THE ETIOLOGY 
AND 
INDICATIONS FOE TEEATMENT 
OF 
IRREGULAR UTERINE ACTION 
DURING LABOR. 
BY 
WILLIAM T. LUSK, M. !>•/ 
PROFESSOR OF OBSTETRICS AND DISEASES OF INFANCY, BELLEVUE HOSPITAL 
MEDICAL COLLEGE. 
[REPRINTED FROM THE N. T. MEDICAL JOURNAL, JUNE, 1873.] 
KE¥ YORK: 
D. APPLETON AND COMPANY, 
5 49 & 55 1 BROADWAY. 
1873. THE ETIOLOGY A1STD INDICATIONS FOE TREAT- 
MENT OF IREEGULAE UTERINE ACTION 
DURING LABOR. 
It seems almost like presumption to invite the attention of 
the profession anew to a subject apparently so well settled as 
the causation of irregular uterine action during labor. Under 
the different titles of rigid os, hour-glass contraction, and the 
like, they are familiar enough, and our standard authors fur- 
nish for each of these conditions severally an accepted expla- 
nation. 
But there is nothing so firmly established in medical science 
as to preclude our instituting, from time to time, fresh inquiry 
as to whether all that is taught as sound doctrine upon any 
given subject has really a firm foundation in anatomy, physi- 
ology, and practical experience. 
I must confess to owing much that is satisfactory to my 
own mind, in connection with the theory of labor, to the teach- 
ings of the late Professor Seyfert, of Prague ; who, confining 
himself almost entirely to oral teaching, it is to be regretted 
has left few permanent memorials of his labors behind. Yet 
among the obstetricians of the present century none deserve 4 
IRREGULAR UTERINE ACTION 
to rank higher than this comparatively little known successor 
to the chair of the great Kiwisch. Many things which he 
taught a few years ago, and which were then regarded as 
wildly heterodox, have since been accepted as welcome addi- 
tions to our stock of ideas. His intolerant, dogmatic spirit, 
his utter lack of fairness toward those who differed from him, 
together with the absence of any published exposition of his 
doctrines, have, however, combined to prevent his receiving 
that acknowledgment to which the originality of his teachings 
justly entitled him. 
To avoid confusion, I propose using in the following dis- 
cussion the term “ labor-pains” in the sense of uterine contrac- 
tions, a distinction made necessary in our language by the fre- 
quency with which we hear it stated that women are having 
strong “ pains,” when upon examination we find only a feeble 
measure of uterine contraction, the word “pains” evidently 
here signifying nothing more than an unduly severe amount 
of physical suffering. 
As examples of irregular uterine action writers distinguish 
pains in excess, deficient pains, cramps of the uterus, and the 
various forms of stricture. Regarding the etiology of these 
conditions, I would beg to be allowed to express my convic- 
tions with a certain degree of positiveness, not with any pre- 
tence at infallibility, but simply to define the limits of the 
discussion. Every busy man will find in the ordinary events 
of his own practice the sort of evidence best qualified for veri- 
fying or disproving the opinions I shall endeavor to maintain. 
Notwithstanding the picturesque descriptions that have 
been given of excessive pains, the question is worth consider- 
ing whether the uterus ever acts with such an undue degree 
of energy as jper se to constitute a pathological condition. In 
cases of obstruction to the passage of the child, strong pains 
may indeed become a source of danger, though even here, as 
was long ago pointed out by the sharpsiglited Michaelis, their 
action is oftentimes beneficial. “ Suppose,” he says, “ they do 
frequently exceed, in cases of contracted pelvis, the limit con- 
sistent with safety, they are not to be looked upon on that ac- 
count as altogether unnatural, for the difficulty of delivery is 
here not to be overcome without danger, and in the strong DURING LABOR. 
5 
pains we have in our possession always the least dangerous 
means of ending the labor.” 
