Part 5

Mortality per 1,000.

Puerperal diseases and Puerperal Accidents of accidents of diseases childbirth childbirth All England, 13 years 1·61 3·22 4·83 England (healthy districts), 10 years, 312,402 deliveries 4·3 England, 11 large towns, 10 years, 1,402,304 deliveries 4·9 Liverpool workhouse 3·4 2·2 5·6 27 London workhouses having deaths 4·1 2·1 6·2 8 military female hospitals 3·9 3·4 7·3 Queen Charlotte’s Lying-in Hospital 14·3 5·3 19·6 King’s College Hospital lying-in ward 29·4 none 29·4 12 Parisian hospitals { 1861 75·2 „ { 1862 56·7 „ { 1863 60·6

We have already seen, as a result of Dr. Le Fort’s tables, that the mortality among women delivered at home, as deduced by him, is 4·7 per 1,000; while in the hospital it is 34 per 1,000, or nearly 7½–fold. Making any reasonable allowance for inaccuracy in the data, still we can hardly escape from his conclusions any more than we can rid ourselves from the consequences which follow from the data given above. We must confront the question called up by the data taken as a whole, viz., What can be the reason of this ascending scale of fatality shown on Table VIII.? Why is it that these death-rates from all causes in childbirth, beginning at 5·1 per 1,000 for all England (town and country), successively become, among the same people 9·, 10·9, 14·3, 25·3, 33·3; and if we cross the channel, why should they mount up to 69, 70, and 95 per 1,000?

Again, why should fevers and inflammations of the puerperal class, which, as we have seen above, give a death-rate for all England of 1·61 per 1,000, mount up in English hospitals to 3·4, 4·1, 14·3, and 29·4? There must be some reason, besides the fact of childbirth, why diseases and accidents of this condition should be 4 times more fatal in a London lying-in hospital, and 15 times more fatal in Parisian hospitals, than they are in towns of England. What, then, are the immediate causes of these excessive death-rates?

CAUSES OF HIGH DEATH-RATES IN LYING-IN INSTITUTIONS.

The determining causes of these death-rates need to be discussed most cautiously;—our information concerning them being so scanty.

We know from Statistics that these Deaths occur, but why they occur and why they vary are questions not yet to be fully answered in our present stage of knowledge (or of ignorance).

At one time a sufficient cause seems to present itself; but the very next outbreak of Puerperal disease may occur under quite different conditions. For years an Institution may escape excessive Mortality; and then it may suffer severely under the same apparent circumstances. All that we can do at present is to see whether there are removable causes in cases where the Mortality is excessive, and to remove them. Fully recognising how much we have need of caution, this subject will be next considered generally and as far as possible in its practical bearings on the points at issue.

There are some important remarks in Dr. Le Fort’s book, bearing on this subject, which may find a place here.

Puerperal Fever.—Dr. Le Fort states, as the result of his enquiry, that the frequency of obstetrical operations modifies the general mortality only in a slight degree; that the excessive mortality in lying-in hospitals is much greater than can be attributed to ordinary hospital influences; that it depends neither on the social condition of the women, nor on the moral conditions under which delivery may occur; that it may be more or less influenced by the insalubrity of particular hospitals, but that puerperal fever is the principal cause of death after delivery; that this disease shows itself in all hospitals, in all maternity institutions, in all climates, in the south of France as it does at St. Petersburg, in Dublin as in Vienna, in London as in Moscow. It exists in America as in Europe.

It is less frequent and fatal during the summer months, attributable in part at least to greater facilities of ventilation following on higher temperature (in other words, to having your windows open instead of shut).

This disease develops itself spontaneously under certain unknown circumstances. When it is about to become epidemic, it is sometimes preceded by the prevalence of erysipelas.

Dr. Le Fort points out that what was considered a severe epidemic in the British Lying-in Hospital, in the year 1770, is ‘unfortunately less than the mean mortality of the Maternité at Paris.’

While admitting that puerperal fever may originate de novo, Dr. Le Fort dwells strongly on the communicability of the disease as an efficient cause of its prevalence.

He adduces opinions of the following physicians—Oppolzer, Rokitansky, and Skoda, of Vienna; Virchow, of Berlin; Lange, of Heidelberg; Schwarz, of Göttingen; Löschner, of Prague; and Hecker, of Munich—on the nature and origin of this fatal disease. Generally they testify to the propagation of puerperal fever by contagion, but they also state that it is a blood disease—a product of foul air, putrid miasms, and predisposition to malignant inflammatory action.

Dr. Le Fort also cites a number of interesting facts, showing that the indiscriminate visiting by attendants of lying-in women and patients suffering from disease, either within or outside the same establishment, has been a means of exciting puerperal fever action.

Admission of Students.—It is one of the contingencies necessarily due to connecting together the teaching of midwifery to students, with other portions of clinical instruction, that no precautions can prevent a student passing from a bad surgical case, or from an anatomical theatre, to the bedside of a lying-in woman, while sad experience has proved that the most fatal results may ensue from this circumstance.

Of course risks of this kind are greatly increased when there are lying-in wards in general hospitals—especially if a medical school be attached to such a hospital.

This risk had not been overlooked in the arrangements for the lying-in wards at King’s College Hospital, under which, while intended solely for the training of midwifery nurses, provision was made for a limited and regulated attendance of students; but, when enquiries came to be made into the probable cause of the high death-rates, it was found that the restrictions laid down as to the admission of students had been disregarded; also that there was a post-mortem theatre almost under the ward windows.

Effect of Numbers.—Dr. Le Fort has examined the influence exercised by numbers—or, in other words, by the size of hospitals—on the mortality after childbirth. His general results may be briefly stated as follows:—

In hospitals receiving annually more than 2,000 lying-in cases, comprising the two Cliniques of Vienna, 1834–63; the Maternités of Paris, 1849–59; of Prague, 1848–62; and of Moscow, 1853–62; and the Lying-in Hospital of Dublin, 1847–54, the death-rate is 40·7 per 1,000.

In hospitals receiving between 1,000 and 2,000 cases a year, including the Enfans Trouvés at Petersburg, 1845–59; the Maternité at Munich, 1859–62, and other places, the death-rate is 36 per 1,000.

In hospitals receiving from 500 to 1,000 cases a year, including Pesth and the Maternité of Dresden, the death-rate is nearly 27 per 1,000.

In hospitals where the number of deliveries is between 200 and 500 per annum, comprehending several places cited, among the rest Edinburgh and the London Lying-in Hospital, 1833–60, the death-rate is 30½ per 1,000.

In hospitals receiving between 100 and 200 cases, as at Frankfort and Göttingen, the death-rate is 27·6 per 1,000.

And in three small establishments receiving fewer than 100 a year, as at Lund, the death-rate is above 83½ per 1,000.

From these facts Dr. Le Fort concludes that the relative mortality in small and large establishments is not favourable to small hospitals, per se. The benefit of subdivision may be neutralised by other circumstances.

We must also protest against massing hospitals, alike only in one circumstance, together for the sake of taking their statistics in bulk in this way, except for the most general purposes—which is indeed all Dr. Le Fort has in view here—especially as our own lying-in institutions of these islands, which come out best individually, appear here confounded amongst the greatest sinners. But Dr. Le Fort’s general conclusion, against the influence of size per se, is no doubt correct.