Future of Obstetrics ~ 1906, Edinburgh ~ Dr. Ballantyne, obstetrician

by faithgibson on September 7, 2012

This 1906 document tells an extraordinary story by a masterful storyteller — none other than Dr. Ballantyne, a Scottish obstetrician and president of the Edinburgh Obstetrical Society in 1906.   On the 68th anniversary of their group’s founding, he has been asked to address his professional colleagues.

After a brief epilogue to the audience,  he begins to describe an extraordinary experience of imagination, in which he was interrupted while trying to write this very speech by a mysterious phone call. The voice on the other end of the phone explains to the dear doctor that normally people get connected to the “Place Exchange”, but tonight he has instead been contacted by the “Time Exchange”.

The mysterious speaker identifies himself as the Centenary Official of the Society, whose name is “One-Nine-Four-Ought” or 1940. While taken aback by these surreal circumstances, Dr Ballantyne has presence of mind to ask all manner of questions about obstetrics in 1940 — some 36 years into the future.

The answers will amaze you on many levels and give you real goose bumps! at this extraordinarly accurate look into the technological future. 

NOTE:  This is an 8,000 word excerpt of a much longer file, which was originally converted to a WORD document via OCR software. It contains a few obvious errors or missing words and had to be reformatted.

When I was sure the OCR had mis-translated a letter (‘R’ mistaken for ‘K’, etc) I corrected it. When an error was obvious, but I was unsure of the correct letter or word, I rendered the text in red.

In many cases I was unsure if the word was simply one I was unfamiliar with, or it was mistakenly rendered by the OCR. In those case, I did nothing.   

 http://www.archive.org/stream/transactions32edinuoft/transactions32edinuoft_djvu.txt

Link to original source material @ www.archive-dot-org

EDINBURGH OBSTETRICAL SOCIETY – FOE SESSION LXVIIL, 1906-1907.

Meeting I~ November 14, 1906.

Dr J. W. Ballantyne, President, in the Chair.
Chas. Kobert Mitchell, M.B., Ch.B., Koyal Maternity Hospital,
Edinburgh; W. D. Osier, M.B., CM., 11 Montgomery Street
Edinburgh ; Dr J. Halley Meikle, 44 Morningside Drive, Edinburgh.

In the original document, the “ADDRESS ON THE FUTURE OF OBSTETRICS” begins on page 3 and continues to page 27:

IV. INAUGURAL ADDRESS ON THE FUTURE OF OBSTETRICS.

By J. W. Ballantyne, M.D., F.R.C.P., F.R.S. Edin., Lecturer on Midwifery and Gynaecology, Surgeons’ Hall and Medical College for Women, Edinburgh; Physician to the Royal Maternity and Simpson Memorial Hospital, Edinburgh, etc.

“Ladies and Gentlemen, Fellows of the Edinburgh Obstetrical Society, to inaugurate, said Dr Johnson, in that famous Dictionary of his, means: “to begin with good omens” or simply “to begin”.

His worthy follower in the art and science of lexicography, Dr James A. H. Murray, in that marvel of patient research and brilliant scholarship, the New English Dictionary on Historical Principles, after quoting Johnson’s early definition, proceeds to amplify and lead out the meaning of the rich and suggestive word inaugurate in this manner:

” to begin (a course of action, period of time, etc., especially of an important character) with some formal ceremony or notable act; to commence, enter upon, to introduce, usher in, to initiate.”

And then our fellow-countryman, with that dry humour which breaks out now and then even in his Dictionary, places within brackets the following additional definition:

“inaugurate, sometimes merely grandiose for begin.”

Now I feel grateful to Dr Murray for so slyly slipping that bracketed addendum into his already full page; for I see, with relief, that I can shelter myself behind it, and can plead that if this address fall short of being a worthy, a notable, and an auspicious ceremonial act at the commencement of this, the sixty-eighth session of our Society’s history, it can at least claim to be, beyond any cavilling, a beginning.

ADDRESS ON THE FUTURE OF OBSTETRICS

A valedictory address naturally enough concerns itself with what is past, and has a ring of finality and farewell in it, vale! vale! sounding out from it with pathetic cadence; but an inaugural address looks forward to the future and dwells upon it, not without hope and expectation of the good and great things that are to come out of it, for at the very heart of the word inaugural lies the root augur, and the augur had, of all men, to be always looking forward.

The Eoman augur was, as we remember, or, as Dr Murray will tell us, if we have forgotten,

a religious official whose duty it was to predict future events and advise upon the course of public business, in accordance with omens derived from the flight, singing, and feeding of birds, the appearance of the entrails of sacrificial victims, and other portents.”

Now, although the primary visual image thus conjured up can hardly be said to reside any longer in the derivative words inaugural, augury, and august; although, also, the augur himself, with his staff and auspicial rites, has long since passed into the thick mists which cover even the brightest phenomena(and he was not very luminous ever) of a bygone age, uttering his vale! yet the augural spirit is not dead in these days, but is as living and insistent now as it ever was during all the centuries which have elapsed since man first began to ask questions about himself and his future.

