Chapter III: Part 3

Until recently, the whole of the deliveries, which amounted to an average of about 500 a year, were under the charge of one paid officer and a pauper who, without any payment or extra diet, delivered nearly every case and worked both night and day.

There are several points in this procedure which are of great importance, as bearing on the general question of successful management of lying-in establishments:—

1. The building, although situated in a large commercial town, is on a high, isolated, and freely ventilated locality.

2. It is not connected with a general hospital or medical school, or with any of their risks.

3. There is a constant change of wards:—pregnant ward, delivery ward, lying-in ward, recovery ward, body of the house. There is, in short, as little risk as possible of the cumulative blood-poisoning process already referred to.

4. Frequent cleansing and lime-washing.

5. Passing women who have been delivered as speedily as possible out of the division altogether, either into the house or outside.

6. The deliveries being conducted by a woman specially attached to the delivery ward, and no part of whose duty it is to attend sick.

7. The immediate isolation or removal of all cases exhibiting feverish symptoms and their treatment out of the division.

8. The reduction of intercommunication between the lying-in and hospital divisions to the smallest possible degree on the part of medical officers and nurses.

The practical result of this system of management has been, as we have seen, that the lying-in division of this workhouse, although working under many singular disadvantages, has escaped the usual fatality of special lying-in hospitals.

During the thirteen years included in the tables there has been no epidemic, and the deaths have almost always been single and disconnected.

The experience of lying-in wards in London workhouses somewhat resembles the experience of Liverpool workhouse.

In the report of the committee appointed to consider the cubic space of metropolitan workhouses, 1867, is given a table, No. 11, shewing the number of deliveries and deaths after delivery during five years in forty metropolitan workhouses.

The leading facts are abstracted in Table VI. Workhouses in which deaths after delivery took place, during the five years, are separated in the abstract from workhouses in which no deaths took place.

There were during these five years in all the workhouses 11,870 deliveries and 93 deaths, giving a death-rate of 7·8 per 1,000. The deaths from puerperal diseases amounted to 39, giving a death-rate of 3·3 per 1,000. There were 20 deaths from accidents of childbirth; being a death-rate of 1·7 per 1,000. The total death-rate due to both classes was 5 per 1,000.

The largest number of deliveries took place in Marylebone and in St. Pancras. In the former, on an average of 243 deliveries per annum, the death-rate was 8·2 per 1,000. One half of this, however, was due to consumption. Of the remaining deaths 3 were due to puerperal diseases (2·4 per 1,000) and 2 to accidents. The death-rate due to puerperal diseases and accidents of childbirth was thus 4·1 per 1,000.

In St. Pancras workhouse, on an average of 200 deliveries per annum, the death-rate was 11 per 1,000, of which 9 per 1,000 were due to puerperal diseases. Recent disclosures with regard to St. Pancras workhouse may to some extent account for this high death-rate. The number of deliveries in these two workhouses bring them almost within the category of lying-in hospitals.

There are four other workhouses in which the annual deliveries are respectively 171, 120, and two of them 111, while in all the others the numbers fall much below 100.

In one such instance (Holborn), where the deliveries have averaged fifty a year, the death-rate was exceptionally high, 24 per 1,000, one half of which was due to puerperal disease. In another instance, St. Mary’s, Islington, with seventy-five deliveries per annum, the death-rate averaged 29 per 1,000. But the causes are not stated, and cannot now be ascertained. In Whitechapel, where there were 111 deliveries per annum, the death-rate was 10·8 per 1,000, one half being due to puerperal diseases.

It is possible that local enquiry might elucidate the causes of this mortality. The cases are, however, exceptional to the experience of London workhouses, viz. that the death-rates from puerperal diseases and accidents of childbirth are scarcely higher than they are in all England, town and country. Let us try to ascertain how far the management adopted may have led to these comparatively favourable results.

The conditions for recovery in a great majority of the London workhouse lying-in wards are at least as favourable as they are in the Liverpool workhouse; in most cases undoubtedly more so, as will immediately be seen when we consider that the average annual number of deliveries in Liverpool workhouse is more than twice that of the two largest London workhouses, and from five to ten times most of the others; that in the London workhouses the rule is to have many unoccupied beds, while this is the exception in the Liverpool workhouse.

The cardinal principle in the management of these London workhouse lying-in wards appears to be this: their occupants are a fluctuating number; often the wards have but one woman at a time, and the cubic space for each of these women is ‘in fact the cubic space of the whole ward.’[18] Sometimes, but only for brief periods, all the lying-in beds may be occupied. For much longer intervals the occupants are very few in number, so that each has a large proportion of cubic space, and sometimes the wards in some of the workhouses are empty. There are no medical schools attached to the institutions, and no medical students who may have passed from a case of erysipelas or from the post-mortem theatre to the lying-in bedside; there is the possibility of removing immediately any case of febrile or other disease which may occur in the lying-in ward into the general sick wards of the workhouse; there is discharge of convalescent cases at the earliest possible period, either to their own homes or to other parts of the establishment; these conditions, together with the paucity of numbers and the occasional vacating and rest of the wards, appear to constitute the main difference between a workhouse lying-in ward and a lying-in hospital.

In both classes of establishments the same attention is doubtless bestowed on ventilation, cleanliness, and frequent change of bedding.

