Chapter I: Part 1

LYING-IN INSTITUTIONS.

LONDON: PRINTED BY
SPOTTISWOODE AND CO., NEW-STREET SQUARE
AND PARLIAMENT STREET

INTRODUCTORY NOTES
ON
LYING-IN INSTITUTIONS.
TOGETHER WITH
A PROPOSAL FOR ORGANISING AN INSTITUTION FOR TRAINING MIDWIVES AND
MIDWIFERY NURSES.

BY

FLORENCE NIGHTINGALE.

LONDON:

LONGMANS, GREEN, AND CO.

1871.

If I may dedicate, without ‘permission,’ these small ‘Notes’ to the shade of Socrates’ Mother, may I likewise, without presumption, call to my help the questioning shade of her Son, that I who write may have the spirit of questioning aright, and that those who read may learn not of me but of themselves?

And, further, has he not said: ‘The midwives are respectable women, and have a character to lose’?

PREFACE.

In the year 1862 the Committee of the Nightingale Fund, with a view to extending the advantages of their Training Institution, entered into an arrangement with the authorities of St. John’s House, under which wards were fitted up in the new part of King’s College Hospital, opening out of the great staircase and shut up within their own doors, for the reception of Midwifery cases. The wards were under the charge of the (then) Lady Superintendent. Arrangements were made for medical attendance, a skilled midwife was engaged, a certain number of pupil nurses were admitted for training; and hopes were entertained that this new branch of our Training School would confer a great benefit on the poor, especially in country districts, where trained Midwifery nurses are needed.

Every precaution had apparently been taken to render the Midwifery Department perfectly safe; and it was not until the school had been upwards of five years in existence, that the attention of the Nightingale Committee was called to the fact that deaths from puerperal diseases had taken place in each of the preceding years.

During the period of nearly six years that the wards were in use, the records show that 780 women had been delivered in the institution, and that out of this number twenty-six[1] had died—a mortality of 33·3 per 1,000.

The most fatal year was 1867, in which year nine out of the twenty-six deaths took place. In the month of January a pregnant woman, who was under treatment for erysipelas in the hospital, was delivered in a general medical ward, No. 4, in the first-built wing of the hospital. A midwife was told off to attend her, who was not suffered to be near the midwifery wards for a considerable time. The erysipelas case died of puerperal fever; and this death was followed by a succession of puerperal deaths in the lying-in wards until November, when the wards were as soon as possible closed.

An analysis of the causes of death showed that, with the exception of one death from hæmorrhage, not a single death had taken place from accidents incidental to childbearing during the whole six years. There were three deaths due to diseases not necessarily concomitants of this condition; while of the others, twenty-three in number, no fewer than seventeen were due to puerperal fever, three to puerperal peritonitis, two to pyæmia, and one to metritis.

