Chapter II: Part 2

The determining causes of these death-rates need to be discussed most cautiously;—our information concerning them being so scanty.

We know from Statistics that these Deaths occur, but why they occur and why they vary are questions not yet to be fully answered in our present stage of knowledge (or of ignorance).

At one time a sufficient cause seems to present itself; but the very next outbreak of Puerperal disease may occur under quite different conditions. For years an Institution may escape excessive Mortality; and then it may suffer severely under the same apparent circumstances. All that we can do at present is to see whether there are removable causes in cases where the Mortality is excessive, and to remove them. Fully recognising how much we have need of caution, this subject will be next considered generally and as far as possible in its practical bearings on the points at issue.

There are some important remarks in Dr. Le Fort’s book, bearing on this subject, which may find a place here.

_Puerperal Fever._—Dr. Le Fort states, as the result of his enquiry, that the frequency of obstetrical operations modifies the general mortality only in a slight degree; that the excessive mortality in lying-in hospitals is much greater than can be attributed to ordinary hospital influences; that it depends neither on the social condition of the women, nor on the moral conditions under which delivery may occur; that it may be more or less influenced by the insalubrity of particular hospitals, but that puerperal fever is the principal cause of death after delivery; that this disease shows itself in all hospitals, in all maternity institutions, in all climates, in the south of France as it does at St. Petersburg, in Dublin as in Vienna, in London as in Moscow. It exists in America as in Europe.

It is less frequent and fatal during the summer months, attributable in part at least to greater facilities of ventilation following on higher temperature (in other words, to having your windows open instead of shut).

This disease develops itself spontaneously under certain unknown circumstances. When it is about to become epidemic, it is sometimes preceded by the prevalence of erysipelas.

Dr. Le Fort points out that what was considered a severe epidemic in the British Lying-in Hospital, in the year 1770, is ‘unfortunately less than the _mean_ mortality of the Maternité at Paris.’

While admitting that puerperal fever may originate _de novo_, Dr. Le Fort dwells strongly on the communicability of the disease as an efficient cause of its prevalence.

He adduces opinions of the following physicians—Oppolzer, Rokitansky, and Skoda, of Vienna; Virchow, of Berlin; Lange, of Heidelberg; Schwarz, of Göttingen; Löschner, of Prague; and Hecker, of Munich—on the nature and origin of this fatal disease. Generally they testify to the propagation of puerperal fever by contagion, but they also state that it is a blood disease—a product of foul air, putrid miasms, and predisposition to malignant inflammatory action.

Dr. Le Fort also cites a number of interesting facts, showing that the indiscriminate visiting by attendants of lying-in women and patients suffering from disease, either within or outside the same establishment, has been a means of exciting puerperal fever action.

_Admission of Students._—It is one of the contingencies necessarily due to connecting together the teaching of midwifery to students, with other portions of clinical instruction, that no precautions can prevent a student passing from a bad surgical case, or from an anatomical theatre, to the bedside of a lying-in woman, while sad experience has proved that the most fatal results may ensue from this circumstance.

Of course risks of this kind are greatly increased when there are lying-in wards in general hospitals—especially if a medical school be attached to such a hospital.

This risk had not been overlooked in the arrangements for the lying-in wards at King’s College Hospital, under which, while intended solely for the training of midwifery nurses, provision was made for a limited and regulated attendance of students; but, when enquiries came to be made into the probable cause of the high death-rates, it was found that the restrictions laid down as to the admission of students had been disregarded; also that there was a post-mortem theatre almost under the ward windows.

_Effect of Numbers._—Dr. Le Fort has examined the influence exercised by numbers—or, in other words, by the size of hospitals—on the mortality after childbirth. His general results may be briefly stated as follows:—

In hospitals receiving annually more than 2,000 lying-in cases, comprising the two Cliniques of Vienna, 1834–63; the Maternités of Paris, 1849–59; of Prague, 1848–62; and of Moscow, 1853–62; and the Lying-in Hospital of Dublin, 1847–54, the death-rate is 40·7 per 1,000.

In hospitals receiving between 1,000 and 2,000 cases a year, including the Enfans Trouvés at Petersburg, 1845–59; the Maternité at Munich, 1859–62, and other places, the death-rate is 36 per 1,000.

In hospitals receiving from 500 to 1,000 cases a year, including Pesth and the Maternité of Dresden, the death-rate is nearly 27 per 1,000.

In hospitals where the number of deliveries is between 200 and 500 per annum, comprehending several places cited, among the rest Edinburgh and the London Lying-in Hospital, 1833–60, the death-rate is 30½ per 1,000.

In hospitals receiving between 100 and 200 cases, as at Frankfort and Göttingen, the death-rate is 27·6 per 1,000.

And in three small establishments receiving fewer than 100 a year, as at Lund, the death-rate is above 83½ per 1,000.

From these facts Dr. Le Fort concludes that the relative mortality in small and large establishments is not favourable to small hospitals, _per se_. The benefit of subdivision may be neutralised by other circumstances.

We must also protest against massing hospitals, alike only in one circumstance, together for the sake of taking their statistics _in bulk_ in this way, except for the most general purposes—which is indeed all Dr. Le Fort has in view here—especially as our own lying-in institutions of these islands, which come out best individually, appear here confounded amongst the greatest sinners. But Dr. Le Fort’s general conclusion, against the influence of size _per se_, is no doubt correct.

As a general rule, statistics appear to show that the great mortality of lying-in hospitals is of periodical occurrence.

Puerperal women, as everyone knows, are the most susceptible of all subjects to ‘blood-poisoning.’ The smallest transference of putrescing miasm from a locality where such miasm exists to the bedside of a lying-in patient is most dangerous. Puerperal women are, moreover, exposed to the risks of ‘blood-poisoning’ by the simple fact of being brought together in lying-in wards, and especially by being retained a longer time than is absolutely necessary in lying-in wards after being delivered, while to a great extent they escape this entire class of risks by being attended at home.

There are no doubt difficulties in assigning the exact effect of every condition to which a lying-in woman may be exposed in contributing to these death-rates, but there are, nevertheless, a few great fundamental facts which arrest attention in such an enquiry.

