1778

First, there is the trained midwifery nurse. Unquestionably of these trained women large numbers have arrogate Ito themselves the assumption of medical knowledge whic]they do not possess, on the strength of the technicateaching which they have received. Midwives of this kin4encroach upon the rights of qualified practitioners whare fully entitled to resist such encroachment, because thrights encroached upon are the reward of their individuaefforts and achievements, and further are the complemento the disabilities and the restrictions which those practitioners have accepted in order to acquire the rights S4

encroached upon. That practitioners do resent tbiiencroachment is perfectly natural, quite legitimate, and ÎIno way unworthy, although some disputants have grosslyexaggerated this aspect of the matter, for by merely referringto advertisements of practices for transfer it, may be seeIthat a very limited amount of this kind of work is held to b(an attractive and desirable feature.

Second, there is the untrained woman, a totally differenikind of difficulty. This sort is at times grossly ignorant,absurdly superstitious, and disgustingly dirty. These defeot,are almost always present, or some of them, in some degree,and although her shortcomings are so to speak casual,nevertheless, she is in the aggregate the cause of an immenseamount of unnecessary and avoidable suffering and waste ojmaternal and infant life. The total damage that she does tcthe community is out of all proportion more grave than thedamage which the trained sort does to the faculty, and it isfrom her ranks mainly that the next sort is recruited.

Third, there is the mistrained midwife possessed of someknowledge which she perverts to illegal uses-a most

dangerous and pernicious criminal. It may be undesirableto enlarge upon her enormities, but only the very simple areignorant of her existence. There is no particular limit toher nefarious practices. She is an astute abortionist andunscrupulous. She keeps dubious homes and refuges andshe is usually in league with the baby-farmer, while doingher best to limit the latter’s trade. Judges know her,coroners know her, the police know her. Sometimes she hasbeen to some extent trained, but more often not, and thedamage, actual and moral, for which she is responsible is

perhaps greater than that of both the other kinds puttogether, although her actual numbers may not be morethan a minute percentage of the total of midwifery nurses.

This, then, being the state of the midwife in general, whatis the state of the midwifery question in naked truth ? 7 Allare agreed, Parliament and profession, that there is some-what requiring remedy. That is where we are now. A

remedy is to be devised. More, a remedy is going to bedevised and enforced. Those who object to all and everyremedy misconceive the position. It is no longer a questionof what does the profession want or not want, it is whichway is the inevitable remedy to be devised and applied ? 7The Houses of Parliament know that well enough. TheGeneral Medical Council knows it well enough. Mr. VictorHorsley, as plainly appears by his speech on the subject atNewcastle, knows it well enough. The strange thing is thata considerable section of the profession does not seem toknow it, and this meeting at Newcastle, with the all butunanimous resolution, plainly did not realise it and refusedto believe it. That, of course, cannot alter the fact, butmay have a very unfortunate effect upon the position of theprofession therein, especially as those present at that meetingare by no means alone in the attitude they are adopting.To return, however, to the actual position. There is

urgent need of a remedy of some kind. Leaders of men areagreed about it, the Duke of Devonshire is not a statesmanto be imposed upon by a mere babbling agitation, and theseleaders are going to provide a remedy. What remedy, then,will they provide ? 7 Manifestly there is every probabilitythat they will provide the ordinary remedy, the easily-enforced remedy, just as was done in the plumbers’ case.The midwives will be registered, there cannot be a doubt

about it, except among those who cannot or will not seewhat is before them. It is therefore extremely necessarythat the profession should devote its energies undivided tothe securing of the best possible measure. Registration maynot be an ideal remedy, it may not be the best practicable, itmay be liable to abuse, it may be difficult to apply to penalpurposes. But it has some advantages. As it is bound tocome, common prudence dictates that its drawbacks shouldbe minimised and its advantages reinforced to the utmostpossible. Its various advantages are sometimes overlooked.It determines who is and who is not a midwife, and that is

no small point when a woman prosecuted for obstetric irre-gularities is to be defended by a skilful advocate. Of itselfthe fact that they are earmarked will have a very considerableeffect in limiting the vagaries and stiffening the consciencesand curbing the malfeasances of those disposed to transgress.It will emphasise the difference between a midwifery nurseand a practitioner of medicine, although it is freely pre-dicted to produce the reverse effect. That it can limit theassurance of the pretentious is unlikely, but it is doubtfulif anything could do that. That it will cut off the most in-

competent is unquestionable, and that it will ultimately bethe undoing of the iniquitous is a,’certaii2ty, since they willfear its publicity and hesitate to accept its protection. Onthe other hand, it is not easy to see how it can make mattersworse than they are already. The plaint that it will create aninferior order of practitioners is untenable and might equallybe applied to the Dentists’ Register, but dentists do not as amatter of fact claim to be general practitioners. There isnow a large proportion of the public which takes the services .

