Notes on Lying-In Institutions

Death-Rates in Lying-in Institutions

We shall next show approximately what are the death-rates in establishments for lying-in women.

We will give an abstract of mortality statistics for a number of these institutions, the general results of which may be stated as follows:—

In eight military lying-in hospitals (Table IV.), in which 5575 deliveries took place, in periods of from 2 to 12 years, there were 50 deaths (excluding a death before admission)—a death-rate of 8·8 per 1,000.

Table IV.—Return of the Number of Admissions for Parturition, and Deaths occurring in the undermentioned Women’s Hospitals (Military). (Supplied by the Director-General, Army Medical Department.)
Station	Period	No. of Deliveries	Causes of Death															Total Deaths
			Puerperal Feve and Peritonitis, Pyæmia, Phlebitis, &c.	Scarlatina	Puerperal Convulsions	Hæmorrhage, Effects of	Ruptured Uterus	Syncope and Exhaustion	Premature Labour and Adherent Placenta	Craniotomy	Inversion of Uterus	Embolism	Metritis	Pneumonia and Bronchitis	Phthisis	Dropsy	Cause not recorded
Devonport	April 1861 to Dec. 1869	158			1													1
Colchester	1865 to Oct. 187	252
Portsmouth	1861 to Dec. 1869	302	2		1					1								4
Aldershot	1857 to Dec. 1869	3,028	14		1	4	1	4	1	1			13	2	1		1	31
Shorncliffe	Up to Dec. 1869	702		1		1				2								4
Chatham	Dec. 1863 to Dec. 1869	342		2							14							3
Woolwich	Nov. 1863 to Dec. 1869	751	55					1				1				1		8
Curragh	1868 and 1869	40
Total		5,575	21	3	3	5	1	5	1	4	1	1	1	2	1	1	1	51

In Liverpool workhouse lying-in wards (Table V.), with an approximate number of 6,396 deliveries in 13 years, there were 58 deaths from all causes—a mortality of 9·06 per 1,000.

Table V.—Statistics of Midwifery Wards in Liverpool Workhouse for Thirteen Years, 1858–70 inclusive. (Abstracted from data supplied by Dr. Barnes, Liverpool.)
Approximate Total Deliveries	Causes of Death																		Total Deaths
	Puerperal Peritonitis	Puerperal Fever	Metritis	Phlegmasia Dolens	Convulsions	Debility and Exhaustion	Obstructed Labour	Hæmorrhage	Rupture of Uterus	Typhus and Relapsing Fever	Measles	Pneumonia	Laryngitis	Phthisis	Heart Disease	Nephritic Disease and Dropsy	Jaundice and Bowel Disease	Not Stated (Inquest)
6396	16	4	1	1	5	5	1	2	1	2	1	3	1	4	5	3	2	1	58

And in 27 London workhouse infirmaries (Table VI.), amongst which deaths took place, having 9,411 deliveries in five years, there were 93 deaths from all causes. The death-rate was 9·8 per 1,000.6

Table VI.—Mortality after Childbirth in Five Years, up to the end of 1865, in Forty London Workhouse Infirmaries in which Deliveries took place. (Abstracted from Report on Metropolitan Workhouses.)
Deliveries			Deaths from Puerperal Diseases	Deaths from Accidents in Childbirth	Deaths from Miasmatic Diseases	Deaths from Consumption and Chest Diseases	Deaths from all Other Causes	Total Deaths
27	workhouses:	9,411	39	20	0	15	19	93
13	„	2,459	0	0	0	0	0	0

The City of London Lying-in Institution, during ten years, 1859–1868, had 4,966 deliveries, and 54 deaths—a rate of 10·9 per 1,000.

The British Lying-in Institution had 1,741 deliveries, and 25 deaths, in 11 years, 1858–1868, giving a death-rate of 14·3 per 1,000 (Table VIII.).

The mortality in Queen Charlotte’s Lying-in Hospital: 9,626 deliveries, and 244 deaths, from 1828 to 1868 (Table VII.), was 25·3 per 1,000.

