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CARELESS AND UNSCIENTIFIC MIDWIFERY,

WITH SPECIAL REFERENCE TO SOME FEATURES OF THE WORK OF MIDWIVES.

READ BEFORE THE MEDICAL AND CHIRURGICAL FACULTY OF THE STATE OF MARYLAND AT ITS NINETY-SEVENTH ANNUAL SESSION, APRIL 23-27, 1895.

By W. S. Smith, M. D.,
Physician to the Police Department, Baltimore.

IN the performance of the various duties that belong to our profession we are ofttimes brought in contact with conditions which arouse our sympathy as well as demand our scientific aid.

In my own professional career nothing has thus far so deeply impressed me as the observations made in the lying-in chamber, where the parturient woman has to undergo not alone the unavoidable and natural pains of childbirth, but too often, also, the far more serious suffering brought upon her by the gross manipulations and hazardous practices of ignorant and officious midwives. These observations, I regret to say, have lately happened with such frequency as to induce me, or, I could more truly say, provoke me, to present this paper to the Faculty; and if I should succeed in attracting your attention to the subject, I shall feel that my crude remarks upon a commonplace and uninviting topic are not altogether valueless. Such a hope, at least, together with a sincere desire to assist, however feebly it may be, in the satisfactory solution of a perplexing problem, constitute my only apology for appearing before you on this occasion.

I know full well that there is no necessity for me to adduce arguments or relate experiences to you to show the incompetency of midwives as we meet them at the present day. Three-fourths of them have absolutely no knowledge of the physiology of labor, or of the dangers to which a lying-in woman is exposed. It is therefore a reasonable and natural deduction that almost everything they do is in violation and defiance of the well known principles applicable to scientific midwifery. Since, however, I am so unfortunate as to reside and practice in a community where they are es

pecially numerous, and it is thought especially unskillful, I have thought that a brief reference to recent cases illustrative of their more common and dangerous procedures might not be uninteresting.

Mrs. K., aged 22 years, was confined in December last; she was a lady with excellent personal and family history, muscular and well-developed, with ample pelvis and normal birth-canal. One week after her confinement I was called to see her in spite of the protestations. of her nurse that she only had "malaria' and would soon be "all right." Her peculiar appearance and the offensive odor emanating from her at once led me to suspect septicemia, and upon examination. my suspicions were confirmed. I found a mass of putrid placental debris in the uterine cavity and a deep laceration of the cervix. The usual treatment of cleaning out the uterus, applying hot carbolized vaginal douches and administering supporting remedies, was at once instituted, but although her temperature fell somewhat, she soon succumbed to the septic intoxication. The husband informed me that she had been given a large amount of ergot in the beginning of labor, which, to my mind, satisfactorily explained the laceration of the cervix, the difficulty in delivering the placenta, as well as the sad events which followed.

Another case of a different character was that of Mrs. F., a young woman whose general health was good, but who had a contracted pelvis. This was her second unsuccessful attempt at delivering a living child, and her sister had died shortly after an instrumental labor. These facts were well known to the midwife, who, notwithstanding, had been

in attendance forty-eight hours when I was called. I found that the membranes had been ruptured and that the uterus was in a state of extremely rigid and tetanic contraction due to the influence of about two ounces of ergot, which had been administered to her, as was said, to expedite (?) her labor. Efforts at version proved unavailing, and not having the necessary instruments, I sent for Dr. L. E. Neale, of this city, who with my assistance, and that of a great deal of perseverance and physical prowess, finally succeeded in delivering by means of cephalotripsy. Fortunately, this woman's uterus was not ruptured, and by the assiduous use of antiseptics, infection was prevented; but it was not through any want of carelessness or of vigorous efforts to force delivery through an impassable mechanical obstruction that she did not meet with the same fate as the lady to whom I have just referred.

I will cite another case, that of Mrs. E., a multiparous woman, who had previously had no difficulty during the parturient period. She had been in labor only about two hours when I was sent for in great haste in the middle of the night; this time the midwife wanted

me.

