A NEW 
EXPLANATION OF THE MIL TROUBLES, 
ECLAMPSIA, AND OTHER PATHOLOGICAL PHENOMENA 
OF 
PREGNANCY AND LABOR. 
Read (in part) before the Wash. Obst. and Gynec. Soc., Feb. 4th, 1887. 
BY 
A. F. A. KING, MD., 
Prof, of Obst., etc., in the Med. Dept, of Columbian University, Washington, D. C., and 
intheUniv. of Vermont; Prest. of the Washington Obstet. and Gynec. Soc., etc. 
Reprinted from The American Journal, of Obstetrics and Diseases 
of Women and Children, Vol. XX., March and April, 1887. 
NEW YORK: 
WILLIAM WOOD & COMPANY, 56 & 58 LAFAYETTE PLACE. 
1887. A NEW 
EXPLANATION OF TIE REEL TROUBLES, 
ECLAMPSIA, AND OTHER PATHOLOGICAL PHENOMENA 
OF 
PREGNANCY AND LABOR. 
Read (in part) before the Wash. Obst. and Gynec. Soc., Feb. 4th, 1887. 
BY 
A. F. A. KING, M.D., 
Prof, of Obst.,etc., in the Med. Dept, of ColumbtSlMJniversity, Washington, D. C., and 
in the Univ. of Vermont; Prest. of the Washington Obstet. and Gynec. Soc., etc. 
Reprinted from The American Journal op Obstetrics and Diseases 
op Women and Children, Vol. XX., March and April, 1887. 
NEW YORK: 
WILLIAM WOOD & COMPANY, 56 & 58 LAFAYETTE PLACE. 
1887. A NEW 
EXPLANATION OF THE RENAL HUMES, 
ECLAMPSIA, AND OTHER PATHOLOGICAL PHENOMENA 
OF 
PREGIANOY AID LABOR. 
Mauriceau spoke of pregnancy as a nine months’ malady, 
and another author wrote, as we are reminded by Dr. Parvin 
(“ Sci. and Art of Obstet.,” p. 210): “ Woman only escapes being 
sick twelve times a year by having an illness which lasts nine 
months.” While these statements are partially true with re- 
gard to some women, we know there are others who enjoy a 
remarkable immunity from illness during gestation and express 
themselves as feeling better, every way, than they did before 
conception took place. 
But why some women are well, and others ill during preg, 
nancy, is, in many cases at least, difficult to explain. Especially 
is this true with regard to the renal troubles of gestation 
and their accompanying pathological phenomena. 
It is the purpose of this paper to present a new explanation 
(or what I think is so) of the etiological relation between 4 
King : The Renal Troubles, etc, 
pregnancy and the nephritic derangements tliat so often at- 
tend it. 
If I am right with respect to this matter, it will he evident 
that many other of the pathological conditions, belonging both 
to pregnancy and labor, may be referred to the same explana- 
tion. This paper, therefore, will not deal with kidney difficul- 
ties only, but embrace other correlative pathological states. 
To further the end in view, I must first call attention to cer- 
tain preliminary considerations which it will be desirable to 
bear constantly in mind. These may be briefly stated as follows: 
1. We must study Nature. As in all other departments of 
medical science, so in obstetrics, the key to progress will be 
found in a studious observation of natural cases and a correct 
interpretation of the things observed. While this has already 
been done by many faithful and enthusiastic clinicians, the re- 
sults are still deficient and the work incomplete. In fact, our 
clinical cases of pregnancy embrace chiefly cases— 
those that exhibit disease. “ The well need not a physician, but 
those that are sick.” In private practice, certainly, pregnant 
women who suffer no ills whatever, usually employ no physi- 
cian ; much less do they submit to the vaginal, abdominal, and 
other examinations which a scientific investigation of their 
cases would require. Yet these natural cases are, of all others, 
those which it is most requisite to understand, and which, it 
may be supposed, would best repay investigation. 
2. Physiology and pathology must be separated. To define 
the normal from the abnormal has always been a prime object 
in the study of disease, and while the statement of so simple a 
proposition may here seem superfluous, it will, I think, appear 
less so when we realize that this attempted definition, in so far 
as it relates to pregnancy and parturition, has hitherto resulted 
in eminent failure. To formulate our definition, we require a 
normal model, with which abnormal variations may be com- 
pared. But where shall this model of normality be found, 
especially among highly civilized communities ? Models of ap- 
proximate health may, however, be observed. Some are normal 
in some respects, others in others. We may at least take the 
normal ingredients from each and put them together, bit by 
bit. To do so will require the study of one thing at a time. 
Then, too, we must be sure that our criteria for judging what is 
normal, and what is not, are fair and just. In this matter ob- of Pregnancy and Labor. 
5 
stetricians seem to be influenced, in a measure, by some such 
principle as “ all is well that ends well.” A clinical report often 
finishes with the remark : “ mother and child both did well; ” 
but nothing may be said of the untold agonies and dangers en- 
dured before the final ending in “recovery” was accomplished. 
In order to be normal, there should have been nothing to re- 
cover from. So again, that which occurs often is considered 
normal, while disease is held to be exceptional. This also is 
wrong, or may be so; for if the etiological factors of disease 
are more frequently present than absent, the abnormal cases may 
exceed in number the normal ones. On the whole it will, I 
think, appear farther on (and no matter from what cause or 
causes) that our leading masters and teachers of obstetric science 
have in several instances not only confounded the normal and 
abnormal together, but have committed the additional mistake 
of calling that normal which is in reality abnormal, and vice 
versa, that which is really natural they have considered natu- 
ral. The differences of opinion with regard to disputed ques- 
tions, so often expressed by equally credible and reliable author- 
ities, and based upon equally accurate observations, have, I 
think, arisen from the observers on one side having met with 
and noted normal cases, and those on the other abnormal ones, 
without either being aware of the mistake. At least such must 
be the conclusion if the views to be expressed in this paper are 
correct. 
3. The natural conditions of pregnancy must be separated 
from the natural conditions of labor. At first sight this again 
would appear to be a superfluous admonition, yet I shall en- 
deavor to show that the error of confounding the two together 
has been repeatedly committed, by the most recent and eminent 
authorities, and with the most disastrous results in impeding 
the progress of obstetric knowledge. So far from the natural 
conditions during the two periods being the same, they are not 
only different, but opposite, for the ends to be attained are di- 
rectly contrary to each other. It is the office of a pregnant 
womb to retain the ovum ; that of a parturient womb to expel 
it. The conditions normal in the one case can scarcely be nor- 
mal in the other. The relevancy of this statement to the mat- 
ter in hand will be more evident farther on. 
With these preliminary reflections, I proceed to the discussion 
of the etiological relation evidently existing between pregnancy King : The Renal Troubles, etc., 
and tlie albuminuria, nephritis, anasarca, uremia, eclampsia, 
etc., that so often accompany it. 
4. Need for further knowledge. While many theories have 
been presented in explanation of the cause of renal troubles, etc., 
during pregnancy, no single one has thus far been universally 
recognized; none has been so distinctly proven as to merit univer- 
sal recognition. Even some of our most recent writers have no 
hesitation in confessing their ignorance upon this subject. Bartels 
writing in Ziemssen’s Cyclop. (Yol. XY., p. 309), says: “ For the 
present there is nothing left for us but to record the fact that 
parenchymatous inhammations of the kidneys and the liver may 
be developed during pregnancy, and to confess that we do not 
know what causes them” On page 306 of the same volume he 
quotes Bosenstein (“ Die Pathologie und Tlierapie der Nieren- 
kranklieiten,” 2te Auflage, 1870, S. 62) to the elfect that the 
pressure occasionally exerted by the gravdd uterus upon the renal 
veins occurs “ under conditions that are not thoroughly known to 
us.” Dr. Althaus (“ Dis. of the Nervous Syst.,” 1877, p. 77) says : 
“ The cause of the appearance of nephritis before and during 
parturition is still obscure.” Even so recently as Dec., 1886, at a 
meeting of the New York State Med. Association, during a dis- 
cussion participated in by many of the leading obstetricans of N ew 
York, Dr, T. Gr. Thomas is reported to have said (Journ. of 
the Am. Med. Assoc., Dec. 4th, 1886, p. 640): “ That while 
we are ignorant of the method by which the puerperium in- 
duces this form of nephritis, we have abundant evidence of the 
fact that, so soon as utero-gestation ceases to progress, the renal 
trouble, as a rule, diminishes and soon disappears.” 
Many other authors acknowledge the same kind of bewilder- 
ment. 
Under these circumstances, there would seem to be ample 
room for the introduction of some new ingredient within the 
heterogeneous tangle of ideas comprising our present viewrs upon 
this subject. In our day, so remarkable for scientific and liter- 
ary progression, when numerous minds are dwelling long upon 
the same questions, and prolific printing presses, pregnant with 
the new conceptions of medical authors, are daily giving birth to 
nascent ideas, one may well hesitate before ascribing to himself 
the sole paternity of any new conception in the domain of medi- 
cine. Nevertheless, truth compels me to say that I have sought of Pregnancy and Labor. 
7 
in vain through a good part of the literature of this matter 
for any reference to the suggestion it is my purpose to introduce. 
5. The cases to he considered. The cases I propose especially 
to consider are those occurring, for te most part, in primi- 
parous women, during the later months of pregnancy, which 
usually begin with edematous swelling of the feet, face, and 
hands, with or without general anasarca, attended with scanty, 
high-colored, albuminous urine, containing renal epithelium, 
tube casts, and blood-corpuscles, and which sooner or later may 
develop headache, gastralgia, nausea, vomiting, derangements of 
the special senses and the usual phenomena of uremia, ending 
(if not relieved) in eclampsia, premature delivery, etc , and some- 
times in death of both child and mother. These are the ordinary 
cases of uremic eclampsia occurring during pregnancy or par- 
turition. That all the cases should not present exactly these 
phenomena, or that the phenomena themselves should not occur 
exactly in this order of sequence, will make but little difference, 
for the etiological views to be proposed will cover one variation 
of the disease as well as another. Convulsions, however, fol- 
lowing severe hemorrhage or profound anemia from other 
causes, and those of a purely hysterical character, and again 
those due to previous chronic epilepsy, should of course be ex- 
cluded, for, unless they occur as accidental complications of the 
uremic kind, they belong to a different category. 
6. Theory and practice. While it must be confessed, and 
with regret, that the substance of this paper is, in the main, 
theoretical, for pronounced cases of albuminuria going on to 
uremia and eclampsia are not of frequent occurrence, yet I hope 
to present the theory with sufficient clearness to secure for it 
such future observations by others as may be required for testing 
its correctness or proving its fallacy. While my facilities for 
clinical observation have been limited, I am still able to present 
a series of cases, twenty-one in number, which will illustrate 
the methods of examination to be suggested, and will also con- 
tribute negative evidence in support of the theoretical views 
propounded, that is to say : the cases (thus far examined1) not 
having albuminuria have been found not to present the condi- 
tions which the theory states produce albuminous urine, etc. 
So far the negative evidence thus furnished has been uniformly 
in favor of the theory. I hope the publication of my views may 
1 Up to Jan. 27th, 1887. 8 
King: The Renal Troubles, etc., 
increase tlie number of examiners in the direction indicated, so 
that positive evidence also may be supplied sooner than my own 
limited field of observation would be likely to supply it. 
7. The theory briefly stated. Disturbances in the renal cir- 
culation and renal functions are produced chiefly by pressure of 
the gravid uterus upon the abdominal aorta or its branches, or 
upon the vena cava or its branches, or upon both or all of these, 
in coiisequenee of the child and womb not maintaining during 
pregnancy their normal lateral obliquity above the pelvic brim. 
