ON THE 
Effect of Atropine 
IN 
DIMINISHING THE PAINS AND SHORTENING THE DURATION 
OF THE 
FIRST STAGE OF LABOR. 
BY 
HENRY L. HORTON, M.D. 
Reprinted from the American Journal of Obstetrics and Diseases of 
Women and Children, Vol. XI., No. III., July, 1878. 
NEW YORK: 
WILLIAM WOOD & CO., 27 GREAT JONES STREET. 
1878. ON THE 
Effect of Atropine 
IN 
DIMINISHING THE PAINS AND SHORTENING THE DURATION 
OF THE 
FIRST STAGE OF LABOR. 
BY 
HENRY L. HORTON, M.D. 
Reprinted from the American Journal of Obstetrics and Diseases 
Women and Children, Vol. XI., No. III., July, 1878. 
NEW YORK: 
WILLIAM WOOD & CO., 27 GREAT JONES STREET. 
1878. ON THE EFFECT OF ATROPINE IN DIMINISHING THE PAINS AND 
SHORTENING THE DURATION OF THE FIRST STAGE OF LABOR. 
BY 
HENRY L. HORTON, M.D., 
New York. 
(With one wood-cut.) 
I confine my remarks mainly to a consideration ot the 
first stage of labor, with special reference to the use of atro- 
pine during that period—a period trying alike to patient 
and physician, as all who have had experience in obstetrics can 
testify. Only within a comparatively recent period have phy- 
sicians regarded the pain and suffering experienced by the 
human female during labor otherwise than as a necessary 
accompaniment of that process, and, as a consequence, they 
formerly abstained from any interference with it, either medi- 
cinally or mechanically, except in very rare cases. Even in 
such cases, assistance was not rendered, in many instances, 
until the system had given strong evidences of its inability to 
perform the allotted task, and had manifested unmistakable 
symptoms of danger—in short, had given every proof of its 
powerlessness to bring about relief unaided. That it may not 
be thought I am using language stronger than the facts warrant, 
I refer to a few authors who were for many years consid- 
ered the most eminent authorities in obstetrics, also to the 
rules laid down by them, indicating the use of the forceps in the 
second stage of labor, which may give you some conception of 
the nature of the assistance they rendered their patients in the 
first stage. 
Dr. Osbourne says, “ In the state indicating the use of the for- 
ceps, all the powers of nature are exhausted, all capacity for 
further exertion is at an end, and the mind as much depressed 
as the body ; they would both together sink under the influence 
of such continued and unavailing struggles.” 
Dr. Collins did not think it right to interfere as long as the 
head advances ever so slowly, unless the child be dead. 
Dr. Denman enjoins us to wait at least six hours, with the 4 
Horton : Effect of Atropine in Diminishing 
head of the child stationary in a position favorable for the use 
of the forceps, before the instrument is applied. 
Dr. Gooch would extend this period of suffering to twelve 
hours. 
When such rules were acted on and strictly followed as to 
the assistance to be rendered during the second stage, what 
must have been the practice as to the assistance to be rendered 
in the first ? 
Dr. Gooch, the author last quoted, in speaking of retarded 
labor in the first stage, from irregular pains and rigid cervix, 
uses this remarkable language : “ I am tired of giving opium 
in these cases; my remedy is tincture of time, the loss of 
which is the only thing to be regretted, for it, at least, pro- 
duces no additional evils. You must keep up the spirits and 
confidence of the patient and her friends. A female com- 
panion who has herself had a half dozen tight labors, and who 
can tell stories of friends who have been a week in labor 
and have done well at last, will be a good assistant to you.” 
Yet if we follow him further, we find that he did not trust 
entirely to this somewhat marvellous tincture, for he says, “ In 
slight cases, where the cervical portion of the uterus is thick, 
hard, gristly, hot and painful, as if in a state of subacute 
inflammation, and the dilatation proceeds very slowly, and the 
os uteri to the touch, instead of conveying the sensation of an 
orifice in a piece of broadcloth, feels like an orifice in an inch 
deal board, warm salt-water injections are of great service, 
relieving, as by fomentation, the sub-inflammatory state of the 
cervix uteri.” 
Dr. Byford, writing as late as 1870, says: “If we wait, it 
will be overcome by the pressure of the uterine contractions 
generally, and as it is to be overcome by force alone, we are 
justified in greatly aiding the uterus with the fingers; the fin- 
gers may be introduced, and the anterior lip of the os pressed 
up towards the symphysis pubis, and retained in that position, 
while the uterus affects the posterior part of the cervix.” 
Now, I do not object to this manual assistance in such cases, 
but do object to the time which he selects for rendering such 
assistance, viz.: during the uterine effort, when the cervical 
fibres are in a state of extreme tonic contraction. I hold 
that it should be rendered at a time when the whole uterus is the Pains in the First Stage of Labor. ' 
5 
in a state of repose. Would the surgeon, if about to reduce a 
dislocated limb, select a time when all the muscles connected 
with the structure of the dislocated joint were in a state of 
tonic contraction ? 
Dr. Leishman, in his System of Midwifery, published in 
1875, referring to the first stage of labor, says: “Even in 
cases when its duration is prolonged far beyond the average, 
this, of itself, is no excuse for interference, unless the general 
symptoms indicate that it is our duty to accelerate the labor by 
such means as are within our reach—a state of matters which 
is of rare occurrence.” 
