the uterus is proportionate to the
intensity of the emotion. A violent fit of anger, serious
fright, or intense grief, may lead to abortion a few days after
the violence of the emotion has disappeared. In other cases
uterine action follows almost immediately upon the emotional
excitement. During religious persecutions women have
aborted suddenly at the stake ; and here the emotion pro-
duced by excessive terror would probably be the chief cause
of the accident. Thus emotion may, under very extreme
circumstances, act upon the uterus, and produce abortion,
even more readily than ordinary excito-motor causes.
In the history of abortion, there has been a too general
tendency to attribute the accident to some particular and
almost universal cause. For instance, at one time abortion
is referred almost exclusively to disease of the ovum ; at
another, to the strumous diathesis ; at another, to disease of
the OS uteri : on this latter point I v^^ould wish to be under-
stood as not undervaluing the researches of Dr. Henry
JBennet, and Mr. Whitehead of Manchester ; but I contend
that the study and recognition of all the manifold causes of
abortion is necessary to the student and the successful prac-
titioner.
The mechanism by which abortion, or the premature ex-
pulsion of the ovum, is effected, varies considerably, accord-
ing to the time, between conception and natural parturition,
at which the accident occurs. When the impregnated ovum
is lost immediately after conception, the phenomena are very
similar to the menstrual period ; when the abortion occurs in
the latter months of utero-gestation, it resembles natural par-
turition. In abortion at various intervals between conception
and parturition, the nearer it is to the time of conception, the
more it appears like menstruation ; the nearer it is to parturi-
tion, the more closely is it imitative of that process. In
the earliest abortions, where conception has preceded a
menstrual period, the motor actions of expulsion are chiefly
confined to the Fallopian tubes ; there is little motor action
MECHANISM OF ABORTION. 147
of the uterus, either of dilatation or contraction, the ovum
being washed away by the menstrual fluid. An exception
must, however, be made in the case of women who have
borne several children, in whom the uterus is sometimes a
contractile organ, even during menstruation. Usually the
uterus does not contract with any force during the first two
or three months, or abortion would probably be far more
frequent than it is. Abortion at this time is rather a me-
chanical dislodgment, by the separation of the ovum from
the uterine parietes, than a distinct motor act of expulsion.
After the ovum, becoming separated from the uterus, has
entered the vagina, it excites expulsive action of the abdo-
minal muscles, similar to those of micturition and defecation.
"When quickening, or the first peristaltic movement of the
uterus, has occurred, the uterus dilates and contracts as in
natural parturition, only less perfectly ; and abortion becomes
gradually divisible into the different stages of natural partu-
rition. There is the dilatation of the os uteri, the distinct
contraction of the uterus at intervals, or in pains, and the
bearing-down, or expiratory actions which expel the ovum
from the vagina. The condition in which the ovum is ex-
pelled varies also according to the time at which it takes
place ; in the early months the ovum is expelled entire, ex-
cept when decomposition has taken place, the fcctus being
involved in the membranes ; but as utero-gestation advances,
the membranes are often ruptured during expulsion, as in
natural labour, and the fa?tus and secundines discharged
separately.
14S
LECTURE X.
The Prophylaxis or Prevention of Abortion — Preventive Measures relating
thereto — I. Mammary Irritation ; II. Dental Irritation ; III. Vesical Irrita-
tion ; IV. Ovarian Irritation ; V. Kectal Irritation; Vl. Vaginal Irritation ;
VII. Uterine Irritation — Uterine, Placental, and Foetal Disease — Respira-
tion of the Foetus — Intra-Uterine Pathology — Prevention of Abortion from
Habit — Epidemic Abortion — Hemorrhage in Abortion — Treatment of
Abortion — Eradication of the Abortive Diathesis — 'J'reatment of the Utero-
Spinal Axis — Sedatives of Pregnancy.
Careful and minute attention to all the various causes of
abortion is the true basis of preventive measures. In the
prophylaxis of abortion, I propose to follow the order I have
already observed in treating of its causes; dealing with the
palliation or removal, in the first place, of the Ex-centric, in
the second, of the Centric, causes of this accident. I now
use the word abortion in its largest sense, including every
variety of premature expulsion of the impregnated ovum.
I. With reference to Mammary irritation, it is hardly
necessary to observe that weaning ought always to take place
as soon as the occurrence of pregnancy during lactation be-
comes evident. Gestation and lactation ought never to be
permitted to go on at the same time in the same individual,
or the infant at the breast and the child in the womb must
mutually suffer. After . weaning, mammary irritation is at
once removed, and instead of the exhausting and abnormal
irritation in the direction /rom the breasts /o the uterus, there
comes into operation that healthful and physiological stimulus
or synergic action /ro/n the uterus to the breasts, which pre-
pares them for the new lactation when the foetus in utero shall
have arrived at maturity.
II. With respect to Dental irritation, it is just necessary to
bear in mind that this is occasionally, and in rare instances, a
source of uterine disturbance. W^hen the processes of denti-
tion (the appearance of the wisdom teeth) and utero-gestation
meet in the same subject, the alveolar irritation should be
PREVENTION OF ABORTION. 149
kept under by leeches or scarification, on just the same prin-
ci})Ie as we should lance the gums during excito-motor dis-
turbance in the first dentition, to prevent spinal erythismus
and convulsions. In the caries so common in pregnancy, and
which often attacks several teeth at the same time, extraction
of the diseased teeth should be avoided as much as possible.
In the first place, as the pain involves the nerves of many
teeth, oftentimes the whole of one side of the jaw affected
being neuralgic, the extraction of one or two of the offending
teeth will not afford permanent relief. The uterine irritation
remaining, the pain is generally transferred, after extraction,
in all its intensity, to the nerves of the neighbouring teeth.
In the second place, caries and toothache do not affect the
nervous system so much as the sudden violence and the emo-
tional disturbance of extraction. It is truly distressing to wit-
ness the almost continual misery in which some women pass
through the epochs of utero-gestation and lactation from faulty
teeth. This is particularly the case with the wealthier classes
of patients ; and the fact should urge very strongly upon
parents the necessity of attention to the permanent dentition
in young girls, for with this process the health of the future
mother is most intimately connected.
III. The preventive measures relating to Vesical irritation
are very simple. In the most formidable irritation of this kind,
— the concurrence of calculus with pregnancy, and which is
necessarily extremely rare, — nothing but palliative measures
can be resorted to during gestation. The cure must be left
to the unimpregnated state. Strangury and urinary deposits,
attended with pain and irritation, must be treated carefully,
but just as in the unimpregnated condition. Distention of the
bladder during pregnancy should be avoided, and actual reten-
tion relieved regularly by the catheter. Attention to the state
of the bladder is the more necessary in pregnant women, as
the accidental distention of this viscus may, in the early
months of pregnancy, cause retroversion of the uterus, and
this, in turn, will produce permanent retention of the urine;
the conditions of the bladder and the uterus thus uniting to
occasion the danger of abortion.
IV. I now come to the preventive measures which relate to
Ovarian irritation. Here ourcautionary plans should be chiefly
devoted to the cataraenial or periodic dates. Patients suffer-
ing from severe ovarian irritation during pregnancy, should be
13
150 REST AND EXERCISE.
treated in the periodic exacerbations niiich in the same way
as we should treat dysmenorrhccal patients during the actual
periods attended by pain and difficulty. Warm hip baths,
not exceeding blood-heat ; warm enemata within the same
temperature; the application of a plaster of opium or bella-
donna over the sacrum ; the application of a few leeches, and
most especially the avoidance of coitus during the periodic
dates of pregnancy, should be directed. As regards the
masked periods of utero-gestation, as they may be called, con-
tinence is as proper in all cases at these times, as it is during
the actual flow of the catamenia. It is during the first half
of pregnancy, or in those women who have suffered from
dysmenorrhoea before impregnation, that moral and physi-
cal sedatives should be most strictly enjoined. I may here ob-
serve, that in dysmenorrhoeal cases the times of conception are
probably times of abortion, the impregnated ovum descending
at once through the Fallopian tubes, uterus, and vagina, with
an apparent return of the catamenial discharge, instead of
tarrying for development in the uterus, so that women, under
these circumstances, may never be conscious of having con-
ceived, though they really have done so. There can be
little question but that many supposed cases of sterility are
of this kind; owing to increased excitability of the motor ap-
paratus of conception, the generative act never goes beyond
impregnated oviposition; abortion follows so closely upon
conception, that neither the conception nor the abortion are
perceived. Such cases, admitting, as they do, of almost cer-
tain remedy, are very different from cases of actual sterility.
I have just said, that in ordinary instances of abortion excited
by ovarian irritation, it is during the early months that pre-
cautionary measures are of most importance; but in those
extraordinary cases in which abortion is caused by the adhe-
sion of the placenta to the os uteri, it is in the latter periodic
dates of pregnancy that the greatest danger is incurred, and
that the greatest care should be given to its prevention. 1
mentioned to you in the last lecture, that, even when not the
exciting cause, ovario-excitor action was still in many cases
the determining cause of premature action of the uterus; so
that in all cases of threatened abortion, and, indeed, of preg-
nancy, it behoves the medical attendant to treat the periodic
dates with circumspection.
The questions of rest and exercise are of considerable im-
REST AND EXERCISE. 151
portance in cases of expected abortion. Some authorities
advise regular exercise ; others, absohite repose from all
exertion. There can be no doubt that walking exercise,
carried to excess, excites all the pelvic organs, both the
uterus itself, and those organs which are in reflex relation
with it; and there can also be no doubt that exercise which
in the unimpregnated state is simply moderate, comes to be
excess in the gravid subject. On the other hand, rest and
the habits of ease and indulgence, living on sofas and pillows,
during pregnancy, favour the accumulation of irritability in
the muscular system, including the uterus, and in this way
often increases the chances of abortion. The safe rule seems
to be, that moderate and regular exercise should be taken
on ordinary occasions, but that repose should be ordered
during the catamenial periods, when abortion is apprehended.
But whenever the danger of abortion is very great, absolute
and continued rest, physical and mental, is necessary. Since
my last lecture, I have been called to a lady, the wife of a
distinguished artist, in an abortion for the fourteenth time.
Within five years she aborted ten times, always aborting
or commencing the symptoms of abortion at the catamenial
periods ; she then bore a living child at the full time, by
remaining in the recumbent position during the whole of preg-
nancy. Since I attended her in that labour she has gone on
aborting, and I have no doubt will continue to do so as often
as she becomes pregnant, unless she submit to perfect rest.
In this case there is no disease whatever of the utero-vaginal
passage, nothing, in fact, but an irritable condition of the
ovario-uterine nerves.
V. The precautionary nieasures connected with Rectal irri-
tation are very simple. They consist chiefly in the avoidance
or removal of intestinal accumulations by laxatives and mild
enemata ; the removal of ascarides, when these worms are pre-
sent ; the palliative treatment of hemorrhoids, all operations
upon the lower bowel being avoided as much as possible
during gestation; and lastly, the avoidance of drastic purga-
tives. It is, in fact, only necessary to recognise the rectum,
not merely as a neighbour to the uterus, but as possessing
an excitor surface and excitor nerves, prone to reflect irrita-
tion upon the uterus, through the spinal centre and utero-
spinal nerves, and the prevention of abortion as a consequence
of rectal irritation becomes easy and well understood. Rectal
152 THE PERIODOSCOPE.
and vesical irritation, as causes of abortion, have always been
recognised, but this recognition is more practical when we see
the exact channels — the mechanism, in fact — by which irrita-
tion is conveyed from one organ to the other. With reference
to abortion caused by any form of pelvic irritation, whether it
be of the bladder, ovaria, rectum, or the uterus and vagina, it
should be especially borne in mind, that every form of pelvic
irritation is increased in intensity by the masked catamenial
dates of gestation : both nervous and vascular excitement are
present at these dates, so that they should always be an object
of caution.
VI. The prevention of Vaginal irritation in women liable to
abortion from habit, or in whom special symptoms lead us to
expect this accident, involves as a preliminary the observance
of the most rigid continence. In women who have aborted
in previous pregnancies, sexual separation ought to be main-
tained during the whole of pregnancy ; and in all irritable
subjects, coitus should be avoided during the ovarian periods
of the gravid state. One useful point in the Periodoscope
I have invented is, that it enables us to point out to our
patients, at a glance, these occasions of special risk. From
not recognising the periodic tendency, women often expose
themselves to unnecessary danger, particularly in the early
months, when, from the increased aptitude for abortion,
the depending position of the uterus in the pelvis, and the
contraction of the vagina, the physical stimulus of coitus is
most exaggerated. It is no doubt for wise purposes, that
in the lower animals, almost universally, the instinct of the
gravid female leads her fiercely to reject the advances of the
male. In cases where tumours in the vagina complicate preg-
nancy, it may become necessary to remove them, both to pre-
vent abortion and to facilitate parturition. In all operations
affecting the vagina, they should be so timed as to avoid the
ovarian periods, and to fall upon what would be the hemi-
catamenial dates, when all irritation and disturbance can be
better borne. I have already referred to the use of the plug
or tampon, sometimes necessary in threatened abortion with
hemorrhage, in cases where we still hope to save the ovum;
the plug should not be so large as to stimulate the vaginal
surface excessively, and it should be fairly introduced into
the upper and roomy part of the passage, so as not to irritate
the ostium vagina; at the same time there should be nothing
PREVENTION OF ABORTION. 153
like hard pressure on the os and cervix uteri. Whenever
the presence of the tampon, carefully applied, permanently
increases the periodic pains felt in threatened abortion, it
should at once be withdrawn, unless we have resolved to
abandon the ovum to its fate. The plug ought never to be
left in the vagina more than twelve hours at a time, otherwise
it becomes extremely foetid and disagreeable, and probably
injurious; it is better even to take it a way and renew it oftener
than this, and to dip it in a weak solution of the chloride of
lime before its introduction.
VII. In threatened abortion from Uterine disturbance we
may have to deal with morbid affections of the uterus, with
disease of the placenta and membranes, or with disease of
the uterus itself.
Any persistent irritation of the uterus, but particularly of
the OS and cervix, as the most excitor parts of the organ, may
cause abortion ; this is as natural as that irritation of the
lungs should produce cough, or that irritation of the stomach
should cause vomiting. In these cases we may have to deal
with malignant disease of the uterus, syphiltic or gonorrhoea!
affections, or simple uterine disease, as inflammation, exco-
riation, or ulceration. In malignant disease complicated
with pregnancy, our treatment can be little else than pallia-
tive ; in syphilitic disorders, we must cautiously pursue that
treatment which would be proper in the ungravid state; and
in inflammatory diseases of the os and cervix, and their
sequelae, we must not shrink, because of the existence of
pregnancy, from the careful use of the local applications
necessary to effect a cure. Unless the uterine disorder be
removed, there must be considerable danger of abortion. A
patient may, it is true, pass through gestation safely, W'ith
considerable disease of the os uteri ; even cancerous ulcera-
tion sometimes exists without inducing abortion ; but there
can be no doubt that the proper measures of treatment, most
cautiously and judiciously pursued, though themselves sources
of considerable uterine irritation, are less likely to cause abor-
tion than is the disease itself, when severe, and allowed to
proceed unchecked. The observations of MM. Boys de
Loury and Costilhes, and the researches of Dr. Henry Ben-
net and Mr. Whitehead in this country, show that infhimma-
tion and ulceration of the os and cervix uteri, with mucous
or purulent leucorrhcea, may co-exist with pregnancy, and
13*
154 PREVENTION OF ABORTION.
that they may act as a cause of abortion ; and it appears
that they can be treated successfully during gestation, with-
out necessarily disturbing this process. Whenever there is
pelvic pain and ieucorrhoeal discharge in gravid patients
\vho have aborted in previous pregnancies, the condition of
the OS and cervix uteri should be positively ascertained.
The treatment found most successful in cases of inflamma-
tion, excoriation, or ulceration of the lower segment of the
uterus, is sufficiently simple — namely, local abstraction of
blood, and occasional cauterization of the diseased sites,
every possible care being taken to prevent local and consti-
tutional disturbance following upon the treatment. I ought
to state, that while I do not doubt the frequent occurrence
of inflammatory disorder and its consequences in the os and
cervix uteri in pregnancy, still the organ has so recently be-
come the subject of common visual examination, that I do
not think the variations of colour, size, hardness, and the
state of the circulation which may be consistent with moder-
ate health in different classes of life, are as yet satisfactorily
made out ; and thus many cases may be set down to disease
which are not truly and decidedly morbid : and in some
cases of this kind, abortion has been positively excited by
the treatment pursued to prevent it.
Retroversion of the uterus, though sometimes a cause of
abortion, generally requires treatment and re-position, for
more immediate symptoms than the premature contraction
of the uterus upon its contents. In plethora of the pelvic
circulation, and in congestion of the uterine vessels not
amounting to inflammation, local depletion by leeches,
either above the pubes, or applied to the os uteri directly,
is advisable. I have often seen great comfort and relief
from the sense of uterine heat and distention, produced by
constantly wearing a pad, wetted with spirit lotion, over the
pudendum.
In the prevention of abortion, morbid conditions of the
Placenta require to be considered. The placenta is to the
foetus what the branchia are to the fish, the blood of the
mother being the fluid medium in which the foetus respires
oxygen during intra-uterine life, a point which has been
ably insisted upon by Professor Simpson. For this reason it
appears to be ,that the blood of the mother during pregnancy
is more highly oxygenated than at other times, approaching
PREVENTION OF ABORTION. 155
to the state of inflaramntion, as may be seen by the buHTy coat
and the greater coagulability present in the blood drawn froin
pregnant women. The placenta has a tendency to become
unfit for foetal respiration towards the end of utero-gestation,
when Nature is preparing for the change from branchial to
pulmonary breathing. There is frequently observed on the
surface of the mature placenta crystals of carbonate of lime,
which must tend to interfere with its functions as a respira-
tory apparatus, and generally, I believe, to facilitate its
separation from the uterus. This caducous preparation of
the placenta, by the deposition of the salt of lime, is proba-
bly connected WMth the demand for ossific matter in the
fceius, but it must also remind you of the deposit of lime
upon the egg of the bird, or of silica in the stems of ripe
fruit, to facilitate its separation from the parent tree ; or we
may compare it to the deposit of earthly salts in the lungs in
old age, as preparatory to the death of the individual. It is
pretty certain that in some cases of abortion in the latter
months, caused by the death of the foetus, the death has
depended on the low respiring power of the placenta, the
placental development having progressed so rapidly as to
render the organ prematurely deciduous. Under these cir-
cumstances, the child dies asphyxiated, unless born into the
atmospheric air, just as the tadpole perishes when its branchial
development has concluded, unless it can oe removed from
water to the air. In the opposite class of cases, we have
sometimes to deal with retention and adhesion of the pla-
centa, because it is not ripe for separation at the time of
labour. Other morbid conditions of the placenta may tend
to the death of the foetus, and indirectly to abortion, such as
inflammation and induration of the organ, tubercular deposit,
or effusion of blood into its structure — placental apoplexy,
as it might be called ; but such morbid states are obscure
in their diagnosis, and very much removed from definite
treatment.
Dr. Power was, I believe, the first to enter fully upon these
non-respiratory causes of abortion, and to propose means for
aiding the respiration of the foetus by purilying the maternal
blood. He recommended the depuration of the blood of the
mother, during pregnancy, by attention to diet, the respira-
tion of pure air, and the careful regulation of all the secre-
tions. In pregnancy, the lungs of the mother have to
156 PREVENTION OF ABORTION.
consume the carbon of two circulations ; and in cases where,
from the pressure of the abdomen upon the thorax, or con-
traction of the chest, the respiration is imperfectly performed,
Dr. Power prescribed the inhalation of air containing an in-
creased quantity of oxygen, or the use of medicines containing
a large quantity of oxygen loosely combined, such as the
nitric acid. More recently. Professor Simpson states that in
cases where the foetal respiration is imperfect, he has found
the chlorate of potash useful on the same principle — that of
arterializing the maternal blood. In cases where the death
of the foetus in utero, by asphyxia, has occurred in former
pregnancies in the latter months, Professor Simpson further
recommends the induction of premature labour before the
death of the child. These facts should at least impress upon
accoucheurs the importance of considering the state of the
blood and the fcetal respiration in all cases of pregnancy. It
is evident that the sanitary condition of the foetus must
always depend upon the purity of its respiring fluid in the
bloodvessels of the mother.
In disease of the Foetus, producing death, and abortion
several times in succession, 1 fear little can be done beyond
attending to the health of both parents. Some have recom-
mended active treatment directed to the foetus, founded upon
the former post-mortem examinations of the foetus ; but a
diagnosis in which, as at present, our knowledge of the
state of the foetus actually in utero depends on the examina-
tion of a previous foetus, can hardly be depended on as a
basis of treatment, notwithstanding the acknowledged ten-
dency to repetition observed in intra-uterine disease. When
the death of the foetus has taken place, the natural result is
an abortion forthwith. The respiratory changes going on in
the placenta cease, and, as a consequence, the utero-placental
circulation is very much diminished, or it is arrested alto-
gether. The temperature of the foetus falls, and the state of
the foetus and placenta excites premature contraction of the
uterus, as mechanically as the rupture of the membranes or
the insertion of a tent in the os uteri. In some compara-
tively rare cases the circulation still goes on in the uterine
portion of the placenta, and the foetus is retained to the full
term. Or in cases of twins, there may be an abortion of a
dead foetus, and the retention of a living one to the full term
of gestation. In all these cases, whether the irritation be in
PREVENTION OF ABORTION. 157
the uterine tissue itself, or conveyed to the uterus by a dis-
eased or dead ovum, the mode in which the uterus is excited
is reflex and spinal, and abortion can only be prevented by
diminishing or removing the utero-spinal excitement.
The prevention of abortion depending on Habit, and occur-
ring at a particular date of pregnancy, chiefly consists in
taking all care to avoid the sources of uterine excitation until
the time of danger has been passed. Dr. Griffin, of Limer-
ick, treating the abortive habit as a periodicity, has proposed
to administer large doses of quinine ; and the suggestion may
be useful in some cases. I strongly suspect that one fre-
quent cause of periodic abortion arises out of immaturity of
the uterus itself. In practice, we meet with many cases
where, although menstruation has appeared, and marriage
has been consummated, the uterus is very small indeed —
not much, if at all, larger than is natural in the young girl.
Such subjects are open to many inconveniences. In cases
of this kind, if conception takes place, the uterus is unfit for
the full development of the gravid state, and when it has
reached the largest size of which it is capable, abortion
inevitably takes place. Sometimes we find in these cases
that the capacity of the uterus for gestation will increase
with every pregnancy, or with increasing years, until after
many abortions, the uterus becomes developed, and the full
period is reached in safety. Other forms of abortion, some-
times set down to habit, may depend on those diseases of
the uterus which are most troublesome at particular epochs
of pregnancy — such, for instance, as retroversion, or ulcera-
tion of the OS uteri.
In cases of Emotional abortion, we can do little in the
way of prevention The indication is of course to keep the
mind, and particularly the uterine system, as tranquil as pos-
sible after all emotional shocks occurring during pregnancy.
As it is generally some few days after-the mental shock that
the uterine disturbance begins, w^e have the time in which to
do this aflforded us ; but the effects of emotion of a severe
kind can never be altogether averted. Where there is already
a tendency to abortion from other causes, emotional disturb-
ances should be especially avoided. We may have the
symptoms of abortion passing away, when some sudden ill
news, an apprehension of fire, or any other acute disturbance,
w-ill produce an instant contraction of the uterus, and the
158 HEMORRHAGE IN ABORTION.
expulsion of its contents. Abortion appears to be prevalent
at particular times ; but this epidemic is generally, I suspect,
rather caused by mental emotion than by physical agencies.
During the present time, when public catastrophes and appre-
hensions of evil are rife, and the throne and the cottage are
alike agitated, I believe there is an unusual tendency to
abortion. I am certain that I have seen several recent cases
referable to this cause.
It is worthy of remark, that in abortion the occurrence of
hemorrhage is far more frequent than in natural labour.
Abortions are, indeed, rarely free from hemorrhage, and a
sanguineous discharge is the commonest symptom of a
threatened premature expulsion of the ovum. When the
circulation between the embryo and the mother is carried on
by the decidua, as it is in the very early months, separation
of any part of the ovum from the uterus must necessarily
produce hemorhage ; but as the placenta is gradually formed
from the decidua and chorion, and the utero-fcetal circulation
becomes circumscribed and localized in one particular part
of the uterus, the chances of hemorrhage are very much
diminished, unless the placental portion of the ovum should
be detached from the uterus. The decidua at first performs
the function of a diffuse placenta, enveloping the whole
embryo, so that separation at any point, in a commencing
abortion, necessarily produces hemorrhage. In this point of
view% the hemorrhage of early abortion is allied to the un-
avoidable hemorrhage of placental presentation. When the
placental portion of the membranes is attached high up in
the uterus, and there is hemorrhage, wnth discharge of the
blood externally, the blood has burrowed its way by gradu-
ally separating the membranes from the uterus, so as to find
a passage, after the manner of dissecting aneurism. Natural
gestation, as distinguished from placenta prsevia, admits of
the expression of the following axioms respecting hemor-
rhage : — The earlier the expulsion of the foetus, the more
certain is the occurrence of hemorrhage, and the less the
danger from loss of blood ; but as pregnancy proceeds
towards the natural termination, the chances of hemorrhage
diminish greatly, while its importance, when it does occur,
increases in an equal degree. In abortion, the danger from
hemorrhage is before the expulsion of the ovum ; in labour
at the full term, it arises after delivery.
REMOVAL OF THE OVUM. 159
In abortion in the early months the uterine hemorrhage
itself is similar to the hemorrhage occurring from other in-
ternal organs, and the means for arresting it are also much
the same. We should aim at closing the mouth of the bleed-
ing vessels, by diminishing the force and frequency of the
circi^lation, by astringents, and by promoting coagulation
by pressure, refrigerants, 8zc. The loss of blood itself so
directly tends to diminish the circulation, that depletion is
seldom necessary in abortion ; the best astringents are the
acetate of lead cr pure tannin given internally ; as refrige-
rants, the cold napkin applied externally, or ice introduced
into the vagina, are useful : while the vaginal plug, or pres-
sure over the pubis, are the best modes of producing coagu-
lation mechanically. But all these remarks apply to the very
early separations of the ovum from the uterus, when the
uterus is not so developed as to be decidedly contractile.
When pregnancy is more advanced, and the organ contracts,
the mouths of the separated vessels are comparatively large,
and new principles must be introduced into the treatment of
the hemorrhage. We can only arrest the flow of blood by
exciting uterine contraction. When we now use the tampon
it is not to produce coagulation, but to excite contraction ;
if we apply cold, it ought to be with the same intention ;
internal astringents are of little or no service. This is a
practical distinction, for if we apply cold to produce coagu-
lation, it should be continuous ; if for contraction, it should
be intermittent. There is, of course, a time in the history
of abortion in the early months, in which a combination of
the two plans are advisable, according to the development
of the uterus.
It is is an important question, — When should the hope of
saving the ovum be abandoned ? Women have gone on to
the full time after amputations, after local injuries in the
neighbourhood of the uterus, and such extensive uterine
hemorrhage, that there could be no doubt a considerable
separation of the ovum from the uterus must have taken
place. There is in some women a remarkable tenacity of
the product of conception, so that the effort to prevent abor-
tion should be persevered in as long as possible. In expected
abortion, one of the most sure indications of such an amount
of disturbance in the uterine nervi-motor apparatus as wmII
probably expel the child, is afforded by sudden relaxation of
160 REMOVAL OF THE OVUM.
the bowels ; before the regular contractions of the uterus set
in, there is o^enerally a diarrhoea, with some amount of
tenesmus. We must judge of the proper times in which to
adopt measures of expulsion and retention by the relation of
the ovum to the os uteri, particularly its protrusion through
the dilated mouth, and the amount of the previous hemor-
rhaore. If such changes in the ovum have occurred as to
warrant our belief in its death, or if the hemorrhage have
endangered the mother, we should not hesitate about its
prompt expulsion. In the later abortions, in the fifth or six
months, auscultation affords a valuable aid to our diagnosis.
If w^e can, in the earlier stage of the threatened abortion,
hear the fcptal heart ; and if, in the course of the hemorrhage
or separation of the ovum from the uterus, we distinguish
the failure and cessation of the heart's action, we may con-
clude the Foetus to be dead, and then think only of the de-
livery of the Mother.
In abortion, the chief danger to the mother is from loss of
blood ; but this is rarely so considerable as to occasion imme-
diate risk, though nothing tends more surely to ruin the
constitution than a succession of hemorrhagic abortions.
Other dangers — such as rupture of the uterus, and convulsions
— are of still more rare occurrence. When it has been de-
cided that the ovum cannot be saved, the uterus must be
emptied as soon as possible. To effect this, the membranes
must be ruptured — a measure which generally diminishes the
hemorrhage considerably, as the proportion of the liquor
amnii to the size of the foetus is greater in the earlier than in
the later months. It is, however, more difficult to rupture
the membranes in such abortions, owing to the undeveloped
state of the os uteri, and the thickness of the membranes
themselves. If the hemorrhage continues, and the ovum
cannot at once be remov^ed,the sponge plug must be had re-
course to, both with the intention of stopping the hemor-
rhage and exciting the uterus to expulsive action; the plug
should now be pressed upon, or even within the os uteri, if
possible. If the os uteri be dilated, we can endeavour to
separate the ovum from the uterus, and bring it down, care
being taken not to break the friable mass it presents. The
ergot of rye should be given to contract the uterus, and so
arrest the hemorrhage, and to aid in expelling the ovum in
cases where it cannot be brought away by the fingers. When
REMOVAL OF THE ABORTIVE DIATHESIS. 161
the uterus cannot be otherwise excited, a purgative enema
will often bring on immediate expulsion. In many cases, a
lingering abortion is terminated by vomiting, the expulsive
effort being more powerful than the bearing-down excited by
the ovum. In other cases, the occurrence of fainting ends
the process, the syncope being accompanied by powerful con-
tractions of the uterus. It often seems as though the unde-
veloped uterus was inadequate to expel its contents w'ithout
the aid of some of the other expulsory processes, such as
vomiting or defecation. When the uterus has been emptied
of its contents, the hemorrhage almost invariably''ceases; if
it does not do so, we maybe almost sure that there are either
some parts of the membranes or coagula retained in the uterus
and vagina, the removal of which, when they produce bleed-
ing, is as necessary as the removal of the placenta in ordinary
labour. It is well known that w^omen do not suffer so much
after loss of blood in abortion as in labour at the full term:
this is because they have not been exposed to the wearying
and irritating effects of full pregnancy, and because the
abdominal pressure is not removed to the same extent ;
still, after abortions, the abdominal bandage should be ap-
plied.
To eradicate the abortive Diathesis, prolonged continence
ought to be observed. A year's entire rest to the sexual
system is not too much in severe cases, during which the cata-
menial periods should be most carefully attended to. Dys-
menorrhoea sljould be relieved, if there happens, as there
frequently will happen, to be a tendency to this disease. Any
disease of the utero-vaginal passage should receive appro-
priate treatment. Everything which can possibly be devised
shoidd be resorted to, to give tone to the uterine nervi-motor
system — such as the administration of iron in delicate sub-
jects, the cold douche to the loins, and general cold bathing.
In very obstinate cases I should be disposed to try the effects
of a continued galvanic current through the spine and the
sexual organs, or to prescribe small and continued doses of
ergotine or strychnine as tonics of the utero-spinal axis. The
general sedatives of the nervous system during pregnancy are,
moderate exercise, spare and cool diet, small bleedings in
plethoric or in sanguine habits, mental quiet, tepid or cold
hip-baths, and, above all, a pure atmosphere. The nervous
system in pregnant women resembles in its irritability the ner-
14
162 REMOVAL OF THE ABORTIVE DIATHESIS.
vous system in infants and young children ; ordinary narcotics
are therefore stimulant rather than sedative, and as such
ought not to be prescribed in ordinary cases during utero-
gestation.
I may mention, in conclusion, that without a knowledge of
Excito-iMotor action, no large, comprehensive, or successful
view can be taken of the pathology and therapeutics of
Abortion.
163
LECTURE XL
Physiological Stages of Labour — I. The Preliminary Stage of Labour ; Pre-
paration for Uterine Action — IL The Stage of Dilatation ; Physiological
as distinct from Mechanical Dilatation — III. The Stage of Propulsion ;
Description of a Contractile Pain in this Stage — IV. Stage of Expulsion ;
Delivery — V. Supplemental Stage — Review of the Order of Motor Action
— Decline of Ansesthesia in Obstetric Practice — Labour placed at the boun-
dary between Physiology and Pathology — The Physical Pain of Parturition
— Ovarian, Uterine, Vaginal, Pelvic, Perineal, and Lumbar Varieties of La-
bour Pain — Distinction between Physical Plan and Physical Shock — Aggre-
gation of Reflex Arcs in the Medulla Oblongata and the xMedulla Spinalis In-
ferior.
Adapting the terms to be used to the nature of the thing
signified, as far as possible, I have endeavoured to make a
physiological division of Labour into its several natural
stages, each stage having its special physiological charac-
teristics.
I shall describe —
L The Preliminary stage, in which the preparations for
actual labour are made.
IL The stage of Dilatation, in which the os uteri is dilated
for the passage of the presenting part of the foetus.
IIL The stage of Propulsion, in which the foetus is pro-
pelled through the os uteri and vagina.
IV. The stage of Expulsion, in which the foetus is expelled
through the external parts.
V. The Supplemental stage, in which the placenta and
membranes are extruded, and in whith the uterus returns to
a state of permanent contraction, and at length to a state of
rest.
I. The Preliminary Stage,
For two or three weeks before the date of parturition there
is a subsidence of the abdominal tumour, the womb sinks
into the pelvis ; the waist, in consequence, becomes smaller,
and the respiration and general mobility are less oppressed.
164 PRELIMINARY.
There is a peculiarity of the female respiration which has been
referred to by Dr. Hutchinson, the inventor of the spirometer,
and which may be mentioned here. The upper part of the
thorax is more mobile in the female than in the male. This
is the cause of the graceful rising and falling of the breasts
in female respiration, in the unimpregnated state; and it is
obviously of importance in the respiration of pregnancy, when
the inferior ribs are much impeded by the abdominal pres-
sure. A few days before the accession of labour, the subsi-
dence of the uterus is still more remarkable, and it now begins
to contract in an equable and continuous manner, as though
gathering itself up for the coming effort. This contraction
of the uterus is moderate, but it is not at all paroxysmal, or
attended by uterine pain.
In the preliminary stage of labour there is, then, the per-
sistent contraction of the whole of the uterus, which I have
just referred to. The uterus becomes firm and ovoid, and is
more readily distinguishable from the rest of the abdominal
contents than before. The abdominal tumour now becomes
distinctly uterine. Owing to the persistent contraction of
the uterus, the mother, missing the rolling movements of the
uterus, frequently imagines the child to be dead. This quiet-
ude of the abdomen just before labour is an additional proof
that the abdominal movements are uterine, and not foetal.
During this stillness the heart of the child may be heard beat-
ing as vigorously as ever, on applying the ear or the stetho-
scope to the abdomen of the mother.
Besides the persistent uterine contraction, there is usually
an irritable state of the sphincters of the rectum and bladder.
The bowels are generally opened two or three times, and there
is a frequent desire to evacuate the bladder. The effect of
these actions of the bladder and the intestines, is to free the
pelvis and lower part of the abdomen from all unnecessary
incumbrance, and so to give room to the parturient canal.
Whenever the actions of the bowels and bladder do not
occur naturally, the bladder should be relieved by the ca-
theter, if necessary, and the lower bowel should be emptied
either by an enema or a laxative.
In the preliminary stage, the only excitor nerves involved
are the ovarian. To these nerves the uniform contraction of
the uterus is due, and the uterine contraction is but an indi-
cation of that spinal excitement which is so soon to become
STAGE OF DILATATION. 165
evident, and under which, causes, which before called forth
no special motor actions, are now to develope all the different
actions of parturition. The ovarian excitement is the fust
in the order of events ; the spinal excitability, the action of
the uterine motor nerves^ and the impulsion of the presenting
part of the child against the os uteri, follow it. The latter,
in its turn, gradually excites the contraction and dilatation of
the next stage of the process.
II. The Stage of Dilatation.
The first signs of actual parturition affect sensation, secre-
tion, and motor action. There is the lumbar pain ; the flow
of mucus tinged with blood from the os uteri and vagina ;
and lastly, there are the motor actions of the uterus and the
neighbouring organs. These are the preparations for the
dilatation of the os uteri and vagina. In actual labour, the
lumbar pain gradually becomes intermittent, instead of con-
tinuous, and each distinct pain is accompanied by contraction
of the fundus and body of the uterus, and by distinct dilata-
tion of the OS uteri. Obstetricians differ much respecting
the nature of these contractions and dilatations, and elaborate
descriptions are often given of longitudinal, and oblique, and
circular fibres, and of one set of fibres overcoming the other,
which really have had no existence, anatomically or physio-
logically. But chiefly, the dilatation of the os uteri has been
considered a mere mechanical distention.
I contend for a positive dilatation of the os uteri, over and
above the mechanical dilatation of this structure by the pres-
sure of the amniotic bag, and the tension exerted on the
opening mouth of the uterus by the contractions of the rest
of the organ. When discussing the different motor actions
of the uterus, I have adduced the proofs which I think show
that the os uteri is an imperfect sphincter, and that, like
other sphincteric muscles, it is subject to reflex dilatation
and reflex contraction. There is this harmony and adapta-
tion existing between the actions of the diflerent parts of
the uterus, — that whenever the fundus uteri contracts, the
OS uteri has a positive tendency to dilate. If it were not so,
— if the OS uteri contracted during the first stage of labour,
as forcibly as it does in some cases of encysted placenta, or
of inversio uteri, no power in the muscular fibres of the body
14*
166 STAGE OF DILATATION.
and fundus could tear it open, much less any fluid pressure
brought to bear against it by the action of the uterus upon
the liquor amnii. Not only the os uteri, but the vagina,
whose sub-mucous fibrous sheath is continuous and identical
with the substance of the uterus itself, has a tendency to
dilate during this stage of labour. In many cases the os
uteri dilates before any considerable pressure is brought to
bear upon it, and this is still more distinctly the case with
the vagina. This physiological, as distinct from a me-
chanical dilatation, appears to be a very simple matter, but
it is, nevertheless, one of considerable controversy among
obstetricians.
Dr. Rigby, for instance, observes that " the os uteri does
not dilate merely by the mechanical stretching which the
pressure of the membranes and presenting part exert upon
it ; it dilates in consequence of its circular fibres being no
longer able to maintain that state of contraction which they
had preserved during pregnancy ; they are overpowered by
the longitudinal fibres of the uterus, which, by their con-
tractions, pull open the os uteri in every direction." There
is here no recognition of the positive dilatation for which I
am contending. Everything is referred to the distention of
the OS uteri by the membranes, and its mechanical extension
by the mechanical force exerted against the os uteri by the
fundus and body of the uterus. The opinion held by Sir
Charles Bell was very similar to this. Another obstetrician,
Dr. Ramsbotham, maintains the independent dilatation of
the os uteri, but does not give the physiology of this point.
Dr. Ramsbotham remarks, " Some physiologists would teach
us to believe that dilatation in labour is entirely a mechanical
act ; that as the uterus contracts, it propels the head first
through the os uteri, by dilating it mechanically, then through
the vagina, and, lastly, through the external parts, solely by
the same forcible distention. It is evident, from the struc-
ture of the organs, that a mechanical dilatation, to such a
great extent, never could take place, unless a corresponding
disposition to relax were given them at the same time ;
therefore we must consider the dilatation of the passages
not entirely dependent on mechanical distention, but that it
is, in a great measure, to be referred to that institute of nature
which induces them to become relaxed and softened when
the uterus is about to commence contraction." The " dis-
STAGE OF DILATATION. 167
position to relax" is nothing else than an active, positive
dilatation ; the " institute of nature" the reflex function.
Viewed by its light, there is no difficulty whatever in com-
prehending the dilatile action of the os uteri. The dilatation
of the OS uteri in parturition, while the uterus is contracting,
is analogous to the dilatation of the cardia with contraction
of the oesophagus, the dilatation of the sphincter ani with
contraction of the rectum, or the dilatation of the cervix
vesica with contraction of the bladder. The only diflference
is one of time ; the sphincteric orifice of the uterus is much
slower in its actions than the sphincteric action of the orifices
of the other organs of expulsion and ingestion. I might refer
to many other authors besides those I have quoted, to show
you the great differences of opinion which have been and
are now held respecting this point.
The direction in which the motor force of the uterus is
exerted is downwards and backwards, in the direction of the
axis of the uterus, and in that of the axis of the inlet of the
pelvis. When the full dilatation of the os uteri has been
reached, the medulla oblongata is for the first time involved
in the process, and sickness generally occurs. The dilata-
tion of the OS uteri tends, by reflex action, to dilate the
cardia, and it often goes on to produce actual vomiting.
When the stomach is emptied of its contents it increases the
freedom of the respiratory movements, and promotes the
dilatation of the parturient canal. Sickness is sometimes
present during the whole of this stage, but, if not, frequently
appears at this juncture.
It is not a little remarkable, that in the early part of dilata-
tion the excitor nerves affected by the pressure of the mem-
branes and foetal head should be in relation with the lower
medulla and the uterus, only, while those which come to be
excited at the time of full dilatation of the os uteri should
affect the medulla oblongata, and the muscles engaged in the
act of vomitincr includinof a considerable number of the
muscles of respiration. Another singular affection of the
muscular system now occurs. A very distinct rigor, or
shivering of the muscles, is often observed at the time when
the OS uteri is completely dilated. This rigor is very similar
to the shuddering produced by the dilatation of other sphinc-
teric muscles. Many persons experience it when the first
morsel of food at a meal is passing the cardia, when the
168 STAGE OF DILATATION.
urine first passes in micturition, or when a catheter is passed,
or when the sphincter ani first dilates. These rigors, accom-
panying the full dilatation of the os uteri, are sometimes so
severe and continued as to excite alarm, lest they should
pass into general convulsions; and this is, in fact, one of
the modes in which the invasion of the puerperal convulsion
occurs. The sequence of events must be kept clearly in
view ; it is the ovarian irritation which excites the equable
contraction of the uterus ; then follow the impression of the
ovum upon the os uteri — the orificial irritation which leads
to the dilatation of the os ; but the orificial irritation is un-
doubtedly secondary to the irritation of the ovaria. It is
at the time of the full dilatation of the os uteri that the
bladder and rectum have the greatest tendency to act. The
sphinctcric orifices of the uterus, bladder, rectum, and
stomach, are frequently all associated in action at this time.
This physiological connection between the cardia and the os
uteri is the basis of the treatment of rigidity of the os uteri
by tartar-emetic or ipecacuan. The retlex action of dilata-
tion between the os uteri and the sphincter ani may also be
resorted to with benefit in rigidity of the uterine mouth; a
warm enema will often do wonders.
The last act of the stage of dilatation is the rupture of the
membranes, and the entire or partial discharge of the liquor
amnii. The membranes having acted as an efficient dilator
of the OS uteri, as far as it dilates by mechanical distention,
suddenly give way, and the uterus becomes smaller in com-
pass, contracting more closely and powerfully upon the foetus.
As long as the membranes are unbroken, the circulation in
the uterus is not materially interfered with, and the contrac-
tions are not so powerful as they afterwards become, on
account of the disadvantages under which the uterine fibres
act. When the quantity of liquor amnii is excessive, the
distention of the uterus prevents any efl^cient muscular
action, and is the cause of one variety of tardy labour.
But as soon as the waters are discharged or diminished, the
uterus contracts closely upon the fcetus, and prepares itself
for the stage of propulsion, which we shall have next to con-
sider. The circulation in the uterus, and consequently the
changes going on in the placenta, are then considerably
interfered with ; so that the stage of propulsion is of much
greater moment to the life of the foetus than the stage of
dilatation, which is now brought to a conclusion.
STAGE OF PROPULSION. 169
In the dllatile stage of labour, the ovarian nerves, and the
nerves of the os and cervix uteri, are acting as spinal excitors ;
and the motor actions excited are almost entirely limited to
ihe uterus : the only motor nerves involved are the uterine
nerves. Until the termination of this stage, none of the other
spinal functions are disturbed, except those of the rectum
and bladder. The uterus is contracting and dilating alone.
The portion of the spinal centre involved is the lower
medulla ; the medulla oblongata, or the functions over
which it presides, not being at all affected.
III. The Stage of Propulsion.
At the time when this stage of labour commences, — namely,
the point at which the liquor amnii is discharged, and the os
uteri becomes fully dilated, — the motor force of parturition is
applied in quite a new direction. The direction in which
the foetus has now to pass is in that of the axis of the outlet
of the pelvis, which is outwards and downwards. It is at
this point that the respiratory muscles come into play, par-
ticularly the abdominal muscles, and thus the new direction
is provided for. Before the dilatation of the os uteri, we
had to consider the foetus as an ovoid mass, and the axis of
this ovoid was the same as the axis of the uterus,, and as the
axis of the inlet of the pelvis. After the dilatation, we may
speak of two axes of the foetus — one the axis of the head, in
its long or occipito-mental diameter, the other the axis of
the body of the foetus. Now this axis of the head, in a
natural presentation, is nearly the same as the axis of the
outlet of the pelvis, through which it has to traverse ; and
the foetal body being flexible, readily passes, as it descends,
from the direction of the superior to that of the inferior pelvic
axis. All these correspondences cannot fail to strike your
attention, but they are only a few of those which accompany
this stage of parturition.
I have already mentioned to you the advantage given to
the uterus by the rupture of the membranes. The same cir-
cumstance is equally favourable to the action of the abdo-
minal muscles. A further adaptation, therefore, becomes
visible in the precise time at which the liquor amnii is dis-
charged. When the bulk of the uterus is increased by the
liquor amnii in addition to the foetus, the abdominal muscles
170 STAGE OF PROPULSION.
are so distended that they could only act with difficulty.
But after the diminution of the size of the uterus by the dis-
charge of the waters, the abdominal muscles are more free
to act, and it is now that they are called upon to aid in the
expiratory actions which propel the head of the child through
the vagina. When voluntary movements of expiration are
unadvisedly made during the stage of dilatation, they are
always awkward and fatiguing to the patient ; but during
the stage of propulsion, the contractions of the abdominal
muscles are so powerful as to be no inconsiderable stimulus
to the uterus itself. I mean that, besides their direct expul-
sive power, the pressure they exert upon the uterus excites
this organ to more powerful action. Thus, in this stage of
labour, when the uterine contractions flag, they can some-
times be renewed by voluntary contractions of the expiratory
muscles..
But there is a cause for the intervention of the respiratory
system, as well as the sign of its utility. I mentioned that,
in the stage of dilatation, the ovarian and uterine nerves
were the excitor nerves of the motor actions which then
occurred. As soon, however, as the fcetal head, protruding
through the os uteri, begins to press upon the vaginal sur-
face, a new set of excitor nerves become implicated. These
nerves are the excitors of the expiratory actions of parturi-
tion. As long as the internal surface of the uterus alone is
irritated, whether by the foetus, a polypus, or other bodies,
the uterus contracts by itself; but as soon as the vagina is
impinged upon, the expiratory force is brought to bear.
Another point worthy of observation is, that the excitor
nerves of the uterus, except at the extreme dilatation of the
OS uteri, when the stomach was disturbed, were in connec-
tion with the lower portion of the true spinal marrow only;
but the vaginal excitor nerves are in relation both with the
lower medulla and the medulla oblongata. By the lower
medulla, and the excitor and motor nerves in relation with it,
reflex actions of the uterus are produced by excitation of
these nerves ; while all the reflex actions of the respiratory
system depend upon the medulla oblongata. If the spinal
marrow were divided in the middle, there could be no
respiratory action in parturition. I have already referred to
cases of this kind in actual practice. Voluntary etforts, and
the forcible efforts of emotion, are often mixed up with the
STAGE OF PROPULSION. 171
pains ; but the essential acts of tliis stage of labour are truly
reflex in their nature. The expiratory actions occur during
the insensibility of puerperal convulsions, ^vhen emotion and
volition are both suspended. If they were not reflex and
physical in their nature, the exhaustion following a strong
labour would be far greater than it is. We see even weakly
women making powerful efforts, but perfectly refreshed
between the pains, and after several hours of severe labour,
easy and composed, complaining of nothing beyond the mere
soreness of the muscles consequent upon their energetic con-
tractions.
But I proceed to describe, seriatim^ the motor phenomena
of the contractile part of a pain in this stage. At the coming
on of each pain, the patient takes a deep inspiration, as a
preliminary. Expiration then takes place slowly and forcibly,
in a succession of gasps, and when the air in the thorax is
diminished, it is suddenly renewed by hasty inspirations.
Each pain consists, as far as the respiratory muscles are con-
cerned, of several sudden and deep inspirations, followed
by prolonged and laborious expiratory efforts, with the glottis
partially or entirely closed. At the acme of a pain in this
stage of labour, the glottis and cardia are entirely closed, the
glottis only opening partially at intervals, and the abdominal
and all the other ordinary and extraordinary muscles of ex-
piration being forcibly contracted. The diaphragm remains
inert, as in vomiting, with the actions of which, except that
the cardia is closed instead of opened, the actions of the
expiratory muscles in labour may be compared. All obste-
tric writers have taught that the diaphragm contracts
in this stage ; but if it be considered for a moment, that the
diaphragm is a muscle of inspiration, while the actions of
parturition are expiratory, the fallacy of such a view of the
action of the diaphragm must at once appear. Of the con-
traction of the abdominal muscles during this stage of labour
there can be no doubt ; and the actions of the diaphragm
and abdominal muscles are antagonistic. It is true that the
floor of the diaphragm, instead of being arched, as in an
ordinary state of relaxation, remains plane, during the efforts
at inspiration, with the glottis closed ; but this is from the
mechanical distention of the chest by the contained air, not
from an active contraction of the muscle itself. Besides
these actions, which are all involuntary and reflex, the
172 STAGE OF EXPULSION.
patient voluntarily aids in fixing the thorax, by holding some
fixed body with her hands, or planting her feet firmly.
More than this, she increases all the expiratory actions by
strong efforts of the will, and by that emotion of labour
which impels her to brave every suffering to effect the birth
of the child. At length when the pain can no longer be
borne, the short gasp or groan is exchanged for a cry which
dilates the glottis, and the pain and contractions subside.
The cry is a motor action, excited by the emotion of pain,
and instantly relieves the uterus of all extra-uterine pressure.
Thus, the glottis may be compared to a safety-valve, which
is thrown open by emotion whenever the pressure becomes
more than can be borne with safety. By the influence of
volition we have this valve entirely under our control, to
open or close it, as may be necessary. When the expira-
tory actions are weak, we can enjoin the patient to hold her
breath, and when they are too intense or too long continued,
we can encourage her to cry out, which is of course equiva-
lent to dilating the glottis, and expiring the contents of the
thorax. During all this time the uterus contracts powerfully.
The excitor nerves involved in the stage of propulsion are,
tlie ovarian^ the uterine^ and the vaginal nerves ; these are in
relation both with the medulla oblongata and the medulla
spinalis inferior. The motor nerves excited to action are, the
uterine nerves and the whole of the motor nerves of the class of
expiratory muscles.
IV. Stage of Expulsion.
This stage of labour is the shortest of the whole progress,
but it is the most important and decisive of all. It often
compresses into a few moments as much suffering and as
much concentrated action of mind and body, as would go to
an age of ordinary life.
All the actions of the propulsive stage continue w-ith un-
abated vigour. The uterus contracts with full power, the
resj)iratory muscles act with immense force. The intervals
between the pains diminish as the close of the struggle ap-
proaches ; and there is often a perfect storm of uterine con-
tractions, without sufficient intermission to enable us to
say distinctly where one pain ends and its successors begins.
When the foetal head is actually passing the ostium vaginae, a
STAGE OF EXPULSION. 173
new set of actions make their appearance. The perinffium,
alter being extended to the utmost, is now retracted over the
head by the action of the levatores ani ; the sphincter ani
and sphincter vesica? dilate suddenly, the vagina contracts
upon the advancing mass, and the head glides rapidly into
the world. The dilatation of the two sphincters, between
which the vagina is placed, compensates admirably for
the absence of a perfect sphincteric muscle at the outlet
of the parturient canal. The efl'ect of this double dilatation
is, that at the precise moment when there is the most immi-
nent danger of laceration, there is a sudden and considerable
removal of tension from the parts endangered. The dilata-
tion of the sphincters is partly dependent on the sensation
and emotion of severe pain, and partly on the reflex dilatation
peculiar to the sphincteric muscles. This view of the subject
gives interest and importance to an action which has never
been looked upon but as a very disagreeable contretemps.
Physiology here, as in many other instances, transmutes the
meanest actions of the economy, rendering them noble by
virtue of their uses ! At the same moment that the orifices of
the rectum and bladder are thrown widely open, there is
generally a dilatation of the glottis. Even from women who
restrain the expression of their emotions during the rest of
labour, a cry of pain escapes at this juncture; this cry is
necessarily accompanied by an open state of the glottis. The
opening of the glottis is not at all accidental or voluntary, but
is as regular and involuntary as its closure during the pro-
pulsive pains. Its effect is suddenly to take away the expi-
ratory pressure from the expulsive action. Without this
combined action of the glottis, and the sphincters of the
rectum and bladder, for the defence of the ostium vaginae,
recto-vaginal laceration must be a very common accident of
parturition. Such would inevitably be the frequent result of
closure of the abdominal and thoracic cavities at all points,
except that of the point of exit for the foetus, in the final
throes of labour.
The excitor nerves involved in the stage of expulsion are,
the ovarian nerves^ the uterine nerves^ the vaginal nerves^ and
the nerves of the ostium vagince; the upper and lower divisions
of the spinal centre are implicated, as in the stage of propul-
sion. The motor nerves excited to action are, the uterine^
15
174 SUPPLEMENTAL STAGE.
vaginal^ and reapiratoi'y nerves^ and the 7iervcs of the sphincter
0711 and sphincter vesiccc.
Altogether, it must be conceded that parturition is the most
voluminous of all the motor functions. The human uterus
contracts sometimes sufficiently to render the hand of a
strong man powerless. In order to illustrate the wonderful
muscular power of the heart, the circulation in the whale
or the elephant is often referred to by physiologists ; but
enormous as is the power of the heart in these animals, the
parturient actions by which they bring forth their enormous
young give us the most colossal idea we can entertain of any
single muscular action. In the human subject, too, there
is a certain grandeur in the combined efforts brought into
play in parturition. In women even of moderate strength
and stature, every voluntary muscle of the body is in strong
action; the excito-motor force is in a state of the greatest
activity ; the uterus, unseen, and without any participation
with the will, is making its immense contractions ; and
emotion imparts strength to both voluntary and reflex ac-
tions. At this juncture it is that the accumulated efforts of a
natural labour pass most readily into the convulsions of the
puerperal state, the most tragic spasm we can ever witness,
often more terrible than even tetanus or hydrophobia itself.
A temporary calm follows the energetic actions which issued
in the delivery of the mother. After the excessive action in
which nerve and muscle seemed strained to the utmost pitch,
there comes a sudden and profound repose ; there is perfect
freedom from pain ; every fibre is relaxed ; only the uterus
now contracts of all the muscles which were so lately strug-
gling. Like some ship which turns from a tempestuous sea
into a safe and quiet harbour, the new mother passes from the
storm of childbirth into the tranquil haven of maternity. In
the pathetic words of Scripture, " A woman when she is in
travail hath sorrow, because her hour is come: but as soon
as she is delivered of the child, she remembereth no more the
anguish, for joy that a man is born into the World."
V. Supplemental Stage.
When the body of the child is born by the motor actions I
have been describing, the contracting uterus follows closely
upon it in its descent, and the action of the uterus, excited
SUPPLEMENTAL STAGE. 175
at this time from the immense irritation of the vagina by the
advancing f(jetus, is frequently sufficient to throw off the pla-
centa, and lodge it in the upper part of the vagina. When
the placenta is not separated in this way by the last expulsive
pain, it remains quietly in the uterus until the appearance of
the first after-pain. During this interval the uterus contracts
WMth tolerable firmness, under the influence of the excitement
of the act of expulsion. If the placenta has been expelled
into the vagina, its presence in this situation excites, after
awhile, bearing-down pains and contractions of the vagina,
similar to those of propulsion and expulsion, only far more
inconsiderable, generally requiring slight traction of the cord
to complete its removal. When the placenta remains in utero,
it becomes separated from the uterine surface by the contrac-
tions of the uterus, and by the arrest of the circulation in the
umbilical cord. It is then removed by a miniature copy of
labour itself; there is a dilatation of the os uteri, and there
are the propulsive and expulsive actions of the uterus and
the expiratory muscles, on a small scale.
After the expulsion of the foetus, the first act of the
uterus is to contract, so as to prevent the occurrence of
hemorrhage. This contraction is induced, in the first in-
stance, by the concluding irritation of the vagina and peri-
neum, on the exit of the foetus. It is subsequently ensured
by a succession of stimuli. Of these, some are uterine, others
are extra-uterine. The bulk of the placenta and membranes
irritate, in the first place, the now contracted uterine surface.
W^hen placental separation has occurred, the abraded surface
of the uterus is intensely excitor; and as the placental mass
passes through the vaginal passage and ostium vaginae, exci-
tation, which insures full uterine contraction, is supplied. It
is a peculiarity of the utero-vaginal canal, that at the termi-
nation of labour, all the surfaces are iiiore instantly excitor,
and the answering motor contractions become more rapid and
more easily provoked. During severe labour, irritation of
the OS uteri, or of the vaginae, will often increase the pains
only in a moderate degree; but now, the introduction of the
hand into the vagina, and irritation of the os uteri, will excite
instant and forcible contraction of the uterus. The extra-
uterine excitors of uterine action now come into play in a
remarkable manner. During the whole of labour, the uterus
has been acting upon the mammae, causing them to become
176 ORDER OF PARTURIENT ACTIONS.
irritable and tumid. In return, as soon as the child is put to
the breast, the slight irritation of the manamary excitor
nerves excites distinct contractions of the uterus. This reflex
relation from the breast to the uterus continues for several
days after parturition, until, in fact, the uterus has returned to
the natural state. As soon as the secretion of milk is estab-
lished, there is, at every afllux of blood to the breasts causing
the sensation termed by women " the draught," an answer-
ing contraction of the uterus. A reflex relation between the
stomach and the uterus is also now set up. Every time the
patient drinks her gruel, or takes her tea, sharp contrac-
tions of the uterus, after-pains, in fact, are excited. Emo-
tion is another aid to the permanent contraction of the
uterus. Any emotion of the mind will generally produce
an after-pain, but the maternal emotion especially. The
emotion produced in the mind of the mother by suckling
her infant induces contraction. A day or two after labour,
merely presenting the infant to the mother, without its actual
application to the breasts, will excite the sensation of the
draught in the mammae, accompanied by a sudden secretion
of milk, and also by contraction of the uterus. Besides
these various sources of excitation to the uterus, the ovarian
stimulus continues, and it is to this latter, I believe, that the
lochial secretion is due. Thus the close of labour, the return
of the uterine system to the quiet of the unimpregnated con-
dition, is as plentifully provided for as the commencement,
or any of the various stages of the process. For some days
after labour the contraction of the uterus is of an active sphinc-
teric kind, but its vascular and other tissues rapidly diminish
in size, and it soon becomes a non-motor organ, as it was
before the time of conception.