This is the pith of the whole matter; and yet one brief state- 
ment of this sort can hardly convey the whole theory without 
further additions, explanations, or qualifications. This state 
ment, however, will constitute the main text and central idea 
of what is to follow. Now it is evident, before we can pro- 
ceed one step farther, it will be necessary to define: 
8. The normal attitude of the child in uiero during preg- 
nancy, before labor begins. The definition I will now pro- 
pose, it must be distinctly understood, does not refer to the 
attitude or presentation of the child during labor, but during 
pregnancy before labor begins. It is as follows: The normal 
“presentation”* and “position”* of the fetus in utero during 
pregnancy, before labor begins, is the dorso-anteriorposition of 
an oblique presentation (commonly, inexactly, and erroneously 
termed a “ transverse ” presentation). A head presentation (as 
this expression is usually meant to imply presentation of the 
head “ toward the centre of the canal of the pelvis and os uteri ” 
with the long axis of the child parallel with the axis of the 
plane of the pelvic brim), is abnormal during pregnancy, etc. 
We must next consider the 
9. Normal position of the gravid uterus. The normal 
position of the gravid uterus, in abdomino, during the later 
months of pregnancy, before labor begins, is the lateral oblique 
position, corresponding, more or less, with the oblique position 
of the child ; the fundus uteri, containing the pelvic extremity 
of the fetus, being usually directed towards the right side (ex- 
ceptionally to the left) of the lumbar vertebrae. (It should here 
be observed that while this definition applies to the position ” 
of the uterus as demonstrated by abdominal palpation, the 
apparent “ position ” is in part really due to the shape of 
1 I use these terms as ordinarily employed by obstetricans when dis- 
cussing the mechanism of labor. of Pregnancy and Labor, 
9 
the organ as it conforms to the shape ot its contents ; for while 
the fundus is towards one side of the mother’s spine, the os and 
cervix may still be found, on vaginal examination, with but 
little or no lateral deviation from the median line.) 
Under caption 7, I have stated the renal troubles, etc., are 
produced in consequence of the child and the womb not main- 
taining their normal lateral obliquity “ above the pelvic brim 
These last four words, further elucidated, lead us to discover a 
10. Contrast between the abdominal and pelvic cavities. 
When the womb and child, after the fifth month of pregnancy, 
have risen from the pelvic cavity into the abdominal cavity, in 
this latter they should remain until the advent of labor. The 
pelvic canal, in so far as it is concerned with reproduction after 
this period of gestation, is simply, or chiefly, the channel of exit, 
and no part of the child should again enter here until it is ready 
to go out and be born ; while the abdominal cavity, above the 
pelvic brim, is the cavern of residence, and here the child 
should remain, and remain in its entirety, until the proper time 
for its exit has arrived, oris immediately impending. The rel- 
evancy of this statement, and the importance of recognizing its 
truth (if it be true), will appear farther on, when I shall call 
attention to an exactly opposite statement almost universally 
made by modern writers, viz., that in primiparous women the 
head descends through the brim into the pelvic cavity even as 
early as three months before labor begins, and which is allowed 
to pass as a normal condition in primiparse. And this leads me 
to remark, that 
11. Normal reproduction is the same in primiparce as in 
midtiparae. The whole process of procreation, and the normal 
position of child and womb, as previously stated, are intrinsically 
the same in primiparse as they are in multiparse. Under nor mad 
conditions, there is no reason why any difference between them 
should occur, and none, I think, will be observed—certainly no 
such exorbitant difference as that in one (multiparse) the head 
should remain during pregnancy “ upon one of the iliac fossse,” 
and in the other (primiparse), “ descend into the pelvic cavity 
three months before full term,” for, be it remembered, the 
same high authorities who, we shall see, admit the difference 
just stated to be normal, also teach that descent of the fetal 
head into the pelvic cavity is (not even the first, but) the second 
stage or step in the “ mechanism of labor.” Can it be that this 10 
King: The Penal Troubles, etc., 
second step in the mechanism of labor normally occurs, in 
primiparse, three months before it is time for labor to begin ? I 
should rather say it is abnormal. If the oblique presentation, 
with the lower end of the fetus resting upon an iliac fossa, be 
normal for one, it is normal for the other. We believe it to be 
so in both. 
i 2. Natural change of presentation before labor. Probable 
exciting cause of actual labor. Just before the end of preg- 
nancy, the uterine contractions premonitory of “ actual labor ” 
serve to alter the long axes of womb and child from their 
oblique position, and bring them sufficiently in line with the 
axis of the plane of the superior strait as to allow the lower end 
(usually the head) of the fetal ovoid, covered of course by the 
elastic walls of the supra-cervical segment of the womb, to slip 
off of the cushioned ledge of iliac fossa on which it has reposed, 
and, now more nearly opposite the centre of the os uteri, com- 
mence its descent into the pelvic cavity. This change in the 
presentation of the child is probably one of the direct exciting 
causes of actual labor. It is scarcely necessary to add that, 
when the premonitory contractions, or actual labor pains, both 
fail, from some exceptional circumstances, to change the axis of 
womb and child from their oblique position, and which happens 
once in about 230 cases, then the abnormality of an oblique 
presentation during labor will result. 
13. Obliteration of cervical canal, and BandVs ring, dur- 
ing the late months are abnormities. When the womb and 
child maintain during pregnancy their normal lateral obliquity, 
the canal of the cervix uteri, from the external to the internal 
os, will remain unobliterated until full term; and which is the 
normal condition both for primiparse and multiparae. Under 
the same normal circumstances, the great thinning of the lower 
uterine segment, the tearing of the decidual mucous membrane, 
the “ formation of a new cervical canal,” and the other tissue 
changes observed by Bandl, will be absent during pregnancy. 
They are abnormal. They may nevertheless occur during labor 
from abnormal mechanical obstruction to delivery. None the 
more, however, does this bring them within the domain of 
physiology. 
14. When the normal obliquity of womb and child is main- 
tained dur ing pregnancy, there will be no injurious compres- 
sion upon any blood-vessels. So long as the child remains of Pregnancy and Labor. 
11 
poised obliquely, like a slanting beam, above and partly across 
the pelvic brim, certainly nothing below the brim will be com 
pressed : that is apparent. Nor, certainly, while thus obliquely 
directed, will the fundus uteri and its contents reach high 
enough to touch the renal blood- vessels, which lie on the second 
lumbar vertebra. It is, therefore, chiefly with the vessels of 
the intermediate space—the aorta and vena cava and their 
branches—that we have here to deal with. Let us recall the 
situation of these vessels. I quote almost verbatim from Gray’s 
Anatomy (2d Am. Ed., pp. 418, 428, 436, 474, 475). The 
abdominal aorta descends “ a little to the left side of the verte- 
bral column, terminates on the left side of the body of the 
fourth lumbar vertebra, where it divides into the two common 
iliac arteries.” “ This point corresponds to the left side of the 
umbilicus, and is on a level with a line drawn from the highest 
point of one iliac crest to the other.” The common iliacs* 
diverging from the termination of the aorta, pass downwards 
and outwards to the margin of the pelvis, and divide opposite 
the intervertebral substance between the last lumbar vertebra 
and the sacrum. The external iliac passes obliquely downwards 
and outwards along the inner border of the psoas magnus 
muscle to the femoral arch. The ascending vena cava is in 
front of the spine, on the right side of the aorta. The common 
iliac veins unite “ upon, the intervertebral substance between 
the fourth and fifth lumbar vertebrae.” Thus we find these 
large vessels and their primitive divisions disposed over the 
most projecting part of the lumbar curve, the aorta being a lit- 
tle on the left of the median line—tliq fourth lumbar vertebra 
being the most prominent in the anterior direction. A trans- 
verse, or obliquely transverse, section of the abdominal cavity 
at this level will exhibit at its central posterior part a sudden 
convex projection made by the lumbar spine, with two moder- 
ate sized lateral concavities which pass forwards to unite in 
forming the larger concavity of the anterior abdominal wall. 
The included space will be somewhat reniform in shape, but it 
will more nearly resemble the surface displayed by making a 
median, longitudinal, antero-posterior section of a fetus in 
utero, provided that the head, spine, and extremities be fiexed, 
as we usually find them. The section of a woman’s abdominal 
cavity, and the section of a fetus thus displayed, will exhibit a 
striking resemblance to each other; and, when the child’s back 12 
King: The Renal Troubles, etc., 
is directed anteriorly, which, it usually is (for in all presentations 
the dorso-anterior positions are most frequent, as well as most 
desirable), and the long axis of its body is placed obliquely 
across the woman’s abdomen, with its head, spine, and extremi- 
ties flexed—under these circumstances the convexity of the child’s 
dorsal surface and of the anterior uterine wall will tit well 
within the concave surface of the anterior wall of the abdomen, 
while the deep and sudden sulcus between the flexed knees and 
forehead of the child (see plate 72, p. 125, Leisliman’s Obstet. 
3d Am. Ed.), covered only by the ductile web of the elastic 
uterine parietes, cushioned inside by liquor amnii, will afford 
space, posteriorly, for the projecting lumbar vertebrae, and the 
large blood-vessels placed upon them. At least that portion of 
the womb in contact with the lumbar vertebrae will contain no 
hard part of the fetus by which injurious compression of the 
blood-vessels could be made. 
It will be further observed that the lower part of the gravid 
womb containing the fetal head, when posed upon the left iliac 
fossa, or rather upon the psoas and iliacus muscles with which 
that fossa is upholstered, will, in consequence of the downward 
and forward inclination of both muscles and fossa, constantly 
tend to glide forwards, and away from the left side of the 
woman’s spine—away from the aorta and iliac vessels, etc. At 
the same time the pelvic end of the fetus will be directed ob- 
liquely upwards and to the right side of the lumbar spine, 
where there is no important vessel to be compressed. 
The long axis of the fetus, when thus obliquely placed, will 
occupy a trebly complex diagonal position. It will be oblique 
to the horizon, the breech being higher than the head ; oblique 
laterally, the breech to the right, the head to the left; and ob- 
lique antero-posteriorly, the head being more in front, the 
breech more behind. By this complex diagonal position the 
womb and child make the very best use of the limited space 
which the abdominal cavity affords, crowding of and pressure 
upon neighboring structures being prevented. 
When, on the contrary, the womb and fetus maintain a verti- 
cal position (i. e., not vertical to the horizon, but with their long 
axes in line with the axis of the plane of the pelvic brim), they 
are continually crowded for space by their abdominal surround- 
ings, and the direction of this crowding is chiefly downwards 
and backwards—in fact towards the lumbar spine and the blood- of Pregnancy and Labor. 
13 
vessels that lie upon it. And finally the lack of space for the 
long axis of the womb compels its lower segment, containing 
the child’s head, to descend prematurely out of the abdominal 
cavity into the pelvic one, which occurs most often in primi- 
parse, and with all the disastrous results to which this abnormity 
sometimes leads, as will be shown hereafter. 
It should not be overlooked that the normal attitude of the 
child, besides being oblique as stated, is also dor so-anterior. 
Should the back of the child be directed towards the mother’s 
spine, the spinal curvature of the fetus (which is observed from 
the earliest stages of embryonic development), so far from 
agreeing with a transverse section of the woman’s abdominal 
cavity, will disa.gree with it, for the convex surface of the child’s 
back will impinge upon the convex projection of the mothers 
lumbar vertebrae, and thus the tendency to injurious pressure 
upon the aorta, etc., would be increased. 
