1. There were 2,346 deaths by accidents of childbirth (hæmorrhage,
convulsions, exhaustion, mania, &c.).
2. There were 1,066 deaths due to puerperal diseases (puerperal fever,
puerperal peritonitis, metritis, pyæemia, &c.).
3. Of the remaining 521 deaths, 137 were due to non-puerperal fevers and
eruptive fevers; 230 were occasioned by consumption and other chest
diseases, and 154 by other causes.
4. By adding together deaths from puerperal diseases and those from
fevers, we find that, out of a total mortality of 3,933, the deaths from
diseases more or less connected with what is called ‘blood-poisoning’
amounted to 1,203, or rather more than 30 per cent. of the total
mortality.
5. The mortality per 1,000 deliveries (or rather per 1,000 births) from
each class of causes in England, in 1867, stands thus:—
Accidents of childbirth 3 per 1,000
Puerperal diseases 1·4 „ „
Others, including non-puerperal fevers ·7 „ „
———
Total 5·1 „ „
The same Report gives the following puerperal death-rates for all
England during 13 years, 1855 to 1867 (see Table II.).
Accidents of childbirth 3·22 per 1,000
Puerperal diseases 1·61 „ „
————
Total, exclusive of other deaths 4·83 „ „
An important element in the analysis of these death-rates is their
relative prevalence in town and country. This is abstracted on Table II.
from the Registrar-General’s Report for a period of ten years, as
follows:—
_Deaths from Accidents of Childbirth and Puerperal Diseases._
England, 64 healthy districts, 312,402 deliveries 4·3 per 1000
Ditto, 11 large towns, 1,402,304 deliveries 4·9 „ „
In other words, out of every 5,000 deliveries in towns there are three
more deaths from accidents of childbirth and puerperal diseases than
occur among the same number of deliveries in healthy districts.
These facts, with a small deduction for the higher death-rates in
lying-in hospitals, give the present mortality in English homes. They
appear to show that puerperal women are subject to something of the same
law of increase of death-rates in towns as other people, but part of the
increase is no doubt due to the higher death-rates in delivery wards in
these towns. The facts also appear to indicate a probable reduction of
death-rates among lying-in women in England, from the extension of
public health improvements both in town and country.
TABLE II.—_Table Showing the Mortality per Thousand after Delivery from
Puerperal Diseases and Accidents of Childbirth._
┌────────────────────────────────────┬────────────────────────────────┐
│ Places │ Mortality Per Thousand │
│ │ Deliveries │
├────────────────────────────────────┼──────────┬──────────┬──────────┤
│ „ │ │ │Puerperal │
│ │ │ │ Diseases │
│ │ │ │ and │
│ │ │Accidents │Accidents │
│ │Puerperal │ of │ of │
│ │ Diseases │Childbirth│Childbirth│
├────────────────────────────────────┼──────────┼──────────┼──────────┤
│King’s College lying-in ward, 5 │ │ │ │
│ years │ 29·4│ 0│ 29·4│
│12 Parisian Hospitals 1861 │ │ │ 75·2│
│ 1862 │ │ │ 56·7│
│ 1863 │ │ │ 60·6│
│Queen Charlotte’s Lying-in Hospital,│ │ │ │
│ 40 years │ 14·3│ 5·3│ 19·6│
│27 London workhouses, in which both │ │ │ │
│ deliveries and deaths have taken │ │ │ │
│ place │ 4·1│ 2·1│ 6·2│
│40 London workhouses, including │ │ │ │
│ those without deaths, 5 years │ 3·3│ 1·7│ 5·0│
│Liverpool Workhouse lying-in wards, │ │ │ │
│ 13 years │ 3·4│ 2·2│ 5·6│
│All England, 13 years │ 1·61│ 3·22│ 4·83│
│Ditto, 64 healthy districts │ │ │ │
│(312,402 deliveries), 10 years │ │ │ 4·3│
│Ditto, 11 large towns (1,402,304 │ │ │ │
│ deliveries), 10 years │ │ │ 4·9│
│8 military lying-in hospitals, 2 to │ │ │ │
│ 12 years │ 3·9│ 3·4│ 7·3│
└────────────────────────────────────┴──────────┴──────────┴──────────┘
_NORMAL MORTALITY AMONG LYING-IN WOMEN IN DIFFERENT COUNTRIES._
The next step in the enquiry is to ascertain, so far as it may be
possible to do so, what is the death-rate among lying-in women delivered
at their own homes in different European countries. Besides the
mortality statistics for healthy districts in England, already given,
the only available data for this information are reports of public
institutes having outdoor midwifery practice, and any records of private
practice which may have been published. In adducing these data, however,
it is necessary to do so with the reservation already made that their
accuracy is only approximate.
The most extensive series of data of this class is given by Dr. Le Fort
in his able treatise ‘Des Maternités,’ for a number of institutions in
different European countries. The facts from Dr. Le Fort’s book are
abstracted on Table III., in which it is shown that out of 934,781
deliveries at home, in Edinburgh, London, Paris, Leipzig, Berlin,
Munich, Greifswald, Stettin, and St. Petersburg, there were 4,405
deaths, equivalent to a mortality of 4·7 per 1,000. When compared with
the Registrar-General’s returns for town districts, this rate is
apparently somewhat too low; it is only an approximation, but still
sufficiently near the rate given by the Registrar-General to show that
there is a true death-rate for home deliveries not far removed from the
Registrar-General’s figure.