The excitor nerves involved in the supplemental stage are
the ovarian^ uterine^ and vaginal^ together with the mammary
and gastric nerves ; the spinal centre and the motor nerves
are affected in the same manner as in the stages of dilatation,
propulsion, and expulsion, only in a minor degree.
We can now review the order of the nervi-motor actions
of labour, the series of excitor surt^aces involved one alter
the other, and the regular succession of stimulus and con-
traction in the different stages of the process. First in the
order of events, there is the excitation of the ovarian nerves,
followed by the equable and continuous contractions of the
LABOUR AND PAIN. 177
uterus. Then there is the pressure exerted by the foetal
head, as yet defended by the liquor amnii, upon the os uteri
and the consequent excitement of the orificial nerves, with
the answering and intermittent contractions of the uterus
In the next place, the vaginal excitor nerves are irritated by
the pressure of the now advancing and undefended head, or
presenting part of the fcetus, an irritation which calls forth
the respiratory actions of labour in addition to the uterine
contractions. Then we have the excitation of the nerves of
the ostium, vaginae, and the remarkable modifications of
motor action thus produced. After the expulsion of the
foetus, the placenta remains to supply an intra-uterine
stimuli, sufficient to affect the now exalted excitability of
the uterine nerves, and thus to cause its expulsion. When
the placenta has been expelled, the excitation of the uterine
surface, from which the placenta has been separated, the
excitation of the mammary nerves by suckling, and by the
secretion of milk, and the excitation of the pneumogastric,
now in excito-raotor relation with the uterus every time food
or drink are taken, are, with the aid of emotion, and the
continuing ovarian irritation which has been present daring
the w^hole of labour, perfectly sufficient in normal cases to
prevent hemorrhage, and gradually to effect the return of the
uterus to the contracted and comparatively small size of the
unimpregnated woman who has borne children.
A year ago, and all women were promised safe and perfect
exemption from the pains of natural labour. Now, however,
the anaesthetic Elixir proves to be but a cup of Circe, instead
of the true birth-help. At the present time when the febrile
excitement of the medical mind upon this subject is rapidly
passing away under the influence of the numerous fatal cases
which have occurred from the use of anaesthetic agents, there
seems a more than ordinary necessity for dwelling upon the
manifold wisdom with which the act of parturition is sur-
rounded. Woman will certainly derive truer comfort, and
a greater measure of safety and freedom from unnecessary
suffering, from physiology, than from a wild therapeutics,
which, in her hour of trial, only offers a choice betwixt
poison and pain.
Parturition is undoubtedly a physiological process, and one
exhibiting the most liberal provisions for its safe and regular
performance. The Final-Cause argument is visibly written
15*
178 PHYSICAL PAIN OF LABOUR.
upon every stage of delivery. There is quite enough of de-
sign in human parturition to furnish a new Paley. Yet the
function stands, as it were, at the boundary between phy-
siology and pathology, being attended by more pain, and
being liable to a greater number of accidents, than any other
physiological act of economy. Labour is a drama, painful to
the individual, and exciting painful interest in those around
her : in the great majority of cases it ends happily, and all the
parties come forward with smiling faces at the close : but at
any act or incident the curtain 7ntiy fall upon a tragedy. A
profound acquaintance with its physiology is the best guar-
antee of its safe conduct, and of the relief of child-birth acci-
dents. Obstetric practice affords one of the most striking
examples in medicine of the near relationship between phy-
siology, living pathology, and true therapeutics.
I know of no good account of the Pain of labour — by this,
I mean, the physical pain as distinct from the uterine con-
traction. Grave discussions have been raised as to whether
pain in travail is natural to the sex. I prefer describing
these pains as they actually exist, to any abstruse disquisi-
tion of this kind, particularly as it is now^ felt by most pru-
dent persons that there is no safe or royal road of escape
from them. They may be diminished, though not destroyed,
and to diminish them they must be understood. The first
physical pain of labour is, I believe, rather oophoralgic than
than hysteralgic ; it is more ovarian than uterine, and is very
similar to the pain of a dysmennorrhceal attack. This kind
of pain continues, though modified by other varieties of
pain, throughout parturition. Patients themselves refer it
almost entirely to the back and loins. By-and-by, true
uterine pain commences, and the pain now encircles the
lower part of the abdomen. The uterine pain is partly
caused by the dilatation of the os uteri, and partly by the
powerful contractions of the uterus upon itself. All violent
and continued muscular contractions produce an acute or
aching pain of the muscles engaged. The purest type of
the contractile uterine pain is seen in the after-pains, when
there is nothing to be expelled, the uterus contracting simply
upon itself, and often exciting intense pain. When the full
dilatation of the os uteri has been reached, and the fcctal
head enters the vagina, the pain of vaginal distention takes
PHYSICAL PAIN OF LABOUR. 179
the place of the dilatile pain of the os uteri. This pain not
only involves the mucous and fibrous sheaths of the vagina,
but the soft parts of the pelvis and the pelvic bones, par-
ticularly the symphysis pubis and the sacro-iliac synchon-
drosis. But the most acute pain of all occurs when the foetal
head engages in the ostium vagina, this part of the par-
turient canal being more plentifully supplied with nerves
than any other part of the utero-vaginal canal. With the
exception of the dilatile pain at the os uteri, which, though
often intense, ceases when full dilatation sets in, all the
varieties of pain I have been enumerating accumulate from
the commencement to the termination of labour. They
even increase in intensity as the course of labour proceeds,
and undoubtedly, the more lingering a labour happens to be,
the more painful will the latter pains of every description
become, the sensibility of every part of the canal becoming
exalted by prolonged excitement.
Besides the pains of the ovaria, uterus, vagina, and peri-
neum and the pelvic pain, there is another important kind of
pain present in almost all labours. This is the compara-
tively superficial pain of the lumbar region. Pressure with
the hands of the nurse w^ill generally relieve this pain, but
sometimes the surface becomes so tender that no pressure
can be endured, and the patient refers her chief suffering to
this region. This painful state of the. posterior lumbar and
sacral nerves of sensation, during parturition, is of a radiate
or reflex kind, evidently depending upon the condition of
the parturient passage. Cases occur in which it is not the
back which is the seat of this kind of pain, but each returning
contraction of the uterus excites severe pain in the thighs,
legs, or feet ; or I have seen it confined to one foot. I am
not now speaking of cramp or painful muscular contraction,
but of simple extra-uterine pain, occurring in the superficial
sentient nerves.
It is a common observation, that the pains of labour differ
very much in kind and intensity at different stages of the
process. The pain felt during the dilatation of the os uteri
diflfers very much from the pain felt during the propulsion of
the child through the vagina, the one being called " grind-
ing," the other, " bearing." These w^ords refer in part to
the kind of pain, in part to the kind of contraction, and they
are expressive in both senses. Not only is there this striking
180 PHYSICAL PAIN OF LABOUR.
difference between dilatile and propulsive pain, but every
step of the parturient function has its special kind of pain.
You have only to consider the nervous endowments of the
different organs and regions concerned in labour to under-
stand this. There is, first, the ovarian pain preceding and
ushering in labour, in which the purely ganglionic nerves
are concerned, and there is the ultimate pain as the fcEtus
passes the perinseum ; this region being, as you are aware,
supplied largely by purely cerebral sentient nerves. These
parts of diverse innervation are as strikingly dissimilar in
their sensations, but in lesser degrees ; the ovarian differs
from the uterine, the uterine from the pelvic, the pelvic from
the vaginal, and the vaginal from the perineal pains ; to say
nothing of the superficial lumbar pain, which is peculiar in
itself.
There is something very remarkable in the diflTering forti-
tude of women in different stages of their sufferings. The
purely uterine pain is extremely depressing. In the stage of
dilatation, or during severe after-pains, when the uterus is
acting alone, women of the highest courage falter, and give
way to the most despairing ideas; but in the propulsive and
expulsive stages, when the whole muscular system is in a
state of the greatest tension, the passionate energy of the
raind is so far in unison with the bodily exertions, that women
will often voluntarily increase their sufferings to the ex-
tremest pitch, before giving way to that laryngeal cry which
generally leads to the remission of the contractions and the
subsidence of the physical pain.
The physical pain of labour, as distinct from the muscular
contractions, is undoubtedly depressing in its effects ; but
still it is unlike other and purely pathological pain, inasmuch
as it may be very distressing, and yet disappear entirely
during the intervals of the pains, so that in a painful labour
the patient may sleep or remain quite cheerful between the
pains, and at the close of delivery may not feel an amount
of exhaustion proportionate to the intensity of her suffering.
After operations, or in very painful diseases, death may be
caused apparently by the simple effects of excessive pain.
But in death occurring after delivery, or during the course
of prolonged parturition, the merely physical pain of labour
must never be considered alone ; it must be viewed in con-
nection with the physical shock of labour as distinct from
PHYSICAL SHOCK. 181
physical pain. Pain affects the cerebrum ; shock affects
the spinal centre, which does not feel pain. Every severe
throe of a protracted labour is a distinct blow to the brain,
in so far as it is painful ; and it is also a distinct blow upon
the spinal centre, as much so as though this organ had actu-
ally been struck. The brain is more resilient, as it were,
under shock than the spinal centre ; and when parturient
women die of sinking, it is from the effects of the successive
shocks of the pains of labour upon the medulla spinalis
rather than upon the cerebrum. This view of the subject
leads to important modifications of the treatment of sinking,
and the effects of shock in parturition.
There is an unpublished experiment, of great interest, by
Dr. Marshall Hall, not performed with reference to parturi-
tion but during his electrogenic researches, which may be
brought to bear upon this point. He took two frogs, divided
the spinal marrow in both, and then immersed them in a
solution of strychnine till they became tetanic. When
allowed to become perfectly still, they would remain with-
out spasm if carefully defended against all external excita-
tation. When in this state, one frog was kept in a state of
perfect repose ; the other was irritated from time to time, so
as to produce strong tetanic action. Of these two frogs, the
first would recover perfectly in a few days, the second would
die very quickly. There was here no sensation of pain,
because the spinal marrow was divided; the exhaustion was
therefore purely of a spinal or physical kind. Dr. Marshall
Hall himself applies this experiment to the treatment of
tetanus ; but it has also an application to the physical pains
of parturition. When women die from prolonged labour,
death occurs, not merely from exhaustion by physical suffer-
ing, but from exhaustion caused by the strong muscular
contraction of the uterus and its associated organs. The
discharge of the vis nervosa and the vis insita in the muscu-
lar contractions of each pain has a depressing effect quite
distinct from, and independent of, the mere painfulness of
each uterine action. Each of the great contractile efforts of
labour has an exhausting effect ; but when more severe, or
continued longer than usual, every returning pain is a dis-
tinct shock. A woman insensible to pain may still sink, and
perish from the spinal shock of labour.
One effect of this shock, as it ordinarily occurs in parturi-
182 TRANSCENDENTAL ANATOMY.
tion, is in a degree to paralyze the rectum and bladder.
Inability to empty the bladder is very common for some days
after a severe labour ; and in rare cases, the atony of the
vesical nerves becomes chronic. This state of the bladder
is commonly referred to physical injury of the cervix vesicoe,
rather than to any nervous shock, but though local injuries
do occasionally occur, causing retention or incontinence of
urine, I am convinced that the inactivity of the bladder after
parturition is, in the majority of cases, the result of nervous
shock. The rectum is similarly and even more constantly
affected after labour, and from the same cause. Constipation
is so constant, that it is almost a matter of routine to pre-
scribe a laxative two or three days after delivery. I am
given to understand that homoeopaths leave the bowels to
chance, or give globules of arnica, — much the same thing,
according to our belief, — and the result is, that the bowels
are often not moved until eight or ten days alter delivery —
a practice which must necessarily predispose the subjects of
it to puerperal fever or convulsive attacks. It is as proper
to relieve the bowels as soon after labour as it can be done
without disturbing the uterus, as it is to relieve the bladder
when retention occurs. Not only the shock of parturition,
but other forms of excitation, affect the rectum and bladder
in the same manner. Excessive sexual excitement produces
inactivity of the rectum and bladder, and these organs are
among the first to be affected in tabes dorsalis. Such facts
are useful, as illustrating the effects of parturient excitement
upon the spinal endowments of the other organs of the pelvis.
The lower part of the spinal marrow may be considered
as the analogue of the medulla oblongata. In the one, there
are congregated the keys of the motor arcs of deglutition,
inspiration, expiration, closure of the eyelids, &c., with all
their various morbid actions ; and in the other, the centres
of the motor acts of parturition, defecation, micturition, and
conception, as far as the pelvic organs are concerned. Pro-
bably in the interval between these two congeries of reflex
spinal arcs in the medulla oblongata and the inferior medulla
spinalis, the cervical and thoracic portions of the spinal
marrow are devoted to the reflex arcs belonging to the trunk
and the upper extremities. The excilor nerves of defeca-
tion and micturition are also in relation with the centre of
the reflex respiratory actions in the medulla oblongata, and
TRANSCENDENTAL ANATOMY. 183
thus the expiratory actions excited in defecation and mictu-
rition are to be explained. The reflex arcs concerned in
parturition are still more extensively diifused. Tlie vagina,
the uterus and the ovaria are, as we have seen, in relation
with the spinal marrow through the medium of the sacral,
lumbar, abdominal, and probably also the thoracic intercostal
nerves. The actions excited in parturition are numerous in
a corresponding degree, and we may compare parturition in
some respects to respiration in the libellula, where each seg-
ment of the insect is a centre of respiratory action. There
is another point of view in which we may consider these
reflex arcs of the medulla oblongata and the lower medulla
spinalis. In those of the invertebrata w^hich admit of sepa-
ration into distinct segments, each of which may live as a
distinct animal, every ring possesses an independent centre
of physical motion. As the vertebras of the vertebrata, are
analogues of the rings of invertebrate animals, there should
also belong to each vertebra the representative of a spinal
centre. Are not the reflex arcs collected together in the
medulla oblongata the spinal centres of the cranial vertebrae?
and are not the reflex arcs of the lower medulla the spinal
centres to the pelvic rudimentary vertebras? This view
brings the reflex motor arcs of the spinal centre into har-
mony wdth the splendid ideas of Oken, Goethe,, and their
distinguished successors in archetypal anatomy.
184
LECTURE XII.
Remarks on Perioilicity — Reciprocal Actions between the Ovaria, Uterus, and
Mammae — -Neural Actions of a Physiological kind between the Organs of
Keproduction — Explanation of the Catamenial Periodicity — Explanation of
the Periodicity of Gestation — Explanation of the Periodicity of Lactation —
The great Genesial Cycle — Ohjecls of the Periodic Arrangements — Prac-
tical Applications.
We have now reached a point in the present course of Lec-
tures, from which we can conveniently glance back upon par-
turition, gestation, conception, and menstruation, or ovulation.
One thing must have struck you in our progress hitherto —
namely, the periodic times observed in all that relates to
Genesis, and Reproduction in the human subject. I wish to
carry your attention backwards, in order to show you some-
thing more of the intimate nature and cause of the genesial
periodicities than I was able to introduce when treating of
Menstruation and the Cause of Labour.
The renewal of the teeth; the appearance of puberty; and
many other phenomena which have been generally considered
as periodicities, are not really so ; they are rather phases of
development, similar to the changes of the tadpole from the
fish to the air-breathing state, or to the metamorphoses of in-
sects. Once passed, they do not return to start again from
the first point, to complete the same process afresh. Even
sleep is modified by so many circumstances as scarcely to
deserve being classed with the real periodic phenomena. The
true periodicities seem to be the catamenia and the other
events in the female processes of reproduction. These are
almost the only pure physiological periodicities, and there is
nothing at all like them in the male subject. There are, in
fact, no strictly periodic phenomena of a physiological type
in the male economy. The distinct periodicities of inter-
mittent and remittent fevers, and the more indistinct periodi-
cities of other fevers and paroxysmal diseases, are common
to both sexes; but these are all pathological phenomena.
Ill the human subject, the catamenia return every twenty-
OVARIAN ACTIONS. 185
eight clnys, reckoning from the commencement of one flow to
the commencement of the next. In the inferior animals the
return of ovulation occurs in some at longer, in others at
shorter intervals. In a great number of cases in all classes
of animals the return is annual. Here the periodicity, if it
can be so termed, often depends on the return of spring and
the solar warmth ; these instances are therefore not strictly
comparable with those cases in which the ovular periodicity
has a shorter interval, and in which it is independent of sea-
son and temperature, as in the human subject.
The following arrangement of the principal facts relating
to the periodic acts of the three important organs of the human
sexual system, will introduce and exemplify the observations
I shall have to make on the cause of the periodic phenomena
of the sex.
I. OVARIAN ACTIONS.
1. Actions of the Ovaria upon the Mammce.
Irritation of the ovaria at the catamenial periods excites
tumidity and pain in the breasts. An altered state of the
mammai is one of the first indications of ovarian excitement.
In dysmenorrhcea, the painful state of the ovaria is accom-
panied by mammary pains. The development of the ovaria
calls forth the development of the mammae at puberty. In
those cases in which lactation and ovulation proceed simul-
taneously, the state of the ovaria, at each recurring period,
influences the mammas, producing a large flow of milk; a
fact I have already mentioned, when speaking of abortion
and its causes.
2. Actions of the Ovaria upon the Uterus.
It is to the excitement of the ovaria at their periodic
times that the secretion of the cataiijenia by the uterus is
owing. At the time of puberty, the development of the ovaria
is the cause of the development of the uterus ; in congenital
absence of the ovaria, the signs of puberty do not appear,
although there may be a perfectly formed uterus.
II. UTERINE ACTIONS.
3. Actions of the Uterus upon the Ovaria.
Irritation of the uterus and ulero-vaginal passage pro-
16
186 MAMMARY ACTIONS.
duces inflammation of the ovaria; this is frequently seen in
abandoned women, in whom the Fallopian tubes are often
adherent to the ovaria from inflammatory action. During
pregnancy, the actions going on in the uterus modify the
ovarian function. The periodic excitements are masked, or
altogether absent; the maturation of the corpus luteum appa-
rently taking the place of the maturation of ovules.
4. Jldions of the Uterus upon the Mammce.
It is to the state of the uterus at parturition that the
secretion of milk in the mammae is due. At every catame-
nial period, the state of the uterus re-acts on the mammae,
increasing the mammary pain and tumidity. In irritation of
the utero-vaginal passage in leucorrhoea or gonorrhoea, or in
cases of uterine tumours, milk is frequently secreted in the
breasts. In cancer, the pathological synergies between the
uterus and the breasts are often very strongly marked. The
synergic actions between the uterus and the breasts pro-
duce, it is well known, one class of the signs of pregnancy.
The enlargement of the mammae, the development of the
nipples, and the formation of the areolae, are examples of
this.
III. MAMMARY ACTIONS.
5. Actions of the Mammce upon the Uterus,
Irritation of the breasts excites the uterus in a decided
manner, and the application of an anodyne liniment to the
breasts will sometimes allay severe uterine pain. The ap-
plication of a blister, or sinapism, for the purpose of exci-
ting the catamenial flow, have been known to produce irrita-
tion and even inflammation of the uterus. The irritation of
the uterus, by the sucking of the child, and by the secretion
of milk after delivery, I have already adverted to. The pro-
duction of abortion by irritation of the mammary nerves is a
still stronger fact of the same kind. In disease, the synergic
action from the breasts to the uterus is quite as definite as
that which exists in the converse direction.
6. Actions of the Mammce upon the Ovaria.
The influence of the mammae upon the ovaria is very dis-
tinctly seen, in the arrest of the ovarian periodicity by lacta-
MAMMARY ACTIONS. 187
tion. As long as suckling is continued, the state of the
breasts prevents the processes of ovulation and the cataraenial
flow. Those cases in which lactation and the catamenia pro-
ceed together are exceptions, as much so, as the concurrence
of pregnancy and the catamenial flow.
The actions of these three organs upon each other form a
physiological Trine, or triangle, which may be represented
thus.
MG^ QJT
Some of the above facts are pathological, others are physio-
logical ; as single facts, they have, many of them, often been
considered, but they have never yet been put together by the
aid of a constructive idea. I think I shall be able to show
you most clearly, that the mere arrangement of them in their
proper order gives us at once a beautiful Theory of the Cause
and Circuit of the sexual Periodicities.
The different organs of the reproductive system affect each
other in a special and peculiar manner in the causation of
their periodic phenomena. The ovaria are the organs in
which, during the continuance of the catamenia, the periodi-
cities are most distinctly manifested, though these organs
doubtless derive their periodic energies through the medium
of the nervous system. We also know that the ovarian
periodicity is specially modified by the condition of the
breasts and the uterus. There is a remarkable synergic
balance preserved between the three great organs of the
sexual system — namely, the Uterus, Mammse, and Ovaria.
In the virgin state, the condition of the ovaria at each
ovarian periodic excitement excites the uterus to secrete the
catamenial flow. When impregnation has occurred, the
changes set up in the uterus during the development of this
organ and its contents, re-act on the ovaria, and interfere
188 THEORY OF PERIODICITY.
with the ovarian periodicities, so that they become masked
during the whole term of pregnancy. At the time of par-
turition, the ovaria and uterus are the seat of a special ex-
citement, and it is this excitement of the uterus and ovaria
which excites the mammae to the secretion of milk for the
supply of the new-born infant. After delivery, the uterus
soon returns to a state of comparative repose, but during
lactation, the actions going on in the mamm2e,like those of the
pregnant uterus in ordinary cases, prevent the full develop-
ment of the ovarian periods. As soon, however, as lacta-
tion and the mammary development have ceased, the uterus,
breasts, and ovaria, all resume their ordinary periodicity,
and ovulation and the catamenial flow proceed regularly
until a fresh impregnation occurs. Thus the catamenial
cycle of twenty-eight days is departed from at conception
for another cycle — namely, that of gestation, which consists
of 280 days, or ten lesser cycles. After the completion of
gestation, a new^ cycle is commenced — that of lactation —
upon the completion of which the system returns to the
simple catamenial cycle. These cyclical and epicyclical
periods are themselves all included in another great period
of development, extending from puberty to the decline of
the catamenia.
These facts seem to me to be quite adequate to explain
the mystery of periodicity, which has hitherto seemed so
profound. Let us first take the Catamenial periodicity.
We have only to recognise a physiological action in the
direction /rom the uterus and mammse towards the ovaria,
and the difficulty vanishes. We already recognise patholo-
gical actions in this direction in the derangements of the
ovaria, caused by irritation of the mammse and uterus, and
unless physiological actions existed, those of a pathological
kind could not possibly occur. We know that it is the state
of the ovaria at the ovarian period which produces the uterine
secretion. This action continues for two, three, four, or five
days, or more, and then ceases. Now I believe that during
the rest of the days of the catamenial cycle of twenty-eight
days, the breasts and the uterus are exerting an influence on
the ovaria of a slower and more moderate character, which
gradually prepares them for the next ovarian excitement.
Thus, in a case in which the catamenial secretion and
mammary disturbance lasts four days, there is, so to speak,
THEORY OF PERIODICITY. 189
a neural discharge from the ovaria to the uterus and mammse
during four days. At the end of this time the activity of the
ovaria declines, and there is now a neural discharge set up
in the contrary direction, so that for twenty-four days the
raammoB and uterus are modifying and directing the actions
of the ovaria. During the intervals between the catamenial
flow, the uterus and mammae are acting upon the ovaria,
causing them to prepare and mature the ovule or ovules of
each ovulation, just as, during the days of the catamenial
flow, the ovaria are acting on the uterus, causing it to pour
out the catamenial secretion — the reason of the distinct
ovarian periodicity being, that this action of the uterus and
mammse upon the ovaria is prolonged for a greater number
days than the reaction of the ovaria upon these organs.
According to this view, the twenty-four days is as much a
periodicity as the four days of the catamenial flow. The
twenty-four days are the term of the uterine and mammary
periodicity, the four days are the term of the ovarian
periodic excitement, and the entire catamenial period of
twenty-eight days is a record of the time taken in one revolu-
tion of the reciprocal actions of the mammae and uterus upon
the ovaria, and of the alternative action of the ovaria upon
the uterus and mammse. If the catamenial flow had lasted
fourteen days, and the apparent quiescence of the uterus had
continued just an equal time, the cause of the periodic times
of the sex would have been evident long ago ; but owing to
the disproportion between the uterine and ovarian times, the
uterine and mammary phenomena of the intervals between
the catamenial flow have never been recognised. All the
facts of the case — and they might be multiplied — seem to me
to point unequivocally to a power of neural induction, exci-
tation, or polarity, existing between the three principal organs
of reproduction, and regulating and producing their func-
tional revolutions or periods, just as «imply and decisively
as gravitation causes the motions of the planetary bodies.
The following diagram presents a view of all the reciprocal
actions which I believe to be constantly going on between
the organs of reproduction, through the medium of the spinal
centre, and its incident and excident nerves. The facts
show that the neural currents, if I may so speak, indicated
by the several arrows, are always acting ; only in certain
parts of the catamenial cycle, the balance is first in favour of
16*
190 THEORY OF PERIODICITY.
one organ, and then of another. Hence arise the special
phenomena, such as the act of ovulation and the secretion of
the catamenia. These points have been amply noticed by
physiologists and obstetricians, because of their prominence,
while the other and equally important parts of the catamenial
cycle have been quite unobserved. This diagram also applies
to the cycles of gestation and lactation; the same neural
actions are still, as I believe, proceeding, only modified, so
as to give different aspects to the different organs, as the
various phenomena of reproduction fulfil their course.
OVARIA
-©UTLRIJS
SPINALCENTRE
Vicarious menstruation is one of the most singular actions
of the economy. Here the s^^nergic actions of the periodic
dates, instead of being limited to the ovaria, uterus, and
mammffi, extend to some other secreting surface, as, for
instance, an ulcer of the leg, or the raucous membrane of the
stomach. The ovarian neural energy, upon which the secre-
tion of the catamenia depends, instead of being directed to
the uterus, makes an erratic divergence to some distant part
or organ.
Cases are on record in which the uterus has been con-
genitally absent, but in which there were present ovarian
pain and irritation, w^ith excitement of the mamma?, at the
proper catamenial dates. It has also been said, that the
catamenial flow may occur regularly in the absence of the
ovaria ; this has not, however, been clearly proved. The
periodic ovarian excitement, in the absence of the uterus,
would probably depend on the mutual actions still proceeding
between the mammae and ovaria. If the catamenia can ever
occur without the existence of the ovaria and ovarian irrita-
PERIODICITY OF LACTATION. 191
tion, the periodicity must be kept up by the actions of the
mammae and uterus. When there is congenital or other
deficiency, either of the ovaria, uterus, or mammae, in the
human subject, the economy is reduced to the condition
which obtains naturally in birds, where the periodicities, so
far as they are independent of external circumstances, must
depend on the mutual action of two organs only, the ovaria
and the oviducal apparatus.
Let us now apply these views to the phenomena of Gesta-
tion. For ten periods the ovaria remain comparatively qui-
escent ; the return of the ovarian excitement is often percep-
tible, but it is nothing like, in intensity, the excitement of
the true periodic excitements before the time of impregna-
tion. When the periodic ovarian excitement is very manifest
during pregnancy, it is morbid rather than physiological.
Throughout the whole of gestation, there is an equable con-
tinuous influence exerted by the uterus upon the mammee.
But the uterus is the organ chiefly acted upon : the mammse
and ovaria appear to be acting upon it during the whole
period, in much the same way that the uterus and mammse
are acting upon the ovaria in the unimpregnated state in the
intervals between the catamenial flow. The answering
actions of the uterus upon the ovaria are very slight, pro-
ducing the indications of the periodic dates, but becoming
more faint as pregnancy advances. The uterine synergy,
instead of promoting ovulation, seems now directed to the
maturation of the corpus luteum. But at the end of the tenth
ovarian period of gestation, the accumulated influence of the
uterus and mammae excite the ovaria, and these organs in
turn re-act on the uterus, just as at a true ovarian period,
but with more force, exciting not only the uterine secretion,
but setting up the motor actions of parturition. Thus the
action of the uterus upon the ovaria, during gestation, is
similar to the action of the uterus upon these organs in the
intervals between the catamenial flow ; and the action of the
ovaria upon the uterus, at the time of labour, is like the
ovario-uterine action of the simple ovarian period.
A similar application of this theory of periodicity may be
made to the phenomena of Lactation. During the predomi-
nance of the mammary function, in strictly healthy subjects,
the uterine and ovarian functions remain almost entirely in
abeyance. The actions between the uterus and ovaria, and
192 THE GENESIAL CYCLE.
from the mammae towards these two organs, are at their
minimum ; the ovario-uterine actions are directed continu-
ously to the mamma;, as the centres of the system of repro-
duction for the time being. In those cases, too, in which
there are slight signs of ovarian excitement, or the occurrence
of the catamenial flow at each period, the ovario-uterine
excitement of the mammffi, and its influence upon the secre-
tion of milk, is very remarkable. Many women, w^ho do not
menstruate during pregnancy, observe the regular excitement
and increase of the mammary secretion, at what would have
been the catamenial periods. The predominant action during
lactation is from the uterus and ovaria towards the breasts,
and this action more than neutralizes, in healthy persons,
the converse action between the mammsB and the uterus
and ovaria. It is the development of the ovaria at puberty
which sets the catamenial cycle in motion ; while the im-
pregnation of the ovule at the time of conception causes
the divergence into the larger cycles of gestation and lacta-
tion.
These views apply to all the periodic phenomena observed
in the functions of reproduction in mammalia, particularly to
the phenomena of oestruation, gestation, and lactation. In
all probability, the periodic shedding and reproduction of
the antlers of the stag, the shell of the crab, the spines of
the porcupine, and the moulting of the feathers in birds, with
many other kindred phenomena in the different classes of
animals, are also caused by actions and reactions similar to
those w^hich maintain the periodicities of the human subject.
But I only allude to these matters incidentally, my immediate
purpose being the explanation of the periodicities of the
human female.
In the unimpregnated state, when the catamenia are regular,
the mutual actions and re-actions between the uterus, breasts,
and ovaria, proceed regularly, preserving each organ in its
physiological condition. At this time the Ovaria are as it were
the centre of the sexual system. The sura of the actions is to
keep up the periodic maturation and dehiscence of ovules from
the ovaria. To this the actions of the breasts and uterus all
tend. When impregnation has occurred, the mutual actions
still go on between the three organs ; but the Uterus has now
become the sexual centre, the actions of the breasts and
ovaria all tending to promote the development of the uterus.
TEE GENESIAL CYCLE. 193
During utero-gestation the ovaria and mammae remain
comparatively quiescent. This state of things continues for
ten sexual periods, until the phenomena of parturition occur.
Another change now supervenes ; the reciprocal actions con-
tinue under a fresh aspect, and the Mammae now become the
centre of the sexual organs, every action becoming subservient
to the maintenance of the mammary glands in the secreting
condition. Probably the physiological times of lactation are
also multiples of the catamenial period, equalling the duration
of pregnancy. In the human subject the duration of lactation
is uncertain, being modified by many causes ; but in compara-
tive lactation the time is more definite. During the continu-
ance of lactation, the peculiar relations of the breasts, ovaria,
and uterus, are preserved, but in a modified form. On the
completion of this process, weaning takes place, and the repro-
ductive system returns to the condition natural to the unim-
pregnated state. The Ovaria again become the physiological
centre of the reproductive organs. The lesser physiological
trine formed by the three organs concerned in the catamenial
periodicity, is not more remarkable than the greater physiolo-
gical trine formed by the successive advance of the ovaria,
uterus, and mammae, to the first place in the circle during
the course of reproduction. Thus in the unimpregnated
female the sexual cycle is formed entirely by the: catamenial
period ; every twenty-eight days the same process is repeated,
and the same course pursued. In the married female, during
the reproductive epoch, the sexual cycle would include the
catamenial period, and also the periods of gestation and lac-
tation. This woidd make one ovarian month for the period
preceding conception, ten ovarian months for the duration of
pregnancy, and ten ovarian months for lactation, if we give the
same time to this process as to gestation, making, altogether,
twenty-one ovarian months. Thus the larger Genesial Cycle
would consist of twenty-one ovarian periods, or 21 x28=588.
At the expiration of 588 days the sexual system would re-
commence the catamenial process, to proceed anew in the
same order, just as, according to the Metonic cycle of the
moon, this planet returns to the same point of the day and
hour every nineteen years; the fact upon which the golden
numbers of the calendar depend.
The following figure is intended to express the functional
revolutions of the Ovaria, Uterus, and Mammae. In a per-
194 THE GENESIAL CYCLE.
fectly physiological state of the organs, one revolution or
larger cycle is fulfilled by each fertile ovulation, gestation,
and lactation, which occurs during the reproductive epoch.
We can now trace the mutual dependence of the links in
the chain of causes which connects all the chief phenomena
of reproduction. We can observe how the development of
the ovaria at puberty sets the catamenial cycle in motion, con-
sisting of the actions of the ovaria, uterus, and mammae. The
first ovarian excitement, which probably appears in the usual
course of growth or development, is, by the actions and re-
actions it excites between these three organs, the cause of all
the phenomena, not only of the first catamenial cycle, but of
all the purely catamenial periodicities w^hich occur in the un-
impregnated state, from puberty to the decline of the catame-
nial function. Again, we may perceive how upon the act of
impregnation another stimulus comes into operation, which
in its turn sets the cycles of gestation and lactation in motion.
The ovario-uterine excitement produced by the impreg-
nated ovule supplies the momentum, which, acting and re-
acting between the reproductive organs, is the cause of the
periodic phenomena of gestation and lactation, including
the cause of labour, and the first secretion of milk in the
mammffi. Upon the conclusion of the cycles of gestation and
lactation, the stimulus imparted at conception having ex-
hausted itself, the organs of reproduction again fall back upon
the catamenial periodicity.
These actions are, as it appears to me, dissimilar to reflex
actions, and they may be referred to a general Law of action
and re-action in the animal economy. They are themselves
the result of a triple synergy, united and tied together, as it
PRACTICAL APPLICATIONS. 195
were, by the spinal centre, and involving neural actions to
and from the nervous centre, and between the organs them-
selves, in no less than twelve did'erent directions, which,
balancing and controlling each other, regulate the functions
of the three organs in their alternating states of rest and
activity. These directions are marked by the arrows in the
triangular diagram. The whole would seem to be an arrano^e-
ment for giving as much simplicity and harmony to the sexual
system in the state of segregation in which it exists in the
higher animals, as is found in those lower animals in which
the reproductive faculty is confined to one organ — namely,
the ovarium. By this tri-synergic andtri-cyclical arrangement,
the triplicate system of the human female approaches towards
Unity. The uterus and ovarium are joined together, and the
most distant organ, the mamma, becomes a strictly acces-
sory structure to the ovario-uterine canal. Another result
of this arrangement is, that in the higher animals, the sexual
system, instead of being dependent on the seasons, or on
other external circumstances, is self-regulated, and brought
into the reproductive condition at frequent and regular in-
tervals.
These views are capable of extensive practical applications.
I see many modes in which they may become useful in the
treatment of disorders of the catamenial function, sterility, and
impotence. They will also prove of importance in elucidating
the nature of many disorders of the reproductive periodicities.
For instance, by their aid we can more readily understand
bow, in the case of sudden suppression of the catamenia, the
ovarian neural energy may take a morbid direction, and be
the cause of disease in some distant organ, as the brain or
lungs. Such an occurrence must be considered, not only as
the arrest of a single secretion, but as a violent disturbance
of the cycle of the catamenial actions. A great part of the
pathology of hysteria consists in interruptions ot the cata-
menial cycle. In abortion, too, there is not merely the imme-
diate disorder, the loss of blood, &c., but there is the sudden
stop put to the cycle of actions proceeding in gestation, and,
also, to the larger genesial cycle. Again, in cases in which
lactation is improperly avoided, these views show very clearly
that the genesial cycle is suddenly perverted. In such cases,
instead of the mammae taking their due share in the reproduc-
tive cycle, the uterus and ovaria are turned back prematurely,
196 PRACTICAL APPLICATIONS.
to tlie functions of ovulation and the catamenia. Doubtless,
Nature intended that in the larger genesial cycle, the ovaria,
uterus, and marameE should have their alternate periods of
repose. This intended rest to the uterus and ovaria, after the
formidable efTorts of gestation and parturition, is entirely
frustrated by the practice of hired nurses. The result is seen
in an increased predisposition to uterine and ovarian disease.
Each genesial cycle is a shock to the constitution, and when-
ever it is cut short by the avoidance of lactation, it is likely
to return again too quickly, and betore the reproductive
organs are ready for the new effort. The time of lactation,
although a drain to the general constitution, is a time of rest
to the uterus and ovaria! I dwell on this point, because a
physical argument is often more powerful than a moral one.
I am here, of course, speaking of healthy persons, who avoid
the healthy duties of nursing, from fashion or convenience.
There are many delicate mothers, to whom the exhaustion of
nursing would be most injurious — who are not, in fact, robust
enough to pass through the full genesial cycle; but it is pre-
cisely in such cases that the period of rest from pregnancy
"which Nature has provided for in lactation, is most especially
necessary ; so that gestation should at least be avoided by
them for a term equal to that of lactation.
. Many other applications will readily suggest themselves.
By an extension of the same principle as that which I have
been tracing between the organs of reproduction, I think we
may acquire a better knowledge of Intermittent Fevers,
perhaps of Asiatic Cholera itself! I would fain hope, that
besides the study of their causes, the publication of the
Periodoscope, which is both a diagram of the reproductive
cycles, and an instrument for measuring them, will give a
new impulse to the observation of the times of the sexual
periodicities. On this point I cannot do better than quote
the words of Lord Bacon : " The forces and motions of things
operate within certain spaces that are not indefinite and
casual, but determinate and finite ; and the due observation
of these spaces, in every subject of inquiry, is of great im-
portance in practice."
197
LECTURE XIII.
The First Extra-Uterine Phenomena of Respiration, and the Attendant
(Changes in the Foetal Circulation — Arrest of Placental Respiration, and
of the Utero-Placental Circulation — Establishment of Respiration in the
Infant — Asphyxia Meontarum — Motor Phenomena of this State in Differ-
ent Animals — 0[)inions of Volkmann, Dr, Marshall Hall, and Edwards
— Treatment of Congenital Asphyxia before Birth and subsequent to
Delivery — Intra-Uterine Causes of Asphyxia — Separation of the Cord —
Secondary Asphyxia.
Excitation of the incident nerves of respiration is the first
phenomena of extra-uterine life. This leads to the motor
acts of respiration, the expansion of the lungs, and the
establishment of the chemical changes between the oxygen
of the air and the blood of the infant. In ordinary cases,
the contraction of the uterus upon the placenta, which ensues
immediately after birth, very much interferes with the utero-
placental circulation, and consequently diminishes the capa-
bilities of the placenta as a respiratory organ. Sometimes
the last expulsive action of the uterus in delivery, severs
the placenta from the uterus altogether. Thus the changes
which naturally occur in the uterus and placenta at the mo-
ment of birth, either at once diminish or entirely arrest the
vascular and respiratory connections between the mother and
child. The changes which occur in the infant have precisely
the same tendency.
When respiration is established, the expansion of the
lungs, besides the formation of new channels in the pulmo-
nary arteries, produces the pressure of the left bronchus upon
the ductus arteriosus, which contributes to its. obliteration.
The altered position of the heart, produced by the sudden
expansion of the lungs, probably aids mechanically in the
closure of the foramen ovale, and the liver necessarily de-
scends so as to exert pressure by its anterior edge upon the
umbilical vein. All these adaptations concur to establish
the new circulation, and to arrest the maternal and fcetal
circulations in the placenta.
17
198 MOVEMENTS OF ASPHYXIA.
Everything relating to the safety of the new-born infant
depends upon the synchronous, or nearly synchronous occur-
rence of these changes. If the utero-placental circulation
and respiration be impeded seriously before the time of birth,
the infant is born in a state of partial or entire asphyxia. If
the respiratory acts of the infant do not ensue properly at
the time of birth, the placental connection with the maternal
system being cut off, the child slowly passes into asphyxia.
Before proceeding to the treatment of these, the two forms
of Asphyxia Neonotarum, it will be useful to refer more
particularly to the establishment of respiration in the new-
born infant.
Legallois, Sir Charles Bell, M. Flourens, and Professor
Miiller, all consider the Medulla Oblongata the primum
mobile of respiration. Professor Miiller also broached the
particular hypothesis, according to which, the first respira-
tion of extra-uterine life is excited by the circulation of
oxygenated blood in the medulla oblongata. But the fact
that a motor act of inspiration is necessary before the first
oxygenation of the blood in the lungs can take place, is
sufficient, as Dr. Baly has ably argued, to set aside this
opinion of Professor Miiller.
Dr. Marshall Hall has, moreover, shown by experiment
and observation, that the first physiological act of respiration
is excited by the impression of the external air upon the
excitor nerves of the surface of the body, and especially
upon the trifacial ; respiration being continued subsequently,
in so far as it is an excito-motory act, through the medium
of the pneumogastric nerves, in addition to these and other
excitors.
To the same physician we owe the distinction between
the reflex motor acts of respiration and those respiratory
acts which are of centric spinal origin ; centric respiratory
acts being those which are excited by certain changes in-
duced in the medulla oblongata itself, by various causes,
such as excessive abstraction of blood, or the circulation of
venous blood only, in the spinal centre.
All the movements of Asphyxia after the occurrence of
insensibility, whether convulsions, spasms, &c., are of this
latter, or centric character ; and as I suppose this fact capa-
ble of application to the explanation of the first respiration
of the infant, in many instances, I shall enter a little into
detail upon the subject of asphyxia in newly-born animals.
MOVEMENTS OF ASPHYXIA. 199
Dr. JMarshall Hall, in his New Memoir on the nervous
system, remarks, '' If, in a young kitten, we remove the
cerebrum, divide the pneumogastric nerves, and open the
trachea, we may perceive a slow but rhythmic respiration
without any abnormal appearance. It" we now close the
trachea, all is changed ; the animal opens its mouth wide,
or gcispSy makes a strong effort at inspiration and expiration^
is drawn together, and variously convulsed. If we remove
the obstruction to the entrance of air into the trachea, the
same slow but rhythmic respiration is established as before.
If we again close the trachea, we have again the special
phenomena of asphyxia."
*' If we immerse a young kitten in water of 98° Fahr.,
we first observe voluntary movements, being attempts to
escape ; then there is a transitory calm; then there are, from
time to time, gaspings, attempts at inspiration, followed by
forcible expirations, with the escape of bubbles of gas, with
mucus, and perhaps blood, from the lungs, and sometimes of
milk from the stomach, and convulsive flexure of the trunk
of the animal."
In the first case, it appears to be the centric efforts at in-
spiration and expiration which re-establishes the respiration
on removing the obstruction to the entrance of air into the
trachea ; in the second, it is a similar centric action which
induces the ineffective and gasping efforts at respiration in
the drowning kitten.
The fcetus in utero has its blood arterialized, though
imperfectly, by gaseous endosmose and exosmose between
the maternal blood in the placental cells and the umbilical
vessels. When its connection with the utero-placental cir-
culation is in any way suspended before extra-uterine respi-
ration has commenced, the infant is in precisely the same
condition as the kitten with its trachea closed, or when
immersed in water.
The following remarks of Professor Volkmann, which
have a very interesting bearing on this point, are quoted by
Dr. M.Hall:
*' When I opened the eggs of fowls or of snakes, contain-
ing a sufficiently developed embryo, under water, movements
were manifested which resembled gaspings for breath, forcible
stretching of the neck, apparently painful turnings and twist-
ings of the body (but not convulsions), in short, motions
200 MOVEMENTS OF ASPHYXIA.
bearing the closest resemblance to the respiratory in asphyxia.
These motions which, in my investigations of the develope-
ment of the snake, I frequently had occasion to observe, do
not, indeed, take place immediately after the opening of the
egg, but after some time; they also continue to increase in
vigour for a certain time, and in the interval the fine red
colour of the blood changes to a purple. The observations
of my former assistant, Dr. Schneider, are still more import-
ant. The latter cut out of the body of a hare, recently
shot, some perfectly mature young ones. At first, the little
animals lay in the transparent membranes as if dead ; they
then began to move, and their motions so much reserable(i
those in asphyxia, that he quickly opened the ovum, in order
to save the young creatures. The same gentleman repeat-
edly observed the birth of puppies. These are brought into
the world uninjured, and lie at first quite motionless. After
some time, movements commence, and the mother usually
awaits this moment to bite off the ovum."
Professor Volkmann also relates the following experi-
ment : —
" I removed the brain of a kitten, with the exception of
the medulla oblongata, cut the vagus on both sides, and
extirpated the lungs, preserving the diaphragmatic nerves.
The breathing, however, continued for forty minutes after
the removal of the brain ! Did I not fear to engage in
theoretical views (hereafter to be developed), I should say
that the inspirations were increased in vigour after the
removal of the lungs. In every case the movements were
very energetic, the diaphragm was powerfully contracted,
the thorax strongly elevated. I repeated the experiment on
several puppies, with exactly similar results. In reality, the
experiments contain nothing unexpected ; for it has long
been known that a separated head will continue to breathe for
a certain time ; in young rabbits, I witnessed it for seventeen
minutes after decapitation."
Dr. Marshall Hall observes, that Professor Volkmann does
not here, or elsewhere, distinguish between ihe physiological
acts of respiration, which are j^ejiex in their nature, and the
respiratory acts occurring in asphyxia, which are centric and
pathological. In an infant newly-born, the impression of the
external air upon the skin, and particularly the afllation of
air upon the face and the anterior surface of the chest and
MOVEMENTS OF ASPHYXIA. 201
abdomen, excites the first respiration as a purely reflex act,
the trifacial and spinal cutaneous nerves being the excitors,
the medulla oblongata the centre of the nervous arc, and the
respiratory nerves of Sir C. Bell, the motors. This form of
respiration goes on quite irrespective of the circulation in the
umbilical cord. The permanent establishment of the pul-
monary circulation, it is true, checks mechanically the
placento-foetal circulation ; but in the first period of extra-
uterine life, we may often observe respiration and the umbi-
lical circulation going on at the same time. For a brief
space only, pulmonary and placental breathing proceed
simultaneously.
If respiration be not established as a purely reflex act,
another distinct series of phenomena appear. The infant
may be born enveloped in the membranes, or it may be born
under the bed-clothes, where, owing to the warm tempe-
rature, and the exclusion of the external air, it is placed in
circumstances highly unfavourable to the commencement of
reflex respiration. Here the infant lies perfectly still as long
as the umbilical circulation and the utero-placental circula-
tion remain unimpeded. When either circulation of the
placenta is arrested, the infant may slowly pass into a state
of true asphyxia, though it has neveryet respired. It begins
to writhe and gasp in the same manner as the mature ovum
of the bird or snake when immersed in water, or like the
foetus of the hare while enveloped in the membranes. If
the human foetus should happen to continue within the mem-
branes, and these are not opened, it passes into perfect
asphyxia, and perishes — a case which has actually occurred ;
if its mouth and nostrils remain free, and excito-motory
respiration does not occur; from the absence of sufficient
external impressions on the excitor nerves, the gasping acts
of inspiration and expiration may themselves pass into
natural acts of respiration, and so preserve the infant. The
centric respiratory acts due to the influence of unarterialized
blood on the medulla oblongata, are gradually changed into
those normally excited by the pneumogastric nerves, in
consequence of the flow of blood into the lungs, and the
impression of carbonic acid upon the terminal fibres in the
air-cells. Thus, then, in addition to the physiological pro-
visions for the establishment of extra-uterine life by the reflex
actions, there is in the pathology of asphyxia, the cause of
17*
202 MOVEMENTS OF ASPHYXIA.
death where the reflex acts do not occur, a new and beauti-
ful provision for the preservation of the offspring of animals,
in this centric excitement of respiratory movements.
Asphyxia from interruption to the placental circulations,
either by continued contraction of the uterus, detachment of
the placenta, or pressure on the umbilical cord, is the com-
mon form in which death takes place in the foetus in the
latter months of pregnancy, or during parturition. Without
doubt, wherever death occurs from this cause, the convulsive
action and the respiratory movements of asphyxia precede it.
Hence it was that the mature embryo appeared to Leclard
to breathe in the liquor amnii, and to inspire fluid instead of
air. In his experiments, the respiratory movements of the
foetus within the membranes were visible to the naked eye,
and matter injected into the amnion by a small orifice was
found in the lungs. Hence, also, it is, that in certain cases
respiration is established during labour, while the foetus is
yet in the womb, or while passing through the vagina. In
cases of vagitus, the child must have breathed before it could
cry ; we can hardly believe the first act of respiration in
such cases is of a reflex kind ; but the transition of the
centric respiratory acts of asphyxia into acts of normal
respiration, when it is possible for air to reach the mouth,
is readily comprehended, if we perceive the nature of the
physiological and pathological causes of the first respiratory
movements.
It is worthy of remark, that in that stage of asphyxia in
which convulsive movements and gasping eflforts at inspira-
tion and expiration take place, the reflex motor system of
nerves is endowed w^ith greater excitability than at other
times. This is a point which has been particularly insisted
on by Dr. Marshall Hall. Slight excitation produces striking
respiratory and other movements. The young of animals,
during their early extra-uterine life, are in a state approaching
to partial asphyxia, and Dr. Marshall Hall has remarked,
that the excitability of the incident nerves of respiration are
greater in proportion, the sooner they are observed after
birth. The elaborate researches of Dr. Edwards show that
asphyxia takes place more slowly in animals which are born
in a state of comparative immaturity, as the kitten, than in
those which are more mature at the time of birth, as the
guinea-pig. The infant is between these animals as regards
MOVEMENTS OF ASPHYXIA. 203
raaturlty at birth, and as regards the length of time it may
be deprived of placental or pulmonary respiration without
perishing. A child born prematurely, is asphyxiated more
slowly than one born at the full time ; and it is weW known,
that a child which has not yet breathed bears the deprivation
of air for a considerable time without dying, while a child
who has once breathed dies almost instantly on the arrest of
respiration.
Thus, then, we are led to the conclusion, that the medulla
oblongata may, in some cases, be the primum movens of re-
spiration. But this does not in any way invalidate the appli-
cation of the discovery of Dr. Marshall Hall to the establish-
ment of natural respiration as a reflex act. The centric
development of respiratory action by centric stimulus is
pathological, or supplemental, to the normal process. All
pathological actions whatever, are probably nothing more
than attempts to perform physiological actions under difficult
or impossible circumstances. In the instance under our
consideration, they sometimes end in the death, and in
others, are the cause of the preservation of the infant. It
must be remarked of Professor Muller, that not only is the
hypothesis of this distinguished physiologist unfounded, but
the exact converse appears to be the truth. When the
medulla oblongata does happen to be the primum movens of
respiration, it is venous and not arterial blood which acts as
the stimulus to the spinal centre.
I am not now describing a rare exception, but a very com-
mon occurrence. In a great many labours, and indeed in
all in which the propulsive and expulsive stages have been
severe, the child is born in a state of semi-asphyxia. Respi-
ration is established in such cases partly as a reflex act, and
partly by the gradual passing of the respiratory movements
of asphyxia into those of natural respiration. A child born
after an easy and moderate labour cries almost at the instant
of birth, the external air, the touch of the bed-clothes, and
the manipulations of the accoucheur, are sufficient to excite
respiration and to keep up the respiratory movements with-
out intermission. In a child born after a difficult and pro-
longed parturition, the skin is generally turgid and empur-
pled, from the imperfect placental respiration which has
been going on during its passage through the uterus and
vagina ; it does not cry or move at the time of birth, but at
204 TREATMENT OF ASPHYXIA.
intervals of half a minute, or a minute, or ev^en longer than
this, it gives an asphyxial gasp, and is then perfectly still
again. Where the asphyxia is not complete, these gasps
become more frequent, and gradually pass into ordinary
rhythmic respiration. The establishment of respiration is
aided by the reflex movements excited by external impres-
sions, and which mix themselves with the asphyxial gaspings.
Thus there are two modes in which respiration may be estab-
lished : the first and purely physiological, by impressions
on the incident excitor nerves, and the corresponding respi-
ratory movements dependent on the medulla oblongata and
the motor nerves of respiration ; the second, by impressions
made on the medulla oblongata, the nodus vitalis, and centre
of respiration, by venous blood, and which are of a patholo-
gical character, but which yet excite respiratory movements
through the medium of the respiratory motor nerves. Even
in the pathology of asphyxia, there would seem to be a pro-
vision for the preservation of life. In other cases, where the
child is feeble and small, or where the causes of asphyxia
have been long in operation, the gasps become weaker and
occur at longer intervals, till at length the respiratory move-
ments disappear altogether, the heart ceases to beat, and the
child is dead. In some cases of this kind, the most energetic
and careful means of resuscitation are of no avail. If reflex
action of the respiratory muscles be induced, it consists of
one inspiratory gasp at each excitation, after which the
asphyxial movements proceed as before. Such cases are
very embarrassing to the practitioner. The child is seen by
those around to be alive, from the movements which occur,
and there is risk of censure if the recovery cannot be effected.
But the fact is, mature infants may be born living, but not
viable ; or rather, they are born dying, and so far advanced
towards dissolution, that no art can recal them to life.
Without thoroughly understanding the physiology and pa-
thology of the first respiration in new-born infants, it is
impossible but that you should feel misgivings when fatal
cases occur to you — misgivings lest you should not have done
enough, or have done rightly.
These physiological and pathological data are of great prac-
tical importance; they must form the very basis of our treat-
ment for the resuscitation of still-born infants. In the mea-
sures taken for their recovery, both the reflex and centric
TREATMENT OF ASPHYXIA. 205
modes of inducing respiration must meet with due attention.
With respect to the former, Dr. Marshall Hall has, with
admirable conciseness, laid down the plan to be pursued.
'' The most important of all our remedies in congenital
asphyxia is the sudden and forcible impression of cold water
on the face and general surface. The quantity of water should
not be great; but it should be applied suddenly, and with
force. The temperature should not be lowered ; on the con-
trary, the dashing of the cold water should be alternated with
a warm bath, succeeded by warm flannels. These, too, may
be applied briskly and suddenly. The efliicacy of the remedy
is in proportion to the degree, the suddenness, the energy of
the alternation. Continued cold depresses the energies of
life, continued w^armth augments them. But it is the sud-
den impression arising from the brisk alternation of the cold
and heat which proves the most efficacious excitor of the
respiratory function, on which recovery depends immediately.
" Other excitements of the surface should also be applied.
In our experiments on kittens, we uniformly found, that to
pinch the tail, the feet, the ears, or the general integument,
with the forceps, did not excite other reflex actions only, but
acts of inspiration! We must imitate these facts. The face
and the general surface should be rubbed roughly, irritated
by a knitting-needle, and struck smartly with the open
fingers. The nostril and the anus are most excitable parts.
Irritants must, therefore, be applied to these parts from time
to time.
*' These means become more effectual after the lapse of an
interval of repose. During such an interval, which obviously
must not be too long, the infant must be placed in a warm
bath, and be afterwards rubbed with warm flannels. The
sudden dashing of cold water w^ll then especially be doubly
efficacious.
** These plans of resuscitation should not only be long-con-
tinued, but they should be continued long after the apparent
institution or restoration of respiration, with the object of
preventing a relapse into secondary asphyxia. Perseverance
is not less necessary in this case than in that of poisoning from
opium. The blood is still poisoned, and a slight comparative
failure in the respiration, as from sleep, may add to the dose
of poison, and prove fatal. My friend, Mr. Henry Smith, has
made a most important remark: — Jlfter inflation of the lungs,
206 TREATMENT OF ASPHYXIA.
secondary asphyxia may prove fatal, and the life of a sup-
posed criminal mother may be placed in fearful jeopardy, even
by the medical evidence.
** Next to the remedies which have been noticed, the ex-
posure of the face especially to a current of cold air will
prove most important ; and even after the infant has been
restored to animation, and clothed, its face should be freely
exposed in a cool atmosphere. The fan may also prove of
great assistance ; the sudden gusts induced by it are espe-
cially useful."
These various means all have reference to the excitor
function of the trifacial and spinal nerves ; there is yet the
other and natural excitor of respiration, the pneumo gastric^ to
which to devote attention. This is done by artificial respira-
tion, in which, if successful, the lungs are distended, the heart
acts, blood is poured in by the puhnonary artery, the proper
chemical changes are effected, and the great internal excitor
of respiration becomes obedient to its natural stimulus. Dr.
M. Hall recommends that artificial respiration should be per-
formed in the following manner : — *
'' The practitioner's lips are to be applied to those of the
infant, interposing a fold of linen, and he is to propel the air
from his own chest, slowly and gradually, into that of the
infant, closing its nostrils, and gently pressing the trachea on
the oesophagus. The chest is then to be pressed, to induce
a full expiration, and allowed to expand, so as, if possible, to
effect a degree of inspiration. But it is important, in doing
this, that the practitioner should previously make several deep
and rapid respirations, and, finally, a full inspiration. In
this manner the air expelled from his lungs into those of the
little patients will contain more oxygen, and less carbonic
acid, and consequently be more capable of exciting the dying
embers of life.
" If all these plans should be tried in vain, I would
strongly advise galvanic or electric shocks, to be passed from
the side of the neck to the pit of the stomach, or in the
course of any of the motor respiratory nerves and their ap-
propriate muscles. No time should be lost in sending for a
proper apparatus; but should the lapse of an hour, or even
more, take place before it can be obtained, still it should be
sent for, and tried."
• New Memoir, page 141.
PREVENTION OF ASPHYXIA. 207
The knowledge of the reflex function of the spinal marrow
must unquestionably give precision to the treatment of con-
genital asphyxia. The knowledge of the centric action of
this organ, at the commencement of extra-uterine life, will
also prove of practical service. Too much cannot be said on
the necessity of persevering to the utmost in our endeavours
to resuscitate still-born children. The subjects of congenital
asphyxia sometimes recover, after every sign of life has seemed
extinct. The device of that noble institution, the Royal
Humane Society, — a child blowing an extinguished torch,
with the motto,
" Lateat scintillula forsan."
is still more appropriate in congenital asphyxia than in the
ordinary forms of asphyxia.
The time for dividing the umbilical cord is a point of some
importance in children born asphyxiated, or who become
asphyxiated immediately after birth, from the non-establish-
ment of respiration. If, in such cases, the connection be-
tween the uterus and placenta continues, the cord should not
be severed, in the hope that some amount of placental respi-
ration may go on, and defer the death of the infant, so as to
give time for appropriate treatment. Dr. King has advanced
the ingenious opinion, that many still-born children perish
because they are rendered exsanguineous by the accumula-
tion of blood in the placenta. Without going so far as this,
I believe injury may arise from delaying the section of the
cord. After the separation of the placenta from the uterus,
which we can ascertain by feeling the placenta at the os uteri
or in the upper part of the vagina, the continuance of the con-
nection can be of no use whatever. On the other hand, it
unnecessarily increases the labour of the fcetal heart, as, in
addition to the proper foetal circulation, it has to assist in im-
pelling blood into the umbilical arteries-, through the placenta,
and back again by the umbilical veins. No good, therefore,
can possibly accrue to the child from the placental con-
nection after the separation of the placenta from the uterus,
and it may be productive of harm. Whenever the child is
dark and turgid at the time of birth, a teaspoonful of blood
should be allowed to escape at the time of dividing the cord.