of the midwife rather than consult a practitioner, and regis-tration cannot greatly alter that proportion, whereas it canbe made a means of defining what a nurse may and maynot do, which is now absolutely vague and indeterminate.Parliament will not abolish midwives for the simple reason

that it will never abolish anything, whether an acknowledgedabuse or not. Parliament will not enforce professionalattendance because it will never enforce any considerationsof health, as in the contagious diseases and notificationinstances, unless it cannot possibly avoid doing so, and hasonly just abandoned the infinitely smaller compulsion ofvaccination. Any such expectation is merely visionary,foredoomed to disappointment, eminently unpractical. Thereis but one course to follow-namely, to secure the bestpossible Bill and to introduce into it all the safeguards thatcan be used and enforced, profiting the while by the sadexperience of the futility of the Act under which the medicalprofession is at present registered. That these ends can beattained or attempted better by others than by those whodevised and matured the Bill of the British Medical Associa-tion is in the highest degree unlikely, but now is the timefor those who consider that Bill capable of further improve-ment to produce and support their opinions.To protest against the inevitable registration is useless.

To demand the impossible abolition is unwise. To endeavourso to influence matters that out of the present seething massof differences and disputations shall crystallise a useful,practicable Act is the only sound policy open to those whodesire to protect the interests at once of the public and ofthe profession. I am, Sirs, yours faithfully,

A PHYSICIAN.

PUBLIC HEALTH OF DUBLIN:A MEASLES AND TYPHOID EPIDEMIC: CENTRAL FEVER

DENS.

(FROM OUR SPECIAL SANITARY COMMISSIONER.)

IN most large towns there are special black spots whichwhen visited supply material for sensational descriptions ofdirt, squalor, and insanitary conditions of the worst order.But these places are exceptional. They may give a death-rate of 40 per 1000 and yet the general death-rate of thetown may not amount to 20 per 1000 per annum. Nota few of such places exist in London and it is notfair to judge a town generally by these particularly badlocal examples of insanitary conditions. Therefore I havetaken in Dublin a fairly broad street, situated in thecentre, within a hundred yards or so of Trinity Collegeand the Bank of Ireland, in fact in the very heart ofthe city. This is Townsend-street, and on entering thisstreet between the Theatre Royal and the Lock Hospitalthere stands a large Protestant mission house and church.I was attracted here because I had heard that, on applyinga test, it was found that the drainage of the Protestantmission house percolated into the cellar of a public-house-afact scarcely calculated to promote the popularity of themission. This had continued for some years, but when thenuisance was discovered the whole of the premises werere-drained, iron soilpipes ventilating on the roof and runningoutside the walls were introduced, with proper traps, flush,&c. Indeed, and whatever else may be said, for, or against,

1779

the Protestant missions in Ireland, they are, so far as I havebeen able to see, setting a good example in respect to sanita-tion. Immediately opposite this mission, the street consistsof three-storeyed brick houses, and barring the fact that theyare let out in tenements there is nothing especially remark-able about them if only viewed casually when passing downthe street. Some of them are, I am told, the property ofTrinity College, at least the College is the original landlord,but it would be impossible to say how many intermediarylandlords there are, and I was further informed that it isdoubtful whether the rents are paid in anything like a

regular manner. But the tenants to whom the rooms aresublet are made to pay very regularly; indeed, it is the

general rule that the poorer the debtor the more strictlyis he forced to pay.The first house which I entered had a narrow passage lead-

ing to a small backyard, where there stood two closets.These being locked, and the tenants supplied with keys,proved to be clean. No key was provided for the closet ofthe house next door, and the result was most marked andunpleasant. The yard, which was loosely paved with roundstones, was soiled in various directions with fascal matter.The closet seat and floor were similarly befouled. Fourfamilies lived in this house, and they are supposed to use thisone closet which is in the yard, though it was in such a filthycondition as to be scarcely approachable. There was awaste-preventer flushing apparatus, but the flush was badlydelivered and insufficient, so that the pan was caked withfilth of the worst description. It is only necessary tolook up at the back windows of this house to judgeof the poverty and dirt existing inside. Those panesthat remained had almost entirely lost their trans-

parency through the dust of ages that adhered to them.One window had no panes remaining at all, the lower

part being boarded up and the upper part open freely tothe wind and rain. One of the inhabitants complainedbitterly of the cold, though doubtless some of these brokenpanes are useful in facilitating ventilation. The inhabitantssaid that sanitary officers frequently visited the house andswept up the yard. It is not so much that the dwellers ofthis and many other similar houses are so very dirty in theirhabits. The worst nuisance is caused by perfect strangerswho simply walk in at all times of the day and night butmore especially at night time. Some of these unwelcomeintruders do not even take the trouble to go to the closet inthe backyard but relieve themselves in the passage of the Ihouse. As it is a tenement house the street door is always Iopen. The last to come home at night is supposed to shut it; i

but how is he to know that all the other inhabitants are 4

indoors ? In the third house I inspected, and while I was in Ithe backyard, a man came in from the street. On being ]questioned he proved to be a perfect stranger. Withoutasking permission of anyone he had come to make use of the 1closet. There was a great quantity of fascal matter in the i

passage of this house and the wall was saturated with urine twhich went through into a shop on the other side of this 7thin partition. E