15. Will pressure of the gravid womb upon the aorta, vena 
cava, and their branches produce renal trouble ? On this point 
there has been much difference of opinion. Many writers speak 
of pressure upon the renal veins, or upon the kidneys them- 
selves, as if these received the brunt of uterine pressure: but 
I think, after the very able disputation of this view by Dr. 
Bartels (Ziemssen’s “ Cyclop.,” Vol. XV.) we can no longer ad- 
mit the supposition. 
It will scarcely comport with my present purpose to review 
the literature of the question proposed at the beginning of this 
section. It must suffice to accord it an affirmative reply, for 
which ample authority might be adduced. Nor is it difficult to 
understand how the cause (uterine pressure) produces the effect 
(renal disturbance). The current of blood in the aorta being 
retarded must necessarily lead to tension of that vessel and its 
branches above the point of compression, and among the first 
of these branches to feel such tension must be the renal arte- 
ries, placed only a very short distance above, and being also of 
comparatively large calibre; while compression of the vena 
cava below, retarding the upward current of venous blood, will 
retard the exit of blood from the kidneys through the renal 
veins. Ilence we might sup'pose, a priori, that the renal con- 
gestion would be either active or passive, according, respectively, 
as the aorta or vena cava were most forcible compressed. 
But another factor that may certainly influence the function King : The Renal Troubles, etc., 
14 
of the kidney, and add to the vascular disturbance produced by 
pressure upon blood-vessels, is compression of the ureters by the 
gravid womb. Lohlein found dilatation of one or both ureters 
in twenty-live per cent of the deaths from puerperal eclampsia, 
and in three per cent only of deaths from other causes (Barnes’ 
“ Obstet.,” p. 292, quoting from Deutsche Med. Zeitung, 1883). 
Admitting ureteral compression as a cause of renal disturb- 
ance, by no means necessitates the exclusion of the vascular 
compression before stated ; in fact, it is more than likely that 
when one occurs, the other will also, and from the same cause. 
But I must here repeat with emphasis that, when the child 
maintains its normal lateral obliquity above the pelvic brim, and 
its dorso-anterior position, nothing will be injuriously com- 
pressed ; while under opposite circumstances, when the head 
presents during pregnancy at the brim, and descends into it 
three months before full term, all neighboring canals, whether 
arteries, veins, ureters, or lymphatics, may receive disastrous 
pressure and interference with the transit of their contents. 
Though not altogether belonging to this section, it may here be 
remarked that pressure of the gravid womb upon the recepta- 
culum chyli and upon the lymphatic vessels from the lumbar 
glands that empty into it (and which lie upon the second, third 
and fourth lumbar vertebrae), has perhaps not received the atten- 
tion it deserves, in contributing to the faulty nutrition, hydre- 
mia, and anemia, often found to exist in some pregnant women. 
But these, again, will escape pressure when the child is normally 
placed as before stated. 
16. The diagnosis of aortic and vena-caval compression 
during pregnancy and labor. Edema and venous congestion 
of the lower extremities is the best evidence of venous obstruc- 
tion higher up. Additional evidence may be found, however, in 
the occurrence of hemorrhoids, varicose veins and thrombi of 
the vulva, and congestion of the vagina and cervix uteri. 
Aortic compression would seem to be indicated by the ob- 
served tension of the arterial system above the obstructed point, 
as shown by tension of the radial pulse, and which is especially 
pronounced in uremic cases. But I must now call attention to 
another mode of diagnosis, which has not been usually prac- 
tised, vizfeeling the pulsation of the femoral arteries below 
Douparfs ligament. In the twenty-one pregnant women that 
I have lately examined in this way, the femoral pulses could of Pregnancy and Labor. 
15 
be easily felt, and appeared to possess tlieir normal tension, but 
in none of these women was there any abnormal tension of the 
radial pulse, nor yet any albuminuria or other indication of 
renal derangement. In none of them either had the head de- 
scended into the pelvic brim, but remained above it poised upon 
one of the iliac fossae. 
17. The relation of eclampsia with renal disturbance and 
with abnormal position of the child, etc., daring pregnancy. 
As is well known, various explanations have been given of the 
eclampsic paroxysms during pregnancy and labor; and while 
the fits are explicable in some cases in one way, and in some in 
another, I hope to show that the several kinds of cases and 
their alleged preceding pathological states may all, or nearly 
all, be traced back to the one chief and original factor of dis- 
turbance, viz., malposition of the child, i. e., presentation of 
one end of the fetal ovoid instead of an oblique presentation, 
as before explained. Let us consider first: 
(a) Cases with albuminuria, nephritis, and uremia. In 
these cases, the convulsions occur much in the same way as they 
do in males suffering from uremia consequent upon Bright’s 
disease. Whether the spasms be due to the retention of urea, 
or its decomposition into carbonate of ammonia, etc., may mat- 
ter little, for disease of the kidney is, in these cases, known to 
be the root of the evil. Hence it brings us back to the origin 
of the renal trouble, which we have already referred to, pres- 
sure of the misplaced fetus and womb upon the aorta, vena 
cava, etc. 
(b) Cases without, or with but little, albuminuria, or kidney 
trouble, but in which albuminuria, etc., may be produced, or 
increased, by the convulsions. These cases are explicable upon 
the “ uterine irritation” theory of Tyler Smith, who maintained 
that true puerperal convulsions were produced either by centric 
irritation of the spinal marrow, or by eccentric (peripheral) irri- 
tation of it, produced “ by an excited condition of an important 
class of incident nerves, namely, those passing from the uterine 
organs to the spinal centre, such excitement depending on preg- 
nancy, labor, or the puerperal state.” But how shall we ac- 
count for this abnormal irritation of the uterine nerves? It 
cannot be considered a physiological condition; and with our 
hitherto prevalent notions of what constitutes normal preg- 
nancy, the occurrence of eclampsia from uterine irritation before 16 
King : The Renal Troubles, etc., 
labor begins is tlie more difficult. When, however, we have 
decided that conditions hitherto called normal, are really ab- 
normal, the matter becomes more easy. I therefore beg to 
maintain that premature obliteration of the cervix uteri, pre- 
mature distention of the cervical canal and lower uterine seg-. 
ment, with thinning of its muscular wall, and tearing of its 
decidua / andpremature descent of the lower end of the fetal 
ovoid below the pelvic brim—all due to a want of that lateral 
obliquity of the fetus during pregnancy, which would have al- 
lowed the weight of the uterine contents to find support upon 
an iliac fossa, instead of upon the lower segment of the womb 
—are amply sufficient to account for the uterine irritation 
which Tyler Smith conceived to be the peripheral excitor of 
convulsions, even when there was but little or no renal disturb- 
ance. And that the spasms, in such cases, should occur with 
more frequency and severity during labor need not surprise 
us in the least, for we then have the additional irritation of a 
child’s head being forced through a sphinctorial orifice (the os 
uteri) which is already in a condition of abnormal irritation, 
from the tissue changes that have taken place in it during preg- 
nancy. More than this, I am strongly inclined to the belief 
that the rigid, thin, feather-edged, undilatable os uteri which so 
often leads to tedious labor in primiparous women is the result 
of these very morbid changes in the os and cervix that have 
previously taken place in the manner described. 
That cases of convulsions, occurring from this reflex uterine 
irritation without albuminuria, should develop albumin in the 
urine during or after the convulsive paroxysms is to be ex- 
plained by the violent contractions of the abdominal walls and 
diaphragm, which occur as part of the spasm, added to the con- 
tractions of labor pains, forcing the gravid womb, itself also 
hardened by spasm and labor pains, against the blood-vessels, 
and thus causing derangement in the renal circulation. 
(c) Cases of convulsions—whether with or without renal 
trouble—have again been ascribed to centric nervous irritation 
occurring as a part of that general irritability, or “ convulsi- 
bility,” which has been considered not uncommon during preg- 
nancy, and which some have thought due to anemia, and others 
to plethora or congestion of the brain and nerve centres. There 
would scarcely seem to be much ground for the anemic view. 
The relief usually afforded by venesection contradicts it; and, of Pregnancy and Labor. 
17 
moreover, tlie tension of the radial pulse is directly indicative 
of a condition of the brain opposite to that of anemia. The 
theory of cerebral congestion or hyperemia, on the contrary, is 
supported on all sides. It becomes necessary, however, to de- 
fine whether this centric cerebral congestion be venous or ar- 
terial in character, for wdiile an excess of arterial blood in the 
brain will produce convulsions, an excess of venous blood will 
not, but, on the contrary, lead to muscular relaxation and coma. 
Venous blood is sedative to the brain ; arterial blood, stimulant. 
It is the excessive venosity of the blood, resulting from spasm 
of the respiratory muscles and consequent suspension of respi- 
ration, that ends the convulsive paroxysm. As the late Prof. 
Joseph Carson remarked in his famous review on Puerperal 
Eclampsia (Am. Jl. Med. Sei., April, 1871, p. 459): “ When the 
brain is finally deluged with black blood, partly from the im- 
pediment to the return of venous blood from the organ, and 
partly from the propulsion of noil-aerated blood into it as the 
heart regains its power, the convulsion subsides and coma is 
substituted for it. This is natural narcotism.” 
The cerebral congestion, productive of eclampsia, therefore, 
must be arterial congestion. And this is easily accounted for 
by pressure of the gravid womb upon the aorta, impeding the 
aortic stream and causing it to back up in the brain; while 
uterine pressure upon the vena cava retards the upward current 
of venous blood and causes this latter to accumulate below the 
point of compression. We may thus reach the conclusion, as I 
endeavored to point out over twenty years ago, that puerperal 
convulsions may be “ due to an abnormal excitation of certain 
central parts of the cerebro-spinal nervous system, caused by an 
increased afflux of arterial blood and a deficient supply of 
venous blood circulating through those centres.” (N. Y. Med. 
Jour., October, 1865, pp. 27-31.) This view has been also 
maintained by several later writers. 
(d) Convulsions may be produced when the nervous system 
has attained the irritability or “ convulsibility ” previously 
noted, by local irritations seated in the stomach, bladder, or 
bowels, or by violent mental emotion, as well as by rude and 
violent manipulations during delivery by version, forceps, and 
other operative procedures. Even the normal phenomenon of 
a labor pain, under the circumstances, may produce a paroxysm. 18 
King: The Renal Troubles, etc., 
(e) Cases may occur in which several or all of the foregoing 
conditions co-exist. 
Thus, then, whether the convulsions he referred to uremic 
intoxication, or to uterine irritation, or to cerebral hyperemia, 
or to reflex local irritation in other viscera, or to several or all 
of these coincidently, they may all be accounted for by pressure 
of the gravid womb and child, when the normal lateral ob- 
liquity of the latter is wanting. 
