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OOMMONPLACE MIDWIFERY."
BY
GEORGE WILLIAM WINTERBURN, M.D.,
NEW YORK.
I went some time ago on a pilgrimage. Glowing accounts
had come to me of the almost miraculous success, and of
the wonders to be seen, at the Sloane Maternity, where
the goddess of Listerian cleanliness reigns in unmitigated
asperity; and the half was not told me. Vidi. Which being
rendered into the vernacular means that I was shown every-
thing, from kitchen to garret.
As probably all the members of this Society have heard
of this Maternity, and few have seen it, a brief description
of my visit may not be uninteresting. That day there were
present in the wards 25 patients; IO post-partum. Two
deliveries had taken place that morning, and another labor
was announced while I was in the building. The average
time of a patient in the institution is twenty days; twelve
post-partum.
* Reprinted from The Homatopathic Journal of Obstetrics, January, 1890.
2 COMMON PLACE MIDWIFERY.
sº-
The woman on arriving at the institution is taken into
the basement and thoroughly scrubbed, inside and out; her
clothes are taken from her, and she is provided with a new,
disinfected hospital suit, her own being baked in a tempera-
ture of 500°Fahr., and put away until she is ready to go
out. One ward is kept empty at all times, and the patients
are rotated from ward to ward in such a way that each
ward is only used ten days, when everything, except the
iron bedsteads, is removed and replaced with new, and the
walls and flooring scrubbed and disinfected; this entails an
enormous expense. Everything is plain but substantial,
the atmosphere of purity and quiet is very tranquillizing,
and the nurses are fair and comely to look upon. The
lying-in women seemed to be doing well, except one who
had just been confined, but the babies all had a dusky look,
which I thought might be owing to the pervasive odor of
carbolic, kreasote and iodoform.
There have been about 600 cases in the institution. The
death-rate is about in the ratio of one to one hundred and
and thirty-five, which coincides with the usual statistical,
statements issued from similar institutions, and is moderate
in consideration of the necessity they are frequently under
of taking mismanaged midwife and other emergency cases.
But the mortality among the babies is excessive, nearly in
the ratio of one to nine; though I was told recent experi-
ence is better than formerly. The mother receives a small
glass of milk every two hours during the first day, and
soft food for the next four or five ; she is kept in bed about
seven or eight days. The child is washed when it is twelve
hours old, and it is then put to the breast; the navel is
dressed with bismuth et iodoform; the average weight at
birth 7.3 lbs. The McLane forceps are used; they have
Tarnier's (possibly others), but do not use them ; perineal
lacerations are frequent. The doctor and assistants, matron
and nurses, cook and laundresses, and other employees,
make a total of twenty-five; about the same as the number
COMMON PLACE MIDWIFERY. 3
of patients. The expenses are frightfully large ; counting
the interest on the plant, about ninety dollars per case.
Taking into consideration the restful quietude of the place,
the orderliness and the cleanliness, I do not see that much
can be claimed for antisepsis. I looked over a large number
of the “record ” sheets, and while they present an excellent
showing, yet fever, eclampsia, and other obstetrical acci-
dents do occur.
It is pleasant to know that we have in our midst an insti-
tution so beneficent in intent and so exemplary in conduct,
and in the interest of helpless, wronged, fate-accursed
womanhood. we may hope that this Christ-like charity may
enlist the co-operative sympathy of others as capable as Mr.
Sloane of providing the wherewithal. I wish we could have
just such an institution in every ward of our city; though
institutional charity is, alas, often deadening to the sensi-
bilities of those who administer it, and gilded misery to
those for whose benefit, it is arranged. I could not help
asking myself as I came away, How long can the Sloane
Maternity continue to defy the law of thrift, that of accom-
plishing results with the least expenditure ? but this is a
question that outsiders are not called upon to solve.
But it was not of other men's work of which I desired to
speak to you to-night. When your Chairman did me the
honor to ask that I should appear before you he suggested
a number of topics: Indications for Craniotomy—Caesarian
Section—The Use of the Forceps—Placenta Praevia—but
while any of these would have proved interesting topics ten
or twelve years ago, I found it impossible to awaken within
myself any special enthusiasm for any one of them in par-
ticular. As for the “indications for craniotomy,” I am glad
to say that I never cracked anybody's skull—not even a de-
fenseless infant's ; as for “Caesarian section,” I know a man,
at least a lawyer, who says he never was born, but I never
helped any one to get into the world in that irregular way ;
4 COMMON PLACE MIDWIFERY.
“forceps” I have used and will speak of them later on ;
“ placenta praevia,” I had one case, and that I muddled dis-
astrously.
In groping about in my mind for a text upon which to
build this paper, there was ever present with me the feeling
that this society was entitled to my best ; and what better
could I offer it than the plain tale of my own commonplace
experience. It is of this, therefore, that I would speak; of
midwifery services rendered mainly to the humble, the dis-
tressed, the blighted ; services hardly worth recounting for
their own sake; but that which has cost me ten thousand
hours of anxiety may furnish one hour's interest to you.
Mr. John Morley, in his “Diderot and the Encylopaedists,”
relates of his hero that one of his friends had an aversion
for women with child. “What monstrous sentiment l”
Diderot wrote ; “for my part that condition has always
touched me. I cannot see a woman of the common people
so, without a tender commiseration.” These words struck
a responsive sentiment within me, and I find the drudgery
of midwifery not only bearable but indeed enjoyable from
the sympathy which the condition arouses within me.
Diderot continues: “The bit of coarse canvas that covers
her, the hair falling about her cheeks, the rags and poor
short skirt that go no more than half-way down her legs,
the naked feet covered with mud—all these things do not
wound me; 'tis the image of a condition that I respect, 'tis
a sign and summary of a state that is inevitable, that is
woful, and that I pity with all my heart.”
To us living in this community, so absorbed in its mate-
rial necessities, so ruled by the “goddess of getting-on,”
these words come as an incentive and a benediction. I do
not know how it may be with others, though it has some-
times seemed as if the average sentiment of the profession
toward obstetrical work was one of tolerance rather than
of liking. I do not believe that that is the best spirit in
which to approach any work; nor is any worthy work done
COMMON PLACE MIDWIFERY. 5
worthily in which the heart is not. In this, as in every
department of human endeavor, different men pursue their
allotted tasks, and embrace their opportunities, from differ-
ent motives; most often without perceiving the real trend
of their intention. Of opportunity it may be said,
“To some she is a goddess great :
To some the milch-cow of the field ;
Their business is to calculate
The butter she will yield.”
But in midwifery the man who cannot say, in all humble-
ness but truly, of his work, “This is the best of me; for the
rest, I ate, and drank, and slept, loved, and hated, like
another; this, if anything of mine, is worth your memory,”
will leave behind him, in the gathering years, shattered con-
stitutions and bereaved hearths as silent witnesses of mis-
placed confidence—misplaced because it rested in him.
It is now something more than a decade and a half since
I first witnessed the ushering of a new life into mundane
activities. I presume we all remember our first experiment
in obstetrical practice, but to me that first experience held
one moment of supreme terror which a myriad of subsequent
commonplaces could not obliterate. Like most fresh young
men I wanted a case, but when suddenly called upon to
assume the responsibility—I rather wished I hadn't. The
groans and complaints of the woman assailed my unaccus-
tomed ears; the perturbation of the husband, who was also
undergoing a first experience, disturbed my equanimity;
while the inconsequential gabble of several female friends,
whose rotundity bespoke experience which I would gladly,
at that moment, have bought with a price, added to the con-
fusion. My own jejuneness of experience was not suspected,
and matters gradually progressed with me in the rôle of
Fabius Maximus. I had read, only the day before, with
anxious preoccupation of mind, all about the proper pro-
* “Sesame and Lilies,” by John Ruskin, page I8.
6 COMMON PLACE MIDWIFERY.
ceeding, on the part of the accoucheur, during the first, the
second, and the third stage of labor; but I found myself
rather embarrassed as to what stage we were in, until the
increasing cries of the parturient made obvious that a crisis
of some sort had arrived. I hurriedly turned down the
sheet, and my affrighted eyes saw protruding from the bulging
vulva a dark, unctuous mass, which resembled a piece of
corrugated liver. My excited imagination swept ott of
recollection all the anatomical and obstetrical lore I ever
knew, and for one solitary instant reigned supreme; but, in
another moment, the hand of Ananke thrust out into the
world a mass of black hair well anointed with vernix caseosa,
and the head of a man-child was born into the world.
In no department of human exertion are the rewards of
Success and the pains of failure more certain and more
potent than in midwifery. The babe was born, and the
doctor was adjudged skillful by the accordant voices of
mother, husband, and friends. Their praise was balm to
my wounded self-esteem ; and I can look back now, through
the vista of experience, on that night with amusement, if
not with complacency, But my trouble was not ended.
There was still a placenta, whose obdurate impassiveness
exhausted all my skill (sic) for the space of three hours, and
nearly wrecked my recent cheaply bought honors. How-
ever, everything was at last disposed of, and my night of
adventure came to an end with the first peep of daylight.
I escaped from the house as one set free from damning
peril, and the sun rose on me and a reviving world.
Since that direful night I have had some experience, and
I trust have learned something; at least a well-covered
poll, barbered au naturel, no longer affrights me. The
nature of that experience may be gathered from the follow-
ing statement, though statistical information conveys, at
the best, only half-truths. As in this instance, it does not
show the subsequent history of the woman and child as
COMMON PLACE MIDWIFERY. 7
related to the labor in question. To say so and so many
women were brought to bed means little unless we can know
how they were brought out of it; whether with damaged
health or renewed vigor. We must know not only the
mortality but the morbility.
Whole number of cases (1874–1889), 617:
I Para. . . . . . . . . . . . . . . . . . 2I5 8 para. . . . . . . . . . . . . . . . . II
2 ” . . . . . . . . . . . . . . . . . . I36 9 “ . . . . . . . . . . . . . . . . . 8
“ . . . . . . . . . . . . . . . . . . IO3 Io “ . . . . . . . . . . . . . . . . . 6
4 “ . . . . . . . . . . . . . . . . . . 76 II “ . . . . . . . . . . . . . . . . 2
5 “ . . . . . . . . . . . . . . . . . . 32 I2 “ . . . . . . . . . . . . . . . . . 3
6 “ . . . . . . . . . . . . . . . . . . I4 13 “ . . . . . . . . . . . . . . . . . I
7 “ . . . . . . . . . . . . . . . . . . 9 I4 “ . . . . . . . . . . . . . . . . I
Total. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 617
Number to whom preparatory treatment was given, 367.
The amount of preparatory treatment varied greatly; in
some cases only one prescription was given, in others the
treatment extended through the entire epoch of pregnancy.
The large number of cases in which an opportunity was
afforded for preparatory treatment was secured by letting
it be known that we would not accept cases at the dispen-
sary unless the engagement was made at least two months
in advance. And while we did occasionally break this rule,
the enforcing it led in many instances to a pre-engagement
of four or five months, especially as we gave the further in-
ducement of free treatment during the ante-parturient
epoch. The dispensary charge was only ten dollars; but
in many cases (40 in one year) this was altogether remitted,
and in others partially.
Number of times attendant on same woman : Once, 428;
twice, IO2; thrice, 64; four times, 13; five times, 7; six
times, 2 ; total, 617. we
The large number of single confinements was due to the
fact that a large portion of these were dispensary engage-
ments ; and the migratory habits of that class are well
known.
Twin pregnancy, 3.
8 COMMON PLACE MIDWIFERY.
Oldest I-para”—37 years 4 months.
Youngest I-para”—I5 years 3 months.
Sex of children : Male, 329; female, 288; total, 617.
Presentations: Head, 598. Vertex: O.L.A., 517; O.D.A.,
23; O.D.P., 41; O.L.P., 12. Brow 3. Face 2. Arm (in-
cluding shoulder), 3. Breech (including footling), 13.
Transverse, 2. Undelivered, I. Total, 617.
Placenta praevia, I.
Deaths; Mother (placenta praevia), 1 ; Child (I shoulder,
I transverse), 2.
Forceps used, times, 64; Chloroform used, times, * 12 I.
The brow and face presentations are hard to rectify, and
impossible after once the head is jammed down into the
pelvis. The two face presentations occurred within a month
of each other. The first I did not discover as early as I
ought to have done, and it had to be born in face position,
under chloroform. The head was shockingly disfigured, but
the child lived. In the other case I made out the face be-
fore the rupture of the membranes, and, having the nurse
push the breech forward, I forced the chin upward, and
slowly shifted it to the O.D.A. position.
I have credited myself with three brow positions; but as
this is difficult, in fact the most difficult of all the head posi-
tions to make out early, and as it was changed, or seemed to
be changed, in each case to a vertex position, I will not
argue with any one who thinks I was mistaken ; it is enough
that the woman was safely delivered and the child was
born alive.
The manipulation of these cases requires two capable as-
sistants; one to lift, with both hands, the uterus bodily, the
other to press, with the hands, upward and inward from
* And it was a tough one.
* She had two living children and three miscarriages before her seventeenth
birthday. -
* Including I7 times in consultation cases.
* Including ether, and ether, chloroform and alcohol. In a number of for-
ceps cases, at the outlet, no anaesthetic was used.
COMMON PLACE MIDWIFERY. 9
outside the brim of the pelvis, while the accoucheur makes
pressure within the os, which will vary according to the
position of the child in the uterus. The woman must lie
upon the side to which the foetal back is turned.
It has ever been my endeavor, since engaging in obstetrical
work, to narrow mechanical interference to cases in which
it was actually unavoidable, and not merely to those in
which it seemed so ; to lessen the resort to instruments,
more and more, as I learned the wonderful capabilities of
the human hand as a diagnostic weapon and as a parturi-
facient; and to make this latter, by trusting to it and tak-
ing counsel with it, as intelligent for the purpose as possible.
I have no desire to laud myself, and small warrant for it if
I had the desire; therefore, if I speak of my own work it is
only with the hope that I may hand on to others, in some
measure, the results of the experience which has been al-
lotted to me.
There is no royal road in obstetrics, as far as I have been
able to discover. The same qualities which make a good
homoeopathic physician make a good obstetrician, provided
he loves this branch of work. If I have had more than the
usual amount of success, and avoided some of the perils
of which I hear so much, this is due to the careful and
minute study of each case in all its surroundings. When
a woman comes to engage me to attend her in confinement,
I do something more than book the date. I am a firm
believer in the power of homoeopathic medication in mid-
wifery, and am sure that the science of the day" has little
* Illustrative of the growth of scientific medical opinion see the London Zancet,
for Aug. 24, 1888, in which is tentatively advanced the idea of the contagious-
ness of diabetes. Drs. Debove, Lecorché and, six other members of the Société
Médicale des Hôpitaux, record numerous cases of what they call conjugal
diabetes ; and the simultaneous appearance of this disease in husband and wife
awakens in the minds of these scientists the idea of contagiousness, or the proba-
bility of it. Contagion includes, of course, the idea of a coccus. This inter-
esting little diabéte has not yet been discovered, but will be, sure ; for witness
the latest conclusions as to pneumonia.
