SCIENTIFIC OBSTETRICS IN PRIVATE 
PRACTICE. 
BY / 
EDWARD P. DAVIS, A.M., M.D., 
PROFESSOR OF OBSTETRICS IN THE PHILADELPHIA POLYCLINIC ; CLINICAL 
LECTURER ON OBSTETRICS AND GYNECOLOGY IN JEFFERSON 
MEDICAL COLLEGE, ETC. 
FROM 
THE MEDICAL NEWS, 
July 8, 1893. [Reprinted from The Medical News, July 8, 1893.] 
SCIENTIFIC OBSTETRICS IN PRIVATE 
PRACTICE.x 
BY EDWARD P. DAVIS, A.M., M.D., 
PROFESSOR OF OBSTETRICS IN TIJ&-PHILADBLPHIA POLYCLINIC J 
CLINICAL LECTURER ON OBSTETRICS AND GYNECOLOGY IN 
JEFFERSON MEDICAL COLLEGE, ETC. 
If one were asked the meaning of the word 
“ scientific,” a proper definition would be found in 
a phrase indicating the possession and dissemination 
of knowledge. A scientific journal is one that con- 
tains and disseminates knowledge of the subject of 
which it treats. Modern medicine is a science in 
so far as it contains valuable knowledge concerning 
human life and disease, and scientific obstetrics is 
the theory and practice of this branch of medicine, 
characterized by accurate knowledge. 
In this one point of the possession or absence of 
accurate knowledge rests the difference between the 
obstetric practice common in the United States 
twenty-five years ago and the theory and practice 
taught at the present day. Impressed with the 
ability of nature to deal successfully with the emer- 
gencies of labor, the practitioner who attended 
obstetric cases has been wont to comfort himself 
with the axiom that labor is a natural process, of 
1 Read before the Section on Obstetrics, American Medical 
Association, Milwaukee, June, 1893. 2 
which he need not seek to ascertain too minutely 
the details. The condition of pregnancy he regarded 
as naturally normal, and hence without especial 
tendency to disease. The lying-in period was to 
him a natural stage in the life of the individual, and 
required at his hands no especial scrutiny. An 
accurate diagnosis as to the factors present in a given 
labor was rarely made, unless some serious emergency 
arose. 
There have been many reasons for this condition 
of affairs. The comparatively recent discovery of 
anesthetics placed at the disposal of the obstetrician 
a means of diagnosis of inestimable value. The 
employment of antiseptics has rendered possible 
manipulations for the diagnosis and treatment of 
labor that formerly were impracticable. Methods 
of diagnosis are now commonly taught and prac- 
tised that, at the period mentioned, were only 
to be seen in practice in the large hospitals of 
Europe. Modern obstetrics has, then, great advan- 
tages in its opportunities to acquire thorough knowl- 
edge of the patient and of her labor, and this, too, 
without the infliction of additional pain, or the in- 
curring of added risk to life. The characteristic 
of modern obstetrics is its scientific element, as 
shown in the accurate knowledge that it requires 
concerning matters formerly thought to prosper 
inevitably through the kind cooperation of Nature. 
Scientific obstetrics is the rule in the modern hos- 
pital, but it is often “ honored more in the breach 
than in the observance ” in private practice. The 
reasons for this are many. First, among all, is the 
common belief, derived largely from physicians and 3 
nurses, that, because labor is a natural process, it is 
bound to proceed successfully without intelligent 
supervision. If this is true, why should a patient 
tolerate palpation, auscultation, or pelvimetry ; or 
why should she take an anesthetic when the mechan- 
ism of labor is interrupted, and a thorough examin- 
ation of the condition present becomes necessary ? 
A common belief that has descended from the days 
of the early craniotomist, or man-midwife, as he 
was termed, is that any interference with labor 
means, practically, the use of forceps, and hence 
the objection to critical examination in an emer- 
gency. Again, it not infrequently happens that a 
complicated labor terminates spontaneously, and 
apparently with success to mother and child. It 
does not occur to the patient and her friends that 
complications may have arisen, by reason of the 
long continuance of the spontaneous labor, that 
could have been avoided had intelligent interference 
been practised. 
There is especial need for scientific obstetrics in 
private practice, because the practitioner is more 
directly responsible for the condition of his patient 
than when he is engaged in hospital practice. He 
lacks in private the experienced observation of trained 
nurses; he misses the intelligent cooperation of 
resident physicians; and experiences the great dis- 
advantage that the absence of order and discipline, 
so common in a private house, entails upon him. It 
is, therefore, especially necessary that he gain 
thorough knowledge of his patient by personal 
observation and study, and this knowledge is the 
essential of scientific obstetrics. The fact that the 4 
best results in obstetric practice are observed in hos- 
pitals, draws attention to the need for scientific 
work in private cases. 