But, with regard to precipitate labors as a consequence of 
excessive uterine action, are they not to be regarded with ap- 
prehension? Precipitate labors are not very uncommon at 
Bellevue Hospital. I have never noticed any thing peculiarly 
unfavorable in their action. Hot long ago, on a Sunday, a 
woman was attending divine service in the chapel of the hos- 
pital. She felt the first labor-pain, and hastened at once to 
the lying-in ward. When she reached the top of the stair- 
case leading to the ward, she was obliged to lie down, and in 
a moment more the child was born. Both the mother and 
child did perfectly wTell. How, it is difficult to see wdiy this 
woman was not to be regarded as really highly favored. But, 
says a recent writer:1 ‘£ The consequences of this state of 
things are sometimes very serious to the child, for it has been 
thrown suddenly on the floor, the cord ruptured, and the 
child much injured.” In this harrowing picture the tragic 
consequences of the rupture of the cord especially affect our 
sensibilities. “ But,”' he adds, “ the dangers to which this 
unnatural action exposes the mother are even more serious; 
for prolapsus and inversio uteri, laceration of uterus, vagina, 
and perinocum, haemorrhage, syncope from the sudden empty- 
ing of the uterus, and subcutaneous emphysema of the head 
and neck from the violent straining, have been the result.” 
It is hard, in this category of ills, to see how inversion or pro- 
lapsus of the uterus is likely to result from its own excessive 
action; and while the occurrence of laceration is not denied, 
even in this case there is reason to question the propriety of 
laying the blame upon the uterus. It is the common experi- 
ence that, when the expulsive pains are good, the tissues rap- 
idly soften. The last sentence in the paragraph quoted prob- 
ably furnishes the key to the real source of danger. It is to 
the violent straining that the accidents enumerated are really 
attributable. They occur in women who possess an undue de- 
gree of reflex irritability, which impels them to excessive use 
of the diaphragm and abdominal muscles. These cases do 
1 Meadows, “ Manual of Midwifery,” p. 295. Lindsay & Blakiston, 
1872. 6 
IRREGULAR UTERINE ACTION 
not call for bleeding, but for the subcutaneous injection of 
morphia, or, best of all, the production of complete ansesthesia 
by chloroform, so as to suspend the action of the voluntary 
muscles. 
Too weak pains are unquestionably oftentimes pathologi- 
cal, but here even we need to discriminate. Under the title of 
“ Symptoms of Primary Weakness of Pains,” 1 Scanzoni de- 
scribes a condition which surely gives rise to no apprehensions, 
and, in consequence, should properly find its place not in the 
pathology, but among the varieties of normal labor. The pa- 
tient is represented as suffering from obscure disagreeable sen- 
sations in the lower abdomen, which rarely rise to the dignity 
of pains, and which interfere neither with sleeping, eating, nor 
the due performance of household duties. Yet under their 
influence the os dilates, the membranes form, and even rup- 
ture. “ The absence of all febrile movement,” says Scanzoni, 
“and the entire quietude of the woman, would lead a superfi- 
cial observer to disbelieve that she had been long engaged 
in labor.” Experience teaches us that, in these cases, we do 
best when we imitate in practice the inlbecility of the super- 
ficial observer, and treat our patient as though she were pre- 
cisely what she appears to be, viz., a pregnant woman. Let 
her eat, drink, and sleep, as usual. Even when the waters 
have passed away, so long as the uterus remains slack, and 
does not compress the foetus, neither mother nor child is en- 
dangered. One case I knew where twelve days elapsed be- 
tween the rupture of the membranes and the birth of a healthy 
living child. Old practitioners, as a rule in such cases, wisely 
abide the event undisturbed, but my intercourse with younger 
men enables me to know how strong the disposition is to lend 
an ear to the importunities of anxious friends “ to do some- 
thing,” and to resort to the by no means indifferent use of 
oxytocics. 
A pathological weakness of pains, i. e., where the weakness 
is a source of danger to both mother and child, occurs rarely, 
except as secondary to, or complicated by, other conditions, 
which first claim our attention. 
Among the causes of difficult labor, especial stress is often 
1 “ Lehrbucli der Geburtshiilfe,” 4te Auflage, S. 241. DURING LABOR. 
7 
laid upon strictures of different parts of the uterus. Thus we 
have in head-presentations, most frequently, stricture of the 
os externum, in breech cases, stricture of the os internum clasp- 
ing usually the neck of the child after the passage of the shoul- 
der, and in the third stage of labor the stricture known as 
hour-glass contraction. These strictures are usually described 
as though they were due to the isolated action of special circu- 
lar bands of muscular fibres at the points at which the strict- 
ures occur. However, revolutionary as it may seem, there is 
tolerably good ground for questioning the pretty generally ac- 
cepted opinion that in the independent action of the circular, 
oblique, and longitudinal layers of muscular fibres, which may 
be demonstrated in the pregnant uterus, we have furnished us 
the key to these forms of abnormal uterine action. The exist- 
ence of such layers is not of course denied, but their impor- 
tance has unquestionably been greatly exaggerated by the de- 
sire of the anatomist to answer the questions of the obstetri- 
cian. 
