Introductory Notes on Lying-in Institutions

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.

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 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)│ │ │ │ │ │ │ │ │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.

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