CARELESS AND UNSCIENTIFIC MIDWIFERY, 
WITH SPECIAL REFERENCE TO SOME FEATURES OF THE WORK 
OF MIDWIVES. 
Read before the Medicae and Chirurgicae Faculty of the State of Maryeand 
at its Ninety-seventh Annual Session, April 23-27, 1895. 
IV S. Smith, M. D., 
Physician to the Police Department, Baltimore. 
In the performance of the various du- 
ties that belong to our profession we are 
ofttimes brought in contact with con- 
ditions which arouse our sympathy as 
well as demand our scientific aid. 
In my own professional career nothing 
has thus far so deeply impressed me as 
the observations made in the lying-in 
chamber, where the parturient woman 
has to undergo not alone the unavoid- 
able and natural pains of childbirth, 
but too often, also, the far more serious 
suffering brought upon her by the gross 
manipulations and hazardous practices 
of ignorant and officious midwives. 
These observations, I regret to say, have 
lately happened with such frequency as 
to induce me, or, I could more truly say, 
provoke me, to present this paper to the 
Faculty ; and if I should succeed in at- 
tracting your attention to the subject, I 
shall feel that my crude remarks upon a 
commonplace and uninviting topic are 
not altogether valueless. Such a hope, 
at least, together with a sincere desire 
to assist, however feebly it may be, in 
the satisfactory solution of a perplexing 
problem, constitute my only apology for 
appearing before you on this occasion. 
I know full well that there is no neces- 
sity for me to adduce arguments or relate 
experiences to you to show the incom- 
petency of midwives as we meet them 
at the present day. Three-fourths of 
them have absolutely no knowledge of 
the physiology of labor, or of the dangers 
to which a lying-in woman is exposed. 
It is therefore a reasonable and natural 
deduction that almost everything they 
do is in violation and defiance of the 
well known principles applicable to sci- 
entific midwifery. Since, however, I 
am so unfortunate as to reside and prac- 
tice in a community where they are es- 
pecially numerous, and it is thought 
especially unskillful, I have thought 
that a brief reference to recent cases il- 
lustrative of their more common and 
dangerous procedures might not be un- 
interesting. 
Mrs. K., aged 22 }7ears, was confined 
in December last ; she was a lad)7 with 
excellent personal and family history, 
muscular and well-developed, with am- 
ple pelvis and normal birth-canal. One 
week after her confinement I was called 
to see her in spite of the protestations 
of her nurse that she only had “malaria” 
and would soon be “ all right.” Her pe- 
culiar appearance and the offensive odor 
emanating from her at once led me to sus- 
pect septicemia, and upon examination 
my suspicions were confirmed. I found 
a mass of putrid placental debris in the 
uterine cavity and a deep laceration of 
the cervix. The usual treatment of 
cleaning out the uterus, applying hot 
carbolized vaginal douches and adminis- 
tering supporting remedies, was at once 
instituted, but although her temperature 
fell somewhat, she soon succumbed to 
the septic intoxication. The husband 
informed me that she had been given a 
large amount of ergot in the beginning 
of labor, which, to my mind, satisfac- 
torily explained the laceration of the 
cervix, the difficulty in delivering the 
placenta, as well as the sad events which 
followed. 
Another case of a different character 
was that of Mrs. F., a young woman 
whose general health was good, but who 
had a contracted pelvis. This was her 
second unsuccessful attempt at deliver- 
ing a living child, and her sister had 
died shortly after an instrumental labor. 
These facts were well known to the mid- 
wife, who, notwithstanding, had been 2 
in attendance forty-eight hours when I 
was called. I found that the membranes 
had been ruptured and that the uterus 
was in a state of extremely rigid and te- 
tanic contraction due to the influence of 
about tw7o ounces of ergot, which had 
been administered to her, as was said, 
to expedite (?) her labor. Efforts at 
version proved unavailing, and not hav- 
ing the necessary instruments, I sent 
for Dr. E. E. Neale, of this city, who with 
my assistance, and that of a great deal 
of perseverance and physical prowess, 
finally succeeded in delivering by means 
of cephalotripsy. Fortunately, this 
woman’s uterus was not ruptured, and 
by the assiduous use of antiseptics, in- 
fection was prevented ; but it was not 
through any want of carelessness or of 
vigorous efforts to force delivery through 
an impassable mechanical obstruction 
that she did not meet with the same fate 
as the lady to whom I have just referred. 
I will cite another case, that of Mrs. 