For instance, firstly, the superficial layer, whose fibres run 
both in a transverse and oblique direction, and which covers 
the uterus like a hood, possesses in the freshly-delivered uterus 
an almost membranous thinness, so that it is hardly conceivable 
how it could have played any very active role in the expulsion 
of the ovum. 
We have, secondly, an inner layer composed of circular 
fibres, continuous with the circular fibres of the Fallopian 
tubes above and those of the vagina below. These fibres are 
a reminiscence of the early development of both uterus and 
vagina from the filaments of Muller. At the os externum, 
and the os internum, they are somewhat more abundant, and 
constitute the so-called “ sphincters ” of those localities. How, 
it is not probable that these circular fibres possess any more 
functional importance in the uterus than they do in the vagina, 
yet I hardly think any one would invoke spasmodic stricture 
of the vagina proper as a cause of dystocia. 
The median layer constitutes the great bulk of the uterine 
walls, and is composed of longitudinal and transverse fibres, 
which in place of being arranged in distinct layers, as is the 
rule in other hollow muscles, form an intricate interlacement, 8 
IRREGULAR UTERINE ACTION 
in the meshes of which are contained the vessels of the organ. 
It is certainly the contractions of this portion of the muscular 
walls which exercise during labor the preponderating influence 
in the expulsion of the contents of the uterus. The longitudi- 
nal bundles are partly derived from the lower transverse fibres, 
and pass downward to become continuous with the longitudi- 
nal fibres of the vagina; and, in part, are longitudinal from 
the beginning, but are closely interwoven with the transverse 
fibres. As they pass down into the cervix, they gradually 
diminish in bulk, and there either interweave with the sphinc- 
ters, or terminate by fine processes in the connective tissue, 
directly underlying the mucous membrane of the vaginal por- 
tion. 
The action of a muscle thus constituted would be to exer- 
cise concentric pressure upon its contents, and in some meas- 
ure, perhaps, to withdraw its lower segment up over the body 
to be expelled. There is strong a priori reason to doubt 
whether the uterus during labor ever contracts except in its 
totality. The evidence to the contrary in the case of the so- 
called strictures is more apparent than real. Take, for in- 
stance, the stricture of the os externum. The tardy dilatation 
may be due to such exceptional conditions as cancerous infil- 
tration, firm adhesion of the membranes to the os internum, 
and, perhaps, to old cicatrices of the cervix. Again, in cases 
where there is loss of parallelism between the axis of the 
uterus and the axis of the superior strait, the presenting part 
may by bearing especially upon the anterior portion of the 
cervix, and the lower segment of the uterus, exercise so little 
pressure upon the os that its sphincter long maintains its in- 
tegrity. But, aside from such instances as these, it is matter 
for consideration whether all the pretended strictures of the 
os, instead of being due to spasm, are not dependent upon in- 
sufficient uterine action. I do not mean to state that such a 
supposition will satisfactorily account for all that has been 
seen by others. It certainly has been true of all the cases that 
I personally have met with in private and hospital practice. 
Persons often speak of the pains being strong, but affirm that 
labor does not progress on account of the resistance offered by 
a firm catgut-like band at the uterine orifice. I have often DURING LABOR. 