Table VII.—Mortality in Queen Charlotte’s Lying-in Hospital, 1828 to 1868.
Deliveries	Deaths from Puerperal Diseases	Deaths from Accidents in Childbirth	Deaths from Miasmatic Diseases	Deaths from Consumption and Chest Diseases	Deaths from all Other Causes	Total Deaths
9,626	138	51	8	32	15	244

The Rotunda Hospital, Dublin, with 6,521 deliveries in the years 1857–1861, yielded 169 deaths—a death-rate of 26 per 1,000. But, if we take the years 1828–1861, with 63,621 deliveries, we find that the deaths were 924, and the death-rate only 14·5 per 1,000—the average annual number of deliveries being almost as many thousands as in Queen Charlotte’s Hospital were hundreds.

Table VIII.—Mortality per Thousand from all Causes after Delivery. (Abstracted from Official Reports and Returns.)
Places		Deliveries	Deaths	Deaths per Thousand Deliveries
12 Parisian hospitals	{1861	7,309		95·1
	{1862	7,027		69·7
	{1863	7,289		70·3
King’s College Hospital, 1862–7		7807	26	33·3
Rotunda Hospital, Dublin, 1857–61		6,521	169	26·0
Queen Charlotte’s Lying-in Hospital, 1828–68		9,626	244	25·3
British Lying-in Institution, 11 years, 1858–68		1,741	25	14·3
City of London Lying-in Hospital, 1859–68		4,966	54	10·9
8 military lying-in hospitals, 2 to 12 years		5,575	50	8·8
Liverpool Workhouse Lying-in Wards, 13 years, 1858–70		6,396	58	9·06
40 London workhouse infirmaries, 5 years		11,870	93	7·8
1 military lying-in hospital (a wooden hut) 1865–70		252	0	0
All England, 1867		768,349	3,933	5·1

The lying-in wards of King’s College Hospital, years 1862–1867 (Table IX.), gave 27 deaths—a death-rate of 33·3 per 1,000 on 780 deliveries.

Table IX.—Mortality after Childbirth in Lying-in Ward, King’s College Hospital, 1862 to 1867.
Deliveries	Deaths from Puerperal Diseases	Deaths from Accidents in Childbirth	Deaths from Miasmatic Diseases	Deaths from Consumption and Chest Diseases	Deaths from all Other Causes	Total Deaths
7818	23	18	0	1	2	27

Lamentable as are these death-rates in many British institutions, they are small in comparison with those which have ruled in many foreign hospitals.

Table X. contains an abstract from Dr. Le Fort’s work of the statistics of 58 lying-in institutions in nearly every country of Europe, and extending in many cases over a considerable number of years. There is only one hospital (at Bourg) in which there was no death in 4 years, out of 461 deliveries.

There is one hospital (at Troyes), with a death-rate of 4 per 1,000 on 460 deliveries in 4 years.

There are two instances of death-rates of 7 per 1,000. There is one of 9, and there are two of 10 per 1,000.

In every other case the death-rates have exceeded these amounts, rising higher and higher in different institutions, until they culminate in a death-rate of no less than 140 per 1,000, at Strasburg, on a four years’ average among 556 deliveries. Le Fort’s data show a striking variation in the death-rates of the same hospitals in different years, as will presently be seen to be the case in hospitals in this country. There are instances in these foreign hospitals of the death-rates varying from 4 to 7–fold in different groups of years in the same hospital.

Le Fort’s data show that in lying-in hospitals in various countries and climates, scattered over nearly the whole of Europe, out of 888,312 deliveries there were no fewer than 30,394 deaths, giving an average death-rate of 34 per 1,000, a rate exceeding the high mortality which led to the discontinuance of our school for training midwifery nurses in King’s College Hospital.

