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

BATH.

The workhouse stands outside the city on a hill surrounded by a large extent of ground, which is cultivated by the able-bodied. The infirmary, though in a separate block, is practically under the same roof as the workhouse, there being a short covered communicating corridor. It is licensed for 230 beds. The house is a very old one, the date, 1834, is inscribed over the door. It is built of Bath stone in the solid style of that part of the country, and its aspect is somewhat of a prison-high walls with asphalte courts. The plan of the main building is the shape of the letter Y, but so much has been added to it since it was first built that at the present time it is almost impossible to discern the original plan.

The infirmary is of ancient date and has no appliances for sick nursing. It is a two-storied building; the wards on the ground floor are dark and squalid in appearance; the first floor wards are better, but there is but little window space and no cross ventilation; the top floor is the brightest and the airiest, the windows admitting of cross ventilation, but there is no ceiling. We can imagine the howlings of the wind, the draughts in those wards when a storm is raging, as it can rage over those hills. The water supply and system of distribution are inadequate, every drop of hot water for the infirmary use has to be carried from a boiler across a court. The matron showed us that a new boiler was being fitted near the women's quarters which she thought would be a great help in working the place. But when we remarked that hot water laid on to every floor was a necessity for a hospital she informed us that the objection to that was that the pipes would burst in the frost. Some of the closets are of the old pattern and some modern; they are well placed for the use of the helpless at night, but they are in immediate communication with the wards, having a cross ventilation; this would, to a certain extent, cut off the foul air from the wards if these windows are kept open by night as well as by day. The bathrooms are few and far between, and have a cold water supply only. In one bath, that for the "eruption ward," the steam for the water is turned on for two hours thrice a week in the afternoon; otherwise all the hot water for the baths or for washing the patients is carried from the boiler by the inmates, and no hot water is procurable at night except by boiling a kettle. The staircases are steep and narrow, enclosed in walls. The ventilation is entirely by means of windows. The wards are warmed by fires and lit with gas. The walls and ceilings are colour washed and profusely adorned with pictures pinned on to the walls. The whole place wanted cleaning, but the matron informed us that the matter was in hand.

When going round the wards in company with the matron and nurse we were struck with the large number of acute cases under the care of the guardians as compared with other infirmaries of a similar size. In the twelve wards there were, on a rough estimate, about sixty patients in bed, and the nurse informed us that there were twenty-four temperatures to be taken that evening, of which half or more she expected to be above the normal. Pneumonia has been and is very prevalent in the neighbourhood, to quote from the medical officer's report (Mr. Craddock, May 23rd): "Amongst others in the infirmary are 4 cases of pneumonia, 4 very bad cases of phthisis, 7 of heart disease, and 16 dirty cases-all requiring the most careful and tender nursing." We most fully concur in this statement of the class of patients in the wards. Besides those above referred to, we saw a woman with internal cancer — ill in every sense of the word, frail and wasted, with a face of great suffering; a bad case of hemiplegia; a man with cardiac dropsy, with a great deal of fluid in the lower part of the body; several men and women with ulcerated legs; besides the unvarying paralysis and bedridden cases, each of whom needs the same care as an infant if they are to be kept in a wholesome state. In the death-certificate book we noticed that in May and June there had been 14 deaths, only 2 of which could be attributed to old age, and the other diseases were pneumonia, cardiac rheumatism, or phthisis. In the children's wards there have been several cases of measles. The lock cases are treated in the ground-floor wards, and their wards have separate offices. The imbeciles and idiots are in another part of the building, under the charge of paid attendants. In this matter and in the provision of separate wards for the sick children this Board sets an example that other boards would do well to follow.