9 
met with, this condition, but have failed to ever find it associ- 
ated witli good pains of a markedly expulsive character. The 
patient usually gives expression to an intense degree of suffer- 
ing, but intense suffering is the constant accompaniment of 
weak pains and prolonged labor, where the uterus presses 
upon or is pressed upon by its contents for any considerable 
period of time. In the condition under consideration, we 
would hesitate to forcibly introduce the hand into the uterus, 
not because of the difficulty of introduction, but because of the 
danger of laceration, blow, were really good pains associated 
with this form of rigid os, the same danger would be incurred 
by pressure from above. Instead of the os arresting the ex- 
pulsion of the foetus, it would be torn through in most in- 
stances like so much paper. As a matter of fact this does not 
take place, because, under the influence of strong pains, tbe os 
rapidly loses its catgut-like feel, and softening and expansion 
occur simultaneously. Sometimes the cervix is both thick and 
hard, so that it has been compared to a band of iron. With 
more show of reason such a condition has been invoked to ac- 
count for the retardation of labor. Yet it is difficult to recon- 
cile with this view the facile disappearance of rigidity under 
the influence of properly directed pressure, as, for instance, when 
the Barnes dilator is employed in cases calling for the speedy 
termination of labor. All have occasion at times to notice the 
speedy dilatation of the rigid os after rupture of the mem- 
branes. The following case will serve as an illustration : 
Mary Brown, primipara, aged twenty, came up to the 
lying-in ward of the Bellevue Hospital, at 7 p. m., on the ICth 
of November. She said that for three or four days she had 
suffered severe pain in the back and abdomen. On examina- 
tion the os was found sufficiently dilated to admit one finger. 
As she had suffered much pain during the night, Dr. Swan, 
the house-physician in attendance, gave her toward morning 
3 ij of the solution of morphia (U. S. Pharmacopoeia), which 
afforded some relief. As there was no change in the cervix, 
Dr. Swan applied the warm douche for twenty minutes. The 
cervix, which before had been soft and supple, expanded 
somewhat, but now became hard and rigid. This condition 
remained unchanged during the day. For the pain chloroform 10 
IRREGULAR UTERINE ACTION 
was administered several times, witli only temporary relief. 
At 10 a. m. an hypodermic injection of viij ttj,. of Magendie’s 
solution was given. Between 12 m. and 7.30 p. m. thirty- 
five drops more were administered subcutaneously in three 
injections. As the patient’s sufferings remained unabated I 
was sent for, and reached the hospital between 8 and 9 
o’clock. As I wTas engaged in making a vaginal examination, 
the membranes ruptured. In ten minutes’ time the cervix, 
which had all day been about the size of a half-dollar, was 
fully dilated. In three-quarters of an hour more a child was 
delivered stillborn, which was partially resuscitated, but its 
death took place after three hours. Immediately after the 
birth of the child, the mother sank into a sound sleep. How, 
this history appears to have but one interpretation. Owing 
to a relative surplus of amniotic fluid, and the tense state 
of the membranes, the concentric pressure exercised upon 
the ovum was wasted upon the periphery, without giving 
rise to the formation of a bag of waters. The pains, there- 
fore, proved unavailing and became feebler and feebler. Af- 
ter the use of the douche, the uterus passed into a of 
tonic contraction, the condition of the cervix affording an in- 
dex of the condition of the entire uterus, in much the same 
way as a furred tongue bespeaks a catarrhal condition of the 
stomach. The mother suffered constant pain, and the exagger- 
ations of the pains at short intervals might have led one to sup- 
pose that she was having severe pains of an expulsive character, 
which were rendered unavailing by the rigidity of the os. 
The almost instantaneous relaxation of the cervix, after rup- 
ture of the membranes and the advent of true pains, should 
guard against such an error. 
It is to be borne in mind that the dilatation of the cervix 
is not simply a matter of mechanical distention. In easy 
labors the cervix undergoes a series of physiological changes 
not only during labor, but sometimes for hours previous, which 
are of very great importance. These consist of an hyperaemic 
condition of the parts, of a serous infiltration separating the 
muscular fibres from one another, and in an increased secre- 
tion of mucus, whereby the cervix becomes softened and 
yielding. How, the activity with which these organic changes DURING LABOR. 
11 
occur stand in intimate relation to the activity of the uterine 
contractions. But this relation is much more marked in pri- 
miparse than in multiparse. In fact, in multiparse we some- 
times tind a complete softening, and a fully dilatable condi- 
tion of the cervix induced by contractions, which have hardly 
excited the notice of the woman. In primiparse, on the con- 
trary, while good pains, under otherwise normal conditions, 
certainly induce softening of the cervix, weak pains effect no 
changes in its tissues. Thus we see that pains which may be 
good enough to accomplish the organic changes in the cervix 
in multiparse, may be utterly inadequate for the same purpose 
in primiparse. I think it is losing sight of this comparative 
difference which has led observers so commonly to attribute 
to the “ rigid os ” of the primiparse the blame that properly 
attaches to the relatively insufficient uterine action. 