TABLE III.—_Table Showing the Death-rate from all Causes amongst Women
Delivered in their own Homes._ (_Abstracted from Dr. Le Fort’s
Tables._)
┌────────────────────────────┬───────────┬──────────┬────────┬────────┐
│ Places │ No. of │ │ │ Deaths │
│ │ Years of │ │ │ per │
│ │Observation│Deliveries│ Deaths │Thousand│
├────────────────────────────┼───────────┼──────────┼────────┼────────┤
│Edinburgh │ 1│ 5,186│ 28│ 5│
│London: │ │ │ │ │
│ Westminster │ │ │ │ │
│ General │ │ │ │ │
│ Dispensary │ 11│ 7,717│ 17│ 2│
│ Ditto Benevolent│ │ │ │ │
│ Institution │ 7│ 4,761│ 8│ 1│
│ Royal Maternity │ │ │ │ │
│ Charity │ 5│ 17,242│ 53│ 3│
│ London │ │ │ │ │
│ population │ 5│ 562,623│ 2,222│ 3·9│
│ St. Thomas’ │ │ │ │ │
│ Hospital │ 7│ 3,512│ 9│ 2·5│
│ Guy’s Hospital │ 8│ 11,928│ 36│ 3│
│ Ditto │ 1│ 1,505│ 4│ 2│
│ Ditto │ 1│ 1,702│ 3│ 1·7│
│ Ditto │ 1│ 1,576│ 11│ 6│
│Paris: │ │ │ │ │
│ 12th │ │ │ │ │
│ Arrondissement│ 1│ 3,222│ 10│ 3│
│ Bureau de │ │ │ │ │
│ Bienfaisance │ 1│ 6,212│ 32│ 5│
│ Ditto │ 1│ 6,422│ 39│ 6│
│ City of Paris │ 1│ 44,481│ 262│ 5│
│ Ditto │ 1│ 42,796│ 226│ 5│
│Leipzig Polyclinique │ 11│ 1,203│ 13│ 10│
│Berlin „ │ 1│ 500│ 7│ 14│
│Munich „ │ 5│ 1,911│ 16│ 8│
│Greifswald „ │ 4│ 295│ 6│ 20│
│Stettin „ │ 17│ 375│ 0│ 0│
│St. Petersburg │ 15│ 209,612│ 1,403│ 6·6│
├────────────────────────────┼───────────┼──────────┼────────┼────────┤
│ Total │ │ 934,781│ 4,405│ 4·7│
└────────────────────────────┴───────────┴──────────┴────────┴────────┘
St. George’s Hospital Statistics for ‘the 6 years preceding 1870 show
only one maternal death in every 305 cases’ in the Out-door Maternity
Department.
From home records, it is hoped at some future time to give many more
data of this kind, and to distinguish the causes of death: puerperal
from non-puerperal mortality, as well as that caused by puerperal
diseases from that caused by accidents of childbirth. At present the
data for doing this are lamentably deficient, if not almost altogether
wanting.
One good recorded fact will here be given. Among 1,929 mothers delivered
at home by Guy’s Hospital in 1869, 5 deaths only are recorded, and none
from puerperal diseases; 2 were from heart disease, 2 from pneumonia, 1
from exhaustion.
_OBJECTIONS TO THE DATA._
The value of the Registrar-General’s results, and of those given by Le
Fort, has been called in question by Dr. Duncan in his work already
cited, partly on the authority of certain results of home practice,
quoted from Dr. M’Clintock, who has collected the statistics of 16,774
deliveries exclusively from home practice. There were among these 45
deaths from accidents of labour, 52 deaths from puerperal diseases, and
34 deaths from non-puerperal diseases; giving a total mortality of 131,
or nearly 8 per 1,000. On considering these figures, the first
impression they convey is not that either the Registrar-General or Le
Fort is wrong. But it is a very painful impression of another kind
altogether. One feels disposed to ask whether it can be true that, in
the hands of educated accoucheurs, the inevitable fate of women
undergoing, not a diseased, but an entirely natural condition, at home,
is that one out of every 128 must die? If the facts are correct, then
one cannot help feeling that they present a very strong _prima facie_
case for enquiry, with the view of devising a remedy for such a state of
things. It must be seen, however, that these statistics of home practice
are as open to the charge of want of accuracy as those of the
Registrar-General or Le Fort. The question can only be settled by
enquiry, and by more carefully kept statistics of midwifery practice;
but in the meantime here are a few facts, kindly placed at my disposal
by Mr. Rigden, of Canterbury, which are by no means so hopeless as those
given by Dr. Duncan.
‘An analysis of 4,132 consecutive cases in midwifery occurring in
private practice during a period of 30 years, particularly in reference
to mortality. Eight mothers died: three from convulsions and coma; 4
from puerperal fever; and one from heart disease, about an hour after a
comparatively easy labour.’
The report states 8, but after it was supplied another death took place,
the day after delivery, making 9 in all. The cause of death is not
given.
Mr. Rigden explains that these figures relate only to the first
fortnight after delivery; but he states that if any other deaths had
taken place within the month, he must have heard of them.
Assuming the Deliveries at 4,133 and the Deaths at 9, Mr. Rigden’s facts
show a total mortality of 2·17 per 1,000, of which less than 1 per 1,000
was due to puerperal fever.
_ESTIMATED APPROXIMATE HOME DEATH-RATE._
In estimating the probable accuracy of statistical data in which there
may be both excesses and deficiencies, sources of error are diminished
by largeness in the numbers employed in striking averages. Bearing this
in mind, and after considering the objections brought against the
accuracy of the figures, there seems no reason for rejecting the
Registrar-General’s average total mortality among lying-in women in
England of 5·1 per 1,000, as affording a sufficiently close
approximation to the present real death-rate among lying-in women
delivered at home, for all practical purposes of comparison with the
death-rates in lying-in hospitals.
_DEATH-RATES IN LYING-IN INSTITUTIONS._
We shall next show approximately what are the death-rates in
establishments for lying-in women.