It is a fact, for instance, that however grand, or however humble, a home may be in which the birth of a child takes place, there is only one delivery in the home at one time. Another fact is, that a second delivery will certainly not take place in the same room, inhabited by the same couple, for 10 months at least, and may not take place in the same room for years. The Registrar-General has shown us that under these conditions the death-rate among lying-in women all over England, and from all registered causes, is about 5·1 per 1,000.

In many London workhouses the number of deliveries yearly is so small that, so far as concerns annual deliveries, they approach more closely to dwelling-houses divided among a number of families than they do to lying-in hospitals properly so called.

Let us now see what relation there is between the annual deliveries and the death-rates in these workhouse wards.

Assuming that the London workhouse lying-in wards have certain conditions in common, we find that twenty-seven infirmaries suffered from lying-in deaths in five years, and that in thirteen there were no deaths in the same years. Now, in each of these twenty-seven hospitals yielding deaths, the deliveries averaged 29 per annum, while in the thirteen infirmaries without deaths the deliveries averaged under 16 per annum.

Again, in twenty-one infirmaries with deaths, the average disposable space for each occupied lying-in bed was 2,246 cubic feet; while in nine infirmaries without deaths the space per occupied bed averaged 3,149 cubic feet. These, however, are only averages, and as such may be taken for what they are worth. There were exceptions to these rules in particular cases.

The facts regarding Waterford Lying-in Institution have a very important bearing on this question of subdivision.

In the years from 1838 to 1844 this hospital consisted of two rooms in a small house. One room was a delivery ward. The other held eight lying-in beds. The total deliveries in this house amounted to 753, and there were 6 deaths = 8 per 1,000. Half this mortality was due to puerperal fever.

In October 1844 this hospital occupied another small house, in which the eight lying-in beds were placed in two rooms instead of one as formerly—four beds per room. Up to October 1867 there had been 2,656 deliveries in this house, and 9 deaths—a mortality of 3·4 per 1,000. There were only two puerperal fever deaths in these 2,656 deliveries.

These facts appear to show that subdivision among lying-in cases has a certain influence in warding off mortality.

But, on the other hand, the death-rates among lying-in cases in particular hospitals are not always in the ratio of the number of occupied beds. A few illustrations of this will suffice.

Thus, in the year 1861, there were in the Rotunda Hospital, Dublin, 1,135 deliveries, on which the death-rate was 51·9 per 1,000. In 1828 the deliveries were 2,856, and the death-rate 15 per 1,000. In the four years 1830 to 1833, the deliveries varied from 2,138 to 2,288, and the death-rates were a little more than 5 per 1,000. In Queen Charlotte’s Hospital the highest death-rate occurred in 1849, during which year there were 161 deliveries. The death-rate was 93·2 per 1,000, while in 1832, with 217 deliveries, the death-rate was just one tenth of this amount.

In the Maison d’Accouchement at Paris, during the five decennial periods between 1810 and 1859,[9] there were 141,476 deliveries, among which there occurred 6,288 deaths, giving a death-rate of 44·4 per 1,000. The lowest death-rate in any of the decennial periods occurred between 1840 and 1849, when it amounted to 41·9 per 1,000. The largest number of deliveries of any period in the half century was during this ten years. They amounted to 34,776; while, in the period from 1850 to 1859, the deliveries were 24,944, and the death-rate 52 per 1,000.

The Dublin Rotunda approximates most to this Paris Maternité in the large number of deliveries, vibrating around 2,000 a year; while, in Queen Charlotte’s Hospital, where, even since its reconstruction, the mortality has been in many years higher than in the Dublin Rotunda, the number of annual deliveries has varied around 200.

_Danger of Puerperal Epidemics._—These facts have a very important bearing on the whole question of lying-in institutions, for they show that, with scarcely an exception, while the lowest death-rate in any given year greatly exceeds the average mortality among lying-in women delivered at home, the inmates of these institutions are exposed to the enormous additional risk of puerperal epidemics.

Take, for instance, Queen Charlotte’s Hospital. There is no reason to believe that less care and solicitude for the welfare of its inmates is exercised than would be the case if they were delivered at home. And yet we find that year by year, from 1828 down to the present time, the institution has only escaped deaths for four years. The lowest death-rate it ever had was in 1835, when it amounted to 4·6 per 1,000. In other years it has been 11, 15, 21, 30, 50, 70, 81, 86, and in one year it rose to the immense death-rate of 93·2 per 1,000.

In 1849 there were, as above said, 161 deliveries out of which fourteen women died from puerperal fever, being a death-rate of 87 per 1,000 from this disease alone.

The statistics of other lying-in institutions afford corresponding data. It is a lamentable fact that the mortality in lying-in wards from childbirth, which is _not_ a disease, approaches closely to the mortality from all diseases and accidents together in general hospitals, and in many instances even greatly exceeds this mortality. It is the more lamentable, because, as need scarcely be stated, the causes of a higher mortality in infancy and old age cannot exist at childbearing ages. Also, childbirth ought certainly not to be a ‘miasmatic disease.’ Unless, then, it can be clearly shown that these enormous death-rates can be abated, or that they are altogether inevitable, does not the whole of the evidence with regard to special lying-in hospitals lead but to one conclusion, viz. that they should be closed? Is there any conceivable amount of privation which would warrant such a step as bringing together a constant number of puerperal women into the same room, in buildings constructed and managed on the principles embodied in existing lying-in institutions?

_Fatality of Lying-in Wards in General Hospitals._—Besides special lying-in hospitals, there are general hospitals which receive lying-in cases. Fortunately, there are not many such in England. But in Paris there are 11[10] general hospitals which receive midwifery cases. A reference to Tables XI., XII., XIII., will show how great the risks are to lying-in women under the same roof with medical and surgical cases; a fact which may be further illustrated by a reference to data for particular hospitals. For example, in 1861, 253 lying-in cases in La Charité gave a total death-rate of 193·7 per 1,000, of which no less than 154·2 was due to puerperal causes. These tables tell their own story, and they throw altogether into the shade the lamentable losses at King’s College Hospital.