I am persuaded that the belief that the pangs of labor are 
simply manifestations of a perfectly normal physiological pro- 
cess in which art lias no right to interfere, prompted Dr. 
Blundell to make use of the expression, “ meddlesome midwif- 
ery is bad midwifery,”—an expression that yet finds a place in 
many of our text-books on obstetrics—and which expression, 
in my humble opinion, has served as a shield for no inconsider- 
able amount of timidity and incompetency, and condemned 
many a sufferer to long hours of the most severe and needless 
torture. I say needless, because I believe that a large pro- 
portion of it can be relieved, and that it is clearly within the 
province of medicine to effect such relief. In speaking thus 
strongly, I would not have you infer that I do not respect the 
authorities in this department; on the contrary, 1 yield to no 
man in my respect for them. True, I do not look upon their 
opinions as being so many hempen cords to bind me, but 
rather as so many silken threads to indicate to me the route 
travelled by others along the many winding labyrinths of the 
science of medicine. For the history of this science furnishes us 
with numerous instances of the most lamentable results of a 
blind subservience to authority—a subservience resembling 
nothing so much as the abject docility of a sightless horse in 
his measured tread along the beaten track around a bark mill. 
I claim that it is the duty of the obstetrician to alleviate 
and shorten, if possible, the pains of labor, at whatever stage 
it may be; provided always that he can do so with perfect 
safety to both mother and child. I hold also that an intelli- 
gent interference, if you choose to call it such—I prefer to 
call it intelligent assistance—is not meddling with labor by 6 
Horton : Effect of Atropine in Diminishing 
any means. Meddling means, when applied to the subject 
under consideration, an interference with the process of labor 
when it is all right and needs only to be left to itself, or, in 
other words, meddling with labor is the being ofiiciously in- 
trusive upon its efforts or operations at a time when it is doing 
its own work well, and is giving strong proof that it is fully 
able to accomplish its own task within a period of time that 
will guarantee, not only the delivery of a living child from a 
living mother, but also that the child will be in a condition to 
live, and that the mother will be uninjured as well as alive. 
For the obstetrician to interfere with the harmonious action 
of these natural forces, in a natural labor, where he should, as 
it were, stand only in amazement at the grand triumphs often 
achieved by these unaided and irrational powers, is simply to 
be stepping beyond his legitimate province. No one, in such 
instances, would be justified in resorting to other than the ex- 
pectant treatment. But, in a given case of labor, though it 
has terminated favorably, in a given time and with a given 
amount of pain, yet could abetter or more skilful management 
have effected the same favorable result with one pang less, or 
one long moment of suffering avoided, then the attendant is 
responsible for that useless pain, that additional moment of 
torture. The great diversity of opinion on the question of 
rendering assistance in the first stage of labor, as well as on 
the question of the application of the forceps in the second 
stage, arises from the fact that there is a boundary line be- 
tween the physiological and pathological territories, and this 
line varies so much in its course between these different do- 
mains that, to a certain extent, its location must long remain 
in dispute. It is with reference to the neutral ground, as it 
were, along this line, that authorities differ so widely. In my 
judgment, questions of this nature cannot be set at rest by 
any arbitrary rule: they must be determined by the physician 
himself in and for each individual case, taking all the facts 
before him. 
One high in authority in the past holds strongly to the doc- 
trine of non-interference in the first stage of labor, and charac- 
terizes all such efforts as are herein alluded to, as “ meddle- 
some interference,” and as pernicious practice. It is to be 
presumed, however, that where there were strongly marked the Pains in the First Stage of Labor. ■ 
7 
pathological conditions, such as a pathological or anatomical 
rigidity of the cervix, he would sanction even an incision of 
that structure; yet that would modify to but a limited extent 
the position which lie takes on the side of non-interference. 
He could not have sat hour after hour at the bedside of a 
patient writhing under the pangs of labor in the first stage, 
with the expulsive and resisting forces in fierce conflict—the 
advantage now with the one, now with the other, but, on the 
average, in favor of the latter—without having his early 
impressions of the exquisite arrangements of nature for the 
accomplishment of certain ends, and her marvellous adapta- 
tion to almost every emergency, rudely shocked at times. All 
of us, 1 believe, have the same exalted estimate of nature’s 
wonderful mechanism, and are frequently astonished at her 
workings in the process of natural parturition ; yet occasion- 
ally we see her battling with conditions which, unaided, she 
is totally unable to overcome, as, for instance, when she is 
met, at the outset, by an obstinately rebellious cervix. Who 
of us, under such circumstances, has not been thankful that 
the science of medicine has placed at our disposal both the 
medicinal and mechanical means to teach her prudence at 
least, if not a lesson ?. 
