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BMJ Reports on the Nursing and Administration of Irish Workhouses and Infirmaries, 1895-6.

CORK UNION HOSPITAL.

Our visit to this infirmary was unfortunately made when the medical staff was away on leave, but we received every attention and assistance from Dr. Hennessy, the locum tenens. There are two resident medical officers, and two visiting doctors who go round the wards every day. The infirmary is in fact a large hospital; it stands inside a considerable enclosure, and consists of separate blocks, scattered about in an irregular manner. The number of patients, including lunatics and fever cases, averages about nine hundred, but on the day of our visit we were informed that there were nearly 1,100 on the doctors' books. The Union buildings are on the south side of the river, just beyond the outskirts of the city. Our impression of all the wards, with the exception of those in the children's block, was that they were overcrowded. We see from the medical officers' report, dated January 1st of this year, that the wards in the male hospital (St. Joseph's) are seriously overcrowded in the winter, "some of the patients having from time to time to sleep double;" this, too, in wards which on the ground floor are low pitched and below the ground level.

The blocks, with the exception of that for the female infirm, are square erections of two or three storeys, with light and air on all sides. In St. Joseph's Hospital, which we visited first, there are about 40 beds in each ward; two wards on a floor being divided from the passage in the middle by partitions which do not reach the ceiling. The lower wards in this hospital are quite unsuitable for the treatment of the sick; in winter they are liable to be flooded in heavy rain, to quote from the report above referred to, and are practically nothing better than cellars. They have repeatedly been condemned by the medical staff, and indeed, when we remember the class of cases placed in these wards — principally infirm or paralysed men — we can picture for ourselves the wretchedness of these cellars. At each end of the passage is a staircase, with duty rooms on the landings, and attached to each block is an operating room, small, but sufficient for the work, and provided with a good light. There are also central dwarf partitions in each ward, the beds being placed round the outside walls, and head-to-head against the partitions. The wards are lofty, but the windows are placed too high to admit of the patients seeing out of them. The walls are plastered and washed in two colours. In some wards there is matting on the floor; in others the boards are uncovered.

The blocks are apportioned as male and female hospitals, lunatics' wards, children's hospital, and female hospital. In the male block the chronic patients are on the ground floor, the surgical cases on the first floor, and the medical cases, chiefly phthisical patients, on the top floor. In the Protestant wards, where there are fewer patients, no such classification obtains. Another block is shared by males and females; the women are on the ground floor, and the men on the first and second floors, to which access is obtained by an outside staircase. On the ground floor are the chronic and infirm women, on the floor above male surgical cases, and on the top floor chronic and infirm men.

The female hospital (St. Catherine's) of two storeys is an irregularly shaped block of older date, the wards of all shapes and sizes, low pitched and plastered, the rafters of the roof being visible in some of the rooms, and the fittings antiquated. We here saw repeated all the objectionable features of structure that we have seen in other buildings in the course of this inquiry. On the ground floor are placed paralytic patients, bedridden and offensive eases; ill the wards above are medical cases, including some severe affections of the chest, and surgical patients; and in a special ward cases of syphilis in married people. There were 116 patients altogether in this hospital, and all the wards were overcrowded, the beds being close together. Between the beds is a small table or low locker; on the table or locker we noticed a shallow metal tray on which to place either the medicine or food of the patient.

The maternity hospital is a small separate block of two wards one above the other holding ten beds each; there is no labour ward, nor indeed any classification; as the bed is emptied, it is filled by the. next patient. We thought the whole department quite behind the requirements of the time. This block has repeatedly been condemned by the medical staff; it is insanitary, outbreaks of puerperal fever having occurred which have led to its being closed from time to time. We understand that plans for a new hospital have been drawn out, but no further steps have been taken.