The only _amende_ that could be made was to shut up the ward; and having done this in the interest of womankind, need it be said that the impression produced by these statistics confirms the conclusion just stated in regard to existing lying-in wards generally, and is that not a single lying-in woman should ever pass within the doors of a general hospital? Is not any risk which can be incurred outside almost infinitely smaller? And as a general hospital must always be a hospital, must not this verdict be an absolute one, not one which can be altered or reversed?

_INFLUENCE OF CONSTRUCTION AND MANAGEMENT OF LYING-IN WARDS ON THE
DEATH-RATE._

Before, however, surrendering entirely the principle of special lying-in institutions, it is only fair to enquire whether the construction, management, and arrangements of existing hospitals of this class may possibly have had any influence upon the mortality, apart from the mere fact of bringing lying-in cases together under one roof.

This question is the more important because we now know that construction and arrangement of buildings exert a notable effect on the death statistics of general hospitals. It is at last universally admitted that airy open site, simplicity of plan, subdivision of cases under a number of separate pavilions, large cubic space, abundant fresh air, mainly from windows on the opposite sides of the wards, drainage arrangements entirely outside the hospital, are essential conditions to the safety of all general hospitals. But, as already stated, it is likewise admitted that lying-in women are peculiarly susceptible to ‘blood-poisoning.’

This being the case, have we any reason to expect other than a high death-rate if we collect lying-in women into such wards, or rather rooms, as are found in many old hospitals?

Nobody with ordinary knowledge of the subject, and desirous simply of benefiting suffering people, would now dream of appropriating buildings of this kind as hospitals for sick. But it is to be feared that the same scruple has not always existed with regard to lying-in women. And as we now know that such buildings give high death-rates among sick and wounded people, there is every reason to fear that they have had their share in raising the death-rate among lying-in women to a greater extent than that due merely to the fact of agglomeration. As instances of the existence of danger from such causes, and also from grave errors in administration, two or three illustrations are here introduced from existing lying-in establishments.

_Maternité, Paris._—We have seen from the statistics that the chief of chief offenders in times past has been the Maternité at Paris. This establishment was in former times the monastery of ‘Port Royal de Paris.’ It is situated in one of the most healthy open spots on the outskirts of the French capital, and, as far as situation is concerned, ought to be healthy. The building was devoted to its present destination in 1795, and has undergone many changes since that date. It contains 228 beds for lying-in women, and, besides, accommodation for 94 pupil midwives. From 1,000 to 2,200 deliveries and upwards take place here annually: from 1840 to 1849 there were as many as 3,400 annually. Until recently it consisted properly of three divisions, delivery wards, cells for delivered women in the process of recovery, and an infirmary.

The delivery ward is well-lighted on two sides, and communicates with an operation theatre, where lectures are also given.

The woman, if progressing favourably after delivery, was removed to one of the cells in what may be called the recovery ward. The construction of these cells was as follows:—a long corridor, with windows on opposite sides, was divided into separate cells, each cell having its own window, by partitions stretching one third across the corridor, but not cut off on the end towards the middle of the corridor. Each cell was provided with a bed and a cradle, so that in walking up the centre of the corridor the divisions, or rather the cells, opened right and left from the passage, like the stalls of a stable. This construction rendered it almost impossible to open the windows. The infirmary consisted of small wards of three or four beds each, into which were moved indiscriminately patients suffering with all classes of disease. And it appears, from Dr. Le Fort’s account, that pupil midwives had at the same time patients in the infirmary, and healthy women, both delivered and not delivered, under their care. Pregnant women are often admitted weeks, and even months before delivery, at the Maternité. [So also at the Midwives’ Clinique at Vienna.]

Recently the cells have been removed from the corridor, and glass partitions have been thrown across from back to front, each division containing six beds, but communicating with the adjoining divisions by means of doors intended to be used only when the service requires it.

The infirmary has been completely separated from this portion of the establishment, but all classes of cases are still transferred into the infirmary as before.

As consequences of these arrangements, we have in the Maternité the following conditions:—

1. The agglomeration of a number of lying-in women under the same roof.

2. An internal construction of the building not suited to give fresh air, to say the least of it.

3. The infirmary until recently connected with the other portions of the building, and even now receiving all classes of cases among lying-in women, whether febrile or not, for treatment.

4. One class of attendants devoted indiscriminately to all classes of inmates.

5. As already mentioned, women admitted and retained within the walls of the establishment before and after the time simply required for delivery and convalescence.

Lastly, an enormous death-rate mainly from puerperal diseases.

_Hôpital de la Clinique, Paris._—This establishment is part of the hospital for clinical instruction, close to the buildings of the École de Médecine. The hospital consists of a parallelogram with a central court, containing not only the clinical surgery wards, but also an amphitheatre devoted to anatomical studies, with a mean number of fifty corpses in the course of dissection.

There are six wards devoted to the midwifery department, arranged in a complicated manner, partly across the corridor, and partly on each side of the corridor, all of them entered from a central passage lighted by the open doors of the wards along the sides. They contained 54 lying-in beds. From 800 to 900 deliveries took place here annually. 18 to 20 days appear to be the average stay. The beds must, therefore, have been pretty constantly full.

The wards devoted to women who have been delivered communicate freely with one another by open doors. The beds are curtained, and the curtains are washed only once in six months, even though the occupants of the bed may have died of puerperal fever. The beds are of iron, and are provided with a spring mattress, over which is a wool mattress. The latter is removed after each delivery, cleansed, and renewed. There is no infirmary for diseases; whether cases of puerperal fever or others, all are treated in the beds in which they are placed after delivery.

The female staff performs its duty to all classes of cases.

Students entered upon the roll for midwifery practice are called into the wards from other parts of the establishment by signals placed in a window.

It is quite unnecessary to search for any more recondite causes of the past excessive mortality of this establishment than these simple facts.

HÔPITAL DE LA CLINIQUE, PARIS.

