The Best Means of Combating Infant Mortality
Abraham Jacobi, M.D.
President's address before the American Medical Association, at the Sixty-Third Annual Session, at Atlantic City, June, 1912.
Journal of the American Medical Association 58(2):1735-1744, June 8, 1912.
|The first page of the original Jacobi paper.|
My principal duty and intense pleasure is to tender my thanks to the House of Delegates which selected me for the highest honor in the gift of the medical profession of America, and to my colleagues of all the fifty states who were good enough to approve of its choice. Nor am I under less obligation for their attendance on this occasion to such citizens, men and women, as by their presence here exhibit their interest in things medical and socio-political.
My everlasting gratitude is due for the mode in which this great honor was conferred on me. Being duly aware of the small measure of my merits, I was overjoyed to have reason to believe that I owed my election to my lack of efforts to secure it. My democratic training and the gentlemanly nature of thirty-five thousand members of the American Medical Association, like the principled citizens of all parties, resent electioneering importunities and abhor the humiliation and demoralization caused by gesticulating and shouting candidates for office and honor. I have the confidence that if there be in this or any other cultured assembly anybody looking for the highest office for the sake of power and preferment only, he will be deservedly disappointed. Whoever sets out to be the first, let him be the last. There is only one thing that is and must forever remain first -- that is the medical profession of America, as represented in this American Medical Association, and its object, which in all its aims is only one and indivisible.
That one and inseparable object is to promote the art and science of medicine, to unite into one compact organization the medical profession of the United States for the purpose of fostering the growth and the diffusion of medical knowledge, of promoting friendly intercourse among American physicians, of safeguarding the material interests of the medical profession, of elevating the standard of medical education, of securing the enactment and enforcement of just medical laws, of enlightening and directing public opinion in regard to the broad problems of hygiene, and of representing to the world the practical accomplishments of scientific medicine.
With all this, my professional friends are conversant. I want to impress it, however, on our guests, lay friends both present and absent, for I want them to understand from the very wording of the constitution of the American Medical Association that their interests and ours are closely related.
In order to be powerful and influential, you must not only be wise but numerous. In last year's official report you were told that it was not prudent to increase our number. In fact, you are 35,000, and the largest medical association of the world. But please remember that yours is also the largest country of the world. There are 100,000 medical men besides us, with the same rights to enter and the same duties to perform. We have been told that reasons of finance are among those which should restrict our number. I appeal to you and to those 100,000 outside. A big bank account appeals to our treasury, but glittering gold never saved a country nor a soul. If you have money, it is yours to spend as you have made it. See to it that your House of Delegates spends it in increasing, and consolidating, and strengthening your Association. Our colleagues in the vast country want to be invited; then they will come in. They must learn what we are, and where their interests are -- and the interests of the public -- from better sources than the hordes of irregular manufacturers and the "freedomers" whose bitter attacks convey what knowledge many millions are permitted to have of the American Medical Association. Let the people understand the meaning of the American Medical Association and its doctors through our doings, and not through the scurrilous lies of our and the people's enemies. My hope is for an annual increase of thousands of members. Multiply and be fertile. Stand still awhile, and you invite decline.
It is by vast numbers only that our profession will ever attain its legitimate influence in politics and in society, and such beneficent power as Socrates, Descartes, Kant and Gladstone claimed for it. The proclamation of a great principle may impress many philosophic minds, but its realization demands the labor of the enlightened democratic masses. That is why from this exalted position of mine I beg to contribute a share to the discussion of a subject which has enjoyed an important place in the best brains and the warmest hearts of our enlightened and philanthropic era. I allude to the great mortality of the infant, and the numerous efforts to combat it. You are acquainted with them all. Many fair results have been accomplished; to add to them, is my ambition. For infants must not be born merely to be sick, or to die.
The Committee for the Reduction of Infant Mortality of the New York Milk Committee has made an arrangement with the Russell Sage Foundation which will furnish a nurse who will look after a thousand pregnant women, with a view to enable them to bear infants with improved resistance. The mother will be provided for in case she is overworked. Which one of the poor is not overworked?
According to the Milk Committee, and other authorities, 17 per cent. of infant deaths are caused by congenital troubles. One-third of all of them occur before the first month has passed. Two great remedies are recommended. One is that no midwife be allowed to handle any of these cases; the other is that after confinement rest be provided for the mothers, and that the children be referred to milk stations. There is no worthier organization than that committee. What it sets out to do, it performs. It cannot help being restricted to charity so long as one-half of us is condemned to ask and take it and the other obliged to give and teach. The latter is probably the most valuable performance of the committee. As its activities, like those of its kind all over the country, are meant to be thoroughly altruistic, it is entitled both to praise and to criticism. I hope it will appreciate the former and make use of the latter.
Look at that program: first, no midwife for any of the thousand mothers. You ask, "But who?" Second. the Milk Station for the child because the charitable people want rest provided for the mothers, at the expense of the baby. If that be a good program for one thousand women and one thousand babies, if that be the best that can be invented or discovered for the one thousand lucky enough to fall into the hands of charity, what is to be done with. or for, or against those millions beyond the reach of the Sage Foundation? But you suggest, these one thousand mothers and babies are to serve as object-lessons only, to be imitated by the millions. The least, then, we must hope and work for, is that the millions of women to be confined and the millions of babies to be born now and in the future, should participate in the same benefaction which is promised a few. The universal object is to save and raise babies. My program is different, inasmuch as it suggests additions and changes.
If 17 per cent. of infant deaths are caused by congenital troubles, study these congenital troubles and obviate them. The baby's life and pathology begin nine months before its birth.
If one-third occur in the first month, study and combat that first month, and the indications arriving during and after labor.
Your dealings are not with children but with infants; not with infants only but with the newborn that is just terminating its embryonal and fetal evolution and expects to be treated like a new-born human animal and not like a calf.
No midwife is to handle the case; indeed no midwife will handle any of your cases, for you have none, with rare exceptions. It is proper attendance, however, which society owes to the woman and the newly-born, as a duty to them and to itself. They are valuable assets, both of them. Unless that be granted, no discussion is competent.
In one of the programs to relieve the coming child and the struggling mother, I read the demands of absolute rest for at least four weeks before and six to eight weeks after confinement; nursing and feeding, both gratuitous when required; and hospitals for the illegitimate and -- when needed -- the legitimate confinements.
By the Milk Committee, satisfactory rest is wanted for the mother. That means she did not have it in time, before or after the baby came. If rest means a long time in bed, and milk station and no breast-feeding, you deprive her of her most important woman's privilege and office in life after child-bearing, and of the facility of getting well radically and physiologically. For without nursing the breast is liable to become atrophic and the uterus subinvolved. And the infant? Well, the infant, to give "rest" to the mother, is deposited on the altar of a milk station.
