Is It Possible to Get Medical Records of Your Baby's Delivery From 1971?

Soc Hist Med. Author manuscript; available in PMC 2008 Aug 13.

Published in final edited course equally:

PMCID: PMC2515560

EMSID: UKMS2143

'Because of Poverty brought into Hospital: . . .'
A Casenote-Based Analysis of the Irresolute Office of the Edinburgh Royal Motherhood Hospital, 1850-1912

Alison Nuttall

^*Section of Economic and Social History, Schoolhouse of History and Classics, Academy of Edinburgh, William Robertson Building, 50 George Square, Edinburgh EH8 9JY, U.k.

Summary

Although the shift from a social to a medical part which occurred in nineteenth-century general hospitals has been explored, the occurrence of such a change in maternity hospitals has non been considered. Recent analyses of such institutions have examined particular aspects but, and thus give a somewhat static picture. This paper uses analysis of patient records (themselves an under-exploited resource) to explore the irresolute function of the Edinburgh Royal Motherhood Hospital from a provider of shelter during childbirth to the destitute to a source of skilled medical intendance. It concludes that, although the Hospital had adopted the outward features of a medical establishment by 1890, its casebooks suggest that its purpose only truly changed in the early twentieth century, and thus tin can perhaps exist more than accordingly linked with national anxiety regarding the wellness of babies and their mothers.

Keywords: Edinburgh, maternity hospitals, patients, personal health records, childbirth, casenotes, casebooks, maternal and child welfare

In 1912, Mrs Henry, a 36 twelvemonth-erstwhile mother of two, was '[b]ecause of poverty brought into Infirmary ...'.^one The married woman of a painter, and already delivered, she was admitted to the Edinburgh Royal Maternity Hospital (ERMH) non because she had adult a medical problem, only because the attention nurses considered her domestic circumstances were besides poor for a puerperal adult female and her baby. The house surgeon obviously felt this was unusual, yet 68 years previously, when the Infirmary was founded, almost all patients were admitted for social reasons rather than medical treatment. The aim of this newspaper is to examine the changing function of the ERMH from its foundation as a clemency in 1844 until the introduction of National Insurance in 1912, through analysis of its patient records.

Significant developments in the historiography surrounding motherhood hospitals take recently taken identify. Formerly, studies tended towards the narrowly institutional and medical, the effect of reliance on administrative records as sources.² Even so, by supplementing these with a wider range of archives, historians accept begun to explore the social implications of the establishment of maternity hospitals. Incorporation of the analysis of admission registers has enabled the infirmary-patient human relationship to be explored through the discrepancy between the alleged aims of the institution and its bodily practice.³ The addition of contemporary writing on midwifery and of account- and day-books to the repertoire has enabled the changing relationships between attendants, patients and benefactors in eighteenth-century maternity hospitals to be examined, not solely in terms of gender,⁴ only also in relation to medical professionalisation and the medical market place-place, and to the evolution of obstetrics equally an academic bailiwick.⁵

A more subtle interpretation of the apparent link between maternity hospitals and puerperal fever has likewise resulted, commencement to redeem their poor medical reputation.^half-dozen A medical narrative has similarly re-emerged from the use of oral history and local regime reports (again in combination with infirmary administration records) to examine the work of belatedly nineteenth- and early twentieth-century maternity hospitals. Still, their employ has inverse the nature of the narrative: the institution is no longer examined discretely, just is set at the centre of a wider picture, to be seen in relation both to the social and economic life of the local customs, and to changes in the nation's health.⁷

Withal, despite a deeper examination of themes in the evolution of motherhood hospitals, what is conveyed is a adequately static picture which, within whatsoever item hospital, fails to communicate the changes over time in its office. This contrasts with general hospitals, whose shift from a social to a therapeutic office has been explored, and closely linked with the development of a split nursing profession, the introduction of antisepsis, and the associated growth in surgery.⁸ Such a shift in function has not been reflected in any examination of a maternity infirmary. Farther, despite the widening range of sources, little use has been made of the potential contribution of personal health records to the history of their originating institution, except as a source of local colour.^ix

The aim of this paper is to examine that shift at the ERMH, using personal health records as the master source to reconstruct its changing purpose from its establishment in 1844 to the introduction of National Insurance in 1912. The paper is divided into three sections. The first contextualises the written report and its sources by describing the history of the ERMH until 1912; the second assesses the registers and casebooks used, whilst the 3rd explores the patients themselves. The paper concludes that, although the ERMH had adopted many of the outward features of a medical establishment (such equally an clarified regime and an increased use of instrumental intervention) by 1890, its patient records show that its purpose perhaps only truly changed in the early twentieth century, and thus can be more appropriately linked with increasing national feet and awareness of the wellness of babies and their mothers.

The Edinburgh Royal Motherhood Hospital, 1844-1912

The ERMH opened in 1844, replacing the Edinburgh General Lying-In Hospital which had been sold following the decease in 1839 of its owner, James Hamilton, Professor of Midwifery before James Young Simpson.¹⁰ The intention was that it would likewise provide relief for the poor and the 'ways for the practical study of the obstetric art'.^xi Fee-paying 'Pupils, Midwives, and House Surgeons' were essential for its financial survival, whilst senior staff embodied its dual charitable and educational role—all occupied honorary posts at the Hospital, but an increasing number taught at either the University or Extra-Landscape Medical Schools.

The charitable remit dominated the Hospital'due south early years. Information technology was managed by a grouping of mainly non-medical Ordinary Directors, to whom the Medical Board reported, and who employed a Matron to manage the House. Appeals for back up dwelt solely on 'the helplessness of poverty', and yielded donations from both individuals and Parochial Boards in Edinburgh and Leith.¹² Although the Professor of Midwifery 'and the other professional gentlemen composing the medical staff' were routinely thanked for their role in the Hospital, in early Annual Reports this occurred but in the final paragraph, with the implication that that role was small-scale.^thirteen

The Directors interpreted their charitable role widely. Unlike many other maternity institutions,¹⁴ the ERMH accustomed both married and un-married women, who were admitted as Indoor patients by the possession of a subscriber's ticket, by being an enrolled pauper, or privately: those already in labour were ever admitted.^fifteen The ERMH was not the only motherhood charity in Edinburgh (in 1870 there were some other four at least, rising to eight by 1903), but all other dispensaries provided attendance in the patient'south home only, reflecting the normal childbirth behaviour of the menstruum. Domiciliary deliveries also dominated at the ERMH, constituting most ii-thirds of the cases it treated prior to 1914. All the same, until the end of the nineteenth century, the Hospital was the only provider of in-patient maternity care in the city.