The argument as to the contagiousness of pnenmonia is not new, but it has
3 *
2 y X * , y
*
3 * l
3 . * , , ”
:
3.
* -
IO COMMON PLACE MIDWIFERY.
to offer to a true homoeopathic physician. Labor is a physi-
ological experience, and manipulation and instrumentation
are no necessary parts of it; though they may be made so
by unphysiological living. But I am now speaking of those
cases which we have under view from the beginning of
pregnancy, and in which there is not irremediable organic
defect. Of course, if after nine months of mismanagement
and neglect we are called upon to take charge of a well-
reached now the phase of scientific demonstration. Netler (Archives Générale
de Medicin) has caught the little rascalion, and made him give an account of
himself. We old fogies who thought that taking cold had something to do with
pneumonia are all wrong. Netler finds that not only is pneumonia a contagious
disease of parasitic origin, and is transmissible either directly or by the inter-
vention of a third person, or by inanimate objects, such as wearing apparel,
bedding, etc., but that the pneumococci are not destroyed by desiccation, though
probably never surviving more than three years, and are diffused through the
air to the distance of three hospital beds; rather an uncertain quantity, as most
of us neglect to carry a hospital bed around with us as a measuring rule. More-
over, they are so malignantly vital that they are found in the saliva of post-
pneumonics many years after the attack, so that the person remains a living ter-
ror to all his friends who approach within three hospital beds of him. But,
worse and worse, this continuing vitality of the pneumococci accounts for the
recurrence of the disease in individuals who have survived it. Not only can a
person who has once had pneumonia communicate it to his wife and children
years afterward, but he can reinfect himself, renewing the cycle of contagion ;
which thus rivals Tennyson’s brook in unmitigated continuousness. This truly
scientific doctrine is now making the circuit of the earth ; it can be found crop-
ping out, now here, now there, in current medical literature, thanks to discreet
editorship.
But the most stupendous exhibition which scientific medicine has made of
itself in recent years is its hallucination in regard to dimethylochinizin, better
known as antipyrin, and other synthetical derivatives from coal-tar. Invented
by Knorr, in 1884, patented in every country, it became a source of phenomenal
income to its lucky discoverer, and a source of disaster to the sick of every clime,
Heralded as a panacea for all morbid conditions; excessively praised and gra-
tuitously advertised by the wise men of Paris and Berlin, of London and New
York, of Vienna and San Francisco; extensively used in the most heterogene-
ous conditions, its supposed phenomenal virtues interpreted variously according
to the preconceptions of would-be explainers; the actual knowledge as to its
precise physiological action could be written on a bit of paper the size of a
baby's hand, while the mass of literature which its use has called into existence,
i
:
;
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:
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:
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COMMON PLACE MIDWIFERY. I
advanced case of labor, we must adapt treatment to circum-
stances; though even here much may be done; if I said
how much I believe might be done I would be considered
fanatical by many worthy practitioners.
PREPARATORY TREATMENT.—Much has been written on
proper preparation for labor. As to the ordinary suggestions
about food and hygiene, I say nothing in this place, but
the chief characteristic of which is a general inclination towards disagreement
and contradiction, would fill an alcove in Astor Library.
It has been my misfortune to lose several friends through the murderous effi-
ciency of this drug in the hands of well-known scientific doctors; a fact which
has contributed doubtless to my interest in its fantastic history, One case in
particular, in which the actors were all well-known men, comes up most vividly
before me as I write. The patient was an ex-army surgeon, who, during the war
of '61, was gradually advanced to one of the highest positions in the medical
service, having charge at one time of six large hospitals in and near Washing-
ton. He was a man of connmanding presence, and great physical endurance,
with a mind broadened by contact with life in all its phases. He had been an
intimate friend of my father for many years, and, like Agrippa, almost persuaded
to accept the new (medical) faith. Somehow he must have passed somebody in
the street who had had pneumonia within three years, for one day in February,
I886, having been exposed in a violent rain-storm, he thought he took cold
(what a zany) 1 and so gave himself a sweat. But the next day he was quite ill;
and his daughter called in Prof. , a well-known alienist, who was in the
house, and he called in Prof. —, a famous gynaecologist, and he Prof. y
a widely recognized authority on diseases of the chest ; and they sat in solemn
conclave. It afterwards transpired that doctor number one offered his services,
and the daughter not thinking her father very ill, and having no one at hand
with whom to advise, as they lived among the Berkshire hills, and were merely
transients in the city, accepted the offer.
Antipyrin was just beginning to be noised about as the latest fad in medicine
and so instead of the whisky, iron and quinine, hitherto the medical arma-
menta of the said chest specialist, antipyrin was afforded an opportunity. Dr.
C., my sick friend, sent for me to come over and see him, and I went ; at least
I went as far as six feet inside the front door, when I was met by one of the
attending physicians, who cordially informed me that it was thought best by
the medical counsel that I should not see: Dr. C., not even socially. I, how-
ever, was informed as to the line of treatment; that he had had a phenomenally
high temperature, Ios" —H Fahr., I believe, but that he had had several 30-grain
doses of antipyrin, and the temperature was now about normal. The wonder-
ful virtues of antipyrin were dwelt upon. To anticipate any further resistance
I 2 COMMON PLACE MIDWIFERY.
confine attention to the more purely medical aspects of the
case ; not but that I appreciate those, while having to con-
tent myself with things as I find them. The majority of
people in New York have to live, by force of circumstances,
amid unhygienic surroundings, and with less and poorer food
than is good for them ; that this is their own fault mostly,
makes it no less evident, and no less true. That is, it
On the part of nature, they were about to administer another 30-grain dose. The
next day, I was told, he seemed to be in a state of collapse, but that his tem-
perature was all right. But the collapse passed into the moribund, and with
the on-coming twilight of a bleak, brief winter day, my good doctor joined the
majority. How many similar histories might be written to the credit of scien-
tific medicine; of its frantic endeavors to lower the temperature, with fatal
additions to the death rate.
Already the ultra-scientist is on the lookout for something to replace this
group of hypothetical exalgics; but Knorr need not despair. The public have
heard of the wonder-working substance; deaf, indeed, they must have been if
they had not ; and it has joined the great procession of noxious agents, mor-
phine, chloral, avena, which any druggist will dispense to any comer, with
money in his hand. In the “upper circles,” however, antipyrin, and to a less
extent, because less famous, its congeners also, are now looked upon with dis-
trust. Semmola declares that the administration of these antipyretics produces
a poisonous rather than a medicinal effect, the repose secured being at the
expe. He of vital force. In Bright’s disease it has proved suddenly fatal, even
when given, as supposed, cautiously and in small doses; though here, as else-
where, “untoward results, not a few of them lethal, are of much more common
occurrence than is generally known or admitted.” The Medical Age, Oct. 25,
1889, page 404, says: “It is now considered as established that this reduction
of temperature is the result of diminished production of heat, and consequently
of enfeebled or diminished vitality due to some action upon the heat center sit-
uated in the corpus striatum. Metabolism is markedly checked, and the volume
of urea diminished ; diaphoresis ensues, but in no way explains the fall of tem-
perature ; and the reflex excitability of the spinal cord is greatly depressed, ulti-
mately, as a result, leading to anaesthesia.” These facts ought to be well known,
but they do not seem to be. Leading pharmacists inform me that prescribing
antipyrin is still, apparently, a favorite occupation, and growing in favor ; the
bulk of the profession do not read.
Nevertheless, antipyrin is doomed. As in society so in medicine, it is not
the commonalty that set the fashion ; and on Olympus antipyrin is no longer
spoken of in terms of praise. But let not the scientific heart falter; already
somebody is cogitating, and soon the trumpet of fame will blazon a new name,
and the acme of professional erudition will be revealed—for a time.
COMMON PLACE MIDWIFERY. I3
is their fault collectively, communally; the individual is
helpless.
The chemical treatment, by which it is sought to prevent
calcifying of the foetal bones, so that their suppleness will
aid quick and easy parturition ; and the moderate-eating
treatment, which is intended to reduce the growth of the
foetus unnaturally, so that by its small size labor may be
expedited, I have seen tried ; though never fascinated by
that especial form of foolishness myself. Whatever weakens
the woman will cause lingering and painful labor. Some of
the worst cases I have had have been those in which the
child weighed less than six pounds.
On the other hand I have tried the use of calisthenics,
and especially the health-lift pretty thoroughly in a number
of cases; and have induced other doctors to do the same.
The idea that muscularity and painless parturition stood in
relation to each other as cause and effect seemed plausible.
I was loath to abandon it, but I have. Not but what I
believe moderate artificial exercise, with which may be in-
cluded massage, will do good when used under careful
supervision ; but cases which have received the most scrupu-
lous watchfulness, in this regard, have yet in the critical
hour proved anything but expeditious and painless. Again,
on the other hand, in the large majority of cases the advan-
tages derived from the health-lift seemed manifest; and I
recommend it in cases where the financial abilities of the
patient make the expenditure of no especial consequence.
The use of mitchella repens to facilitate labor has given
me great satisfaction ; but it is rather difficult to determine
how much credit is due to a drug under these circumstances.
The labor might have proven easy without medicinal inter-
ference; and even in the case of a woman who, having had
two or three tedious or painful labors, is given mitchella,
and its exhibition is followed by an unusually easy delivery,
we cannot definitively determine that the mitchella deserved
the credit. I have seen too many multiparae in which a
I4. COMMON PLACE MIDWIFERY.
difficult labor succeeds an easy one, or vice versa, not to be
cautious in the application of any aphorism. While in no
one case can we say positively that mitchella, cimicifuga, pul-
satilla, cyclamen, or the remedy given, did actually promote
painless parturition, yet the general trend of experience
leads me to believe that much is accomplished when the
therapeutic agent is wisely chosen. Not every case will
profit by mitchella, nor can I say always why I give it, ex-
cept that the “still, small voice " within affirms the choice;
but, in general, mitchella is demanded when by previous
experience a tedious labor is anticipated, and when the
present condition is one of depressed spirits without the
loss of sleep, with tardy digestion, much flatulence, and
dulled sensorium. My manner of using it is to leave with
the patient a small vial of the first decimal dilution, with
instruction to dissolve, ten drops in a couple of ounces of
water, and take in divided doses during the course of the
day. When so given, during the eighth or ninth month,
the delivery has always been easy. I have kept no record
of the number of cases in which I have used it, but judg-
ing by recollection, and the present state of the pound
bottle of the fluid extract which I bought, of Parke, Davis
and Co., in August, 1878, and from which I have prepared
all my dilutions, I should say the number somewhat ex-
ceeded seventy, and, by a singular idiosyncrasy of mine,
they were all multiparae. Primaparae I have always pre-
pared for labor by the use of calcarea, sulphur, thuja, pulsa-
tilla, Cyclamen, cimicifuga, and in rarer cases by other medi-
CamentS.
When I notice that a woman, about to become a mother,
looks pale and wan, that her hair is unnaturally dry, that
her teeth sometimes ache, that she has a little, teasing dry
cough, and other evidences of deficient secondary assimila-
tion and of trophic debility, I give calcarea 30, once a week;
adding, in some cases, powdered bone to her dietary. When
without any positive symptom of disease I notice a lethargy
COMMON PLACE MIDWIFERY. I5
of the entire system, the functions performed, but performed
tardily, I give sulphur (sometimes 6, 30, 200, or cm.); occa-
sionally preceding this, when I want to make a sharp im-
pression, by a nine day course of the old-fashioned sulphur,
cream of tartar and molasses. The administration of a
crude drug heightens the subsequent sensitiveness of the
system to its dynamic action in infinitesimal doses.
A first pregnancy brings to the surface many latent ills,
whose evidence may be so indeterminately expressed as to
escape attention; but we ought to be on the watch for
these, mindful of the frailties of human nature. Thuja is a
grand remedy in some of these cases, and under its influence
for a week or two, I have seen a young woman suddenly
bloom out, in the early months of pregnancy, like a rose-
bush under the June sun. Yes, I hear some one say, who
hasn't, and without thuja P But I mean cases which, to the
experienced eye, show a buried taint, which needs something
more than love and maternity to uproot. Thuja, under
these circumstances, and after experimenting with poten-
cies, I give in tincture, one, two, or three drops daily, in
divided doses.
Pulsatilla needs neither comment nor commendation.
You all know its influence in correcting the minor ailments
of the last weeks of pregnancy. I recollect hearing my
father say, as long ago as 1865 or '66, that its alleged power
in preventing or correcting mal-position was through its in-
fluence on the bowels of the foetus, causing fermentation
of the meconium, and ballooning of the abdomen by gas.
Schultz has shown, by his salt water and alcohol experiment,
that immediately after birth the breech is heavier than the
head, under ordinary circumstances. And I can testify to the
fact, observed many times, that in cases in which the mother
has taken pulsatilla for several weeks prior to confinement,
the babe is almost sure to have a movement of the bowels
quickly after birth, and often just at the moment of delivery.
As, in other cases, several hours are apt to elapse before a
I6 COMMON PLACE MIDWIFERY.
movement occurs, this would seem to indicate some influ-
ence on the part of pulsatilla.
The following rather amusing instance may serve to
“point a moral,” or may merely “adorn a "pointless “tale.”
I was engaged to attend a 3-para in August, 1881. When
the engagement was made she said : “Oh, doctor, I wish
you could give me something so that I wouldn't have to
suffer so long.” Enquiry developed the fact that in previ-
ous labors the pains had been extremely distressing but in-
effectual, the labors lasting one or two days. She, of course,
was not able to distinguish between “first stage,” and
“second stage,” or to give any very satisfactory particulars,
except that she was firm in the belief that she had suffered
more than her share. I replied, with due professional
suavity : “Yes, I can do that much for you anyway.” So
about a month before the expected time I sent her a pack-
age of pulsatilla 30 powders, with instructions to take one
every night on going to bed. On Sunday morning, August
21, I was sent for, while I was eating my breakfast. Re-
membering her tale of tedious labor, I finished my break-
fast somewhat leisurely, mindful that dinner might be un-
certain, and then gathering together my obstetric parapher-
nalia went over to her house, which was on the next block.