18. Puerperal convulsions of the apoplectic type. 1 have 
always considered the separation of this class of cases from the 
more common epileptic variety as an unnecessary complication 
of the subject. Should a woman, during an eclamptic seizure 
of the ordinary epileptic kind, rupture a cerebral blood-vessel, 
or become the subject of serous effusion or extravasation in the 
cranium, and in consequence remain comatose, paralyzed, and 
die without any return of sensibility, the case is forthwiths et 
down as an apoplectic convulsion, and so in truth it is, but at 
the same time the apoplexy occurs only as a complicating acci- 
dent of epileptic eclampsia. We do not therefore need a sepa- 
rate etiology for apoplectic convulsions—they are secondary 
accidents of the epileptic cases. Our ideas of etiology can no 
more be based upon the lesions found in the brain in apoplectic 
cases, than they can upon lesions found in the lung, for pulmo- 
nary emphysema, edema, and apoplexy also occur as compli- 
cating accidents of the epileptic seizures. To base our ideas of 
etiology upon the fatal lesions that suddenly cause death is like 
examining the burst tubes and boiler of a locomotive engine 
after a railroad collision; these teach us nothing of, and would 
never suggest, the true cause of the accident, viz., a want of 
that lateral obliquity in the direction of the train which pre- 
vented it from switching off on one side so as to avoid colli- 
sional impact with its fellow. So, in like manner, the ruptured 
cerebral or pulmonary blood-vessel occasionally resulting from 
an eclamptic paroxysm afford no suggestion as to the cause of 
the convulsion. 
19. Causes of disturbance of the normal lateral obliquity of 
womb and child, and of their premature descent below the pel- 
vic brim, especially in primipa/rce. While the conditions stated, 
and also their causes, occur most frequently in primiparous 
women, they also occur with less frequency in multiparse. The 
reason most generally alleged for injurious pressure of the of Pregnancy and Labor. 
19 
gravid womb being greater in primiparae than in multipart, is 
tension of the abdominal walls—they liave not, it is said, been 
stretched by a previous pregnancy. While it may not be possi- 
ble to present evidence in refutation of this idea, and while the 
tension referred to must perhaps be admitted as a contributing 
factor in producing abnormal pressure, yet it seems to grate 
against reason when we are pushed to the supposition that a 
young female in the best of health, and in the prims of woman- 
hood, has been endowed by Nature with every provision for 
normal reproduction, except that her abdomen will not grow. 
The diminutive, unimpregnated womb expands to its gigantic 
full-term proportions readily enough, and the other structures 
of the reproductive system execute the respective changes re- 
quired of them by pregnancy, and yet by some strange omis- 
sion in the natural make-up of the female, capacity for abdomi- 
nal expansion, commensurate with the gro wth of th e uterus, has 
not been provided for ! As I have said, this supposition grates 
against reason. We can scarcely admit the natural lack of 
capacity for abdominal expansion in a healthy woman. We 
must therefore seek for some artificial or abnormal factor or 
factors, by which natural abdominal expansion has been inter- 
fered with or prevented. These will not be difficult to discover, 
especially in priiniparous women. Among them (there may be 
others) are dress, corsets, coitus, and certain abnormal postures. 
When we consider how very seldom the physician examines, 
per vaginam, young primiparous women in the erect posture 
and with their usual clothing intact, there is little positive evi- 
dence as to whether or not the mere pressure of waist-bands, 
with the weight of skirts appended to them, exercise any inju- 
rious pressure upon the abdomen and fundus uteri during preg- 
nancy. We usually make such examinations in the recumbent 
posture and witli the clothing for the most part removed. Yet 
while clinical evidence on either side may be lacking, we can- 
not escape from what we already know with regard to the mo- 
bility of the uterus. We observe it to descend from its own 
weight during the first two months of pregnancy; and then 
later as, growing larger, its slanting external surfaces (small be- 
low, large above) impinge against contiguous structures, the 
slippery wedge (or cone) glides gradually upwards above the 
pelvic brim. We note how easily it may be depressed by the 
gynecologist’s bimanual examination. Examined by inspection, 20 
King : The Renal Troubles, etc., 
we observe the vaginal portion of the cervix to move up and 
down, even by so slight a force as that exercised by the action 
of the diaphragm in respiration—an observation rendered 
doubly evident during coughing, laughing, sneezing, etc. 
All considerations lead us to the conclusion that the opposing 
factors of ascent and descent are, in a state of nature, somewhat 
nicely balanced; and that when one predominates over the 
other, in conformity with the natural requirements of different 
periods of pregnancy, the predominance is not in any greatly 
superfluous or redundant degree. Hence it is not unreasonable 
to suppose that the pressure of waist-bands and the weight of 
appended skirts, when the female is erect, may contribute to 
disturb this balance, and either prevent or retard the womb 
rising at the proper time, or injuriously compress it when it has 
risen. This seems to have been understood (practically at least) 
by the women of Rome, centuries ago, who, as Parvin reminds 
us (“ Obstetrics,” p. 211), “laid aside their girdle, the fascia 
mammillaris, when they became pregnant.” 
But if the pressure of skirts and waist-bands, comparatively 
light and loose though they be, is in any degree prejudicial, how 
much greater must be the injury inflicted by the wearing of 
corsets ! 
We do not yet, I think, thoroughly enough appreciate the in- 
fluence of wearing them upon the pregnant womb. The woman 
will often enough stand before us, and lifting up the lower 
anterior border of the corsets, declare “ they are quite loose.” 
And so they seem to be as she, unconsciously perhaps, draws in 
the abdominal wall. But note what takes place when she sits 
down. The spine is no longer so erect; the constriction at the 
waist is crowded down towards the pelvis; the expanding lateral 
borders of the corset far overlap the iliac crests ; while in front 
the median point of the stays—near the navel while the woman 
stood erect—now dips to the mons Veneris or even completely 
over it to the inter-femoral space. A distended abdomen will 
inevitably bulge forward in the sitting posture, for the spine 
and thighs then more nearly approach each other and so shorten 
the vertical diameter of the abdominal cavity. Corsets, there- 
fore, which may appear loose enough while the female stands 
erect, may exert much greater pressure in the sitting posture. 
And, farther, should the pregnant woman stoop to pick up a 
pin or other trifle from the floor—a not uncommon occurrence of Pregnancy and Labor. 
21 
certainly—tlie pressure then exerted upon the fundus uteri 
would be still more increased. And now if these effects follow 
corsets loosely (?) worn, by what measure shall we compute the 
pressure when they are confessed to be moderately tight, “ merely 
to preserve the figure as long as possible ” ? And finally, when 
the unfortunate victim of an illegitimate pregnancy laces as 
tightly as she can, and with reckless disregard of consequences, 
in order to conceal her condition, the pressure upon the womb 
must then be far beyond the natural means provided for main- 
taining the organ in the abdominal cavity. And thus perhaps 
it is why seduced women are frequently the subjects of puerperal 
eclampsia, though usually this has been ascribed to mental or 
emotional causes. 
Let us not fail to note also, and particularly, that corsets, 
whether tightly or loosely worn, exert symmetrical pressure, 
equal on both sides, and hence the womb and child, forced 
out of their normal and lateral^obliquity, have 
their long axes maintained more nearly parallel with the axis of 
the plane of the pelvic inlet, and thus, instead of resting obliquely, 
supported below upon one of the iliac fossae, in the cavity of 
the abdomen, drop, or are forced prematurely, into the cavity 
of the pelvis. It is almost needless to repeat that it is in the 
primiparous woman that this pathological condition is most 
frequently observed : and it is she also, generally speaking, who 
is most concerned about her figure. After having had one 
child, she becomes, as a rule, less fastidious in this particular, 
and submits to the inevitable with less resistance. 
In addition to skirts, girdles, and corsets, we may next con- 
sider the weight of the hands and arms (or rather forarms) 
superimposed one over the other above the fundus uteri. As 
these limbs are thus disposed over the upper region of the ab- 
domen, the additional pressure upon the enlarged womb must be 
considerable. It is almost unnecessary to say that this gesture 
or position is an exceedingly common one with pregnant females 
when in the presence of company by whom they do not desire 
their situation to be observed. Such women also, even when 
standing erect, adopt an unnatural attitude, that of bending 
forward, in order to conceal their condition, which is exactly 
opposite to their normal posture. Naturally, and in order to 
preserve the centre of gravity of the body against the tendency 
to fall forwards occasioned by the weight of the pregnant womb King : The Renal Troubles, etc. 
22 
in front of the spine, the pregnant woman stands with the head* 
shoulders, and spinal column inclined backwards (as explained 
by Matthews Duncan), and Montgomery refers to tliis normal 
posture (“ Signs of Pregnancy,” p. 7) as giving to the female 
“ that pompous air which is so often unjustly attributed to a 
wish to make a display of her condition.” 
And next with relation to coition during pregnancy. The 
abstract statement that coition during pregnancy is at all times 
unphysiological, though intrinsically true, need not here be dis- 
cussed.1 It will suffice to observe that the dorsal decubitus of 
the female, with flexion of the thighs towards the abdomen, and 
with a part of the weight of the superimposed abdomen and 
body of the male, must tend to force the uterus down towards 
the pelvic cavity, and contribute to conteract the normal tendency 
of the organ to rise and remain above the pelvic brim. It may 
be added that coitus, as a rule, will be repeated more frequently 
in young newly-married primiparse than in older, multiparous 
women. 
On the whole, I think we are justified in concluding that the 
abnormal factors now cited will be sufficient to explain disturb- 
ance of the womb and child from their normal lateral obliquity 
and their premature descent below the pelvic brim, especially 
in primiparae, without our being compelled to refer these ab- 
normities solely to the tension of the abdominal muscles. We 
ought, however, perhaps to consider that the want of natural 
expansion in the abdominal walls during pregnancy may be due 
to actual deformity or tissue changes in these walls, produced 
by the compression of tiglit-lacing, continued possibly for years, 
before the occurrence of conception. 
With relation to dress during pregnancy, we freely indorse the 
statement of Dr. B. W. Richardson (“ Preventive Med.,” p. 650) 
that “ the clothing of the expectant mother requires special care, 
since under the present system it is the worst that by any 
mortal ingenuity could be devised. The clothing should be light, 
warm, and borne entirely from the shoulders; anything like 
tight bands or corsets round the body are equally injurious to 
mother and child.” 
1 I have already expressed my own views on this subject in a paper 
read before the Washington Obstetrical and Gynec. Soc., Jan. 2d, 1885; 
and again, briefly, before the Anthropological Soc. of Wash. (See Trans. 
Anthrop. Soc., of Wash., vol. 1, pp. 86, 87, March 1st, 1881.) of Pregnancy ancl Labor. 
In fact, the wonder is, that so many pregnant woman escape 
witli only the slighter ailments occasioned by pressure upon the 
gravid womb. That, in spite of the artificial appendages to her 
person, and the other abnormal influences just mentioned, woman 
should but rarely suffer serious or fatal injury must lead us to 
exclaim that Nature is indeed beneficent, and her resources un- 
expectedly ample. 
Anthropologists tell us that there are, still living in this world 
250,000,000 inhabitants, whose wardrobes consist of something 
less than the “ traditional fig-leaf.” It would be extremely in 
teresting, as well as profitable, to ascertain the position of the 
womb and fetus in the pregnant women of these tribes, and 
whether the renal and other troubles of their primiparae 
occur as frequently as among the clothed women of civilized 
nations. But we have, I think, no reliable data upon this point 
at present. 
20. Do convulsions, nephritis, etc., occur in cases of “ trans- 
verse ” presentation during labor, and in most of which cases 
the child was, it may be presumed, oblique and wholly above 
the pelvic brim during pregnancy f 
When I had reached the theoretical views previously ex- 
pressed, it was - difficult to avoid the a priori conclusion that 
women with transverse presentation ought to be more or less 
exempt from the effects of uterine or fetal pressure upon 
neighboring blood-vessels. On consulting the works of recent 
obstetric authors upon this point, I find many of them are com- 
pletely silent with regard to it. At least I find no reference 
to it—and I have searched with tolerable care—in the works 
either of Leishmann, Playfair, Lusk, Bames, Parvin, Byford, 
Meigs, Galabin, Ramsbotham, Jr., or Velpeau (Meigs’ transla- 
tion). They appear to have paid no attention to the relation of 
eclampsia, etc., with cross presentations. At the same time, it 
will be observed that in discussing the “ obstetric treatment ” 
of eclampsia, they refer exclusively, or almost exclusively, to 
head presentations. None of them tell us what to do in the 
wav of obstetric treatment in cases of convulsions when the 
child is presenting transversely, and which would seem to indi- 
cate, though not, of course, with any certainty, that they have 
seldom or never met with such cases. 