During the early 1860s, in that location were two pregnant developments in the Hospital. It ran into financial issues, and, not unconnected, there was a shift in the residue of power betwixt the Directors and doctors. After a promising start, subscription income offset levelled off past 1855, and so cruel in real terms.^sixteen The ERMH plainly remained feasible just every bit the issue of a loan from Simpson.¹⁷ The Hospital's financial difficulties continued until the mid-1870s, worsened past the need to repay the loan to Simpson's manor,^eighteen but the decision to spend the donations 'collected to perpetuate the retentiveness of Sir James Simpson' on custom-built premises at 79 Lauriston Place, which the ERMH occupied from 1879 to 1939, gave it a secure base of operations from which to expand.¹⁹ Subscription income rose, and from 1881 Almanac Reports enthused about the work of Auxiliary and Lady Collectors.

Peradventure resulting from the debt to Simpson, the doctors became more involved in the running of the Hospital after 1860, sometimes to the irritation of the Directors. Relations betwixt them and the Matron soured, amid accusations of dirty wards: at their first attempt to forcefulness her resignation in 1861, she was supported by her employers, the Directors, but in 1863 her divergence was negotiated to 'preclude any unpleasant collision between the Directors and the Medical Board' at the Almanac Full general Meeting.^twenty In a suspension from custom, the meeting at which a new Matron was appointed took place at 52 Queen Street, Simpson'south home. From 1863, too, doctors began to attend the Directors' meetings, and by 1864 both Simpson and John Moir (Consulting Medical Officer) were Ordinary Directors. However, within a fortnight of Simpson's death, the Directors asserted their right 'to elect to the vacancies which may occur in the Medical Lath and staff of the Hospital',²¹ and ramble changes in the early 1870s emphasised the separateness of the ERMH's medical and charitable managements by excluding the Professor, as a Medical Officeholder, from the Directors.²² Notwithstanding, Professor Alexander Simpson'south²³ plans to connect the Hospital more closely with both medical schools were slowly accepted during the 1880s,²⁴ and by the 1890s whatever antagonism had largely gone.

The importance of the Infirmary every bit 'a proper school for the instruction in Midwifery . . . to students and nurses' grew:²⁵ by the final quarter of the nineteenth century, it played a prominent part in the didactics of medical students from both Edinburgh University and the Extra-Mural Medical Schools. Its honorary medical staff expanded from 4 in 1870 to viii in 1906, all also involved in obstetric teaching. It benefited from the professionalisation of midwifery: in 1904 the ERMH was recognised equally a grooming institution past the Central Midwives' Board (England and Wales), and its Leith branch was established in 1907 specifically to provide more cases for midwives in training every bit required by the Board.²⁶

This summary of the early on history of the ERMH presents a picture of its apparent steady advance as a medical institution, if not from 1861, when its doctors first became actively involved, then from 1879: information technology remains to be seen whether this is borne out past its patient records. The post-obit section describes those records, and their assay.

The Birth Registers and Casebooks of the ERMH

The ERMH recorded its administrative activities privately in both Directors' and Medical Lath Minutes and publicly in Annual Reports. Detailed records of its patients were kept by the firm surgeons in its Casebooks, Indoor and Out, and in the Registers of Births. In the Casebooks are recorded patients' medical data, with additional nursing data for Outdoor patients from 1907.²⁷ The Births Registers contain patients' social information, and are the principal focus of this newspaper.

With both Infirmary funds and the possibility of maternal death (or absconding) in mind, the ERMH Rules and Bye-Laws required all patients to furnish the Infirmary Secretary with

correct information in reference to her age, place of birth, and parentage, . . . the diverse places in which she has resided. . . . If . . . married, she shall be required to give the name and residence of her husband, and . . . similar information regarding the places in which he has resided;—if unmarried, the name and residence of the kid's father, and whatsoever other information regarding him which may be required.²⁸

It is this information which appears in the Register of Births, although a smaller Births Register was introduced in 1877 and maintained by the Matron. The new Registers contain less information: most notably, patients were no longer asked directly if they were married, and the details of the baby'due south father were omitted if the child were illegitimate. However, the mother'south occupation was recorded in place of that of the father when she was unmarried, then marital status tin still be deduced. Information on the mother'south own family, such as her father's employment, and whether (and where) her parents still lived, was also no longer collected.

This paper is based on whole year analyses of all patient data from the Hospital from four discrete years, approximately xx years apart.²⁹ Although the Births Registers constitute an nigh continuous record from 1847, record-keeping in the Casebooks was less meticulous, and the years for study (1850, 1870, 1890 and 1912) were selected for the completeness of the information they contain, and their proximity to the decennial census, a source of boosted information on Outdoor patients in the three earlier years studied. 1912 was the concluding yr of Hospital records before the introduction of Maternity Benefit for the wives of insured persons under the new National Insurance Act began to alter the childbirth behaviour of its working-class patients. All the cases treated by the Hospital in each twelvemonth were recorded. Indoors, where data from Casebook and Birth Register records were linked, the Casebooks were used as the primary documents, and patients listed in them were identified in the Births Register by name (small variations in spelling and recognised abbreviations were allowed), age, and appointment of commitment. Only in 1890 was there an absolute correlation between the 2 records.^xxx In 1850, 21 patients appear only in the Births Annals, whilst in 1870 2 women who did and then were described as 'not pregnant' after a week's stay.³¹ In 1912, one of the iii excluded cases died undelivered, whilst two were admitted mail service-delivery.³² The data thus collected were subjected to minimal manipulation, classification and coding. When possible, actual numbers are used in the following account, with percentages used for comparisons.

