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

PLYMOUTH.

The Plymouth Workhouse has to do with over 600 inmates, and of these 184 are infirmary beds. The infirmary is under the same management as the workhouse, but it is in distinct buildings. This house is much to be commended for the arrangements that are made for the care of the imbeciles and the feeble minded; they are lodged in a separate building of modern construction, with skilled attendants as responsible officers, and are well provided with amusements and suitable occupations; would that the same could be said of the sick department!

The wards are located in a building immediately behind the house, so close that the air and light space is not adequate to the needs of the sick: like many other infirmaries in this county, it is quite behind the age, and as we walked round it we questioned whether its stubborn walls could be adapted to the present day. The plan of the infirmary is a middle block with the male and female wards on each side, on ground, first, and second floors, with annexes at right angles to the ground and first floors. There are about 80 beds on each side, in wards of varying capacity, the smallest holding 6 beds, and the largest 12. Besides these wards there is a small detached ward on the female side and a corresponding ward on the male side, each holding 10 beds; these are light, pleasant wards, and are made warm by the erection of a small porch to the entrance. It seemed to us that these wards were well adapted for the isolation of the lock patients, whom we found mixed up with the general patients. The appearance of the wards was cheerful; the windows are large, there are pictures and plants as decoration, armchairs and matting giving an air of comfort. There are no day rooms for the infirm; all the patients must eat, sleep, and on the male side smoke, in the one room, unless they can come down to the airing courts for a change of scene.

The patients are not classified, except that we found that the more convalescent cases were in the large wards at the top of the building, from which they had a fine view over the Sound; still among the convalescents we saw a man suffering with acute rheumatism; in deference to his feelings the Tobin ventilator, which was near to his bed, was rendered useless by a book being placed over its aperture. The wards were nearly full, and we were struck by the large number of acute cases among them; quite half of the patients were in bed. We saw a pneumonia chart, on which the height of the temperature recorded, and the steady descent, indicated that the man had been very ill. There was a man quite crippled with rheumatic arthritis, another with cancer, a sloughing sore in the groin the result of hernia, an ununited fracture of the thigh, phthisis, disease of the hip-joint, gastritis, several patients with bad legs — these we noted with a hasty glance at the bed cards, and the medical officer afterwards confirmed our opinion as to the large number that were under treatment. Add to these hospital cases the usual infirmary patient, the helpless, paralytic, and incontinent cases, and we can have a fair idea of the amount of nursing required of the two (!) nurses who are responsible for the sick in Plymouth Infirmary.

The nurses are distributed on the male and female sides of the buildings; the nurse on the female side is not trained, though she has had long experience in the work; she has charge of the children's ward. The nurse on the male side, who had only just been appointed, was trained, though from our impression, gathered as we went round, she had not been accustomed to nursing under the Poor-law administration. They were supplemented by the wardsman and woman, taken from among the paupers, one of whom was detailed for duty in each ward; one wardsman was well over 60 years of age, and, on consideration, we see the selection of these inmates must be restricted to old men and women who have been inmates for some time, as the younger men, unless in exceptional cases, could not be trusted to attend on the sick and infirm. There is no trained night nurse; the inmates are responsible at night, and the matron informed us that if a patient required feeding or watching during the night, that "watchers" were sent from the house to sit up at night. There are no bells or means of communication from any of the wards, nor is there telephonic communication with the doctor, who lives at some little distance from the workhouse.

