Part 6

As a general rule, statistics appear to show that the great mortality of lying-in hospitals is of periodical occurrence.

Puerperal women, as everyone knows, are the most susceptible of all subjects to ‘blood-poisoning.’ The smallest transference of putrescing miasm from a locality where such miasm exists to the bedside of a lying-in patient is most dangerous. Puerperal women are, moreover, exposed to the risks of ‘blood-poisoning’ by the simple fact of being brought together in lying-in wards, and especially by being retained a longer time than is absolutely necessary in lying-in wards after being delivered, while to a great extent they escape this entire class of risks by being attended at home.

There are no doubt difficulties in assigning the exact effect of every condition to which a lying-in woman may be exposed in contributing to these death-rates, but there are, nevertheless, a few great fundamental facts which arrest attention in such an enquiry.

It is a fact, for instance, that however grand, or however humble, a home may be in which the birth of a child takes place, there is only one delivery in the home at one time. Another fact is, that a second delivery will certainly not take place in the same room, inhabited by the same couple, for 10 months at least, and may not take place in the same room for years. The Registrar-General has shown us that under these conditions the death-rate among lying-in women all over England, and from all registered causes, is about 5·1 per 1,000.

In many London workhouses the number of deliveries yearly is so small that, so far as concerns annual deliveries, they approach more closely to dwelling-houses divided among a number of families than they do to lying-in hospitals properly so called.

Let us now see what relation there is between the annual deliveries and the death-rates in these workhouse wards.

Assuming that the London workhouse lying-in wards have certain conditions in common, we find that twenty-seven infirmaries suffered from lying-in deaths in five years, and that in thirteen there were no deaths in the same years. Now, in each of these twenty-seven hospitals yielding deaths, the deliveries averaged 29 per annum, while in the thirteen infirmaries without deaths the deliveries averaged under 16 per annum.

Again, in twenty-one infirmaries with deaths, the average disposable space for each occupied lying-in bed was 2,246 cubic feet; while in nine infirmaries without deaths the space per occupied bed averaged 3,149 cubic feet. These, however, are only averages, and as such may be taken for what they are worth. There were exceptions to these rules in particular cases.

The facts regarding Waterford Lying-in Institution have a very important bearing on this question of subdivision.

In the years from 1838 to 1844 this hospital consisted of two rooms in a small house. One room was a delivery ward. The other held eight lying-in beds. The total deliveries in this house amounted to 753, and there were 6 deaths = 8 per 1,000. Half this mortality was due to puerperal fever.

In October 1844 this hospital occupied another small house, in which the eight lying-in beds were placed in two rooms instead of one as formerly—four beds per room. Up to October 1867 there had been 2,656 deliveries in this house, and 9 deaths—a mortality of 3·4 per 1,000. There were only two puerperal fever deaths in these 2,656 deliveries.

These facts appear to show that subdivision among lying-in cases has a certain influence in warding off mortality.

But, on the other hand, the death-rates among lying-in cases in particular hospitals are not always in the ratio of the number of occupied beds. A few illustrations of this will suffice.

Thus, in the year 1861, there were in the Rotunda Hospital, Dublin, 1,135 deliveries, on which the death-rate was 51·9 per 1,000. In 1828 the deliveries were 2,856, and the death-rate 15 per 1,000. In the four years 1830 to 1833, the deliveries varied from 2,138 to 2,288, and the death-rates were a little more than 5 per 1,000. In Queen Charlotte’s Hospital the highest death-rate occurred in 1849, during which year there were 161 deliveries. The death-rate was 93·2 per 1,000, while in 1832, with 217 deliveries, the death-rate was just one tenth of this amount.

In the Maison d’Accouchement at Paris, during the five decennial periods between 1810 and 1859, there were 141,476 deliveries, among which there occurred 6,288 deaths, giving a death-rate of 44·4 per 1,000. The lowest death-rate in any of the decennial periods occurred between 1840 and 1849, when it amounted to 41·9 per 1,000. The largest number of deliveries of any period in the half century was during this ten years. They amounted to 34,776; while, in the period from 1850 to 1859, the deliveries were 24,944, and the death-rate 52 per 1,000.

The Dublin Rotunda approximates most to this Paris Maternité in the large number of deliveries, vibrating around 2,000 a year; while, in Queen Charlotte’s Hospital, where, even since its reconstruction, the mortality has been in many years higher than in the Dublin Rotunda, the number of annual deliveries has varied around 200.

Danger of Puerperal Epidemics.—These facts have a very important bearing on the whole question of lying-in institutions, for they show that, with scarcely an exception, while the lowest death-rate in any given year greatly exceeds the average mortality among lying-in women delivered at home, the inmates of these institutions are exposed to the enormous additional risk of puerperal epidemics.