_MANAGEMENT OF MILITARY LYING-IN WARDS._

The lying-in arrangements provided for soldiers’ wives are as follows:—

The rule is that women shall be delivered in quarters, provided there be decent accommodation. At a number of the larger stations, where suitable married quarters have not yet been fully provided, there are female hospitals, attached to which, as we have already seen, is a delivery and lying-in ward, with the usual offices. In the specially constructed hospitals the wards are of a good size, well-lighted, warmed and ventilated. If all the beds were occupied, the space would be 1,300 cubic feet per patient. But this is an event which rarely or never happens, so that there is always plenty of room and good ventilation.

If[19] a woman requires admission, her husband applies to the medical authorities for a ticket. No woman with a disease considered to be infectious is admitted. The women usually follow their ordinary avocations until obliged to proceed to hospital by imminent labour. They are taken there in cabs, all the necessary arrangements for the lying-in having been made, if possible, by previous intimation. The woman is delivered in the delivery ward, and is thence transferred to the lying-in ward. As a rule, the lying-in pavilion in these female hospitals is distinct in all its arrangements for nursing from the pavilion for general cases. Infectious cases are not received into the same hospital, except at Aldershot.

In these hospitals for soldiers’ wives the time which elapses from the admission to the discharge of the women is usually ten, and in some cases twelve days.

At Aldershot four ‘Sisters’ are now at work in the soldiers’ wives’ hospital. One was trained as midwife, and took charge of the midwifery cases early in 1867. The Sister midwife has sole charge of the lying-in women for five or six days. They are then passed into a third ward, and are nursed by the Sisters who attend the ordinary cases (which are, however, of course in a separate ward).

The Sisters do not help the midwife, as a rule. Only the Superior, on an emergency, and one for scrubbing floors periodically, enter the midwifery wards (i.e. the delivery and lying-in wards).

In 1869 Aldershot had no fatal case among the lying-in women.

[The ‘infection wards’ are nursed by ordinary nurses, and in cases of children by the parents.]

It will be seen, therefore, that at Aldershot the midwife has nothing to do with the general cases, and the matron is not now the midwife. Both there and at Woolwich the lying-in nursing is quite separate from the general nursing.

The medical officer remarks, as to the two deaths in 1869 at Woolwich: ‘Two cases of puerperal peritonitis after bad labours, requiring instrumental and other assistance, died, but the disease did not extend. My opinion is that the coldness of the wards, though objectionable, has a great deal to do with the comparative immunity hitherto enjoyed as regards the germination and extension of contagious diseases.’

It need scarcely be said that these new hospitals are models of cleanliness.

In the Colchester Hut the patient is received into a separate compartment, of which there are four, where she is delivered and remains until discharged to quarters.

It is very rarely indeed, if ever, that all the four compartments are occupied simultaneously. The average stay is ten days; the average number of deliveries a year under 50.

This hut does not form part of a hospital. It is a separate establishment, solely for lying-in women, as such accommodation should always be.

_Note._—There is another reason, though it may be termed a fanciful one, for altogether disconnecting lying-in institutions with general hospitals, and even with the name and idea of hospital. It is this: there must be a certain death-rate in a general hospital, receiving as it does fatal diseases and fatal accidents, as long as men and women have fatal diseases and fatal accidents.

But lying-in is not a fatal disease, nor a disease at all. It is not a fatal accident, nor an accident at all.

Unless from causes unconnected with the puerperal state, no woman ought to die in her lying-in; and there ought, in a lying-in institution, to be no death-rate at all.

It is dangerously deadening our senses to this fact—viz., that there ought to be _no_ deaths in a lying-in institution—if we connect it in the least degree with the name of hospital, so long as a hospital means a place for the reception of diseases and accidents.

In French statistics, this confusion of ideas, were it not ghastly, would be ludicrous. ‘Admissions,’ under the head ‘Malades,’ include not only the lying-in women, but the new-born infants, which appear to be ‘admitted’ to life and to hospital together, as if life were synonymous with disease, so that, e.g. 4,000 ‘Admissions,’ in such a year, to the Paris Maternité would mean 2,000 deliveries, 2,000 births—[and—how many deaths?]

_RECAPITULATION._

In summing up the evidence regarding excessive mortality in lying-in institutions and its causes, it appears:—

1. That, making every allowance for unavoidable inaccuracies in statistics of midwifery practice, there is sufficient evidence to show that in lying-in wards there reigns a death-rate many times the amount of that which takes place in home deliveries.

2. That a great cause of mortality in these establishments is ‘blood-poisoning,’ and that this arises from the greater susceptibility of lying-in women to diseases connected with this cause. From whence it follows that in many lying-in wards, as at present arranged and managed, there must be conditions and circumstances apart from those belonging to the inmates personally, which aid in the development of this morbid state.

3. That the risks to which lying-in women are exposed from puerperal diseases are increased by crowding cases in all stages into the same room or under the same roof; by retaining them for too long a period in the same room; by using the same room for too long a period without cleansing, evacuation, rest, and thorough airing: but that the death-rate is not always in proportion to the number of lying-in cases which have passed through the hospital.

It follows from this that, other things being equal, a high death-rate may take place in a small hospital constantly used up to its capacity as well as in a large hospital constantly used up to its capacity.

4. That there are superadded causes in some establishments which add greatly to their dangers. Among these may be reckoned the following:—

(_a_) Prevalence of puerperal fever as an epidemic outside the
hospital.

(_b_) Including midwifery wards within general hospitals, thereby
incurring the risk of contaminating the air in midwifery
wards with hospital emanations.

(_c_) Proximity to midwifery wards of post-mortem theatres or other
external sources of putrescence.