In the treatment of this affection there is no occasion to 
resort to bleeding, to tartar-emetic, or to plastering the cervix 
with belladonna-ointment. In the course of time the tonic 
contraction generally disappears of itself. But while it lasts 
the patient’s condition is one of acute suffering. To allay 
this suffering we are frequently called upon to use morphia 
either by the mouth or hypodermically. Opiates often ac- 
complish wonders in one of two ways. Owing to the pro- 
longation of the labor, and its attendant pain, the patient’s 
nervous energies have become exhausted. The arrest of the 
pain enables the woman to sleep, and, with the recuperation 
of power that comes upon awakening, good pains follow 
which bring the labor to a happy termination. In other cases, 
after the employment of opium, or the administration of an 
anaesthetic, the parts apparently relax, and an acceleration of 
labor follows. Opium, when it produces this effect, has been 
regarded as an oxytocic. How, in these cases we have first 
the arrest of pain, then the occurrence of regular uterine ac- 
tion, and as a consequence the rigid os yields. It is possible 
that the beneficial effect of the anodyne or anaesthetic is due 
directly to its quieting action upon the spinal nerves. The 
uterus derives its motor nerves chiefly from the sympathetic 
system. When from disease of the spinal cord there is total 
paralysis of the lower extremities and bladder, labor has been 12 
IRREGULAR UTERINE ACTION 
known to proceed undisturbed.1 It lias been surmised3 that 
the nerves of the uterus derived from the cerebro-spinal system 
possess inhibitory properties. Of course, we are here resort- 
ing in part to theory, but, if it be true, it readily explains 
how severe pain may suspend uterine action, and how the 
tranquillizing of pain would restore to the motor nerves their 
full energy. 
In cases where anodynes and anesthetics fail us, we have 
seen how favorable results may occur from rupture of the 
membranes. 
On some occasions we find, on examination, the cervix 
partially dilated, a segment of the head presenting, but the 
cervix continues hard and unyielding. The patient is noisy, 
and screams out with every pain. Now, in a number of in- 
stances, I have had an opportunity to demonstrate in the pres- 
ence of the members of the hospital staff the speedy disappear- 
ance of all rigidity, with complete dilatation, by simply ask- 
ing the woman to hold her breath, and reenforce the uterine 
pains by the action of the auxiliary muscles. With my finger 
upon the cervix I have known a very few pains, thus rein- 
forced, to put an end to a long period of delay and suffering. 
In all cases where we desire to quickly overcome rigidity, 
or where other methods have proved inffectual, we possess a 
certain means in the use of the Barnes dilator, which acts 
most beneficially by both the mechanical pressure it exercises 
on the cervix, and by stimulating the dormant energies of the 
uterus. 
But we cannot proceed further with our subject without 
laying down some distinction between good pains and those 
of an opposite character. This is not quite so simple as might 
at first appear. Good pains have nothing to do with mere 
frequency, or the suffering of which they are the source. 
In every pain we have alternating contraction and relaxa- 
tion of the uterine muscular fibres. In good pains the excur- 
sions thus formed need to possess a certain degree of ampli- 
tude. When the excursions are short, and the pains at the 
1 Frankenliauser, “Die Nerven derGebarmutter/’ p. 47. June, 1870. 
* Schroeder, “ Lehrbuch der Geburtsliulfe,” 2te Auflage, S. 99. Frank- 
enhauser, l. c. DURING LABOR. 
13 
same time strong, they give rise to clonic uterine contrac- 
tions. When the excursions are absent, and are replaced 
by a hardening of the uterus which closely compresses its 
contents, even in the intervals of the pains, we have the 
condition to which we have given the name of tonic contrac- 
tion. Where there is any obstacle to delivery, these condi- 
tions may pass by insensible gradations into one another. The 
transition from weak pains to a state of tonic contraction is 
common in primiparae, in cases where, from hydro-amnion, 
twin-pregnancy, or other causes, the uterus is overdistended, 
or where, from any reason, the efforts of the uterus are un- 
availing to expel its contents. Sometimes, following a state 
of prolonged tonic contraction, after the evacuation of the 
uterus, its walls collapse like those of a pricked bladder. 
The stage of exhaustion or paralysis has been reached. 