The first sound which assailed my ears as I went into the
room was the Squall of a new-born, and I soon learned that,
feeling rather heavy and distressed, she was sitting on the
lounge, when having a premonitory pain she started for the
bed, but a severe pain seized her before she got there, and
the child was born on the edge of the bed, and not respec-
tably and decorously in it as well-mannered children are
wont to be. After removing the secundines, and getting
the mother tidied up, I was just leaving my final instruc-
tions, when she looked up into my face and said, with an
innocency of expression and tone which I was in doubt
whether to understand as concealing a latent sarcasm : “I
think, doctor, your powders act almost a little too quick.”
COMMON PLACE MIDWIFERY. 17
It is only in a minority of our cases that we have an op-
portunity of watching the course of pregnancy from the
beginning, or near the beginning. Especially are we
hampered in our treatment of first pregnancies. Young
married women seem to consider pregnancy a crime, or at
least an unfortunate accident, to be hidden from view as
long as possible. It is a sensible mother, whose daughter,
about to share in the universal experience, entrusts her to
the guidance and oversight of a wise physician. At this
crisis of physical experience nature is very mobile, she
yields to the gentlest suggestions, and the various ills in-
herited from maculate ancestry may now be modified, cor-
rected, or removed. But, alas, mothers are rarely sensible,
and physicians are not always wise.
THE FIRST STAGE.-In spite of numerous theories which
have been promulgated we are in entire ignorance of the
‘reason why labor occurs at a fixed epoch. That it does so
occur we not only have the consent of universal experience,
but in extended pregnancies the added time seems always
to be one or two lunar months. Thus in a case, I-para, to
which I was called in consultation by Dr. Thos. Newby, in
February, 1879, I declined to use forceps, as the condition
of the woman did not, in my opinion, demand instrumental
interference, although she had been, more or less, in “pain "
for two days. The pains gradually died out, and on the
twenty-eighth day thereafter she was delivered, naturally
and easily, of a boy weighing nearly nine pounds. So, also,
in another case, in Brooklyn, the wife of a music teacher,
5-para, became pregnant at the middle of August, 1883. On
May Io, 1884, labor commenced, and the pains at one time
were severe, but the uterus was anteverted to such an ex-
tent that the os could not be felt by digital examination.
On the second day the pains gradually ceased. Delivery
was effected on July 5, just fifty-six days later, after an easy
labor lasting three hours. The child, a girl, weighed eight
&
18 COMMON PLACE MIDWIFERY.
pounds, thirteen ounces. The mother is quite diminu-
tive.
Whatever may be the immediate provocative of parturi-
tion, there can be little doubt that the initiatory force lies
in the uterine parieties, and that the first stage of labor is
purely the contraction of the uterus upon itself, accom-
panied by a stretching and thinning of the lower segment.
But in the second stage observation compels me to award
more than accessory influence to the effort of voluntary
muscles. In this I go beyond what seems to be the usual
opinion, and coincide nearly with the views advanced by
Haughton, of Dublin."
The sum of the muscular force exerted during this stage
of labor is very much greater than is usually supposed.
A woman of average muscular ability, with the feet sup-
ported and the diaphragm fixed, will exert traction with
each hand of from sixty to one hundred and ten pounds
during the crisis of the second stage. This I have ascer-
tained by numerous experiments. And while the force so
expended does not in itself expedite the movements of the
foetus, it is an exemplification of the immense forces in
action at the moment. The amount of this available force,
exerted by the abdominal muscles, as well as the muscu-
lar force of the uterine parietes, has been calculated by
Haughton, by Lagrange's formula,” as follows:
ſº I I
P=Tx|, +.
in which P represents the sum of the forces acting on one
square inch perpendicularly to the membrane; T, the tensile
strain on one inch broad, acting tangentially to the surface,
of the membrane; and p and p’ denote the radii of the
principal curvatures of the membrane at the point consid-
"“On the Muscular Forces employed in Parturition: their Amount and Mode
of Application,” by Rev. Samuel Haughton, M.D., in The Dublin Quarterly
Journal of Medical Sciences, May, 1870.
* Mécanique Analytique, page I47.
COMMON PLACE MIDWIFERY. I9
ered. The force P arises from hydrostatical pressure within
the uterus. If the surface is spherical, or becomes So, then
2T
P = ſo (2.)
Now if we assume the uterus to be a prolate ellipsoid 12
inches long by 8 inches across, its mean curvature will equal
that of a sphere whose diameter is 9.158 inches. The vol-
ume of the gravid uterus is expressed by the formula
v=_*-r a Ö”
3
in which V stands for volume, ºr for the ratio between the
circumference and diameter, and a and b the semiaxes.
Substituting for a and & their numerical value, the contents
of the uterus is shown to be 402. I3 cubic inches, and the
surface 270.66 square inches. These figures differ somewhat
from those deduced by various authorities, but they are
accurate enough for the purpose.
The mean weight of the muscular fiber of the uterus at
term is 1.56 pounds, and its mean thickness O. I 5 Ig inch.
Now a cubic inch of muscular fiber will lift IO2.55 pounds;
and this multiplied into O. I 519 equals I 5.577 pounds.
. . . if in equation 2 we substitute these values, T = I 5.577,
and ſo = 9. I58, the maximum hydrostatic pressure produced
by uterine contraction = 2 X 15.577* = 3.4O2 pounds to the
square inch. The mean rupturing pressure of the mem-
branes, as determined by Duncan and Tait,” is I.2O48
pounds, and the maximum 3. I pounds. Thus we have a
maximum power of 3.4 to overcome a maximum resistance
of 3. I ; certainly a beautiful adjustment of means to an end,
and exemplification of the Law of Thrift. It would be a
waste of force to endow the uterus with more power than is
necessary to complete the first stage, as the abdominal
muscles already exist, and can be advantageously used.
* “Researches in Obstetrics.” New York: William Woods and Co. 1868.
2O COMMON PLACE MIDWIFERY.
The average area of the pelvic canal is ºr X 4.5 inches,
which multiplied by the pressure 3.4O2 = 54. IO6 pounds, the
extreme force exerted by the uterus in parturition. The
force required to expel the foetus has been calculated by
various experimenters, and the mean value is about 106
pounds, equal to a hydrostatic pressure inside the uterus of
6.28 pounds to the square inch. But though this hydro-
static pressure is very much beyond the effort of the unaided
uterus to overcome, yet there is no danger of injury to that
organ, as its rupturing strain varies from 17 to 25 pounds to
the square inch.
By an interesting mathematical calculation Haughton has
shown that the force exerted by the abdominal muscles is
equal to 32.926 pounds to the square inch, and this multi-
plied into 4.5 × 7 = 523.65, the maximum muscular effort
exerted by the abdominal muscles over the pelvic area.
This mathematical induction was verified by experiments
upon two men, each of whom was able to exert a force,
using the abdominal muscles only, of 38.47 pounds to the
square inch. The experiments were pushed to the point of
producing slight peritonitis in each case.
Playfair brings forward to negative this the instance of
inertia of the uterus, when voluntary action is incapable of
producing delivery.” But no one would claim that mus-
cular power can be applied to the whole surface of a patu-
lous uterus in such a way as to void its contents; and
Playfair is certainly wrong in assuming that the whole
structure would collapse under the pressure indicated by
Haughton, for Dr. George Winship, the Boston strong man,
has conclusively demonstrated that a force of 4000 pounds
may be applied to the abdominal region without its being
crushed by the strain.
I never thank any one for delaying sending for me until
near the end of the first stage. The mental and moral con-
*
* “Midwifery,” page 167. Macmillan, 1889.
COMMON PLACE MIDWIFERY. 2 I
dition of the woman during the first stage presages the
physical difficulties of the second, and to be a witness of
these is to be forewarned of dangers to come. Most cases
of labor would terminate favorably without the presence of
the physician. If in such normal cases we find waiting
tedious, it is our duty to remember that our real value is
small, and our influence chiefly a moral one. If, however,
we are really needed, that is, have any higher work to do
than falls within the compass of an ordinary midwife, the
time to do it is in the first stage, when false positions can
be rectified, and the ease and safety of labor promoted. I
am speaking now to homoeopathic physicians, strong in the
faith because able to transmute faith into works. I am
aware that it is inadvisable to display much enthusiasm
over the dynamic forces of medicine in a homoeopathic
medical society. The chilling atmosphere of disbelief when
any remarkable success is alleged in those cases that trench
upon the domain of surgery—as for instance, the cure of
a cartilaginous stricture—is in marked contrast with the
interest taken in a new curette, or an axis-traction forcep.
During the first stage one can do so much by attention
to the arrangement of the bed, of the infant’s clothes, and
the other minor auxiliaries and paraphernalia of labor, to
establish that confidence and mutual sympathy which
should exist between the woman and her doctor, that to
miss this opportunity is to sacrifice half our usefulness.
If turning is necessary now is the time to do it, by exter-
nal manipulation. If there is one invariable aphorism in
obstetrics it is turn early, before the thinning of the lower
segment of the uterus makes it dangerous.
THE SECOND STAGE.-At the beginning of the second
stage voluntary effort, on the part of the woman, is usually
needed or else the progress of labor will be slow, while
toward the end this should be moderated, in order to avoid
the too rapid descent of the foetus. Therefore, at the
22 COMMON PLACE MIDWIFERY.
beginning of this stage I command quiet on the part of the
patient, with the greatest possible effort during pains and
complete muscular laxness between them ; but as the head
approaches the perineum I encourage her to cry out, as this
prevents the diaphragm being used as a fulcrum, and leaves
the work to involuntary action. This gives the vagina and
perineum time to stretch, and often prevents rupture.
As a partus accelerator I have used ustilago maidis quite
extensively; probably in 70 or 80 cases; but not frequently
in later years. It hastened delivery, but like ergot, though
to a less extent, increases the painfulness of the “ after-
pains.” In using it, I put a teaspoonful of the fluid extract
into half a goblet of water, and of this mixture give a tea-
spoonful every five minutes, more or less, pro re mata. The
usual effect is an entire cessation of the pains for twenty
minutes or a half-hour, when they return in full vigor. In
a small minority of cases it will do good; but doubtless I
used it in many cases which would have done equally well
or better without it. It is better, both for mother and
child, that the labor should last an hour or so longer, than
that it should be abbreviated by that much, and the woman
suffer from severe after-pains for two or three days.
During the second stage I use the bi-sulphate of quinine
freely. Not in all cases, very rarely in cases which I have
had opportunity to overlook during the previous months,
though even here sometimes a few grains does good. Cin-
chona has no direct influence on uterine fiber; it is not a
parturifacient, but given in small, repeated doses it will
change a delaying, painful, inefficient labor into a normal
one. My obstetrical practice has been largely among the
poor of the sixteenth and twentieth wards, mainly among
that class whose only crime is poverty, and who, amid un-
couth and somber surroundings, often reveal a refinement
of feeling and appreciation of moral excellence, which has
aroused within me the deepest sentiment of brotherhood
and solidarity. In such households, if the occupancy of two
COMMON PLACE MIDWIFERY. 23
or three mean little rooms deserves so grand a designation,
the mother often comes to bed in a half-starved state, be-
cause the brood of little ones about her must not go unsat-
isfied. To such a woman, burdened in body and yet more
in mind, quinine in doses of one or two grains every five or
ten minutes until twelve or fifteen grains have been taken,
will bring courage and buoyancy, and for the nonce make
life seem worth living. I am in the habit of supplying my-
self with a quantity of these pills, and feeding them to the
patient one by one. I call them my “courage pills,” and
whether it is the kindly sympathy with which they are
given, or whether it is my confidence in their utility, or
whether it really is the virtue of the drug, I know not, only
I know the response is often magical. The whining, fret-
ful, despairing mood passes, and the woman braces up and
has her baby in good style,
Through the courtesy of the late Mr. Robbins, of Mc-
Kesson & Robbins, I had the opportunity of experiment-
ing, some ten or eleven years ago, with a large number of
the salts of quinine.
I was furnished with upwards of a hundred specimens,
many of them made for the first time, and most of them
proving to be mere chemical curiosities. My desire was to
find a salt which would strike the happy mean between de-
liquescence and stability. Nothing was produced which,
on the whole, for cheapness, reliability, and prompt action
is superior to the bi-sulphate. This salt, while absolutely
stable under all atmospheric conditions, is more readily dis-
solvable in saliva and the gastric juices than any other that
is not acted upon by moisture in the air. As the result of
numerous trials it was definitively ascertained that when
the mucous surfaces were in a normal condition the physio-
logical effects were perceived within five or six minutes
after ingestion. *
Lard is a most useful adjunct in the lying-in chamber,
and I always use it when I can get it; but, as I have a
24 COMMON PLACE MIDWIFERY.
brother-in-law in the business who says it cost him fifty
thousand dollars to learn how to make a prime article so as
to be able to sell it for less than the cost of the leaf, I am
rather particular as the quality of the lard I use. If I can
do so I have the leaf purchased at the hog butcher's, and
tried out at home. Then we have an article which, for ob-
stetrical use, is superior to anything in the line of grease—
lanonin, vaseline, olive oil, or what not.
Having secured a good article I use it freely; occasion-
ally a couple of pounds in the conduct of a case. Nothing
produces such a cooling effect on the heated membrane of
the vagina as a good coating of lard. It requires some dex-
terity to carry a chunk of lard the size of a hen's egg up
into the vagina without leaving the best share of it outside
the vulva, and smeared on the bed-clothes; but when
once the knack is acquired we have at our command an un-
equaled āccelerator of parturition. It is well known that
lard applied to an inflamed tissue, dermal or mucous, not
only reduces the local inflammation, but the systemic tem-
perature as well, and in obstetric work I have seen its appli-
caſion, as I have described, in many instances so quiet
nérvous tension as to reduce the pulse-rate five or ten beats,
in as many minutes. Carrying small pieces the size of an
almond well within the os, and rubbing it thoroughly into
the tissues, not only breaks down moderate rigidity, but
prevents º: of the cervix by making the muscular
fibers mofe elastic. Lard has great penetrating power, and
when used early and often, it will increase the elasticity of
the perineum and prevent rupture. I ascribe the infre-
quency of this complication in obstetrical cases, in my
experience, to leaving the perineum alone, and the free use
of lard. If you take care of the presenting part, the peri-
neum will take care of itself; and if you use lard early
enough and unstintedly enough you give it the best aid in
your power.