(_Former arrangement of Lying-in Wards._)
]

The above plan, taken from M. Husson’s ‘Étude sur les Hôpitaux,’ will show the arrangement of wards and beds in this place. [Dr. Le Fort says that the number of beds in each ward has since been reduced by a third.]

_Queen Charlotte’s Lying-in Hospital, London._—Plate I. shows a plan and section of Queen Charlotte’s Hospital, as rebuilt in 1856.

On each floor are 6 wards, containing 3 beds each, in which the patients are delivered, with an average of 1,000 cubic feet to each patient. On each floor, also, is one convalescent ward, containing 6 beds. Two floors are devoted to patients: one for married, and one for single women. As soon as 3 patients have been delivered in a ward, it remains vacant for 8 or 10 days, and is cleansed. Patients are removed as soon as possible to the convalescent ward. When a case of fever occurs, the ward is freshly whitewashed, and not occupied again for at least a month.

PLAN I

SECTION.

_Queen Charlotte’s Lying-in Hospital._

FIRST FLOOR PLAN.

_Scale_

_M & N HANHART, LITH._
]

In this building we have three floors and a basement. A drain runs from back to front of the building, right across the basement—a most unsafe course for a drain in any inhabited building.[11]

It will be seen that the rooms are placed on opposite sides of a main corridor running the lengthway of the building on each floor; that the corridors of the different floors communicate by the stairs; that the ventilation of each room communicates with the ventilation of every other room through the corridors; that none of the rooms have windows on opposite sides, and that there are water-closets having a ventilation common to that of the building. Now every one of these structural arrangements is objectionable, and would be considered so in any good hospital, and nobody now-a-days would venture to include all of them in a general hospital plan. They are hence _à fortiori_ altogether inadmissible in a building for the reception of lying-in women.

We have thus, in Queen Charlotte’s Hospital, the following defects:—

1. Agglomeration of a number of cases under the same roof.

2. A form of construction unsuited for hospital purposes.

3. No means of removing outside the building febrile or other cases of puerperal diseases from the vicinity of patients recovering after delivery.

Since 1856, notwithstanding the great improvements, the death-rates per 1,000 have been 12·2, 8·8, 81·2, 70·3, 54·2, 39·2, 15·5, and so on: in several years very considerably larger than the mortality which led to the closing of the lying-in wards in King’s College Hospital. These varying deaths lead to the exercise of much caution in drawing conclusions as to their causes; but the main fact remains, namely, there are the death-rates, and they are many times greater than occur among London poor women delivered at home.

_Midwifery Wards, King’s College Hospital._—The following plan shows the provision which existed for training midwifery nurses at King’s College Hospital.

MIDWIFERY WARDS, KING’S COLLEGE HOSPITAL.

(_Plan of Third Floor._)
]

_A, A._ Accouchement Wards, used alternately.

_B._ Recovery Ward.

_C._ Contains Linen Presses, and Infants’ Baths, &c., for Ward
use.

_D._ Superior’s Bed-room.

_E._ Midwife’s Room.

_F._ Post-mortem Theatre.

_G, G._ General and Provision Hoists.

_K._ This roof is not higher than the basement.

_x._ Ventilating openings on a level with upper part of opposite
window.

_a, a, a, a._ Doors cutting off communication with either Accouchement
Ward when necessary.

_b._ No. 4 Ward.

The plan shows the relation of the delivery wards to the recovery ward, and to the other parts of the hospital; to the lecture room, post mortem theatre, &c. The main defects in the construction are: the back to back wards; proximity of these wards to the general wards of the hospital; the large staircase, common to both sets of wards, although its size and openness, and the windows opposite each other and on each floor, ensured ventilation, and separated the respective blocks; the position of the post-mortem theatre, the smell from which, as stated on the best authority, could be distinctly detected in the wards. As already stated, students were admitted from other parts of the hospital to the midwifery wards.

_RESULTS OF IMPROVED LYING-IN WARD CONSTRUCTION._

A few instances of improved lying-in ward construction, together with the death-rates in these establishments, will next be given.

_Military Female Hospitals._—These buildings vary in constructive arrangements. Some are much better than others, and during recent years lying-in wards of improved construction have been provided in connection with several newly erected military female hospitals. The earlier plans of the new female hospitals consist of a block formed of two pavilions joined end to end, with a passage across the block to separate the pavilions from each other. Each pavilion contains a single ward, with its own separate offices and nurses’ rooms. It has windows on opposite sides, with one large end window, and abundant means of warming and ventilation. One pavilion is devoted to general cases, the other to lying-in cases.

The midwifery ward has space for twelve beds. Each bed has a superficial area of ninety square feet, and a cubic space of 1,350 feet. The wards are fifteen feet high.

Two hospitals on this plan have been in use at Woolwich and Chatham for upwards of six years. During this period there have been at the two 1,093 deliveries, and 11 deaths. At Chatham there was one accidental death from removal of the patient to hospital, and out of 342 deliveries there have been no deaths from puerperal diseases. There were, however, two deaths from scarlet fever, occurring while this disease was prevalent in soldiers’ families in the garrison. At Woolwich, among 751 deliveries, there have been 8 deaths, of which five were from puerperal diseases, but of these five deaths one took place in a woman who had gastric fever at the time of admission, and in other two women puerperal peritonitis came on after instrumental delivery. There was one death from embolism, one from exhaustion, and one from dropsy. The total death-rate in these two hospitals has been under 10 per 1,000. The deaths due to diseases and accidents of childbirth have been 6, or at the rate of 5½ per 1,000.

Of the other military hospitals, the statistics of which are given in Table IV., Devonport and Portsmouth are unsuitable adapted buildings. Aldershot Hospital consists of a number of huts joined together as a general female hospital, with accommodation for all kinds of cases, including lying-in cases. This arrangement is a very undesirable one, and the results have been unsatisfactory.

Table XIV. shows that the total mortality in this hospital has been 10·1 per 1,000. Of the total deaths 27 are attributed to diseases and accidents of childbirth, affording a mortality of 8·8 per 1,000, or double that of the healthy districts of England.