(_d_) Admitting medical students from general hospitals or from
anatomical schools to practice or even to visit in midwifery
wards without special precautions for avoiding injury.

(_e_) Treating cases of puerperal disease in the same ward, or under
the same roof, with midwifery cases.

(_f_) Permitting the same attendants to act in infirmary wards and in
lying-in wards, and using the same bedding, clothing,
utensils, &c., in both.

(_g_) Most probably also—especially in certain foreign hospitals—want
of scrupulous attention to ventilation, and to cleanliness in
wards, bedding, clothing, utensils, and patients, and in the
clothing and personal habits of attendants.

In short, the entire result of this enquiry may be summed up, in a very few words, as follows:—A woman in ordinary health, and subject to the ordinary social conditions of her station, will not, if delivered at home, be exposed to any special disadvantages likely to diminish materially her chance of recovery. But this same woman, if received into an ordinary lying-in ward, together with others in the puerperal state, will from that very fact become subject to risks not necessarily incident to this state. These risks in lying-in institutions may no doubt be materially diminished by providing proper hospital accommodation, and by care, common sense, and good management. And hence the real practical question is, whether it is possible to ensure at all times the observance of these conditions.

The great mortality in lying-in hospitals everywhere is no doubt a strong argument against such a result being attainable; so much so that, in the absence of this security, the evidence in the preceding pages appears sufficient to warrant the question being raised, whether lying-in hospitals, arranged and managed as they are at present, should not be forthwith closed?

Can any supposed advantages to individual cases of destitution counterbalance the enormous destruction of human life shown by the statistics?

Without vouching for the entire accuracy of Le Fort’s data, they may still be taken generally as showing approximately the penalty which is being paid for the supposed advantages of these institutions. It is this: (see Table XV.) for every two women who would die if delivered at home, fifteen must die if delivered in lying-in hospitals. Any reasonable deduction from this death-rate for supposed inaccuracy will not materially influence the result.

TABLE XV., _abstracted from_ TABLES III. _and_ X., _showing Comparative Mortality among Lying-in Women in Hospitals and at Home_. ┌──────────────────────────────────────────┬──────────┬──────┬────────┐ │ │ │ │ │ │ │ │ │ Deaths │ │ │ │ │ per │ │ │Deliveries│Deaths│Thousand│ ├──────────────────────────────────────────┼──────────┼──────┼────────┤ │Total for all hospitals │ 888,312│30,394│ 34│ │Total delivered at home │ 934,781│ 4,405│ 4·7│ ├──────────────────────────────────────────┼──────────┼──────┼────────┤ │Excess of deaths per thousand delivered in│ │ │ │ │ hospitals │ │ │ 29·3│ └──────────────────────────────────────────┴──────────┴──────┴────────┘

The evidence is entirely in favour of home delivery, and of making better provision in future for this arrangement among the destitute poor.

_CAN THE ARRANGEMENT AND MANAGEMENT OF LYING-IN INSTITUTIONS BE
IMPROVED?_

Must we, then, surrender the principle of lying-in institutions altogether, and limit the teaching of midwifery nurses solely to bedside cases at home, notwithstanding the well-known difficulties of teaching pupils at the beginning of their course elsewhere than in an institution? We will try to reply to this question; and, in doing so, perhaps some light may be thrown on another question, viz.: how to improve existing lying-in establishments so as to reduce the mortality in them.

Evidence sufficient has been collected to show that no one panacea will enable us either to possess a perfectly healthy building, or to improve existing hospitals.

Much has been written about the saving effect of small hospitals; but it is certain, from what has been already said, that the small-hospital idea is not sufficient of itself. It is, however, a very important idea, because all hospital problems are simplified by subdivision of the buildings. So far as we know, every one who has carefully studied the subject has given a preference to small lying-in establishments over large ones; but we should certainly be disappointed if we trusted to smallness of size alone for reducing the mortality.

The evidence further shows that in any new plan infirmary wards must be kept quite detached from lying-in wards. They should be in another part of the ground, and should be provided with their own furniture, bedding, utensils, stores, kitchen, and attendants.

The same arrangement, at least in principle, should be carried out at all existing lying-in establishments, and every case of disease should at once be removed from the lying-in wards to the infirmary, and be separately attended there.

In our proposed midwifery school the whole attendance would be supplied by midwives and pupil midwives, with a physician accoucheur, to make his visit twice a day, to be sent for in time of need, and to give instruction to the pupil midwives by lectures and otherwise; and in this way we should escape the dangers of introducing medical students.

Applying the same principle to lying-in wards to which medical students are admitted, there can be no doubt that a responsibility of the very gravest kind attaches to all teachers and managers of lying-in hospitals who do not satisfy themselves that students admitted as pupils have nothing to do, either with general hospital practice, or with anatomical schools, during the period. Midwifery instruction should be treated as a matter quite apart.

What has been already said need scarcely be repeated, about the dangers of connecting midwifery wards with general hospitals. The simple facts are sufficient to show that all midwifery wards of this class should be at once closed.

As a general result of this enquiry, applicable to all lying-in wards, the evidence shows that very much indeed of the success depends on good and intelligent administration and management.

Suppose that all these precautions could be carried out, will the cost and difficulty of giving effect to them necessarily lead to the abolition of all accommodation for midwifery cases, or for teaching midwifery?

We reply, No. The facts already adduced clearly show what may be done in this matter.

