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and the introduction of antisepsis into surgery by Lister, 1872, and later the adoption of antisepsis and, finally, asepsis into the practice of midwifery, it appears as though not much is left to be done.
It has been asked: "What more do you want?" The answer is: Facilities for teaching midwifery; so that every woman in the land may enjoy the benefit to be derived from a thorough knowledge of the science and art of obstetrics. In Germany, France and England, and to a considerable extent in this country, the theoretical and practical instruction given in this department has made great progress within the last fifty years. Still, in many of our medical schools, practical instruction in obstetrics is sadly neglected. There has been of late years a marked and rapid progress in the manner and method of teaching and healing art in America. Indeed, it may be truly said that many of our medical colleges are fully equal to some of the best colleges abroad. Among the list of able and faithful teachers and practitioners of midwifery whom this country has produced, but a few have left indelible foot-prints for our guidance upon the path of obstetric progress. Most prominent of those who adorn the pages of history are Wm. P. Dewees (17681841), who first called attention to the dangers of cardiac thrombosis in child-bed, and Hugh L. Hodge, of more recent date, who constructed a pair of forceps, still extensively employed. He was also the inventor of a pair of craniotomy scissors, placental forceps, and a cranium depressor. Marmaduke B. Wright, of Cincinnati, first described and published, 1854, the combined method of version; it is one of the most important manipulations to correct abnormal positions of the child in utero. Wright's publication antedates Braxton-Hicks. But the latter, living in London; and the former in Cincinnati, accounts for the fact that this method of version is known as that of Braxton-Hicks. It is no compliment to American authors on obstetrics to have neglected the merits of M. B. Wright. The only one who mentions Wright and gives him full credit, is that famous author and teacher, Theophilus Parvin. John Stearns, in 1807, discovered the use of ergot and its effect upon the womb. Jackson, of Boston, in 1847 first used in this country sulphuric ether during labor. The names of G. S. Bedford, W. H. Byford, Penrose, I. E. Taylor, Fordyce Barker, Albert Smith, Ellwood Wilson and Theophilus Parvin also merit mention. The writer here takes the opportunity to place on record the fact that the tincture of veratrum viridi is the most important remedy in the treatment of eclampsia. It was first employed by Dr. Baker, of Eufula, Alabama, in 1859. It is the remedy par excellence in the treatment of puerperal convulsions.
Does it not appear strange that with such a list of distinguished accoucheurs the teaching of practical obstetrics has, until of late, found so little favor with the profession in the United States? Up to within the last generation pictures and manikins, were considered to be amply sufficient to illustrate and teach successfully the most complicated and difficult phases of natural as well as artificial delivery.
With the advent of improved microscopy new and attractive fields for investigation and research have been opened, and the energy and ambition of the student and young practitioner have naturally drifted in that direction. Everyone appears anxious to discover something new. Because of this other equally and more important branches of the medical science have been sadly neglected. Again, the tendency of the present day is distinctly, and with perfect propriety I admit, towards specialism. A reputation may be quickly made in a specialty. It usually means less work and better pay. Obstetrics as a specialty has received the least attention. Because it not only requires extensive knowledge and considerable responsibility, but it also entails hard work, loss of sleep, and frequently very little or no pay. All this in connection with popular prejudices, social and religious, professional and political, has kept the art of obstetrics in the background and the student as well as the young practitioner, is disposed to regard obstetrics of secondary importance. Add to this that every one who, within the past 75 years, has made an attempt to raise the standard of teaching midwifery, that is, to teach it clinically, upon the living, just as is done in all other departments, has been assailed, not only by the wrath and abuse of the profession, but also by popular indignation, in which assaults the newspapers seemed ever ready to lend a disgraceful and destructive aid.
