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.

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