How reliable was the evidence recorded in the Births Registers? The quoted passage from the Hospital Rules suggests that the answers resulted from direct questioning, reducing opportunities for deceit or misinterpretation. Withal, it is evident that not all inmates told the truth in all respects: in every year examined, one or 2 tried to deceive the Infirmary in respect of their married status, and were later detected.³³ In 1850, near all the unmarried women (153 of the 155 whose records were complete) claimed to be able to identify the baby's father, simply the men in question might non accept admitted their paternity. However, the real value of the Births Registers lies not in the individual entries, merely in the links that can be fabricated with the same patients' medical data, and therefore in the possibilities the ERMH material offers for studying the ii together. The following department uses the patients' social and wellness records from the four selected years as the primary source to reconstruct the changing purpose of the Infirmary, relating this to the business relationship of its development given in administrative documents.

Indoor and Outdoor Patients at the ERMH, 1850-1912

As a result of its provision of both in- and out-patient care, the ERMH effectively served 2 populations, who differed in more than their place of delivery. The main focus of this paper will be on the Indoor patients, the result of the richness of the sources, while the larger proportion of Outdoor patients, more than conventional in their determination to evangelize at home, serve as a comparing. The principal differences between the two populations were their historic period distribution, and the proportions of married and single. Changes in these bespeak the altering function of the ERMH over the 62 years of this study.

Given that obstetric problems tin can touch on whatsoever age from menarche to menopause, if the part of the Infirmary had been primarily medical from the beginning, 1 would look the average age of the patients to conform to the Scottish data on maternal age at delivery (collected in 1855 merely), and for Outdoor and Indoor patients to be similar in age distribution.³⁴ This is not the case. If the ages of all Outdoor patients in the iv years studied are contrasted with the 1855 data (Figure 1), information technology can exist seen that in 1850 they were younger, their height child-bearing age being 20-25 years in contrast to a peak at 25-thirty years in the national figures. However, in 1870 their age distribution blueprint conformed to that of the 1855 census figures, although at a lower level. Thus, whilst Outdoor acme changeable historic period was too 25-thirty years, just 24 per cent of 'dispensary' mothers fell into this category. Past 1890, 30 per cent did. Such closeness to the norm suggests that by so the 'dispensary' was delivering a typical population of parturient women. This trend was maintained in 1912, when 27 per cent of Outdoor patients were aged between 25 and 30.

The ages of ERMH outdoor patients, 1850-1912, compared with 1855 data collected from all mothers. Sources: ERMH Outdoor Casebooks, 1850, 1870, 1890, 1912; 1871 Census of Scotland, Table XIX, 'Number of Mothers at Each Quinquennial Age . . .'.

When the exercise was repeated for all Indoor patients, it was found that they were consistently younger than the national average. However, this was not merely the result of the loftier proportion of single inmates: married women who used the ERMH between 1850 and 1890 were besides younger than average, every bit shown in Effigy 2. Although by 1890 they conformed to the demography pattern, peaking at 25-xxx years, an excessive number were still younger than the norm.³⁵ But in 1912 did the historic period distribution of married patients arroyo the norm as represented in the census, with the implication that it was merely in the twentieth century that the function of the ERMH changed to get a source of medical intendance for all significant women, and not principally a provider of shelter for the poorest and youngest mothers.

The ages of ERMH indoor married patients, 1850-1912, compared with 1855 information collected on age at commitment. Sources: ERMH Indoor casebooks, 1850, 1870, 1890, 1912; 1871 Census of Scotland, Table XXII, 'Number of Married Women at Different Ages who bore . . .'.

Married women dominated the Outdoor Casebooks throughout. In 1850, 64 per cent were recorded every bit 'Mrs'; past 1912, 100 per cent of those in the 'main clinic' book, and 97 per cent of those in the Leith Students' External Casebook (hereafter SECB) were so entered, the convention in the Leith SECB of giving both the mother's proper noun and her married title ('Kate Lynch, Mrs Campbell'), suggesting that this was non but courtesy.³⁶ Indoors, the reverse was the case, and single patients predominated until the twentieth century. In 1850, 58 per cent of patients were single, and in 1870, 74 per cent. Still, by 1912, only 48 per cent were unmarried, and this pass up in the proportion of single in-patients, with its corresponding ascent in married in-patients, is a major indicator of a alter in the Hospital's role.

Despite their minority status for much of the catamenia nether consideration, this paper focuses on the changing experiences of married Indoor patients in the four years surveyed. During the nineteenth century, virtually all married women delivered amid their family, typically in their own habitation: to undergo infirmary delivery was then unusual it implies the being of a definite and identifiable motive for so doing. This newspaper suggests that such motives bespeak patients' expectations of the Hospital and therefore its likely part. In dissimilarity, the motives of single women must always be unclear. Their position in Scottish society became increasingly marginal every bit the national illegitimacy charge per unit vicious, whilst they remained equally vulnerable to obstetric bug as whatsoever other patient.³⁷

The information on the 93 married women who attended the ERMH in 1850 bear witness that its charitable role was dominant: nigh came for social reasons. Although one-half the population of Edinburgh in the 1850s were immigrants, they constituted three-quarters of the Indoor married patients, 82 living in the city at the time of their admission. A quarter were Irish, the wives of 'navigators' unable to return dwelling due to the famine.³⁸ Their presence highlights the accuracy of the Directors' claim that the Infirmary's clientele came from the poorest in social club, and from those who had no local family unit support to phone call on during labour and the puerperium. In contrast, one-half of the Outdoor patients traced were Edinburgh natives.

Evidence of patients' family groundwork further suggests that lack of family resources and back up contributed to their admission. Throughout the unabridged period studied, patients at the ERMH were almost uniformly poor in origin. Although rare examples such every bit Jane Grierson, a medico's girl who had an illegitimate child in May 1850, stand out, the majority of patients, married and single, were the daughters of labouring men, often, like Dr Grierson, already expressionless.³⁹ These women married men in similar occupations to their fathers', continuing to be poor and without resource.

