ON LYING-IN INSTITUTIONS, ESPECIALLY 
THOSE IN NEW YORK. 
BY HENRY J. GARRIGUES, M. D., 
N. Y. 
In 1875, the International Congress of Physicians at 
Brussels adopted the following resolutions: - 
" 1. A thorough reform in the help afforded to lying-in 
women, is of urgent necessity. 
" 2. Large lying-in hospitals ought to be abolished. 
" 3. They ought to be replaced by small institutions with 
separate rooms. 
" 4. There ought to be a house for occasional use in the 
neighbourhood of the establishment, having an entirely dif- 
ferent administration, and different physicians. 
" 5. Confinements at the homes of the patients ought to 
be encouraged as much as possible, by assistance being 
supplied to pregnant and lying-in women at their abodes. 
"6. By having the women confined in the houses of the 
midwives, at the expense of the city government, and 
under its control, the number of births in the lying-in 
institutions, and the general hospitals, is limited, and the 
mortality diminished. This measure is desirable under 
normal circumstances, and becomes a necessity during an 
epidemic." 
Such resolutions, adopted by so competent a body of pro- 
fessional gentlemen, cannot be without weight, and will, 
earlier or later, have their influence, for good or evil, on the 
fate of lying-in women among the poor. They are to be re- 
garded as the blossoms of a tree that has been growing for 
twenty years. In 1856, Tarnier of Paris, aroused by the 
great death-rate in the Maternity Hospital of that city, 2 
ON LYING-IN INSTITUTIONS. 
examined the registers of the twelfth arrondissement, 
mostly inhabited by the poor, in which the hospital is 
situated, in order to find the proportion between the mor- 
tality in private houses and in the hospital. Well know- 
ing that physicians, for many different reasons, are apt to 
attribute the death of their patients to anything rather 
than to child-bed, he took this precaution: Whenever a 
woman between fifteen and fifty years of age had died, he 
examined the register of births in order to ascertain if she 
had been confined during the month before her death, and 
he counted as having died from puerperal disease every 
woman in this category. Although, by this procedure, he 
ran the risk of obtaining a greater number of deaths in 
private houses than ought to be classed under the head of 
puerperal disease, he found only fourteen deaths in 3,222 
confinements, and of the fourteen women four had been 
confined in the Maternity Hospital, and left it, sick. Ac- 
cordingly, the mortality in'private houses was only ten in 
3,222, or one in 322, whilst it was one in nineteen in the 
hospital.1 
Two years later, when the great discussion on puerperal 
fever took place in the Academy of Medicine, in Paris, 
Depaul2 said : " Since puerperal fever is, doubtless, found 
only in rare cases in private practice, as compared with 
those in buildings especially destined for lying-in women, 
are we not forced to demand that lying-in women be no 
more brought together in special buildings ; that they be 
spread, as much as possible, through the different hospitals ; 
and, still better, that means be found to help them at their 
homes ? " On another occasion he showed the excellent 
results of such help given at the homes of the patients.3 
Tarnier's researches were followed by similar ones in 
many large European cities, all of which went to show the 
1 Gazette des Hopitaux, 1866, p. 151. 
2 De la Filvre Puerperale, Communications cL VAcadimie Imp 4- 
riale de Medecine. Paris,- 1858, p. 54. 
8 L. c., p. 371. HENRY J. GARRIGUES. 
much larger mortality in lying-in asylums than in private 
houses ; and, finally, Le Fort of Paris united all these fig- 
ures, added new ones, and came thus to the semblance of 
statistics for nearly two million confinements:1 In hospitals, 
888,312, with 30,594 deaths, i. e. one in 29; in cities, out- 
side of the hospitals, 934,781 confinements, and 4,405 deaths, 
i. e. one in 212. 
Le Fort's views were adopted by Kennedy of Dublin, who 
read a paper on the subject, which gave rise to a long dis- 
cussion in the Obstetrical Society of that city.2 
In London, Miss Florence Nightingale3 published a 
volume on the subject, in which she not only admitted the 
accuracy of Le Fort's results, but adduced many facts from 
England, intended to corroborate his views, although in the 
mean time they had been exploded by the facts and logic of 
Matthews Duncan.4 In her philanthropic enthusiasm, this 
great sanitary reformer goes so far as to say (p. 64) : "Un- 
less 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 ! " This is a 
consequence of these other assertions of hers (p. 73): " That 
lying-in patients should be perfectly well in health ; " and 
(p. 86): " That a case of puerperal fever, or peritonitis, 
ought never to arise after delivery in a properly conducted 
and managed institution." She ignores, probably, the fact 
that even an entirely normal woman, when pregnant, suffers 
from hydremia, not to speak of the manifold abnormal con- 
ditions which influence the puerperal state. 
At first sight the figures of Tarnier and Le Fort seem 
overwhelming, and they have, indeed, exercised and still 
exercise a great influence on many minds, inducing them to 
3 
1 Le Fort, Des Maternitts. Paris, 1866, 1, p. 84. 
5 Dublin Quarterly Journal of Medical Science, 1869, vols. xlvii. 
and xlviii. 
8 Florence Nightingale's Introductory Notes on Lying-In Institu- 
tions. London, 1871. 
4 Matthews Duncan, Mortality of Childbed and Maternity Hos- 
pitals. Edinburgh, 1871. 4 
ON L YING-IN INSTITUTIONS. 
condemn lying-in hospitals altogether; but on closer exam- 
ination they lose much of their force. In the first place, 
the figures of Tarnier, stating the mortality among lying-in 
women, during a certain year, in a poor district of Paris, 
were soon completely refuted, not being a faithful statement 
of the mortality in general in that locality. Danyau1 having 
heard from a midwife, who had an extensive practice in the 
said district, that there had been a severe epidemic in 1854, 
engaged Tarnier himself to investigate the details, who 
found that, during the first four months of that year, twenty 
women had died from puerperal fever, out of 1,205 that had 
been confined in the twelfth arrondissement, outside of the 
hospital, which gives a mortality of one in sixty, and, at the 
same time, the ravages of the disease are said to have been 
still worse in some neighboring districts. This shows the 
necessity of taking a long series of years, if the statistics 
are to have any reliability at all ; a bad year may be fol- 
lowed by a good one, and vice versa. 
Most of Le Fort's other figures are of still less value. 
The elements in his statistics are of too heterogeneous a 
character to form a homologous whole; and some of them 
are quite valueless, as, for instance, when he cites Stettin 
as having no mortality in policlinic practice.2 There is no 
country in which medical statistics are so good as in Eng- 
land, and, when it can be proved that even the data of the 
Registrar-general of that country show too low a mortality 
for city practice, we may infer that the discrepancies are 
still greater in most other countries. Now, Dr. Barnes 3 
says : " It is stated in the Registrar-general's Report for 
1856, that the mortality in childbirth in England and Wales, 
in 1847, was one in 167, and that it had fallen to one in 227, 
in 1856. Now, having applied to Dr. Elkington for the 
puerperal statistics of Birmingham, I learn that the regis- 
1 Fiiyre Puerpirale a I' Academic, p. 402. 
a L. c., p. 33. 
8 Dublin Quarterly Journal of Medical Science, voE xxviii., 1859, 
p. 100 ; quoted by M. Duncan, 1. c., p. 12. HENRY J. GARRIGUES. 
5 
trar of that town says that no one ever specifies the deaths 
in childbed or from 'puerperal fever.'" Matthews Dun- 
can says :1 "In 1870, with our great registering machinery 
all at work, we cannot find out what is the mortality of 
childbed in London." 
Generally, the figures showing the mortality in the city 
will be too small. This is especially the case when the 
research is confined to puerperal fever, as it is in many 
places. The views about this disease differ so much, that 
very often one physician will use this term, and another 
will use a different one. A great many cases will be hid- 
den under other heads, as peritonitis, parametritis, pneu- 
monia, typhoid fever, etc. When, however, the question is 
about the value of lying-in hospitals, those distinctions are 
of no importance. It is immaterial whether the patients 
die from one cause or from another. If it be true, as I think 
it undoubtedly is, that the mortality from puerperal fever 
is somewhat higher in hospitals than in private practice, 
although infinitely less so than pretended by Tarnier and 
LeFort, on the other hand, deaths from hemorrhage, rup- 
ture of the uterus, eclampsia, in short, all cases that have 
nothing to do with infection, are oftener prevented in hos- 
pitals, in which skillful obstetricians are always at hand, 
than in the city. 
What we want to know is, how many per cent, of confined 
women die in hospitals, and how many in private houses ? 
But even this cannot be ascertained exactly. 
The plan adopted by Tarnier is the best, and gives a 
pretty good result when registers of deaths and births are 
well kept, but if the latter are not reliable, many children 
not being registered, as is the case in the city of New York, 
the number of recorded deaths in childbed would be too 
small. On the other hand, some lying-in hospitals transfer 
their sick patients to other hospitals, a circumstance which 
tends to make their mortality appear smaller than it really 
is. However, I think these figures will be less erroneous 
1 Duncan, 1. c., p. 13. 6 
ON LYING-IN INSTITUTIONS. 
than any others. Adopting this method, Duncan 1 found 
the total mortality during the first six weeks after confine- 
ment in home practice, to be one in 107 in Edinburgh and 
Glasgow, during 1855. 
McClintock 2 has indicated another way by which we are 
able to estimate the total mortality in childbed in the city. 
By taking the house-practice of nine entirely reliable phy- 
sicians, he obtains a total of 16,774 cases, with forty-five 
deaths from accidents in labor, fifty-two from puerperal 
diseases, and thirty-four from non-puerperal diseases. The 
total of deaths being one hundred and thirty-one, he cal- 
culates that the deaths occurring in childbed, from non- 
puerperal diseases, form considerably more than one fourth 
of the fatal cases, and, consequently, one fourth is not at 
all too much to allow for the deaths omitted in the regis- 
tration returns of deaths in childbed. Duncan 3 has ap- 
plied this method for correcting the numbers indicating the 
deaths of childbed returned by the Registrars-general in 
different countries. 
Paris in 1862 returned 1 in 160; corrected, 1 in 120. 
St. Petersburg returned 1 in 149; corrected, 1 in 112. 
Dublin returned 1 in 114; corrected, 1 in 86. 
Edinburgh from i860 to 1865 returned 1 in 162 ; corrected, 1 
in 122. 
The statistics of Copenhagen, a city of 200,000 inhabi- 
tants, give us the means of trying still another method of 
ascertaining the total mortality connected with childbed. 
In Copenhagen,4 outside of the Maternity Hospital, 
108,737 women were delivered during the twenty-five 
years from 1850 to 1874, 885 of whom died of puerperal 
fever, i. e. 1 in 123, and whilst the number of the confine- 
1 Duncan, 1. c., p. 157. 
2 Dublin Quarterly Journal, 1869, vol. xlviii., p. 267. 
B Duncan, 1. c., pp. 19-21. 
4 Stadfeldt, Les Maternitds Illustrtes par la Statistique de 23 A ns 
de la Maternity de Copenhague, Copenhague, 1876, p. 5. HENRY J. GARRIGUES. 
7 
ments is entirely reliable, that indicating the deaths is too 
small. As the physicians there do not act as accoucheurs 
in normal cases, which are left to midwives, they are only 
called when the trouble has declared itself. Accordingly, 
the blame for neglect, or bringing contagion, if blame there 
be, does not fall on them, but on the midwives, and, con- 
sequently, a potent factor that lowers the number of deaths 
from childbed fever, returned in countries in which the 
doctor is himself the accoucheur, is not present in the 
above returns. But, as the diagnosis, in itself, is subject 
to controversy, there is no doubt that a large number of 
deaths that properly belonged to puerperal fever have been 
registered in the class of abdominal inflammations (peri- 
tonitis, metritis, hepatitis). The ratio 1:123 is, conse- 
quently, too small, even when we speak of puerperal fever 
alone, and if we add the mortality from other causes than 
puerperal fever during birth and childbed, the fraction will 
be a considerably larger one. Prior to 1873, we have no 
direct means of ascertaining this last number, but since the 
beginning of that year, all deaths connected with parturi- 
tion and the puerperal state are registered in two classes, 
one for puerperal fever, and another for childbirth and 
childbed, exclusive of puerperal fever :1 - 
Year. 
Deaths from Puerperal Fever. 
Deaths in Childbirth and Child- 
bed excepting Puerperal 
Fever. 
1873 
45 
17 
1874 
38 
21 
1875 
44 
l6 
Total .... 