The following table gives the actual fates and dates:—

_Midwifery Statistics, King’s College Hospital._ ┌─────┬──────────┬─────────────────────────────────────────────┬───────────┐ │Year │ Total │ Fatal Cases │ Deaths to │ │ │Deliveries│ │ Labours │ ├─────┼──────────┼─────┬──────────────┬────────────────┬───────┼───────────┤ │ │ │Date │ Nature of │ │Date of│ │ │ „ │ „ │ of │ Labour │ Cause of Death │ Death │ „ │ │ │ │Birth│ │ │ │ │ ├─────┼──────────┼─────┼──────────────┼────────────────┼───────┼───────────┤ │ 1862│ 97│Nov. │Natural │Puerperal │Nov. 25│1 in 32·3 │ │ │ │ 6 │ │ peritonitis │ │ │ │ │ │ │ │Phthisis and │ │ │ │ │ │„ 30│Twins │ puerperal │Dec. 27│ „ │ │ │ │ │ │ fever │ │ │ │ │ │Dec. │Natural │Puerperal │Dec. 20│ „ │ │ │ │ 10 │ │ peritonitis │ │ │ ├─────┼──────────┼─────┼──────────────┼────────────────┼───────┼───────────┤ │ 1863│ 105│Jan. │Natural. Child│Puerperal fever │Jan. 16│1 in 52·5 │ │ │ │ 10 │ still-born │ │ │ │ │ │ │April│Natural │Puerperal fever │May 20 │ „ │ │ │ │ 29 │ │ │ │ │ ├─────┼──────────┼─────┼──────────────┼────────────────┼───────┼───────────┤ │ 1864│ 141│Feb. │Natural │Puerperal fever │Feb. 25│1 in 47 │ │ │ │ 16 │ │ │ │ │ │ │ │April│Induced │Pyæmia │April │ „ │ │ │ │ 14 │ │ │ 29 │ │ │ │ │Dec. │Born in cab │Hæmorrhage │Dec. 7 │ „ │ │ │ │ 1 │ │ │ │ │ ├─────┼──────────┼─────┼──────────────┼────────────────┼───────┼───────────┤ │ 1865│ 163│Jan. │Natural │Embolism │Feb. 12│1 in 32·6 │ │ │ │ 30 │ │ │ │ │ │ │ │Feb. │Natural │Puerperal fever │Feb. 18│ „ │ │ │ │ 8 │ │ │ │ │ │ │ │ │ │Puerperal │ │ │ │ │ │June │Forceps │ metritis and │July 30│ „ │ │ │ │ 24 │ │ pelvis │ │ │ │ │ │ │ │ cellulitis │ │ │ │ │ │ │ │Laceration of │ │ │ │ │ │Oct. │Forceps │ perinæum, │Nov. 3 │ „ │ │ │ │ 20 │ │ puerperal │ │ │ │ │ │ │ │ fever │ │ │ │ │ │Oct. │Natural │Puerperal fever │Nov. 9 │ „ │ │ │ │ 29 │ │ │ │ │ ├─────┼──────────┼─────┼──────────────┼────────────────┼───────┼───────────┤ │ 1866│ 150│Jan. │Natural │Gastro-enteritis│Jan. 20│1 in 30 │ │ │ │ 10 │ │ │ │ │ │ │ │ │ │Retained │ │ │ │ │ │Mar. │Natural │ placenta, │April │ „ │ │ │ │ 24 │ │ puerperal │ 10 │ │ │ │ │ │ │ fever │ │ │ │ │ │Oct. │Placenta │Emphysema and │ │ │ │ │ │ 8 │ prævia. │ bronchitis │Oct. 10│ „ │ │ │ │ │ Turning │ │ │ │ │ │ │Nov. │Forceps │Peritonitis │Nov. 15│ „ │ │ │ │ 10 │ │ │ │ │ │ │ │Dec. │Natural │Puerperal fever │Dec. 31│ „ │ │ │ │ 4 │ │ │ │ │ ├─────┼──────────┼─────┼──────────────┼────────────────┼───────┼───────────┤ │ │ │ │(Had │ │ │ │ │ 1867│ 125│Jan. │ erysipelas │Puerperal fever │Jan. 30│1 in 13·8 │ │ │ │ 10 │ when │ │ │ │ │ │ │ │ admitted[2])│ │ │ │ │ │ │ │ │Considerable │ │ │ │ │ │Feb. │Natural │ hæmorrhage, │Feb. 22│ „ │ │ │ │ 7 │ │ puerperal │ │ │ │ │ │ │ │ fever │ │ │ │ │ │„ 8 │Natural │Puerperal fever │Feb. 22│ „ │ │ │ │April│Turning │Puerperal fever │April │ „ │ │ │ │ 12 │ │ │ 22 │ │ │ │ │May │Natural │Pyæmia │May 27 │ „ │ │ │ │ 18 │ │ │ │ │ │ │ │June │Natural │Puerperal fever │June 19│ „ │ │ │ │ 4 │ │ │ │ │ │ │ │July │Natural │Puerperal fever │Aug. 11│ „ │ │ │ │ 26 │ │ │ │ │ │ │ │Nov. │Twins: 1st │ │ │ │ │ │ │ 5 │ dead, 2nd by│Puerperal fever │Nov. 10│ „ │ │ │ │ │ turning │ │ │ │ │ │ │ │ │Laceration of │ │ │ │ │ │„ 8 │Forceps │ vagina, │Nov. 14│ „ │ │ │ │ │ │ puerperal │ │ │ │ │ │ │ │ fever │ │ │ ├─────┼──────────┼─────┼──────────────┼────────────────┼───────┼───────────┤ │Total│ 781│ │ │ │deaths:│1 in 28·9 │ │ │ │ │ │ │ 27 │ │ └─────┴──────────┴─────┴──────────────┴────────────────┴───────┴───────────┘

Under these deplorable circumstances the closing of the wards was a matter of course; and since that event we have been anxiously enquiring whether it would be justifiable to re-open our Midwifery Nursing School under other conditions.