As explanatory of these several conditions we need to bear 
in mind what is often lost sight of in the earlier stages of labor, 
that the uterus, in addition to contractility, likewise possesses 
retractile properties. These are shown in a very marked way 
by the manner in which the uterus closes upon its contents 
after the rupture of the membranes; so, too, by the manner in 
which the uterus follows down the foetus during the period of 
expulsion. But even before the rupture of the membranes the 
same retractile disposition manifests itself. Normally the 
gradual closure of the uterus upon the ovum leads with a 
dilated os, to the permanent formation of the bag of waters. 
When from any reason the cervix does not dilate, as the uterus 
retracts, the excursions made by the labor-pains shorten, which 
thus, when strong, assume the clonic form. The same process 
leads finally to the close investment of the ovum by the uterus, 
when the only indication of contractility which remains is the 
increased hardening of the uterus at short intervals. Pains of 
this kind have lost all their expulsive character. Yet they 
are not unfrequently described as “ good,” and the delay at- 
tributed to a rigid os. In a similar condition of the uterus, 
when the head is on the floor of the pelvis, the arrest is often- 
times attributed to a rigid perimeum. But it is a matter of 
every-day experience that with really good pains the perinseum 
speedily loses its rigidity. Of course it is not denied that, in 14 
IRREGULAR UTERINE ACTION 
primiparse, the organic changes which effect the softening of 
the perinseum need for their accomplishment relatively stronger 
pains than in multiparse. The weak pains which are the con- 
comitants of a rigid perinseum are reenforced in some primi- 
parse by the energetic action of the abdominal muscles. Then 
if rigidity persists, the perinseum commonly tears instead of 
impeding labor. To the same retractile properties of the 
uterus are to be ascribed the irregular pains so common in 
cross-birtlis, and contracted pelvis. 
In somewhat rare cases, after the head has travelled through 
the cervix, the entire uterus passes into a state of tonic contrac- 
tion. The fibres which embrace the child’s neck may prevent 
the advance of the shoulders. We then have what is termed 
stricture of the os internum. It is not due to the spasm of any 
special bundle of circular fibres, but the uterus, as it retracts 
upon its contents, becomes conformed to the irregularities of 
the foetus. The small size of the child’s neck permits a more 
complete retraction of the muscular fibres at that point. This 
anomaly occurs, however, much more frequently in pelvic 
births after the passage of the shoulders. In head-presentations 
we should not use forceps, nor in breech-deliveries should wre 
resort to forcible attempts at extraction. In either case the 
indication is to excite expulsive pains, and this is best fulfilled 
by kneading and compressing the uterus, seeking thus by a 
vis-a-tergo to overcome the constriction. 
After labor is completed, the tonic contraction, or, more 
properly, retraction of the uterus, is the safeguard Nature sets 
up against haemorrhage. As a result of the abuse of ergot, or, 
in other cases, from an abnormal adherence of the placenta, 
the stage of tonic contraction may be reached before the expul- 
sion of the placenta. A somewhat exaggerated form of this 
condition produces the familiar hour-glass contraction. In the 
body of the uterus complete retraction is prevented by the 
presence of the placental mass. Near the os internum, as 
there is no obstacle to the retraction of the muscular fibres, a 
constriction results; while below, the cervix, as is usual fol- 
lowing confinement, has a funnel-shape, and hangs loosely in 
the vagina. In general terms, tllen, the hour-glass form may 
be said to be due to tonic retraction of the uterus proper com- DURING LABOR. 
15 
bined with a sub-paralytic condition of the cervix. Usually 
following confinement the tonic condition is at first intermit- 
tent, and followed by periods of relaxation. In hour-glass 
contraction the tonicity is for a long time persistent. As haemor- 
rhage is rare, await the final relaxation of the uterus and 
expulsion of the placenta, which is accomplished by the recur- 
rence of pains of a normal character. 
It is not, however, altogether safe to leave our patient be- 
fore this termination has been reached, for, exceptionally, the 
muscular fibres of the body of the uterus may relax prior to 
those of the lower segment, and thus haemorrhage may result. 
Injections of ice-cold water in such cases not only restrain the 
haemorrhage, but induce oftentimes a regular expulsive uterine 
action. So soon as a portion of the placenta can be reached 
by the fingers introduced into the vagina, we may hope by 
gentle manipulations to gradually etfect its removal. I am 
now convinced that rarely if ever are we called upon to deliver 
the placenta in hour-glass contraction by force. 