We will give an abstract of mortality statistics for a number of these
institutions, the general results of which may be stated as follows:—
In eight military lying-in hospitals (Table IV.), in which 5575
deliveries took place, in periods of from 2 to 12 years, there were 50
deaths (excluding a death before admission)—a death-rate of 8·8 per
1,000.
TABLE IV.—_Return of the Number of Admissions for Parturition, and
Deaths occurring in the undermentioned Women’s Hospitals (Military)._
(_Supplied by the Director-General, Army Medical Department._)
┌───────────┬──────┬──────────┬───────────────────────────────────┐
│ Station │Period│ No. of │ │
│ │ │Deliveries│ Causes of Death │
├───────────┼──────┼──────────┼────────────┬──────────┬───────────┤
│ „ │ „ │ │ Puerperal│ │ │
│ │ │ │ Feve and│ │ │
│ │ │ │Peritonitis,│ │ │
│ │ │ │ Pyæmia,│ │ │
│ │ │ │ Phlebitis,│ │ Puerperal│
│ │ │ „ │ &c.│Scarlatina│Convulsions│
├───────────┼──────┼──────────┼────────────┼──────────┼───────────┤
│Devonport │April │ │ │ │ │
│ │1861 │ │ │ │ │
│ │to │ │ │ │ │
│ │Dec. │ │ │ │ │
│ │1869 │ 158│ │ │ 1│
│Colchester │1865 │ │ │ │ │
│ │to │ │ │ │ │
│ │Oct. │ │ │ │ │
│ │187 │ 252│ │ │ │
│Portsmouth │1861 │ │ │ │ │
│ │to │ │ │ │ │
│ │Dec. │ │ │ │ │
│ │1869 │ 302│ 2│ │ 1│
│Aldershot │1857 │ │ │ │ │
│ │to │ │ │ │ │
│ │Dec. │ │ │ │ │
│ │1869 │ 3,028│ 14│ │ 1│
│Shorncliffe│Up to │ │ │ │ │
│ │Dec. │ │ │ │ │
│ │1869 │ 702│ │ 1│ │
│Chatham │Dec. │ │ │ │ │
│ │1863 │ │ │ │ │
│ │to │ │ │ │ │
│ │Dec. │ │ │ │ │
│ │1869 │ 342│ │ 2│ │
│Woolwich │Nov. │ │ │ │ │
│ │1863 │ │ │ │ │
│ │to │ │ │ │ │
│ │Dec. │ │ │ │ │
│ │1869 │ 751│ 5[5]│ │ │
│Curragh │1868 │ │ │ │ │
│ │and │ │ │ │ │
│ │1869 │ 40│ │ │ │
├───────────┼──────┼──────────┼────────────┼──────────┼───────────┤
│ Total │ │ 5,575│ 21│ 3│ 3│
└───────────┴──────┴──────────┴────────────┴──────────┴───────────┘
┌───────────┬────────────────────────────────────────────────────┐
│ Station │ │
│ │ Causes of Death │
├───────────┼───────────┬────────┬──────────┬─────────┬──────────┤
│ „ │ │ │ │ │ │
│ │ │ │ │Premature│ │
│ │ │ │ │ Labour│ │
│ │ │ │ Syncope│ and│ │
│ │Hæmorrhage,│Ruptured│ and│ Adherent│ │
│ │ Effects of│ Uterus│Exhaustion│ Placenta│Craniotomy│
├───────────┼───────────┼────────┼──────────┼─────────┼──────────┤
│Devonport │ │ │ │ │ │
│ │ │ │ │ │ │
│ │ │ │ │ │ │
│ │ │ │ │ │ │
│ │ │ │ │ │ │
│Colchester │ │ │ │ │ │
│ │ │ │ │ │ │
│ │ │ │ │ │ │
│ │ │ │ │ │ │
│Portsmouth │ │ │ │ │ │
│ │ │ │ │ │ │
│ │ │ │ │ │ │
│ │ │ │ │ │ 1│
│Aldershot │ │ │ │ │ │
│ │ │ │ │ │ │
│ │ │ │ │ │ │
│ │ 4│ 1│ 4│ 1│ 1│
│Shorncliffe│ │ │ │ │ │
│ │ │ │ │ │ │
│ │ 1│ │ │ │ 2│
│Chatham │ │ │ │ │ │
│ │ │ │ │ │ │
│ │ │ │ │ │ │
│ │ │ │ │ │ │
│ │ │ │ │ │ │
│Woolwich │ │ │ │ │ │
│ │ │ │ │ │ │
│ │ │ │ │ │ │
│ │ │ │ │ │ │
│ │ │ │ 1│ │ │
│Curragh │ │ │ │ │ │
│ │ │ │ │ │ │
│ │ │ │ │ │ │
├───────────┼───────────┼────────┼──────────┼─────────┼──────────┤
│ Total │ 5│ 1│ 5│ 1│ 4│
└───────────┴───────────┴────────┴──────────┴─────────┴──────────┘
┌───────────┬──────────────────────────────────────────────────────┐
│ Station │ │
│ │ Causes of Death │
├───────────┼─────────┬────────┬────────┬──────────┬────────┬──────┤
│ „ │ │ │ │ │ │ │
│ │ │ │ │ │ │ │
│ │ │ │ │ │ │ │
│ │ │ │ │ Pneumonia│ │ │
│ │Inversion│ │ │ and│ │ │
│ │of Uterus│Embolism│Metritis│Bronchitis│Phthisis│Dropsy│
├───────────┼─────────┼────────┼────────┼──────────┼────────┼──────┤
│Devonport │ │ │ │ │ │ │
│ │ │ │ │ │ │ │
│ │ │ │ │ │ │ │
│ │ │ │ │ │ │ │
│ │ │ │ │ │ │ │
│Colchester │ │ │ │ │ │ │
│ │ │ │ │ │ │ │
│ │ │ │ │ │ │ │
│ │ │ │ │ │ │ │
│Portsmouth │ │ │ │ │ │ │
│ │ │ │ │ │ │ │
│ │ │ │ │ │ │ │
│ │ │ │ │ │ │ │
│Aldershot │ │ │ │ │ │ │
│ │ │ │ │ │ │ │
│ │ │ │ │ │ │ │
│ │ │ │ 1[3]│ 2│ 1│ │
│Shorncliffe│ │ │ │ │ │ │
│ │ │ │ │ │ │ │
│ │ │ │ │ │ │ │
│Chatham │ │ │ │ │ │ │
│ │ │ │ │ │ │ │
│ │ │ │ │ │ │ │
│ │ │ │ │ │ │ │
│ │ 1[4]│ │ │ │ │ │
│Woolwich │ │ │ │ │ │ │
│ │ │ │ │ │ │ │
│ │ │ │ │ │ │ │
│ │ │ │ │ │ │ │
│ │ │ 1│ │ │ │ 1│
│Curragh │ │ │ │ │ │ │
│ │ │ │ │ │ │ │
│ │ │ │ │ │ │ │
├───────────┼─────────┼────────┼────────┼──────────┼────────┼──────┤