This question is discussed in the following pages, from a basis of statistical facts supplied by the best authorities; and a few proposals have been added, with the view of turning to the best account our past experience, by extracting from it any leading principles which may present themselves for practical application in the future construction and management of Lying-in Institutions, and more especially in connection with means of training Midwifery nurses.

These Introductory Notes, collected and put together under circumstances of all but overwhelming business and illness, are now thrown out merely as a nucleus, in the hope that others will be kind enough to supplement, to add, and to alter; in fact, only as a hook with a modest little fish on it—a bait to catch other and finer fish.

The facts themselves, the nucleus, have been made as correct as it was possible, and as would have been done for a finished work. But the facts themselves are only put forth as feelers—feelers to feel my own way.

I need scarcely say either that these ‘Notes’ are not at all meant to discuss every point which presents itself in Midwifery statistics. On the contrary, they are, for the moment, purposely limited to the consideration of facts immediately relating to the present object.

Let me thank once more with true gratitude all those who have so kindly supplied me with help and information, some of whose names will appear in the following pages.

CONTENTS.

PAGE
PREFACE vii–x
_Table of Midwifery Statistics, King’s College Hospital_ ix
_What is the real normal Death-rate of Lying-in Women?_ 1
MIDWIFERY STATISTICS 2
NORMAL DEATH-RATE OF LYING-IN WOMEN IN ENGLAND 4
TABLE I.—_Mortality after Childbirth in England, 1867_ 4
TABLE II.—_Mortality per 1,000 after Delivery from Puerperal
Diseases and Accidents of Childbirth_ 6
NORMAL MORTALITY OF LYING-IN WOMEN IN DIFFERENT COUNTRIES 7
TABLE III.—_Death-rate from all Causes amongst Women delivered in
their own Homes_ 8
OBJECTIONS TO THE DATA 9
ESTIMATED APPROXIMATE HOME DEATH-RATE 11
DEATH-RATES IN LYING-IN INSTITUTIONS 11
TABLE IV.—_Admissions and Deaths in Childbirth in eight Women’s
Hospitals (Military)_ 12
TABLE V.—_Statistics of Midwifery Wards in Liverpool Workhouse_ 13
TABLE VI.—_Mortality after Childbirth in forty London Workhouses_ 13
TABLE VII.—_Mortality in Queen Charlotte’s Hospital_ 14
TABLE VIII.—_Mortality per 1,000 from all Causes after Delivery_ 15
TABLE IX.—_Mortality in Lying-in Ward, King’s College Hospital_ 15
TABLE X.—_Death-rate from all causes in Lying-in Hospitals_ 17
TABLE XI.—_Mortality per 1,000 among Lying-in Women at Paris
Hospitals, 1861_ 20
TABLE XII.—_Mortality per 1,000 among Lying-in Women at Paris
Hospitals, 1862_ 20
TABLE XIII.—_Mortality per 1,000 among Lying-in Women at Paris
Hospitals, 1863_ 21
CLASSIFICATION OF CAUSES OF MORTALITY IN LYING-IN INSTITUTIONS 21
CAUSES OF HIGH DEATH-RATES IN LYING-IN INSTITUTIONS 23
_Puerperal Fever_ 24
_Admission of Students_ 25
_Effect of Numbers_ 26
_Danger of Puerperal Epidemics_ 31
_Fatality of Lying-in Wards in General Hospitals_ 32
INFLUENCE OF CONSTRUCTION AND MANAGEMENT OF LYING-IN WARDS ON THE
DEATH-RATE 33
_Maternité, Paris_ 34
_Hôpital de la Clinique, Paris_ 36
_Queen Charlotte’s Lying-in Hospital, London_ 38
_Midwifery Wards, King’s College Hospital, London_ 40
IMPROVED LYING-IN WARD CONSTRUCTION 41
_Military Female Hospitals_ 41
TABLE XIV.—_Classification of Causes of Death in Childbirth in
Eight Women’s Hospitals (Military)_ 43
_Proposed new Female Hospital at Portsmouth_ 45
SHOULD MEDICAL STUDENTS BE ADMITTED TO LYING-IN HOSPITAL
PRACTICE? 48
INFLUENCE OF TIME SPENT IN A LYING-IN WARD ON THE DEATH-RATE 50
EFFECT OF GOOD MANAGEMENT ON THE SUCCESS OF LYING-IN
ESTABLISHMENTS 52
_Liverpool Workhouse_ 53
_Summary of Cases Delivered in the Lying-in Wards of
Liverpool Workhouse, 1868–1870_ 53
_Summary of Deaths and Causes of Death in the same,
1858–1870_ 54
_London Workhouses_ 58
MANAGEMENT OF MILITARY LYING-IN WARDS 62
NOTE _on altogether disconnecting Lying-in Institutions even with
the very name of Hospital_ 64
RECAPITULATION 65
TABLE XV.—_Comparative Mortality among Lying-in Women in
Hospitals and at Home_ 68
CAN THE ARRANGEMENT AND MANAGEMENT OF LYING-IN INSTITUTIONS BE
IMPROVED? 68