Omitting a consideration of the minor details of 
private obstetric practice, we urge the importance 
of a thorough examination by the practitioner of all 
pregnant patients. We are well aware of the fact 
that many cases are not seen by their attendants 
until labor is far advanced, and no opportunity has 
been given to examine the patient during preg- 
nancy. This is growing to be, however, less the 
case than formerly, and especially in first preg- 
nancies, when the natural dread of an untried 
experience brings the patient to the physician com- 
paratively early. This scrutiny of the pregnant 
patient should be directed especially to ascertaining 
the condition of the organs of elimination, and the 
success attending their action. The examination of 
the urine should be an invariable practice, and 
valuable information will be given by ascertaining 
not only the presence or absence of albumin, but 
by careful microscopic study of the sediment, and 
also an estimation of the amount of urea excreted. 
In the Maternity Department of Jefferson Medical 
College Hospital we have for some time derived 
valuable information regarding a patient’s elimina- 
tive powers by ascertaining the quantity of urea 
excreted. The presence of albumin is of itself a 
trifling matter, unless the microscope reveals evi- 
dence of decided structural change in the kidney. 
At or after the seventh month of pregnancy it 
becomes the duty of the attending physician to 
ascertain the mother’s size, and the relative size of 5 
the fetus and the position that it occupies in the 
mother’s pelvis. This is a procedure commonly 
thought unnecessary, and reserved for the lectures 
of those who teach obstetrics. That such is not the 
case is well exemplified by two fatal cases, seen by 
me recently in consultation, in both of which embry- 
otomy upon the dead fetus was necessary. Two well- 
developed male children were sacrificed to a lack of 
diagnostic skill on the part of the medical attendant, 
and to complete the unfortunate history of those two 
cases, the lives of the mothers were lost on account of 
the stupid laziness of the physicians, who neglected 
to use antiseptic precautions during labor. In both 
cases the child had perished before the consulta- 
tion, and the embryotomy was performed to spare 
the medical attendant from reproach and criticism 
for his failure to deliver the mother. These four 
lives could have been saved had proper precautions 
been taken. 
The practice of general medicine, including 
obstetrics, in country towns or villages, often taxes 
to the utmost the skill and wisdom of the so-called 
“country doctor.” As a result, he has a range of 
experience unknown to his city brother, and becomes 
by natural development more assured, self-reliant, 
and efficient. He is the man who, above all others, 
can appreciate the value of any method of practice 
that shall add to the positive knowledge he has of his 
patient. We do not ask him to provide himself with 
elaborate or costly pelvimeters, or instruments for 
diagnosis, but, as is our custom in lectures at the 
Philadelphia Polyclinic, we do urge upon the gen- 
eral practitioner a knowledge and practice of palpa- 6 
tion, auscultation, and of such a method or methods 
of estimating the size of the mother’s pelvis and the 
relative size of the fetus as may be within the scope 
of his possibilities. No student graduates from a 
well-appointed medical college who is not in the 
possession of this knowledge, and certainly the gen- 
eral practitioner already established cannot afford to 
be behind the recent graduate in his resources. The 
objections urged against the examination of pregnant 
patients, including the measurement of the pelvis, 
are based upon needless exposure of the patient, or 
rude and unskilful manipulation. We have yet 
to find a private patient, of whatever station in 
life, who offers the slightest objection when her 
physician asks that he be given an opportu- 
nity to acquire a knowledge that shall the better 
enable him to care for his patient, particularly if, 
by so doing, he subjects her to no exposure, nor to 
tedious and painful manipulation. The abdomen 
of the patient may remain covered by one thick- 
ness of cotton or linen, without in the least incon- 
veniencing the physician, and medical students 
under my instruction are taught to make their ex- 
aminations in this manner. 
One of the great advantages accompanying this 
mode of practice is the lessening of vaginal examin- 
ations, which are a source of considerable danger to 
the patient. It is perfectly possible by palpation alone 
to follow the head of the child as it descends through 
the pelvic canal and impinges upon the pelvic 
floor. The character and efficiency of the pains of 
labor may also thus be accurately observed, and 7 
oftentimes valuable assistance can be rendered by 
external pressure gently and judiciously applied. 
When the mechanism of labor is interrupted, a 
thorough internal examination is at once indicated. 
This is often impracticable without the administra- 
tion of an anesthetic. The practitioner should be 
prepared to interfere for the assistance of the pa- 
tient. Forceps should be prepared and ready. The 
rectum and bladder should be emptied, and, while 
it is not necessary to state to the patient that an 
operation is to be performed, yet, while she is under 
the influence of the anesthetic, it may be found wise 
to terminate the labor. It is often impossible to 
accurately diagnosticate a faulty position of the 
head without an anesthetic, the resistance and suf- 
fering of the patient being so great that sufficient of 
the hand cannot be introduced to make a thorough 
examination. When, however, such an examination 
has been made, and before the examining hand has 
been withdrawn, the forceps may often be accurately 
applied to the sides of the child’s head, and the 
labor brought to a successful termination. In other 
cases, version and extraction may be found neces- 
sary. In either event, examination of the patient 
under anesthesia will spare her hours of suffering, 
and will often save the life of an infant, and some- 
times that of the mother. 