│ Total │ 1│ 1│ 1│ 2│ 1│ 1│
└───────────┴─────────┴────────┴────────┴──────────┴────────┴──────┘
┌───────────┬────────┬──────┐
│ Station │Causes │Total │
│ │of Death│Deaths│
├───────────┼────────┼──────┤
│ „ │ │ │
│ │ │ │
│ │ │ │
│ │ Cause│ │
│ │ not│ │
│ │recorded│ „ │
├───────────┼────────┼──────┤
│Devonport │ │ │
│ │ │ │
│ │ │ │
│ │ │ │
│ │ │ 1│
│Colchester │ │ │
│ │ │ │
│ │ │ │
│ │ │ │
│Portsmouth │ │ │
│ │ │ │
│ │ │ │
│ │ │ 4│
│Aldershot │ │ │
│ │ │ │
│ │ │ │
│ │ 1│ 31│
│Shorncliffe│ │ │
│ │ │ │
│ │ │ 4│
│Chatham │ │ │
│ │ │ │
│ │ │ │
│ │ │ │
│ │ │ 3│
│Woolwich │ │ │
│ │ │ │
│ │ │ │
│ │ │ │
│ │ │ 8│
│Curragh │ │ │
│ │ │ │
│ │ │ │
├───────────┼────────┼──────┤
│ Total │ 1│ 51│
└───────────┴────────┴──────┘
In Liverpool workhouse lying-in wards (Table V.), with an approximate
number of 6,396 deliveries in 13 years, there were 58 deaths from all
causes—a mortality of 9·06 per 1,000.
TABLE V.—_Statistics of Midwifery Wards in Liverpool Workhouse for
Thirteen Years, 1858–70 inclusive._ (_Abstracted from data supplied by
Dr. Barnes, Liverpool._)
┌───────────┬─────────────────────────────────────────────────────┐
│Approximate│ Causes of Death │
│ Total │ │
│Deliveries │ │
├───────────┼───────────┬─────────┬────────┬──────────┬───────────┤
│ „ │ Puerperal │Puerperal│Metritis│Phlegmasia│Convulsions│
│ │Peritonitis│ Fever │ │ Dolens │ │
│ │ │ │ │ │ │
│ │ │ │ │ │ │
├───────────┼───────────┬─────────┬────────┬──────────┬───────────┤
│ 6396│ 16│ 4│ 1│ 1│ 5│
└───────────┴───────────┴─────────┴────────┴──────────┴───────────┘
┌───────────┬──────────────────────────────────────────────────┐
│Approximate│ Causes of Death │
│ Total │ │
│Deliveries │ │
├───────────┼──────────┬──────────┬──────────┬───────┬─────────┤
│ „ │ Debility │Obstructed│Hæmorrhage│Rupture│ Typhus │
│ │ and │ Labour │ │ of │ and │
│ │Exhaustion│ │ │Uterus │Relapsing│
│ │ │ │ │ │ Fever │
├───────────┼──────────┬──────────┬──────────┬───────┬─────────┤
│ 6396│ 5│ 1│ 2│ 1│ 2│
└───────────┴──────────┴──────────┴──────────┴───────┴─────────┘
┌───────────┬───────────────────────────────────────────────────────┐
│Approximate│ Causes of Death │
│ Total │ │
│Deliveries │ │
├───────────┼───────┬─────────┬──────────┬────────┬───────┬─────────┤
│ „ │Measles│Pneumonia│Laryngitis│Phthisis│ Heart │Nephritic│
│ │ │ │ │ │Disease│ Disease │
│ │ │ │ │ │ │ and │
│ │ │ │ │ │ │ Dropsy │
├───────────┼───────┬─────────┬──────────┬────────┬───────┬─────────┤
│ 6396│ 1│ 3│ 1│ 4│ 5│ 3│
└───────────┴───────┴─────────┴──────────┴────────┴───────┴─────────┘
┌───────────┬──────────────────┬──────┐
│Approximate│ Causes of Death │Total │
│ Total │ │Deaths│
│Deliveries │ │ │
├───────────┼────────┬─────────┼──────┤
│ „ │Jaundice│ Not │ „ │
│ │ and │ Stated │ │
│ │ Bowel │(Inquest)│ │
│ │Disease │ │ │
├───────────┼────────┬─────────┼──────┤
│ 6396│ 2│ 1│ 58│
└───────────┴────────┴─────────┴──────┘
And in 27 London workhouse infirmaries (Table VI.), amongst which deaths
took place, having 9,411 deliveries in five years, there were 93 deaths
from all causes. The death-rate was 9·8 per 1,000.[6]
TABLE VI.—_Mortality after Childbirth in Five Years, up to the end of 1865, in
Forty London Workhouse Infirmaries in which Deliveries took place._
(_Abstracted from Report on Metropolitan Workhouses._)
┌────────────────────┬─────────┬──────────┬─────────┬───────────┬──────┬──────┐
│ Deliveries │ Deaths│ Deaths │ Deaths │Deaths from│Deaths│Total │
│ │ from│ from │ from │Consumption│ from │Deaths│
│ │Puerperal│Accidents │Miasmatic│ and Chest │ all │ │
│ │ Diseases│ in │Diseases │ Diseases │Other │ │
│ │ │Childbirth│ │ │Causes│ │
├────────────────────┼─────────┼──────────┼─────────┼───────────┼──────┼──────┤
│27 workhouses: 9,411│ 39│ 20│ 0│ 15│ 19│ 93│
│13 „ 2,459│ 0│ 0│ 0│ 0│ 0│ 0│
└────────────────────┴─────────┴──────────┴─────────┴───────────┴──────┴──────┘
The City of London Lying-in Institution, during ten years, 1859–1868,
had 4,966 deliveries, and 54 deaths—a rate of 10·9 per 1,000.
