308 Statistics of the Waterford Lying-in Ho~]~ital.

There was no Tost-mortem examination, but the appearance of the body immediately after death left no doubt on my mind that the hemorrhage was into the stomach.

Death from hemorrhage into some vital organ is not an un- common termination to purpura. The case is interesting, occurring as it did, at the same time with the purpuric fever, and yet being a typical uncomplicated case of purpura hemorrhagica.

ART. XV.--Description and Statistics of tire Waterford Lying-in Hospital, in ~llustration of the Conditions under which tlte Occurrence of Puerperal Fever in such .Establishments may be Zessened or Prevented. By JOH~ ELLIOTT, A.M., M.B.; M.R.C.S., Eng. ; Medical Attendant to the Workhouse, Fever, and Lying-ln Hospitals, Waterford.

IT is not probable that puerperal fever has of late years become more prevalent or fatal than formerly in Lying-in Hospitals. Indeed, such an undesirable and unexpected result would seem scarcely consistent with the hygienic and sanitary precautions and improvements which have been so largely and generally introduced into those Institutions ; for although one may not be convinced that the outbreak of zymotic disease is always due to preventible causes, yet the general adoption of the measures above alluded to, as well as improvements in treatment, one would suppose must have limited the range and lessened the mortality of this terrible scourge. How- ever this may be, and whether the mortality from puerperal fever be greater or less in Lying-in Hospitals than of old, it is certain that it has excited so much dissatisfactlon,as to ori~nate the inquiry whether these establishments, extensive and magnificent as they are, should not be closed; and the patients, for whom they are intended, be relieved and treated at their own homes. This dissatisfaction may, indeed, have been quickened into activity under the influence of the questioning and critical spirit which is testing all established insti- tutions as well as all received opinions; nevertheless, the important question thus raised has already attracted considerable attention, and been the subject of keen discussion, as well within the ranks of our profession as amongst the lay public ; and the interest already excited is pretty sure to increase rather than diminish, unless the circumstances under which it has originated can be altered for the

By D~. J onN ELLIOTT. 809

better. The alternative to which this inquiry points would also prove very injurious to various interests, and not last nor least to the interests of the patients themselves. Any modification, there- fore, of Lying-in Hospitals, consistent with their maintenance as hospitals, is worthy of consideration, provided it remedy the evil which threatens their very existence.

Facts, however, rather than theories, are the desiderata for this purpose. I t is, therefore, felt that the experience afforded by the working of a Lying-in Hospital, however small, which, for more than twenty-nine years, has never been closed for a single day on account of puerperal fever, and in which, during that period, 3,409 women have been received and delivered, with the loss of only five of that lmmber by that fatal disease, is not without value as a contribution towards the consideration of this important subject. Under the influence of this feeling alone, the following description of this institution and its working is subjoined.

A Lying-ln Charity for the relief of poor women at their own homes had been in existence in Waterford from the commencement of the present century. It had been got up and mainly supported by the Society of Friends ; and in the year 1838, at the instance and with the aid of the same benevolent body, it was determined to supplement and extend the benefits which had been derived from the charity, by the establishment of a Lying-in Hospital, sufficient for the wants of the town, which should be supported, as the former had been, entirely by voluntary contributions, and managed, like it, by a committee of ladies.

Some preliminary difficulties having been surmounted, and the necessary funds having been collected, the hospital was opened in the month of March, 1838, at a small house rented for the purpose, in an elevated and airy part of the town.

Of this house, only two rooms were available for the occupation of the patients. One was a very small room, in which were two narrow couches or beds, on which the patients were delivered; and the second, a larger room, in which were eight beds. Into this last-mentioned apartment the patients were removed at the end of some hours after delivery, and they continued to occupy it dur- ing their stay in the hospital. This larger ward was lighted by three windows with a louvred pane in the upper sash of each. The door was removed from its hinges, so that the entrance was rendered a mere door-way, necessarily open at all times; the bedsteads were plain iron couches, very roomy, but devoid of tester, curtains, or

310 Statistics of the Waterford Lying-in Hospital.

valance of any kind; the beds were of straw, inclosed in a sack or ticking, and changed for each patient.

Into this hospital 753 women were received and delivered between March, 1838, and October, 1844, a period of six years and six or seven months. Of these, six died, three of the deaths being the result o£ puerperal fever in one or other of its forms, thus giving a total mortality of 1 in 125½, being a per centage of 0"79 or 4-5ths nearly; and a mortality from puerperal fever of half the amount, viz., 1 in 251, or 0"39 per cent.

In October, 1844, the hospital was removed to the house which has been in continued occupation to the present time. This house is less favourably circumstanced as to its surroundings than was the former. I t is situated in a narrow street, about 25 feet wide, in a poor and rather densely inhabited neighbourhood, and the ground on which it stands is rather low.

I t consists of six rooms. On the ground floor is a board-room to the front, and behind it a kitchen; on the first floor a small apartment to the rere, in which are two delivering couches; and to the front, an apartment or ward in which are four beds for the reception of patients after delivery, and during convalescence.