The same thoroughness in treatment should ob- 
tain in the diagnosis and treatment of injuries to the 
genital tract. By the term “ laceration of the peri- 
neum,” we understand a solution of continuity that 
extends more deeply than the posterior commissure 
or fourchet. We are aware that a laceration in the 8 
median line may extend beyond the fourchet, and 
still not impair the supports of the uterus to any ap- 
preciable degree. When we read and hear of large 
numbers of cases of labor in which no laceration of 
the perineum has occurred, we are impressed with 
the fact that those who record such extraordinary 
experiences either consider that a laceration of the 
perineum usually extends into the rectum, or else 
that they did not accurately examine the cases. The 
examiner may be readily deceived by a superficial 
examination by the finger only of the genital canal, 
soon after labor. Clotted blood often filis a torn 
surface, giving to the finger the same continuity of 
smoothness that marks the uninjured mucous mem- 
brane. It is only by the thumb and finger, one 
inserted in the rectum, or, better still, by actual 
inspection, that the condition of the genital tract 
after labor can be accurately ascertained. Consider- 
able observation of labor-cases, and the careful em- 
ployment of the best-known means for preventing 
laceration of the perineum, have convinced me be- 
yond reasonable doubt that such an injury is inevi- 
table in many cases. It is negligent not to discover 
it; it is lazy and dishonest not to endeavor to repair it. 
Fortunately, in these matters, public sentiment is 
demanding the advantages of scientific obstetrics. 
We recently had occasion to tell a young woman 
that she had sustained a laceration of moderate 
extent that ought to be closed. She said that if 
such was the case, she earnestly desired that it be at 
once repaired, as her sister had suffered from the 
neglect of her physician in not suturing a similar 
laceration. We are furthermore helped in dealing 9 
with these questions by the fact that experience 
shows us that excellent results may be obtained as 
late as twenty-four or thirty-six hours after the oc- 
currence of a laceration. It is far better practice 
to give the patient and physician twenty-four hours’ 
rest after a trying labor, and then, under anesthe- 
sia, or with the use of cocaine, close a laceration 
under favorable circumstances, than to further 
exhaust a weak patient, and with poor light and 
laboring under great fatigue, to improperly perform 
the physician’s duty. If torn surfaces are found 
glazed over, the simple expedient of scraping them 
with the blade of a pair of scissors, or with a curet, 
will suffice to secure union by first intention. 
It is burdening you with a trite observation to 
speak of the importance of obstetric antisepsis or 
asepsis, and yet the same reasoning that enables the 
practitioner to assert that in his 1000 cases he has 
never had a lacerated perineum, leads him likewise to 
claim that his 1000 cases he has never had a case of 
puerperal septic infection. He may have avoided 
signing a death certificate for a pat ent recently deliv- 
ered, the certificate bearing the words “peritonitis,” 
“blood-poisoning,” “ inflammation of the bowels,” 
or “puerperal fever” ; but cases occasionally perish 
some weeks after labor, with “jaundice,” “pneu- 
monia,” “congestion of the liver,” or “malaria,” 
that, on closer study will be found to be the results 
of puerperal septic infection. The faithful practice 
of aseptic or antiseptic precautions greatly lightens 
the load of responsibility that the practitioner of 
obstetrics must carry. 
Not the least of the advantages derived from the 10 
scientific practice of obstetrics lies in the avoidance 
of interference by those who have no right to molest 
the patient. The practitioner’s best efforts are often 
thwarted by ignorant and meddlesome persons. 
He cannot, however, honestly forbid interference, 
unless he knows positively that there is no occasion 
to molest the patient. He will obtain the best results 
in obstetric practice who does the work himself, 
unless he can command, for certain things, the 
assistance of a trained nurse. Thoroughness in 
diagnosis, the faithful observance of antisepsis in 
treatment, and the protection of his patient from 
meddlesome interference, will give the best results. 
Such a method of procedure is thoroughly scien- 
tific, for it demands the best knowledge, the most 
careful and skilful manipulation, and, above all, 
an honest and fearless attempt to meet the diffi- 
culties that may arise. In the present stage of 
medical science, every woman has a. right to de- 
mand such treatment, and if a practitioner of 
medicine cannot give his patient such care, he 
must inevitably, by the inexorable law of the 
“survival of the fittest,” give place to those who 
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