Part 7

_Summary of Deaths and Causes of Death in the Lying-in Wards of Liverpool Workhouse for Years 1858–1870._ ┌────────────┬────┬────┬────┬────┬────┬────┬────┬────┬────┬────┬────┬────┬────┐ │ │1858│1859│1860│1861│1862│1863│1864│1865│1866│1867│1868│1869│1870│ ├────────────┼────┼────┼────┼────┼────┼────┼────┼────┼────┼────┼────┼────┼────┤ │Morbus │ │ │ │ │ │ │ │ │ │ │ │ │ │ │cordis │ 2│ │ 1│ │ │ 1│ │ │ │ │ │ │ 1│ │Pneumonia │ 1│ │ │ │ │ 1│ │ │ │ 1│ │ │ │ │Puerperal │ │ │ │ │ │ │ │ │ │ │ │ │ │ │peritonitis │ 1│ 1│ │ 1│ 6│ │ 2│ 2│ 3│ │ │ │ │ │Phthisis │ 1│ │ │ │ 1│ │ 1│ │ │ 1│ │ │ │ │Debility │ 2│ │ │ │ │ │ │ │ │ │ │ │ │ │Epileptic │ │ │ │ │ │ │ │ │ │ │ │ │ │ │convulsions │ │ 1│ 2│ 1│ │ │ │ │ │ │ 1│ │ │ │Puerperal │ │ │ │ │ │ │ │ │ │ │ │ │ │ │fever │ │ 1│ 1│ 1│ │ │ │ │ │ │ │ │ │ │Jaundice │ │ 1│ │ │ │ │ │ │ │ │ │ │ │ │Phlegmasia │ │ │ │ │ │ │ │ │ │ │ │ │ │ │dolens │ │ 1│ │ │ │ │ │ │ │ │ │ │ │ │Exhaustion │ │ │ 2│ │ │ │ 1│ │ │ │ │ │ │ │Relapsing │ │ │ │ │ │ │ │ │ │ │ │ │ │ │fever │ │ │ 1│ │ │ │ │ │ │ │ │ │ │ │Measles │ │ │ 1│ │ │ │ │ │ │ │ │ │ │ │ Inquest │ │ │ 1│ │ │ │ │ │ │ │ │ │ │ │Laryngitis │ │ │ │ 1│ │ │ │ │ │ │ │ │ │ │Obstructed │ │ │ │ │ │ │ │ │ │ │ │ │ │ │labour │ │ │ │ 1│ │ │ │ │ │ │ │ │ │ │Typhus, post│ │ │ │ │ │ │ │ │ │ │ │ │ │ │partum │ │ │ │ 1│ │ │ │ │ │ │ │ │ │ │Hæmorrhage │ │ │ │ 1│ │ │ │ │ 1│ │ │ │ │ │Uræmia │ │ │ │ │ │ │ 1│ │ │ │ │ │ │ │Rupture of │ │ │ │ │ │ │ │ │ │ │ │ │ │ │uterus │ │ │ │ │ │ │ │ 1│ │ │ │ │ │ │Bright’s │ │ │ │ │ │ │ │ │ │ │ │ │ │ │disease │ │ │ │ │ │ │ │ │ │ 1│ │ │ │ │Invaginated │ │ │ │ │ │ │ │ │ │ │ │ │ │ │bowel │ │ │ │ │ │ │ │ │ │ │ 1│ │ │ │Instrumental│ │ │ │ │ │ │ │ │ │ │ │ │ │ │labour │ │ │ │ │ │ │ │ │ │ │ │ │ │ │(fever) │ │ │ │ │ │ │ │ │ │ │ │ 1│ │ │Metritis │ │ │ │ │ │ │ │ │ │ │ │ 1│ │ │Dropsy │ │ │ │ │ │ │ │ │ │ │ │ │ 1│ ├────────────┼────┼────┼────┼────┼────┼────┼────┼────┼────┼────┼────┼────┼────┤ │Deaths │ 7│ 5│ 9│ 7│ 7│ 2│ 5│ 3│ 4│ 3│ 2│ 2│ 2│ ├────────────┴────┴────┴────┴────┴────┴────┴────┴────┼────┼────┼────┼────┼────┤ │Approximate deliveries:[16] average estimated at 500│ │ │ │ │ │ │per ann. │ 450│ 625│ 511│ 443│ 442│ └────────────────────────────────────────────────────┴────┴────┴────┴────┴────┘

