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

LAMBETH INFIRMARY.

The Lambeth Infirmary presents no very extraordinary features. It offers, on the whole, an average example of the management of these establishments in London, being in some respects better, and in some worse, than those which have formed the subject of previous reports by this Commission.

The most notable circumstance in connexion with this infirmary is the very large number of more or less diseased persons which it contains. The whole workhouse is nominally licensed by the Poor-law Board to accommodate 1100 inmates. The actual average number is 850; but in winter the full quota is reached, and even exceeded. According to the estimate of the surgeon, nearly five-sixths of the total population are more or less the subjects of medical care. The proportion of "the cases which come under the head of acute sickness is difficult to ascertain. The wards, two in number, which are called (by the custom of the house) "sick wards," contain about 70; but this is but a small portion of the cases of severe illness in the workhouse. Indeed, in the return procured by Mr. Farnall, we find the "sick" estimated at 456, and the "old and infirm requiring occasional medical attendance" at 102. If we add to these the lunatics — about 70 in number — and the occupants of the lying-in wards, we get a total of 638; and this is probably below the mark. In fact, we have a sick population equalling that of Guy's Hospital in number; and, as far as regards medical diseases, probably not much below it in the proportion of serious cases requiring careful attention. What is almost more important is the fact of the union under one roof of a large hospital, a lunatic department of considerable size, and a small but constantly-replenished lying-in department; since it is plain that we have here a complicated system of management, demanding very ample and liberal means for working it, and an organization of the best kind, if it is to be properly conducted.

We have no reason to suppose that the guardians of Lambeth are exceptionally remiss in the performance of their duties. On the contrary, certain facts which we observed, in that department of the workhouse which it was our object to inspect, rather prepossessed us in their favour; and it was, therefore, with some surprise that we read the account of the gross abuses prevalent in their casual wards which has lately been so forcibly narrated in the columns of the Pall-mall Gazette. But, on reflection, it is easy for us to perceive that such abuses would naturally result from the application to the singularly difficult problem of tramp-management, of that defective knowledge of which their infirmary, good as it is in some respects, fully convicts the Lambeth guardians.

The workhouse buildings form a long rectangle, divided into two completely enclosed squares, which contain the male and female departments respectively. On the whole, the situation might be called tolerably open, since there are streets on three sides of it (that on the east being a very wide one), cottage gardens on the fourth, and on the south side an extensive view of the country over the tops of some low houses. But this advantage is neutralised by the improper form of the buildings, which impedes the free circulation of air through the premises. The majority of the severe cases of acute and chronic disease are warded in the buildings on the north and south sides of the enclosure: most of these wards have two rows of windows, and their aspect helps to render them cheerful. The staircases are by no means well calculated for assisting ventilation by diffusing currents of air. The buildings have also the objectionable feature of great height; and the wards which are especially devoted to the more severe cases of acute illness are on the third story. As regards the wards themselves, we must notice, in the first place, that the cubic space varies between 600 and 600 feet, or more than the latter allowance in summer. The defects which would inevitably result from this important deficiency in the first element of ventilation are fortunately somewhat mitigated by the careful attention paid to subsidiary means by the medical officer. Nothing, however, con atone for the want of proper cubic space; and it is certain that some of the infirm wards must become very foul at times, especially when (as at night, in the absence of any proper attendant) the windows are closed. In one instance a more flagrant defect woe noticed, the windows of an infirm ward having been deliberately blocked up by the erection of the new casual wards: here the ventilation was extremely bad. With regard to the arrangements and furniture of the wards, we may remark that the bedsteads and bed furniture are good, with the exception of the single mattress, which is made of flock, and in several instances was found lumpy and bad. The subsidiary appliances and comforts (e.g., bed-rests, bed-pulls, screens, stomach and foot warmers, &c.) were deficient on the occasion of our first visit; but we are glad to say that there has been a considerable improvement since that time. As regards the means of washing, the great defect must be noticed, that nothing like a proper system of bath rooms or lavatories attached to each ward exists; but, on the other hand, a separate handbasin is provided for each patient, there is a very plentiful supply of clean towels, and much pains seems to be taken to ensure that the ablutions are carried out in a decent and sufficient manner. Hot water is provided in nearly every sick or infirm ward by means of a boiler, and is constantly at hand. The waterclosets are in several instances unsatisfactory: in the first place, some of them are inside the wards; and, secondly, we noticed one or two in which there was a very deficient water-supply. On the occasion of our first visit two closets smelt very badly, and on cross-questioning the nurse with respect to one of them it was apparent that complete absence of water-supply for as much as twenty-four hours together was not an uncommon circumstance. We believe that our remonstrances produced a beneficial change; for when we last visited the house nothing like a bad smell was noticed in any of the closets. But it is clear that the present system of waterclosets can never work well; for they are deficient in numbers, and often badly situated.