I shall be as brief as possible, for I do not believe that the speaker should have all the fun at the expense of his audience. On the other hand, I want to say my own things in my own way -- perhaps taught by Jonathan Swift, who preferred to express his opinions "for the amelioration of his hearers, more than for their entertainment."
What the world wants is healthy babies. What the baby wants is full health and weight; that means a competent mother, sufficiently fed to have a quiet night, free from excessive labor during the day, exempt from a local curable disease that may interfere with the development of the child within her or undermine her well-being, her nursing qualities, and future pelvic and general health. What the mother wants is what she has a right to expect, as a reward for the service she renders to mankind in the shape of a healthy child: a place as healthy as the best hospital without disrupting the family. Modern society is built up on the family, the crude teachings of anarchical and a few early socialistic doctrines notwithstanding. No woman will consent to being taken to a hospital unless desperate need compels her to go. To tell a woman she may die unless she go is a cruel sentence. Society is beginning to appreciate that it owes human beings a human dwelling-place, with air enough to breath in. If you build houses unfit to breath in, you steal air which is common property. What society wants is men and women citizens. But in order to be able to rely on their cooperative functions, it must see to it that in its book of ethics the term of charity is supplanted by responsibility. It is useless to call that socialism or communism. It is the substratum of every religion and every humanistic philosophy. I like to avoid the term socialism and its alleged dangers, but only by abolishing the social causes engendering them.
Poets have told mankind that once, in the best olden times, the world was a garden, and they want it to become so again; statesmen -- not politicians -- have exerted themselves to disseminate prosperity and influence; great physicians have looked for means to ward off disease and prolong an enjoyable life; jurists have endeavored to make the globe habitable by locking up or killing criminals, or the hopeless and dangerous insane. They all deal with those who are alive and, justly or wrongly, in possession of the surface of the earth. We are expected to deal with the present only, and to fight the evils which seem to be uncontrollable now and in the near future. Is there no way to prevent those who are born into this world from becoming sickly both physically and mentally? It seems almost impossible as long as the riches provided by this world are accessible to a part of the living only. The resources for prevention or cure are inaccessible to many -- sometimes even to a majority. That is why it has become an indispensable suggestion that only a certain number of babies should be born into the world. As long as not infrequently even the well-to-do limit the number of their offspring, the advice to the poor -- or those to whom the raising of a large family is worse than merely difficult -- to limit the number of children, even the healthy ones, is perhaps more than merely excusable.
I often learn that an American family has had ten children, but only three or four survived. Before the dead ones succumbed they were a source of expense, poverty and morbidity to the few survivors. For the interest of the latter and the health of the community at large, they had better not have been born.
Theoretically and practically the addition of unhealthy, sickly, sick and contagious children is a misfortune to the newcomer, to his parents, and to society. Therefore a clean bill of health should precede matrimony. The clergymen who refuse to marry couples without it are good citizens, and the health departments are bound to see to it that contagious diseases, mainly sexual diseases, should be reported, watched, and cured. Nor is this all: Hereditary influences propagate epilepsy, idiocy, cretinism. Such persons must not be permitted to propagate their ailments.
Now we build asylums for the diseased, neuropathics, and drunkards; nurseries and schools for epileptics, cretins, and idiots; sanatoriums for incipient tuberculosis, and refuges -- still too few -- for the dying consumptives, withal conscious of the fact that our only hope of finally exterminating tuberculosis lies in the perfect but comfortable isolation of hopelessly advanced cases. Surely we try to cure and to prevent. Do we not begin at the wrong end? Consumptives, and epileptics, and semi-idiots are permitted to propagate their own curse, both what is called legitimately and illegitimately. Human society should have pity on itself and its future. The propagation of its degenerate, and imbecile, and criminal should be prevented. We have no positive laws yet for the syphilitic and gonorrheic who ruin a woman's life, deteriorate her offspring -- if she have any -- and impair the human race. We have come to this: that half of us are obliged to watch and nurse, and support the other half, many of whom should never have been born. In morals and in money, the degenerate are an expensive detriment. The only protection for the nation, for mankind, is to assure a healthy, uncontaminated progeny. Strict laws are required to accomplish that; such laws as will be hated by the epileptic, the consumptive, the syphilitic, and the vicious. No law ever suited the degenerates against whom it was passed, and it is unfortunate that while disease and incompetency and vice are to a high degree hereditary and contagious, moral health and virtue are not so to the same degree. Now those for whom the responsibility of the state does not exist are exactly those who are most entitled to it -- the newly born.
Altogether, babies have a strenuous time of it, not only after birth. Heredity, degeneracy or incompetency is often caused by social influences. Financial temptations or necessity make women select not the strong and healthy men, but the old and rich. Their children are having less and less vigorous offspring. Rich and profligate boys spend their sexual powers on prostitutes and save little for possible babies. The lack of children in American families is not always due to voluntary abstinence. Thus the future of the American population has to rely on the offspring of the immigrants, and the American type of the next century will not be much influenced by those whose ancestors came on the Mayflower. Modern industry reduces the vigor and vitality of men, and woman and child labor exhausts the mothers and fathers of the future and present generations. Millions of men are prevented from contracting a marriage by pecuniary want and the impossibility of satisfying their sexual hunger except with prostitutes. That is true not only with regard to factory hands, clerks, and employees generally, but to the picked men of the people. Army and navy, the millions of soldiers and marines of all the nations of the globe, whom we are told by our self-styled leaders to imitate, withdraw the vigorous men from natural modes of living and labor and propagation, and prevent them from marrying in time; and wars, the cynosures of our coarse politicians who take the place that should be filled by statesmen, kill and cripple and deteriorate the best muscle of the land and tempt them into perdition. Only the "weaklings" are left -- and their offspring! It is sad to contemplate the short-sightedness of our loud-mouthed leaders and their heelers.
The history of the newly born is pictured on their bodies. Pinard weighed numerous new-born babies. Those born in poverty were 10 per cent. less in weight than the others. Many were premature, their mothers injured and sick afterward, and without milk. Of that class, from three to four times as many die when at home as when in a well-regulated and well-fed hospital. Their subinvolved uteri and parametritides are very common occurrences and are the sources of lifelong invalidism and treatment. Those few are fortunate who need not complain like the woman healed by Jesus, who had suffered all her life from her illness and from the physicians. Those are not so fortunate who are treated according to the last magazines' academic discussions demanding an early day for getting up. A woman of the million, permitted or ordered out of bed to work, is the pivot of her poor household or her small farm or shop, or the live part of her lifeless factory machine. She is not like one of your first class paying hospital appendicitis patients who may be ordered out of bed for a half hour or a few hours daily, and will not be harmed thereby. She will continue to convalesce when she returns home. But the woman of the middle class or the poor who is told or permitted to rise early from an appendical wound, a uterine wound, or after confinement will add to her endometritis, her phlegmon, and her adhesions. All that is why even apparently simple questions of medicine will never be answered without the consideration of social questions, and medicine must more and more become the guide in the solving of social problems.
