Part 1

LYING-IN INSTITUTIONS.

LONDON: PRINTED BY SPOTTISWOODE AND CO., NEW-STREET SQUARE AND PARLIAMENT STREET

INTRODUCTORY NOTES ON LYING-IN INSTITUTIONS. TOGETHER WITH A PROPOSAL FOR ORGANISING AN INSTITUTION FOR TRAINING MIDWIVES AND MIDWIFERY NURSES.

BY

FLORENCE NIGHTINGALE.

LONDON:

LONGMANS, GREEN, AND CO.

1871.

If I may dedicate, without ‘permission,’ these small ‘Notes’ to the shade of Socrates’ Mother, may I likewise, without presumption, call to my help the questioning shade of her Son, that I who write may have the spirit of questioning aright, and that those who read may learn not of me but of themselves?

And, further, has he not said: ‘The midwives are respectable women, and have a character to lose’?

PREFACE.

In the year 1862 the Committee of the Nightingale Fund, with a view to extending the advantages of their Training Institution, entered into an arrangement with the authorities of St. John’s House, under which wards were fitted up in the new part of King’s College Hospital, opening out of the great staircase and shut up within their own doors, for the reception of Midwifery cases. The wards were under the charge of the (then) Lady Superintendent. Arrangements were made for medical attendance, a skilled midwife was engaged, a certain number of pupil nurses were admitted for training; and hopes were entertained that this new branch of our Training School would confer a great benefit on the poor, especially in country districts, where trained Midwifery nurses are needed.

Every precaution had apparently been taken to render the Midwifery Department perfectly safe; and it was not until the school had been upwards of five years in existence, that the attention of the Nightingale Committee was called to the fact that deaths from puerperal diseases had taken place in each of the preceding years.

During the period of nearly six years that the wards were in use, the records show that 780 women had been delivered in the institution, and that out of this number twenty-six[1] had died—a mortality of 33·3 per 1,000.

The most fatal year was 1867, in which year nine out of the twenty-six deaths took place. In the month of January a pregnant woman, who was under treatment for erysipelas in the hospital, was delivered in a general medical ward, No. 4, in the first-built wing of the hospital. A midwife was told off to attend her, who was not suffered to be near the midwifery wards for a considerable time. The erysipelas case died of puerperal fever; and this death was followed by a succession of puerperal deaths in the lying-in wards until November, when the wards were as soon as possible closed.

An analysis of the causes of death showed that, with the exception of one death from hæmorrhage, not a single death had taken place from accidents incidental to childbearing during the whole six years. There were three deaths due to diseases not necessarily concomitants of this condition; while of the others, twenty-three in number, no fewer than seventeen were due to puerperal fever, three to puerperal peritonitis, two to pyæmia, and one to metritis.

