_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._
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[12]│ 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[13]│ 2[14]│ 2[15]│ 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:[16] 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.