The records of obstetric literature, however, are not entirely 
barren on this question. 24 
King: The Renal Troubles, etc., 
Dr. Robert Collins, one of the masters of the Dublin Lying- 
in Hospital (Collins’ “ Midwifery,” Am. Ed., 1838, pp. 102-103), 
remarks : “ There was but one case of convulsions, during my 
residence in the Hospital, where the child presented preternat- 
urally; there was not one case with a preternatural presentation 
during Dr. Clarke’s residence, and Dr. Labatt has stated the 
same fact in his lectures while master of the Hospital. In 
these three different periods there were 48,397 women deliv- 
ered, so that from this we may infer, where the presentation is 
preternatural, there is little cause to dread the attack.” 1 must 
here specially remark that no statement is here given as to 
whether the preternatural case was a breech, face or transverse 
presentation, for in those days a preternatural presentation was 
understood to mean “ any presentation other than that of a 
head.” With relation to this particular case, however, men- 
tioned by Dr. Collins, we are fortunately no longer in doubt, 
for he states (p. 103) that “ thirty cases of convulsions occurred 
in the Hospital during my mastership ; ... in fifteen of the 
30 the patients were delivered bv the natural efforts; in six, 
delivery was effected by the forceps ; in eight, by the perforator 
and crotchet; and in one the feet presented. 
Denman (“ Introduction to Pract. of Mid.,” 7th ed., 1832, p. 
430) says : “ I was for many years persuaded that convulsions 
happened only when the head of the child presented ; but ex- 
perience has proved that they sometimes occur in preternatural 
presentations.” He does not specify that they occur in trans- 
verse presentations, and his definition of preternatural presen- 
tation (p. 337) includes breech and inferior extremities as well 
as shoulder and superior ones. 
Dr. Fleetwood Churchill observes (“ Tlieo. and Pract. of 
Mid.,”Am. ed., 1866, p. 475) that “when convulsions occur at 
the commencement of labor, it might naturally be attributed, in 
some cases at least, to mal-presentation of the child ; but this is 
not the case. Mal-presentation is observed very rarely in cases 
of convulsions.” His definition of “ mal-presentation ” (p. 409) 
includes any part other than the head. 
Dr. Carl R. Braun (“ The Uremic Convulsions of Preg- 
nancy,” etc., translated by Duncan, 1858, p. 56) says : “Faulty 
position of the child is so seldom found in eclampsia that we 
are not warranted in assuming a causal relation between the 
two.” On page 156, referring to the obstetric treatment of of Pregnancy and Labor. 
25 
eclampsia, he further remarks : “ Presentation of the shoulder 
and pelvis, which are very rarely observed at this ” (referring 
to the expulsive) “ stage of labor in eclamptic cases are to be 
treated on general principles,” etc. This is just about what any 
one would say, in writing a complete essay on the subject 
whether such cases had or had not been met with. The state- 
ment also mingles together presentations of the shcndder and 
pelvis, which is unfortunate ; for it will be seen farther on that 
breech presentations may be associated with eclampsia. 
Dr. Gunning S. Bedford (“ Obstetrics,” 1867, note to page 
497) says: “ It is an interesting fact to note that when convul- 
sions occur during labor they do so, in the great majority of 
cases, in head presentations ; and, strange as it may appear to 
those who have not examined the subject, they are extremely 
rare in mal-positions of the fetus.” 
Bigby (“ On Midwifery,” 1851, p. 329) remarks : “ It is rare 
to find convulsions complicated with mal-position of the child ; 
indeed, so uncommon is the occurrence of it under these cir- 
cumstances, that we may feel almost certain, on being sum- 
moned to a case of convulsions, that there will be little chance 
of this additional difficulty being superadded.” 
Dr. Thomas More Madden tells us that “ in almost every in- 
stance of puerperal eclampsia that I have met with the pre- 
sentation was natural, and the experience of most other practi- 
sioner is similar to my own, on this point ” (“ Proc. Dublin 
Obstet. Soc.,” May 9th, 1874, p. 162). 
In a paper by Dr. Fr. Schauta, Clinical Assistant to Prof. 
Spath, of Vienna (See Archiv fur Gyndcol.,” vol. XVIII., p. 
274, 1881), containing statistics of the obstetric clinic of the 
Vienna Hospital, from its foundation in 1834 till the end of June 
1880, we find a record of 134,345 deliveries, embracing 344 
cases of convulsions. Of these 344 cases of eclampsia the 
presentation was noted in 315, as follows: 
Head presentation, .... 304 
Pace “ .... 4 
Breech “ ..... 5 
Footling “ .... 1 
Transverse “ ..... 1 
Total, . . 315 
It may be worth while to mention here that in 306 of these 
eclampsia cases, of which further details are given, there were 
253 primiparse and only 53 multipart ; total, 306. 26 
King : The Renal Troubles, etc., 
With regard to the presentation, Dr. Schauta remarks that 
the enormous prevalence of head presentation attracts attention 
which cannot even be explained when we consider that a ma- 
jority of the women suffering from eclampsia were in their 
first pregnancies. 
Thus the records of the Vienna Hospital furnish one case of 
convulsions associated with transverse presentation of the child. 
1 shall have more to say of this unique case presently. 
Dr. F rancis Id. Kamsbotham ( of Dbstet., A.m* ed., 
1861, Keating, p. 425) mentions 59 cases of convulsions which 
he personally attended, and of the 62 children (there were three 
twin cases) he says : 
41 were expelled naturally by the head ; 
6 were delivered by craniotomy; 
6 by forceps; 
5 by turningy 
4 presented with the breech. 
Total, 62 
Eliminating the four breech cases, all the rest, it may be pre- 
sumed, were head presentations, except perhaps the five deliv- 
ered by turning. Of these last, however, we must note that he 
makes no mention of them having been transverse cases, as it 
is most likely he would have done had they been so, inasmuch 
as he did specify the breech cases. Moreover, turning is one of 
the methods of treatment he recommends in eclampsia, regard- 
less of the presentation; thus he says (p. 433, see also 434): 
“ Should the membranes be unbroken, we may turn the child 
and deliver by the feet.” Futhermore he tells us (note to page 
353) that he “ delivered two hundred women under transverse 
presentations. Many of these cases presented a formidable ap- 
pearance,” the membranes having been ruptured as long as from 
two to seven days, in several, before the operation. In four 
evisceration or decapitation was necessary, but in no instance 
does he mention the complication of eclampsia. 
He remarks further that in none of the cases did he bleed, 
except in a few “ to relieve the inflammation from which the 
soft structures were suffering, and to remove tumefaction 
Now, had there been convulsions in any of these cases, I think 
he would have bled for that complication, and would also have 
recorded the fact, for on page 432, under the head of “ Treat- of Pregnancy and Labor. 
27 
ment of Convulsions” he says: “ Bleeding is our great reliance 
—the lancet is our sheet-anchor.” 
On the whole, therefore, I think we may fairly conclude that 
the entire 59 cases of eclampsia did not include a single one 
coupled with transverse presentation. 
In 7,404 deliveries in the Lying-in Charity of Guy’s Hospi- 
tal (“ Guy’s IIosp. Ilep.,” 2d series, No. 2) there were fourteen 
cases of puerperal convulsions, all of them being head presenta- 
tions, except one, which was “ footling and funis presentation 
with partial presentation of the placenta.” 
Dr. Robert Lee’s “ Midwifery ” (pp. 403-409, 1844) contains 
a tabular statement, with only irregular brief details, of 54 cases 
of convulsions, given in numerical order. Of these I make 
the following synopsis: 
Under group 1 we may include those in which it is dis- 
tinctly stated that the “head” presented, and those in 
which forceps, perforation, or craniotomy wTere employed, 
and which we infer were head cases. The number in this 
group was, . . . . . .23 
Face presentation, forceps used, ... 1 
Under another group T include those of which it is said 
“ labor wras natural,” or “ delivered without assistance,” 
or “ by natural efforts,” and which we may presume were 
head presentations. This number was, . . .15 
Another group contains no mention or suggestion, either 
as to presentation or mode of delivery. This number 
being, ...... 10 
Case No. 44. Convulsions at seventh month, not delivered, 
got well, went to term, . . . . .1 
Case No. 41. “ Safely delivered,” ... I 
Case No. 52. “ Artificial delivery ” had recourse to, . 1 
Case No. 1. “Easily turned and delivered,” ) o 
Case No. lb. “Turning,” i 
Total, . . .54 
While, of course, it would be unfair to assume that in these 
cases of Dr. Lee’s there was no transverse presentation, yet we 
cannot help hut remark that no mention is made of such a case. 
Turning (in the two last-named cases) may have been employed in 
any presentation. Dr. Lee. it is true, mentions one case of face 28 
King : The Renal Troubles, etc., 
presentation (Case No. 31). It is likely he would have men- 
tioned a transverse one had it occurred. But of this we must re- 
main in doubt. 1 present the record for whatever it may be 
worth on either side. 
Dr. Lee also presents a statement (pp. 335-339), again with 
meagre details, of 71 cases of shoulder presentation, some of them 
a longtime in labor, and submitted to great violence during de- 
livery. lie says (p. 334) : “ In a great proportion of these the 
operation of turning was undertaken in the most unfavorable 
circumstances both for the mothers and their children, after 
the liquor amnii had entirely escaped, and the uterus had not 
only been contracting many hours around the child, but re- 
peated unsuccessful efforts had been made to deliver. Seven 
died from rupture of the uterus. Of the 71 cases, twelve 
were twins, and one triplets.” But he mentions no case com- 
plicated with eclampsia. 
Dr. Merriman (“Difficult Parturition,” 1838, pp. 147-148) 
gives 48 cases of convulsions, hut with meagre details, as 
follows: 
In 6 convulsions after delivery. Children all alive. No 
mention of presentation. 
3 were twins. “ All delivered without artificial 
assistance.” 
11 were delivered by forceps. 
9 delivered by perforator. 
4 the operation of version was resorted to. Two of 
the women recovered. All the children were 
dead-born. 
14 delivery without extraordinary assistance. 
1 died undelivered. No mention of presentation. 
Total, 48 
Here again, unfortunately, the want of details leaves us in 
doubt. All we can say is that no case of transverse presenta- 
tion is mentioned. 
Dr. John Ramsbotham (“ Practical Observations in Mid.,” 
1842) presents sixteen observations (cases) of eclampsia as 
follows: 
Convulsions -previous to labor: 
CVII. Died undelivered. Sectio cadav.: “ Uterus with 
child in it was in a natural and healthy state.” of Pregnancy and Labor. 
29 
CYIII. Fetus and secundines expelled during one of the 
paroxysms. 
CIX. Child expelled naturally. 
OX. Child expelled dead during her struggles. 
CXI. Twins. Breech presentation: delivered by hand 
grasping feet. Second child delivered in same way. 
CXII. Os dilated. “Turning on account of imminen 
danger of woman.” 
CXII I. Natural and easy labor. 
CXIY. Natural labor. 
CXY. Natural labor, though turning had been considered. 
