Florence Nightingale

“ The cardinal principle in the management of these London workhouse lying-in wards appears to be this: their occupants are a fluctuating number; often the wards have but one woman at a time, and the cubic space for each of these women is ‘in fact the cubic space of the whole ward.’ [18] Sometimes, but only for brief periods, all the lying-in beds may be occupied. For much longer intervals the occupants are very few in number, so that each has a large proportion of cubic space, and sometimes the wards in some of the workhouses are empty. ”

“ Applying the same principle to lying-in wards to which medical students are admitted, there can be no doubt that a responsibility of the very gravest kind attaches to all teachers and managers of lying-in hospitals who do not satisfy themselves that students admitted as pupils have nothing to do, either with general hospital practice, or with anatomical schools, during the period. ”

“ But for a training school of midwives and midwifery nurses other accommodation is required, and of a far more costly character.
It is true that any sort of building may be leased or bought and altered, or added to, and told off as a training school; but after what has been said, to take such a course would be to ensure killing a certain number of mothers for the sake of training a certain number of midwives. If we are to have a training school at all, we must, before all things, make it as safe for lying-in women to enter it as to be delivered at home ”

“ Unless from causes unconnected with the puerperal state, no woman ought to die in her lying-in; and there ought, in a lying-in institution, to be no death-rate at all.
It is dangerously deadening our senses to this fact—viz., that there ought to be no deaths in a lying-in institution—if we connect it in the least degree with the name of hospital, so long as a hospital means a place for the reception of diseases and accidents. ”

“ The reason why there must be two delivery wards for each floor of a lying-in institution, to be used alternately, one ‘off,’ one ‘on,’ is that one delivery ward on each floor must be always vacant for thorough cleansing, lime-washing and rest for a given period, say month and month about.
It is understood that newly-delivered women cannot be removed from one floor to another. And it is quite necessary to have the means of keeping a corridor, along which a newly-delivered woman is to be moved, at a proper temperature. ”

“ That, making every allowance for unavoidable inaccuracies in statistics of midwifery practice, there is sufficient evidence to show that in lying-in wards there reigns a death-rate many times the amount of that which takes place in home deliveries. ”

“ No woman with a disease considered to be infectious is admitted. The women usually follow their ordinary avocations until obliged to proceed to hospital by imminent labour. They are taken there in cabs, all the necessary arrangements for the lying-in having been made, if possible, by previous intimation. The woman is delivered in the delivery ward, and is thence transferred to the lying-in ward. As a rule, the lying-in pavilion in these female hospitals is distinct in all its arrangements for nursing from the pavilion for general cases. ”

“ One feels disposed to ask whether it can be true that, in the 10hands 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. ”

“ 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 ”

“ 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? ”

“ Can any supposed advantages to individual cases of destitution counterbalance the enormous destruction of human life shown by the statistics?
Without vouching for the entire accuracy of Le Fort’s data, they may still be taken generally as showing approximately 68the penalty which is being paid for the supposed advantages of these institutions. It is this: (see Table XV.) for every two women who would die if delivered at home, fifteen must die if delivered in lying-in hospitals. Any reasonable deduction from this death-rate for supposed inaccuracy will not materially influence the result. ”

“ 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 28retained 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. ”

“ 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.
The absolute loss of life in Parisian lying-in wards has been greater than in those of any other capital city. ”

“ 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 ”

“ It has been already shown that great improvements are required in the manner of keeping midwifery statistics, and that many data are wanting for this purpose. It would be altogether wrong to deal with these statistics on the same 74principles as if they were general hospital statistics. Lying-in is neither a disease nor an accident, and any fatality attending it is not to be counted as so much per cent. of inevitable loss. On the contrary, a death in childbed is almost a subject for an inquest. ”

“ The rule is that women shall be delivered in quarters, provided there be decent accommodation. At a number of the larger stations, where suitable married quarters have not yet been fully provided, there are female hospitals, attached to which, as we have already seen, is a delivery and lying-in ward, with the usual offices. In the specially constructed hospitals the wards are of a good size, well-lighted, warmed and ventilated. If all the beds were occupied, the space would be 1,300 cubic feet per patient. ”