The most important circumstance connected with the management of the sick in Lambeth Workhouse is, after all, their numbers in proportion to the medical and nursing starff. The surgeon, Mr. Bullen, is precluded from private practice, and actually spends the greatest part of every day in the building; but he is non-resident, and there is no one on the spot to attend to the numerous cases of emergency which must be constantly occurring in the night and at other times among such a large sick population. Mr. Bullen receives £300 a year; a sum which at first sight seems liberal, but which is really a very inadequate remuneration for the services of a medical officer who devotes his whole time to the service of the guardians. As an illustration of the kind of work which is included in his attendance on the seven or eight hundred sick and infirm inmates, we may mention that the lunatics number about seventy, and that among these are by no means a small proportion of severe cases of mania, and of insanity from drink. There are no proper means of seclusion for such cases, and the medical attendant is consequently exposed to a very anxious responsibility in caring for these unfortunates before they can be removed to an asylum — a process which appears to be much delayed in some instances.

The most acute cases of sickness are lodged in two wards (one male and one female), which are called the "sick wards," and contain about seventy patients. These wards, though far too crowded, are most creditably managed; they are generally filled with cases so severe in character that they might well occupy the entire attention of one medical man. By the care of the surgeon, diet and prescription cords have been introduced; these are regularly filled Tip. The guardians provide all drugs, and there is a very intelligent resident dispenser, who is, however, very improperly burdened with the additional duties of superintendent nurse of the mala infirmary. There appears to be no limit set to the discretion of the medical officer in ordering drugs of an expensive kind, and he likewise possesses and freely exercises authority in ordering special articles of diet for the sick and infirm. But the enormous number of cases requiring frequent medical attention in the house make it impossible that the surgeon should do full justice to his duties.

Equally conspicuous is the inadequacy of the nursing staff. On the male side there are — the dispenser aforesaid, who is also superintendent of the infirmary, and a male superintendent of lunatics; on the female side there is a superintendent sick-nurse, who also acts as midwife, and a superintendent of the lunatics. These are the only paid nurses for a body of sick people as large as, and scarcely inferior in importance to, the population of one of our largest hospitals. The remaining nurses, seventy-two in number, are all of them paupers; they are remunerated merely by a somewhat superior diet to that of the house; for the most part they take their meals in the wards to which they are attached; and, in short, there is nothing in their position to give them any marked superiority over the commonest paupers. Owing to the vigilance of the surgeon and of the superintendent of the male infirmary, we believe that the ward management is carried on, at least in the daytime, without any of those graver negligences which have been remarked in some workhouse infirmaries. But it is only necessary to mention that there is no organized system of night-nursing — nothing but pauper helps detached for this duty on particular occasions — to show the unsatisfactory basis on which the whole management rests. Often as we have had occasion to protest against this common fault of workhouse infirmaries, we have never been more struck than at Lambeth with the sufferings it must indict on numbers of helpless, diseased and infirm persons, many of whom must frequently be in grievous need of feeding and tendance in the course of the night. With no resident surgeon to give an occasional glance at the wards in the night, with no regular night-nurses, and with no separate infirmary kitchen, it is obvious that the condition of the infirm wards, especially during the night, must be highly unsatisfactory.