Convulsions during labor : 
CXYI. Head above brim. 
CXYII. Cliild naturally expelled. 
CXYIII. Head presentation. Forceps. 
CXIX. Head presentation. 
CXX. Head presentation. 
Convulsions after labor: 
CXXI. Easy, natural labor. 
CXXII. Labor quite natural. 
Among the 16 cases thus presented by Dr. John Bamsbotham, 
it is most probable, though not of course certain, that there was 
no case of transverse presentation. 
Dr. J. T. Ingleby (“ Obstetric Medicine,” London, pp. 44-59) 
gives brief details of 34 cases of convulsions, which he has grouped 
together as follows, and of which it may be presumed he would 
have mentioned any transverse presentation, had one occurred. 
Group 1. 8 cases of convulsions occurring during pregnancy, 
previous to labor: 
Case 1. Head presentation. 
“ 2. Rigid os. No mention of presentation. 
“ 3. Delivered of a living child. 
“ 4. Labor pains came on naturally. Seventh month. 
“ 5. Labor ensued at ninth month. 
“ 6. Died undelivered at seventh. iSectio cadciv.: “Uterus 
and its contents in a natural state.” 
“ 7. Os uteri easily admitted two fingers : then three. 
“ Passage of hand into uterus difficult, otherwise 
delivery could not have been more easily or 
speedily accomplished.” 30 
King : The Renal Troubles, etc., 
Case 8. Labor occurred and slie was shortly delivered of a 
living child. 
Group 2. Five cases of convulsions before labor, terminating 
in delivery. 
Case 9. Os relaxed ; membranes ruptured, and patient soon 
delivered. 
“ 10. “ As coma became more profound” turning was ac 
complished. 
“ 11. Twins. Children expelled by natural efforts. 
“ 12. “ She was delivered of twins.” 
u 13. Labor pains commenced and terminated in delivery 
of a dead child. 
Group 3. Convulsions occurring during dilatation of os 
uteri. 
Case 14. Perforator and crotchet used. 
“ 15. Speedily and safely delivered by natural pains. 
“ 16. In all respects the same as the last. 
“ 17. Forceps used. 
“ 18. Artificial delivery. No mention of presentation. 
“ 19. No mention of presentation. 
“ 20. Forceps when os dilated. 
Group 4. Convulsions arising after full dilatation of os uteri. 
Case 21. Head. Forceps. 
“ 22. Safely delivered. No mention. 
“ 23. Head. Forceps. 
“ 24. Head. Forceps. 
“ 25. Forceps. 
Group 5. Convulsions arising after birth of child and before 
birth oi placenta. 
Cases 26, 27, 28. No mention or suggestion of presentation. 
Group 6. Convulsions arising after delivery of secundines. 
Cases 29, 30, 31. No mention as to presentation. 
Case 32. Natural labor. 
“ 33. Natural and easy labor. 
Cases 34, 35. No mention. 
Of these 35 cases, Nos. 7 and 10, it appears, were delivered 
by version, but the reason given for the operation in No. 10, 
viz., because coma became more profound, would indicate 
that it was done to hasten delivery o?ily, and not on account 
of transverse presentation. 
Dr. Robt. Dunn, F.K.C.S., reports (“ Obstet. Trans.” London, of Pregnancy and Labor. 
31 
vol. I., p. 280) 4,049 cases of midwifery observed in privaet 
practice from 1831-1850, but of these 228 were premature, 
or abortions. How many were abortions and how many “ pre- 
mature ” is not stated. Eclampsia was met with only four times. 
Of these “ the attack in one instance did not supervene until 
after the birth of the child and expulsion of the afterbirth. In 
the other cases the forceps were used and craniotomy practised.” 
Thus they were probably all head presentations; at least no 
mention is made of a transverse one. 
In a most valuable collection of cases of puerperal convul- 
sions, no less than two hundred and ninety-seven in number, 
published by Dr. John W. Richardson, of Tennessee (Xashville 
Journ. of Med. and Surg. 1872, vol. X., X. S., p. 28), it is un- 
fortunate that no mention is made of the presentation or mode 
of delivery, except in a very few. And while no mention is 
made of transverse presentation, I am sorry to have to leave out 
this valuable collection from our list of figures. Excluding 
them, therefore, let us see how many cases of labor we have now 
put together. They are as follows: 
Dublin Hospital (Drs. Collins, Clarke and Labatt), 48,397 
Guy’s Hospital, ..... 7,404 
Yienna Hospital, .... 134,345 
Dr. Dunn’s obstetric cases, excluding the 228 “ abor- 
tions or premature labors,” . . . 3,872 
Total labors, . . 194,018 
Now, if we add together the several collections of eclampsia 
cases previously cited, viz., Francis H. Ramsbotham’s 59; 
John Ramsbotham’s 16 ; Dr. Merriman’s 48 ; Dr. Lee’s 54 ; Dr. 
Ingleby’s 35, it gives us a total of 212 cases, and this number 
allowing one eclampsia case for every 500 labors, would represent 
106,000 labors. Adding this number, 106,000, to the 194,018 
labors obtained above, gives us a total of 300,018 labor cases, 
with only one distinctly stated instance of the coincident oc- 
currence of puerperal eclampsia with transverse presentation 
during labor. With regard to this one case, we have no concise 
or particular account, which is unfortunate, for a case so ex- 
tremely unique ought to be submitted to a most searching cross- 
examination, both with a view of detecting any possible error in 
the record, and more particularly in order to hnd out any excep- 
tional conditions in the case itself, by which the rare occurrences 32 
King : The Renal Troubles, etc., 
observed might be accounted for. Nothing short of a carefully 
conducted autopsy could render the examination of such a case 
complete, for there may have been (which indeed is not very 
uncommon) an anatomical variation in the position and division 
of the aorta or its branches, or a variation in the number of the 
vertebrae, etc. 
I do not desire, however, to lay any great stress upon these 
possibilities ; as will at once appear when I confess, and proceed 
to explain that the clinical proof of my theory, afforded by the 
foregoing figures, and others might be added, as well as by the 
quoted statements of the several writers alluded to, really 
amounts to very little or nothing. In fact, having built up this 
apparent bulwark of clinical evidence, I must next proceed, as 
fairness demands, to batter it down, if possible. I think it was 
Sidney Smith who said : “ There is nothing so uncertain as fig- 
ures, except facts,” by which I suppose lie means to imply that 
alleged facts are often found to be otherwise, as figures may be 
construed to prove almost anything. Since puerperal eclamp- 
sia—so say the books—only occurs once in about 500 labors, and 
since transverse presentation during labor only occurs once in 
about 230 labors, it would require, excluding any causal relation 
between the two, 230 times 500 deliveries, viz., 115,000 cases, 
to produce a single instance of the coincidence of a transverse 
presentation during labor with eclampsia. No wonder, then, 
that the masters of the Dublin Lying-in Hospital did not meet 
with such a case in their 48,397 labors; and no wonder that the 
general practitioner states that the coincidence is extremely rare, 
for who of us attends 115,000 labor cases? But though the 
evidence thus presented may go for little or nothing, it must be 
remembered that it only refers to the coincidence of eclampsia 
with transverse presentation daring labor. The real question 
we are considering is : Whether eclampsia occurs (and, if so, with 
what frequency) when the child remains oblique, and in the 
dorso-anterior position, above the pelvic brim during preg- 
nancy. That is to say : Given a thousand women in whom 
this normal (or what 1 call normal) attitude of the fetus is 
maintained until approaching full term, and another thousand 
in which the child presents by the head (face or breech), the 
presenting part descending into the pelvic cavity two or three 
months before the full term, in which thousand will the renal 
troubles, eclampsia, etc., occur most often ? Now while, as al- of Pregnancy and Labor. 
33 
ready stated, a clinical record of the first thousand is difficult to 
obtain on account of the necessary examinations not being made, 
because the women suffer no ills requiring a physician, yet it is 
very well known that the oblique position of the fetus is the 
rule in multiparse (in whom eclampsia, etc., are less apt to oc- 
cur), and some lateral obliquity of the uterus and consequently 
of the fetus (the fundus being usually to the right of the lum- 
bar vertebrae) is so common as to be almost universally recog- 
nized as a normal condition, and many theoretical explanations 
have been adduced to account for it. If now we ask ourselves 
why a decidedly oblique position of the child, with its head 
resting upon one of the iliac fossae, is not admitted to be the 
normal attitude during pregnancy, in primiparse and multiparae 
alike, the reasons seem to be wanting, if we except the one 
statement that such presentations are more apt than others to 
result in transverse presentations during labor. But this last 
is a rare departure from the normal course of things: ordinarily 
the oblique presentation does “right itself,” and bring the long 
axis of the child in line with the pelvic axis. As before stated, 
the normal attitude of the child during pregnancy oughti to be 
not only different, but opposite to the normal attitude during 
labor, for the natural purposes of the two periods respectively, 
viz., retention of the ovum and expidsion of it, are directly op- 
posite to each other. 
I do not think there is at present on record any direct clinical 
evidence touching the relation of renal troubles, etc., with ob- 
lique presentations during pregnancy other than that deducible 
from the occurrence of transverse presentations during labor, 
in the very large majority of which last (though not absolutely 
in all) it may be inferred the child was oblique before labor set 
in. There is ample authority for the statement that exception- 
ally, owing to the irregular contraction of the uterus, etc., ahead 
presentation during pregnancy may be converted into a trans- 
verse (oblique) one during labor; such cases have been occa- 
sionally observed. 
While, however, clinical data on the point in question may 
at present be wanting, we cannot help but remark that the con- 
dition of the woman’s nervous system, as regards its so-called 
“ convulsibility,” appears to be peculiarly imexcitable in trans- 
verse labor cases, as is evident from the violent manipulations 
and operations to which the women may be subjected without 34 
King: The Renal Troubles, etc., 
provoking eelampsic seizures, as already noted in the cases 
quoted from Dr. Francis H. Kamsbotham (see p. 26) and Dr. 
Lee (p. 28). It would seem that the peculiar irritability of the 
nervous system, which, during pregnancy, predisposes to spas- 
modic seizures, must have been totally absent in these cases ; and 
which is probably to be referred to absence of aortic and vena- 
caval compression as previously explained (see p. 17). 
In looking through the journal literature of the “ Index Cata- 
logue of the Library of the Surgeon-General’s office,U. S. Army,” 
under the caption of “ Labor Complicated with Transverse Pre- 
sentations,” with a view to discover cases associated with eclamp- 
sia, the research embracing over three hundred journal articles 
(one hundred and sixteen of which I have real with care, and 
the others by title only), each reporting from one or two to six, 
eight, or ten cases, I have found only one in which renal dis- 
ease, albuminuria, eclampsia, and shoulder (transverse) presen- 
tation during labor co-existed. This case occurred in 
the service of Prof. Isaac E. Taylor, of New Fork, at 
the Bellevue Hospital. It is reported in the Amer. Med. 
Times, N. Y., Dec. 1st, 1860, p. 382, and is in many respects so 
interesting, as well as rare, as to deserve special examination, 
though it is to be regretted that the record is in some par- 
ticulars less complete than could be desired. Dr. Taylor has 
kindly sent me, recently, the following brief transcript of the 
case from the hospital record: 
Name of mother, Bridget West; name of father, unknown ; 
nativity, Ireland ; single ; age 28 ; number of pregnancies, first; 
date of last menstruation, Sept. 15th ; date of commencement of 
labor, May 31st, 1860, 6 a.m. ; presentation scapula; child 
turned, died ; mother died of uremic convulsions four days after- 
wards; date and hour of termination, June 1st, 4:30 p.m. ; first 
stage, hours; second stage, 10 hours ; third stage, 15 min- 
utes; number of child, 1; sex, male; weight, 8 lbs.; stillborn. 