In addition to lack of family back up, most half of the married in-patients gave a different address for their husband, whilst v did not know his whereabouts at all. Some were separated past the hubby'due south work: Alexander Mercer, a 'Hardware Merchant', was in 'Kelso, en route for Tranent'; four men were 'at bounding main'.⁴⁰ Three husbands were absent for other reasons: one was in Calton Prison,⁴¹ whilst two were themselves in-patients.⁴² The overwhelming impression is that married in-patients were prevented from having a conventional lying-in in their ain home past broken relationships, family mobility, sick-wellness and poverty, and that the Hospital met this need. The husbands of traced Outdoor patients had more than settled occupations, while three couples lived with other adults, giving them admission to additional domestic support. For instance, Philip and Margaret Clark, both Edinburgh-built-in, lived in Scott'south Entry with their 2 children, her sister (a firm retainer), and a lodger,⁴³ whilst Thomas and Margaret Clifford, from Ireland, lived in Blackfriar's Wynd with their son and her widowed female parent.⁴⁴

The domestic circumstances of the married in-patients resident in Edinburgh in 1850 suggest very strongly that their selection of the Hospital was based on their lack of family ties and support, an interpretation reinforced by the low take-up by Edinburgh-born women. It has been observed that using infirmary or dispensary intendance potentially gave poor women gratis access to the foremost obstetricians in the metropolis, but this does not explicate the conclusion to become an Indoor rather than an Outdoor patient, given that both could call on senior doctors for medical help.⁴⁵ Fears about childbirth may accept played a office in the determination to attend the Hospital, but the bear witness suggests a minor role for this compared to social circumstances.

11 married in-patients had no recorded Edinburgh connections and seem the grouping about probable to have come to the ERMH seeking obstetric help. Still, even here social need appears dominant. 5 women were non living with their husband, while but ii had sorry obstetric histories. Catherine Linch, a twoscore year-old Irish-born collier's wife from New Lanark, had borne ane kid and miscarried 9: she delivered a live male child afterwards a short labour.⁴⁶ Catherine Seymour, anile 26, from a Newcastle address, just born in Burton-on-Trent, had had three miscarriages earlier she delivered a stillborn girl in the Hospital. Nevertheless, Richard Seymour, printer, was recorded as living in Kingston-upon-Hull, and this separation surely contributed to his married woman'southward employ of the ERMH.⁴⁷

Obstetrically, in that location was trivial difference between the Indoor and Outdoor married populations. Using the labour classifications employed in the Casebooks, those Indoor patients living outside Edinburgh were least probable to evangelize normally (82 per cent).⁴⁸ This is, still, an anomaly, resulting from the ambiguous way information were recorded, rather than a reflection of any search for obstetric intendance. Indoor patients resident in Edinburgh were almost probable to deliver normally (92 per cent), there being a higher charge per unit of preternatural births among Outdoor patients. I instrumental delivery took identify amid the married Indoor patients, in dissimilarity to iii Outdoors. Once more, the circumstances combined social and medical needs, the mother beingness the primigravid married woman of Thomas Hutchison, himself a Royal Infirmary patient.⁴⁹ Chloroform was recorded as being used twice, both times Indoors. The combined medical and social data of married patients in 1850 overwhelmingly indicates that the Directors were correct to emphasise the Infirmary's charitable role: its medical role was minimal.

The troubles that the ERMH underwent during the 1860s, including closure due to puerperal fever in 1869, reduced the number of patients who attended in 1870, and only forty married women were admitted. Immigration was a less noticeable feature. However, 23 were born outside the Edinburgh area, with the implication that they lacked local family back up. Although the Births Register no longer recorded whether the woman's begetter was still living, entries show that half the women were separated from their husbands, sometimes through employment: William Reddy, for example, was the House Steward at Lisfallen House, Perthshire.^fifty The whereabouts of 4 husbands were unknown, the wife of i being admitted from the Canongate Poorhouse.⁵¹ As in 1850, those Outdoor patients traced announced to have had more stable lives: only one spouse had an occupation likely to pb to separation. In add-on, six families shared accommodation with other adults or their own older employed children, suggesting access to more domestic support.

In keeping with its continued charitable focus, obvious medical reasons for admission to the ERMH were rare: as in 1850, there was little obstetric difference between Indoor and Outdoor married patients. Labour was more likely to exist classified as normal Indoors (94 per cent), although this is largely the consequence of 20 Outdoor labours beingness unclassified, and a higher rate of recorded preternatural deliveries in the 'dispensary'. Equally in 1850, there was one death among married women. Three Edinburgh-born Indoor patients had crusade for anxiety, such every bit dues-partum haemorrhage or prematurity, as did a proportionate seven Outdoor cases. Mrs Stewart, born in the Canongate, and admitted in her fourth pregnancy, was 'artificially induced . . . & delivered past turning', which suggests she had a severely contracted pelvis.⁵² Notwithstanding, there was fiddling obstetric difference between those Edinburgh residents delivered in their own homes, and those delivered in the ERMH. Virtually were in-patients for social rather than medical reasons.

In dissimilarity to 1850, just three married women entered who had no Edinburgh connections. One, Mrs Mary Blackness, a 38 year-sometime watchmaker's wife from Marykirk, was admitted from Dalkeith Poorhouse, the result of the ERMH'south prior arrangements with local poorhouses.⁵³ Nine days later mother and son were sent back, farthermost illustrations of the argument that the married patients who used the Infirmary were principally the victims of social disruption and poverty that prevented them from delivering at home. However, the other ii women living outside Edinburgh had existent cause for anxiety, and appear to have sought admission for medical reasons. Both were expecting their quaternary kid, had no living children, and predictable problems at delivery. Mrs Boyle, 24, a labourer's married woman from Glasgow, had lost three previous children in infancy:⁵⁴ she delivered a live son on 29 April, but at belch on six May the baby was described as 'not expected to survive the twenty-four hour period'.⁵⁵ Mrs Airey, 28, an engineer's daughter, came 'from Penrith to be prematurely delivered in consequence of contracted pelvis'. Following induction she laboured for 'iii to four days', until 'Dr Keiller dilated Bone artificially, turned and extracted' a stillborn daughter.⁵⁶ These ii women, together with Mrs Stewart, are the only married patients it is possible to identify clearly every bit beingness in need of skilled obstetric help and using the Infirmary to access it. Despite the involvement of senior medical staff in these cases, the overall impression is that in 1870 the ERMH was still a identify of social rather than medical care, and that, for its inmates, 'hospital admission was only ane symptom of a more than fundamental social ailment'.⁵⁷