Is it a wonder then, that men, who have felt the necessity of better opportunities and more liberal facilities for teaching obstetrics, have shrunk from taking the initiative to secure the necessary privileges? Men whose wives and children depend upon them for their daily bread which they honestly earn, could ill afford to take such risks. Those who are surrounded by all the comforts of life usually become indifferent to the wants of others. But, at last, those who recognized the necessity for better opportunities for teaching obstetrics, assumed a determined attitude. Pioneers strong and fearless have arisen who braved the dangers in their way.
Dr. James P. White, of Buffalo, N. Y., was first to establish an obstetric clinic in the United States. A perfect cyclone of professional wrath, popular indignation and persecution by the daily press and the laity arose immediately and lasted for many months. He bore and braved the almost annihilating storm of slander and ridicule which was heaped upon him, and like a true and noble hero, who knew the righteousness of his cause, he remained steadfast and proved himself not only invincible but victorious. All the obstetric clinics of the present and of the future, in this country, should be but as monuments to perpetuate his memory. It required but one man of true metal, courage and perseverance to take the lead; others soon followed. Thus we have since seen a well-established out-door obstetric clinic in Boston, under the guidance of Profs. Richardson and Green, of Harvard University. In 1890 a "midwifery dispensary" was started in New York City, with
Profs. E. W. Lambert, M.D.; W. T. Lusk, M.D.; T. M. Markoe, M.D.; and W. M. Polk, M.D. as consultants; and J. W. Markoe, M.D.; J. Clifton Edgar, M.D.; S. W. Lambert, M.D.; and H. M. Painter, M.D., as attending physicians. In Philadelphia a clinic was inaugurated and successfully conducted under the efficient management of Prof. Parvin and his then assistant, Prof. Ashton. But as in Buffalo so in Boston, New York and Philadelphia the men at the head of these clinics had a difficult battle to fight.
The speaker well remembers the war that was waged against the man who first attempted the teaching of practical obstetrics in the State of Ohio. I was then a student in the Medical College of Ohio in Cincinnati. What a frenzied howl went up. The town was almost convulsed with excitement; but the man who was "guilty of crime," delivering a woman before the class, stood calm and collected at his post, defending himself against the many poisoned arrows projected against him. These were trying moments for the College. The name of Prof. Thaddeus A. Reamy goes down into history as the first pioneer in this department, and the Medical College of Ohio as the first institution which took the lead in this direction among her sister institutions west of the Alleghany Mountains.
Because of his own experience in the establishment of an Out-Door Obstetric Clinic in Cincinnati, September 1889, the speaker appreciates all the more the services rendered by the pioneers in this department in Buffalo, Boston, New York and Philadelphia. It took the Faculty of the Medical College of Ohio just one year before they granted him the privilege to go ahead with the Out-Door Obstetric Clinic. It was a success from the start and the clinic exists today.
Notwithstanding the rapid and satisfactory progress in the teaching of obstetrics of late years, there still remains a great deal to be done before the practice of midwifery is what it should be. The public must be taught that a woman pregnant is undergoing the most marvelous physical changes during the period of development of a new being within her; that, ordinarily, her condition is equal to the task; but that, quite frequently, it is not. The laity should and must be taught that many of the accidents that befall women in labor may be successfully avoided or satisfactorily overcome if a competent and conscientious accoucheur is consulted early in pregnancy. And what is of equal importance is, that the pregnant woman and her friends be convinced that a lying-in hospital is the best, cheapest and safest place for confinement. The most luxurious home does not equal in safety the most modest and well-kept maternity hospital. Rich women, especially those of boundless wealth, should set the example for their less favored sisters and be delivered in maternity hospitals. There should be lying-in hospitals for the rich and poor alike.
For years there has been a cry against the continuance of the ignorant midwife. Today the midwife is unequivocally condemned; apparently
no allowance is made for those who are competent. The speaker readily admits that the average midwife of today, aye the large majority, should not be tolerated. But, as in the past, there are a few laudable exceptions. If we measure others should we object to applying the same measure to ourselves? Much mischief, misery and even death has resulted through the ignorance of officious and stupid midwives; but is it not equally true that women in labor have suffered as much, if not more, from the daring and ignorant physician as well as from those who are careless and indifferent, though otherwise competent? If the careless and ignorant midwife must be exterminated, should not the careless and ignorant physician meet a like fate? I do not confine my references to this country; but include all of the so-called civilized world which, at this moment, is not easily defined.