In the matter of rupture of the perineum the personal
COMMON PLACE MIDWIFERY. 25
equation of the accoucheur counts for much. I know a
surgeon of New York, of large experience and much culture,
who confided to a fellow-practitioner, not so very long ago,
that he had never seen a truly natural case of labor in all
his round of experience. Another surgeon, resident these
many years in Brooklyn, widely known and highly honored
in that community, told me a couple of years ago, in reply
to an inquiry of mine as to the frequency of rupture of the
perineum in his practice, that rupture occurred in a majority
of cases, and in primipara always. Another popular ac-
coucher, a member of this society, whose daily experience
includes a case of obstetrics, that is, who has for years
averaged more than 365 cases a year, answered the same
inquiry by the assertion that rupture occurred so rarely that
it might almost be said to be unknown. Evidently these
men differ in the management of their cases.
The consensus of authoritative opinion seems to indicate
that perineal laceration is unavoidable in about fifteen per
centum of all cases, not including slight tears confined to
the frenulum ; but with the free use of lard, and lifting the
child's head upward and forward, while at the same time
preventing the too rapid descent of the body by requiring
the woman to breath deeply during a pain, nearly all of
these accidents may be avoided. If, nevertheless, the ten-
sion is so great that rupture seems imminent, by having the
nurse draw the perineum forward it may be saved intact.
This maneuver is best accomplished by inserting two fingers
into the anus, with the palmar surface of the hand lying in
the same plane as the posterior wall of the perineum.
Episiotomy I have never practiced, and I believe with Lusk
that it is essentially the operation of young practitioners;
and I didn't hear of it soon enough. The same may be
said of incisions through the vaginal portion of the cervix.
When the mucous surface of the vagina is abraded or
torn, I use a weak decoction of calendula flowers, at a tem-
perature slightly above that of the body (IOO’—IO5° Fahr.).
26 COMMON PLACE MIDWIFERY.
Care must be exercised not to have it too strong, just
giving forth a faint odor of the flowers, or frightful Oedema
of the parts may occur. I have used carbolized, thymolized,
and chloridized washes, but I come back every time to cal-
endula as the most satisfactory in every way; though for a
cleansing wash I sometimes use sulphate of copper, in the
ratio of one to a hundred, at a temperature of 120° Fahr.,
or thereabouts. It is antiseptic, astringent, coagulates
albumen, and thus stops bleeding from any small arterial
twigs which could not be reached easily otherwise.
ANAESTHETICS.—I have used various anaesthetics, mainly
chloroform, ether, and a combination of the two with alco-
hol ; and, on the whole, I prefer chloroform, and now use
this altogether when I require anything of that nature. I
have passed through three phases in regard to chloroform.
At first I was afraid of it, and did not use it even sometimes
when I would have liked. Then when I began to use it I
gradually became enthusiastic about it, and used it in almost
every case, not usually to the point of complete anaesthesia,
but dulling the sense, and often, I fear, prolonging the labor.
It was not long, however, before it dawned upon me that
this was senseless practice; that the pain was physiological
as well as the labor; and that morbid pain in labor could be
controlled homoeopathically, if the doctor knew how to do
it. I, therefore, began to study, for this particular use,
such drugs as valerian, zincum, cimicifuga, ignatia, coffea,
aconite, chamomilla, caulophyllum, and the like. I have
not abolished pain in my cases, however. Nor am I alto-
gether sure that I would do so if I could ; pain has its uses
as well as adversity; but intolerable pain, morbid pain,
whether the morbosity be in the mind or in the muscle, may
be made tolerable and physiological.
I have never used cocaine in the vagina, as some do, for
the same reason that I now rarely use chloroform ; but I
have tried one expedient which acts admirably if the woman
comMONPLACE MIDWIFERY. 27
can be induced to persist in it. That is deep and rapid
breathing. This will produce a form of narcosis, sufficient
to dull the severest pain, and yet has none of the disadvant-
ages of drug-anaesthesia; but women rarely have persistency
of purpose to keep it up continuously enough to receive
the full benefit. This form of treatment is best adapted to
those women who do everything pugnis et calcibus, or to
such who are easily controlled by the operator's will. Hyp-
notism offers an encouraging field in this latter class.
RIGID OS UTERI.-I was once completely baffled by a
headstrong and rebellious os; I could neither coax it nor
drive it. After having lubricated it with lard without the
slightest effect on its persistent rigidity, doused it with hot
water, tried chloroform to the point of anaesthesia, tried gel-
semium until the patient thought she saw two of me, tried
just sitting still and doing nothing, until at last I made up
my mind that I was ignominiously beaten, and sent for
good old Prof. Burdick. The os was dilated to somewhere
about two inches and a half across, was as thick as my
finger, and as hard as a piece of steel. When Burdick came
I told him the whole story, and he sat there and looked at
me, and then at her, and back at me, for about three min-
utes. What was my surprise then to have him ask for my
forceps and begin to apply them. This was a difficult feat,
and quite beyond me at that time; and, indeed, I remem-
ber it made great beads of perspiration stand out on his
forehead. But once applied, steady traction for ten or fif-
teen minutes took all the obstinateness and pluck out of
that bit of tissue, and thenceforth the labor progressed sat-
isfactorily.
Of late years I have adopted the plan of rimming the os,
the only objection to which is that it is exceedingly fatigu-
ing to the accoucheur, in a persistent case. Seated on the
edge of the bed I insert a finger past the first phalange into
the os, curling it so as to catch the inner surface as by a
28 COMMONPLACE MIDWIFERY.
hook, and begin slowly to make it travel about the edge,
applying considerable pressure. The amount of pressure is
not of so much importance as the evenness and steadiness
with which it is applied. To keep this up for fifteen min-
utes requires a large amount of pluck and endurance. I
used to get tired, and, abandoning it after a few minutes,
try a hot water douche, and if that did not answer, then
sensible doses of gelsemium; but now I get tired and go
right on, though sometimes the finger will be numb for a
space of two days thereafter. I have used the Molesworth
dilator, which is easy to apply, but then there is always un-
certainty as to what it is doing. The fact is, the only
obstetrical instrument I have any fondness for is the human
hand. I have, for this purpose fortunately, a small and very
flexible hand, and wherever I can get that I prefer it to all
the curettes, forceps, and dilators that ever were made.
FORCEPS.—I have used the forceps 47 times in my own
cases, and 17 times in consultation. They are a great
temptation when one is tired and sleepy and wants to go
home and to bed. I put temptation, in more recent years,
as far from me as possible by leaving my forceps at home,
and only sending for them when their usefulness to mother
or child is made manifest. When I first owned a set I was
quite proud of them, and lugged them around everywhere,
rather glad of an excuse to use them, and sillily proud of
myself when I had yanked a child into the world an hour
before his time.
I bought soon after graduation a set of Burdick's, and
have never had occasion to use any other. One can do
better work with an accustomed tool than with another, and
nothing is gained by trying first one pattern and then a
different, if the choice has been well made at first. I have
read much of what has been written as to axis-traction, and
have examined Tarnier's instrument, and Simpson's and
Lusk's modifications, with interest. The theory is excel-
COMMON PLACE MIDWIFERY. 29
lent; but I am inclined to think that as a matter of prac-
tice it will never come into general use. If I were doing
now as much obstetrical work as I did once, and had avail-
able as capable assistants as I had then, I should certainly
use Lusk's Tarnier sufficiently to have a right to an indi-
vidual opinion ; which I have not now.
Embryotomic deliveries I have taken part in, but never
as principal; but the impression left upon my mind by what
I have seen, what I have heard, and what I have read, is
that the necessity for them mostly lies in want of prevision.
The idea that is in my mind is well expressed by one who
has a right to be heard on this or any question in midwifery:
“By the general substitution of methods of delivery com-
patible with the safety of both mother and child, the propor-
tion of cases in which embryotomic instruments are em-
ployed has been so minimized as to "lead to a confident
expectation that all such implements as the craniotomy for-
ceps, the perforator, the cephalotribe will be relegated from
the obstetrical armamentum, to the chamber of horrors of
Some future museum of surgical instruments. At any rate,
from the progress recently made in this respect, we have
reason to look forward to a not distant day when the great
objects of obstetrical science, the delivery of a living child
with safety to its mother, may in nearly every instance be
secured.” ”
TYING THE CORD.—My practice is to tie the cord after
it has become pulseless; tying twice and severing between
the two ; that on the placental side partly for cleanliness,
but more for the purpose of keeping the placenta as large
as possible—the fuller it is the less elastic it becomes, and
so the more easily is detachable. In dressing the umbilical
stump of the cord I untie the knot, so as to permit the re-
tained blood to outflow, strip off the jelly of Warton, and
then retie. This procedure lessens the size of the stump,
* Thomas More Madden, M.D.
3O } COMMON PLACE MIDWIFERY.
and encourages dry gangrene. Since doing this I have had
no trouble with it in any case.
Budin,” in 1875, instituted an inquiry as to the amount
of blood lost in severing the cord, by comparing the quan-
tity which flowed from the placental end when the cord was
divided immediately on the birth of the child, with that
which escaped when the cord was not cut until the delivery
of the placenta. The result of careful weighing, in a long
series of cases, was that this difference averaged three
ounces. Schücking,” two years later (1877) corroborated
these results. Zweifel,“ in the following year, in a series of
one hundred cases, found that the difference in the amount
of blood loss between immediate cutting of the cord and
delaying until the placenta was expelled by Credé's method
was three and a half ounces. Hofmeier,” in 1879, varied the
experiment by weighing the child immediately after birth,
and again on the tenth day. In 90 cases, in 40 of which the
cord was cut early, and in 5o late, the loss of bodily weight
was much less in the latter than in the former. Porak
energetically combated these several assertions, and
claimed that vomiting, jaundice, and other ills followed
late cutting of the cord ; that the loss of blood was bene-
ficial rather than otherwise, and that infants usually suf-
fered from plethora ; but his views are not sustained by
general experience. Engel,” the last prominent man, who
has written on this subject, as far as I am aware, claims that
even trivial losses of blood are serious, and that in those
children in which it is limited to a minimum, it will be noticed
that they are rosier, cry less, sleep better, and are later in
demanding to be suckled ; all these things must be bene-
ficial not only to the child but to the mother also. But
* Bulletin Therapie. I5. ii, 1876.
18 Berlin Ålinic Wochenschrift. Nos. I and 2. 1877.
* Centralblatt fºr Gynaekologie. I. 78. 1879.
* Zeitschrift fºr Geb. und Gynaek. Bd. iv. 1879.
* G. von Engel. Centralblatt fºr Gynaekologie. Nos. 46. I4. xi. I885.
COMMON PLACE MIDWIFERY. 3 I
Engel claims a still more important advantage from late
severance of the cord ; namely, that it has a weighty influ-
ence on vitality, especially in infants prematurely born.
Of these, during four years when he tied the cord immedi-
ately on delivery, he had 90 cases of premature birth in his
clinic of these 17 died (18.88 per cent.); in the following
four years, when he delayed tying the cord until all circu-
lation through it had ceased, he had 74 premature cases, of
which seven died (9.45 per cent.). He claims that in other
respects the treatment was the same, and that the lessened
mortality was secured solely by late ligature of the cord.
The amount of blood saved to the child, by late ligature,
is thus equal to from one-fourth to one-third of the entire
amount in its system ; stated in this way no one can doubt
the value of late ligature. Yet I know doctors who do not
tie the stump at all, just let it bleed until it stops. At least
they say they do.
The circulation in the cord ceases sometimes as soon as
the child is born, but in cases otherwise normal this is
extremely rare. Schroeder has seen the pulsation still con-
tinuing after a lapse of fifteen minutes. He says: “If an
umbilical artery and vein be cut across during this continu-
ance of pulsation, it will be observed that while the con-
tents of the former are expelled by successive jerks, those of
the latter flow out in a continuous stream. Further, it can
be seen that the blood ceases to flow from the artery sooner
than it does from the vein.” The reason for this longer
continuance of circulation in the vein would seem to me to
be that the artery contracts under the influence of cold,
while the vein is much less susceptible, and cannot contract
as the artery does. If the cord is kept warm by wrapping
it in hot flannel the circulation may be maintained much
longer; this applies, of course, to the uncut cord.
The transfusion of blood from the placenta to the child is
thus seen to be dependent on inter-uterine action to some
extent; though, in fact, vascular contractility plays but a
32 COMMONPLACE MIDWIFERY.
subsidiary rôle in this phenomenon. The transfusion is
mainly due to aspiration, the first deep inhalation of air
into the lungs accomplishing often the major part of this
transfer. Thus in the German experiments, when the cord
was cut the instant the body emerged and before breathing
commenced the blood-loss was three ounces or more, while
in Dr. Brakenall's experiments, at the Sloane Maternity,
where the cord was severed after breathing was established
but before the cord had ceased to pulsate, the amount of
blood lost was from an ounce to an ounce and a half.
Thus cardiac action and vascular contractility form the two
opposing forces upon the combined effect of which depends
the possibility and quantity of arterial transfusion from the
fast dying placenta to the revivified child.
Since my attention was directed to Hofmeier's experi-
ments I have used most strenuous endeavors to preserve to
the child every possible drop of blood. In only one in-
stance has a child born alive perished during its first month.
Often and often multiparous mothers have said to me how
much better, or stronger, this child was than former ones,
in which presumably some other method may have been
pursued. This reinforces what is said by Engel.
THE PLACENTA.—If I do not misread current literature,
the opinion of the day favors a somewhat extended interval
between the birth of the child and the delivery of the pla-
centa. Playfair voices this by picturing the latter as a
miniature of the former, and indicates half an hour as a usual
and proper interval between the two ; strongly reprehend-
ing a quick delivery of the placenta as likely to cause
haemorrhage, inversion, or some similarly untoward result.
In this respect, however, the English school is far behind
the modern German; as will be seen from the following sum-
mary of a method enunciated by Ahlfield, of Leipsic, about
a year ago, and entitled “ Expectant Method, or Credé
COMMON PLACE MIDWIFERY. 33
Manipulation.” ” Ahlfield's argument is claborate, but the
substance of it is this: After the delivery of the child and
division of the cord, the external genitals are cleansed with
sublimated or carbolized cloths. At intervals of five minutes
the parts are to be inspected, so that the progress of the
case may be known, and haemorrhage checked if it occur.
If after waiting an hour and a half the placenta has not been
extruded by natural evolution, the urine is to be drawn,
and the secundines expressed by the usual manipulation.