127 
54 
These data are for the whole city, inclusive of the Lying- 
in Hospital. If we now take these numbers as a basis, and 
suppose that the deaths caused by childbirth and the puer- 
1 Reports of monthly mortality in Ugeskrift for Lceger, i. e. Physi- 
cians' Weekly Journal. 8 
peral state, exclusive of puerperal fever, be proportionally 
divided between the Lying-in Hospital and the rest of the 
city, we would have to add 376 to the above named 885 
caused by puerperal fever during twenty-five years, in order 
to have the total mortality of childbed in Copenhagen, out- 
side of the Lying-in Hospital, which would then be not 
1:123, but 1 :86. It may be that the Lying-in Hospital 
has a comparatively greater amount of patients with hemor- 
rhage, rupture of the uterus, and eclampsia, and conse- 
quently a greater number of deaths from these causes, 
which would diminish the death-rate of the city, outside of 
the hospital, proportionally. But on the other hand we 
have seen that a certain number of deaths, that belonged 
to puerperal fever, have not been registered at all as ap- 
pertaining to childbed. If we could find this number, the 
mortality connected with childbed, outside of the hospital, 
would probably be even more than 1 in 86. At all events 
we get a number vastly different from the average given by 
Le Fort, 1 in 212.1 
Still another way to obtain an idea of the mortality in 
childbed, in cities, outside of the hospitals, is to take the 
results in private practice of prominent obstetricians. This 
has been done in Great Britain and Ireland. Thus, Dun- 
can 2 gives the results of his own private practice as eight 
deaths in 736 cases, or 1 in 92. One of the fatal cases was 
not attended by himself during labor, and may be omitted 
ON LYING-IN INSTITUTIONS. 
1 In speaking of McClintock's statistics Miss Nightingale (pp. 9, 10) 
says : " One feels disposed to ask whether it can be true that, in the 
hands of educated accoucheurs, the inevitable fate of women under- 
going, not a diseased, but an entirely natural condition at home, is 
that one out of every 128 must die ?" In Copenhagen, where mid- 
wives are employed instead of accoucheurs, the mortality, outside of 
the hospital, during twenty-five years, has averaged I in 123 from 
puerperal fever alone, and the total mortality in childbed is probably 
not less than 1 in 86, which goes far to prove that the patients do 
not fare better in the hands of " trained midwives " than when treated 
by " educated accoucheurs." 
2 Duncan, 1. c., p. 22. HENRY y. GARRIGUES. 
9 
from the statistics. The mortality will then be 1 in 105. 
In the discussion in Dublin, McClintock1 adduced his re- 
sults in private practice as being 652 cases with six deaths, 
or 1 in 108, and those of other prominent obstetricians, 
forming together 16,108 cases, with 120 deaths, or 1 in 134. 
All these patients were from the middle and upper ranks 
of society. If among this favored class the mortality in 
childbed amounts to 1 in 134, what must it be in the 
wretched abodes of poverty, with all its attendants of filth, 
impurity, and want ? 
All these different methods taken together give an aver- 
age of little less than 1 in 100: - 
Edinburgh, and Glasgow in 1855 . . . 0.93 per cent. 
Paris in 1862, St. Petersburgh, Dublin, Edinburgh ) 
from i860 to 1865, corrected j °'92 Per cent- 
Copenhagen 1.16 per cent. 
Prominent Obstetricians 0.75 per cent. 
4)3-76 
o-94 
and, if we leave out the exceptional results of prominent 
obstetricians, in wealthy practice, we obtain 1 in 100 as 
representing the mortality connected with childbed in large 
cities, outside of the hospitals. I have shown that the mor- 
tality in Copenhagen is certainly much higher, probably 
about 1 in 86, which is exactly the same proportion as was 
obtained by Duncan, for Dublin. At all events, we see 
that one of Le Fort's figures is decidedly erroneous. Let 
us now consider the other one. 
Compiling the statistics for a great number of lying-in 
asylums, and lying-in wards in general hospitals, he comes 
to the result that their average mortality is 1 in 29, and 
condemns them. This judgment is manifestly unjust. It 
may be true that the Lariboisiere hospital, in Paris, has had 
an average mortality of almost 8 per cent, of lying-in 
1 Dublin Quarterly Journal, 1869, vol. xlviii., p. 268. 10 
ON LYING-IN INSTITUTIONS. 
women.1 It may be a fact that in one service of the 
Vienna Lying-in Hospital the average mortality for the six 
years, 1841 to 1846, was almost 10 per cent. ;2 that in the 
Maternite of Paris, during five years, 1860-1864, it averaged 
11 per cent.,3 and that during four weeks (April 13 to May 
10, 1856), every third woman died in this establishment,4 
and so forth ; but this cannot fairly be used as an argument 
against all lying-in hospitals. One hospital with good re- 
sults proves more than any number of hospitals with bad 
results. Such an institution is the Rotunda of Dublin, 
which is more than a century old, and in which there have 
been more than 190,000 deliveries, with a mortality of only 
1 in 72? For long periods it has even been 1 in 100, and 
less. During Kennedy's mastership, the mortality was in- 
deed much higher than before, in one year running up even 
to 1 in 14 ;6 but it was hinted, during the Dublin discus- 
sion, that perhaps his great interest in pathological speci- 
mens might not have been without influence. For the last 
seven years (1869-1875) we learn from Johnston's most 
interesting reports 7 that the mortality has been 1 in 48, or 
2.1 percent. In order to explain the comparatively high 
mortality, Atthill calls attention to the fact that the hospital 
1 Gazette des Hopitaux, 1866, p. 151. 
2 Semmelweis, Die rEtiologie, der Begriff und die Prophylaxis 
des Kindbettfiebers, Wien, 1861, p. 3. 
8 Billet, De la Fiivre Puerp'erale et de la Riforme des Maternitts, 
Paris, 1872, p. 59. 
4 Ibid., p. 53. The same author tells (p. 19) that Dr. Chalvet 
found 36, and Dr. Kuhlmann 46, per cent, of organic matter in the 
dust taken from the walls of the Saint Louis Hospital at Paris, 
to which it had adhered for many years; and Miss Nightingale 
(p. 37), in criticising the Clinique of Paris, says : "The beds are cur- 
tained, and the curtains are washed only once in six months, even 
though the occupants of the bed may have died of puerperal fever." 
Who can, with such facts before him, wonder that the lying-in institu- 
tions of that city have been more murderous than those of any other. 
8 Duncan, 1. c., p. 19 and 148. 
• Dublin Quarterly Journal, 1869, vol. xlvii., p. 292. 
7 Dublin Journal of Medical Science, 1870-1876. HENRY y. GARRIGUES. . 
11 
was formerly extensively resorted to by the wives of the 
artisan class; but this is no longer the case, whilst the desti- 
tute, who are peculiarly prone to disease, the wretched vic- 
tims of seduction, and the bad cases - sent in because 
they are bad - are as numerous as ever. And McClintock 
showed how the number of primiparae had increased - dur- 
ing Collins' mastership 30J per cent., during his own 37, 
and now about 47 per cent. 
Whilst speaking of the good results obtained in the Ro- 
tunda, it may be well to mention that this hospital is 
also a school that serves for the instruction of students, 
and is sought by physicians from all countries who want to 
improve their knowledge of midwifery. This institution 
ought to be studied by those who want to construct a new 
lying-in asylum. As I have not seen it myself, I will only 
point out the chief features, from a description of it by 
another author.1 It is situated on elevated ground, and has 
125 beds. The rooms are distributed in groups of two or 
three, one larger and one or two smaller, which all commu- 
nicate with one another and with a corridor, so that they 
can be isolated. The larger room is first filled with pa- 
tients, and as soon as any one is taken sick, she is brought 
into one of the small rooms, which is now separated from 
the large one, and has its own nurse. There is ample room 
for every patient, from 1,265 *° 2>2oo cubic feet. The ven- 
tilation is excellent. The greatest cleanliness prevails 
throughout the establishment. The wards are not con- 
stantly in use. As soon as the large one in one group is 
full, the next group is used, and so on ; so that the first 
does not come into requisition again before having been 
1 Kayser, Den Kongelige Fodselsstiftelse i Kjdbenhavn, i. e., The 
Royal Maternity of Copenhagen, Copenhagen, 1845, p. 63. I prefer 
to give this old description taken from a foreign visitor; but those 
interested in the subject will do well to compare it with Johnston's, 
in his first report, in which is also found a plan of the building. The 
only change that has been made is that a ward in the auxiliary build- 
ing has been appropriated to patients laboring under uterine com- 
plaints. 12 
ON L YING-IN INSTITUTIONS. 
aired and cleaned. Beside that, the institution has a sepa- 
rate building, which is used whenever it is deemed advis- 
able to close the main building. 
But if it is well to study a lying-in hospital that is con- 
sidered the best in the world, it is perhaps still more useful 
to study institutions that have been bad, and have been im- 
proved, in order to see by what means the end has been 
attained. Such an establishment is the Royal Lying-in 
Hospital of Dresden.1 A new building was opened on the 
17th of October, 1869. During the first two years, the 
establishment had a very low mortality ; then came an epi- 
demic, as shown by this table: - 
Year. 
Confinements. 
Deaths. 
Per Cent. 
1869 
l8l 
2 
1.1 
1870 
981 
II 
1.1 
1871 
968 
9 
•9 
1872 
991 
52 
5.2 
On the 6th of October, 1872, Winckel became physician- 
in-chief of the institution, and made the following changes. 
The patients were confined in larger rooms than before. 
The beds were elevated, in order to insure free circulation 
of air under them. Every ward was kept empty three or 
four weeks. In order to find out who was the carrier of 
the infection, he allowed one midwife pupil to deliver sev- 
eral patients one after the other, and as soon as one of the 
confined was taken severely sick, the nurse was prohibited 
from examining any other woman. In the same way he 
proceeded with his assistant physicians, so that at last 
Winckel performed all operations himself during two 
months, and all the natural labors were taken care of by 
the matron, with one or two pupils. These excellent meas- 
1 Winckel, Berichte und Studien aus dem Koniglich Sachsischtn 
Entbindungsinstitut in Dresden, 1874 and 1876, I., pp. 13, 20-25 ; II., 
PP- 13, 3 b 43- y. GARRIGUES. 
13 
ures brought the death-rate down immediately, and for the 
two following years the results were very good ! - 
Year. 
Women Confined. 
Deaths. 
Per Cent. 
1873 
i,on 
1,018 
23 
2-3 
I874 
13 
1.2 
1875 
1,095 
15 
1-3 
The study of the Lying-in Asylum of Copenhagen is still 
more useful, for the reason that it is a very old establish- 
ment, with exact records, that it has been one of the very 
worst in Europe,1 that, at different times, different means 
have been tried to improve it, and that, of late, its mortality 
from puerperal fever has been wonderfully diminished. Be- 
fore I give any figures, I should state that they do not in- 
dicate the total mortality, but only that from puerperal fever, 
whilst the above figures for Dresden and Dublin give the 
whole mortality ; but as our object is now to compare the 
death-rate in the hospital itself, at various periods, this does 
not make any great difference, the measures adopted bear- 
ing only on infection in the widest sense of the word, - 
miasma, contagion, introduction of septic matter, - in 
short, poisoning in any way. 
The asylum has been in its present location since 1785. 
Up to 1845, it was merely enlarged by the addition of 
neighboring buildings. It suffered often from so-called 
epidemics of puerperal fever, and the status seemed to be- 
come worse in the course of years. During 22 years, 
(1822-1843), 21,149 women were confined there, 1,096 of 
whom died, or 1 in 19.2 This terrible mortality led to the 
1 Kayser, 1. c., p. 31, shows, by comparative statistics for a long 
series of years, for Paris, Stockholm, Vienna, Dresden, London, 
Prague, Berlin, Wurzburg, and Dublin, that their asylums were all 
more successful, and that an institution in Amsterdapi was the only 
one which had worse results. 
2 Kayser, 1. c., p. 31. These figures indicate the total mortality 
from whatever cause. 14 
ON LYING-IN INSTITUTIONS. 
abandonment of the building in 1845. It then stood empty 
four years, and was reconstructed on an entirely new plan. 
All the wards were changed into separate rooms, each with 
a window, and only one bed, without direct intercommuni- 
cation, but all opening into a large corridor with numerous 
windows. Excellent ventilation was provided by shafts 
running from every room to a common shaft, in which a 
great fire was kept burning, so as to produce a strong cur- 
rent, whilst fresh air was constantly entering the wards from 
without. The house was heated by hot water circulating 
in iron pipes. The water-closets were separated from the 
sick-rooms by the corridor, and the whole ground was 
drained. 
The house, in its new condition, attracted the admira- 
tion of all visitors. Professor Braun, of Vienna, for in- 
stance, says that it is " the best and most remarkable re- 
cently built lying-in hospital, and that everything has been 
done in order to put a stop to epidemics of puerperal 
fever." 1 It contained forty-four separate sick-rooms, only 
one half of which were occupied at a time, whilst the others 
were aired. As the number of beds available was not 
large enough for those who sought admission, an entirely 
new system was adopted. Those who could not be accom- 
modated were placed with midwives in private families, 
under the treatment of the physicians of the hospital. The 
patients are only admitted when labor sets in, and all those 
who suffer from hemorrhage or other causes, and all in whom 
any operative treatment is anticipated, are kept in the hos- 
pital proper, and finally the number (forty or fifty a month) 
is filled out by patients in whom everything seems to be 
normal, the remainder being sent to the branch places in 
the city. In spite of all these costly efforts, the result was 
not satisfactory : - 
1 Semmelweis, 1. c., p. 307. HENRY J. GARRIGUES. 
15 
Quinquennium. 
Women Confined. 