Table X.—Table Showing the Death-rate from all Causes amongst Women Delivered in Lying-in Hospitals. (Abstracted from Dr. Le Fort’s ‘Des Maternités.’)
Maternity Hospitals		No. of Years of Observation	Deliveries	Deaths	Deaths per Thousand
Vienna Maternité		50	103,731	2,811	25
	Students’ Clinique	30	104,492	5,560	53
	Midwives „	30	88,083	3,064	34
	Académie Joséphine	1	277	24	86
Prague	Maternité	15	41,477	1,383	33
Munich	„	4	4,064	86	21
Göttingen	„	8	1,029	32	32
Gratz	„	3	3,089	97	31
Greifswald Clinique		4	316	18	56
Bremen Hospital		6	139	10	71
Halle Clinique		1	102	3	29
Berlin Clinique de l’Université		1	401	11	27
Frankfort-on-Main Maternité		7	1,213	13	10
Leipzig	Ancienne „	46	5,137	89	17
	Nouvelle „	3	594	20	33
Pesth Clinique		5	2,571	86	33
Moscow Maternité de la Maison des Enfans Trouvés		11	11,556	230	19
Ditto		10	16,721	436	26
Ditto		10	27,759	776	28
St. Petersburg	Clinique de la Faculté	6	376	34	90
	Hospital Kalinkin	15	1,288	20	15
	Institut des Sages
	Femmes	15	8,036	238	29
	Maternité des Enfans
	Trouvés	15	16,011	825	51
Dublin Maternité		58	84,390	875	10
Ditto		7	21,867	309	14
Ditto		5	12,885	198	15
Ditto		7	16,391	158	9
Ditto		7	13,167	224	17
Ditto		7	13,699	179	13
Ditto		7	13,748	163	11
London Lying-in Hospital		28	5,883	172	29
Edinburgh Hospital		1	277	3	10
Stuttgart „		1	424	3	7
Zurich Maternité		1	200	20	100
Stockholm „		1	650	37	56
Göttenburg „		1	223	18	80
Lund „		1	33	2	60
Freiburg en Breisgau		3	281	10	35
Jéna Clinique		4	308	21	67
Dresden Maternité		51	15,356	373	27
Paris Maternité		8	15,307	610	39
Ditto		10	23,484	1,114	47
Ditto		10	25,895	1,293	49
Ditto		10	26,538	1,125	42
Ditto		10	34,776	1,458	41
Ditto		10	25,094	1,298	51
Ditto		5	9,886	1,226	124
Total for ditto		63	160,704	8,124	56
Paris Clinique de la Faculté		5	1,654	117	70
Ditto		10	9,079	359	39
Ditto		10	9,462	379	40
Ditto		5	4,100	288	70
Total for ditto		30	24,295	1,143	47
Paris, St. Antoine		9	28	5	178
Ditto		10	32	15	468
Ditto		10	129	20	155
Ditto		10	788	65	82
Ditto		10	2,359	134	56
Ditto		5	1,868	110	58
Total for ditto		54	5,204	349	67
Paris, Hôtel Dieu		8	833	36	43
Ditto		10	658	34	51
Ditto		10	1,757	81	46
Ditto		10	2,338	17	7
Ditto		10	3,012	106	35
Ditto		10	11,744	325	27
Ditto		5	4,972	232	46
Total for ditto		63	25,314	831	32
Paris, St. Louis		3	4	0	0
Ditto		10	128	2	15
Ditto		10	1,282	51	39
Ditto		10	2,832	173	61
Ditto		10	2,736	102	37
Ditto		10	7,244	200	27
Ditto		5	3,812	252	66
Total for ditto		58	19,038	780	40
Paris, La Charité		3	648	84	126
Lyons „		4	3,325	91	17
	Hôtel Dieu	4	2,016	33	16
Rouen Hôpital Général		4	1,275	9	7
Bordeaux Maternité		4	714	30	42
Lille		4	683	25	35
Rheims		4	646	15	23
Strasburg		4	556	78	140
Grenoble		4	554	20	36
Bordeaux, St. André		4	547	36	65
St. Etienne		4	515	8	15
Toulouse		4	493	9	18
Bourg		4	461	0	0
Troyes		4	460	2	4
Marseilles		4	444	16	36
Châteauroux		4	423	20	47
Amiens		4	396	5	12
Colmar		4	396	26	65
Nantes		4	340	17	50
Nancy		4	320	9	28
Orleans		4	301	3	9
Total for all hospitals			888,312	30,394	34

The absolute loss of life in Parisian lying-in wards has been greater than in those of any other capital city.

