BMJ Reports on the Nursing and Administration of Provincial Workhouses and Infirmaries, 1894-5.

STOCKPORT.

A visit to this workhouse takes us to one of the busy centres of industry. Tall chimneys pouring their smoke into the air and the whirring sound of machinery testify to the activity of the town.

The workhouse stands in the midst of all this hum, overshadowed by the chimney of a neighbouring mill, and the traffic of the streets passes its gates. The building wears an aspect of venerable antiquity, which, as we found, is by no means belied by its internal arrangements; indeed, we were introduced to a pair of boilers which have quite as much right to a place among the relics of a bygone age as Stevenson's "Rocket." Any mill owner among the guardians would be ashamed to make use of such ancient machinery in his works. We were surprised to find the house so full at this time of year; 724 was the record for the day in a house licensed for 690. The master informed us that the depression of trade had pressed very heavily on the operatives of the town, and he was at his wits' end how to bestow the inmates. Every available inch of space was utilised, as we saw; the inmates were packed like sardines in a tin. As we went round we thought with a shudder of the almost certain fate of these paupers in the event of a fire.

The hospital claimed our attention first. It is an almost impossible task to present a clear idea of a place so completely without plan or method. There were over 300 patients in the male and female blocks; these stand facing each other, with an open space of ground between them, to which either sex seems to have access. The female block is the older: some of its wards are no better than barns.

On the first floor of the female block was a ward holding 40 beds, divided lengthwise by a low partition, 20 beds on either side. The walls were roughly plastered, showing the lines of the bricks through; the roof was pitched, with beams stretching across. There was a stove in the middle of the room, The windows were set high in the wall, and had small panes, four in the middle of each being swung on a pivot for ventilation, and there were also ventilators at the gable ends of the walls. In this ward quite half the patients were in bed. There was a woman with typhoid fever, with cases of paralysis, rheumatism, bad legs, phthisis, old age; the "dirty" cases being mixed up with the other patients in the wards. There was practically no classification: we saw here two children in one bed with ophthalmia. This ward was overcrowded, the beds being close together. The wards vary in size, some having only six beds, and are distributed on the ground and first floors in groups, with a separate steep staircase, stone or wood, to each group, so that the unhappy nurses have to go up and down innumerable steps in their round of duties. There was one convenience for this group of wards, placed on the first landing on the staircase; it was in such an unwholesome condition that the stench was perceptible at the ward door, some half dozen steps above it. It was supposed to be flushed by a trickle of water, but even that streamlet was dry; the pan was quite foul.

The lock patients on both male and female sides are in separate wards on the second floor; but on the female side the eight beds were, on the occasion of our visit, full; and there were other patients who could not be accommodated in the special ward; these were of necessity placed in the general wards. The wards for the lock patients are part of the hospital, but they have separate offices.

The lying-in ward has 9 beds, including the labour bed; there is no means of privacy for the poor woman in labour except such as can be secured by the use of screens, and any inmate of the ward who is awaiting her own time of trial must hear all that takes place behind the screens. This ward has no separate offices it is placed close to the sleeping quarters of the nurse.

The children's ward is on the ground floor, it has eight cots and four beds for adults, the latter being the result of the overcrowding. Most of the infants had marasmus, and the ward was far too small to be healthy with the addition of four adults. In a room opening immediately out of it were some fixed basins and a small movable bath; no separate closet. An old pauper woman and a younger one, mother of some of the children in the house, were the attendants in this ward. The nurse on the female side has the supervision of the ward, but she must of necessity leave all details to these inmates, and these critical cases, which require the most careful feeding and cleanliness, are thus left mainly to the haphazard care of irresponsible paupers, and at night receive such attention as a sleepy inmate or an overworked night nurse could bestow, The poor little things looked sorry objects.

The general impression of the female wards was that they were dangerously overcrowded; we saw a door labelled "to be used only in case of fire," so crowded with beds in its access that in such an emergency it would have taken some time to render it practicable; also that they were comfortless and barnlike in aspect, that the patients required more nursing and hospital treatment than the nurses were able to give them, owing to the number that they had to attend to, and that the little children showed the signs of the ignorant handling of their pauper attendants.