Hurrying to her bed-side I found an absolutely normal presentation; in fact, the child's head was resting on the perineum almost at the vulvar outlet, but all pains had ceased. Nothing could be easier. The forceps were applied, the head was simply lifted from its resting place, and delivery was completed without the slightest trouble. Here was a case of simple uterine inertia, with a non-resistant perineum in which an oxytocic was clearly indicated, and would have given relief in a short time. None, however, had been employed, and the greatest fears were entertained for the woman's safety.

In the practice of a certain other woman, whom I have in mind, I was for a time somewhat at a loss to understand the remarkable number of still-births. As they occurred for the most part in healthy multiparae, I concluded that the cause could be traced to her rather than to any abnormalities with which she had to deal. After I had learned

the extent of her obstetric work and discovered the freedom with which she used her "forcing drops" the mystery was cleared up. At least, in several cases I am able to say that every other cause was carefully excluded, and I was irresistibly led to believe that nothing else explained the fatalities. The mode of action of ergot in these cases being a mechanical compression of an incarcerated cord, an interference with uteroplacental circulation, or a peculiar toxic influence which it is known to have.

Many other cases might be cited, but these few I think will bear me out in saying that monthly nurses are almost always utterly ignorant of the conditions with which they have to deal, entirely unfamiliar with the indications for the use of drugs, inexcusably negligent in not calling for aid when they know it is required, and criminally culpable for their assumption of the functions of a physician in the most serious cases. The injury that is being done by these. audacious and unskilled individuals, both in the sacrifice of human life and the production of chronic invalidism, is simply incalculable. Tarnier, the celebrated French obstetrician, has said "In the country as in the town, in the most magnificent palace as in the humblest cottage, the enemy of the lying-in woman is the microbe." This is a forcible statement of a scientific fact, and I would not amend it save to say that it is not the microbe per se that is at fault, but the hand which permits or causes its transportation to the vulnerable parts of woman's organism. And the typical old gin - guzzling midwife, with her pockets full of pockets full of forcing drops," her mouth full of snuff, her fingers full of dirt and her brains full of arrogance and superstition, is at least the greatest palpable enemy of a physiological puerperium. There is, as I have intimated, something peculiarly pathetic in the death of a woman under such circumstances as I have related; and while I would not raise my hand to hinder any human being in the proper pursuit of an honorable avocation, I think that some corrective influence should be brought to bear upon this stupendous wrong.

·

In other countries, notably in England, Germany and Denmark, especial precautions are taken by police and sanitary authorities to supervise the work of midwives and hold them to strict account ability. Indeed, in many of our own large cities the question has been agiiated with more or less effect. Is it not time that we also should take some decided steps in this direction?

I shall now speak of the attitude and hrabit of the general practitioner in his. obstetric work. The wonderful achievements of recent years point unmistakably toward the path along which a practically unanimous profession will eventually tread. Indeed, all specialists in this line and all the large Maternities are at present pursuing substantially the same course in obstetric management. But among private practitioners there is still shown an adherence to antique methods which is greatly to be deplored. Why this should be, it is somewhat difficult to explain. BacteriBacteri ology, that prolific realm in the microscopic world, is, as we must admit, often based on uncertain theories, and is still chiefly an experimental branch of pathological research; but, new though it is, it has already led to the most brilliant practical results, and has influenced to a greater degree our knowledge and our treatment of disease than any other department of medical science. And, among its accomplishments, nothing, it seems to me, should be more cheering and gratifying to us than the light which it has thrown upon the subject of puerperal infection. I think we may safely say that the introduction and scientific application of asepsis and antisepsis to surgical and obstetric practice marks the greatest advance in medical science which the present century has seen. It is now almost universally admitted that the so-called accidents and complications of the puerperal state are due to an infection, that the infecting agent is a micro-organism which gains entrance to the blood through some part of the genital tract, and that unless such organism be introduced these affections will not take place. And yet there are practitioners who hoot the idea of the

aseptic or antiseptic management of labor. I would not be considered an enthusiast on this subject, but, if err I must, I would rather err upon the side of unwarrantable enthusiasm than upon that of unjust and unreasoning apathy. I would not be carried away by the alluring suggestions and golden promises that are being held out by microscopists throughout the world, for "Oft expectation fails, and most oft there where most it promises;" and, on the other hand, I would not be so blinded by custom and prejudice as to fail to recognize and profit by the enduring and substantial facts which have been laid before us.