In vulgar form it is seen in the irresponsible and sensational sisterhood of the lady palmists, the crystal-gazers, and the Sibylline vendors of wonder- working remedies and charms. It assumes scientific shape in the daily forecasts of the weather to be expected in these islands, although it must be owned that the meteorologist, being limited to observations made upon the surface of the earth, and having no stations high up among the clouds, sometimes fails as completely in his foretelling as does the itinerant gipsy.

In our own profession we seek, in a legitimate and proper fashion of course, to pierce the veil which hides the future from us, and we have recourse to the bacteriologist with his opsonic index and Widal test, to the histologist with his methods of cyto-diagnosis and differential blood-counts, and to the cryoscopist with his osmotic and ionic actions.

There is, in a sense, the would-be augur in us all; and, having now in hand the giving of an inaugural address, I bethought me that I also might try to play the augur’s part and endeavour to forecast the future of obstetric theory and practice.

If I fall far short of what you may expect; if I fail to please even myself (as is indeed very likely); if the manner and form of the forecasting be contrary to the traditions of Inaugural Addresses in learned societies; if, in striving not to be dull, I become extravagant ; and if, in seeking to restrain fancy I run the risk of being prosaic; then let the blame rest upon the etymologies which have led me into such difficult territories, and please let it be remembered that after all “inaugurate” may be only “grandiose for begin.”

In Touch with the Future.

I suppose that it was one evening in the autumn that the events I am going to relate apparently took place. I had, I fancy, been reading about some of the marvels of modern psychology, had been learning how a personality can be dissociated (on paper at least), had been grasping, with some difficulty, that the ego is not one but two or three, and had been trying, without entire success, to understand the mysteries of the subliminal and the supraliminal.

Then I had begun to wonder what subject I should choose for an inaugural address to the Society which had so highly honoured me by placing me in its Presidential Chair. I was not finding the question one which admitted of easy solution. My mind, in freakish fashion, began to hunt ideas, starting a new one every few minutes, and chasing it until another idea suddenly emerged from the sub-conscious somewhere of brainland and engaged its attention.

The house was very quiet, and my thoughts wandered on, undisturbed by any extraneous interruptions, save the occasional fall of a cinder into the fireplace, or the coming of a sort of breathless bark from my dog, enjoying doubtless the exciting pleasure of a subconscious chase after some old enemy. Suddenly the telephone gave one of those undecided, apocopated, monosyllabic tinkles that we usually leave unanswered, and regard as due to a fault in the apparatus or an error of the operator. On this occasion, however, I put my ear to the instrument and whispered ” Hullo ! ”

To my surprise, an answering ” Hullo!” very faint and distant, but quite distinct, came back.

“Who are you? “I asked.

“One nine four nought,” was the reply {the year 1940}.

“Thank you,” I said, ” but I don’t want to know your number; I wish to know who you are, and where you are ringing up from.”

“I am not ringing up from anywhere,” said the voice ; ” you are on the Time Exchange, and until you grasp that notion firmly you cannot understand who I am.”

“I beg your pardon,” I exclaimed in great surprise ; ” I have heard of many Exchanges, but never of the Time Exchange.”

“That I can quite well believe,” replied my unknown correspondent. “It was only on rare occasions that you in the beginning of the Twentieth Century got switched on to the Time System instead of the Place System ; you happen to have been attached to-night, and I thought I might venture to ring you up and have a talk. So, now do you know who l am?”

“I am really very sorry,” I replied, ” but I haven’t an idea.”

“I thought you might have guessed,” he said. “I am an Official of the Edinburgh Obstetrical Society, and the time from which I am ringing you up is one nine four nought, or, if you prefer it, nineteen hundred and forty, the Centenary year of the Society’s existence. You are not forgetting,” he added, “that our Society was born in 1840, having been conceived, so to say, in the last month of 1839.”

For the moment I was too surprised to answer this startling communication from the future; but I soon recovered myself and made a suitable reply to the Centenary Official’s remark.

The Future of Obstetrics.

The next question that came to me over the wires stimulated my curiosity and determined the course of our conversation: it was:

” Now, is there nothing you would like to ask me about obstetrics in 1940? “

“If you will let me get my thoughts gathered together,” I replied, ” there are hundreds of questions I should like to ask you.”

“I do not promise to answer them all,” replied Nineteen Forty as I may call him, “for there are some matters which I could not make plain to you without a great deal of preliminary explanation, and we have not time for that; but I will do what I can to satisfy your curiosity.”

“What sort of preliminary explanation do you mean?”

“Well, this simply: Obstetrics has not been the only subject of study in which there have been advances and discoveries; there have been great changes in surgery, still greater ones in medicine, and a revolution in physics and physiological and pathological chemistry; it would require a series of lectures to bring your general knowledge of these matters up to the level required for the perfect understanding of all that has been accomplished in obstetrics.”

“I fully grasp the situation,” was my reply. “I am now in a position similar to that in which an old friend of mine found himself in 1906: he had been in Central Africa for fifteen or twenty years, and he came back to his native land to find the pathologists speaking the (to him unknown) language of bacteriology. He had the greatest difficulty in making up leeway, and indeed never quite succeeded in doing so.”

“You are really in a worse state than he was,” said Nineteen Forty, ” but I shall try to make things as simple as I can.”