The house diet of the Lambeth Workhouse is made up as follows:— 90 oz. of bread, 11 pints of gruel, 15 oz. of cooked meat, 36 oz. of potatoes, 28 oz. of suet or rice pudding, 3 pints of pea-soup, and 3 pints of broth per week. On comparing this scale with those of twenty-two workhouses, which are now before us, we find that it holds a medium place as regards liberality, though in our opinion it is decidedly insufficient. The old people, we are glad to notice, can obtain daily half a pint of beer at the discretion of the medical officer, in addition to the trifling allowances ordered by the Poor-law Board; but this, and the other additions or alterations which the surgeon is obliged to make in an immense number of cases, must entail great labour on him, in addition to his more strictly medical duties. There are various tabulated forms of sick diets, but it is hardly necessary to record them at length, because the whole diet of the sick is bona fide at the discretion of the medical officer, and is constantly modified by him. As an instance of the liberality which is very properly exercised in cases of acute sickness, we copy the following diet of an actual patient suffering from diffused abscess in the leg with much prostration:— Breakfast, 6oz. of bread, 1 pint of tea; dinner, 4oz. of bread, 8oz. of cooked mutton, 12 oz. of potatoes; supper, 6oz. of bread and butter, 1 pint of tea; besides extras as follows:— An egg, 1 pint of porter, broth, 4 oz. of wine, and eventually 6oz. of brandy. The only "sick diet" which struck us as deficient in nutritive value is No. 6, used for the lying-in ward; it consists of 16 oz. of bread, 2 pints of tea, 1 pint of strong beef-tea (1 lb. of beef to the pint). This strikes us as very low, unless it be intended merely for the actual day of confinement, which does not seem to be the case.

The quality of every kind offered appeared to us to be very good; the cooking also is fair. But the sick diets would be much more advantageously prepared if there were a separate infirmary kitchen; the want of this is an obvious evil.

Though it scarcely lies specially within the scope of our inquiry, we may naturally be expected to say something of the condition of the "casual" wards which have recently attracted so much notice. The shed in which the writer in the Pall Mall Gazette was condemned, for his sins, to sleep, was not employed as a sleeping ward at the time of any of our visits; and the regular casual wards presented nothing remarkable except that, if anything, they were rather above the average level of apartments provided for this purpose at other workhouses. Nevertheless, they are a very proper subject for some remarks we desire to make. The ventilation was remarkably deficient — a common thing in casual wards. It was obvious that when the place was filled there would be much less than 300 cubic feet of space for each sleeper; and this, combined with the insufficient window ventilation, had the evident effect of concentrating the noxious vapours which exhale from the filthy creatures who sleep in these wards to a really dangerous extent. Our visit was paid at four o'clock in the afternoon; yet, even then, the air of the place was heavy with the genuine tramp odour. If our readers will take ' the trouble to reflect on the frequency with which these wretched wanderers bear about them the seeds of latent typhus, they will gain ? considerable inkling of one way, at least, in which the persistence and steady growth of that disease in London is fostered. Coming out of the tramp wards into the adjacent yard we were assailed by another and quite a different stench; on inquiry we found that this proceeded from a large wooden covered tank, placed against an adjoining wall, and filled with the decaying vegetable refuse and slops of the house. We ascertained that this mess of mistiness was stored in this place by the direct orders of the master, and that it was habitually allowed to remain there for a fortnight at a time, in order that it might ferment itself into a highly stimulating and delicious wash for pigs! The odours from it ascend, in the meantime, to the windows of the casual wards and of the inferior officers' sleeping apartments. This arrangement hardly needs to be characterised; and it would be significant enough if merely the result of carelessness, but we believe that ' it was made with great deliberation and is regarded with some pride.

There is nothing in the mortality occurring at Lambeth to call for special remark. Cases of epidemic disease, when it is practicable, are sent away to the hospitals. At the same time there is an excellent infection ward, in which cases of' infectious disease, which cannot be at once got rid of, are isolated; and it affords us much pleasure to record the success with which a very large and sudden influx of small-pox cases, about two years ago, was dealt with in this manner. Of forty-two cases, from first to last, only two died; and the disease' did not spread at all to the rest of the house, owing to the precautions token. No other epidemic of any consequence has visited the house for a number of years past.

We sum up our general conclusions on the Lambeth infirmary as follows: —

1. The buildings must be wholly condemned as a residence for the severely sick. A new infirmary ought to be built on modern principles.

2. The medical officer ought to be more highly paid, and be provided with one, or more properly two, resident qualified assistants possessed of hospital experience.

3. Not less than twelve paid and trained nurses would be required, in order to place the nursing department on a decently proper footing, including regular night attendance.

4. An infirmary kitchen ought to be established; also a special diet provided for the aged and infirm, whether under medical care or not.