In the last century, Pugh, a writer on midwifery, recom-
mended, in cases of reverse delivery, when the body of the
208 PREVENTION OF ASPHYXIA.
child has been expelled, and the head remains in the inferior
straight of the pelvis, that the fingers should be introduced
into the vagina, and the index and second finger placed in
the child's mouth, in order to establish respiration, a space
between the two fingers being made for the admission of air.
He pointed out, that unless such means are resorted to, in
cases where it is difl[icult to extract the head immediately,
death ensues from pressure on the umbilical cord. He also,
in some cases, conveyed a tube, which he describes as being
flat and flexible, into the child's mouth, for a similar purpose.
Many years after this. Dr. Bigelow, in a most ingenious paper
on the subject, described cases in which he had saved the
lives of several infants, by establishing respiration in the same
manner, while the head lay in the vagina.
Dr. Bigelow observes, that when the head is thus placed,
the attendant *'is apprised, by a convulsive jerk or spring of
the body, that a state of extreme danger exists, and that the
time has come at which the child must breathe, or will
speedily die. If at this period the fingers be introduced, so
as to reach the mouth of the child, it will be perceived that
each jerk of the body is attended with a gasp and convulsive
eflfort at inspiration, performed by the mouth and chest of
the child. In this state of things, if air be conveyed to the
mouth of the child, it will immediately breathe, and the
efforts of nature may in most cases be safely waited for to
assist in expelling the head."
These convulsive movements, and the gasping attempts at
respiration, are no other than the centric movements of
asphyxia which I have been describing ! It is mentioned by
Dr. Bigelow, that the mere admission of air may be sufficient
to establish respiration ; but this physician further observes,
that where the attempts at respiration are imperfect, they
may be powerfully assisted by douching the surface of the
body of the child with cold water. Here Dr. Bigelow availed
himself both of the centric and reflex modes of establishing
respiration, and thus practical men are often found in advance
of physiology and science ; it is, however, scientific principles
which can alone render improvements in practice universal :
men require to have reasons for acting, in addition to mere
empirical success, before they will implicitly follow in any
given path.
In all vigorous children who die of asphyxia before deliv-
PREVENTION OF ASPHYXIA. 209
ery these centric attempts at respiration must take place,
and would end in the more or less complete establishment
of the function, if the access of air could be provided for.
Notwithstanding the pressure exerted externally on the
thorax by the parturient contractions, it is certain, that in
some instances the child breathes and cries while still in the
pelvis ; probably the number of these cases would be greater
if any means were taken to promote intra-vaginal respiration.
The cases in which the attempt ought to be made are those
in which death is apprehended from continuous contraction
of the uterus, detachment of the placenta, whether from the
fundus, or the os and cervix uteri, cases of turning, footling
or nates presentations, and all other cases in which the
placental circulation is interfered with, or in which long-
continued pressure on the umbilical cord occurs. Where
the feet descend first, we have the convulsive flexure of the
body to warn us of the approach, or, rather, of the actual
presence of asphyxia, and we can act accordingly; but in
head presentations there are no signs of danger, except those
to be gathered from the sensations of the mother, and the
movements of the mouth of the foetus. It is extremely pro-
bable that mothers are correct in referring the date of the
death of the child in utero, at the close of pregnancy, or
during parturition, to the lime when these movements of
asphyxia are felt.
From the time of the full dilatation of the os uteri and the
evacuation of the liquor amnii to the birth of the foetus, the
utero-placental circulation is impeded by the greater energy
of the uterine contractions, and the diminished size of the
uterus ; hence the placental respiration of the foetus is inter-
fered with. It is to the long continuance of this part of labour
that the semi-asphyxia so often witnessed is chiefly due.
When the membranes rupture before the dilatation of the os
uteri, the hazard of asphyxia during the course of labour is
of necessity increased. The intervals between the pain in
the propulsive and expulsive stages of labour are the breathing
times of the foetus ; it is, therefore, of the greatest importance
that the pains should be not incessant and continuous. This
is one reason why the ergot of rye, which produces con-
tinuous contractions, is dangerous to the foetus, and the more
so the earlier it is administered.
In other cases, the danger of asphyxia is increased by
210 TREATMENT OF ASPHYXIA.
pressure on the uinbillical cord, as well as by impediment to
the utero-placental circulation. This happens in cases of
turning, prolapsus of the cord, breech presentations, twisting
of the cord round the head or arms of the foetus, and in cases
in which, after delivery of the head, delay occurs in the
extrication of the breech and inferior extremities.
It will certainly be proper, in all cases of impaction of
the head in the pelvis, separation of the placenta, cord pre-
sentation, or continuous action of the uterus, to reach the
mouth of the child as soon as possible, and if it be still
living, to apply a tube such as that recommended by Dr.
Bigelow, in order to facilitate the establishment of respiration
in the way pointed out by that accoucheur. The same may
be done in cases of turning, where the delivery of the head
cannot be immediately effected ; for it is well known that
in these cases chihlren frequently die who were alive but a
few minutes before entire delivery. When the delivery is
reverse, and only the head or the upper part of the child
remains impacted in the vagina, it must be borne in mind
that the time for making the attempt to save the child is when
the movements of asphyxia, or reflex attempts at respiration,
commence. Passing the fingers into the mouth, or the
insertion of a tube, will be of no use unless when the centric
or reflex efforts at respiration are being made. It will be of
little service before these movements occur, unless as a
measure of precaution ; and when they have ceased, it can
be of no use whatever, unless respiratory acts can be re-ex-
cited by reflex action ; and then we have to deal with com-
plete asphyxia, not simply with the new-born infant who
has not yet attempted to respire. In all cases where the
body of the child is expelled, and the aflflux of air, or the
manipulations of the attendant, have excited reflex attempts
at inspiration while the head is yet unborn, the mouth ought,
if possible, to have air admitted to it either by the fingers or
by a respiring tube ; otherwise, there is the danger already
spoken of — namely, the ingurgitation of the liquor amnii
into the lungs."
In cases where the feet and trunk of the child are first
delivered, and where the mouth cannot be reached by the
accoucheur, all sources of excito-motion should be avoided.
This is a point of very great importance. The hands of the
attendant should be warm, and the cold should be excluded
SECONDARY ASPHYXIA. 211
as much as possible, otherwise forcible acts of inspiration will
be induced before air can possibly reach the mouth, and the
child may be destroyed by taking the liquor amnii into the
lungs instead of air, or it may be exhausted by futile efforts
at respiration.
The Secondary Asphyxia, which affects infants and others
after their resuscitation, is very remarkable. It is different
from asphyxia proper, inasmuch as, though exposed to the
air freely, the centric movements do not now end in the
establishment of the respiratory process, but in death. Pre-
vention is the thing which should be aimed at, and for this
purpose free exposure to cool air, stimulation of the ex-
ternal thorax, and of the trifacial nerve, should be practised.
To this end, the nostrils may be irritated with a feather, the
soles of the feet may be irritated, the face may be fanned or
sprinkled with cold water, and the cool hand may be applied
to the chest occasionally, until the respiration is thoroughly
established, and the undue quantity of carbonic acid removed
from the circulation. It would seem that the cause of death
in secondary asphyxia depended on a different cause from
that operating in ordinary asphyxia. Mr. Erichsen, in his
able essay on asphyxia, in addition to the ordinary modes of
treatment, strongly urges the propriety of artificial respiration
with oxygen gas; probably, as the foetus is in the condition
of a cold-blooded animal, the atmospheric air is as powerful
a stimulus to the foetus as oxygen to the adult. Care, how-
ever, should be taken, in breathing into the air-passages of
the infant, to render the air of the operator's chest as pure
as possible, by repeatedly inspiring and expiring deeply
during the process of insufflation.
The entire subject of asphyxia in adults, or those in whom
perfect respiration has been established, requires to be studied
by the light thrown on the subject by enrachiology. It pro-
mises a rich practical harvest to any one who enters on the
investigation duly prepared. Physiology and Pathology may
both be turned into the channel of Therapeutics.
212
LECTURE XIV.
Applications of Physiology to Obstetric Pathology and Therapeutics — Disor-
ders arising from Excess of Nervi-Motor Action — Disorders arising from
Perversion of Nervi-Motor Action — Disorders arising from Deficiency of
TVervi-Motor Action — The Relation of Nervi-Motor Action to Instrumental
Delivery and Manual Operations — A new Classification of Obstetric Thera-
peutics, etc.
Your attention has hitherto been directed, in the present
course, chiefly to the Physiology of Parturition and the sub-
ordinate functions of the sexual -system ; I propose, in future
lectures, to dwell more especially on the direct applications
of this branch of physiology to Obstetric Practice. I should
not have urged the views of nervi-motor action which I have
placed before you, so strongly as I have done, had I not be-
lieved them to be, beyond all question, rich in these practical
applications.
A great many of the complications and accidents of partu-
rition and the puerperal state, met with by the obstetrician,
do, without doubt, depend either upon excess, perversion, or
deficiency of the nervi-motor actions peculiar to childbearing;
and before dealing with them effectively in their pathology
and therapeutics, it was absolutely necessary to understand
these actions in their physiology.
Let me first briefly refer to those aflfections which depend
upon Excessive nervi-motor action, either of the uterus, or
of the general nervi-motor system, caused by the condition
of the uterus at parturition. In the first place, there is
Precipitate Labour, which depends chiefly on an excitable con-
dition of the uterus, and which consists of too rapid or pro-
longed contractions of this organ, and of the associated mus-
cles which contribute to delivery. Another form of ex-
cessive action is seen in spasmodic contraction, or Rigidity
of the Os Uteri — I mean, not the mechanical closure depend-
ant on the unyielding state of the non-contractile tissue of
the OS uteri, and which slowly gives way uncler continued
EXCESS OF NERVI-MOTOR ACTION. 213
pressure, but rather that form of contraction which depends
on the condition of its contractile fibres, and which often gives
way after long resistance, almost instantaneously. The most
common form of Rupture of the Uterus is that caused by ex-
cessive uterine contractions, the uterus, in fact, rupturing
itself by its own inordinate etforts. This form of rupture may
either take place in acute labours, when it is often the result
of mere force, or in prolonged labours, after the uterus has
been weakened either by pressure, inflammatory action oc-
curring during parturition, or a form of softening dependant
on long-continued muscular contraction. Then, again, Lacem-
tion of the Perinceum is another kind of rupture caused indi-
rectly by the excessive muscular efforts of labour. The uterus
bears the child upon the perina^um so forcibly and prema-
turely, as to lacerate this part, purely as the result of
mechanical pressure. An excessive action of the uterus in
the early stages of labour may be the cause of any, or, indeed,
of all these disordered actions. It must be borne in mind,
that in all labours not rendered abnormal by mechanical diffi-
culties, there must be some one point in the process, often of
the most insignificant kind, from which the departure from
healthy parturition takes place, and upon which the accidents
of excessive or deficient action follow. The one sole aim of
the accoucheur in natural labour, is to keep the process in the
purely physiological track. It is impossible to insist too
much on this point.
Rupture of the membranes, occurring prematurely, may
bring the head of the child into direct contact w^ith the os
uteri, and the excitation consequent upon this may either
cause rigidity of the os uteri, rupture of the uterus, or lacera-
tion of the perineeum ; or it may induce any of the other
complications dependant on excessive nervi-motor action in
parturition. After-pains^ when present to a morbid extent,
are nothing more than a form of excessive nervi-motor action
of the uterus, attended by increased sensibility. Encysted
Placenta^ when dependant, as it frequently is, upon spasmodic
closure of the os and cervix uteri, also belongs to this class
of affections. The sphincteric closure of the os uteri in such
cases is similar to spasmodic rigidity of the os uteri, only it
is more purely motor, and the one occurs 6e/bre delivery, the
other after the birth of the child. Another post-partum
accident, namely, Inversion of the Uterus^ depends, as I hope
18*
214 DEFICIENCY OF NERVI-MOTOR ACTION.
I shall be able to demonstrate to you, more frequently upon
irregular and excessive motor action of the uterus itself, than
upon any mechanical displacement; this inversion is, I am sure,
more nearly allied to intus-susception, than to hernia or me-
chanical prolapse. Introcession of the fundus first occurs,
then intus-susception, and lastly inversion. Another form of
irregular and excessive motor action produces Hour-glass
Contraction, or local constriction of the uterus, which takes
the place of the uniform contraction of the organ, that should
follow delivery. We may aptly compare hour-glass contrac-
tion of the uterus to local spasmodic contraction of the intes-
tines, such as often happens in the colon. I have already
treated fully oi Jlbortion, which is entirely a nervi-motor dis-
order, belonging to the class of causes I am now referring to ;
in fact, abortion obviously could not occur without premature,
excessive, and spasmodic action of the uterus.
Allied to the excessive actions of the uterus are the general
spasmodic or convulsive actions, or the local spasmodic ac-
tions, extra-uterine in their seat, which may attend or follow
parturition. Such are Vomiting, Strangury, Tenesmus,
Cramp, and also the Metastatic Pains, as they have been
called, which, instead of afl'ecting the uterus, expend them-
selves upon the abdominal, or lumbar muscles, or the thighs
of the patient. I conclude this list of excessive or perverted
actions of the muscular system in parturition, w^ith Puerperal
Convulsions, a disease the pathology and therapeutics of
which are essentially nervi-motor, and the treatment of which
can at the best be but empirical, without a profound study of
the nervous system. The cause of these motor excesses or
perversions may be in the state of the circulation, or in
the condition of the spinal centre; they may depend on
excess of the natural stimulus to parturient action in the par-
turient canal, or they may be the result of irritation of those
extra-uterine excitor nerves, which have the power of acting
reflexly upon the uterus, such as the rectum, bladder, and
stomach.
Such are the more important accidents and complications of
parturition of a motor kind which originate in Excess of the
natural actions.
A second class of motor derangements incidental to partu-
rition depend on Deficient nervi-motor actions of the uterus
and the related organs. Such, for instance, is Uterine Inertiay
DEFICIENCY OF NERVI-MOTOR ACTION. 215
in which the organ is sometimes neither capable of being
stimulated by the natural excitants of parturition, nor by any
artificial stimulus which we can apply. In other cases, the
inertia is not complete, but the uterine actions are so in-
frequent and feeble as to be the cause of Tardy Labour. Such
cases are merely the reverse of precipitate labour, the ex-
citability and the motor action being diminished instead of
exalted. In cases of inertia or tardy labour, or in those cases
in which uterine inactivity has followed upon excessive action,
Sinking is liable to occur. This state involves, not merely
a failure of uterine nervi-motor power, but a general failure
of the vis nervosa^ including respiration and the action of the
heart, and, unless arrested by the most vigorous measures,
leads to dissolution. In cases of labour in which there is
inactivity of the uterus without separation of the placenta,
tardy labour with its complications are the sole result ; but
when this inactivity co-exists with separation of the placenta,
or occurs after its exclusion, we have Uterine Hemorrhage.
The essential cause of uterine hemorrhage, whether occurring
before or after delivery, depends upon failure of the uterine
nervi-motor power. Mere separation of the placenta during
the progress of labour would not necessarily cause hemor-
rhage, unless relaxation of the uterus occurred between the
pains. Where failure of uterine action depends, not upon
the absence of nervi-motor power, but upon the absence of
sufficient stimulus, the arrest of the hemorrhage is easy; but
when there is also real failure of motor power, the case be-
comes of a graver kind. There may be combined with, and
indeed causing, the hemorrhage, the same general depression
of the nervous system which, in cases where there is no he-
morrhage, results in sinking. Of course the hemorrhagic
complication greatly increases the gravity and danger of these
important cases.
In uterine hemorrhage, and in uterine inertia before deliv-
ery, the same essential conditions exist. It is purely acci-
dental that in one case the placenta should be undetached,
and that there should be simply an arrest of the actions of
labour ; while, in the other case, the placenta being severed,
the same cause produces the most alarming hemorrhage
which can occur in the living body.
I have here been speaking of hemorrhage from the fundus
and body of the uterus ; but there is also the variety of he-
morrhage, depending on the separation of the placenta from
216 DEFICIENCY OF NERVI-MOTOR ACTION.
the OS and cervix uteri — Placenta Prxvia. These vitally
important cases, though produced merely by the mechanical
position of the placenta, depend very much, in their treat-
ment, upon the nervi-motor actions of the uterus. There
can be no safety until the os and cervix have contracted
either upon themselves, or upon the advancing foetus.
Whether these cases are treated by turning, or by the ex-
traction of the placenta, the loss of blood is invariably
arrested by contraction, or pressure, or both, and by no other
means. Another consequence of failure of uterine action is
seen in certain cases of Retained Placenta^ where the secun-
dines are not separated and expelled from the uterine cavity,
from the absence of contractile power. Such cases are
exactly opposite to the cases I have already referred to, as
caused by sphincteric contraction of the os and cervix, and
in which the placenta may be perfectly detached from the
uterine parietes, but cannot be expelled. Some cases of
retained placenta are known to depend on morbid adhesions
of the placental structure to the uterus ; but in other cases
the placenta is removable, or actually detached, and only
waits for uterine contraction and the dilatation of the os uteri,
or for mechanical extraction.
In this category of deficient action, I may refer to those
singular complications of labour which depend on paralytic
affections. It is w'ell known that labour may occur, more or
less completely, in cases of cerebral or spinal paralysis.
Cases are on record of perfect or imperfect parturition in
women affected with General Paralysis^ or with Hemiplegia
or Paraplegia ; and such cases are most interesting, as
throwing a great light both upon natural and morbid labour.
In these cases we see the nervous system reduced to its ele-
ments still more completely than by the most skilfully devised
experiments. Throughout the class of morbid affections
dependent on deficient motor action, the deficiency may
arise either from inadequate excitor stimulus, or from defi-
cient excitability and motor power in the uterine nervous
system.
It often happens that, in the same labour, various morbid
complications occur, at one stage depending on excess, and
in another stage upon deficiency of nervi-motor action.
Thus a rapid and powerful labour may be followed by com-
plete inertia, with hemorrhage, after delivery. Here the
excessive action previous to the birth of the child becomes
DEFICIENCY OF NERVI-MOTOR ACTION. 217
a cause of the subsequent inertia. On the other hand, a
tedious labour, with feeble action of the uterus, may be fol-
lowed by violent and long-continued after-pains, the tardy
progress of the labour having produced such an excitable
condition of the utero-spinal system, that slight excita-
tion produces the most severe and painful contractions.
Some of the disorders of the reproductive system may be
caused both by the exalted and the depressed activity of the
motor organs. Sterility^ for instance, may probably occur
either from a state of inactivity or excessive contraction of
the Fallopian tubes. I may here mention, incidentally, that
I have recently devised and performed a new operation con-
nected with these tubes, for the removal of sterility, which
I shall shortly publish.
Such are the principal accidents and derangements of labour
of a motor kind which depend on deficiency of the natural
actions.
We may divide the motor derangements of Labour into
two classes : —
Class I.
1. Abortion.
2. Precipitate Labour.
3. Rigidity of the Os Uteri.
4. Rupture of the Uterus.
5. Laceration of the Perineum, &c.
6. Excessive After-Pains.
7. Encysted Placenta.
8. Inversion of the Uterus.
9. Hour-Glass Contraction.
10. Metastatic Pains,
11. Puerperal Convulsions.
Class XL ,
1. Uterine Inertia.
2. Tardy Labour.
3. Sinking.
4. Uterine Hemorrhage.
5. Placenta Previa.
6. Retained Placenta.
7. Labour with Paralysis.
I have thus shortly grouped together the two great Classes
218 OPERATIONS AND SPECIAL THERAPEUTICS.
of disordered parturient actions, for the sake of comparison
and contrast ; those which depend on excess, and those
which depend on deficiency, of motor power, the kinetic
and the akinetic affections. I cannot but believe such a
mode of viewing them will be more likely to fix the princi-
ples upon which they depend, and upon which their treat-
ment must be founded, more firmly in the mind than any
isolated consideration of their phenomena. Viewed in the
way I have pointed out, one affection becomes the interpreter
of another, and we get something like a systematic arrange-
ment, instead of a mere catalogue of disordered actions.
Hereafter I shall go into this subject, which I have now only
glanced at, more in detail.
I proceed to take a brief view of the relation which exists
between nervi-raotor action and the various Operations and
special Therapeutics on which we rely in obstetric practice.
We cannot use the forceps, or give a dose of the ergot,
without due reference to the nature and causes of uterine
action, and without understanding them, unless we are con-
tent to practise empirically. The same intimate connection
as that which I have sketched in the pathology of this
department, can be shown to exist throughout the entire
armamentarium obstetricum.
How much of the success and safety of Turnings for
instance, depends on the due appreciation of the motor con-
dition of the uterus at the time of the operation? A fami-
liarity with the various causes of uterine contraction readily
enables us to avoid all those which are not inevitable, and
to soothe the organ when it is preternaturally excited. In
the application of the Forceps or the Vecfis, it is important
to distinguish between the mechanical assistance gained by
the instruments themselves, and the increased motor action
excited by the mere introduction and use of instruments.
Laceration and rupture occur quite as often from the exces-
sive reflex actions excited by instruments, as from mechanical
violence. These observations apply equally to Craniotomy^
and the use of the Crotchet. In another important obstetric
operation, the Induction of Premature Delivery^ everything is
excito-motor. The great object is to apply irritation to the
OS uteri so as to excite reflex actions of the uterus. This is
equally the case whether we puncture the membranes, and
thus bring the head into contact with the os uteri, or whether
we depend on external orificial irritation. In the most for-
OBSTETRIC THERAPEUTICS. 219
midable operation within the range of obstetrics — namely,
the Ccesarian Section^ the motor action of the uterus is an
important element. If any great improvement in the per-
formance of this operation should ever take place, it will
probably depend on the study of the motor action of the
uterus with reference to the incisions which are necessary to
effect delivery in this manner. At present it is by no means
settled in which direction or position the uterus can be
opened so as to afford the least risk of uterine or peritoneal
inflammation.
In the special Therapeutics of the Obstetric Art, almost
everything is nervi-motor. All the Manipulations of the
accoucheur in examining and assisting the patient, must have
reference to the uterine actions they may excite. It should
never be forgotten that he has to deal with an excitor sur-
face, and that, too, in a state of high excitability. Every
point of the parturient canal, from the ostium vaginse to the
fundus uteri, has its excito-motor fibres, and every digitation
we resort to is reflected back in an increase of the contractile
pains.
Besides manipulative aid, there are a variety of measures
having special relation to motor action resorted to by accou-
cheurs. If we give an Eiiema^ during or after parturition, it
is not merely the bowel which is evacuated, but the uterus re-
ceives its share of reflected excitement. Enemata are, indeed,
marked utero-spinal excitants. The Abdominal Bandage.,
too, is not merely a compressor of the abdominal parietes,
but by irritating the surface of the uterus, it increases its
expulsive efforts. Another very important agent in obstetrics
is Temperature, This is of immense service in exciting the
uterus in its states of inertia, whether in tardy labour or in
hemorrhage. This one subject of temperature, the effects of
heat and cold, and of their alternation, upon the parturient
uterus, is well worthy of separate .study. We have certainly
not as yet made that use of temperature which we may easily
derive from it. Obstetricians dash cold water upon the
hemorrhagic uterus, but without any reference to principle,
either in the application of the remedy or in the physiological
action of the organ. In heat and cold, rightly understood,
which are always at our command, the accoucheur has his
most potent weapons. Another remedy, the Ergot of Rye,
has been used and abused, but it has never been understood ;
220 OBSTETRIC THERAPEUTICS.
it is at present a purely empirical drug, and a remedy can
only be perfected when we have carried the study of it on-
wards to its effects, and backwards to its physiological rela-
tions. I do not know that it has ever happened to obstetri-
cians to discuss the principle upon which the ergot acts;
hence it has been used in a confused manner, sometimes in
combination with a mass of other remedies, and sometimes
it has been depended on alone, to the exclusion of other ap-
plications, which should always be used simultaneously with
the ergot. The obstetric use of Opimn is also, up to the pre-
sent day, a problem. It is by no means settled whether opium
acts as an excitant, or as a sedative, of uterine action. If an
accoucheur wishes to perform the operation of turning, and
finds the uterus firmly contracted upon the foetus, he gives a
dose of opium to promote relaxation of the uterine fibres; the
same practitioner will give the same dose of opium, in a case
of hemorrhage with uterine inertia, having in this case the
intention of promoting uterine contraction ! Such manifest
discrepancies must either be wrong altogether, or the appa-
rent contradiction must admit of being reconciled. In the
present state of our knowledge upon this point, no reflecting
practitioner can use opium with decision and satisfaction. It
is only recently that Galvanism has been used in midwifery,
but the use of this agent has been purely empirical, and, con-
sequently, of very limited value. It has been used to arrest
hemorrhage, but no one would think, in a case of dangerous
flooding, of trusting to this means alone. Numerous other
remedies are almost always supplied simultaneously. Hence
it happens that unless the just value can be given to each
agent, we incur the risk of placing too much or too little re-
liance upon the means used. We are apt to attribute in-
creased eflTect to the mere number of our remedies, when it
may happen that all are merely repetitions of each other, with-
out any accumulative power. I shall make this appear plainly
when I come to speak of uterine hemorrhage. One of the
most singular classes of obstetric medicines are Emetics,
which are so useful in dilating the os uteri in cases of rigidity,
and in contracting the body of the uterus in some kinds of
hemorrhage. This property of inducing contraction of the
body of the organ, and dilating its orifice, is often of singular
utility. Finally, I may refer to Bleeding, which in obstetrics
frequently has a diflerent significance from that which it holds
PRETERNATURAL PRESENTATIONS. 221
in general medicine and surgery. We frequently prescribe
venesection purely with reference to nervi-motor action, when
there is spasmodic rigidity of the whole of the uterus, or of
the OS uteri, or when the pains, though otherwise natural, are
so rapid and intense, as to make us dread rupture. Thus we
bleed to produce comparative inertia, on the one hand, and
yet we see that one of the most fatal results of inertia after
parturition is loss of blood. I menti-on these points as seem-
ingly paradoxical, though we may easily reconcile them with
each other. I might add, as we shall see hereafter, that there
is one form of puerperal convulsion in w^hich bleeding is the
only remedy; and another, which is caused by loss of blood
alone. In mere practical men, these and similar contradic-
tions are a constant source of difficulty, and it is physiology
which alone can render them luminous and clear.
Another field for the practical study of nervi-motor action
is afforded by Preternatural Presentations. In the strictly
natural presentation, all is arranged so as to provide, as far
as possible, for the safety and security of both mother and
child. The labour is neither too long nor too short; but in
all the preternatural presentations, — I here mean all those
which are not presentations of the head, — the motor actions
are deranged from their proper order. In head presentations,
the latter part of the labour is almost always rapid, and upon
this the safety of the foetus greatly depends. In Breech and
Footling Presentations^ the latter part of the labour is the
slowest part of the process, and hence the danger to the child
in these presentations. The head is delivered slowly, because
the parts are not sufficiently dilated, but still more because
the uterus has not been excited to such a state of powerful
reflex action and great excitability as that which is induced
when the head descends first. In another presentation, and
one of the most dangerous which can occur, — I mean Pla-
centa Prccvia, — much of the peril depends on the circumstance
that the os uteri, instead of being excited by the head of the
foetus during the pains, is only pressed upon by the interme-
diate cushion formed by the placenta. The pains are conse-
quently deficient in motor power, and there is not sufficient
mechanical pressure exerted to arrest the hemorrhage. In
another variety of presentation, that of the Hand, or the Mrm,
or Shoulder J or the Hand and Head, the mechanical pressure
of the advancing foetal mass is greater than usual, and the
19
222 PRETERNATURAL PRESENTATIONS.
motor actions of the uterus are exaggerated in a corresponding
degree; hence one important source of the danger of lacera-
tion and rupture in such cases. These dangers are in part
mechanical, it is true, but they are still more dependent on
excessive uterine contraction. In every other form of mal-
presentation, the physiological motor action of the uterus is
necessarily deranged, being either in excess or deficiency,
when compared with th'e natural standard.
223
LECTURE XV.
Causes of Excessive Uterine Action : — Ovarian Irritation ; Emotion ; Early
Kupture of the Membranes; Voluntary Eflbrts ; Position of the Patient;
The Foetus; State of the (circulation ; Digitation — Rules for Manipulation
in Precipitate and in Tardy Labours — Sedatives of Excessive Parturient
Action ; — Ovarian Treatment ; Bleeding; Nauseants ; Opium; Regulation
of Emotion; Abdominal Bandage ; Rest, etc.
Before entering on the study of the particular accidents of
parturition and the puerperal state which arise out of ex-
cessive motor action, I wish earnestly to direct your attention
to the chief Causes upon which such excess depends, and to
the means by which we can moderate or remove those unruly
efforts of the uterus and its associated organs which become
so dangerous in their results.
Ovarian irritation is one important cause of precipitate
labour and undue uterine action. The ovaria are the vis a
(ergo of parturition. In some cases, the ovarian stimulus,
which in its normal degree produces the proper, physiological
excitability of the uterus, on which natural labour depends, is
excessive, and induces in the spinal centre and the utero-
spinal nerves a state of excitability almost of a tetanic kind.
All the motor actions of labour are immoderately increased.
The whole surface of the parturient canal becomes intensely
excitor, and first the liquor amnii, then the head and trunk of
the fcetus, and the manipulations of the accoucheur, produce
the most rapid and powerful contractions, so that every ute-
rine pain amounts to a local convulsion. Unless the nervous
energy becomes exhausted by the uterine actions of the ear-
lier stages of labour, the excitability increases with the pro-
gress of parturition, and reaches its acme at the time of deliv-
ery. The physical pain is in proportion to the motor action,
being increased by the great pressure exerted on the uterine
nerves, and by the sudden and forcible impulsion of the pre-
sentation through the passages; in such cases, the morbid
uterine motor action, and the injury done to the parturient
224 CAUSES OF EXCESSIVE UTERINE ACTION.
canal, may be said to partake, the one of the nature of cramp,
and the other of violent contusion.
Though the nerves of the ovaria are the primary excitors
of the neural energy exhibited in parturition, there are
other organs, independent of both uterus and ovaria, which
exalt the excitability of the spinal centre and the utero-spinal
nerves. Thus a loaded state of the rectum, excitability of
the bladder, and certain states of the stomach, act upon the
uterus, and produce excessive action of the latter organ.
The most important of these sources of excitation is the
rectum, which, when loaded, will sometimes derange the
whole function of labour, rendering the contractile pains
quite uncontrollable. During labour the uterus attracts, as
it were, to itself, the reflex effects of local irritation in any
part of the body.
Emotion is another cause of precipitate labour. We have
more difficulty in defining the limits of this cause than those
causes which are physical in their nature. Emotion is truly
capricious and Protean in its results in parturition. The
same kind of emotional disturbance which in one patient
produces the most rapid labour, will, in another, suspend the
pains altogether. Sometimes an emotional disturbance will
suspend a labour for a considerable time, and then precipi-
tate labour will be caused by some other emotion occurring
in the course of the same parturition. Thus I once saw a
case in which labour had set in regularly, and bade fair to
be concluded within the ordinary period ; but it happened
that this patient heard of a poor woman, in whom she took
an interest, being in labour, and in extreme danger, at the
same time with herself. This intelligence entirely arrested
her labour for several days, until, in fact, she heard of the
safe delivery of the other party, when her own labour again
became active, and terminated very speedily.
Many other causes of precipitancy or excess may occur
during the course of labour. One of these is early rupture of
the membranes, which acts by bringing the body and head
of the foetus into direct contact with the internal surface of
the uterus, and especially with the os and cervix uteri.
Another cause of rapid labour, akin to this, is where the
quantity of liquor amnii is very small, so that at the com-
mencement of labour, when the uterus begins to contract
upon its contents, it at once meets with solid instead of fluid
resistance within its cavity.
CAUSES OF EXCESSIVE UTERINE ACTION. 225
Improper voluntary efforts are quite enough to complicate
a labour seriously. Violent volition appears to influence the
uterus somewhat as it does the heart, and it moreover causes
the uterus to be squeezed forcibly between the abdominal
muscles in front, and the unyielding spinal column behind.
Powerful voluntary efforts in the early stages of labour,
before the dilatation of the os uteri, and the rupture of the
membranes, are always mischievous. In ordinary labour,
some amount of voluntary or instinctive action of the mus-
cular system, and particularly of the expiratory muscles, is
quite natural during the stages of propulsion and expulsion.
In acute or severe labour, these voluntary exertions are pro-
ductive of great mischief The efforts of the already excited
uterus are assisted by the expiratory efforts, and the uterine
actions are increased still more by the mechanical pressure
of the abdominal parietes upon the uterus. Hence the
serious accidents of this variety of morbid parturition often
occur at the moment when patients are making some obvious
voluntary effort, either in the height of a pain in the propul-
sive stage of labour, or while straining at defecation or mic-
turition.
The position maintained by the patient during her labour
has a considerable influence upon the action of the uterus.
It is well known that standing or stooping during the pains,
or leaning over the back of a chair, or holding to the bed-
posts, will increase the intensity of the contractile pains.
This is evidently because the presenting part is thus brought
to bear with increased mechanical force upon the uterus or
vagina. The same thing occurs from standing or walking
between the pains, particularly after the rupture of the
membranes, at whatever stage of the labour this may have
occurred.
The foetus is of course the mechanical excitor of the motor
power of the uterus, and the other special motor actions
of labour. It may, from its formation, or the way in which
it presents, be a more powerful excitor than usual, and thus
render the parturient actions excessive. Such, fur instance,
is the case when the ossification of the fcetal head is un-
usually mature, so as to exert great mechanical pressure upon
the soft parts. The same thing happens when the foetal head
is of the natural size, but where there is deformity of the
pelvis, so as to arrest the head either at the brim or outlet.
19*
226 CAUSES OF EXCESSIVE UTERINE ACTIOrf.
So also, in certain presentations, as the bead and arm, or the
shoulder, the increased pressure, and the difficulty of im-
pelling the fcfitus onwards, will often rouse the uterus, in a
reflex manner, to inordinate exertions. The relation of
uterine action to the resistance it meets with is often so
exact as to give the uterus the appearance of instinctive
power. The resistance, whether dependent on the size and
position of the foetus, or the small size or malformation of the
pelvis, becomes in effect an excitor of motor action. Hence
there are important distinctions between labours which are
accompanied by precipitate and excessive action of the
uterus, with a capacious pelvic canal, and those in which the
same state of the uterus is combined within a small or dis-
torted pelvis.
The accidents, too, of precipitate or excessive labour are
different in pelves of different diameter. Thus women in
whom the pelvis is below the usual size, are liable to lacera-
tions and contusions, w^hile in those in whom the pelvis is
roomy, inversio uteri is more probable, and severe labours
in such cases are apt to be followed by prolapsus and pro-
cidentia, particularly if bodily exertion be resorted within a
short time after parturition. It sometimes happens, that with
violent action of the uterus after the discharge of the liquor
amnii, and in the absence of all pelvic impediment, little or
no progress is made towards delivery, because the uterus so
firmly embraces the foetus as to reverse its own function,
and retains it in situ, instead of expelling it. This condition
is only to be removed by moderating the violence of the
uterus. In cases where excessive action is uncompli-
cated by mal-presentation, pelvic impediment, rigidity of
the OS uteri or other contingencies which may modify its
effects, the result is />reci/?z7a/e labour. Where such compli-
cations occur, the parturient actions may be excessive, but
the labour may become lingering and laborious. The
exalted condition of the uterus, which if it remained within
due bounds would tend to overcome impediments, often
renders labour difficult and dangerous by its violence ; so
that in many cases in which the duration of labour is preter-
natural, we may have to deal with precisely the same element
which meets us in labours which are simply acute or pre-
cipitous.
The whole excitor surface, from the fundus uteri to the os
TAKING A PAI?;. 227
externum, may be rendered preternaturally susceptible of sti-
mulus by the ovaria alone, or by the other conditions I have
been describing, but the state of the circulation is another
distinct cause of parturient excitability. In febrile and in-
flammatory diseases, particularly the exanthemata, small-pox,
rubeola, &c., occurring at the time of parturition, the utero-
spinal nerves become remarkably excitable, and labour runs
a rapid course. The states of the blood in which albumen
and kiestein are eliminated copiously from the kidneys, are
also accom})anied by marked increase in the excitability of
the spinal centre and the utero-spinal nerves.
When labour is proceeding naturally, excessive digitation,
whether at the os uteri, in the vagina, or at the os externum,
will often convert it into precipitate labour, or labourattended
by excessive uterine action. Constant digitation and exami-
nation, in labours having a tendency to rapidity, are among
the most constant and mischievous vices of a meddlesome
midwifery.
But I must remark, more at length, on the practice of fre-
quent examination during labour. *' Taking a pain," as it
is termed, is necessary to ascertain the state of the parturient
canal, particularly the os uteri, and to ascertain the presenta-
tion and mechanism of the individual labour. Beyond this,
the manipulations frequently resorted to have no precise
intention, except it be to satisfy the mind of the: patient and
her friends, and impress them with the belief that the accou-
cheur is rendering assistance during the pains — a belief
generally without foundation. No principle has been recog-
nised in making examinations, nor any distinction made
between the effects of frequent digitation, in cases w^here
laceration or other dangers are impending from excessive
action, and others in which peril is incurred from inertia. I
believe that in the present practice of midwifery, particularly
among young accoucheurs, manipulation is more frequently
resorted to in acute than in tardy labours. There is a natural
anxiety not to have seemed to fail in rendering assistance in
those cases in which the most instant of the accidents of mid-
wifery occur ; and hence the fingers are almost constantly
within or at the mouth of the vagina. The idea is unfor-
tunately implanted in the minds of lying-in women, that the
accoucheur can render them mechanical assistance durinsf
each pam, and in accordance with this unfounded expecta-
tion, much useless show of doing so is often made.
228 TAKING A PAIN.
The application of the principle of nervl-motor action to
obstetrics, clearly shows the system of frequent examinations
during labour to be wrong in principle, and likely to produce
mischief, particularly in acute labours. No one having a clear
comprehension of the motor function of the uterus can doubt
that all manipulation of the parturient passages, from the intro-
duction of the hand into the uterine cavity, down to the gen-
tlest manipulation at the os externum, or at the os uteri, must
increase, in a greater or lesser degree, the muscular contrac-
tions which constitute a pain. The effects may not follow
instantly, because of the influence of the ganglionic nerves,
which has been already referred to, but the subsequent train
of reflex actions are most certainly increased in intensity,
however carefully the manipulation is performed. In tran-
quil labours the examinations may not produce any great
increase of excito-motor action, but in acute labours, where
the vis nervosa is very abundant, and the contractions of the
uterus and expiratory muscles are excessive, frequent ex-
aminations must necessarily prove injurious. They may oc-
casion laceration of the vagina or parinceum, rupture of the
uterus, or attacks of convulsion from their excitation of the
incident nerves concerned in parturition.
With respect, also, to the proper time for taking a pain, a
question may be fairly raised respecting the propriety of the
common practice, in violent labours. The introduction of
the hand during the persistence of a pain, when the nervi-
motor organs are in a state of great activity, can answer no
other purpose than that of imposing on the mind of the pa-
tient, while it is in many cases calculated to do positive
injury, as mechanical excitation during a pain calls forth a
greater amount of reflex motor action than when it is applied
in the remissions. This principle has been recognised and
acted upon to a certain extent in some cases by accoucheurs,
though it has not been applied to ordinary examinations.
For instance, we are always told, in performing the opera-
tion of turning, to press the hand onwards in the intervals
between the pains, but to keep it perfectly still while the
pains continue, lest. rupture of the uterus should occur from
the increase caused in the expulsive force by the stimulus of
the hand. Digitation is the same in principle, whether it be
within the uterus or at the perinccum, and it is absurd to have
one rule for manipulation in the one case, and a contrary
rule in the other.
TAKING A PAIN. 229
I belieV'C it may be laid down as a ride, that in well in-
formed women, when the uterus acts powerfully, when the
labour is progressing satisfactorily, and the presentation is
found to be strictly natural, no further manipulation should
be resorted to, except for the purpose of ascertaining pro-
gress, until the head of the child presents externally. This
is a point on which delicacy and science alike concur. If
frequent examinations are made while the uterus is acting
vigorously, it must be at the hazard of complicating the
labour, and causing accidents. Besides the mischief accru-
ing from increased action, digitation may weary the uterus
by constant action at the time when the os uteri or the ex-
ternal parts are undilated, — a serious waste of the uterine
power in delicate women, — or it may occasion the too early
rupture of the membranes, either by the hand of the opera-
tor, or by the energetic reflex actions w^hich its presence in
the vagina excites.
Two important rules for practice are clearly deducible from
a knowledge of the sources and modes of uterine action.
In the first place, manipulation should be avoided as much
as possible in acute labours, where the pains are severe or
frequent, and where any additional irritation of the excitor
nerves of parturition must increase the reflex action of the
uterus in the first and second stages, and of the uterus and
expiratory muscles in subsequent stages. In natural labours,
the expiratory actions do not commence until the os uteri
is dilated, and the head advanced to the vagina; but if the
vagina be greatly irritated by the examinations, they may
occur before their proper time. When the examinations are
clearly necessary in such cases, the hand or finger should be
introduced on the subsidence of one pain, and withdrawn
before the appearance of another; or the hand should be
kept quiet during the pains, so as to cause as little excitation
as possible. Dr. Rigbyhas already insisted upon this point.
It is not meant that cases may not occur in which manipula-
tion may be imperative, notwithstanding an excess of excito-
motor action; still the above will be found to hold good as
a general rule.
In the second place, where the action of the uterus is weak
and inefficient, examinations should be resorted to more fre-
quently, not merely for the sake of ascertaining progress, but
for a specific purpose — namely, to increase the reflex, uterine,
230 UTERINE EXCITATION.
and expiratory contractions, and thus to accelerate the deliv-
ery of the patient. Where the action of the uterus is feeble,
the examinations should be made during the continuance of
the pains, so as to increase their power.
The term excitation, in its application to spinal pathology,
has a peculiar meaning, very different from sensation or irri-
tation. It may be said that sensation belongs to the cerebral,
irritation to the vascular, and excitation to the true spinal
system. It cannot be too much dwelt upon, that there is no
relation whatever between pain and spinal action, whether
pathological or physiological. This one idea alone, when it
comes to pervade the whole obstetric art, w^ill, I have no
doubt, effect a great change in the practice of midwifery.
When any considerable augmentation of the vis nervosa
occurs in the spinal system, moderate stimulation frequently
excites stronger reflex actions than actual violence would do.
In the case of the stomach, we see the act of vomiting more
readily excited by tickling the fauces with a feather, than by
ruder measures. The part which is the excitor of vomiting
may even be ulcerated without exciting this act, so likewise
will gentle manipulation of the os uteri, under certain cir-
cumstances, produce more excessive motor actions than me-
chanical violence, or even rupture of the organ. This im-
portant fact, so capable of salutary application, has never
been more than faintly recognised. The stimulability of the
spinal system requires special study with reference to these
points; but no advance could be made without a knowledge
of the principle of reflex spinal action. Wanting this prin-
ciple, I believe the practice of taking pains, even in the most
careful manner, has caused nearly as many accidents as the
ruder forms of malpraxis. The uterus has been ruptured by
the uterine action excited by taking a pain, and a fatal con-
vulsion has been caused by even the cautious introduction
of the hand into the uterus. Denman relates a case of puer-
peral convulsions, in which gentle attempts at dilating the os
uteri during a pain, excited or increased the fits. Dr. Rams-
botham has detailed two most interesting cases in which
rupture of the uterus occurred while careful examinations
were being made at the acme of the pains. The same au-
thor also gives an interesting case of convulsion excited by
the introduction of the hand into the uterus for the purpose
of removing a retained placenta. Cases similar to the latter
SEDATIVES OF UTERINE ACTION. 231
are to be found in the works of other obstetric writers, and
have a most important meaning when viewed by the light
which physiology sheds upon the act of parturition.
And now for the reduction of this nervous polarity or
excitability, however induced, whether by irritation of the
extremities of the ovario-uterine nerves, by irritation of extra-
uterine nerves, by the influence of emotion, or by intra-
vascular causes. Let us trace the incident nerves, down-
wards from the nerves of the ovaria to the nerves supplying
the outlet of the vagina, examining^ those sources of irritation
\vhich admit of diminution or removal. We cannot forbid
the ovaria to exert that wonderful influence upon the uterus
which causes it to commence the expulsion of its contents, but
we can do much to prevent its becoming dangerous and ex-
cessive. There is a form of precipitate and severe menstrua-
tion as well as severe and precipitate labour ; and it has
often been observed that those women who suffer from dys-
menorrhcca invariably pass through severe confinements. In
dysmenorrhoeal cases, therefore, the ovarian periods of preg-
nancy should be as carefully treated as though dysmenorrhoea
were actually present. Rest ; the avoidance of physical ex-
citement; laxatives to keep the rectum free from irritation ;
with cold hip baths in the intervals between these periods,
are the best remedies. Properly managed, the most obstinate
dysmenorrhoea, w^hich refuses to yield to treatment in the un-
impregnated state, may be cured during the state of compa-
rative rest in which the ovaria continue during pregnancy.
The mere occurrence of gestation, without any unusual care,
will often effect a cure. At the time of labour itself, quiet
of mind and body, warm or opiate enem.ata, are the best
means for soothing the ovarian nerves. Little can be done,
however, during labour, compared with what may be effected
by way of prevention during pregnancy. It seems not im-
l^robable, that by the actions of labour, and the contractions
of the uterus and the abdominal muscles, a good deal of
pressure is exerted on the ovaria, sufficient to keep up their
excitability until the expulsion of the foetus. This pressure
may sometimes be the cause of oophoritis occurring after
delivery.
Bleeding is an important means of reducing uterine action.
A good deal of doubt is often expressed respecting the effi-
cacy of venesection in acute labours, because bloodletting is
232 SEDATIVES OF UTERINE ACTIO??.
frequently followed by rapid temporary contraction of the
litems. But this effect of depletion soon passes away, and
leaves the organ less excitable than before. There is, how-
ever, in different women, some variability in the influence
of bleeding on the excited uterus. The simple effects of
depletion in women of strong and full circulation are, I
believe, sedative; it lessens the effects of fulness of the cir-
culation upon the nervous system, and lessens the excita-
bility of the uterus itself, by diminishing the quantity of
blood circulating in the organ; but at the time of parturi-
tion, various modifying circumstances may occur. If there
should be fainting, the uterus contracts powerfully, if the
mind should be disturbed by the operation, there may be
powerful contractions depending upon emotion. These causes
may sometimes more than counterbalance the immediate
effects of bloodletting. It is in cases of fatal hemorrhage
that we see the immense influence of loss of blood upon the
uterine contractions ; here there is complete failure of the
nervous and muscular power of the organ. In moderate, or
free bloodletting, the effects are of the same kind, but within
the limits of safety. In acute labours, in subjects with a weak
circulation, bleeding is of course improper, and would fail of
its effects. In such cases, the avoidance of excitation must
be chiefly relied on.
Nauseating doses of the potassio-tartrate of antimony have
a similar eflTect to bloodletting, though less powerful, lis use
should not be pushed to emesis, or it will then excite uterine
contraction. Emetic tartar is well adapted for cases which
do not bear bloodletting, or to follow moderate venesection.
A further use of this medicine is, that by its action on the os
and cervix uteri it diminishes the chances of rupture and
laceration.
Opium is a remedy generally believed to have a sedative
effect upon the uterus when in action. It is prescribed in
numerous cases w- ith a distinct view to this eflTect. We have,
however, had no very clear account given of the mode in
which it acts upon tlie spinal system in parturition. I believe
the chief influence of opium, in calming uterine action, to be
limited to the control of emotion ; by removing or diminish-
ing pain and fear, it takes away some important causes of
uterine action. But it may indirectly increase uterine action
by inducing sleep, which is well known to recruit the uterine
SEDATIVES OF UTERINE ACTION. 233
motor power. I believe opium generally, by its purely phy-
sical anil direct effects, increases rather than diminishes ute-
rine action, and that this is the secret of its utility in uterine
hemorrhage. Looking to its physical action alone, it is ab-
surd that we should give opium before turning, to allay ute-
rine contraction (a constant practice), and that it should also
be given in hemorrhage to produce contraction (a practice
upon which many obstetricians rely). Some explanation was
necessary to reconcile these apparent contradictions in obste-
tric therapeutics.
Volition, which, when powerfully exerted in accordance
with the instinct of the patient, and in harmony with the re-
flex actions, is a source of mischief in acute and severe la-
bours, may be made a preservative. To this I have already
alluded when treating of the physiology of labour. When
w^e wish to use volition as an auxiliary to sedative measures,
we have simply to direct the patient to cry out, or to talk
during the pains, after the expiratory actions have commenced.
We thus thwart the reflex closure of the glottis, and suspend
the series of expiratory efforts, and their direct and indirect
action upon the uterus. This is often of essential value in
the latter part of the propulsive, and during the whole of the
expulsive stages.
'I'he regulation of emotion is also a point ()f considerable
importance in labours attended by excessive action. The
patient should be kept in a cheerful frame of mind ; her ap-
prehensions soothed or removed as much as possible ; and no
exciting or distressing intelligence should be communicated
(luring her hour of trouble. The accoucheur who studies the
control of the emotions of his patient has an immense advan-
tage over him who conducts a labour merely as a mechanical
process. He should arrange and combine both the moral and
physical powers of his patient, for her safety in the time of
trial: just as the pilot, with a richly-freighted ship under his
guidance, in a dangerous passage, studies every cord and
fibre of his vessel, estimates their strength and endurance,
learns where to direct the strain, where to defend from vio-
lence, and cheers and encourages the while, the human hearts
who depend upon his skill for safety.
I have seen it recommended, that in precipitate and severe
labour the abdominal bandage should be applied firmly round
the uterus, with the view of diminishing its excitement.
20
234 SEDATIVES OF UTERINE ACTION.
Nothing could be more mischievous than such a proceeding;
it would inevitably increase the force and frequency of the
uterine contractions by the mechanical pressure of the abdo-
minal muscles on the organ of labour. The use of the abdo-
minal bandage should therefore be reserved for cases of
moderate uterine action or uterine inertia. At the same time,
it must be borne in mind that it is in cases where the contents
of the uterus are precipitately withdrawn, that pressure, or
rather support, is most necessary to the abdomen after deliv-
ery; but here the bandage should be used, not with any
reference to motor action, but on the same principle as after
tapping in ascites — namely, to lessen the effects of the sudden
"withdrawal of pressure from the abdominal vessels.
In fine, in all cases of excessive action the patient should
lie down, and be kept as quiet as possible during the pains;
the rectum should be emptied by an enema early in the course
of the labour; digitation should be avoided as much as pos-
sible, and only resorted to, to ascertain the presentation, and
most cautiously, from time to time, to learn the progress of
the labour ; in the examinations, especial care should be taken
to avoid rupturing the membranes; and if the membranes
can be preserved without rupture until the dilatation of the
perineeum has been effected, so much the better. No pres-
sure should be made on the perinaeum, but the head should
be prevented by direct pressure from passing rapidly through
the ostium vaginae. Tlie mind of the patient should be kept
as tranquil as possible.
Labour is, as I have already remarked, sometimes so in-
tense as to be almost tetanoid in its character: it would in-
deed be quite proper to recognise a tetanic variety of partu-
rition. Here the avoidance of all emotional and physical
disturbance should be as absolute as in tetanus itself. Be-
tween the pains, perfect quiet should be preserved, and during
the uterine contractions all unnecessary excitation of every
kind should be avoided.
235
LECTURE XVI.
Rupture of the Uterus — Causes of this Accident — Excessive Motor Action
of the Uierus Itself — Prevention of Uterine Rupture — Importance of Mode-
rating Excessive Uterine Action — Laceration of the Perinaeum — Causes of
this Accident — Observations on the Prevalent Plan of Supporting the Peri-
naeum by Manual Pressure.
Rupture of the Uterus is perhaps the most appalling of
all obstetric acccidents. When rupture has occurred, the
utmost that art can do affords but a faint chance of the pre-
servation of life. Any suggestions, therefore, which tend
to throw light upon its causes, and to point out measures for
its prevention, are of great importance. To effect these ob-
jects, the study of reflex obstetrics will, I believe, prove
more adequate than anything which has hitherto been pro-
posed.
Rupture of the uterus has been attributed to softening of
the uterus during gestation, to deformity of the pelvis, to a
cutting action of the sharp linea-ilio-pectinea, to excessive
contractions of the uterus, to mechanical violence through
awkward or ill-timed attempts to turn the child, and to the
mechanical effects of unskilful instrumentation. Other causes
of less note have been enumerated, but the foregoing are the
most important. I do not think sufficient prominence has
been given to uterine motor action, which, in many cases, is
the sole cause of the mischief, and which plays an important
part in all. To this point, therefore, I shall principally ad-
dress myself in the present lecture.
It is an interesting and remarkable fact that rupture of the
uterus seldom happens to primiparous women. It is thus
opposed to laceration of the perinaeum, which occurs w^ith the
greatest frequency in primiparse. Some practical applications
must lie under circumstances apparently so enigmatical.
What are the peculiar differences between first and subse-
quent labours to which we can refer the antithesis which
exists between rupture and laceration? It appears to me, as
236 RUPTURE OF THE UTERUS.
the action of the dilatation of the perinEeum is almost purely
mechanical, it is quite natural that its distention in first la-
bours should be the most dangerous, while in subsequent
deliveries its distention or dilatation should be comparatively
easy. On the contrary, the actions of the uterus, both of
dilatation and contraction, are chiefly nervi-raotor, and it is
equally natural that the nervi-motor actions should become
more perfect and forcible with each succeeding labour. This
is the case with the reflex uterine actions, and not only so,
but the voluntary efforts of parturient women are more con-
siderable in multiparous than in primiparous women. Be-
lieving rupture of the uterus to depend on the contractions
of the uterus itself, in the great majority of instances, I see
in these circumstances a sufficient explanation of perinaeal
laceration in first labours, and of rupture of the uterus in
those which occur subsequently to the first. What I contend
for is this, that the uterus is not generally burst open by the
advancing foetus, or crushed between the foetal head and the
bony pelvis, w^hether natural or morbid ; but that it tears
and rends itself by its own contractions.
A strong proof of the importance of uterine contraction
in causing rupture is yielded by the fact, that sometimes the
peritonaeal coat of the organ is torn in situations and shapes
in which no mechanical pressure could have acted. In some
cases, the peritonaeal aspect of the uterus only is ruptured,
and the patient dies from hemorrhage into the peritonseum, if
any of the large uterine vessels are torn. Rupture may also
occur during pregnancy, either from disease of the uterus,
or from external injury, or violent contractions of the ab-
dominal muscles, or contractions of the uterus. It is gener-
ally said, in the latter case, to be caused by the movements
of the child ; but I have already given you my reasons for
attributing the supposed foetal movements to the uterus. Of
course, in pregnancy, there can be no suspicion of pelvic
pressure or distention by the foetal head. The accident is
more common, too, in labours with male than female chil-
dren. This appears to depend on the large size of the head,
and the consequent increased action of the uterus excited
by the head, and which is necessary to impel it through the
pelvis.
In some points of view we may compare rupture of the
uterus with rupture of the heart. It is remarkable that rup-
RUPTURE OF THE UTERUS. 237
ture of the left ventricle should be more frequent than rup-
ture of the right side of the heart. We now know that the
nerves of the left side of the heart are larger than those of
the right, and the greater muscularity of the left ventricle I
need not remark upon. These facts account for the frequency
of rupture on the left side of the organ, the heart, like the
uterus, being torn by the violence of its own contractions.
If rupture of the heart depended on any other general cause
than this, rupture of the right ventricle, as the weakest part
of the organ, must be most common; and it is a significant
fact, that in those rarer cases of rapture of the heart caused
by external injury, it is the right ventricle which is first and
most frequently injured. Among the more important causes
of rupture of the heart are violent and long-continued ac-
tions, excited by excessive emotional disturbance and violent
physical exertion. It is not probable, also, that violent and
prolonged muscular action, whether of the heart or of the
uterus, favours rupture by softening the muscular structure,
becoming thus a predisposing, as well as an actual, cause of
laceration? It is well known that in hunted animals the
muscles are found preternaturally soft. The prolonged
efforts of the uterus, in some cases of laborious labour, pro-
bably first induce softening, and then laceration. It is only by
observing all the facts of uterine rupture, and pursuing it
through its peculiarities and analogies, that we can acquire
a preventive knowledge of this fatal accident. ,
Many cases of rupture occur when the irritation exerted
in the parturient passage, and the uterine reflex action brought
to bear against them, is, from some obvious cause, greater
than usual. When, for instance, the hand and arm present,
or when the head is above the natural size.
Or the accident may take place at a moment when some
extra amount of volition, emotion, or extra-uterine reflex
action is brought to bear upon the uterijs. As, for instance,
when the patient is making voluntary efforts to evacuate the
rectum and bladder, or when the uterus is contracting forci-
bly from mental emotion, or during the powerful extra-uterine
reflex actions of vomiting. The situation of this accident
is most frequently at the os and cervix uteri.
In rare cases the whole of the os uteri is separated from
the rest of the uterus, and remains in the vagina, in the
shape of a ring. No mere mechanical pressure could effect
20*
238 RUPTURE OF THE UTERUS.
this; at least, it seems to me impossible to believe that the
pressure of the head of the child in a contracted pelvis cuts
through the uterine neck. I prefer to consider it the result
of muscular action of the body and fundus, combined with
rigidity of the os uteri ; the internal mechanical pressure of
the foetus, and the external pressure of the pelvis being ad-
juncts rather than principals, in causing the accident.
It is well known that the uterus is sometimes ruptured by
the violence of its own contractions when there is no foetus
within its cavity. Denman relates an interesting case from
the presence of a polypus in utero. Several years ago, I
witnessed a case in which it occurred from a collection of
hydatids. In these cases, uterine pains similar to those of
labour are excited in such force as to tear the structure of
the uterus. They offer an aditional proof that this accident
depends more on muscular contraction than upon mechani-
cal injury.
Undoubtedly, cases of rupture do occur which are de-
pendent upon softening of the uterus from inflammatory ac-
tion, either during or before labour, or upon malignant disease
of the uterus; but such cases are rare when compared with
rupture of the uterus from self-contraction; and while we
cannot often prevent softening, we can do much to prevent
excessive uterine and extra-uterine action of every kind.
There are also cases of rupture depending upon external
mechanical violence, but these are generally the result of
accidents beyond our control.
Rupture may occur under very difTerent conditions of the
uterus, as regards its motor actions. It may happen before
parturition has actually commenced, when the only contrac-
tions present are those wandering motions of the organ
which have been hitherto mistaken for the movements of the
foetus ; it may take place in the early part of labour, when
the OS uteri has not as yet dilated, and when the contracted
state of this part of the uterus is in direct antagonism with
the actions of the body and fundus ; or, lastly, it may occur
after the full dilatation of the os uteri, when the foetus has
fully engaged the parturient canal, and consequently, w4ien
the OS uteri has passed from a contractile to a dilatile condi-
tion, and is acting powerfully upon the foetus, in harmony
with the rest of the organ. The immediate cause of rupture
may either be some act of volition, or emotion, or it may be a
RUPTURE OF THE UTERUS. 239
reflex action, or a simple peristaltic action. Examples of each
of these forms of rupture can readily be selected from collec-
tions of cases.