If, during the period of expectancy, bleeding is discovered
it should be arrested by massage; but if this fails, and
the amount of blood-loss seems serious, then the uterus
is to be emptied as quickly as possible. Winckel, Dohrn,
and a host of major and minor stars in the obstetric field,
announce their allegiance to the doctrine of expectancy,
and the satellites are falling into line, with a sublimated rag
in one hand and a five-minute glass in the other; but pres-
ently the wheel of Ixion will revolve, and Science will be
delivered of a new opinion.
In my salad days I always proceeded to the delivery of
the placenta with caution and deliberation ; but in 1879 I
made a complete change in my method. I now deliver the
placenta as quickly as possible. I will state the method
briefly. Unless there is obvious reason for haste, I delay
the last act in the second stage of labor, by pushing back
the advancing head during two or more pains, so that when
the head does begin to pass the vulva the operation is
quickly accomplished, and with one more effort delivery is
complete. Now, turning the child over on its back, I an-
nounce the sex, and tickling it under the arms, set up reflex
action, and vigorous respiration. Many infants will give
two or three feeble cries, and then doze off ; this I do not
permit. To secure the greatest dilatation of the lungs in
that first critical moment is my constant endeavor. I am
in no haste to tie the cord, and do so only after the child has
"American Journal of Obstetrics, Nov. 1888.
34 { COMMON PLACE MIDWIFERY.
had several minutes of squalling, which I cordially encour-
age. Nothing is more soothing to a mother's ear than the
cry of a new-born child; and thus, in this first half-automatic
act of the new-born is subserved two useful purposes, and
thus begins, with the earliest moment of separated life, the
weaving of that cord of dual beneficence which binds
mother and child more strongly than the prenatal fleshly
tie. *
The cord severed, the babe wrapped in a blanket and laid
aside, I at once proceed to the removal of the secundines.
With the left hand I outline the collapsed womb. If it is
ovoid in shape, the placenta is yet within it, and pulling on
the cord would possibly do mischief. But if the uterus is
round it is empty, and then, encouraging the woman to make
a sneezing effort two or three times, with the right hand I
seize the presenting edge of the placenta and dexterously
bring it into the world, rotating it slowly so as to gather
together all the membranous shreds which are hanging to
it. This operation rarely takes more than three minutes, is
never followed by hamorrhage, causes hardly any pain as
the parts have not yet recovered from the numbness pro-
duced by the pressure upon them of the child's head, and
relieves the nervous tension under which the woman must
remain until she knows this final act in the drama of travail
is complete. Thus in eight to twelve minutes after the birth
of the child, the after-birth is on its way to the kitchen range,
the mother is lying well-wrapped and at ease, and the doc-
tor and nurse are at liberty to turn their attention to this
youngest candidate for citizenship.
If the placenta, however, has not descended into the vagina
during the time preliminary to the cutting of the cord, a
somewhat different procedure is necessary. Slapping the
back of my right hand into a saucer of lard which is stand-
ing within convenient reach, I draw it into cone-shape,
by pressing the tips of the fingers together, so that each
touches each. I pass it up, in this shape, within the OS, and
COMMON PLACE MIDWIFERY. 35
grasp the placenta firmly with the tips of two or more fingers,
while at the same time I gently manipulate, with the left
hand, the uterus, through the abdominal walls. I say
manipulate, but the action really is a gentle stroking of the
uterus, from above downward, and from side to side, much
as one would stroke a cat's back, only with a firmer touch.
Doubtless the ability to give off magnetism, by concentra-
tion of will-force, has much to do with the success of this
maneuver, for in two or three minutes, while exerting trac-
tion (not on the cord but on the presenting edge of the
placenta) little more than necessary to overcome the actual
weight of the placenta and its membranes, these begin to
slide down toward the vulva, and the uterus contracts solidly
down upon itself.
I always note the time of the babe's first cry, and also the
time when I have washed my hands after depositing the
secundines in the vessel appointed to receive them. The
interval is often not more than ten minutes, rarely fifteen,
and even in the most difficult cases has never, to the best
of my recollection, exceeded twenty, in my last three hun-
dred confinements. Doubtless when one acts in accordance
with a well thought-out rule of procedure, the mere atten-
tion to routine suppresses emotion ; but really the delivery
of the placenta causes me no more anxiety than the dress-
ing of the stump of the cord, or the pinning of the maternal
bandage. -
A brief digression will explain the mechanism of placental
delivery. In a perfectly normal labor the moment succeed-
ing the passage of the child into the world is one of ex-
treme relaxation of all the parts. The placenta still being
adherent there is no ha-morrhage, and the uterus can be
felt in a flabby condition, extending upward above the um-
bilicus, and apparently nine or ten inches long, and three or
four broad. In this relaxed condition it is often difficult to
find if the omentum is at all large, and when made out feels
for all the world like a piece of bowel. If the case is left
36 COMMON PLACE MIDWIFERY.
A
to itself this condition may continue for some time, perhaps
even extending into hours, and without danger, as the
uterus is completely full, and ha-morrhage cannot occur
until the placenta begins to peel off, which it will not do
until by contraction of the uterine walls the placental site
is reduced to an area of four and a half square inches. It
is a common error to suppose that there is a uterine cavity,
a space unoccupied, after the birth of the child. This is
not so. A diagram, produced by Stratz,” shows a frozen
section through the uterus of a woman who died at the
termination of the second stage. This uterus, which is ten
inches in length by about three and a half in thickness, is
everywhere in close contact with the retained placenta, the
uterine walls following the sinuosities of its surface. This
is believed to be a fair representation of things as they
exist normally at the beginning of the third stage.
With this state, of a foreign substance capsuled within
the uterus, we may have haemorrhage, or we may not; the .
mere mechanical retention of the placenta is certainly not a
source of haemorrhage, but indeed rather the reverse.
Now I think we have here the testimony of nature as to
the place and scope of homoeopathic medication in uterine
haemorrhage. Why is it with the placenta entirely detached
and retained in the uterus we have no haemorrhage, while
with only a partial detachment we often have severe blood-
loss? That is, with a part of the uterine vessels torn across
there is considerable bleeding, but in another case with all
of them ruptured we have no bleeding. In both cases the
uterine cavity is acknowledged to be approximately equal
to the placental mass ; for the best observers are agreed
that practically there is no empty space, the uterine walls
and the placenta everywhere touch unless forced apart by
clots, the entering hand, or other foreign substance. It
would seem that the difference between the two cases is a
* “The Sectional Anatomy of Labor,” by A. H. Freeland Barbour, M.D.
Edinburgh Medical Journal, October, 1887, page 320.
COMMON PLACE MIDWIFERY. 37
pathological one; the adherency and the bleeding are two
expressions of one fact. This being so, our answer should
be the remedy homoeopathic to the case, and our ability to
prescribe that is the measure of our knowledge.
Circulation having stopped in the placenta, that organ
hardens by the congelation of the blood within it, and act-
ing as an irritant in the womb, causes contraction ; the
ensuing diminution of the placental site, a diminution to
which the placenta cannot accommodate itself, causes sep-
aration, and the downward push of the descending fundus
the extrusion of the placental mass and of any clots which
may have been formed. If a severe pain can be induced
the detachment takes place in one effort, but when the
pains are feeble the detachment is partial. If partial it
most usually begins in the center, and as the uterus again
relaxes the blood is aspirated into the hollow between the
uterine wall and the placenta ; in this cavity thrombi form,
which block up the vascular mouths, and prevent exces-
sive bleeding. Traction on the cord will cause bulging at
the center, and will increase the probability of this form of
separation. If the separation occurs at the upper edge the
haemorrhage will be dammed in by the body of the placenta,
and thus held in check. It is only when the separation is
from below that dangerous haemorrhage can occur; and the
firmer and more extensive the adhesion above may be, the
greater the risk. Flooding cannot occur while the placenta
remains completely attached to the uterus, and can only
become dangerous when relaxation after a pain leaves the
upper portion adherent and the lower hanging free.
Haemorrhage is not probable when the placenta is com-
pletely detached and retained, as this then acts as a tampon,
the healthy uterus rarely relaxing more than just sufficient
to keep its parieties in contact with the placental mass.
The cause of the non-separation of the placenta depends
on the defective development, or pathological condition, of
*ex
38 COMMON PLACE MIDWIFERY.
the spongy layer, or of the mesh-work layer. The patient
has probably had an endometritis. In all cases which I
have had a previous history of uterine inflammation could
be traced.
Now what shall we do with these cases P Winckel, of
Leipsic, counsels expectancy; but after two hours would
proceed to deliver manually. This may be taken as a fair
index of the most enlightened old-school practice of the
day. Has homoeopathy anything better to offer P I think
it has. The difficulty is to find the key-note for the
remedy ; but why should this be more difficult here than in
an impending abortion, or in Asiatic cholera P. We know
we can cure these by homoeopathic medication, why not the
former ? Lilienthal mentions ten or a dozen drugs for this
condition, but I know of no reason for limiting the selection
to these. My own experience covers but half a dozen
cases, only two of which were really serious, and each of
these was apparently benefited by a remedy in Lilienthal's
list; but, while I was then, and am now, ready to defend
my action in these cases as truly scientific, I am not sure
that anybody else here present will think so.
The first of these cases was in August, 1883. The patient,
4-para, was the wife of the janitor of an apartment house,
situate on Thirty-third Street. The labor was uneventful
and rather brief, the second stage lasting less than two
hours. The child was a well-developed male, weighing
seven pounds six ounces. On proceeding to the delivery
of the placenta in my usual way, I found that while I could
induce fairly strong pains, the placenta did not move, and
as during the relaxations there was no haemorrhage, it was
evident that the placenta remained attached over the whole
site. Had there been detachment in the center there might
have been no visible haemorrhage, but the uterus would
have become globular ; as it was it remained about twice
as long as it was thick, and during a remission could be felt
just above the umbilicus. The question now arose, should
COMMON PLACE MIDWIFERY. 39
I attempt to peel it off digitally, or wait? The most experi-
enced obstetricians state that in peeling off the placenta, in
these cases of firm attachment, the division is apt to occur
in the plane of the juncture between the mesh-work layer
and the spongy layer. That is, the foetal placenta and the
membranes come away, leaving the maternal placenta be-
hind. Thus the uterus is lined with a layer of dead tissue,
and we all know what that means. Sometimes when force
is used the whole placental mass comes away, bringing with
it the superficial surface of muscle. Now if this is what
occurs in large maternities, where they have a constant suc-
cession of difficult cases, and where they have appliances to
meet all emergencies, and fresh attendants to replace tired
ones, what is the ordinary practitioner to do, alone, in a
dark basement bedroom P I can testify as to what one
practitioner did—he sat down and waited—but as he sat
waiting he asked himself, What remedy is homoeopathic to
this case? The woman was a tall blonde; easy, good-
natured disposition ; had a history of considerable uterine
trouble, and had probably had endometritis about two
years previously, following a miscarriage. The only clinical
symptoms which could be elicited were these: the pains,
though not extremely severe, were long lasting, and did not
seem to involve the whole uterus equally; they made her
feel faint, but the faintness was not accompanied by unusual
pallor; there was a slight dyspnoea, and demand for fresh
air, but this may not have been a clinical symptom, as the
weather was warm, and the patient confined in a room whose
floor was several feet below the grade. No remedy seemed
so likely to be helpful as pulsatilla, which was given in the
thirtieth potency. Its first apparent effect was to put an
end to the pains. In less than an hour the patient was
sound asleep, and, it then being after the breakfast hour, I
returned to my own house, leaving word to be sent for if
the pains returned. At noon I saw the patient. She had
had a long and refreshing nap, was feeling comfortable, no
4O COMMON PLACE MIDWIFERY.
pains; pulsatilla continued. Thus everything remained, no
haemorrhage, no pains, for fifty-six hours. The patient, and
her family, became very dissatisfied, and even if they had
not been I should have been in no enviable mood. I knew
it was best to wait, I believed nature was, with the help of
pulsatilla, working out her own salvation; but I also real-
ized that if anything did finally go wrong I would be
severely censured, that I had the consensus of professional
opinion against me. But in the early evening of the third
day, about fifty-six hours after the birth of the child, there
were two or three brief, sharp pains, and the placenta
passed the vulva; and when I called, an hour or two later,
I found it had been disposed of by the woman who was
acting as volunteer nurse. This was a disappointment, as I
would liked to have examined it, or sent it to some one who
was more competent; but I was too greatly relieved by this
happy termination of my anxiety, to feel much displeasure.
Nor do I really think much was lost by the failure to make
a rigid examination of these secundines. The microscope
might have told of the nature of the fault; but it is more
than probable that the evidences of this had disappeared
under the kindly influences of time and pulsatilla. If, owing
to a previous endometritis, the ripening of the placenta was
delayed, and if, under the influence of pulsatilla, this natu-
ral process was hastened to completion, then the extruded
mass would hardly evidence an abnormality which had dis-
appeared. The patient made an unusually quick and com-
plete convalescence, and on the tenth day (from the begin-
ning of confinement) was up, looking remarkably well. In
fact, she about a month subsequently stated that she felt
stronger and “more like herself" after this confinement
than after either of the other four. *.
Another case of retained placenta was treated with gossy-
pium. The patient, a spare, restless sort of a woman, was
anaemic, and the blood was dark and watery. The child was
born at 3 o'clock A. M., and the placenta came away at
COMMON PLACE MIDWIFERY. 4 I
about 9 o'clock. The woman made a slower convalescence
than in the previous case; but this was due not to the re-
tention of the placenta, but to impoverishment. The other
four cases were quickly relieved, the longest being about
three hours; but as massage was used in each, and faradi-
zation of the breasts and abdomen in one, I cannot say how
much credit should be given to the medicaments adminis-
tered. A properly regulated faradic current applied to the
breasts will do more to bring about a natural delivery of the
secundines than the form of manipulation designated as
Crede.
Finally, I am strongly of the opinion that adherent pla-
centa need never occur, if proper treatment is given during
pregnancy. We do not like to discredit ourselves, even to
ourselves; we like to think we are in the right, and the
fault was not with us; I know I do, and human nature is .
much of a muchness everywhere; but most obstetric bug-
a-boos disappear before common-sense and experience.
“Abnormal adhesions and hour-glass contractions are more
frequently encountered in the experience of the young
practitioner, and they diminish in frequency in direct ratio
to increasing years.””
More serious, to my mind, are those cases in which, after
an exhausting labor, the lower segment of the placenta de-
taches while the upper remains firm. The wearied womb
refuses to be aroused to action, the flow of bright-red blood
is continuous, and the necessity of prompt action is apparent
to the least experienced eye. These cases have been “few
and far between '' in my practice, but I have had some anx-
ious minutes over them. If after the first gush which fol-
lows the feet of the child into the world, I notice a little rill
of blood trickling out from the lower segment of the vulva, I
at once administer a dose of belladonna or ipecacuanha, the
prescription depending on the well-known characteristics of
* Braun's Lectures. Berlin, 1869.