A decided physical inferiority at birth is a common occurrence. Ballantyne experienced in the Fulham Infirmary as high a percentage as 21.9. They are called unfit, when born of overworked, underfed, and neglected women. Their number is much smaller and very trifling when their mothers, when poor, are looked after long before the uterine life is terminated or when circumstances, financial or sanitary, are more favorable.
Many premature, feeble, thin babies of unpromising weight may be saved when there is ample care, such as a midwife will more readily give than a doctor. If that be absent. the baby's life is endangered. Is salvation worth while? Who can tell, unless you try? Kant, Goethe, Helmholtz were puny waifs, whose lives were despaired of. But they have furnished elements of culture to the world of which we might have been deprived if they had been without the midwife's care and close attention. Licetus is said to have been 5 1/2 inches long. He died when 80 years old. He wrote eighty books, not many of them poor. That is an achievement, though not always pardonable, or even laudable. There are more men 80 years old, but they are not all guilty of writing eighty books.
Hard labor up to confinement interferes with the life or the health of the fetus and the new-born. The least that can be done for the mother is a reduction of working hours during pregnancy, and protracted rest after confinement. The woman's worst occupation is that with metals, mainly lead. Their percentage of premature births and miscarriages was 53.6, while those with other work furnished another sufficiently formidable number, viz., 17.2. Lead, mercury, phosphorus, copper, iodin, anilin, and nicotin have been found in the amniotic liquor and in the fetal organism. The indication is clear: less work, less hours, no directly unsanitary occupation, several months' absolute rest after confinement. The living result will be hardier and heavier, and more resistant babies.
When the baby is born, it wants many things: among others air and food, mostly food. Maternal milk is the only safe nutriment for the little stranger. Its quantity is not much influenced by emotions, cares worries; occasionally, only, by medicines taken by the mother, or rarely by her average food. Its quality is only temporarily altered by menstruation, and never causes a change that justifies the interposition of artificial feeding. The daily quantity is rarely less than a quart. Maternal affection, the wish to nurse, the act of suckling increases the quantity. There is no such thing as absolute absence of milk secretion. Essential alterations in the articles consumed by the nursing woman are not demanded. As her appetite is mostly increased, she is entitled to so much more than her average consumption as is required by the one or two pounds needed by her baby. She may eat and drink what she digests and was used to; she may perform her duties, attend to her labors -- even some factory work -- and fill her time as her station in life suggests. There is no reason why she should not spend time in shopping, concerts, theaters, lectures, and parties, except the dog parties reminding you of 1790 -- even the suffrage parades -- provided she will not forget that she has a baby at home to welcome and feed. The checking of babies, with or without baby carriages, by department stores, is a convenient innovation, which improves the chances of babies, women, and merchants alike. Elections are no longer so exciting, dangerous, or murderous as they were in our large cities as late as twenty or thirty years ago -- so there is no objection to woman suffrage, whether it be considered a plaything, a civic duty, or a disease. Even so, there is no danger, for infectious diseases in the mother are no contraindication to nursing, unless it be a small-pox case in an antivaccinationist: for not injurious bacteria but beneficient antibodies pass into the milk and improve the baby's power of resistance. All of these considerations prove the dangerous tendency of those of our colleagues who in their mistaken subserviency to the ignorant suggestions of fashionable and lazy ladyships fall in with their and the dairymen's teaching that cows are their proper God-sent substitutes. These accommodating friends of ours are, through short-sighted complacency, enemies of the race.
The mother's milk has certain protective properties not possessed by any artificial food or the milk of another animal. Experiments have proved that the latter may propagate the artificial immunity toward certain vegetable poisons -- the ricin and abrin; and a wet-nurse may immunize her nursling by being herself immunized through diphtheria antitoxin. So the mother who ever was so thoroughly infected with scarlatina or measles will, at least for the time she is nursing her baby, protect the latter against those infections. The infected milk of an animal will not have that effect; immunity is secured only by the milk of the same -- that is, the human animal -- which proves that we are superior to our animal brethren and sisters; unfortunately, only so long as we are young. Many of us when we lose our infancy lose our superiority.
The attentive doctor and the diligent midwife know that our women, poor and rich, suffer from no organic mammary degeneration. Large and small breasts can be educated into competent milkers. They can be roused into action after days and weeks of comparative inactivity, and into renewed efficiency after a recess of one or more weeks. It is quite well known, what I alluded to, that the very suckling of the baby is the best educator of the breast. That is why for the hundreds of thousands of mothers, the doctor should be the oracle; the midwife of the people, with her future education and her diligence, the trainer. Both should remember, or rather, learn, that a better milk-supply is guaranteed by not improperly and untimely straining the breasts' function. You do not milk a cow every two hours. A healthy new-born baby should never have the breast more than once every three hours; after the third month, he must get along with five meals in twenty-four hours, and he will turn out a baby worth having.
Milk contains substances organic chemistry never discovered or measured. They are the ferments which circulate in the blood. Some aid in the digestion of albumin; others, of fat and starch. Besides, there are defenders in it of the circulating blood; the alexins (Hans Buchner) destroy bacteria; agglutinins immobilize bacteria by bunching them; antitoxins formed in the infected vigorous animal destroy the poisonous toxins of the bacteria. When they are not sufficient -- for instance in bad eases of diphtheria -- we inject antitoxins formed in the blood-serum of another animal -- for instance of horses. Any mother that ever had a mild or bad case of diphtheria -- or, for that matter, certain other infectious blood diseases -- accumulates some antitoxins in her blood and tissues, and in her future milk, and thus protects both it and her nursling. It is possible that so long as the infant is at the breast it is for that very reason less liable to take diphtheria. The fact is that few babies of the first half year become diphtheritic. That is the period of nursing at its mother's breast -- its mother's or another human female's, not, however, that of another animal. It is not chemistry alone. but also biology, which distinguishes the milk of their organic producers. Old Doctor Heim was told by a so-called "noble" mother: "I keep an ass for my baby. Ass's milk is as good for my baby as my own would be, is it not?" "Yes, yes," said the old man, "just as good for young asses."
In Berlin half of the babies were breast-fed in 1890; in 1900 only one-third of them. At the same time, another German town, Barmen, nursed four-fifths of its babies -- during one year 99 per cent. Of 575 starving and neglected women in a Berlin institution, 88.3 per cent. could nurse their infants; why? they were better fed than before, and gave up only when the Moloch of industry reclaimed them as victims. After these poor babies had enjoyed the privileges of some of the rich -- viz., health and life -- they were sacrificed again on the altar of anti-social circumstances. For during the first year of life, of 1,000 breast-fed babies seventy have died; of the artificially fed, 270 up to 430. They have been counted by the statisticians, by the parents and by the undertakers.