The male infirmary is a more modern building; the wards are arranged somewhat on hospital lines, holding from 10 to 12 beds each; there is some attempt at classification; for instance, we found all the phthisical patients in one ward, cases of ulcerated legs in another, and the lock patients in a third. There is a bath room and a lavatory to each division, the latter with a flush, though in one instance (from neglect on the part of the wards-man) there was no water supply, and the pan was foul. The block is built in divisions, to accommodate 150 beds. Each has a separate staircase, and they do not communicate on each floor, so that the officers have to pass up and down the stairs continually — a very heavy addition to the fatigues of the insufficient staff. In the ward set apart for the phthisical patients we saw a man very ill, cheeks flushed, eyes half closed, lips dry, breathing shallow, attitude prone. He was unwatched, nor did we see any feeder or cup near suggestive of ministration; the matron called a pauper wardsman to see after him. A large proportion of the patients were in bed suffering from every class of ailment; there was no separation of the offensive cases, except the lock patients above mentioned. There was not the same overcrowding as on the female side. The heating pipes which are in every ward are carried about 18 inches from the ceiling. Their diameter is about an inch and a half. Whether they are placed at that height for the sake of safety or from motives of economy, it is at least certain that their heat-giving powers must be thereby rendered practically nil.

The old and infirm are lodged in the house in rooms formerly used as school rooms, but now filled with beds, eight to fifteen in a room. Here we found chronic patients, rheumatic gout, slight paralysis, heart disease, old age; many of the patients were up. The beds were close together on one side of the ward leaving an aisle on the other for benches, a table, an arm chair or so. The patients lived in these rooms night and day.

There are no day rooms either in the hospital or in this quarter, the only outlet being the airing courts, asphalted yards, having in some cases a grass plot or a flower bed in the middle. The men smoke in the wards, and of course in the winter they must often be kept in the one ward for days together.

The imbeciles and fit cases are lodged in separate buildings, that for the women being more airy and cheerful than the men's. They are looked after by attendants. We noted with surprise that there was no protection to the windows in the women's ground floor sleeping rooms; the windows are between four and five feet from the ground. The men's quarters are dreary and cheerless. the ground floor sleeping rooms off the corridor have only a skylight in a pitched roof and a small window; one such room, holding three beds, was pestilential, so much so that we thought that some offensive matter must have been left in a commode, but these proved to be empty. There is a padded room on both male and female sides.

The nursing of all these patients scattered up and down these buildings is complicated. There are a husband and wife who have their quarters in the hospital; the man assists the nurse of the male block, with the dressings, and looks after the male infirm and aged and the male imbeciles; he has no assistants but the pauper inmates. The wife nurses in the female hospital, and has two assistant nurses, and with these looks after the aged and infirm. This nurse is the midwife; she has had no hospital training, But has had long experience in the work. The nurse in the male block, who is assisted by the man above mentioned, is responsible only for the patients in the male hospital.

At night there was until quite lately one nurse for all these patients, those in the hospital, the aged, the infirm, and imbeciles; but the guardians have recently appointed two more nurses, one of whom is to be on night duty, The night nurse by her rules is supposed to visit every ward once an hour, and she has a clock to peg. We can only say that if she has done so it is a wonder that she is alive to tell the tale, and that the round must have been the merest routine, for she could have had no time to look at individual cases, and feeding or prolonged attention to any one patient would be out of the question. We wish we had had time to count the number of stairs that the poor woman would have to ascend and descend hourly. The whole thing is a grim farce in which human lives are jeopardised. There are also two inmates up at night in each block.

A disused laundry has been adapted to isolation purposes, making two small wards wherein suspicious cases are detained for inspection or until removal.