E., a multiparous woman, who had pre- 
viously had no difficulty during the par- 
turient period. She had been in labor 
only about two hours when I was sent 
for in great haste in the middle of the 
night ; this time the midwife wanted 
me. Hurrying to her bed-side I found 
an absolutely normal presentation ; in 
fact, the child’s head was resting on the 
perineum almost at the vulvar outlet, 
but all pains had ceased. Nothing 
could be easier. The forceps were ap- 
plied, the head was simply lifted from 
its resting place, and delivery was com- 
pleted without the slightest trouble. 
Here was a case of simple uterine iner- 
tia, with a non-resistant perineum in 
which an oxytocic was clearly indicated, 
and would have given relief in a short 
time. None, however, had been em- 
ployed, and the greatest fears were en- 
tertained for the woman’s safety. 
In the practice of a certain other 
woman, whom I have in mind, I was for 
a time somewhat at a loss to understand 
the remarkable number of still-births. 
As they occurred for the most part in 
healthy multiparae, I concluded that 
the cause could be traced to her rather 
than to any abnormalities with which 
she had to deal. After I had learned 
the extent of her obstetric work and dis- 
covered the freedom with which she 
used her “forcing drops” the mystery 
was cleared up. At least, in several 
cases I am able to say that every other 
cause was carefully excluded, and I wras 
irresistibly led to believe that nothing 
else explained the fatalities. The mode 
of action of ergot in these cases being a 
mechanical compression of an incarce- 
rated cord, an interference with utero- 
placental circulation, or a peculiar toxic 
influence which it is known to have. 
Many other cases might be cited, but 
these few I think will bear me out in 
saying that monthly nurses are almost 
always utterly ignorant of the conditions 
with which they have to deal, entirely 
unfamiliar with the indications for the 
use of drugs, inexcusably negligent in 
not calling for aid when they know it is 
required, and criminally culpable for 
their assumption of the functions of a 
physician in the most serious cases. 
The injury that is being done by these 
audacious and unskilled individuals, 
both in the sacrifice of human life and 
the production of chronic invalidism, is 
simply incalculable. Tarnier, the cele-. 
brated French obstetrician, has said “In 
the country as in the town, in the most 
magnificent palace as in the humblest 
cottage, the enemy of the lying-in 
woman is the microbe.” This is a for- 
cible statement of a scientific fact, and I 
would not amend it save to say that it is 
not the microbe per se that is at fault, 
but the hand which permits or causes 
its transportation to the vulnerable parts 
of woman’s organism. And the typical 
old gin - guzzling midwife, with her 
pockets full of “forcing drops,” her 
mouth full of snuff, her fingers full of 
dirt and her brains full of arrogance and 
superstition, is at least the greatest pal- 
pable enemy of a physiological puerpe- 
rium. There is, as I have intimated, 
something peculiarly pathetic in the 
death of a woman under such circum- 
stances as I have related ; and while I 
would not raise my hand to hinder any 
human being in the proper pursuit of an 
honorable avocation, I think that some 
corrective influence should be brought 
to bear upon this stupendous wrong. 3 
In other countries, notably in England, 
Germany and Denmark, especial precau- 
tions are taken by police and sanitary 
authorities to supervise the work of mid- 
wives and hold them to strict account- 
ability. Indeed, in many of our own 
large cities the question has been agi- 
iated with more or less effect. Is it not 
time that we also should take some de- 
cided steps in this direction ? 
I shall now speak of the attitude and 
habit of the general practitioner in his 
obstetric work. The wonderful achieve- 
ments of recent years point unmistak- 
ably toward the path along which a 
practically unanimous profession will 
eventually tread. Indeed, all specialists 
in this line and all the large Materni- 
ties are at present pursuing substanti- 
ally the same course in obstetric man- 
agement. But among private practi- 
tioners there is still shown an adherence 
to antique methods which is greatly to 
be deplored. Why this should be, it is 
somewhat difficult to explain. Bacteri- 
ology, that prolific realm in the micro- 
scopic world, is, as we must admit, often 
based on uncertain theories, and is still 
chiefly an experimental branch of path- 
ological research ; but, new though it 
is, it has already led to the most bril- 
liant practical results, and has influenced 
to a greater degree our knowledge and 
our treatment of disease than any other 
department of medical science. And, 
among its accomplishments, nothing, it 
seems to me, should be more cheering 
and gratifying to us than the light which 
it has thrown upon the subject of puer- 
peral infection. I think we may safely 
say that the introduction and scientific 
application of asepsis and antisepsis to 
surgical and obstetric practice marks 
the greatest advance in medical science 
which the present century has seen. It 
is now almost universally admitted that 
the so-called accidents and complications 
of the puerperal state are due to an in- 
fection, that the infecting agent is a 
micro-organism which gains entrance 
to the blood through some part of the 
genital tract, and that unless such or- 
ganism be introduced these affections 
will not take place. And yet there are 
practitioners who hoot the idea of the 
aseptic or antiseptic management of la- 
bor. I would not be considered an en- 
thusiast on this subject, but, if err I 
must, I would rather err upon the side 
of unwarrantable enthusiasm than upon 
that of unjust and unreasoning apathy. 