Wittingly or unwittingly, surely not meaning it as a grotesque joke, the Nestlé Food Company has a picture on the cover of their circular. It represents a woman with immense wings -- perhaps meaning an angel -- flying off with two babies to unknown parts.
The mortality of babies below 1 year has been found -- not estimated -- to be, for the exclusively breast-fed, 6.98 per cent.; for those brought up on a mixture of breast-milk and artificial food, 9.87; for those fed artificially, 19.75. That means that somebody or something is to be held responsible for the deaths of thirteen babies who should live in good health and with good prospects. Babies turned over to milk stations, because their mothers are told to "rest" may easily belong to that class. It is true, not every baby can be nursed, but the exceptions are scarce. One was born of a mother who died of sepsis carried in part by a dirty midwife or by an infected or ignorant doctor. That is true, statistically, even now that other doctors boast of their asepsis. My own past life does not class me among those others. So I may plead guilty, and no one has a right to blame me for exaggerations. I am, or have been, in the same boat with some of you. Of the five hundred tracheotomies I performed before the Listerian era, of a thousand I assisted in, of thousands of scarlatina, measles, erysipelas during epidemics, and even hospital gangrene during war times -- too many occurred while soap and water existed without being used at the proper time and in the proper places. We did not know better, but you do. Every case of death of sepsis in the mother should burn hell into the conscience of whoever permits it nowadays; every case of death from lack of breast-milk should cause a trial for homicide against a doctor or midwife, or mother. For the latter, it is true, there are, if not excuses, many explanations. Some mothers must get up after three days to do washing and scrubbing, and do it without a sufficient quantity of food -- starving women make no milk -- must make a scanty living in the factory, or in a small business; others go to afternoon teas and bridge parties, or have been taught by their fashionable doctors who agree with them in their suggestions that modern milk has proved that a woman's udder may be replaced by a cow's bosom, that a milk laboratory's clerk will furnish printed schedules for the modification or alteration or substitution of food adapted for every month of an orderly Fifth Avenue infant.
But after all, truth will crop out. There is rarely a woman who cannot nurse her infant.
Ignorance can be learned from and taught by doctors, by midwives, by nurses, but ripe wisdom also. As half of our babies in all countries, are born under the supervision of midwives, it is these who, when their education will no longer be so hopelessly neglected as in our country, in their more intimate contact with the people can exert the widest influence. They will best overcome the prejudice which derives from the well-clad people the notion that breast-feeding is no longer fashionable; they will prepare the nipples, teach cleanliness and antisepsis such as they have been taught in the schools of the -- I hope -- near future. Edith Peiper reports an increase within five years of from 55.7 to 72.5 per cent. of women who gave exclusively breast-milk to their babies in a public institution.
In a large midwifery school of Germany (Stuttgart), the percentage of women who nursed their babies increased from year to year under proper treatment and teaching. Of one hundred women, only 22 to 25 per cent. gave their babies breast-milk to the exclusion of other foods before 1884. Exclusive breast-milk feeding was furnished by 41.1 per cent. in 1884; 61.4 in 1887; 84.3 in 1888; 100, in 1902, 99.5 in 1903. All of these women were poor or in very moderate circumstances, but they were looked after and fed before confinement and after. It takes missionary work to accomplish results of that nature.
In our country, it is calves that are looked after by our government. The babies have no votes yet. They will wait.
I must give you a few more figures, though I may bore you. But I have more sympathy with the world's babies than even with you. I want every incredulous Thomas to leave this place convinced that every baby has not only the right to suck a mother, but also the facility.
Dietrichs reports the mortality statistics of 628 infants of the poorest married women of Cologne. Of 100 children born alive, three of those who were nursed for nine months or more, died before the end of their first year; of those nursed from three to nine months, twelve; less than three months, thirty-five; of those who were fed artificially, forty-seven. Forty-seven dead out of 100 born alive, in one year.
Perhaps a report by Prinzing is equally convincing in connection with the mortality of other than intestinal diseases. During the years 1895 and 1896, the mortality of Berlin babies under one year, when breast-fed, was 7.09; when fed artificially, 38.6. Of 1000 babies, congenital debility killed 14 of the breast-fed; 43.6 of those raised artificially. Of 1000 babies:
Atrophy and marasmus
Bronchitis and pneumonia
Pertussis and diphtheria
* Alfred von Lindhelm, saluti juventutis, 1908.
The illegitimate infants fared much better than the legitimate ones. That sounds paradoxical, but the former, when controlled by the authorities, were obliged to nurse their babies; the latter were the babies of mothers who returned to domestic and factory work, and were exposed to neglect and early and improper artificial feeding, mostly by strangers. Among living infants of the second year, the proportion is reversed, for obvious reasons. The lessons to be derived from these facts are intelligible. A social improvement of the mothers, but that only, will add to the chances of the infant population.
Boek found that of infants who died of intestinal diseases, 61.4 per cent. were fed on flours; 24.3 per cent. on cow's milk; 15.8 per cent. on a mixture of breast-milk and cow's milk, and 1.4 per cent. on breast-milk.
During the siege of Paris (1870-71) the women were compelled to nurse their own babies, on account of the absence of cow's milk. Infant mortality under a year fell from 33 to 7 per cent. During the cotton crisis of 1860 there was a famine. Men and women starved, and on account of no money for artificial food, the women nursed their babies. One-half of their mortality disappeared. In the poor forest districts of the Westerwald the bottle-fed babies had a mortality of 20 per cent.; the breast-fed babies, one of 8 per cent.
In the Berliner klinische Wochenschrift (No. 28, 1911) Professor Franz publishes the report of the gynecologic divisions of the Charité. One hundred per cent. of his puerperal women nursed their babies. Dr. Kahn accomplished mostly the same results.
It is true that private practice does not reach the same number. Among the well-to-do, with better surroundings, better food, more rest, but greater indolence, less sense of responsibility, more money to throw away and more accommodating doctors to amuse them, and with more money with which to buy inferior food, the percentage of nursing women is smaller. Their daughters will know better, provided the doctors -- we and our successors -- will teach them.