Take, for instance, Queen Charlotte’s Hospital. There is no reason to believe that less care and solicitude for the welfare of its inmates is exercised than would be the case if they were delivered at home. And yet we find that year by year, from 1828 down to the present time, the institution has only escaped deaths for four years. The lowest death-rate it ever had was in 1835, when it amounted to 4·6 per 1,000. In other years it has been 11, 15, 21, 30, 50, 70, 81, 86, and in one year it rose to the immense death-rate of 93·2 per 1,000.

In 1849 there were, as above said, 161 deliveries out of which fourteen women died from puerperal fever, being a death-rate of 87 per 1,000 from this disease alone.

The statistics of other lying-in institutions afford corresponding data. It is a lamentable fact that the mortality in lying-in wards from childbirth, which is not a disease, approaches closely to the mortality from all diseases and accidents together in general hospitals, and in many instances even greatly exceeds this mortality. It is the more lamentable, because, as need scarcely be stated, the causes of a higher mortality in infancy and old age cannot exist at childbearing ages. Also, childbirth ought certainly not to be a ‘miasmatic disease.’ Unless, then, it can be clearly shown that these enormous death-rates can be abated, or that they are altogether inevitable, does not the whole of the evidence with regard to special lying-in hospitals lead but to one conclusion, viz. that they should be closed? Is there any conceivable amount of privation which would warrant such a step as bringing together a constant number of puerperal women into the same room, in buildings constructed and managed on the principles embodied in existing lying-in institutions?

Fatality of Lying-in Wards in General Hospitals.—Besides special lying-in hospitals, there are general hospitals which receive lying-in cases. Fortunately, there are not many such in England. But in Paris there are 11 general hospitals which receive midwifery cases. A reference to Tables XI., XII., XIII., will show how great the risks are to lying-in women under the same roof with medical and surgical cases; a fact which may be further illustrated by a reference to data for particular hospitals. For example, in 1861, 253 lying-in cases in La Charité gave a total death-rate of 193·7 per 1,000, of which no less than 154·2 was due to puerperal causes. These tables tell their own story, and they throw altogether into the shade the lamentable losses at King’s College Hospital.

The only amende that could be made was to shut up the ward; and having done this in the interest of womankind, need it be said that the impression produced by these statistics confirms the conclusion just stated in regard to existing lying-in wards generally, and is that not a single lying-in woman should ever pass within the doors of a general hospital? Is not any risk which can be incurred outside almost infinitely smaller? And as a general hospital must always be a hospital, must not this verdict be an absolute one, not one which can be altered or reversed?

INFLUENCE OF CONSTRUCTION AND MANAGEMENT OF LYING-IN WARDS ON THE DEATH-RATE.

Before, however, surrendering entirely the principle of special lying-in institutions, it is only fair to enquire whether the construction, management, and arrangements of existing hospitals of this class may possibly have had any influence upon the mortality, apart from the mere fact of bringing lying-in cases together under one roof.

This question is the more important because we now know that construction and arrangement of buildings exert a notable effect on the death statistics of general hospitals. It is at last universally admitted that airy open site, simplicity of plan, subdivision of cases under a number of separate pavilions, large cubic space, abundant fresh air, mainly from windows on the opposite sides of the wards, drainage arrangements entirely outside the hospital, are essential conditions to the safety of all general hospitals. But, as already stated, it is likewise admitted that lying-in women are peculiarly susceptible to ‘blood-poisoning.’

This being the case, have we any reason to expect other than a high death-rate if we collect lying-in women into such wards, or rather rooms, as are found in many old hospitals?

Nobody with ordinary knowledge of the subject, and desirous simply of benefiting suffering people, would now dream of appropriating buildings of this kind as hospitals for sick. But it is to be feared that the same scruple has not always existed with regard to lying-in women. And as we now know that such buildings give high death-rates among sick and wounded people, there is every reason to fear that they have had their share in raising the death-rate among lying-in women to a greater extent than that due merely to the fact of agglomeration. As instances of the existence of danger from such causes, and also from grave errors in administration, two or three illustrations are here introduced from existing lying-in establishments.

Maternité, Paris.—We have seen from the statistics that the chief of chief offenders in times past has been the Maternité at Paris. This establishment was in former times the monastery of ‘Port Royal de Paris.’ It is situated in one of the most healthy open spots on the outskirts of the French capital, and, as far as situation is concerned, ought to be healthy. The building was devoted to its present destination in 1795, and has undergone many changes since that date. It contains 228 beds for lying-in women, and, besides, accommodation for 94 pupil midwives. From 1,000 to 2,200 deliveries and upwards take place here annually: from 1840 to 1849 there were as many as 3,400 annually. Until recently it consisted properly of three divisions, delivery wards, cells for delivered women in the process of recovery, and an infirmary.