Many high authorities have recommended that in all cases
in which there are premonitory signs of laceration, delivery
should be effected by artificial means. An idea that the
uterus will remain quiescent under the mechanical excitation
necessary to extract the child, seems to me but too evident
in this advice. Dr. Burns says, " When the pelvis is con-
tracted, and there is any symptom indicating the risk of lace-
ration taking place, the forceps are instantly to be employed,
for when such symptoms exist in any case when the forceps
are applicable, it would be criminal to delay." Another hio^h
authority. Dr. F. Ramsbotham, observes, " It would be more
desirable, indeed, if some precursors of this dreadful occur-
rence were discovered, that delivery might be efTected before
the laceration happened, and thus the peril be averted." And
again the same obstetrician remarks, "If by any symptoms
we could be previously convinced that the accident would
happen, it might always be prevented by timely delivery."
In framing this principle of treatment, I do not think the
motor cause of rupture has been sufficiently borne in mind,
or that the effects of manipulation and instrumentation in in-
creasing the motor actions of parturition have been properly
estimated. Yet these excellent authors, as well as many other
writers on obstetrics, have described cases in which the ute-
rus has been ruptured, evidently by the use of instruments,
or by manual interference. The study of motor action ena-
bles us to detect at once the fallacy involved in the recom-
mendation of that which frequently proves the cause of rup-
ture, as the best mode by which to avert it.
As I insisted in the last lecture, during the excitable con-
dition of the utero-spinal nerves present in parturition, no
manipulation or instrumentation can take place, either within
or at the entrance of the vagina, which does not, besides
its own mechanical effect, excite reflex motor action of the
uterus. The reflex action may not occur instantaneously on
the application of the excitation, which may be made in the
intervals between the pains; but when the pains arrive, the
irritation is necessarily felt in an increase of the contractile
actions. This fact alone should make us chary of applying
any new stimulus to the already over-excited uterus.
240 RUPTURE OF THE UTERUS.
In some of the most candid accounts of the immediate
circumstances attending laceration, it is seen that the rent
occurred at the very time when manipulation was going on,
and when the lacerating force was being increased by the
obstetric attendant. If a minute account w^ere generally
published, it is probable that this would appear to be the truth
in a greater number of instances. In a case recorded by the
eminent accoucheur I have already quoted (Dr. Ramsbotham),
the narration is as follows: — " I attended an unmarried
woman, pregnant w^ith her first child, who was in as comfort-
able circumstances as her situation would admit of. When
labour set in, the os uteri opened with no difficulty, and the
child was born in four or five hours from the time I was sum-
moned. She again became pregnant, but it was under dif-
ferent circumstances, and her mind was much more disturbed
than on the first occasion. On the accession of labour, the
membranes broke early, the pains soon became exceedingly
violent, the head was urged powerfully against the undilated
and rigid os uteri, irregular muscular spasms supervened, and
at the end of about five hours from the rupture of the mem-
branes, when the dilatation did not exceed the diameter of a
shillings while 1 was instituting an examination in the acme of
a strong pain, with the greatest possible care, I felt the os
uteri split on the right side, and I traced the rent consider-
ably upwards through the cervix. At the same moment, the
head passed into the vagina, and was expelled by the con-
tinuance of the same contraction. During the progress of
this labour, I bled the patient to syncope three diflferent times,
and exhibited opium freely, my mind being impressed with
a dread of the very accident which occurred. It is an instruc-
tive case, because it proves, that although an os uteri has re-
laxed and dilated readily in a first labour, it may, on after
occasions, possess a high degree of unnatural rigidity, and
that, too, independently of any discoverable disease in the
organ itself. It proves, also, that the much-vaunted power
both of bleeding and opium will not always avail in remov-
ing rigidity. The poor creature died, on the fourth day after
delivery, of uterine inflammation."
I would sincerely desire to avoid reflecting on the treatment
pursued in this case, but I conscientiously believe that a know-
ledge of the principles of reflex action would prevent manual
examination, as the rule, at the height of a strong pain in a
LACERATION OF THE PERINiEUM. 241
case of rigidity of the os uteri, in which, as in this, the rup-
ture of the uterus was dreaded. I say this, however, with a
full recognition of the impossibility of preventing the acci-
dent in some cases by the most judicious management.
In a second case related by Dr. Ramsbotham, the parti-
culars are somewhat similar. It occurred in a patient suffer-
ing from anasarca. " The os uteri, from the beginning of
labour, bore a thick, soft, puffy, oedematous character; its
dilatation proceeded slowly and painfully ; the membranes
broke at one in the morning, when it was dilated to the size
of a crown; at four, its diameter was little more; and while
I was in the act of examining^ during a strong pain^ as in the
last-mentioned case, I felt the uterus tear at the back part, in
a direction upwards."
The true preventive treatment in anticipated rupture of the
uterus, lies in the reduction of the excitability of the utero-
spinal nerves and their spinal centre, and in the avoidance of
all excitor causes of every kind whatsoever, which are not
inevitable to the particular labour. In fact, the treatment
must be essentially the treatment of excessive parturient
action, both uterine and extra-uterine, due regard being had
to the particular accident which threatens. When instru-
ments are used, operations performed, or medicines adminis-
tered, in such cases, one question should ever be before the
mind of the obstetrician, — Will the mechanical, or other ex-
pected advantage compensate, or more than compensate, for
the nervi-motor action certain to be excited by interference?
This question must be solved in every case, before the pre-
ventive treatment of this accident can be placed on its right
basis. One thing is perfectly clear to my mind — we ought,
in labours accompanied by excessive uterine action, no more
to use unnecessary irritation of the os uteri, than we should
use irritation of the rima glottidis in asthma or croup; of the
fauces in excessive vomiting; or of the sphincter ani in the
tenesmus of dysentery. The questions of the reduction of in-
flammation, of removing obstructions, and of affording me-
chanical aid, are all highly important in themselves, but they
are undoubtedly subsidiary to the nervi-motor condition of
the parturient organs.
Laceration of the Perinseum is by no means an uncommon
accident in midwifery. As I have already remarked, it is
242 LACERATION OF THE PERINEUM.
more frequent in primiparae than in subsequent births, while
rupture of the uterus is almost confined to post-prirnal labours.
It generally occurs during the pain by which the head or the
trunk is expelled through the os externum, and in most cases
it begins at the vaginal margin of the perinseum, extending
towards the anus, and sometimes throwing the two cavities
into one. Occasionally it happens that the rend takes place
in the middle of the perineum, the injury being so extensive
as to admit of the passage of the child, while the anterior
edge of the perineum remains perfect. My able colleague,
Dr. Robert Barnes, has made the interesting observation, that
a slight laceration of the anterior part of the vagina, similar
to that which so often occurs to a small extent in the poste-
rior raphe, is very common in first labours.
It is generally admitted that laceration of the perinseum
occurs from the head of the child passing through the vagina
so rapidly, that the perinseum has not sufficient time to dilate ;
the accident rarely happens where the labour is tedious or
protracted. Now, if it can be shown that the support of the
perinseura, which, in other words, means pressure applied to
the perinaeum, and to the posterior part of the vagina, does,
by exciting reflex action, increase the energy of the pains, it
would at once be granted, that such a practice must neces-
sarily increase, instead of diminish, the danger of laceration,
unless the mechanical pressure preserved the perinaeum in
some other way, so as to more than compensate for the in-
creased action of the expelling powers.
Denman, one of the most candid of all writers on mid-
wifery, seems to have had a vague suspicion of the ineffi-
ciency of the common plan, though, like most other author-
ities, he laid great stress upon the necessity of pursuing it.
Speaking of parturition in the lower animals, he says,
" Though no means are used to prevent the laceration of the
perinseum in quadrupeds at the time of parturition, it is
remarkable that they are rarely or never liable to it, except
in those cases in which the necessity of their situation is
supposed to require assistance It is therefore reason-
able to suppose that the frequent occurrence of this lacera-
tion in the human species, allowing that it is in some cases
and in some degree unavoidable, ought to be imputed to
some accidental cause, or to error in conduct, rather than to
any peculiarity in the construction of the part, or in the cir-
LACERATION OF THE PERINiEUM. 243
cumstances of their parturition, because, when women are
delivered without assistance, I have not in any case observed
any very considerable hiceration." In another part of his
work he repeats, that " none of the classes of animals are
ever liable to a laceration of the perinaeum, except when
extraordinary assistance is given in cases of otherwise insu-
perable difficulty, and it is well known that the laceration in
any important degree does not universally, or perhaps gener-
ally, happen to those women who are delivered before
proper assistance can be given." On another occasion he
admits that one of the most desperate cases of laceration
which ever occurred in his practice, was in a lady with
whom he had been most assiduous (on the ordinary prin-
ciple of supporting the perinseum) in his endeavours to pre-
vent it.
Dr. Collins considers that frequent examinations in slow
labours excite inflammation, and that they are " a very fre-
quent cause of lacerations of the perineum, as in proportion
to the amount of inflammation in this part, the more reluc-
tantly will it be found to yield to the passage of the head,
and the more likely is laceration to be the consequence."
Dr. Fleetwood Churchill is still more decided : '' I really
believe that it would be better not to touch the perina?um at
all, than to make injudicious pressure. It has been my lot
to witness more than one case where rupture was owing to
excessive and injudicious support." In continental prac-
tice, laceration is very, common, and continental accou-
cheurs not only support the perineum, but apply various
unctuous substances, and dilate the vagina, by introducing
the closed fingers, and then opening them so as to stretch
the parts in the intervals of the pains. Thus, it is evident
that laceration may occur when the greatest attention is paid
to the management of the perinseum on the recognised plan,
and that some authorities consider this great anxiety about
it, together with the manual interference it gives rise to, as
one cause of laceration. Those, however, who have held
this opinion, have thought chiefly of the inflammatory state
of the parts which digitation produces. Little or nothing
has been said about the increased motor action which such
irritation excites.
Now to the question — Does irritation of the perinseum
excite reflex actions of the uterus and the respiratory mus-
244 LACERATION OF THE PERINEUM.
cles? All the egestive canals are under the control of the
spinal marrow, and there is certainly no other instance in
which irritation of any part of the canal does not excite the
expulsive act. The excitor power, too, is generally most
abundant about the external orifices. We see this in the
sneezing produced by irritation of the nostrils, the vomiting
from tickling the fauces, the cough from irritation of the
larynx, and in many other cases. In the same way that the
OS uteri is the most powerful excitor of uterine action, so I
believe the os externum to be the part of the vagina most
strongly excitor of the expiratory muscles. At other parts
of the labour, the child often remains stationary ; but when
once the pressure of the head is brought to bear on the edge
of the perinaeum, it is speedily followed by the most forcible
pains which occur in the whole course of labour, and which
do not cease until the patient is either delivered or exhausted.
I have frequently observed that the moderate pressure recom-
mended as a guard to the perineeum, in which this strongly
excitor surface is irritated on the one side by the advancing
head, and on the other by the hand of the accoucheur, exerts
a sensible influence upon the pains, increasing both their
frequency and force ; and I have obtained the same admission
from many experienced accoucheurs. I know of many gen-
tlemen largely engaged in midwifery practice, who, without
attempting to account for it on principles similar to those I
have advanced, are so convinced from experience of the
mischief of supporting the perlnaeum, that they entirely avoid
it. This view of perinaeal irritation was one of the first
things which occurred to me when I began to investigate the
function of parturition and its diseases by the aid of reflex
physiology.
The consequences of the accident, when it occurs to such
an extent as to preclude the adhesion of the fissure by sur-
gical means, are truly deplorable. The subjects of it are
entirely unfitted for the conjugal state, and in many cases
there is no power of retaining the faeces. I have seen in-
stances where the unfortunate sufferers were compelled to
sit throughout the day on a bed-chair, and to sleep at night
on a prepared mattrass, because of the injury to the sphincter
aui. Happily, at the present time, autoplastic surgery
promises to do mudi for the relief of such miserable suf-
fering. Still, extensive laceration must always be a very
serious matter.
LACERATION OF THE PERIN.^UM. 245
The prevention of (his accident is always an object of
solicitutie to the accoucheur, even in the most perfectly
natural hibours. The chief rule laid down by the great
majority of obstetric writers is the support of the perineeum
by the hand during the passage of the head and trunk. This
we are directed to do with the most unremitting perseverance
when there is an apprehension of rupture. The late Dr.
Hamilton stated that he had supported the perineum for
nine hours together, without intermission! i'his mode of
prevention is generally considered as almost infallible ; and
when laceration of the perina:um takes place in spite of it,
the young practitioner generally blames himself for not
having been sufficiently assiduous in its protection. Pressure
on the part liable to the accident — simple mechanical pres-
sure— is the chief thins: recommended when the labour is
acute, or the perinaBum unyielding, soothing fomentations,
the evacuation of the rectum, the application of soothing
ointments, &lc., being applied as accessories. Now I confess
I do not know a more absurd situation than that of an accou-
cheur, doomed to squeeze the sphincter ani for hours together.
Not that I would for one moment ridicule any practice which
could be useful, for utility is before and above all in the
practice of our art ; but I believe this plan to be well nigh
as useless as it is absurd — in fact, it seems a true reliquum
of the midwife, and it would be no small boon to obstetrics
to relieve it from such a barbarism altogether.
Even if there were no such principle as reflex motor action,
and no danger whatever of exciting inflammation, it may be
fairly questioned whether the long-continued pressure of the
hand acting in a merely mechanical manner, is so adequate
to support the perineum as is generally supposed. Pressure
on the mouth of a distensible tube through which a large
solid body is passing, can have little eflect in preventing
laceration, unless it does this by preventing the advance of
the distending body. It is not a little singular, that pres-
sure exerted on the os uteri by the head of the child within,
and the rim of the pelvis without, should be considered a
common cause of rupture of the uterus, while the pressure of
the perinaium between the hand of the attendant and the
head of the child, should be deemed a means of preserving
this part from laceration ! There is no such great difference
between the structure of the two parts, and the circumstances
^\
246 LACERATION OF THE PERIN^.UM.
in which they are placed, as to warrant the opposite conclu-
sions so generally arrived at.
The knowledge of the principle of reflex motor action
would teach us that in acute labours, in which lacera-
tion chiefly occurs, where the pains are excited in sufficient
or excessive force by the foetus, all external sources of motor
action should be avoided. On the other hand, in cases
where there is no danger of accident, when the pains are
weak or deficient, external means of exciting parturient
action may be resorted to beneficially. It follows, from all
I have said, that if there be any truth whatever in the exist-
ence of excited motor actions in labour, from irritation of
the parturient canal, pressure on theperinseum and posterior
part of the vagina is resorted in those cases where there is a
possibility of its being mischievous, and avoided when it
might prove serviceable.
Still there is one way in which I believe the support of
the perineum by the hand may be of service, and which
indicates distinctly the proper mode of managing cases in
which the danger of laceration exists. This is by mechani-
cally retarding the advance of the head. If by exerting
pressure we excite uterine action, and at the same time pre-
vent its eflfects by retarding the head, we do wrong and
right at the same time, and the right may more than counter-
balance the wrong; but if we practise the right alone, the
gain will be far greater. This we may do simply by moder-
ate pressure on the head of the child. I apply this pressure
by the tips of the fingers and the thumb of the right hand,
arranged so as to press in an annular form upon the present-
ing part. By acting thus we do no injury to the child; we
retard the advance, but we excite no unnecessary and unna-
tural motor action. The only circumstances in which I would
recommend perineal pressure are in those cases in which the
perinffiura is largely developed in its posterior portion, and
where the head of the child, instead of advancing under the
pubic arch, is urged very forcibly against the posterior por-
tion of the perina:um, the anterior being little dilated. In
some cases of this kind, support is advisable, the motor ac-
tion excited being of less consequence than the retardation
of the head, which is advancing in an improper direction.
But besides the immediate management of the periniTum,
much may be done in the way of precaution during the pro-
LACERATION OF THE PERINM^UM. 247
gross of labour. Where there is the apprehension of this acci-
dent, the indication throughout is to raorlerate the motor
action, so as to give time for the gradual dilatation of the os
externum. To fulfil this, the examinations should be as
seldom as may be consistent with proper attention to other
points, such as ascertaining the presentation, and making
those changes in the position of the presenting part which
may be required. Great care should be taken to preserve
the membranes entire until the os uteri is fully dilated; it is
even beneficial if they should remain unbroken so as to act
with fluid pressure on the perineum. Besides attention to
these points, the rectum, the bladder, and the stomach, should
be kept from irritation, lest these organs should become ex-
citors of unnecessary parturient action. Volition and emo-
tion require to be cautiously regulated ; as both voluntary
emotional motor efTorts frequently produce laceration. The
best mode of preventing this is to encourage the patient to
cry out, the open state of the glottis taking ofT the pressure,
and rendering voluntary and emotional efforts alike impossi-
ble. Emotional motor action may often be thus neutralized
by exciting a voluntary cry; but sometimes emotion is so
powerful as to defy this control; the woman, in a state of
desperation almost amounting to rage, makes the most tre-
mendous efforts at expulsion : in such cases, Denrnan states
that he has obtained a respite by suddenly tellirig her that
the child was actually born!
248
LECTURE XVII.
Rigidity of the Os Uteri — Different Forms of Rigidity — Treatment — Encysted
Placenta — Nature and 'JV^^atment of this Affection — Hour-Glass Contrac-
tion— Seats of (contraction — Its ('auses and Treatment — Inversion of the
Uterus — Mechanical and Moti)r 'I'heories — Description of this Accident—
Ke-position of the Uterus — After-Pains — Their Causes and 'J'realmtnt.
RIGIDITY OF THE OS UTERI.
In a former lecture of the present course, when giving the
physiology of the dilatation of the os uteri, I described the
contractile and the non-contractile tissues of which this part
of the organ is composed. I endeavoured, at the same time,
to show that the opening of the os uteri during parturition,
depends, in part, upon the mechanical distention of the non-
contractile tissue, and partly upon the muscular dilatation of
the contractile fibres which enter into the composition of the
OS and cervix uteri. Rigidity of the os uteri in labour may
consist either in the absence of distensibility or of dilata-
bility, or in both of these states combined. The rigidity
may be perfect, the os uteri remaining quite undilated, or
it may dilate to a certain extent, and then refuse to yield
farther.
During the premonitory and the succeeding stage of la-
bour, particularly w^ith a first child, and still more when a
first labour occurs late in life, the distensile element is fre-
quently hard and unyielding. In multiparae also, when con-
tusion or injury has occurred in former labours, or when the
OS and cervix have been the seat of disease in the unimpreg-
nated state, this form of rigidity is very common. It also
occurs in cases in which the os uteri is heated, irritable, or
inflamed, and where it is consequently not lubricated by the
customary secretion. This form of rigidity is precisely similar
to rigidity of the perina^um.
The other form of rigidity occurs in cases where the causes
of acute labour or of excessive uterine action are in opera-
RIGIDITY OF THE OS UTERI. 249
tion. Instead of the kindly physiological dilatation of the os
uteri during the contractions of the body and fundus, the os
uteri contracts with the rest of the organs, thus reversing its
proper function. The contraction continues also, or the part
remains rigid, in the intervals betv^'een the pains. Any irri-
tation of the OS uteri, whether by the head of the foetus when
brought to bear against it during a pain, or by the finger of
the accoucheur, causes it to contract still more firmly. It is
in this form of sphincteric rigidity that rupture of the uterus
is to be especially dreaded.
In numerous cases, both the muscular and mechanical forms
of rigidity exist, and mechanical rigidity is itself sometimes
a cause of spasmodic closure of the os uteri. The heat and
irritability of the os uteri render it morbidly excitable, and
the pressure of the liquor amnii, or the presentation, instead
of exciting a reflex dilatation of the mouth of the uterus, ex-
cites it to spasmodic contraction. As I have before observed,
this state may be considered as a tenesmus uteri, and it is
analo2;ous to the tenesmus affectino; the bladder and rectum,
in certain of their disordered conditions.
The treatment of rigidity of the os uteri niust have refer-
ence to its twofold nature, and must be modified according
as the rigidity is chiefly mechanical or sphincteric in its
nature.
Time and patience, waiting for the result of the uterine
actions, and avoiding all uterine excitation, are generally
sufficient to overcome the ordinary cases of rigidity, espe-
cially if the liquor amnii has not been evacuated. At every
pain there is a physiological attempt to dilate the os uteri,
and this at length succeeds in most cases, except in those in
which the os uteri is diseased.
In plethoric cases, bleeding is often of great use; it tends
powerfully to lessen the mechanical rigidity, and to promote
the yielding of the sphincteric contraction. Bleeding from
the arm is generally practised, but I have no doubt that in
some cases not admitting of general depletion, and irredu-
cible by other means, the application of leeches to the os uteri
would prove of great service. Leeches are now so frequently
applied through the speculum to the os uteri, for disorder of
the unimpregnated uterus, that there could be no objection
to their use during parturition. Nauseating doses of anti-
mony, or ipecacuanha, are important remedies in rigidity of
21*
250 ENCYSTED PLACENTA.
the OS uteri; they act, in the first place, by diminishing the
mechanical rigidity, on the same principle as they act in
strangulated hernia ; and in the next, they promote the mus-
cular dilatation of the uterine mouth, by producing nausea,
and thus bringing the reflex relation between the uterus and
the stomach into play. The reflex relation which exists
between the cardia and the os uteri, which I have so often
referred to, is most valuable as a therapeutic agent. Warm
eneraata are also useful in rigidity; they act upon the uterus
as a local fomentation, and they excite arrother salutary reflex
action — namely, that which exists between the sphincter ani
and the os uteri. The dilatation of the sphincter ani, and
even of the sphincter vesicse, exerts a sensible influence upon
the OS uteri, when its closure is simply or chiefly sphincteric.
A w^arm bath, or a hip-bath, or warm fomentations, tend to
relax both contractile and mechanical rigidity. In those
cases of closure of the uterus, arising from insuperable
rigidity of the non-contractile tissue, the ultimate remedy is
incision of the os uteri, at the most rigid portion of the ring
it presents. In cases in which rigidity is irreducible by
ordinary means, and consists of sphincteric or spasmodic
contraction, the os uteri may be sometimes dilated mechani-
cally by the fingers, or if this should be impossible, or if danger
should be apprehended, incision into the os uteri is necessary
here also. But in all kinds of manipulation at the os uteri,
the utmost caution ought to be observed, lest rupture of the
uterus, or convulsions, should be excited by the means taken
to avoid a lesser difficulty.
ENCYSTED PLACENTA.
This is an uncouth name sometimes given to cases in which
the sphincteric contraction of the os uteri comes on rapidly
after parturition, before the placenta has been expelled.
The placenta, in these cases, may be either attached to the
uterus, or it may have been thrown off, and be lying close
within the contracted os uteri. This complication is most
common after acute labours, or in prolonged labours, where
the pains have been excessive, up to the time of delivery.
Excepting that it occurs after delivery, instead of in the early
stage of parturition, it is comparable to that form of rigidity
in which sphincteric contraction of the os uteri is predomi-
ENCYSTED placp:nta. 251
nant. Owing to the increased mobility which the os uteri
acquires during the progress of labour, the post-partum con-
tractions are more forcible than any active contraction which
occurs before delivery ; and the rigidity is never mechanical,
because of the great dilatation which has occurred during
the progress of the labour.
In treatment, it is of considerable importance to deal
promptly with these cases. The longer the os uteri remains
contracted, the more difficult will its dilatation, so as to ad-
mit of the extraction of the placenta, become. If the placenta
can be felt close to the os uteri, gentle but firm traction of
the cord, held as near as possible to its root in the placenta,
should be used, so as to convert the placental mass into a
dilator. If this plan should not be successful, the os uteri
must be slowly dilated by the fingers, so as to admit the
hand or fingers, according as the placenta may be required
to be detached from the uterus, or merely withdrawn from
the cavity. The utmost gentleness consistent with the
necessary force should be employed ; and if necessary, any
threatening of convulsion or laceration should be prepared
for by bloodletting. If the patient's mind should be excita-
ble, or the dilatation of the os uteri should be painful, an
opiate is of great use; but it acts rather by soothing mental
emotion and allaying pain, than by reducing the spasm of
the OS uteri. We can often beneficially assist the eifects of
traction of the umbilical cord in dilating the os uteri, by gentle
pressure exerted externally upon the abdominal surface at
each recurrence of the uterine contractions; svveeping the
placenta as it were into the pelvis and towards the os uteri,
by the hand, while steady traction of the cord is being kept up.
The foregoing remarks apply to cases in which the placenta
is either whollv adherent to the uterus, or the uterus at laro^e
IS so firmly contracted upon the separated placenta as to pre-
vent internal uterine hemorrhage. Cases, however, occur,
in which spasmodic closure of the os uteri is attended with
separation of the retained placenta, and inertia of the body
and fundus. In such cases, dangerous internal hemorrhage
is inevitable, and the removal of the contraction of the os
uteri becomes quite secondary in importance to the arrest of
the hemorrhage. Our first object here must be to excite
such an amount of uterine contraction as to stay the loss of
blood. In all cases where the first ste])S taken for the dilata-
252 HOUR-GLASS CONTRACTIONS.
tion of the os uteri, which of themselves tend to produce
uterine contraction, are ineffectual, the uterine inertia should
be treated most energetically per se, without any reference
to the state of the os uteri.
HOUR-GLASS CONTRACTION.
In some cases of retained placenta the uterine spasms is not
situated at the os uteri, but at the junction of the cervix uteri
with the body of the organ; in the same situation, in fact, as
the narrow portion of the organ in the unimpregnated state,
and at which the greatest resistance is met with in the intro-
duction of the uterine sound. In other cases the constriction
is still higher up, involving the body of the uterus, being
similar in its nature to those band-like spasmodic contrac-
tions, which are sometimes observed in the large intestine.
In the lower animals, where the uterus in its anatomy resem-
ble an intestine, there can be no difficulty in understanding
this form of annular contraction.
In other cases, the hour-glass contraction occurs after the
separation of the placenta, when it may be the cause of in-
ternal hemorrhage, because of the inertia of that portion of
the uterus which is above the stricture. After the expulsion
of the fcetus, the contractions of the uterus ought to be uni-
form in the entire organ, so that in hour-glass contraction
there is always a double departure from the physiological
condition of the uterus ; there is both spasm and inertia.
The treatment of these cases must be conducted on the same
principles as cases of sphincteric contraction of the os uteri; but
we have an additional remedy, of considerable efficiency, in
frictions applied to the abdomen over the uterus. True and
complete hour-glass contraction is a rare affection; but in
very many cases of post-partum hemorrhage, portions of the
uterus are spasmodically contracted, while others are so re-
laxed as to admit of the flow of blood from the mouths of the
vessels on its internal surface. Occasionally it happens that
one lateral half of the uterus will be contracted while the
other half is relaxed. In cases of hemorrhage, with hour-
glass contraction, there may be no escape of blood per vagi-
nam, the effiised fluid being confined in the upper chamber
of the uterus by the stricture.
The causes of the hour-glass contraction may be any of the
INVERSION OF THE UTERUS. 253
causes of acute, irregular, or tardy labour ; but it most gener-
ally occurs after rapid parturition, particularly the rapid
transit of the child through the external parts. Coagula in
the uterus, the retained placenta, or improper traction of the
cord, and mental emotion, are all exciting causes of the acci-
dent.
INVERSION OF THE UTERUS.
This accident has sometimes been attributed to inverted
action of the uterus, but more generally to mechanical trac-
tion of the cord, and to injudicious attempts at removing the
retained or adherent placenta. When inversion is referred
to traction of the umbilical cord, whether in consequence of
a short funis, the sudden birth of the foetus while the mother
is in the upright position, or the attempts of the obstetrician
to remove the placenta, it is always believed to depend on
the merely mechanical force which is in operation. It is
considered that the fundus uteri is dragged down mechani-
cally through the os uteri and vagina, the uterus being sup-
posed to be passive during the occurrence of the inversion.
From the best consideration I have been able to give the
facts of inversion, I am persuaded that it depends in all cases
mainly upon an active condition of the uterus. Where it
takes place without any mechanical interference, there can
be no doubt of the preternatural and perverted activity of the
uterus. But I am convinced, that even in cases where the
placenta is attached to the centre of the fundus, and when
the cord is drawn through the vagina with any amount of
force likely to be exerted by an accoucheur, it is not a mere
mechanical displacement which produces the accident, but
the irritation of the fundus uteri, by traction, excites con-
traction of the fundus, thus producing that contraction and
descent of the fundus uteri, which is the first stage of the
accident. The common opinion has, very naturally arisen,
from observing, in some cases, that the fundus uteri, when
the placenta is firmly attached, follows the advancing cord,
while traction is being used. According to my view, the
depression of the fundus uteri, even in these cases, is not a
simple yielding of the part, according to mechanical princi-
ples, hut an active contraction, excited by the irritation of
the fundus uteri by the traction of the placenta.
To pursue the steps by which complete inversion is pro-
254 INVERSION OF THE UTERUS.
duced. There is first, cup-like depression of the fandiis
uteri ; coincident with, or immediately following upon, this
depression, there is hour-glass contraction of the body or
lower portion of the uterus. The annular contraction of the
body of the uterus grasps the introcedent fundus as it would
a foreign body, and carries it downward, for expulsion
throusfh the os uteri, the os uteri beincj at this time either in
a state of inertia, or actively dilated, just as at the end of
the second stao^e of labour. After the inverted uterus has
passed through the dilated os uteri, this part of the organ
becomes contracted, preventing reversion from taking place.
Thus, there is, first, depression of the fundus uteri, with
annular or hour-glass contraction of the body of the uterus,
and dilatation of the os uteri. Next, there is intus-susception of
the fundus by the body of the uterus. Lastly, complete inver-
sion occurs, with contraction of the os uteri upon the inverted
organ. If we wished to describe this accident in three
words, they would be — introcession — intus-susception — in-
version. The displacement may not be complete; it may
in some cases stop at introcession; in others, at intus-suscep-
tion, and then return to the natural state; or it may remain
intus-suscepted. Inversion produces violent disturbance of
the nervous system, and is frequently attended by alarming
hemorrhage. But the symptoms of the intus-suscepted uterus
are still more violent. The strangjulation of the fundus is
almost as severe a shock to the system as actual rupture. In
inversion, the hemorrhage is somewhat arrested by the os
uteri acting as a tourniquet to the uterus. We may com-
pare perfect inversion of the uterus to intus-susception of
the intestinal canal, only that the intus-suscepted portion of
intestine is not protruded externally. Probably, many cases
of prolapsus ani should be called inversion of the rectum,
rather than prolapsus.
Inversion generally occurs quickly after the delivery of
the foetus, between the expulsion of the child and the expul-
sion of the placenta. I have known it to take place after
the death of the mother, and after rupture of the uterus had
occurred. In the latter case, the foetus was passed into the
j)eritonaeal cavity, while the uterus became inverted, and pro-
truded through the vagina. The predisposing causes of
the accident are the causes of acute labour and excessive or
irregular action of the uterus. It is of very great importance
AFTER.PALNS. 255
to understand clearly the real nature of inversion, as it is
one of those accidents which is most confidently referred to
rnal-practice. The less it is considered a mechanical dis-
placement, the less tlisposition will there he to attribute its
occurrence to the accoucheur; owing to the prevalence of the
mechanical idea, obstetricians have sometimes been blamed
most unjustly in cases of inversion.
The treatment consists of the mechanical re-position of the
uterus. Immediate steps should be taken to reduce the in-
version, because of the rapidly increasing contraction of the
OS uteri, which, by impeding the circulation, causes an in-
crease in (he size of the tumour. The size of the uterus
should be reduced as far as possible by pressure, and by de-
taching the placenta in cases Vvhere it still adheres. By
moderate but sustained force the uterus is then to be passed
up through the vagina and os uteri. After the organ has
been partly passed through the os uteri, the muscular action
of the uterus itself assists in restoring it to the proper posi-
tion. It is reinstated with a sudcien jerk, causing a consider-
able report at the moment of its restoration. In cases where
intus-susception exists, the hand must be passed through the
OS uteri, so as to overcome the annular contraction, and to
restore the intus-suscepted portion to its projjer position.
Cases of intus-susception and inversion require careful
watching until the uterus has permanently contracted,
AFTER-PAINS,
A certain amount of periodic uterine contraction after la-
bour, attended with some degree of pain, is strictly physio-
logical, the object to be effected being the safe and permanent
contraction of the uterus. When these pains are excessive
or long-continued, they become pathological, and are then
proper objects of treatment. Some accoucheurs, believing
them to be always beneficial in their results, are very jealous
of any attempts to moderate their force or duration ; but there
can be no doubt that, if unchecked, they will, in come cases,
pass on to metritis and other morbid conditions of the uterus,
or they may excite an attack of puerperal convulsion.
'Whilst a physiological amount of after-contraction of the
uterus should never be interfered with, excessive or patho-
logical action should always be moderated, if possible. It
256 AFTER-PAINS.
is true that we sometimes observe morbid after-pains, by ex-
pelling coagula from the uterus, effect their own cure, in
removing the source of irritation, just as we see vomiting
or purging relieve themselves by the rejection of morbid
matters from the stomach and intestinal canal ; but we often
see vomiting or diarrhcea, when once induced, continue long
after the irritating matters have been expelled. And so it is
with the uterus. The one is as legitimate and imperative a
subject for treatment as are the other two.
At each after-})ain the entire uterus is contracted into a
hard and painful ball, or it is irregularly contracted so as to
feel firmer in some places than in others. It often happens
that each after-pain is attended by a discharge of coagula,
or of the lochial fluid, though sometimes there is an absence
of all discharge per vaginam. In ordinary cases, after-pains
increase in severity with every succeeding labour, and as a
general rule, they are more troublesome the shorter the
duration of the individual labour. Cases, however, occur
— those in which there has been dysmenorrhoea, with great
irritability at the ovarian periods of pregnancy — in which
after-pains are very distressing in primiparse. As to the seat
of the pain, it is partly uterine and partly lumbar, the latter
probably being dependent upon the ovaria. Sometimes the
contractions are not confined to the uterus, but the abdominal
muscles become affected, cramps or spasmodic twitchings of
the limbs occur, and the pain which begins in uterine con-
traction alone, may, by an extension of reflex action, termi-
nate in convulsion.
The main cause of excessive after-pains consists in the
excitable condition in which the uterine and ovarian nerves,
both as regards reflex action and sensation, are left after
parturition. In this state of excitability, the uterus is roused
to contractions by the ovarian stimulus, by the state of the
surface from which the placenta has separated, by coagula
within the uterus, and by various extra-uterine stimuli.
Thus, when the after-pains are excessive, the physiological
reflex relations between the breasts and the stomach, and the
uterus, excite the most painful action of the latter. The
patient can neither drink nor apply the child to the breast
without renewing the agonies of labour. Any emotional
disturbance aggravates the suffering; the acts of coughing,
sneezing, defecation, micturition, or even voluntary move-
AFTER-PAINS. 257
ments of the patient in changing her position, &c., pro-
duce violent pains, chiefly because of the compression of
the uterus by the abdominal muscles. But the uterus is
sometimes in such a tetanic state that the slightest movement
of any part of the body excites it to violent spasmodic action.
The treatment of after-pains is very simple. It consists in
the removal of coagula from the vagina and os uteri, the
avoidance of all the extra-uterine causes of uterine contrac-
tion, and the application and administration of opiates. A
great objection is made to opiates by some persons, as I have
already said. I do not, however, believe that a moderate, or
or even a full dose of opium, really weakens the uterine
contractions; on the contrary, I believe it allays the sensi-
bility of the uterus, and at the same time increases rather
than diminishes its contractility. Gentle friction with the
linimentum opii over the abdomen is often very useful; but
I have found still greater benefit from the application of this
liniment to the mammse. By a reflex action it allays the
excessive sensibility of the uterus, \vhen thus applied. Pro-
bably, when applied to the abdominal surface, its sedative
influence is also of a reflex kind. The sensorial connection
between the nerves of the abdominal surfiice and the ab-
dominal and pelvic organs is very striking in some diseases.
For instance, in peritonitis, there is actual and intense ten-
derness of the skin of the abdomen in addition to the tender-
ness of the subjacent peritonaeum. This is a slight digres-
sion; but I mention it to show the reflex sensory connection
between the surface and internal organs, which in the case
of after-pains, may be made of considerable therapeutic
service.
In excessive after-pains, without hemorrhage, "without the
presence of coagula, and in the absence of the other signs
and consequences of inertia, the infant should not be applied
to the breast for some hours after delivery ; not, in foct
until the uterus has become calmed from its state of morbid
excitability. Early and constant stimulation of the breasts
by the child is a common cause of irritable uterus for many
days after delivery. This agency, so salutary in all cases of
impending inertia, is often made, unnecessarily, a cause of
miserable sufl'ering, at a time when the patient is little able
to endure it, and without any counterbalancing good, if the
uterus has contracted healthily. I repeat, we want no more
22
258 ANALYSIS OF MORBID ACTIONS.
than safe contraction ; every after-pain beyond this point is
both unnecessary and mischievous. By excessive stimula-
tion of the uterus after delivery, the foundation is often laid
of prolapsus or procidentia.
It will be useful to compare all these irregular actions
with each other. The resemblance between Rigidity of the
OS uteri and the most simple form of Encysted Placenta —
namely, sphincteric closure of the os uteri with retention of
the placenta — is at once obvious. The same contracted state
of the OS uteri is present in Inversion, after the uterus has
descended through the os uteri. In the form of encysted
placenta, or irregular action of the uterus, constituting Hour-
glass Contraction, we have precisely the same condition of
the middle portion of the uterus as that which obtains in the
second stage of inversio-uteri. In simple hour-glass con-
traction, the cavity of the uterus is divided into two parts by
the contraction of the middle portion of the organ ; but when,
owing to irregular action of the fundus, this part of the organ
descends into the cavity of the uterus, and the hour-glass
contraction then occurs, the fundus uteri is seized by the
contracting ring of the uterus, borne down through the os
uteri and vagina, and inversion is thus rendered complete.
After the inversion, the os uteri, which dilates to allow the
inverted uterus to pass, becomes firmly contracted. Again :
all these abnormal actions, occurring after delivery, are but
modifications of excessive Aftcr-Pains. In severe after-pains,
it is easy to feel with the hand that the uterus becomes hard
and prominent at particular points, and soft and depressed
at others. From these irregular contractions the more serious
irregularities of uterine action arise. Sphincteric closure of
the OS uteri prematurely, is the most simple derangement ;
next comes the annular contraction of the upper part of the
cervix, or the body of the uterus, in hour-glass contraction ;
and lastly, the phenomena of inversion, which is the most
compound of all these disordered actions. Thus, rigidity of
the OS uteri, encysted placenta, inversion of the uterus, hour-
glass contractions, and excessive after-pains, are merely
modifications of irregular uterine action, and they are all
convertible one into the other.
These views materially simplify our comprehension of
these post-partum accidents. Hitherto they have only been
CASE OF ACUTE LABOUR. 259
treated of in an isolated manner, and with little reference
to uterine physiology, or their evident relationship to each
other.
[Since the publication of the former lecture, the following
case has been communicated to me. It illustrates much that
I have said in the last three lectures, when treating of acute
or precipitate labour, and excessive uterine action. I gladly
insert it here, because I am sure that no one can give more
sound or trustworthy testimony on such a subject than my
friend, Mr. Henry Smith, the relator of the case, who, though
he has written little, has, I venture to say, performed a larger
number of physiological experiments than any other man
in Europe of the present day. Many years ago. Dr. Marshall
Hall dedicated his work on the Circulation of the Blood to
this gentleman, who had aided him in the performance of
the extensive series of experiments upon which that work
was founded. Since that time, Mr. Henry Smith, though
engaged in general practice, has occupied himself, almost
daily, with experiments upon the nervous system.]
*' 67, Torrington-square, Nov. 8th, 1848.
** My dear Sir, — I was called by a medical friend, last
night, to a case which I think may be worthy of record, as
illustrative of the effects of the reflex and spinal actions in
parturition. The patient was a young woman, twenty-six
years of age, primiparous. The labour was such as you
designate ' acute,' the pains being rapid and strong. Ex-
amination per vagina excited strong contractions of the
uterus, and even touching the external parts brought on or
increased the uterine contractions, and aggravated the pains,
so that her medical attendant, finding the presentation and pro-
gress of the labour satisfactory, refrained from any further
examination or interference. The child was born after a
short labour of four hours, but after the head was expelled,
an interval of ten minutes elapsed before the shoulders and
trunk followed, the uterus appearing to be exhausted. The
placenta was removed by gentle traction. It was now found
that there was uterine hemorrhage, with complete inertia of
the uterus. The accoucheur applied cold, with pressure,
over the uterus, and gave her half a drachm of the ergot of
rye. These measures arrested the hemorrhage, which did
260 CASE OF ACUTE LABOUR.
not proceed to any alarming extent. Shortly after taking
the ergot of rye, she was seized with violent pain and
bearing-down, which continued at rapid intervals, so as to
alarm the by-standers. I now saw her. The pulse was
good, and the heat of the skin and expression of the coun-
tenance natural. Violent pains succeeded each other in
rapid succession, accompanied by cramp in the limbs, and
trembling and spasmodic contraction of the muscles of the
arms and fingers. Pressure over the pubis could scarcely
be borne, and introducing the finger into the vagina brought
on the pains. The uterus was found firmly contracted, and
the vagina filled with coagula. Under these circumstances,
absolute quietude and the avoidance of every kind of excite-
ment were strictly enjoined. Twenty drops of laudanum
were given, and ordered to be repeated in smaller doses,
with tincture of henbene and bicarbonate of potash, till the
pains were relieved. The pains and spasmodic actions
gradually subsided in about five hours, and when I saw her in
the morning, thereappeared tobe nothing unusual. The child
was now applied to the breast, which produced only moder-
ate pain, and she made no complaint, nor had any unfavour-
able symptom.
** This case is peculiarly interesting in three points of
view. First. As showing the effect of excitation in pro-
ducing uterine contraction by reflex action. Secondly. In
the succeeding state of exhaustion and inertia of the uterus.
Thirdly. In the reproduction, by the ergot of rye, of vio-
lent uterine action, accompanied by tetanic or spasmodic
contraction of other muscles through the central spinal
system.
^' I beg you to make any use of the above you please, and
remain, yours very truly,
" Henry Smith.
"To Dr. Tyler Smith."
261
LECTURE XVIII.
Extra-Uterine Reflex Actions of an Abnormal Character, occurring Before,
During, and After Parturition — False or Spurious Labour-Pains — Metas-
tatic Pains — Reflex Actions aflfecting the Stomach, Abdominal Muscles,
Bladder, Intestines, Heart, Larynx, &c. — Rigors — Diuresis — Partial Con-
vulsive Action — Tympanitis — Reflex Counter-Irritation — The Sensation of
the Draught in the Breasts — The Motor Actions of the Mammse.
During, before, and after parturition, a number of irrepjular
reflex actions of a morbid character take place, some of which
have been described under different names, and in a discon-
nected manner, but all of which may, I think, be usefully
grouped together as regards practice. Of these the most
important are what are called " false" or " spurious" labour-
pains, and ** metastatic" pains occurring either during or
subsequently to delivery.
It might be supposed that in so important a reflex function
as that of parturition, various irregular reflex actions would
occur, some of them unimportant, others of sufficient import-
ance to complicate or retard labour.
I. The terms, "false pains," "spurious pains" are applied
to certain actions which occur before labour, and stimulate
the true labour-pains with more or less closeness, except that
the uterus does not contract with its true rhythm or periodi-
city ; nor does any dilatation of the os uteri, or parturient
impulsion of the foetus, occur. Such pains sometimes aflfect
the abdominal muscles, these muscles becoming contracted
spasmodically, at irregular intervals, with pain in the mus-
cles themselves, and tenderness of the abdominal surface.
Sometimes these spurious pains consist in a painful state of
the bladder ; at others, the rectum is the seat of periodic
pain ; a sensation of bearing-down affects the bladder or
rectum, and there are constant but ineffective calls for the
evacuation of these organs. Occasionally, the pain, instead
of being abdominal or pelvic, is femoral ; considerable pain
22*
262 SPURIOUS PAINS.
being experienced in the thighs from the ilium downwards
to the knee. In some cases these pains affect the uterus
itself, and labour is confidently expected. But the uterus,
instead of being uniformly contracted, as it is at the true
commencement of labour, contracts irregularly ; hard and
painful balls are formed in different parts of the organ, which
are constantly changing their position in the abdomen..
Many women suffer in this way during the last two or three
months of parturition, and are constantly w^atching in vain
for the advent of labour. Sometimes, women of irritable
habit, who have had several children, are so pestered by
these painful and partial contractions, that they declare they
are in labour the whole forty weeks of gestation. This form
of spurious pain appears to consist of an exaggerated form
of the peristaltic movements of the uterus during pregnancy.
The causes of the various irregular actions which occur
before labour are not very difficult of detection. There is,
first, that general irritability of the economy which accom-
panies, or is produced by, the state of gestation. Upon this
irritability various secondary causes operate. The most
important are, emotional disturbances, such as fright, or
anxiety ; irritation of the gastric or intestinal mucous mem-
brane by indigestible food, or accumulated faeces ; great
muscular exertion, want of sleep, and excessive fatigue.
Any of these causes are sufficient, towards the close of preg-
nancy, to excite irregular reflex actions in the uterus, or the
other organs affected by spurious pains.
These pains are frequently arrested by quieting the mind
of the patient ; and nothing tends to do this more than the
assurance that labour is not present, or likely to occur imme-
diately. The mind may be further soothed by an opiate,
which, at the same time, allays the sensations attending or
constituting the false pains. All sources of reflex irritation
should be avoided as much as possible. The bowels should
be kept free from irritation by the mildest aperients ; if sick-
ness and gastric irritation should be present, the promotion
of vomiting, by warm water, or chamomile infusion, is often
of signal service ; the state of the bladder and the renal secre-
tion should also be carefully attended to. When the pains
affect the abdominal and femoral muscles, frictions with an
anodyne liniment, and warm applications, or the warm bath,
should be recommended. Muscular rest is always proper in
these cases.
SPURIOUS PAINS. 263
II. During parturition various irregular actions occur, which
have been termed " metastatic pains." The term metastasis
ought, however, to make way for irregular reflex action,
which would describe the phenomena more exactly. The
metastatic action is nothing more than this : the reflex motor
power, instead of being reflected to the proper muscular
structures, affect other muscles which should remain in a state
of repose during labour ; or certain muscles, which should
be in physiological action, are excited spasmodically, while
others continue inert when they should be in a state of ac-
tivity. What may be called an overflow or a misdirection
of reflex motor power takes place in these cases.
These extra-uterine reflex actions, of an irregular type,
sometimes eflfect the abdominal muscles in tlie stage of dila-
tation, [he uterine contractions being more ineffective than
usual. Sometimes they consist of spasmodic cramps of the
thighs or legs, and I have occasionally seen the hands
affected with cramp at each returning pain. In this form of
parturient disturbance w'e ought to include violent vomiting,
and violent irritation and action of the rectum and bladder.
Another singular modification of these irregular pains is
seen in those cases in which the pains appear to return with
tolerable regularity, but are wholly inefficient. There is
abundance of physical pain, but little or no motor contraction.
Each pain seems to exhaust itself in sensation instead of mo-
tion. The pain in such cases does not affect the uterus so
much as the back and thighs of the patient.
In almost all these cases the uterus acts imperfectly ; the
diversions of the reflex function, evidently diminishes its pro-
per physiological activity.
With these irregular extra-uterine actions w-e must class the
rigors which affect the whole muscular system in some cases
of labour. I have formerly adverted to the rigor which occurs
in many cases at thecompletion of the dilatation of the os uteri,
and which is ordinarily a transient affection. Some women,
however, are thus affected during a great part of their la-
bours. Every muscle shakes just as though the cold fit of an
ague were present. When these rigors are severe and long
continued, they depress the patient very much, and render her
quite unfit for the exertions of the expiratory efforts of the
stages of propulsion and expulsion. Occasionally, however,
they are followed by heat of surface and greater muscular
energy than usual. I have never Keen them actually pass
264 IRREGULAR ACTIONS AFTER DELIVERY.
into genera] convulsions, but sometimes they have been so
severe as to threaten momentarily to end in this disorder.
Each natural labour-pain affects the heart in a slight degree,
but after the pain has passed away, the heart'saction becomes
regular again. In some subjects the disturbance of the heart
is much more severe, each pain increasing or diminishing the
frequency and force of the pulse to a morbid extent, the effects
of which are not recovered from in the intervals between the
pains.
During parturition itself, the uterus and ovaria are the great
centres of irritation, by which the abnormal reflex disturb-
ances are excited. The uterine irritation must be soothed, as
far as possible, on the principles laid down when treating of
acute labour. A sound sleep is often more efficacious than
any other means in arresting the irregular actions, or chang-
ing them into the regular actions of labour. As in spurious
pains occurring before labour, all the emotional influences
should be soothed, and the reflex causes of uterine excitation
furnished by a loaded bladder, stomach, or intestine, removed
as far as possible. In these cases, our chief attention must
be directed to the reduction of the spinal erethismus which
exists, when the irregular and violent actions are pretty sure
to subside into the legitimate actions of parturition.
III. After delivery, various irregular actions, related to
those we have been considering, take place.
The "rigor" of parturition sometimes occurs with intense
severity immediately after the delivery of the child. The
dilatation of the os externum appears to produce it, as dis-
tinctly as the dilatation of the os uteri in ordinary cases. The
most severe rigors I have seen have occurred between the
expulsion of the child and the placenta. The patient suffers
from the most distressing sensation of cold ; her teeth chatter
violently, and she shakes the bed or the whole room with her
violent shiverings.
Following upon delivery, we may have a partial convul-
sion, if such a term be allowable. Each action of the uterus
will, in such cases, be attended by spasmodic actions of the
extremities and the abdominal muscles, almost like those
which occur in cholera. But there is no insensibility, or any
of the cerebral com])lications of puerperal convulsions. Still
more frequent is a cramp-like aflbction of the abdominal mus-
cles, but it would be diflficult to decide whether this arises
IRREGULAR ACTIONS AFTER DELIVERY. 265
from uterine irritation, or from the state in which these mus-
cles are left after the violent contractions of the latter stages
of labour. These cramps and partial spasmodic actions, how-
ever, attend the after-pains, and are increased by all the causes
of severe after-pains.
Affections of the bladder are very common after partu-
rition; in some cases there is great irritability, with painful
spasm at the neck of the bladder on each attempt at micturi-
tion ; in others, there is inertia, almost amounting to paralysis.
It is often a long time before the bladder returns to its na-
tural tone in such cases.
Sometimes the actionof the urinary bladder is so excessive,
that, combined with the abdominal contractions and the
relaxed state of the parts within the pelvis, consequent upon
the evacuation of the uterus, it produces prolapsus of the
bladder. This is the more likely to occur, if the ergot has
been given before or after delivery, an observation for which
I am indebted to my friend Dr. Robert Barnes. The same
remark applies to the production of prolapsus uteri after the
employment of ergot.
A morbid state of the lower bowel is very common after
parturition. Generally, there is a sense of debility, with con-
stipation. During severe labours, when the dilatation of the
perineeum is difficult, a considerable amount of prolapsus ani
occurs. After delivery this disappears, but there is often
great torpidity of the bowel in such cases. Another source
of disturbance to the rectum arises from the frequent lacera-
tion of the fraenum at the anterior edge of the perinaeum.
A further reason for inactivity of the bowels, after delivery,
arises out of the removal of abdominal pressure from the in-
testines. This appears to cause a temporary loss of power in
their muscular coat. Besides mere inactivity, we sometimes
see the intestines enormously distended with flatus, without
sufficient power to expel it. This form of tympanitis fre-
quently gives the young accoucheur much anxiety, though
the first aperient generally removes all signs of it from the
abdomen.
Although, generally speaking, the bowels are torpid after
delivery until relieved by medicine ; yet sometimes, a day or
two after delivery, a spontaneous diarrhopa sets up, appa-
rently excited by the accumulations which have taken place
in the colon during pregnancy. Many women have occa-
266 IRREGULAR ACTIONS AFTER DELIVERY.
sional attacks of diarrhoea during the latter part of pregnancy,
from the same cause.
Within proper limits, all the extra-uterine actions excited
by parturition are as beneficial as the actions of the uterus
itself. Among the other organs excited by the parturient
uterus, the kidneys deserve to be mentioned. A most salu-
tary diuresis frequently takes place during the first few days
succeeding labour. In patients who have suffered from albu-
minuria during pregnancy, or whose extremities are affected
with oedema, the increased action of the kidneys is most
beneficial. An oedematous condition of the whole body will
frequently disappear entirely during the first twenty-four
hours after parturition. Of course, in such cases, it is of
more than usual importance to watch the state of the bladder,
and to prevent any of the ill consequences of retention.
Among the extra-uterine disturbances of a motor kind, I
ought not to omit a peculiar and troublesome cough, from
which women recently delivered often suffer much distress.
This cough is accompanied by constant irritation of the
throat and larynx. It is generally more relieved by food
and the pressure of the abdominal bandage, than by seda-
tives or the ordinary means of allaying cough. I have seen
it produce more inconvenience than even severe after-pains.
It particularly interferes with the sleep and repose so neces-
sary to recruit the strength of patients recently delivered.
Each time that the patient sinks into insensibility, she is
roused by a painful sense of strangulation, and a prolonged
fit of coughing. The cough is purely irritative, being quite
unconnected with inflammatory action or increased secretion
in the larynx or bronchi. This form of cough, if allowed to
continue, becomes most troublesome a day or two after de-
livery, at the time when the secretion of milk from the breasts
is fully established. Some w^omen suffer from this affec-
tion in a more moderate form during the whole of lacta-
tion, particularly after suckling the child and before taking
food.
Thus, after the completion of labour we hav^e to deal with
morbid states arising out of the highly excitor condition of
the uterine and vaginal surfaces, and the associated excitors
which are active during parturition, and we have also to con-
sider the paralyzing effects of excessive parturient action upon
the uterus anil those organs which are in reflex relation with
MOTOR ACTIONS OF THE MAMM^. 267
it. The chief indications are, as in the disturbances occurring
before or during labour, to subdue the uterine and other ex-
citor tendencies by repose, by soothing nneasures of a local
kind, and the removal of irritation, mental and physical.
The organs which have been weakened by the excessive
efforts of the uterus should be strengthened by rest and gentle
stimulation. Mechanical displacements of course require
special treatment. At whatever date of gestation, parturition,
or the puerperal state, the irregular actions which have been
referred to occur, they are to be considered in precisely the
same light as excessive or deficient reflex motor actions fol-
lowing the regular reflex channels. Let there be irritation
of the intestine, for instance, it makes little difference, as
regards treatment, whether the result is simply increased
action of the bowels, or whether the excitation is reflected
upon the uterus so as to produce uterine action ; we have
but to remove the cause, and the effect, whether immediate
or remote, ceases. But this is obvious, and need not be
dilated upon.
Throughout gestation and parturition, the reflex motor
actions and synergies excited in distant parts by the state of
the uterus are abundantly evident ; but the principle of coun-
ter-irritation also appears, in some instances, to affect the
spinal system in a very remarkable manner. The arrest of
the ovarian function during the whole term of pregnancy I
have adverted to in a former lecture. I have, during the
present course, mentioned that in some instances we see
asthma perfectly relieved by gestation, to reappear after par-
turition. It is well known that the ravages of phthisis are
stayed in an extraordinary manner by the condition of the
reproductive organs in pregnancy. In some cases of epilepsy,
the fits are suspended altogether during gestation. We may
have obstinate vomiting during the whole of pregnancy, but
with a total disappearance of the gastric irritability as soon
as labour has set m. All these and other similar facts require
to be classed together for further observation and study. It
is evident that the principle of counter-irritation exists,
though obscurely, a.nd in rare cases, in spinal pathology and
therapeutics; and that physiological or pathological irritation
of one organ under the influence of the spinal marrow may
diminish the irritation or excitement of other organs. It
would be very important if we could define the limits of this
form of counter-irritation with anything like accuracy.
268 MOTOR ACTIONS OF THE MAMMiE.
When describing the Genesial cycles of ovulation, gesta-
tion, and lactation, I have referred to the influence of the
parturient uterus, in exciting the secretion of milk in the
breasts. I may here mention another singular relation be-
tween the uterus and the mammoB. Undoubtedly, it is the
after-pains which first excite the sensation connected with
the secretion of milk, termed the " draught." At first, it is
the after-pains which excite this synergic action in the mammae,
at each time of their occurrence. 'The " draught'^ may be
considered, in fact, as a part of the after-pain. The same
uterine irritation which excites that reflex action in the uterus
which constitutes the after-pain, also excites the mammary
sensation. After a time, the uterine irritation and motor
action cease, but the mammary action is now continued
independently of the uterus. Other stimuli besides those
connected with the uterus continue to excite it, particularly
the excitement of the vStomach on receiving food or drink,
and the excitement of the nipple by the sucking of the child.
Still we cannot, if we consider the matter attentively, refuse
to see in the " draught" the residuum, the representative of
the after-pain, just as the after-pain is the successor of the
true labour-pain. These reflex metamorphoses are in the
highest degree interesting. We may observe the gradual
transmutation of the throes of labour into the agreeable sensa-
tion accompanying the secretion of food for the infant in the
mammary organs.
At each returning ovarian period after parturition, these
mammary sensations are increased in intensity. This is par-
ticularly the case when the catamenia appear during lacta-
tion ; but the increase is evident even in those cases in which
the catamenia are absent.
The orifices of the milk ducts in the nipple appear to be
endowed with some amount of motor action. In the nipple
of the woman who is neither impregnated nor nursing, a
decided amount of erection may take place. This could not
occur without some motor provision ibr retarding the return
of blood from the nipple. But the contraction and dilatation
of the orifices upon the surfaces of the nipple during lactation
are quite distinct from the erectile properties of this part at
other times. I consider these orifices to be endowed with a
power of contraction and dilatation, because in many cases
the sight of the child, or the mere preparation of her dress by
the young mother for suckling the infant, or the sensation of
MOTOR ACTIONS OF THE MAMM^. 269
the draught, will cause a free flow of milk without actual
suction, and this flow will cease on the removal of its causes,
as suddenly as it had occurred. At other times, after the
withdrawal of the child, the milk is for a short time expelled
in a lull stream, and to a considerable distance. Some force
beyond, and very different to, mere distention, appears to
expel the contents of the mamma3. The researches of Pro-
fessor Owen have demonstrated the existence of a constrictor
muscle for injecting the milk into the mouth of the young ani-
mal, in the platypus. Some rudimentary provision of this kind
appears to exist in the mammalia, and in the human female.