G. Dufort reports on conditions prevalent in four districts of Belgium. Women objected to nursing, with a mortality of from 153 to 252 per one thousand, in the first year. Then the government and a private organization took measures to improve the percentage of breast-feeding women. Not all governments mix up with such things. Some are not on the job, some are on the slump. This percentage increased in certain localities where it was lowest, within two years, from 4.3 per cent. to 17.02. That increase was due to the midwives who were taught by premiums, by the practitioners and by clergymen. You see doctors and priests are still good for something. In other districts the percentage of breast-feeding was 56.6 per cent. in 1907; in the first half of 1908, 57.1 per cent.; in the second half of 1909, it was 74.12 per cent. That means an increase obtained by the country midwives in two years of 17.6 per cent. More, there were midwives who could report 94.9 per cent. in the first half of 1908, and at the end of 1909, 100 per cent.
The same midwives made it their business to extend the duration of breast-feeding. In 1907, there were fifty-seven babies who did not receive the breast through their first year exclusively; this number was reduced to forty-eight at the end of 1909. Of the infants who were kept at the breast exclusively through six months, 64.7 per cent. extended this time to nine months; 75.4 per cent. in 1909. The author again and again refers to the powerful influence the midwives -- after having been instructed -- exerted among the population -- the women and the babies.
In 1900, the German Empire lost 426,485 infants under a year old. That means 27.5 per cent. of those born alive. Of these, 61,340 are reported to have died of congenital debility. What is this debility? How did it occur? Something has caused it during embryonic and fetal life. A disease of the embryo or fetus. Infection through the placenta; starvation of the mother by poverty; overwork in a factory; poisoning by a chemical; prolonged labor; unattended labor; unskilled attendance, and some of the other causes I am going to mention.
Whatever among these influences can be avoided or cured saves infant life. It is our duty to look for the causes of debility and death in order to escape from them. We have spent more care on the health and efficiency of the cow and her milk than of the mother and her milk. No doubt the efforts to improve the chemistry and physics of cow's milk, and the beneficient activity of medical and lay milk commissions have borne fruit, and the safeguarding of milk by sterilization, pasteurization, and modification has saved lives, but we must look for a higher percentage of salvation. That can be reached, for even the average mortality of a single, mostly poor, country -- Norway -- has reached as low a standard as 8 per cent. under one year. Wherever financial circumstances are more favorable that should not be the lowest percentage.
What, after all, is a midwife, whose presence at or attendance on a confinement case must be shunned? An editorial of the Boston Medical and Surgical Journal, that cautious and elegant magazine, gives the following definition:
"The midwife may be defined as a person attempting to practice obstetrics without complete or even adequate medical education. The tolerance of such persons is an anomaly in an enlightened civilization. The midwife is a relic of medievalism, unhappily extant in the Old World, but whose persistence in our own community should not be encouraged by any form of recognition."
Meanwhile, Holland, Belgium, France, Italy, require a two years' course of schooling for their midwives; Norway, Sweden, and Denmark, one year. Germany has had its midwifery schools for more than a century. Many countries subsidize their midwives, who live and practice in sparsely settled districts. Great Britain established in 1902 its Central Midwives Board, to supervise and control midwives for the specified purpose of preventing the death of women in childbirth, infant mortality, blindness, and physical degeneration.
There are in England and Wales 17,790 trained and untrained midwives -- too many yet of the latter class. The British Empire's 108 midwifery schools -- including four in the East Indies and one in Hong Kong -- have not yet afforded sufficient facilities. But the British Medical Journal emphasizes the fact that even in the old type of midwives there is a great improvement in cleanliness and obedience to rules, one of which is the calling in of medical aid in cases with a purulent discharge.
And we? Fifty per cent. of all the births in the United States are attended by non-medical women -- in New York, 42; Buffalo, 50; St. Louis, 75; Chicago, 86. The patients so attended are negroes, aliens, and natives born of aliens; that means one-half of our population; that means those who during the disappearance -- voluntary, wanton or not -- of the original stock and by additional immigration and multiplication will form what within two generations will be the type of the two hundred millions of Americans then living. And where are our midwives? Where are the 108 schools which little Great Britain deems -- on account of their scant number -- insufficient for her urgent needs? Where are the American safeguards of our fetuses and new-born? When our experienced and far-seeing president of Bellevue and Allied Hospitals established a small school of midwifery, he was applauded for his exceptional foresight and altruism. We think nowadays that the ocean is only a short bridge, but the experiences of Europe, established on a solid and constant foundation, do not travel on it. That is the way of indolence by which we negligently murder our forests, lay dry our river beds, cause our freshets, and kill or cripple our newly born. I wonder in which other country we could be expected to accept what I lately read, that people cannot receive obstetrical service under the midwife, "no matter how well trained for her vocation;" -- I ask why not? -- or agree with a well-meaning author who sympathetically cries out: "Professors are teaching midwives, so medical students are deprived of their professors' time;" or throw up our hands when Stokel tells us that it is "a curious fact that even among people of refinement the older and dirtier the midwife, the greater seemed the confidence placed in her ability and judgment." That is as sound, perhaps, as when the great English opsonin scientist publicly arraigns habitual bathing for its dangerous effect in admitting microbes through the clean skin -- a desirable bedfellow he! -- or when Knott  tells us that "Lady Lawson, who died at the age of 116, never practiced ablution of any kind, or hardly in any degree, because, as she alleged, those persons who washed themselves were always taking cold or laying the foundation of some dreadful disorder," or the occasional preference given to an old doctor not though but because he is habitually intoxicated. There is still another line of mistaken altruism: Fenwick fears lest a midwife, scantily trained, compete with a physician. I should say, if she succeeds, it serves him right unless he owns a superior training. A pretty good doctor will not do for you or your wives or cases, any more than a pretty good egg for your breakfast.
Is there anybody here who remembers that when fifty years ago the question of licensing of midwives was brought up before the Medical Society of the County of New York, it was voted down with all con except one? Ask our New York doctors about it. We know better now, and feel better about it. For we feel like citizens at present. We have also been told that all countries have found "the practice of midwives unsatisfactory." The fact is, however, that other countries pretend to know their own business, and constantly add to the facilities and education of midwives as we do those of doctors. Some assert also that the attendant on a midwifery case must either be a trained obstetrician or a subordinate "like our excellent trained obstetrical nurse." "The obstetricians are the final authority to set the standard. They alone can properly educate the medical profession, the legislators, and the public." Who educated them, if you please, if not the professional schools, and they themselves as best they could afterwards? The midwives are not even mentioned as worthy to be educated. Do our obstetricians demand all the obstetric practice? I am prepared to bid a hearty welcome to the evening-dress obstetrician -- who charges $200 or $300 or $500 a job -- to the confinement where the man earns ten or fifteen dollars a week, or the woman thirty-seven cents a dozen, and the children nothing.