Teaching of Obstetrics

“Being a teacher,” I now said,” I should like to hear about your methods of conveying obstetric information in the year 1940.”

“Ah,” said my correspondent, “you were, as perhaps you suspected, on the eve of great changes in your teaching methods in the year 1906. You were under the intolerable burden of having to give fifty or one hundred hours of purely theoretical teaching in order to fulfill the requirements of the examining boards.

You delivered, each day, a lecture of an hour’s length, containing usually a bald statement of a number of facts discoverable in almost any reputable textbook upon the subject; you occasionally tried to relieve the weariness and monotony of your exposition by a passing reference to a specimen or a diagram, or by the introduction of an anecdote or a personal experience; you adopted a didactic or a grandiloquent style, or, worse still, you read slowly and closely from a bulky bundle of manuscript notes.

You occasionally put forceps on to the doll in the phantom, but you lectured all the time, and you expected your students to be taking down your words in their note-books, when you were directing their attention to the movements of your hands in the act of inserting the blades of the instrument.

All this was altered at once when in the University and College Regulations the words ‘hour’s instruction‘ took the place of ‘lecture‘. Instead of having to give fifty or a hundred lectures, you were asked to supply fifty or a hundred hours of obstetric instruction, a very different thing, as you can imagine. Of course some lecturers preferred to go on in the old way, and they were at liberty to do so; but many chose to vary the methods which had been in vogue.

Here, for instance, is a plan which was adopted not so long after the time at which you now are. Each student was supplied with a neatly printed and fairly full statement of the subject of demonstration to be taken up on the following day; to this were attached two or three blank sheets for the noting down of additional facts, for the drawing of a few diagrams, or for the indication of the page or pages in a large text-book where full details might be found. Having perused this syllabus or epitome the night before, the student came prepared to follow and appreciate the teaching his teacher was ready to give him. It might take the form of a demonstration of pelvimetry in normal and malformed pelvises.

On a number of tables were several models of the well-formed and the deformed pelvis, with callipers of various kinds lying beside them. The teacher at first gave a very concise and clear statement of the measurements of the diameters in the normal and in the abnormal pelvis, and of the bearing which these measurements had upon labour, and indicated the various ways in which the diameters could be estimated.

The class then broke up into sections for the application of principles which had been enunciated; and, supposing there were a hundred students, ten men went to each of ten tables, and tested the methods and familiarised themselves with the apparatus. On another day the demonstration would consist of the examination of a large number of slides under microscopes, illustrating the appearances of placentas from two months up to the full term, or of the uterine musculature at various stages of development. On another day the electric phantom would be brought into action. ”

“I beg your pardon,” I here interjected; “what was the electric phantom?”

“It was a skilfully made model of the abdomen and pelvis with the full-time uterus inside. By a somewhat complex apparatus, a doll representing the foetus could be expelled from the interior through the canals, exhibiting in its progress the whole mechanism of labour. The rate could be regulated to a nicety, so that a twelve hours’ or a twelve minutes’ labour could be imitated; further, the process could be interrupted at any stage (when the head was on the perineum, for instance), and the details explained.

A student could be placed in charge of the phantom labour at any time, the most favourite being of course the period of vulvar dilatation and of the passage of the head ; if he made any mistake in the method he adopted for the delivery of the head and for the safety of the perineum, he could be checked and shown the right plan. By the touching of a button the pelvis could be narrowed at the inlet or outlet, or be deformed in other ways, and by the use of dolls of various sizes, representing mature, premature, and post-mature foetuses, different kinds of delay or varieties of mechanism could be exhibited. The dolls’ heads were so constructed as to permit the occurrence of moulding.”

“I can quite understand the value of teaching such as you describe,” I said to Nineteen Forty; and I suppose it was supplemented by clinical instruction in the Maternity Hospital?”

“That, of course,” was the reply, and also at the various small maternity sub-centres, scattered over all our large cities. They were sets of two or three rooms, with accommodation for ten or twelve patients, under the charge of an assistant obstetric officer and one or two nurses; in them normal or nearly normal cases were confined, leaving the central institution for the complicated and operative labours.

But these were comparatively early changes in our teaching methods,” went on my informant; “others soon followed. One, for instance, was the introduction of the kinematograph and the gramophone. By a perfecting of the methods of obtaining differential radiograms, it became possible to represent internal processes, such as the passage of a stone down the ureter, or of the infant through the passages, by the kinematograph.

The pictures thus obtained were thrown upon the screen and utilised in the teaching of obstetrics; in this way, for instance, the mechanism of labour could be shown and the somewhat cumbrous and uncertain electric phantom replaced. By the gramophone we were able to reproduce and illustrate the cry of the parturient woman in the different stages of labour, and the various sounds made by healthy, by premature, and by semi-asphyxiated infants, as well as by those whose birth had been accomplished by the use of forceps. The different kinds of movement made by the foetus in utero (rotatory, calcitrant, vibratory, or singultant) could be shown by the kinematograph, while the neophone reproduced accurately the foetal heart sounds and the uterine bruit.”

” Stop! stop! ” I said, ” I cannot follow you any further in your novelties of obstetric teaching.”