Having thus briefly, and it may be, too strongly, stated 
some of my views in reference to rendering assistance in 
labor, I will, for a moment, call attention to the anatomy and 
physiology of its first stage. This is said to commence with 
the beginning of the regular uterine efforts, and to end with 
the complete dilatation ot the cervix. Yet there is another 
and antecedent stage which has been called by some writers 
the painless or insensible stage of labor, in contradistinction 
to the painful or sensible stage that is soon to follow. This 
usually painless stage commences from eight to fourteen days 
prior to the beginning of what we call the first stage. A de- 
scription of this preparatory stage is best given in the language 
of Cazeaux: “In the last fortnight the internal orifice soft- 
ens, and yields to distention, then expands from above, so that 
the upper half of the neck gradually becomes confounded 
with the cavity of the body: the lower part of the ovum will, 
evidently, engage in the dilated portion, and soon comes in 
contact with the parts in the neighborhood of the external 8 
Horton : Effect of Atropine in Diminishing 
orifice. This contact occasions a progressive irritation of the 
nerve-fibres of the lower half of the cervix, which, by reacting 
upon the body, excites its contractions, until finally, the entire 
neck being effaced, the irritation reaches its maximum, and 
labor commences.” 
The phenomena manifested in the first stage of labor relate 
almost wholly to the obliteration of the external os, and its 
distention to such a degree as to admit of the passage of the 
fetus from the cavity of the uterus above into the vagina be- 
low. The sufferings experienced by the female during this 
stage are of a marked and peculiar character, and are borne by 
her with less patience and much less fortitude than those of 
the second stage. She seems instinctively to dread the former, 
for the reason, I presume, that she imagines she is not accom- 
plishing any desired results, or getting any nearer her final 
delivery. Those of you who have watched closely the cries 
and movements of a female in labor, will probably remem- 
ber that, while the first stage impressed you particularly 
as one of pain and suffering, the second gave you as strong an 
impression that it was one of exertion and work. You will 
also remember that any attempt at an examination during the 
first stage is, in the majority of cases, productive of additional 
suffering from which the patient shrinks, and that she pleads 
for something to relieve her of what she considers needless 
pain. 
I believe that it is a well-known fact that there is a marked 
difference in the amount of pain endured during parturition, 
between individuals belonging to savage tribes, and those 
belonging to the civilized races, and that this difference be- 
comes more apparent if we select for our comparison the 
more highly civilized among the latter. In the latter we find 
not only much less muscular power, in the uterus as well as in 
other parts, but we also have to deal with systems which, by 
means of false habits of life, are less adapted to endure pain. 
And it is not alone the results of these false habits with which 
the obstetrician has to contend. One other element, which 
frequently taxes the resources of his art to the utmost, is the 
mental condition which is often the legitimate attendant upon 
the leading of a so-called fashionable life. The dilatation of 
the cervix is not simply a mechanical stretching, brought about the Pains in the First Stage of Labor. 
9 
wholly by the action of the longitudinal fibres of the uterus 
acting on and over the inclosed fetus, the presenting parts of 
which they are mechanically forcing through the circular fibres 
of the cervix, but there is also a physiological process taking 
place, especially in all perfectly normal and easy labors. This 
process consists in a general infiltration of a serous fluid into 
its muscular structure, softening and separating its fibres to 
such a degree as to make them pliable and easily distensible 
by only a fair amount of effort on the part of the longitudinal 
fibres. Now it may be easily conceived how a muscular 
tone, such as that which frequently obtains under a high state 
of civilization, together with a nervous system sensitive to pain 
by so much the more as the mental condition lacks will force, 
would present us with a case departing widely from the normal 
type of labor. Nor is it all surprising that, under such condi- 
tions, we have to encounter a rigidity of the cervix of the 
spastic variety which, by the way, I believe to be far more 
frequent than the two other varieties combined. This variety 
I regard as arising particularly from an excessively sensitive 
condition of the inner walls of the cervix, producing such an 
intense degree of pain as to embarrass greatly the strong 
rhythmical action of the expelling fibres, and which condition, 
if left to itself, must inevitably condemn the patient to suffer 
on, until the resisting force slowly succumbs to the expelling, 
and allows the labor to pass on to the second stage. 
Some two years ago, I had under my care a patient suffer- 
ing from a most severe form of prolapsus ani, which had re- 
sisted all the usual treatment Her condition, at tlie time she 
came under my charge, was pitiable indeed. She was obliged 
to remain constantly in a recumbent position, and even in 
this position the bowels did not always remain in place. 
After trying a few astringents, anodynes, etc., without avail, I 
injected, hypodermically, one-sixtieth of a grain of strychnia 
into the structure of the sphincter ani. This, followed daily 
for about two weeks, so far relieved her that she has not since 
been troubled with the distressing malady to any considerable 
extent. 
Strychnia having acted so well as a tonic agent to that mus- 
cle, I decided to try atropine upon the same muscle, where an 
antispastic effect was the object to be attained, and for this 10 
Horton: Effect of Atropine in Diminishing 
purpose selected a case of swollen strangulated hemorrhoids 
occurring after parturition. The use of it in the afore-men- 
tioned condition was so satisfactory that I now always resort 
to it in severe cases of that nature. The hypodermic use of 
atropine having resulted so favorably in relieving the spasmo- 
dic action of the sphincter ani, I determined to try an injec- 
tion of it into the substance of the cervix during the first stage 
of labor, when labor was delayed in consequence of a rigidity 
of that structure, of the spastic variety. 
The first step towards carrying my design into effect, was 
to procure a suitable syringe and needle. This, which is shown 
herewith, I had made, and for it I am indebted to the skill of 
Messrs. Otto & Sons, of New York City. 
Case I.—The first case in which I had an opportunity to make 
practical application was that of Mrs. O , primipara, aged 42. 
