Rural obstetric practice a generation ago

Correspondence Rural

Obstdric

Practice

a Generation

The following letter was received recently from Dr. Milford, Iowa, in response to a general appeal to the for assistance in compiling data on home deliveries. It that Dr. Smith’s letter was of too much historic value filing cabinet, and consequently permission was sought minor alterations. This request was graciously granted, JOURNAL offered his cooperation.

Ago

Ferdinand J. Smith, of physicians of the State occurred to the recipient to justify its burial in a to publish it after a few and the Editor of the E

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D

. PI,ASS.

MIdford, Iowa April 29, 1938. My

dear Doctor Phss: have recently received your letter and the enclosed questionnaire, but cannot be of assistance to you since I am no longer in practice, although I have records of over four thousand confinement cases attended during my professional life. There are, however, certain data which 1 can give you from memory in the hope that they may be worth while. I was graduated from the Medical Department of the State University of Iowa on March 2, 1887, after three courses of lectures of four months each. My undergraduate, practical experience in the office of Dr. W. F. Peck, then Chief Surgeon of the Rock Island Railroad and Dean of the Medical Department at Iowa City, was limited to surgery. I did not see the ordinary diseases of childhood, lung fever, typhoid fever or, in fact, any other internal medical cases until I began to practice medicine. The only obstetrics I saw was what the Professor of Obstetrics, Dr. J. C. Schrader, demonstrated on a manikin, which was, I suppose, better than nothing. The majority of my obstetric deliveries occurred between the time of my graduation and January, 1904, when I was appointed full-time Professor of Chemistry and Dean of the Junior College of Medicine at Drake University, Des Moines. I remained in these positions for several years, but during the vacation periods had a small obstetric practice near Lake Okoboji where I spent the summers. In June, 1913, I resumed the practice of medicine and until 1919 was very active, especially in obstetrics. During this period, there were two days, on each of which I attended five confinements. From 1919 I lived at my home on Lake Okohoji and for some years did considerable practice, but gradually began to taper off and am now retired. I still remember my first obstetric case. I arrived at the patient’s home, examined her but failed to locate anything, and then began to get excited, since I did not seem to get anywhere. Finally I decided it was foolish to worry, Why worry9 The mares, the cows, the ewes, all the farm animals had their offspring without assistance and got along fine. In good time, I was able to locate the presenting part and to determine the position and was gratified to find it normal. By continuing to exercise masterly inactivity, the baby eventually arrived, as big as life and twice as natural. After severing the cord, I watched the old neighbor lady wash and dress the baby, and assisted her in dressing the cord. I was beginning to think about going home when she suggested to me that it might be a good time to remove the afterbirth. I was very glad that she spoke of it but did not tell her so, because I had forgotten all about it. On examination I found the placenta in the vagina and removed it easily. After this experience, I went to my I