The following table gives the actual fates and dates:—

_Midwifery Statistics, King’s College Hospital._ ┌─────┬──────────┬─────────────────────────────────────────────┬───────────┐ │Year │ Total │ Fatal Cases │ Deaths to │ │ │Deliveries│ │ Labours │ ├─────┼──────────┼─────┬──────────────┬────────────────┬───────┼───────────┤ │ │ │Date │ Nature of │ │Date of│ │ │ „ │ „ │ of │ Labour │ Cause of Death │ Death │ „ │ │ │ │Birth│ │ │ │ │ ├─────┼──────────┼─────┼──────────────┼────────────────┼───────┼───────────┤ │ 1862│ 97│Nov. │Natural │Puerperal │Nov. 25│1 in 32·3 │ │ │ │ 6 │ │ peritonitis │ │ │ │ │ │ │ │Phthisis and │ │ │ │ │ │„ 30│Twins │ puerperal │Dec. 27│ „ │ │ │ │ │ │ fever │ │ │ │ │ │Dec. │Natural │Puerperal │Dec. 20│ „ │ │ │ │ 10 │ │ peritonitis │ │ │ ├─────┼──────────┼─────┼──────────────┼────────────────┼───────┼───────────┤ │ 1863│ 105│Jan. │Natural. Child│Puerperal fever │Jan. 16│1 in 52·5 │ │ │ │ 10 │ still-born │ │ │ │ │ │ │April│Natural │Puerperal fever │May 20 │ „ │ │ │ │ 29 │ │ │ │ │ ├─────┼──────────┼─────┼──────────────┼────────────────┼───────┼───────────┤ │ 1864│ 141│Feb. │Natural │Puerperal fever │Feb. 25│1 in 47 │ │ │ │ 16 │ │ │ │ │ │ │ │April│Induced │Pyæmia │April │ „ │ │ │ │ 14 │ │ │ 29 │ │ │ │ │Dec. │Born in cab │Hæmorrhage │Dec. 7 │ „ │ │ │ │ 1 │ │ │ │ │ ├─────┼──────────┼─────┼──────────────┼────────────────┼───────┼───────────┤ │ 1865│ 163│Jan. │Natural │Embolism │Feb. 12│1 in 32·6 │ │ │ │ 30 │ │ │ │ │ │ │ │Feb. │Natural │Puerperal fever │Feb. 18│ „ │ │ │ │ 8 │ │ │ │ │ │ │ │ │ │Puerperal │ │ │ │ │ │June │Forceps │ metritis and │July 30│ „ │ │ │ │ 24 │ │ pelvis │ │ │ │ │ │ │ │ cellulitis │ │ │ │ │ │ │ │Laceration of │ │ │ │ │ │Oct. │Forceps │ perinæum, │Nov. 3 │ „ │ │ │ │ 20 │ │ puerperal │ │ │ │ │ │ │ │ fever │ │ │ │ │ │Oct. │Natural │Puerperal fever │Nov. 9 │ „ │ │ │ │ 29 │ │ │ │ │ ├─────┼──────────┼─────┼──────────────┼────────────────┼───────┼───────────┤ │ 1866│ 150│Jan. │Natural │Gastro-enteritis│Jan. 20│1 in 30 │ │ │ │ 10 │ │ │ │ │ │ │ │ │ │Retained │ │ │ │ │ │Mar. │Natural │ placenta, │April │ „ │ │ │ │ 24 │ │ puerperal │ 10 │ │ │ │ │ │ │ fever │ │ │ │ │ │Oct. │Placenta │Emphysema and │ │ │ │ │ │ 8 │ prævia. │ bronchitis │Oct. 10│ „ │ │ │ │ │ Turning │ │ │ │ │ │ │Nov. │Forceps │Peritonitis │Nov. 15│ „ │ │ │ │ 10 │ │ │ │ │ │ │ │Dec. │Natural │Puerperal fever │Dec. 31│ „ │ │ │ │ 4 │ │ │ │ │ ├─────┼──────────┼─────┼──────────────┼────────────────┼───────┼───────────┤ │ │ │ │(Had │ │ │ │ │ 1867│ 125│Jan. │ erysipelas │Puerperal fever │Jan. 30│1 in 13·8 │ │ │ │ 10 │ when │ │ │ │ │ │ │ │ admitted[2])│ │ │ │ │ │ │ │ │Considerable │ │ │ │ │ │Feb. │Natural │ hæmorrhage, │Feb. 22│ „ │ │ │ │ 7 │ │ puerperal │ │ │ │ │ │ │ │ fever │ │ │ │ │ │„ 8 │Natural │Puerperal fever │Feb. 22│ „ │ │ │ │April│Turning │Puerperal fever │April │ „ │ │ │ │ 12 │ │ │ 22 │ │ │ │ │May │Natural │Pyæmia │May 27 │ „ │ │ │ │ 18 │ │ │ │ │ │ │ │June │Natural │Puerperal fever │June 19│ „ │ │ │ │ 4 │ │ │ │ │ │ │ │July │Natural │Puerperal fever │Aug. 11│ „ │ │ │ │ 26 │ │ │ │ │ │ │ │Nov. │Twins: 1st │ │ │ │ │ │ │ 5 │ dead, 2nd by│Puerperal fever │Nov. 10│ „ │ │ │ │ │ turning │ │ │ │ │ │ │ │ │Laceration of │ │ │ │ │ │„ 8 │Forceps │ vagina, │Nov. 14│ „ │ │ │ │ │ │ puerperal │ │ │ │ │ │ │ │ fever │ │ │ ├─────┼──────────┼─────┼──────────────┼────────────────┼───────┼───────────┤ │Total│ 781│ │ │ │deaths:│1 in 28·9 │ │ │ │ │ │ │ 27 │ │ └─────┴──────────┴─────┴──────────────┴────────────────┴───────┴───────────┘

