on a convulsive or precipitate type, dyspnoea being marked and the range of respiration being superficial, until it was ultimately suspended altogether.

H. C. Wood 3 thus summarises the action of veratrum viride:

"Veratrum viride has no distinct local action, yields readily its active principles to absorption and probably to elimination, though concerning its fate in the system we have no definite information. The free sweating which accompanies its marked action may be simply the result of a profound arterial depression, there being no proof that the drug exerts a specific influence upon the glands of the skin. Similarly the excessive secretion of bile which it sometimes induces may be a secondary result due to the severe vomiting.

"By the depressing action of jervine upon the heart muscle and upon the vaso-motor centres, veratrum viride lowers the arterial pressure, in the beginning slowing the pulse by a direct influence of jervine upon the heart muscle and by the stimulating influence of veratroidine upon the pneumogastric nerve, but later increasing the rapidity of the pulse by paralysing the pneumogastric nerve (veratroidine), and probably also by some action upon the heart muscle (jervine).

"Chiefly, if not solely, through a centric influence, it causes violent vomiting, and, in rare cases, when there is in it an excess of veratroidine, purging. On the motor side of the spinal cord it acts as a powerful depressant, but is without influence upon the cerebrum, the motor nerves, and the muscles. Probably, on account of the vaso-motor paralysis which it produces, favouring an increase of heat dissipation, it decidedly lowers animal temperature, a fall of as much as four or even more degrees sometimes occurring in the poisoned lower animals before death."

REFERENCES.-1 Jardine, Brit. Med. Journ., 17th January, vol. xiv., p. 141. 2 Fothergill, Med. Annual, 1919, p. 136. 3 H. C. Wood, Therapeutics: Its Principles and Practice, 1905. R. J. Collins, Archives of International Medicine, July 1915, vol. xvi., pp. 54-58. 5 Fothergill, Med. Annual, 1918, p. 434. Glendinning, Med. Annual, 1916, p. 468. 7 Haultain, Trans. Edin. Obst. Soc., 1912-13, vol. xxxviii., p. 306. Leçons de Pharmocodynamie et de Matière Médicale, pp. 725-728.

Pouchet,

SOME OBSERVATIONS ON SEVENTY YEARS

OF COUNTRY MIDWIFERY PRACTICE.

By C. E. DOUGLAS, M.D., F.R.C.S.E., Cupar-Fife.

THE communication which I venture to bring before you this evening has three objectives in view. First, to examine the statement frequently made and supported by statistics, that puerperal mortality is as high to-day as it was seventy years ago; second, to question the opinion, also widely held, that the bulk of this mortality is the result of instrumental and other interference with the course of labour; and third, to suggest that this matter of puerperal mortality might profitably be examined from a somewhat new standpoint to which I will finally direct your attention.

The material from which any conclusions arrived at are drawn is the experience gained in a mixed small town and country practice from the end of "the forties" till the present day, of cases in all classes of society, from those in the county houses around to the tramps in the lodging-houses. Needless to say they are not the experience of one man. But they cover a period of obstetric history of more importance than any (if we except that of the epoch-making invention of the Chamberlen forceps), a period which began before chloroform was generally used in obstetrics, before Oliver Wendell Holmes' pronouncement had taken the ear of Europe, and when antiseptics were undreamed of. They fall naturally into three series, one embracing the "fifties" and a little more; another beginning with my early days from 1880 into the "nineties"; and the rest up to a recent period. I shall give you the figures upon which the positions I wish to take up are based; I shall then describe the development of our science in one or two directions; and, finally, shall lead up to my main endeavour, namely, to establish the rule that the parous woman, ipso facto, is apt to die.

I.

Now, as regards the statement that the mortality of to-day is no better than that of old times, hear the two following pronouncements. Dr Ewan J. Maclean1 says: "Taking a quinquennial period of seventy years ago, the puerperal death-rate from all causes was 4.9 per 1000 as compared with 4.2

sixteen years ago, and deaths from puerperal fever account for 50 per cent. of them."

Your former President, Dr F. W. N. Haultain,2 says: "The mortality from puerperal causes in Scotland is as high as it was fifty years ago, viz., about 5 per 1000, or I in 200 cases." But, before we take statements such as these at their face value, we might usefully consider the authority on which they are based-that is the parish registers of the time. Registration in its present form was hardly known. In England, indeed, while there had been church registers since the middle of the sixteenth century, the State only took over the business of registration of births and deaths in 1836, and it was not until 1874 that either became compulsory. In Scotland, the corresponding date was 1854, and we may be sure that anything like accuracy would be the growth of some years at the very least.