If we exclude Aldershot as being unfit for childbirth cases, we find that in the other seven hospitals the total mortality, as shown in Table XIV., has been 7·4 per 1,000. The mortality from puerperal diseases in these hospitals has been 2·7 per 1,000, and from diseases and accidents of childbirth 5·4 per 1,000.

Table XIV. ┌────────────┬────────────────────────────────────────────────────────┐ │ │ All Women’s Hospitals (Military) │ ├────────────┼──────────┬──────────┬────────────┬──────────┬──────────┤ │ │ Puerperal│ Accidents│Diseases and│ Others│ Total│ │ │ Diseases│ of│Accidents of│ │ Mortality│ │ │ │Childbirth│ Childbirth│ │ │ ├────────────┼──────────┼──────────┼────────────┼──────────┼──────────┤ │Deaths per │ 3·9│ 3·4│ 7·3│ 1·5│ 8·8│ │ 1,000 │ │ │ │ │ │ │ deliveries│ │ │ │ │ │ ├────────────┴──────────┴──────────┴────────────┴──────────┴──────────┤ │ │ ├────────────┬────────────────────────────────────────────────────────┤ │ │ Aldershot Women’s Hospital │ ├────────────┼──────────┬──────────┬────────────┬──────────┬──────────┤ │ │ Puerperal│ Accidents│Diseases and│ Others│ Total│ │ │ Diseases│ of│Accidents of│ │ Mortality│ │ │ │Childbirth│ Childbirth│ │ │ ├────────────┼──────────┼──────────┼────────────┼──────────┼──────────┤ │Deaths per │ 4·9│ 3·9│ 8·8│ 1·3│ 10·1│ │ 1,000 │ │ │ │ │ │ │ deliveries│ │ │ │ │ │ ├────────────┴──────────┴──────────┴────────────┴──────────┴──────────┤ │ │ ├────────────┬────────────────────────────────────────────────────────┤ │ │ Other Women’s Hospitals, excluding Aldershot │ ├────────────┼──────────┬──────────┬────────────┬──────────┬──────────┤ │ │ Puerperal│ Accidents│Diseases and│ Others│ Total│ │ │ Diseases│ of│Accidents of│ │ Mortality│ │ │ │Childbirth│ Childbirth│ │ │ ├────────────┼──────────┼──────────┼────────────┼──────────┼──────────┤ │Deaths per │ 2·7│ 2·7│ 5·4│ 2·0│ 7·4│ │ 1,000 │ │ │ │ │ │ │ deliveries│ │ │ │ │ │ └────────────┴──────────┴──────────┴────────────┴──────────┴──────────┘

There are two camp hospitals for lying-in cases, consisting only of wooden huts, appropriated for the purpose, which have yielded very important experience. One of these is at Colchester, the other at Shorncliffe.

The Shorncliffe Hospital is an old wooden hut of the simplest construction, with thorough ventilation. It is situated on a rising ground close to the sea, and facing it, so that the sea breeze sweeps right through it. It is scarcely more than a makeshift. And here are the results.

Table IV. shows that up to December 1869, there had been 702 deliveries in the hut, among which there was one death from scarlet fever, and one from hæmorrhage, besides two deaths following on craniotomy. There was not a single death from any puerperal disease.

Colchester Lying-in Hospital, of which a plan and section are given on Plate II., is nothing more than an ordinary officer’s wooden hut, divided by partitions into four compartments, with a transverse passage cutting them off from each other. This hut has been in use for a considerable number of years as a place of lying-in for soldiers’ wives living in the camp, and there have been altogether between 500 and 600 deliveries in it. The matron states that during the whole time the hut has been in use for its present purpose, no death has taken place in it. But as statistics have only been kept since 1865, we shall limit our attention to them. They show that, up to the end of October 1870, there had been 252 registered deliveries, and no deaths.

PLAN II

SECTION ON LINE A.B.

_Scale of Feet_

PLAN OF WOODEN LYING-IN HUT COLCHESTER CAMP.

_v. Foul air outlets._
]

The results of these two makeshift hospitals, when compared with the figures already given for lying-in establishments generally, are certainly remarkable. They are both detached buildings, having no connection with any general hospital. Their construction ensures a plentiful supply of fresh air at all times. They contain very few beds, and these beds are occupied, seldom or never, all at one time. Indeed, it is stated that in the Colchester hut there is scarcely more than one, or at most two beds, constantly occupied throughout the year. Also, soldiers’ wives lying-in rarely remain more than ten days, though sometimes twelve in hospital. There is, therefore, no crowding; scrupulous cleanliness is observed; there are no sources of putrid miasm in or near the lying-in huts; and they have their own attendants. The data in Table IV. show that there have been 954 registered deliveries in the two huts, and four deaths, of which three were due to puerperal accidents, and none to puerperal diseases.

PROPOSED HOSPITAL FOR WOMEN, PORTSMOUTH.
]

A. Wards.

B. Spare Wards.

C. Sculleries.

D. Nurses.

E. Lavatories.

F. Linen.

G. Baths.

H. Kitchen.

I. Cook’s Room.

K. Store.

L. Medical Comforts.

M. Store.

N. Coals.

_Proposed new Female Hospital at Portsmouth._—When military female hospitals were first designed, it was intended that they should receive only lying-in and general cases from married soldiers’ families in separate pavilions. But at a subsequent date zymotic cases were admitted into the same pavilion with general cases. Very decided objections were, however, urged against this step by medical officers, and the next hospital planned was divided into three distinct pavilions. It was intended for Portsmouth garrison, and is shown in the annexed figure.

A female hospital on this plan has been erected at Dublin, with the two end wards built in the line of the corridor beyond the ends of it, in place of at right angles to the corridor, as shown in the proposed Portsmouth plan. By this form of construction the cases received from soldiers’ families can be divided into three classes: general, infectious, and midwifery—each class in its own separate building. Such, however, has been the feeling of medical officers as to the undesirableness of trusting even to this amount of separation, that at Dublin the ‘infectious’ cases have been removed to another locality altogether. The same separation had been already effected at Chatham and Woolwich.