Under these deplorable circumstances the closing of the wards was a matter of course; and since that event we have been anxiously enquiring whether it would be justifiable to re-open our Midwifery Nursing School under other conditions.

This question is discussed in the following pages, from a basis of statistical facts supplied by the best authorities; and a few proposals have been added, with the view of turning to the best account our past experience, by extracting from it any leading principles which may present themselves for practical application in the future construction and management of Lying-in Institutions, and more especially in connection with means of training Midwifery nurses.

These Introductory Notes, collected and put together under circumstances of all but overwhelming business and illness, are now thrown out merely as a nucleus, in the hope that others will be kind enough to supplement, to add, and to alter; in fact, only as a hook with a modest little fish on it—a bait to catch other and finer fish.

The facts themselves, the nucleus, have been made as correct as it was possible, and as would have been done for a finished work. But the facts themselves are only put forth as feelers—feelers to feel my own way.

I need scarcely say either that these ‘Notes’ are not at all meant to discuss every point which presents itself in Midwifery statistics. On the contrary, they are, for the moment, purposely limited to the consideration of facts immediately relating to the present object.

Let me thank once more with true gratitude all those who have so kindly supplied me with help and information, some of whose names will appear in the following pages.

CONTENTS.

PAGE PREFACE vii–x _Table of Midwifery Statistics, King’s College Hospital_ ix _What is the real normal Death-rate of Lying-in Women?_ 1 MIDWIFERY STATISTICS 2 NORMAL DEATH-RATE OF LYING-IN WOMEN IN ENGLAND 4 TABLE I.—_Mortality after Childbirth in England, 1867_ 4 TABLE II.—_Mortality per 1,000 after Delivery from Puerperal Diseases and Accidents of Childbirth_ 6 NORMAL MORTALITY OF LYING-IN WOMEN IN DIFFERENT COUNTRIES 7 TABLE III.—_Death-rate from all Causes amongst Women delivered in their own Homes_ 8 OBJECTIONS TO THE DATA 9 ESTIMATED APPROXIMATE HOME DEATH-RATE 11 DEATH-RATES IN LYING-IN INSTITUTIONS 11 TABLE IV.—_Admissions and Deaths in Childbirth in eight Women’s Hospitals (Military)_ 12 TABLE V.—_Statistics of Midwifery Wards in Liverpool Workhouse_ 13 TABLE VI.—_Mortality after Childbirth in forty London Workhouses_ 13 TABLE VII.—_Mortality in Queen Charlotte’s Hospital_ 14 TABLE VIII.—_Mortality per 1,000 from all Causes after Delivery_ 15 TABLE IX.—_Mortality in Lying-in Ward, King’s College Hospital_ 15 TABLE X.—_Death-rate from all causes in Lying-in Hospitals_ 17 TABLE XI.—_Mortality per 1,000 among Lying-in Women at Paris Hospitals, 1861_ 20 TABLE XII.—_Mortality per 1,000 among Lying-in Women at Paris Hospitals, 1862_ 20 TABLE XIII.—_Mortality per 1,000 among Lying-in Women at Paris Hospitals, 1863_ 21 CLASSIFICATION OF CAUSES OF MORTALITY IN LYING-IN INSTITUTIONS 21 CAUSES OF HIGH DEATH-RATES IN LYING-IN INSTITUTIONS 23 _Puerperal Fever_ 24 _Admission of Students_ 25 _Effect of Numbers_ 26 _Danger of Puerperal Epidemics_ 31 _Fatality of Lying-in Wards in General Hospitals_ 32 INFLUENCE OF CONSTRUCTION AND MANAGEMENT OF LYING-IN WARDS ON THE DEATH-RATE 33 _Maternité, Paris_ 34 _Hôpital de la Clinique, Paris_ 36 _Queen Charlotte’s Lying-in Hospital, London_ 38 _Midwifery Wards, King’s College Hospital, London_ 40 IMPROVED LYING-IN WARD CONSTRUCTION 41 _Military Female Hospitals_ 41 TABLE XIV.—_Classification of Causes of Death in Childbirth in Eight Women’s Hospitals (Military)_ 43 _Proposed new Female Hospital at Portsmouth_ 45 SHOULD MEDICAL STUDENTS BE ADMITTED TO LYING-IN HOSPITAL PRACTICE? 48 INFLUENCE OF TIME SPENT IN A LYING-IN WARD ON THE DEATH-RATE 50 EFFECT OF GOOD MANAGEMENT ON THE SUCCESS OF LYING-IN ESTABLISHMENTS 52 _Liverpool Workhouse_ 53 _Summary of Cases Delivered in the Lying-in Wards of Liverpool Workhouse, 1868–1870_ 53 _Summary of Deaths and Causes of Death in the same, 1858–1870_ 54 _London Workhouses_ 58 MANAGEMENT OF MILITARY LYING-IN WARDS 62 NOTE _on altogether disconnecting Lying-in Institutions even with the very name of Hospital_ 64 RECAPITULATION 65 TABLE XV.—_Comparative Mortality among Lying-in Women in Hospitals and at Home_ 68 CAN THE ARRANGEMENT AND MANAGEMENT OF LYING-IN INSTITUTIONS BE IMPROVED? 68