Deaths from Puerperal 
Fever. 
Proportion. 
1850-54 
4,783 
128 
I : 37 
1855-59 
5,526 
142 
1 : 39 
1860-64 
5,555 
385 
1 : 14 
1865-69 
5,8u 
158 
1 : 37 
Since 1865, the hospital has been closed six or eight 
weeks every year, and all the patients have been sent to 
the branch places, or, if they preferred, have received pe- 
cuniary help, with which they themselves have provided for 
their confinement. Though the mortality, after the adop- 
tion of these measures, fell from its high rate of more than 
seven per cent., it did not go below what it had been dur- 
ing the first ten years. 
Then Stadfeldt,1 who had been the chief of the es- 
tablishment since 1865, influenced by the remarkable re- 
sults obtained in the surgical services of the city by the 
adoption of Lister's method of operating and dressing 
wounds, introduced a strict preventive antiseptic treat- 
ment. The corridor has the shape of a T. One of the 
small wings, with three rooms, is separated from the rest, 
and is used only for deliveries. From two to six hours 
after delivery, the patient is brought, in the bed in which 
she has been delivered, into one of the rooms opening on 
the other part of the corridor. The establishment being 
a school, in which midwives are trained, there are from thirty 
to forty pupils. Every pupil goes with her patient from the 
delivery department to the lying-in department, and when 
the patient leaves, the nurse takes a bath, and her body 
and clothes are thoroughly disinfected in the following way. 
Connected with the window of a small room is a hose which 
covers the head so as to allow free respiration, while her 
person and wardrobe are subjected for a quarter of an hour 
to the fumes of sulphurous acid. Immediately before and 
after every physical examination, the physicians and nurses 
1 Stadfeldt, 1. c., p. 11-14. i6 
ON LYING-IN INSTITUTIONS. 
wash their hands with a solution of carbolic acid. All in- 
struments used in operations are disinfected with this sub- 
stance ; syringes and catheters are of metal, and always 
kept in carbolized water. When possible, the confinement 
itself takes place under a spray of the same disinfectant. 
Sponges have been banished, and replaced by oakum. 
Vaginal injections with carbolized water (i : 125) are used 
in every patient twice a day ; all lesions are dressed with 
carbolized ointment, and the genitals covered with carbol- 
ized oil, which, of late, has been replaced by salicylic acid 
in ten parts of wheat flour, powdered over the parts two or 
three times a day. The patient rests on a sack filled with 
chaff, both sack and contents being burned when the pa- 
tient leaves the asylum. Besides that, each has a pillow of 
hair, and blankets. If the confinement has presented any 
pathological accidents, these articles are sent to the laun- 
dry, and the upholsterer, for thorough cleansing. The 
room remains empty for some days after each confinement, 
and when practicable, a whole series of rooms, with their 
corridor, are emptied, disinfected, and aired. The same 
bed-pans, syringes, and catheters are never used for the 
sick and the well. The water-closets are disinfected every 
day. The after-births, and the soiled oakum and wadding, 
are immediately thrown temporarily into a pail containing 
a strong solution of chlorinated lime, and burnt the next 
morning. Dead bodies are removed as soon as possible, 
and the physicians are forbidden to make post-mortem ex- 
aminations. 
Since this preventive antiseptic treatment was introduced, 
the mortality from puerperal fever has diminished prodig- 
iously. During the twenty years from 1850 to 1869, in 
which everything was done to combat miasma, out of 21,675 
women who were confined 813 died of puerperal fever, or 
1 in 26, whilst during the five years from 1870 to 1874, in 
which the chief efforts were turned against direct poisoning 
by physicians, nurses, and instruments, there were 5,304 
women confined with sixty-one deaths from puerperal fever, HENRY J. GARRIGUES. 
17 
or only 1 in 87 (highest yearly mortality 1 in 75, lowest 1 in 
170). This number has no absolute value comparable with 
the results in other lying-in hospitals, nor with the mortality 
in private houses in the same city, for it comprises the 
patients treated in the branch places supervised by the ad- 
ministration of the asylum, but it has full relative value, as 
the same system existed for the twenty preceding years, 
and the only change made was the adoption of antiseptic 
prophylaxis. 
Bischoff1 of Basel has used a treatment based on the 
same principle, and is well satisfied with the results, as have 
been also Fritsch in Halle,2 and Fehling in Leipzic. 
In France, where the death-rate in lying-in institutions 
has been worse than anywhere else, and where the war on 
these establishments began, we hear of late of one that 
works well. Helot, Surgeon-in-Chief to the General Hos- 
pital at Rouen, has obtained the following results: - 
Year. 
Deliveries. 
Deaths. 
Proportion. 
Per cent. 
1855-1859 
i >979 
54 
I : 37 
2.7 
1860-1869 
4,001 
47 
1 : 85 
I.28 
For the two years 1863-1864 the mortality is compared 
with that in the city outside of the hospital. 
1863. 
City, 2,484 deliveries, 28 deaths, or 1 in 88 
Hospital, 394 deliveries, 4 deaths, or .1 in 98 
1864. 
City, 2,407 deliveries, 16 deaths, or 1 in 150 
Hospital, 365 deliveries, 3 deaths, or 1 in 1224 
1 Bischoff, Zur Prophylaxis des Puerperalfiebers, Basel, 1876, 
pp. 8-14. 
2 Fritsch, Ueber das Puerperalfieber und dessen lokale Behand- 
lung, Leipzig, 1876 (Volkmanirs Klinische Vortrdge, No. 107). 
8 Rident, La Maternity de I'Hospice Glnlral de Rouen, Paris, 
1871, p. 23. 
4 Ibid. p. 27. 18 
Accordingly, in the first year the mortality in the hospi- 
tal was smaller than that outside, and in the other not much 
larger. In Dublin, the good results are attributed to clean- 
liness, ventilation, and early surgical interference; in Rouen 
the first two and the use of aconite as soon as the pulse 
rises even to the normal frequency, seem to be the chief 
features. 
But,-however well lying-in hospitals may be constructed 
and managed, the mortality in them is, and must be, some- 
what larger than in private houses, say i| percent.1 as 
compared with 1 per cent.; but this is not the fault of the 
institutions, nor is it peculiar to them. If it is higher in 
asylums than in large cities, outside of them, it is likewise 
greater in large cities than in small towns, and smallest in 
the country. Thus the mortality from puerperal fever has 
averaged 1 in 123 during twenty-five years (1850-1874), in 
Copenhagen, outside of the Maternity,2 whilst in all the 
small towns together, in Denmark, the mortality from this 
cause was only 1 in 219 or 0.45 per cent, during ten years 
(1857-1866).3 
In sixty-four healthy districts of England the mortality 
from accidents in childbirth and puerperal disease, in 1867, 
is given as 0.43 per cent.; in eleven large towns as 0.49 per 
cent. ;4 but, as we have stated before, these numbers are too 
small. Hegar gives, for a district in Baden, with a healthy 
and wealthy population, mostly farmers, for the three years 
1864-1866: 34,553 deliveries, 253 deaths, or I in 137, or 
0.73.5 
But this greater wholesomeness of country places and 
ON LYING-IN INSTITUTIONS. 
1 Leipzig, 1.9 (Credd, Bericht uber die Entbindungsschule zu Leip- 
zig wdhrend go Jahre, i860) ; Dresden, 1.7 ; Wurzburg, 1.6 (Winc- 
kel, 1. c., ii., 297); Dublin, 1.4 (Duncan, 1. c., p. 148). 
2 Stadf.eldt, 1. c., p. 5. 
8 Stage, Barselfeberen i Danmark udenfor Kjobenhavn (Puerperal 
Fever in Denmark, outside of Copenhagen), Copenhagen, 1868, p. 37. 
4 Nightingale, 1. c., p. 5, according to Registrar-general's Report. 
5 Hegar, Die Sterblickkeit wahrend Schwangerschaft, Geburt, und 
Wochenbett. Freiburg im Breisgau, 1868, p. 2. HENRY J. GARRIGUES. 
19 
small towns, as compared with capitals,1 is not peculiar to 
lying-in women ; it applies to all classes of patients, and 
especially to surgical cases. We cannot bring all lying-in 
women out of large cities. The question is, then, how we 
can best provide for those who live in them. 
The mortality in lying-in hospitals must always be larger 
than in the city, outside their walls, because they have a less 
favorable class of patients. The majority of patients who 
seek the lying-in asylums are unmarried, and it cannot be 
doubted that this circumstance has a bad influence on their 
chances of recovery. Whatever views we may entertain of 
the nature of puerperal fever, which is the chief cause of 
death in lying-in hospitals, we may be sure that in this dis- 
ease, as in all others, the condition of the patient has at 
least a great influence on the favorable or unfavorable 
course of the disease, when once it is engendered ; and we 
cannot doubt that a poor girl who is ashamed of her con- 
dition, who is anxious as to what will become of herself and 
her offspring, who has been driven away from her place 
when her state could not be longer concealed, and who has 
suffered from cold and hunger, is more apt to become in- 
fected with puerperal fever, and certainly more apt to suc- 
cumb to its attacks on her feeble and worn-out body. 
Next, it must be taken into consideration that lying-in 
hospitals have a very large number of primiparae, and sta- 
tistics show everywhere a considerably larger mortality 
among this class of lying-in women than among those who 
1 Exceptionally, a very high mortality may occur even in the coun- 
try, not only during a so-called epidemic, but even spread over a 
series of years. Hegar (1. c., p. 42) gives a striking example of this : 
Sprachbrucken, a village near had the following death- 
rate : - 
In i860, 18 women confined, with 1 death. 
In 1861, 26 women confined, with 4 deaths. 
In 1862, 29 women confined, with 4 deaths. 
In 1863, 24 women confined, with 3 deaths. 
In 1864, 25 women confined, with 1 death. 
Total . . 122 women confined, with 13 deaths, or 10.6 per cent. 
> 20 
ON LYING-IN INSTITUTIONS. 
have borne children before. Thus Duncan1 quotes the 
following statistics : - 
Women 
Confined. 
Deaths. 
Proportion. 
Per cent. 
Johnston Sinclair: primiparae . 
4,535 
83 
I : 54 ■ 
1.8 
multiparae . 
9,213 
80 
1 : H5 
.86 
McClintock & Hardy: primiparae . 
2,125 
35 
I : 60 
1-65 
multiparae . 
4,5io 
30 
I : 150 
.66 
Married women in Edinburgh and 
Glasgow in 1855 : primiparae . . 
3,722 
5o 
I : 74 
1-34 
multiparae. • 
12,671 
103 
1 : 123 
.81 
In Germany, Veit had 17 against 10 per cent. ; G. 
Braun, 6.8 against 3.7 per cent. ;2 Hecker3 5.2 against 3.4. 
Faye, in Christiania,4 had 1,632 primiparae with seventy-eight 
deaths, against 1,327 pluriparae with thirty-one deaths, or 4.7 
per cent, against 2.3 per cent. We see accordingly that the 
mortality among primiparae is about one and three fourths 
times greater than among the pluriparae. Many are the 
reasons that may be given to account for this higher death- 
rate. Primiparae are more exposed to certain diseases that 
threaten life, e. g., albuminuria and eclampsia; the nar- 
rower genital tract is more extensively wounded by the 
passage of the child ; operative interference is oftener nec- 
essary ; the mere fact that labor lasts longer with them 
renders them more likely to be infected before delivery, 
either by poison carried on fingers or instruments, or by 
emanations in the locality in which they are confined. 
Further, it must be borne in mind that many patients are 
brought from their homes to the lying-in hospitals because 
the labor presents difficulties that could not be overcome 
1 Duncan, 1. c., p. 37. 
2 Winckel, 1. c., ii. 277. 
8 Hecker u. Buhl, Klinik der Geburtskunde, i., 226, and ii., 212. 
4 Faye and Vogt, Statistiske Resultater stottede til 3,000 paa Fbd- 
selsstiftelsen i Christiania undersogte Svangre ogFodende samt Born 
(Statistical Results derived from 3,000 Pregnant and Parturient Wom- 
en, as well as their Children, in the Lying-in Institution of Christiania). 
Christiania, 1866, pp. 67, 73. HENRY J. GARRIGUES. 
21 
outside. As a negative illustration of the influence of this 
item, I do not know any better than the statistics of the 
lying-in wards of the Liverpool Workhouse. The exact 
number of deliveries is not known for the earlier years, but 
can be estimated at 500 a year, which gives during the thir- 
teen years, 1858 to 1870, a total of 6,396 deliveries, with 
fifty-eight deaths, or 0.9 per cent. The last five years, for 
which the statistics are recorded exactly, show 2,471 pa- 
tients, thirteen of which died, or only 0.5 per cent. These 
excellent results are obtained though two thirds of the 
patients are unmarried, and consequently a great number 
primiparae, and although the establishment, with an average 
of 500 deliveries a year, has only twenty-five beds, so that 
twenty deliveries come on every bed a year. There may 
be many other reasons to account for this marked suc- 
cess, but as. none of those indicated by Miss Nightingale,1 
from whom I borrow the facts, are peculiar to this institu- 
tion, I think the one I have pointed out may not be without 
influence. Whilst many a wife in the middle walks of soci- 
ety submits to being transported to a regular lying-in insti- 
tution when her case proves to be above the resources of 
her medical attendant, it is not to be supposed that she 
would go to a workhouse, and thus institutions of the 
latter class escape many cases that deteriorate the statistics 
of the former. 
