pressure forward by means of the fingers of one hand inserted into the rectum. It is hardly necessary to add that, when the fillet is used, it should be passed over the anterior thigh, that only moderate tractions should be employed, that these are most effective when made during the pains, and that very great aid can be secured by conjoint pressure upon the opposite pole of the foetus, exerted by a skilled assistant during the tractions.

The main drawback to the popularizing of the fillet is the fact that its passage around the groin by the finger alone is by no means easy in the very class of cases in which it is principally indicated; viz., those in which the breech is high up in the pelvis and difficult of access. To be sure, with patience, the knotted end of a handkerchief can sometimes be pushed around the flexure of the thigh, or, failing in this, an elastic catheter with an attached loop may be guided by a finger in the groin between the thighs, to serve as a means of conducting the fillet into position. Because of the difficulties, however, attendant upon both of these plans, many porte-fillets have been devised. The one I now exhibit, which is a modification by Ollivier of an instrument invented by Tarnier for carrying a cord around the neck of the child in neglected shoulder-presentations, is an ingenious device. It consists of a long-handled blunt hook, tunneled in the center, and terminating in an olive-shaped bulb. The central canal permits the passage of a long piece of whalebone, the extremity of which is provided with a metallic eye to which a loop can be attached. When the whalebone is withdrawn, the eye occupies a hollow space in the olive-shaped extremity of the blunt hook. Below the handle, the end of the whalebone is supplied with a button to prevent it from being accidentally withdrawn into the canal. A screw above the handle serves to fix the whalebone at whatever point may be deemed desirable. The blunt hook is adjusted by passing it upward along the surface of the child, directed to the front to a point above the pelvis, and then directing the curve so as to adjust it to the groin. The whalebone is then easily pushed forward until it is felt by the finger of the operator between the thighs of the fœtus. The metallic eye is next directed outside of the vulva by the

fingers, and the attached fillet is easily withdrawn by reversing the process described.

The fillet employed may be of any material. Every care should be taken to adjust it without forming folds or creases. In emergencies, the nearest object has to serve the purpose. Ollivier recommends passing a lacing through a piece of rubber tubing of the size of the little finger. The lacing should be sewed to the extremities of the tube, a projecting portion serving to attach the tube to the eye at the end of the whalebone of the porte-fillet. The rubber tubing in his experiments admirably answered the purpose of protecting the tissues of the child from injurious pressure.

In the absence of other appliances, or in case failure should attend the measures already described, it is well to remember that the blunt hook owes its evil reputation, not so much to its inherent defects, as to lack of proper caution in its employment. It will not break the femur if it be adjusted in the groin. It will not produce serious contusions if the blunt end be carefully guarded by the finger. Injuries to the maternal organs can occur only when leverage-movements are made. The pressure of the curved portion upon the groin is not likely to produce serious lesions. Steady downward tractions, made with moderate force and with a hand in the vagina to guard the point of the instrument and to give warning of beginning extension of the thigh, will as a rule suffice to prevent the occurrence of serious accident.

Finally, it is proper to state that no instrument is capable of furnishing so secure a hold of the breech as the cephalotribe. If the child be dead, a fact rarely to be determined with positiveness except in cases in which the cord can be felt, the cephalotribe should be screwed tightly to the breech, and it may be trusted to act as a perfectly reliable tractor.

25

WOMEN AS MIDWIVES.

By THOMAS H. MANLEY, M. D., of New York County.

Read November 19, 1884.

MR. PRESIDENT AND FELLOWS OF THE NEW YORK STATE MEDICAL ASSOCIATION: I have chosen for a theme a subject seldom discussed in medical assemblies, but one, nevertheless, of much interest and of the utmost importance; of importance no only to us as physicians and surgeons, but to the residents of this vast metropolis and State, nay, to the whole nation. Although its consideration by a society of medical men is somewhat novel, and the views which I entertain on the subject have been bitterly opposed by many eminent and able members of the profession, still I am persuaded that, when these views are properly explained and the object to be attained is better known, they will be supported in a friendly spirit.

I propose to discuss, Mr. President, the question of "Women as Midwives," and to place before you some facts of interest in connection with the subject, to show you, no matter how much one may disapprove of the proposition, that the time has come when we must provide mothers belonging to the poorer classes with intelligent, responsible, and trained midwives.

It may seem incredible, but it is true, that at the present time more than two thirds of the wives of working-men are delivered by attendants called midwives, women, the majority of whom are ignorant of the first principles of obstetrics. As a rule, however, they safely confine their patients.

I find, by inquiries made of the health-officers of Boston,

Brooklyn, and Philadelphia, that more than one half of the confinements among the working-people in those cities are attended by the same class; and, in passing, it may be well to acknowledge that, although these female attendants have been ignorant and untrained, they have accomplished much good, even if they have now and then lost a life.

The fact that so many thousands have been and are annually delivered by midwives would seem to imply that they are needed. Any one who has examined into the matter will see that the number of such deliveries is rather increasing than diminishing.

From all the information I can gather from different sources, from my own observation, and from that of others, I think I may assert, without fear of contradiction, that there is an urgent and imperative demand for trained midwives; and that, properly educated in their craft, they are, as a rule, in normal confinements, to be depended on to bring the parturient woman safely through her travail. It would seem rather paradoxical, but it is true, nevertheless, that the artificial means often resorted to to shorten labor and save life, as exemplified in the application of the forceps and the administration of ergot, have unquestionably been only too often the agencies through which fœtal life has been destroyed, and the mother's parts bruised, mutilated, and torn, leaving a large number of these unfortunate subjects for the table of the gynecologist.

Professor Gross, in presenting his last essay to his professional brethren at the recent meeting of the American Medical Association in Washington, warned them against too frequent meddling with natural labor, and charged that the forceps is largely responsible for the torn cervix and perinæum. Several took exceptions to these utterances coming from a surgeon; but at a meeting at the Academy of Medicine in this city, lately held, its president, a widely known obstetrician and gynæcologist, asserted that the most distinguished gynecologist of the present day might feel proud of having written Dr. Gross's paper. I make this digression simply to prove that many women would do better in labor if their attendants would leave more

to nature; in other words, if they would or could take more time.

The small fee usually paid to the general practitioner is often inadequate; and his reliance on the use of ergot and the application of the forceps is due to his desire to terminate labor hastily. The majority of child-bearing women are among the poor, many of whom are unable to pay anything to the physician. This condition of things being well known to us, how shall it be remedied? The problem to my mind seems easily solved. Qualify midwives to attend those who desire their services. Let those with means secure a physician. Select midwives from the multitude of our intelligent and vigorous young women, many of whom are well educated but have no opportunity of applying their education. The demand for young women of fair and advanced education, although yearly enlarging, is altogether too limited. Open a school for midwives, which in its organization and management shall deserve the approval of the medical profession and the State; and throw open the doors of the maternity hospitals, so that female students may be taught practical midwifery.

There are many confinements in this city which might be, and are not utilized for teaching; and this is the fault of medical men. Not only are our lying-in hospitals closed to female students of obstetrics, but young medical graduates are turned out on the world with nothing more than a merely theoretical knowledge of this important branch of medical science, not having been permitted, while students, to deliver women in our public institutions.

Not long ago, I heard a young obstetrician proclaim, at a meeting of the County Medical Society, that there were in this city fifty young doctors who would attend gratuitously all the cases of obstetrics they could obtain. I must take emphatic exception to that statement. If the speaker had said there were that number of medical students who would give their services and attendance, it would have been nearer to reason and truth; for, as a rule, no matter what may be said to the contrary, the vast majority of medical graduates immediately depend on what