_CHAPTER II._ CONSTRUCTION AND MANAGEMENT OF A LYING-IN INSTITUTION AND TRAINING SCHOOL FOR MIDWIVES AND MIDWIFERY NURSES 72 I. CONSTRUCTION OF A LYING-IN INSTITUTION 74 1. _How many Beds to a Ward?_ 74 TABLE XVI.—_Proposed Registry of Midwifery Cases_ 75 2. _How many Wards to a Floor?_ 76 3. _How many Floors to a Pavilion (Hut or Cottage)?_ 76 _How many Beds to a Pavilion or Hut?_ 76 _How many Pavilions or Huts to a Lying-in Institution?_ 76 4. _How much Space to the Bed?_ 77 _The Delivery Ward_ 77 5. _How many Windows to a Bed?_ 78 6. _What are Healthy Walls, and Ceilings, and Floors?_ 78 7. _What is a Healthy and Well-lighted Delivery Ward?_ 79 8. _Scullery, Lavatory, W.C._ 81 9. _How to ventilate Lying-in Wards_ 83 10. _Furniture, Bedding, Linen_ 84 11. _Water supply, Drainage, Washing_ 85 12. _Medical Officer’s Room and Waiting-Room_ 85 13. _Segregation Ward_ 86 14. _Kitchen_ 86 SITE 86 II. MANAGEMENT 90 _First Rule of Good Management_ 90 _Second Rule of Good Management_ 91 _Third Rule of Good Management_ 93 III. TRAINING SCHOOL FOR MIDWIVES 94 DESCRIPTION OF SKETCH-PLANS OF PROPOSED INSTITUTION 100 _A Lying-in Institution For 40 beds (32 to 36 occupied), with a training school for 30 pupil Midwives and Nurses_ 102 APPENDIX: MIDWIFERY AS A CAREER FOR EDUCATED WOMEN 105

LIST OF PLANS.