The British Lying-in Institution had 1,741 deliveries, and 25 deaths, in
11 years, 1858–1868, giving a death-rate of 14·3 per 1,000 (Table
VIII.).
The mortality in Queen Charlotte’s Lying-in Hospital: 9,626 deliveries,
and 244 deaths, from 1828 to 1868 (Table VII.), was 25·3 per 1,000.
TABLE VII.—_Mortality in Queen Charlotte’s Lying-in Hospital, 1828 to
1868._
┌──────────┬─────────┬──────────┬─────────┬───────────┬───────┬───────┐
│Deliveries│ Deaths │ Deaths │ Deaths │Deaths from│Deaths │ Total │
│ │ from │ from │ from │Consumption│ from │Deaths │
│ │Puerperal│Accidents │Miasmatic│ and Chest │ all │ │
│ │Diseases │ in │Diseases │ Diseases │ Other │ │
│ │ │Childbirth│ │ │Causes │ │
├──────────┼─────────┼──────────┼─────────┼───────────┼───────┼───────┤
│ 9,626│ 138│ 51│ 8│ 32│ 15│ 244│
└──────────┴─────────┴──────────┴─────────┴───────────┴───────┴───────┘
The Rotunda Hospital, Dublin, with 6,521 deliveries in the years
1857–1861, yielded 169 deaths—a death-rate of 26 per 1,000. But, if we
take the years 1828–1861, with 63,621 deliveries, we find that the
deaths were 924, and the death-rate only 14·5 per 1,000—the average
annual number of deliveries being almost as many thousands as in Queen
Charlotte’s Hospital were hundreds.
TABLE VIII.—_Mortality per Thousand from all Causes after Delivery._
(_Abstracted from Official Reports and Returns._)
┌───────────────────────────────────┬───────────┬─────────┬───────────┐
│ Places │ │ │ Deaths per│
│ │ │ │ Thousand│
│ │Deliveries │ Deaths │ Deliveries│
├───────────────────────────────────┼───────────┼─────────┼───────────┤
│12 Parisian hospitals {1861 │ 7,309│ │ 95·1│
│ „ {1862 │ 7,027│ │ 69·7│
│ „ {1863 │ 7,289│ │ 70·3│
│King’s College Hospital, 1862–7 │ 780[7]│ 26│ 33·3│
│Rotunda Hospital, Dublin, 1857–61 │ 6,521│ 169│ 26·0│
│Queen Charlotte’s Lying-in │ │ │ │
│ Hospital, 1828–68 │ 9,626│ 244│ 25·3│
│British Lying-in Institution, 11 │ │ │ │
│ years, 1858–68 │ 1,741│ 25│ 14·3│
│City of London Lying-in Hospital, │ │ │ │
│ 1859–68 │ 4,966│ 54│ 10·9│
│8 military lying-in hospitals, 2 to│ │ │ │
│ 12 years │ 5,575│ 50│ 8·8│
│Liverpool Workhouse Lying-in Wards,│ │ │ │
│ 13 years, 1858–70 │ 6,396│ 58│ 9·06│
│40 London workhouse infirmaries, 5 │ │ │ │
│ years │ 11,870│ 93│ 7·8│
│1 military lying-in hospital (a │ │ │ │
│ wooden hut) 1865–70 │ 252│ 0│ 0│
│All England, 1867 │ 768,349│ 3,933│ 5·1│
└───────────────────────────────────┴───────────┴─────────┴───────────┘
The lying-in wards of King’s College Hospital, years 1862–1867 (Table
IX.), gave 27 deaths—a death-rate of 33·3 per 1,000 on 780 deliveries.
TABLE IX.—_Mortality after Childbirth in Lying-in Ward, King’s College
Hospital, 1862 to 1867._
┌──────────┬─────────┬──────────┬─────────┬───────────┬───────┬───────┐
│Deliveries│ Deaths │ Deaths │ Deaths │Deaths from│Deaths │ Total │
│ │ from │ from │ from │Consumption│ from │Deaths │
│ │Puerperal│Accidents │Miasmatic│ and Chest │ all │ │
│ │Diseases │ in │Diseases │ Diseases │ Other │ │
│ │ │Childbirth│ │ │Causes │ │
├──────────┼─────────┼──────────┼─────────┼───────────┼───────┼───────┤
│ 781[8]│ 23│ 1[8]│ 0│ 1│ 2│ 27│
└──────────┴─────────┴──────────┴─────────┴───────────┴───────┴───────┘
Lamentable as are these death-rates in many British institutions, they
are small in comparison with those which have ruled in many foreign
hospitals.
