27

1T.—31

A study of these recorded cases of fatal intracephalic injuries (the majority to be found in German literature) also reveals the frequent mention of twilight sleep. Again, this might be only the incidental result of the greater popularity of twilight sleep a decade ago among some of the German obstetricians. The fact, however, cannot be over looked that this method of pain-relief lengthens the second stage of labour, and in a large number of cases requires termination of labour by forceps, and may impair the life or future health of the child in that it supplies two definite factors [viz., prolongation of labour and resorting to forceps] which are commonly held responsible for intracranial injuries. However, it is gratifying to our national amour propre that we do not have to depend solely on American or Continental authorities for original and authoritative pronouncements regarding the fundamental principles underlying the science and practice of midwifery, particularly as regards safeguarding mother and child. 1 shall refer presently to the remarkable practical and scientific pioneering work done in London by Dr. Herbert Spencer some thirty-five years ago. But one has to go more than half a century back to find the sound eternal foundations of the science of safe midwifery, laid down for all time by the greatest and most far-seeing obstetrician the world has ever produced. In his classic book on " The Mortality of Child-bed and Maternity Hospitals," published in 1870, Dr. Matthews Duncan said: — There is no obstetrical doctrine more deeply impressed on all the valuable literature of our profession than this : that the mere duration of labour, considered in itself and apart from other causes of danger likely to spring up as the process becomes protracted, is of little importance, so far, at least, as recovery of the mother is concerned. This doctrine is embodied in the ever-recurring inculcation of patience, as the highest virtue of both mother and attendant, in many and various circumstances of distress during labour. Sometimes it is expressed in an apophthegm, " Meddlesome midwifery is bad " ; at all times it is diligently instilled into the minds of young midwives and accoucheurs. . . . Tins is one of the best-recognized and most valuable doctrines in obstetrics, it is therefore of the utmost consequence to defend and confirm it. Tne proposition does not affirm that the mere duration of labour is of no importance quite the reverse. . It says nothing in regard to the very important effects of the duration of labour after bad symptoms or dangerous complications have supervened. It asserts that the duration of labour is in itself (per se) only an inconsiderable part (probably a very inconsiderable part) of the many causes of the mortality of women from parturition and its consequences. Perhaps the strongest evidence in favour of this proposition is the fact that it is the ancient and generally received opinion of the profession. It rests upon what may be called tho instincts of all experienced accoucheurs, in a science like medicine, where so little is capable of absolute demonstration, ancient traditions, especially if supported by the opinions of the great and wise, are. among the most valuable and trustworthy guides of practice. It was reserved for later British investigators, such as Dr. Herbert Spencer and Dr. Eardley Holland, not only to confirm what Matthews Duncan laid down concerning the safety of the mother, but to more than justify his anxieties for the child. They have shown us that modern " meddlesome midwifery " —from unnecessary and undue handling and internal examination of the mother, to the abuse of twilight sleep or chloroform, and forced, rapid delivery through the agency of drugs, forceps, &c. —is responsible for an infinity of harm, quite apart from the risks of puerperal fever. If there were no such things in the world as microbes or sepsis it would still be incumbent on us to reduce to a minimum the protraction of labour by twilight sleep, &c., or its sudden termination by forceps or other artificial means. Until then, large numbers of children will continue to be damaged by undue delay or by grave mechanical injuries to their internal organs —especially the brain and nervous system —inflicted in the course of forcible delivery; and the minds and stability of many children will suffer along with their bodies. With supreme fairness and common-sense, Dr. Janet Campbell says in her report on " Maternal Mortality,"— Closer co-operation between midwife and doctor is obviously all to the good, and deserves every encouragement; but if the doctor is summoned mainly to secure the speedy termination of labour for the convenience of those concerned, the practice needs discriminative vigilance. Operative intervention often entails increased risk to mother and child, especially as usually carried out in working-class homes, and if the doctor is summoned to apply forceps merely because tne second stage is somewhat prolonged and tho patient clamours for relief, much of tho advantage of employing a midwife with time to watch the case and facilitate natural delivery disappears. This has an important bearing on a suggestion made recently by Dr. Paget, Inspector of Maternity Hospitals, at the opening of the Health Department's campaign against maternal mortality, that, with due precaution, qualified midwives should be allowed to administer chloroform, where necessary, in the absence of a doctor. The reasonableness of this is obvious, because without such provision there must necessarily be anxiety on the part of the mother not to let the doctor out of her sight, lest she should be compelled to bear pain beyond her power of endurance, and the result in too many cases would continue to be delivery by forceps. It is only fair to mention Dr. Paget's suggestion, because it is in keeping with the fact that no member of the Health Department's medical staff has ever suggested that the mitigation of pain by means of anaesthetics in confinement should be cut off : the phrase " Back to Nature " in this particular connection, attributed to myself and my colleagues, has never been used by any of us—it is the gratuitous invention and imputation of persons stubbornly and bitterly opposed to reform and determined to maintain the utterly unjustifiable status quo. We have in New Zealand an utterly unjustifiable still-born rate and infantile-mortality rate within a week of birth, but the large number of survivors who are more or less gravely damaged for life involves really a much graver wrong. After detailing various grave injuries to the skull, brain, and nervous system, &c, resulting from precipitate delivery, Dr. Ehrenfest proceeds : — It will be well tv remember that these ropresent injuries observed in obstetrical clinics, where surely the majority of oparations are in expart hands, atil parformad in gonoral only under well-defined indications. A reduction in the number of these injuries . . . can be achieved only by limitations in the number of forceps applications.