In spite of English complaints concerning the insufficiency of midwife attendance, the reports are very promising. In 1910 there were 321 midwives in Liverpool, 198 in Birmingham, 159 in Manchester. In Liverpool, the average number of cases per midwife was seventy -- one had 500 cases. Of all the births attended to there were by midwives in Liverpool, 71.9 per cent.; in Birmingham, 63.2 per cent.; in Manchester, 57.2 per cent. Still-births attended by midwives were 391 in Liverpool, 212 in Birmingham, 279 in Manchester. Their honest discipline is exhibited in the following figures: Medical assistance was called by 1,015 midwives in Liverpool, by 674 in Birmingham, and 2,279 in Manchester. The indications for such calls, under universal rules, are high temperatures, abortion, laceration, illness of the patient, imperfect removal of the placenta, puffiness, convulsions, large varicose veins, sores on genitalia, malposition, trauma, hemorrhage, venereal diseases.
This very day the system under which they work with us in an absolute lack of system, slovenly and shiftless -- no instruction is offered, no examination demanded, no supervision enforced, and the babies swell the universal mortality.
What is it that a midwife should be taught? Common sense and the experience of other countries should tell us, for we have none -- I mean experience. We are only told that she is dirty, ignorant, untrained, superstitious, septic, the cause of invalidism, degeneracy, and blindness. That is a list of statements exhibiting more temper than knowledge. For, indeed, in thirty-three of the fifty states and territories there is no law restraining the practice of midwifery or what is so called. In three there is no restriction whatsoever. In thirteen there is no provision for training, but there are, curiously enough, laws requiring examination and licensure. What is it, after all, that every one of our states -- indeed, after a while, the federal government -- should demand on the part of a midwife who is to be the obstetric guide of fifty millions of Americans? In my opinion, she must have as moral a character as you expect in a male or female student of medicine or man generally -- and, for that matter, of any American outside a penitentiary; a good common school education without Latin or Greek; a fair health so as to endure the hard work she means to undergo in future; a reputation for love of work and conscientiousness; and such knowledge of popular physiology and anatomy as the program of our future midwifery schools will designate. What they must surely teach, like the English schools, are four topics -- the care of expectant women, the conduct of normal labor, the care of babies immediately after birth, the simple principles in an urgent case of artificial feeding -- and the diagnosis of abnormalities, so as to advise the calling in of medical skill. As there are many, I shall spend a few minutes on the consideration of some of them.
The fact is, that of one hundred deaths under a year, 2.2 occur by injuries during birth, ten on the first day of life, twenty-five during the first two weeks, thirty-four during the first four weeks. Most of them should be saved through perfected knowledge and art, more skilful attendance than half our population enjoys, and greater acquaintance with the dangers of the newly born. You notice that a large number die from other than the usual causes, viz., indigestion.
A calamity never prevented by one of us, possibly by an attentive and painstaking nurse or midwife, is death by suffocation.
There were in England and Wales during ten years, 10,009 overlain infants; in 1900, 1,774. In Liverpool, out of 960 inquests, there were 143 on babies that had died of suffocation from the same causes, by accident or malice; in London in 1900, 615; in 1901, 511; in 1902, 588. In London, they had annually 8,000 official inquests, one out of fourteen which were on overlain infants. A serious complication of labor is asphyxia. It may be caused by the mother or by the fetus. Disorders of placental circulation, mostly toward the end of labor, early loss of amniotic fluid, respiratory and cardiac disorders, disruption of the placenta, compression of the cord and cerebral pressure can mostly be prevented or moderated by appropriate aid. Asphyxiated babies may die, however, within an hour, or the first few days. Those who do not die are apt to be worse off. They are very liable to become paralytic, idiotic or epileptic. Little shares that opinion, the contrary assertions of others notwithstanding, that a large percentage of cases of spastic encephalitis ("Little's Disease") is produced by congenital asphyxia. Hundreds of times, both in obstetric and in pediatric practice, have I, when looking for etiologic factors, received the uniform answer that the baby did not cry for some time after birth, and that the attendant had to work over it minutes, or even hours. Asphyxia must not be tolerated. A few moments' delay adds to the danger which may be averted by knowledge and skill. Losing a baby is a loss and bereavement; crippling it for life is worse. Accidents of the kind can be avoided by much less than the profound knowledge of medical experts, few of whom will ever deign to attend a mere case of common confinement. The statement on a certificate that the new-born is a stillbirth means a statistical fact, not an explanation, still less an excuse.
Atelectasis is more apt to be relieved, and death from it more readily prevented, by a midwife than by one of us, no matter by what it is caused. Soft cartilages in the premature, feeble muscles, defective nerve centers and lungs, but mainly hepatization, early pleural effusion, struma and compression of the brain are the usual causes. Frequent changes of position, warm and cold baths, shaking, forced inspiration, occasional closure of the mouth and nose -- so as to fill the medulla oblongata with an extra momentary dose of irritating carbon dioxide -- an interrupted momentary Faraday stimulation and all the procedures demanded in asphyxia are advisable in atelectasis. A midwife should and can master all or most of these measures, as well as a doctor. The former is more efficient because she mostly uses more diligence and will spend more time than most of us.
The observing obstetrician or pediatrist or midwife has an opportunity to notice all sorts of microbic infections, such as tetanus, hemorrhages and the intense forms of syphilis. Its worst form is the pemphigus of the soles of the feet, which must be recognized within a few days. The midwife is the readiest to make the diagnosis, and to recognize the necessity of treatment. That does not mean her treatment, just as little as she will undertake the treatment of melena, sclerema, jaundice, sepsis, dermatoses, erysipelas, traumata or umbilical defects or diseases.
Some of the septic diseases of the newly born for the cure of which the doctor is always too late, or incompetent, are those which go by the name of Buhl, of Winckel, etc. They develop before any symptom is perceptible. The poisons which cause them are probably multiple and connected with the rapid metabolism occurring during, and immediately after labor. Many cases look like acute atrophy of the liver, or pernicious vomiting; or the main symptom is fatty degeneration, or hemorrhage, or intense jaundice. Overdoses of chloroform in predisposed women have been accused. Intense asphyxia I have seen coupled with, or causing it. There are many such cases which can be prevented by appropriate and instant aid, such as I plead for. Many, I believe, will be cured by vaccine therapy, provided it can be employed in time. That is possible only when the indication for it is suggested, or only suspected by a person who is on the spot and better taught than a common neighbor or nurse.
The mouth of the newly born is exposed to injury resulting from the antediluvian tendency of not leaving well enough alone. The habit of washing and rubbing the oral cavity of the newly born, even by clean fingers and rags, hurts the very thin mucous membrane covering the posterior part of the alveoli, and the punctated epithelial accumulations on both sides of the raphe. Doctors and nurses and midwives who do not know how to omit interference are dangerous. For the forcible removal of the epithelium leads to invasion of cocci and bacilli, and the mycelium of thrush. The latter, though easily cured by a strong solution of borax in glycerin, need not occur in the baby's mouth, for its habitat in the vagina of the mother is quite accessible, both in a private home and in obstetrical wards and in foundling institutions. A consecutive invasion of the stomach and intestines, of blood-vessels and lymph ducts, even of the kidneys and nerve-centers, may easily be avoided by a person who has been taught to prevent and to cure.