“I was afraid you would begin to find there were difficulties in understanding all the details,” was my friend’s reply,” and yet I have only begun to name some of the new methods invented by science for the imparting and for the testing of obstetric knowledge. I was going on to tell you of the micro-kinematograph, by which all embryological processes and organogenetic readjustments could be first represented and then reproduced upon the screen for teaching purposes.

I intended then to give you an idea of the automatic and registering gramophone for use at oral examinations, which excluded all conscious and unconscious bias in the testing of candidates for degrees, for it rolled out questions in an expressionless tone of voice, and recorded without feeling the answers given in reply; and I was hoping to have interested you in the great development of clinical teaching which took place soon after 1906, and more especially after an examination in Clinical Obstetrics was insisted upon by nearly all universities. Perhaps, however, it would be well if I passed on to some other subjects, for, after all, the advances in the clinical teaching of Midwifery were already indicated and could be recognised and foretold by any thinking and observant man, even at the time at which you are.”

Obstetrical Societies.

” What, then, may I ask, have you to tell me about our own and kindred societies in the Twentieth Century?” was the next question which I put to Nineteen Forty.

“There was a great and beneficial change in the life and activities of the various learned societies in Edinburgh soon after 1906. By means of a munificent gift from a wealthy man with strong scientific leanings, a large central hall to serve as a meeting-place for all the Edinburgh societies was built. Our own Society was, of course, one of these.

But this was found to be a suitable occasion for a rearrangement of the energies and spheres of the different learned bodies, and so gynecology was united with surgery to form a large surgical society, the Obstetrical Society devoted itself entirely to midwifery, the Medico-Chirurgical Society became the Royal Medical Society by fusion with the old undergraduate organisation bearing that name (the surgical members of both allying themselves with the newly formed surgical society), and the Pathological Club increased its membership and instituted Anatomical, Physiological, and Psychological Sections.

Similarly, the other scientific societies rearranged themselves. Each society had its own afternoon or evening in the month; but, in addition, there were conjoint meetings on special occasions, when, for instance, the Medical, Surgical, and Obstetrical Societies would unite together for the discussion of subjects in which each had an interest. The Royal Society was, as it were, the mother of us all. Through the benefactions of the generous donor already mentioned, the fee for membership was made quite a nominal one, and the member’s ticket admitted to all the meetings, but it only conferred powers of contributing to or speaking at one of the societies and at the conjoint meet ings in which that society took part.

The most wonderful part of the hall of the societies was the phonograph room; at least it will seem so to you,” said my friend, Nineteen Forty. This room,” he continued, “was in telephonic communication with all the learned societies in the world, and if you wished to hear the papers read at different places you had only to switch yourself on to any one you might choose. In this way, you missed none of the asides and interruptions which are so often the very soul and life of a discussion. Furthermore, the speaker, knowing that his words were audible all over the world, was very careful as regards his statements, and rarely claimed priority for any suggestion, therapeutic or otherwise.”

“But what about understanding the language in which the discussion was taking place ? ” was the question which I could not prevent myself from here asking.

“You surely do not think for a moment that the world, and especially the scientific world, was content to go on till 1940 without adopting a universal language,” was the answer I received to my question ; and I was so taken aback by the tone of reproach in my friend’s voice that I had no remark ready, and so lost my opportunity of finding out what the universal language was. Before I had time to recover myself I found that Nineteen Forty was beginning to describe to me some of the changes which had taken place in the practice of midwifery, and as I did not wish to miss anything of what he was saying, I had to give him my attention

Obstetric Practice.

“You must know,” he was saying, ” that the discovery which revolutionised obstetric practice in the twentieth century was that of a tocophoric serum.”

” What was that? ” I asked. “A serum obtained from the blood of pregnant animals which had been treated with cultures from the blood of a human placenta, obtained preferably from a case of placenta praevia,” was the reply.”

Its introduction into use gave us the means of safely, speedily, and certainly inducing healthy action of the uterus. In this way a labour could be brought on and a child born with almost the same degree of certainty with which it used to be possible to perform a surgical operation. The day, and in some cases even the hour, could be arranged, and a midwifery case became a certain part of the day’s work instead of an uncertain contingency in the middle of any night.

In the nineteenth century the introduction of anaesthesia abolished the pains of labour and brought in a new era of obstetric advance; in the twentieth century the discovery of this tocophoric serum did away with the uncertainty of the supervention of labour, and had an almost equally great influence upon our subject. The profession earned the gratitude of countless patients, who said something like this: ‘In the past you relieved our pains and sent us to sleep in the midst of our agony; but now you have released us also from the intolerable bondage of our uncertainty, and we thank you for this new boon.’

Post-mature confinements, with their risks and delays, were in this manner done away with ; a time suitable alike for patient, nurse, and obstetrician, and calculated as accurately as possible to coincide with the full term of pregnancy, was fixed upon; and the labour was conducted with the same care and aseptic precautions as a gynaecological or other operation.”

“But what about premature labours?” was the question with which I here checked my friend’s flow of description.

“I expected that remark,” was his reply. ‘You must know that the special investigation given to the pathology of pregnancy in the early part of the twentieth century bore good fruit in the discovery of means of successfully preventing the premature termination of pregnancy, and such abnormal labours became very rare.