Passing through the gates which divided the children's quarters from the adults, we came to the schools and the children's hospital (St. Agnes) which is a modern building, a block of two storeys, containing wards, operating theatre, day room (the only day room, in the whole hospital department), offices, and nurse's room. On the ground floor we found the older children, both medical and surgical, and, above, the younger children and the infants. There is one large ward on each floor, with beds or cots all round and back to back down the middle of the ward. At the end, a small space was partitioned off as a day room. The hospital was made bright and cheerful with toys, pictures, flowers, and all accessories necessary for the small patients : in a corner a pile of bed trays was standing ready to be placed on the beds at the fast approaching dinner hour. Upstairs the babies were in pretty iron cribs, and the other children in cots. The wards were rather upset, as the lavatories and bath rooms were in the hands of the workmen; but in spite of this, their clean appearance and the bright aspect of the little patients were a pleasant contrast to many sad places we had recently seen. The operating theatre is on the first landing. There were 74 patients in this division.

The fever hospital, which stands within this enclosure, but quite apart, is a modern building for 60 beds. The entrance is in the middle, with wards on either hand for male and female patients and nurses' rooms and offices. In the ground floor wards was a man with typhoid fever, and in the wards above some children recovering from scarlet fever. The sanitary arrangements have been erected on the most approved principles, four baths with hot and cold water; two new turret closets are provided in this block. The wards are lofty and well ventilated, with ample space for beds and necessary furniture. The nurses' quarters are very cramped in this division; the probationer nurses who are sent from nursing institutions to learn fever nursing, have to sleep in apartments partitioned off the wards, an arrangement which has naturally been severely condemned by the medical staff. There is a hot-air disinfecting chamber in connection with this block.

The patients in the hospitals were too numerous to describe in detail, but they are such as would be found in every general hospital, suffering from every form of disease, and in every stage. The saddest ward was that for paralytic and helpless women; they were crowded together in an ill-ventilated ward, which was far from sanitary when we entered it, and it must be worse at night. We made careful inquiries into the 60 patients under her care by day, and that at night the average number is 200 per nurse; as a matter of fact, some of the blocks are left at night without a responsible nurse on duty. We have not yet mentioned the "deputies" — inmates employed in the wards by day and by night as assistants to the official nurses. These "deputies" have certain privileges, such as better rations, and they form a large body of pauper nurses, who supplement more or less the insufficient nursing staff of this vast hospital. Our calculation, too, gives an apparent result which is more favourable than the actual facts, for the fever hospital, even if nearly empty, as at the time of the visit, absorbs one nun with her two assistant nurses, and the children's block has one nun to supervise it; the rest of the patients divided among the remaining nurses would give a larger figure to each nurse. It is hard to understand how a hospital can be worked at all under the circumstances, and that any results are possible is very greatly due to the energy and watchfulness of the medical staff. With a better trained and more numerous nursing staff it is safe to say that the quicker and more complete recovery of the patients would soon recoup the ratepayers for the extra outlay.

The lunacy department is an important branch of the work in this Union. The wards are sadly overcrowded, the lunatics having quite outgrown the accommodation originally assigned to them. There is on the female side room for 130 patients, and the average is 160. The beds in this division are touching each other, and there are nearly always 30 patients sleeping double. This class comprises epileptics, imbeciles, and harmless lunatics. In the women's ward the greater number of the patients were up and put to some form of employment; one day room was used by the more capable, who were engaged in needlework; it was a comfortable room, warm and cheerful, but too small for the satisfactory handling of this class. Beyond this was a dormitory, through it we passed into a long corridor, simply a lean-to shed, which cannot be properly warmed or supervised, and wherein were congregated a large number of lunatics. Here we saw patients who were, we judged, more insane, as there was no appearance of occupation, and the women were talkative and restless. We understood that others of the women were employed in the laundry.