In the milking of the cow, the fluid is expelled with far more
force than can apparently be attributed to the mechanical
action of the fingers of the milkers. The fact that in the
human subject the milk is expelled in a strong jet after the
suction of the infant, shows clearly that there must be a power
of dilatation, and also that, in ordinary cases, the dilatable
orifices are firmly closed, otherwise milk must constantly
escape, instead of remaining as it does in the raammaB as in
reservoirs. I have been told by good authorities, that in
savage women the milk will spurt out frOm the nipple without
any pressure or suction by the infant. In some cases, too,
of sore nipple, the agony suffered by the mother is quite dis-
proportionate to any visible soreness or inflammation of the
part. The nipple may be touched and handled without
giving much pain ; but the instant the child is applied, severe
suffering is experienced, and the child cannot get a free sup-
ply of milk. It seems to me, that in such cases there is a
painful sphincteric contraction of the mouths of the milk
ducts. The lactatory sphincters, if they may be so termed,
under ordinary circumstances, remain closed; but they are
dilated by the influence of emotion, the sensation of the
draught, and the mechanical irritation of suckling. In some
cases of sore nipple, it has appeared tq me that the irritation
which should dilate these orifices, being present to a morbid
extent, excites them to painful contraction instead of physio-
logical dilatation.
In these cases, cooling applications, rest to the nipj)le by
partially feeding the child for a short time, or the use of an
artificial nipple, are the proper remedies, instead of ointments
and astringent applications.
There are three conditions of the breasts w^hich require to
23
270 MOTOR ACTIONS OF THE MAMM^.
be studied with reference to motor action. The erection of
the nipple; the distention of the mammee attending the sen-
sation of the draught, and the increased secretion of milk
■which takes place at this time ; and lastly, there is the dilata-
tion and closure of the lactatory orifices of the nipple. The
sensation of the draught appears to be to the whole breast
w4iat erection is to the nipple. Each of these conditions —
the erectile state of the entire gland, the erectile state of the
nipple, and the dilatation and closure of the orifices — must
necessarily depend upon some motor action in the mammse.
The motor structures concerned in these actions remain to be
discovered.
The laminar ovarium and the simple sexual duct in fishes
are evidently archetypes of the complex mammary, uterine,
and ovarian apparatus of mammalia. In the progress of the
animal scheme, the mammse have become peifectly distinct
in the higher animals from the parturient canal. In the lower
mammalia, the breasts are nearer to the other organs of the
reproductive system than in the human subject. In the
pigeon, the sexual and intestinal canals are connecfed together,
and the mammary function is discharged by the stomach, a
milky fluid being secreted and returned with the food intended
for the young bird. On a future occasion I hope to be able
to pursue this interesting subject at greater length.
271
LECTURE XIX.
Natural and Morbid Conditions of the Reflex Function in the Infant at the
time of Birth — The Influence of Muscular 'J'one — 'I'he Colostrum — The
Meconium — Icterus Neonotarum — The Acts of Suction and Deglutition —
'I'he State of the Infimtile Mammae — Morbus Cerulaeus — Tetanus Nascen-
tium — Congenital Contractions of the Extremities.
Great excitability of the spinal centre and its excitor and
motive nerves exist after birth, and particularly after the
establishment of respiration. In utero, the foetus is defended
with much care from excitor stinauli, and it has never, up
to the time of birth, been influenced with any degree of in-
tensity by that cause which acts upon the surface more
powerfully than all other causes — namely, alternations of tem-
perature. Alternations of temperature is the great awakener
of the spinal function. During pregnancy, the muscles of
of the infant appear to be kept in a state of moderate contrac-
tion from muscular tone, a property dependent upon the
spinal marrow, and to this I have attributed the ovoid posi-
tion and the consequent presentation of the foetus in the na-
tural manner. All the muscles seem to be contracted by what
John Hunter called the " sphinctorial action" of muscles,
being uninfluenced by volition or emotion, and only slightly
by reflex action. In consequence of this uniform contraction
of the muscles, the flexors, as the strongest, curve the body
into the shape preserved by the foetus during pregnancy, and
which becomes most perfect at the time of parturition. This
contraction of the body and limbs is very evident when
turning is performed, in cases of head presentation. Besides
the influence of tonic contraction in producing the ovoid
shape of the foetus, it acts in keeping the individul limbs in
their proper position. If the limbs were freely moveable by
reflex action or otherwise, arm-presentation must inevitably
be very common ; but the closure of the arms and hands
across the breast prevents this in the most perfect manner.
This sustained position of the arms is an adjunct during la-
272 THE MECONIUM.
hour to that peristaltic action of the uterus from the os uteri
upwards, which tends to prevent the arms from being forced
down with the head during the pains. After birth, and the
establishment of respiration, though the reflex function comes
into full operation, the contracted state of the limbs is very
evident. The contraction of the hand and foot is indeed
often so great as to produce the apprehension of deformity.
It becomes the first business of volition and emotion to exer-
cise the muscles of the limbs, so as to free them from the
ante-natal contraction, and reduce them ultimately to the in-
fluence of volition and emotion. Every voluntary and
emotional movement contributes to this end, and so, proba-
bly, do the reflex movements of the limbs which so constantly
occur during infancy ; but experience shows us that it is long
before the limbs of the child become perfectly mobile.
Under the influence of new and powerful stimuli, the re-
flex actions which constitute the first external life of the
infant, are subject to various derangements. Shortly after
birth, children are subject to special disorders, some of which
never occur after early infancy. I propose briefly to consider
the ailments thus produced. Some are caused by the ingesta
and egesta, others by various causes operating on the excitor
nerves of the surface, and some, perhaps, upon the spinal
marrow itself.
The Colostrum sometimes produces sickness in the child
for several days after the first secretion of milk, each attempt
to take the breast being followed by retching or actual vomit-
ing. The gruel, sugar, butter, &c., which nurses are so fond
of dosing children with before the milk appears, under the
false impression that they must otherwise be starved, con-
tribute to the derangement of the infant stomach, as yet un-
used to ingesta of any kind. Medicine is seldom if ever
required in these cases ; after a short time the milk secreted
becomes less irritating, and the stomach of the child grows
more accustomed to ingesta. If the sickness should be
troublesome, the breasts of the mother should be drawn for
a day or two, to remove the irritating secretion, and the child
fed with gruel or arrow-root.
The Meconium generally purges the new-born infant, and
a meconic diarrhoea may occur soon after delivery, accom-
panied by considerable pain, and a tenesmus of the lower
bowel. Disturbance of the bladder is also likely to occur.
ICTERUS. 273
Either the urine first secreted by the kidne^-s is too irritating
in some cases, or the irritation of the rectum aflects the
bladder reflexly, for some amount of difficulty and pain in
evacuating the urine is found to be common during the first
few days after birth. In cases of marked vesical irritation,
I have seen infants only a few hours old afTected with com-
plete erection of the penis. Of course this act is in such
cases purely physical and reflex. If the meconium should
either prove too irritating, or if the dark evacuations should
continue longer than usual, a dose of castor oil is all that is
necessary to remove this matter from the intestines. To re-
lieve the bladder, and the painful state of the rectum, warm
fomentations, or a sponge wrung out with hot water, and
placed over the genitals and perina3ura, are very efficacious.
In cases of mere retention, either of the fa?ces or urine, the
application of cold will sometimes excite reflex action of
these organs. In breech presentations, the afflux of cold air
to the nates, as well as the mechanical pressure, produces
the expulsion of the meconium. Throughout infancy, nurses,
while encouraging children to the evacuation of the bowels
and bladder, instinctively blow with the breath upon the face
or belly of the infant, and thus assist in producing the reflex
phenomena of these actions. When the foetus is dead, the
escape of the meconium, during or before labour, is purely
mechanical ; but when living, it is partially or entirely a
motor action.
The Icterus Neonotarum, which so frequently affects the
new-born infant, is a very curious affection. In three or
four days after birth, this partial jaundice is at its height, all
the tissues, as well as the skin, being sometimes stained of a
bright yellow colour. In children in whom the affection is
severe, and who happen to die at this period, the layer of fat
beneath the skin is almost as deeply coloured as the skin it-
self. There are certain phases through which, in the opinions
of nurses, a child has to pass before it reaches its proper
fairness of complexion. At first it is of a bright red colour,
from the effects of the air upon the surface, from which the
caseous matter which covered it at birth has been removed.
After the redness has reached its acme, the icterode tint
begins to appear, and it is usual for nurses to prognosticate
the fairness and beauty of the infant, from the intensity of
these colours in the first instance. I suspect this form of
23*
274 PHYSIOLOGY AND PSYCHOLOGY.
jaundice depends upon spasmodic closure of the gnll-ducts,
in consequence of the passage of the first ingesta along the
duodenum. In its mildest forms, this condition can hardly
be considered pathological, or if so, it is almost universal,
for there are few children in whom, a few days after birth,
the bile-tint may not be discovered in the skin or conjunctiva.
It seldom lasts more than three or four days, its subsidence
being as spontaneous as its appearance. A mild aperient,
repeated once or twice, or warm- water enemata, are some-
times required in severe cases.
The acts of Suction and Deglution are performed with the
utmost perfection immediately after birth. We seldom have
to observe any inability in these respects. As soon as the
child has breathed it begins to suck its own tongue, and use
its lips busily in the movements of suction. Even before
respiration has taken place, it will suck the finger placed in
its mouth, or at all events seize it firmly. After the establish-
ment of respiration, the mere action of the air upon the lips
excite the movements of suction. The slio^htest touch of
the lips or neighbouring skin excite them most readily. Chil-
dren, even during sleep, will embrace the nipple firmly be-
tween their gums, and it is remarkable that premature chil-
dren hang upon the breasts by the mouth more constantly
than those born at the full term ; in this point of view bear-
ing some resemblance to the young of marsupiata, which are
actually suspended from the mammae by the contraction of
the mouth in sucking. I have seen the movements of suck-
ing as perfectly performed by an acephalous foetus as by a
well-formed child. This shows that the fact is entirely in-
dependent of the cerebrum. It is remarkable that suction,
as a reflex act, should be almost lost after the period of in-
fancy has passed. With the development and appearance
of the teeth, an alteration of the nervous endowments of the
mouth must take place, by which mastication becomes sub-
stituted for suction. A curious part of the mechanism of
sucking, is the ring or ridge of bullae which appears on the
inner surfaces of the lips of infants, forming as it were a
double labial apparatus. After a child has taken the breast
this appearance is seen at its height, when it slowly disap-
pears until the next application of the infant.
Writers on psychology have always been puzzled by the
first movements of the fcctus after birth, unknowing, before
INFANTILE MAMMtE. 275
the discovery of the reflex function, to what motor powers
of the economy to refer them ; hence the most ludicrous
mistakes have been made in the discussions upon the intel-
lect and instincts of the newly-born foetus. An analysis of
the earliest and purely reflex and physical movements of the
foetus and infant will form a most interesting chapter, at the
very threshold of psychology, and one which is as yet entirely
unwritten. The time and manner in which emotion and the
will become mixed up with the purely physical movements,
will be well worthy of study, but it is beyond all question,
that before the nervous centres have been acted upon by the
changes occurring in the blood from respiration, there is, and
can be, no more sensation, emotion, or volition, than pertains
to a state of asphyxia. All the movements up to this point
of existence are physical, and so are all the chief actions
which occur immediately after the establishment of respira-
tion. The very perfection of the acts of suction and deglu-
tition at birth depend upon their being physical and not psy-
chical acts. To insure the perfect sucking of the child, it
is only necessary that the placing the child at the breast
should not be too long delayed, and that the nipple should
be of a proper size and prominence. Malformations of the
mouth of the infant are of course excepted. Though the
oral actions of the child are generally perfect, the results to
the mother are often most painful and disagreeable. The
reflex closure of the gums upon the nipple is so rough as to
quite mangle it, producing those fissures v;hich are so trou-
blesome to young nurses, and which often render the early
period of lactation a most harassing business. As a result
of suction in these cases, the nipple is sometimes completely
removed, the organ being incised by the gums of the child as
cleanly as though it had been removed by the knife.
The Infantile Mammae are in a very curious condition at,
and shortly after, the time of birth. -These glands in the
child of both sexes, secrete milk, sometimes in considerable
quantity. Nurses squeeze the secretion from the breasts,
particularly in female children, though it is quite as abundant
in the male, with an idea, as they term it, of freeing the
*' nipple strings." This notion is absurd enough, but the
secretion may be so profuse as to require its removal, lest
suppuration should ensue. Where the breasts are not re-
lieved, the secretion thickens to the consistence of curd, and
276 TETANUS NEONATORUM.
each gland becomes converted into a hard and painful
tumour. In the young infant the nipple is very imperfectly
developed, and the opening of the gland appears to consist
of a single round orifice, or depression ; whetlier this part
possesses any motor properties, I cannot say, probably it
does not. I merely refer to it as one of the orifices of the
body at the time of birth, and which, like the others that
have been mentioned, is at first unusually irritable. After
the subsidence of the infantile secretion, the breasts become
quite inactive, until they are developed in the virgin by the
stimulus of puberty.
The Morbus Coeruleus can hardly be considered as a motor
dehmgement. It arises from the mechanical continuance of
the open state of the foramen ovale, and the consequent
admixture of the blood of the two sides of the heart. The
cause of the convulsions occurring in this condition is
obscure. They may be referred either to irritation of the
heart itself, or to the circulation of venous or mixed blood
in the arteries. But it is less important to discuss this mal-
formation and its consequences, as they are almost beyond
the reach of remedies.
Tetanus Neonatorum is a disease of more importance than
any of the morbid conditions wdiich have just been consid-
ered, but it is fortunately a rare malady in this country.
The pathology of this affection is at present very little known.
It could not well assume the precise form without a know-
ledge of the reflex physiology of the spinal marrow. Tetanus
appears to be excited in infants a few days after birth, by
irritation of the umbilicus; by irritation of the intestinal
canal ; by the influence of temperature, particularly alterna-
tions of temperature ; and by deficient ventilation, and neglect
of cleanliness. '
We can readily understand how, in some cases, irritation
of the umbilicus, in consequence of the decay and separation
of the umbilical cord, should excite (he spinal centre, just as
a wound produces tetanus in the adult, particularly when we
consider the excitable condition of all the spinal functions
immediately after birth. We can understand, too, that the
irritable condition of the sphincters and the intestinal canal,
when acted upon, for the first time, by their appropriate
stimuli, may sometimes be the cause of this disease. These
are the chief eccentric causes of spasmodie disease to which
TETANUS NEONATORUM. 277
the young infant is liable, if we except the convulsions of
primary and secondary asphyxia, which have already been
treated of in these lectures. The excitability of the spinal
function is continued throughout infancy, as shown by the
tendency to convulsions after operations, and the laryngis-
mus and convulsions of dentition. The eccentric causes of
trismus nascentium appear to be aggravated by other agen-
cies, such as deficient ventilation, and the influence of tem-
perature, &c.
But these latter causes of infantile tetanus may produce
the disease of themselves. It is comparatively prevalent in
warm countries, where women, soon after delivery, bathe
themselves and their infants in the waters of rivers and lakes,
such children being placed, thereby, in the extremes of heat
and cold. Tetanus from cold is not confined to infants. It
is well known that adults, after sleeping in the open air by
night, or after severe exposure to cold of any kind, are some-
times attacked with tetanus. That very common affection,
contraction of the sterno-cleido-mastoid, and other muscles
of the neck, after exposure to cold winds, seems to be as
much a tetanic affection as trismus itself. I have seen cases
of this kind of torticollis which could not but be considered
as local forms of tetanus. But how does cold in the infant
or in the adult produce the tetanic affection ? What are the
avenues by which they affect the spinal centre ? These
questions require to be answered, and there are, unfortu-
nately, but few facts or experiments which bear upon them.
A series of experiments, showing the influence of extreme
and continued cold upon the nervous centres, would be very
valuable. In the case of the brain, we know that extreme
cold produces insensibility before the destruction of life.
Torpor of the cerebral faculties is one of the first indications
of the dangerous effects of cold. In these cases of death
from cold, how is the cerebrum affected ? Is it through the
blood, its languid circulation or congelation, or is it by the
physical influence of cold on the nerves of sensation and the
cerebrum; or, thirdly, is it by a reduction of the temperature
of the brain itself? Similar questions may be asked respect-
ing the spinal marrow and the tetanus which follows upon
the application of cold. Does the cold affect the spinal
centre and its excitor and motor nerves mediately or imme-
diately ; are the muscles themselves aflected to any great
278 TETANUS NEONATORUM.
extent ; or is the influence of cold felt through the peripheral
or the central portions of the spinal S3'stem ? There are
reasons for believing that both the brain and spinal marrow ;
the centres and the nerves of sensation and volition ; the ex-
citor and the motor nerves; are all simultaneously affected. A
limb affected with cold becomes at once insensible, involuntary,
and in-excito-motor. The nerves are incapable of trans-
mitting impressions in any direction. In the infant, both
the cerebrum and spinal centre are less perfectly defended,
anatomically, against cold than in the adult.
The primary effect of cold, both as regards the brain and
spinal marrow, and their nerves, seems to be that of para-
lysis ; this effect extends to the entire nervous system, and
it may at once be carried to a mortal extent. But the tetanus
produced by cold is secondary, perhaps reactionary ; it is
slowly induced, and it does not appear until the immediate
effects of exposure to cold have passed away. This secondary
effect of cold is apparently a derangement of the spinal
centre. All that we can say, in the present state of our
knowledge, is, that cold appears to affect the polarity or
excitability of this organ, which, in certain cases, augments
until, in children or adults, tetanus is established.
An able American physician, Dr. Sims, has recently en-
deavoured to show that infantile tetanus may depend upon
the imperfect ossification and articulation of the cranial
bones, which permit, in some cases, the pressure of the occi-
pital bone upon the medulla oblongata, during and subse-
quent to parturition. The most important proofs of the truth
of this view adduced by Dr. Sims, are those derived from
treatment. He appears to have found the convulsions
relieved by the readjustment of the cranial bones. There
are, however, as it appears to me, weighty objections to
such an hypothesis. Displacements and injuries of the
cranial bones, if they really occur, must be as common in
this country as in America, whereas tetanus is extremely
rare amongst us. I have seen, too, the convulsions caused
by pressure on the medulla oblongata in an anencephalous
fcEtus, and they bore but little resemblance to tetanus.
Other agencies besides cold and mechanical injury produce
similar results, such, for instance, as heat, thermometric
variations, deficient ventilation, and, probably, electrical
conditions of the atmosphere. Hence it is that infantile
CONGENITAL CLUB-FOOT. 279
tetanus is sometimes epidemic in particular localities, in tro-
pical climates. In this it resembles the traumatic tetanus of
armies, which rages or is absent at particular times. Thus
we may make out with tolerable distinctness the centric and
the eccentric varieties of tetanus neonatorum.
The treatment of infantile tetanus, so far as we are ac-
quainted with it, may be summed up in a few words. It
consists in the removal of all sources of irritation of excitor
nerves, and in the avoidance of all physical stimulus. Ab-
solute quiet should be preserved as far as possible. A
fit of crying, any voluntary or reflex action, even respiration,
may pass into the tetanic spasm and destroy life. In the
tetanus of adults, apparently the most trivial impression
upon the skin, such as standing on a cold floor, or j)utting
on a cold shirt in changing the linen, have each destroyed
patients after the disease had appeared to be quite subdued.
Congenital Club-foot and deformities of the Hand appear,
in many cases, to be little more than an exaggeration or per-
petuation of that state of tonic contraction of the extremities
which is natural to the foetus in utero. At the time of birth
in the human foetus, an amount of contraction frequently
exists which would be pathological in the adult. The feet
are generally contracted inwards, and the hands are often
contracted laterally, the fingers being turned outwards away
from the thumb, so as to place the phalanges almost at right
angles wdth the metacarpal bones. This contraction of the
hand is sometimes seen in the adult exactly as it exists in
the young infant, and is a very disagreeable deformity. It
is a tonic contraction of the muscles, and is quite different
and opposite to the reflex or convulsive action in which
the thumb is turned inwards into the palm. In the case of the
feet we see the first efforts at walking attended by a consider-
able amount of reflex action. Every time the child is placed
upon the ground, the feet fly off from the surface, so that it is
difficult to keep them steady, and this constitutes one of the
difficulties in teaching infants to w^alk. Probably it becomes
an additional cause of talipes, when the surface of the sole
is unusually excitor, and when the child is placed upon its
feet injudiciously. There are certainly cases on record in
which contractions have occurred to adults from excessive
reflex actions excited in the lower limbs. Many of the
deformities of youth, and some of the operations of ortho-
2S0 PSYCHOLOGY OF LOCKE.
paedic surgery, would, I stron!:^ly suspect, be saved by
attending to the condition of the .limbs of infants soon after
birth, and at the time of the first attempts at walking. Dr.
Marshall Hall has even thrown out the suspicion, that some
cases of talipes may be caused in utero by contractions
excited by the practice of applying the cold hand to the
abdomen during pregnancy.
Such is a very brief sketch of the more important disorders
of the Reflex function which occur shortly after birth.
Everything relating to the beginnings of independent life
and mind in the foetus is also most interesting in a physiolo-
gical point of view. It is by attending to physiology rather
than to metaphysics that we shall be enabled to solve some
of the profound problems proposed by Locke, respecting the
origin of ideas. We must study the order in which reflex
and centric spinal actions of the muscles (the first extra-ute-
rine movements of the muscular system), the oxygenation of
the blood, and the consequent development of sensation, emo-
tion, with the movements of emotion, volition, and Conscious-
ness, occur. Studied step by step, they may be made the
interpreters of each other. Our great metaphysician has been
blamed for studying the origin of ideas in the infant; but it
may eventually appear, that he was only wrong because suf-
ficient data did not exist in his day upon which to base the
inquiry he had undertaken.
281
LECTURE XX.*
Puerperal Convulsion — Opinions of Contemporary Authors in this Country
respecting the Cause of Puerperal Convulsion — Extracts from Drs. F. If.
Ramsbolham, Rigby, Burns, Robert Lee, Fleetwood Churchill, Locock,
Collins, and Merriman — Opinions of Ur. Marshall Hall — The Cerebral Hy-
pothesis— Its Errors, and the Causes which have given rise to them — (Con-
vulsion really referable to the Spinal Marrow and not to the Brain — Tost-
mortem F^allacies — Causes of the Cerebral Phenomena of Convulsion —
Modes in which Morbid States of the Cerebrum may cause Convulsion —
Distinction between Cause and Effect in the Pathology of this Disease.
Eclampsia parturientium, puerperal epilepsy, or puerperal
convulsion, as the convulsion of parturition is called by dif-
ferent authors, is one of the gravest maladies met with in ob-
stetric practice. I'he best and most common term is puer-
peral convulsion, except that it must be held to include con-
vulsion occurring at any period of pregnancy, and for some
time after delivery, as well as during parturition. Every con-
vulsive attack occurring between the commencement of preg-
nancy and the close of lactation is impressed with peculiar
characters depending on the condition of the nervous system
which obtains during the processes of reproduction. Setting
aside tetanus and hydrophobia as special affections, all con-
vulsive disorders may be arranged in three groups — 1. The
convulsion of infancy; 2. The epileptic convulsion; and 3.
The convulsions which belong to the eras of gestation, par-
turition, and lactation.
Before endeavouring to apply the physiology of the reflex
function to the explanation of the causes, and the principles
of treatment, of puerperal convulsion, I propose to display the
various opinions of contemporary writers in this country.
The following extracts from authors of reputation contain the
most recent views which have been propounded concerning
the nature and causes of this disease.
* The substance of the present and the three succeeding lectures apnearej
in the Lancet in 184-1 and 1845.
24
282 CAUSE OF PUERPERAL COxWULSION.
I. "The most usml proximate cause of puerperal convul-
sion is, \irohcih\y J pressure on the brain^ this pressure being
sometimes produced by the rupture of a vessel causing a sud-
den effusion of blood; sometimes by serous exudation into
the ventricles or between the membranes; sometimes, and by
far the most frequently, by simple congestion of the cerebral
vessels the7nselves. But the disease has often proved fatal,
without any organic lesion being evident on dissection, and
without even the vessels being observed to be preternaturally
full. — Into the remote causes it is not my wish to enter at any
length, because the subject is at best but unsatisfactory, and
little understood. They have been ascribed to articles of food
remaining undigested on the stomach, or irritation existing
in some other part of the alimentary tube ; to general irrita-
bility of constitution ; to a delicate and luxurious mode of
living ; to the depressing passions; to an overloaded state of
the system; to over-distention of the uterus; to distention of
the bladder ; and to the death of the child. But the affec-
tion, in my opinion, originates most frequently in some de-
ranged state of the uterus itself, probably in its nervous sys-
tem, and consists in some irritation propagated fro77i that organ
to the brain.'''' — Dr. F. H. Ramsbotham, " Principles of Ob-
stetric Medicine and Surgery."
II. '' The exciting cause of eclampsia parturientium is the
irritation arising from the presence of the child in the uterus
or passages, or from a state of irritation thus produced con-
tinuing to exist after labour. The predisposing causes are,
general plethora; the piressure of the gravid uterus upon the
abdominal aorta; the contractions of that organ during labour,
by which a large quantity of the blood circulating in its
spongy parietes is driven to the rest of the system ; constipa-
tion ; deranged bowels ; retention of urine ; previous injuries
of the head, or cerebral disease ; and mucli mental excite-
ment. Also, ' in persons of hereditary j)redisposition, spare
habit, irritable temperament, high mental refinement, and in
whom the excitability of the nervous, and subsequently the
sanguiferous, system, is called forth by causes apparently triv-
ial.'"_Dr. RiGBY, "A System of Midwifery."
III. '' Convulsions of the kind lam considering evidently
are connected with gestation or parturition ; they occur at no
CAUSE OF PUERPERAL CONVULSION. 283
Other time, and are more frequent in a first labour They
arise particularly from uterine irritation, but also seem fre-
quently to be connected with a neglected state of the bowels.
.... The sympathetic irritation is almost invariably accom-
panied by an affection of the vascular system, productive of
fi;reat determination to the head^ either directly or indirectly,
through the medium of the spinal nerves, which aggravates
the evil, and becomes indeed the chief source of danger. I
am inclined to think that, in a majority of instances, the
spinal cord is first affected by the state of the uterine nerves,
and immediately afterwards the head suffers A strong
predisposition is given to this condition of the nervous system
by a bad state of the bowels, and labour seems to bring the
matter to a serious crisis. ... On inspection after death, we
sometimes find turgescence of the vessels of the brain, or
slight effusion of serum, but very often no mark of disease is
to be discovered anywhere." — Dr. Burns, " Principles of
Midwifery."
IV. " Those women are most predisposed to the disease
who have had hysteria or epilepsy in early life, who have suf-
fered from injuries of the head, or who have had violent
attacks of fever, with severe affections of the brain. Depress-
ing passions of the mind appear to produce a predisposition
to the disease. Unmarried women, who are excluded from
society, and often addicted to the improper use of stimulants,
are peculiarly liable to puerperal convulsions and mania.
Terror, and other violent mental impressions, and sometimes
the pains of labour alone, are sufficient to excite convulsions.
The disease occurs, not only in strong plethoric young women
with their first children — in such as are of a coarse thick
make, with short thick necks — but in w^eak, irritable, nervous
females. There are some cases w^here irregularities of diet,
especially the use of very indigestible food and stimulants,
appear, without any other cause that can be discovered, to
give rise to the disease. There are many cases in which the
peculiar condition of the nervous system of the uterus appears
to be the sole cause, and in ail cases it is the principal pre-
disposing cause, for the fits of convulsions occur in most
women in the first pregnancy and labour, and at no other time
but during pregnancy and labour , and they often suddenly
cease when the labour is completed, after every remedy has
284 CAUSE OF PUERPERAL CONVULSION.
been employed, without avail, except artificial delivery. The
condiiion of the brain, on luhich the loss of consciousness and
convulsions depends, is obviously produced by sympathy with
the nervous system of the uterus; and the fits return and in-
crease in violence, till the uterus is emptied of its contents,
and it is on them the irritation of the nerves of the uterus
alone depends." — Dr. Lee,'' Lectures on Midwifery."
V. " /^ is exceedingly difficult to state anything very definite
as to the cause of epileptic (puerperal) convulsions. Doubtless
they arise from the sympathy of the brain with the irritation
of some different, and often distant, organ — it may be the
stomach, the uterus, or the bowels. Intemperance in eating
or drinking may give rise to it. Persons previously afflicted
with convulsive affections are certainly predisposed to them
at this time. Mental emotions and frights occasionally cause
convulsions. In some cases, doubtless, they are owing to the
efforts made during the labour-pains, by which an accumula-
tion of blood takes place in the head. Atmospheric influence
appears to have some effect in determining the frequency of
the disease." — Dr. Fleetwood Churchill, '' Theory and
Practice of Midwifery."
VI. " The immediate causes of puerperal convulsions are
often very obscure. They appear sometimes to depend on a
loaded state of the vessels of the brain ; at other times, the brain
appears to be influenced by distant irritation, either in the
uterus or in the digestive organs ; and again, in some cases,
puerperal convulsions are induced by a peculiar irritability of
the nervous system. — The immediate attack may be brought
on by a loaded or disordered stomach, or by food, however
small in quantity, of an indigestible kind. Some substances —
shell-fish, for instance — have been found very frequently to
induce convulsions in the puerperal condition, when at other
times they may have been taken by the same individual with
perfect impunity. A sudden fright, afflicting intelligence, or
any unexpected or depressing mental emotion, may excite
the paroxysm. — The violent straining caused by labour-pains,
and even the disturbance of the frame by the earlier uterine
contractions, causing a temporary rush of blood to the head,
will sometimes bringon convulsions." — Dr. Locock, " Cyclo-
paedia of Practical Medicine."
CAUSE OF PUERPERAL CONVULSION. 285
VII. Speaking of the relative frequency of convulsions in
head-presentations, Dr. Collins observes, " This fact might
be brought forward to support the opinion that puerperal
convulsions were caused by the irritation produced in the
dilatation of the mouth of the womb. This, however, is not
the case, as we not unfrequently fmd patients attacked when
the OS uteri is completely dilated, and all the soft parts
relaxed. I conceive we are quite ignorant as yet of what the
cause may be, nor could I ever find on dissection any appear-
ance to enable me to even hazard an opinion on the subject.^'' —
Dr. Collins, ''Practical Treatise on Midwifery."
VIII. ''There have been three especial causes assigned as
usually producing this disease:
1. General irritability of the constitution.
2. Irritability of the uterus from distention.
3. An overloaded state of the system.
" And practitioners have been influenced in their treatment
of the complaint by the opinions they have entertained of its
cause : thus, those who have attributed the convulsions to
general irritability, have considered opium as the proper
remedy ; those who have thought distention of the uterus the
cause, have recommended immediate delivery ; those who
believe an overloaded state of the system to be the cause of
the convulsions, employ large bleedings, and other evacu-
ants." — Dr. Merriman, " Synopsis of Difficult Parturition."
These quotations are sufficient "to show the very great dis-
crepancy and uncertainty of opinion which has prevailed
among the most eminent obstetric writers respecting the
causes of puerperal convulsion.
As a contrast to this confusion, the views of the discoverer
of the functions of the Spinal Marrow may be brought for-
ward. With a few graphic and masteTly touches, he stamps
the malady as one of the diseases of this division of the
nervous system. He says: —
" The principal causes of puerperal convulsion, besides the
peculiar condition of the uterus itself] are, indigestible food, a
loaded and morbid state of the bowels, a distended condition
of the bladder, &c., mental shock or anxiety, muscular effort,
hemorrhage, &c." Dr. Marshall Hall further believes, that
all these and similar causes act upon the spinal marrow and
24*
236 CAUSE OF PUERPERAL CONVULSION.
its system of excitor and motor nerves. This view of the
subject I propose to develop at greater length than Dr. M.
Hail has hitherto done, but in accordance with his physio-
logical and pathological doctrines. One of the chief sources
of error respecting the true pathology of puerperal convulsion
is, the incorrect idea which is commonly held by practical
men respecting the part played by the vascular condition of
the brain in its production. As a preliminary step, therefore,
it must be of great importance to attempt to place this matter
on a correct physio-pathological basis.
It may be gathered very plainly, from the quotations given
above, that the general opinion is in favour of considering
direct or secondary cerebral congestion as the grand cause of
convulsions in the puerperal state. By this, obstetric waiters
mean congestion of the whole organ, or, at all events, they
have never, so far as I am aware, made any attempt to define
the part of the brain which must be affected before convul-
sions can occur, a matter of great moment, both in pathology
and practice.
It is a well-established fact in experimental physiology,
that mechanical irritation of the spinal marrow within theca
vertebralis, of the medulla oblongata, and the corpora quadri-
gemina, will cause convulsions. It is also well proved that
irritation of every other part of the brain and cerebellum may
be carried to any extent without producing convulsive action.
Loss of voluntary motion maybe thus caused, but the involun-
tary and spinal motions, those which in morbid excess con-
stitute spasm and convulsion, remain unaffected. When the
whole of the lobes of the cerebrum and cerebellum have been
carefully removed, convulsions may be occasioned to any
extent by irritation of the cranial termination of the spinal
marrow. All these data have been abundantly proved by
the vivisections of MM. Magendie, Schoeps, Flourens, Hert-
wig, and Dr. M. Hall. In one interesting experiment per-
formed on the dog, Dr. M. Hall found, that while irritation
of the brain produced no effect, pinching the dura mater
lining the cranium, to which branches of the fifth are dis-
tributed, excited convulsions, so that the brain is actually in-
excitor of spinal action, while the meninges are strongly
excitor. The brain itself, although the sensorium commune,
has neither nerves of common sensation nor of excito-motion.
'Ihis is supported by pathological observation. A tumour
CAUSE OF PUERPERAL CONVULSION. 287
gradually developed in the brain itself may excite no cerebral
or spinal symptoms, while a spicula of bone on the inner
surface of the skull may occasion epilepsy. When the
tumour does produce convulsion, it is either by pressure on
the medulla oblongata, or the extension of irritation to the
membranes.
It would appear to be a necessary deduction from these
and numerous other facts, that whether we use the term
spinal marrow, or any other term, we are bound to consider
the medulla spinalis and oblongata with the corpora quadri-
gemina, as forming together one distinct organ — as being a
division of the nervous system, which pathologically, as well
as physiologically, must be looked on as separate from the
brain, the cerebellum, and the simple sensory and voluntary
nerves. Long ago Professor Miiller proclaimed, ** This is
an important distinction which we owe to Flourens, and
must at a future period have a great influence on the
pathology of cerebral diseases."
Thus, then, we should have — 1. The Cerebral System,
composed of the brain and cerebellum, in connection with
that part of the spinal chord which conveys sensation and
voluntary motor power to and from the brain, which might
be termed the intra-vertebral chord ; and 2. The Spinal
System-, consisting of the spinal marrow^ (exclusive of that
part of it devoted to the functions of volition and sensation),
together with the medulla oblongata and the corpora quadri-
gemina. This division into the Cerebral and Spinal systems,
though they are each of them both cranial and vertebral, as
regards anatomical position ; the spinal extending into the
brain, and the cerebral situated partly within the vertebral
canal, is in nowise theoretical, but a matter of fact, admitting
of the most severe physiological proof. Such a division is of
great moment for our present pathological purposes; and it is
necessary, as we proceed, to keep the mind close to the sub-
ject, drawing a clear line of demarcation between those parts
which belong to each respectively. We cannot have con-
vulsion without the pre-existence of some irritation of the
spinal division of the nervous system. Clearly, we cannot
get convulsion from the cerebral portion alone. It is a most
striking fact, that the anencephalic infant dies of convulsion,
in the complete absence of the cerebrum.
Let us now glance a moment at some of the presumed
288 CAUSE OF PUERPERAL CONVULSION.
causes of puerperal convulsion ; and first of all, let us con-
sider the subject of cerebral congestion.
During the pregnant and puerperal states, there is a greater
tendency to fullness of the circulation than at other times,
and in labour, especially in some of its stages, this vascular
plethora particularly affects the head. In the second stage
of labour, when the presence of the head of the foetus in the
vagina has excited the reflex action of the expiratory muscles,
there is, during every pain, partial or entire closure of the
glottis. This interferes with the circulation ; and moreover,
during the severe pains, a state of partial asphyxia takes
place, as may be seen by the distended state of the veins of
the head and neck. The same venous congestion must occur
in the medulla oblongata and the spinal marrow, owing to the
impediment to the return of venous blood, particularly its
upper portion, though this has escaped the notice of WTiters
on the subject.
It would follow from the above, that if simple pressure on
the cerebral vascular system caused convulsions to as great
an extent as obstetric authors generally suppose, they ought
certainly to occur far more frequently during the second
stage of labour than at any other time. But this is not the
fact, as patients frequenly fall into convulsions before labour
has commenced, or during the first stage, when the respira-
tory system is undisturbed, or the patient may pass through
the second sta^re of labour, when the disturbance of the
circulation is at its maximum, without any sign of convulsion;
and the fits otlen appear for the first time, after delivery has
been completed.
These facts alone are, I submit, suflBcient to overturn the
most generally received opinion as to the cause of puer-
peral convulsions. The error has arisen partly from observ-
ing the immense distention of the vessels of the upper part
of the body during paroxysm, and partly from the conges-
tion and serous or sanguineous effusion sometimes found after
death. But it can be made clearly evident that these signs
are, in the majority of cases, not so much the causes, as the
results J of the disease. Rarely, excepting in convulsions oc-
curring during a pain in the second stage of labour, can the
congestion of the brain be fairly considered \\ie first exciting
cause of the convulsions ; and even here we have other
causes in operation — the irritation of the exciter nerves of
CAUSE OF PUERPERAL COiNVULSION. 2S9
the uterus, and the erethismus of the spinal marrow, as well
as the vascular fulness within the cranium.
In this and many other diseases there has been a great
tendency to consider any morbid change discoverable after
death as the cause of the malady present during life. Post
hoc^ ergo propter hoc, hcis had too extensive an application
in this department of pathological reasonings. It has been
usual, in fatal cases of puerperal convulsions, to examine the
brain, and to place all the lesions discovered in it on record,
as causes of the disease. Yet what could be more unphilo-
sophical than, in a case of convulsions from afflicting intel-
ligence, followed by effusion into the ventricles and death,
to assign the effusion as the cause of the malady. The patient
falls into the convulsion instantly, on the very moment, that
she hears of the death of a friend; she recovers her sensi-
bility, but the convulsion is repeated, and she gradually
becomes comatose, and expires. In such a case there can
be no doubt but that the emotion is the cause of the disease,
and that the effusion is an eff'ect of the obstructed circulation
within the cranium, which the convulsion always causes.
Practitioners have been further misled by the headache and
other cerebral disturbances frequently preceding the fit, and
by the marked unconsciousness during the fit itself, and often
in the intervals. Thus attention has been diverted from the
convulsive action which is the essential part of the malady,
and from its especial seat in the spinal, rather than the cere-
bral, portion of the nervous system.
To go a step farther, and inquire in what mode the ob-
structed circulation is commonly produced, with its sequela?
of cerebral congestion, effusion, hemorrhage, &c. In the
first place, the contractions of the uterus propel a certain
quantity of blood from its parietes into the rest of the system.
In the next place, the violent spasm of all the muscles of
the body in connection wdth the spinal marrow during the
fit, must, in a similar manner, pour out a still larger quantity
of blood into the arteries and veins. But the most efficient
cause is the venous congestion which takes place from the
spasmodic closure of the glottis and the sphagiasmus, which
interrupt oxygenation in the lungs and the return of the
blood trom the head.
These are, I believe, the efficient causes of the serous effu-
sion, coagula, and the vascular detention, sometimes found
290 CAUSE OF PUERPERAL CONVULSION.
after death from puerperal convulsions, and which are so
generally referred to as the causes of the disease. It will
be seen that I have taken no notice of the pressure of the
gravid uterus upon the abdominal vessels on which some
writers have insisted. It appears to me, that if the uterus
pressed only on the abdominal aorta, we might recognise
such pressure as a cause of vascular distention in the upper
part of the botly ; but it presses equally on the inferior cava,
nay, if any difference, still more than on the aorta, because
of the diti'erent structure of the arteries and veins ; so that
we ought to look on this variety of compression as an efficient
tourniquet taking off the pressure of the blood of the inferior
extremities, instead of a cause of cerebral congestion.
But though physiological and pathological facts and rea-
sonings lead us to the conclusion that the hemispheres of the
brain can have no direct influence in causing convulsion, yet
in the true puerperal attack, and in epilepsy, the brain is in-
dubitably affected during the fit, while in the spasms of tetanus
and hydrophobia, sensation, and the intellectual faculties,
remain unimpaired.
Dr. M. Hall attributes great influence to the spasmodic
closure of the glottis in convulsions attended by loss of sen-
sation, and its open state in hysteric attacks, or spasmodic
diseases in which sensation is preserved. He points out that
for some days or hours before the accession of the epileptic
or puerperal convulsion, there is sometimes stiffness of the
muscles of the neck, and an affection of the larynx, made
evident by an alteration of the voice. .To the effects of these
muscular contractions in the neck in impeding the return of
blood by the veins, and to the effects of the partial or entire
closure of the glottis in obstructing the circulation, and
causing asphyxia, Dr. M. Hall is inclined to refer the sudden
annihilation of consciousness which takes place in epilepsy
and puerperal convulsions, and also the loss of consciousness
without convulsion ; the spasmodic contractions acting in
much the same mode as the pressure of the cord on the veins
of the neck and the larynx, in strangulation. I shall have
to describe hereafter the manner in which eccentric irritation
may, it is believed, excite contractions of the neck and larynx,
producing, successively, sphagiasmus and laryngismus, wliich
in turn proiiuce sutTicient pressure and excitement of the
brain and medulla oblongata by impeding the return of
CAUSE OF PUERPERAL CONVULSION. 291
blood from the head, to cause either simple loss of conscious-
ness, or simple convulsion, or convulsion and apoplexy.
That venous congestion of the head and partial asyhyxia
are caused by the convulsive actions in epilepsy and the true
puerperal disease, none can doubt who have watched the
phenomena of these affections. But it has been objected by
Dr. Watson and others, that the explanation is scarcely appli-
cable in epileptics to the 'petit mal^ where the entire seizure
consists of a transient but complete loss of consciousness
without convulsion. The same may be said of the incom-
plete seizure in the puerperal state. It sometimes happens,
that when the causes of puerperal convulsions are in opera-
tion, patients are suddenly seized with loss of consciousness,
or they are affected w4th mortal faintness, and die instantly,
without any convulsion. In the latter case, as Dr. M. Hall
has remarked to me, it must be the heart which is affected,
and not the brain, as even the removal of the brain would
not extinguish life so immediately as it is destroyed in these
oases; and we know that the beat of the heart is interrupted
both at the onset of epilepsy and the puerperal convulsion.
In the former case, the brain is the organ chiefly affected,
and loss of sensation the only phenomenon wdiich appears,
the motor function of the spinal marrow being comparatively
undisturbed. Thus, it would seem that the same causes
which affect simultaneously the motion of the heart, the
consciousness of the brain, and the action of tl'e muscles
under the influence of the spinal marrow, so as to produce
the complete group of phenomena constituting the puerperal
convulsion, may, instead of exciting the convulsion through
the agency of the spinal marrow, j^roduce their effects on
the heart or on the cerebrum separately, and so cause either
loss of consciousness and volition, or arrest of the action of
the heart. There are some normal excito-motor acts in
which sensation is also powerfully affected ; the relation be-
tween the act of coitus and the cerebral portion of the epi-
leptic attack has often been reverted to since the time of
Hippocrates.
In thus attempting to set a limit to the influence of the
brain in convulsive diseases, 1 do not mean to deny that
effusion of blood or serum, or vascular congestion of the
brain, particularly in the propulsive stage of labour, may
occasionally cause puerperal convul^^ion, but such instances
292 CAUSE OF PUERPERAL CONVULSION.
are not fre(iiient enough to justify the general theory. Further,
even when convulsions are thus caused, it is not the Brain,
but the Spinal Marrow, which is affected so as to produce
them. Mere irritation of the brain, as w^e have seen, will
not cause convulsion, but mechanical or vascular pressure
on the brain, so as to afft'Ct the medulla oblongata by counter-
pressure, immediately brings on an attack. Thus, take two
experiments on dogs, performed by Dr. M. Hall, and Dr.
Blundell ; in one, mere injury of the brain produced no
efiect, but pressure so as to affect the medulla, caused con-
vulsions ; in the other, pressure, occasioned by tying the
aorta beyond the origin of the carotids, had the same effect
as direct cerebral pressure in producing convulsions. In
this manner, we must recognise fulness of the cerebral ves-
sels, w^hether primary, or the result of muscular action, as a
cause of puerperal convulsion.
There is, and I repeat it, this remarkable peculiarity about
puerperal convulsion. The convulsion itself may in some
cases produce that state of the brain which is the cause of
the disease in other cases. Thus, there may be cerebral
congestion in the first instance, and a fit of convulsion from
the intra-cranial pressure upon the medulla oblongata ; or
there may be a fit excited by uterine or gastric irritation,
which will produce a congested state of the brain similar to
that which existed in the first instance as a cause of the con-
vulsive dTsease. Or, to put the matter still more strongly : —
During the excessive exertions of the propulsive stage of
labour, when ecchymosis in the conjunctiva is not uncom-
mon, a vessel gives way in the brain, producing, in rapid
succession, effusion, and convulsion as a result of intra-cranial
pressure. Here the coagulum is the cause o/the convulsion.
Again, irritation of the os uteri during its dilatation may
excite convulsion, and during a fit, the cerebral vessel shall
give way, from the violence of the attack itself. Here the
coagulum is caused by the convulsion. If a post-mortem
examination were made, the same morbid appearances would
be found in both these cases, but their interpretations should
be widely diiferent. This peculiarity has, without doubt,
contributed greatly to obscure our knowledge of the patho-
logy of puerperal convulsion.
In the preceding quotations and observations, I think I
have shown that puerperal convulsion has been almost uni-
CAUSE OF PUERPERAL CONVULSION. 293
versally referred by obstetric authorities to the cerebrum,
and that this cerebral pathology has bec^i of the most vague
and unsatisfactory character. Nothing like a successful
attempt has ever been made to define the order in which
the several causes operate. Predisposing and exciting causes,
uterine irritation, mental emotion, impediments to the circu-
lation, apoplectic effusion, determination of blood to the
head (as it is termed), intemperance in diet, previous epi-
lepsy, have been heaped together, without any very distinct
meaning; all, however, being held to be subordinate to a
morbid state of the brain. As a consequence of this, the
same confusion has reigned in the therapeutics of the malady.
I believe I have shown that we must not look to the cere-
brum for the chief part of the pathology of puerperal con-
vulsion ; and I have pointed out some of the sources of the
pathological errors which have prevailed ; in doing this, I
have endeavoured to discriminate between those cases in
which the brain, is affected as a cause, and those in wdiich its
pathological condition is the eff^ect of the convulsion. In the
next Lecture, I propose to give some account of the causes
of this malady, grouping them round the reflex function,
instead of the phenomena of cerebral disturbance ; and 1
hope to be able to demonstrate that the cases of obstetric
writers abundantly disprove the common cerebral specula-
tion. I believe it will only be necessary to place their prac-
tice in juxtaposition with their hypothesis, to overturn the
latter ; the clinic will destroy the theory.
25
234
LECTURE XXI.
Centric Causrs of Puerperal Convulsion — (/crebral Counter-Pressure — Tiri-
tation of the Spinal Centre — Slates of the Blood — Emotion — Atmospheric
Jnlluences — Eccentric (Causes of Convulsion — Irritation of the Uterus —
Irritation of Intra-Cranial Excitor INerves — Irritation of the Ovaria — Irrita-
tion of the Bowels — Irritation of the Stomach — Irritation of the Bladder,
«&c. — Summary of Causes.
Convulsion, like the other disorders of parturition arising
from excessive nervi-motor action, may be divided into
those of centric and those of eccentric orisfin. This division
is the most convenient for an investigation of the causes of
the disease.
CENTRIC OR DIRECT CAUSES OF PUERPERAL CONVULSION.
Any mechanical or emotional stimulus applied in excess
to the spinal centre itself, may excite convulsion during
the puerperal state. In all women the excitement of the
nervous system inseparable from parturition is a predisposing
cause of the attack, which is provoked whenever any other
suiiicient exciting cause supervenes upon this parturient ex-
citability.
'I'he centric causes of convulsion maybe either intra-cranial
or intra-vertebral, or both. 1 proceed to speak first of the
intra-cerebral causes.
A clot of blood, or serous effusion, occurring in any part
of the brain, may cause convulsion by mechanical counter-
pressure upon the medulla oblongata. In full states of the
circulation, convulsion maybe caused by cerebral distention
alone. Here it must be the counter-pressure on the medulla
oblongata which, in part at least, produces the disease.
Any disease of the brain, of the membranes, or of the skidl,
capable of exerting internal pressure, may cause convulsion
in this manner.
The intra-vertebral causes of convulsion consist chiefly of
disorders of the spinal meninges, and upon conditions
DIRECT CAUSE OF CONVULSION. 295
affecting the substance of the spinal centre itself. Probably,
excessive distention of this organ wilh blood excites con-
vulsion ; it is certain that the opposite condition, spinal
anaemia, becomes a powerful exciting cause. In cases of
irremediable uterine hemorrhage, convulsion is the common
form by which death occurs ; or a convulsion may occur
from loss of blood before the patient is in extremis. I shall
moreover, endeavour to show hereafter, that in some cases
of convulsion arising from other causes, excessive blood-
letting comes in at length as a cause of the fits, the thera-
peutics of the disease trenching distinctly upon its pathology.
In animals killed by bloodletting, either in experiments or
at the shambles, convulsion always occurs during the act of
dying.
The state of the blood circulating in the spinal centre, as
regards its constitution, is an important cause of centric con-
vulsion. All agencies which interfere with the proper depu-
ration of this fluid during pregnancy, or on the approach of
parturition, contribute to render the blood a morbid stimu-
lant to the spinal system. Such are the constipation and
insufficient secretion from the bowels caused by the mechani-
cal pressure of the gravid uterus upon the intestines. The
albuminaria, sometimes present, and w4iich also appears to
be caused by pressure on the kidneys and the renal vessels
and nerves, accumulates noxious elements in the blood.
The encroachment of the abdomen upon the thorax must also
render the due oxygenation of the blood difficult. Asphyxia
invariably produces convulsions, and when it occurs during
parturition, must produce this disease. The act of abortion
from asphyxia seems to be almost a part of the general con-
vulsion excited by the deprivation of oxygen. In criminals
and others who die by hanging, convulsion is observed. In
the reports of suicides and executions, these convulsive
actions are termed struggles, and are' supposed to involve
consciousness and suffering, during th^e dying moments,
whereas they are purely physical, and excited centrically,
by the state of asphyxia. In the asphyxia of drowning, the
same convulsive actions are present. I mention these facts,
as, though not strictly relevant, they illustrate the effects of
partial or entire asphyxia in parturition. There are various
other sources of sanguineous impurity, all of which con-
tribute their quota towards rendering the blood morbidly
296 DIRECT CAUSE OF CONVULSION.
irritating to the nervous centres. It deserves to be borne in
mind that the depuratory functions ought, in order to pre-
serve health, to be increased during gestation, as the debris
of the fnetal, as well as the maternal system, have to be
eliminated by the organs of the mother. Besides these
forms of toxsemia, the state of the blood which obtains in
fevers, or during the excitement of the first secretion of milk,
may excite convulsive disorder. In all these cases theaffec-
tion of the nervous svstem is centric, and not reflex.
There are various predisposing causes of puerperal con-
vulsion, external to the patient herself, which deserve con-
sideration. It has been found that certain states of the at-
mosphere increase the tendency to this disease. There
seems, in fact, to arise at certain times a convulsive consti-
tution of the atmosphere, so that this disease is more frequent
than at others. The same has been observed of many spas-
modic diseases — tetanus, laryngismus, pertussis, spasmodic
asthma, chorea, are all aggravated or relieved by variations
of wind, temperature, and other atmospheric changes. The
atmospheric epidemical influences must be distinguished
from those depending on emotion ; it is found that within
certain circles, convulsions are common from the influence
of fear. One patient suffering from convulsion, her pregnant
friends are rendered timid, and consequently predisposed to
this aflfection.
These are all physical causes of disease ; but there is
another and very etTective cause of puerperal convulsion
which is psychical in its character. I refer to the influence
of Emotion.
Emotion, then, is a very important cause of centric con-
vulsion in the puerperal state ; important both on account of
the severity of the attack when thus induced, the greater
absence of premonitory signs, and the obstinacy of the
disease as regards treatment. It is a very old and true
observation, that convulsion is often met with in single
women whose minds have been depressed by the sense of
shame and misery inseparable from their condition during
gestation. But any violent emotion of the mind, whether
of joy or sorrow, the agreeable or disagreeable, may excite
a convulsive attack. The return of a husband, the first
sight of the infant alter the hours of intense expectation, the
pain and dread of parturition, or any intelligence whatever,
DIRECT CAUSE OF CONVULSION. 297
suddenly communicated, may hurl the patient into convul-
sion. I myself recently saw a case in which a husband
returning from a distant and perilous journey a day or two
after his wife's delivery, in the very act of greeting him she
fell into convulsion ; and instead of embracing a conscious
mother, he held the rigid form of an epileptic. The fit is
sometimes produced by emotional causes of a trivial cha-
racter. Mauriceau related a very singular case in which
puerperal convulsion was excited by the disgust caused in
the mind of a patient by the entrance into her apartment of a
coxcombical friend, whose dress was powerfully scented.
The following case from Dr. Merri man's Synopsis, which is
most graphically related, illustrates the danger and severity
of the emotional form of convulsion more strikingly than any
other with w'hich I am acquainted.
Case 1. — " My uncle, the late Dr. Merriman, was one day
sent for in great haste, to one of the villages in the neigh-
bourhood of London ; on his arrival at the house of the pa-
tient to whom he was called, he found her undelivered, and
quite dead. At the moment, jittle information as to the cause
of her death could be obtained: but some time afterwards the
following particulars w^ere communicated to him :
*' The woman had been servant to a lady who was Dr.
Merriman's patient, and left her to marry a man, in business
as a poulterer. She soon become pregnant, and made up her
mind to be attended by the doctor she had been in the habit
of seeing at her former mistress's labours. J3ut when she
mentioned this her intention to her husband, he objected to
it; alleging that Dr. Merriman would not attend her at such
a distance unless he received a larger fee than it would be
prudent in them to pay ; and that there was living in their
owri neighbourhood a most respectable apothecary, who was
a customer ; and who, on that and other accounts, was a more
proper person to be employed.
^' A great deal of unpleasant altercation took place between
the husband and wife upon this subject, and was frequently
renewed, and the relations of both parties were appealed to
on the occasion ; all, or the majority, of whom thought the
husband right in maintaining his opinion, and censured the
wife as pertinacious and self-willed ; so that she felt herself
compelled, though very reluctantly, to give way ; and the
gentleman in question, who of course knew nothing of these
25*
298 DIRECT CAUSE OF CONVULSION.
family disputes, was engaged to attend her, notwithstanding
her constant dechiration, that ' she hated the very sight of
him.'
'^ When the first symptoms of labour came on, and her
nurse and some female friends were assembled, it was pro-
posed that her accoucheur should likewise be sent for ; but
she begged that he might not, as she was sure she was not
bad enough yet. After a time it was again proposed to send
for him, but she still objected. Again and again her friends
tried to prevail upon her to see him, but all in vain : if it had
been her own doctor, as she termed it, she would willingly,
she said, see him ; but as it was, Mr. J should not come
near her till he was really wanted.
" At length, one of the women in the room, disgusted with
so much obstinacy, w^ent down stairs, and told the husband
that the presence of her medical attendant was absolutely re-
quired, and accordingly he was immediately sent for.
*' Unfortunately, and certainly very inconsiderately, he was,
on his arrival, without being announced, introduced at once
into her room. The shock of thus suddenly and unexpectedly
seeing the man, against whom she had been long nourishing
such a perverse dislike, occasioned her to scream out, and
she fell back upon the bed in a fit, from which she never re-
covered. In the confusion which ensued, a messenger was
sent in great haste to London for Dr. Merriman ; but, as
already stated, before he arrived at the house, the woman was
quite dead.
" No attempt had been made to extract the child, nor could
leave be obtained to open the body; so that the immediate
cause of her death was never discovered ; but that the
sudden emotion was the exciting cause, seems unquestion-
able."
The anatomical mechanism by which emotion produces
convulsion is not understood. An attempt has been made to
call movements resulting from impressions on the nerves' of
special sense and the emotions they excite, reflex cerebral
movements. But movements of this kind are clearly differ-
ent altogether from the reflex physical movements ; they may
arise from the memory as well as from sensual impressions.
It would be introducing confusion to apply to them the term
reflex. We know that emotional movements may occur
CONVULSION OF REFLEX ORIGIN. 299
in limbs paralyzed to voluntary motion. Thereforo, the
mechanism of emotional movements and emotional convulsion
can hardly be the same as the mechanism of voluntary motion.
That the mechanism of puerperal convulsion is spinal and not
cerebral is evident, because the fit may occur during apo-
plexy with perfect loss of voluntary motion. But it is still a
great mystery how emotion and psychial and cerebral func-
tions, should affect the great physical organ of motor action.
Here we have a chasm which we cannot bridge — at which
the human intellect recoils — the separation between the
physical and the psychical, body and soul, in the living
economy.
Such being the principal Centric causes of puerperal con-
vulsions, let us now consider the Eccentric^ or those caused
by irritation of incident, excitor, nerves, acting through them
upon the spinal marrow, and its motor nerves.
ECCENTRIC OR REFLEX CAUSES OF PUERPERAL CONVULSIONS.
First in importance is, Convulsion from Irritation of the
Uterus itself and the Uterine Passages.
The statistics of labour demonstrate that puerperal convul-
sions occur with far greater relative frequency when the head
presents, than in other presentations. From this it has been
inferred that the pressure on the os uteri was a princii)al
cause. But the acute mind of Dr. Collins saw that this coin-
cidence could not be considered as cause and effect, for con-
vulsions frequently come on when the os uteri is entirely
dilated, before the dilatation has commenced, or after de-
livery. Neither this eminent obstetrician nor any other has
taken the pressure of the head on the vagina sufficiently into
consideration, in connection with the fact, that irritation of
the vagina excites more extensive reflex muscular actions
than irritation of the uterus itself. This gives a physiological
explanation to the fact respecting the frequency of convul-
sions in head-presentations with first children, the irritation
of the excitor nerves of the os uteri and the vagina being un-
doubtedly greater under such circumstances than any other.
I might adduce numbers of cases in support of this view; in
fact, any ease in which all remedies have been tried in vain,
but in which the convulsions cease immediately after delivery,
contains its proof. It must always be borne in mind, when
300 COxWULSION OF REFLEX ORIGLf.
considering the causes of excito-nriotor diseases, that irritation
of the peripheral incident nerves is not dependent on, or to
be measured by, the mere intensity of pain. Jt has been
shown, again and again, that the most powerful reflex action
of the vis nervosa may be caused without any sensation what-
ever; indeed, in puerperal convulsions the causes operate
sometimes during a state of perfect coma, or they may com-
mence while the patient is in a profound syncope. The term
irritation, when applied to spinal action, must therefore, as I
have often observed, be received with its peculiar significa-
tion.
Convulsions may be brought on by the mere .presence of
the fcetus in utero, there being no other exciting cause; or
they may occur from the causes of spinal irritation depending
on the first changes which take place in the uterine system
preparatory to labour, before the os uteri has commenced its
dihitatlon. They are sometimes caused by the irritation of a
dead fcetus, which it is well known is more strongly excitor
of reflex action than a living ovum. The mere distention of
the uterus by the liquor amnii, particularly in cases where
there is a large quantity of this fluid, has appeared to give
rise to convulsions.