At the same time the tocophoric serum gave us a means of interrupting pregnancy, when for medical or obstetric reasons (such as pelvic contractions, heart disease, etc.) it was regarded as desirable so to do.”

The Falling Birth-Rate.

“But the great principle of obstetric practice in the twentieth century,” continued my informant was the securing of the safety of the infant.”

“You mean,” I said, “that the falling birth-rate forced obstetricians everywhere to reconsider all their methods, operative and otherwise, from the standpoint of the life of the infant? ”

“Yes, indeed,” was the reply; “and I shall now try to make this plain to you. I must introduce some statistics to bring out my meaning, but you, of course, can take your ear from the instrument if you are bored.”

“Truly, I shall do no such thing,” I protested.

“In 1906 the falling birth-rate in our own and in all civilised lands was at length beginning to attract the attention it deserved. The birth-rate for England and Wales was 35*2 for the decade 1865-1874; it was 34*7 for the next decade; for the next period of ten years (1885-1894) it had fallen to 31*2; and during the last ten years (1895-1904) it has sunk to 29*0. So much for England and Wales.

Sir Henry Littlejohn had a still more depressing account to give of the capital of Scotland. In 1871 the natality in Edinburgh was 34*8 (almost the same as that of England and Wales at the same time); in 1881 it was 32*2 ; in 1891, 28*2 ; in 1901, 24-99; and in 1905 it was 22-99. 1 Even with these figures

The figures for 1906 are now available: the number of births was 7042, and the birth-rate was 22’41 per 1000. The descent, therefore, is steadily going on, and the number of babies born in 1906 is actually less than the number in 1881, although the population has so greatly increased.

{page 16 – text missing] … before you the full gravity and meaning of the position was not recognised in 1906. In order to grasp the significance of the movement, look at the matter thus. In 1881, when the population of Edinburgh was (in round figures) 228,000, the number of babies born was 7360; in 1905, when the population had increased to 336,000,the number of babies born was 7741, whereas, if the rate had been maintained, it ought to have been 10,846. There was therefore a shortage of over 3000 babies.

It is only fair to the country in general to state that Edinburgh occupied almost the worst position in this matter of a falling birth-rate. Of the sixteen large towns of England and Scotland, there was only one (Bradford) that had a lower birth-rate than Edinburgh; and while London registered 27, Dundee had 28, Manchester, Birmingham, Aberdeen, and Leith had 29, Glasgow and Greenock had 30, and Liverpool had 33.”

“But,” I here interruped, as my friend paused to note the effect of these undeniably startling figures, “the death-rate had fallen as well as the birth-rate, and so we were no worse than we were before.”

“Let us take the Edinburgh statistics again,” was the reply. “In 1881 the death-rate was 1886; in 1905 it was 1425, the lowest ever reached till then. While, however, the death-rate was slowly falling from 18 to 14, the birth-rate had come rapidly down from 32*23 to 22*99. If this rate of descent had in each case been maintained for another quarter of a century the two rates would have reached almost the same figure, and any increase in the population of Edinburgh would have had to be put down to immigration, for the birth-rate had been falling much more quickly than the death-rate.

Further, while it was conceivable that the natality of Edinburgh would continue to fall till it reached a vanishing point, it was not thinkable that its mortality would do likewise. There might come a year when there were no births, but it could hardly be expected that in that year there would occur no deaths.

All these things, however, were to the inhabitants of Edinburgh in 1906 as idle tales; they heeded them not. And yet, to Edinburgh obstetricians at least, the subject of the falling birth-rate was a grave problem, and it became no less grave as the twentieth century proceeded on its way. To put the matter very practically,” said Nineteen Forty, “there were many more doctors settled in Edinburgh in 1906 than in 1881, but the number of babies being born was practically the same. I expect some of you had shrinking lists of midwifery engagements to deplore, but I forbear to press the point.”

” Can you give me now any hints as to the way in which obstetricians in the twentieth century met the dangers of the falling birth-rate ? ” was my next question.

“That I will gladly do,” was my friend’s answer; “but, first, I must point out what perhaps was little recognised or altogether overlooked in 1906. I refer to the aggravations of the falling birth-rate.”

The Aggravations of the Falling Birth-Rate.

“What were these aggravations?” I asked.

“In the first place, there was the infantile death-rate. You were proud, in 1906, of the fall that had taken place in the general death-rate of the country during the preceding half century, and your pride was justified; for there had been a reduction by more than fifty per cent, of the number of deaths between the ages of five and twenty-five years, and between twenty-five and thirty-five there had also been a notable decrease.

But there was one circumstance about which little was said, and about which no pride could be felt: the infantile death-rate was practically unchanged at the end of these fifty years of hygienic progress and material advancement.

To quote from the Report of the National Conference on Infantile Mortality (p. 99), held in London in June 1906: ‘In the twenty years ended 1874, we find that out of every 1000 children born alive in England and Wales, 153 never completed their first year, while in the twenty years ended 1904, the ratio was 148 per 1000.’