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obstetric cases with a feeling of c~onfidence, c:onvinc,ed that the main tliing to do was io give nature a, chancre. This may br the reason why I never last ;L mother. The mothers’ ages ranged from 1:: to 3%’ vears. 1’111~ average numhrr of c~hildren to each mother was about a, dozen; there-&re few with less than six, and in two families r attfndetl the twenty-first ant1 tvc-enty-seroml c~onfincments, respectively. There were very few stillhorn c*hiltlrrn. Of course, I had experience with all the normal fetal positions as well as with many abnormal, or undeliverable, presentations, in which it was neeessnry to use the appropriate operative procedures. There were quite a number of shoulder presentations, which I delivered by turning, usually under ether, but in quite a few cases without any anesthesia. One patient had twelve hr,eech presentations, one shoulder presentation, which J turned, and one normal cephalic presenta,tion. I can recall two face presentations. The first, with the chin forward and to the right, gave no trouble other than a prolonged period of delivery. In the se(aond case, the chin was to the left and posterior. The patient was :i2 years old, and this was her first baby. I was called hy telegraph at nine in the evming, and reached tlw home, 2.5 miles distant, by daylight the next morning (horse and buggy days). The bag of waters had ruptured. and most of the fluid had escaped, but there was no dilatation and with eacah pain there was :I further loss of fluid. Ry that evening, the patient It was not unt,il 11 :IKl P.M. was becoming impatient, and J suggested consultation. that the ronsultant arrived. He thought it would be best to turn, but ‘I told him that there was practically no water left in thr uterus and that it woultl he imponsit)l+: to turn under such circumstances. Nevertheless, he insisted upon trying and, with the consent of the patient, made the attempt, but found that he could not even Then he introduce his hand into the uterus-there was too little dilatation. wanted to introduce forceps and deliver instrumentally, and the husband asked him to try. I demurred and told him it would he dangerous, but in spite of this he went ahead. Naturally, he failed even to introduce the blades, and then gave I+ morning I was able to diagnose a chin it up for a bad job and went, home. posterior, which is ordinarily not, delivrrablc. The only other proecdurc, except to give nature more chance, was craniotomy, whicxh was refused. Exactly at noon, the head adjusted itself PO Hiat the rhin was in the anterior position, and in a short The child was dead, but the mother matle :I good rrtovery time the baby was horn. and the next time had twins, T forgot to say that this first hahp weighed 12 pounds xt birth. All of these deliveries were nondurtetl in town or farm homes. In those days, physicians did not look upon childbirth as a disease, but rather as a physiologic. process whirl1 should be treat,ed aarordingly, unless there were c30mplicating conditions. The water supply was usually from surface wells, rarely from cisterns, and light was obtained from a candle or kerosene lamp. h doctor was expec+d to be able I can still do it. There were no into pass a catheter without. exposing the paCent. door bathrooms, and the toilets were the old-fashioned privy vaults. Instead of toilet paper, it was quite customary to use (qorn (‘ohs. In the wholr of Sioux County, I knew of but one bathroom. The great bulk of the people were then able to pay the standard obstetric ft~. whicli was $5.00 in town and $10.00 in the country, regardless of time or distance. The longest trip I made to attend a confinement, was from Alton, in Sioux County, to hlvord, in Lyon County, a distance of fully fifty miles. If I were to pracltice obstetrics now, I would refuse to attend a patient anywhere else than in the home. Patients bec:ome immune to any bacterial organisms in their own homes, whereas, even in the best regulated hospitals there are of necessity a great variety of organisms from many Sources. There was no prenatal care. Sometimes the husband or, more rarely, the wife would drop in at, the offire to advise me about the date of the coming event and to urge me to come quickly when I received a call. Patients did not report for examination or bring urine specimens for testing. It was only when edema romplicated bhe pregnancy that we called for some urine and examined it for albumin and casts. Blood pressure appliances were not, yet in use, and bacteriology was still in jts in. f army.

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In my first cases of puerperal eclampsia (six months after I began practice), 1 used large doses of morphine hypodermically, to reduce the convulsions, and hot packs. The baby was born prematurely and eelampsia did not develop until four hours after delivery. The patient made a good recovery. All of my other puerperal convulsive patients were treated with Norwood’s tincture of Veratrum viride, 15 minims hypodermically, repeated every thirty minutes until the pulse rate was 55 to 155 per minute. At the same time the patient was wrapped in a cotton flannel blanket wrung out of hot water, and ear corn, taken out of boiling water, was placed down both sides of the patient’s body outside the blanket and under the quilt. This Wits, continued until the edema was very much lessened and, in some cases, this result was achieved in no more than thirty minutes. It was rare that there were any more convulsions after such treatment. I had 18 or 20 eclamptic cases in my own praetire and in consultation with other physicians, and did not lose a single mother. If treatment was begun early enough, the child also usually survived. (A paper on t.his subject was presented before the Northwestern Iowa Medital Society, April 30. 1919, and was published in the .7ournal of the Iowa State Medical Society, in August, 1919.) The great bulk of my deliveries were spontaneous: among more than 4,000 cases, there were not over 30 instrumental deliveries. Onc.e, I used the instruments on an aftercoming head, for fear that the baby might be asphyxiated. When I did use forceps, I produced traction with only two fingers, having found that this maneuver gave the patient much relief from pain by relieving the uterus of part of its muscular labor. I never gave anything to increase the activity of the uterus before delivery, except in certain cases where my experience indicated the liability of a relaxed uterus with consequent hemorrhage. In these instances, I gave a capsule containing 10 gr. of quinine sulfate immediately before birth. If this had not been done and hemorrhage appeared, I applied cloths wrung out of freshly dratwn well water over the lower abdomen, and gave a teaspoonful of fluid extract of ergot. Perineal wounds were repaired immediately with catgut sutures. A wash boiler half full of boiling water served to sterilize dishes, old muslin and towels and also provided a supply of sterile water. There were no rubber gloves available, but I washed my hands thoroughly with soap and hot water, used a nail brush carefully, and sometimes immersed my hands in a solution of permanganate of potash. The vulva was not shaved. Vaginal examinations were made only when indicated to follow the course of Examinations per rectum had not yet labor or to explain the cause for delay. been introduced. If an anesthetic was used, it was not given until the head engaged the perineum and was employed then only to safeguard the perineum. Ether was the usual anesthetic and was generally administered by one of the old On one occasion, I had the hired man give ladies, or, perhaps, by the husband. the ether, because the husband would not do it and no old ladies happened to be available. Unless there was a bronchial condition contraindicating its employment, I always felt safe in using ether. When there was evidence of bronchial involvement, I would either dispense with an anesthetic entirely or would give chloroform myself. Many labors, even t.hose with the first child, were terminated within eight hours, partieularly in women having a lanky build, whereas plump women Faulty, even though not usually had a harder time of it in their first labors. ahnormal, positions led to more severe first labors than if the fetus were in a more normal position. As a rule, the second child came more easily, t,he third one much more so, and after that it was nip and tuck betwren the stork and myself. My patients were almost entirely of German and Dutch extraction. I was much impressed by the fact that most of the mothers were comparatively youthful looking. In. certain large family groups it was difficult to pick out the parents from the older children. In those days there were no trained nurses, but the older women, who had arrived at the end of their childbearing, would help out their younger neighbors. And They did as they were told without question. they acquitted themselves well. Every one of my living babies was blessed with a living mother. And I was not the only doctor who had such an experience. It is my personal conviction that there is altogether too much meddlesome midwifery on the part of physicians, and that