Constipation of the newly born should be recognized by the midwife. What I described nearly half a century ago as congenital constipation is the result of an excessive length of the sigmoid flexure. When its continuance for one or two days suggests it, enemata should empty the bowels. Unless that be done, moderate and later on serious costiveness is an accompaniment of the dilatation of the descending colon, and auto-intoxication. "Hirschprung's disease" is rarely a fully developed congenital dilatation. If a midwife be too alert she is capable of preventing an operative interference. I was one of the alert midwives. None of my cases ever terminated on an operative table.
Ophthalmia is the source, not only of blindness, but of death through general septicopyemia under the general symptoms of multiple abcesses and arthritis. A series of cases I, like others, have observed, of vulvo-vaginitis, endometritis, and peritonitis. That endometritis is always of long duration, may for anatomic reasons relapse indefinitely for many months or years, and often gives rise to contagious dissemination in families, in hospital and asylum wards, by careless nurses and gregarious bathing.
Uric acid infarction of the baby is a frequent occurrence of the second day until the end of the first week. It is rarely observed by the doctor (if any was employed) who sees the new mother perhaps once a day, if at all. Thus in this respect the well-to-do mother is worse off than the poor who is seen by a midwife whose visits are more frequent and more extended.
The tissues of the newly born contain more water than those of the adult; the difference amounts to 10 per cent. Loss of water is badly tolerated, while large quantities are eliminated at once through the lungs, kidneys and skin, and some through the intestines. Without a proper supply, the tissues deteriorate and the physiologic equilibrium is lost. That was always so -- the newly born is conservative -- and was considered normal. The baby had to be satisfied with reading in every text-book -- even in the old ones from which some new ones are compiled -- that he has to please the attending oracles by giving up 10 or 20 per cent. of his weight within a week or two. However, as the mother has but little milk during the first days, the least the baby should have a right to expect is water -- at least teleology ordains it so -- the more so as the first mammary secretion means colostrum, which contains three or four times as much protein as the milk of later weeks -- that means 3 or 4 per cent. That is mainly so -- even still more so -- when the baby is premature and endowed with less vitality than when born at full term. Neither you nor I shall undertake to change that, but the danger connected with it requires correction, and if artificial feeding be resorted to at all the food should be amply diluted. There is another reason for so doing. Uric acid sediments and renal stones are comparatively frequent in small infants. They are caused by the uric acid infarctions which, as a speedy result of the rapidly changing metabolism, are found in the diapers on and after the second day of life. Besides forming gravel and calculi, they give rise to occasional attacks of colic, to small hemorrhages and frequent cases of nephritis, with, or mostly without, pyelitis. Neither I nor my pupils and friends have seen so many stones and inflammations since, for the last forty years, we made it our rule to feed the newly born on plenty of water. It is also demanded for the purpose of rendering the chemical and physical condition of cow's milk casein more digestible. As long as a human baby is not permitted to live on its mother, that fact is important to consider. Artificial feeding during the first days and weeks should furnish more than 75 or 85 per cent. of water, which is normal even for the adult. Altogether, our infants and children are not supplied with water in sufficient quantity at any time. In our era of equality for all sexes and colors, we should recognize the rights of all ages.
When you are hungry, you want to eat; when thirsty, you drink. The baby wants its equal rights. But no matter whether it is hungry or thirsty, it is condemned to receive the same food to quench both its hunger and its thirst. When it cries with hunger, it justly receives food from the bottle or breast; when it cries with thirst, it is given the same food from the same bottle -- not mere water. I have often felt like presenting a bill to the legislature or to the professional philanthropist, enforcing, when father, mother and physician are thirsty, beefsteak and potatoes. I wonder how they would like that. A German pediatrist improves the method of giving water by giving the new-born tea and saccharin. What tea is, I do not know; what saccharin is, we do know. It is found to be a poison. That should, however, not have been the reason why our magnanimous Agriculture and Treasury Departments twice postponed the execution of a law which forbids its indiscriminate sale by the manufacturers of foods.
Midwives are more fortunate than we doctors. They need not know so much as a few taskmasters ask of them -- for instance, two German professors, Salge and Siegert, who are so interested in the babies as to insist on midwives being examined on the intricate problems of metabolism. I fear, after having been a midwife sixty years ago and since, I could not pass to-day. Then, they need not know all the mixtures and mathematical formulas concocted by twenty of my pediatrist friends, each one of whom is sure that the other nineteen are quite wrong. Nor need they be acquainted with the fifty artificial foods which were recommended by the Deutsche medizinische Wochenschrift a short time ago and again rejected -- all of them -- in the very same year.
The teaching of midwives is not so difficult as part of our profession imagines it to be. We are defective ourselves, for there is a fact which seems to be agreed on by our college teachers, viz., that our young doctors are incompetent to conduct a normal or abnormal labor. As that is so, we, the practitioners, should try to learn some lessons by theory but more by practice. Their incompetence is the result of the insufficiency of our medical school instruction, which is acknowledged to have been scanty in spite of our four years' medical courses. The schools furnish neither systematic obstetricians nor competent general practitioners. I shall not be hard on them, however, for I was a teacher myself. That is why the number of septic infections and of still-births is liable to be large in their practice. If that occur in the green tree -- viz., among the men and women with medical diplomas -- what can we expect from the untutored?
We speak against midwives and their detrimental doings, and their unreliability. Teach them their duties, which are not many; furnish bedside instruction -- which even for a hundred thousand physicians is scanty or none -- so that they will learn the manual care of labor; let them be taught not to use medicines, not to operate, not to try even to remedy, as a rule, wrong fetal positions; teach them the use of soap and water, and antiseptics; enforce by law and custom the frequent change of their own clothing; forbid the simultaneous attendance on two or more cases; see that the midwife does not attend a labor case as long as in her family or immediate neighborhood there is a case of contagious disease, and she will cause or disseminate no puerperal sepsis. She must be examined and licensed and protected, like you and me.
Registration alone, however, will not do. Nor will our complaints do. Our responsibility does not cease when we decline it. Our duty does not end by sending and collecting a bill for an individual medical service. A death not prevented, a life not saved, is a blot on our escutcheon. The people want more. We are not yet -- as the British government proposes -- official state employees of the people. If there were not an excess of individualism among us, the attempt to force socialistic coercion on the profession of England would not have been made. Not yet.