In most of the abnormal conditions heretofore mentioned 
we have called attention to the coexistence of excessive pain, 
and have noticed the connection between intolerable pain and 
long-continued reciprocal pressure between the uterus and its 
contents. 
But acute suffering sometimes attends upon the prelimi- 
nary stages of labor. In the latter days of pregnancy in the 
primipara, and for a few hours preceding the advent of true 
labor-pains in multiparse, contractions occur, which normally 
scarcely attract the attention of the patient. In rare instances, 
however, the suffering they occasion is intense. Hysterical 
women suffer in this way, from pains, which would not be 
noticed by others, and for their relief it becomes necessary to 
resort to such palliatives as warm baths, opium, and chloro- 
form in small doses. 
But even where hysteria does not exist as a cause, the 
pains may be so severe, while the cervix has still its normal 
length, that the woman believes herself in labor, and, indeed, 
the contractions are really as painful as in actual labor. 
There are no febrile symptoms indicative of an inflammatory 
condition of the uterus and its appendages. The pain is like 16 
IRREGULAR UTERINE ACTION 
tliat in the rheumatism of a muscle. Though the term rheu- 
matism of the uterus is applied to this condition, its pathology 
is uncertain. Indeed, in reading the ordinary descriptions 
given of it, it is hard to resist the conclusion that the writers 
have confounded together a number of distinct affections, 
such as hysterical hypersesthesia, intestinal irritability, and 
early stages of inflammation. Seyfert declares it to be due 
to deficient elasticity of the peritoneal covering of the uterus, 
resulting from preexisting peritoneal inflammation. Practi- 
cally important is the disappearance of these pains upon the 
induction of intense diaphoresis. We have seen patients, who 
have been treated for days by hypodermic injections of mor- 
phia, with only moderate results, relieved as if by magic, by 
placing them in a warm bath, and then covering them with 
blankets, giving in addition hot drinks and Dover’s powder, 
until they became bathed in abundant perspiration. 
It is often difficult, toward the close of pregnancy, to distin- 
guish between the colic pains due to fecal accumulation, or 
the presence of gases in the stomach and intestines, troubles to 
which pregnant women are especially disposed, and uterine 
contractions of a painful character. Indeed, in the former 
case the uterus becomes involved to some extent, so that the 
cervix is often felt, during one of these cramps, to simulta- 
neously harden. Moreover, after labor has actually begun, it 
may become complicated by colic-pains, which exercise in turn 
a suspensive influence upon parturition. But the colic-pains 
are themselves intermittent, and are, therefore, liable to be 
mistaken for labor-pains. Thus we may become involved in 
perplexities which time alone can solve. Even when we have 
made out our diagnosis of “ false labor-pains,” and give an 
opiate for the relief of our patient, we never can be quite sure 
that the first result of quieting the pain may not prove the 
acceleration of labor. Where this does not occur, Ve should 
guard against the return of the trouble by clearing out the 
bowels either by purgatives or enemata. 
In normal labors the pulse becomes more rapid at the 
beginning of each pain, and continues to increase in frequency 
until the pain has reached its acme, when a gradual declina- 
tion follows. But sometimes labor is attended by marked DUEING LABOE. 
17 
febrile symptoms. There exists not only rapidity of pulse 
during the intervals of the pains, but a continuous elevation 
of temperature. ]STow, if at the same time the uterine con- 
tractions are the source of extraordinary suffering, there is 
strong reason for suspecting that the labor is complicated by 
inflammatory conditions of the organs concerned in parturition. 
Thus a latent pelvi-peritonitis may be converted into the acute 
form by the several acts which comprise an ordinary labor, or 
the prolonged tonic contraction of the uterus upon the foetus 
after the rupture of the membranes, especially in neglected 
shoulder presentations and in contracted pelves, may give rise 
to inflammatory conditions of the uterus itself. In either case 
the association of febrile symptoms with intense pain should 
awaken serious apprehension. Especially ought we to be 
forewarned against the indulgence of a sense of false security, 
because of the treacherous lull in the symptoms that, as a rule, 
takes place when the labor is at an end. After a day or two 
we may expect a chill and the return of the fever. In these 
early stages of metritic and pelvi-metritic trouble there is little 
question as to the value of mild purgatives. A ten-grain dose 
of calomel has oftentimes a most beneficent action in arrest- 
ing the disease. Where the advance of labor renders the induc- 
tion of artificial diarrhoea impracticable, opiate clysters, though 
of inferior value, soothe the pain and are our next most valu- 
able resource. 