On the upper or second floor are also two rooms ; one to the rere occupied by the resident midwife, and another to the from, in which are four beds for the reception of patients.

Each of the wards, in which are four beds, is lighted by two window~, with a louvred pane in the upper sash of each. The door of each is removed from the hinges as in the former hospital; and the bedsteads and bedding as before. Behind this house or hospital, if it be worthy of that appellation, is a small yard, in which are a wash-house, ash-pit, privy, and house for the storage of straw, but the drainage and sewerage are by no means perfect. These details, which may appear to some tedious or trifling, are given, because a knowledge of them is necessary for a due appreciation of the results.

Into this hospital, from October, 1844, to this day, that is during a period of twenty-three years, there have been received and deli- vered 2,656 women. Of these nine have died, two of that number, of puerperal fever in the form of puerperal hysteritis, being a total mortality of 1 in 295~; or a per-eentage of deaths of 0"33, and a mortality from puerperal fever of-1 in 1,328, being a very small fraction indeed.

I t will have been seen that in the first hospital where two

By DR. JOH:N ELLIOTT. 311

apartments only were devoted to the immediate use of the patients, eight beds were grouped together in a single ward; and that in the present hospital three apartments are available for their use, so that the same number of beds is divided between two wards; and it will be noticed, as a significant fact~ that whereas the mortality from puerperal fever was, in the first hospital, 1 in 251, during a period of six years and six months, the mortality from the same cause has been, in the present one, only i in 1,328~ during a period of twenty-three years.

In this, as in larger hospitals, and especially in Lying-in Hospitals, the number of patients together under treatment has varied greatly ; there have been occasions when all the beds were occupied at the same time; and once or twice it has been found necessary to receive even more than the proper number ; generally there have been only one, two, or three in hospital at the same time, and not unfrequently the hospital has been for some days, or a week, or even longer, completely empty.

This arises as well from the system under which the patients are admitted, as from the nature of the cases. They acquire their claim on the hospital by tickets of admission, which they obtain during their pregnancy from the subscribers to the hospital, who receive one ticket of admission for each sum of 10s. which they con- tribute. With these the women come to the hospital when their labour commences, and they must be received.

The annual admissions have varied from 79 (the smallest number within a full hospital year) to 152. The largest number of deaths from all causes that has taken place within any one year is three; and this annual mortality has occurred twice in the years 1842 and 1860; the other deaths took place singly in different years. There was one period of six years, in which 566 women were delivered without the loss of one of the number from any cause ; and another interval of four years similarly favoured, during which 558 women were delivered. This last period included three years, in which there was a comparatively large number of deliveries--in 1862, 142; in 1863, 150; and in 1864, 152.

The first death from puerperal fever, which was indeed the first death that occurred, took place in September, 1841, the second in January, 1842, the third in August, 1843, the fourth in January, 1860, and the fifth in May, 1866. Thus it is seen that the hospi- tal had been open more than three years before this disease proved fatal in a single instance; and that there was an interval of more

312 Statistics oj the Waterford Lying-in Hospital.

than sixteen years, from August, 1843, to January, 1860, during which 1,811 women were delivered, without a death from this cause.

I have presented the various aspects under whichthese statistics may be viewed, as I have given details of construction and arrangement, because mere numerical results, unless thus accompanied and guarded, have little practical value in the way of either warning or example. To complete what may be required in this way, it may be added that the town of Wate~ord contains about 28,000 inhabitants, a large proportion of whom are very poor; that it is not remarkable for being very healthy, and that it generally comes in for a full share of the zymotic diseases which afflict Ireland, as well puerperal as other. Indeed puerperal fever has prevailed through the town, during years, in which the hospital was nearly or altogether free from it.

After what has been said, it is probably not necessary to do more than touch on the leading reasons why an hospital so situated, not distinguished by external hygienic advantages, and ministering to the poorest of a needy population, should have been favoured during a period of nearly thirty years, and notably during the last twenty-three years, with such a general exemption from the scourge, which has marred the usefulness of other large and magnificent institutions, enjoying advantages of various kinds, in which this small hospital, ff it be worthy of such a name, is deficient.

In the opinion of some, the comparatively small size of the town may have a favourable effect, because the difficulty of maintaining health, and of escaping from disease, under circumstances which favour its invasion, as in the case of parturient women, is ceeteris paribus, increased as the population becomes massed together. But the causes, more directly influential in this instance, will, no doubt, be found :--[st, In the small size of the hospital and of its wards, or rather in the small number of patients which they receive at the same time. 2nd, In the fact, that the hospital is periodically empty. 3rd, In the delivery of the women on beds, and in an apartment other than those occupied by them during convalescence: an arrange- ment which becomes possible only in a small establishment with wards immediately adjacent. Lastly, ]n the precautions by free ventilation, and the nature of the bedsteads and bedding, to prevent or dissipate the fomites of puerperal disease.