Between 1870 and 1890 in that location were considerable changes in the Infirmary. Routine medical involvement was ensured past senior individuals taking responsibility in rotation; an antiseptic regime was adopted in 1881. Its educational part expanded as Edinburgh's medical schools grew: in 1870, 27 medical students had attended cases, just 180 were recorded in 1890; the number of nurses in training doubled over the same menstruation. The 1891 appointment every bit Matron of Miss Edward, previously a Royal Infirmary staff nurse of 'cracking and varied Hospital feel',⁵⁸ further indicates the direction the ERMH wished to accept. Instrumental intervention in labour was deployed earlier, the result of the development of more effective forceps, and of an increasingly pro-active attitude among doctors,⁵⁹ and this was to the benefit of both mothers and babies. The casenotes signal that a longer rest later delivery was now encouraged, in keeping with the communication for the puerperium expressed in a series of public wellness lectures given in 1881.^sixty

Despite these organisational changes, there was petty alteration in the social circumstances of the Hospital'due south married in-patients, of whom in that location were 86 in 1890. 51 were non natives of Edinburgh or Leith, including six living outside the city, and ii with no recorded connection. The new Births Registers no longer incorporate information near the woman's own family, or a separate address for her husband. Still, the husband's occupation was still recorded, and for the starting time time there was a major difference in the domestic circumstances of women born within or outside the metropolis. Almost a third of spouses of not-natives were engaged in occupations where accommodating a domicile delivery might be difficult,⁶¹ in contrast to simply three of those married to Edinburgh-born women. As in earlier years, their wives were using Infirmary care to replace the family back up lost through distance or employment. In contrast, the husbands of families traced from the Outdoor Casebook had more settled employment, while three couples shared their homes with other adults: either a boarder, or their own employed children. Dissimilar many married women Indoors, Outdoor patients had piece of cake admission to adult and family unit support.

As in 1870, very few married in-patients had no recorded connection with Edinburgh, the women near likely to have an obstetric motive in attending the ERMH. Mrs MacLachlan, 27, born in and living in Linlithgow, came in her 6th pregnancy to exist induced prematurely for a known rickety pelvis: her son died.⁶² In contrast, Mrs Bell was an English language-born actor's wife, currently living in Dunfermline, who delivered without problems.⁶³

Although Indoor married patients remained atypical of the childbearing population as a whole, an early on indication of the shifting role of the Infirmary can exist seen in the growing number of local-born women clearly admitted on medical grounds. This is apparent when the caste of perceived maternal feet shown by Indoor and Outdoor local residents is compared in those cases where the mother and her 'friends' were witting of possible complications.⁶⁴ In 1890, 11 of the 80 Indoor married inmates resident in Edinburgh or Leith had reason for anxiety (xiv per cent), compared with only iii per cent of married Outdoor patients (17 out of 593). Six were referred to the Infirmary by an outside physician, the get-go fourth dimension this practise has been noted. Further prove of nascent alter in local understanding of the purpose of the Hospital tin can be seen when the Edinburgh-resident Indoor married patients are compared according to their place of nascency. Reasons for maternal feet were more than mutual among Edinburgh-born Indoor married patients (six instances amidst 35 women, 17 per cent), than amongst those born exterior Edinburgh merely now resident (five instances in 45 women, xi per cent). Such cases were markedly more common than among Outdoor patients (3 per cent).

Yet, the 'anxious' group was small, and most patients did not see the Infirmary every bit a medical resource. For example, when Mrs Moffat suffered uterine rupture and the attending doctors '[t]ried . . . to get her removal to hospital . . . neither she nor her relatives would permit it'.⁶⁵ There was no differentiation in treatment: more Outdoor patients had serious commitment problems, yet were nevertheless treated at home.⁶⁶ Hospital publicity material recognised this continuing suspicion, and, even when fund-raising for carve up accommodation for married admissions, stressed the care given to domiciliary cases.⁶⁷ Married women built-in outside the city, the larger sub-grouping of in-patient Edinburgh residents, persisted in seeking admission for social reasons. 16 were delivering their first babe (37 per cent), with the husbands of ten potentially employed away from home, but the women's good wellness indicates that they were using the Hospital every bit a substitute for the social support of their family.⁶⁸ Although past 1890 the ERMH had adopted many of the trappings of a general hospital, its patient records suggest that its function was unchanged, and that most patients still used information technology as a substitute for family support. But a small-scale group had begun to turn to it for obstetric assistance and care.

The ERMH connected to develop betwixt 1890 and 1912. All senior staff were associated with either the University or Extra-Landscape Medical Schools. Its midwifery training plan was canonical by the new Central Midwives' Board for England and Wales, and the numbers of such pupils increased. Nonetheless, its long-established method of teaching applied midwifery to medical students had been robustly criticised by ane of its ain assistant physicians, Robert Milne Murray, and by 1912 medical students attended indoors for a month, and and so spent 2 months in one of Edinburgh'due south many dispensaries, at present administratively linked to the ERMH.

In 1908 Milne Murray'southward widow similarly criticised the in-house care the Hospital gave, claiming that the food was poor, handling was both grudging and public, and therefore that patients were reluctant to attend.⁶⁹ The Directors responded by declaring their intention to address any problems and to expand the medical aspects of the Hospital.^lxx Mrs Milne Murray'southward criticisms illustrate the growing public interest in improving the childbirth experience of all poor women. Both local and national authorities shared her concern, although their primary focus was rather the survival and wellness of newborn infants: from 1907 the Hospital was required to notify the Edinburgh Public Health Department of all the births its staff attended, to brand time to come wellness surveillance possible. As a result of notification, in 1912 the Medical Officer of Health could report 6,700 live births in the city, of which 2,200 were attended by charities.⁷¹ The ERMH was a major player, providing virtually 2-thirds of charitable attendances. Indoors and Out, in 1912 the ERMH recorded 1,442 cases in Edinburgh lone.