Table X. contains an abstract from Dr. Le Fort’s work of the statistics
of 58 lying-in institutions in nearly every country of Europe, and
extending in many cases over a considerable number of years. There is
only one hospital (at Bourg) in which there was no death in 4 years, out
of 461 deliveries.
There is one hospital (at Troyes), with a death-rate of 4 per 1,000 on
460 deliveries in 4 years.
There are two instances of death-rates of 7 per 1,000. There is one of
9, and there are two of 10 per 1,000.
In every other case the death-rates have exceeded these amounts, rising
higher and higher in different institutions, until they culminate in a
death-rate of no less than 140 per 1,000, at Strasburg, on a four years’
average among 556 deliveries. Le Fort’s data show a striking variation
in the death-rates of the same hospitals in different years, as will
presently be seen to be the case in hospitals in this country. There are
instances in these foreign hospitals of the death-rates varying from 4
to 7–fold in different groups of years in the same hospital.
Le Fort’s data show that in lying-in hospitals in various countries and
climates, scattered over nearly the whole of Europe, out of 888,312
deliveries there were no fewer than 30,394 deaths, giving an average
death-rate of 34 per 1,000, a rate exceeding the high mortality which
led to the discontinuance of our school for training midwifery nurses in
King’s College Hospital.
TABLE X.—_Table Showing the Death-rate from all Causes amongst Women
Delivered in Lying-in Hospitals._ (_Abstracted from Dr. Le Fort’s ‘Des
Maternités.’_)
┌────────────────────────────┬───────────┬──────────┬────────┬────────┐
│ Maternity Hospitals │ No. of │ │ │ Deaths │
│ │ Years of │ │ │ per │
│ │Observation│Deliveries│ Deaths │Thousand│
├────────────────────────────┼───────────┼──────────┼────────┼────────┤
│Vienna │ │ │ │ │
│ Maternité │ 50│ 103,731│ 2,811│ 25│
│ „ Students’ │ │ │ │ │
│ Clinique │ 30│ 104,492│ 5,560│ 53│
│ „ Midwives „ │ 30│ 88,083│ 3,064│ 34│
│ „ Académie │ │ │ │ │
│ Joséphine │ 1│ 277│ 24│ 86│
│Prague Maternité │ 15│ 41,477│ 1,383│ 33│
│Munich „ │ 4│ 4,064│ 86│ 21│
│Göttingen „ │ 8│ 1,029│ 32│ 32│
│Gratz „ │ 3│ 3,089│ 97│ 31│
│Greifswald Clinique │ 4│ 316│ 18│ 56│
│Bremen Hospital │ 6│ 139│ 10│ 71│
│Halle Clinique │ 1│ 102│ 3│ 29│
│Berlin Clinique de │ │ │ │ │
│ l’Université │ 1│ 401│ 11│ 27│
│Frankfort-on-Main Maternité │ 7│ 1,213│ 13│ 10│
│Leipzig Ancienne „│ 46│ 5,137│ 89│ 17│
│ „ Nouvelle „│ 3│ 594│ 20│ 33│
│Pesth Clinique │ 5│ 2,571│ 86│ 33│
│Moscow Maternité de la │ │ │ │ │
│ Maison des Enfans Trouvés │ 11│ 11,556│ 230│ 19│
│Ditto │ 10│ 16,721│ 436│ 26│
│Ditto │ 10│ 27,759│ 776│ 28│
│St. Clinique de la │ │ │ │ │
│ Petersburg Faculté │ 6│ 376│ 34│ 90│
│ „ Hospital │ │ │ │ │
│ Kalinkin │ 15│ 1,288│ 20│ 15│
│ „ Institut des │ │ │ │ │
│ Sages │ │ │ │ │
│ „ Femmes │ 15│ 8,036│ 238│ 29│
│ „ Maternité des │ │ │ │ │
│ Enfans │ │ │ │ │
│ „ Trouvés │ 15│ 16,011│ 825│ 51│
│Dublin Maternité │ 58│ 84,390│ 875│ 10│
│Ditto │ 7│ 21,867│ 309│ 14│
│Ditto │ 5│ 12,885│ 198│ 15│
│Ditto │ 7│ 16,391│ 158│ 9│
│Ditto │ 7│ 13,167│ 224│ 17│
│Ditto │ 7│ 13,699│ 179│ 13│
│Ditto │ 7│ 13,748│ 163│ 11│
│London Lying-in Hospital │ 28│ 5,883│ 172│ 29│