The published report of the case in the Am. Med. Times 
contains other points of interest, to wit: On admission the 
patient could “not see out of her left eye, and has not had 
the use of her left leg/or some time.” The muscles of left arm 
are partially paralyzed, so that she carries it in a semi flexed po- 
sition. Sensation on left side of body unimpaired. These motor 
troubles are explained by the revelations of the autopsy, to wit: 
“On section of the substance of the brain no fluid was found in 
the substance of the ventricles. The optic thalamus and the 
corpora quadrigemina of the right side were decidedly softened. 
Vessels over both hemispheres tinged with blood. Slight of Pregnancy and Labor. 
35 
subarachnoid effusion. On the upper posterior portions of the 
posterior lobes there was found a subarachnoid clot (each clot 
about the size of a half-dollar) pressing slightly upon the sub- 
stance of the brain. Kidneys of normal size, fatty, and some- 
what granular. Laceration of cervix uteri two inches long. 
The patient, on admission, was of rather pale complexion, with 
marked edema of lower extremities. Convulsions first began 
one hour after delivery, the labor being 34f hours’ duration. 
Urine at this time (no record of its previous examination) highly 
albuminous, scanty, and high-colored. Urine continued albu- 
minous, though in a less degree, until death of patient on fourth 
day. 
Now, while this case presents the coincidence of albuminuria 
and eclampsia with transverse presentation during labcn■, there 
still remains a doubt as to whether the child was transverse or 
oblique during pregnancy before labor began. In fact, we find 
in the record some circumstances which of themselves suggest 
the probability, or at least possibility, of the presentation hav- 
ing become transverse during labor. First we note that the 
patient was partially hemiplegic on left side for some time be- 
fore labor began, while the autopsy revealed decided softening 
of those parts of the brain by wdiich left hemiplegia would be 
produced. It may well be asked whether such a functional 
derangement of the motor powers would produce irregularity 
or onesidedness in the uterine contractions and bearing-down 
efforts, and thus lead to displacement of the child from its origi- 
nal position. 
Labor began at 6 A.m., May 31st. First vaginal examination 
at 7:30 a.m., found dilatation of os had begun; soft parts in 
good condition ; pains pretty good. No mention of presenta- 
tion. Os not fully dilated till 4 p.m. ; she then had a few bear- 
ing-down pains, when suddenly they ceased. Examination at this 
time, externally and per vaginam, led to the conclusion that the 
position was an unnatural one, but as there was no engagement 
of the fetus, and as the bag of waters remained intact, the exact 
diagnosis could not be made. She continued in this condition, 
and spent a good night, sleeping quietly till 4 a.m. (June 1st), 
when she had a return of her pains, which, however, were so 
slight that when Dr. Taylor saw her again at 1:30 p.m. she was 
walking about the ward. Dr. T. now made out a presentation 
of the scapula. As the bag of waters was still intact, Dr. Taylor 
deemed it best to try first version by external manipulation. 
Several efforts were made to lift the head from the hypogastric 
region and bring it down. These attempts repeatedly failed, 
even with chloroform. On resorting to version by internal 
method, Dr. T. felt what he thought was a hand and foot. He 36 
King : The Renal Troubles, etc., 
brought down the left hand, the palm of which looked down- 
wards and towards the mother's left thigh. Carrying the hand 
to the fundus, the left foot was brought down, and delivery 
completed at 4:30 p.m. She remained comfortable about an 
hour, when convulsions came on, and were repeated every hour 
or two during the night, etc. (See Americ. Med. Times.) 
Such are the items of interest from the published record. I 
must call attention to the circumstance that no suspicion of a 
transverse presentation was recorded after the first examination 
at 1.30 a.m.j and not until after the bearing-down efforts had 
suddenly ceased at 4 r.M., the bag of waters not being ruptured 
and the os uteri fully dilated. It is curious, also, that the head 
is recorded to have been in the hypogastric region, instead of 
in an iliac fossa. Can it be that the case was originally a head 
presentation, and that the shoulder was forced down during 
labor—the head partially receding—when the pains suddenly 
ceased ? That the pains frequently cease in cross-births after 
the rupture of the membranes is fully understood, but that they 
should do so with the os fully dilated, and without rupture of 
the sac, is not so easily explicable. That the shoulder pre- 
sented when Dr. Taylor felt the scapula at 4.30 p.m., May 31st, 
after the labor had gone on ten hours, cannot be doubted ; but 
that it presented originally, or that the child was transverse 
during pregnancy, must, under the circumstances, ever remain 
in doubt. In contracted pelvis, cases have been observed 
(Denman) in which, on examination, the head was found pre- 
senting, while on subsequent examination the arm was dis- 
covered presenting, the head having receded. However, not to 
prolong the discussion of this case, it may be fairly stated that 
evidence in proof of the child having been transverse before 
labor began is wanting, and cannot now be supplied. 
Of the other case reported in the statistics of the Vienna 
Hospital I have no particulars whatever. In any future cases 
of the occurrence of this rare coincidence, it may be hoped all 
sources of error will be eliminated by a complete history of the 
case during pregnancy, and, in case of an autopsy, that search 
be made for anomalous variation in the division of the aorta 
and in the distribution of its branches. In Quain’s “ Anatomy 
of the Arteries ” (London, 1844, p. 415), we find the following 
abstract, giving the place of division of the abdominal aorta in 
4fi- bodies examined : of Pregnancy and Labor. 
37 
The division occurred on the 
third vertebra (lumbar) : 
above the middle, 1 
on “ “ 2 
below “ “ 3 
6 
The division occurred between the third and fourth 
vertebra, ........ 
12 
The division oc- 
curred on the 
fourth vertebra: 
above the middle, . . 43 
on the middle, or nearly so, 36 
below the middle, . 47 
126 
The division occurred between the fourth and fifth 
vertebra, 30 
The division occurred on 
the fifth vertebra : 
above the middle, 21 
below “ “ 1 
22 
196 
Hence it is evident that in considering the question of uterine 
pressure upon the aorta and its branches we cannot assume, as 
is usually done, that this blood-vessel is always located and 
divided in the same place, and every autopsy (in cases dying of 
eclampsia) which essays to be complete must include an exam- 
ination of this matter. Dr. Quain further tells us (p. 417) that 
the end of the aorta, instead of being always to the left of the 
median line of the body, is “ frequently observed lying on the 
middle of the bone, without any deviation to either side, and in 
a few instances it was inclined to the right of that point.” This 
also, in considering the theory of uterine pressure, should receive 
attention in post-mortem examinations. 
Leaving it, therefore, for future clinical observations to deter- 
mine whether the uremia, eclampsia, etc., of pregnancy will 
occur when the child remains oblique and above the brim during 
pregnancy, it may here be further remarked that observations 
as to the position of the fetus during the several months of 
pregnancy, and as to the frequency of eclampsia during the 
several months, show a remarkable synchronism between eclamp- 
sia and 'W/ioblique positions of the child. Thus cases of eclamp- 
sia are exceedingly rare before the sixth month of pregnancy, 
and are more and more likely to occur during the several suc- 
ceeding months ; so we find from the results of observations 
made by Dubois at the Maternity Hospital of Paris “ that the 
position (presentatiou V) of the fetus, with the head lowest and 
over the os uteri does not begin to be assumed till about the end 
of the sixth month, and that it is taken up with increasing fre- 38 
King: The Renal Troubles, etc , 
quency and certainty from that period onwards to the full term 
of pregnancy.” (Leishman’s “System of Medicine,” Third 
Am. ed., 1879, p. 128.) 
To this statement I may add that during the first few months 
of pregnancy the uterine walls are (comparatively) solid and 
inelastic, while the fetus is soft; but there comes a time later 
on—beginning about the sixth or seventh month—when the 
solidity and inelasticity of the fetus increase, while the womb 
loses these qualities and becomes soft, supple, and elastic to such 
a degree that the formerly soft embryo is now sufficiently solid 
to give shape and position to the uterine cavity surrounding it, 
when, and still more so as pregnancy advances, the posture of 
the fetus becomes susceptible of change by forcible impressions 
made upon the exterior of the abdomen by corsets, dress, etc. 
And thus it would appear the normally “ transverse ” (really 
oblique) position of the fetus is more likely to be disturbed by 
these external impressions after the sixth month, and hence the 
greater liability to albuminuria, eclampsia, etc., after that time. 
As relevant to the causes of the normal attitude of the fetus 
in utero, about which there has been so much discussion and 
difference of opinion by Dubois, Simpson, Scanzoni, Duncan, 
and others, it may be of interest here to observe that the matter 
will be at once simplified, and the inquiry substantially changed, 
when we recognize the oblique position as being normal, and 
the presentation of a head as an abnormal deviation produced 
by external factors, for then the gravitation theory will not be 
so easily called in question, inasmuch as Dubois ascertained by 
plunging the fetus in water and suspending it by the funis, that 
it was not the head, but the scapula or back which hung down- 
wards and first touched the bottom of the vessel (Leisliman, p. 
126). Thus while the fetus floats during the early months, it 
would gravitate (the woman being erect) into an oblique or 
shoulder “ presentation,” the “ position ” being dorso-anterior, 
and it is probable this early posture, in the absence of disturb- 
ing influences from without, would persist during the later part 
of gestation, or until within a few days of delivery. 
21. Treatment Deducible from the New Theory.—If the 
theoretical views now presented be true, the treatment deducible 
from them will be easily reached. To prevent albuminuria, 
nephritis, etc., during pregnancy, the causes interfering with 
normal obliquity of the child (viz., corsets, coitus, etc.) must be of Pregnancy and Labor. 
39 
removed or forbidden. After the third or fourth month, when 
the womb begins to rise out of the pelvic cavity, every impedi- 
ment to its assuming its normal oblique position should be, 
even thus early, interdicted ; and so with every influence likely 
to (as Dr. Barnes puts it) “ drive ” or “ force ” the womb down 
into the pelvic cavity, whether during the ulast three months” 
or the preceding three. Everything likely to disturb the (as 
already described) nicely adjusted balance between the forces 
determining the ascent and descent of the pregnant womb must 
be avoided or removed. (See pages 19, 20.) 
WlieD, on examination during the later months, the womb 
and child are found tmoblique and forced prematurely into the 
pelvic cavity, the faulty position must be remedied. To do this, 
I should be inclined to recommend complete anesthesia to relax 
the abdominal wall, and then bipolar manipulation, lifting the 
lower segment of the womb and child out of the pelvic cavity 
and towards that iliac fossa opposite to the side on which there 
still remains a slight deviation of the fundus (such will usually 
be the case) with one hand, and with the other assist the fundus 
to get 7nore decidedly on the side of the lumbar vertebrae. 
Placing the woman continuously, for a few days perhaps, in 
the latero-prone position and on her right side, the hips ele- 
vated on pillows, or for a short time in the genu-pectoral posi- 
tion, might accomplish the result, even without manipulation 
per vaginam. 
Should the worst have almost come to the worst, with pro- 
nounced albuminuria, nephritis, and even eclampsia, there 
would still be substantial hope that the alarming phenomena 
would disappear by replacing child and womb obliquely above 
the brim, thus relieving renal congestion and cerebral arterial 
tension, as well as the “ uterine irritation ” of a prematurely 
distended cervix, etc. Whether the desired replacement will 
be accomplished by posture alone, or by manipulation alone, or 
by both combined, future clinical experience must determine. 
