) STATISTICS PRIVATE OBSTETRIC PRACTICE, BY JAMES C. BLISS, M.D. COMMUNICATED TO THE NEW YOJ^MEDJCAL TOTJKNAL. It will, I trust, be a matter of interest to have presented to the readers of the Journal, the Statistics of a number of cases in Private Obstetric Practice, the results of which may serve as a basis for some practical deductions. I am not aware that anything of the kind has been given to the public in this country; and our public Institutions, are comparatively in their in- fancy, and have not as yet been made available for this purpose. In presenting these details I am aware that the materials are too meagre to give that certainty to general results, which are to be derived from the more ample and abundant means afforded by the large Institutions of Europe ; and which might be obtained also, from a wider field of obser- vation in private practice; but it may be the means of directing the profession to this field of inquiry, and aid, to some extent, the researches of any who may be led hereafter to pursue the subject on a more extended scale. Nothing can be more unphilosophical, and more likely to bewilder, and lead to error in the practice of medicine, than modes of treatment founded on statistical results. It is calculated to retard legitimate inqui- ries, and the progress of sound medical science; and it is not a little re- markable, that some of the most distinguished and popular members of the profession in our day, have deserted the only safe and rational path of investigation, to deduce systems of practice from principles so extremely fallacious. But while there are conclusive objections to our attempting to arrive at truth in the practice of medicine in this way, the same does not hold good in the obstetric art. Many of our rules of practice, if not founded upon, are at least confirmed by these investigations. The value of the excellent work of Dr. Collins, of Dublin, is greatly enhanced by the very precise, accurate, and elaborate details and tables contained in his volume. It has been through the influence of this example of Dr. Collins, that I have been led to prepare this paper. The facts contained in such inquiries have a bearing on many branches of human knowledge, and when little items serve to swell the aggregate, they are not without their importance ; and in this point of view, the motives for presenting. this paper will be appreciated. tjy. 2 Bliss on Private Obstetric Practice. Months in which Births occurred. I have made a record, more or less full, of Eight hundred and twenty cases of delivery. Of this number, 815 were born in the following months, viz., In the month of January, •• 52 " " February, - 63 " " March, - 74 " " April, - 57 " " May, - 62 " " June, - 71 " " July, - 65 " " August, - 81 " " September, - 75 " " October, - 80 " " November, - 72 " " December, - 63 It will appear from this table, that the greatest number of births oc- curred in the month of August, and the fewest in January. In the former month they amounted to 81, while in the latter there were but 52. In the month of October there were SO, in September 75, and March 74. These facts show that the greatest number of conceptions occurred in the months of December, February, January, July, March, and October; and in the order in which they are named. Sex. The sex of Seven hundred and ninety-seven children has been noted. Of this number 395 were males and 402 females. This shows a sum- ming up considerably at variance with most reports, the number of male children generally preponderating from three to ten per cent over the other sex. According to the registry of Dr. Collins, a little more than 8-15ths of the total births were males. Presentation. The presentation in Seven hundred and seventy-one deliveries is' recorded. Of this number there were : Natural presentations, - 738 Breech " - 15 Funis & Breech " - 1 The foot " - 8 The face " - 1 The face towards the pubis 7 The arm and abdomen 1 It will appear from this, that in about one case in 22 the presentation was preternatural. The proportion in the Dublin Lying-in Hospital, according to Dr. Collins, was one to every thirty, but it will be remarked that in his Treatise he does not include presentations of the face, and the face towards the pubis, among preternatural presentations. Should these be included, the proportions will not probably very materially differ. Premature Births. Of the 820 cases, forty are noted as being premature births. That is, about one in twenty were born before the full period of pregnancy was completed. r l & 1847 J Bliss on Private Obstetric Practice. 3 Still Births. Out of the same number, viz., 820, twenty-one were born dead. This shows a small fraction over one still-birth to every thirty-nine deliveries. In the Dublin Lying-in Hospital, a little short of every 15th child was born dead. This discrepancy between Hospital and private practice is doubtless owing to the difference in condition and character of the patients. Funis around the IVeck. The Funis was around the neck once in 127 cases. " " " twice in 21 " " " " 3 times in 6 " " " " four in 1 " A little over every fifth child, according to this record, had the cord around the neck at birth. Premature Rupture of the Membranes. In seventy-nine cases of the 820, the membranes broke before or at the accession of labor. The duration of labor, in seventy-five of these cases, was as follows, viz : One hour - 1 Twelve hours - - 9 Two " - 2 Thirteen u - 1 Three " - 4 Fourteen tc - 3 Three and a half _ 1 Fifteen u - 1 Four hours - 6 Sixteen u - 2 Four and a half - 1 