They prove, in the first place, that lying-in women should, as a rule, be delivered at home. And, as a consequence, that whatever provision may be made for cases of special destitution, or for midwifery teaching, such provision should be assimilated as far as practicable to the conditions which surround lying-in women in fairly comfortable homes.

These conditions are realised, and in some instances no doubt improved on, in the better class of workhouse lying-in wards, and of lying-in huts for soldiers’ wives.

The favourable results arrived at in many of these institutions appear to show that a little more care would lower the death-rate still further.

In every instance where it is considered necessary to organise lying-in accommodation by voluntary effort, the same principles should be kept in view.

The success which has attended Waterford Lying-in Hospital, already mentioned, shows how much may be done in rendering such accommodation a real boon to the poor.

A single hut, like the Colchester Hut, erected in a needy locality, would supply, and that safely, all the accommodation wanted. But for a training school of midwives and midwifery nurses other accommodation is required, and of a far more costly character.

It is true that any sort of building may be leased or bought and altered, or added to, and told off as a training school; but after what has been said, to take such a course would be to ensure killing a certain number of mothers for the sake of training a certain number of midwives. If we are to have a training school at all, we must, before all things, make it as safe for lying-in women to enter it as to be delivered at home; and having made up our minds what is necessary for this purpose, we must pay for it.

CHAPTER II.
_CONSTRUCTION AND MANAGEMENT OF A LYING-IN INSTITUTION AND TRAINING
SCHOOL FOR MIDWIVES AND MIDWIFERY NURSES._

To apply all this experience to the construction and organisation of a school for midwives and midwifery nurses[20] is the next thing:—

Everybody must be born, and every woman, at least in this kingdom, is attended at the birth of her child by somebody, skilful or unskilful. Except in the case of multiple births, there are therefore as many attendances as there are births in the Returns of the Registrars-General.

This it is which makes the subject of midwifery nursing of such paramount importance.

Lying-in is an operation which occurs in England to seven women out of a hundred annually. In 1868 there were 786,858 children born alive in this country, wherefore for the midwives and midwifery nurses to be trained there will always be occupation and custom enough; whereas the occupation and custom for a surgical operator is, it is to be hoped, comparatively small, except in Franco-German wars. Even there we may trust that 7 out of 100 had not to undergo an operation. Certainly to 7 out of every 100 annually a surgical operation in England does not occur.

Between midwifery nursing and all other hospital nursing there is this distinction, viz.: the operator is herself the nurse; and the head-operator (or midwife) ought to be a woman, and _is_, in Paris and Vienna, and elsewhere.

Lying-in patients are to be compared to surgical (or operation) patients, _not_ to medical patients, and _should_ be perfectly well in health.

Since lying-in is not an illness, and lying-in cases are not _sick_ cases, it would be well, as already said, to get rid of the word ‘hospital’ altogether, and never use the word in juxtaposition with lying-in women, as lying-in women should never be in juxtaposition with any infirmary cases.

As to amount of work, necessary administrative conveniences and the like, a lying-in institution is to be compared to a surgical, _not_ medical hospital, or rather to a hospital for operations.

It has been already shown that great improvements are required in the manner of keeping midwifery statistics, and that many data are wanting for this purpose. It would be altogether wrong to deal with these statistics on the same principles as if they were general hospital statistics. Lying-in is neither a disease nor an accident, and any fatality attending it is not to be counted as so much per cent. of inevitable loss. On the contrary, a death in childbed is almost a subject for an inquest. It is nothing short of a calamity which it is right that we should know all about, to avoid it in future. A form of record is appended (Table XVI.), which appears to afford the means of registering the required information.

I. _CONSTRUCTION OF A LYING-IN INSTITUTION._

What then, first, should be the principles of construction for a lying-in institution, in order to combine safety for the lying-in women with opportunity of training for the pupil midwives? And,

1. _How many Beds to a Ward?_

Not more than four.

Or single-bed wards might be arranged in groups of four.

Also, it must always be borne in mind that four beds mean eight patients. There are two patients to each bed (unless it is meant to kill the infants) to use up the air, which is besides used up by a necessarily far larger number of attendants than in any general hospital. For, during the time the mother is incapable of attending to the infant, the infant is incapable of attending to itself. Also, an exhausted mother, and feeble, almost lifeless infant, cannot ring a bell or make themselves heard. Indeed, an infant which cannot cry is in the greatest danger.

TABLE XVI.—_Proposed Registry of Midwifery Cases._

NOTE.—Should any death take place in a woman discharged from the
institution within a month from the time of her delivery, a record
of this death, its date, and cause, to be entered in the column of
Remarks. In the same column should be entered remarks on abnormal
configuration, or on abnormal conditions of health which might
influence the result of the delivery.

For all this provision must be made. There are scarcely two points in common between a lying-in institution and a general hospital.

2. _How many Wards to a Floor?_

Only one four-bed ward, or four one-bed wards in a group.

3. _How many Floors to a Pavilion (hut or cottage)?_

Two, at most. In every alternate pavilion better only one floor, unless the pavilions be so far apart as to cover an extent of ground which would make administration almost impossible, and cost fabulous.

_How many Beds to a Pavilion or Hut?_

There would therefore be no more than eight beds, and in each alternate pavilion no more than four beds.

_How many Pavilions or Huts to a Lying-in Institution?_

Not more than four two-floored pavilions, two one-floored pavilions, and two two-floored delivery pavilions; unless, indeed, building space can be given, with all its cost and administrative difficulties.