The data from 1912 advise that the medical part of the Hospital was expanding. Information technology has already been shown that the ages of married inmates now conformed to the national data, and that the number of married women using the ERMH had increased to outnumber the single. Married patients were still as divided betwixt those who were Edinburgh-born and those who were non, merely, in contrast to earlier years, approximately a quarter of those who were born outside Edinburgh withal lived outside the area. This group suffered an extremely high proportion of obstetric issues. Social reasons for admission had declined markedly, with the married man's occupation condign a less decisive cistron. Merely eighteen of those men whose wives were born outside Edinburgh (11 per cent) had occupations where accommodating a confinement might have been difficult, but, in dissimilarity to 1890, thirteen of those whose wives were Edinburgh-built-in had similar occupations. In 1912, unlike the before years studied, there was scant evidence of social distress among married Indoor patients: for Mrs Henry to be admitted by reason of poverty alone was plainly anachronistic.

There was now differentiation in the handling of Indoor and Outdoor married patients. Among Edinburgh residents admitted to the Hospital, the intervention rate at commitment was 20 per cent; in the 'main dispensary' it was 3 per cent, whilst in Leith it was 2 per cent. Even more telling, no serious problems were tackled Outdoors, but the patients were transferred to hospital without whatever recorded objection, and no mother died at dwelling house. Maternal ill-health was recorded in simply four Outdoor cases. Overall, the Outdoor services were at present geared to treating well women in labour and the puerperium, and transferred to in-patient care those patients who did not meet this description.

The change in function of the ERMH is also seen in the increase in married in-patients who were resident outside Edinburgh, the keen bulk of whom at present had serious health problems. In 1912, at that place were 45 patients in this category, 14 per cent in dissimilarity to 7 per cent in 1890, when only ane of the six non-residents had an obvious medical reason for admission. In 1912, only five of the 45 had no recorded problems. Their data are very distinctive, and indicate the obstetric need of the women, and thus their presumed reason for admission. The intervention rate in this group was 71 per cent, compared with xx per cent among in-patients resident in Edinburgh. Chloroform was used in 29 per cent of their cases, compared with 5 per cent in the instance of other inmates, and less than ii per cent Outdoors. Unsurprisingly, reasons for maternal anxiety can be found in 60 per cent of these women, in dissimilarity to 8 per cent of other in-patients, and less than 4 per cent of Outdoor patients.

Despite the presence in this grouping of five women for whom the ERMH must take been their last promise of having a live child, more than a quarter were primiparae. However, in contrast to 1890, even these women appear to take sought access on medical grounds: only two delivered without problems. For example, three were eclamptic, and two suffered from contracted pelvis, Mrs Roberts being admitted from Linlithgow 'after labour had lasted for three days'.⁷² Mrs Murdoch of Kinlochleven suffered from chorea gravidarum and died the night after her admission.⁷³ Overall, a quarter of patients resident exterior Edinburgh died in the Hospital, when the maternal mortality rate among other in-patients was 3 per cent. Their perinatal mortality rate was 58 per cent, compared with 17.v per cent among Edinburgh residents Indoors, and approximately 4.5 per cent Outdoors.

The evidence of married patients' backgrounds as well suggests a widening social range of patients at the ERMH, compatible with its increasing medical part. Whilst the majority of spouses continued to come from 'the industrial class', 16 per cent were at present categorised as 'commercial'. 7 wives of clerks were admitted, all equally emergencies. For case, clerk's wife Mrs Gillespie of Morningside was described equally 'salubrious & athletic. . . .[P]erhaps overdoes (!) golf as a sport. . . .[A]lways jolly . . . leads a regular life'. She had engaged both her family physician and a 'trained nurse' for her solitude, only when she developed '[f]its associated with pregnancy', Dr Martin arranged her admission.⁷⁴ Her case non simply shows that illness was forcing those who would not usually have considered using the ERMH to do so (the event of increasing use of more intensive treatment), but also that it was becoming a resource for wellness professionals in Edinburgh and beyond.

Until the early twentieth century, the Hospital'due south purpose had been divers, not by the presence of the poor, simply by the almost complete absence of the obstetrically needy. By 1912, this had changed, and medical reasons for access had increased amid the married women in-patients. Comments from the casebooks as well advise that the Infirmary now had a reputation as a eye of expertise in Scotland to which general practitioners could refer difficult cases routinely. The ERMH had moved from providing shelter for married women unable to organise lying-in for themselves, to supplying a significant minority with necessary medical care that they could non provide independently.

Conclusions

The ERMH casebooks are a rich source, and provide clear prove of the Infirmary'due south changing function betwixt 1844 and 1912. They show that a shift from a social purpose to a medical role occurred in maternity hospitals, only as it had in general hospitals. Nonetheless, whereas in full general hospitals the shift was directly associated with the development of antisepsis, professional nursing and surgery, for the ERMH at least, it was non chronologically linked to advances in technology. Instead the change in function appears to have occurred 20 years after either the commencement of increased intervention, or the introduction of antisepsis: in 1890 the ERMH presented itself equally a medical establishment, simply its patients continued to perceive it every bit a place of shelter. This discrepancy had gone past 1912.

Clearly this raises the question of what did bring about the actual change in function at the ERMH, if information technology were not the direct consequence of improving technology. The new chronology suggested past the casebook data implies that the true development of its medical function should rather be linked with the changes in attitudes to kid wellness and maternity care which occurred in the early twentieth century. Ultimately these attitudes would find public expression in the published enquiry of the Co-operative Women's Guild, and in the introduction nationally of local maternity and child welfare schemes in the years following the Great War.⁷⁵ The change in the role of the ERMH from the first of the twentieth century perhaps suggests that it was making an early (and entirely charitably-funded) contribution to the expansion of motherhood care which would become and so of import in the inter-state of war menses, although clearly this is an area which would crave further research.