Less than a year ago, the New York Academy of Medicine passed, among others, the following resolution:
"Whereas, some of the results of obstetrical malpractice are unnecessary blindness, mental and physical degeneracy, and death of infants, and unnecessary suffering, invalidism, and death of mothers; and whereas both doctors and nurses in this country are given instruction in the treatment and care of child-bearing women and new-born infants, there is no existing provision for the adequate training of women who take into their keeping the lives and future well-being of this large number of both mothers and infants, be it resolved that the Section of Obstetrics and Gynecology of the New York Academy of Medicine recommends that measures be taken in this state to secure state legislation which shall provide for the training, registration, licensure, supervision, regulation, and control of women engaged in the practice of midwifery."
It is useless to attempt a comparison of a midwife with a medical man. They must be considered individually. The ignorant doctor in obstetric work is the inferior of a well-informed midwife, and vice versa. I remember only two cases of sudden death caused by atmospheric air entering a large uterine vein -- in both instances resulting from the nozzle of a fountain syringe introduced into the uterus before the air had all been expelled. In both cases it was a medical colleague that did it. That does not prove that we doctors do not know how to clean a uterus without pumping air into a vein -- but I know of no midwife that could have done worse. Still, ignorance, like sinfulness, makes all mankind kin. The greater number of annual labor cases in the United States -- more than a million -- are attended by midwives. As long as these cases are uncomplicated, the presence of a bright trained woman should be, and is, welcome. She must have learned to distinguish the position of the fetus, and know when to call a doctor; how to do, in his absence, a version in cases of emergency; how to attend the eyes; hemorrhages depending on incomplete uterine contraction or from injuries -- one of which is tearing off of the placenta -- and how to recognize eclampsia, inversion of the uterus, the presence of a mechanical obstacle like fibroma or a contracted pelvis. She must know how to deal with asphyxia. More than anything, she must have been taught to appreciate two things: first, how to keep absolutely clean -- that means to disinfect herself and her hands; second -- and therein lies a secret of success -- not to leave the woman. That is more than you or I do, or usually did.
The results of midwife practice do not always compare unfavorably with those of our professional brethren: Of 116 cases of ophthalmia neonatorum which were treated in the Massachusetts Eye and Ear Infirmary in one year, 114 were in infants attended by physicians, and two by midwives. Of thirty-three cases treated in the New York Eye and Ear Infirmary in one winter, twenty-two occurred in the practice of physicians, and eleven in that of midwives. Of the eleven midwives, three had used nitrate of silver; of the twenty-two doctors, only one. According to these reports, if it were wise and proper to generalize, the doctors should be replaced by midwives.
In a period of years, 1905-10, the City of Manchester, England, has the following to say about puerperal fevers, and recoveries and deaths following them, in the practice of midwives and of doctors. In the practice of midwives there were 219 cases of puerperal fever, with forty-one deaths; in the practice of doctors, 275 with eighty deaths, in the cases attended by midwives and doctor, 100, with twenty-six deaths.
Nor are midwives' cases, those reported in 1910, inferior in results -- forty-five puerperal fevers were treated at home, with a mortality of ten = 22.2 per cent.; in Monsell Hospital, sixty-six cases with sixteen deaths = 24.2 per cent.; in other institutions, twenty cases with five deaths = 25 per cent.
The absence of skilled assistance from a confinement is one of the causes, not only of death, but of what is still worse, of degeneracy of the new-born. How many, nobody can tell. But it is worth while to reduce the number of 60,000 weak-minded or mental degenerates with which we are credited in the state of New York alone. The statement on a birth certificate that the new-born is a still-birth means a fact, not an explanation, still less an excuse. Many of them could be avoided if the women of the United States were protected against ignorance and indolence. When I was in active obstetric practice fifty years ago, I met in the tenement-house population many a case, which should have been saved if any bystander had known enough to afford manual assistance, such as that of a well-informed midwife. That, however, is only part of the possible mishaps. What proper assistance may prevent is a vast number of paralytic, spastic, idiotic, semi-idiotic, or epileptic conditions, mostly during infancy and childhood. How many? I do not know. But I have seen hundreds personally. Questions were as follows: How was that baby born? Did it take long? How long? Was it an instrumental case? Did the baby cry immediately? Was anybody present to help you? Did it take the doctor, who was called in, long, a minute, ten minutes, or one-half of an hour to make the baby cry? The answer gives the history of asphyxia, which -- and that is my point -- could have been prevented, or relieved, at once by a midwife. I hope there are many general practitioners here, such as I am or have been. They know how much they would have wished to be present on the spot, or to have a midwife to attend when they did not care to attend or could not do so. How many cases might have been carried to a safe end, when a little aid would have prevented intracranial hemorrhage caused either by direct lesion or thrombosis, can be surmised only when you remember the many patients with meningeal hemorrhage or inflammation who die within a week.
Now, my friends, you have been kind to me and patient, as hundreds of times before. That is why I shall now finish in a minute with a few conclusions for those who with me are convinced that healthy women and living vigorous infants are the best possessions of this nation. They will not be conquered with treasures and cannon and corpses of countless men; they need conservation only. What I want is that a pregnant women should be in a condition to carry her fetus to its legitimate end in health and vigor, and be able to nurse her infant. Every text-book talks to us of the inability of women to do so, and indicates formulas and tradeshops and factories from which to graduate toothless young Americans. One hundred per cent. of our women, however, can be made to nurse, even the "flower and fashion" of the land. From two to three times as many babies will live when breast-fed compared with the number of those whom they complacently try to raise on artificial foods. By breast-feeding you will save 100,000 babies that now die or become invalids, from no other cause but unnatural feeding.
Dangers which now attend the process of parturition for more than one-half of the women of this country must be modified, relieved, or removed by the presence of a person instructed to conduct a normal labor and, when needed, to call timely aid. We want, for the benefit of the women who need midwives, 200 midwifery schools after English or German pattern. Let no legislature of any state pass without a bill or law to safeguard the newcomers and their mothers.
A town without an ample supply of good doctors and midwives and a village without one or two competent and responsible and licensed midwives, are like a tenement house without a fire-escape or a Titanic without lifeboats.
19 East Forty-Seventh Street.
 Bluhm: In Weyl's Manual of Hygiene, vol. viii.
 Fuerth, Henriette: Die Mutterschats-Versicherung, 1911.
 Fifty years ago I could refer only to anatomic reasons which secured the very young against diphtheria.
 Dr. A. Balestre and Dr. M. d'Oelsnitz (Bericht, ueber den III Internationalen Congress fuer Saeuglingsfuersorge Berlin, Sept. 11-15, 1911, p. 789) express their satisfaction with the results of the Infant Protective Society of Nice, which was founded twenty-five years previously, mainly for the encouragement of maternal breast-feeding.
 Feb. 23, 1911.
 Brit. Med. Jour., Dec. 17, 1910.
 Med. Rec., New York, Dec. 3, 1910.