Finally, we must remember that the lying-in hospitals 
are destined for the poof. Before deciding the question if 
lying-in hospitals are to be or not to be, we must ask what 
the fate of these same poor women would be, if such insti- 
tutions did not exist. Most of them would get miserable 
help and bad nursing, some would not know at all what to 
do, and put an end to their lives by suicide. It has been 
said that we may give them pecuniary help. This is indeed 
a good plan with all those who have a home; another good 
way is that followed by the Asylum in Copenhagen, of 
having places in the city in which the lying-in women are 
1 Nightingale, 1. c., pp. 52-58 and 91* 22 
under the control of the institution. But only to give 
money, and allow the patients to shift for themselves, has 
not given good results. This is done in Copenhagen with 
some patients, during the summer vacation, when the lying- 
in hospital is closed for two months, but it has been found 
that these patients, of late years, have presented a higher 
mortality than the Asylum itself,1 and it is not difficult to 
account for it. By this system there will be established 
places in which the pregnant can be confined at a very 
cheap rate, and so in fact small lying-in hospitals be formed 
without any control, and without all the precautions taken 
in good hospitals to avoid infection. 
The mere existence of a visible building that bears the 
name of a lying-in asylum will further contribute to save 
some lives, for many a poor destitute woman will only know 
in this way where to apply in her trouble, while she may 
not be aware of the existence of some invisible society that 
distributes money to persons of her category. 
It may also be safely said that all operative help that may 
be needed will be found better in a lying-in asylum than in 
any other way that is accessible to the poor. Dr. Barker 2 
gives some statistics about the epidemic of puerperal fever 
in New York, in 1873, which show that the mortality from 
childbirth, rupture of the uterus, hemorrhage, placenta 
previa, and puerperal convulsions, in those parts of the city 
in which mainly the poor reside, was almost twice as great 
as in the wards in which the wealthy have their residences. 
The difference may be produced by other causes, but a 
potent factor is, without doubt, the difference in the skill 
with which the cases are treated, and in the care with which 
the patients are nursed. 
Lying-in hospitals are then for a great number of women 
- especially the unmarried, but also for many poor married 
women - most beneficial institutions, in which a friendly 
shelter, skilled assistance, and sufficient nursing may be 
found, all of which cannot be secured elsewhere. 
ON LYING-IN INSTITUTIONS. 
1 Stadfeldt, 1. c., p. 15. 
2 Barker, The Puerperal Diseases, p. 518. HENRY J. GARRIGUES. 
23 
But it is not only in this direct way that the institutions 
benefit the destitute ; they do indirectly the same for them 
and for all child-bearing women, by forming establishments 
for clinical teaching in midwifery. It is now admitted by 
all, that the study of any practical branch of medico-chirur- 
gical science must be built on clinical demonstration and 
observation, and in no branch is it more needed than in 
obstetrics, in which so often prompt interference averts or 
remedies great evils. Those who oppose lying-in hospitals 
pretend that the instruction can be given in what are called 
policlinics, that is to say, by treating patients at their 
homes; but this is a very poor substitute. A student has 
only a limited portion of time to devote to this study, and 
during this time he will see infinitely more in his attend- 
ance upon a regular lying-in hospital, in which a number of 
patients are assembled in one building, in which all except 
quite rare cases will probably occur while he studies there, 
and in which he always has a teacher at his side, whenever 
he is intrusted to do anything himself. It has been said that 
the instruction and the frequent vaginal examinations form- 
ing part of it are a chief source of mischief in lying-in 
hospitals, and there is no doubt about the truth of the 
statement, when special precautions are not taken to avoid 
infection ; but modern science has given us means of mak- 
ing examinations perfectly safe. Stadfeldt1 states that dur- 
ing the five years after the introduction of the prophylactic 
antiseptic treatment, when the mortality was brought down 
to less than one third of what it had been for twenty years, 
the number of pupils of both sexes was a half larger than 
before. 
When the lying-in asylum is to be a school in which ob- 
stetricians are practically formed, it must not be too small. 
It need not indeed have three or four thousand patients a 
year, as in Vienna, and in the Maternitd of Paris. So 
large institutions are difficult to manage, especially when 
we consider the necessity for constant vigilance <over the 
1 Stadfeldt, I. c., p. 14. 24 
ON LYING-IN INSTITUTIONS. 
whole personnel, in order to enforce antiseptic prophylaxis. 
On the other hand, institutions with a hundred confine- 
ments a year would be poor schools, if the number of pupils 
were not very limited. Regarded only as schools, they 
ought to be as large as possible, but their first and chief 
destination is to be hospitals in which patients have as fair 
a chance of recovery as possible; it is only in the second 
line that their indirect usefulness as schools can come into 
consideration. The right plan in large cities is, then, to 
•calculate them for as large a number of patients as can be 
supervised by one man, with proper assistance. The chief 
of the establishment must be able to control all his sub- 
ordinates, so that he may be personally sure of their obe- 
dience to the strict rules, in all their minute details, the 
importance of which has been shown by modern science 
and experience. It is of course impossible to indicate 
exactly what this maximum is, but for practical purposes 
it suffices to cite establishments like those of Copenhagen 
and Dresden, with 1,000 to 1,200 confinements a year, which 
work well. 
I started from the resolutions of the physicians assembled 
in congress at Brussels, in 1875, which led me to study the 
question of lying-in hospitals, and, having given here an 
outline of what I have found, I will revert to those resolu- 
tions, and give my opinion of them. 
1. "A thorough reform in the help afforded to lying-in 
women is of urgent necessity." Knowing how large the 
mortality is in many lying-in hospitals, and how much it 
can be diminished, everybody must heartily subscribe to 
this general remark. 
2. " The large lying-in hospitals ought to be abolished." 
This I can only agree with in a very qualified way. As I 
have said, I think the maximum limit ought to be the num- 
ber that can be sufficiently watched. So I think the very 
large establishments, with many thousand confinements a 
year, had- better be altered, and ought certainly not to be 
introduced into this country. But experience has shown that a thousand patients a year, or a little more, are manageable, 
and such a number is desirable for the purpose of instruct- 
ing students, and of furnishing material for scientific re- 
search. 
3. "Separate rooms" contribute much to prevent the 
spread of infectious diseases, and to procure that quiet 
which is so beneficial to lying-in women. If they can be 
had, so much the better. By following the antiseptic treat- 
ment strictly, they are less necessary ; but, at all events, 
wards ought to have only a small number of beds, so that 
they can be often kept empty, be disinfected, and aired. 
4. "A separate building for occasional use" is, of course, 
also a great advantage, but the possibility of having it will 
depend on the means at hand, and even without this, if 
there be rooms enough for isolation and disinfection* a 
lying-in hospital may do much good. 
5. " Confinements at the houses of the patients ought to 
be encouraged as much as possible, by assisting pregnant 
women." If they have homes that are not too miserable, 
and can secure sufficient assistance, this is a good plan, 
which has given good results at Paris ; but if the women 
are very poor, if they have filthy homes, if there are many 
children, a drunkard for a husband, or other disturbing in- 
fluences, I think that they have better chances in a good 
lying-in hospital. At all events, they must be controlled, 
so that they really stay at home, and do not go to other 
places, in which they may be more exposed than in a 
good hospital. 
6. " Confinement in the houses of midwives, under the 
supervision of the government." This supervision ought 
to be exercised by physicians, and all the same precautions 
taken against infection as in the hospital, and even then, 
experience in Copenhagen1 has shown that other private 
families are to be preferred. 
HENRY J. GARRIGUES. 
25 
1 Stadfeldt, 1. c., p. 7. 26 
ON LYING-IN INSTITUTIONS. 
II. 
After having thus discussed the value of lying-in hos- 
pitals in general, I will examine those of New York. 
There are two kinds of such institutions, - those that 
are in the hands of private associations, and those under 
the direction of public commissioners. To the first class be- 
long the Lying-in Asylum, the Infant Asylum, the Infirm- 
ary for Women and Children, and the Nursery and Child's 
Hospital ; to the second, the Charity Hospital, and the 
Emigrant Hospital. The former are all small, with an 
average number of yearly confinements not exceeding 150 ; 
the latter are comparatively large, with about 400 to 500 
confinements. 
A. Lying-in Asylum, 8$ Marion Street. 
This establishment has two different departments, viz.: 
a hospital, in which only respectable married women are 
admitted ; and an out-door department, through which pa- 
tients are treated at their homes, marriage not being re- 
quired. Both classes of patients are treated gratuitously. 
Out-door Patients. The register of this department 
shows for 24 years (1852-75) an average of patients 
per annum.1 They are attended by students, who only 
seek more skillful help when it is needed. They have a 
printed blank to fill out, containing the name, age, resi- 
dence, etc., with a column for remarks. The resident phy- 
sician tells me, however, that he does not think that the 
students see their patients more than once or twice after 
confinement. Thus the fate of the mothers is rarely regis- 
tered, and if so, it is often done in such vague terms as 
" Mother and child died three weeks after confinement," 
without giving any particulars, or cause of death. Conse- 
1 According to the report of 1876, the entire number of those who 
had received care at the Asylum since its foundation was 4,134, and 
at their residences, 15,222. quently the records of this part of the work of the institu- 
tion cannot be used for scientific purposes.1 
In-door Patients. The hospital is situated in the midst 
of a very populous part of the city, surrounded by crowded 
and filthy tenement-houses and high factories. Neverthe- 
less, it has a pretty good supply of air, not being contigu- 
ous to any other building, and having a large yard in the 
rear. Then the site is high, and the soil is said to be dry. 
The building itself was erected in 1830, and has adopted 
very few modern inventions. The parlor floor and base- 
ment are devoted to offices, kitchen, etc. The third story 
is not used except during epidemics. Thus the hospital 
proper is confined to the second floor. It is divided by a 
large, clear, well aired corridor, into two equal parts, each 
consisting of two large rooms, with six beds apiece for 
lying-in women, and separated by a smaller one, in which 
on one side of the building is found the delivery-bed, and 
and on the other a bed for the nurse. This floor is heated 
by two stoves, one in each of the small rooms. Besides, 
there are open fire-places in every one of the large rooms, 
which, however, the matron, Mrs. Hope, tells me are only 
used in exceptional cases, when, on suspicion of disease in 
a lying-in woman, it is particularly desirable to have the 
air changed as rapidly as possible. Artificial ventilation is 
only provided for by an opening into the flue, at some dis- 
tance from the ceiling of each of the four large rooms ; but, 
as the building has windows on all four sides, it is easy to 
let the air circulate through all parts of it. The bedsteads 
are of iron ; the bed-clothes consist of two straw mattresses, 
a straw pillow, arid quilts. The delivery-bed has the straw- 
sack protected by a large piece of sheet rubber, on which 
is placed an old piece of ingrain carpet corresponding with 
the buttocks. This is removed with all the blood, etc., 
immediately after delivery, while the patient remains ten or 
twelve hours on this bed before she is moved ' to another 
HENRY J. GARRIGUES. 
27 
1 It is by relying on this kind of registers that Le Fort has been 
led into error. 28 
ON LYING-IN INSTITUTIONS. 
in one of the four lying-in wards. The soiled linen is 
washed immediately, and the placentae are thrown into a 
water-closet in the basement. The resident physician, 
Dr. T. B. Stirling, told me that, as a rule, no antiseptics 
were used in the hospital. 
From the above it will appear that this house is kept very 
much in the style of an old-fashioned private house, and 
this is perhaps one of the reasons why it obtains such good 
results. Wash-stands communicating with the sewer, and 
dumb-waiters running from floor to floor, unless very intel- 
ligently managed, often do much harm. 
Another fact that goes far to explain the success of the 
treatment in this hospital is the remarkable cleanliness 
that prevails throughout. I have inspected every corner 
of the three stories in use, and I must confess that few 
private houses rival it in cleanliness, and none surpass it. 
So we may fairly exclude, in speaking of this institution, 
one of the sources of infection that are supposed to produce 
puerperal fever, namely, what has been called nosocomial 
miasma, i. e., deleterious emanations from the floor, the 
walls, the bed-clothes, and other articles found in a hos- 
pital. 
Then the asylum has very little connection with hospi- 
tals. It is not a school either for students or for nurses. 
Its inmates are not subjected to numerous examinations by 
persons coming from the dissecting-room or the wards of 
large hospitals containing cases of erysipelas, septicemia, 
caries, and gangrene. 
Another favorable feature of the house is that all the 
patients are married, which gives moral strength, and less- 
ens the number of primiparae. 
The asylum being in a wholesome condition, it is also an 
advantage for its patients that they are allowed to stay 
some time in the establishment before their confinement. 
In this way they 'become habituated to the surroundings, a 
circumstance much insisted upon by surgeons before un- 
dertaking any great operation ; the condition of a woman HENRY J. GARRIGUES. 
