Introductory notes on lying-in institutions

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.

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:—

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?

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:—

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.

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

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.