Saw her first in the afternoon of November 18th, 1877. From the 
marked irregularity of the pains, both in frequency and force, I 
diagnosed what are termed “ false pains,” and accordingly gave 
morphia—learned the next morning that she had passed a moder- 
ately comfortable night, though not entirely free from pain. An 
examination at this time disclosed a hard, undilated, and apparently 
unyielding os—ordered more morphia, but when I left was not 
without some misgivings as to the future of the case. Early in 
the evening of same day visited the patient again, and found her 
about the same as when I left, excepting that the pains had now be 
come somewhat more regular in their occurrence, and of greater 
duration and force. An examination showed that the os was still 
but little disposed to relax its grasp in front of the vertex of the 
fetus, which could be felt pressing firmly against its inner surface. 
Now, that I might possibly assist the uterus in its task, I injected 
into the structure of the cervix, by the needle, about one-fiftieth of 
a grain of atropine. I proceeded as follows: After hooking the 
anterior lip of the cervix with the index finger of the right hand, 
and drawing it slightly forwards, I carried the needle along the 
palmar surface, keeping the point pressed quite firmly against it, so 
as to avoid wounding the maternal parts. After carrying its point 
well within the cervix, I raised it from the finger, and, by a slight 
traction, buried it somewhat deeply into the muscular structure of 
that portion of the uterus. After discharging its contents, I 
retained it in that position a few moments, in order that the ab- 
sorption of the atropine might be certain to take place, as, without the Pains in the First Stage of Labor. . 
11 
taking such precaution, I should not have been certain but that it 
was washed away by the flowing of the blood caused by the 
puncture of the needle. Having patients in the immediate neigh- 
borhood, and supposing I should have ample time, I visited 
them, but was surprised, on my return after an absence of only 
ninety minutes, to And the child not only born, but washed as well. 
After giving the patient one drachm of fluid extiact of ergot, I re- 
moved the placenta without difficulty, and without the slightest 
evidence of uterine inertia or hemorrhage. The child was probably 
a little below the average in weight, but well, and showed no symp- 
toms of having been affected by the belladonna. 
Case II.—Mrs. S , aged 33, sixth child. The history of this 
case is, in short, one of placenta praevia. A diagnosis had been 
made three months previous, since which time she had had re- 
peated, but not very alarming, hemorrhages. Because of there 
being no hemorrhage, and it being night-time, it was eight 
hours subsequent to the commencement of labor pains before I 
was summoned. She thought that, as these pains were not, 
at first, any more severe than others she had experienced in 
the course of the preceding months, they would probably pass 
away, as those had done, or that, at least, she could wait until 
morning. At the time of my visit, which was November 20th, 1877, 
the uterine efforts were feeble, but occurred at regular intervals. 
An examination showed that the os was dilated to about one and a 
half inches in diameter, but evinced no great tendency to yield to 
the weak efforts made by the uterus. The margin of the placenta 
could be distinctly felt on the right side of the uterus, but was high 
enough up to lead me to expect a favorable result. I now injected 
into the substance of the cervix one-fortieth of a grain of atropine, 
then at once ruptured the membranes, and applied a moderately 
tight bandage in order to hold firmly and continuously the vertex 
of the fetus against the inner wall of the cervix, and lessen as much 
as possible the risk from hemorrhage, which might occur at any 
moment during the process of dilatation of the cervix. About four 
strong efforts of the uterus now followed in rather quick succes- 
sion, during the last of which the os appeared to offer no further 
resistance, and the head of the child cleared it at once, and settled 
into the excavation. One drachm of ergot was now given, and the 
uterus was firmly compressed by the hand during its succeeding 
efforts, at the third of which a full-sized and healthy child was 
expelled. The uterus, still under the pressure of the hand, in a few 
moments surrendered its misplaced placenta. This was followed 
by only a moderate hemorrhage. I found the patient next morning 
with the pupils dilated, and complaining of a dry throat and dim- 
ness of vision, which, I assured her, would speedily disappear. 
Case III.—Mrs. E. M., aged 24 ; primipara. Saw her first Dec. 
loth, 1877, at 10.30 a.m. ; learned that she had been in more or less 
pain for eight and a half hours. The pains, at that time, had a 
periodicity of about eight minutes. An examination showed that 
the os would readily admit the entrance of the index finger between 12 
Horton : Effect of Atropine in Diminishing 
each of the efforts, but that, during an effort, it became hard and 
resisted its introduction. It was plainly a case of spastic rigidity 
of the cervix. Three hours after, although it had yielded a little, 
it still retained enough of its spastic character to lead me to expect 
a long and tedious first stage, at least. After waiting two hours 
more, there being no very marked change in the condition of the 
cervix, and the patient being pretty thoroughly wearied with 
her thirteen and a half hours of pain, I injected one-fortieth 
of a grain of atropine. Returning in forty minutes from another 
call, I found that the os had lost its spastic condition, also that the 
uterine effort was much greater. I now ruptured the membranes, 
after which I was able to diagnose the position of the vertex, which 
was that of R. O. A. From this time the labor progressed so 
rapidly, that a healthy female child was born in ninety-five minutes. 
One drachm of ergot was then given, and placenta removed. No 
symptoms of uterine inertia appeared. 