Let us now see what the arrangements are for this class of cases. The lying-in department of Liverpool workhouse is situated in a wing of the female general hospital, contiguous to the surgical wards. The wing has windows along the two opposite sides and at one end; but the space is so divided off by partitions as to form five wards, each of which has windows along one side only. The wards are allotted in the following manner:—

Two of them, opening into each other, and facing the same way, contain each twelve double beds, affording accommodation for 24 inmates per ward, 48 in all, at 345 cubic feet per inmate. These two wards are devoted to the reception of pregnant women before delivery. The opposite half of the wing is divided into two wards, corresponding to the two pregnant wards; one of these is the delivery ward, and contains seven beds, at nearly 1,200 cubic feet per bed.

Entering from this delivery ward is the lying-in ward, lighted by windows at the end. This ward contains 14 beds, at 900 cubic feet per bed. The other ward, entering from the delivery ward in the same line, is for convalescents, and contains eleven beds, at 762 cubic feet per bed. The W. C.’s, &c., are between the wards in the wing, in a very objectionable position.

For these and the following details I am indebted to the kindness of Mr. Barnes, who also supplied me with the statistics abstracted on Table V.

The following is the routine management of this establishment:—

All the wards are lime-washed three or four times a year. They are shut up and fumigated after the occurrence of any serious case of illness. The floors are washed daily.

The beds in the pregnant, lying-in, and convalescent wards, are generally all or most of them occupied; but the number of occupied beds in the delivery ward rarely exceeds four or five.

The bed clothes are changed after each delivery, and the beds, which are of straw, after every third delivery.

The patients consist for the most part of unmarried women.[17] They are admitted into the pregnant wards, where they remain for a varying interval of from days to months, from whence they are removed to the delivery ward; about a fifth part of the women are admitted directly from the town to the delivery ward.

They remain on an average eight hours in the delivery room, whence they are removed to the lying-in ward, where they remain five or six days. They are then admitted to the convalescent ward, and are finally discharged fourteen days after labour, one half to the town, the other half into other parts of the workhouse.

An important part of the management is that the inmates of the pregnant wards only inhabit those wards at night, being engaged during the day in various occupations within the workhouse, but not about the lying-in women, as in the Paris Maternité.

Cases are not taken into the lying-in division unless labour has begun, or is supposed to be imminent.

Any case of illness occurring in the lying-in department is at once removed to the ‘class sick nursery,’ to the lock or other division.

The nurses engaged in the lying-in division attend also cases in the ‘class sick nursery,’ and are periodically changed. Any case which they cannot manage is referred to the resident medical officer on duty.

There are three of these officers, who relieve each other every eight hours day and night. The officer on duty is liable to be called on to visit any part of the workhouse or hospital during his turn of duty, so that it might happen occasionally that the medical officer might be called from the hospital to the lying-in division.

If feverish symptoms show themselves in any patient in the lying-in division, the practice is to isolate the case or to transfer it to some other division of the workhouse. The ward is then closed, fumigated, cleansed, and lime-washed, before being again used.

This proceeding has only been necessary twice within the last four years.

Until recently, the whole of the deliveries, which amounted to an average of about 500 a year, were under the charge of one paid officer and a pauper who, without any payment or extra diet, delivered nearly every case and worked both night and day.

There are several points in this procedure which are of great importance, as bearing on the general question of successful management of lying-in establishments:—

1. The building, although situated in a large commercial town, is on a high, isolated, and freely ventilated locality.

2. It is not connected with a general hospital or medical school, or with any of their risks.

3. There is a constant change of wards:—pregnant ward, delivery ward, lying-in ward, recovery ward, body of the house. There is, in short, as little risk as possible of the cumulative blood-poisoning process already referred to.