29 
delivered, even without any obstetric operation, is in many 
respects much like that of a patient upon whom an opera- 
tion has been performed. The woman not only gets phys- 
ically accustomed to the place in which she is to be deliv- 
ered, but she becomes acquainted with the persons who are 
to help her ; if she comes from a poor home, from one in 
which she had to endure fatigue, in which she received no 
care, and in which food was scarce and unsuitable, she 
soon feels the benefit of rest, comfort, and a strengthen- 
ing diet. 
Finally, the Lying-in Asylum in Marion Street has the 
great advantage of not being crowded. During the last 
twenty-one years the number of confinements has averaged 
but ninety-one a year, and when I went through the wards I 
found only one patient lying in bed. This circumstance 
gives plenty of room, plenty of air, makes it easier to keep 
everything clean, permits the isolation of sick women, and 
makes it possible when disease is .spreading to close the 
whole establishment. To this extremity the managers have 
been reduced several times. As far as I can ascertain it 
has been done four times since 1840. Whenever a few 
deaths have announced an endemic, the establishment has 
been shut up for four or six weeks, and thoroughly cleansed. 
As to the way in which the disease has spread, it must 
be observed that the same nurses have always taken care 
of the sick and the well patients ; and that antiseptics are 
not used in the hospital as a preventive.. If, when next an 
endemic threatens, the patients attacked be isolated each 
with her nurse, and if physician and matron disinfect their 
hands thoroughly with a strong solution of carbolic acid 
before examining other patients, it may, perhaps, be found 
that the disease will stop without the necessity of depriv- 
ing many poor women of the benefit of admission into the 
asylum. 
For the earlier years I have not been able to obtain suffi- 
cient data about the death-rate ; I will therefore only give 
them from the year 1856 : - 30 
ON LYING-IN INSTITUTIONS. 
Year ending in 
Spring. 
Women 
Confined. 
Deaths. 
Year ending in 
Spring. 
Women 
Confined. 
Deaths. 
1856 
135 
3 
1867 
IO4 
2 
1857 
107 
0 
1868 
60 
2 
1858 
137 
2 
1869 
73 
O 
1859 
78 
3 
1870 
8l 
O 
i860 
87 
0 
I87I 
76 
O 
l86l 
95 
1 
1872 
76 
I 
1862 
121 
2 
1873 
68 
3 
I863 
78 
0 
1874 
86 
1 
1864 
95 
0 
1875 
95 
0 
1865 
1866 
82 
94 
0 
1 
1876 
95 
0 
21 years, 1923 confinements, 21 deaths, or 1 in 91 = 1.1 per cent. 
B. New York Infant Asylum. 
This institution was opened at No. 24 Clinton Place, on 
November 23, 1871. As indicated by the name, it is 
chiefly intended to benefit children of the age of two years 
and under; but, at the same time, it gives shelter to preg- 
nant women, in order to prevent the maternal abandon- 
ment of homeless infants, and to diminish the moral dan- 
gers and personal sufferings to which homeless mothers 
are exposed J1 it is, consequently, to be considered among 
the lying-in hospitals of New York. 
The asylum occupies a private brick house, consisting of 
three stories and a basement, in a good quarter of the city. 
A pressing necessity being felt for more room, the neigh- 
boring building, No. 26, was rented from August, 1875, 
until May 1, 1876, passages being made through the wall 
separating the two houses. The buildings are in the com- 
mon style of good private dwellings. There is no ventila- 
tion except by windows, doors, and open fires. 
This institution differs from the Lying-in Asylum in 
Marion Street in being particularly destined for women who 
1 Act of Incorporation, § 2. HENRY J. GARRIGUES. 
31 
have gone astray, only very few married women being re- 
ceived. On the other hand the managers aim at a high 
moral tone in their wards. Prostitutes, for instance, are 
not admitted, and only exceptionally is a girl admitted for 
a second time. Consequently a great majority of the in- 
mates are primiparae, a fact which has been proved to be of 
the highest importance for the prognosis. 
Year. 
Primiparse. 
Pluriparae. 
1872 
27 
2 
1873 
45 
9 
1874 
60 
IS 
1875 
92 
671 
1876 
82 
19 
5 years . . 
306 
112 
A general lying-in hospital rarely, if ever, has so great a 
number of primiparae as this institution. We see, for in- 
stance, by the excellent reports of Winckel,2 that the Royal 
Lying-in Hospital in Dresden during years had 1,778 
primiparae and 1,599 pluriparae, or 1 : 0.9. In Copen- 
hagen, the proportion is about the same : 109 primiparae to 
every 100 pluriparae ;3 in Christiania4 there are 1,632 primi- 
parae to 1,327 pluriparae, or 1 : 0.8 ; in St. Petersburg,5 dur- 
ing 32 years, 14,683 primiparae, 24,506 pluriparae, or 1 : 1.6; 
in the Rotunda of Dublin,6 in 1870-1871, 747 primiparae 
and 1,501 pluriparae, that is to say, that there were not even 
1 The unusually great number of pluriparas in this year is partly due 
to the thirty-five "ambulance cases," nearly all of whom had borne 
children before. 
2 Winckel, Studien und Berichte, ii., 277. 
8 Stadfeldt, 1. c., p. 4. 
4 Faye and Vogt, 1. c., p. 73. 
6 Bidder and Sutugin, Aus der Gebdranstalt des Kaiserlichen Er- 
ziehungshauses, St. Petersburg, 1874, p. 6. 
6 Johnston's Reports in Dublin Journal of Medical Science, 
1871-1872. 32 
ON LYING-IN INSTITUTIONS. 
half as many primiparae as pluriparze, and we have seen that 
the proportion had been still less before that time. In the 
Infant Asylum there have been almost three times as 
many primiparae as pluriparae. 
The house No. 26 Clinton Place was particularly adapt- 
ed to the so called ambulance cases, that is to say, urgent 
cases of labor occurring among charity patients below Four- 
teenth Street. Since this house was given up on May 1, 
1876, such cases have been sent to the Charity Hospital, 
and only when the applicant has been in very pressing 
need of help has she been received into the Asylum in 
Clinton Place. 
Many patients are of respectable families, and are able 
to pay either $100 at once or $12 a week. The majority 
enter the institution early, from a fortnight to two months 
before confinement. Most of the patients stay with their 
children until these are weaned, but some are restored im- 
mediately to their families. A feature that must be very 
pleasant to the inmates, and which at the same time must 
yield valuable results, is the secrecy that surrounds the 
institution. Only the physician, the matron, and the nurse 
enter the wards, visitors being only admitted to the parlor. 
In this way a good deal of emotion is avoided, and all of us 
know what a puissant influence the moral condition of the 
parturient and the confined woman has on the course of 
her delivery and childbed. 
The institution has been fortunate as to mortality, only 
five mothers having died out of four hundred and eighteen 
who have been confined in the house since the opening of 
the Asylum, three of which deaths are asserted not to 
have occurred from puerperal fever. This good result is 
ascribed to the circumstance that there is no crowding in 
the house; that the sick are isolated ; that everything is 
kept clean ; and that carbolic acid is used for sprinkling 
the floors ; but the chief remedy here, as in Marion Street, 
has been the closure of the house, to which measure the 
managers were obliged to have recourse from the 8th to the 28th of December, 1875, and from May 29 to June 24, 
1876. They finally became convinced that the house was 
not fit for lying-in purposes, and the last confinement took 
place there on October 13, 1876. Since then the house 
has not been used for lying-in women, the majority of the 
pregnant women having been sent to the other establish- 
ment, which the society owns, on the corner of Tenth 
Avenue and Sixty-first Street, and a few to their country 
place at Flushing. 
Before passing from the consideration of the old place I 
want to convey my thanks to Drs. Burrall and Nicoll, who 
have been kind enough to answer my numerous questions 
regarding the institution. 
In the new place there have only been thirty-eight con- 
finements and no deaths, as I was told by the resident phy- 
sician, Dr. Angell: but as this is to be, in future, the lying- 
in hospital of the institution, I will briefly mention its 
principal features. The site is exquisite, on high rocky 
ground between the Hudson River and Central Park, so 
that plenty of air, and the pleasurable view of a beautiful 
landscape are secured. The principal building, a three- 
story brick house, stood on the ground when it was pur- 
chased in 1873. The following year a new brick building 
was constructed in contact with the other, and now a 
wooden pavilion is being constructed for lying-in women, 
which will have one large ward with ten beds and two small 
rooms with two each. The idea is, when there arises any 
suspicion of infection of the building, to tear it down, 
and build a new one. This is certainly a very good plan. 
Nowhere, perhaps, is the barrack-system more appropriate 
than in lying-in hospitals. But it must not be forgotten 
that this plan is rather expensive, and from a sanitary 
stand-point the system of separate rooms that are disin- 
fected after every confinement, and left empty for some 
days, is to be preferred. Good ventilation and a thorough 
use of the antiseptic treatment as a preventive of endemics, 
would probably go far tp rid the institution of the puerperal 
3 * 
HENRY J. GARRIGUES. 
33 34 
ON LYING-IN INSTITUTIONS. 
diseases that have troubled it hitherto, although they have 
ended in recovery. It seemed to me that the air in the 
wards was rather close, and it is a fault that all three ven- 
tilators in the new building are placed on the same side of 
the ward, and at no little distance from the ceiling. 
C. Infirmary for Women and Children. 
This institution was founded in 1853, but began first in 
1858 to take lying-in women. It is connected with the 
Medical College for Women, and is in some respects a gen- 
eral hospital, but it has only few surgical cases, and patients 
with contagious diseases, such as erysipelas, typhoid fever, 
etc., are not admitted. The hospital has thirty-five beds 
in all, thirteen of which are for obstetric cases. Until i860, 
the establishment was situated on the corner of Bleeker and 
Crosby streets, from which place it moved to 126 Second 
Avenue. Since 1874 it has occupied a beautiful three-story 
stone building, No. 5 Livingston Place, which forms the 
eastern side of Stuyvesant Square. In the rear, the whole 
block, one of the finest in the city, has open yards, so that 
the air has unobstructed access from two sides, whilst the 
building on the other two sides is contiguous with other 
houses. It was hot originally constructed for a hospital, 
but considerable improvements have been made, so that it 
seems to be very well adapted to its present purposes. Al- 
though, in general, it is not desirable to have lying-in wards 
in a general hospital, the circumstances here are quite dif- 
ferent from those in a large male hospital. As the patients 
and physicians are all women, it is not likely that there will 
be much operative surgery, and contagious internal diseases 
are excluded. There may, however, be some danger for the 
lying-in wards, e. g., from a strumous girl with caries, or 
from a woman with a sloughing carcinoma. 
The lying-in wards are in the upper story, and consist of 
a large room with eleven beds, a small one with two, and a 
confinement room with one. Occasionally other rooms are 
used in order to isolate sick patients. The patient is re- HENRY y. GARRIGUES. 
35 
moved immediately after confinement to the small ward, 
where she stays for a week, after which time she goes into 
the large ward for another week. 
The house is heated by steam-pipes, which are also used 
for ventilation. In the large ward there is a ventilating shaft 
with two very large openings, one near the floor, the other 
near the ceiling, through which a strong current passes 
from the room into the shafts. Besides, there is a large 
opening in the middle of the ceiling. Nevertheless, Dr. 
Cushier, the resident physician, told me that the air was not 
fresh enough when the windows were closed. Therefore, 
one of the windows in the large ward, and one on the stair- 
case are always open, day and night, summer and winter. 
Perhaps they go rather far in this respect, for it ought to be 
remembered that cold has a decidedly bad influence on 
lying-in women ; and though the rate of mortality, as we 
shall presently see, is very small, the doctor told me frankly 
that they were constantly troubled with puerperal diseases. 
I don't mean to say that the wards are too cold. The ther- 
mometer suspended in the middle of the room is kept be- 
tween 65° and 70°, but when the door stands open, as it 
usually does, there is established a draught between the two 
open windows which passes over half the ward. 
The bedsteads are of iron with wire spring bottoms. The 
mattresses are filled with straw, and only blankets are used 
for covering the patients, as in all the institutions, except 
that in Marion Street. Most of the patients are treated gra- 
tuitously ; those who can afford it, pay $16 for their con- 
finement. Some enter from a few days to several weeks 
before confinement, but quite as many do not present them- 
selves before that time. They stay two weeks, after con- 
finement, and longer, if they are sick, no transfers taking 
place to other hospitals. This institution, like that in Clin- 
ton Place, has a very great number of primiparae. The 
exact records kept during the last six years show more than 
twice as many of them as of pluriparae (407 : 196). The es- 
tablishment differs from all others of the same kind in this 36 
respect, that, to a certain extent, the patients are utilized as 
clinical material for the instruction of students. Three 
students live in the house, two for six months each, one for 
two or three months; and it is only after having had a 
certain number of confinements in the house that they are 
sent alone to cases of similar description among the out- 
door patients. There is quite a number of such patients, 
but they are soon lost sight of, as in most institutions of the 
kind, and consequently it is impossible to obtain available 
figures to compare the results reached in the hospital with 
those in the homes of the lying-in women. 
