Part 11

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│ 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│ 2│ 2│ 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:—

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: 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. 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.