There was, it is true, a slight improvement — 148 instead of 153 — but was it an adequate, a satisfactory, even a noteworthy degree of improvement, when contrasted with the fifty per cent, improvement between the ages of five and twenty-five? This, then, I call the first aggravation of the falling birth-rate: fewer babies were being born, and yet they were dying off practically as rapidly during the first year of life as they had ever done.

“A second aggravation was your ignorance, in 1906, of the stillbirth-rate and the abortion-rate of your country. You did not know how many pregnancies ended in the birth of infants who never lived outside the mother’s uterus, who, in the words of one of the nineteenth century poets, exchanged the amnios-skin of this world for the shroud, the amnios-skin of the next.’ You hoped, perhaps, that fewer stillbirths were happening, but you dreaded lest your hopes should turn out ill-founded; at any rate you did not know, for there was no registration of stillbirths to reveal the frequency of such ante-natal catastrophes.

In reality, a steady increase was going on, as Dr Kaye’s Yorkshire statistics, local though they were, proved. He found that in 1901 there were 47*6 stillbirths per 1000 live-births, and the number steadily increased until in 1905 it was 56*3. ‘Apply these figures/ said Dr Kaye {Report of the National Conference on Infantile Mortality, 1906, p. 104), ‘to the whole country (England and Wales), and it means that the number of stillbirths has grown from 44,270 in 1901 to 52,350 in 1905, an increase of over 18 per cent., while the total live-births have decreased in actual numbers. Then as to the abortion-rate, you must surely,” said the Official of 1940, ‘have had some feelings of dismay when, in 1906 and in preceding years, you reflected upon the wastage of ante-natal life by reason of abortions.

You could hardly shut your eyes to and stop your ears against the testimony of text-books and journal articles which, with striking unanimity, attested the frequency, the growing frequency, of abortion. Some placed the frequency of miscarriage at one to every three or four pregnancies; others stated that one in every five gestations ended in abortion.”

Here I interrupted my informant with the remark that I did not think the abortion-rate was so high as that.

“What reasons have you for doubting it?”

“Well,” was my reply, “in the last series of 100 indoor labours under my care in the Edinburgh Royal Maternity Hospital there were not many women who gave a history of having aborted.”

“But,” said my friend, “did you exclude the primiparas and the women under thirty years of age?”

“No,” I replied.

“Suppose you do that; how do your statistics stand now?”

“In the 100 cases there were 21 women of thirty years of age and over, and of them 8 gave a history of previous abortions.”

“There you are,” said Nineteen Forty in triumph; “thirty-eight per cent. of your patients who had reached the middle of reproductive life had aborted! Besides,” he continued, “you had only the patients’ word for the number of their abortions; it is much more likely that they under-estimated than over-estimated the frequency of such occurrences, especially early miscarriages of six weeks. You must, after all, admit that not fewer but more abortions were occurring in Great Britain in the early years of the twentieth century. There was yet another aggravation to the falling birth-rate, to which I must, for a moment, refer. That was the curiously significant increase in the number of deaths ascribed to premature birth which began to be noticeable in the mortality returns.

The infantile mortality from premature birth, which in 1865-1874 was 11-9 per 1000 (for England and Wales), had in 1875-1884 grown to 13-7, in 1885-1894 to 16-8, and in 1895-1904 to 19-8. The most striking thing about this increase was that it began as soon as and no sooner than the birth-rate commenced to decline. One can hardly refuse to ascribe some significance to that fact.

“Now, let me gather together these various statements,” said Nineteen Forty, “and you will see better how you really stood in the year in which you are living. The infantile death-rate, notwithstanding all recent advances in hygiene and the laborious study of the diseases of infancy, was no better than it was fifty years previously. There was reason to believe that the number of stillbirths and abortions was increasing; and these, although they constituted deaths in a real sense if not in a forensic one, were not included in the mortality tables. The number of infantile deaths ascribed to premature birth was increasing, pointing to a probable increase in the total number of premature births occurring. Finally, there was the progressive and serious fall in the birth-rate. What could the obstetricians of the twentieth century do but strive to counteract these evils? “

Checking the Falling Birth-Rate.

“How did they check the falling birth-rate?” was my question, for my informant at this stage in our conversation seemed to expect me to say something.

They did not check it, they could not check it,” was the startling reply; “but they checked the aggravations of it, and so secured some salvage from the wreckage of life which was occurring before, at, and immediately after birth. This salvage more than compensated for the decline in the birth-rate, and thus the civilised nations of the earth were able to maintain their position to some extent, at any rate, if not entirely.

So now you see why I so strongly emphasised the aggravations of the falling birth-rate. But matters got much worse before they began to improve.”

“In what way?” I asked. “I will tell you,” was the reply.

“The checking of the falling birth-rate was, as I have said, not an obstetrical problem at all; at least it was not one which obstetricians could hope to solve. The falling of the birth-rate was not due to less knowledge or less skill in the obstetricians of the day, or to want of training of the midwives and monthly nurses, or to the neglect of chloroform or the forceps, or to the excessive use of these means of relieving pain and hastening the second stage of labour, or, indeed, to any other thing which lay in the power of the medical man to do or leave undone.

