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

GREAT YARMOUTH.

The old fishing town possesses a large house for the reception of those, fisher-folk or others, who seek maintenance within its walls. The house is at the outskirts of the town, at a short distance from the grand old church of St. Nicholas, the pride of the town and of the kingdom. The medical officer, Dr. Collier, was awaiting us by request from the Board of Guardians, and, after some unusual and rather tedious formalities had been complied with, we were admitted within the gates.

The workhouse is a red brick building of ancient date, and its rambling structure, altered and patched from time to time, is an indication of the change that has come over the character of the work carried on within these buildings. At the present time the inmates number 424; of these, 198 are on the medical relief book, and 84 are certified lunatics; that is, more than half of the total number are under the charge of the medical officer.

The infirmary is difficult to describe; we found a ward on the female side, adjacent to, but quite separate from, the imbeciles' wards, in which female lock cases are put at one end, screened off from other patients when the wards are crowded. Passing out of the main building by a covered passage, we reach the sick wards situated on the ground and first floors.

The women are lodged in the old wards, situated on either side of a lobby and wide staircase, terminating on a roomy stone landing. Off this and between the wards is a room which might be (but is not) a bath room; it contains fixed basins, a wash-up sink, and a coal bunker. There are four long wards in each block, holding from 12 to 15 beds each. The beds are close together, and the wards, serving also as dayrooms, are overcrowded when all the beds are occupied; this remark applies equally to the male and female blocks.

The windows in the old block are only on one side; in the opposite wall, more than half way up, are semicircular glazed openings. In the more modern block the windows are on each side and of the same size. The ventilation is by means of the windows and of the open fireplaces at each end of the ward. The walls are colour or whitewash, and a few pictures are hung about.

The male infirmary is in a similar building, though of more recent date, and it forms part of the same block as the female department. Here, also, there is no day room or outlet for the men except into the grounds. The bedsteads are mostly of an old pattern and narrow; in the male infirmary there are a few new ones: those for the epileptics are low and wide. The bedding is flock or straw, with a few feather beds.

Only a small proportion of the patients were in bed at the date of our visit; among these we saw a little lad of about 9 or 10, in the male ward (there is no children's ward), recovering from typhoid fever; a man with malignant disease of cervical glands, another with rheumatism, periostitis of the leg, and various forms of bladder trouble classed in one ward; on the female side a had case of pericarditis, a case of gumma, which was being treated with poultices; phthisis, and the usual amount of paraplegia, old age and infirmity that form the majority of cases in a workhouse infirmary. The doctor informed us that he is not supposed to do any operations except in emergency, nor did we judge that the staff of nurses at his disposal would be adequate for skilled nursing.

The nursing staff consists of an attendant on the female side, assisted by an inmate who is paid, and by two attendants on the male side, none of these being trained; there is no night nurse, trained or untrained. In conversation with the matron as to the course pursued in dealing with the case of pericarditis, she told us that she had to share the nursing with the ward attendant, and that among them they pulled the woman through, and the same in the case of the child with typhoid fever; but it was evident that the acute cases put a great strain on the nursing staff. Another point that came out in conversation was that, on account of this same strain, the day staff, which begin work at 6.30 A M., close the wards as early as possible in the evening, with the result that the helpless patients may be, and often are, from 8.30 P.M. until 6.30 A M. without anyone to minister to their needs. Can this be tolerated? Is it not most inhuman to leave nearly 200 infirm, old and sick folk for eight or ten hours with only such assistance as they can render each other? Again, if the medical officer has an acute and anxious case in his wards his responsibility is immeasurably greater that he has no skilled nurses to watch progress in his absence.

The imbeciles are lodged in the wings at the ends of the main building; on the male side there were 40 patients, with a capacity for receiving 49, and on the female side there were 49 with beds for 54. All the certified patients are treated in these blocks, but otherwise there is no classification; epileptics, idiots, and lunatics, all meet and live together in the same day room. These day rooms have access to the pleasant gardens which serve as the airing courts. The sleeping rooms are of all sizes, the single room for the noisy patient, and the dormitories for the epileptics. In the event of acute illness the patient would be treated and nursed in these quarters. There is a padded room in each block; an unfortunate woman was secluded, being at present too violent to be at large. Such a patient on release from the padded room is placed in a single room to test her quietness and convalescence.