42 COMMON PLACE MIDWIFERY.
each ; I direct the nurse, or any one who may be at hand,
to chafe the breasts while I massage the uterus. It would
be convenient to have a good faradic battery at hand; but
I never had except once, by accident. I have had cases
where the loss has been considerable before it was finally
checked. In two such cases I have given half-drachm doses
of ergot (Parke, Davis & Co's normal liquid), and in several
others Hayden's Styptic. The latter is composed of blended
tinctures of cinnamon, fire-weed, and ergot, made with old
French brandy. It improves with age, and it is best, there-
fore, to buy it by the pound, and leaving it sealed, set it
where a strong sunlight can play on it. In a year or two it
will be ripened, so that a small dose acts more efficiently
that a large one of the freshly prepared. Dr. Hayden often
keeps it six or eight years; I have some that was in the
cask eight years, and which is now fast approaching its ma-
jority. This preparation of Hayden's is a more desirable
styptic than pure ergot, as the after-pains are not increased
by it, while after using tinctura ergota the after-pains are
apt to be severe and long lasting.
Occasionally even in desperate cases the homoeopathic
remedy is so clearly outlined that even a mongrel homoeo-
pathist need not err. Thus trillium, platina, Sabina, phos-
phorus, ferrum, cinchona, have been given with evident
benefit; but usually the choice is difficult, and a mistake
fatal. f
Quickly cutting the cord and injecting cold water into
the placental end of the umbilical vein will distend and
harden that viscus, and induce contraction of the uterine
parieties. This works nicely sometimes, but I can hardly
speak of it as a modus par excellence ; if it fails the patient
will almost certainly have a hard chill.
Hegar,” of Berlin, called attention, nearly thirty years
ago, to the fact that nature had a way of managing cases of
* ALFRED HEGAR, M.D., Pathologie and Therapie der Placentarretention.
Berlin : 1862. -
COMMON PLACE MIDWIFERY. 43 .
adherent placenta which trenches upon the marvelous :
that the entire placenta may be retained, may be absorbed,
and no evil consequences arise. There are, at least, six
such cases on record ; Naegele reports two, Villeneuve,
Porcher, Thrush, and Reamy, each one. As a matter of
general interest I reproduce these cases in brief synopsis.
The first four are from Hegar, the fifth from a paper by Dr.
Thrush,” read before the Cincinnati Obstetrical Society,
and the last from a verbal report of the case to the same
society.”
CASE I. (Naegele's).-Patient a primipara; labor at about
seven months gestation; the long, thin cord is torn out
from its insertion in the placenta; midwife watches eight
days and nights at bedside of patient. For four days
moderate lochial discharge, no foetor; twenty-four hours
after labor slight febrile movement; no pain in abdomen ;
no milk. Eleven weeks thereafter patient menstruates
again ; subsequently conceives a second time, and after the
lapse of fifteen months gives birth to a mature child, the
entire labor being normal. Nothing was ever seen of the
placenta of the first pregnancy.
CASE II. (2d of Naegele).-Multipara; labor at term
normal to close of second stage, then hour-glass contraction;
retention of the placenta; haemorrhage. Thirty hours after
labor; fetid discharge; removal by hand of about half of
placenta; no lochia subsequently. Thirteen weeks later
menses return ; patient entirely recovered ; remaining half
of placenta never discharged. Two years subsequently re-
newed pregnancy; labor this time normal throughout.
CASE III. (Villeneuve's).-Patient a multipara; aborted
at six months, giving birth to triplets; placentae of last two
foetuses come away spontaneously, but that of the first is re-
tained. On intra-uterine exploration placenta is detected
* “Retention of the Placenta in Labor at Term,” by J. F. Thrush, M.D.
The American Journal of Obstetrics. Vol. x. page 389.
* The American Journal of Obstetrics, 1887, page 507.
44 COMMON PLACE MIDWIFERY.
in right upper and anterior region of the uterine cavity;
cord torn out from its placental attachment. The lochial
discharge is less than normal; patient is convalescent by the
eleventh day after labor, and leaves hospital. Twenty
days later has an attack of haemorrhage, lasting almost un-
interruptedly for eight days, nothing but blood passing
away during the time. No discharge of placenta.
CASE IV. (F. Y. Porcher's, of Charleston).--Patient a
multipara; third pregnancy; labor at term ; child born in
breech presentation. Immediately hour-glass contraction ;
placenta retained; hand passed into uterus without difficulty;
afterbirth everywhere adherent. Ergot given in full doses;
three days thereafter cord and a portion of membranes
pass in a state of decomposition ; copious foetid discharge; at
three weeks after labor patient convalescent; a month later
is seized with pain and a sense of weight in the pelvic
region ; uterus found low down, placenta felt through open
Os, still adherent ; a week subsequently another paroxysm
of pain, os this time closed. A year later patient entirely
well. No placenta ever discharged.
CASE V. (Thrush's).-Nov. 25, 1875, about 7 P.M., called
to Mrs. R., age thirty-three, said to be in labor—first child.
Arrived; heard that “the waters had broke ’’ four hours
previous; large amount escaped ; for severals days past had
pain; small of back—lower abdomen. Much annoyed by
constant uneasiness, amounting often to positive pain, refer-
able upper and right side of abdomen ; large projecting
tumor; noticed many weeks. Patient believed labor “over-
due.” Menstruated last, first week of January, forty-sixth
week. ‘Bloody discharge in February, unlike usual flow, she
felt confident was not monthly sickness.
Exploration showed cervix obliterated,—os dilated for
passage of two fingers. Extremity of foetus forming tumor
spoken of by patient. Remained at house during night.
No material progress on 26th. “Lifeless body” extracted.
Child, female, weighed 124 pounds. No haemorrhage.
COMMON PLACE MIDWIFERY. 45
Looked for placenta. Taking cord as guide, found it high
up in right side of uterine cavity, immovably fixed not
detachable. No pain. Traction on the cord led to rupture
of cord, gave way at point of insertion. Gave fluid extract
of ergot. Fifteen months after, nothing has shown what
became of placenta. Patient now apparently pregnant.
CASE VI. (Reamy's).-Had but one case in which absorp-
tion took place—a woman in sixth month of utero-ges-
tation. Placenta not delivered—no offensive discharge.
Three years after, again pregnant. No attempt at delivery
of placenta, no haemorrhage, no ill effects observable.
Where absorption occurs patient rarely dies. Changes in
uterine tissue help to prevent decomposition. Activity of
uterine circulation helps to prevent decay. With morbid
adhesions, very often friable condition of womb at placental
site; hence womb liable to rupture or break at this point,
especial care to be observed. -
POST-PARTUM HAEMORRHAGE.-Real post-partum ha-mor-
rhage, that is, flooding coming on after the third stage is
completed, whether this happens after half an hour, or after
two or three days, is a most serious thing, and there is no
emergency in midwifery which leaves less time for reflection.
In one case occurring suddenly nearly an hour after the
delivery of the placenta, and when I had my overcoat and
hat on ready to leave the house, I stopped by passing my
hand up into the uterus, and tickling the inner parieties with
my fingers; the uterus contracted down on my hand, and
the flow ceased. I never saw a woman lose so much blood
in a minute or two ; it was just such a haemorrhage as one
would see from a severed jugular. I had heard of rivers of
blood; I saw one that night.
The value of the faradic current in these emergencies is
undoubted, and I always leave a two-cell battery, in running
order, at the side of my desk so as to send for it if I appre-
hend any danger of haemorrhage. I also, during the first
stage of labor, secure a nice juicy lemon, so as to have it
46 COMMON PLACE MIDWIFERY.
handy in case extensive bleeding occurs in the third stage,
or later. Half a lemon carried up into proximity with the
bleeding surface, and the juice squeezed out against it, will
put an end to the bleeding. Ice is good, but not as good,
nor as easy to handle, as a piece of lemon, and adds to the
already existing shock. I use ice, and ice-water, to effect
the expulsion of a retained placenta, but rarely in haemor-
rhage from an empty uterus.
I very much doubt if the ergot treatment of post-partum
haemorrhage is any considerable advance on the brandy and
opium of years ago, especially when this was fortified with
small doses of capsicum. In fact I have ceased to carry
ergot, and do not remember to have used it for three or
more years, except as it forms part of the formulary of Hay-
den's styptic, in which combination it ceases to be ergot, in
my opinion.
The pulse-rate is a fair index of the safety of the patient.
If after delivery it remains above one hundred beats a minute
flooding is imminent. Now is the time to show how good
a homoeopathist you are.
Even in cases which have been in every particular normal,
it is my custom to leave a small vial of Hayden's styptic
with the nurse; with directions how to use it, if haemorrhage
sets in. Only twice, as far as I now recollect, has this pre-
caution been of service, and the same vial has done duty in
many successive cases; but the mental relief that one feels
in thus providing for a contingency well repays the small
trouble of it.
ACCIDENTAL FOETAL DEATHS.—Of these I have had two
at term, and they were both interesting enough to deserve
relating. I will take the last case first. The woman was a
well-developed and pleasant-faced blonde ; such a one as
you would expect to be a good breeder. Her mother was a
monthly nurse, and had been known to me for some years
previous to the time of which I speak. She was an unus-
ually intelligent woman, and the daughter was well educated
COMMON PLACE MIDWIFERY. 47
for one in her station. She was married to a man some
years older than herself, a painter by trade and a superior
workman, but who spent his surplus wages on horses and
horse racing, and was generally fast. Him I never saw, but
subsequent events led me to suspect that he had a syphilitic
experience before marriage. However this might be, the
wife was bonny and attractive; such men are apt to get the
nicest wives. The mother came to engage me, and I sub-
sequently called on the daughter. Nothing was said about
any previous children, and I imbibed the notion that this
was a first pregnancy. In fact the woman was so young,
so bright, and fresh-looking that I jumped at a false con-
clusion without inquiry. Why under all the circumstances
these two women should have failed to tell me of the two
still-born children, both of whom died in the act of delivery,
a certainly startling event when it occurs once, much more
when it re-occurs, I cannot decide, except that it was blind
fate. When I saw her for the first and only time before
the confinement in which I attended her, she was so well
that I could find no peg on which to hang a prescription ;
nevertheless I suggested that she should come to my office
and report progress three or four weeks before the expected
event. But I heard no more until one morning about half
after three o'clock, when it was announced that “the waters
had broke,” and I was wanted in a hurry. I got there
without unnecessary delay; but with the exception that the
amniotic fluid had escaped, without any severe pains prior
thereto, the case did not seem to betoken need for special
haste. Digital examination showed the os high up and out
of reach ; the pains were very moderate, and the woman
was able to take short naps in between ; the interval from
pain to pain being certainly twenty minutes or more. This
state of things continued all through the morning, and as I
had a number of cases to see, a lecture to deliver, and was
due at the dispensary at two o'clock, I left the case in the
hands of a student, with a messenger at his service, so that
he could send for me instantly if needed. I returned to
48 COMMONPLACE MIDWIFERY.
the case at 5:30 o'clock, and found everything in the same
state as when I left. The pains had been irregular, and not
severe, and the prospect of speedy delivery was far from
encouraging. I determined, however, to make a thorough
examination under chloroform, and proceeded to do so at
once; up to this time the child was known to be alive. I
found the foetus lying on its back with its head in the right
iliac fossa, and both feet doubled up and level with the foe-
tal chest. After much trouble I succeeded in seizing the
right foot by passing my hand up over the right shoulder,
and making traction caused the body of the child to make
a complete revolution. These manipulations brought on
active pains, and the child was quickly in the world. There
was a brief delay as the head reached the outlet, but not
long enough to account for the catastrophe which ensued.
The child was born asphyxiate, but as I anticipated that I
was prepared for it. Without cutting the cord I submerged
the body in a basin of cold water and then into one of hot
(about 120° Fahr.), and endeavored to induce respiration;
but there was no response. The child was a finely developed
boy weighing in the neighborhood of eight pounds. Not to
make too long a story of it, I worked over that child for more
than two hours, administered tartar emetic 6, and Subse-
quently camphora S, succeeded by hot flannels and other
means in keeping up external warmth, but at last gave out
from sheer inability to go on. From first to last the child
made not the slightest effort. When I sank down in utter
exhaustion the old lady said: “I 'spected 'twould be that
way; she always loses her children that way ’’; and then I
learned of two similar experiences in previous years. I do
not think it was the chloroform that did it, for this was
used stintedly and cautiously, complete anaesthesia being
maintained only for a few moments at a time, and although
it was used continually for more than an hour, that is until
the breech presented at the outlet, the child was not born
in the limp condition which is seen often after continued
COMMON PLACE MIDWIFERY. 49
chloroform narcosis; and, as I was told, anaesthetics were
not used in the previous cases, and as those likewise were
healthy in appearance and well-developed, it is more than
probable that the death of all three is to be accounted for
along the same lines. The premature rupture of the mem-
branes was possibly due to the pressure of the head cross-
wise; the cord and placenta were normal in appearance ;
there was no event during pregnancy which could be cited
as a probable cause for the death of the foetus, which
appeared to be purely accidental. This case taught me the
advantage of the most rigorous inquiry into the history of
the woman when engaging to take care of her during an
approaching confinement. I thought I had been careful
before, but this case showed plainly that confidence in one's
opinions does not satisfactorily replace adequate knowledge
of the facts.
The other case of accidental foetal death was caused by a
complicated position the like of which I have never seen
described. On February 26, 1882, I was sent for to attend a
case on Twenty-sixth Street, near Seventh Avenue; the
patient was the wife of the pastry-cook in a leading hotel,
and had already given birth to four children. She was a
plump, jolly little body, and as the previous labors had
been normal, as far as I could learn, no apprehension was
felt of trouble to come. I arrived at the house about seven
o'clock, and found the woman in great pain. Before I
could make an examination the membranes broke, and a
hand was thrust forth. This I replaced and shortly the
other hand presented. This being likewise returned was
followed by the first hand and a foot; both of which were
spontaneously withdrawn one after the other. The child
was in cross-position, prone, the head in the left iliac fossa.