“ At Woolwich, among 751 deliveries, there have been 8 deaths, of which five were from puerperal diseases, but of these five deaths one took place in a woman who had gastric fever at the time of admission, and in other two women puerperal peritonitis came on after instrumental delivery. There was one death from embolism, one from exhaustion, and one from dropsy. The total death-rate in these two hospitals has been under 10 per 1,000. The deaths due to diseases and accidents of childbirth have been 6, or at the rate of 51⁄2 per 1,000. ”

“ The whole question of these poor young women—unmarried mothers of a first child—is full of difficulty. It would never do, morally, to make special provision for them. And for this very reason we seem bound to receive such, conditionally, into well regulated lying-in institutions, and afford some kindly care to prevent, at the very least, their sinking lower. But it would not be right to leave any admissions for single women in the hands of any young assistant, or morally inexperienced person. ”

“ There are no medical schools attached to the institutions, and no medical students who may have passed from a case of erysipelas or from the post-mortem theatre to the lying-in bedside; there is the possibility of removing immediately any case of febrile or other disease which may occur in the lying-in ward into the general sick wards of the workhouse; there is discharge of convalescent cases at the earliest possible period, either to their own homes or to other parts of the establishment ”

“ 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 51to support this conclusion also. These do not retain together women not yet in labour, women in labour, women delivered, and convalescent women. ”

“ And it is impossible to send them out after delivery, till recovery is fairly confirmed.
In workhouses the question is solved by women being admitted into the body of the house during pregnancy, and discharged into the body of the house, if not to their own homes, when quite convalescent.
In Liverpool Workhouse fourteen days after labour the lying-in women are thus discharged. Fourteen, eighteen, twenty-one days, are the average of a woman’s stay in the lying-in division in London workhouses.
A soldiers’ wives’ hospital takes in no unmarried women to lie-in. ”

“ The excessive susceptibility of lying-in women to poisonous emanations, the excessively poisonous emanations from 79lying-in women—these constitute a hospital influence on lying-in cases brought together in institutions, second to no influence we know of exercised by the most ‘infectious’ or ‘contagious’ disease.
The death-rate is not much higher among women lying-in at home in large towns than in healthy districts. Therefore the agglomeration of cases together and want of management required to meet it must bear the blame. ”

“ The experience of these small military female lying-in hospitals has shown the favourable effect of simplicity of construction, plenty of space, light, and fresh air, perfect cleanliness, a small number of lying-in beds, not by any 47means constantly occupied, administration separate from that of general hospitals, and allowing the lying-in women to return to quarters in as few days after delivery as their recovery admits. ”

“ 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 32instances even greatly exceeds this mortality. ”

“ This space has to be occupied, not only by the lying-in woman and her infant, and perhaps a pupil midwife washing and dressing it at the fire, but often by the midwife, an assistant, possibly the medical officer, and pupil midwives. In a four-bed ward there is space common to all the beds.
The Delivery Ward. Ought to be separate in every lying-in institution; must be separate in an institution of more than four or five beds, though in separate compartments. ”

“ Civil lying-in institutions almost invariably have to make exceptions and take in unmarried women.
In workhouses they are not the exception, they are the rule. Married women are the exception.
It is to be observed that married women will rarely come in an hour before, or stay an hour after it is necessary, in any lying-in institution.
Ten to twelve days is ‘the average period of hospital 89treatment’ in Colchester, Woolwich, and other soldiers’ wives’ lying-in hospitals. ‘Women of this station of life cannot, as a rule, be prevailed upon to submit to longer detention,’ it is added. ”

“ The estimated cost of these plans is large; but if we must have lying-in institutions at all, it is only ‘penny wise and pound foolish’ to cripple either space or necessary appliances, or the means of regularly and periodically vacating every ward and every ward-office destined for the use of lying-in women. ”

“ The pavilion to be in rotation unoccupied for the purposes of cleansing must necessarily be the whole pavilion, with all its sculleries and ward offices, since the process of cleansing is—turning out all the little furniture a lying-in ward ought ever to possess, bringing in lime-washers, possibly scrapers and painters, leaving doors and windows open all day, and even all night. ”

“ 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. ”