Many honorable and able physicians do not follow aseptic and antiseptic principles because they considered them superfluous. They have had, they say, hundreds of cases of confinement without losing a single patient. This at first sight seems a strong and convincing argument, but, while they may not have had a death from what they choose to call puerperal metritis, peritonitis, or even acute puerperal septicemia, if they would go a little beyond the usual period of the lying-in and search for their cases of pneumonia, pericarditis, endocarditis, arthritis, abscess and typhoid fever, they would find many of them traceable to puerperal infection. Besides this, mortality alone is not the only factor to be taken into consideration. Innumerable cases of permanent ovarian, tubal and uterine disease date their origin from the parturient chamber. Another argument used by the opponents of scientific midwifery is that labor is a natural process, and requires, as a rule, no scrutiny or precautions on the part of the accoucheur. This is equally untenable, for no matter how naturally or with what comparative ease a woman may pass through her confinement, she is in all cases a wounded woman; presenting to us, not only the extremely sensitive and receptive uterine wound, but numerous tears, contusions and abrasions of the genital tract, which, while they may not be perceptible to us, are yet sufficiently large to admit myriads of pathogenic microbes. There is always a certain

amount of traumatism connected with the parturient act, and no woman can with scientific accuracy be said to be free from danger because her labor has been normal. Then again it has been said that aseptic midwifery involves an expenditure of money and a waste of time, and is for that reason inapplicable in many cases. The truth is that, with a proper appreciation of the object to be attained, it may be so simplified as to be practicable in any household. Fortunately, public sentiment is being enlightened on this subject and is beginning to demand the advantages of scientific work in midwifery. And, as we are in a certain sense the guardians of those who have committed their physical welfare to our professional keeping, we should feel that they have a right to demand the best treatment which knowledge and experience have placed at our disposal, and that ours is the duty to give it to them. Real progress in science cannot be measured, as we know, by laboratory researches, but by the degree of service which such researches render the physician in the advancement of the healing art.

ner.

I began my paper in an apologetic strain, and I shall close it in like manI am conscious of the fact that I have offered nothing new, and that to most of you my remarks seem like a thrice-told tale. It may be, however, that there are some general practitioners among us who, like myself, have not hitherto sufficiently appreciated the importance of the work that is going on around us. To such especially would I direct my humble effort, with the hope that in our future labors in this important field we shall look with greater favor and consideration upon the magnificient results which have been obtained by the faithful observance of aseptic and antiseptic methods. I do not know to what extent the Faculty has in former years considered or discussed the subject of midwives, but I am convinced that there is urgent need for some definite co-operation on the part of the profession designed to restrict, if not to eradicate, the great evils which flow from the unbounded and unguided freedom with which careless and ignorant women are accustomed to pursue their self-appointed work.

THE EXTERNAL APPLICATION OF PILOCARPIN IN NEPHRITIS.-Mollière (British Medical Journal) advocates the treatment of the various forms of Bright's disease by the inunction into the skin of the trunk of a dilute ointment of nitrate of pilocarpin. This method of administering pilocarpin was first suggested and applied, chiefly for affections of the joints, by the author's brother, Daniel Mollière, in 1882. He believed that he in this way secured a purely local diaphoresis with a minimum dose of the alkaloid, and without the inconveniences and dangers (collapse, etc.) which sometimes attend its subcutaneous injection. The modus operandi in cases of Bright's disease is as follows: An ointment is made of nitrate of pilocarpin with white vaseline I in 1000 or 2000. About 3 iij of this is rubbed into the skin over the whole of the trunk, which is then enveloped in a