Case IV.—Mrs. C. H., aged 21, primipara, taken with labor 
pains at 1.30 a.m , Dec. 22d, 1877. Saw her at 8 am.; pains were 
short, sharp, and recurring at rather long intervals. Examination 
disclosed that the os would readily admit the point of the finger 
during repose of the uterus, but that, while the latter was in its 
active stage, it seemingly partook of the general contraction going 
on within the body of that organ, and then at once became firm and 
unyielding. At ten o’clock, dilatation nad taken place to the extent 
of about one inch in diameter, but there was still rigidity during 
each uterine effort. Judging that the os was offering too great 
resistance for the weak efforts of the uterus to overcome in a 
reasonable time, I injected of a grain of atropine. In twenty 
minutes, the pain had become much greater in force, and in ten 
minutes more, dilatation was so far complete as to warrant me in 
rupturing the membranes. This gave exit to only a small 
amount of fluid. The head, which was found to be in the R. O. I. 
position, slowly engaged in the superior strait, and reached the cav- 
ity of the sacrum at about 12 m. I now gave, though somewhat 
reluctantly, one-half teaspoonful of ergot, which did not, however, 
produce any appreciable effect. At 1 p.m., the head was slowly 
approaching the inferior strait, with the pain lessening in force. 
The patient being weary, begged me to relieve her, to which 
reasonable request I assented; but, not wishing to evoke a power 
which I could not control, I applied the forceps instead of giving 
ergot. In fifteen minutes, a strong and healthy child claimed our 
companionship. I could not discover that the pupils of the child 
were in the least disturbed by the atropine, though the mother, for 
a time, complained of a dry throat and dimness of vision. 
Cask V.—Mrs. L. M., aged 27, primipara. With the exception 
of occasional attacks of neuralgia, she had always enjoyed good 
health. Was called to see her in the afternoon of January 12th, 
1878. According to a previous calculation of mine, she yet lacked 
twenty-eight days of being at full term. Found her suffering con- 
siderable from pain which I diagnosed as neuralgia, and gave mor- the Pains in the First Stage of Labor. 
13 
phia. A digital examination of the cervix showed that there was a 
strong probability that my calculation as to her time was erro- 
neous, and that she was then near her full period, and that the 
pains of labor would shortly claim her attention instead of the neu- 
ralgia from which she was then suffering. As she had not slept for 
about twenty-four hours, I prescribed fa grain of morphia, com- 
bined with three drops of tincture of gelseminum—the latter to 
obviate the nausea that, at times, follows the use of an opiate—the 
dose to be repeated hourly, until she was relieved. She passed a 
moderately comfortable night, and by next morning was entirely 
free from pain. At eleven o’clock that evening, I saw her, pursu- 
ant to a summons, and learned that, at 5 o’clock that afternoon, the 
waters came away, unattended by any positive pain, however; also, 
that she did not have any pain until nine o’clock, at which time well- 
marked labor pains commenced. An examination showed that the 
os was hard, unyielding, and undilated, and its rim almost cord-like 
•during the action of the uterus. I soon ascertained that there was 
a considerable quantity of amniotie fluid yet to escape. During 
the repose of the uterus, at which time the os was most pliable, I 
cautiously elevated the head of the child, and allow ed the water 
slowly to escape; being careful, however, not to elevate the head so 
far as to allow a loop of the cord to slip under it. At fifteen 
minutes past eleven, I injected fa of a grain of atropine into the 
tissue of the cervix. In a few moments, the pains increased in force 
and duration. In forty-five minutes, dilatation was complete, the 
head cleared the cervix, and engaged in the superior strait, then 
slowly descended into the excavation. The patient now became 
very nervous, and, knowing that she could be relieved by the for- 
ceps, begged me to apply them. This I did, and by a very slight 
traction during each pain, the head soon rested upon the perineum, 
and began to distend the vulva, at which point, as is my invariable 
custom, I removed the instrument. In a few minutes, the child 
was born, and in jnst one hour and forty-five minutes from the time 
1 injected the atropine. The child cried lustily, and manifested not 
the least symptoms of having been in such close proximity to a part 
which had had injected into it a maximum dose of atropine. The 
mother complained of a dry throat, and the pupils were dilated. 
Slight hallucinations continued for about a day. 
Case VI.—Mrs. W., aged 22, primipara. Below the average in 
stature, but well formed. Saw her Jan. 21st, 1878, at 10 a.m. 
She had been in labor twelve hours, during the last four of which it 
had been quite severe. An examination disclosed that the os was 
dilated to the diameter of just one and a quarter inches, and had a 
hard, cord-like rim during each pain, which was only moderate in 
force. I at once injected fa- of a grain of atropine, which, in this 
case also, had the effect apparently to increase the force of the uterus, 
and also to so thoroughly and efficiently overcome the spastic 
action of the circular fibres that full dilatation was accomplished in 
forty minutes. I then ruptured the membranes and diagnosed an L. 
O. 1. position of the vertex, which slowly descended into the excav- 14 
Horton : Effect of Atropine in Diminishing 
ation. Being quite satisfied that nature, if unaided, would prove 
unable to complete the labor within a limit of time which would be 
safe for both mother and child, I applied the forceps, and brought 
the head to the inferior strait, from which point nature completed • 
the delivery. Mother and child both did well, and neither mani- 
fested any symptoms of having absorbed any atropine. 