This paper has likewise sought to employ personal health records as the principal source for the history of the ERMH, and to requite them a greater role than merely a source of local colour. Their employ undoubtedly restores the importance of its patients to an institution, if not suggesting that their actions can shape its behaviour, at least showing the reality of its care. In improver, they reveal popular attitudes to childbirth, and its persistence every bit a social rather than a medical event, even in a metropolis famous for its medical associations. Withal, at the ERMH casebook data have provided much more than. They have suggested an alternative chronology for the development of the Hospital, at variance with any conclusions that might exist reached about the Hospital'south purpose based on its administrative history, the careers of its medical staff, or its location in a city with a long medical tradition and a big medical school.

Acknowledgements

The author would like to thank the Wellcome Trust for its generous back up; Dr Michael Barfoot, Lothian Wellness Services Archivist, for his invaluable archival noesis; Professor Roger Davidson for his patient guidance; the staffs of the Lothian Health Services Annal and Edinburgh Academy Special Collections for their assistance, and the 2006 Canadian Order for the History of Medicine Almanac Conference, to whom this article was presented in an early course, for their helpful comments.

This is an author-produced postprint version of an commodity published in 'Social History of Medicine'. The definitive version is bachelor online at http://shm.oxfordjournals.org/cgi/reprint/hkm042?ijkey=p06H7nntEwYzCZ&keytype=ref

Footnotes

¹Lothian Health Services Annal (LHSA), 1912 Indoor Casebook (ICB) [LHB3/16/3], case 28, Professor Halliday Croom'south quarter, Births Register entry (BR) 497 [LHB3/14/7]. Patients' surnames for the year 1912 have been anonymised.

²See, for example, Browne 1947; Young 1964; Rhodes 1977; Dow 1984; Dewhurst 1990; Farmar 1994. A rare exception to this approach, which examines British maternity hospitals as a whole, is Gunn in Poynter (ed.) 1964.

^threeQuiroga 1989.

⁴Versluysen in Roberts (ed.) 1981; Donnison 1988.

⁵Ross 1986; Croxson 2001; Schlumbohm 2001.

⁶DeLacy 1989; Cody 2004.

⁷Marks in Fildes et al. (eds) 1993; McCalman 1998.

^viiiPorter 1997, pp. 368-81; Rosenberg 1987, pp. 118-22; Rosner 1982, pp. 1-7.

⁹It could be argued that the exception is Nancy Dye'south detailed examination of the New York Midwifery Dispensary, which does analyse medical records to explore changing attitudes to childbirth and medical care among the immigrant poor. However, her work is focused on a dispensary, not a infirmary, and on irresolute approaches to childbirth among patients, not within an establishment (Dye 1987).

^xSir James Young Simpson Bt (1811-1870), Professor of Midwifery and the Diseases of Women and Children, University of Edinburgh, 1839-lxx.

¹¹ First Annual Report 1845, p. five.

¹² Outset Annual Report 1845, p. 8.

¹³ Beginning Almanac Report 1845, p. half dozen.

^fourteenDonnison 1988, p. 38; Dow 1984, p. 31; Young 1964, pp. seven, 53.

¹⁵LHSA, Directors' Minutes (DMERMH) [LHB3/i/2], 22 February 1862.

^xviSubscriptions and donations received in the ERMH's first year of operation had totalled £493 13s 10d (Showtime Almanac Report 1845, p. nine); past 1860 subscription income had fallen to £145 11s 10d. (Seventeenth Annual Report 1861, p. 8).

¹⁷ Fourteenth Annual Report 1858, p. five; LHSA, DMERMH [LHB3/1/2], two May 1856.

^xviiiLHSA, DMERMH [LHB3/ane/3], six March 1871.

^nineteenSimpson in Gibson et al. (eds) 1893, pp. 46-7.

²⁰LHSA, DMERMH [LHB3/1/two], 31 March 1863.

²¹LHSA, DMERMH [LHB3/one/iii], 18 May 1870.

²²LHSA, DMERMH [LHB3/one/3], 4 July, 10 November 1871.

²³Sir Alexander Russell Simpson (1835-1916), Professor of Midwifery and the Diseases of Women and Children, Academy of Edinburgh, 1870-1905.

²⁴LHSA, DMERMH [LHB3/1/3], 23 November 1878, 24 January 1879, xiv, 21 Apr 1884.

²⁵LHSA, 26th Annual Report (ARERMH) [LHB3/7/26] 1870, p. seven.

²⁶LHSA, DMERMH [LHB3/1/iv], 21 January 1907.

²⁷These are recorded in the Students' External Casebooks [LHB3/xviii/14-43].

²⁸ Rules and Bye-Laws n.d., 'Patients', Dominion i.

²⁹These analyses form the basis of the author's thesis (Nuttall 2003).

³⁰In 1850, delivery records constituted 92.8 per cent of patient records found; in 1870, 97.9 per cent, and in 1912, 99.iv per cent.

³¹Patients Ednie and Ferrier, admitted 2 March 1870 (LHSA, Births Register [LHB3/14/2], entries united nations-numbered).

³²Evidently considered butterfingers from entry in either Casebook or Register, these cases are recorded only in the final form of clinical record, the Special and Ordinary Casebooks (SOCB), which contain narrative accounts of unusual cases. [LHSA, LHB3/17/1-17].

³³For case, LHSA, 1912 ICB [LHB3/sixteen/3], Professor Halliday Croom's quarter, case 134, BR600 [LHB3/xiv/7].

³⁴Demography of Scotland 1871, Vol. 2, pp. lxiii-lxvii, especially Table XIX, 'Number of mothers at each quinquennial historic period who diameter children in 1855 . . . and the pct at each age'. The amount of information required was reduced in 1856, as local registrars were over-burdened (Sinclair 2000, p. 40). Still, these are the merely nineteenth-century British data on the age of mothers at delivery (Anderson (ed.) 1996, p. 300).