thick layer of cotton wool and waxed linen, the whole maintained in place by bandages. This "carapace" may be left on for several hours, or even until the reapplication of the dressing on the following day. In ordinary cases this treatment may be repeated daily for ten to fifteen days. Mollière finds the results of this treatment exceedingly satisfactory, even when, as in his later cases, the usual restriction of diet and other routine treatment have not been combined with the inunction. In acute cases threatened uremia is averted and the dyspnea is relieved; there is profuse diaphoresis and salivation, increase in the amount of urine, and diminution of albumen, and a rapid disappearance of anasarca. The cure is rapid and complete. In chronic cases he claims that it produces greater alleviation of symptoms and prolongation of life than any other remedy.

SOCIETY REPORTS.

ASSOCIATION OF AMERICAN
PHYSICIANS.

TENTH ANNUAL MEETING, HELD AT THE ARMY
MEDICAL MUSEUM AND LIBRARY, WASHING-

TON, D. C., MAY 30 AND 31, 1895.

THE meeting was called to order by Dr. William Osler, who delivered the President's Address, in which he asked how far the Association had fulfilled the object it had in view at the beginning, and if the aspirations and hopes had been realized in the advancement of scientific medicine. This was an organization with no code of ethics, no medical politics; no one cared who were the officers and who were not. It was not asked from what part of the country a member came, but has he done good work, and still more if he has anything worth saying and can he say it? Nine volumes of transactions show what has been done. Some of the most noteworthy papers of the past ten years have been brought to light before this association and all the questions of the day have been discussed. The clas

sical works of Fitz and Draper have been brought before the Association, and in the discussions such subjects as the diagnosis of diseases of the stomach, of the pancreas, dysentery, infarction and other affections of the bowels, heart disease, sclerosis of the arteries, the mutual relation of renal, arterial and cardiac changes, anemia and chlorosis, thrombosis in chlorosis, myxedema treated with thyroid extract, removal of the ovaries and tubes, subphrenic abscess, acromegaly and lead poisoning

had all been discussed.

Dr. Osler said "Our Association has had already a potent influence on the study of pathology and clinical medicine in this country. We need, however, a larger growth of men who are devoting themselves exclusively to these branches. The rapid progress of the medical schools has increased the number of teaching positions in the scientific branches and there is at present an actual scarcity of thoroughly trained pathologists and bacteriologists to fill them. There is no need to insist upon

the necessity of accurate and careful training in the development of workers. in these branches. I do not think the profession of this country understands as yet the art of training special clinical physicians who have taken too much for granted that such men develop readily in the routine of family practice. True, along this path some of the most noted men of our ranks have traveled, but the time has come when able young men should be encouraged to devote themselves to internal medicine as a specialty, content to labor and wait during the first ten or fifteen years of professional life with pathology as the solid basis of development. Such men will pass to the wards through the laboratories thoroughly equipped to study the many problems of clinical medicine, they will gain the confidence of their professional brethren and by their accuracy and skill through them will reach the public and a large practice. Such an opportunity and career is within the reach of every physician in any city with a hospital of fifty beds."

Dr. Osler then referred to the fact of a number of members that had died since the formation of the Association and particularly eulogized Drs. Alfred L. Loomis and Wm. C. Dabney, who had died in the past year.

Dr. B. K. Rachford of Cincinnati then read a paper entitled Leucomain Poisoning, in which he said that this kind of poisoning might manifest itself in a true migraine, as a migrainous epilepsy, or as a migrainous neurosis. In these cases he had by carefully examining the urine isolated two substances, xanthine and paraxanthine, which were evidently the cause of these troubles. These were present nearly always during the attacks and disappeared in the intervals. Usually it took a large quantity of urine to discover even a trace of them, but in these attacks they were easily isolated. In his experiments he found that the permanganate of potassium was an antidote and had used it in some cases with success.

Dr. F. P. Kinnicutt of New York asked if he had examined the urine in cases of tetanus. He had had two cases

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