Part 6

Table XIV. ┌────────────┬────────────────────────────────────────────────────────┐ │ │ All Women’s Hospitals (Military) │ ├────────────┼──────────┬──────────┬────────────┬──────────┬──────────┤ │ │ Puerperal│ Accidents│Diseases and│ Others│ Total│ │ │ Diseases│ of│Accidents of│ │ Mortality│ │ │ │Childbirth│ Childbirth│ │ │ ├────────────┼──────────┼──────────┼────────────┼──────────┼──────────┤ │Deaths per │ 3·9│ 3·4│ 7·3│ 1·5│ 8·8│ │ 1,000 │ │ │ │ │ │ │ deliveries│ │ │ │ │ │ ├────────────┴──────────┴──────────┴────────────┴──────────┴──────────┤ │ │ ├────────────┬────────────────────────────────────────────────────────┤ │ │ Aldershot Women’s Hospital │ ├────────────┼──────────┬──────────┬────────────┬──────────┬──────────┤ │ │ Puerperal│ Accidents│Diseases and│ Others│ Total│ │ │ Diseases│ of│Accidents of│ │ Mortality│ │ │ │Childbirth│ Childbirth│ │ │ ├────────────┼──────────┼──────────┼────────────┼──────────┼──────────┤ │Deaths per │ 4·9│ 3·9│ 8·8│ 1·3│ 10·1│ │ 1,000 │ │ │ │ │ │ │ deliveries│ │ │ │ │ │ ├────────────┴──────────┴──────────┴────────────┴──────────┴──────────┤ │ │ ├────────────┬────────────────────────────────────────────────────────┤ │ │ Other Women’s Hospitals, excluding Aldershot │ ├────────────┼──────────┬──────────┬────────────┬──────────┬──────────┤ │ │ Puerperal│ Accidents│Diseases and│ Others│ Total│ │ │ Diseases│ of│Accidents of│ │ Mortality│ │ │ │Childbirth│ Childbirth│ │ │ ├────────────┼──────────┼──────────┼────────────┼──────────┼──────────┤ │Deaths per │ 2·7│ 2·7│ 5·4│ 2·0│ 7·4│ │ 1,000 │ │ │ │ │ │ │ deliveries│ │ │ │ │ │ └────────────┴──────────┴──────────┴────────────┴──────────┴──────────┘

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 │ 2nd Clinique │ │ │ │ Students │ 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: │ 511│ 443│ 442│ 1,396│ │ natural │ │ │ │ │ │Number of women attended in labour: │ 4│ 1│15[12]│ 20│ │ premature │ │ │ │ │ │Number of women attended in labour: │ 164│ 159│ 142│ 465│ │ married │ │ │ │ │ │Number of women attended in labour: │ 351│ 285│ 300│ 936│ │ single │ │ │ │ │ │ Males born │ 295│ 223│ 228│ 746│ │ Females born │ 216│ 225│ 223│ 664│ │Mothers who died in or from labour │ 2[13]│ 2[14]│ 2[15]│ 6│ │ Children born dead │ 79│ 58│ 58│ 195│ │Women confined at or above 40 years of │ 8│ 4│ 9│ 21│ │ age │ │ │ │ │ │Women confined at or below 20 years of │ 105│ 98│ 81│ 284│ │ age │ │ │ │ │ │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:—