When a convulsion has once happened, the fit may be re-
peated from causes of uterine irritation apparently trivial,
Irritation of the os uteri is one of these. Uenman relates the
following, of a case which occurred to him : — " When the os
internum began to dilate, I gently assisted during every pain ;
but being soon convinced that this endeavour brought on,
continued, or increased the convulsions, I desisted, and left
the work to Nature." A similar case was once related to me
by Dr. Heming. In other cases, fits have been produced by
the hand of the accoucheur in the operation of turning, or by
the irritation caused by the use of instruments. Irritation of
the os externum is also a powerful excitor of spasuiodic ac-
tion. Many women die from the violence of the convulsion
caused by the passage of the child through the external parts.
On another occasion I shall have to relate a case in which
successive fits were caused by irritation of the uterus from in-
judicious attempts to apply an abdominal bandage.
The following are two interesting cases of puerperal con-
vulsions from irritation or excitation of the excitor nerves of
the uterus and uterine passages, the irritation being conveyed
CONVULSION OF REFLEX ORIGIN. 301
to the spinal marrow and reflected back on the motor nerves
of the whole spinal system, so as to cause the convulsions.
The first is related by Dr. Ingleby: —
Case 2. — " A highly esteemed friend of mine once found
it necessary to pass his hand into the uterus, for the purpose
of removing an adherent placenta, the ergot of rye having
been previously administered. The introduction was care-
fully performed. The straining and opposition to his efforts
on the part of the woman were exceedingly great ; and at the
moment when the operator'' s hand had reached the organ ^ my
own hand making the counter -pressure on the abdomen, the
patient became violently convulsed, and died in less than a
minute."
The second is from Dr. F. H. Ramsbotham, who relates
a case of convulsions in which the fits were relieved by
bleeding, and the woman remained fifty hours after the
attack, before labour came on. In less than five hours she
was delivered without any recurrence of the fits; but as the
placenta did not come away. Dr. Ramsbotham was sum-
moned, two hours al''ter the expulsion of the child. He
remarks that, "Under no greater anxiety than usual when
the placenta is retained, I proceeded in the ordinary way to
remove it. The moment 1 had passed my hand completely
into the uterine cavity, the patient turned upon her abdomen,
and without uttering any expression of pain, went into a con-
vulsion." The woman died in about two hours.
Convulsion from Irritation of Intra- Cranial Excitor JYerves.
It may appear a nice distinction to classify convulsion
arising from cerebral pressure on the medulla oblongata, and
convulsion caused by irritation of the membranes, under dif-
ferent heads. Yet the one is centric, the other eccentric.
Cerebral pressure affects the medulla oblongata directly, me-
ningeal irritation reaches it reflexly, so that some distinction
is really demanded. The known intra-cranial causes of
puerperal convulsion of a rellex character are, bony spiculi,
inflammation of the meninges, the extension of red softening
of the brain to the membranes, or the extension of irritation
from a coagulum in the substance of the brain. Thus, in
puerperal convulsion we have to study the brain and its
envelops under many and very important points of view ;
302 CONVULSION OF REFLEX ORIGIN.
1, as the scat of some of the most important changes which
occur during the fit; 2, as the seat of an important class of
centric causes of convulsion; and 3, as the source of irrita-
tion acting upon the spinal centre in reflex forms. As a
reflex cause of convulsion we must study the hrain as we
would the uterus, the stomach, the intestines, &c.
Convulsion from Irritation of the Ovaria.
Every practitioner must have observed cases of epilepsy
depending upon the periodical return of ovarian irritation at
the times of the catamenia. This form of epilepsy is very
common. Some female epileptics suffer from an attack at
the commencement of each catamenia) flow, and at no other
time. Others have the fits in greater severity and frequency
at each returning period. Such cases prove the influence of
the ovaria in exciting convulsion in the female economy.
Indeed, during their seasons of activity the ovaria are the
paramount source of all convulsive affections. Possibly this
may be the reason why some epileptics are, in great measure,
free from convulsion during pregnancy, the ovaria being at
this time in a state of comparative quietude. I have shown
that at parturition the ovarian irritation recurs, and J have
no doubt that it is now a frequent cause of puerperal con-
vulsion and puerperal mania. The connection between
puerperal mania and ovarian irritation is often seen in cases
of mania of an erotic type. In puerperal convulsion, the
ovarian irritation of parturition is probably an assisting cause
in all cases, and in some cases the chief cause. By far the
majority of cases occur within the time of the lochia! period,
that is, between the first sanguineous discharge, or **show,"
and the time of the disappearance of the sanguineous lochia.
Convulsion from Irritation of the Intestinal Canal.
Irritation of the bowels, especially of the lower part of the
intestinal canal, is well known to cause convulsion under
other circumstances besides those connected with the puer-
j)eral state. Thus worms, the severe action of purgative
medicines, the collection of indurated fa?ces in the bowel,
have all been known to cause epilepsy, and the convulsions
of children. It cannot therefore be wondered at, that when
CONVULSION OF REFEX ORIGIN. 303
the excito-motor system is under the additional stimulus of
either pregnancy, labour, or the peurperal state, these and
similar sources of excitation should cause puerperal con-
vulsions. 1 subjoin two cases, the second of which is par-
ticularly instructive, and the author of it relates several others
bearing- equally strong upon this point. The first case is by
Dr. R. Lee :
Case 3. — "Mrs. II , aged twenty-four; first pregnancy,
ninth month. Cons'ipation and headache for several days;
severe fits of convulsion, insensible in the intervals; pupils
dilated; pulse eighty, full and strong; face flushed; os uteri
slightly dihitetl ; feeble, inegular, uterine pains. After vene-
section and /Vce evacuation of the bowels^ the fits ceased, and
she was delivered the next day, without assistance, of a
living child." — Dr. R. Lee, " Clinical Midwifery.
The next is a case of the late Dr. Ingleby's: —
Case 4. — "Elizabeth Roden, aged twenty-three, had be-
come very plethoric during the latter months of pregnancy,
but, with the exception of drowsiness, had not experienced
any of the premonitory symptoms of convulsion. She was
delivered, at six p.m., June 25ih, of her first child, after a
very natural and easy labour, and at nine was seized with a
violent convulsion, which lasted ten minutes. Mr. Bindley
saw her at half-past eleven ; the fits had recurred several
times ; she was now partially sensible, but the stupor was
considerable; presently, the paroxysm returned; she rolled
her head about, struggled, saliva issued from the mouth ; the
pulse was full but not iVequent, the head hot, and the face
llushed, the lochias sparing, and the bowels constipated.
Mr. Bindley ordered leeches, cold to the head, and camphor
and opium.
" 26th, Eight A.M. — The fits have frequently recurred during
the night. In the intervals between the attacks she lies in a
state of coma, and has stertorous res{)i ration. V. S. to 5xxv;
head to be shaved, and cold cloths applied. Calomel, jalap,
and the purging mixture, were ordered. — Two p.m. The
convulsions continue ; the teeth had become so firmly fixed,
that it was found impracticable to give her the medicine ;
pulse 100. The blood does not present an inflammatory
crust. Cold to be continued. — Seven p.m. The convul-
sions have recurred. R. Croton oil, eight minims; spirits of
wine, 5ij; cinnamon water, ^ij. A drachm every three
hours, uniil the bowels are moved.
304 CONVULSION OF REFLEX ORIGIN.
"29th, Eight A.M. — A surprising quantify of dark green
and very ojfensive fcvculent matter has been discharged^ in-
eluding a multitude of ascarides. She now became sensible,
but was unconscious of her illness, and did not remember
having been delivered. From this time, WMth very slight
deviations, she gradually and completely recovered."
Convuhion from Irritation of the Stomach,
Gastric irritation has long been looked on as a cause of
puerperal convulsions, though the true rationale has never
been given by obstetric writers. T subjoin two cases. Of
the nature of the first I believe there can be no doubt, and in
the second, the evidence of a loaded state of the stomach,
coupled with the fact, that neither venesection, evacuation
of the bowels, nor careful delivery, afforded any relief, are
sufficient reasons for considering it a case in point.
Case 5. — "Mrs. H., a young woman, of a very healthy
constitution, had passed through the period of childbirth very
well on former occasions, as well as on that which preceded
the present subject of consideration. She had been delivered
of her child nearly a month, and had ceased to require any
medical attendance. She had entirely left the chamb'er in
which she had been confined, and had returned to her
ordinary modes of life.
" On waking one morning she complained of pain in her
head, but it was not sufficiently violent to confine her to her
room ; she therefore went into the drawing-room, where she
was left in the afternoon, with one of her children.
" Her husband was in a room underneath, and having
heard something fall upon the floor with great violence, he
had concluded that the child had fallen on the ground, bat
on opening the door he saw his wife lying on the grountl,
senseless, convulsed, snorting, and foaming at the mouth.
He immediately sent in great haste to the writer. When he
arrived, the convulsion had ceased, but she was lying in a
comatose state. Bleeding from the orifice of a large vein,
purging, blistering, and low living, at length succeeded in
removing the pressing symptoms, antl she at length recovered,
but for a long time she continued to be liable to pains in the
head.
" On investigating the cause of this attack, it appeared
CONVULSION OF REFLEX ORIGIN. 305
that on (he day before, she had indulged in eating oysters. She
had in all other points adhered to a very simple and regular
diet, and no other circumstance had occurred to which the
disease could have been attributed.
'* The conclusion to be drawn from the consideration of
the cases which have been related above [six similar cases
are detailed] is, that the state of pregnancy not only induces
such a flow of blood to the head as to dispose it to be vio-
lently affected by the strong exertions of labour, so as to
induce puerperal convulsions, but also to render it liable to
be particularly acted upon for some time after childbirth, by
sympathy with the stomach, when indigestible substances, espe-
cially the Jishes of the bivalvce class, have been eaten.''^ — Dr.
John Clarke, in the fifth volome of *' Transactions of the
College of Physicians."
Case 6. — " Mrs. P., aged twenty-six, first pregnancy, full
period ; returned home after midnight from a large dinner-
party, at wdiich she had partaken of a variety of dishes and
wines, and had been seated near a large fire. Labour came on
at four A.M., and soon after she became incoherent, and said
she felt her teeth falling out of her head. On attempting to
drink some warm tea she bit a large piece from the edge of
the china cup, and crushed it between her teeth. Convul-
sions of great violence immediately followed. Copious
venesection and an enema gave no relief. In an hour and
a half the head of the child was within reach of the forceps,
and it was applied, and the child was extracted alive. She
died at eleven a.m." — Dr. Lee,, " Clinical Midwifery."
Convulsion from Irritation of the Bladder.
L-ritation of the bladder is a less frequent, though un-
doubted, cause of puerperal convulsions. The following is an
interestirrg case which occurred more than a century and a
half ago, in the practice of La Motte :
Case 7. — " Le 18 Mars de Pannee 1695, la femme d'une
personne de cette ville, me fit prier de I'aller voir. Elle
etoit reduite a I'extremite, par un accident des plus facheux,
qu'elle soufroit depuis plusieurs niois. J'y allai promptement,
et je trouvai cette pauvre femme avec une douleur dans le
has ventre, non des plus vives, mais continuelle, accompag-
nee de mouvemens convulsifs et souvent de convulsions
26
306 CONVULSION OF REFLEX ORIGIN.
assez violentes, pour faire craindre un accouchement pre-
mature. Elle etoit dans le settieme mois de sa jrrossesse :
ce que j eus peine a croire en ce qu'elle ne me paraissoit pas
seulement grosse a terme et pour accoucheur d'un jour i
I'autre, mais assez pour me persuader qu'elle I'etoit de deux
enfans, tant son, ventre avoit de volume en toutesses dimen-
sions, avec beaucoup de peine a marcher, et des envies con-
tinuelles d'uriner, sans le pouvoir faire, que tres peu et goutte
a goutte.
Apres avoir reflechi sur tons ces accidens, je fis coucher
cette femme sur un paillasse devant le feu, en la meme situa-
tion que pour I'accoucher ; apres quoi ayant voulu introduire
ma sonde dans I'uretre, j'y trouvai de la resistance. Je
trempai mon doight dans I'huile, que je coulai dans le vagin ;
je trouvai la tete de I'enfant, qui comprimoit le cou de la
vessie, qui interceptoit presque entierement le cours de
Purine. Je la repoussai doucement le plus haut qu'il me
fut possible. Des le moment que le cou de la vessie se
trouva degage et que Purine eut son issue libre il en sortit
une telle quantite qu'il n'est pas possible de croire que la
vessie fut capable d'en contenir autant, ni de se dilater
jusqu'a un tel exces, sans se rompre. La malade se trouva
soulagee sur Pheure, et se porta bien jusqu'a son accouche-
ment."
The next is another case of the variety of vesical convul-
sions, which was related, with reference to a paper of mine
upon this subject, by Mr. Vines, of Reading.
Case 8. — "Susan C v^g*^^ twenty, of spare habit and
nervous temperament, had enjoyed tolerably good health,
and was about eight months advanced in her first pregnancy,
when she was suddenly seized with convulsions on Friday,
11th of October, 1844. The medical man first in attend-
ance bled from the arm to sixteen ounces, and ordered ape-
rient medicine. On the following day, ten a.m., when I first
saw the patient, her symptoms were as follow: — The face
and whole surface of the body livid, features distorted, frothy
mucus about the mouth, ccdema of the upper extremities,
frequent and violent convulsions, requiring two or three per-
sons to hold her, perfect unconsciousness; there was also
inordinate and tumultuous action of the heart, with a quick,
feeble, and fluttering pulse.
" Treatment, — Cold water repeatedly dashed on the face
CONVULSION OF REFLEX ORIGIN. 307
and neck; warm applications to the extremities ; half a grain
of the acetate of morphia to be taken directly; a mixture of
sulphuric ether with camphor julep every four hours. At
four P.M. the child was expelled from the uterus, the mother
being perfectly unconscious of the circumstance — an interest-
ing physiological fact.
"October 13th. — The patient's general appearance im-
proved ; still, however, unconscious, and occasionally con-
vulsed. Applies her hands to the head, which feels extremely
hot. The hair to be removed ; leeches applied to the temples,
and afterwards wet rags ; continue the medicines. — Eight p.m.
Patient very restless, heat of head diminished, but uncon-
sciousness still continues. Findings upon examination, the
lower pari of the abdomen enormously distended, I was led to
suspect retention of urine. Ji catheter was at once passed, and
five and a half pints of turbid urine, having a strong ammo-
niacal odour, drawn off. The removal of the water was
follow^ed by great impovement of all the symptoms, and on
the return of consciousness the patient expressed herself sur-
prised on being told of what had happened. To take eight
grains of Dover's powder at bedtime.
*' 14th. — Has passed a good night; general appearance
of patient better ; has had no return of the convulsions since
the evacuation of the bladder ; is troubled, however, with
cough, and complains of tenderness of the chest. To take
a saline with ipecacuanha wine and tincture of hyoscyamus.
The catheter to be used morning and evening. Repeat the
Dover's powder at bedtime.
15th. — Has slept tolerably well ; makes no complaint of
pain ; the bowels confined. There is still retention of urine,
caused probably by the great distention of the bladder on
the previous days. To take an aperient, continue the cough
medicine, and the use of the catheter.
" The after-treatment of this patient consisted in the ad-
ministration of gentle tonics, mild aperients, and the use of
the catheter ; turpentine liniment applied over the loins and
public region. The bladder was remarkably slow in recover-
ing its action, and the urine retained for a considerable time
its turbid appearance and disagreeable odour. The infusion
of buchu was given with decided advantage."
Irritation of the kidney has been know to excite epilepsy,
and most probably it would act as a cause of puerperal con-
308 CONVULSIOx\ OF REFLEX ORIGIN.
vulsion: La Motte and others have recorded cases of this
kind. It is an old remark, that oedema of the face and neck
forms a frequent premonitory sign of the attack ; and Dr.
Lever has made the interesting and important observation
that albuminuria is present in many instances. These points
require further examination, with special reference to the
diiTerent modes in which spinal action may be excited.
Other causes than those which have been given, occasion-
ally operate on the spinal system, but all act in accordance
with the principles already advanced. Professor Ingleby
suspected that irritation of the Mammse might cause convul-
sions. Not long since, I saw a case of puerperal convulsion
for which no other cause could be assigned than excessive
soreness of the nipple, with mammary induration. The skin,
too, as an important excito-motor organ, must be studied in
relation to puerperal convulsions. The same may be said
of the liver, and other organs supplied by the pneumogas-
tric nerve.
Such are the principal causes of puerperal convulsions, to
the modus egendi of all of which the physiology of the true
spinal marrow supplies as full and perfect an explana-
tion as we have of the causes of any disease whatsoever;
and it must be remembered, that wanting this mode of solu-
tion, the whole disease formed, confessedly, one of the pro-
foundest enigmas of pathology.
In conclusion, to give a summary of the whole subject, the
the true puerperal convulsion can only occur when the central
organ of this system — the spinal marrow, has been acted on
by an excited condition of an important class of its incident
nerves — namely, those passing from the uterine organs to the
spinal centre, such excitement depending on pregnancy,
labour, or the puerperal state. While the spinal marrow
remains under the influence of either of these stimuli, con-
vulsions may arise from two series of causes — those acting
primarily on the spinal marrow, or centric causes, and,
secondly, those affecting the extremities of its incident nerves
— causes of eccentric or peripheral origin.
I. Causes acting immediately on the Central Organ : —
1. Pressure exerted on the medulla oblongata by conges-
tion, coagula, serous effusion within the cranium, &c.
CONVULSION OF REFLEX ORIGIN. 309
2. Loss of blood.
3. Morbid elements in the blood.
4. The influence of emotion.
II. Causes acting on the extremities of Excitor Nerves : —
1. Irritation of the incident spinal nerves of the uterus and
uterine passages.
2. Irritation of excitor nerves within the cranium.
3. Irritation of the incident spinal nerves of the rectum.
4. Irritation of the ovarian nerves.
5. Irritation of the gastric and intestinal branches of the
pneumogastric nerve.
6. Irritation of the incident spinal nerves of the bladder.
7. As probable causes, may be enumerated, irritation of the
cutaneous nerves, of the nerves of the mammse, and of the
hepatic and renal branches of the pneumogastric.
Though the subject distinctly admits of this division, several
causes may act together, and centric and eccentric causes
may be in operation at the same time. I have made no
attempt at a division into predisposing and exciting, proximate
and remote causes, as other authors have usually done, be-
cause it is evident that a cause which in one case is the ex-
citing or proximate, may in another be the predisposing or
remote cause. Thus, irritation of the uterus may be the pre-
disposing, and irritation of the stomach the exciting cause, in
one instance, while in another, irritation of the uterus is both
the predisposing and the exciting cause ; hence, any such
division must be, to a great extent, arbitrary, and devoid of
precise meaning. For instance: Dr. Ramsbotham,in a pas-
sage I have quoted, says, " The most usual proximate cause
of puerperal convulsion is probably pressure on the brain,"
whereas it can be shown that cerebral pressure is usually a symp-
tom produced by some exciting cause previously in operation.
The same authority mentions irritation of the stomach and
intestines among the remote causes^ though there can be no
doubt of their being generally exciting causes when they
exist as causes of any kind. It would be easy to lengthen
the series of cases I have selected to illustrate ray views, but
what I have chiefly desired to do has been to place the clinic
of obstetric writers in opposition to their hypotheses. I think
26*
310 CONVULSIOx\ OF REFLEX ORIGIN.
the cases now adduced are of themselves sufEcient to over-
turn the theoretic opinions quoted in the last lecture.
The views of the nature and causes of puerperal convulsions,
developed in the present lecture, are, as I believe, capable
of important practical application in the treatment and pre-
vention of the disease. This branch of the subject I propose
to consider hereafter; but in the next lecture I shall endea-
vour to describe the actual phenomena of puerperal convul-
sion. I shall attempt to show how the various causes operate
in producing the fit.
Sll
LECTURE XXII.
Physiology of Sleep — Convulsive Erethismus — Sphagiasmns — Laryngismus
— Odaxisraus — Pharyngismus — Cardiasmus — The Convulsive Paroxvsm —
Relation of Convulsive Action to Labour-Pains — Relation of Puerperal Con-
vulsion to Epilepsy, Puerperal Mania, Apoplexy, and Cerebral Syncope, &c.
HA^^XG discussed the causes of puerperal convulsion, let us
turn to the study of the successive actions which these causes
call forth ; in other words, let us endeavour to obtain some
account of the phenomena which constitute the fully-formed
attack. There are a multitude of points worthy of attention,
occurring between the eccentric or centric irritation which
makes little or no sign, and the terrific strus^gle of the fit
itself.
And, first, I would express the highest admiration of the
singular power with which Dr. Marshall Hall has himself ap-
plied the reflex function to the convulsions of infancy, epi-
lepsy in the adult, and apoplectic aflJections, in the series of
papers which first appeared in The Lancet, and which were
afterwards printed for private circulation. These essays are
the most perfect compositions which have ever issued from
the mind of their author, and in my opinion, they constitute
a new step in the application of spinal physiology to practical
medicine. Dr. M. Hall has not himself yet treated of puer-
peral convulsion in the same method as he has treated the
epileptic form, and the infantile malady, though he has ex-
pressed his intention of so doing at a future opportunity. In
the meantime I venture to take up this important subject,
with the hope that it may not suffer in my hands, until Dr.
M. Hall shall fulfil his intention.
In his large work on the "Xervous System," Dr. M. Hall
has referred to the stiffness of the muscles of the neck and
the laryngismus of epilepsy, as important means in effecting
the unconsciousness and the cerebral fulness of epilepsy. In
the second volume of his ^'Observations and Suggestions,"
he first, I believe, broached' the theory that cervical contrac-
tions produces sleep. " In the " Essays" on the theory of con-
312 PHYSIOLOGY OF SLEEP.
vulsive diseases, great prominence is given to the reflex con-
tractions of the cervical muscles and the consequent compres-
sion of the veins and impediment to the return of venous blood
from the cerebrum, in causing the fully-developed phenomena
of conv^ulsion. I propose to extend these views to puerperal
convulsion, preserving, at the same time, an independence
or diflference of opinion on some important points.
According to Dr. M. Hall's opinion, on the suspension of
volition, the platysma myoides, and perhaps the other muscles
of the neck, contract upon the jugular and other veins so as
to compress them gently, and produce slight cerebral ful-
ness, and it is this which predisposes to, and produces sleep.
He compares the contraction of the platysma on the with-
draw^al of volition, to the contraction of the orbicularis palpe-
brarum from the same cause. It has seemed to me that the
orbicularis muscle is itself concerned with the platysma in
the production of sleep. The dilatation of the orbicularis
cannot be the mere result of the contraction of the levator
palpebrae, and the influence of volition ; it must be an active
and involuntary state, and I have little doubt that the impres-
sion of light upon the retina is an exciting cause of this reflex
dilatation. The action of light on the irides is evident; and
if w^hat I have said be correct, we have the same excitor, the
branches of the third nerve distributed to the retina, and sus-
ceptible to the impression of light (just as the pneumogastric
in the lungs is to carbonic acid), producing two distinct re-
flex actions, one the due contraction of the iris, the other the
due dilatation of the orbicularis. Or it may be, that very
strong light produces reflex contraction of the orbicularis.
In some animals, birds, for instance, the connection between
the absence of the stimulus of light, the closure of the orbi-
cularis, and sleep, is very marked. On the instant almost
that light is withdrawn, the orbicularis closes, and sleep
begins, so that birds may be put to sleep in the day-time by
artificial darkness. It may be objected that certain birds and
animals have the orbicularis closed in the day-time, and
dilated at night, or are in the same condition by night or day.
But in such cases, either there is very great power of modi-
fication, as in the case of the cat, or the retina is so sensitive
to light, as in the case of the owl, that in strong daylight the
eye is closed to avoid pain. It has seemed to me that the
pressure on the veins by the orbicularis, and the diminished
quantity of blood sent to the structure of the eye during its
PHYSIOLOGY OF SLEEP. 313
state of repose, may have some influence upon the cerebral
circulation in the human subject.
But this is in the nature of a digression. Taking sleep as
caused by some kind of compression of the cervical veins,
and slight venous distention of the cerebrum, Dr. M. Hall
has based the pathology of convulsion upon this physiological
process. The actions of convulsions are, in the first place,
merely an excess of the actions which occur nightly during
sleep. I need hardly refer to the frequency with which the
invasion of epilepsy occurs while the patient is falling asleep,
or the frequency with which apoplectic effusions take place,
during the night-time.
Thus, then, we must, according to his view, look on sleep
as an erectile state of the cerebral tissue. The compression
of the cervical veins necessarily injects the brain and the
medulla oblongata. It was some time ago stated by a
physician in Dublin, that the plexus choroides was the
organ of sleep. This organ was supposed to become dis-
tended during sleep, so as to press upon the cerebral sub-
stance. I am not aware whether the mechanism for injecting
the plexus physiological was described or not. It is quite
possible that cervical pressure might do this, and the struc-
ture of this plexus renders its varying vascular fulness a
matter of probability. It seems to me also that the rete
mirahile deserves especial study with reference to the pro-
duction of sleep, and we must also study the condition of
the thyroid body as an important diverticulum of the cerebral
circulation.
If we consider the sleep of the brain its erectile condition,
"we must not hesitate to compare the brain with other erectile
organs. Of course I am speaking of a very gentle venous
distention, and not one which in extent can be compared
with other forms of erectile action. We must compare them
with this limitation, that the injection of the cerebral vessels
is small when compared with other and more erectile organs
in their state of activity. It may seem insane or ridiculous
to compare the erection of the penis, the erection of the
mammee at the time of the draughty the erection of the nipple,
the erection of the cheek, so to speak, in blushing, with the
state of the brain in sleep. Yet the same principle is pro-
bably involved in all these instances ; namely, retardation of
the return of venous blood by mechanical means. Muscular
314 PHYSIOLOGY OF SLEEP.
action, venous compression, and vascular distention, are the
phenomena witnessed in each case, though the extent to
which it occurs in different cases has been sufficient to cause
their identity to be overlooked. These actions are in all
cases involuntary and reflex, though, as in the case of other
reflex actions, emotion exerts a powerful influence. In the
case of the brain it appears to be the platysma myoides which
is chiefly in action ; in the mammse, the dentated fibrous
fascia surrounding these glands appears to be concerned ; in
the case of the penis, the dartos contributes to the tension
which accompanies and produces erection. Thus w^e have
several superficial fibrous structures, or panniculate mus-
cles, all contributing to the same kind of function. Other
erectile actions in animals may be mentioned as probably
depending on a similar cause, such as the pouting of the
pigeon, tlie erection of the wattles of the turkey, or the comb
of the cock.
The singular function of hybernation is intimately con-
nected with natural sleep. It may be found that hyberna-
tion, like sleep, depends upon venous congestion, within
the limits of physiology, and that involuntary muscular con-
traction is concerned in the long winter sleep of animals, as
in ordinary sleep. In the hedge-hog, for instance, during
winter, the pamiiculiis carnosus contracts so as to give it the
shape of a round ball. May not this motor action have much
to do with its prolonged repose }
But it may be asked — What have these points to do with
puerperal convulsion ? Obviously very much, if it has or
can be made at all clear that these functions are in physio-
logy what convulsion, laryngismus, and paroxysmal apo-
plexy are in pathology. Bacon says, that to perceive remote
similarities belongs to one of the highest faculties of the
human mind. Remote but true analogies placed by the
mind side by side, are powerful means of elucidating the
most hidden truths. Physiological insight can often apply a
simple fact, like a torch, to the illumination of important
classes of facts, as yet in obscurity. In the ordinary reflex
actions, we find enough to explain the violent convulsive
actions of the general muscular system in epilepsy or the
the puerperal fit, but in that peculiar series of reflex con-
tractions concerned in causing the erectile state of the cere-
brum by venous pressure, we seem to approach the me-
SPINAL ERETHISMUS. 315
chanism by which the train of convulsive actions are pro-
duced.
The premonitory sip^ns of puerperal convulsion are various
in different cases. There are generally, headache, giddi-
ness, flashings before the eyes, ringings in the ears, intoler-
ance of light, and other signs of disturbance of the cerebral
circulation, before the fit occurs. But in some cases the
premonition is extremely brief, or the attack is instantaneous.
The patient suddenly loses her sight, and falls into the fit,
or she sees the fiery circles, which give the name eclampsia,
before her eyes for a moment, when the convulsion is at once
established. Or sudden and transient loss of consciousness
may occur several times, before any obvious convulsion sets
in. These premonitory symptoms of puerperal convulsion
are in reality the symptoms of the particular condition of the
spinal nervous system in which convulsions occur; they are
the signs of what may be termed the convulsive erethismus.
Grave disturbance of the spinal system cannot reveal itself
in its own sphere except by convulsive action. It appears
that disturbance of the spinal centre produces disorder of the
cerebrum ; and that in this way it is made evident before
any convulsive action occurs. But in some cases it must be
borne in mind, the sphagiasmus may produce cerebral symp-
toms. However, it is undoubted that the convulsive ery-
thismus is often attended by head symptoms before any
sphagiasmus or other spasmodic action has occurred. Be-
sides this, the synergic relations between the uterus and the
brain are very intimate, and the condition of the uterine
organs which sets up the spinal erethismus, sets up an irri-
table state of the brain, which, though it would not of itself
produce convulsion, renders convulsion more dangerous to
the cerebrum than it would otherwise prove. This makes
the chief difference between the state of the brain in the
epileptic and the puerperal attack. Hence arises the ten-
dency to apoplexy, phrenitis, or puerperal mania, after the
occurrence of puerperal convulsions. We might say the
same of the premonitions of epilepsy, and of the convul-
sions of children, only that all the premonitory symptoms
are usually more intense in puerperal convulsion than in the
epileptic seizure. The convulsive erethism and its causes
require special study. Our means of preventing convulsion
are in reality the means of subduing this ercthismal con-
dition.
316 SPINAL ERETHISMUS.
Spasm and convulsion never occur but in special condi-
tions of the spinal system. The scalpel gives us nerves.
Experiment and observation reveal the function of these
nerves in connection with the spinal centre. We know that
the physical stimuli supplied to the peripheral extremities of
the excitor portions of the reflex nervous arcs, excite the
various physiological reflex motor actions of the economy.
We know that food excites the reflex movements of degluti-
tion ; that the changes of respiration supply the stimuli
which excite the reflex movements of respiration ; that the
foetus excites the motor actions of parturition. We know,
too, much of the laws which regulate these actions. But
we do not know the intimate changes which occur in the
nervous tissues to effect the phenomena we observe. We
see the cause, we witness the eflfect, we can trace the track
by which the effect is produced, and we can imitate'Nature,
and even excite the various physiological actions artificially,
but we know little of the intimate mechanism of nervous
action. To pass over from physiology to pathology. We
have here the same kind of knowledge, and this knowledge
is most powerful to prevent, avert, and relieve the diseases
of the spinal system. We see irritation applied to the ex-
trem.ities of excitor nerves, and instead of physiological
actions, we behold local spasm, or general convulsion, or
paralysis. We can trace with tolerable certainty the laws
which produce these morbid actions, but we cannot see in
the nerve, or nervous centre, any change which should make
us augur in the one case a reflex physiological, in the other,
a reflex pathological act. Something is going on either in
the nerve, or in the spinal centre, beyond our present com-
prehension. But to understand that which is, without such
knowledge, perfectly intelligible in the production of con-
vulsion, it Vk'ill be necessary to indicate as nearly as possible
the hidden mechanisms which potentially give convulsion to
nerve and muscle.
Place the nipple between the gums of the infant, and it
it excites the movements of s-uction and deglutition, and
nothing more. Let the same gums be irritated continuously
by the advancing teeth, and instead of producing at once
a reflex action of any kind, the irritation slowly excites the
whole of the spinal system to such a pitch of intensity, that
every nerve and muscle connected with this system is, afler
awhile, engaged in successive fits of violent convulsion.
SPINAL ERETHISMUS. 317
Nay, more, the touch even of the surface by a feather is
sufficient to invoke an attack, which may in a moment prove
fatal. The entire system is, so to speak, loaded or saturated
with excitability, which it discharges with terrific danger to
life and limb on the slightest provocation. And so long as
the alveolar irritation continues, the excitibility, or morbid
augmentation of the vis nervosa^ increases ; while, if the local
disorder be removed, the excitability, — the charged state
of the spinal centre, diminishes. The fits become less violent
and less frequent, and causes which before produced convul-
sions, either do not produce them at all, or if provoked they
are diminished in intensity, until at length the normal condi-
tion of excitability is re-established, and excitation, instead
of producing spasm, excites only normal reflex action. The
level of physiology is reached again.
So in the case of the uterus. The foetus maybe descend-
ing through the parturient canal, or the preparations for its
descent may be progressing. In one case it may excite only
those reflex actions which are proper to the completion of
labour. Everything may go on safely and regularly from the
commencement to the termination of delivery. But in
another case, the natural reflex actions may be arrested, or
they may proceed naturally, but over and beyond these
actions, the convulsive erethism of the spinal system which
terminates in convulsion, may be induced. Now, the irri-
tation which should excite the reflex actions of parturition,
excites convulsions ; or other irritations besides those con-
cerned in the production of labour, induce the seizure ; or,
from time to time, without any obvious or special irritation,
the augmented motor power overflows from the spinal system
to the muscles in the shape of violent fits of convulsion. So
far we may describe what actually takes place. These are
simply matters of fact, without intermixture of speculation
or hyothesis.
Whatever the exciting cause of the convulsion may be in
a given case, whether reflex or direct, the state of incubation
— the convulsive erethism, must have preceded the fit. It
is this augmented excitablity which really constitutes the
essence of convulsion. There may be two patients, with
their various organs, in precisely the same state, so far as
our means of diagnosis extend, and the progress of labour
the same ; the one falls into convulsion, the other proceeds
27
318 SPHAGIASMUS AND LARYNGISMUS.
naturally with the parturient function. The only difference
is in the erethismal condition induced in the spinal system by
the persistent irritation, a difference, which we can only see
and understand from its effects. W.e do not know why in
the one case the line of physiology should be preserved, while
in the other pathology becomes dominant. We know the
-causes and we see the effects, of spinal erethismus, but we
do not know how it occurs, or in what it essentially consists.
When we know as much of the vis nervosa as we do of light,
heat, or electricity, perhaps this problem may approach its
solution, but at present we can only learn its most outward
phenomena.
The first motor result of this morbid erethism, and the
local irritation to which this itself is attributable, is Sphagias-
mus, a contraction of the muscles of the neck. In puerpe-
ral convulsion, this spagiasmus takes place to such an extent
as considerably to impede the flow of blood from the head.
It is to this I)r. M. Hall chiefly refers the insensibility of
convulsion. The mechanism of this symptom is a reflex
action of the platysma-myoides and the various other muscles
of the neck, so as to impede the return of venous blood from
the brain and upper portion of the spinal marrow, by the
vertebral and the internal and external jugular veins. It
seems to be an excess of the physiological actions which
appear to occur in sleep, or blushing. The effects of spha-
giasmus are seen in the swollen state of the neck, the tur-
gidity of the superficial veins, and the more or less perfect
loss of consciousness and volition. These phenomena may
occur separately, or they may merge in, and form part of, the
general convulsion.
The next result or sympton is Largyngisnius^ or partial or
entire closure of the larynx by spasmodic actions of the
laryngeal muscles. There is either total arrest of the respi-
ration, or stridulous expiration, with hasty inspiration, occurs.
Of course, as a primary result of laryngismus, the oxygena-
tion of the blood in the lungs is impeded or suspended, and
partial or entire asphyxia ensues. Then comes the terrific
convulsion of the fully-formed puerperal attack. The head
and neck are not only gorged, but they are gorged with
black blood, and discoloration, with turgidity of the skin,
eyes, and tongue, quickly take place. The tongue, black and
swollen almost to erectionj is thrust out of the mouth, and
ODAXISMUS AND PHARYNGISMUS. 319
the injection of the salivary glands produces a large increase
in their secretion. Dr. M. Hall believes that without the
laryngisnfius and the partial asphyxia, with the circulation of
venous blood in the brain, and its impeded return from
sphagiasmus, true convulsion, with loss of consciousness,
could not occur. These reflex clutchings of the neck an,d-
the air tubes, in sphagiasmus and laryngismus, are certainly
among the most important phenomena of convulsion, whether
we consider them as symptoms, or as the causes of the ulterior
actions which complete the fit.
The next symptom in time or importance is the Odaxismus,
or closure of the jaws. The teeth are shut, and owing to
the protrusion of the tongue and the swollen state of the
cheeks, both tongue and cheeks are bitten. I once saw the
point of the tongue actually severed during an attack. The
odaxismus will occur before consciousness is entirely lost.
If in the state of semi-consciousness a glass or cup be given
to the patient to drink out of, she bites a piece out of it.
This has again and again occurred in such cases. In conse-
quence of the closed state of the teeth, the increased secre-
tion of saliva, and the impeded passage of air through the
larynx, the breath is expired through the teeth with a harsh
sibilant sound, which is quite pathognomonic of the true
puerperal convulsion. The hissing respiration, and the
bloody saliva thrown out of the mouth during a severe attack,
are among the most frightful parts of the seizure, where all
is terrible.
Besides the spagiasmus, laryngismus, and odaxismus,
another spasmodic action occurs in the upper part of the
body. There is Pharyngismus^ a difficulty, or perfect ina-
bility to swallow. Matters placed at the base of the tongue,
or in the upper part of the pharynx, do not, as usual, excite
the act of deglutition, but remain to increase the dangers of
suffocation. It is in this state of pharynx that my friend Mr.
Simpson, of Stanford, has excited the deglutition of nutriment
and remedies, by placing the substance to be swallowed in
the upper part of the pharnyx and then douching the face
W' ith cold water. This affusion of cold water excites dilata-
tion of the pharnyx and deglutition, just as in the case of
the larynx it excites dilatation of the glottis and forcible in-
spiration. This is an important therapeutical point, both in
loss of power and in spasmodic closure of the pharyngeal
320 CARDIASMUS.
tube. Pharyngismus is present in some cases of epilepsy,
and in tetanus and hydrophobia. I once witnessed a fatal
case of hydrophobia in which the pharyngismus appeared to
continue several hours after death, for the secretion of saliva
was kept up, and instead of passing down the cesophagus, it
escaped in the state of foam from the mouth and nostrils.
All these phenomena undoubtedly happen, and they are both
important symptoms and causes of convulsion ; they are
equally important in the treatment of the disease.
But it has struck me that these are not all the causes
of impeded circulation and cerebral distention in cases of
powerful convulsion. I would add Cai'dia.wius to the other
preliminary spasmodic actions. I have carefully watched
such cases, and I have thought greater swelling and rigidity
of the neck has existed, than could be accounted for by
sphagiasmus and laryngismus. The whole neck has appeared
distended, becoming broader and fuller during the convul-
sion from the chin to the clavicle, than I could comprehend
to happen from pressure of the cervical veins, unless, in-
deed, this pressure occurred in the greatest force in the sub-
clavian region. The excessive lividity and turgidity of the
whole surface of the body in the severe puerperal attack, is
greater, too, than would happen from simple asphyxia. The
whole body appears like the head and neck above the cord,
in strangulation. It has appeared to me that some cause
adequate to produce this must exist at the very root of the
venous system. 3 fay it not be that the muscular fibres of the
right auricle contract spasmodically so as to erect, as it were^
the entire venous system, from the cavas to the capillary vessels 9
Here I have in view the compression of the dorsal veins of
the penis, and its consequent distention and muscular action.
Instead of one organ, the whole body is in an erectile con-
dition, and the physiology of erectile organs appears to pre-
sent us with the types of the pathology of convulsive disease.
It was for the sake of illustrating this opinion that I dwelt
on these physiological acts at the commencement of the
present lecture. This view is remarkably in accordance with
what we find in post-mortem examinations, where the auricles
and ventricles are perfectly emptied of blood. I believe
this cause of convulsion to be especially prominent in those
cases in which the fit occurs instantaneously, without pre-
vious warning, when the patient drops as if shot. This
MOTOR ACTIONS OF CONVULSION. 321
view applies equally to the convulsions of infancy, epilepsy,
and paroxysmal epilepsy.
When these momentous contractions of a spasmodic kind
are all complete, the paroxysm of convulsion is raised to its
height. They disturb the cerebral and spinal circulation to
a considerable extent, but especially the cerebral, and it is
now that the danger to the cerebrum occurs. In some of these
cases the commencing contortions of the convulsion, instead
of siinply impeding the return of blood from the cerebrum
and medulla oblongata, at once produce effusion of serum or
blood within the cranium. The convulsion becomes at the
onset changed into apoplexy, but the convulsion is neverthe-
less continued by pressure and counter-pressure. Effusion
may happen at the commencement of the first attack, but
more frequently it takes place after the intra-cranial vessels
have been weakened by several seizures.
In the puerperal convulsion, still more than in the epileptic
seizure, the progress of spasmodic action is from above down-
wards. The face and neck are first convulsed, then the arms,
trunk, and inferior extremities. As the torrent of convulsion
passes downwards, the pelvic sphincters become affected, and
involuntary passage of the urine and fceces occurs. If partu-
rition is going on, the uterus contracts as in a labour-pain.
In the epileptic convulsion in the male, it is well known that
erection and emissio seminis may take place during the
paroxysm. The uterus is sometimes emptied of its contents
in the most precipitous manner: more rapidly indeed than
under any other circumstances whatever, except in abortion
from excessive mental emotion. It sometimes happens that
at the commencement of a fit, the os uteri has scarcely com-
menced its dilatation, but after a short convulsion with ute-
rine action, the child is found entirely expelled. Children
have died asphyxiated occasionally from being born under
these circumstances and receiving no attention from the ac-
coucheur or nurse. The influence of the convulsion upon
the orifices of the pelvic organs is almost as marked as that
upon the orifices of the gastric and respiratory canals. The
convulsion now occupies the whole of the muscular system,
until at length the sphagiasmus, laryngismus, odaxismus, car-
diasmus, and pharyngismus relax, and with them the general
convulsive action diminishes. Thus the convulsive erethism
first affects the medulla oblongata and the reflex arcs in
27*
322 EPILEPSY AND PUERPERAL CONVULSION.
connection with this part of the spinal centre; afterwards
the medulla spinalis, and then the analogue of the medulla
oblongata in the lower portion of the medulla, are successively
aflfected.
It must be borne in mind that whatever the cause of the
erethismus and the convulsion may be, it is in these modes
that the cause probably operates. The whole muscular system
is not affected simultaneously with convulsion, but certain
muscles are first affected, which by their influence upon
the nervous centres rouse the general muscular system to the
state of spasm. In the sphagiasraus, laryngismus, odaxismus,
and pharyngismus, and also in the spasm of the auricle,
the medulla oblongata is the portion of the spinal centre which
is concerned. The spinal influence is sent to the heart
through the branches of the pneumogastric w^hich join the
cardiac nerves. Thus it will be seen that the anatomy
of the nervous supply to the heart favours the opinion I
have ventured to form respecting its state of spasm in con-
vulsion.
The general convulsive action varies very widely. Some-
times there is violent spasm and straightening of the limbs
without much movement; at others, it is almost impossible
to keep the patient in bed. The spasms may affect one balf
of the body more than the other, or they may be almost con-
fined to one side. Sometimes the convulsion isopisthotonic,
and the body of the patient is bent from the vertex to the
heel, like a bow. The duration of the fit is very uncertain ;
it may continue but for a few seconds, or it may last several
hours. In consequence of these variations in the seizure in
different subjects, many varieties of puerperal convulsion have
been proposed, such as the tetanic, the epileptic, &c. But
such a division is of little use in practice, and is, indeed,
quite arbitrary. All puerperal convulsive action, attended
by unconsciousness and laryngismus, may be classed toge-
ther; the variations observed are merely in intensity, severity,
and duration, and not in kind, or in the mode in which they
are caused.
In the puerperal convulsion occurring during parturition
itself, the fit may follow or precede the labour-pain regularly,
or it may be altogether independent of the action of the
uterus. In some cases, the convulsive action of the head and
neck first occurs, and then, after the convulsion has reached
EPILEPSY AND PUERPERAL CONVULSION. 323
the lower part of the trunk, the uterine contraction begins.
Here the labour-pain becomes, as it were, a part of the con-
vulsion, and is excited by it. In other cases, the pains
proceed regularly, but at the commencement of each pain, a
convulsion occurs. The pain begins first, and then the con-
vulsive action. Here the action of the uterus evidently
excites the convulsion. There are still other cases in which
the convulsions occur without producing, or being followed
by, labour-pain ; the uterus seems altogether exempt from
the convulsion, but the pains proceed as usual in the in-
terval between the attacks, the patient being generally insen-
sible.
After an epileptic convulsion, the patient usually recovers
consciousness, though even here there is great tendency to
somnolence after the fit. This somnolence is probably in part
owing to the tendency to continued sphagiasmus of a less
decided kind than that which ushers in the actual attack.
In the puerperal convulsion, there is in some cases a return of
consciousness in the intervals between the fits, but generally,
and particularly in convulsion during the progress of partu-
rition, there is coma or insensibility in the intervals. Even
the return of the pains do not stimulate the patient to a
recovery of consciousness. During the uterine contraction,
she may moan and move about in the bed, and the uterus is
felt to be hard and erect, but there is neither consciousness
nor volition. Here, perhaps, the reflex actions of labour are
observed in their greatest purity. All the reflex actions of
the various stages of labour continue intact. In the propul-
sive stages, the respiratory actions are excited, the breath is
held, and the reflex movements of expiration are performed
just as in natural labour. When there is perfect insensibility
during the intervals, either some effusion or disease has
probably taken place within the cerebrum, or the sphagiasmus
and laryngismus still continue, though Hot to the same extent
as in the actual fit. This insensibility during the intervals
should always be carefully watched. We must distinguish
between stertor and laryngismus. The more profound the
insensibility, the greater the danger. Whenever the insensi-
bility is more protbund than the amount of cervical contrac-
tion present can account for, or when there is paralysis of any
of the limbs, we should suspect intra-cranial effusion. This
mixture of convulsions with apoplexy and paralysis is one of
324 EPILEPSY AND PUERPERAL CONVULSION.
the most formidable complications we can meet with. Simple
puerperal convulsion, when it proves fatal, destroys the
patient by exhaustion, like tetanus, leaving no post-mortem
signs ; it is far otherwise when the convulsion passes into
apoplexy.
The differences between puerperal convulsion and epilepsy
are quite as great as the differences between the convulsions
of infancy and epilepsy. Epilepsy is generally a chronic,
puerperal convulsion always an acute disorder. The one is
connected with the ordinary functions of the body, the other
attends an extraordinary function of limited duration ; namely,
child-bearing. The cases of epilepsy which at all approach
puerperal convulsion are those in which the epileptic is seized
with numerous successive fits within a short period. But
even here, the epileptic almost always regains his conscious-
ness between the fits ; while it is as constantly absent during
the intervals of the severe puerperal attack. Altogether, the
puerperal attack is more severe than the epileptic, hence the
dangers to brain and limb are greater. It is seldom that
epilepsy terminates fatally until the patient has been worn
down by repeated seizures, extending over a long period of
time, while in the attack of puerperal convulsion, whose
duration is almost reckoned by hours, a fatal result is fre-
quent.
The suspected affinities between epilepsy and puerperal
convulsion deserve attention. It would seem, a priori^ that
epileptics or persons who had been subject to convulsion
during infancy, would be far more likely than others to
attacks of convulsion during the puerperal state. It would
also seem probable that patients suffering from puerperal con-
vulsion should become subsequently liable to epileptic at-
tacks. But experience does not positively support either of
those probabilities. There are reasons for believing that
many puerperal cases arise in those who have been the sub-
jects of convulsion or hysteria in early life. This is evident
from the clinical reports of cases, particularly those of Dr.
Robert Lee. But so many children suffer from convulsive
affections during dentition and the other affections of early
life, that it would be difficult to maintain that such coin-
cidences are in the nature of cause and effect. Dr. Lee does
not support any such opinion, he merely relates the fact that
in forty-eight cases of puerperal convulsion, three had pre-
HYSTERIA AND PUERPERAL CONVULSION. 325
viously sufTered from epilepsy, and three from hysteria. It
has often happened that epileptic patients have had no signs
of convulsion during parturition. Not long since, I had the
opportunity of watching the case of a young married lady,
an epileptic, who had an attack of e\n\epsy,post coilUy at the
time she believed herself to have conceived, but who
remained free from convulsion during the whole of her
pregnancy and labour. This was the more striking, because
her appetite was so capricious that she could not be restrained,
particularly during the early months of pregnancy, from
taking the most indigestible food. I have before referred^
to the principle of counter-irritation which sometimes obtains
in the spinal system, and during gestation that change in the
innervation of various important organs is effected physiolo-
gically in epileptic patients, which is so valuable, and which
we often attempt in vain by the use of remedies. I have had
occasion to mention the rest given to the ovaria by pregnancy;
and as ovarian irritation is so very frequent a cause of epi-
lepsy in the female, it may be that this repose contributes to
remove the tendency to epilepsy during gestation ; so that
pregnancy may actually be a means of cure in the ovarian
variety of epilepsy. With reference to the next point, I
believe epilepsy rarely follows puerperal convulsion. I have
not been able, at least, to find cases in w^hich it has occurred.
The subjects of puerperal convulsions do not appear to be
more liable than other persons to convulsions after the puer-
peral period has passed. They are, however, liable to con-
vulsions in successive labours, unless carefully attended to.
Instances of this have been often recorded. On the whole,
then, puerperal convulsion must be considered as a special
disorder, having no very marked affinity for other forms of
convulsion, particularly the epileptic form.
It is important to distinguish the hysterical convulsions
of parturition and pregnancy from the true puerperal con-
vulsion. In the hysterical convulsion, the pharyngismus is
the most prominent symptom about the neck. The spha-
giasmus is comparatively trifling, and the laryngismus of the
true puerperal attack is almost entirely absent. Instead of
the hissing respiration and the closing larynx, there are
screaming and other indications of an open state of the glot-
tis. There is sensibility in the intervals of the hysterical
attacks, and volition appears not to be altogether abolished
326 CEREBRAL EPILEPSY.
during the spasmodic actions. Generally, in hysterical
spasms, the thumb, instead of being turned inwards in the
palm of the hand, is clenched on the outside of the closed
fingers. Hysterical affections are chiefly confined to the early
months of pregnancy, while puerperal convulsions belong to
the later months and the puerperal period. It is, however,
of very great importance, on tlie one side, not to be imposed
upon by hysterical disease, and, on the other, not to treat the
true puerperal convulsion as hysteria.
In laughing, particularly in violent laughter, the veins of
tfthe neck and face are visibly distended. Convulsions or
even apoplexy have occurred during a fit of laughing. In
other words, sphagiasmus occurs as the result of the motor
action of laughing. So in crying, the same fulness of the
veins is observed, and from the same cause. Thus we see
the meaning of the connection between laughing and crying
and hysteria. All that is cerebral in an hysterical attack is
merely an excess of the actions of laughter and weeping,
together with pharyngismus. The globus hystericus^ or the
spasmodic contraction of the sphincter guise, as the superior
constrictor of the pharynx was called by the older anatomists,
is to hysteria what laryngismus is to true convulsion. Emo-
tion seems to exert the same influence upon the pharynx,
which reflex action does upon the larynx. The risiis sardo-
nicus is another variation of sphagiasmus, in which the pla-
tysma myoides is one of the muscles principally concerned.
In singing, some degee of sphagiasmus is present, from the
state of the muscles of the neck ; in great vocal eflforts this
becomes very considerable. Those who have watched the
great cantatrice of the North — the incomparable Lind — during
one of her wonderful scenes, in which song and madness are
combined, must have observed the swollen state of the veins
of the head, and the almost convulsive workings of the
muscles of the neck, face, and larynx, which are increased
until she seems upon the very point of falling into the mad-
ness she impersonates.
Dr. M. Hall has described a cerebral epilepsy, in which
sphagiasmus is the immediate cause and symptom of the
attack, and in which the cerebrum is alone involved. He
says: — "From this symptom (sphagiasmus), which must be
viewed in its double aspect of contraction of certain muscles
of the neck, and of compression of the veins of the neck, all
CEREBRAL EPILEPSY. 327
that is purely cerebral in epilepsy immediately arises; affec-
tions of the senses — the eye, the ear, the senses of smell and
taste, and often touch, affections of the intellect, &c.; thus
before the eyes there are flashes of light, flocci volitantes, or
mist ; in the ears there are various noises, as of a cataract,
or of machinery, or musketry ; there is the smell or taste of
musk or faeces, and the sense of touch is affected by the well-
known aura epileptica. In re2:;ard to the intellect, we have
the ' oblivium' and the * delirium breve' so beautifully de-
scribed by Heberden, with various affections of the sleep and
the memory." And again, Dr. M. Hall observes, '^ all that
depends on sphagiasmus, all that falls short of laryngismus,
may be viewed, in general terms, as cerebral epilepsy; whilst
all that is beyond this term is violent convulsion, with its
further still more fearful consequences — congestion of the
cerebrum, of the cerebellum, and doubtless also of the medulla
oblono-ata. How well does the classic Heberden admonish
us, that — 'instante accessione epileptica diligentur providen-
dum est, ut omnes illa^ vestium partes, quse collum cingunt
quam primum laxentur ; hoc enim inierdum adeo tumet ut
strangulationis metus impendeatV^
This cerebral convulsion occurs at the commencement of
every puerperal convulsion, and sometimes the attack does
not pass beyond cerebral seizure. There is sudden loss of
consciousness, and sphagiasmus without general convulsion.
In the epileptic disease, the cerebral seizure is generally
transient, but in the puerperal state the cerebral seizure may
occur, and be followed by hours or even days of insensibility,
or the patient may not awake, except to puerperal insanity.
In some cases, the cerebral seizure alone proves fatal, passing
into apoplexy before any convulsive action is set up. In
others, it leads to cerebritis and meningitis.
Not long since, I saw, with Dr. Cormack of Putney, in the
same lady, in a dangerous abortion, cerebral syncope, con-
vulsive action of the muscles of the upper part of the body,
and delirium. These three conditions alternated with each
other, and were all accompanied with, or produced by, spha-
giasmus. Whenever she fainted, or was delirious, or con-
vulsed, the same fulness of the neck was observed.
During the whole of labour, after the full dilatation of the
OS uteri, some amount of sphagiasmus is present. In the pain
itself there is cerebral excitement, but in the intervals
328 MANIA AND PUERPERAL CONVULSION.
between the pains, the patient is heavy, or she may fall asleep
until roused by the next pain. The heaviness after a pain
appears to depend on the slightly congested state of the
cerebrum, which continues after the active contraction has
ceased, or some amount of sphagiasmus may continue during
the pains. It is probably on this state of the cerebrum that
some of the perfect freedom from pain, and forgetfulness of
suffering in the interval, depend.
At the moment of birth, when the muscular actions and the
consequent disturbance of the cerebral circulation are at the
highest pitch, the mother may become furiously insane for a
few moments. There can be little doubt that this paroxysmal
insanity depends upon the impeded return of blood t>om the
head, produced by the state of the cervical muscles. This
transient insanity very well illustrates some other forms of
paroxysmal mania occurring during the puerperal state.
x\s puerperal convulsion is so generally a more acute
disease than epilepsy, the relation between this convulsion
and mania is more immediate than the connection between
epilepsy and mania. In epilepsy, after the brain has been
disordered by numerous attacks, it is common for insanity to
occur. But in the puerperal disorder, insanity may follow
in a few hours from the time of the first seizure. Not only
is the convulsive seizure more acute, but the spinal erethis-
mus which produces the convulsion affects the cerebrum so
as to predispose it to insanity, cerebral inflammation, soften-
ing, effusion, &c. The relation between the cerebral seizure,
the full puerperal convulsion, and puerperal mania, is in
every point of view most intimate, and the one very fre-
quently runs into the other. Generally, the order in which
they occur is as I have placed them, and it sometimes hap-
pens that the maniacal paroxysm is the first to be developed,
and the convulsion follows. This supervention of convulsion
upon mania is more frequent after parturition than it is before
or during labour, but this complication occasionally occurs
during pregnancy. In paroxysmal mania of the puerperal
type sphagiasmus is always present. The causes of the
disease are similar to the causes of convulsion, and are often
relieved by the identical measures which relieve convulsion.
Gooch pointed out how miraculously puerperal mania was
sometimes relieved by the removal of alvine accumulations.
Here the irritation of the intestines must produce the erethis-
SLEEP. 329
mal condition, the sphagiasmus, and the cerebral disorder, but
the stress of the disorder, instead of falling on the spinal
system after this point, takes the cerebral form. Thus, the
detection of sphagiasmushas an important application in thera-
peutics. Observing it, we act in the light instead of in the dark.
Must we view the actions of convulsion and of its related
diseases as purely destructive ! Or can we see a germ of
intention towards salutary acts in the economy in these
singularly dangerous and alarming diseases ? The reflex
causes of convulsion, puerperal and epileptic, are chiefly
irritations of the mucous canals. In convulsion, all the
egestive acts of the economy are frequently performed with
greater energy than under any other circumstances. The
stomach is emptied, the fcetus is expelled, the rectum and
bladder are contracted, though accompanied by the terrible
actions which are so perilous to life. It seems, then, that
we may detect a latent intention in these seizures, and one
which, if at all indicative of treatment, would point to the
measures which should really be pursued.
There is another question of practical importance wdiich
may be referred to. Can we learn anything of the phy-
siognomy of the dififerent forms of convulsion ? The con-
vulsions of infancy, of epilepsy, of hysteria, and of the puer-
peral paroxysm, possess each of them their distinctive phy-
siognomies taken in the mass. Can we learn the physiognomy
of the uterine as distinct from the gastric convulsion, or of
the reflex from the direct attack in the puerperal disease ?
Have the muscular spasms any characteristic peculiarities
according as they arise from irritation of one organ or another,
or according as the irritation affects the periphery, or the
centre of the spinal system ?
When discussing the cause of sleep, I referred to the state
of the ophthalmic circulation. There- is a peculiarity in the
venous circulation within the orbit which may in part explain
the connection between closure of the orbicularis palpebrarum
and sleep. The ophthalmi(t, frontal, and facial veins com-
municate very freely by means of the angular branch of the
ophthalmic at the inner canthus of the eye. It is precisely
in this situation that the orbicular contraction is most con-
siderable during sleep. In the upright posture, or in any
position, when the eyelids are open it is extremely likely
28
330 SLEEP.
that the whole or a great portion of the venous hlood of the
orbit returns towards the heart by way of the frontal and
facial veins, while during sleep and the consequent compres-
sion of the angular vein the blood may return by way of the
ophthalmic vein, so as to increase the cerebral venous con-
gestion of sleep. Thus the angular vein may, in the healthy
state of the orbicularis, be one of the auxiliary mechanisms
of sleep.
331
LECTURE XXIII.
Bloodletting in Puerperal Convulsion — Dilatation of the Glottis — Applica-
tion of Cold — Administration of Opium — Hegulation of Emotion — Treat-
ment of Sphagiasmus and Cervical Muscular Action — Removal of the
Refltx Causes of Convulsion — Evacuation of the Stomach, Bowels, Blad-
der, and Uterus — A Case, and a Commentary thereon.
After having considered the prevalent theories, the causes,
and the phenomena of puerperal convulsions, it still remains
to give an account of the treatment of this malady.