4. _How much space to the Bed?_

The _minimum_ of ward cubic space for a lying-in woman, even where the delivery ward is, as it ought always to be, separate, is 2,300 cubic feet in a single-bed ward, and 1,900 cubic feet in a four-bed ward.

[In ordinary army wooden huts, where the air comes in at every seam, this space may be less.]

As it is a principle that superficial area signifies more than cubic space, the surface of floor for each bed should not be less than 150 square feet per bed in a four-bed ward, and in a single-bed ward not less than 190 square feet, because this is the total available space for all purposes in a single-bed ward. This space has to be occupied, not only by the lying-in woman and her infant, and perhaps a pupil midwife washing and dressing it at the fire, but often by the midwife, an assistant, possibly the medical officer, and pupil midwives. In a four-bed ward there is space common to all the beds.

_The Delivery Ward._

Ought to be separate in every lying-in institution; _must_ be separate in an institution of more than four or five beds, though in separate compartments.

Every delivery bed should have a superficial area of not less than 200 square feet, and a cubic space of not less than 2,400 cubic feet.

5. _How many Windows to a Bed?_

One at least to each bed. Two beds and two windows on each side of the four-bed ward.

In a single-bed ward the bed should not be placed directly between window and door. And it must never be in an angle. There must be room for attendants on both sides the bed.

This is still more essential in a delivery ward. Each bed should be lighted on _both_ sides by windows, and should have at least five feet of passage room on either side.

6. _What are healthy Walls and Ceilings and Floors?_

Oak floors, polished; furniture also; impervious glazed walls and ceilings, or frequent lime-washing.

All that has been so justly said as to the necessity of impervious polished floors and walls for hospitals applies tenfold to lying-in institutions, where the decomposition of dead organic matter, and the re-composition of new organic matter, must be constantly going on.

It is this, in fact, which makes lying-in institutions so dangerous to the inmates.

And it may literally be said that the danger increases as the square of the number of in cases.

Lying-in ‘infection’ is a very good illustration of what ‘infection’ really means, since _parturition_ is not infectious or ‘contagious.’

The excessive susceptibility of lying-in women to poisonous emanations, the excessively poisonous emanations from lying-in women—these constitute a hospital influence on lying-in cases brought together in institutions, second to no influence we know of exercised by the most ‘infectious’ or ‘contagious’ disease.

The death-rate is not much higher among women lying-in at home in large towns than in healthy districts. Therefore the agglomeration of cases together and want of management required to meet it must bear the blame.

As to floors, the well-laid polished floor is _a sine quâ non_ in a lying-in institution, where, with every care, slops, blood, and the like, must frequently be spilt on the floor.

7. _What is a healthy and well-lighted Delivery Ward?_

There must be two separate delivery wards for each floor of the whole lying-in institution, so arranged and connected _under cover_ that the lying-in women may be removed after delivery to their own ward. And for this purpose the corridors must admit of being warmed during winter, especially at night, so as to be of a tolerably equable temperature.

Unlimited hot and cold water laid on, day and night, W.C. sink, bath-sink, clean linen, must be close at hand.

In a pavilion hospital one single-bed ward should be attached to each delivery ward, for an exhausted case after delivery, till she is able to be moved to her own ward.

The delivery ward should be so lighted and arranged that it can be divided, by curtains only, into three if not four compartments.

No woman being delivered should see another delivery going on at the same time.

The delivery bedsteads stand in their compartments.

Each delivery bed should have window light on either side, and also ample passage room all round and on both sides the bed.

Care should be taken that no bed should stand exactly between door and window, on account of draughts.

The curtains, of washing material, are only just high enough to exclude sight, not high enough to exclude light or air, and are made so as to pull entirely back when not wanted. Each area enclosed by the curtains should of course be sufficiently ample for pupils, attendants, and patient; also for a low truck on broad wheels covered with india-rubber, to be brought in, on which the bedstead with the clean warm bedclothes is placed, and the newly-delivered woman conveyed to her own ward.

[A woman very much exhausted would be carried in the delivery bed to the bye-ward attached to each delivery ward.]

The reason why there must be two delivery wards for each floor of a lying-in institution, to be used alternately, one ‘off,’ one ‘on,’ is that one delivery ward on each floor must be always vacant for thorough cleansing, lime-washing and rest for a given period, say month and month about.

It is understood that newly-delivered women cannot be removed from one floor to another. And it is quite necessary to have the means of keeping a corridor, along which a newly-delivered woman is to be moved, at a proper temperature.

The position of the delivery wards should be as nearly as possible equidistant from the lying-in wards, and should be such that the women in labour, on their way to the delivery ward, need not to pass the doors of other wards.

A separate scullery to each delivery ward is indispensable; such scullery to be on at least an equal scale to that of ward sculleries. Hot and cold water to be constantly at hand, night and day. A sink-bath is desirable for immediately putting in water soiled linen from the beds and the like.

The scullery should contain a linen-press, small range with oven, hot closet at side of the fire-place, sink with hot and cold water, &c. A small compartment should contain a slop-sink for emptying and cleansing bed-pans, and a sink about six inches deep and sunk below the floor, which is intended for filling and emptying a portable bath, and which when not required for this might be used for soaking linen, &c.

Beyond the scullery, so as to be as far removed as may be from the traffic of the main corridor and the noises of the delivery ward, should be the bye-ward, with not less than 2,100 cubic feet of contents.