Antiseptics are used to a certain extent. A sheet dipped 
in a solution of carbolic acid is suspended before the door 
of the small room in which the newly confined are kept. 
The same article is used for washing the hands when any 
suspicious patient has been examined, and for disinfection 
of the soiled linen ; but a regular preventive antiseptic 
treatment is not in use. The placentae are thrown into the 
ash-barrel, rather an objectionable way of getting rid of 
them. 
The lying-in wards have only been closed once, namely, 
for two months in 1873, after an alarming epidemic. 
Through the kind cooperation of Dr. Cushier I am enabled 
to give the following statistics, tnost of which have never 
been published: - 
ON LYING-IN INSTITUTIONS. HENRY J. GARRIGUES. 
37 
Year. 
Women Confined. 
Deaths. 
Totals. 
Primiparae. 
Pluriparae. 
Deaths. 
Primiparae. 
Pluriparze. 
1858 
38 
0 
1859 
45 
I 
i860 
54 
I 
1861 
59 
2 
1862 
67 
O 
1863 
49 
0 
1864 
60 
O 
1865 
70 
JCannot 
1866 
92 
1867 
73 
■ be 
1868 
48 
1869 
72 
found. 
1870 
90 
63 
27 
0 
1871 
in 
71 
40 
0 
1872 
138 
IOI 
37 
4 
2 
2 
1873 
88 
71 
17 
1 
X 
O 
1874 
55 
23 
12 
1 
O 
I 
1875 
28 
16 
12 
0 
1876 
"3 
62 
5i 
2 
I 
2 
During the nineteen years, from 1858 to 1876, 1,350 
women have been confined. Leaving out the years for 
which the death-register cannot be found, we have 995 con- 
finements, with 12 deaths = 1.2 per cent., which, when we , 
consider that the hospital receives so great a number of pri- 
miparae, and that it has only been closed once in nineteen 
years, must be regarded as an excellent result, better than 
that obtained in the best lying-in hospitals in Europe. But 
in order not to draw any hasty conclusions, we must re- 
member that the whole number of patients during the nine- 
teen years has not much exceeded that of a single year in 
the institutions of Dublin, Dresden, or Copenhagen, and 
that, consequently, it is not likely there have been, even 
proportionally, so many bad cases among the patients 
treated. In a large number there will be a certain propor- 
tion of rare cases, but it is not said that the corresponding 
proportion is found in a small number. 
1 These words relate to deaths. 38 
ON L YING-IN INSTITUTIONS. 
D. Nursery and Child's Hospital. 
(a.) City Establishment. This institution was founded 
in 1854, but first became a lying-in hospital in 1865. It 
occupies a splendid three story and basement brick-house 
that stands alone on the southeast corner of Lexington 
Avenue and Fifty-first Street, and only communicates with 
the other buildings belonging to the same establishment by 
a corridor. It has sixty-four beds for pregnant and confined 
women, namely, a double ward with twenty-seven beds for 
those who are waiting; two wards, each with eight beds, 
for those confined within two weeks; and a large one 
with sixteen beds, in which the women remain four weeks 
before passing into the nursery. Finally, there are five 
small rooms, each with one bed, located in the contiguous 
building, and used for patients who are affected with 
contagious puerperal diseases, or who need more rest on 
account of their delicate condition than can be obtained 
in the wards. All these localities are spacious and well- 
lighted. The beds are quite luxurious. The bedsteads 
are of iron, with elastic wire bottoms, and the clothes 
consist of a horse-hair mattress, a pillow, and blankets. It 
must be a comfort for a poor sick woman to rest on this 
princely couch, but it is a question whether she does not 
occasionally pay for this comfort with disease or death. I 
believe that it is safer to have ticks filled with straw, and 
to burn the contents and wash the cover after every de- 
livery. 
Some of the patients are able to pay $25 for their con- 
finement, but most of them are admitted gratuitously. The 
great majority of them are unmarried, and 70 per cent, are 
primiparae, according to the statement of the resident phy- 
sician, Dr. Beckwith. They generally enter six weeks be- 
fore confinement. About four fifths leave the house four 
or six weeks after being confined, but some stay a whole 
year in the nursery. The sick are always taken care of in 
the house, and not removed to other hospitals. The pa- ZZ£7W?y J. GARRIGUES. 
39 
tients are not used for clinical purposes, no instruction 
being given in the house. 
Antiseptics (carbolic acid, salicylic acid, and chlorine) 
are only used for vaginal or intra-uterine injections in sick 
women, never as preventives. 
As for ventilation, there are a certain number of apertures 
in the walls near the ceiling, which lead into flues commu- 
nicating with the outside, but not with the heating ap- 
paratus. This system has proved altogether insufficient, 
and the excellent air found in the house is admitted through 
open windows, and through the doors communicating with 
the hall, which is covered with a cupola open at the sides. 
The rooms are heated by hot air, admitted through regis- 
ters in the wall near the floor, which plan is apt to give a 
dry atmosphere, and to incommode those whose beds are 
next to the openings. 
The soiled linen is immediately put into cans outside the 
windows, which are emptied every morning. The placentae 
are burnt in the laundry. 
The records show the following statistics : - 
• Year. 
Women Confined. 
Deaths. 
Per Cent. 
1865 
IO 
? 
1866 
91 
? 
1867 
91 
4 
4-4 
1868 
70 
2 
2.9 
1869 
94 
2 
2.1 
1870 
126 
5 
4-o 
. 1871 
147 
3 
2.0 
1872 
202 
22 
10.9 
1873 
232 
6 
2.6 
1874 
225 
8 
3-6 
1875 
146 
0 
0.0 
1876 
146 
8 
5-5 
12 years. 
1,580 
• 
If we leave out the first two years, during which the 
number of deaths is unknown, we have ten years with 1,479 40 
ON L YING-IN INSTITUTIONS. 
confinements and sixty deaths, i. e. 4.1 per cent. The year 
1872 showed a mortality of 10.9 per cent., and although'no 
death occurred in 1875, we see by the report of Dr. Judson 
that twice during the year (March 1, 1875, to March 1, 1876), 
owing to the development of puerperal peritonitis in the 
City Nursery, all pregnant women were transferred to the 
Country Branch Hospital on Staten Island,1 and the fol- 
lowing year has again a mortality of 8 in 146, or 5.4 per 
cent. Disastrous epidemics may occur as an exception 
anywhere. If we regard the year 1872, with a mortality 
of almost 11 per cent., as such an exception, and leave it 
out altogether, we have 1,277 confinements, with thirty-eight 
deaths, or 3 per cent. This is indeed below the average mor- 
tality of 3.4 per cent, in lying-in hospitals, as computed by 
Winckel,2 but it is almost three times larger than that of 
the Infants' Asylum and the Infirmary, which have a similar 
class of patients, and twice that found in the best Euro- 
pean lying-in hospitals. There is no reason why this splen- 
did hospital should not give the very best results obtainable 
in hospital practice, and it is of the utmost importance to 
try to find out why it fails. It appears from the medical 
report3 presented on the 1st of March, 1876, that new 
sewers have been constructed. The author of it, Dr. Beck- 
with, says that " the old ones, made of brick, were defec- 
tive in every respect. They were insufficient in size, with- 
out any inclination toward the street, leaky, and under- 
mined by rats which came from the main sewer. They 
were without traps, and were almost unprovided with air- 
pipes to the roof. The new ones are round cement pipes, 
capacious in size, water tight, and evenly inclined toward 
the main sewer. Each one is trapped at the point where it 
enters the building, so that air from the sewer cannot enter 
the cellar, and has two good-sized vertical air-pipes which 
end with protruding caps two feet above the level of the 
1 Twenty-second Annual Report, March i, 1876, p. 28. 
3 Winckel, 1. c., ii., pp. 297, 298. 
8 Report, 1876, p. 23. HENRY J. GARRIGUES. 
41 
roof. It is impossible for rats to enter them or undermine 
them. The whole institution is therefore now free from 
sewer odors, which formerly penetrated everywhere through 
the waste-pipes and hot air flues." This is, of course, a 
very gratifying improvement, but the mortality has not di- 
minished since the change, but, on the contrary, the year 
1876 has been the worst of all except 1872, which I have 
excluded as exceptional. I would, therefore, beg leave to 
call attention to the fact that the doctor, with a highly 
creditable zeal for scientific investigations, makes, as he 
told me, as many post-mortem examinations in the house 
as are permitted by the friends of the deceased patients. 
This circumstance, in connection with the other, that he 
limits himself in ordinary cases to mere common cleanli- 
ness by washing his hands with soap and water, and does 
not use antiseptics for disinfection, may perhaps account 
for some of the morbidity and mortality from which the in- 
stitution has suffered. That dead bodies, even of those who 
have not died of puerperal fever, contain a subtle poison 
that clings tenaciously to the hands, was first discovered by 
the English obstetricians (Storrs and others), and it will be 
remembered that Kennedy's interest in pathological anat- 
omy was suspected to be the cause of the high mortality 
during his mastership. But no one insisted more strongly 
or rather vehemently on this point than Semmelweis of 
Vienna ; at first he even went so far as to think that this 
was the only source of puerperal fever, but later so modi- 
fied his views that he defined puerperal fever as a fever 
brought about by the absorption of any putrescent animal 
matter.1 At the same time he thought he had found 
an absolutely sure preventive in the anointing of the hands 
with oil before touching such matter, in order to avoid 
its entrance into the pores of the skin, and in subsequently 
washing them not only with soap and water, but with a 
solution of chlorinated lime.2 His theory and practice 
were tested in the large lying-in hospital of Vienna, with 
1 Semmelweis, 1. c., p. 102. 2 Ibid., p. 269. 42 
very satisfactory results. He showed by the records of 
the hospital that, from its foundation in 1784 until the 
year 1823, the mortality was small; there had been twenty- 
five years in which it did not even reach 1 per cent., and 
4 per cent, had only occurred once during the whole period 
of forty years. This was before the study of pathological 
anatomy, that has surrounded the Vienna school with so 
well-merited a lustre, had been introduced. From that 
time until 1847 the mortality increased very much, even up 
to above 12 per cent.1 In 1840 the hospital was divided 
into two services. In the first, students were instructed ; 
in the second, midwives. All the patients that presented 
themselves on four days of the week going into the first 
service, and those who came on the intermediate three days 
being put in the second service, so that there was not the 
least difference in the nature of the cases on both sides. 
Nevertheless the service in which the students were in- 
structed had, during the years 1841-1846, 20,042 women 
confined, with 1,989 deaths, or 9.92 per cent., while the sec- 
ond service, in which midwives, who did not dissect and 
make autopsies, were trained, had 17,791 women confined 
with only 691 deaths, or 3.38 per cent.2 The difference is 
so striking, and the numbers are so large, that a mistake is 
scarcely possible. Towards the middle of the year 1847, 
Semmelweis introduced the use of chlorine as a disinfect- 
ant, and the result was a remarkable fall in the mortality : - 
ON LYING-IN INSTITUTIONS. 
1 L. c., p. 61-63. 
1 L. c., p. 3. According to Spath (Medizinische Jahrbiicher, 1864, 
Heft II. und III., p. 150), the separation of students and midwives 
took place at the end of April, 1839, and he counts the period till June, 
1847. Consequently, the numbers given by him are somewhat larger 
than those in the text, but the proportion between the two services 
is about the same. He states also (p. 147), that the transfer of sick 
patients into other hospitals, whose death is not counted here, took 
place on a greater scale from the clinic of the students than from that 
of the midwives, which makes the difference between the two still 
greater. 7. GARRIGUES. 
43 
Year. 
Confinements. 
Deaths. 
Per cent. 
1846 
4,oio 
459 
11.4 
1847 
3,490 
176 
5-o 
1848 
3,556 
45 
1.27 1 
He regards self-infection as so rare that not one out of a 
hundred lying-in women dies from it.2 Spath's table 3 shows, 
indeed, that even after this time the mortality sometimes 
ran high, e. g. in 1854, the first clinic 9.1 per cent., the sec- 
ond 6.2, but upon the whole it has become much smaller. 
Semmelweis's theory has been attacked by eminent ob- 
stetricians, such as Scanzoni, Carl Braun, and Hecker, but 
at the same time they adopted his precautions. On the 
other hand many great authorities defended his views, while 
they were new, such as Michaelis, Skoda, Chiari, Dietl, etc. 
Since that time the theory, divested of its exclusiveness, 
has been constantly gaining ground, and the practice of 
using disinfectants as a preventive of puerperal fever is the 
greatest improvement that has been made in our efforts to 
combat this terrible disease. If, therefore, the number of 
those who are taken sick, and those who die in the Nursery 
and Child's Hospital, should continue unsatisfactory in spite 
of the improvements in the sewerage, it would be wise to 
have the autopsies performed by another physician, not in 
charge of the lying-in women, and to adopt the preventive 
antiseptic treatment spoken of in detail in the first part of 
this paper. If even this does not bring down the mortality 
considerably, there is only one thing remains to be done; 
the entire separation of the departments for lying-in women 
and sick children, so as to make two different institutions of 
them. 