In treating of the pathology of puerperal convulsions, I
have endeavoured to show that the disease must always
depend on one of two causes, — either on direct irritation of the
spinal marrow^, or on some irritation of excitor spinal nerves.
If there be any truth in this view, it is evident that remedies
also should be divided into those which allay irritation of the
spinal centre, and those which remove irritation from the
incident excitor nerves, or diminish their excitability. A
large and important class of diseases are referable to the
spinal system, and every branch of this new department of
pathology calls for some therapeutic division of this kind.
Medicines must be studied with reference to their effects on
the different divisions of the nervous system. Unless the
spinal marrow be dissevered, therapeutically, as well as
physiologically, from the other nervous centres, the anomaly
presents itself, of remedies which act as stimulants to the
spinal marrow, but as sedatives to the brain, and vice versa.
Indeed, on looking to the three great divisions of neurology
— the Brain, the Spinal Marrow, and the Ganglionic System
— remarkable instances at once present themselves of thera-
peutic agents which affect them severally in the most oppo-
site modes. Thus the ergot of rye increases the contractions
of the uterus, an organ chiefly under the control of the spinal
marrow, but it depresses the action of the heart, which is
under the control of ganglionic nerves ; strychnia affects the
purely spinal actions to an intense degree, leaving the func-
332 BLOODLETTING IN PUERPERAL CONVULSIONS.
tions of the brain perfectly intact ; while coniiim, on the
other hand, afTects, in poisonous doses, both the spinal
marrow and the brain, producing at once delirium and con-
vulsions.
The spinal system being that which is chiefly involved in
puerperal convulsions, all remedies resorted to in this disease
must be studied with especial reference to spinal physiology
and pathology.
Remedies affecting the spinal system very naturally divide
themselves into those which act on the central organ, the
spinal marrow, and those which aflfect the extremities of
incident spinal nerves. I propose, in the first instance, to
consider the remedies of direct or centric action.
Bloodletting. — The action of bloodletting on the spinal
marrow is greatly modified by the condition of the circula-
tion. In fulness of the vascular system, it is the most powerful
sedative of spinal action we possess. Hence, venesection is
the grand remedy in the simpler form of puerperal convul-
sion, where the disease chiefly depends on stimulation of the
spinal marrow by excess of blood, or on the mechanical
pressure exerted by the blood on that organ, together with
the counter-pressure of the distended brain on the medulla
oblongata. In such cases, bleedingshould be performed with a
view to its sedative action on the spinal marrow, and to avert
the mechanical eflfects of vascular pressure from this organ.
Alone, it will frequently be suflficient to subdue the disease,
particularly when the fits come on before the beginning of
labour, or after delivery. But another most important inten-
tion of bloodletting should never be lost sight of — namely,
that of preserving the brain from injury during the convul-
sion. Besides the /jrmari/ cerebral congestion, which may
have been the cause of the attack by its counter-pressure on
the medulla, the convulsive action itself, with the glottis
closed, and the various sphincteric actions in operation
which were considered in the former lecture, exerting great
muscular pressure on the whole vascular system, and causing,
as they must, the greatest turgidity of the vessels of the head,
are dangerous sources of fatal cerebral congestion, or of
serous or sanguineous effusion. As in the case of epileptics,
women in puerperal convulsions frequently die of apoplexy,
produced by the immense pressure exerted on the cerebral
column of blood during the fits. It is in great measure from
BLOODLETTING IN PUERPERAL CONVULSIONS. 333
the effects of bloodletting in warding off accident from the
brain that bleeding is so universal in this disease. The due
recognition of the distinct operation of bloodletting on the
cerebral and spinal systems is of the utmost consequence.
In plethoric states of the circulation, it is in this disease
curative in its action on, the spinal mtirrow, preventive in its
action on the brain.
In the absence of definite ideas regarding the effects of
bloodletting in this malady, it has been often pushed to
excess, or practised where it should have been altogether
avoided. In the numerous cases where, beside vascular ex-
citement of the spinal marrow, some irritation of spinal excitor
nerves exists as a conjoined cause of convulsion, repeated
bleedings will often fail to subdue the disease, unless the
eccentric irritation be at the same time removed. When
irritation of the uterus, the rectum, or the stomach, is in part
excitor of the convulsion, bleeding «/o7ie cannot be relied on.
It may at first diminish the impressibility of the central organ,
rendering it less susceptible of the incident irritation, but if
persisted in to a large extent without the removal of the
eccentric irritation, it becomes in the end positively injurious,
by increasing instead of diminishing the excitability of the
spinal marrow.
In vascular plethora, depletion is undoubtedly a sedative
to the spinal system, but when the circulation is reduced con-
siderably below par, loss of blood becomes an actual stimu-
lant to this organ. Hence it is that the reports of those who
have most pertinaciously followed bloodletting, exhibit the
loss of a greater number of patients than those who have been
more cautious in this respect. The propriety and extent of
venesection must be estimated, then, not by the violence of
the disease, but by the state of the circulation in the interval
of the fits, and with especial reference to the different effects
of vascular plethora and vacuity upon the spinal centre. I
should avoid these manifest repetitions had I not thoroughly
convinced myself that patients rightly bled in the first in-
stance are frequently subjected to successive depletion until
loss of blood itself becomes the cause of the final seizures.
Nothing is, I believe, more certain to remove this deplorable
source of mischief than the distinct perception of the effects
of venesection on the spinal marrow, the true organ of puer-
peral convulsion.
28*
334 DILATATION OF THE GLOTTIS.
Similar remarks would apply with almost equal force to the
other parts of the common antiphlogistic regimen. Nearly
allied to the modus operandi of bleeding are the efTects of
nauseating doses of emetic-tartar, which have been found so
serviceable in the treatment of puerperal convulsions by Dr.
Collins. It is more than probable that this remedy acts as
a sedative on the spinal system through the medium of its
effects on the circulation.
In the convulsion occurring in delicate anaemic women,
bleeding is generally inadmissible, becoming in fact, under
such circumstances, an exciting cause of the disease. Still,
in cases approaching to this state, cautious bleeding may
he sometimes necessary to jo^'e^eri^e the brain from injury, but
here venesection requires to be followed promptly by stimu-
lants: such cases are, however, rare in comparison with
those in which fulness of the circulation exists at the onset of
the disease.
Dilatation of the Glottis. — During the attack of convulsion
the glottis is partially or entirely closed. The greatest
authority on this point, Dr. Marshall Hall, questions if true
convulsion could ever occur without this state of the glottis,
and the cerebral and spinal congestion which it occasions.
We know that the epileptic attack is sometimes warded off
by the dash of cold water on the face or chest, so as to ex-
cite a sudden inspiration and the dilatation of the glottis. It
is on the same principle, that of exciting a strong inspiratory
act, that we stimulate the nostrils or sprinkle the face with
cold water in syncope. Excitation of the incident nerves of
inspiration has in the same way been known to prevent the
puerperal convulsion.
Harvey gives an instance in which stimulation of the trifa-
cial nerve within the nostrils recovered a woman who became
comatose during labour. Denman also relates an interesting
case, in which a convulsion was excited during every labour-
pain, but in which he kept off the attacks, until delivery was
completed, simply by throwing cold water on the face with
a bunch of feathers at each accession of pain. It was found
that this mode of proceeding, from which he augured so
favourably from its effects in this and other cases, did not
prove equally efficacious on all occasions. He observes, that
this is " a sate remedy," which cannot be said of all measures
resorted to in this disease. It must certainly be productive
OPIUM. 335
of benefit in cases where the glottis is not so firmly locked as
to render its dilatation by this means impossible. Even if it
does nothing to prevent the accession of the fit, every time
we can dilate the glottis, and cause a full inspiration, we take
off a considerable amount of Avascular pressure from the
nervous centres, and lessen the proportion of venous blood in
the system.
The Application of Cold.— Co\<\, applied to the head in the
form of napkins, lightly wrung out of cold or iced water, ice
itself, or a full stream of cold water poured from a height, has
become an approved remedy in puerperal convulsions. It
therefore becomes an interesting question — How does cold
thus used act on the nervous system? It may act as a seda-
tive on the cerebral portion of the spinal marrow, or it may
lessen the distended state of the cerebral circulation, and thus
relieve the counter-pressure of the brain on the intra-cranial
portions of the spinal system. Probably it acts in both of
these modes. When used in the form of the continuous
douche, as sometimes recommended, it would, in addition,
tend to excite acts of inspiration, and thus dilate the glottis.
The primary sedative action of cold on the spinal centre would
seem to be shown satisfactorily by the reputed good effects
of cold applied to the whole length of the spinal column in
tetanus.
The application of cohl to the spine as\vell as to the head
may hereafter be found beneficial in puerperal convulsions.
Whenever cold in any form is resorted to, its use, except for
the purpose of exciting the respiration, must be continuous,
as the intermittent application of cold, locally or generally,
would excite instead of allay the spinal system. The benefit
derivable from cold appears to arise from its local action on
the nervous centres, because in tetanus, the purest form of in-
creased morbid spinal action, cold applied to the spine is ser-
viceable, whereas, when applied to th^ whole surface of the
body, it is extremely dangerous, and even fatal.
Administration of Opium. — It is an object of very great
therapeutic importance to ascertain the true effects of opium
on the spinal system. One author maintains that opium
diminishes the contractions of the uterus in after-pains, an-
other, that it increases their energy. Some recommend it in
uterine hemorrhage, as an efficient means of exciting uterine
contractions, while some blame its administration on the plea
336 OPIUM.
that it produces uterine inertia and hemorrhage. Some,
again, maintain that it retards, and others that it accelerates,
the progress of labour. With respect to the propriety of its
use in convulsions, there is a great discrepancy of opinion.
Though we may not yet have sufficient data to form a
perfect and decisive judgment, I believe we can at the pre-
sent time make a very considerable advance in the right
direction.
"When the amphibia are in a state of narcotization from
opium, the whole excito-motor system is exalted to an intense
degree. The slightest irritation of the surface of the body
produces universal convulsions. If this fact were applicable
to man, it would be an argument to show that it is a power-
ful spinal stimulant, as it certainly is in the amphibia. In
the state of narcotization by opium in man, there is no posi-
tive evidence that the incident spinal nerves are more excitor
than at other times ; still, in poisoning by opium, convulsions
occur, particularly in children, as one of its common toxicolo-
gical effects. In poisoning by belladonna, convulsive action
is much more rare, and it has been found by Dr. Hutchinson,
of Nottingham, a successful cultivator of spinal pathology and
therapeutics, that belladonna exerts a sedative influence on
the spinal marrow in tetanus. That opium does not, in man,
allay excitement of the spinal marrow, is shown by its failure
in the treatment of tetanus and hydrophobia, the purest
and most intense forms of morbid spinal action. The patient
maybe poisoned by opium without any reduction of thespasm.
Mr. Bonney, in a paper on the effect of opiates, has inge-
niously sugjjested that they prove indirectly stimulant to the
reflex actions, because the arrest of the cerebral functions
they occasion, increases the muscular irritability. I think
there are reason for supposing that, besides this effect, which
is very probable, opium is a direct excitant of the spinal sys-
tem. It aggravates convulsions, when there is already a
state of insensibility from other causes, and when, therefore,
this explanation could not be received. It is the general
opinion of practical men, that opiates are injurious in the con-
vulsions of children, in epilepsy, and in puerperal convul-
sions; and it is certainly of little or no value, probably,
indeed, it is prejudicial, in tetanus, hydrophobia, and other
severe diseases of increased action in the excito-motor
system.
REGULATION OF EMOTION. 337
Some striking distinctions must be made respecting the
administration of opium under different circumstances, parti-
cularly in puerperal convulsions. If a dose of opium be
given in this disease in a full state of the circulation, before
bleeding, there is an aggravation of the disorder; while if
it be given in puerperal convulsions in an ansemic subject,
or after excessive depletion, it is of great service. If in a
case of convulsions opium be given at the commencement,
it is dangerous in its effects; but the same medicine is fre-
quently valuable in the advanced stage of the same case
when the vascular system has been powerfully depleted.
Thus it would appear evident that in convulsions with a full
state of the circulation, opium is a siimitlant to the spinal
marrow, while in convulsions with aneemia, it is distinctly
sedative. It is certainly an important })oint in practice, that
the effects of opium in puerperal convulsion depend on the
state of the circulation ; that in plethoric or inflammatory con-
ditions it is always dangerous, while in anseraia and debility
it may always be used beneficially.
Emotion. — The regulation of emotion is of considerable
importance in preventing the accession of convulsions w'hen
they are threatened, and in averting the return of the attacks,
in the intervals where consciousness is retained. Mental
excitement of every kind should be soothed, and avoided as
much as possible. The sight of the infant, of alarmed friends
or relatives, unpleasant intelligence, noises in the sick cham-
ber, or still more trifling matters, have caused or renewed
convulsions. Perfect quiet and repose within the sick room,
and the absence of all signs of excitement on the part of the
attendants, are of the utmost consequence ; the calm or
timid look of the professional man may either excite or
prevent a fit. The phsychical effects of emotion upon the
spinal marrow — an otherwise purely /^//yma/ organ, in health
and disease — is one of the most striking and indubitable facts
furnished by the pathology and physiology of the spinal system.
RelifJ" of the Sphagiasmus and other Spasmodic Contrac-
tions of the JYeck. — During ordinary labours care should be
taken to avoid increasing the tendency to cervical contrac-
tions ; this is still more important in labours with symptoms
of spinal erethisraus, or threatening convulsion. Care should
be taken that during the propulsive and expulsive stages of
labour the reflex contractions about the neck should not be
33S REMOVAL OF REFLEX CAUSES.
increased by excessive voluntary efforts, or by violent emo-
tional disturbance. When the neck becomes tumid at each
returning pain, the reflex cervical contractions should be
moderated by directing the patient, not only to withhold
voluntary action of this kind, but to cry out during the
pains, so as to keep the larynx open. In this way sphagias-
mus and laryngismus may both be prevented by volition, in
some cases. It the cervical symptoms are severe, venesec-
tion should be practised before the accession of convulsion,
as a preventive measure. Whenever fulness of the neck
occurs, either before or after labour, so as to create an appre-
hension of convulsion, blood should be taken from the head
by leeches, or by cupping. There is no point of greater im-
portance in the prophylaxis of puerperal convulsion than an
attention to the state of the cervical region ; it is to convul-
sion what the pulse is to inflammation.
Removal of Reflex Causes of Compulsion. — In threatened
convulsion, or after the invasion of the disease, it is of the
utmost importance to seek out and remove all sources of
reflex irritation. Remote causes of irritation should be
sought for, and removed with the greatest care. The state
of the Stomach, the Intestines, the Breasts, the Bladder,
and other organs in reflex relation with the uterus, should
be examined. The recollection of the cases in which I
detailed the different reflex varieties of convulsion will at
once suggest the appropriate remedies for the relief of these
organs. If the fit has occurred after a full meal, or after
indigestible food, an emetic of the sulphate of zinc should be
administered. If there should be vascular fulness, venesec-
tion ought to be performed. The bleeding should precede
the emetic, to diminish the danger to the cerebrum from the
action of vomiting, for emetics given incautiously have occa-
sionally produced sudden death in puerperal convulsion.
However, when the gastric irritation is undoubted, no patient
should be sufTered to continue in the fits with the stomach
unrelieved. It may seem superfluous to urge this, but I have
known cases of convulsion from gastric irritation, in which
the most sedulous attention has been shown to almost every
other organ in the body, except the right one. Still more
important than the stomach is the state of the bowels. In
convulsions the intestines are very commonly loaded ; it
immediately becomes a question how to relieve them without
REMOVAL OF REFLEX CAUSES. 339
producing orreater irritation by the operation than already
exists from their loaded condition. The most v.iolent drastics
have been given in such cases without any ceremony, as
though the more rudely the materies morbi were grasped,
the more effective the remedy. But it is of great importance
to avoid irritating the intestinal canal unnecessarily. I have
known puerperal convulsions produced by giving a brisk
cathartic too soon after delivery. In fact, there is little dif-
ference between irritant drugs and irritant faecal matter.
Therefore, whenever the bowels can be opened without pur-
gatives administered by the mouth, but by aperient enemaia^
the latter are greatly to be preferred. When we give a
cathartic, we never know how long it may remain to fret
the bowels, but an enema is sure to return almost imme-
diately. Washing out the bowel is less irritating than drastic
cathartics, and equally effective in removing ftecal accumu-
lations. A. copious enema of warm water, repeated until
free evacuation has been produced, has often relieved con-
vulsion. If the w^arm-water injection should be insufficient,
castor oil, or turpentine, may be added. Sometimes the
constipation is so obstinate as to refuse to yield either to
enemata or cathartics, and the contents of the bowels posi-
tively require to be dug out. I have seen a case of this
kind, in which the faeces were as hard as the albuvi grcBCum
of the dog, and in which their excavation was followed by
almost instant relief of violent convulsions. The state of the
bladder should always bo attended to in puerperal convul-
sion, particularly as, duringtheinsensibility of the intervals, the
patient is unable to inform the attendant of its distended condi-
tion. This may be a slight thing to mention, but the catheter
has sometimes relieved convulsion when the lancet has failed.
But the great seat of reflex irritation in puerperal convul-
sion is in the parturient canal. There is only one direct
mode in which uterine irritation can be allayed during puer-
peral convulsion, except by the removal of the foetus. This
is by the evacuation of the liquor amnii. In cases of puer-
peral convulsion, puncturing the membranes takes off a con-
siderable amount of distention from the uterus ; diminishinof
the size of the organ, and the quantity of blood circulating
through it. Hence, though it renders the uterus more
active, by bringing its parietes into contact with the foetus,
it renders the organ itself less irritating to the general
340 REMOVAL OF REFLEX CAUSES.
spinal system. The evacuation of the liquor amnii is to the
uterus what the partial action of an emetic or an enema is to
the stomach and intestines. In convulsion from uterine
irritation, much may be done by the avoidance of all unne-
cessary dilatation and interference with the vagina and os
uteri. During convulsions, all operations upon the partu-
rient canal, whether they consist of examinations, dilatation
of the OS uteri and the vagina, the artificial removal of the
foetus, or the extraction of the placenta, should be performed
with the greatest care, and with the conviction of the ease
with which renewed fits may be excited by any irritation of
the uterine passages.
The relation of artificial delivery to puerperal convulsion
is a matter of deep interest. Some obstetricians have re-
commended that it should always be performed by turning,
craniotomy, or the forceps, when the fits are obstinate and
severe. In deciding this point, the particular characters of
individual cases must be considered. The general principle
which w^e may deduce is, that whenever artificial delivery
can be eflTected with less irritation than w^ould be produced
by the continuance of the child in the parturient canal, and
its expulsion by the natural process, it is advisable that it
should be performed, if the situation of the mother be perilous.
It must be with reference to this principle — namely, to the
irritation of anj' particular operation, and the irritation of the
statu quo — that turning, craniotomy, or the forceps, must be
decided upon. All these operations have destroyed patients ;
and, on the other hand, numbers have died undelivered,
from uterine irritation. The question of interference is one
for which no arbitrary rule can be laid down, but which
must be decided in each individual case by the particular
circumstance, due reference being had to the excitability of
the uterus under the stimulus of the foetus, and under arti-
ficial interference. The point to aim at should be, never to
produce more irritation than we remove, and not to destroy
the patient by an excessive temporary irritation instituted for
her permanent relief, by the entire evacuation of the par-
turient canal. Of course, the greater the operation neces-
sary to delivery, the greater is the deliberation necessary
before it is commenced. In manipulating upon the uterus
under such circumstances, we must never for a m.oment lose
sight of its reflex connection with the spinal marrow. Such
REMOVAL OF REFLEX CAUSES. 34X
are the principles upon which we must attack the uterus in
puerperal convulsion. Every measure we resort to for the
relief of uterine irritation and the evacuation of its contents
exerts a salutary influence upon the ovaria, and there is no
other mode of relieving ovarian irritation that we can resort
to, except it be constitutional treatment, or the evacuation
of the rectum and bladder.
Perhaps I cannot conclude this subject better than by
quoting a case, and a commentary upon it, which I published
two or three years ago. The case occurred in the practice
of, and was published, in the first instance, by, a highly re-
spectable accoucheur; in condensing it from his own account
I have most scrupulously adhered to every important particular
of his narration. The example may be more forcible than
precept.
Case. — The medical attendant w^as summoned at one a.m.,
and found the patient had been in labour three hours. The
OS uteri was dilated to nearly the size of a crown-piece, but
remained rigid ; the membranes were unbroken, and a foot
jiresented. The patient had suffered from headache during
the latter part of pregnancy, and this pain continued during
labour. At half-past two a.m. she w^as seized with the first
convulsion during a pain, upon which thirty ounces of blood
were taken from the arm, the hair removed, and cold applied
to the head. The second fit speedily occurred, and thirty
ounces of blood was again drawn. Delivery was now de-
cided on ; the membranes were ruptured, and the feet brought
down, after which the head was extracted by the forceps.
During the operation the third fit occurred. Ihe child was
still-born, but the fourth fit followed so rapidly that the at-
tendant was diverted from the means proper for its recovery,
and the child was lost. A second child was now found pre-
senting with the head ; at this period tlie bladder was evacuated
hy the catheter. The membranes wereruptured by the hand,
and the head was rapidly brought down to within reach of
the forceps by a powerful pain. 'Vhe fifth fit now occurred.
The patient was again bled to twenty ounces, and the forceps
immediately applied, the delivery being completed at four a.m.
On attempting to apply a bandage over the uterus^ the sixth fit
came on. A consultation was now held, and ten or twelve
ounces of blood were taken. In less than twenty miniites
there was a seventh attack. The patient being now comatose,
29
342 REMOVAL OF REFLEX CAUSES.
with cold extremities, and a scarcely perceptible pulse, sina-
pisms were applied to the legs; and at this juncture, being,
as nearly as can be gathered from the narrative, about three
hours and a half from the first seizure, and after seven attacks
of convulsion, a stimulaiwg enema was exhibited. At seven
A.M. the sinapisms had acted, and the enema had " brought
away a copious offensive dejection.'''^ Cold applications to the
head were continued, and two grains of calomel were given.
From the time the bowels were thus acted on, the patient
remained fice hours without any recurrence of the fits ; but
at two P.M., the bandage was again attempted to be applied,
and the eighth fit instantly occurred. Alter a second con-
sultation, a blister was placed on the scalps mercurial frictions
were ordered, and calomel every hour. In the three succeeding
hours to the time of the application of the blister — that is, up
to six p.u.,fve more fits of unabated severity took place. The
respiration and the action of the heart were now inaudible,
and at this juncture the blister was removed from the scalp,
and the back rubbed with spirits of turpentine, after which
the sacrum was covered by a blister, and an enema of
hyoscyamus, valerian, and assafcetida administered. By ten
o'clock P.M. the respiration was again audible, and the pulse
was perceptible in the extremities, while there had been no
return of the fits. Up to five a.m. of the following day, three
more anodyne enemata had been administered, no material
alteration having taken place in the other parts of the treat-
ment; but after the thirteen fits of which the occurrence is
detailed, the patient continued free from convulsion, and
eventually recovered.
In the reflections by the original relator of this rase, there
is considerable confusion as regards its pathology. In one
place, he considered he had " to contend with sanguinary
apoplexy, which fortunately, proved to be only of a conges-
tive character ;" an idea to which the copious bloodletting
was probably attributable. In another, he considered the
primary irritation to be seated in the ''nervous ganglia" of
the uterus, which probably led to the application of the blis-
ter in the sacral region. How the two causes were, in his
estimation, connected together, he does not attempt to ex-
plain. Indeed, he does not appear to have entertained them
both at the same time. In his remarks on his own treatment,
he strongly suspected the loss of less than ninety ounces of
REMOVAL OF REFLEX CAUSES. 343
blood might have sufficed ; and he was persuaded, that if
the after-treatment — that is, the anodyne enemata, and the
blister to the sacrum — had been earlier employed, *' the
patient would have been spared much suffering, and relieved
from the agonizing .pulsative headaches, and other ills
attendant upon an extensive loss of blood." He conceived
that "the blister to the scalp proved injurious rather than
beneficial, as it was followed by more determination to the
brain, evinced by greater lividity of the countenance in the
intervals, and a more rapid succession of the fits."
Commentary. — I believe I should be warranted by the
facts, by the history of the disease, and by the circumstances
attending the application of the different parts of the treat-
ment, in considering this case one of convulsions caused by
a loaded state of the lower bowel, the woman being predis-
posed to the attack by the excitable state of the spinal mar-
row incident to labour. The fits continued in spite of vene-
section and delivery. After seven attacks in little more than
three hours, the bowels were cleared by an enema, and the
fits immediately ceased for five hours, and then only recurred
when the attendant endeavoured to put on an abdominal
bandage. When six more attacks had supervened, and the
patient was in extremis^ anodyne enemafa, and a blister to
the sacrum, were resorted to. From this time the fits ceased
altogether. The credit of this second remission is given by
the relator partly to the injections, and partly to the counter-
irritation. This I think erroneous; the enema acted at once,
and the fits, which were following each other rapidly (five
severe ones having occurred within four hours), ceased at
once also, while the blister had only acted "pretty effica-
ciously" at the end of three hours.
Looking to the principles I have endeavoured to lay down
respecting the pathology of puerperal convulsions — that the
convulsions are caused by irritation applied to the extremities
of excitor spinal nerves, or by irritation of the centric organ,
it is clear that the irritation in this case was chiefly eccentric,
and that at least one half of the fits depended on reflex
sources of spinal irritation supplied by the accoucheur.
Thus, one fit occurred from the first application of the
forceps, another was caused by the irritation of the uterus in
the first attempt to apply the abdominal bandage, and a third
344 REMOVAL OF REFLEX CAUSES.
fit by the second attempt at its application. The fourth
bleeding brought on a convulsion, the woman having proba-
bly, at this time, reached the state in which convulsions of
centric or direct origin occur from loss of blood. Five more
fits followed the application of the blister to the scalp, the
author candidly acknowledging that this proceeding proved
injurious. On the whole, I do not hesitate to assert, that if,
before or after delivery, the intestine had been washed out
by an enema, as it should be in almost every case of puer-
peral convulsion, and the patient kept perfectly free from
irritation, there would have been no tfttack after the birth of
the second child, and the patient would have had six fits, or
a less number, instead oi thirteen!
The conclusion drawn by the accoucheur is curious —
namely, that of recommending, in future cases, the conjoined
use of anodyne and anti-spasmodic enemata, and counter-
irritation over the sacrum. Now, it is not a question of the
application of blisters to one place or another; vesication of
the sacrum would excite the spinal marrow nearly as much
as vesication of the scalp. In applying an anodyne to the
rectal excitor nerves, and an excitant to the posterior sacral
nerves, he attacked the spinal marrow, on the one hand, with
a stimulant, on the other, with a sedative. It was like put-
ting a horse to each end of a cart, and applying the w^hip —
of course, the quickest and strongest had the mastery. In
active diseases of the excito-motor system, such as tetanus or
convulsion, counter-irritants are most unphilosophical ; they
as clearly increase spasmodic action as pinching the limb of
a frog, tetanic from strychnia, increases its convulsions, and
in the same manner — namely, by the irritation of excitor
spinal nerves.
I trust my intentions in the present remarks will not be
misunderstood. I have not the most remote desire to make
a criticism or an attack on the management of any particular
case. Through the one selected, I have aimed at errors
widely prevalent, for I maintain that the average practice in
puerperal convulsions is not superior to that adopted in this
particular case. With the light of spinal pathology and
therapeutics thrown full upon the subject, it would be easy
to go among the recorded cases of this malady, and here lay
a finger on the case of a patient suffered to die of an excito-
motor disease with her stomach full of indigestible food, or
REMOVAL OF REFLEX CAUSES. 345
a loaded rectum, in fact, untreated ; there, on the case of
another, in which the convulsions at first depended on fulness
of the circulation, but in which bleeding after bleeding was
performed, till at length the fits same to be caused by very
emptiness of the bloodvessels, the convulsions being kept up
in the meantime by some irritation supplied by the attendant :
as, for instance, in the foregoing case, in which the sixth
attack, having been most indubitably caused by the irrita-
tion of the bandage, was treated by a bleeding, which in
turn excited other fits, and this at a time when perfect rest
was alone required. The due admixture of principles with
empirical practice must remove such anomalies from obstetric
medicine.
29*
346
LECTURE XXIV.
Causes of Uterine Inertia — States of the Liquor A mnii — Slate of the Ahdominal
Muscles — Uterine Displacements — Peculiar Dan2;ers of the Propulsive and
Expulsive Stages — Complication of Labour with 'I'horacic, Abdominal,
and Paraplegic Disease — Causes of Deficiency of Eiicito-motor Action —
Treatment of Uterine Inertia — Kest — Opiates — Evacuation of the Liquor
Amnii — Examinations — Stimulant Encmata — Abdominal Bandage-^ Posi-
tion— Ergot of Rye — Galvanism — Instrumental Interference.
Many conditions of the liquor amnii may interfere with the
due contraction of the uterus.
Excessive distention of the uterus by the amniotic fluid
produces comparative inertia, from the disadvantage at
which the contractile tissue acts under such circumstances.
Owing to this cause, the stage of dilatation is sometimes
rendered excessively tedious. The remedy is simple ; it
consists in rupturing the membranes, and in exerting pressure
upon the abdomen.
Uterine action is also interfered with by rigidity of the
membranes, and the consequent retention of the liquor amnii
after the stage of dilatation has passed by. When the os
uteri is fully dilated, and the fluid pressure of the membranes
has no further purpose to serve in parturition. It is inade-
quate to excite through the mediuiu of the uterus and vagina
those powerful efforts which characterize the stages of propul-
sion and expulsion. Hence, if the membranes remain un-
broken after the orificial dilatation, the labour-pains of the
subsequent stages are not stronger than those of the stage of
dilatation, and they are consequently unequal to the projec-
tion of the foetus. The remedy is obvious here also — namely,
to evacuate the membranes on the full completion of the
stage of dilatation. This may be done by the finger-nail,
or the stilet, but generally the former is sufficient.
Again, the uterus is sometimes enfeebled by premature
rupture of the membranes. If at the commencement of the
dilatation of the os uteri the liquor amnii be expelled, the
CAUSES OF UTERINE INERTIA. 347
uterine actions are generally increased beyond the natural
strength, but there are cases in which the escape of the waters
at this time quite suspends the actions of labour ; the uterus
appears baulked of its aim, and becomes inert for many
hours or even days. In any case, the membranes should be
preserved, unless the quantity of liquor amnii is excessive,
with the utmost care in natural labours, until full dilatation
has been reached.
There is another source of inertia of the uterus connected
with the liquor amnii — namely, the slow discharge of the
waters. In normal cases, the waters escape with a gush, or
in a short time after the rupture of the membranes, when the
uterus closes at once with the foetus, in order to propel it
through the vagina. But it sometimes happens, either because
of the undilated state of the os uteri, or a small aperture in
the membranes, or, as is more common, the closure of the
vagina by the advancing head ; that the waters dribble away
in small quantities at each returning pain. The uterine action
is feeble from the w^ant of resistance, and the effect of the
pain upon the foetus is inconsiderable, because at each return-
ing action of the uterus its force is spent in expelling a
small quantity of fluid instead of impelling the solid contents
of the uterus forwards. We can only relieve this state of
things by pressing the head back during the pains, and also
in the intervals, so as to allow the liquor amnii to flow freely.
When the waters have completely escaped, the uterus
becomes abundantly active in such cases.
There are certain mechanical conditions of the uterus
itself which interfere with its efficient moter action.
In patients with a relaxed state of the abdominal mus-
cles, particularly multipara}, the falling of the gravid uterus
forwards, and its suspension over the arch of the pubis,
place the organ at a great disadvantage as regards contraction.
In these cases the uterus at the full term is anteverted to such
an extent as to hang down to the thighs, or even to the knees.
In women thus affected, labour is very apt to be over-terra,
and when it does occur, it is prolonged and feeble. A great
amount of pain and contraction of an ineffective kind is
spent in getting the uterus into such a shape and position as
to enable it to act on the foetus. The supine position, the
support of the abdominal parietes and the uterus by an ab-
dominal bandage, and by the hand of the accoucher during
348 CAUSES OF UTERINE INERTIA.
the pains, are the measures for remedying this form of
gravid displacement. In patients subject to anteversion
during pregnancy, care should be taken to prevent this con-
dition as far as possible, by well-adjusted mechanical support
to the abdomen, and by directing the patient to lie upon her
back. Unless the fcetal head can be directed against the os
uteri by these measures, the uterine actions are inevitably
feeble during parturition. Dr. Ashwell relates, in his admi-
rable work on the diseases of women, the case of a lady who
had lost part of the abdominal muscles by ulceration, and
who, on becoming pregnant, suffered from abdominal hernia
of the gravid uterus. Her condition at the seventh month
is thus described: "Through the aperture in the abdominal
muscles the uterus had gradually passed, soon after rising out
of the pelvis; and in proportion to its subsequent growth,
the fundus had descended lower and lower, not covered, as
in ordinary pregnancy, with the abdominal enlargements
entire, but only invested with the peritoneeum and skin; so
that at this period the gravid womb formed an immense
ovoid tumour, the greater extremity being inferiorly, reach-
ing nearly to the left knee, the tumour gradually diminishing
in breadth as it approached the abdominal aperture. The os
and cervix were, however, within, so that there must have
been great stretching of the uterine walls in the erect posi-
tion, and there must also have been considerable curvature
at this point." When labour came on, there were, as might
have been expected, much time and pain consumed in con-
sequence of the disadvantage under which the uterus acted.
This case is but an exaggeration of what occurs in all cases
of considerable anteversion, when, though the abdominal
walls are entire, they are too distended to contract with
proper energy.
Cases are on record of gestation with complete proci-
dentia. Capuron relates one in which impregnation had
taken place through the os uteri, and in which the full term
of pregnancy was reached. At the time of parturition, the
uterus, instead of being supported by the abdominal muscles,
was left entirely to its own contractions, and these were in-
sufficient to expel the child, which was at length removed by
incisions made into the uterus.
Cases also occur in which the uterus is only partially
developed, one part of the uterus being of the proper thick-
CAUSES OF UTERINE INERTIA. 349
ness and the rest exceedin^rly thin. Or the whole of the
uterus is insufficiently developed, resembling the dilatation
with attenuation, which occurs in cardiac disease. In a case
of this kind the parturient actions are necessarily weaker than
they ought to be, and little can be done to strengthen them.
The labour is necessarily prolonged, unless the expiratory
actions should happen to be unusually powerful, or the pas-
sages unusually relaxed. Indeed, if powerful uterine actions
were possible under such circumstances, the danger of rup-
ture would be very great. Feeble parturient action may be
expected as the rule, whenever the foetus can be felt with
great distinctness during pregnancy, through the uterus and
abdominal parietes. In such cases, the uterus and abdominal
muscles should be supported by the abdominal bandage, from
the commencement to the termination of labour.
Labour sometimes proceeds with inertia, in consequence
of the OS uteri being directed too far backwards. On intro-
ducing the finger during a pain, the os uteri can only be
reached with difficulty, owing to its position. The head, or
presenting part of the child, can be felt distinctly through
the anterior portion of the uterine neck. Frequently three or
four inches of the uterine wall can be felt in these cases be-
tween the pubic arch and the orifice of the womb. Whether
this condition of the anterior and lower part of the uterus de-
pends upon malposition of the organ, or upon some irregu-
larity in its development during gestation, it would be diffi-
cult to say ; but I am inclined to think that the anterior lip
and the neighbouring portion of the uterine cervix are much
larger and more extended in these cases than usual. In such
a state of things, the stage of dilatation is necessarily tedious.
It is as difficult for the presentation to get beyond this impe-
diment, as it is to pass over an extended and rigid perinseum.
After considerably delay, the partial, prolapse of the uterus
gradually recedes between the foetal head and the pubic arch,
or it returns sudderdy with a jerk during the acme of a pain.
To remedy this impediment, I recommend patients to lie
upon the back during the pain, and, when it is possible, I
endeavour with the forefinger to pass the anterior lip up-
wards above the pubis, in the intervals between the pains.
The irregular actions of the uterus and other organs, already
described when speaking of metatastic and irregular pains,
are often a source of tardy labour. Sometimes the uterus,
350 CAUSES OF UTERINE INERTIA.
instead of contracting^ as a whole organ, contracts at certain
points, while it remains relaxed at others ; and consequently
the pains occur without any real progress to the labour. This
partial contraction of the uterus can be felt through the abdo-
minal parietes. It is removed by friction, the removal of
intestinal or vesical irritation, with anodynes to allay pain.
When the uterus is tender upon pressure, in the intervals
between the pains, — the state of rheumatism as it is called, — •
it is sometimes necessary to bleed, in order to allay the dis-
ordered state of portions of the organ.
Bat besides all these forms of retardation, there is an im-
portant class of cases, in which the development and condi-
tions of the uterus are quite natural, but still the uterine con-
tractions are feeble and inetfective. There is no want of
stimulus, the presentation, the condition of the foetus, and the
liquor amnii, being quite natural, nor is there any deficiency
in the muscular structure of the uterus; but still the uterine
action is below the physiological standard. There is a defi-
ciency of the excito-motor principle. The stimulus and the
muscle are in the normal condition, but the connection be-
tween the two, by w^ay of the excito-motor arcs, is inefficient.
In what this deficiency essentially consists we do not know,
as all that really takes place within the nervous structures is
enveloped in mystery; but we can ascertain and remove
many of its causes.
The causes of deficiency of excito-motor power, are, —
1. The condition of the reflex motor arcs, and the spinal
centre. There may be feeble action, and even total arrest of
the action of labour, w^ithout any morbid condition which we
can discover, in any organ or structure, except the nervous.
We arrive at the nerves as the cause of delay by the exclu-
sion of all other detectible causes.
2. The reflex-motor power may be feeble, from the age of
the patient. In women w^ho have borne several children, the
motor power often increases in vigour with each parturition ;
but in females who become pregnant for the first time after
forty years of age, the reflex-motor actions are generally
feeble, and hence, as well as from the increased resistance,
labour in such subjects is generally prolonged.
3. Emotion frequently deranges or altogether suspends the
actions of labour. Emotion is the true Proteus of the animal
economy. In no part of the system are its transformations
CAUSES OF UTERINE INERTIA. 351
more remarkable than in the reflex function, and especially
in the actions of parturition. An emotional impulse, occur-
ing in a labour otherwise perfectly normal, may either excite
the motor actions to the pitch of general convulsion, or it
may perfectly suspend them. The uterus maybe acting with
|ifrfect vigour, but some emotional shock occurs, and sud-
denly contractions are suspended for many hours or even
days. How often does it happen that the entrance of the
accoucheur during the progress of labour perfectly suspends
the uterine action for a time. In certain constitutions the
reflex function is more mobile than in others, and in parturi-
tion it is, in the hysterical temperament especially, that these
suspensions of action are most likely to occur. There is also
an indirect mode in which emotion may retard labour — •
namely, when the patient is so timid that she spends the
whole time of her pains in crying out, and consequently, by
the open state of the glottis, interferes greatly with the respi-
ratory actions.
4. Uterine action may be perverted or suspended by gas-
tric or intestinal irritation, but particularly by the latter. It
is matter of fact that intestinal accumulation, \vhich in one
case produces acute labour, and in another, violent extra-
uterine action, shall in a third, arrest the action of labour en-
tirely for a time. Everything depends upon the true diag-
nosis of these variable conditions of the uterus and the
utero-spinal nerves. The enema which in one case, by re-
moving faecal irritation, allays the dangerous violence of the
uterus, in another, rouses the torpid organ to a state of na-
tural activity.
5. Debility may depress the spinal function to such a de-
gree as to interfere with parturient action. But in debility
a certain amount of relaxation or deficiency of resistance in
the uterine passages generally runs }:^arallel with the dimin-
ished reflex motor power, so that in many cashes of weak
retlex uterine action from debility, labour is little if at all
prolonged.
6. The presentation has a [narked influence on the deve-
lopment of reflex motor power. We see abundant reasons
why the natural presentation of the head, and the retention
of the liquor amnii until after the dilatation of the os uteri,
should conduce to the greatest safety of both mother and
child. As long as the membranes remain unbroken, the ac-
352 CAUSES OF UTERINE INERTIA.
tion of the uterus is moderate, and the fcetal circulation is
little if at all interfered with, as compared with the interfe-
rence of the swbscquent stages. But as soon as the liquor
amnii is evacuated, the foetus becomes subject to pressure,
both during the pains and in the intervals. The constitution
of the mother is also liable to become disturbed during the
passage of the foetus through the pelvis and parturient canal.
Thus, both on account of mother and child, it is important
that the stages of propulsion and expulsion should proceed
without delay. The greater th6 delay in these stages the
greater is the danger to both mother and child. This delay
is prevented by the irritation of the head in natural presenta-
tions, and by the excitor function of the vaginal nerves.
7. Other causes of deficient parturient action arise out of
certain diseases with which pregnancy and parturition may be
complicated ; such, for instance, as chronic disease of the
heart and lungs, in which the breath cannot be held to a
sufficient extent, for the expiratory efforts of the propulsive
and expulsive stages. Here the uterus loses all the stimulus
of the expiratory pressure. The same happens in acute dis-
eases of the chest at the time of parturition, when the expira-
tory efibrts are prevented by pain, as in pleuritis or pneu-
monia. Ascitis, or diseases of the liver, also interferes wMth
the expiratory actions of the abdominal muscles. Paraplegia
in the middle portion of the spinal marrow interferes with
the actions of labour, by cutting off all communication be-
tween the uterus and vagina, and the medulla oblongata.
Here the uterine actions are rendered feeble, just as when
the parturient function of the medulla oblongata is interfered
with by thoracic or abdominal disease. In paraplegia from
disease of the lower portion of the medulla spinalis, the
actions of labour, uterine and extra-uterine, are almost if
not entirely suspended. These points are abundantly proved
by the records of cases of pregnancy in complication with
paralysis.
But when either the breech, arm, hand, foot, or placenta,
present, the uterine actions and the expiratory actions are
feeble, in consequence of the diminished irritation supplied
to the excitor nerves of the vagina and the os uteri. Hence
the length of time which elapses in such cases before the
rupture of the membranes, and between the rupture of the
membranes and the expuL^ion of the child. This explains
CAUSES OF UTERINE INERTIA. 353
the increased foetal mortality in extra-cranial presentations.
The reflex function is only called forth to the proper degree
when the head of the child is in the vagina, and in cases of
breech or loot presentation, or in arm cases after turning has
been performed, the reflex power is not fully in operation
until sometime after the umbilicus has passed into the vagina.
In head-presentations, on the contrary, the umbilical cord
does not become subject to the full amount of vaginal
pressure until the head has been born, and respiration has
commenced. Thus, then, in all the extra-cranial presenta-
tions, the parturient actions are comparatively feeble, and
from the retention of the particular presentation serious con-
sequences to the life of the child arise. The uterine inertia
from mal-presentatation is greater in footling cases where
both feet present, it is less in cases where only one foot pre-
sents, and still less in nates cases.
8. But still more important than any of the preceding
varieties of uterine inertia, is the form of parturient inaction
which sometimes occurs in the course of difficult or laborious
labours, from exhaustion of the excito-motor power. In
perfect health, the reflex action goes on with increased in-
tensity up to the time of delivery. Every pain seems to be
a stimulus to that which follows it. But in certain cases,
when labour is continued beyond the usual time, when it
has been excessively acute in the first instance, or when the
patient is exhausted from any cause, the pains act as shocks
to the spinal centre, which becomes, after awhile, quite
paralyzed. This may go to such an extent as to render the
uterus quite immoveable under any stimulus we can apply to
it. in ordinary cases, it often happens that labour-pains are
suspended, from temporary exhaustion, and after a period of
rest, resumed ; but in more serious cases, the uterine exhaus-
tion is permanent, and without assistance would never be
resumed. The graver form of sinking may arise merely
from the prolongation of labour ; in others it is caused by
the disturbance of the pelvic organs, or disease of the par-
turient canal from long-continued pressure. The most serious
form of all is that which accompanies, or, in fact, produces,
uterine hemorrhage. Not only is failure of excito-motor
power a serious matter in itself, but is an indication of a
critical state of the whole system. When decisive paralysis
of the utero-spinal system has occurred during labour, it
30
354 TREATMENT OF UTERINE INERTIA.
slowly extends to the heart and respiratory muscles, when
death occurs from sinking. Thus, continued failure of excito-
motor power is as dangerous and fatal as its excesses: on
the one hand, we have death from sinking, on the other,
death from rupture and laceration. The treatment of this
form of inertia, of course, consists of endeavours to re-excite
the parturient actions, or of delivery by artificial means.
It has often been observed that delay during the propulsive
stage of labour is much more dangerous than delay during
the stage of dilatation. The dilatation of the os uteri, when
there is no actual disease of the organ, may oocupy many
days without producing danger, but so soon as the vagina is
involved, protracted delay becomes a serious matter. The
reason for this has not been \ery clearly made out. The
reflex-physiology of parturition appears to supply the expla-
nation.readily enough. While the uterus and uterine nerves
alone are involved, the effects of delay are almost confined
to the uterus. But as in physiology we see the irritation of
the vagina and vaginal nerves involve the respiratory system,
and indeed the whole muscular system ; so in pathology we
see a corresponding extension of results from vaginal irrita-
tion. Vaginal irritation, combined with uterine excitement,
is therefore more dangerous than uterine irritation alone. Not
only are the constitutional relations of the vagina during
labour more extensive than those of the uterus, but when
the foetal head has fairly engaged in the pelvis during the
propulsive stage, the mechanical pressure and injury of the
vaginal tissues are likely to occur, while little mischief could
happen in the dilatile stage, with the vagina uninvaded, and
the uterus defended by the liquor amnii. It is during the
vaginal stages of labour, then, that sinking and failure of
constitutional power are likely to occur, and it must be borne
in mind, that the merely prolonged retention of the bead in
the vagina, without any local mischief of a marked kind,
may prove dangerous, or even fatal.
What are the means which we possess of re-exciting the
uterus to contraction when the ])ains flag, or cease entirely ?
When the uterine actions, previously strong, become feeble,
a few hours' rest is the most simple remedy, and will often
recruit the nervous energies, after which the labour is gener-
ally resumed, and goes on to a fiivourable termination. Rest
from labour-pain, when accompanied by sleep, is still more
TREATMENT OF UTERINE INERTIA. 355
certainly efficacious. We must, however, carefully distin-
guish between that anaount of cessation from pain which
may lead to resumption of the labour, and that which is
allied to sinking. In the one, the pulse is good, the mind
tolerably cheerful, and 'the stomach in such a state as to retain
nourishment, stimulants, or febrifuge remedies ; while in the
other, the pulse is extremely quick and feeble, the mind does
not rally, and the stomach generally rejects ingesta of all
kinds. When it is thought advisable to allow a patient a
few hours' respite from labour-pain wuth the expectation of
re-exciting labour, a full dose of opium should always be
given. It produces sleep, and at the same time stimulates
the spinal centre. So that after sleep obtained from opium,
the patient frequently wakes up, roused by a strong labour-
pain.
During labour attended by feeble uterine contraction, we
must adopt a different rule in making examinations from that
which is proper in acute labours. The examinations should
be more frequent and prolonged, being made with a view to
increase the reflex actions, by supplying additional stimulus
to the parturient canal ; whereas, in the present practice, I
believe, a more constant digital attention is given to acute
than to tardy labours.
I have already remarked that in tardy labours the liquor
amnii should be evacuated as soon as the os uteri has dilated,
or even before this time if there is the tendency to dilate, or
if the quantity of liquor amnii be excessive. The membranes
should be ruptured during the presence of a pain, as soon as
the amniotic bag has been formed, as at this point of a pain
there is greater probability that the whole of the liquor amnii
will be expelled at once, so as to bring the solid pressure of
the foetus to bear upon the os uteri.
In feeble pains, the finger and thumb should be extended
in the vagina before the advancing head, so as to distend
the vagina at each pain. When the head bears upon the
perineeum, pressure should be made upon the perin?eum, so
as to compress it between the hand and the presentation,
with a view to excite the reflex parturient actions. As a
general rule in labours with inertia, an examination should be
made at every pain in the propulsive and expulsive stages.
The abdominal bandage is of considerable importance with
reference to tardy labour. Some accoucheurs recommend its
356 TREATMENT OF UTERINE INERTIA.
application in all cases during labour. I believe it ought
always to be avoided as dangerous, in acute labour, until the
uterus has been emptied of the foBtus, when the abdominal
bandage and compress are exceedingly useful measures ; but
the bandage out to be applied firmly, and reset from time to
time, during the whole progress of tedious labours. The
inert or energetic action of the uterus ought always to decide
us respecting the application or omission of the abdominal
bandage. Stimulant enemata are often of the greatest
service in exciting the torpid or inactive uterus. When
there are faecal accumulations, it takes away a cause of inertia,
and when these are absent, it powerfully excites the uterus
to reflex action. An abortion or a tedious labour, when ap-
parently hopeless, may often be completed in a very short
time by a turpentine enema. I look on enemata as most
important obstetric aids, and I am sure they have not been
sufficiently employed in practice. When the uterus is inex-
citable in any other reflex manner, it will often act energetic-
ally at the time when the bowels are moved by an injection.
We thus reproduce not only uterine contractions, but also
expiratory actions, which are so important in expelling the
ovum. The enema syringe, I am persuaded, ought to take
the place of the forceps in many cases where the forceps are
now used, particularly in cases where the head is resting on
the perinseum. It should be used, not merely with a view
to evacuate the rectum and large intestines, but with a dis-
tinct view to the reflex stimulation of the uterus.
The position of the patient in tardy labour is an important
point. She should be encouraged to sit, or stand, or move
about the room, instead of being placed to lie down. During
the pain her hands should be held, the feet fixed, and she
should be encouraged to increase the reflex action of parturi-
tion, by holding her breath as much as possible, and by
making voluntary eflforts at expiration. When the bowels
are opened by an enema, the patient should sit upon a night-
chair during the action of the enema. By mere attention to
position alone, during the various acts of parturition, we may
increase the mechanical excitor action of the foetus upon the
parturient canal to a very great degree.
There is a mode of exciting increased reflex action of the
uterus — first practised, I believe, by Mr. Simpson of Stam-
ford— well deserving of notice. He applies cold to the ab-
TREATMENT OF UTERINE INERTIA. 357
(lominal surface, alternating the cold with warm applications,
so as to husband and increase the excito-motor power. In
the lower animals it is a common practice to inject cold water
into the vagina in lingering cases; and if there were cases
calling for such a mode of exciting the uterus in the human
female, there can be no doubt of its efficacy.
The most celebrated obstetric adjuvant is without doubt
the ergot of rye. This is a medicine of direct, and not of
reflex, spinal action. It is of extreme value in cases w^hen
from the state of the passages there is no danger of laceration
or rupture. Its action on the uterus through the spinal centre
is as special as the influence of emetic-tartar upon the respira-
tory muscles. Aloes, cantharides, and the ergot of rye,
appear to affect the lower portion of the medulla spinalis,
just as emetics, or expectorants, affect the medulla oblongata.
As the ergot of rye affects the life of the child, either as a
direct poison, or by interfering with the materno-foetal circu-
lation, it should not be given, if possible, too long before
the time of birth. The effect of the ergot upon the uterus is
peculiar ; it not only produces the intermittent pains of labour,
but it constricts the uterus during the intervals between the
active pains. On account of the influence of the ergot upon
the child, it ought not to be used until the reflex modes of
exciting the uterus had been tried in vain. Ipecacuanha has
occasionally been used with the same intention as the ergot.
"With the vomiting it occasions, it produces uterine contrac-
tion. The biborate of soda is a remedy of the same action
as the ergot of rye, but inferior to it in activity.
A mode of exciting uterine action by stimulating the mus-
cular structure of the uterus directly has been practised by
Dr. Radford, of Manchester. This accoucheur imitates the
pains of labour by galvanic shocks passed directly through
the substance of the uterus. The principle upon which gal-
vanism must act when it produces contraction, is obvious.
In addition to all these modes of producing nervi-motor
action, the strength of the patient must be sedulously sup-
ported by nutriment and stimulants, during prolonged labours.
When these measures, or such of them as may be suitable
to the particular case, have been tried without effect; when
the patient is sinking (and in sinking especially, delivery is
the remedy); when the child's life is in danger; or when it
is already dead; the forceps or craniotomy must be resorted
30*
358 TREATMENT OF UTERINE INERTIA.
to. The great aim of obstetrics is to resort to instrumental
operation as seldom as possible, consistently with the pre-
servation of the lives of mother and child. The greater the
perfection we acquire in exciting the uterus to act physio-
logically, the more infrequent will obstetric operations
become.
359
LECTURE XXV.
The Treatment of Uterine Hemorrhage: — I. By Exciting Reflex Uterine
Action; II. By Direct or Centric Utero-Spinal Action; III. By Exciting
the Uterine Muscular Irritability; IV. By Mechanical Measures; V. By
Astringents and Refrigerants — Profound Importance of the Apphcation of
Physiology to Practice — Proper Organization of Remedies.
Obstetric practice scarcely offers a more interesting field than
the various hemorrhages incident to gestation, parturition,
and the puerperal state. My endeavour, in the present lec-
ture, will be, to give a physiological account of the modes
of arresting Uterine Hemorrhage, and of the modus operandi
of the most important agents which are used in Obstetrics,
for this purpose. Uterine hemorrhage evidently belongs to
the class of maladies arising, not from excessive nervi-motor
action, but from deficient nervi-motor power. The great
object of treatment in this class of disorders is to arouse and
produce this power. It \v\\\ be seen that all the more im-
portant measures for arresting hemorrhage from the uterus
are intimately connected with the Spinal functions. I shall
not enter upon the discussion of the causes of uterine hemor-
rhage, or the sources whence the blood flows, except to say,
that though it has recently been questioned, I know of no
fact which shows that in the dangerous floodings of parturi-
tion the blood comes from other than the uterine arteries and
veins, and chiefly the latter; and that the arrest of hemor-
rhage consists in the mechanical or muscular closure of the
vessels from which the blood is poured out. My observa-
tions are of course not intended to apply to the minor hemor-
rhages from the maternal and foetal vessels of the placenta.
I. The Different Modes of Exciting Reflex Contrac-
tion OF the Uterus in Uterine Hemorrhage.
Reflex contractions may be excited by stimuli applied to
certains organs at a distance from the uterus; by stimuli
360 REFLEX UTERINE ACTION.
applied to certain other organs and surfaces in the vicinity of
the uterus; and lastly, by stimuli applied to the uterus itself.
I. THE MAMMARY NERVES.
The fact that irritation of the mammary organs will arrest
hemorrhage was known to Hippocrates. Mauriceau also
makes mention of it. The explanation given was, however,
that the hemorrhage from the uterus became moderated,
because of the revulsion of blood to the breasts. This could
be of little real importance, if we consider the utmost vas-
cularity of which the mammae are capable, when compared
with the large amount of blood which may escape from the
uterus. The actions of the mammae upon the uterus have
been excited by sinapisms, by cupping-glasses, by drawing
the breasts artificially, and by the sucking of the child. Of
these the latter is the most etfectual.
II. THE PNEUMOGASTRIC NERVE.
The gastric division of the pneumogastric is another remote
excitor of the uterus. Its influence is chiefly seen after the
delivery of the child, which is also the time when the flow of
blood from the uterus is most profuse. Hot or cold drinks,
or even taking food into the stomach, excites the uterus. I
have no doubt the caudle of former times, though otherwise
injurious, must have had considerable influence in contract-
ing the uterus. Emetic substances taken into the stomach
exert an influence upon the uterus; and ipecacuanha has
long been known as a remedy in uterine hemorrhage. Of
all the gastric excitants of the uterus, the most useful is two
or three ounces of iced water, suddenly swallowed.
III. THE LOWER INTERCOSTAL AND LUMBAR NERVES.
The cutaneous nerves of the abdominal parietes are ex-
citors of the uterus in an extraordinary degree. The sudden
impression of cold or heat upon the abdominal surface will
almost always excite the most energetic contraction of the
uterus affected with inertia, and from which hemorrhage is
taking place. We may contract the relaxed and diffuse
uterus to a firm ball, by douching the abdomen with cold
REFLEX UTERINE ACTION. 361
water from a height ; or by plashing a towel, taken out of
cold water, upon the naked abdomen ; or by suddenly placing
the hand, taken out of iced \vater, upon the umbilicus. Jf
the surface of the abdomen should be cold, the sudden im-
pression of heat produces a similar contraction. In all these
instances it is the extremities of the cutaneous nerves of the
abdomen which are afTected by the stimuli. The result takes
place too instantly to permit the belief that any sensation of
cold or heat passes through the abdominal parietes to the
uterus itself. The extremities of the cutaneous nerves of the
abdomen are, in fact, almost as distant from the uterus as
the superior intercostal nerves which supply the mammary
glands.
About the true mode of action of irritation of the mam-
mary and pneumogastric, and the superficial abdominal
nerves, there can be no doubt whatever. These nerves are
too remote from the uterus, in their peripheral extremities,
to admit of any other explanation save that of the Reflex
Function.
The next group of organs through the medium of which
uterine hemorrhage may be arrested by reflex contractions,
are in the immediate neighbourhood of the uterus.
I. THE NERVES OF THE VULVA AND PERINEUM.
Cold applied to the vulva, in any of the forms already
mentioned, will excite the arrest of hemorrhage. In the san-
guineous discharges of early pregnancy, cold applied to the
external parts is often useful, by favouring coagulation. Its
refrigerant is, however, very different from its reflex action.
In the former, the effect is slowly produced, and depends on
the sustained influence of cold ; in the latter, its effect is
instantaneous, and depends on the repetition of the sudden
impression of cold.
II. THE NERVES OF THE VAGINA.
If we pass the hand into the vagina, and close it so as to
distend and irritate this canal, we induce contraction of the
uterus. If we pass a lump of ice into the vagina, the same
effect is produced. Cold injections into the vagina simply,
are very efficient modes of restraining hemorrhage. Plug-
362 REFLEX UTERINE ACTION.
ging the vagina with linen or sponge soaked in cold or iced ■
water, will sometimes arrest hemorrhage, particularly in
hemorrhages occurring before delivery, or in cases of threat-
ened abortion. Of course, one action of the plug is gradual
and mechanical, and simply depends on preventing the flow
of blood, — and thus favouring coagulation. But it has
another action, causing contraction of the uterus. It is to
this latter action that I am now directing attention.
TIT. THE VESICAL NERVES.
It is well known, that the injection of cold water into the
bladder will contribute to the arrest of uterine hemorrhage,
though there are many other modes of proceeding which are
more eligible than this. I have no doubt that the injection
of any irritant into the bladder, or the use of irritant diuretics,
would have a similar influence upon the uterus.
IV. THE RECTAL NERVES.
In uterine hemorrhage we may sometimes command the
flow of blood by irritating the nerves of the rectum. This
may be done by injecting cold water into the intestines, by
the injection of purgative or stimulating enemata ; and I
have no doubt by aperients administered by the mouth, if
time permitted their exhibition. The best mode of stimula-
ting the rectum is by the injection of cold water, or the use
of stimulant enemata, as salt-and-water, or turpentine.
