4. That there are superadded causes in some establishments which add greatly to their dangers. Among these may be reckoned the following:—
(a) Prevalence of puerperal fever as an epidemic outside the hospital. (b) Including midwifery wards within general hospitals, thereby incurring the risk of contaminating the air in midwifery wards with hospital emanations. (c) Proximity to midwifery wards of post-mortem theatres or other external sources of putrescence. (d) Admitting medical students from general hospitals or from anatomical schools to practice or even to visit in midwifery wards without special precautions for avoiding injury. (e) Treating cases of puerperal disease in the same ward, or under the same roof, with midwifery cases. (f) Permitting the same attendants to act in infirmary wards and in lying-in wards, and using the same bedding, clothing, utensils, &c., in both. (g) Most probably also—especially in certain foreign hospitals—want of scrupulous attention to ventilation, and to cleanliness in wards, bedding, clothing, utensils, and patients, and in the clothing and personal habits of attendants.
In short, the entire result of this enquiry may be summed up, in a very few words, as follows:—A woman in ordinary health, and subject to the ordinary social conditions of her station, will not, if delivered at home, be exposed to any special disadvantages likely to diminish materially her chance of recovery. But this same woman, if received into an ordinary lying-in ward, together with others in the puerperal state, will from that very fact become subject to risks not necessarily incident to this state. These risks in lying-in institutions may no doubt be materially diminished by providing proper hospital accommodation, and by care, common sense, and good management. And hence the real practical question is, whether it is possible to ensure at all times the observance of these conditions.
The great mortality in lying-in hospitals everywhere is no doubt a strong argument against such a result being attainable; so much so that, in the absence of this security, the evidence in the preceding pages appears sufficient to warrant the question being raised, whether lying-in hospitals, arranged and managed as they are at present, should not be forthwith closed?
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 the 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.
| Table XV., abstracted from Tables III. and X., showing Comparative Mortality among Lying-in Women in Hospitals and at Home. | |||
|---|---|---|---|
| Deliveries | Deaths | Deaths per Thousand | |
| Total for all hospitals | 888,312 | 30,394 | 34 |
| Total delivered at home | 934,781 | 4,405 | 4·7 |
| Excess of deaths per thousand delivered in hospitals | 29·3 | ||
The evidence is entirely in favour of home delivery, and of making better provision in future for this arrangement among the destitute poor.
CAN THE ARRANGEMENT AND MANAGEMENT OF LYING-IN INSTITUTIONS BE IMPROVED?
Must we, then, surrender the principle of lying-in institutions altogether, and limit the teaching of midwifery nurses solely to bedside cases at home, notwithstanding the well-known difficulties of teaching pupils at the beginning of their course elsewhere than in an institution? We will try to reply to this question; and, in doing so, perhaps some light may be thrown on another question, viz.: how to improve existing lying-in establishments so as to reduce the mortality in them.