4. Frequent cleansing and lime-washing.

5. Passing women who have been delivered as speedily as possible out of the division altogether, either into the house or outside.

6. The deliveries being conducted by a woman specially attached to the delivery ward, and no part of whose duty it is to attend sick.

7. The immediate isolation or removal of all cases exhibiting feverish symptoms and their treatment out of the division.

8. The reduction of intercommunication between the lying-in and hospital divisions to the smallest possible degree on the part of medical officers and nurses.

The practical result of this system of management has been, as we have seen, that the lying-in division of this workhouse, although working under many singular disadvantages, has escaped the usual fatality of special lying-in hospitals.

During the thirteen years included in the tables there has been no epidemic, and the deaths have almost always been single and disconnected.

The experience of lying-in wards in London workhouses somewhat resembles the experience of Liverpool workhouse.

In the report of the committee appointed to consider the cubic space of metropolitan workhouses, 1867, is given a table, No. 11, shewing the number of deliveries and deaths after delivery during five years in forty metropolitan workhouses.

The leading facts are abstracted in Table VI. Workhouses in which deaths after delivery took place, during the five years, are separated in the abstract from workhouses in which no deaths took place.

There were during these five years in all the workhouses 11,870 deliveries and 93 deaths, giving a death-rate of 7·8 per 1,000. The deaths from puerperal diseases amounted to 39, giving a death-rate of 3·3 per 1,000. There were 20 deaths from accidents of childbirth; being a death-rate of 1·7 per 1,000. The total death-rate due to both classes was 5 per 1,000.

The largest number of deliveries took place in Marylebone and in St. Pancras. In the former, on an average of 243 deliveries per annum, the death-rate was 8·2 per 1,000. One half of this, however, was due to consumption. Of the remaining deaths 3 were due to puerperal diseases (2·4 per 1,000) and 2 to accidents. The death-rate due to puerperal diseases and accidents of childbirth was thus 4·1 per 1,000.

In St. Pancras workhouse, on an average of 200 deliveries per annum, the death-rate was 11 per 1,000, of which 9 per 1,000 were due to puerperal diseases. Recent disclosures with regard to St. Pancras workhouse may to some extent account for this high death-rate. The number of deliveries in these two workhouses bring them almost within the category of lying-in hospitals.

There are four other workhouses in which the annual deliveries are respectively 171, 120, and two of them 111, while in all the others the numbers fall much below 100.

In one such instance (Holborn), where the deliveries have averaged fifty a year, the death-rate was exceptionally high, 24 per 1,000, one half of which was due to puerperal disease. In another instance, St. Mary’s, Islington, with seventy-five deliveries per annum, the death-rate averaged 29 per 1,000. But the causes are not stated, and cannot now be ascertained. In Whitechapel, where there were 111 deliveries per annum, the death-rate was 10·8 per 1,000, one half being due to puerperal diseases.

It is possible that local enquiry might elucidate the causes of this mortality. The cases are, however, exceptional to the experience of London workhouses, viz. that the death-rates from puerperal diseases and accidents of childbirth are scarcely higher than they are in all England, town and country. Let us try to ascertain how far the management adopted may have led to these comparatively favourable results.

The conditions for recovery in a great majority of the London workhouse lying-in wards are at least as favourable as they are in the Liverpool workhouse; in most cases undoubtedly more so, as will immediately be seen when we consider that the average annual number of deliveries in Liverpool workhouse is more than twice that of the two largest London workhouses, and from five to ten times most of the others; that in the London workhouses the rule is to have many unoccupied beds, while this is the exception in the Liverpool workhouse.

The cardinal principle in the management of these London workhouse lying-in wards appears to be this: their occupants are a fluctuating number; often the wards have but one woman at a time, and the cubic space for each of these women is ‘in fact the cubic space of the whole ward.’[18] Sometimes, but only for brief periods, all the lying-in beds may be occupied. For much longer intervals the occupants are very few in number, so that each has a large proportion of cubic space, and sometimes the wards in some of the workhouses are empty. There are no medical schools attached to the institutions, and no medical students who may have passed from a case of erysipelas or from the post-mortem theatre to the lying-in bedside; there is the possibility of removing immediately any case of febrile or other disease which may occur in the lying-in ward into the general sick wards of the workhouse; there is discharge of convalescent cases at the earliest possible period, either to their own homes or to other parts of the establishment; these conditions, together with the paucity of numbers and the occasional vacating and rest of the wards, appear to constitute the main difference between a workhouse lying-in ward and a lying-in hospital.