Eighteen u - 2 Five hours - 8 Twenty u - 3 Six " - 4 Twenty-four - 2 Six and a half - - 1 Thirty a - 1 Seven hours - 3 Thirty-two u - 1 Eight " - 3 Thirty-four (< - 1 Nine " - 2 Thirty-six a - 3 Ten " - 1 Forty-three u - 1 The average duration of labor, under these circumstances, was 10^ hours. This shows that this occurrence did not very materially retard the progress of parturition. Number of Pregnancies. The pregnancies of 690 cases are recorded. Of the First pregnancv there were 184 cases. " 138 " " 116 " " 78 " " 60 " " 26 " " 32 " " 10 " " 14 " " 12 " " 10 « " 5 " " 5 .i Second a Third u Fourth << Fifth a Sixth a Seventh a Eighth it Ninth a Tenth u Eleventh u Twelfth a Thirteenth 4 Bliss on Private Obstetric Practice. This shows that a fraction over every third birth, was the first child. Every fifth " second " A little short of every sixth " third " A little less than every ninth " fourth " Every eleventh and r5^ fifth child " Twenty-sixth and i sixth " " Twenty-first and -i- seventh " " Sixty-ninth " eighth " " Forty-ninth " ninth " " Fifty-eighth " tenth " " Sixty-ninth " eleventh " One hundred and thirty-eighth twelfth " One hundred and thirty-eighth was also the thirteenth " Monsters. Of the whole number, two only of the Foetuses were monsters. Twins. There were, out of the whole number, eight twin births. This shows a proportion much less than occurs in the Lying-in Hospitals in Europe. The number, as above stated, is one to every one hundred and two cases, while in the European reports it is as follows, viz : In Frai ice one to every ninety- five births In Germany a eighty a In Eng land a ninety ■two it In Scotland tt ninety -five a In Ireland 11 sixty-three it See Collins'' Treatise, Am. Ed. p- 153. Durat on of Labor. The duration of labor is noted in 809 cases, and is as follows, viz : Ten minutes - - 1 case 11 hours _ - 4 cases % of an hour - - 1 a 12 a . _ 13 a 1 " - - 3 cases 13 it _ _ 3 tt 1* - - 4 a 14 a _ _ 14 a 2 hours - • 4 a 15 a ,. _ 1 11 Ol It *2 - - 4 a 16 a » _ 2 a 3 " - - 6 a 17 it _ _ 4 a ql a <*2 - - 5 u 18 a _ _ 6 it 4 " - - 13 it 19 a _ _ 2 a 5 « - - 8 a 21 a _ _ 1 a 6 « - - 18 a 24 it _ . 5 a 61 - - 1 a 26 it _ _ a 7 " - - 4 u 29 tt _ _ u 71 a '2 - - 1 u 30 j it „ _ 3 a 8 " - - 7 a 32 a _ a 81 " °2 - - 1 it 36 it _ _ a 9 " - - 10 a 37 a _ a 10 " - - 3 a 43 a it 10£ " - - 1 it 46 tt - . n The average duration of labor, in these 809 cases, was a fraction over ten hours. Bliss on Private Obstetric Practice. 5 Instrumental Delivery. Out of the whole number three were cases of instrumental delivery. The proportion is one to every two hundred and seventy-third case. This shows a proportion much less than occurs in the European Hospitals, or in the private practice of those from whom we have reports. An interesting table is given in Dr. Collins' Treatise, to which reference has been so frequently made. The following is the average proportion of instrumental deliveries which he has collected from different sources: In Dresden, Dr. Carus delivered with instruments " Giessen, Dr. Ritger " " « Berlin, Dr. Kluge " " Cologne—Drs. Minden and Merrem delivered with instruments, Breslau—Professer Andree delivered with instru- ments, Heidelberg—Nagele, " " Magdeburg—Dr. Voigtel, " " Breslau—Dr. Kiister, " " Marburg—Dr. Casper Siebold, " " Vienna—Dr. Boer, " " Paris—Mad. Boivin, " " London—Dr. Merriman, in private practice, " " Dr. Bland, Westminster Gen. Dispensary, u Dr. A. B. Granville, same institution, Dublin—Drs. Cusack and Maunsell, Wellesley Disp'y, " Dr. Beatty, New Lying-in Hospital, " Dr. Joseph Clark, " " " Dr. Collins, " " In the three cases in which instrumental delivery was resorted to, the forceps were used twice, and the perforator and crotchet once. The first case in which forceps were employed, labor was rendered tedious by narrow pelvis, and the face of the child being towards the pubis. Delivery was accomplished at the end of 33 hours, the child being dead. The mother recovered slowly. An abscess formed around the hip some weeks after her confinement, which was attended with fever and great debility. Her health was ultimately restored, and she subsequently bore a living child without any untoward circumstances. The second case was that of a lady 42 years of age, with her first child. She had been attended by a practitioner 81 hours previous to my being called. The head was so far advanced that delivery was readily accomplished. The child was living, notwithstanding the long con- tinued pressure it had suffered. The mother also had a good getting up, and without any unfavorable symptom intervening. The third case was that of a patient laboring under violent puerperal convulsions, with whom all the usual remedies had been employed with- out success. Delivery was attempted with forceps, which failed in con- sequence of violent convulsions being brought on whenever any effort was made with the instrument. The child was delivered by diminish- ing the head and using the crotchet. The cellular tissue of the patient was enormously distended by dropsical effusion. The patient was not seen by the writer after the birth of the child, she being in charge of 1 in every 13 1 u 9 1 it 15 1 in every 12 1 It 35 1 It 28 1 a 5 1 a 36 1 it 9 1 tt 96 1 a 1S3 1 a 98 1 it 158 1 it 80 1 it 34 1 a 99 1 it 162 1 tt 114 6 Bliss on Private Obstetric Practice. another physician, but he understood she died some days afterwards of effusion in the chest. In the case of presentation of arm and abdomen, the child, which was large, was turned and delivered by ihe feet. It was born dead. The