The unsuitability of the structure was very evident as we went round; the staircases are steep, and the passages narrow; in the top-floor wards the lavatories are down five steep steps, and then there is a long passage to be traversed before the closet is reached; this arrangement is healthy, but it must be trying to the old people to crawl up and down those stairs, and it necessitates the use of the commode for the infirm during the day. Then there are no places for the clothing. In one ward we saw the man's clothing on the ground; the matron said that he required his trousers for leaving, the ward, and that they were as often as not found thrown down on the floor. There are no lockers for the patients, and very few cupboards. We inquired for a bath, and were shown a little room off a landing, and a large reservoir covered by a heavy wooden cover, and on this piles of plates, jugs, etc., so that we felt that that bath was not in daily use. No hot water is laid on; there is no slop sink, so that the heart of the nurses must sink at the impossible task of doing their work in a businesslike way under such circumstances. The wards being divided and scattered on so many floors makes the work harder, and supervision almost impossible. The small size of some of the wards, having no cross ventilation, makes it a most difficult problem to keep them sweet. The ward in which the cases of syphilis were located was not at all wholesome, nor was it quite apart from the other patients. There was a want of neatness about the wards. It seems hardly decent that the vessels and urine bottles should be left casually under the beds or by the side of the patients; but these will be until the system of nursing is organised more on the lines of a hospital. The bedsteads are of all widths, and the bedding is either straw or mill puff, and a water mattress where needed.

The children's ward has twenty-four cots in it; it forms part of the infirmary building. There was a pauper nurse in the ward, who works under the female nurse. There were very few patients in the ward when we visited. There was a child with hare-lip waiting to enter the South Devon Hospital for operation, a case of diarrhoea, and a little babe not ailing much. We were sorry to see that the tube feeding bottle was in use, and taking that and the pauper attendant into consideration we were not surprised that the babe had diarrhoea. These tender little ones need more care than they can receive from a nurse overwhelmed with the charge of adult patients, her duties being delegated to an inmate.

The sunk hot-water tank in the court from which the hot water for the infirmary is obtained appeared to us a very dangerous and unsatisfactory contrivance; this circular tank is nearly flush with the ground; it has a trap door lid, which was open as we passed by, a railing two-sides of a square, high enough to allow of a small or careless person falling on to the tank and of a child tumbling in, is the only protection; the women draw the water by dipping a bucket in, and they cannot be trusted to close it each time.

The lying-in ward is in the main part of the house; it is on the first floor, and holds 4 beds. In the ward beneath is the room in which the pregnant women sleep until they have reached the period of labour; then they are transferred to the labour ward above. This ward is so small that privacy for the parturient woman is practically out of the question, and the women awaiting their trial must be painfully aware of all that is taking place; this ward also is destitute of comforts; we saw a poor woman who had had a severe time — indeed, her face told the tale — seated on an upright hard settle, eating some unappetising gruel. In a hospital that woman would have had a couch or resting chair to save her strength. We could not ascertain that there was any means of bringing these poor women up the stairs other than on their feet when their time had come. The "nurse" is not trained, but she has been at the work some time; her room is on the same landing as the lying-in ward, facing it. Could not this room be taken into the labour department, and the nurse be quartered elsewhere? There are separate offices for this ward.

For the infectious cases there is a small isolation building in the grounds; this is for temporary use only, as the patient, when the complaint is declared, is removed to the infectious hospital belonging to the town.

RECOMMENDATIONS.

As we pass from one to another of these country infirmaries we are obliged to reiterate the same recommendation: Build a new infirmary; make it into a separate department, and use the old building for something else. And yet one shrinks from suggesting a course that must fall heavily on the ratepayers; but these buildings were erected at a time when the needs of the sick were not so well understood, and they cannot be adapted without an unnecessary expenditure of service and labour, which makes the working extravagant. When the new building is erected, then the staff of nurses and the methods of working will group themselves in order. But until this is done an increase in the existing staff would make a great improvement in the sick nursing. We would suggest two trained nurses on the male and the same number on the female side, and one nurse on the male and one on the female side at night. We must also point out that an ample supply of hot and cold water for the infirmary, with two bathrooms on each side, is most essential; add to this the separation of the lock patients in isolation wards, and all has been done that is possible with the existing buildings. If the lying-in ward could be transferred to the hospital department and be worked by one of the female nurses holding a midwife's certificate, it would be a great improvement; but we could see no place available; a new ward would have to be built.