8. _Scullery, Lavatory, W.C._

The necessary consumption of hot and cold water is at least double or triple that of any general hospital. Sinks and W.C. sinks must be everywhere conveniently situated.

There must be a scullery to each four beds; the scullery must needs be much larger and more convenient than in a general hospital. There is often more work to be done by night than by day in a lying-in institution.

All the ward appurtenances, scullery, lavatory, &c., must stand empty for thorough cleansing, when the ward to which they belong stands empty in rotation for this purpose, and must not be used for any other ward. For each four-bed ward, or group of four one-bed wards, or for each floor of each pavilion, there must therefore be one scullery, with a plentiful unfailing supply of hot and cold water, with sinks and every convenience. The reason for this is two-fold:—

(1) To allow each scullery, with the other ward offices, to be thoroughly cleansed and whitewashed with its own group of four beds.

(2) The work in a scullery and in all the other ward appurtenances day and night, night and day, is many-fold that which it is in a general hospital scullery.

Besides this, general hospital patients ought never to be allowed to enter the scullery.

In a lying-in scullery the infants, most exacting of all patients, must frequently be in the scullery.

Even under the very best circumstances there are many lying-in cases among weakly women where the mother’s state is such as to render it necessary for a ‘crying’ infant to be washed and dressed elsewhere than in its mother’s ward. These infants are best washed, in that case, in the scullery, which must be so arranged that infants can be washed and dressed without being exposed to a thorough draught, and that nurses and babies may not be hustling one another.

There must be a good press in each scullery. A supply of clean linen and other necessaries will have to be kept in each press in each scullery.

The slop-sink and other appurtenances must be arranged so as to make allowance for the fact that the going backwards and forwards for water, hot and cold, or to empty slops in a lying-in institution—where half the patients can do nothing for themselves, and the other half (the mothers) are supposed to be ready for discharge when they can go to the ward offices for themselves—is more than it is in general hospitals.

Fixed baths are not necessary. But there must be means for filling with hot water moveable infants’ baths at all hours at a moment’s notice, since an infant’s life often depends on immediate facility of hot-water bathing.

And this besides the daily regular night and morning washing of infants.

There must be also a moveable bath for each ward for the lying-in women, with the means for supplying it with hot and cold water and for emptying it. Lying-in patients are not able to use either fixed baths or lavatory.

Glazed earthenware sinks should alone be used, as being by far the safest and cleanest.

9. _How to Ventilate Lying-in Wards._

The best ventilation is from opposite windows. Each window should be in three parts, the third or uppermost to consist of a flap hung on hinges to open inwards and throw the air from without upwards.

Inlet valves, to admit fresh air, and outlet shafts, to emit foul air, must be added to complete the natural ventilation.

10. _Furniture, Bedding, Linen._

As little ward furniture as possible. As much clean linen as possible.

A very large and convenient clean linen-store, light and dry, must be assigned to the matron: very much larger than would be required for a general hospital; but no general hospital in London supplies a good standard for such.

There must be in each scullery, besides, a clean linen-press.

There should be a very ample and convenient place for bedding.

Mattresses, blankets and the like, have to be renewed, taken to pieces and washed—especially those used in the delivery ward—many times oftener than in any general hospital.

The rack for linen should be along the middle of the linen-store.

There should be space for a bedding-rack along one end, taking about three feet six inches from the length of the room for linen. Space for some spare mattresses and bolsters will be necessary; and they should be stowed near to a lift.

A linen-store requires thorough lighting, ventilating, and warming. Three windows are better than one. The linen must of course be kept dry and aired.

11. _Water Supply, Drainage, Washing._

Unlimited hot and cold water supply, day and night, should be laid on all over the buildings.

All drains and sewers must be kept outside the walls of the buildings, and great care should be bestowed on trapping and ventilating them, to prevent foul air passing into the institution.

The washing in a lying-in institution is, it need not be said, very large, and should be conducted quite at a distance. Sink-baths, for immediately putting in water soiled linen, are necessary.

12. _Medical Officer’s Room and Waiting-room._

No dispensary, especially no dispenser, is needed in a lying-in institution.

A medical officer’s room is necessary. The medical officer is not resident. He makes his morning and evening visit, and is called in by the head midwife for any difficult case. He gives instruction, scientific and practical, to the pupil midwives. [These lectures are given in the pupil midwives’ mess-room.]

In the medical officer’s room should be kept the instruments, to which a fully qualified head midwife also has a key. The medical officer keeps the notes of cases, &c., and of instruction to the pupil midwives in this room.

The few, very few, drugs needed in a good lying-in institution are kept here, or in the head midwife’s sitting-room.

A waiting-room is necessary.

There must be a room where the head midwife can examine a woman, to know if labour is imminent.

This might be done in the medical officer’s room or the waiting-room.

13. _Segregation Ward._

A ward is unfortunately necessary, completely isolated, where a sick case, brought in with small-pox or erysipelas or the like, could be delivered and entirely separated from the others, or where a case of puerperal fever or peritonitis (though such ought never to arise after delivery in a properly constructed and managed institution) could be transferred. But if, unfortunately, puerperal fever should appear in the hospital, no new admissions should be allowed until the buildings have been thoroughly cleansed, lime-washed, and aired.

The segregation ward must have a nurse’s room, and a provision of sink, slop-sink, &c.

14. _Kitchen._

The kitchen should be well placed, conveniently near, yet sufficiently cut off from the main corridor by a neck of passage and intermediate offices.

