The Lancet Reports on Metropolitan Workhouse Infirmaries, 1865-66: St Marylebone.

ST. MARYLEBONE INFIRMARY.

The St. Marylebone infirmary is only second to that of St. Pancras in size and importance. According to the Poor-law Board's estimate, the whole workhouse is adapted to contain 1800 inmates. The sick wards contain 323 beds; and, besides these, there are numerous infirm wards scattered through the body of the house, in which from 500 to 600 chronically diseased persons are lodged.

The infirmary proper, containing the sick wards, is separated from the rest of the house, and stands on the best part of the workhouse enclosure. Its principal length faces the wide Marylebone-road, from which it is divided by a wall, and, inside the latter, is an area of open ground more than equal in extent to that on which the building stands. On the two shorter sides, it is bounded respectively by Northumberland- street (forty feet wide), and by a narrow and densely populated court. In the rear, the infirmary is separated from the body of the house by the yards belonging to the men's portion of the general house and to the department for insane men. The principal mass of infirmary buildings is arranged in a quadrangle, to which admission is obtained by a separate lodge-gate. The area thus completely enclosed is small; the buildings which surround it are three stories high on the one side, only two stories on the other. The arrangement of the body of the house and of the quadrangular part of the infirmary is very ill-calculated to favour the circulation of currents of air through the premises, owing to the irregular form of the buildings, which enclose a number of small confined yards. The quadrangle and front of the infirmary were built in 1792, and subsequent additions were made in 1817 and 1825. The elevation of the site and the character of the soil are all that could be desired for hospital purposes; and the general system of drainage and water-supply are excellent.

The wards of the infirmary proper are distinguished by an unusual, though still by no means an adequate, allowance of space. In summer, when the house is comparatively empty, this reaches to 700 or 800 cubic feet, and sometimes a good deal more, and it never sinks below 600 feet. But it must be remarked that this is effected by the unusual height of the rooms, their superficial area being very contracted. The aspects are various (unfortunately very few of the wards have a double row of windows), and accordingly their lightness and cheerfulness vary very greatly. Some of the wards, and especially those for idiotic patients, are particularly cheerful-looking in summer time, from the fact of their opening on the garden, and from being decorated with prints, a luxury which is conspicuously wanting in most of the sick wards. The "infirm wards" may be divided into two classes: those belonging to the first are bare and wide; those belonging to the second are bare and narrow. Many of these infirm wards are also very deficient in provisions for ventilation; but it must be acknowledged that throughout the house great pains are taken to make the most of such means as exist. The ward furniture is in some; wards really good; in others, poor and mean. There are no short beds, as at St. Pancras. Basins and towels are decidedly more plentiful than at the last-named infirmary, and there is a proper supply of hot and cold water to each ward; but lavatories are as yet supplied to only a few wards, and there is a great deficiency of proper bath-rooms. The water-closets in the infirmary are on the "latrine" system, which, but for the vigilant care which is displayed by the officials, might degenerate, as it so often does, into a nuisance. At the time of our visit not the least annoyance from this source was perceptible; but we must protest against the practice of erecting closets to contain several people at once, without proper intervening screens. The closets here arc lofty and well-ventilated on the whole. But in the infirm department there are several closets which are so bad that they ought to be immediately removed, as they are a source of real danger to the inmates of the wards to which they are attached. In concluding our description of the wards, it is proper to mention that convalescent patients enjoy a garden, to which they can repair on every fine day; they are furnished with uniform clothes for this purpose, their own having been taken away to be cleansed. The idiots have also separate gravelled yards (one for males and one for females), in which they have a swing, and are allowed to keep rabbits, birds, &c. There is not, as at St. Pancras, any deliberate attempt made to treat acute insanity on the large scale; such patients are always dismissed, without loss of time, to the Asylum.

The nursing system, though far enough from perfection, shows that a step in the right direction has been taken; for there are fourteen trained and paid female nurses for the sick wards. These officials appear to perform their duty well, and to do their best to train the pauper assistants who are under their direction; but it is astonishing to find that the night-nursing of this very large infirmary is altogether entrusted to paupers. The influence of the matron is most excellent and valuable.