This group of organs, it will be observed, is in the imme-
diate vicinity of the organ from which the blood flows, and
they are in great measure supplied by nerves having the same
origin as the uterine nerves. But what I wish to insist upon
is this, that all the actions I have been describing are reflex
in their nature. Physiology repudiates the idea of uterine
contractions, excited by means of continuity or contiguity of
the organs excited, and the organ which contracts. The
peripheries of the nerves of the bladder, rectum, vulva, and
vagina, receive the impression, and the incident nerves, the
spinal centre, and the motor nerves of the uterus distributed
to its muscular structure, are all concerned in the muscular
contractions which ensue. Thouo:h the organs excited are
near the uterus, which contracts, the route of the nervous
REFLEX UTERINE ACTION. 363
action is precisely the same as it was in the case of the
stimuli applied to the mammary or the pneumogastric nerve.
I make these observations because I still see the obsolete
notion, which so long perplexed physiology, of referring all
such actions to the sympathetic nerve, and to the mere ana-
tomical distribution of nerves to neighbouring organs from
the same source, cited by some authorities as sufficient to
•account for all such motor phenomena as those which take
place between the different pelvic organs respectively.
They look at the nerves interlacing and communicating
with each other, and their minds do not reach to the neces-
sity of considering the spinal centre as the organ which
connects the peripheries of excitor and motor nerves, and
without which their contiguity or distance would be equally
useless.
I now come to the consideration of the contraction of the
uterus, and the arrest of hemorrhage by irritation of the
uterus itself, through the medium of stimuli applied to —
I. THE UTERINE NERVES.
The power we possess over the uterus by this mea.ns is
very great indeed, and the modes by which we can exert it
are very various. We may excite the nerves of the external
surface of the uterus, the nerves of the internal surface, or
the nerves of the os uteri. When we produce uterine con-
tractions by irritating the uterus through the abdominal sur-
face, we act on the first series of nerves ; when we inject
cold water into the uterine cavity, we act on the second ;
and when w^e irritate the os uteri by digitation, we act on
the third. These measures are of great importance in our
attempts to rouse the uterus itself to action. We may excite
the organ by introducing ice into the cavity, by injecting
cold water into the cavity, or by injecting stimulating solu-
tions. Dr. Arnott, of Brighton, proposed to place a bladder
in the uterus, and then to inject the bladder, chiefly with
a view to the mechanical distention of the uterus, and the
arrest of the bleeding on mechanical principles. If, how-
ever, such a proceeding were operative at all, it would be
on a different principle. Various substances have been pro-
posed for injection into the uterine cavity, and I wonder it
has not been proposed to inject the ergot of rye, particularly
364 REFLEX UTERINE ACTION.
as it is said that M. Velpeau excited parturient action in the
common fowl, by placing the ergot upon the sphincter ani.
It would probably excite the internal surface of the uterus,
just as. sulphate of zinc excites the gastric mucous surface.
Besides digital irritation of the uterus through the abdominal
parietes, there is another external mode of inducing uterine
reflex action, in the use of the abdominal bandage. The
compression of the uterus thus occasioned increases uterine
action, or evokes it when it has disappeared ; it is certainly
one of the best means we have of preventing that inertia of
the uterus after delivery which so strongly tends to hemor-
rhage. The introduction of the hand into the uterus, or the
irritation of the os uteri by the fingers, or the whole hand,
excites the uterus very powerfully. Besides the mere intro-
duction of the hand, irritation of the internal surface of the
organ by the tips of the fingers is sometimes practised. A
very recondite mode of arresting uterine hemorrhage was
suggested by Sig. Mojon, an Italian physician. He pro-
posed to inject the umbilical vessels with cold fluids or
astringent solutions, and Professor Miiller appears to speak
approvingly of the practice. The very act of hemorrhage
itself sometimes supplies the source of irritation which pre-
vents further loss of blood. After blood has been poured
out, firm coagulation takes place, and the coagulum becomes
a salutary irritant to the uterus. In this list of uterine local
excitants, I may mention certain obstetric manoeuvres, which,
though often performed with other intentions, act upon the
same principle as those which I have now been considering.
For instance, in hemorrhage occurring before the rupture of
the membranes, the liquor amnii is evacuated. This is
generally done with a view of lessening the size of the uterus,
and of diminishing the quantity of blood which circulates in
its structure, and also of brino-ins the child into immediate
contact W'ith the uterine surfaces, after the manner of a plug.
But besides this, the body of the child becomes an excitor
of reflex action. So also, in cases of placenta pra^via,
whether the rash plan of tearing away and extracting the
placenta, or the old method of separation of the placenta and
turning, be adopted, the hemorrhage is arrested partly by
the foetus acting on the principle of a plug, but partly, and
still more, by the contraction of the uterus consequent upon
the irritation necessarily incurred in separating the placenta.
DIRECT UTERINE ACTION. 365
When the placenta is extracted, the fostal head comes into
immediate contact with the excitor surface of the os uteri.
Wlien turning is resorted to, the extremities and trunk of
the child become uterine excitors.
Now, in all these varied actions, the excitor nerves, the
spinal centre, and the motor nerves are concerned. The
uterus does not contract simply and singly from any inherent
power belonging to the organ itself. Its actions from these
sources of excitation depend mainly on its connection with
the spinal marrow. Doubtless there are other forms of ac-
tion mixed up with those which are purely reflex, and to
these I shall presently revert ; but what I would contend for
is, that much of the uterine action consequent upon irritation
of the uterus itself, is as strictly reflex, as much produced
through the medium of incident and motor nerves, and the
spinal centre, as are the uterine actions caused by irritation
of the mammary or rectal nerves. This is what I cannot too
much insist upon.
II. The Different Modes of Exciting Direct or Centric
Spinal Contractions of the Uterus, in Uterine Hemor-
rhage.
1. If we administer a dose of the ergot of rye to a patient
sufl'ering from hemorrhage, we observe, in many cases, that
uterine contraction will follow. The tact has been knov^'n
extensively enough, but the question has never been properly
asked. How does the ergot act? or if asked, the question has
certainly never been answered. It has been said, confusedly,
that ergot has a special action on the uterine contractile fibre,
or that it excites the nerves of the uterus; and these vague
sayings have satisfied, or seemed to satisfy, the obstetric
mind. I have no doubt that the. true channel through
which the ergot acts is the blood, and that the organ
it reaches and aflects, through this channel, is the spinal
centre. We may illustrate its modus operandi by referring
to the action of emetic substances on the stomach. There
are certain substances which, when taken into the stomach,
immediately excite all the motor actions of vomiting. This
happens, tor instance, when sulphate of zinc comes into con-
tact with the mucous membrane of the stomach. Sulphate of
31
366 DIRECT UTERINE ACTION.
zinc, then, appears to excite the actions of vomiting in a re-
flex form. If there are any such medicines adapted to pro-
duce uterine action, by simple contact with the uterus, just
as cold water does, they remain to be discovered. But again,
in the case of the stomach, there are other medicines — the
potassio-tartrate of antimony, for instance, which acts as an
emetic only after it has been taken into the circulation, and
which acts more promptly when injected into the blood itself.
I believe the action of this medicine to be perfectly analogous
to the action of the ergot of rye; that the one acts upon the
medulla oblongata and the motor nerves of vomiting; the
other, upon the lower medulla spinalis, and the motor nerves
of uterine action. The ergot, therefore, is a remedy of centric
utero-spinal action. We shall presently see that these in-
quiries in the mode of action of remedies are not without a
practical use. The ergot, in addition to its utero-spinal
action, sometimes produces vomiting, thus affecting the
medulla oblongata, as well as the lower segments of the
spinal centre ; but it is remarkable that, though an excitant
of motor action in these instances, it diminishes the frequency
and force of the heart's action. This action of the ergot is
favourable in some cases of hemorrhage, but unfavourable in
others, where failure of the circulation, and dissolution, ap-
pear to be imminent.
2. Ipecacuanha is another medicine which is sometimes
given in uterine hemorrhage. This medicine, by its emetic
action, excites contraction of the abdominal muscles, and
compression of the uterus, which in turn may re-excite some
amount of uterine reflex action, but over and beyond this it
appears to have a special action upon the uterus, increasing
its contractile power beyond what we could imagine to occur
from the merely secondary effects o-f vomiting. Ipecacuanha,
then, appears to influence both the medulla oblongata and
the lower medulla spinalis. This double action of ipecacu-
anha upon the tw^o extremities of the spinal centre is very
extraordinary. It would be worth while to try, in uterine
hemorrhage, the efl'ect of an injection of sulphate of zinc,
with a view to ascertain whether it exerts the same specific
influence of the lining membrane of the uterus and its
nerves, as it does upon the pneumogastric nerve in the sto-
mach.
DIRECT UTERINE ACTION. 367
3. Opium is also, in hemorrhage, a remedy of direct spinal
action. In moderate loss of blood it undoubtedly promotes
uterine contraction, and arrests the hemorrhage. A good
deal has been said and written about this and other remedies
acting beneficially, by equalizing the circulation of the blood ;
but this is an explanation utterly incompetent in the case of
hemorrhage from the uterus after delivery. Opium is an ex-
citant of spinal action of the direct kind, and thus it is that
its administration is beneficial in hemorrhage, with uterine
inertia, and injurious in puerperal convulsion, of the active
kind. In both disorders its use and abuse have been empi-
rical, and but little understood.
4. As a minor remedy of the same spinal relations as the
foregoing, the biborate of soda may be mentioned. It may be
said, briefly, that all stimulants taken into the stomach and
received into the blood have a centric spinal action in he-
morrhage from the uterus.
5. But one of the most important agencies of a centric kind,
and one difTerent in its nature from the foregoing, consists in
the influence of emotion. The former actors have been phy-
sical in their nature, this is purely psychical in itself, though
its effects are evident in material motor contraction. In some
cases of dancjerous hemorrhao^e, the mere arrival of the ac-
coucheur in whom the patient places confidence, will be suffi-
cient to contract, for a time, the uterus, and restrain the loss
of blood. Hence the control of all outward signs of appre-
hension in the obstetrician is, of the utmost moment to his
patient. A depressed look, or a faltering word, may destroy
a life which hopeful words and a strong will would have
saved. It is remarkable, as exemplifying the influence of
emotion, that when a hemorrhagic patient is sensible, so as
to know her child, the act of suckling the child is much more
efficacious than when she is insensible ; though, as I have
shown you, insensibility in nowise lessens the vigour of the
reflex actions. Where sensibility is present, the influence of
emotion comes in aid of the reflex action. It is also more
efficacious for a woman to suckle her own child than that
of another person. It is only the hopeful and confident
emotions which excite muscular contraction. The depress-
ing passions paralyze the uterus as well as other muscles,
and they are, in truth, not unimportant as causes of hemor-
rhage.
363 SIMPLE MUSCULAR ACTION.
III. The Different Modes of exciting Uterine Action
BY Stimulating the Muscular Irritability of the
Organ.
1. When we excite the uterus to contraction by the direct
application of cold in any of the forms I have before adverted
to, we produce, as I have explained to you, reflex actions,
but we also call forth another power — that of the muscular
irritability. Cold, applied to a muscle separated from the
rest of the body, and denuded of nerve-fibres as far as possi-
ble, still contracts. Thus, then, in the direct application of
cold, two distinct modes of contraction are appealed to — the
one depending^ on the reflex function ; the other, and more
simple, upon the motor power inherent in the muscular fibre
itself.
2. When we irritate the uterus mechanically, whether by
squeezing the uterus through the walls of the abdomen, or by
irritating the organ by the tips of the fingers; by simply intro-
ducing the hand into the uterine cavity, or by actively irrita-
ting the OS uteri or the internal surface of the uterus by digi-
tation, we invariably rouse the muscular irritability. We at
the same time call forth a greater or less amount of reflex
action, according to the excitability of the utero-spinal
nerves; but this is invariably mixed with the increased action
dependent on the excited muscular power. After death,
when the nervous centres have lost their energy^ this form of
contraction may still exist, or it may be excited by direct
irritation.
3. I have mentioned, on a former occasion, the fact, that in
patients perfectly paraplegic, with entire loss of refJex uterine
power, the uterus has been excited to contractions sufficient
to expel the foetus by means of galvanism. Dr. Radford, of
Manchester, applied this power to the arrest of uterine hemor-
rhage. One pole of a galvanic trough being placed within
the OS uteri, and the other applied over the fundus, it has
been found, that on making and breaking the galvanic circle,
powerful uterine contractions occur. It is said that the uterus
can be made to contract by this agency when it will obey no
other stimulus, and I have little doubt that this is correct. It
accords with all we know of the influence of galvanism upon
the muscular fibre. The contraction of the uterus from gal-
vanism is probably the most simple mode in which we can
MECHANICAL ACTION. 369
act upon the irritability of the muscular fibre without compli-
cating it with reflex actions. The reflex actions excited by
passing galvanic currents through muscles are very slight, if
they occur at all. This is proved by a great number of ex-
periments. There is^ however, one important disturbing
agency, in the application of galvanism, which must be taken
into account. The application of this remedy, and the painful
sensations it excites, disturb the emotions considerably. In
some cases the emotional excitement increases the influence
of galvanism ; in others, it weakens or suspends it altogether.
This is probably the reason why, in some cases, galvanism
has produced little or no contractile effect.
IV. The Different Modes of Arresting Uterine
Hemorrhage Mechanically.
1. There are various modes of compressing the uterus
mechanically, which are resorted to in cases of hemorrhage.
One mode is that of grasping the uterus through the abdo-
minal parietes, and holding the organ so firmly as to prevent
the further effusion of blood, while other means are being
applied to ensure the permanent contraction of the organ.
Another mode sometimes followed is that of introducing one
hand into the uterus, and then exerting pressure with the
other hand externally, so as to compress the bleeding por-
tion of the organ between the two hands. A third mode of
mechanical arrest, and one which is exceedingly useful, con-
sists in the abdominal bandage, made to embrace the pelvis
tightly, and having several towels or napkins, folded into a
conical shape, placed underneath. I have mentioned to you
the proposal to distend a bladder within the uterus, with a
view to distend the uterus mechanically, and so arrest the
loss of blood ; but this seems to me to be mechanism carried
to mischievous excess, and \vith a forgetfulness of the fact,
that the distention of the uterus must also distend the gap-
ing mouths of the vessels from which the blood escapes.
2. Compression of the aorta, so as to cut off the supply of
blood to the uterus, and prevent arterial hemorrhage, has
been insisted on by Baron Dubois, M. Chailly, and others.
Several years ago, I pointed out that the directions given by
obstetricians were wrong, and that we should make pressure
upon the inferior cava instead of the aorta. The great he-
31*
370 MECHANICAL ACTION.
morrhages, those which kill, are from the veins, and not from
the arteries, and further, not from the veins which are return-
ing blood from the uterus, but from the vena cava and the
heart itself. When the uterine veins are open, there is a
great column of blood between the uterus and the right
auricle, to the sudden escape of which there is no let or
hindrance except uterine contraction. In those patients who
have died from loss of blood, injections driven into the
inferior cava from the right auricle readily escape into the
uterine cavity by the uterine veins. Compression has been
successful because it has been difficult or impossible to
comply with the directions for pressing upon the descending
aorta, without, at the same time, compressing the inferior
vena cava. The compression of the great vessels is, however,
at best, palliative, not curative, but it may give time for the
application of other remedies.
3. The various forms of plugging the vagina and the uterus
are a distinct class of obstetric remedies in hemorrhage.
Mechanical plugging is extremely useful in hemorrhage in
many forms of abortion, in certain hemorrhages during
delivery, and in cases of placenta prsevia. The sponge or
linen plug is useful in moderate floodings of the impregnated,
and also of the unimpregnated uterus. This form of plug,
when it fills the whole of the vagina, acts by preventing the
escape of blood externally ; this favours the coagulation of
the blood effused behind the plug; and though the plug
itself does not reach to the bleeding surface, the coagulated
blood is converted into a secondary plug, which acts directly
upon the mouths of the bleeding vessels. But besides
the common form of tampon, we often convert the foetus
itself into a plug, having precisely the same mechanical
action. Thus when, in hemorrhage before delivery, we rup-
ture the membranes, besides the other results, the body and
limbs of the fcetus come into direct contact with the hemor-
rhagic tissue. So in placenta praevia, when the presentation
is allowed to remain, but the placenta is torn away, the
foetal head becomes in effect a tampon to the os and cervix
uteri of the most powerful kind. Again, when turning is per-
formed in these cases, the feet are brought down, and
engaged in the os uteri as a plug. These instances only
differ from the plug of sponge or linen in their being more
effective, and in being applied from within instead of from
ASTRINGENTS AND REFRIGERANTS. 371
without. After delivery, no form of plugging can be of
much service.
V. The Arrest of Uterine Hemorrhage ry Astringents
AND Refrigerants.
1. This exposition of the principles of treatment would be
incomplete without referring to the action of astringents
and refrigerants. These remedies, consisting of the acetate
of lead, the mineral acids, alum given internally, and used
in the form of injection, the sustained application of local
cold, &c., are useful in all hemorrhages which do not pro-
ceed from patulous vessels sufficiently large to require the
contraction of the muscular organ in order to close them, or
when the uterus is so little developed as to render its
muscular contraction impossible. Here we are restricted to
mechanical remedies and medicines of the class I am con-
sidering. Such are hemorrhages occurring in the course of
uterine disease, or in menorrhagia ; uterine floodings in the
early months of pregnancy ; and the profuse lochial dis-
charges which sometimes occur a few days after delivery,
when the uterus has become perfectly contracted.
Such are the principal modes of arresting uterine hemor-
rhage. They are more numerous and interesting than pertain
to any other organ of the body. This is natural enough,
when we reflect that the uterus is the only organ which
secretes a sanguineous fluid physiologically, and that it
affords the only mstance in which large bloodvessels with open
mouths, leading to fatal hemorrhage, may be but the slightest
conceivable divergence from a physiological process, in the
separation of the maternal and foetal circulations after deliv-
ery. You may observe the profusion of appliances which
we possess for the arrest of uterine hemorrhage. There is
no other malady which can afl^ict the human frame, in which
we have such an absolute fertility of remedies. Yet par-
turient women are constantly perishing from hemorrhage.
The truth is, that the many remedies for hemorrhage have
been so jumbled together, and so ill understood, that they
have never been used in the systematic measure they really
admit of. The methods of obstetrication have been ample
enough, but the directions for their selection and combina-
372 PHYSIOLOGY AND THERAPEUTICS.
tion have been very deficient. You have seen how suscep-
tible all the remedies in this grave and important casuality
are of physiological arrangement ; how, indeed, the mere
touch of physiology has been sufficient to marshal them in
something like due order and proportion. It would, I am
sure, be impossible to find any subject within the entire
range of medicine, of equal importance, of which this might
be said with more perfect truth.
Thus you see how profoundly physiology impresses itself
upon our therapeutics in the treatment of uterine hemorrhage.
It will not do for those who are too idle to study the matter
to say — We will be practical — we will leave the physiology
of the question to be decided by others. Physiology pro-
tests against being thus postponed — it will not be put otf —
for it is inseparable from practice. Without a physiological
comprehension of the points of treatment, what is likely to
happen ? In the arrest of hemorrhage many remedies will
probably be tried, either in succession, or in confused com-
bination ; but instead of a judicious combination of the
several modes by which uterine contraction may be pro-
duced, mechanical means, or reflex or direct actions, wmII be
trusted to alone, in such wise, that though many remedies
appear to be used, only one or tw^o principles — and those,
perhaps, not the most important — will be invoked. It
is just like the old Mithridatic formulary! Thus, sup-
pose cold applied to the rectum, cold to the abdomen,
iced water given the patient to drink, and the child placed
at the breast : there is great appearance of activity, but
in reality only the reflex action of the uterus has been
excited, which would have been equally powerful if only
one eflficient mode of excitation had been tried. Or again,
after one mode of reflex action had been tried in vain, the
reflex function being exhausted, it would only be waste
of time to endeavour to excite reflex action by applying irri-
tation to other incident nerves ; yet this is often done. We
do not use all the resources which physiology places at our
command, unless we call forth, in a dangerous hemorrhage,
the reflex spinal action, the direct spinal action, the irrita-
bility of the muscular fibre, and apply the mechanical
methods of arresting the flow of blood from the uterus. If,
for instance, instead of the jumble of reflex actions, we apply
PHYSIOLOGY AND THERAPEUTICS. 373
alternate heat and cold to the abdominal surface, give a dose
of ergot, irritate the uterus through the abdominal parietes,
and grasp it with the hands, we apply all the modes of
inducing uterine contraction, and we thus get far more than a
fourfold increase of contractile power.
374
LECTURE XXVI.
Hemorrhage at differenl periods of Gestation — The Principle of Alternation
in the Application of Cold or other Stimuli to Excitor jVerves — Hemor-
rhage at the Commencement and the Early and Latter Months of Gestation —
Hemorrhage in Placenta Previa — Hemorrhage occurring during Labour —
Principle of the Arrest of Hemorrhage in Placental Presentation — Hemor-
rhage occurring after Delivery — Conclusion.
I NOW come to the consideration of the modes in which the
various remediesfor hemorrhage are to be applied in individual
cases. Having laid down the principles upon which the
arrest of uterine hemorrhage in all its forms must depend,
much would still remain to be said about the measures proper
in different classes of cases. No two events can be more dif-
ferent than uterine hemorrhage occurring in the first month of
gestation and uterine hemorrhage taking place shortly after
the delivery of the child, and the expulsion of the placenta.
In the one case the stream of blood passing to and from the
uterus is inconsiderable, the openings from which blood
escapes are small, and if the uterus is not contractile, at all
events it is not dilatile. But, after delivery, the circulating
channels in the uterus are immense, and unless closed by
uterine contraction, they must gape widely, and pour forth
blood in full streams. We may consider the heart a con-
tractile organ placed at one extremity of a large column of
blood, and the contractile uterus at the other. Unless the
uterus contracts and supports this column of blood, the result
is just the same as though the heart itself were studded with
perforations. The treatment of hemorrhage at the com-
mencement and termination of pregnancy must be as ditf'erent
as the nature of the loss of blood, and it must vary consider-
ably in the different epochs of gestation.
A thousand facts testify, that although the stimulus which
excites reflex action often excites sensation and emotion
simultaneously, yet ordinary sensibility and its results are not
at all concerned in the production of purely reflex motor
ALTERNATION OF STIMULUS. 375
actions. Some of the most perfect instances of reflex motor
action occur when the part irritated has been separated from
the cerebrum, or when sensation and consciou^;ness have
been perfectly suspended. But although common sensation
takes no part in the pr/^duction of the purely physical reflex
spinal actions, another principle, that o{ alternation^ is of the
very highest importance in all the physical motor actions.
A surface which is quite insensible to pain, manifests its im-
pressibility when appealed to by an alternation of stimuli —
by the successive application of heat and cold. If we wish
to invoke the reflex function in all its power in any organ,
the stimulus applied to it must be alternated. Dr. Marshall
Hall insisted upon this in his New Memoir, and recently he
has more fully shown the importance of this principle in
Reflex Physiology. The application of the principle of
alternation is of especial moment in all that relates to parturi-
tion. In natural labour, we see that at the close of each pain
the uterus becomes unimpressible by the stimulus acting upon
it, and the pain remits, until its impressibility is restored by
an interval of repose. This is probably the explanation of
the intermittent nature of labour-pains. In practice, the
principle of alternation may be made of great service, and
nowhere more so than in the treatment of uterine hemor-
rhage. My able friends, Mr. Simpson, of Stamford, and
Mr. W. F. Barlow, have both made some very interesting
observations on the influence of heat and cold, when used in
alternation, in exciting uterine action in uterine inertia. I
believe Mr. Simpson w^as the first to point out the importance
of the principle of alternation in exciting the uterus. In
uterine hemorrhage, neither heat nor cold, continuously
applied, excites the full amount of uterine action. They
must be applied alternately. A surface exposed to con-
tinuous cold becomes at length who]ly inexcitor ; but now^,
the application of heat becomes powerfully excitor, and after
awhile the surface again becomes impressible by cold. In
applying temperature to the arrest of uterine action by con-
traction, these facts should be constantly borne in mind.
Whatever the excitor surface acted upon, cold and heat
should be applied alternately. This plan both increases and
husbands the reflex motor power. Some principle was
necessary here, for it is astonishing how uncertain practice
has been without such guidance. There has been an oscilla-
376 TREATMENT OF HEMORRHAGE.
tion between the feeble and the rash application of cold.
Dr. Locock has well remarked that when cold is applied, as
it often is, by napkins, and these are suflTered to remain, the
heat of the parts soon converts them into a reeking fomenta-
tion, quite inadequate to the purpose intended. Of the error
of this plan there can be doubt. Dr. Arnott, of Brighton, a
most ingenious physician, passes somewhat into the other
extreme. He has recommended an apparatus for causing a
constant supply of cold w^ater to a small reservoir, to be
applied immediately over the abdomen — the abdomen being
placed under much the same conditions as it would be in the
bed of a running stream, except that the water is not in direct
contact with the abdominal surface. I ought, however, to
say that Dr. Arnott perceives the influence the injection of
cold water must necessarily exert in contracting the uterus.
An additional reason, besides the superior effects of alterna-
tion, for avoiding the continued use of cold, is found in its
depressing influence. When the powers of life are weakened
by loss of blood, danger may arise from the sedative etlects
of cold. Obstetricians have often quoted the observation of
Sir Richard Blackmore to Chapman, upon a case in which
cold was used. " If you had used less cold applications,
this patient would have died from loss of blood ; and if you
had continued them longer, you would have extinguished the
powers of life." When we adopt the principle of alternation
in the use of temperature, while we obtain the fullest measure
of benefit, we avoid the constitutional effects of simple cold
as a depressing agent.
Hemorrhage at the commencement of pregnancy must be
treated on nearly the same principles as menorrhagia. Cold
should be applied continuously, with a view to produce
coagulation, and to lessen the local circulation. Astringent
medicines are useful, as in hemorrhages from other mucous
surfaces. The tampon may be used, but simply as a me-
chanical remedy, to prevent the escape of blood, and thus to
favour coagulation at the mouths of the vessels. The uterus
must be treated altogether as a non-motor organ.
In the early months of pregnancy, when the motor tissue
of the uterus has been somewhat developed, hemorrhages
should be treated partly on the plan just laid down, and
partly with reference to its contractile })ower. If necessary,
in addition to the above modes of restraining hemorrhage,
TREATMENT OF HEMORRHAGE. 377
and promoting coagulation, the flow of blood must be arrested
by firm uterine contraction. We should choose the best
measures for rousing the reflex and direct uterine action, and
that form of action dependent upon its muscular irritability.
Much must depend, however, upon whether the ovum has
been expelled or not, and upon whether we have or have
not abandoned the idea of preventing abortion.
In the latter months of normal gestation, plugging the
vagina, both for the sake of its mechanical and reflex motor
results, should be practised. The moderate application of
cold, on the alternate plan, either to the vulva or the ab-
dominal surface, or the use of a cold or purgative enema,
will be proper. But nothing very heroic can be done, until
it has been decided whether hemorrhage is of sufficient im-
portance to bring on premature expulsion of the ovum.
This point once settled, — either that labour must come on in
the natural course of things, or that it is justifiable to induce
premature delivery artificially, — everything becomes simple.
We should prepare for the direct action of the spinal marrow
by administering a dose of the ergot, and then we should
proceed to puncture the membranes. The latter measure,
as I have already described, powerfully invokes the reflex
actions of the uterus, and converts the body of the foetus into
an effi('ient plug.
In hemorrhages occurring at the time of parturition, before
the delivery of the child, these measures should, in severe
cases, be had recourse to without hesitation. In many cases,
however, simply rupturing the membrane will be sufficient.
This should invariably be practised. I am here speaking of
cases in which the placenta is attached to the fundus uteri.
When flooding during labour resists all the ordinary modes
of arrest ; when neither plugging, the alternate application of
cold, ru[)ture of the membranes, nor -the administration of the
ergot of rye, in suitable cases, is of any avail, we must
evacuate the uterus, if possible, by turning, the use of the
forceps, or even by craniotomy, if the life of the mother
should be in imminent danger. In cases of placenta prrevia,
or in hemorrhage after delivery, we have the source of the
hemorrhage somewhat under command, but in ordinary
hemorrhage during delivery, the situation of the placenta at
the fundus uteri place it beyond our reach. We can only
act directly upon it after the delivery has been effected. In
32
378 TREATMENT OF HEMORRHAGE.
turning, or applying the forceps, we do not arrest the hemor-
rhage merely because we remove the foetus, but because the
reflex, irritation of the hand of the accoucheur and the de-
scending child, or of the blade of the forceps, and the force
used in extraction, excites the uterus more powerfully than
any other measures we can adopt. When the hemorrhage
continues after the artificial extraction of the child, it must
be treated as an ordinary case of flooding after labour.
When the placenta is attached to the os or cervix uteri, the
hemorrhage which follovvs the separation of the placenta is
called unavoidable; when the placenta is planted at the fundus,
the hemorrhage attendant on its separation is called acci-
dental. There is, however, very little, if any, meaning in
these two terms, thus applied. Whenever separation of the
placenta has taken place, whether at the os or fundus uteri,
hemorrhage is inevitable and unavoidable^ unless the uterus
is either contracted, or unless some mechanical pressure is
made on the separated surfaces.
In the hemorrhage of placenta previa occurring before the
term of natural labour, the great object is to arrest the hemor-
rhage, if possible, so as to preserve both mother and child
until the end of gestation, or, at all events, until the fcetus
becomes viable. At the time of parturition there is no safety
but in the delivery of the mother, and repressive measures
are only necessary until the uterus is in a state to admit of
turning. The only modes of restraining or repressing hemor-
rhage in placenta praevia, when the placenta has begun to
separate, are by plugging the vagina, and keeping the circu-
lation as quiet as possible. But the elTicient remedy for the
arrest of the flooding is delivery by turning. The very
operation of turning converts the hand and the arm of the
operator into a plug, and when the feet are brought down,
they and the body of the fcetus in turn plug the os and cervix
so effectually, that further hemorrhage is impossible. I am
not here speaking of the propriety of saving the child, but of
the mere arrest of hemorrhage. When the placenta has been
entirely separated, or is removed artificially, the head of the
fcetus instead of the feet becomes turned into a tampon.
Besides the plugging effect, there is, as 1 have before ob-
served, a large amount of reflex action called forth by turning,
or by the substitution of the head of the child for the soft
placenlaj at the os uteri. In turning, the muscular irritability
TREATMENT OF HEMORRHAGE. 379
of the uterus is necessarily stimulated. In these cases, the
evacution of the liquor amnii is to be avoided, if possible,
lest it should render the turninj^ more difficult; and the ergot
of rye, and other centric stimuli, are improper, for the same
reason. Where it is .impossible to turn, and the life of the
mother demands it, craniotomy should be performed. In
these dangerous cases, promptitude in action is of the highest
importance; here as in other critical enterprises, delay is
equivalent to defeat.
In hemorrhage from the fundus uteri, the separation of the
placenta, which is the cause of loss of blood, tends power-
fully to excite the uterus to contraction, from the direct effects
of the separation upon the uterine tissue, and the reflex
action it induces. It is only w^hen the irritation caused by
the detachment of the placenta from the uterus is not enough
to excite efficient contraction, that any hemorrhage occurs.
So in the case of placental presentation, the detachment of
the placenta excites local contraction. There is not only
the irritation of separation, but the lower segment of the
uterus has been rendered unusually excitable by the increased
development it undergoes from the implantation of the pla-
centa in this situation. But in separation of the placenta at
the fundus, the consequent uterine contraction is an unmixed
good. In placental detachment at the os and cervix uteri
the contraction is more abortive, and frequently mischievous.
It does not entirely arrest the hemorrhage, owing to the
partial separation, and the soft mass against which the con-
traction is exerted, while it hinders the descent of the head
in the form of a plug, often prevents the introduction of the
hand for turning, and renders the subsequent extraction of
the child by turning or craniotomy difficult, and sometimes
impossible. Hence the uterine irritation and contraction
excited by detachment of the placenta from different uterine
localies is a subject of great importance. In placenta previa,
before the direct contact of the foetal head with the lower
segment of the uterus, the local contraction may be accom-
panied by considerable inertia of the fundus and body of the
organ; hence the complication of placenta pr^evia with tardy
labour.
This view of the mode in which hemorrhage is arrested in
placenta prsevia after the detachment of the placenta, by
orificial contraction, is supported by what we observed in
3S0 TREATMENT OF HEMORRHAGE.
turning in these cases. It often happens that in placental
presentation, after entire or partial separation of the placenta,
if turning is performed the os and cervix uteri grasp the body
and neck of the child so firmly, as to render its extraction a
difficult operation. It has sometimes occurred that mother
and child have perished during the attempts to free the foetal
head from the contraction of the cervix. Again, in cases of
placenta preevia the introduction of the hand for the purpose
of turning, is generally more difficult than usual, because of
the rigid and contracted state of the os uteri. There is, then,
every reason for believing, that the mode in which hemor-
rhage is arrested in all placental separations, whether at the
OS or fundus, are the same — namely, the contraction of the
uterine tissue at the seat of the separation. The active con-
traction of the OS uteri from separation of the placenta,
explains in part the arrest of hemorrhage in some cases by
artificial detachment of the placenta, if we could consent to
destroy the foetus by this measure. I believe the cause and
nature of the increased motor action of the os and cervix in
these cases, have to a great extent escaped observation ; the
rigidity has been considered simply mechanical, and the
contraction accidental. The following case, from Dr. Robert
Lee's Clinical Midwifery, a little work of the utmost value
in obstetrics, beautifully illustrates the increased rigidity and
contraction of the os and cervix uteri in placental presenta-
tion :
" On the 12th Jannary, 1839, Mr. Jones, of Carlisle-street,
Soho-square, called me to see a lady in the eighth and a half
month of pregnancy, who had been attacked with uterine
hemorrhage a month before. It first took place without any
accident or pain, and the quantity lost was about half a pint,
and it produced little effect upon the constitution. She re-
mained quiet for several days, and then got up, and only
felt a little weak. For ten days she went about, but the
hemorrhage returned on the fifteenth day after the first attack,
but not to a great extent. Seven days after this, a third and
more profuse hemorrhage took place. It gradually went off,
but not so quickly as the other attacks. At one o'clock, 12th
January, it was renewed to an alarming extent, w^ithout any
pain ; about a quart of blood was suddenly lost, and she
became extremely faint. At four a.m. the discharge still
continued. When I first saw her, at seven o'clock, she felt
TREATMENT OF HEMORRHAGE. 381
faint, the pulse was rapid and feeble. The upper part of the
vagina was filled with a large clot of blood, which adhered
to the OS uteri. By displacing this at the back part, I could
distinctly feel the placenta adhering all round to the neck of
the uterus, which was. thick and rigid, and very little dilated.
The effect produced by the hemorrhage was so great, that it
was evident death would soon take place if the delivery
were not speedily completed ; and the state of the orifice
was such, that it was certain the hand could not be passed,
but with the greatest difficulty. At eight o'clock. Dr. Mer-
riman saw her with us, and agreed that immediate delivery
was necessary. I passed the right hand into the vagina,
and insinuated my fingers between the uterus and placenta
at the back part, and reached the membranes. But the
rigidity of the orijflce loas so great, that though I employed
great force for a considerate time, I could not succeed in getting
the hand into the uterus. Dr. Merriman recommended rup-
turing the membranes, and I was proceeding to do this with
the fingers, when I felt one of the feet of the child, which I
grasped and brought down into the vagina, enveloped in the
membranes, which then gave way. Nearly half an hour elapsed
before the version could be completed, and when it was effect-
ed, the neck of the uterus grasped the neck of the child so firmly,
that I experienced the greatest difficulty in extracting the head,
and not till I had made pressure for some time with the finger,
and dilated the orifice of the uterus. A great discharge of
blood instantly followed, the placenta was removed, and
every means employed to stop the hemorrhage, but the
breathing became hurried, the extremities cold, and she died
in less than an hour after deliv-ery. Dr. Merriman informed
me, that a patient of his had actually died under similar
circumstances, before the head could be extracted."
In this case it is most interesting that there should have
been such a great amount of orificial rigidity before the uterus
had been entered by the hand, and such a great amount of
contraction afterwards, when the head of the foetus came to
pass through the os and cervix. I have no doubt the rigidity
chiefly consisted in a state of active contraction. If the case
had been one of simple mechanical rigidity, the cervix uteri
would scarcely have been affected by sudden and violent
contraction immediately after its mechanical distention. We
32*
382 TREATMENT OF HEMORRHAGE.
might as well expect the rigid perinaeum to contract after its
distention by the fcetal head. A cause of uterine rigidity,
reduced by mechanical means, is the least likely of all to be
followed by spasmodic contraction. Dr. Lee says, that in
some of these cases of placenta prffivia, the os and cervix
grasp the foetus like a rope.
Hemorrhage occurring after delivery, from the entire or
partial separation of the placenta, with uterine inertia, calls
for all the resources of our Art. If the placenta should only
be partially separated, that viscus should be entirely detached
and removed. This operation, by exciting the muscular
and reflex powers of the uterus, will often arrest the hemor-
rhage at once. When hemorrhage occurs after the complete
evacuation of the uterus, the inertia upon which it depends
may be either partial or entire. When the inertia is partial,
the uterus contracts sufficiently to expel coagula or large
gushes of blood from time to time, thus giving palpable evi-
dence of the jeopardy of the patient. But in total inertia,
there is a discharge of blood per vaginam; the uterus is too
feeble to expel the vital fluid effused into its cavity, and the
organ becomes immensely distended and diff'use. The beat
of the heart fails or ceases, the temperature falls suddenly,
the functions of the brain are suspended, and the patient is
suddenly precipitated into the very jaws of death.
In either case, whetlier the hemorrhage be internal or ex-
ternal, if it has taken place to a dangerous extent, the vital
powers must be carefully and instantly preserved, and every
possible measure taken to prevent further loss of blood, and
to insure the contraction of the uterus.
The vessels of the uterus should either be compressed
mechanically, between the hands, or the venous and arterial
flow of blood from the heart should be prevented by pressure
on the aorta and inferior cava.
Stimulants (brandy, as the strongest, is the best) should be
given by the mouth ; the head of the patient should be kept
low, as the continued action of the heart will depend greatly
on the state of the cerebral circulation. The inferior extre-
mities should be raised, and it has been recommended to
place ligatures, or tourniquets, upon the extremities, in order
to reinforce the circulation as much as possible. As quickly
as may be, the ergot of rye should be given with the stimu-
CONCLUSION. 3S3
lants, to ensure the direct action of the spinal marrow upon
the uterus. This form of action may be excited even after
the uterus refuses to obey stimuli of reflex action.
The reflex actions should be excited by allernate cold
douching and warm applications to the abdominal surface
and vulva, and by the application of the child to the breast,
or by causing the nurse to suck the breasts. The drinks
should be given cold or iced, to stimulate the pneumogastric
nerve.
The muscular irritability of the uterus should be stimulated
either by irritation through the abdominal parietes, the appli-
cation of galvanism, or the introduction of the hand into the
uterus. Where the latter is resorted to, the uterus should
never be injured by improper pressure. Irritation, not force,
is required !
As a last resource, transfusion has been recommended in
these cases ; but it is at such moments, above all others, that
we require instant remedies, and transfusion is, alas! an
operation causing more time than life will often wait for.
We may suspect that in the fortunate recoveries by trans-
fusion which are on record, the patient would have recovered
by other means.
Here we have exhausted and combined all our most potent
remedies; but they will rarely fail, when properly directed,
unless, indeed, the patient is already cadaveric when they
are commenced. As there is no malady in which the sudden
danger to life is greater than in uterine hemorrhage, so, most
fortunately, there is no contingency in which the resources
of Art are more powerful or numerous.
I now bring the present Course of Lectures to a conclu-
sion. I have experienced considerable difficulty in attempt-
ing to advance, even by one step, a department so extensive
as that of Obstetrics. This, however, by the help of phy-
siology, not heretofore applied in this department, except in
the most cursory manner, I have striven to accomplish.
Whether I have succeeded in placing this branch of medi-
cine on a physiological basis, sufficiently broad to influence
practice, time alone will determine. I feel sanguine, how-
ever, as to the result. Since the commencement of the pub-
384 CONCLUSION.
lication of these leetures, I have received much encourage-
ment from distinguished members of the profession (many of
whom were strangers to me), expressive of their approval of
the principles I have endeavoured to enunciate. These
flattering encouragements will embolden me to pursue still
farther the development of physiological doctrines in the
direction of Parturition and Obstetrics.
385
APPENDIX.
Some of the following notes, which I have thrown together
in the form of an Appendix, will be found to elucidate cer-
tain points treated of in the preceding Lectures.
Ovular Theory of Menstruation.
In the January number of the " British and Foreign
Medico-Chirurgical Review," the ovular theory of men-
struation is referred to in a review of Drs. Ashw^ell and
Meigs. An objection is taken to the periodic maturation
and discharge of ovules in the human female,, partly on the
grounds of certain circumstances relating to the period of
impregnation in Jewish women. The Reviewer observes : —
" It has yet to be shown that the human female is the
subject of a periodic sestrum once a month, and that at this
time vesicles are maturated and an ovum discharged, which
may be impregnated during its slow progress through the
sexual organs, whenever it may come in contact with the
semen. We believe that about eight days is given for this
transit of the ovum, w^hich, in fact, limits the period of con-
ception to this time after the menstrual period. And yet
the Jewish women who are bound to observe continence
for just this time after menstruation, are notoriously a prolific
race ?
In the " Lancet" of December 14, 1844, there is a com-
munication by Dr. Girdwood, which contains some import-
ant facts respecting this question. I quote the following
from Dr. Gird wood's paper, as it meets the difficulty started
by the Review^er : —
3S6 APPENDIX.
*' That conception takes place about, and most probably
antecedent to, the time of the periodic discharge, is illus-
trated, on a great scale, by the nation of the Hebrews. It is
the custom amonsjst Jews, who are scrupulous, for the wife
to retire from the society of her husband for a period of
thirteen days, reckoning from the first day of being " nyddar"
— that is to say, by those who are strict, five days are kept,
as prescribed by the Rabbinical law (for the purpose of
making security doubly sure), in addition to the eight days
enforced by the law of Moses. I have it from most excel-
lent authority, from individuals of this nation, for whose
probity of conduct and veracity I have the highest respect,
that after extensive inquiries made ainongst their friends and
relations, they find, that no pregnant female, observant of
this Rabbinical law, can calculate within fifteen days when
to expect her accouchement. In fact, that event generally
takes place a fortnight later than expected ; and this is ac-
counted for when we learn that the Jewesses reckon their
gestation from the day of their purification, and not, as the
Christians, from the time that the catamenia were last evident
— that is to say, from the time when the impregnability of the
ovum was last at its acme. I was led to this inquiry, from
having remarked, than an Israelitish married woman I had
for years attended during her confinements, gave birth always
later than the period of her reckoning. I may add, as a fact,
that in general, among this singular people, no female is
found to be a mother before at least nine calendar months
and a half have elapsed."
The subjoined extract is from a letter addressed to me
by Dr. Power, and it is in the main confirmatory of the
opinion expressed by the reviewer on the point to which it
refers : —
" There appears one discovery still necessary to render
the ovular theory of menstruation perfect : — namely, the de-
tection of the ovule in the menstrual discharge, or in the
vagina at the time of menstruation. All the dissections
which have yet been made tend only to confirm the original
observations of Kergringius and Cruickshank, relating to
the bursting of the Graafian vesicle. Indeed, I am not satis-
fied that the bursting of a Graafian vesicle and escape of the
APPENDIX. 387
ovule of. Baer is the general occurrence or Law, and am
inclined to believe that the ovule, when impregnation does
not take place, having lost its vitality, is not unfrequently
absorbed within the ovarium."
. In three cases in wbich Dr. Ashwell had opportunities of
examing the ovaria of women who died during the flow of
the catamenia, there were no signs of the rupture of Graafian
vesicles, and the escape of ovules. In one of these cases,
the woman had menstruated regularly for several years, and
yet the ovaria were perfectly smooth ; " there was neither
rent nor cicatrix marking the site, either of a present or
former maturation and escape of a Graafian vesicle." Still
Dr. Ashwell admits the periodic return of ovarian excite-
ment as the condition of menstruation, though this excite-
ment may not always reach the point of maturing and dis-
charging ovules.
Abdominal Movements of Pregnancy.
One of my students, distinguished for his diligence and
accuracy of observation, has supplied me with the following
note : —
3, Great Queen-street, Westminster, March 1.
Dear Sir, — My brother (a farmer in the country), for a
.great part of the year waters his cows from a cold gravel
spring, of which water they drink several gallons each, twice
a-day. It is whilst they are drinking of this water (always
intensely cold), that the strong jerkings and apparent kickings
take place in the flanks of the cows near calving ; and these
motions, seen so frequently at such tiii^es, are observed on
no other occasion.
Dear Sir, yours, very obediently,
\Vm. K. Parker.
<*ToDt. W. Tyler Smith."
Can it be that the cold aflfects the fcetal calf, or is it that
reflex uterine contractions are excited through the medium
of the stomach ? I suspect it to be the latter. I know it has
3S8 APPENDIX.
been asserted that taking food and drink into the stomach
of the pregnant woman excites reflex actions of the fcetus.
But this is clearly impossible ; there can be influence of
temperature between the human stomach and uterus ; and
where is the reflex arc extending from the pneumogastric, to
the muscles of the fcetal limbs ? Such movements are un-
doubtedly reflex uterine actions. I would have it distinctly
understood, that I do not deny the existence of foetal move-
ments before the time of birth. What I contend for is, that
a large amount of motor action, which has hitherto been
attributed to the foetus, does in reality belong to the gravid
uterus.
Precipitate Abortion.
A case occurred during the loss of the *' Ocean Monarch"
by fire, which illustrates the rapidity with which abortion
may take place during death from asphyxia. The following
is a description of one of the bodies found a few days after
the loss of this ill-fated vessel : —
" The deceased is of slender make, having on her head a
Dunstable bonnet, and a dress of blue, hail-showered print,
blue cotton skirt, or top petticoat, and red flannel under pet-
ticoat, and a red-and-white woollen plaid shawl. Under her
dress, she had on a man's waistcoat of woollen cloth, with a
small red flower on a light ground, and small metal buttons.
On the wedding-ring was a gold ring, marked on the inside
with the initials ' G. W.' Round her neck was a double
row of coral neck-beads, with a gold clasp, and her hands
appeared much scorched. This woman had beeen throiun
into prematiu^e confinement ^ and was partly delivered of a
child^ which was brought with her on shore. She appeared to
be about Ibity-three years of age.
Two Cases of Amyelitic F(etus.
Case 1. — A case of amyelitic foetus has been kindly for-
APPENDIX. 389
warded to me by Mr. Hoadley Gabb, of Hastings, which is
quite as important as M. Lallemand's case (p. 102), and
bears equally strong upon the question of the fatal move-
ments.
*' It will afford me. much pleasure to give you a history of
the case your letter referred to, which was not only interest-
ing to me, from the malformation of the foetus, but also from
the mother (who had previously had four healthy children)
having attained a most enormous size, so that the abdominal
parietes appeared on the verge of sloughing from distention ;
this was subsequently accounted for by the immense quantity
of liquor amnii.
*' Another feature of the case was new to me, and occa-
sioned me some anxiety. The uterus remains as enlarged for
some days as that of a w'oman six months advanced in preg-
nancy; and for a night and day after delivery as much liqour
amnii was discharged, though without pain, as is usual at an
ordinary labour.
*' The placenta came away easily; there w^as no hemor-
rhage. The foetus, which was within a fortnight of its proper
time, according to the mother's calculations, was small ; it pre-
sented these peculiarities : —
*' The head w^as placed without the intervention of a neck
between the shoulders, so that the chin rested on the ster-
num. The face was natural, excepting being broader than
usual.
*' The skull consisted only of the frontal, the inferior por-
tions of the temporal bones (there were no squamous por-
tions), and the anterior half of the occipital bone, so that
there was no foramen.
" The brain was large enough to fill the skull if it had been
perfect; it was merely covered behind, apparently by its
membranes. The hemispheres were as plainly divided by
the falx cerebri as they usually are on the removal of the cal-
varium.
''My impression is, that there was no cerebellum, but of
that 1 am not quite certain.
'' The posterior portions of the cervical and dorsal vertebra?
were wanting ; they appeared as if the integuments, together
with all the vertebrae, excepting the bodies and transverse
processes, had been removed with a knife, and had recently
cicatrized.
33
390 APPENDIX.
*' The llgamentum nuchse was divided into two fasciculi,
and attached to the transverse processes.
" Tliere was no spinal cord^ nor any rudiment of one ; the
bodies of the vertebra were only covered by a thin, semi-tran-
sparent membrane.
'' The other portions of the body were normal.
*' The apparent motions of the foetus were so evident a day or
two before its birth, that the mother drew her husbandh atten-
tion to her dress being raised by them.
" These are all the peculiarities that a superficial examina-
tion afforded. Circumstances would not permit me to dissect
the foetus, which 1 much regret.
" P.S. — From the little resistance offered by the formation
of the head of the child, I was not there until half an hour
after its birth, as my house is a mile from where the mother
resides. The child, the nurse informed me, was born dead,
and, indeed, from the fact of the blood beins: coagjulated in
the funis, must have been so some time prior to its birth, as
labour was very rapid."
Case 2. — I have received the following particulars of an-
other highly interesting case of amyelitic foetus from M. Con-
stantine Zaviziano, Professor of Midwifery in the Ionian Uni-
versity, Corfu. In a letter addressed to me, he writes: —
*' I am fully aware of the opinions which you entertain in
respect to the abdominal movements commonly attributed to
the foetus, which are observable during pregnancy ; and
having perused with much interest the case published in the
* Lancet' (vol. ii. 1848, p. 400), with your remarks thereon,
I take the liberty of bringing under your notice another
case of amyelitic foetus, which foetus I still have in my pos-
session.
" The mother of the foetus in question is about eighteen
years of age ; this was her first pregnancy, //'o/ti tlie third
month of which she began to feel abdominal movements, and
these continued to increase up to the seventh month, when she
miscarried without any apparent cause. 'J'he movements
were so strong during her pregnancy, that they were not only
felt, but were visibly apparent to the mother and her atten-
dant. From the following description of the foetus it must
absolutely be retained, that the movements could not be other
than those of the uterus, and therefore quite independent of
APPENDIX. 391
the muscular contractions of the fcetus. Likewise, the move-
ments felt by the mother in the third month of pregnancy
could not well be attributed to the foetus, on account of the
small development of the muscular system at this time. In
addition to what you have stated in your Lectures, published
in the * Lancet,' I also beg leave to subjoin, that there can
be no practising physician who has not known of pregnant
women who first became aware of the fact of their having
conceived, from feeling unusual abdominal movements in
the first stage of pregnancy ; and others again, who feel
such movements without having conceived, in consequence
of some other extraneous body existing in the cavity of the
uterus.
*' The miscarriage to which I have alluded took place with-
out any dangerous consequences to the mother. The foetus
is of the usual size ; the neck is entirely wanting, and the
head appears to rest between the shoulders, with the face
upon the sternum ; the face is most hideous, the mouth very
wide, from which the extremity of the tongue is observable;
the base of the nose is large, and flattened out; the eyes are
large, and protruding much from their sockets, with a space
between them of about nine lines ; the ears are well formed ;
there is no frontal bone, but the inferior portions of the tem-
poral bones exist, without any squamous portions, however ;
the sphenoid bone exists, likewise, and the anterior half of
the occipital bone. Of all the vertebral column, nothing is
to be found but the bodies and the transverse processes. The
basement of the cranium, as above described, and the ante-
rior part of the vertebral channel, were covered with a species
of semi-transparent membrane. There was no trace of hrain^
cerebellum^ or spinal marrow.
*' And now, having brought this case of amyelitic foetus,
which I trust will also prove of some interest, before you,
permit me to subscribe myself, &c., &c."
This case is remarkably similar to that published with en-
gravings by M. Lallemand.
Such cases prove,to a demonstration, that abdominal move-
ments of gestation cannot in all cases be attributed to the
foetus ; we are obliged to refer them in these cases to the
uterus. Time was, when the absurd notions that the foetus
sat upright in utero during pregnancy, and that, at the time
392 APPENDIX.
of labour, it assisted by its own efforts in its emergence from
the worab, were as universal as the present belief that the
abdominal movements belong entirely to the foetus. I am
convinced that more correct observation will prove the latter
to be, in its exclusive sense, as untenable as the former, of
which, indeed, it seems to be a relic.
Cause of Labour.
The following extract from Dr. Fleetwood Churchill's work
on the " Theory and Practice of Midwifery," shows how per-
fectly the idea of the regular duration of pregnancy, and the
relation of parturition to the catamenial periodicity, may
exist, without any idea of the cause of labour. Dr. Churchill
is perfectly conversant with *'the fact," that the average dura-
tion of labour is 280 days, or a time equalling ten catamenial
periods ; and he suspects that labour comes on at the tenth
period after impregnation, but " the exciting cause" is quite
undiscovered. It is the knowledge of an excitor spinal nerve
in the ovarium which is the one great point wanting, and
without which the mere fact of periodicity is confused and of
little value.
I insist upon this point strongly, because attempts have
been already made by those who confound cause with mere
coincidence and time, to set aside my claim to whatever merit
may lie in the detection of the Cause of Labour. The passage
I quote, proves that it is quite possible to have a tolerably
accurate notion of the " utero-ovarian periodicity" of preg-
nancy, and yet to consider that " all search has hitherto
failed in discovering the exciting cause of labour." Obstetri-
cians might have gone on, as they had done before, from
generation to generation, repeating to themselves the fact,
that the duration of gestation is a multiple of the catamenial
period, without any conception of the ovaria-uterine ner-
vous arc, which excites the uterus to parturient action.
Dr. F. Churchill commences his chapter on Parturition
thus : —
" We have now arrived at the last great function of the
uterine system — that of Parturition, with its abnormal va-
riations.
''It consists in the expulsion of the foetus and its appen-
APPENDIX. 393
daores from the cavity of the uterus, and effects the separation
of the child and the mother.
" It occurs, as we have seen already, at the end of nine
calendar months and a week — ten lunar months — forty weeks,
or 280 days, a few days being allowed either way.
'' The magnitude and importance of the event, and the
regularity with which it takes place, have induced physiolo-
gists of all ages to assign causes for it, but as yet without
success.
" Thus it has been supposed that the uterine action is ex-
cited by the struggles of the foetus for the want of adequate
nourishment, or from the constraint of its position, or from
the endeavour to breathe : by others it has been attributed to
the acrid nature of the liquor amnii. Buffon has likened the
process to the dropping of ripe fruit. Hervey, Burdach, and
others, attribute it to the uterus having attained its maximum
of irritability at the exact time that the foetal development is
complete. It would be easy to fill pages with similar ex-
planations, but these may suffice : they are all either more
elaborate expressions of the fact, or mere hypotheses.
*' But though all search has hitherto failed in discovering
the exciting cause of labour, it has established the fact, that the
periodicity which we found to characterize the other uterine
functions, prevails here also. For example, abortion or pre-
mature labour, when not the result of external accidental
causes, occurs very generally at a monthly, or what, but for
conception, would have been a menstrual period.
" Again, as remarked by Stark and others, the normal
period for parturition corresponds to a menstrual period ; on
this principle Kluge calculates the duration of pregnancy in
every case at 280 days, and so much more or less, as
impregnation took place immediately before or after men-
struation. Speaking generally, lahour may be looked for at
about the tenth period after the last appearance of the cata-
menia.
" Lastly, in extra-uterine gestation, an attempt at labour
occurs very generally at about the same period.
" So that, taking the monthly discharge as the type of
utero-ovarian periodicity, we may observe that it continues,
though at times less demonstrably, throughout the whole
period of the functional activity of the sexual system."
394 APPENDIX.
Emotional Contagion in Puerperal Convulsion.
There can be no doubt but that puerperal convulsion may
extend from one patient to another through the influence of
emotion, like epilepsy, chorea, stammering, and some other
spasmodic diseases. There is one remarkable instance of
this on record, possessing an historical interest. Convulsion
occurring after a tardy labour, depending on the arrest of a
large foetal head, in a pelvis below the average capacity,
was the cause of the death of the Princess Charlotte in 1817.
After her decease it is well known that convulsions were
unusually prevalent among puerperal women, particularly in
the higher circles. All women went into labour under the
influence of the terror excited by an event which in that day
was felt as a grief at every fireside. I believe that within a
short time subsequent to this melancholy accident, two or
three other fatal cases of puerperal convulsion occurred in
the practice of Sir Richard Croft, and led to his suicide. A
misfortune, relentless as the ancient Ate, pursued to the
grave this accomplished physician, who a few years before
had entered upon a seemingly brilliant career, as the son-
in-law and successor of Denman, and the brother-in-law of
Baillie.
Peculiar Malady Incident to the Decline or the
Catamenia.
There is a peculiar malady which has never been described,
belonging to the period of '' the change of life," or the cata-
menial crisis, and allied in its nature to sphagiasmus, which
I shall take some future opportunity of elucidating fully.
The so-called " heats and chills" of this period consists of a
real paroxysmal affection, allied in its nature both to inter-
mittent fever and epilepsy, particularly to the cerebral variety
of the latter ; sometimes it terminates in epilepsy, or mania,
or even apoplexy. In fact, this malady is a fruitful soiirce
of mania occurring in the female after the decline of the
catamenia. The disorder I refer to appears to consist of
compression of the veins of the neck, and distention of the
APPENDIX. 395
cerebral circulation, attended by vivid sensations of heat,
flushing of the face and neck, with f^iddiness ahnost amounting
to insensibility. These symptoms are soon followed by
relaxation of the neck ; great coldness or chills, and faint-
ness, with perspiration, over the whole surface of the body.
The paroxysms are sometimes so violent as to wake patients
out of their sleep, and the apprehension of the attack pro-
duces the greatest uneasiness in excitable patients. These
paroxysms occur many times in the twenty-four hours, in
women of delicate health at this epoch. Let any practi-
tioner inquire and analyze the symptoms of women at the
catamenial decline, and he will find the affection of which I
have given the outline tobe very common ; it is a most import-
ant subject of study, as being the basis of many of the dis-
orders of the nervous system, which occur after the cessation
of the catamenia.
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"We can nnhesiiaiingly recommend this volume as one of the very best of its kind.
American Ule^ical Journal
We will adopt ii as a textbook for tlie use of our own pupi's and we must recom-
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Fro7?i Professor Rives, of Providence.
I th'nk it admirably cali-ulated to fulfil the o iject lor which it was compiled, and it
has afford d me ii.uch pleasure to recommend it to several of ray country friends, as
well as to my pupils
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BEING A .MANUAL OK T li: SOIENCR. WiP.i ITS APPLICATIONS TO
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BY D. PKREIRA GARDNER, M.D.,
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By far the greater mimber of medical siudents will find tins work of Dr Gardner
better adapted to their wiints than any other with which we are acquaintcfl.— O/i/o
Medical aid Surgical Journal.
Admirably adapted lo the end and design. We shall be much disappointed if it is
not adopied as a textbook mi all our American Colleges.— iV. Y. Journ of Medicine.
An excellent work — one likely to be of great use to the student, and of no small
value to the practitioner. — Charleston Medical Journal.
4
Date Due
.
LIBRARY OF THE
UNIVERSITY OF MASSACHUSETTS
MEDICAL CENTRE AT WORCESTER