_SITE._

The site of a lying-in institution must be open, airy, surrounded with its own grounds, not adjoining or near to any other building, still less to any hospital or any nuisance or source of miasm. But it must be in the immediate vicinity of any large centre of population from which the lying-in women come.

And this involves the question of receiving-rooms.

Should there be a receiving-room, as well as a waiting-room?

The lying-in woman’s name is put down for admission some time beforehand.

Lying-in hospitals differ as to their rules whether or no to admit women any time before labour is imminent. If they are not so admitted, they often have to be sent back again home.

It is now believed to be the soundest principle that the fewer days a lying-in woman spends in a lying-in institution, beyond the time she is actually under treatment, the better; and this involves that she should not be admitted till labour is imminent—even at the risk of the infant being born in cab or lift (which _has_ happened).

Lying-in institutions must (unfortunately) be, therefore, in the immediate neighbourhood of great towns or centres of population.

[Even those London Boards which are building their excellent new workhouse infirmaries in the country, are forced to keep their lying-in wards in the old workhouses in the town.]

The difference, however, as has been shown by our statistics, is not so great between the mortality of women lying-in at home in the country and in the town as should make us pronounce against lying-in institutions in great centres of population—provided they have a large and entirely isolated area completely to themselves, perhaps a proportion of two acres to fifty beds.

But this involves another question.

A large proportion, alas! of workhouse lying-in women (we have seen two-thirds at Liverpool[21]) are unmarried. Of these many have no home.

It is difficult to send these women back again, even if labour is not actually imminent. And it is impossible to send them out after delivery, till recovery is fairly confirmed.

In workhouses the question is solved by women being admitted into the body of the house during pregnancy, and discharged into the body of the house, if not to their own homes, when quite convalescent.

In Liverpool Workhouse fourteen days after labour the lying-in women are thus discharged. Fourteen, eighteen, twenty-one days, are the average of a woman’s stay in the lying-in division in London workhouses.

A soldiers’ wives’ hospital takes in no unmarried women to lie-in.

Civil lying-in institutions almost invariably have to make exceptions and take in unmarried women.

In workhouses they are not the exception, they are the rule. Married women are the exception.

It is to be observed that married women will rarely come in an hour before, or stay an hour after it is necessary, in any lying-in institution.

Ten to twelve days is ‘the average period of hospital treatment’ in Colchester, Woolwich, and other soldiers’ wives’ lying-in hospitals. ‘Women of this station of life cannot, as a rule, be prevailed upon to submit to longer detention,’ it is added.

The average number of days in King’s College Hospital lying-in ward was sixteen. None were permitted to leave under fourteen days. Twenty-one days were _allowed_, in ordinary cases. It is feared this might be too long; but so very many weakly, half-starved women sought admission, that to send some away sooner was ‘to ensure a breakdown,’ it is stated.

In a civil lying-in institution it would not be by any means desirable absolutely to exclude single young women _primiparæ_; it would be grievous to some of these poor things to be sent among the (often hardened) wretched women of the workhouse. The whole question of these poor young women—unmarried mothers of a first child—is full of difficulty. It would never do, morally, to make special provision for them. And for this very reason we seem bound to receive such, conditionally, into well regulated lying-in institutions, and afford some kindly care to prevent, at the very least, their sinking lower. But it would not be right to leave any admissions for single women in the hands of any young assistant, or morally inexperienced person.

The principle appears to be that, if pregnant women are to be received some time before and kept some time after delivery, the excess of time should not be passed in the lying-in wards, but in separate accommodation.

II. _MANAGEMENT._

Construction, however, in a lying-in institution, holds only the second place to good management in determining whether the lying-in patients shall live or die. And without such management, no construction, however perfect, will avail.

And the first elementary principle of good management is to have always one pavilion of four or eight beds, according as it is of one floor or of two, standing empty in rotation for purposes of thorough cleansing. _A fortiori_—one delivery pavilion on each floor is always to be vacant alternately.

The pavilion to be in rotation unoccupied for the purposes of cleansing must necessarily be the _whole_ pavilion, with all its sculleries and ward offices, since the process of cleansing is—turning out all the little furniture a lying-in ward ought ever to possess, bringing in lime-washers, possibly scrapers and painters, leaving doors and windows open all day, and even all night.

Every reason for having each ordinary pavilion ward completely separate, and individually _pavilionised_, applies with tenfold force to the delivery ward. Each must be complete in itself, with all its appurtenances and bye-ward for extreme cases, as a little pavilion. There is no possibility for properly cleansing and lime-washing the delivery ward _not_ in use, unless this be the case.

_One_ delivery ward, however spacious and well arranged _constantly_ used, would be a centre of deplorable mischief for the whole institution. This makes _two_ delivery wards for each floor of the institution indispensable, to be used alternately for the whole floor at given periods.

_N.B._ Liverpool Workhouse with 25 lying-in beds, exclusive of delivery beds, has had an average of 500 deliveries _a year_ for eleven years. A civil lying-in hospital in or near a large town is generally _just as full as it is permitted_ to be. Five or six hundred deliveries or more _a year_ might be reckoned upon; occasionally three or four deliveries a night. Sculleries will be _always_ in use, _day and night_. All this renders it imperative that an inexorable rule should be made and kept to, viz. that every lying-in pavilion should be vacant in rotation, each delivery pavilion alternately, for thorough cleansing.

2. The second elementary principle of good management is to remove every case of _illness_ arising in the institution, and every such case admitted into the institution, at once to an isolated sick ward or infirmary ward.