The provisions are pretty good in quality, and we have nothing to remark under this head, except that it is highly desirable that a separate infirmary kitchen should be established for the use of so large a number of persons as must require extras and delicacies. The house diet, though not sufficiently varied, is tolerably liberal as compared with that of other workhouses; arid the sick diets are entirely under the control of the medical officer, who appears to avail himself freely of the privilege of ordering extras for the "sick, "and to a considerable extent for the "infirm." We would suggest that the use of more than three-quarters of a pint of milk per diem is desirable for children between two and five years of age, though this allowance is munificence itself compared with the half-pint of milk- and-water and the bi-weekly extra of rice-milk which prevails at Bermondsey.

The position of the medical officer at the St. Marylebone infirmary is a subject which we approach with delicacy and reluctance. Dr. Randall is well known in the profession, and it would be a mere impertinence to speak of his character or abilities; but we may say here that it is obvious that he exerts himself to the uttermost to manage the affairs of the infirmary thoroughly well. Nevertheless we cannot approve of the conditions under which he holds office. Formerly, the infirmary of the St. Marylebone Workhouse possessed a proper hospital staff of physicians and surgeons commensurate with its size and importance; but the guardians, having for some reason become tired of the system, abolished it, and appointed one medical officer, at a salary of £950, to take the whole medical charge of the place, requiring him for that salary to pay for a resident house-surgeon, a dispenser, and for all the drugs and medical necessaries. Now we do not hesitate to say that no single house-surgeon, although superintended by the daily visits of the ablest physician in Europe, could with anything like efficiency conduct the medical management of the enormous number of patients who, either constantly or frequently, require attention in the St. Marylebone infirmary. We have only to repeat the number of patients to make this clear at once. There are 323 sick, and from 500 to 600 infirm, a large proportion of whom require frequent medical inspection; and there is an average of five midwifery cases per week, which are, indeed, attended by the midwife, but always under the superintendence of the medical officer, who must give his assistance in cases of difficulty. For all this work the medical resident receives the salary of £100 per annum, with board, washing, &c. The dispenser receives £90 a year. It is fair to say that Dr. Randall is not a mere perfunctory master of his hard-worked house-surgeon, but works energetically with him, and divides the duties with him as far as he possibly can. But the whole arrangement is unsatisfactory, more especially the fact that the cost of supplying drugs and medical appliances falls on the superior medical officer; for although, in the hands of Dr. Randall, the patients are in no danger of being deprived of any needful but expensive drugs, the position of that gentleman is anomalous, and must be uncomfortable.

The medical history of St. Marylebone infirmary for some years past presents no record of any very serious epidemic, except one of small-pox in the winter 1863-4. 254 cases were admitted from the neighbourhood in the course of nine mouths; but being properly isolated, by the prudence of Dr. Randall, they did not communicate the disease to a single other inmate. The total mortality was very small — only 22 in all, of whom 8 were brought in moribund, and 18 had never been vaccinated. A less important, but very interesting circumstance, was an outbreak, some years since, of trismus neonatorum, among the infants recently born; this was at last put an end to by emptying and shutting up the ward for some time, and thoroughly cleansing, painting, and whitewashing it.

The mortality for the four years, from 1861 to 1864 inclusive, was as follows — 559, 584, 608, and 624. On analysis of the heaviest of these years (1864) it is obvious that there is nothing unusual in the character of the fatal illnesses, although the average death-rate is high in proportion with that observed, for instance, at St. Pancras, which has a much larger population.

General conclusions. —

1. St. Marylebone infirmary possesses an excellent site, which ought, if possible, to be retained for hospital purposes.

2. the house ought to be removed.

3. The infirmary is built upon an antiquated plan, and ought to be replaced by one of modern construction.

4. If the present infirmary building be retained, it requires many improvements, as indicated above, which it would be difficult to carry out.

5. The general management of the infirmary and the house reflects the greatest credit on Mr. Douglas, the master, and on his wife, the matron.

6. The medical officer is taxed with an amount of work which it must be quite impossible for him to get through. He ought also to have at least three resident medical assistants.

7. The plan of "farming out" the whole medical duties and medical expenses to one physician is highly improper. It surrounds the medical officer with temptations to negligence, to which no official should ever be exposed.