In both classes of establishments the same attention is doubtless bestowed on ventilation, cleanliness, and frequent change of bedding.

_MANAGEMENT OF MILITARY LYING-IN WARDS._

The lying-in arrangements provided for soldiers’ wives are as follows:—

The rule is that women shall be delivered in quarters, provided there be decent accommodation. At a number of the larger stations, where suitable married quarters have not yet been fully provided, there are female hospitals, attached to which, as we have already seen, is a delivery and lying-in ward, with the usual offices. In the specially constructed hospitals the wards are of a good size, well-lighted, warmed and ventilated. If all the beds were occupied, the space would be 1,300 cubic feet per patient. But this is an event which rarely or never happens, so that there is always plenty of room and good ventilation.

If[19] a woman requires admission, her husband applies to the medical authorities for a ticket. No woman with a disease considered to be infectious is admitted. The women usually follow their ordinary avocations until obliged to proceed to hospital by imminent labour. They are taken there in cabs, all the necessary arrangements for the lying-in having been made, if possible, by previous intimation. The woman is delivered in the delivery ward, and is thence transferred to the lying-in ward. As a rule, the lying-in pavilion in these female hospitals is distinct in all its arrangements for nursing from the pavilion for general cases. Infectious cases are not received into the same hospital, except at Aldershot.

In these hospitals for soldiers’ wives the time which elapses from the admission to the discharge of the women is usually ten, and in some cases twelve days.

At Aldershot four ‘Sisters’ are now at work in the soldiers’ wives’ hospital. One was trained as midwife, and took charge of the midwifery cases early in 1867. The Sister midwife has sole charge of the lying-in women for five or six days. They are then passed into a third ward, and are nursed by the Sisters who attend the ordinary cases (which are, however, of course in a separate ward).

The Sisters do not help the midwife, as a rule. Only the Superior, on an emergency, and one for scrubbing floors periodically, enter the midwifery wards (i.e. the delivery and lying-in wards).

In 1869 Aldershot had no fatal case among the lying-in women.

[The ‘infection wards’ are nursed by ordinary nurses, and in cases of children by the parents.]

It will be seen, therefore, that at Aldershot the midwife has nothing to do with the general cases, and the matron is not now the midwife. Both there and at Woolwich the lying-in nursing is quite separate from the general nursing.

The medical officer remarks, as to the two deaths in 1869 at Woolwich: ‘Two cases of puerperal peritonitis after bad labours, requiring instrumental and other assistance, died, but the disease did not extend. My opinion is that the coldness of the wards, though objectionable, has a great deal to do with the comparative immunity hitherto enjoyed as regards the germination and extension of contagious diseases.’

It need scarcely be said that these new hospitals are models of cleanliness.

In the Colchester Hut the patient is received into a separate compartment, of which there are four, where she is delivered and remains until discharged to quarters.

It is very rarely indeed, if ever, that all the four compartments are occupied simultaneously. The average stay is ten days; the average number of deliveries a year under 50.

This hut does not form part of a hospital. It is a separate establishment, solely for lying-in women, as such accommodation should always be.

_Note._—There is another reason, though it may be termed a fanciful one, for altogether disconnecting lying-in institutions with general hospitals, and even with the name and idea of hospital. It is this: there must be a certain death-rate in a general hospital, receiving as it does fatal diseases and fatal accidents, as long as men and women have fatal diseases and fatal accidents.

But lying-in is not a fatal disease, nor a disease at all. It is not a fatal accident, nor an accident at all.

Unless from causes unconnected with the puerperal state, no woman ought to die in her lying-in; and there ought, in a lying-in institution, to be no death-rate at all.