Crossing the street, but still remaining in the neighbour- chood of these tenement houses, I came upon a gateway which iwas large enough to admit of the passage of a cart. It was v

very unevenly paved with round stones, so that the carts f

experienced a severe jolting as they went in and out ; conse- s

quently some of their contents were shaken out. This proved o

to be manure, blood, and offal, as this entrance led to three pprivate slaughter-houses. But, apart from this, there were falso urine and human as well as animal fsecal matter, for it Iseems to be quite a common thing for a section of the popula- e

tion of Dublin to relieve themselves in the open air wherever (they find a passage or dark recess. The passage or court t1led to a long yard which at the end turned at right a,angles. At this extremity, and facing the entrance from the pstreet, were what must have been originally intended afor coach-houses, but three of these are now con- tlverted into slaughter-houses and are, of course, absolutely’Unsuited for such a purpose. Yet all three slaughterers p:had obtained licences from the city. Facing two of these cc

slaughter-houses the ground was paved with flagstones w

which had recently been cemented together. This, however, slwas of little or no use, for the drain inlet was several feet irbeyond, opposite the third slaughter-house, and here there wwas no cement, but only an irregular round stone pavement, 1>>which could not prevent the blood and filth from percolating biinto the subsoil. All the washing and sweeping from the b(two slaughter-houses passed over this before it could reach re

the gully of the sewer. The blood coagulated between thestones. A neighbour pointed out some poultry in the yard.Many of them were lame and had swollen legs. He thoughtthat they injured their limbs on these rough stonesand that the filth lying about poisoned the scratchesor wounds. The walls around bore traces of dampreaching to some considerable height, and this dampwas not water alone, but blood, manure, and all otherkinds of liquid slaughter-house filth. Yet overlooking thisyard are the St. Andrew’s National Schools where hundredsof children breathe the effluvia wafted to them from thishidious quagmire of blood and offal. Doubtless this placeis sluiced out frequently. There was no large accumula-tion of manure or offal at the time of my visit, but whatevercare may be taken such a yard is absolutely unsuited forthe purpose. Nor will surface sweeping and washing alterthe terrible state of pollution of the subsoil. The mostelementary of all rules is that the flooring of a slaughter-house should be absolutely water-tight and that every particleof moisture should go straight into the drain and not haveany opportunity of sinking into the earth.Dublin, Dec. 13th.

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NOTES FROM INDIA.

(FROM OUR SPECIAL CORRESPONDENT.)

Bombay City again threatened with Plague.-DitJioulties ofPlague Administration in Native States.-T7ie Want ofPreparations in Calcutta in the Event of a Severe Out-òreak.-The Progress (If the Epidemio: General Imaprove-,nie,nt.

THE health of Bombay city continues very unsatisfactoryand there are indications that the city will suffer fromanother recrudesence of the plague. The general mortality-is high, being at the rate of 5340 per 1000 per annum, whilethe quinquennial average is only 35’43. Not only this, butthe deaths from plague show a decided tendency to increase,and it is very probable that the disease is more prevalentthan the published figures would indicate. I have drawnattention to this point for some weeks past, and as the usualinterval between outbreaks in large cities has expired in

Bombay the probability is that another development hasalready commenced. In view of the disastrous characterof the recent outbreak in Poona the prospect in Bombaygives rise to great misgiving. The amount of inocula-tion which by a variety of devices has been done is smallcompared with the immense population (over 820,000),and all other plague measures have proved useless forprotecting the city.There seems to have been a much larger amount of

plague in the Nizam’s dominions than has been officiallyreported. Unfortunately, considerable friction with regardto plague administration has also occurred between thePlague Commissioner and one of the district talukdars.A village, named Gangawati, afflicted with plague wasdesired to be evacuated, but the orthodox Mohammedanin charge of the district was of opinion that therewas no plague and refused to issue the necessary orderfor its evacuation. The Prime Minister hearing of thissent an English revenue officer to the district and theorthodox talukdar was ordered to have nothing to do withplague measures. The matter, however, was carried stillfurther by appeal to the Resident and to the Government ofIndia, but in the meantime the village in question had beenevacuated. It is now reported that the Plague Commissioner(Lieutenant-Colonel Lawrie, I.M.S.) has refused to under-take any longer the duties while the talukdar of Lingsugsar,against whom serious charges of persistently obstructing theplague operations in the Nizam’s dominions have been .

alleged, is allowed to continue in charge of that district bythe native Government.The Plague Commissioner in his official letter says : "At

present plague work in Hyderabad is a sham and I cannotconsent to be party to it." This difficulty is one, of course,which could only have occurred in a native State, but itshows that the official returns with regard to plague do notindicate the immense number of concealed cases of plaguewhich must be continually taking place. For some timepast the returns from Hyderabad have been very irregular,but the numbers reported as occurring in this State havebeen sufficient to cause considerable fluctuation in the weeklyreturns for the whole of India.