During all this time the pains had been very severe, but
now they gradually died out, and a period of rest super-
vened lasting nearly three hours. I gave pulsatilla 6 dur-
ing this period. Soon after noon the pains again became
5O COMMON PLACE MIDWIFERY.
severe, but short and unsatisfactory, and no progress being
evident, foreseeing that assistance would be needed, I sent
about four o'clock for Dr. Maria B. Hayden; and on her
arrival proceeded at once to administer chloroform prepar-
atory to manual delivery. I introduced my hand and
seized the foot I found presenting. It came down several
inches and then stuck fast. I made as much traction as I
dared but it would not budge. Passing my hand along the
leg up into the uterus I found the foetal head jammed in
between its two thighs; the head and shoulders being bent
forward and downward over the abdomen. Every effort to
free the head failed, until at last putting the woman into the
1<nee shoulder position it disengaged and podalic delivery
took place. The woman made a good recovery, and I have
since attended her in two normal labors.
PLACENTA PRAEVIA.—My experience in placenta praevia has
been brief and unfortunate ; though fortunate in its brevity.
My one case was in December, 1881. The woman, 3-para,
was middle-aged, and very stout, the pregnancy nearing the
end of the eighth month. I had seen her once, about a
month previously; at that time everything seemed moving
along all right, though I found her taciturn and unwilling
to say much about herself. About two o'clock, on the day
of the case, the husband came to my house, just as I was
starting for the dispensary. He stated that his wife was
feeling very badly, and had lost a “lot of blood,” which
he seemed to think came from the bowels. I did not want
the case, feeling sure there was no prospect of a fee,
and scenting danger in the air. So I tried to induce him to
go for some other physician, promising to look in after dis-
pensary hours. I especially disliked at any time to break
in on the dispensary service, when I had every day forty or
more patients. But he would not be put off, so I made
believe I did not want to go because he would not pay for
the service. This he promised to do within half an hour,
COMMONPLACE MIDWIFERY. 5 I
would meet me at his own house, and started off ostensibly
to get the money. I felt sure that his promises were fraud-
ulent, as they proved, for he did not turn up until long
after his wife was dead, and then, of course, without any
money. Having foolishly made that excuse instead of
sticking to my text of dispensary duty, I felt in honor
bound to go, and went, sending to the dispensary for two
of the students, Drs. House and Morehouse, who met me
at the case about three o'clock. When I reached the house
I found the woman had lost an immense quantity of blood
—a half bucket full, the attendant said—and was flooding
furiously. There were no pains, had been none, and none
could be induced subsequently. The abdomen was very
large, and the omentum enormous, making external man-
ipulation ineffectual. The uterus was high, and the os
pointed back into the hollow of the sacrum ; I could not
find it with my finger. I had carried a capacious syringe
with me, and at once gave a thymolized hot douche, con-
tinuing it for some minutes, but producing no effect. We
then gave teaspoonful doses of normal liquor ergotae, every
two or three minutes, plugging the vagina meanwhile with
strips of muslin saturated with liquor ferri subsulphatis.
But all to no purpose; the blood soaked down through
the muslin as fast as we could apply it. Shortly the woman
became delirious, then stupified, and at four o'clock was
dead.
I am quite able to criticise the conduct of the case; and
Sir James Simpson” has furnished the key to that criticism,
He once said that to plug the vagina in placenta praevia
was fool's practice Doubtless the hand should have been
introduced into the vagina, the os found, and the mem-
branes ruptured, after the manner of Wielobycki. This
would probably have precipitated the labor, brought the
uterus down into the pelvis, and given the woman a chance
* Dublin Medical Journal, vol. lxxxiii. page 194.
52 COMMON PLACE MIDWIFERY.
for her life; though the great loss of blood, and her gen-
eral atonic condition presaged extremest danger under any
treatment. Wielobycki, of Edinburgh, was the first, I
believe, to demonstrate the utility of rupturing the mem-
branes, by means of a catheter, and allowing the liquor
amnii to drain away slowly. Dr. Reuben Ludlam, of Chic-
ago, says: “This little operation, which any one could
make, in case the woman was at term or not, would arrest
the flow by plugging the cervix from within, and the con-
tractions induced would put a sort of Esmarch's bandage
on the organ so as to prevent an excessive flow of blood.””
Prof. Guernsey, of Philadelphia, said in regard to perforat-
ing the membranes, in cases of placenta praevia, with a
female catheter: “I have not heard of a single case of loss
of the mother where this method of procedure has been
followed, and the child is almost invariably saved. It must
be remembered to evacuate the liquor amnii very slowly.
Every accoucheur knows what bad effects follow the empty-
ing of the uterus rapidly under such circumstances; the
atony thereby produced is more to be dreaded than the
former state. When the placenta is only partially over the
os, even if it be but the edge of it, the same principle and
practice holds good.”” Wielobycki in twelve consecutive
cases saved all the women, and nine of the children by this
method.”
POST-PARTUM CHILL is usually provided against by
having a couple of flat-irons hot, and an extra pair of
blankets at hand. With a hot iron wrapped in newspaper
at her feet, plenty of bed-clothes over her, and a nice warm
drink to sip, even the most nervous woman will forget to
shiver. Successful midwifery practice is largely made up
of a series of forethoughts, by which all the minor discom-
forts and major emergences are provided against.
* The Clinique, Oct, 1889, page 364. * Obstetrics, page 85.
* British Journal of Homoeopathy, vol. iv.
COMMON PLACE MIDWIFERY. 53
RETENTION OF URINE.—It is rarely that any trouble of
this sort is experienced. Only once have. I used the
catheter, and then for the first three days only. Stram-
onium is a grand remedy, though nux vomica and arnica
are sometimes needed. Probably the habit of giving a
dose of arnica immediately after labor is complete has obvi-
ated much subsequent distress. The retention of urine in
the new-born is always overcome by a dose of aconite, or
the application of a sponge wrung out of hot water, on the
pubes. I have never had a case of imperforate urethra.
THE CHILD'S NAVEL.—I understand it is customary to
re-dress the stump of the cord daily. I never permit it to
be touched after the first dressing, which consists in reduc-
ing it to as dry a state as possible, as already described,
thoroughly saturating it with lard, and wrapping it in a bit
of old linen, of which I generally have a supply with me.
Good, pure lard is much better than vaseline, or any of the
oils, and cotton waste, or cotton batting, are sure to be heat-
ing and irritating if greased. When the cord drops off on
the fourth, or fifth, day, if the navel looks raw or unhealthy,
a large raisin, such as is found on the top layer of the box,
split, the seed removed, and the inner surface applied to
the navel, and held in place by a strip of adhesive plaster, is
all sufficient.
Sometimes a boy ruptures himself, at the navel, by over-
much crying. A piece of cork, of proper size to fit into the
umbilicus, stitched onto a flannel bandage, will retain the
extruding part until adhesion takes place. If the rupture
is a bad one, a small plaster made of marrow, out of a long
(beef) bone, and the fluid extract of comfrey (symphytum)
may be placed under the cork ; or surgeon's plaster may be
used to retain the comfrey plaster in position.
THE AFTER-PAINS.—Feeling the importance of absolute
rest after labor, the subject of after-pains has had my most
54 COMMON PLACE MIDWIFERY.
earnest attention. As they have a physiological basis, we
cannot altogether dispense with them, but with the excep-
tion of a few refractory cases—not more than a dozen in
all—I have succeeded in controlling them so that they
were not a source of real suffering, and in the cases where
I failed, I believe it was ignorance on my part that pre-
vented the administration of the proper remedy, rather than
any poverty on the part of the materia medica. The fact is
that either rhus, arnica, bryonia, or sepia are called for in
nine out of ten cases; and in the tenth case we fail to make
the nicer distinction required, and routinely give arnica
when we ought to have given ferrum, or belladonna, or
nux vomica, or, perhaps, coffea. I am satisfied that in
many cases a nice warm meal is better than any medicine.
Still, I have had several cases in which the pains were ex-
haustingly severe, and in which I was glad to turn to nitrite
of amyl. This potent drug is a very efficient controller of
after-pains; and used cautiously I see no reason to appre-
hend harm from it. A neat way of using it is to saturate a
small piece of tissue paper with five or six drops, stuff this
into a two-drachm vial, and request the patient to draw the
cork and inhale the odor, when she feels the pain coming
on. It acts with magical celerity.
LYING-IN DIET--A generous diet is good for a lying-in
woman. Judgment must be exercised not to overdo the
matter, and not to tempt the appetite by too great variety;
but suiting the bill of fare to the habits and condition of
of the patient, I am confident that a more nutritious dietary
than is ordinarily permitted will be acceptable and benefi-
cial to our patients. A poached egg on the first day, a few
nice roast oysters on the second, and a bit of steak, or a
chop, on the third day; in addition to the usual oatmeal
porridge, warm milk, tea and toast, cambric tea, etc., are
samples of what my patients get, and I have thanks and
Smiles in return. Milk is an important item, and while
COMMON PLACE MIDWIFERY. 55,
most city-bred women have an idea that it does not agree
with them, by beginning with a tablespoonful at a time and
gradually increasing the amount, in a few days they will
be able to drink a quart or more per day with relish. Effer-
vescing drinks are useful and grateful to the patient, not
only for the relief of thirst, but as favoring the action of
the skin and kidneys. Mixed with milk they form a most
welcome addition to the usual lying-in dietary. In order to
avoid diluting the milk, I am accustomed to put a heaping
teaspoonful of one of the granulated effervescent salts, Con-
gress, Vichy, Seltzer, or Kissengen, in a tumblerful of it,
and administer while effervescing.
I used to make it one of my “forethoughts” during the
first stage, to have the materials all ready for a nice cup of
tea, to be handed to the patient as soon as the binder was
applied; but more recently I have acquired the habit of
carrying one of those triangular bottles of Armour's Beef
Extract in my satchel, and immediately after the delivery of
the placenta, while the nurse is preparing the babe for the
bath, to make a nice cup of beef-tea for the mother; and one
for myself, generally. That the novelty of having some-
thing to eat, made by the doctor himself, is pleasing to the
patient, and she is in a frame of mind to be very grateful
for any little attention, is not the best consequence of this
service. Five times out of six the comfortable feeling in
her stomach produces drowsiness, and often I leave her in a
beautiful sleep.
In arranging the dietary for a lying-in woman it should
be remembered that the blood is deficient in albumin. The
red corpuscles are materially diminished in number, the ratio
to normal being, according to Becquerel and Rodier, as
III.8 is to I27.2. Cazeau insists that the pregnant state is
essentially analogous to chlorosis, but Willcocks” shows that
in the pregnant state the individual blood-corpuscles are
* “Observations on the Blood in Chlorosis and Pregnancy,” by Fred. Will-
cocks, F.R.C.P., in Lancet, Dec. 3, 1881.
56 COMMON PLACE MIDWIFERY.
Quite normal in appearance, and are simply lessened in com-
parative number. There is, also, toward the end of the
pregnant epoch, more or less drain of sugar and albumin, in
the urine. These losses must be made up by efficient
feeding.
Then, in addition to this, it must be remembered that
there is a great quantity of effete material thrown into the
mother's system after labor, and to get rid of this promptly
requires a well-toned nervous system, which can be secured
only by plenty of food and plenty of rest. In regard to the
first of these our best guide, of course, is the feelings and
desires of the patient, and while I can, on theoretical
grounds, imagine many wise restraints to be observed, yet
in actual practice I am a high-feeder; and have not in a
single instance to regret it. It is my endeavor to so con-
duct the lying-in that the woman may say when the babe is
a month old that she never felt better in her life; and I do
very usually hear that. Absolute rest I get as much of as
possible, coaxing along for one day more, and one day more,
and making the progress from bed to lounge, and lounge to
easy-chair, and easy-chair to the next room, and so on, as
gradual as possible. The involution of the uterus takes two
months; and while after the first two weeks, in ordinary
cases, if appetite has been good, sleep abundant, and spirits
tranquil, only moderate caution is necessary, yet I do my
best to eliminate all chances of subinvolution, and its train
of miseries. This may not be in the interest of my fellow-
laborer, the gynaecologist, but he must excuse my lack of
fraternal thoughtfulness. To the child just born it is the
greatest service within my capacity. An enfeebled mother
makes an unhappy child. How many a blow have I seen
struck, how many a fretful speech have I heard, because the
mother was impoverished in blood and worn with overwork.
PUERPERAL FEVER.—In re puerperal fever I have had
two cases of my own, and have seen others in consultation.
COMMON PLACE MIDWIFERY. 57
I distinguish here broadly between fever simply occurring
during the puerperium, and fever due to septic influence.
Both my cases were the result of sewer-gas infection, which
I believe in cities is a frequent cause of this alarming con-
dition. The attention of the profession was directed to
sewer-gas as a cause of puerperal fever by Prof. Playfair, “
about three years ago. Shortly after this, while the Lanced
article was still fresh in my mind, I was called to a case
which proved, before I was done with it, one of the most
annoying in all my obstetrical experience. The woman,
I-para, was unusually healthy and robust; the labor lasted
from 3 o'clock A. M., to IO A. M., which was not over long
for a I-para, and was normal in all respects. The case pro-
gressed favorably without any untoward symptoms until
the tenth day, when on calling, as I supposed for the last
time, I found her suffering from rheumatoid pains about
the hips and in the right wrist and ankle joints. There was
not much fever, IOO.5° Fahr., but considerable restlessness
and sleeplessness, and I had noticed for several days a low-
ness of spirits, which, however, I had assigned to family
reasons. The restlessness, sleeplessness, and apprehensive-
ness led me naturally to cimicifuga as the remedy, which I
gave in the sixth decimal potency. The next day she
seemed better, and as I was anxious to go out of town, and
as she did not seem desirous for my continued attendance,
I left her sufficient medicine to last some days, and departed.
I heard no more of the case for two months, when, being in
the neighborhood, I called to see how mother and child were
faring. To my amazement and chagrin I found she was as
yet barely able to sit up, and bore every evidence of a severe
illness. It would seem that the good effects which appar-
ently followed the administration of cimicifuga lasted but a
day or two, when the pains increasing in severity the hus-
band, who was a policeman, called in the precinct surgeon-
* “Defective Sanitation as a Cause of Puerperal Diseases,” by W. S. Play
fair, M.D., LL.D., in Zancet, Feb. 5, 1887.
58 COMMON PLACE MIDWIFERY.
He treated the case for some days, and then called in con-
Sultation a well-known specialist, who, of course, when he
learned that I had been in attendance, pronounced it a case
of malpractice ; said that the whole trouble was due to a
piece of the after-birth which had been left in the womb ;
and was absolutely horrified when he learned that the case
had been conducted, from beginning to end, without the
paraphernalia of carbolic antisepsis. That a portion of the
placenta, or any of its membranes, had been retained within
the uterus, I knew to be impossible ; first, because I make
too careful an examination of the secundines to be readily
deceived, and secondly, because the lochia had been normal
throughout, in complexion and odor, though perhaps rather
Scanty for so robust a young woman.