│Edinburgh Hospital │ 1│ 277│ 3│ 10│
│Stuttgart „ │ 1│ 424│ 3│ 7│
│Zurich Maternité │ 1│ 200│ 20│ 100│
│Stockholm „ │ 1│ 650│ 37│ 56│
│Göttenburg „ │ 1│ 223│ 18│ 80│
│Lund „ │ 1│ 33│ 2│ 60│
│Freiburg en Breisgau │ 3│ 281│ 10│ 35│
│Jéna Clinique │ 4│ 308│ 21│ 67│
│Dresden Maternité │ 51│ 15,356│ 373│ 27│
│Paris Maternité │ 8│ 15,307│ 610│ 39│
│Ditto │ 10│ 23,484│ 1,114│ 47│
│Ditto │ 10│ 25,895│ 1,293│ 49│
│Ditto │ 10│ 26,538│ 1,125│ 42│
│Ditto │ 10│ 34,776│ 1,458│ 41│
│Ditto │ 10│ 25,094│ 1,298│ 51│
│Ditto │ 5│ 9,886│ 1,226│ 124│
│Total for ditto │ 63│ 160,704│ 8,124│ 56│
│Paris Clinique de la Faculté│ 5│ 1,654│ 117│ 70│
│Ditto │ 10│ 9,079│ 359│ 39│
│Ditto │ 10│ 9,462│ 379│ 40│
│Ditto │ 5│ 4,100│ 288│ 70│
│Total for ditto │ 30│ 24,295│ 1,143│ 47│
│Paris, St. Antoine │ 9│ 28│ 5│ 178│
│Ditto │ 10│ 32│ 15│ 468│
│Ditto │ 10│ 129│ 20│ 155│
│Ditto │ 10│ 788│ 65│ 82│
│Ditto │ 10│ 2,359│ 134│ 56│
│Ditto │ 5│ 1,868│ 110│ 58│
│Total for ditto │ 54│ 5,204│ 349│ 67│
│Paris, Hôtel Dieu │ 8│ 833│ 36│ 43│
│Ditto │ 10│ 658│ 34│ 51│
│Ditto │ 10│ 1,757│ 81│ 46│
│Ditto │ 10│ 2,338│ 17│ 7│
│Ditto │ 10│ 3,012│ 106│ 35│
│Ditto │ 10│ 11,744│ 325│ 27│
│Ditto │ 5│ 4,972│ 232│ 46│
│Total for ditto │ 63│ 25,314│ 831│ 32│
│Paris, St. Louis │ 3│ 4│ 0│ 0│
│Ditto │ 10│ 128│ 2│ 15│
│Ditto │ 10│ 1,282│ 51│ 39│
│Ditto │ 10│ 2,832│ 173│ 61│
│Ditto │ 10│ 2,736│ 102│ 37│
│Ditto │ 10│ 7,244│ 200│ 27│
│Ditto │ 5│ 3,812│ 252│ 66│
│Total for ditto │ 58│ 19,038│ 780│ 40│
│Paris, La Charité │ 3│ 648│ 84│ 126│
│Lyons „ │ 4│ 3,325│ 91│ 17│
│ Hôtel Dieu │ 4│ 2,016│ 33│ 16│
│Rouen Hôpital Général │ 4│ 1,275│ 9│ 7│
│Bordeaux Maternité │ 4│ 714│ 30│ 42│
│Lille │ 4│ 683│ 25│ 35│
│Rheims │ 4│ 646│ 15│ 23│
│Strasburg │ 4│ 556│ 78│ 140│
│Grenoble │ 4│ 554│ 20│ 36│
│Bordeaux, St. André │ 4│ 547│ 36│ 65│
│St. Etienne │ 4│ 515│ 8│ 15│
│Toulouse │ 4│ 493│ 9│ 18│
│Bourg │ 4│ 461│ 0│ 0│
│Troyes │ 4│ 460│ 2│ 4│
│Marseilles │ 4│ 444│ 16│ 36│
│Châteauroux │ 4│ 423│ 20│ 47│
│Amiens │ 4│ 396│ 5│ 12│
│Colmar │ 4│ 396│ 26│ 65│
│Nantes │ 4│ 340│ 17│ 50│
│Nancy │ 4│ 320│ 9│ 28│
│Orleans │ 4│ 301│ 3│ 9│
├────────────────────────────┼───────────┼──────────┼────────┼────────┤
│ Total for all hospitals │ │ 888,312│ 30,394│ 34│
└────────────────────────────┴───────────┴──────────┴────────┴────────┘
The absolute loss of life in Parisian lying-in wards has been greater
than in those of any other capital city.
This is clearly shown in the ‘Statistique médicale des Hôpitaux de
Paris,’ kindly supplied to me by M. Husson, the Director of the General
Administration of ‘Public Assistance’ at Paris, of whose many proofs of
ability, activity, and benevolence, it is not here the place to speak.
From this the following facts are abstracted. The death-rates are
therein given for 12 hospitals receiving lying-in cases, only one of
which, however, is a lying-in hospital (the ‘Maison d’accouchement’),
and will be found in Tables XI., XII., XIII.
In 1861 the average death-rate in these establishments was no less than
95·1 per 1,000.
In 1862 it was 69·7 per 1,000.
In 1863 it was 70·3 per 1,000.
TABLE XI.—_Mortality per Thousand among Lying-in Women at the
undermentioned Parisian Hospitals during the Year 1861.
