Part 10

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.