On a review of these conditions, in order to decide how far they may be suitable for adoption elsewhere, some, such as louvred win- dow panes, open doorways, straw beds, and uncurtained bedsteads, might not be readily submitted to among a population less hardy,

By DR. JOHN EL~mTT. 313

and less accustomed to privation than ours. But the principles which they exemplify, and which of course are well known and of general application, must be kept in view, and enforced with what- ever modifications of details may be found inevitable, if puerperal disease is to be avoided.

I t may also be thought, that however great the sanitary advantages derivable from a small or cottage hospital, such a structure is not economical, looking to the accommodation it affords; nor could the principle be carried into operation, so as to meet the more extended requirements of a large community. With reference to the first objection it may be remarked, that an inspection of the annual reports of the hospital, for the last ten years, shows that within that period 1,269 women have been delivered, at an average annual expense for each of 15s. 9d., including the cost of baby clothes. The total average annual outlay for the same years has been £98; of this sum, more than half has been absorbed by the rent of the house, £12, and by the payment of the hospital staff, which consists of a resident midwife at £25, and a servant at £13 10s., board wages, in all £50 10s. ; which constitutes an unvarying outlay quite independent of the number of patients admitted. Now during the ten years in question, the annual admissions have varied from 15~9 to 114. I f then we take the first number as a measure of the capability of the hospital, it is evident that a much larger number of women might have been admitted with a corresponding diminu- tion of the average expense for each, as the unvarying outlay, which constitutes half that expense, would have been divisible among a larger number of inmates.

Thus during the years in which the largest numbers of womenM vlz., 152 and 150--were admitted, the average expense for each woman was 13s. 6d., and l ls . 6d., respectively. I f then, the wants of a district required, or it were desirable for educational or other influential reasons, to bring together, or rather into close proxi- mity, a larger, nay a much larger number of patients, this could be done with a due regard to economy, and without sacrificing the principle of segregating them into small houses and small wards; wherever such houses could be found, or built immediately adjacent to each other.

For instance, were the requirements of Waterford greater, one or more houses, precisely similar to that now occupied, might be rented immediately adjoining, at the same rent of £12 for each. These would give an additional accommodation of twelve beds each,

314 Statistics of the Waterford Lying-in Hospital.

a s the apartment used for a board-room in the present hospital, might, in each adjoining house, be occupied as a ward ; one board- room being sufficient for two or three, or more adjoining hospitals. Thus two such houses would afford twenty beds, and so on in pro- portion. Nor would the advantages peculiar to such a mode of construction be endangered by immediate proximity; provided no interior communication were permitted between the several buildings. One resident midwife, assisted, as she probably would be, by pupils, male or female, would also be found sufficient for twenty beds, thus further diminishing the average cost of each.

Again, if a rent of £12 be taken to represent a building capital of ;£150 or £170, it is evident that an outlay of about £300 or £340, might be made to give accommodation for twenty patients, or indeed for more, as constructions, especially intended for hospital purposes, would certainly give more accommodation within the same space, and be more convenient than dwelling-houses converted to the same uses. Such a building, or a row of such buildings, might be rented or constructed in the poorest neighbourhoods, where they would be most needed, and where their very proximity would itself be a great advantage to those for whose use they are chiefly and primarily intended. This last consideration is also an additional inducement, especially in large cities, for dividing hospital relief of this kind, provided sufficient accommodation be grouped together in each chosen locality, to meet the wants of the neighbourhood, and to present a field sufficiently large, to afford the experience necessary for educational requirements, with the consideration due to the convenience of the medical attendants and teachers.

Subjoined is a recapitulation of the statistics already given, with the addition of some others likely to prove interesting.

PRESENTATIONS.

Vertex, - - - 3,271 Vertex with hand, 18 Face, 11 Upper extremities, 8 Lower extremities, 88 Funis, 9 Placenta, 4 Head and feet, - 1 Hand and foot, - - 1 Not specified, - - - 47

3,458

By DR. JOHN ELLIOTT.

OPERATIONS.

Embryulcia, - - 15

Forceps, - - - 17

Turning, - 7

39

CAUSES O F D E A T H .

Puerperal fever, 5 Rupture of uterus, - 5 Hemorrhage, . . . . 1 Collapse or exhaustion, - - 1 Convulsions, - - - 1 Spasmodic cholera, 1 Chronic broncho-pneumonia, 1

15

315

W i t h respect to the above summaries it may be stated that the forceps has probably been used more frequently than is recorded in the hospital register. The number of deaths from rupture of the uterus is comparatively large; the rupture was, however, in all the eases, spontaneous, and, in one, if not two instances, the sufferers were brought to the hospital in a dying state, having obviously sustained the lesion before admission. The greater number of these cases also occurred many years since, when the axiom that "meddle- some midwifery is bad:' and the principle of trusting to nature had, perhaps, an undue influence over practice. Were similar cases met with now, the event would probably be different, at least in some of them.

B I R T H S . Born Alive. Still-born. Total.

Males, 1,712 - 95 - 1,807 Females, 1,593 - 58 - 1,651

3,305 153 153

Total births, 3,458 Women delivered, 3,409

Twin cases, - 49