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there is too much chance for infection in hospitals. Perhaps t,ha fact that. too many of the mothers or (and) fathers have been infected with venereal disease may contribute to the present higher death rate. Such complicat,ions were not common in the country wheu 1 was practicing. One case, whi& I had, was rather unusnal : a Dut-ch woman, only recently ovet from Holland, gave birth to a babp on a Saturday night. I saw that there was another one coming and waited quite a while, hut finall? decided to go home and wait until I was called. A week from the following Monday, the patient did a la.rge washing and that night I assisted her with the birth of t.he second habp. She made a good recovery. Another patient, :I primipara, attended a neighborhood party the Tf the experience hurt day after her baby ivas born and took part in the dancing. her in any way, there was no evidence of it.. T have left the most unusual case I erer saw for t.he last. 1 was called bp :L man who said that his wife had given birth to a baby some hours before, and that the two old ladies who had cared for her had advised him to obtain the services of a physician as quickly as possible because she looked terribly ill. 1 went with him immediately and when we came to the home ‘I could see that she had been bled white. There was no pulse at the wrist and only very feehle heart sounds were audible with the stethoscope. It was evident that she was about to die? SO I told him that she was beyond the benefit of any treatment and that, if he and his wife had anything to say to ea(~11 other, it should be done quickly. Instead of complying, he ran out and told his boys to get on horseback and to bring back as many physicians as they could find. \t’hen he returned to the house, his wife was dead. The two old ladies told me that they had repeatedly suggested to the patient that she have a doctor, but that she had insisted t,hat the pains were not ye6 sufficiently strong. Finally, she had one terrific pain, the most agonizing they had ever seen, during which the head was born. There were no more pains, but the two old ladies extracted the rest of the child by drawing the head down until the body was delivered, and then cut. the cord. The two ladies went to another room to wash and dress the baby, and then went back to see how t.he mother was getting on. They found her looking terribly bad and immediately had the husband come for me. The child, which was the patient’s t,welfth or thirteenth, weighed 21 pounds and is still living. She was not more than average in size and was the mother of quite a hunch of children. What happened, of course, was a rupture I think that this was of the uterus with hemorrhage into the abdominal cavity. a case of carrying a child much past the normal time. Now, Dr. Plass, this is probably not exactly what you want, but. on t,he other hand it is. These people had as good care, perhaps better, than most mnt,hera hare now, because the physiologic processes were allowed to go on without intrrference, and it is after all the duty of the physician to allow nature every opportunity to do it,s own work in its own way. Tt is wonderful how an ovrrl>large head and a small hirth canal, if given plenty of time, will conform to each other with a resulting normal delivery. Remember, too, that in all these confinements I had consultation only four times, the balance were taken care of by myself with ,such assistance as wah available in the home or in the immediate neighborhood. Doctors were few and far apart and, since each had his own work to do, we became accustomed to The roads were atrocious, onl> taking the entire responsibility upon ourselves. dirt roads, and sometimes next to impassable. I did most of my traveling on horseback with a saddle bag for medicines and instruments. I would start, out izt the morning, make a round trip, and frequently on getting home would find other work waiting for me. If I were a young man again, I would set myself up as a specialist in obstetrics, although I fear that the modern mother would not apI believe that many obstetric difficulties would disappear prove of my wa.ys. if our women would develop their muscles from childhood up by suitable housework-doing t,he family laundry, scrubbing, and other heavier tasks. I am too old to take up the practice of medicine any more: it is now nearly 52 years since I left Iowa City and engaged in practice. 1 was a general practl-