(Abstracted from ‘Statistique Médicale des Hôpitaux,’ 1861.)_
┌──────────────────────┬──────────┬───────────────────────────────────┐
│ Hospital │ Total │ Mortality per Thousand │
│ │Deliveries│ │
├──────────────────────┼──────────┼──────────┬─────────────┬──────────┤
│ „ │ „ │Puerperal │Non-Puerperal│ Total │
│ │ │ │ │ Deaths │
├──────────────────────┼──────────┼──────────┼─────────────┼──────────┤
│Hôtel Dieu │ 1,057│ 43·5│ 16·1│ 59·6│
│Pitié │ 468│ 72·6│ 34·2│ 106·8│
│Charité │ 253│ 154·2│ 39·7│ 193·7│
│St. Antoine │ 350│ 71·4│ 34·3│ 105·7│
│Necker │ 234│ 29·9│ 29·9│ 59·8│
│Cochin │ 56│ 142·9│ 35·7│ 178·6│
│Beaujon │ 276│ 43·5│ 3·6│ 47·1│
│Lariboisière │ 782│ 69·1│ 15·3│ 84·4│
│St. Louis │ 802│ 58·6│ 13·7│ 72·3│
│Lourcine │ 41│ 24·4│ │ 24·4│
│Cliniques │ 875│ 75·4│ 34·3│ 109·7│
│Maison d’Accouchements│ 2,115│ 99·8│ 12·8│ 112·5│
├──────────────────────┼──────────┼──────────┼─────────────┼──────────┤
│ Total │ 7,309│ 75·2│ 19·8│ 95·1│
└──────────────────────┴──────────┴──────────┴─────────────┴──────────┘
TABLE XII.—_Mortality per Thousand among Lying-in Women at the
undermentioned Parisian Hospitals during the Year 1862. (Abstracted
from ‘Statistique Médicale des Hôpitaux de Paris,’ 1861, 2, 3.)_
┌──────────────────────┬──────────┬───────────────────────────────────┐
│ Hospital │ Total │ Mortality per Thousand │
│ │Deliveries│ │
├──────────────────────┼──────────┼──────────┬─────────────┬──────────┤
│ „ │ „ │Puerperal │Non-Puerperal│ Total │
│ │ │ │ │ Deaths │
├──────────────────────┼──────────┼──────────┼─────────────┼──────────┤
│Hôtel Dieu │ 975│ 35·8│ 9·2│ 45·1│
│Pitié │ 462│ 45·4│ 10·8│ 56·2│
│Charité │ 270│ 62·9│ 25·9│ 88·8│
│St. Antoine │ 311│ 61·0│ 19·2│ 80·3│
│Necker │ 190│ 52·6│ 21·0│ 73·6│
│Cochin │ 24│ 41·6│ 83·3│ 124·9│
│Beaujon │ 257│ 38·9│ 19·9│ 58·8│
│Lariboisière │ 816│ 34·3│ 13·5│ 47·8│
│St. Louis │ 704│ 79·5│ 8·5│ 88·0│
│Lourcine │ 45│ 22·2│ —│ 22·2│
│Cliniques │ 769│ 79·3│ 14·3│ 93·6│
│Maison d’Accouchements│ 2,204│ 63·5│ 11·3│ 74·9│
├──────────────────────┼──────────┼──────────┼─────────────┼──────────┤
│ Total │ 7,027│ 56·7│ 12·9│ 69·7│
└──────────────────────┴──────────┴──────────┴─────────────┴──────────┘
TABLE XIII.—_Mortality per Thousand among Lying-in Women at the
undermentioned Parisian Hospitals during the Year 1863. (Abstracted
from ‘Statistique Médicale des Hôpitaux’, 1863.)_
┌──────────────────────┬──────────┬───────────────────────────────────┐
│ Hospital │ Total │ Mortality per Thousand │
│ │Deliveries│ │
├──────────────────────┼──────────┼──────────┬─────────────┬──────────┤
│ „ │ „ │Puerperal │Non-Puerperal│ Total │
│ │ │ │ │ Deaths │
├──────────────────────┼──────────┼──────────┼─────────────┼──────────┤
│Hôtel Dieu │ 925│ 26·7│ 4·1│ 30·8│
│La Pitié │ 544│ 44·1│ 1·8│ 46·0│
│Charité │ 256│ 66·4│ 19·5│ 85·9│
│St. Antoine │ 410│ 63·4│ 11·6│ 78·0│
│Necker │ 232│ 38·8│ 21·6│ 60·3│
│Cochin │ 68│ 73·5│ 14·7│ 88·2│
│Beaujon │ 313│ 19·2│ 12·8│ 31·9│
│Lariboisière │ 870│ 31·0│ 9·2│ 40·2│
│St. Louis │ 871│ 23·0│ 9·2│ 32·1│
│Lourcine │ 43│ 27·9│ │ 27·9│
│Clinique │ 751│ 30·6│ 18·6│ 49·3│
│Maison d’Accouchements│ 2,006│ 130·1│ 7·4│ 137·6│
├──────────────────────┼──────────┼──────────┼─────────────┼──────────┤
│ Total │ 7,289│ 60·6│ 9·7│ 70·3│
└──────────────────────┴──────────┴──────────┴─────────────┴──────────┘
_CLASSIFICATION OF CAUSES OF MORTALITY IN LYING-IN INSTITUTIONS._
The next thing is to endeavour to show to what causes these death-rates
are to be attributed. Unfortunately Dr. Le Fort’s tables do not enable
us to distinguish the causes of death. But the data supplied by British
and Parisian hospitals allow the causes to be classified to a certain
extent under the heads adopted by the Registrar-General in his Reports.
A classified arrangement of this kind is given in Table II., and may be
resumed, with the view of showing the enormous differences in
death-rates among puerperal women under different conditions, as
follows:—
_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.
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,[9] 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[10] 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.
The delivery ward is well-lighted on two sides, and communicates with an
operation theatre, where lectures are also given.
The woman, if progressing favourably after delivery, was removed to one
of the cells in what may be called the recovery ward. The construction
of these cells was as follows:—a long corridor, with windows on opposite
sides, was divided into separate cells, each cell having its own window,
by partitions stretching one third across the corridor, but not cut off
on the end towards the middle of the corridor. Each cell was provided
with a bed and a cradle, so that in walking up the centre of the
corridor the divisions, or rather the cells, opened right and left from
the passage, like the stalls of a stable. This construction rendered it
almost impossible to open the windows. The infirmary consisted of small
wards of three or four beds each, into which were moved indiscriminately
patients suffering with all classes of disease. And it appears, from Dr.
Le Fort’s account, that pupil midwives had at the same time patients in
the infirmary, and healthy women, both delivered and not delivered,
under their care. Pregnant women are often admitted weeks, and even
months before delivery, at the Maternité. [So also at the Midwives’
Clinique at Vienna.]
Recently the cells have been removed from the corridor, and glass
partitions have been thrown across from back to front, each division
containing six beds, but communicating with the adjoining divisions by
means of doors intended to be used only when the service requires it.
The infirmary has been completely separated from this portion of the
establishment, but all classes of cases are still transferred into the
infirmary as before.
As consequences of these arrangements, we have in the Maternité the
following conditions:—