_CHAPTER II._
CONSTRUCTION AND MANAGEMENT OF A LYING-IN INSTITUTION AND
TRAINING SCHOOL FOR MIDWIVES AND MIDWIFERY NURSES 72
I. CONSTRUCTION OF A LYING-IN INSTITUTION 74
1. _How many Beds to a Ward?_ 74
TABLE XVI.—_Proposed Registry of Midwifery Cases_ 75
2. _How many Wards to a Floor?_ 76
3. _How many Floors to a Pavilion (Hut or Cottage)?_ 76
_How many Beds to a Pavilion or Hut?_ 76
_How many Pavilions or Huts to a Lying-in Institution?_ 76
4. _How much Space to the Bed?_ 77
_The Delivery Ward_ 77
5. _How many Windows to a Bed?_ 78
6. _What are Healthy Walls, and Ceilings, and Floors?_ 78
7. _What is a Healthy and Well-lighted Delivery Ward?_ 79
8. _Scullery, Lavatory, W.C._ 81
9. _How to ventilate Lying-in Wards_ 83
10. _Furniture, Bedding, Linen_ 84
11. _Water supply, Drainage, Washing_ 85
12. _Medical Officer’s Room and Waiting-Room_ 85
13. _Segregation Ward_ 86
14. _Kitchen_ 86
SITE 86
II. MANAGEMENT 90
_First Rule of Good Management_ 90
_Second Rule of Good Management_ 91
_Third Rule of Good Management_ 93
III. TRAINING SCHOOL FOR MIDWIVES 94
DESCRIPTION OF SKETCH-PLANS OF PROPOSED INSTITUTION 100
_A Lying-in Institution For 40 beds (32 to 36 occupied),
with a training school for 30 pupil Midwives and Nurses_ 102
APPENDIX: MIDWIFERY AS A CAREER FOR EDUCATED WOMEN 105

LIST OF PLANS.

NO.
1. QUEEN CHARLOTTE’S LYING-IN HOSPITAL, LONDON _to face page_ 38
2. WOODEN LYING-IN HUT IN COLCHESTER CAMP „ 44
3. PLAN OF A LYING-IN WARD, FOUR BEDS „ 100
4. PLAN OF A LYING-IN FLOOR, FOUR ONE-BED ROOMS „ 101
5. PLAN OF A LYING-IN INSTITUTION FOR 40 (32 TO 36 OCCUPIED) BEDS,
WITH TRAINING SCHOOL FOR 30 PUPIL MIDWIVES „ 104

NOTES ON LYING-IN INSTITUTIONS.

