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Bulletin of the Lying-in Hospital
The issue of the present number marks the inauguration of the tenth volume of the publication of this BULLETIN. Since its inception it has been the aim of the medical board of the hospital to include in its pages a record of the original and scientific work and activities of the members of the attending staff. Increasing interest in its contents is evident from the numerous abstracts and references to its articles in general medical literature.
By way of comment, on this occasion, it may be opportune to refer to the work of the Lying-In Hospital since it was started at the location of the present sub-station in the tenement district of lower New York, just twenty-five years ago. During the period from 1890 to 1893, the special work of this service was developed under the name of the "Midwifery Dispensary" and in 1893 amalgamated with the Society of the Lying-in Hospital. The name of "Midwifery Dispensary" was dropped and the Society assumed the responsibility of the work of the former. The history of the Lying-in Hospital up to that time had been one of inaction, it having been under the management of a board of governors who did little more than keep the funds of the Society invested. During the period from 1890 to 1915 there have been 92,517 confinements taken care of by the hospital and 5990 students instructed in practical obstetric procedures. The institution has likewise served as an incentive to the founding of similar hospitals in other cities and in this sense has greatly extended and uplifted the practice of obstetrics. In 1902 through the generosity of the late J. P. Morgan, Esq., the present building was dedicated to the work of the institution and the latter has continued in an uninterrupted and increasing volume since that time.
A function of every general hospital, which is as important as the care of its patients, is the prevention of illness or its recurrence. In a hospital devoted to maternity work this is a factor, but not so prominent a one, because normal labor is a more or less physiological process of which only aberrations assume a pathological significance. A better appreciation of obstetrics among the profession has led to the adoption of numerous prophylactic measures which will insure to the expectant mother a better
opportunity for safe delivery as regards both herself and her offspring. A modern hospital should, as already stated, take into consideration not only the immediate care of its patients but also provide to some extent for their antecedents and future care. As regards maternity hospitals but little has been done in this direction. Those women who are not in a position to pay for the services of a physician, should in justice to themselves apply for treatment in a maternity hospital much earlier than is usually the custom. If a woman, especially a primipara, presents herself soon after she realizes that she has become pregnant, very much can be done to obviate the numerous complications which often attend pregnancy. The importance of this so-called prenatal work is now quite generally recognized although few institutions have taken the proper steps to carry it on. Not only should the expectant mother be examined in the earlier months of pregnancy to determine the presence of abnormalities or whether she will prove a fit subject for normal labor, but such women should also be instructed in the hygiene of pregnancy, in the avoidance of all factors that will harm either themselves or their offspring. Such prenatal work means stronger and healthier children and mothers better able to bear them, it means a less number of abortions, it means a less number of cases of toxemia of pregnancy and other complicating conditions. Not only does it require earlier examinations of the patients than is usually the case but they must be followed up either by nurses detailed for this purpose or by requiring them to present themselves at regular intervals at the hospital. At the present time no reputable practitioner of medicine who takes obstetrical cases would consider that if he saw the patient at the sixth month, a single urinary examination would be sufficient until the time of her delivery. There is no reason why such, observations should not be extended to the hospital case and why women should not present themselves at least once a month for observation even if they are apparently normal at the time of the first examination. In cases where at the time of the first examination the urine shows evidences of abnormal ingredients, such women should be particularly instructed in the dangers attending these abnormal conditions. The instruction of the expectant mother might be carried out by the physician in the form of informal talks given to such women at stated intervals, although with the mixed foreign population that we have in New York City, this may prove a difficult matter. Classes for mothers have, however, been successfully conducted by a number of organizations with whom the hospital might work in conjunction if unable to carry out this part of such a program itself. A great deal of benefit can be secured by visits from regularly instructed nurses who would supply the human element that is so often lacking in the relations between the hospital and its patients. It is this lack which often drives the expectant mother to consult a midwife, for she believes, rightly or wrongly, that she can thus secure a greater personal interest in her case. Properly trained
nurses selected for their particular fitness for such work, can do more in a short time to teach the women of the poorer classes to select hospitals in preference to midwives than any other agent. A further development of this nursing system will again be considered later on.
It may also be opportune at this point to refer to maternity hospitals as substitute agencies for the midwife, a question which is becoming more acute day by day. Those who advocate the retention of the mid wife system can point with a certain degree of justice to the fact that today there is no efficient substitute for the work done by these women. To a certain extent this is true but where the demand is present the supply will naturally follow and if the women of the class who patronize the midwife can be shown that better obstetric care may be procured under other circumstances, they will quickly enough employ the same. One reason why the midwife is often selected to attend a woman in confinement is her proximity to the home of the patient. She can be readily reached for an engagement and likewise can be readily called at the time of labor. Although our hospital is ready to take patients from any part of the Greater City, its clientele is largely limited to the Borough of Manhattan below Forty-Second Street and it is in this district that our Out-patient Service finds its limits. Attention may be called to the fact that from the southern to the northern boundaries of this district is a distance of over four miles and from the East River to the Hudson, a distance of from one and one-half to two miles in its wider portions. The hospital draws patients from the most extreme boundaries of this district and when they are attended in their homes it means long distances to cover by both doctors and nurses. Many women however throughout this section are either unaware of its existence or unable to take the long trip to the hospital or the present sub-station for a personal examination. The service could be profitably increased and a great many worthy women reached if a more extensive system of substations was instituted. This could be done at a comparatively small expense if a method similar to that employed at present by the Pittsburgh Maternity Service is followed. To encourage early registration and examination of the patient and to avoid the expense of street car fare and the necessity to leave their family in case the patient is a multipara, eight sub-stations were established in different sections of that city by the Pittsburgh institution. On one day of the week a physician and a nurse are in attendance at each of these sub-stations. To obviate the large item of expense necessary for the payment of rent, various charitable institutions open their doors for these weekly clinics. The system has met with great success and can well be copied in our own case. There are a number of charitable institutions and social centers scattered all along the west side south of Forty-second Street down to the Battery and up on the East Side, the managers of which would undoubtedly grant the privilege of employing their quarters for the purpose referred to if such a system of clinics was organized.