This is clearly shown in the ‘Statistique médicale des Hôpitaux de Paris,’ kindly supplied to me by M. Husson, the Director of the General Administration of ‘Public Assistance’ at Paris, of whose many proofs of ability, activity, and benevolence, it is not here the place to speak. From this the following facts are abstracted. The death-rates are therein given for 12 hospitals receiving lying-in cases, only one of which, however, is a lying-in hospital (the ‘Maison d’accouchement’), and will be found in Tables XI., XII., XIII.

In 1861 the average death-rate in these establishments was no less than 95·1 per 1,000.

In 1862 it was 69·7 per 1,000.

In 1863 it was 70·3 per 1,000.

Table XI.—Mortality per Thousand among Lying-in Women at the undermentioned Parisian Hospitals during the Year 1861. (Abstracted from ‘Statistique Médicale des Hôpitaux,’ 1861.)
Hospital	Total Deliveries	Mortality per Thousand
		Puerperal	Non-Puerperal	Total Deaths
Hôtel Dieu	1,057	43·5	16·1	59·6
Pitié	468	72·6	34·2	106·8
Charité	253	154·2	39·7	193·7
St. Antoine	350	71·4	34·3	105·7
Necker	234	29·9	29·9	59·8
Cochin	56	142·9	35·7	178·6
Beaujon	276	43·5	3·6	47·1
Lariboisière	782	69·1	15·3	84·4
St. Louis	802	58·6	13·7	72·3
Lourcine	41	24·4		24·4
Cliniques	875	75·4	34·3	109·7
Maison d’Accouchements	2,115	99·8	12·8	112·5
Total	7,309	75·2	19·8	95·1

Table XII.—Mortality per Thousand among Lying-in Women at the undermentioned Parisian Hospitals during the Year 1862. (Abstracted from ‘Statistique Médicale des Hôpitaux de Paris,’ 1861, 2, 3.)
Hospital	Total Deliveries	Mortality per Thousand
		Puerperal	Non-Puerperal	Total Deaths
Hôtel Dieu	975	35·8	9·2	45·1
Pitié	462	45·4	10·8	56·2
Charité	270	62·9	25·9	88·8
St. Antoine	311	61·0	19·2	80·3
Necker	190	52·6	21·0	73·6
Cochin	24	41·6	83·3	124·9
Beaujon	257	38·9	19·9	58·8
Lariboisière	816	34·3	13·5	47·8
St. Louis	704	79·5	8·5	88·0
Lourcine	45	22·2	———	22·2
Cliniques	769	79·3	14·3	93·6
Maison d’Accouchements	2,204	63·5	11·3	74·9
Total	7,027	56·7	12·9	69·7

Table XIII.—Mortality per Thousand among Lying-in Women at the undermentioned Parisian Hospitals during the Year 1863. (Abstracted from ‘Statistique Médicale des Hôpitaux’, 1863.)
Hospital	Total Deliveries	Mortality per Thousand
		Puerperal	Non-Puerperal	Total Deaths
Hôtel Dieu	925	26·7	4·1	30·8
La Pitié	544	44·1	1·8	46·0
Charité	256	66·4	19·5	85·9
St. Antoine	410	63·4	11·6	78·0
Necker	232	38·8	21·6	60·3
Cochin	68	73·5	14·7	88·2
Beaujon	313	19·2	12·8	31·9
Lariboisière	870	31·0	9·2	40·2
St. Louis	871	23·0	9·2	32·1
Lourcine	43	27·9		27·9
Clinique	751	30·6	18·6	49·3
Maison d’Accouchements	2,006	130·1	7·4	137·6
Total	7,289	60·6	9·7	70·3

Classification of Causes of Mortality in Lying-in Institutions

The next thing is to endeavour to show to what causes these death-rates are to be attributed. Unfortunately Dr. Le Fort’s tables do not enable us to distinguish the causes of death. But the data supplied by British and Parisian hospitals allow the causes to be classified to a certain extent under the heads adopted by the Registrar-General in his Reports.