Case VII.—Mrs. J. A., aged 36 ; tall, thin, pale, and delicate. 
Had suffered for six years from occasional attacks of asthma of the 
most severe form, for the relief of which she had sought every 
known remedy, including continental travel ; had one labor pre- 
vious to the present one, which occurred twelve years before, at 
which time she came very near losing her life from post-partum 
hemorrhage. About the period when the asthma commenced, I 
found there was a retroversion and descent of the uterus, which 
added much to her general distress, until relieved by a properly 
adjusted soft-rubber pessary. Two years ago last winter, she came 
near dying from double pneumonia, from the shock of which she did 
not fully recover until the present pregnancy began, the influence of 
which upon her system was such as to effect almost a renewal of 
life. From certain circumstances attending this case, it could be 
definitely ascertained that the conception could not have occurred 
after the 25th day of June, 1877 ; consequently, the period of ges- 
tation was protracted ten days beyond the usual period, delivery hav- 
ing taken place on the 10th day of April, 1878. For two weeks 
prior to the 280th day, she suffered from pressure much more than 
is usual. On the evening of April 7th, her husband called and 
stated that she was losing the cheerfulnes and hopefulness which 
she had always exhibited in a marked degree during illness, and 
was giving way to despondency and forebodings. I told him I had 
no doubt this was caused by the fact that the pregnancy had 
exceeded the allotted period, and that the only reason I could assign 
for such excess was that the uterus had become distended beyond 
its contractile power, and that about the only thing which could be 
done was to assist the uterus in its feeble efforts. At 12 m., on the 
8th of April, on examination, I found the uterus, or rather the 
cervical portion of it, the same as it had been for several days, to 
wit: the os firmly closed by a rather hard and unyielding rim that 
would not permit even the point of the index-finger to pass. The 
interna] os was wholly obliterated, as the vertex of the child could 
be felt lying firmly pressed against the internal surface of the 
external os. I now injected one-fortieth of a grain of atropine 
into the structure of the cervix, but with considerable difficulty, on 
account of the os being so firmly closed, which prevented me from 
performing the operation with the precision I desired. Saw the 
patient two and a half hours after; found the os so much less resist- 
ant that it required but slight force to pass the index-finger ; there 
was no uterine effort. At 6 p.m., the os being about as at the pre- 
vious call, T injected, this time easily, -fo of a grain of atropine. At 
the same time, using the needle as a tenaculum, I drew the os, 
which was still moderately high up, downwards and forwards, and the Pains in the First Stage of Labor.. 
15 
held it in that position by the needle, while with the index linger 
I swept around the inner surface of the cervix, between it and the 
membranes, freeing the latter from the former, as high up as possi- 
ble to reach. At 10 p.m., found the pupils markedly dilated, and 
the patient complaining of a very dry throat; the os admitted two 
lingers readily ; the membranes were still intact. The position of 
the vertex could now be determined, which was R. O. I. No effort 
at contraction was manifested by the uterus. My first suspicion as 
to the cause of delay in this case was now shown to be a certainty, 
namely, that it was due to a too wide distention of the uterine 
walls. Feeling that still further delay could, at most, only 
result in the loss of a little more of Dr. Gooch’s “tincture of time,” 
I decided to wait until morning, at least. At 10 a.m. of the 9th, I 
found the os quite easily dilatable, but with no effort, as yet, on the 
part of the uterus. At 8 p.m., there was no change, except that the 
os was still more soft and dilatable, with an occasional slight 
uterine effort. As the patient was not suffering so much as to pre- 
vent her from obtaining a reasonable amount of sleep, and as I 
was myself greatly in need of the “ chief nourisher in life’s feast,” I 
decided to leave the membranes as they were, and wait again until 
morning. I' was, however, sent for, and saw the patient again at 3 
a.m., April 10th, just thirty-nine hours after the first injection. I 
learned that affairs remained unchanged until midnight, but at that 
time the pressure had begun to increase, and had continued so to 
do, moderately, up to the time of my call. The reason the patient 
gave for not sending for me before was that she had been waiting 
for pains to come on. A examination showed the condition to be 
about the same, excepting that the uterus was now making regular 
and well-marked efforts, during which the membranes were tense, 
but manifested not in the slightest the form of a “dilating wedge.” 
Seizing an opportunity, at the close of one of these efforts, I rup- 
tured the membranes, and relieved the uterus of the greater por- 
tion of its amniotic contents. From this time onwards, the labor 
progressed actively, and, in fact, about the only obstacle it encoun- 
tered was from the great elongation of the cervix, the tissue of 
which seemed to be hardly sufficient in quantity to permit its dis- 
tending to such extent as would allow the child to pass. The child 
proved to be a male, weighing 8f pounds. At no time was there 
any of that sharp, cervical pain which adds so greatly to the suffering 
of a patient, although the cervix was so thinned that, it was like a 
piece of parchment to the touch. Soon, however, the head cleared 
and descended to the floor of the pelvis. I now gave one drachm of 
fluid ergot, to guard against a repetition of what occurred in her 
former labor. In a few moments after, at 4.45 a.m , the child was 
born. There was no uterine inertia, and the child was not in the 
least affected by the atropine. 