And now to recur once more to the subject of weak pains. 
In all cases the strength of the pains must be proportioned 
to the obstacles to be overcome. Only then are they to be 
regarded as too weak when they prove inadequate to accom- 
plish delivery without detriment either to the mother, to the 
child, or to both. 
Previous to the rupture of the membranes the existence 
of weakness of pains can hardly be determined. Only after 
rupture are we in a condition to recognize the presence of 
primary weakness. Primary weakness becomes dangerous 
when the uterus, instead of exercising expulsive action, re- 
tracts upon its contents so as to closely invest the foetus. In 
such a case the child’s life is compromised both by pressure 
and by interference with the utero-placental circulation. 18 
IRREGULAR UTERINE ACTION 
Secondary weakness results where an obstacle exists which 
the pains prove ineffectual to overcome. As in primary weak- 
ness, this condition may be attended with risk to the life of the 
child, and with suffering to the mother. 
In these cases, unless relief is afforded by art, there is the 
special danger that the long continuance of the pressure may 
lead to inflammatory troubles, which will influence unfavora- 
ly the puerperal state. 
Lastly, the prolonged retraction of the uterus may be fol- 
lowed by the entire cessation of the pains, and thus paralysis 
result. Uterine retractility is not precisely the same force as 
that which causes the expulsion of a fluid from an over-dis- 
tended elastic bladder, for retractility and contractility are in 
the uterus rarely disassociated from one another. When the 
uterus ceases to contract, it forfeits, in the rule, its retractile 
properties likewise.1 
In the treatment of a pathological weakness of pains we 
have one of two courses open to us. We may either effect 
delivery by resorting to a judiciously-selected operative pro- 
cedure, or, by applying the whip and the spur, we may seek to 
compel the uterus to perform its proper functions. Both from 
training and inclination, I prefer in most, if not all cases, to 
adopt the first alternative. Yet I am not quite ready to deny 
that ergot may be profitably employed for primary weakness, 
at even an early stage of labor. The efficacy of uterine ac- 
tion is more nearly related to the innervation than to the mus- 
cular development of the organ. In cases of defective ner- 
vous power, ergot perhaps may have a wider application as a 
remedy than is at present assigned to it. Most that has been 
written regarding its use relates to its administration in large 
doses. I desire here simply to mention the fact that I have 
seen small doses of ergotine given in the Prague Hospital with 
the view to awaken such a degree of uterine activity as would 
suffice to bring about the moulding of the head in a moder- 
ately-contracted pelvis.2 The ordinary formula consisted of— 
1 Vide Breisky, “ Ueber die Bebandlung der puerperalen Blutungen.” 
(Yolkmann’e Sammlung klinische Yortrage, No. 14, p. 92.) 
2 Summer, 1865. DURING LABOR. 
19 
3 • Ergotine 3 j. 
Tinctura cinnamomi et syr. simpl. aa § j. 
M. et sig. Teaspoonful every three or four hours. 
In these doses it appeared to produce good results, and 
certainly did no harm, unless, perhaps, by leading to the post- 
ponement of a more vigorous line of treatment. 
Some mention ought perhaps to be made here of a plan for 
supplementing weak pains that has been long employed by 
practitioners, but for which the rules have been more recently 
formulated by Kris teller, consisting of regulated pressure 
made through the abdominal walls upon the fundus uteri. 
This method, to which Kristeller has given the name of ex- 
jpressio foetus, in some cases enables us to bring about de- 
livery without the employment of an extractive force. Yet 
the number of such cases is limited, and its principal applica- 
tion will always, it is likely, be found as a support to other 
operative procedures belonging to midwifery. Those who are 
not accustomed to resort to this plan will be astonished, upon 
trial, to find how much a scientifically-applied vis-a-tergo fa- 
cilitates forceps-deliveries, and extraction following versions. 
In conclusion, I have only to add that, while I, of course, 
expect that many recollections will occur to members of this 
Society which seem at variance with some of the views here 
presented, I feel at the same time confident that, if, in future, 
they carry the principles I have enunciated with them to the 
bedside, they will find them in close accordance with sober, 
careful observation.