II. MANAGEMENT. Construction, however, in a lying-in institution, holds only the second place to good management in determining whether the lying-in patients shall live or die. And without such management, no construction, however perfect, will avail. And the first elementary principle of good management is to have always one pavilion of four or eight beds, according as it is of one floor or of two, standing empty in rotation for purposes of thorough cleansing. A fortiori-one delivery pavilion on each floor is always to be vacant alternately. The pavilion to be in rotation unoccupied for the purposes of cleansing must necessarily be the whole pavilion, with all its sculleries and ward offices, since the process of cleansing is-turning out all the little furniture a lying-in ward ought ever to possess, bringing in lime-washers, possibly scrapers and painters, leaving doors and windows open all day, and even all night. Every reason for having each ordinary pavilion ward completely separate, and individually pavilionised, applies with tenfold force to the delivery ward. Each must be complete in itself, with all its appurtenances and bye-ward for extreme cases, as a little pavilion. There is no possibility for properly cleansing and lime-washing the delivery ward not in use, unless this be the case. One delivery ward, however spacious and well arranged constantly used, would be a centre of deplorable mischief for the whole institution. This makes two delivery wards for each floor of the institution indispensable, to be used alternately for the whole floor at given periods. N.B. Liverpool Workhouse with 25 lying-in beds, exclusive of delivery beds, has had an average of 500 deliveries a year for eleven years. A civil lying-in hospital in or near a large town is generally just as full as it is permitted to be. Five or six hundred deliveries or more a year might be reckoned upon; occasionally three or four deliveries a night. Sculleries will be always in use, day and night. All this renders it imperative that an inexorable rule should be made and kept to, viz. that every lying-in pavilion should be vacant in rotation, each delivery pavilion alternately, for thorough cleansing. 2. The second elementary principle of good management is to remove every case of illness arising in the institution, and every such case admitted into the institution, at once to an isolated sick ward or infirmary ward. This is must, not may. Though we should have no puerperal fever or peritonitis in a building of this make, yet unfortunately other institutions will send in (say) erysipelas or small-pox patients seized with labour. Sad experience tells that this unprincipled practice has often proved fatal to many other inmates of the lying-in institution, turning an institution into a hospital. Every sick case should therefore be completely isolated, in a separate sick ward, from the lying-in women. And if admitted before delivery, her delivery should take place in this separate ward. N.B. The nurse's dinner and meals may be prepared in the general kitchen and sent to her. The patient's arrowroot, gruel, &c., must be made, and her beef-tea warmed, in the sick or segregation' building, and all linen must be sent to the ward well aired. Is it desirable to connect the 'segregation' ward by any covered passage with the rest of the lying-in institution? There is much to be said for and against. The ward, it is to be hoped, will not often have to be used at all. But small-pox has appeared after labour. There might be danger in taking a patient from the institution to this ward through the open air, in all weathers, unprotected by any covered passage. On the other hand, when once the patient is in the ward, complete isolation is by far the best, for the sake of all the others. And there is by no means the same necessity for a passage as in the other parts of the institution where any night there may be three or four ordinary delivery cases to be conveyed through the passages. A covered ambulance for sick cases is not, however, a nice thing, though often suggested.1 1 The only difficulty is as to protecting the patient (a lying-in woman) during the transit in cold or wet weather; but perhaps some cover might be contrived for the bed or litter on which she is carried, which would be light, easily removable, and which could be exposed to the free action of the open air when not in use. 3. The first two may be called universal and essential principles of good management in every lying-in institution, large or small, however perfectly constructed. Here is a third, hardly less essential, wherever there is more than one bed to a ward, viz. to remove a lying-in woman three times during her stay in the institution. The average course of an ordinary case may be reckoned thus: Seven or eight hours in the delivery ward. Nine or ten days in the convalescent ward. The nearer wards to the delivery ward in use should always be made the wards for women immediately after delivery; the farther wards for the same women when removed for their convalescent stage. In a single-bed ward the woman may remain in her own ward from after her delivery till her discharge; that is, no further removal after her delivery is necessary. 4. Cases of extreme exhaustion after delivery, which are better out of the delivery ward yet cannot be moved many yards, should be carried in their beds to the bye-ward adjoining the delivery ward, till they are somewhat recovered. These must have a constant watcher by them. 5. In a lying-in institution about three times the quantity of linen and bedding for each patient is necessary of what is used at a general hospital. The day's and night's provision of linen is kept in each ward scullery, and in the scullery of each delivery ward in use. The linen-store in the store-room, and the bedding-store, need to be very complete and ample. The bedding, that is, the mattress and blankets, of any one bed in the delivery ward should not be used for more than three or four delivery cases in succession without undergoing some process of purification-and this quite independent of any accident, the mattress of course being protected by Macintosh sheeting. III. TRAINING SCHOOL FOR MIDWIVES. The few words which will here be added on the management of a midwifery training school are not at all to be understood as a manual for practical instruction, which it is quite impossible to introduce here, but as simply treating of the management, in so far as this determines some constructive arrangements as imperative, and others as to be avoided. No charity or institution, I believe, could possibly bear the expense of a single-bed ward, or even of a four-bed ward lying-in establishment, for a pretty constant succession of thirty-two patients, unless there were a training school. [Thirty-two single-bed wards, an administrator would say, would require sixteen nurses, independently of midwives!!] Even with a training school, the first year would be one of great difficulty, since all well managed training schools 'take in' pupils as much as possible at only two periods of the year, so as never to have the whole of the pupils fresh hands at once. But the first batch must necessarily be all fresh hands. A raw girl cannot be turned in to sit up with |