The nursery is quite a large department; at the time of our visit there were 36 infants and young children. The babies are on the first floor, and the older children on the ground floor. The labour mistress is the responsible officer; she has in addition the supervision of the laundry. We found the nursery well supplied with pauper nurses, old and young; everything looked clean and healthy but there was no sign of play or merriment (do pauper children never play?), nor did we see any toys. The infants are all slung in hammocks, made of coarse ticking — a temporary contrivance of the matron's until she can be supplied with cradles, which we hope are ordered. We asked the matron what guarantee she had that the milk issued for the infants was really given to them; she informed us that now all the infants' food was prepared in the kitchen, as she had found that the paupers either skimmed the milk or drank it. The older children sleep with their mothers in another part of the house, the mother and child sharing a bed.

The medical officer, Dr. Bale, who lives in the next street to the workhouse, visits twice and at times three times a day. He has a small surgery in the hospital, where he performs such minor operations as may be necessary; there being a large infirmary in Stockport, the patients treated in the workhouse are those that are destitute.

RECOMMENDATIONS.

There is only one possible course to recommend: the building of a new infirmary, and we understand that the Local Government Board is urging this course on the guardians, but that local opposition stands in the way. We can only say that any attempt to improve the existing buildings would be waste of money. We were much impressed with the energy of the officers, who were doing their utmost for the patients under most discouraging circumstances.

STOCKPORT.

We have received some corrections from Dr. Bale, the medical officer of the Stockport Union. In the first place he objects to the statement that in the large female ward there was only one fireplace; our Commissioner states that there was only one small stove in each division, quite inadequate for the purposes of warmth. 2. There was not a case of typhoid fever in the ward, the case referred to having recovered; our Commissioner says that the woman looked so ill that their attention was attracted by her appearance, and the matron stated that she had typhoid fever; the nature of the cases quoted in the reports is not for clinical purposes, but as showing the nature of the work required of the nurses. 3 The medical officer states that one of the assistant nurses on the female side is instructed to devote her attention to the children, and Dr. Bale thinks that our Commissioner should have instanced some signs of ignorant handling. In reply, our Commissioner states that taking into consideration the amount of work required of the assistant nurse, and the scattered nature of that work, the children's pauper nurse must have received nothing but mere supervision; the marasmus cases were up, without any warm clothing about the loins or extra wraps about the chest and shoulders, and the anxious wan expression of a marasmus child was very marked in their faces. 4 The male block accommodates 88 beds, and not 150 as stated in our report Our Commissioner replies that there are few facts more difficult to arrive at than actual figures; the matron in giving the numbers may have included the male beds in the workhouse infirmary, but she certainly gave the figures as quoted. 5. In addition to the heating pipes there are fires in the wards; the criticism refers to the situation of the pipes and their calibre, as being unfit for heating purposes. 6. The nursing on the male side is as follows: A male superintendent nurse who is thoroughly efficient and of long experience, is entirely responsible for all male hospital patients he has an assistant nurse under him, and only has temporary charge of the male imbeciles when their regular attendant is on leave of absence. The statement made by the matron to our Commissioner is as follows: "There is a nurse for this block (male block), she is assisted by the male nurse for the dressings, and heavy cases, and he has charge of all the male patients in the house and the imbeciles." The female nurse of the male block was off duty when the visit was made and the assistant female nurse was on duty in that block. 7. Two nurses are on duty at night, and have been for many years. Our Commissioner states that the information given was that there was one night nurse on duty, but that owing to the representations of the officials, more nurses had been appointed; we regret if we have made this statement on imperfect information, and it may be that the discrepancy arose in not distinguishing between the nurse and her assistant. We give space to these corrections as received from Dr. Bale, but they leave untouched the overcrowding, the imperfect sanitary arrangements, the insufficient and untrained staff of nurses, the absence of classification, the neglect to provide proper furniture in the nursery, or a paid nurse for the infants, and other details. We see that the Guardians at their meeting, when they considered Dr. Bale's answer to our charges, congratulated themselves that the report only told them what they knew before; this may be a satisfactory frame of mind for an official; but we fancy that the report has told the ratepayers something that they did not know before; to them we look to champion the cause of the hapless poor who are left to the tender mercies of the Stockport Guardians.