The causes lay deep among the roots of the somewhat artificial conditions of the sexual relationships in modern society. A nineteenth century writer (Kenan) said: ‘The spread of an enlightened selfishness is, in the moral world, a fact of the same nature as the exhaustion of coal-fields in the physical world; in each case the existing generation is living upon and not replacing the economies of the past.’

His words apply very exactly to the enlightened selfishness which was the root-cause of the falling birth-rate. The era of personal comfort first, and at any cost; the age of late marriage, because the entrants upon the matrimonial state wished to begin, not where their parents began, but where they were prepared to leave off; the period of frequent holidays and expensive amusements could hardly be described as other than ‘selfish/ although it might be doubted whether it deserved the honour of being entitled ‘enlightened.’ In any case, such an age was not one in which frequent child-bearing was likely to be thought of with favour, or carried through with enthusiasm.

If there was ergophobia in the one sex, there was maieusophobia in the other. Nor was a popularisation of the knowledge of the nature and mode of use of ‘checks’ to conception likely to raise the average size of families.

“Matters did not improve after 1906. In fact, it was not long till rumours began to circulate regarding the existence of a new institution, the ‘ City without a Child,’ a sort of municipal agennesia, wherein mental productivity and financial success were held in high esteem, while the reproduction of the race was nothing accounted of. The inhabitants renounced the pleasure and the honour of having families, but gladly accepted all other pleasures and honours that came in their way.

The citizens occupied their days in making money, and their nights were not spent round the fireside in the home. They were described as curious places, these experimental childrenless cities: no schools, no toy-shops, no Christmas-trees, no happy young boys and girls on the roadways; nothing but hard-visaged men and steel-eyed women, and bustle and racket, and vain hopes and restless desires; and by-and-by an alarming increase in the frequency of suicide, and in the number of the inmates of the palatial asylum which stood upon a hill overlooking the town. So, in the end, the attempt to reduce the birth-rate to nil was the cause of its gradual ascent again; and the experiment of race-suicide was in that sense a failure.

“In the meantime the medical profession, and especially the obstetricians, had been busily endeavouring to save something from the wastage of ante-natal life, and to keep alive many of the new-born infants who formerly used to succumb to death in various forms during the first few months of post-natal existence.”

Estimation of the Wastage of Ante-natal Life.

“In the first place,” continued the Official of 1940, “the obstetricians of the early part of the twentieth century set themselves the task of estimating the annual loss of life at and before birth.

With the help of a Stillbirth Registration Act, and with the assistance of the army of skilled monthly nurses which the Midwives Bill had called into being, statistics of stillbirths and abortions were obtained. The results were startling, appalling in fact; but after the first excitement incident thereupon had died down, it was seen that in the very magnitude of the loss of ante-natal life that had been going on lay the hope of the future. By diminishing the antenatal death-rate, by checking the frequency of abortion, it was recognised that there was a means ready to hand to counter-balance the falling birth-rate. If a fifth of the stillbirths and abortions could be prevented, it was seen that the loss accruing from the smaller number of births would be compensated.

Further, it was discovered that many of the cases which went to produce the high infantile mortality of 148 per 1000, during the first year of life, were deaths of prematurely born infants. So it became apparent that to check the frequency of premature births would give a means of reducing the high infantile death-rate; in this direction also there lay compensation for the failing birth-rate. You can almost forecast for yourself now the lines along which obstetric practice began to advance,” said my friend of 1940; “but I will indicate them very briefly.”

Study of Pregnancy, Normal and Pathological.

The hygiene of pregnancy began to be studied in detail and with an enthusiasm and thoroughness never before arrived at. Patients were encouraged to consult their medical attendants regarding the rules of health in pregnancy, and the latter were prepared to give the advice sought. It was recognised that pregnancy was a severe and a long-continued testing of the structural and functional integrity of all the organs of a woman’s body.

It was soon seen that while an unmarried or a non-pregnant woman might with impunity, or apparent impunity, break many of the laws of hygiene, a pregnant patient did so at her peril ; and every medical man made it his duty to revise with the pregnant patients all the rules relating to the care of the bodily functions, putting right what was wrong, and warning against possible errors in diet, clothing, habits, and the like.

“Further, in cases of doubt, consultations were freely asked for and given, it being recognised that it was better to check the beginnings of evils in pregnancy than to wait till an abnormal gestation had developed into a labour dangerous for infant and mother alike.

Whereas in your time,” said my informant, “consultations in pregnancy were seldom asked for, save to determine whether the induction of abortion should be carried out in order to try to save the mother’s life at the expense of that of her foetus, in the new era the specialist was called in early enough for his remedial measures to avail both the maternal and the infantile lives. In this way, not only were pathological pregnancies often prevented altogether, but in many instances they were so energetically treated in the early phases that they yielded to therapeutic means that would have been of no use at later stages.

Eclampsia was one of the first of the gestational maladies which began to benefit by such a revolution in the management of pregnancy. Whereas it had been common for the urine of a pregnant patient never to be tested — indeed, in many cases it was not customary for the medical attendant to be told about the pregnancy or summoned to the patient till labour was in the first stage — now, the doctor was engaged to look after his patient in the early weeks of her pregnancy as well as in the hours of her labour and in the days of her puerperium. His duties included regular analysis of the urine, as well as the supervision of all the details of the gestation, and the correction of any of the symptoms which might arise.