The first step to be taken in the discussion is to enquire, What is the real normal death-rate of lying-in women? And, having ascertained this to the extent which existing data may enable us to do, we must compare this death-rate with the rates occurring in establishments into which parturition cases are received in numbers. We have then to classify the causes of death, so far as we can, from the data, with the view of ascertaining whether any particular cause of death predominates in lying-in institutions; and, if so, why so? And finally, seeing that everybody must be born, that every birth in civilised countries is as a rule attended by somebody, and ought to be by a skilled attendant; since, therefore, the attendance upon lying-in women is the widest practice in the world, and these attendants should be trained; we must decide the great question as to whether a training school for midwifery nurses can be safely conducted in any building receiving a number of parturition cases, or whether such nurses must be only trained at the bedside in the patient’s own home, with far more difficulty and far less chance of success.

_MIDWIFERY STATISTICS._

It must be admitted, at the very outset of this enquiry, that midwifery statistics are in an unsatisfactory condition. To say the least of it, there has been as much discussion regarding mortality and its causes among lying-in women as there has been regarding the mortality due to hospitals. Yet there appears to have been no uniform system of record of deaths, or of the causes of death, in many institutions, and no common agreement as to the period after delivery within which deaths should be counted as due to the puerperal condition. Many of the most important institutions in Europe merely record the deaths occurring during the period women are in hospital, and they appear not unfrequently to do this without any reference to the causes. Similar defects are obvious enough in the records of home deliveries; and hence it follows that the mass of statistics which have been accumulated regarding home and hospital deliveries, admit of comparison only in one element, namely, the total deaths to total deliveries, and this only approximately.

Dr. Matthews Duncan, in his recent work on the ‘Mortality of Childbed and Maternity Hospitals,’ has dwelt forcibly on these defects in midwifery statistics, and has made out a strong case for improvement in records. But, as will be afterwards shown, with all their defects, midwifery statistics point to one truth; namely, that there is a large amount of preventible mortality in midwifery practice, and that, as a general rule, the mortality is far, far greater in lying-in hospitals than among women lying-in at home.

There are several of what may be called secondary influences also, which must affect to a certain extent the results of comparison of death-rates among different groups of lying-in cases. Such are the ages of women, the number of the pregnancy, the duration of labour, and the like. It is impossible, in the present state of our information, to attribute to each, or all of these, their due influence; neither, if we could do so, would it materially affect the general result just stated. But it is otherwise with another class of conditions, of which statistics take no cognizance. Such are the general sanitary state of hospitals, wards, houses, and rooms where deliveries take place; the management adopted; the classes of patients; their state of health and stamina before delivery; the time they are kept in midwifery wards before and after delivery. These elements are directly connected with the questions at issue, and yet our information regarding them is by no means so full as we could wish—indeed is almost nothing.

Our only resource at present is to deal with such statistical information as we possess, and to ascertain fairly what it tells us. This we shall now endeavour to do, beginning with an estimate of the normal mortality due to childbirth in various European countries.

_NORMAL DEATH-RATE OF LYING-IN WOMEN IN ENGLAND._

In the Registrar-General’s Thirtieth Annual Report, 1867, there is an instructive series of tables, giving approximately the present normal death-rate among lying-in women in England.

One of these tables (abstracted on Table I.) shows that, including deliveries in lying-in hospitals, there were in England, during the year 1867, 768,349 births, and that 3,933 women died in childbed. This gives an approximate total mortality of 5·1 per 1,000 from all causes.

TABLE I.—_Mortality after Childbirth in England, 1867_ (_Registrar-General’s Thirtieth Annual Report_). ┌────────┬──────────┬─────────┬─────────┬───────────┬────────┬────────┐ │ Total │ Deaths │ Deaths │ Deaths │Deaths from│ Deaths │ Total │ │ Births │ from │ from │ from │Consumption│from all│ Deaths │ │ │Accidents │Puerperal│Miasmatic│ and Chest │ Other │ │ │ │ in │Diseases │Diseases │ Diseases │ Causes │ │ │ │Childbirth│ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ ├────────┼──────────┼─────────┼─────────┼───────────┼────────┼────────┤ │768,349 │ 2,346 │ 1,066 │ 137 │ 230 │ 154 │ 3,933 │ └────────┴──────────┴─────────┴─────────┴───────────┴────────┴────────┘

The causes of mortality are also given in Table I. as follows:—

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._