The following case, though not strictly illustrative of the 
topic of this essay, inasmuch as it is an instance of the so- 
called hour-glass contraction occurring during the second stage 16 
Horton: Effect of Atropine in Diminishing 
of labor, is yet entitled to insertion by reason of its close 
approximation to the foregoing cases, both in its nature and the 
means adopted for relief. So far as my examination shows* 
none of the systematic treatises on obstetrics satisfactorily 
discuss cases of this kind, and the young practitioner might 
long remain in ignorance of complications of this nature* 
which, as I believe, are of much more frequent occurrence 
than is supposed, and which are not seldom incorrectly diag- 
nosed : 
Case VIII.—Mrs. G. H , aged 27, third labor. Was called to 
see her at 9 p.m., April 27th, 1878; both her previous labors were 
much less painful and shorter than the average ; learned that she 
had been in pain since 12 m., but that during the past two hours only 
had it been strongly marked. The action of the uterus differed 
from a perfectly normal action in respect only that its efforts were 
short and sharp, and the intervals of repose were irregular in dura- 
tion. The efforts were abrupt, reaching their highest pitch of inten- 
sity at once, and subsiding as quickly. An examination showed 
that there was a most profuse, glairy discharge, that the os was 
high up and dilated to about two inches, and freely dilatable. The 
patient had passed one month beyond her own reckoning, and, as 
is usual, had become nervous about herself, and to this nervousness 
I attribute the apparently slight deviation in the action of the 
uterus from the normal type, above referred to, and supposed this 
would be rectified as soon as the labor had gotten fully under way. 
I therefore ruptured the membranes and allowed the vertex to im- 
pinge upon the inner surface of the cervix. I was confident that 
the labor would prove to be short and easy, and unqualifiedly, 
though perhaps unwisely, expressed that opinion, but 1 was doomed 
to disappointment. Notwithstanding the apparently strong efforts 
of the uterus, the roomy nature of the pelvis, the copious dis- 
charge, the non-resistance of the cervix, and the favorable position 
of the presenting part, it being R. O. I., the labor did not progress, 
the head did not enter well within the pelvic brim and remain there. 
So far as I could ascertain, the muscles of the uterus were 
acting with reasonable energy and a fair amount of co-ordination, 
although I was hindered somewhat in my examination by the great 
quantity of adipose tissue contained in the structure of the abdominal 
parietes; but notwithstanding these favorable conditions and numer- 
ous changes of position and form and persistent pressure over the 
fundus of the uterus in the direction of the axes of the superior 
strait, the labor remained the same until about 2 p.m. I was now 
convinced that some unusual cause, other than the slight irregularity 
above mentioned, retarded delivery. I accordingly passed my hand 
into the vagina and grasped the head, which, on examination, I 
found to be freely movable circularly around the pelvic brim during 
the repose of the uterus, as if attached by an ordinary swivel hook. 
Watching my opportunity, I gently passed the fingers along over the Pains in the First Stage of Labor. 
17 
the globe of the head, and between it and the anterior wall of the 
cervix uteri, and carried them fully up to the neck of the child, 
where I found a circular uterine band, so firm to the touch that it 
resembled nothing so much as the unyielding cervix so often met 
with at the beginning of labor. The entire body of the child, ex- 
cept the head and a small portion of the neck, lay wholly beyond 
this tetanically contracted ring at the lower segment of the uterus, 
and which was, without a doubt, composed wholly of the tissue of 
the uterus of that point. The posterior lip of the cervix was so. 
infiltrated with serum as to be greatly thickened and elongated, 
and it hung pendulous in the vagina. The anterior lip was in a 
similar condition, but only to a limited extent. Knowing that 
delay would only aggravate the case, and cause no inconsiderable 
danger to mother and child — to the mother from exhaustion, 
inflammation, and further infiltration and probable sloughing of the 
cervix, and to the child from compression—I injected into the ante- 
rior lip of the cervix fa of a grain of atropine, combined with 
of a grain of morphine. Probably, under the conditions, if a more 
distant point had been selected for the injection, it would have 
answered the purpose as well. The only thing worthy of note at 
first was the length of time which elapsed before the compound 
took effect. This I attributed to the almost pathological condition 
of the structure into which the injection was made. In about one 
hour, however, the patient gave evidence of its operation. There 
was dryness of the throat, dizziness, an almost complete subsidence 
of effort on the part of the uterus, and tendency to sleep. This 
latter, however, I attributed rather to exhaustion. On another ex- 
amination now made, in the same manner as the former, I found 
there was a total absence of the constricting circular band. On 
the contrary, the uterine cavity and vagina together formed one 
continuous canal, at the upper or blind extremity of which the 
child was closely packed. I introduced my short forceps, turned 
the patient upon her left side and firmly flexed the thighs, after 
which I seated myself in a position somewhat facing the perineum, 
and properly adjusted and locked the forceps in the fronto-mastoid 
diameter. After giving a full dose of ergot, and gently kneading 
the fundus uteri for a short time, a moderate expulsive force was 
manifested, which I aided by moderate and persistent tractile force 
upon the forceps, which did not amount to what might be called 
pulling. This caused the head to rest upon and distend the per- 
ineum in a short time, at which point that valuable auxiliary to 
labor, reflex action, came to my assistance, and before I could 
remove the second blade of the instrument, a large and healthy male 
child was born. Both mother and child did weil. 