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specialists rolled into one, as I heard the general man our number in answer to an attorney’s question concerning him and a specialist,. Fraternally

and

sincerely

described by the ‘difference

yours, FERDINAKD

J. SMITH,

M.D.

The writer of this letter, Dr. Ferdinand J. Smith, was born in Chicago, February 37, 1862. In 1883, he received the B.S. degree from the Iowa State College (Ames), and the following year, 1883-84, was Instructor at the Massachusetts Institute of Tec:hnology. During 1884, he also spent some time in Germany and was made a member of the Deutache Medizinische Gesellschaft in Berlin. From 1884 to 1887 he attended the College of Medicine, State University of Iowa, and was graduated in March, 1887, with the M.D. degree. ~Cmmediately after graduation, he settled in Alton, Iowa, where he did general practice until 1904, when Ire went to Des Moines as Dean of the Junior College of Medicine and Head of the Department of Biological Chemistry at Drake University, after having spent some months at Heidelberg in Kossel’s laboratory. In 1909, he wan made Dean of Men at the University, a position which he held until 1913, when t,be Drake Medical Department was discontinued. During his early years as a prartitioner, Dr. Smith was surgeon to the C. & N. TV. R. R. (1887) and to the C. M. St. P. and Omaha R. R. (1889). Upon leaving Des Moines in 1913, he resumed the practice of medicine at Little Rock, Iowa, where he remained until his retirement. During this interval he was active in medical society work and helped to organize the Northwest Iowa Medical Association. From 1918 to 1919 he served as coroner for Lyon County and at one time was Bacteriologist to the Auxiliary State Health Laboratory for Northwest Iowa. As late as 1937, he was President of the Dickinson County Interprofessional Asaoc.iation. In spite of a heavy professional burden, Dr. Smith prepared many papers on medical subjects. Within the last few years he published “The Transition from Franklin Medical School to the Keokuk College of Medicine of the State Unian interesting treatise dealing with the early history of medical versity of Iowa,” education in the state.

To tlar

E’ditol-: on the Endomet,rium in Association with the In the paper by Herrell on “Studies Normal Menstrual Cycle, with Ovarian Dysfunctions and Cancer of the Uterus, ” published in the April number of t,he AMEWXN J~IJR~;,\I, OF OBSTETRICS 4ND GYKECOLOGY, the author takes issue with a number of authors, including Novak and Yui, that hyperplasia of the endometrium is often found in association with adenocarrinoma of the uterus, and then presents very impressive evidence from his olvn He prefers, howseries of cases that such an association is exceedingly common. ever, to apply to the Swiss-cheese pattern of proliferative endometrium the designation of “proliferative type of endometrium wit11 cystic clrange.” He does not, in quoting our paper, explain that we particularly emphasized that only the postmenopausal type of hyperplasia was considered important from this standpoint, and that we took great. pains to discuss the frequent, misapplication of the term hyperplasia, which, however, is so firmly entrenc-hed in the litrrature that no one individual’s fiat will dislodge it. “The term hyperplasia, therefore, as we have many times stressed, is a rather loose and not an altogether satisfactory one; but it is now so well established that it would not be easy to dislodge it. The proper evaluation of the histologic variations of hyperplasia can be made only if one bears in mind that they represent merely the reaction of the endometrium to varying degrees of estrin stimulation, and that there is an insensible gradation from the normal proliferative or interval type of endometrium to the so-called mild hyperplasia than to the hyperplasia of frank