The patient had remained all this time in an inner room,
as per the annexed plan ; in which A, is the sitting-room ;
B, the room in which the patient was confined ; D, another
bedroom ; E, dining-room ; and F, kitchen. Upon remov-
ing the bed at C, I found that the baseboard at I had sprung
so that there was a space between it and the floor of nearly
an inch, and beneath this an opening of half an inch or
more between the flooring boards, so that the gases from an
imperfectly working water-closet trap passed directly up-
ward over the patient's bed.
As the progress of the case had been so unsatisfactory
under the champion of antisepsis I was rather grudgingly
asked to resume the conduct of it, which I did ; removing
the bed to the point K, in room A, and closing room B.

COMMON PLACE MIDWIFERY. 59
entirely. With this change, and under the arseniate of
cinchona, 3 and 6, the patient gained rapidly, and at the end
of the then current month removed, on my advice, to new
apartments. But for my fortunate social call, and the con-
sequent discovery of the real source of the fever, my reputa-
tion in that family would have been very low indeed. In
fact, I never was forgiven, so strong was the impression that
somehow the lingering convalescence was to my discredit,
and although I had had all the work of the family connec-
tion—six separate households—for seven or eight years,
and had had nine babies, I have never been called since.
My other case of puerperal fever was some two years
earlier, and although I knew the drains were bad, I did not
ascribe the fever to that cause, at the time. The case got
well; I cannot justly claim to have cured it.
ECTOPIC PREGNANCY.—The scholarly paper read by Dr.
Ostrom at the last meeting of this society,” and the discus-
sion which ensued, and especially the case reported so lucidly
and interestingly by Professors Danforth and Doughty,”
would have led me to ask if the usual hour for adjournment
had not already long past. Has homoeopathy anything to
say to these cases? I do not ask this in a critical spirit, but
as one who is groping in the dark. I can understand the
fascination of surgical work, and the necessity for it; I can
understand also the all but irresistible pressure of professional
bias in favor of dealing with such cases with the knife, all
the more irresistible because so unconscious ; and I can
understand how by so doing one at least escapes the cen-
sure which certainly follows when medical treatment proves
as unavailing to save life as surgery frequently does; and,
then, it is always so comfortable to be in with the majority.
But there are some members of this society who study
materia medica as others do surgery, and it is to them I
put the question ; I do not know the answer.
99 Published 30 Vide.
60 ." COMMON PLACE MIDWIFERY.
Some six years ago I had a case which I stumbled over
in a manner which makes me blush when I think of it; but
the woman is alive and well. Was it my ignorance or
stupidity that saved her? The one Dr. Danforth treated is
dead; and no one will doubt that that case was treated
with consummate ability, and with ripe knowledge of the
science of the day.
The question between materia medica and surgery is not
personal but generic; it has been asked by Carroll Dunham,
by Constantine Hering, by Henry S. Guernsey, by all the
great names in homoeopathy; it is one which never can be
answered as a finality until some day when we have a homoeo-
pathic Darwin ; nevertheless it behoves us to ask the ques-
tion, and earnestly to seek the answer, for even a Darwin
can only construct with what has been gathered together
by predecessors in the field of observation.
The case to which I have referred was this: On August
I 3, 1883, about two o'clock in the afternoon, I was sum-
moned to see a lady on Forty-third Street, under the fol-
lowing circumstances: She lived in an apartment house, and
had gone into the cellar to look over some trunks, and was
found there, in an unconscious condition, by the janitor,
and carried into his sitting-room in the front basement ;
and he, knowing that I was the family physician, sent one
of his children to my office. The patient was about twenty-
eight years old, had been married some six or seven years,
had had one child, since dead. She was of the English
type, large and robust, and prided in her physical'endurance.
I found her comatose, extremities and indeed the entire
surface of the body cold, pulse slow and feeble, face natural
in expression, pupils slightly dilate. The weather was
sultry, and I at first supposed I had to do with the mingled
effects of heat and alcohol, as she was a dipsomaniac,
though a lady by birth and education, and both the daugh-
ter and wife of professional men. She drank only at long
intervals, but would when the fit seized her consume a quart
COMMON PLACE MIDWIFERY. 6I
of whisky at a single sitting, and would then appear to the
ordinary observer none the worse for it. I never knew a
man who could carry a load of whisky as easily as this
woman could, and I doubt if a half-dozen people in the
world had ever discovered her failing. Whether she really
had had anything of that nature on this day I never knew,
as they had poured some brandy into her throat before my
arrival, and thus confused the diagnosis; she always denied
afterwards having had anything, but she always did deny.
However, I gave her some nux vomica, first decimal, to
antidote any free alchohol there might be in the circula-
tion, and applied friction and hot flannels to the surface to
induce reaction. This having no very apparent effect after
several hours, I then gave belladonna 200. The skin gradu-
ally assumed a natural feeling and temperature; she could
be aroused by not over-gentle shaking, but at once relapsed
into a stupor. This continued for a week, when she gradu-
ally became less and less difficult to maintain in a conscious
state, though for fifteen or sixteen days she would drowse
off if left alone. After the first week, while asleep she
would maintain long conversations with imaginary friends,
especially with an officer in the army who had been an in-
timate friend of the family for many years, and these con-
versations could be directed to any topic by simulating the
voice of the person she believed was present. This was a
very interesting phase of the case. There were others that
were not so. The natural functions of the body were per-
formed Scantily but automatically. No food could be taken,
even a few teaspoonsfuls of milk or beef tea would cause
frightful retching. The only thing she could retain was
champagne, and this had to be fed by the teaspoonful.
There was also a tendency to spasmodic movement of the
muscles of the face, of the fingers, and of the toes. All these
things led me to fear an attack of apoplexia.
After sixteen days the condition of things was about like
this : The patient as she lay in bed presented no abnormal
e
* * *
* * *
º
* >
:
62 COMMON PLACE MIDWIFERY.
appearance when asleep; during these somniloquies she
would seem to be merely talking with her eyelids shut. But
when awake she was despondent, certain she was going to
die, but apathetic as to living. She made her will and bid
good-by to her friends. Muscular power did not seem want-
ing when she chose to exert it, but her hands trembled so
that she could not hold anything; even the signature to her
will was indistinct, though her natural chirography was bold
and good. Though the rest of the skin was normal in
appearance and temperature, her nose was cold all the time;
not pinched as in a patient's with a chill, but like a healthy
person who has been out in the frosty air. There seemed
to be a complete loss of both the sense of taste and of
appetite, with difficulty in swallowing any solid. All sorts
of little dainties were prepared for her, but with the excep-
tion of ices and ice-cream she could take none. Even the
sight of solid food caused nausea, and when we compelled
her to take some it was followed by faintness, and the
vomiting of thick slime. The bowels did not move, or but
scantily, and urine was passed involuntarily during the
somnolent period. She had had some years before (1877–
1878), following small-pox, a rupioid erruption on the scalp,
which was cured by apis. Now some of these old cicatrices
reopened and began discharging a thick creamy pus; these
sores were fistulous with hard, bluish-red edges. During a
somniloquy she had spoken of herself as being pregnant ;
speaking of it then as that there were to be two deaths in
one; and this she admitted afterwards in the waking state.
She had had the May period all right, but in June the
menses did not appear; according to this she was now
pregnant thirteen or fourteen weeks. The janitor's wife,
when we undressed her, on the day she was taken ill,
remarked that she looked as if she were in the family way,
and I noticed that the abdomen was distended and hard ;
though this could hardly have been due to an ordinary
pregnancy of eleven or twelve weeks. If, however, there
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COMMON PLACE MIDWIFERY. 63
had been haemorrhage into the tube from a ruptured tubal
foetal cyst, and the blood retained by a blocking up of the
tube, the abdominal hardness might be accounted for, as
well as the collapsed state in which she was found. Cer-
tainly there had been no vaginal discharge up to this time.
I believed that the belladonna had held the case in check,
and prevented intercranial effusion; and now after a lapse
of six years, with every desire to know the truth and to
speak the truth, I still feel that belladonna saved her life
during that critical fortnight. There are many little events
that float as it were on the surface of such an epoch, too
elusive to state intelligibly on paper, but which do, however,
produce distinct impressions on the watchful practitioner's
mind, impressions no less powerful in settling opinion
because thus subtle, and in this way I sensed rather than
proved the value of belladonna at this time. We all, I think,
have in cases that arouse our intense interest an inward feel-
ing, too elusive to be called a thought, as to how a case is
going, whether for us or against us. I have heard of doc-
tors who have declared the patient doing well, and stepped
into the next room to make a prescription, and were sum-
moned back to see the patient die in five minutes, but this
can only be accounted for by crass inattention.
But now, after sixteen days, as belladonna seemed to be
accomplishing very little, although I had given it a fair trial
in varying potencies (2OO, 12, 30, 6) I concluded to give
silicea, and for this reason : The patient suddenly and from
no known cause is taken seriously ill after years of fine
health. Either, therefore, the cause is a deep-seated one,
or else she had somehow come under the influence of some
powerful inhibitory force. This latter did not seem reasona-
ble, as there was no evolution of symptoms; these had not
changed in nature during the period she had been under
observation, nor did she seem like one under septic influ-
ence. It appeared probable that we had to do with a deep-
seated organic discord which required a tissue remedy to
64 COMMON PLACE MIDWIFERY,
uproot. There was, it is true, no such distinct call for
silicea as would warrant the assertion that in it, and it only,
we had the true homoeopathic indication fulfilled. Silicea
has the following symptoms :
Gloomy, feels as if she would die.
Desponding, melancholy, tired of life.
Apathetic, faint-hearted.
Eruption on occiput; moist, offensive, burning, itching,
discharging pus.
Cold nose.
Loss of taste and appetite, with difficult swallowing.
Nausea to fainting.
Vomiting of tenacious mucus.
Involuntary micturition.
Trembling of the hands.
Somnambulism.
Silicea was given in the 200th potency (Carroll Dunham's),
a few pellets, dry on the tongue, daily at noon. In less
than a week there was a marked change for the better; the
somnolence gradually disappeared ; the mental equipoise
was restored ; appetite returned ; the functions were per-
formed naturally ; the ulcers on the scalp healed : and be-
fore the end of September she went into the country for a
brief change of air, in well-advanced convalescence.
I now looked forward to no further trouble with the case,
save such as might arise through the advancing epoch of
pregnancy; but on November 5, I was summoned on ac-
count of a sudden and copious haemorrhage from the uterus.
She had lost a great deal of blood, perhaps a pound, and
was very much prostrated, but the flow ceased before my
arrival. She had felt severe cramping pains, and had gone
to the water-closet, and most of the loss had taken place
there. I had a few two-grain bi-sulphate of quinia pills in
my pocket, and gave her one of these every five minutes
until she had had six. I was afraid to give aromatic spirits
of ammonia because of its liquifying influence on the blood,
COMMON PLACE MIDWIFERY. 65
and I feared further haemorrhage. After waiting an hour,
and no untoward symptom arising, I left Some cinchona 6,
and departed. I was back and forth a number of times,
but she had no more bleeding, and in a few days recovered
from the prostration. In making an examination I found
the os soft and swollen, and the whole condition of things
not like what we ordinarily find at the end of pregnancy.
I suspected placenta praevia. As, however, there was no
further haemorrhage I did not feel justified in suggesting
operative interference, as there was hope, at least, for a liv-
ing child.
At the end of the seventh month, January II, 1884, there
was a similar haemorrhage, not quite so copious nor so sud-
den, and as it had not stopped when I arrived at the house
I gave trillium 3, and packed the vagina with lint soaked in
liquor ferri subsulphatis. This seemed to cause an intense
burning sensation, and was removed; leaving behind it an
acrid leucorrhoea which lasted several days. She was in a
low state of health during the next two months, with pains
and aches, depression of spirits, but with no special indica-
tion of disaster to come. On March 6 she was taken with
labor pains, and I was summoned about two o'clock. An
examination revealed a strange state of things. The uterus
was about the size usual at the fifth month, but behind and
above and to the left of it was a tumor much larger than the
uterus, and fluctuant. This I, of course, ought to have dis-
covered earlier, but the marked disinclination of the patient
to physical examination had deterred me from insistance.
The pains were regularly intermittent, and seemed to
involve both the uterus and the tumor, so much so that I
was in doubt whether we had not a bicorneal uterus to deal
with. The cervix was soft and dilatable, and there was an
insignificant bleeding just enough to worry me. I have a
constitutional dislike to throwing off responsibility. I had
much rather fight my way through any difficulty than to
ask assistance, and when I no longer feel competent to
66 COMMON PLACE MIDWIFERY.
manage a case would rather give it up entirely, than to
share responsibility with a consultant. In fact I almost
never ask for help in that way. I did now suggest sending
for Dr. Helmuth, but the patient objected, and as there
seemed no immediate danger, and the pains were not severe,
I waited. The pains gradually died out, the patient went
to sleep. The next day the pains returned with more force,
and I now desired to administer an anaesthetic and make a
thorough examination. But the patient was willful and
would not have it, and I finally got angry and threw up the
case, advising her to call somebody she would be guided by.
The relation which had existed between the family and
myself had been cordial and of long-standing, and I believed
that a stranger might do better for her; evidently my
authority and usefulness was at an end. But the next day
I went to the house to see how she fared. Nothing special
happened. The pains died out gradually and did not
return. She had irregular haemorrhages, but none of moment,
and these gradually grew less and less in quantity and fre-
quency; but in the course of a year she completely recovered
health, and is now as robust and vigorous as any one need
wish to be ; though the monthly period has never been re-
sumed. I have never treated her since, and understand she
has had none. She is now about thirty-four years old, and
though evidently something is wrong, no one would suspect
it by her appearance or manner.
This case does not do me any credit as a diagnostician,
but it does furnish food for thought. The woman is alive
and seems now none the worse for her experience. Sup-
posing that tubal pregnancy had been diagnosed in August,
1883, where would she be now P Certainly no better off
than she is, and more probably in her grave.
And so I make an end of a story too long drawn out, with
the hope that the defects of it in the telling, and the mis-
takes of it in the doing, may serve some one somewhere to
do better than I have done. No one who has tried to do
COMMON PLACE MIDWIFERY. 67
well can look back on the work of years without intense
regrets. That work must have been done poorly indeed
that does not leave a man in the mental attitude of wishing
he could go back again and do it all better; but, happily
alike for the wise and for the foolish, there is no going back;
only this, we can help somebody else to do it all better, and
this is a higher joy than doing it ourselves.
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