Well-kept statistics, before this world-war, show that within the German Empire, annually, 8,000 women die during labor and confinement throughout Germany. In this country, where statistics of death and diseases are poorly kept, it is conservatively estimated (by De Lee, Chicago) that 20,000 women die every year of puerperal causes. In only one-fourth of these cases is death due to eclampsia, apoplexy, rupture of the uterus, hemorrhage, heart disease or injury; in the other three fourths, the cause of death results from preventable puerperal complications.
Think what these figures mean. Accordingly, Germany has lost from puerperal causes during the last fifty years 400,000 women in the act of birth; in the United States of America, for the same period of time, 1,000,000 women have been the toll demanded by death in the confinement chamber alone. It may be that the figures are only approximately correct, inasmuch as our population had been increased by 40,000,000 during the last 45 years. But this is also true of the population of Germany; the latter increased during the same period from 40,000,000 to 60,000,000. But if the population continues to increase at the same rate in both countries within the next 50 years, and the death rate from puerperal causes remains the same, it will by far make up the difference in the figures given above. One thing, we cannot get away from; is this: Up to the present in the worlds history, more women have died from preventable causes in the confinement chamber, than there were ever men killed in all the battles of the past and present. What is worse is that there is no need for this dreadful mortality in obstetrics even though it be but a fraction of one per cent. But this is not all; the morbidity of pregnancy labor and confinement is from three to four times higher than the mortality. These are appalling figures. They are undeniably true.
There was a time when men and women who practiced obstetrics could be reasonably excused for accidents and bad results. They did not know better; they were not taught better for reasons already stated. They simply did the best they knew. That time should be past. Any
one who practices obstetrics today should be well informed upon the subject. The opportunities of the present are ample; our text-books, some of them, almost perfect. For these reasons no one has a right to accept care of an obstetric case who has not fully mastered:
(1) The physiology and prophylaxis of pregnancy, of labor and of the puerperium.
(2) The diagnosis of the attitude of the fetus in utero, the capacity and shape of the maternal pelvis, and the various presentations and positions:
(3) Every obstetrician should be perfectly familiar with the mechanism of labor of every position of the various presentations. He should know the mechanism of labor by heart and be able to recite it with as much ease as the sailor-boy does the points on the compass.
(4) All should know when to wait and when to interfere especially when and when not to use the forceps.
(5) Every one should know how to do a primary perineorrhaphy, how to prevent and arrest postpartum hemorrhage, and also know the origin of bleeding from the uterus during the last trimester of gestation.
(6) All should be well prepared to meet any emergency; and thisand this alone is the best reason why a hospital should be chosen by every woman for the delivery of her child.
Of the teacher of obstetrics we expect one who is fully acquainted with gynecology and abdominal surgery. It is he who must be able to perform a vaginal or abdominal Cesarean section, operate for ectopic gestation in any form; or open the abdomen promptly in case of complete rupture of the uterus.
Neither man nor woman, no matter how well qualified he or she may be, has a right to accept the care of an obstetric case, unless they understand obstetrics thoroughly and are willing to devote the necessary time and talent to the case.
SPINA BIFIDA IN THE NEW-BORN.
A STATISTICAL REPORT OF ALL CASES THAT HAVE OCCURRED IN THE SERVICE OF THE NEW YORK LYING-IN HOSPITAL.
JAMES A. HARRAR, M.D.,
SPINA BIFIDA (Rhachischisis) as one meets with it in the text books on surgery, and its actual occurrence in a large obstetrical service, are quite two different propositions. The text-books either give the subject but scant notice or else speak rather cheerfully of the