It is dangerously deadening our senses to this fact—viz., that there ought to be _no_ deaths in a lying-in institution—if we connect it in the least degree with the name of hospital, so long as a hospital means a place for the reception of diseases and accidents.

In French statistics, this confusion of ideas, were it not ghastly, would be ludicrous. ‘Admissions,’ under the head ‘Malades,’ include not only the lying-in women, but the new-born infants, which appear to be ‘admitted’ to life and to hospital together, as if life were synonymous with disease, so that, e.g. 4,000 ‘Admissions,’ in such a year, to the Paris Maternité would mean 2,000 deliveries, 2,000 births—[and—how many deaths?]

_RECAPITULATION._

In summing up the evidence regarding excessive mortality in lying-in institutions and its causes, it appears:—

1. That, making every allowance for unavoidable inaccuracies in statistics of midwifery practice, there is sufficient evidence to show that in lying-in wards there reigns a death-rate many times the amount of that which takes place in home deliveries.

2. That a great cause of mortality in these establishments is ‘blood-poisoning,’ and that this arises from the greater susceptibility of lying-in women to diseases connected with this cause. From whence it follows that in many lying-in wards, as at present arranged and managed, there must be conditions and circumstances apart from those belonging to the inmates personally, which aid in the development of this morbid state.

3. That the risks to which lying-in women are exposed from puerperal diseases are increased by crowding cases in all stages into the same room or under the same roof; by retaining them for too long a period in the same room; by using the same room for too long a period without cleansing, evacuation, rest, and thorough airing: but that the death-rate is not always in proportion to the number of lying-in cases which have passed through the hospital.

It follows from this that, other things being equal, a high death-rate may take place in a small hospital constantly used up to its capacity as well as in a large hospital constantly used up to its capacity.

4. That there are superadded causes in some establishments which add greatly to their dangers. Among these may be reckoned the following:—

(_a_) Prevalence of puerperal fever as an epidemic outside the hospital.

(_b_) Including midwifery wards within general hospitals, thereby incurring the risk of contaminating the air in midwifery wards with hospital emanations.

(_c_) Proximity to midwifery wards of post-mortem theatres or other external sources of putrescence.

(_d_) Admitting medical students from general hospitals or from anatomical schools to practice or even to visit in midwifery wards without special precautions for avoiding injury.

(_e_) Treating cases of puerperal disease in the same ward, or under the same roof, with midwifery cases.

(_f_) Permitting the same attendants to act in infirmary wards and in lying-in wards, and using the same bedding, clothing, utensils, &c., in both.

(_g_) Most probably also—especially in certain foreign hospitals—want of scrupulous attention to ventilation, and to cleanliness in wards, bedding, clothing, utensils, and patients, and in the clothing and personal habits of attendants.

In short, the entire result of this enquiry may be summed up, in a very few words, as follows:—A woman in ordinary health, and subject to the ordinary social conditions of her station, will not, if delivered at home, be exposed to any special disadvantages likely to diminish materially her chance of recovery. But this same woman, if received into an ordinary lying-in ward, together with others in the puerperal state, will from that very fact become subject to risks not necessarily incident to this state. These risks in lying-in institutions may no doubt be materially diminished by providing proper hospital accommodation, and by care, common sense, and good management. And hence the real practical question is, whether it is possible to ensure at all times the observance of these conditions.

The great mortality in lying-in hospitals everywhere is no doubt a strong argument against such a result being attainable; so much so that, in the absence of this security, the evidence in the preceding pages appears sufficient to warrant the question being raised, whether lying-in hospitals, arranged and managed as they are at present, should not be forthwith closed?

Can any supposed advantages to individual cases of destitution counterbalance the enormous destruction of human life shown by the statistics?

Without vouching for the entire accuracy of Le Fort’s data, they may still be taken generally as showing approximately the penalty which is being paid for the supposed advantages of these institutions. It is this: (see Table XV.) for every two women who would die if delivered at home, fifteen must die if delivered in lying-in hospitals. Any reasonable deduction from this death-rate for supposed inaccuracy will not materially influence the result.