(£.) Country Branch. The Nursery and Child's Hospital 
has, since 1870, a branch hospital on Staten Island, about 
1 L. c., pp. 56, 61. 8 L. c., p. 145, table iii. 
2 L. c., p. in. 44 
ON LYING-IN INSTITUTIONS. 
four miles from West Brighton. It was at first only used 
for children, and is chiefly so yet, but has had a lying-in 
department since 1872. It is located on high ground in the 
interior of the island, and commands a beautiful view over 
country and bay toward the west. It consists of quite a 
number of small cottages, one of which serves at present 
for a lying-in asylum. On the ground floor, on either side 
of the hall, is a ward with six beds, and three rooms, each 
with one bed, for lying-in women. In each of the large 
rooms is an open fire-place and a stove. There is no ven- 
tilation except by doors and windows. In a low garret are 
twelve beds for pregnant women. This makes in all thirty 
beds in this pavilion, but they have 120 for women, and the 
lying-in department can be much extended. 
The bedsteads are like those in the city establishment, 
but have straw sacks instead of hair mattresses. 
The hospital has often had trouble from puerperal dis- 
eases, when either another building has been used or all 
the women have been sent to the city nursery. 
Antiseptics are little used; only the sick are syringed 
with carbolized water. 
The establishment has been used but so short a time for 
lying-in women, that its statistics have but a limited value. 
So far as they go, the mortality has been higher than one 
would expect in so new a hospital, and one of so small di- 
mensions, situated in the country, with such facilities for 
change of locality : - 
Year ending March i. 
Confinements. 
Deaths. 
1872 
6 
O 
1873 
? 
? 
1874 
34 
I 
1875 
82 
3 
1876 
144 
2 
1877 
99 
5 
5 years. 
365 
11, or 3 per cent. HENRY J. GARRIGUES. 
45 
E. Charity Hospital. 
After having examined the different lying-in institutions 
belonging to private societies, I will now state what I have 
been able to learn about the public establishments of the 
kind. The only one in which lying-in women from the 
city are now sheltered, is the Charity Hospital on Black- 
well's Island. In this large general hospital four wards in 
the upper story are used for this purpose. Two large wards, 
with thirty-five and thirty beds respectively, are reserved 
for pregnant women ; the confinements take place in two 
small rooms, each with one bed. After confinement, the 
woman is brought into the neighboring lying-in ward 
with thirty-four beds. If her temperature runs high, she is 
transferred to a smaller ward with twelve beds, the unoccu- 
pied ones of which are used for pregnant women. These 
are thought to be safe from infection, although this might 
some day prove a mistake, cases having been observed in 
which puerperal fever has appeared before confinement. 
Those who only admit infection through wounds, have 
explained such cases by an absorption through the ex- 
coriations so common in the vagina and around the os in 
pregnant women.1 Children suffer from exactly the same 
disease. Sometimes the mothers are perfectly well, as 
observed by Hecker,2 so that the infection in these cases 
probably takes place through the navel. But in other cases 
the children have been born dead, or sick, when we must 
suppose that the mothers were infected before their con- 
finement (Buhl3). Depaul4 describes the case of a pupil 
midwife in the Maternity Hospital of Paris, who, whilst 
washing the genitals of one of her patients suffering from a 
grave puerperal fever, felt instantly an unpleasant sensa- 
1 Lieven found ulcers or erosions in eighty-one of a hundred preg- 
nant women. Wiirzburger Medicinische Zeitschrift, 1869, v., p. 188. 
2 Hecker, 1. c., i., 224. 
8 Ibid., p. 255. 
4 Fievre Puerperale, p. 31. 46 
O2V LYING-IN INSTITUTIONS. 
tion, was taken sick the same evening, and died on the 
third day, " with all the symptoms of the most characteristic 
puerperal fever." The post-mortem examination corrobo- 
rated the diagnosis ; and Depaul adds that she was found to 
be a virgin, and not in a menstrual period. Thus, there 
can be no doubt of the possibility that the pregnant women, 
located in the same ward as those affected with puerperal 
fever, may be attacked, and even though they escape infec- 
tion it can scarcely be regarded as a good moral preparation 
for their own confinement to witness the sufferings and the 
death of their fellow patients. At the same time, this 
crowding of pregnant women into the ward in which the 
sick are treated, is not favorable for the latter, owing to the 
diminished quantity of fresh air, the noise, and so on. 
Finally, even the collection in the same room of patients 
suffering from puerperal fever is deleterious to them, since 
the atmosphere is easily loaded with dangerous effluvia, 
so that slight cases are made worse by the proximity of 
a severe case, or by the mere crowding. Such patients 
ought always to be isolated, if possible. 
When, on account of an endemic, it is thought necessary 
to have the wards fumigated and painted, the patients are 
sheltered in a pavilion containing three wards with thirty- 
six beds in all. 
The beds stand very near one another in the main build- 
ing ; in the large wards, not only on the sides of the room, 
but also in groups in the middle. The wards are heated by 
hot air. The ventilating apparatus consists of a number of 
square apertures in the ceiling, leading through the garret 
to the outer air. This system having proved utterly insuf- 
ficient to secure the necessary supply of fresh air, the win- 
dows have to be kept open day and night, summer and 
winter. 
All the patients are admitted gratuitously, and a large 
number of them are unmarried. Consequently there is 
here, as in all similar institutions, a large number of primi- 
parae. The time of admittance varies from a few days to HENRY y. GARRIGUES. 
47 
four months before labor; the patients leave generally 
from ten to fourteen days after confinement. When sick 
from puerperal diseases, they are not transferred to other 
departments, so that we get the correct number of deaths 
by the table presently to be given. The patients are not 
used for purposes of clinical instruction. 
There is a medical staff of eight, one for each of the de- 
partments of the hospital, and a chief-of-staff for the whole 
hospital. Each of the eight stays for two months in the 
lying-in service. They take care of the natural confine- 
ments, and apply to the chief for help in abnormal cases. 
They are very properly forbidden to have anything to do 
with the dead-house. It is also a useful precaution that the 
fever patients are treated by a separate physician and nurse, 
in order to avoid infection of the well lying-in patients. 
The placentae are removed with the dead bodies to the 
Potter's Field, on another island, and buried there. 
As to the important question of antiseptics, they are 
used more extensively here than in any other hospital. 
The physicians wash their hands with a solution of carbolic 
acid, before every examination ; the same is used for vag- 
inal injections three times a day in every confined woman, 
and oftener when the temperature runs high. As I wanted 
especially to know if these excellent measures had been 
adopted previous to the bad endemics from which the 
wards have suffered, I was told by Dr. Kitching, the chief 
of the medical staff, that although carbolic acid had always 
been used, its use had been much extended of late, and 
especially that disinfection before examining any patient 
had been introduced quite recently. The doctor added that 
he thought that the whole amount of puerperal disease was 
due to carelessness on the part of physicians and nurses, e.g. 
by using gum catheters and sponges that had been used in 
sick women. Nurses are probably not more conscientious 
here than elsewhere, and not knowing the results of scien- 
tific experiments and of practical applications thereof with 
regard to antiseptics, they are apt to look upon the orders 48 
ON LYING-IN INSTITUTIONS. 
given them on this head as quite superfluous ; and, as a 
good antiseptic treatment gives always more trouble, they 
are apt to deceive the physicians as much as possible. 
Bischoff1 of Basel relates how a bottle of carbolic acid was 
poured on the floor, before his tfisit, in order to make it 
appear that the injections he had ordered, had been given ; 
and I have myself seen a matron avoid the ablutions with 
carbolic acid as often as she could, in order to preserve the 
smoothness of the skin on her hands. If, therefore, all the 
benefit of which it is capable, is to be derived from the pre- 
ventive antiseptic treatment, a very effective supervision is 
needed. 
The lying-in wards having only been used for two and a, 
half years, the statistics comprise only a short period: - 
Year. 
Births.2 
Deaths. 
Per cent. 
1874 
389 
7 
1.8 
1875 
5°7 
9 
1.8 
1876 
485 
20 
4-i 
Total 
b38l 
36 
2.6 
Of these thirty-six deaths, only eleven are said to have 
been caused by puerperal fever, which would give a mor- 
tality of 0.8 per cent. ; but, as has been stated, we never 
can know the exact mortality from childbed-fever, either in 
hospitals or in the city, since, even if we suppose all con- 
cerned are willing to state the truth, their statement would 
still be utterly unreliable on account of the great difference 
in the views upon what is puerperal fever and what is not. 
Thus it is better to take what we can obtain more exactly, 
namely, the total number of deaths occurring within a short 
time after confinement. 
It will appear from the above sketch that this institution 
has several weak points : its connection with a general hos- 
1 Bischoff, 1. c., p. 8. 
1 It would be better to register the number of confined women. HENRY J GARRIGUES. 
49 
pital ; the overcrowded wards ; no means of isolating the 
sick ; no room for a regular change ; and deficient ventila- 
tion. It has been decided to separate the lying-in depart- 
ment from the hospital, and two pavilions, each with sixty 
beds, are being constructed for this service on the island. 
This will remedy one of the evils by separating the lying-in 
women from the cases in the wards of the general hos- 
pital ; but, as the number of beds is now ill, it will not 
give much greater facilities to have 120, and the accommo- 
dation will be even less if the pavilion with thirty-six beds 
(the Paralytic Hospital) be abandoned, which occasionally 
has been used for a change, while the wards in the hospital 
have been disinfected.1 
If the number of beds seems large as compared with the 
Dublin Rotunda, which has more than twice as many con- 
finements a year, and only 119 beds, six being reserved for 
patients with uterine disease, it must be remembered that 
here patients are only admitted when labor is imminent, 
while in the Charity Hospital of New York the women 
sometimes live in the house and occupy the beds of the 
wards as much as four months before confinement. Upon 
the whole it would be better to separate entirely the preg- 
nant from the parturient and lying-in women, and keep the 
latter fifteen days. Then one of the new pavilions with 
sixty beds would be a suitable accommodation. 
1 Before the month of June, 1874, the charity lying-in women were 
treated in Bellevue Hospital. Dr. Lusk has informed me that up to 
1873 the records were very defective. Of the following year and a 
half he has given a very detailed and interesting account in two pa- 
pers, Clinical Report of the Lying-in Service at Bellevue Hospital for 
the Year 1873 {Hew York Medical Journal, August, 1874), and 
The Genesis of an Epidemic of Puerperal Fever {American Jour- 
nal of Obstetrics, vol. viii., No. 3, November 1875). In 1873 there 
were 449 patients, 209 of whom were primiparae, and 25 deaths, or 5.6 
per cent. From January 1 till June 11, 1874, the number of confined 
was 166, of which 31 died, or 18.7 per cent. Then it was deemed 
necessary to leave this hospital. 50 
ON L YING-IN INSTITUTIONS. 
F. State Emigrant Hospital on Ward's Island. 
This is a general hospital, founded in 1847. It occupies 
a splendid brick building, erected in 1864, which is com- 
posed of five pavilions united by large corridors. * In each 
pavilion are two large, high, airy, and well-lighted wards, 
one above the other. The obstetrical department has two 
wards on the lower floor, each with twenty-four beds for 
lying-in women, another large ward with twenty beds for 
pregnant women, and a small confinement room with two 
beds. The two wards are used alternately for a month 
each. A few hours after confinement the patient is 
brought into one of the beds of the large wards. There 
are no rooms for isolation, but a woman attacked with puer- 
peral fever is removed to another building. The wards are 
heated by steam, circulating in iron pipes, and by hot air 
introduced through traps in the middle of the room, near 
the floor. In summer time fresh air enters in this way. 
The vitiated air is drawn out through ventilators near the 
ceiling, which open into shafts connected with the heating 
apparatus. The women lie on sacks filled with straw, which 
is renewed when it is thought proper to do so. 
The patients are exclusively poor immigrants, and are 
treated gratuitously. They are often admitted early, and 
stay a month or six weeks after confinement. They are not 
utilized for clinical purposes. The physician-in-chief, Dr. 
Ford, says that the number of primiparae and pluriparae is 
about equal. 
Antiseptics are not used except for lotions and vaginal 
injections in sick women. The placentae are thrown into 
the river. 
I regret that it is not possible to get the statistics of this 
institution for the thirty years it has been in use. Before 
1852 there are no reports. For the years 1853-1867 they 
exist in such varying forms that they cannot be used for 
illustrating the death-rate, but some traits are of interest. 
Thus we learn that prior to March, 1853, the women were HENRY J. GARRIGUES. 
51 
confined in the large hospital building, and were at that 
period transferred to separate buildings. During the years 
1852 to 1854 the hospital suffered a good deal from puer- 
peral fever : - 
In 1852, 574 women were admitted inclusive of "some 
immediately after delivery," 523 births1 took place, 124 
cases of puerperal fever occurred, and 68 women died. 
In 1853, 712 admitted, 644 births, 49 cases of puerperal 
fever, " under which head are included metritis, phlebitis, 
and peritonitis ; " 44 died. 