I would not be carried away by the al- 
luring suggestions and golden promises 
that are being held out by microscopists 
throughout the world, for “Oft expec- 
tation fails, and most oft there where 
most it promises ; ” and, on the other 
hand, I would not be so blinded by cus- 
tom and prejudice as to fail to recognize 
and profit by the enduring and substan- 
tial facts which have been laid before us. 
Many honorable and able physicians 
do not follow aseptic and antiseptic 
principles because they considered them 
superfluous. They have had, they say, 
hundreds of cases of confinement with- 
out losing a single patient. This at 
first sight seems a strong and convincing 
argument, but, while they may not have 
had a death from what they choose to 
call puerperal metritis, peritonitis, or 
even acute puerperal septicemia, if 
they would go a little beyond the usual 
period of the lying-in and search for 
their cases of pneumonia, pericarditis, 
endocarditis, arthritis, abscess and ty- 
phoid fever, they would find many of 
them traceable to puerperal infection. 
Besides this, mortality alone is not the 
only factor to be taken into considera- 
tion. Innumerable cases of permanent 
ovarian, tubal and uterine disease date 
their origin from the parturient cham- 
ber. Another argument used by the 
opponents of scientific midwifery is 
that labor is a natural process, and re- 
quires, as a rule, no scrutiny or precau- 
tions on the part of the accoucheur. 
This is equally untenable, for no matter 
how naturally or with what comparative 
ease a woman may pass through her 
confinement, she is in all cases a wound- 
ed woman ; presenting to us, not only 
the extremely sensitive and receptive 
uterine wound, but numerous tears, con- 
tusions and abrasions of the genital 
tract, which, while they may not be 
perceptible to us, are yet sufficiently 
large to admit myriads of pathogenic 
microbes. There is always a certain 4 
amount of traumatism connected with 
the parturient act, and no woman can 
with scientific accuracy be said to be 
free from danger because her labor has 
been normal. Then again it has been 
said that aseptic midwifery involves an 
expenditure of money and a waste of 
time, and is for that reason inapplicable 
in many cases. The truth is that, with 
a proper appreciation of the object to be 
attained, it may be so simplified as to be 
practicable in any household. Fortu- 
nately, public sentiment is being en- 
lightened on this subject and is begin- 
ning to demand the advantages of 
scientific work in midwifery. And, as 
we are in a certain sense the guardians 
of those who have committed their 
physical welfare to our professional 
keeping, we should feel that they have 
a right to demand the best treatment 
which knowledge and experience have 
placed at our disposal, and that ours is 
the duty to give it to them. Real prog- 
ress in science cannot be measured, as 
we know, by laboratory researches, but 
by the degree of service which such 
researches render the physician in the 
advancement of the healing art. 
I began my paper in an apologetic 
strain, and I shall close it in like man- 
ner. I am conscious of the fact that 
I have offered nothing new, and that to 
most of you my remarks seem like a 
thrice-told tale. It may be, however, 
that there are some general practitioners 
among us who, like myself, have not 
hitherto sufficiently appreciated the im- 
portance of the work that is going on 
around us. To such especially would I 
direct my humble effort, with the hope 
that in our future labors in this import- 
ant field we shall look with greater 
favor and consideration upon the mag- 
nificient results which have been ob- 
tained by the faithful observance of 
aseptic and antiseptic methods. I do 
not know to what extent the Faculty 
has in former years considered or dis- 
cussed the subject of midwives, but I 
am convinced that there is urgent need 
for some definite co-operation on the part 
of the profession designed to restrict, if 
not to eradicate, the great evils which 
flow from the unbounded and unguided 
freedom with which careless and ig- 
norant women are accustomed to pursue 
their self-appointed work. 
Reprinted from the Maryland MEDICAL Journal, June 8, 1895.