Close observation of lying-in cases has led to further change in the construction, and it is now proposed to adopt for lying-in wards in female hospitals a different form of arrangement altogether: namely, to divide the lying-in pavilion into separate one-bed rooms, as shown on Plan IV.

The experience of these small military female lying-in hospitals has shown the favourable effect of simplicity of construction, plenty of space, light, and fresh air, perfect cleanliness, a small number of lying-in beds, not by any means constantly occupied, administration separate from that of general hospitals, and allowing the lying-in women to return to quarters in as few days after delivery as their recovery admits.

But there is one remarkable instance in which a plan of construction, on the principle of the earlier British military female hospitals described above, has been adopted without having led to equally satisfactory results.

The new ‘Maternité’ belonging to the Hôpital Cochin at Paris has been constructed on a ground-plan similar to that at Woolwich, viz., with two pavilions projecting in line from a centre, and containing two ten-bed wards. It is in two floors, with small wards on the upper floor. Part of its sanitary arrangements are certainly not what we should adopt in this country, but there are many hospitals in which there are worse defects.

Puerperal fever appeared in this hospital within a month of its being opened.

Where so much attention had been paid to construction, the causes of the fever must be looked for somewhere else than in the ward plan.

Dr. Le Fort has stated that puerperal fever cases had been retained temporarily in the wards after the development of the disease; that the same nurses took charge, not only of cases of disease in the isolated wards, but also of women making healthy recoveries; and that there is nothing to prevent the medical attendant passing almost directly from the autopsy of a puerperal fever case to render assistance to a healthy woman.

This experience is very important. It shows how much the safety of lying-in hospitals depends on common-sense management, and that it would be disastrous to trust to improved construction alone, while everything else is left to take its own course.

We now arrive at the consideration of an elementary point:—

_SHOULD MEDICAL STUDENTS BE ADMITTED TO LYING-IN HOSPITAL PRACTICE?_

This is a very grave question. Medical students were admitted to the lying-in wards at King’s College Hospital. Was this one cause of the occurrence of puerperal diseases there?

There are facts, it is true, such as those supplied by the Maternité and Clinique at Paris (the latter only admitting medical students), in both of which establishments the mortality is excessive, which on first sight appear to show that the presence of medical students in a lying-in hospital is not necessarily a cause of adding to a mortality already excessive. But on the other hand there are facts, such as those given by Dr. Le Fort, admitting of a comparison being made between the mortality in lying-in wards to which medical students are admitted with the mortality in other wards of the same establishment not admitting students, which appear to establish the point conclusively. The special case he cites is the following:—

At Vienna there are two lying-in cliniques, one for students and one for midwives. They are both situated in the same hospital, and their external conditions are insufficient in themselves to explain the facts now to be noted. Puerperal fever prevailed in the hospital during the same months in ten separate years, from 1838 to 1862, and the following table gives the mortality per 1,000 in each set of clinical wards:—

┌────────────────┬────────────────┬─────────────────────────────────┐ │ YEARS │ MONTHS │ MORTALITY PER 1,000 │ ├────────────────┼────────────────┼────────────────┬────────────────┤ │ „ │ „ │ 1st Clinique │ 2nd Clinique │ │ │ │ Students │ Midwives │ ├────────────────┼────────────────┼────────────────┼────────────────┤ │ 1838 │June │ 9│ 247│ │ 1839 │July │ 150│ 34│ │ 1840 │October │ 293│ 58│ │ 1842 │December │ 313│ 37│ │ 1844 │November │ 170│ 33│ │ 1844 │March │ 110│ 7│ │ 1845 │October │ 148│ 13│ │ 1846 │May │ 134│ 4│ │ 1847 │April │ 179│ 7│ │ 1856 │September │ 13│ 105│ │ 1862 │December │ 63│ 2│ └────────────────┴────────────────┴────────────────┴────────────────┘

Is it not quite clear that some bad influence was at work in this case on the students’ side, which was not in force on the pupil midwives’ side? That there was something else in operation besides epidemic influence is shown by the much greater frequency and severity of puerperal diseases in the one clinique than in the other. We may assume the fact without attempting to explain it, as a proof of the necessity of separating midwifery instruction altogether from ordinary hospital clinical instruction; and does not this Vienna history throw fresh light on the experience already alluded to of our midwives’ school in King’s College Hospital?

_INFLUENCE OF TIME SPENT IN A LYING-IN WARD ON THE DEATH-RATE._

This very important element in the question of mortality has been already referred to. There appear to be no extant statistics to show the relation of the death-rate to the period of residence. This much, however, is known—that in the establishments where the death-rate is highest the probable effect of length of residence appears not to be considered, while in the cases cited where the death-rates are lowest the women leave the hospital as soon as they are able to do so.

Dr. Le Fort, however, quotes Tarnier and Lasserre of Paris, and Späth of Vienna, as holding that the death-rate is lower among women admitted some time before labour. ‘They become acclimatised’ (an odd expression, when applied to the foul air of an establishment where there should be no foul air). He also says that puerperal fever is very rare among women brought into hospital _after_ delivery, and he asks whether ‘contamination does not take place principally and almost solely at the moment of accouchement.’

One can only repeat, what indeed Le Fort states, that in these most important points of enquiry, the very elements are yet wanting to us.

Some hospitals have rather plumed themselves on their humanity in giving shelter to poor lying-in women as long as possible, while in military lying-in hospitals soldiers’ wives are obliged to go home as soon as they can, to help the domestic earnings. In the first class the death-rate is high, in the last it is low.

The low death-rates in workhouse lying-in wards appear to support this conclusion also. These do not retain together women not yet in labour, women in labour, women delivered, and convalescent women. Their principle, on the contrary, is to receive women when labour is imminent, and to send them out of the ward as speedily as possible.

A moment’s consideration will be sufficient to show how important a point in management this is. If there is any danger at all to puerperal women in a lying-in institution (a fact which has been proved), is it not clear that the danger must become cumulative? It will increase in a certain ratio as the length of residence increases.