The obstetrician of 1940 finds it difficult to understand why his brethren of the early part of the century paid so much attention to the one month of the puerperal period and so little to the nine months of pregnancy. To him the time of preparation for labour was not less but more important than the time of recovery from the effects of labour, for he found that if the former was normal the latter was little likely to be pathological.

“Along with this development of the study of the management of pregnancy and of the treatment of the disorders of the pregnant state came a marked advance in the knowledge of ante-natal maladies. The mystery of trans-placental trans- mission was elucidated, and stillbirth by reason of foetal diseases and defects became rare. So-called ‘habitual’ abortion and intra-uterine death were soon shown to be due in every instance to some definite and ascertainable cause; and the hopelessness which had previously characterised all attempts at treatment gave way to the enthusiasm inspired by frequent success.

New and more effective means of keeping prematurely born infants alive were adopted with the best results, and the favourite British operation of the induction of premature labour for contracted pelvis took an enhanced position of esteem among other methods of obstetric intervention.

As I have already said, the appreciation of the value of foetal life was the fact which dominated obstetric theory and practice in the twentieth century. Embryulcia, craniotomy, and all such destructive procedures yielded to methods which gave a chance of survival to the child, and thus Cesarean Section, Vaginal Section, and the Induction of Premature Labour took their rightful place in the list of obstetric operative measures.

By means of the knowledge which obstetricians gained regarding the state of their pregnant patients {eg, by pelvimetry, physical examinations, etc.) it was possible to detect pelvic contractions, tumours, and the like before the supervention of labour, and so to avoid interference at the time when the occurrence of the phenomena of childbirth was the cause of additional risk and danger.

For instance, it became rare for a medical man to be summoned to a full-time labour in which there was an undetected pelvic contraction, and thus, emergency Cesarean Sections or (worse still) craniotomies were hardly ever heard of.”

The Problem of Cancer.

“I have greatly benefited by what you have told me,” I said to Nineteen Forty; “but can you satisfy my curiosity about one other matter? It is scarcely an obstetric problem, perhaps, but it is a very pressing one: I refer to the discovery of the cause and cure of cancer.”

“I cannot reveal much,” was the reply,” but I am permitted to throw out some hints. For instance, it was not long after 1906 that it came to be recognised that there was a curious parallelism between great philanthropic movements and note-worthy life-saving and pain-relieving discoveries.”

“What do you mean? ” I queried. “Well, take the case of the abolition of slavery in the British possessions at a cost of £20,000,000 ; that was a great and a beneficent and an unselfish act on the part of one section of mankind for the amelioration of the condition of another and a suffering section; it was soon followed by the discovery of anaesthesia — that priceless boon. Of course, the anaesthetics themselves had been in existence for years, but their effects were till then unknown.”

“I think I see what you mean,” I said; “and was there any great philanthropic advance pending in 1906, or soon thereafter, which made it possible for the discovery of the cause and cure of cancer to take place as a corollary thereto? ”

My friend hesitated a little before he replied, and then said slowly:”The greatest boon that mankind could voluntarily bestow upon itself would be the abolition of war, would it not?”

” You think,” said I, ” that it was that great international blunder — the appeal to arms to settle disputes — that was delaying the discovery of the cure of cancer ? ” My informant did not answer this question; at least, if he did, I, in my excitement, failed to catch his reply. So I went on and said to him : ” I myself have of late years been inclined to look to the chorion-epithelioma and its embryological relations for the elucidation of the problem of the origin of malignancy ; but I have a friend who believes that the secret lies in the hands of the botanists. He is sure that in the differences of the life-conditions of fungi and bacteria are to be found the explanation of the origin and the theory of the cure of cancer.”

“Tell him to make experiment,” was the reply which came to me somewhat indistinctly, for it appeared as if my telephone were not recording very clearly. I spoke again, but it seemed as if the connection had been cut ; so, as I did not wish to be rude, I asked for the Time Exchange, No. 1940, and got switched on again. ” I wished to thank you very warmly for so kindly giving me so much information about the future,” I said. u Can you answer one other question, a personal one ? ” I asked. ” You described yourself at the beginning of our conversation as an Official of the Obstetrical Society of 1940; can you give me no other clue to your identity?”

“I am the President,” was the reply.

“Indeed, then,” I said, “I am highly honoured, sir, to have made your acquaintance.”

I heard what sounded like a laugh, and then this rejoinder came back to me over the wires : ” You call me sir, but is it impossible that the President of 1940 should be a woman?

I awoke with a start, to find my telephone ringing furiously ; and a call to a serious case at the Maternity Hospital was soon engaging my thoughts. But I have sometimes wondered whether it was all a dream; whether it was not in part an ” uprush of the subliminal consciousness/’ as the psychologists call it ; whether it was not, in certain details, a vision of that future so rapidly advancing upon us, when:

Much that is wrong shall be righted,
And man shall see, never affrighted,
Clearly his duty, and do it,
E’en if his life-blood go to it.”

On the motion of Br Ritchie, seconded by Br Craig, a hearty vote of thanks was unanimously accorded the President (Dr. Ballantyne) for his address.