NO. 1. QUEEN CHARLOTTE’S LYING-IN HOSPITAL, LONDON _to face page_ 38 2. WOODEN LYING-IN HUT IN COLCHESTER CAMP „ 44 3. PLAN OF A LYING-IN WARD, FOUR BEDS „ 100 4. PLAN OF A LYING-IN FLOOR, FOUR ONE-BED ROOMS „ 101 5. PLAN OF A LYING-IN INSTITUTION FOR 40 (32 TO 36 OCCUPIED) BEDS, WITH TRAINING SCHOOL FOR 30 PUPIL MIDWIVES „ 104

NOTES ON LYING-IN INSTITUTIONS.

The first step to be taken in the discussion is to enquire, What is the real normal death-rate of lying-in women? And, having ascertained this to the extent which existing data may enable us to do, we must compare this death-rate with the rates occurring in establishments into which parturition cases are received in numbers. We have then to classify the causes of death, so far as we can, from the data, with the view of ascertaining whether any particular cause of death predominates in lying-in institutions; and, if so, why so? And finally, seeing that everybody must be born, that every birth in civilised countries is as a rule attended by somebody, and ought to be by a skilled attendant; since, therefore, the attendance upon lying-in women is the widest practice in the world, and these attendants should be trained; we must decide the great question as to whether a training school for midwifery nurses can be safely conducted in any building receiving a number of parturition cases, or whether such nurses must be only trained at the bedside in the patient’s own home, with far more difficulty and far less chance of success.

_MIDWIFERY STATISTICS._

It must be admitted, at the very outset of this enquiry, that midwifery statistics are in an unsatisfactory condition. To say the least of it, there has been as much discussion regarding mortality and its causes among lying-in women as there has been regarding the mortality due to hospitals. Yet there appears to have been no uniform system of record of deaths, or of the causes of death, in many institutions, and no common agreement as to the period after delivery within which deaths should be counted as due to the puerperal condition. Many of the most important institutions in Europe merely record the deaths occurring during the period women are in hospital, and they appear not unfrequently to do this without any reference to the causes. Similar defects are obvious enough in the records of home deliveries; and hence it follows that the mass of statistics which have been accumulated regarding home and hospital deliveries, admit of comparison only in one element, namely, the total deaths to total deliveries, and this only approximately.

Dr. Matthews Duncan, in his recent work on the ‘Mortality of Childbed and Maternity Hospitals,’ has dwelt forcibly on these defects in midwifery statistics, and has made out a strong case for improvement in records. But, as will be afterwards shown, with all their defects, midwifery statistics point to one truth; namely, that there is a large amount of preventible mortality in midwifery practice, and that, as a general rule, the mortality is far, far greater in lying-in hospitals than among women lying-in at home.

There are several of what may be called secondary influences also, which must affect to a certain extent the results of comparison of death-rates among different groups of lying-in cases. Such are the ages of women, the number of the pregnancy, the duration of labour, and the like. It is impossible, in the present state of our information, to attribute to each, or all of these, their due influence; neither, if we could do so, would it materially affect the general result just stated. But it is otherwise with another class of conditions, of which statistics take no cognizance. Such are the general sanitary state of hospitals, wards, houses, and rooms where deliveries take place; the management adopted; the classes of patients; their state of health and stamina before delivery; the time they are kept in midwifery wards before and after delivery. These elements are directly connected with the questions at issue, and yet our information regarding them is by no means so full as we could wish—indeed is almost nothing.

Our only resource at present is to deal with such statistical information as we possess, and to ascertain fairly what it tells us. This we shall now endeavour to do, beginning with an estimate of the normal mortality due to childbirth in various European countries.

_NORMAL DEATH-RATE OF LYING-IN WOMEN IN ENGLAND._

In the Registrar-General’s Thirtieth Annual Report, 1867, there is an instructive series of tables, giving approximately the present normal death-rate among lying-in women in England.

One of these tables (abstracted on Table I.) shows that, including deliveries in lying-in hospitals, there were in England, during the year 1867, 768,349 births, and that 3,933 women died in childbed. This gives an approximate total mortality of 5·1 per 1,000 from all causes.