The staff employed in these blocks contrasts very favourably with that for the infirmary; in each block there is a superintendent nurse, with two assistants by day and one night nurse, those for the men being male nurses. The women are employed as far as possible in needle work or in the laundry the latter more as an occupation; there was one old woman who amused herself all day at the washtub. The men have a billiard table, and work in the grounds.

The lying-in ward is close to these wards on the first floor. It holds eight beds, two of which were occupied at the time of our visit. There is no separate labour ward. The midwife is non-resident; she works in the district; after the confinement is over the patient is taken in charge by an inmate. The doctor holds himself responsible for the confinement cases, and endeavours always to be present. He pointed out the freedom from puerperal fever, the last case having occurred almost out of recollection. The ward is near to the matron's rooms.

The nursery we found in a remote part of the buildings, at the end of a new block originally intended for sick wards but at present used for the school children. The room in itself is not bad, but there is practically no supervision over the two paupers placed in charge of the children. The nurse of the female side is in her block at a little distance, and the matron would not be near the nursery unless she went there on purpose. We saw five infants, three of whom were suffering from marasmus in a greater or less degree. and we also noticed the usual absence of anything like childlike or cheerfulness. Is the pauper infant a separate species, without the joyousness of childhood? These babes exist, they cannot be said to live.

From the foregoing account it will be seen that there is practically no means of classification. We found that the doctor put all the bladder cases in one ward, and he managed, as far as possible, to have the paraplegic and hemiplegic cases in the imbecile wards, because the attention given there was more efficient than in the infirmary; he was therefore able to say that he had no cases with bedsores. There are no small wards in the infirmary for isolation cases, and there is no classification possible either in the infirmary or in the imbecile wards.

The male lock cases are in a small separate building, holding twelve beds in two wards, under the care of a male attendant; there are separate offices. The male receiving ward is a wooden shed, the female receiving ward a small room at the end of the corridor parallel with the imbeciles' corridor, but approached by a separate door. It had the appearance of a makeshift.

Infectious cases are isolated in a small ward near the tramps' quarters. Scarlet fever would be removed to the sanitary hospital close to the workhouse; for small-pox special arrangements would have to be made.

The water supply is inadequate; in no closet that we tested was there anything like a flush, and in one instance the trickle did not empty the pan of its contents. There is no water laid on to the upper floor of the imbecile wards but on the lower floor there are baths with hot and cold water. The matron informed us that the town and the guardians were at variance on this question of the water supply, and that the officials were much hampered by its insufficiency, especially for the baths. There are no bath-rooms in the infirmary; all the work is done with movable baths, which have to be baled.

We learned that Yarmouth Workhouse is in a state of transition; there are plans for the removal of the children to a distance, and this would set free the new block containing suitable sick wards; but everything is at a standstill until certain differences of opinion among the members of the Board are got over. Meanwhile the old buildings are turned and twisted, altered and patched like a worn-out garment. There are bells from the wards to the matron's quarters, but no telephone to the doctor's residence, three quarters of a mile away; he is fetched when necessary by an inmate. Nor has the doctor any surgery in the building; he is indebted to the courtesy of the master for a place in which to keep his drugs. The ward medicines are kept in miscellaneous cupboards in the wards.

RECOMMENDATIONS.

We were much impressed with the absence of plan in these buildings; the several erections appeared to be too close to each other, and admitted of no adaptation. We would suggest that the plans referring to the children he hastened on, but, though this would relieve the congestion, yet the vacated block would not make a complete infirmary, and some more radical scheme seems therefore necessary. New hospital wards are wanted, and increased space for the imbeciles, a better situation for the nursery, and, that which is of first importance, a staff of trained nurses, for day and night, sufficient for the nursing of 200 or more patients a large proportion of whom, being helpless chronics, must be reckoned as a permanent charge on the staff.