This is _must_, not may.

Though we should have no puerperal fever or peritonitis in a building of this _make_, yet unfortunately other institutions will send in (say) erysipelas or small-pox patients seized with labour.

Sad experience tells that this unprincipled practice has often proved fatal to many other inmates of the lying-in institution, turning an institution into a hospital.

Every sick case should therefore be completely isolated, in a separate sick ward, from the lying-in women. And if admitted before delivery, her delivery should take place in this separate ward.

_N.B._ The nurse’s dinner and meals may be prepared in the general kitchen and sent to her. The patient’s arrowroot, gruel, &c., must be made, and her beef-tea warmed, in the ‘sick or segregation’ building, and all linen must be sent to the ward well aired.

Is it desirable to connect the ‘segregation’ ward by any covered passage with the rest of the lying-in institution?

There is much to be said for and against.

The ward, it is to be hoped, will not often have to be used at all.

But small-pox has appeared after labour.

There might be danger in taking a patient from the institution to this ward through the open air, in all weathers, unprotected by any covered passage.

On the other hand, when once the patient is in the ward, complete isolation is by far the best, for the sake of all the others.

And there is by no means the same necessity for a passage as in the other parts of the institution where any night there may be three or four ordinary delivery cases to be conveyed through the passages.

A covered ambulance for sick cases is not, however, a nice thing, though often suggested.[22]

3. The first two may be called universal and essential principles of good management in every lying-in institution, large or small, however perfectly constructed.

Here is a third, hardly less essential, wherever there is more than one bed to a ward, viz. to remove a lying-in woman three times during her stay in the institution.

The average course of an ordinary case may be reckoned thus:—

Seven or eight hours in the delivery ward.
Five or six days in the lying-in ward.
Nine or ten days in the convalescent ward.

The nearer wards to the delivery ward in use should always be made the wards for women immediately after delivery; the farther wards for the same women when removed for their convalescent stage.

In a single-bed ward the woman may remain in her own ward from after her delivery till her discharge; that is, no further removal after her delivery is necessary.

4. Cases of extreme exhaustion after delivery, which are better out of the delivery ward yet cannot be moved many yards, should be carried _in their beds_ to the bye-ward adjoining the delivery ward, till they are somewhat recovered.

These must have a constant watcher by them.

5. In a lying-in institution about three times the quantity of linen and bedding for each patient is necessary of what is used at a general hospital.

The day’s and night’s provision of linen is kept in each ward scullery, and in the scullery of each delivery ward in use.

The linen-store in the store-room, and the bedding-store, need to be very complete and ample.

The bedding, that is, the mattress and blankets, of any one bed in the delivery ward should not be used for more than three or four delivery cases in succession without undergoing some process of purification—and this quite independent of any accident, the mattress of course being protected by Macintosh sheeting.

_III. TRAINING SCHOOL FOR MIDWIVES._

The few words which will here be added on the management of a midwifery training school are not at all to be understood as a manual for practical instruction, which it is quite impossible to introduce here, but as simply treating of the management, in so far as this determines some constructive arrangements as imperative, and others as to be avoided.

No charity or institution, I believe, could possibly bear the expense of a single-bed ward, or even of a four-bed ward lying-in establishment, for a pretty constant succession of thirty-two patients, unless there were a training school.

[Thirty-two single-bed wards, an administrator would say, would require sixteen nurses, independently of midwives!!]

Even with a training school, the first year would be one of great difficulty, since all well managed training schools ‘take in’ pupils as much as possible at only two periods of the year, so as never to have the whole of the pupils fresh hands at once. But the _first_ batch must necessarily be all fresh hands. A raw girl cannot be turned in to sit up with a newly-delivered woman and new-born infant. And a midwife cannot be spared to each girl all to herself, to teach her how to handle an infant. [That is, in each single-bed ward.]

The whole nursing service of a large four-bed or one-bed ward lying-in institution is so complicated, so different from that of a general hospital with its 20 or 32–bed wards, that it is difficult to provide for.

In even guessing at what the nursing accommodation should be for so completely new an experiment as a lying-in institution of 40 beds in single-bed or four-bed pavilions, we must begin by stating the probable requirements, the whole being tentative.

The staff would have to be at least as follows:—

One matron.

One head midwife.

One assistant midwife.

One deputy assistant midwife (for the first year).

To establish a really good training school,

Thirty pupil midwives.

[Two experienced good nurses in addition might be necessary for the first year.]

One cook.

One housemaid.

One or two other female servants, such as scourers—or more (number required depending on the flooring used).

Though this staff appears enormous, it is calculated upon the plan of giving only one night nurse to every four beds,—upon the supposition that 32 occupied beds will give a constant succession of cases, enough to provide instruction for almost as many pupil midwives;—upon the principle that for systematic instruction there must be a fair number of pupils; as, if every moment of their time is occupied in active duties, they cannot be well trained;—and also upon the obvious fact that it would be impossible, from its extravagance, to nurse such a construction without pupils.

[For the _second_ year, if a portion of the pupils are to be made thorough midwives, and their time of training two years, possibly the deputy assistant midwife, and probably both the nurses, might be dispensed with.

The second-year pupil midwives ought to be quite competent, each to be in charge of two or three first-year’s pupils and several patients, taking these patients from the beginning, and teaching pupils to handle new-born infants, look after ordinary lying-in cases, and the like; and most excellent practice it is for the young teachers.]

As to scourers, the nature of the floors decided upon will determine what are wanted.