In 1854, 894 admitted, 701 births, 35 deaths, among 
which were 19 from puerperal fever. For the three follow- 
ing years the mortality among lying-in women is not indi- 
cated. After that time there occurred only sporadic cases, 
as far as can be seen, but for two years (1863-1864) infor- 
mation about the mortality is again wanting. Only since 
1868 do the reports give full details as follows : - 
Year. 
Women con- 
fined. 
Admittances 
immediately 
after Confine- 
ment. 
Total. 
Deaths from 
all causes. 
Per cent. 
1868 
594 
59 
653 
29 
4-4 
1869 
479 
63 
542 
12 
2.2 
1870 
47i 
35 
506 
6 
1.2 
1871 
379 
33 
412 
IO 
2.4 
I872 
389 
94 
483 
18 
3-7 
1873 
380 
73 
453 
16 
3-5 
1874 
283 
23 
306 
I 
o-3 
1875 
214 
14 
228 
5 
2.2 
1876 
170 
13 
183 
2 
1.1 
9 years 
3,359 
407 
3,766 
99 
2-9 
It would not be fair to take the number of confinements 
only as a basis, as evidently the 407 brought immediately 
after confinement have contributed their part to the deaths. 
On the other hand, when we class them with the confined, 
1 The still-born not being counted, this does not indicate the num- 
ber of confined women. 52 
ON L YING-IN INSTITUTIONS. 
we favor the institution a little, since probably some of the 
immigrants who are delivered outside die during labor, and 
would have done so if they had been brought to the hospi- 
tal, but this number would not make any material difference 
in the total death-rate. When the mortality seems pretty 
high it must be borne in mind that the patients are all of 
a most pitiable class. Destitute and strangers in the large 
city, their moral force must oftentimes be as much pros- 
trated as their physical, when they feel the pangs of labor, 
and do not know where to apply for assistance; and when 
they get the information, they are transported in labor, or 
immediately after confinement, from a ship or from an abode 
in the city, perhaps through wind and cold, to a far off 
island. It is also an unfavorable circumstance that the 
lying-in asylum is part of a general hospital; in this respect 
the pavilion system does not seem to make any great differ- 
ence. The Lariboisi£re hospital; in Paris, which is built on 
this plan, and is one of the most luxurious in the world, has 
an uncommonly high mortality in its lying-in wards. But 
this unfavorable connection is offset by great advantages, 
such as an open situation, good ventilation, and a frequent 
change of wards. The results obtained might perhaps be 
improved by the adoption of the preventive antiseptic treat- 
ment. 
The following table shows the statistics for all the lying- 
in hospitals in New York, as far as I have been able to ob- 
tain them : - HENRY J. GARRIGUES. 
53 
Women 
con- 
fined. 
Deaths. 
Per 
cent. 
Primi- 
parae. 
Pluri- 
parse. 
Number of Beds. 
For 
Lying- 
in. 
For 
Preg- 
nant. 
Total. 
I. Lying-in Asylum. 
1856-1876 (21 
years) ; only 
married . . . 
1,923 
21 
1.1 
24 
II. Infant Asylum, 
.1872-1876 (5 
years) . . . 
418 
5 
1.2 
306 
112 
not 
fixed. 
III. Infirmary for 
Women and 
Children, 14 
years .... 
995 
12 
1.2 
1870-1876 (7 
years) . . . 
623 
8 
1'3 
407 
196 
- 
13 
IV. Nursery and 
Child's Hospital 
a. City, 1867-1876 
(10 years) 
L479 
60 
4-1 
37 
27 
64 
b. Country, 
1872 and 
1874-1877 (5 
years) . . . 
365 
11 
3-o 
18 
12 
30 
V. Charity Hospi- 
tal 1874-1876 
(2| years) . . 
1,381 
36 
2.6 
46 
65 
ill 
VI. Emigrant Hos- 
pital 1868-1876 
(9 years). . • 
3,766 
99 
2.9 
- 
- 
48 
20 
68 
It would be interesting to compare these numbers with 
those indicating the total mortality in childbed in the city 
outside the hospitals, but they are still more difficult to ob- 
tain here than in most other places. Nevertheless, Dr. W. 
T. Lusk 1 has collected valuable statistics, which, connected 
with the data contained in the foregoing pages, may serve 
to give us a fair estimate of the proportionate death-rate. 
Mortality in Childbed in New York Outside the Hospitals. 
As the registration of births in New York is so defective, 
that the number obtained from the Bureau of Vital Statis- 
1 Lusk, " On the Nature, Origin, and Prevention of Puerperal 
Fever." Transactions of the International Medical Congress, in 
Philadelphia, September, 1876, Philadelphia, 1877. 54 
ON LYING-IN INSTITU7I0NS. 
tics would be much too small, Dr. Lusk has tried to get it in 
an indirect way. Statistics for Boston and London show- 
ing a yearly increase by birth of thirty per thousand of the 
population, he has assumed this as a standard, but in order 
to be sure not to estimate the number of births at too low a 
rate, he has even supposed the yearly increase by birth in 
New York to be thirty-three per thousand. The census 
for 1870 gives to the city a population of 942,292. The 
average annual increase from i860 to 1870 was 15,000. He 
has taken the same number as the probable average in- 
crease since 1870. The inaccuracy in this calculation is 
not considerable enough to affect materially the propor- 
tions. His researches embrace the nine years from 1867 
to 1875. He has not been able to go further back because 
the certificates of death before that period are so defective 
that nothing can be based upon them. In the way indi- 
cated he comes to the result that the number of births 
during the named nine years may be roughly set down as 
284,000. 
The number of deaths is taken from the certificates, and, 
as shown in the first part of this paper, is consequently too 
small. From all causes during pregnancy, confinement, and 
the puerperal state, it reached 3,342. Of these 1,947 were 
due to metria, and 1,395 to other causes. Under pregnancy 
are given deaths in which pregnancy existed, and probably 
contributed to the result. The whole number under this 
heading, thirty-one in nine years, is so small that it cannot 
materially impair the result. 
Although the author has estimated the number of births 
rather liberally, and although, on the other hand, the number 
of deaths, here as everywhere, is too small, he comes to the 
conclusion that, " the total number of deaths to the entire 
number of confinements is in the proportion of one to 
eighty-five." 
Of the 3,342 deaths, 420 occurred in hospitals, and con- 
sequently 2,922 in the city, outside the hospitals. To these 
we know that a considerable number has to be added, pre- HENRY J. GARRIGUES. 
55 
senting not only deaths due to childbed which have been 
registered otherwise, but many due to causes unconnected 
with childbed, though occurring during the lying-in times, 
a class of patients that has been counted in making up the 
death-rate in the hospitals, and that never will appear to the 
same extent in the death certificates from private practition- 
ers. But this is disputable ground, and we had better 
leave it altogether. We can do without it. We will still 
find an enormous mortality in the city outside the hos- 
pitals. 
If we simply deduct the deaths that occurred in hospitals 
the death-rate in the city would be 2,922 in 284,000, or one 
in ninety-seven, but this fraction is evidently too small. 
We ought also to deduct the number of confinements hav- 
ing taken place in hospitals. Unfortunately we do not 
know this last number exactly, but we can come pretty near 
to it. Eirst, we will take from my tables the number of 
women who were confined in hospitals during any part of 
the nine years examined by Dr. Lusk: - 
Years. 
Women 
Confined. 
Lying-in Asylum ...... 
1867-1875 
719 
Infant Asylum 
1872-1875 
317 
Infirmary for Women and Children 
1867-1875 
703 
Nursery and Child's Hospital . 
1867-1875 
L333 
Charity Hospital 
1874-1875 
896 
Emigrant Hospital 
1868-1875 
3J89 
• 
7J57 
Next we will add 615, which took place at Bellevue Hos- 
pital during 1873 and the first half of 1874, when it ceased 
to be used for lying-in women. This gives 7,772. 
Finally, we must add the number of births that occurred 
in this hospital during the preceding six years, and in the 
Emigrant Hospital during 1867, and we shall not err much 
by supposing that there were on an average four hundred 
women confined a year in each place. This would give 56 
2,800 additional births to be deducted from the city's ac- 
count. A few have taken place in other hospitals, but we 
cannot ascertain their number, which will, at all events, be 
without any importance. 
Thus, from the number of 284,000 births we have to de- 
duct 10,572 which took place in hospitals. We find, then, 
that to the charge of the city outside the hospitals should 
be assigned 273,428 births, with 2,922 deaths, or about one 
in ninety-four, or almost 1.1 per cent., which is the same 
death-rate as in the Lying-in Asylum, and almost the same 
as in the Infirmary for Women and Children ; nay, it is even 
greater than that in the Dublin'Rotunda during the whole 
time (1757-1814), comprised in Le Fort's tables.1 We may, 
therefore, conclude that the mortality in childbed in New 
York, outside the hospitals, is such that there is not only 
no occasion to be afraid of them, but that it may even be 
warrantable to encourage hospital confinements among the 
poor. This is still more enforced by the statement of Dr. 
Lusk 2 that, " excluding cases confined in hospitals, nearly 
one thirtieth of all the deaths, and one twenty-fourth of 
the cases of metria, were reported by four practitioners. 
Ten practitioners out of 1,200 signed the death certificates 
of one fifteenth of the women dying from puerperal causes, 
and one tenth of the cases of metria." If, already under 
existing circumstances, it is safer for the destitute to be con- 
fined in the lying-in asylums than in the city, this will be 
much more so if proper attention be paid to the management 
of lying-in hospitals. If the old ones be improved as much 
as possible, and new ones constructed and managed on the 
ON LYING-IN INSTITUTIONS. 
1 Le Fort, 1. c., p. 21. In the Preston Retreat, a small lying-in hos- 
pital for reputable married women, in Philadelphia, with a yearly aver- 
age of one hundred labors, Dr. Wm. Goodell has treated 756 women, 
and only lost six, i. e., one in 126, or 0.8 per cent. ("On the means 
employed in the Preston Retreat for the prevention and treatment 
of puerperal diseases." Extracted from the American supplement to 
the Obstetrical Journal of Great Britain and Ireland, for July and 
August, 1874, pp. 3 and 12.) 
2 L. c., p. 26. HENRY J. GARRIGUES. 
57 
best plan taught by modern science and experience, espe- 
cially in regard to draining, capacity, ventilation, isolation, 
and antiseptic; prophylactic as well as curative, treatment, I 
think that we will soon see the mortality lessened consid- 
erably. In order to ascertain that fact, it is, however, of 
the greatest importance that statistics be properly kept 
both in and outside the hospitals. Only when the most 
accurate possible details are recorded for a long period, can 
we obtain a reliable result as to the mortality in lying-in 
asylums compared with city practice. 
CONCLUSIONS. 
This paper having become rather lengthy, it may, per- 
haps, not be superfluous briefly to sum up the conclusions 
arrived at. 
1. Lying-in hospitals with a number of yearly confine- 
ments not exceeding a thousand are not to be feared, when 
they are properly managed. 
2. Most of those in New York are in a satisfactory con- 
dition, although there is room for improvement in details. 
3. The adoption of a preventive antiseptic treatment is 
especially advisable. 
4. It would be desirable to have the medical schools 
brought in connection with a comparatively large lying-in 
hospital. 
5. Statistics being an indispensable source of informa- 
tion, it is to be hoped that henceforth more attention will 
be paid to the exact and clear recording of facts of this 
nature. 
POSTSCRIPT. 
This paper had already gone through the press when I 
received Grunewaldt's lecture on the subject,1 in which he 
gives the results obtained in St. Petersburg in small asy- 
1 O. von Griinewaldt: Kleine Gebarasyle oder grosse Gebdranstal- 
ten ? (Volkmann: Sammlung Klinischer Vortrdge, No. 123, Leip- 
zig, 1877.) 58 
ON LYING-IN INSTITUTIONS. 
lums. The first of these established in 1869. Since 
then their number has increased to twelve. Up to July 1, 
1877, 10,400 women had been confined in them gratui- 
tously, of which only 103 died in consequence of their child- 
birth and childbed, inclusive of those transferred to the hos- 
pitals, i. e. 0.99 per cent. These institutions have almost all 
four beds inclusive of the confinement bed, and can accom- 
modate one hundred and twenty patients a year. They 
are mostly established in hired houses and spread all over 
the city, especially in the remotest and poorest districts. A 
chief feature that goes far to explain the small mortality, is 
the circumstance that as soon as an infectious disease ap- 
pears, no more patients are received. The patient is trans- 
ferred to a hospital, unless she be the only one in the house, 
and the asylum is shut up and disinfected. Another im- 
portant fact is, that the chiefs of these asylums have the 
right to send any parturient woman in whom an operation 
is anticipated to one of the large lying-in hospitals, and 
even though they do not always make use of this right, the 
statistics show uncommonly few operations. The author, 
although evidently speaking with much satisfaction of this 
new kind of lying-in institutions, finishes his lecture by 
saying that the same principles might be followed with the 
same results in the largest lying-in institutions, and that 
the work in a school with a large material has greater ideal 
value, and benefits the whole world as far as it shares the 
results of scientific conquests.