³⁵The census information showed that 19-22 per cent of married mothers were in the historic period range 20-25 years. At the ERMH in 1890, it was 31.v per cent. Further, only 2 per cent of married Scottish mothers were anile less than xx, simply at the ERMH, the figure was 5 per cent.

³⁶This was washed for 353 of the 474 presumed married patients. Even so, the culling mode, 'Kate Lynch or Campbell', used on 37 occasions, is less clear. A further 84 had just their married name entered, whilst an additional 17 had no title and have been considered to be unmarried.

³⁷Smout 1986, p. 173, Table vii: in 1861-5, 9.79 per cent of live births were illegitimate: past 1911-v, the figure was 7.21 per cent.

³⁸Thorburn 1851, pp. half dozen-vii, Table Xv, pp. forty-ane.

³⁹LHSA, 1850 ICB [LHB3/xvi/A], instance 2050, BR731 [LHB3/14/1].

⁴⁰LHSA, 1850 ICB [LHB3/16/A], instance 2197, BR863 [LHB3/14/1].

⁴¹LHSA, 1850 ICB [LHB3/16/A], case 2062, BR747 [LHB3/fourteen/1].

⁴²For example, LHSA, 1850 ICB [LHB3/xvi/A], case 2199, BR873 [LHB3/14/ane].

⁴³LHSA, 1850 Outdoor Casebook (OCB) [LHB3/18/2], case 3279; Edinburgh Census 1851, Volume 723, Enumeration Book 2.

⁴⁴LHSA, 1850 OCB [LHB3/18/two], case 3144; Edinburgh Census 1851, Volume 728, Enumeration Book five.

⁴⁵Quiroga 1989, pp. 44-6; Leavitt 1986, pp. 74-7.

⁴⁶LHSA, 1850 ICB [LHB3/sixteen/A], example 2167, BR841 [LHB3/14/i].

⁴⁷LHSA, 1850 ICB [LHB3/16/A], instance 2055, BR735 [LHB3/fourteen/1].

⁴⁸These were: 'normal'/'natural' (cephalic presentation, labour completed inside 24 hours); 'laborious' (cephalic presentation, labour in backlog of 24 hours), subdivided into 'lingering'/'tedious' (ending in a natural birth), and 'instrumental'; 'preternatural' (breech or trunk presentation); and 'complex' (complications on the part of either the female parent or child, including multiple pregnancy).

⁴⁹LHSA, 1850 ICB [LHB3/sixteen/A], instance 2024, BR686 [LHB3/14/1].

⁵⁰LHSA, 1870 ICB [LHB3/16/A], case 1706, BR-, admitted 31 May 1870, [LHB3/14/2].

⁵¹LHSA, 1870 ICB [LHB3/16/A], case 1637, BR-, admitted 25 Apr 1870, [LHB3/14/2].

⁵²LHSA, 1870 ICB [LHB3/16/A], case 1599, BR-, admitted 5 February 1870 [LHB3/14/2].

⁵³LHSA, 1870 ICB [LHB3/16/A], example 1720, BR-, admitted 3 August 1870, [LHB3/14/two].

⁵⁴She may too accept had social problems: her hubby's address is 'dashed', and not recorded.

⁵⁵LHSA, 1870 ICB [LHB3/sixteen/A], instance 1643, BR-, admitted 29 April 1870, [LHB3/14/ii].

⁵⁶LHSA, 1870 ICB [LHB3/16/A], case 1615, BR-, admitted 5 March 1870, [LHB3/14/ii].

⁵⁷Rosenberg 1987, p. 118.

⁵⁸LHSA, 47th ARERMH [LHB3/7/47], 1891, p. 7.

⁵⁹Nuttall 2006.

^lxEdinburgh Health Gild 1881, pp. 115-38.

⁶¹Eight were soldiers, 4 in domestic service, 2 were 'travellers', whilst one was an actor.

⁶²LHSA, 1890 ICB [LHB3/sixteen/2], Dr Berry Hart'southward quarter, example 38, BR64 [LHB3/14/4].

⁶³LHSA, 1890 ICB [LHB3/sixteen/2], Dr Halliday Croom'south quarter, case 35, BR218 [LHB3/14/four].

⁶⁴Typical complications included ante-partum haemorrhage, prematurity, cardiac disease, or eclampsia. The general change in approach to the management of labour which took place between 1870 and 1890 (Nuttall 2006) means that intervention at delivery cannot be used as a reliable indicator of increased medical demand.

⁶⁵LHSA, 1890 OCB [LHB3/18/5], Dr Underhill's quarter, instance 34; 1890 SOCB [LHB3/17/6] p. 76.

⁶⁶These cases besides included two abdominal operations, and a placenta praevia; difficult cases handled Indoors included ii placental presentations, and one uterine rupture.

⁶⁷LHSA, 48th ARERMH [LHB3/7/48], 1892, p. ix.

⁶⁸Only xi of those built-in in Edinburgh were primiparae (31 per cent), iii of whose husbands were likely to exist absent.

⁶⁹Murray 1908 [LHB3/26/vi].

⁷⁰Middleton and Robertson 1908 [LHB3/26/7].

⁷¹Williamson 1913, pp. 17-18.

⁷²LHSA, 1912 ICB [LHB3/16/iii], Professor Halliday Croom'southward quarter, case 29, BR485 [LHB3/fourteen/seven]; 1912 SOCB [LHB3/17/thirteen], pp. 210-eleven.

⁷³LHSA, 1912 ICB [LHB3/16/iii], Dr Haultain's quarter, case 49, BR122 [LHB3/xiv/vii]; 1912 SOCB [LHB3/17/xiii], pp. 42-4.

⁷⁴LHSA, 1912 ICB [LHB3/16/iii], Dr Haultain's quarter, case 117, BR485 [LHB3/14/7]; 1912 SOCB [LHB3/17/13], pp. 90-2.

⁷⁵See, for case, Llewellyn (ed.) 1915; Lewis 1980; Lewis in Garcia et al. (eds) 1990.

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