Blood-poisoning, if once begun, will not stop of itself unless the subject of it be removed from the cause, or the cause from the subject, if it stop even then. To retain both subject and cause together is simply to render certain that which under better management might have been evanescent. The more this question is considered the more important does it appear, as involving an element exercising a very considerable influence on the ultimate fate of inmates of lying-in institutions. The institution, by retaining its inmates, becomes a hospital; and, as such, subjects its inmates to hospital influences while in the most susceptible of all conditions.

The absence of information in almost all published statistics on the point would be grotesque, if it were not alarming from the carelessness it shows. With some difficulty the following few meagre data have been scraped together as to the average number of days lying-in women spend in the undermentioned institutions:—

Soldiers’ Wives’ Hospitals 10 to 12 days
Liverpool Workhouse Lying-in Wards 14 „
London Workhouse Lying-in Wards 14, 18, 21 „
Paris Maternité 17, 18 „
Paris Clinique 18, 20 „
King’s College Hospital 16 „

This involves the question of management, which is next to be considered.

_EFFECT OF GOOD MANAGEMENT ON THE SUCCESS OF LYING-IN ESTABLISHMENTS._

The most important experience which can be had as to the effect of good management in preventing the development of puerperal diseases is afforded by the results of midwifery cases in workhouse infirmaries. In none of these institutions is there any great refinement of construction or of sanitary appliances, and nevertheless their death-rates have been much lower than those of maternity institutions generally.

In Table V. are given the statistics of the lying-in wards of Liverpool workhouse for thirteen years. During this period there were an approximate number of 6,396 deliveries and 58 deaths, giving a total death-rate of 9·06 per 1,000.

Of these deaths 22 were from puerperal diseases—equal to a death-rate of 3·4 per 1,000. There were 14 deaths from accidents of childbirth—equal to a death-rate of 2·2 per 1,000. The aggregate death-rate from puerperal diseases and accidents of childbirth was 5·6 per 1,000.

These deaths are said to include all among puerperal women delivered in these lying-in wards, whether occurring within or without the maternity division. Mr. Barnes, the medical officer of the establishment, states that he can ‘answer for this with certainty’ during the last 5 years. Also, that no lying-in woman is discharged out of the workhouse unless in perfect health, so that no puerperal death can have happened after discharge. Mr. Barnes has farther been kind enough to supply data for the following 3 years’ statistics, to show the general character of the cases which have furnished these low death-rates.

_Summary of Cases Delivered in the Lying-in Wards of Liverpool Workhouse 1868–9–70._ ┌─────────────────────────────────────────┬────────────────────┬──────┐ │ │ Years │Total │ ├─────────────────────────────────────────┼──────┬──────┬──────┼──────┤ │ „ │ 1868 │ 1869 │ 1870 │ │ ├─────────────────────────────────────────┼──────┼──────┼──────┼──────┤ │Number of women attended in labour: │ 511│ 443│ 442│ 1,396│ │ natural │ │ │ │ │ │Number of women attended in labour: │ 4│ 1│15[12]│ 20│ │ premature │ │ │ │ │ │Number of women attended in labour: │ 164│ 159│ 142│ 465│ │ married │ │ │ │ │ │Number of women attended in labour: │ 351│ 285│ 300│ 936│ │ single │ │ │ │ │ │ Males born │ 295│ 223│ 228│ 746│ │ Females born │ 216│ 225│ 223│ 664│ │Mothers who died in or from labour │ 2[13]│ 2[14]│ 2[15]│ 6│ │ Children born dead │ 79│ 58│ 58│ 195│ │Women confined at or above 40 years of │ 8│ 4│ 9│ 21│ │ age │ │ │ │ │ │Women confined at or below 20 years of │ 105│ 98│ 81│ 284│ │ age │ │ │ │ │ │Greatest age at delivery │ 46│ 42│ 44│ —│ │Youngest age at delivery │ 17│ 16│ 15│ —│ │Number of first confinements │ 223│ 207│ 105│ 535│ │ Twin births │ 1│ 5│ 7│ 13│ │ Triplets │ 0│ 0│ 1│ 1│ │Labours followed by flooding │ 3│ 0│ 0│ 3│ │Labours accompanied by convulsions │ 2│ 1│ 2│ 5│ │Labours accompanied by retained placenta │ 3│ 0│ 3│ 6│ │ Forceps cases │ 7│ 4│ 4│ 15│ │ Craniotomy cases │ 1│ 0│ 0│ 1│ │ Version cases │ 2│ 0│ 1│ 3│ │Presentations: head │ 484│ 426│ 425│ 1,335│ │Presentations: breech │ 22│ 12│ 15│ 49│ │Presentations: feet │ 4│ 10│ 11│ 25│ │Presentations: arm │ 1│ 0│ 0│ 1│ └─────────────────────────────────────────┴──────┴──────┴──────┴──────┘

Subjoined is also a Table of the deaths and causes of death year by year for 13 years:—