Another factor in the success of the midwife is the belief on the part of the patient that such a woman serves the purpose of a nurse during the confinement. In the case of the better class of midwives this is not a fact, as such women make their calls just as an ordinary physician, but there are hundreds of women who take obstetric cases and reside in the home during the period, doing all the ordinary work of the household in addition in taking care of the mother. This is one of the greatest problems in the institution of an out-door maternity service among the poor and has been met in some degree in our institution by providing household assistance in such instances. The method might be extended to much wider limits by organizing a system of visiting nurses who can make the necessary postpartum visits, leaving the doctors on the staff to attend to the abnormalities and the increased number of labor cases which will occur with the extension of the hospital facilities. The question of visiting nurses for obstetrical cases constitutes one of the most essential demands of an outdoor maternity service and a move to furnish the same should be one of the highest forms of charitable endeavor.
It has been claimed that many women object to entering the hospital or being confined by the doctors on the out-door service for both personal and economic reasons. The former may be summed up in the lack of personal interest which is so prevalent among the poorer classes, in the retention of the instinct born abroad that a man must not attend a case of labor and in the timidity and aversion which many of the foreign born women display to being attended by strangers to their language and their customs. These are not insurmountable difficulties and we find that in most instances the objections can be readily overcome if such patients are properly approached. Of course in the case of a multipara with a family of children, the mother's presence in the home acts as a restraining influence and such women are less apt to come to the hospital during subsequent confinements unless it is absolutely necessary. They may be provided for in their homes, however, particularly if a proper nursing service is instituted in connection with the actual obstetric work. It has also been found that foreigners do not object to the attentions of a physician if they can be made to realize that such help will be extended. Among many races in our work we have found that the women will readily enough accept the attentions of our hospital doctors if the matter is brought to their attention and explained. The various social workers have done a great deal to overcome such prejudices and their efforts ought to be encouraged.
Another field of hospital endeavor in which this institution ought to take a material interest consists in providing people of moderate means with accommodations for their delivery. At the present time the facilities of this character in New York City are entirely inadequate and although the poor are provided with free beds and those in better circumstances with a sufficient number of private rooms at prices ranging from $25.00 upwards,
there is practically no provision made for those who can pay a fee of approximately ten dollars a week, to obtain proper hospital care and attention. It simply means that in many instances the wives of men earning in the neighborhood of twenty-five dollars a week are unable to secure proper attention, particularly for their first labors or in case operative interference is necessary, unless they are placed in the free ward. This results in a lessened respect for the medical services extended to them and brings them in a certain sense within the pauper class. This question has been fully discussed in a paper published in a recent number of the BULLETIN (Maternity Hospital Care of the Woman of Moderate Means. Vol. IX, No. 3, January, 1914). In arranging for a service of this character acknowledgment must be made that a fee of ten dollars per week does not reimburse the hospital for the necessary expenses connected with the care of these patients but, nevertheless, it must be regarded as a true form of real charity and in this light only.
Such in brief are a few thoughts that intrude themselves in a discussion on the activities of this institution for the next decade, when it is hoped that an editorial in a similar anniversary number ten years hence will be able to record substantial progress in the directions noted.
A REPORT OF ALL ABDOMINAL CESAREAN OPERATIONS PERFORMED IN THE SERVICE OF THE LYING-IN HOSPITAL.*
By ASA B. DAVIS, M.D., Attending Surgeon.
WE desire to bring before the Fellows and place upon the records of this Association a report of all the abdominal Cesarean sections done in one hospital by a limited number of surgeons acquiring their operative material from the same source. This work has extended over a period of a little more than twenty years. To be exact: from December 24th, 1893 to September 10th, 1914. By far the larger part of these operations have been done in the past ten years.
The Lying-in Hospital is now writing its sixty-second thousand histories of women attended in its Out-patient Department; its twenty-ninth thousand histories of patients attended in the hospital. Deducting some two thousand cases attended before any Cesarean sections were done and also the abortions, gynecological and the general cases, it is fair to state that this hospital has delivered something over eighty thousand women at or near the full term of their pregnancies during the time given above.
A search of its records shows that from this number of cases, five hundred and seventy-one deliveries have been by abdominal Cesarean *Read at the Annual Meeting of the American Association of Obstetricians and Gynecologists, September 14, 1914. Appears also in American Journal of Obstetrics.