mother recovered without any unfavorable circumstance following. Puerperal Convulsions. Four cases were preceded by puerperal convulsions. This is in the proportion of one to every 205 births—while, under the mastership of Dr. Collins, only one in every 555 occurred in the Dublin Lying-in Hos- pital. One of the cases is detailed under the head of instrumental deliveries. In every case, it occurred with the first child. In each instance, also, there was infiltration in the cellular membrane. In one case only was the urine examined, and in this it was found to be albuminous. The patients, with the exception of the first noticed, were relieved of the convulsions before delivery, by bleeding, stimulating injections, purga- tives, and counter-irritants. The children were all born dead : two were in a state of decomposition, and there was reason to believe all died previous to the attack. The patients all did well, with the excep- tion of the one described under the head of instrumental deliveries. ffidema existed in these cases previous to the occurrence of convul- sions, and it was considerable, except in one instance, which does not correspond with the observations of Dr. Dewees. In the detail of cases in my note book, several are noticed in which convulsions were threatened, in all of which there were bloated counte- nances, and more or less oedema in other parts of the body. In one of these cases the urine was albuminous. These facts would seem to show that Dr. Lyman, whom Dr. Dewees quotes, is correct in stating that oedema is a precursor of convulsions. The detection of albumen in the urine of females, threatened with or laboring under this disease, has thrown much light on the pathology of the affection ; and further inquiries will probably remove much obscu- rity, which, no doubt, has led practitioners, in many instances, to con- found hysteria with this formidable complaint. In one of the cases, in which the attack occurred in the seventh month, labor came on, and the fcetus was delivered three days after the convulsions had ceased. The child was in a state of partial decompo- sition. The observation, that convulsions more commonly occur in the first labor than in subsequent ones, appears to be confirmed by these cases ; and likewise, that they happen more frequently when the child is dead, although the latter observation is questioned by some of our best writers. In all the cases the presentation was natural. Placenta Prcevia. The placenta was attached over the mouth of the uterus in three instances. This is in the proportion of one to every 273 cases. In one instance, the edge of the placenta was over the mouth of the uterus. The patient had repeated hemorrhage for two months previous to delivery, but it was at no time alarming. Labor commenced with profuse flooding, followed by syncope. The vagina was plugged, which Bliss on Private Obstetric Practice. 7 arrested the hemorrhage till the head advanced so as to make pressure. The mother was safely delivered, but the child was dead and exceed- ingly blanched. In the second case, I was called to a patient who was attended by a popular female. She had been flooding for ten hours,—was in a state of extreme exhaustion, and swooned immediately after I entered her room. The hand was passed up through the edge of the placenta—the feet brought down, and the child delivered in three minutes from the commencement of the operation. The child was born alive, but the mother, although she lost less than a pint of blood at the time, died at the end of an hour and a half after the birth of the child. In the third case, the patient was taken with flooding on Sunday, but not profuse. On Wednesday, a profuse hemorrhage suddenly occurred. A physician was called in, who found, as he stated, the os uteri dilated to the size of a shilling. When seen an hour afterwards by the writer, the flooding had been so great and the exhaustion so extreme, that tbe patient was almost moribund. On examination, a small portion of the placenta was found protruding from the mouth of the womb. The feet of the child were brought down and secured by a tape, and attempts made to deliver in this way, but decomposition had made such progress that the feet were immediately separated from the legs ; and, notwith- standing the relaxation which had taken place in the mother from the great exhaustion, it was found difficult to effect delivery on account of the condition of the foetus—the abdomen being very much distended by effused fluid in its cavity. The finger was passed through its parietes, through which opening the fluid rushed out. The finger was then hooked over the pelvis, and in this way the body was brought down and delivered. The patient survived but about twenty minutes. The loss of blood was inconsiderable at the time of delivery. The whole of the cases might be presented in detail with some other particulars not adverted to above, but it would be extending this paper beyond what would be desirable for the Journal. The arrangement and bringino- together all the various particulars has cost some labor, but the writer will be amply compensated if it shall lead other members of the profession to give to the public similar inquiries and observations. There is one thing that perhaps ought to be adverted to in comparing the results given above, with those of public institutions, and that is, that most of the patients were among a class of females who could command the comforts and conveniences of life, and were therefore less exposed to accidents than those less favorably situated.