Be that as it may, I have some figures in my possession which tend to show that the belief that the maternal mortality was as low then as now is erroneous, and that on the contrary it was considerably higher. I have the midwifery case-book of my predecessor in this practice, a practice taking in all kinds of patients, principally the wives of agricultural workers, a strong, healthy body of women, with practically never a rickety pelvis. He and his brother were in practice together from the end of 1847 to 1864, when the book ends. There are in it the names of 936 cases. Of these only 6 or 7 per cent. required interference, so that 93 per cent. were normal cases. The abnormal cases are shown in the Table. They correspond in frequency very much as at present, but have some points of difference which bear on the subject-matter of this paper. Thus, we note that they are very "modern" in three respects, the low proportion of forceps cases, only 21 in the whole series, or I in 44, or 2.2 per cent., the small number of versions, only two, both in placenta prævia, and the practice of craniotomy. There is a very large proportion, 93 per cent., in which no operative interference is reported; and lastly, and most importantly, there is a very high maternal mortality of which four-fifths are in non-operative cases. Twenty maternal deaths in 936 cases means a mortality of 21 per 1000. In only four of these is any operative action noted-one a forceps case, one a breech, one a case of twins, and one a retained placenta, which died on the twenty-fourth day, probably then a septic

case. In the other 16 cases no operation was reported, and we may infer that they died either from sepsis, or what was much more common in those days, from exhaustion in a day or two. We are accustomed to read of such cases even in the general literature of the period. It is needless to say how accurate an observer was Charles Dickens, and the death of Mrs Dombey is probably typical of many cases of the time. But from whatever cause, twenty mothers died in this practice in sixteen years. This is so much at variance with modern experience that I approached the Registrar-General for Scotland, giving him the names and addresses and dates. He very kindly had a search made for me, and though unable to trace my cases he gave me names of eleven other women who had died in child-bed in Cupar in the years from 1847 to 1854. These may be taken as having occurred in the practices of the other doctors and midwives in Cupar at the time, and they go to confirm the impression that at that time there was a considerably higher mortality amongst women than at the present day.

To form a correct appreciation of the situation in those years we should have a clear idea of the state of knowledge and the rules of practice laid down by teachers at that time. Take, for example, the Practical Observations of James Hamilton, Professor of Midwifery in Edinburgh, published in 1836. It is true that my predecessors qualified in 1845 and 1848; but James Y. Simpson had only recently succeeded Hamilton in the Chair; they were students of the College, not of the University; and I know of no work published after Hamilton that would be likely to have been an authority to them. Hamilton's teaching was then dominant. Let us see what

it consisted of.

A tedious first stage was treated by venesection in the first instance, followed by "an opiate enema"; if this did not suffice, the os was dilated manually. The second stage was mainly concerned with support of the perineum, for hours if need be—he mentions having done this for twelve hours without leaving the patient—and “fine lard,” to the extent of a pound for a case, was used to lubricate the passage. The third stage was a still more extraordinary performance. You felt along the cord till you could reach the centre of the placenta, and if this could be done it was ready for extraction. Twisting the cord round the fingers of the right hand you pulled on it till it came away, again supporting the perineum

with the left hand. If the placenta were retained for more than an hour it should be removed. (This appears to be an innovation on the practice of leaving it for a long time.) If adherent, the placenta is to be grasped by the examining hand, and "pressure is now to be made upon its substance, bringing its circumference towards its centre and detaching leisurely and carefully all that can be separated by this manipulation. The separated mass is to be extracted by pulling with the navel string."

"3

Simpson's teaching, it may be observed, is very similar.*

When we come to discuss the "forceps question," I shall have to quote again from this interesting writer; but we may reasonably say that a system which deals with its tedious cases, not by operation but by venesection, opiate enemata, and manual dilatation without antiseptic precautions; that lubricates the passages with "fine lard"; and that pulls out all its placentæ by the "navel string" and removes adherent placenta by pulling at the centre in a "leisurely" manner, is not a system from which we could expect results comparable with those of modern methods.

I now put beside this series another of cases occurring in the same area, which series I shall presently divide into two. These fell during the year 1880, when I began practice in Cupar, till 1923, and comprise 2200 cases in approximately 1600 women. Of these cases 557 were abnormal in some way, being 26 per cent., leaving 74 per cent. of "normal" cases. The abnormalities were as follows: Forceps cases 393, being 18 per cent., or 1 in 5.5; twins 28, or I in 78; pelvic and crossbirths 35, or 1 in 62; placenta prævia 15, or 1 in 146; postpartum hæmorrhage II, or I in 200; retained placenta 40, or I in 55; eclampsia 10, or 1 in 220; prolapse of cord 4, or I in 550; accidental hæmorrhage 8, or I in 275; monstrosities II, or I in 200; brow 2, or I in 1100, and one each of face presentation and hæmatoma vulva. This shows a total of 557 cases, or 26 per cent., in which interference of some kind was required as against 60, or 7 per cent. in the first series.

The maternal deaths were II in number, being 5 per 1000. Of these, two were eclampsias; one forceps case had mitral valvular disease with bronchitis and died suddenly on the fourth day; one forceps case was sent to Dundee by my locum tenens, and was delivered there, but died two days afterwards from exhaustion; one normal labour was a case of advanced