The male lunatics are in worse quarters; there are two dormitories and a day room, all dreary, darkrooms, over-crowded and ill-ventilated; there are 70 patients in quarters intended for 50; some of these sleep in the dining hall. As there are very many days when the yards are not available on account of the weather, this class must have a sad and monotonous lot. Several of the men are employed in outdoor labour. The patients themselves looked, on the whole, well cared for. There is one attendant on this side, assisted by "deputies"; on the women's side a trained nurse and an assistant do the work, with the help of "deputies." At night these wards are visited by an official. The whole of this division has been repeatedly condemned by the inspector and the medical staff.

The bedding in the greater part of the hospital is the familiar straw tick on an iron frame of old pattern; there are a few spring beds scattered about — six or seven dozen; we believe. In the lunatic ward the bedding is all straw; some of the bedsteads for this class seem to us to be narrow and ill-suited to cases of epilepsy. Straw pillows also are in use throughout the hospital. In this respect we saw great need of improvement.

There is one large kitchen to serve the whole workhouse, from which the food is distributed to the various sections, except to the fever hospital, which has a separate kitchen. We were sorry not to see the transport of the food to the hospitals, but as the main articles of diet are of a liquid nature, most of it would be carried in cans. We note on looking through the dietary sheet which lies before us, that the beef tea is made about half the usual strength, though we are informed that in the fever hospital beef tea of twice this strength is given to the patients. The proportions are half a pound of meat to a pint, and the whole of the sick diet seems deficient in nourishing and stimulating food. The question of the diet under the Irish Poor Law urgently calls for revision, and we trust that an opportunity will be given us of drawing public attention to the matter.

The sanitary system is, as we should expect, more abreast of modern requirements; closets are placed in the turrets in all the blocks except that for the female infirm, and in this group of closets there was an automatic flush which was not working well, and the trough was in a foul state. This system has come under the scourge of the doctors, who are now agitating for improved sanitary service — both bathing and closets for the female infirm wards. The other closets had the usual two-gallon discharge, and were in good order. There is a bathroom for each floor, with a hot and cold water supply, except again in the female infirm wards. The hot water is supplied from a central boiler. There was a small furnace outside the fever block for the destruction of the typhoid stools. The fever hospital has its own laundry, the other departments being served by a central laundry.

RECOMMENDATIONS.

We formed the opinion that the Cork Union Hospital compares favourably in many respects with other establishments of the same size, but as we went round we felt how much more might be done for the patients if the nursing were better in quality and sufficient in quantity. Our comparison of the number of the patients with the number of the nurses justifies our contention that the patients are in the hands of the pauper attendants. We should recommend the entire remodelling of the system of nursing, the wards being placed under a charge nurse (whether this charge nurse is or is not a member of a religious order is, from our point of view, irrelevant to the question); under these, assistant nurses and probationers, in the proportion of one charge nurse, two trained nurses, and four probationers to a floor, the inmates to be employed as scrubbers, cleaners, and as messengers. This calculation is based on the computation that there are 80 beds in the two wards; if the number of patients in the wards were reduced there might be fewer probationers. Turning to the structure, we note that the modernising of the buildings has stopped short, and that in the case of St. Joseph's Hospital patients are still being kept in wards which are quite insanitary, and which have repeatedly been condemned by the medical officers. With the amount of ground at the disposal of the Board there is ample space for the increase of the buildings in the directions that we have indicated, and we earnestly urge the provision of more wards for the men, a new block for the females, and improved accommodation for the lunatics. Day rooms might with great advantage be included in the building operations; they are an immense relief to the wards and a great boon to the more convalescent of the patients; they also aid in the classification of cases — a point in which this hospital is deficient. The maternity ward is also quite unworthy of the Union; an extension of premises to include a labour ward and a convalescent ward would be a great help in the work. The airing courts need enlargement, especially that for the lunatics. We have probably called down the wrath of the guardians by our candid criticisms, but we feel sure that the verdict of the public will be given for us, and that if the Board takes a bold and progressive course the rate-payers will uphold them. Such a course is always true economy in the end.

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