_Summary of Deaths and Causes of Death in the Lying-in Wards of Liverpool Workhouse for Years 1858–1870._ ┌────────────┬────┬────┬────┬────┬────┬────┬────┬────┬────┬────┬────┬────┬────┐ │ │1858│1859│1860│1861│1862│1863│1864│1865│1866│1867│1868│1869│1870│ ├────────────┼────┼────┼────┼────┼────┼────┼────┼────┼────┼────┼────┼────┼────┤ │Morbus │ │ │ │ │ │ │ │ │ │ │ │ │ │ │cordis │ 2│ │ 1│ │ │ 1│ │ │ │ │ │ │ 1│ │Pneumonia │ 1│ │ │ │ │ 1│ │ │ │ 1│ │ │ │ │Puerperal │ │ │ │ │ │ │ │ │ │ │ │ │ │ │peritonitis │ 1│ 1│ │ 1│ 6│ │ 2│ 2│ 3│ │ │ │ │ │Phthisis │ 1│ │ │ │ 1│ │ 1│ │ │ 1│ │ │ │ │Debility │ 2│ │ │ │ │ │ │ │ │ │ │ │ │ │Epileptic │ │ │ │ │ │ │ │ │ │ │ │ │ │ │convulsions │ │ 1│ 2│ 1│ │ │ │ │ │ │ 1│ │ │ │Puerperal │ │ │ │ │ │ │ │ │ │ │ │ │ │ │fever │ │ 1│ 1│ 1│ │ │ │ │ │ │ │ │ │ │Jaundice │ │ 1│ │ │ │ │ │ │ │ │ │ │ │ │Phlegmasia │ │ │ │ │ │ │ │ │ │ │ │ │ │ │dolens │ │ 1│ │ │ │ │ │ │ │ │ │ │ │ │Exhaustion │ │ │ 2│ │ │ │ 1│ │ │ │ │ │ │ │Relapsing │ │ │ │ │ │ │ │ │ │ │ │ │ │ │fever │ │ │ 1│ │ │ │ │ │ │ │ │ │ │ │Measles │ │ │ 1│ │ │ │ │ │ │ │ │ │ │ │ Inquest │ │ │ 1│ │ │ │ │ │ │ │ │ │ │ │Laryngitis │ │ │ │ 1│ │ │ │ │ │ │ │ │ │ │Obstructed │ │ │ │ │ │ │ │ │ │ │ │ │ │ │labour │ │ │ │ 1│ │ │ │ │ │ │ │ │ │ │Typhus, post│ │ │ │ │ │ │ │ │ │ │ │ │ │ │partum │ │ │ │ 1│ │ │ │ │ │ │ │ │ │ │Hæmorrhage │ │ │ │ 1│ │ │ │ │ 1│ │ │ │ │ │Uræmia │ │ │ │ │ │ │ 1│ │ │ │ │ │ │ │Rupture of │ │ │ │ │ │ │ │ │ │ │ │ │ │ │uterus │ │ │ │ │ │ │ │ 1│ │ │ │ │ │ │Bright’s │ │ │ │ │ │ │ │ │ │ │ │ │ │ │disease │ │ │ │ │ │ │ │ │ │ 1│ │ │ │ │Invaginated │ │ │ │ │ │ │ │ │ │ │ │ │ │ │bowel │ │ │ │ │ │ │ │ │ │ │ 1│ │ │ │Instrumental│ │ │ │ │ │ │ │ │ │ │ │ │ │ │labour │ │ │ │ │ │ │ │ │ │ │ │ │ │ │(fever) │ │ │ │ │ │ │ │ │ │ │ │ 1│ │ │Metritis │ │ │ │ │ │ │ │ │ │ │ │ 1│ │ │Dropsy │ │ │ │ │ │ │ │ │ │ │ │ │ 1│ ├────────────┼────┼────┼────┼────┼────┼────┼────┼────┼────┼────┼────┼────┼────┤ │Deaths │ 7│ 5│ 9│ 7│ 7│ 2│ 5│ 3│ 4│ 3│ 2│ 2│ 2│ ├────────────┴────┴────┴────┴────┴────┴────┴────┴────┼────┼────┼────┼────┼────┤ │Approximate deliveries:[16] average estimated at 500│ │ │ │ │ │ │per ann. │ 450│ 625│ 511│ 443│ 442│ └────────────────────────────────────────────────────┴────┴────┴────┴────┴────┘

Let us now see what the arrangements are for this class of cases. The lying-in department of Liverpool workhouse is situated in a wing of the female general hospital, contiguous to the surgical wards. The wing has windows along the two opposite sides and at one end; but the space is so divided off by partitions as to form five wards, each of which has windows along one side only. The wards are allotted in the following manner:—

Two of them, opening into each other, and facing the same way, contain each twelve double beds, affording accommodation for 24 inmates per ward, 48 in all, at 345 cubic feet per inmate. These two wards are devoted to the reception of pregnant women before delivery. The opposite half of the wing is divided into two wards, corresponding to the two pregnant wards; one of these is the delivery ward, and contains seven beds, at nearly 1,200 cubic feet per bed.

Entering from this delivery ward is the lying-in ward, lighted by windows at the end. This ward contains 14 beds, at 900 cubic feet per bed. The other ward, entering from the delivery ward in the same line, is for convalescents, and contains eleven beds, at 762 cubic feet per bed. The W. C.’s, &c., are between the wards in the wing, in a very objectionable position.

For these and the following details I am indebted to the kindness of Mr. Barnes, who also supplied me with the statistics abstracted on Table V.

The following is the routine management of this establishment:—

All the wards are lime-washed three or four times a year. They are shut up and fumigated after the occurrence of any serious case of illness. The floors are washed daily.

The beds in the pregnant, lying-in, and convalescent wards, are generally all or most of them occupied; but the number of occupied beds in the delivery ward rarely exceeds four or five.

The bed clothes are changed after each delivery, and the beds, which are of straw, after every third delivery.

The patients consist for the most part of unmarried women.[17] They are admitted into the pregnant wards, where they remain for a varying interval of from days to months, from whence they are removed to the delivery ward; about a fifth part of the women are admitted directly from the town to the delivery ward.

They remain on an average eight hours in the delivery room, whence they are removed to the lying-in ward, where they remain five or six days. They are then admitted to the convalescent ward, and are finally discharged fourteen days after labour, one half to the town, the other half into other parts of the workhouse.

An important part of the management is that the inmates of the pregnant wards only inhabit those wards at night, being engaged during the day in various occupations within the workhouse, but not about the lying-in women, as in the Paris Maternité.

Cases are not taken into the lying-in division unless labour has begun, or is supposed to be imminent.

Any case of illness occurring in the lying-in department is at once removed to the ‘class sick nursery,’ to the lock or other division.

The nurses engaged in the lying-in division attend also cases in the ‘class sick nursery,’ and are periodically changed. Any case which they cannot manage is referred to the resident medical officer on duty.

There are three of these officers, who relieve each other every eight hours day and night. The officer on duty is liable to be called on to visit any part of the workhouse or hospital during his turn of duty, so that it might happen occasionally that the medical officer might be called from the hospital to the lying-in division.

If feverish symptoms show themselves in any patient in the lying-in division, the practice is to isolate the case or to transfer it to some other division of the workhouse. The ward is then closed, fumigated, cleansed, and lime-washed, before being again used.

This proceeding has only been necessary twice within the last four years.