To speak accurately, there is no system of nursing; there is one fully-trained nurse to "nurse" all these patients, and she has to help her two assistants, one who has been in the workhouse one year and nine months, uncertificated; the other, who has had only a scrappy training at an infirmary, supplemented by work as a draper's assistant, and a young girl, not trained, who held some other appointment in the house; the nurse is also the midwife. On inquiring from the nurse how much time she had for actual nursing, she informed us that by the time she had looked at the serious cases, made her notes, issued her orders to her subordinates, filled the medicine bottles, and looked through the wards, the time was gone. Under these circumstances it did not surprise us to hear that the paupers gave the medicine, or from the medical officers that a poultice had been left on a pneumonic chest for twenty hours unchanged, or from the nurse that the hours of work for the nurses began at 6 A.M. and ended at 10 P.M. Paupers are largely employed in the infirmary. Every ward has its inmate who is the wards-man or woman; some of these are ancient inhabitants, well-meaning no doubt, but as useful in the ward as they would be in a glass manufactory. The patients are left in the charge of paupers during the night, two on the male side, one on the female. This latter "night nurse" is put to bed in the daytime in one of the wards that she minds in the night. The men are not treated to such a mockery of sleep; they are over in the house somewhere. The woman with internal cancer above referred to complains of the rough handling at night, but the pauper "night nurse" is not to blame. Such being the case, the nurse informed us that the assistants took it in turn to be called on alternate nights to administer the stimulants, and the doctor informed us that he had no guarantee that the extras ordered were given in the night, nor could there be any systematic feeding. It must also daunt a nurse to see the vast amount of work around her, and to know that she cannot do one tithe of it properly, especially with the help that is provided for her; we are not surprised to hear that the nurse has resigned. All the appliances for the hospital are on the same meagre scale; we were informed that there are three roller towels for the use of each ward, of about twenty-three beds; these are changed three times a week; there is one comb somewhere about for the patients, perhaps a brush; cleanliness under these circumstances is impossible. There are two patients with bedsores, and, considering the nature of the cases and the want of system in the nursing, we are surprised that there are so few.

Mr. Craddock has brought this state of things before the Board in the strongest and plainest terms possible, and the readers of this Journal will understand that any conscientious officer responsible for the treatment of the sick shrinks from being a party to the continuance of such a state of things; but no amount of words will undo the grievous harm that is being done to the sick whilst it lasts. Poulticing in cases of pneumonia cannot be carried on in a regular manner; feeding in cases of typhoid fever would lack that regularity that constitutes its great value, and so on through all modes of treatment necessary in acute cases. We understand that a night nurse has been engaged by the guardians — one night nurse to 230 beds! She would have to be as strong as a donkey and as active as a flea if she is to see after that number of patients; nor do we see that there is any provision for the complication of the two serious cases requiring attention in opposite ends of the building. The medical officer lives a mile from the infirmary, and his house is not in telephonic communication with the infirmary, nor are there any bells of communication through the building.

The bedding is chaff for the dirty cases and flock in the general wards; the bedsteads are narrow, they have laths; the mattresses that are supplied are not of sufficient thickness to cushion the laths; the sheets were clean, also the blankets on the patients' beds. We did not see any screens, but the matron informed us that they had been ordered. The utensils in nearly all the wards were under the beds. There were hardly any cupboards, and we saw the medicines on the window-sills. The beds in some wards were crowded so that the nurse would not be able to attend to her patient without moving them.

The lying-in ward holds four beds; there is no labour ward, and when, as happened lately, several women were in labour at the same time, some were confined in the general ward. This ward is an end taken off a long ward.

The isolation hospital is in a distant part of the grounds, almost out of sight. We did not visit this building as it was closed. There are, we believe, four beds in it, and it is intended for patients from the workhouse. The medical officer, in the report above quoted from, states that in January last a man suffering from typhoid fever was nursed there entirely by paupers. The rooms provided for the nurses are not good; the only sitting room (of course, poor things, they never sit) is the surgery, redolent of drugs, and we could not ascertain that any separate bath room or lavatory accommodation was set apart for their use. There are no slopsinks; the only place of that kind that we saw was a small fixed basin outside some of the wards, presumably for the officials to wash their hands. In the rooms where the wash-up for each ward was done we saw no convenience of sink, bowl, or other necessary. The matron informed us that she had five separate laundries under her charge for male and female, sick and able-bodied, and for the children; we mention this to show how very rudimentary the arrangements are in this house.

RECOMMENDATIONS.

We should recommend that new infirmary buildings be provided; that twice as many nurses be engaged for attendance on the sick, not of necessity all fully trained; and that the nursing staff be put under the sole control of a matron, who shall also be a nurse; that the paupers be kept for the cleaning and the service of the infirmary; and that the doctor's residence be put in telephonic communication with the infirmary. In no other way do we see that it would be possible to create a satisfactory state of things for the sick; the existing infirmary is crowded, both in the wards and in the offices, and no amount of patching and remodelling would overcome the stubborn facts of structure.