A classified arrangement of this kind is given in Table II., and may be resumed, with the view of showing the enormous differences in death-rates among puerperal women under different conditions, as follows:—

Mortality per 1,000.
		Puerperal diseases	Accidents of childbirth	Puerperal diseases and accidents of childbirth
All England, 13 years		1·61	3·22	4·83
England (healthy districts), 10 years, 312,402 deliveries				4·3
England, 11 large towns, 10 years, 1,402,304 deliveries				4·9
Liverpool workhouse		3·4	2·2	5·6
27 London workhouses having deaths		4·1	2·1	6·2
8 military female hospitals		3·9	3·4	7·3
Queen Charlotte’s Lying-in Hospital		14·3	5·3	19·6
King’s College Hospital lying-in ward		29·4	none	29·4
12 Parisian hospitals	{ 1861			75·2
	{ 1862			56·7
	{ 1863			60·6

We have already seen, as a result of Dr. Le Fort’s tables, that the mortality among women delivered at home, as deduced by him, is 4·7 per 1,000; while in the hospital it is 34 per 1,000, or nearly 7½–fold. Making any reasonable allowance for inaccuracy in the data, still we can hardly escape from his conclusions any more than we can rid ourselves from the consequences which follow from the data given above. We must confront the question called up by the data taken as a whole, viz., What can be the reason of this ascending scale of fatality shown on Table VIII.? Why is it that these death-rates from all causes in childbirth, beginning at 5·1 per 1,000 for all England (town and country), successively become, among the same people 9·, 10·9, 14·3, 25·3, 33·3; and if we cross the channel, why should they mount up to 69, 70, and 95 per 1,000?

Again, why should fevers and inflammations of the puerperal class, which, as we have seen above, give a death-rate for all England of 1·61 per 1,000, mount up in English hospitals to 3·4, 4·1, 14·3, and 29·4? There must be some reason, besides the fact of childbirth, why diseases and accidents of this condition should be 4 times more fatal in a London lying-in hospital, and 15 times more fatal in Parisian hospitals, than they are in towns of England. What, then, are the immediate causes of these excessive death-rates?

Causes of High Death-Rates in Lying-in Institutions

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 1110 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.

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.

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.

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 Diseases	Accidents of Childbirth	Diseases and Accidents of Childbirth	Others	Total Mortality
Deaths per 1,000 deliveries	3·9	3·4	7·3	1·5	8·8
	Aldershot Women’s Hospital
	Puerperal Diseases	Accidents of Childbirth	Diseases and Accidents of Childbirth	Others	Total Mortality
Deaths per 1,000 deliveries	4·9	3·9	8·8	1·3	10·1
	Other Women’s Hospitals, excluding Aldershot
	Puerperal Diseases	Accidents of Childbirth	Diseases and Accidents of Childbirth	Others	Total Mortality
Deaths per 1,000 deliveries	2·7	2·7	5·4	2·0	7·4

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.

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.

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 Students	2nd Clinique 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: natural	511	443	442	1,396
Number of women attended in labour: premature	4	1	1512	20
Number of women attended in labour: married	164	159	142	465
Number of women attended in labour: single	351	285	300	936
Males born	295	223	228	746
Females born	216	225	223	664
Mothers who died in or from labour	213	214	215	6
Children born dead	79	58	58	195
Women confined at or above 40 years of age	8	4	9	21
Women confined at or below 20 years of age	105	98	81	284
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.

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.

If19 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.
	Deliveries	Deaths	Deaths per 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.