Introductory notes on 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.

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.

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]

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.

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.

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.

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.

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.

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:—

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 11^[10] general hospitals which receive midwifery cases. A reference to Tables XI., XII., XIII., will show how great the risks are to lying-in women under the same roof with medical and surgical cases; a fact which may be further illustrated by a reference to data for particular hospitals. For example, in 1861, 253 lying-in cases in La Charité gave a total death-rate of 193·7 per 1,000, of which no less than 154·2 was due to puerperal causes. These tables tell their own story, and they throw altogether into the shade the lamentable losses at King’s College Hospital.

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

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

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

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

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

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

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

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

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

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

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