61 Lehrbuch der gesammten Gynaekologie, S. 885.
62 Ibid., S. 748.
63 Recherches sur la mortalité des femmes en couches dans les hôpitaux, Paris, 1879.
When the maternity service was transferred in 1872 from Bellevue Hospital to Blackwell's Island, it became necessary to make some provision for so-called street-cases—i.e. women taken suddenly in labor without homes, and representing the extremes of penury and want. At first they were received, in part, by the various private institutions of charity in New York City, but these in 1877 decided to exclude them thenceforth, on the ground that their condition at the time of their reception was such as to endanger the lives of the inmates for whom the charities were specially provided. An old engine-house was then put in readiness by the city, and under the name of the Emergency Hospital was placed under the charge of Henry F. Walker64 and myself. The number of confinements in the Emergency has averaged 220 annually. The death-rate from all causes has been 2 per cent., which, though large, is not an unfavorable showing when we remember that the patients all belong to the homeless class, that all were taken in labor before their entrance, and that many of them were in a deplorable condition at the time of their admission. The hospital, too, receives a considerable number of patients annually who are sent there only after protracted, and often severe, operative measures have been fruitlessly attempted outside its walls.65 The building possesses, for maternity purposes, two fairly ventilated rooms. Excellent nurses are furnished by the New York Training School for Nurses. Mr. Osborn, a liberal private citizen, has had constructed in the rear, but detached from the main house, a small pavilion, modelled after that of Tarnier, for the reception of infectious cases. The Commissioners of Charities have promptly responded to every call made upon them to extend the facilities for the care of patients.
64 Dr. Walker has since resigned, and my present colleague is Prof. Wm. M. Polk.
65 From Oct., 1883, to Aug., 1884, there have been confined 168 women in the hospital. Twenty were brought in from the street just after the birth of the child. Of these 188, not one suffered from any puerperal affection. There were 2 deaths—1 from intestinal ulcerations, possibly the result of the corrosive sublimate irrigations, and 1 from exhaustion. This latter patient had been thirty-six hours in labor before she was brought to the hospital, and died four hours after admission. Under the admirable management of Miss Hart, the matron, in addition to the slight mortality, there has likewise been almost complete absence of even trivial temperature elevations.
Surely these results do not support the idea that it is better for a woman to be confined in a street-gutter than to enter the portals of a lying-in asylum. Goodell's experience shows that a hospital for respectable married women may be so conducted that its inmates may enjoy absolutely a greater degree of safety than do women in their homes surrounded by all the aids that wealth can command. Equally good results are not to be obtained in hospitals which are open to unfortunates of every class. But there is much misapprehension and confusion of ideas respecting the fate of these women when no charitable provision is made for them. In Copenhagen the Maternity Hospital is closed for from six to eight weeks in the summer-time. During this period unmarried parturient women receive pecuniary assistance from the hospital to enable them to obtain a place in which to be confined. Now, Stadfeldt reports a larger mortality among this class than among those delivered in the hospital. Yet they are confined at a favorable season of the year, without any communication with the furniture, the sage-femmes, or the physicians of the hospital. As they fortunately receive nothing but money, that can hardly be suspected of communicating contagion. What their fate would be in New York City perhaps may be judged from the following facts: Excluding cases confined in hospitals, nearly one-thirtieth of all the deaths and one-twenty-fourth of the cases of metria between 1867 and 1875 are reported by four practitioners. Ten practitioners out of twelve hundred signed the death-certificates of one-fifteenth of the women dying from puerperal causes, and one-tenth of the cases of metria. But it is not to be supposed that these deaths were all the result of malpractice and incompetence. The true history of most of them probably was that the doctor was engaged to attend the case of confinement for a small fee, with the understanding that he should make no calls subsequently, unless specially summoned by the friends of the patient. The latter, left to ignorant care or perhaps without any assistance whatever, and exposed to all the pernicious influences bred by poverty, when illness supervened probably did not call the physician to her aid until the time for help had passed, so that in the end his professional functions were confined to procuring the requisite permit for burial.
Humanity demands that charity should furnish places of refuge in which poor outcasts can receive assistance during the perils of child-bearing. If we must, then, have maternities, we should make them safe, and this can be in great measure accomplished by remembering the twofold source of danger arising from a poisoned atmosphere and direct inoculation. A hospital must be clean, spacious, and well-ventilated, or its atmosphere will become charged with the spores of septic fungi and produce nosocomial malaria. The most rigid sanitary precautions observed by the attendants will not prevent a badly-ventilated ward from becoming unwholesome, unless unoccupied wards are kept to which patients can be transferred upon the first admonition of danger. Goodell states that at the Preston Retreat the wards are used invariably in rotation. In connection with the Maternity at Copenhagen there are a number of small supplementary hospitals scattered through the city, which serve as safety-valves for the central institution. Artificial methods of ventilation render the task of keeping the wards wholesome comparatively easy. They do not need, however, to be complicated and expensive. The good repute of the Rotunda Hospital, it seems to me, is in large measure due to the natural ventilation afforded by open fireplaces.
In the Vienna Clinic, according to C. Braun, the mortality between 1834 and 1862 averaged 6 per cent., and in 1842 the enormous total of 521 deaths to 3067 confinements was reached. With the introduction in 1862 of what is known as Böhm's heating and ventilation system an immediate improvement was experienced. In the sixteen years from 1863 to 1878, inclusive, the total mortality has been 1.6 per cent., though in that time 5464 practitioners have received an obstetrical training in its wards. In commenting upon this change, Braun says: "I have now from practical experience arrived at the knowledge of the fact that the rapid and thorough prevention of putridity by adequate ventilation is to be regarded as a good preventive measure against puerperal fever; that it is not the number of patients in a lying-in hospital, nor yet the number of patients in a single room, but the deficient circulation of air—a fault which may inhere to separate compartments in the smallest maternities—which is the important feature in the spread of puerperal fever; that puerperal women are to be protected from childbed diseases not by isolated buildings and gardens, nor by walls, but by the permanent introduction of great quantities of pure, warm air." He then adds, what is in thorough accord with my own experience, "Before new institutions are built greater attention than heretofore should be paid to the ventilation of the old structures, and, where this is found defective, a system should be substituted corresponding to the scientific requirements."
In the year 1872 puerperal fever destroyed 28 women of 156 who were confined in the Bellevue Hospital. The service was then broken up, and a great outcry arose against "tainted hospitals." Wooden pavilions were accordingly erected on Blackwell's Island for the reception of lying-in women. These buildings were constructed upon what is known as the cottage plan. They were favorably situated in an airy location remote from the general hospital. They were, however, heated by large iron stoves, and no means of ventilating the wards was provided, except by lowering the windows. In less than three months from their occupancy an epidemic of puerperal fever made it necessary to remove the service for a time to the Charity Hospital. The same result followed every subsequent attempt to utilize them for maternity purposes, until, after three years' trial, it was found necessary to abandon them altogether.