From the cases just stated, we must necessarily draw one of 
two conclusions—either, first, that the atropine had a most 
markedly beneficial effect, or, second, that they were just so 
many cases of coincidences. I have said nothing, as may 
have been noticed, about other forms of rigidity; namely, the 18 
Horton: Effect of Atropine in Diminishing 
pathological and anatomical. This is for the reason that I 
have not as yet had opportunity to apply this treatment in 
such cases. 
In the former variety, I cannot conceive how the treatment 
herein described could be of any service, except that it might 
deaden that sharp, cutting pain which necessarily accompanies 
such a condition, and which, if unrelieved, produces the same 
effect as is observed in a case of spastic rigidity; that is, it em- 
barrasses the efforts of the uterus so much as to render its ex- 
pulsive force nearly or quite unavailing. In the anatomical 
variety it might be of service by acting on and relieving any 
spastic element which might be present as a concomitant. 
It is claimed by some writers that a rigidity of the cervix 
will generally be found attendant upon an insufficient uterine 
force, and a consequence of it. My own impression is, that 
this is an error, arid that a more reasonable supposition is, 
that the cervix becomes spastically rigid, because inordinately 
sensitive to the pressure within, which pressure causes pain so 
acute' as to shock the entire nervous system to such a degree 
that the expulsive force of the uterus is greatly embarrassed, 
and that thus weak pains are found to result, indirectly, from 
an over-sensitive cervix. If this be so, it is obvious that, if we 
subdue the irritability of that structure, and lessen that severe 
pain which embarrasses the action of the uterus at this stage 
of labor as quickly and effectually as a severe cramp in the 
limb would interfere with the second stage of labor, we shall 
then restore the equilibrium of the nervous system, and the 
nervous force will become properly distributed; the spastic 
rigidity will disappear, and the body of the uterus will act at 
suitable intervals of time, and with a due degree of force. 
This oversensitive condition of the cervix, under such cir- 
cumstances, appears to be a wise provision of nature ; for let us 
suppose that the expulsive force was not in the least affected 
by this sensitive condition of the cervix, and should drive the 
fetus through it regardless of its spastic character ? How many 
more than at present should we have of cases where the thin 
and delicate lining of the cervix would be lacerated to such an 
extent as to cause the latter to be hypertrophied, raw, and 
angry, and remain pouting through a torn and ragged os—a 
condition in which it might remain for months, or even years, the Pains in the first Stage of Labor. 
19 
and which, if unrelieved, would condemn the sufferer to life- 
long invalidism. 
Let us suppose that, in a given case of labor, the expulsive 
force is twenty pounds, and the resisting force precisely the 
same. It would not require that the physician should be 
endowed with any great amount of prevision to enable him to 
foretell what the result would be, so long as these forces con- 
tinned in the same relative proportion. It certainly would 
not be good practice for him to seek to augment the expelling 
power, if sound judgment would sanction an effort to lessen 
the resisting power. It is obvious that, if he could succeed in 
lessening it by ten pounds, it would be equivalent to doubling 
the expelling force. 
I have said nothing about mechanical dilators, and the use 
of anodynes and anesthetics, for the reason that all are 
well acquainted with their use, in cases where indicated. 
There is, however, one other remedy often resorted to in 
cases of rigidity of the cervix, to which I wish to call 
attention more particularly. If refer to the hot douche. This, 
as is well-known, is used to accomplish the same end in case of 
rigidity in labor at term, as when used to bring on premature 
labor—that is, to soften and render more or less pliable and 
distensible the cervical ring. But we also know that, before 
such a condition can be brought about, more or less fluid of a 
greater density than water must be effused or infiltrated into 
its connective tissue, and the muscular fibres of which that 
structure is so largely constituted must be separated to a cer- 
tain extent. I think that keeping a structure like that of the 
cervix for a long time in immediate contact with pure water, 
at a temperature higher than that of the body, would neces- 
sarily set up more or less exosmotic action. If so, the effect 
would be the reverse of that of pliability and distensibility. To 
use a strong comparison, it would bring about a condition like 
that of the washerwoman’s fingers, after she has been a whole 
day at the tubs. 
It is stated by many authorities upon obstetrics at the pre- 
sent time, I believe, that even if labor in the first stage be con- 
siderably prolonged, no great danger is to be apprehended. 
This is true only so far as the immediate effects upon the 
mother are concerned; but the exhaustion of muscular con- 20 
Horton : Atropine in Diminishing Labor Pains. 
tractility during the first stage may be so great, by reason of 
such prolongation, as to render mechanical assistance abso- 
lutely essential for the completion of the second stage. Again, 
a muscular structure that lias been overtaxed, allowing it to 
have been overtaxed by time and not by force, is, as is gene- 
rally known, more susceptible to inflammatory action, and, in 
the case of the uterus, which has to undergo such an impor- 
tant change after parturition, it is found that, in addition to a 
susceptibility to inflammation, it is not, after unduly prolonged 
efforts, in a condition favorable for such change. 
I have presented herewith the results of my labors towards 
the attainment of what has been to me a long-sought object, 
viz., the abbreviation and diminution of the pains of labor in 
its first stage. How far I have been successful, or how far my 
suggestions will be found worthy of approval, time and expe- 
rience will determine.