Fortunately, however, wTe are not even now entirely lacking 
in clinical demonstration of the methods suggested and their 
utility. 
Dr. Barnes (“ Syst. of Obstet.,” p. 301-302), under the caption 
of “ Postural Treatment ” of puerperal convulsions, tells us 
that “ Graily Hewitt and Routli, believing that the disturbances 
of the abdominal and renal circulation, caused by pressure of 40 
King : The Renal Troubles, etc., 
the gravid uterus, exercised a powerful influence in provoking 
eclampsia, placed the patient in such a position as to diminish 
this pressure. Routh had seen marvellous benefit from the 
knee-elbow posture.” Dr. Barnes only adds on this matter the 
following brief comment: “ It must often be difficult to adopt 
this posture; but the side or semi-prone posture may be tried.” 
This brevity is perhaps to be accounted for by the circumstance 
that he does not believe in the “ pressure theory ” of eclampsia, 
etc., but refers them more directly to “ changes in the blood.” 
I have not been able to find any record of Hewitt and Routh’s 
observations, except that of one case by Dr. Routh (.Brit. 
Gy nee. Jotirn., vol. I., p. 315) mentioned by him before the 
Brit. Gynecological Society during a discussion in which he 
said “ he had already mentioned elsewhere (reference not given) 
a case of long and continued eclampsia, in which the prolapsed 
cord had slipped out, but the moment he placed the woman on 
her belly (?) to induce its resuming its normal position, the fits 
stopped and did not recur. He explained this by the removal 
of pressure, and Dr. Bantock had also noticed that large fibroids 
of the uterus had induced albuminuria which at once disap- 
peared on removal of the tumor, from the cessation of pressure, 
as he (Dr. Bantock) also believed.” In a subsequent discussion 
before the same Society (Part Y. of Journal, May, 1886, p. 38) 
Dr. Routh again mentioned this case, saying: “ It was a shock- 
ing case to look at, and had resisted treatment. When being 
about to deliver by forceps,1 the cord prolapsed. He placed 
her on her belly to allow reduction of the cord, after Dr. Simp- 
son’s method. The cord was reduced, and the convulsions at 
once ceased, the pressure being thus removed from the kid- 
neys” (?). Ho comment appears to have been made by the 
Society on Dr. Routh’s observation. Dr. Bantock’s observations 
(mentioned by Routh) refer to a case of fibroid tumor in which 
there was pronounced albuminuria and general anasarca. Within 
twelve hours after removal of the tumor there remained only a 
trace of albumin, and within three days the anasarca had dis- 
appeared. In a case of ovarian tumor, the albuminuria disap- 
peared even after a preliminary tapping {Brit. Gynec. Journ., 
vol. I., p. 311). 
With relation to Dr. Routh’s case, it is scarcely possible to 
agree with him in the remark that the immediate cessation of 
1 It was, therefore, presumably, a head presentation. of Pregnancy and Labor. 
41 
the tits was clue to removing pressure from, the kidneys. Ure- 
mic contamination of the blood could not have been so rapidly 
relieved. I should rather believe the convulsions ceased because 
removal of pressure from the aorta and vena cava at once re- 
lieved tension of the cerebral arteries, and allowed the normal 
proportions of venous and arterial blood in the brain to be re- 
instated. (See caption 17, p. 17). And again, the genu-pectoral 
position relieved the distended cervix and os uteri from the 
pressure of the presenting head, thus removing a peripheral ex- 
citor of the eclamptic paroxysms. 
I)r. Lusk (“ Sci. and Art of Mid.,” p. 571) remarks that “ Loh- 
lein recommends placing the woman in the latero-prone posi- 
tion, in ordei to diminish as much as possible the pressure upon 
the ureters and upon the renal veins ” (?). Dr. Lusk makes no 
farther comment on this method. 
Dr. Aveling (on “ Posture in Gynecic and Obst. Pract.,” p- 
132) states that the postural treatment of convulsions may be 
preventive or curative, and both ends are to be obtained in the 
same manner. He recommends that patients during gestation, 
suffering from albuminuria, should not remain upright longer 
than necessary. “ When convulsions have arrived, and parturi- 
tion cannot be completed, such posture should be recommended 
as will remove the uterine pressure. The semi-prone position, 
with the hips raised, would be the best.” He, however, gives 
no clinical data, farther than to refer to the case published by 
Dr. Brown-Sequard, and of which also Dr. Bedford says : “ Dr. 
Brown-Sequard lias positively ascertained the influence of pres- 
sure upon the renal vessels in a lady who had albumin in her 
urine during the ninth month of pregnancy. He placed her in 
such a position that the pressure was much diminished, and after 
a certain time the urine ceased to contain albumin. When the 
ordinary attitude was resumed, there was soon a reappearance of 
albumin in the urine.” (Bedford’s “ Obstet.,” 3ded., 1867, p. 508). 
I cannot assent to the relief being due to removal of pressure 
upon the renal blood-vessels, as I have already explained. But 
no matter about this: for, if placing the woman in a posture 
that will divert uterine pressure from the spinal column towards 
the abdominal wall, and from the pelvic cavity towards the dia- 
phragm, will relieve the renal trouble; that is what we require. 
If it be objected that placing the woman in the genu-pectoral 
position, when eclampsia occurs during labor, would cause the 42 
King: The Renal Troubles, etc., 
presenting part to recede and thus retard the delivery, it may 
be replied that the temporary maintenance of this posture, say 
for an hour or two, or even longer, if necessary, might so far re- 
store the normal proportion of venous and arterial blood in the 
nerve centres as to reduce the “ convulsibility ” of the nervous 
system, and permit of speedy delivery by podalic version, the 
patient being now able to bear thenecessary manipulation with- 
out an eclampsic tit being excited. Moreover, the peripheral 
excitor of the convulsion—pressure of the os and cervix uteri— 
would be relieved. Furthermore, most cases of eclampsia during 
labor are to some extent premature labors. If, therefore, the 
genu-pectoral posture should postpone delivery (the waters re- 
maining intact), so much the better, provided the complication 
of eclampsia and renal trouble were removed. 
22. Evidence conflicting with the theory.—On this point it 
may be said, first: that while head presentation, with (in prim- 
iparse) descent of the head below the pelvic brim “three 
months ” before full term, is so common as to be recognized as 
the usual condition (see Lusk’s “ Sci. and Art Mid.,” 3d Am. 
ed., pp. 84, 91; and Barnes’ “ Syst. of Obstet.,” 1st Am. ed., 
1886, p. 200, 201), yet renal troubles, albuminuria, uremia, 
and eclampsia are comparatively rare. To this statement we 
may reply that, in all pathological conditions, the factors or 
causes of disease exert their deleterious effects in diflerent de- 
grees. Nature is adequate, in many instances, to contend against, 
compete with, and outvie the evil by compensative processes. 
And again in some, perhaps many cases, the (what I call) 
abnormal position of the child may, owing perhaps to large size 
of the pelvis or other unknown circumstances, occur and be tol- 
erated without material ill effects, or only with moderate func- 
tional derangement; while in others the worst results are pro- 
duced. Thus we find albuminuria, etc., during pregnancy, in 
all shades of degree. We find it to appear and disappear—to 
come and go—just as might be expected from movement of the 
uterus, or active motions of the child, or change of posture of 
the patient, these changes altering the degree of pressure made 
upon neighboring blood-vessels. I have nowhere contended that 
want of fetal obliquity and the occurrence of descent of the 
head will always lead to renal trouble ; but rather that, when 
the child remains obliquely above the brim, etc., renal troubles 
etc., will not occur. of Pregnancy and Labor. 
Secondly: It may be objected that when albuminuria and 
uremia have occurred, they are often relieved by medicinal and 
other remedies while the position of the womb and fetus still 
remains unchanged. This is undoubtedly true. But, on the 
other hand, we recognize in these methods of treatment com- 
pensative processes by which the evil has been mitigated and 
perhaps the epoch of severer danger postponed. Surely there 
are other cases in which such compensative measures utterly 
fail, and premature labor, with death of child and mother, occur 
in spite of treatment. Furthermore, who shall say that restora- 
tion of the child and womb to their normal (?) position would 
not be a more speedy and preferable method of treatment than 
prolonged medication with violent drugs ? If the genu-pectoral 
posture will relieve immediately, it should be practised, and the 
drugs be discarded. 
Thirdly: It is often alleged that eclampsia, etc., occurs with 
more frequency in narrow pelves, in which there is also a greater 
frequency of transverse presentation. I reply that this refers 
to transverse presentation during labor. Narrow pelves are 
exactly those cases in which head presentations before labor are 
liable to change to oblique ones during labor. Moreover, it 
may still be questioned whether the statement that eclampsia 
and contracted pelves are frequently coincident be really true. 
We need further information on this point. Otto Spiegelberg- 
states (“ Trans. Am. Gynec. Soc.,” vol. II., p. 165) that “ eclamp- 
sia is remarkably frequent in twin pregnancies, although it has 
been proved by statistics not to be so in or with 
narrow pelves ” (Spiegelberg quotes from Lohlein, in the 
Zeitschrift f. Geburtshulfe u. Frauen hr an khe iten, I., 1875, p. 
64). 
Fourthly: The theory I have presented fails to explain the 
occurrence of uremia, eclampsia, etc., in the early months of 
pregnancy, as well as the cases of eclampsia that occur after 
delivery, unless we conceive, with respect to the latter, which is 
not unreasonable, that the ordeal of a long labor, coupled per 
haps with laceration of the cervix or other soft parts, and with 
exhaustion or hemorrhage, were, to speak figuratively, last 
straws on the camel’s back, by which the final overthrow of the 
nervous system into an eclampsic paroxysm, was brought about. 
The convulsion, it should be remembered, is often one of the 44 
King : The Renal Troubles, etc. 
final phenomena—the last link in the chain of a long series of 
antecedent pathological conditions. 
23. Conclusion: Fully aware that the views I have main- 
tained are, in the main, theoretical, and that they require clini- 
cal evidence to prove or disprove them, I hope the subject has 
been presented in such a manner as will lead to new lines of 
research which may end in some practical good. Especially is 
it desirable that we should study again, and, if necessary, recon- 
struct our ideas of what constitutes the normal attitude of the 
infant during the later months of pregnancy. I cannot dismiss 
the idea that the recognition of an oblique, dorso-anterior posi- 
tion above the pelvic brim, during the later months, as the 
truly physiological attitude for both primiparse and multiparse 
will open a door for the philosophical explanation of phenomena 
that have hitherto been puzzling and inexplicable both in the 
domain of pathology and physiology. 
In conclusion, I beg to acknowledge my indebtedness to the 
library of the Surgeon-General’s office, U. S. Army, for the 
facilities for research it has afforded me in the preparation of 
this paper; and it gives me pleasure to tender my most cordia 
thanks to the kindly assistance given me by Drs. J. S. Billings 
and Robert Fletcher, of the Surgeon-General’s office, as well as 
by Dr. Thos. W. Wise and his assistants in the library. I must 
also tender my thanks to Dr. Thomas J. Chew, of the “ Washing- 
ton Asylum ; ” to Dr. P. J. Murphy, of the “ Columbia Hos- 
pital,” of this city; and to Prof. Thos. Opie and his assistants, 
Drs. L. F. Ankrim and W. P. Spratling, Jr., of the “ Maryland 
Lying-in-Asylum,” for their kind assistance.