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

SOUTH DUBLIN UNION.

As the city of Dublin is divided by the river into north and south portions, it has two unions corresponding to these divisions; that in the south being the larger, and regarded by the authorities as somewhat of a model to other unions. The group of buildings stands on the outskirts of the city, on the road to Inchicore; they are clustered round an old Foundling House, which, with the old Houses of Industry scattered over the country, were taken over by the Poor Law Commissioners when, in 1840, the Poor Law was introduced into the country. The blocks, of varying size and character, are built of grey stone, which gives a prison-like aspect to the exterior, and the whole forms a large establishment capable of accommodating 3,000 or more inmates; these include able-bodied, infirm, sick, lunatics (that is, feeble-minded and idiots), and children. The government of the establishment is in the hands of the master and matron.

The sick department is divided into "Catholic" and "Protestant" Hospitals, and there is a separate hospital for the children. The Roman Catholic patients are nursed by the nuns (Sisters of Mercy) and the Protestant by deaconesses, some of whom have been trained in the Tottenham Hospital, and formed part of the body under Dr. Lazeron. The nuns are untrained as nurses; they also nurse in the Children's Hospital.

The hospitals are supervised by a resident medical officer, who has 1,000 or more patients under his care, and there are three visiting doctors, each of whom has charge of one department. The matron who, in the absence of the master, kindly accompanied us round the building, gave us every facility for inspection, and all the information in her power. The wards gave us the impression of being overcrowded, an impression which a closer view confirmed. They are long, narrow rooms, not lofty, and as the windows are small, and not carried up to the cornice, the ventilation is imperfect; the beds are placed side by side, with only enough space between them to stand in, and that amount of space is not always possible; in some of the wards the rafters are unceiled, and on the top storeys the roofs are pitched. The walls have a smooth surface painted in two colours. As these wards are occupied by the patients without the relief of a day room, and as in winter they would be more crowded, with less ventilation than on a summer day, and with more artificial light, we felt convinced that the cubic allowance was insufficient. The ground plan of the hospitals forms three sides of a square, the Protestant Hospital taking one side, with the male patients on the top floor and the females on the two lower floors. The Children's Hospital stands adjacent and accommodates over 100 patients; among these are the delicate children, and those who are unfit for school life.

The patients are classified as medical, surgical, and phthisical. Besides these a few female lock patients are kept apart and retained under treatment because they have children, but the bulk of these cases are sent to the Government Lock Hospital. Mild cases of epilepsy are treated in these wards; simple idiots are also brought into the wards for treatment. A small bed card was over each bed; it was the regulation card, giving no clinical information. We noticed also a few temperature charts. The class of cases are such as would be found in any general hospital; indeed, there could, be no difference except that there were more cases of hopeless paralysis and senility.

The nursing in the part under the nuns is carried on under the triple disadvantage of being done by an untrained staff, of the nursing of the male patients being confined to supervision only, and of the night nursing being in the hands of a different staff. We noticed at once the difference between the work of the trained and untrained nurses, though the nuns brought system and order into their wards, their work was just lacking in that attention to details of nursing which can only be learnt in a hospital. Pauper help is very largely used in nursing the sick; the supply of nuns or of deaconesses is about one to each large ward containing from 45 to 50 beds, or to a group of smaller wards, so that too mush reliance is placed on the inmates, or "deputies" as they are called. These paupers receive extra rations, and have some privileges, besides such bribes in kind or money as they may may receive from the patients. On the female side most of the deputies are women of indifferent character, retained in the house because of their children; on the male side we noticed some able-bodied deputies who ought to have been earning their living outside, and off the rates. We omitted to mention that there is a wardmaster — an officer responsible for the control of the ward under the nuns.

At night there is one nurse for the male side and one for the female side, assisted by a staff of deputies, one or more of whom sit up in each ward. By this arrangement a large and important hospital is practically nursed by paupers, especially at night.

The patients in the separation ward appeared to be looking after themselves, or at best were in charge of an inmate. It is hard to conceive a more dismal hole than that in which we found these cases — a small, dark ward, crowded with women and children of a very low type, dirty and untidy in their persons and clothing, the unfortunate infants uncared for except by their mothers; the whitewashed walls, dirty floor. and pitched roof, small windows, low wooden frames, and straw beds, presented a picture of official neglect which we shall not soon forget. The door is locked on these inmates from 7 P.M., and they are left to get through the night with such decency and cleanliness as can be obtained by the use of pails, etc., and under no vestige of control.

The children's hospital is a bright and cheerful spot among these dreary surroundings; the wards are large, walls painted in two colours, cots down the middle, and small bedsteads round the walls, with toys, pictures, and plants giving it a pleasant appearance. The boys' and girls' wards duplicate each other on the ground floor. There is also a good playground, but no dayroom to relieve the wards in bad weather. The children are treated here until the age of 14 or 15. The hospital is nursed by the nuns and the inmates. The cases include every variety — the chronic hip-joint, or spinal case, with cases requiring active surgical treatment, or of acute medical diseases; some convalescents were running about.

The nursery for healthy infants under 2 years occupies two floors, that for the day being on the ground floor, and above is the room where the mothers sleep with their infants. In the day nursery there was a large number of babies, some in wooden cradles or being nursed by their mothers. The cradles are filled with straw, covered by a sheet and blanket; some of the cots that we looked into had wet sheets and straw; in some the food had been upset and not cleansed; many of the infants were untidy and ill cared for, the whole nursery showing want of control and supervision. The atmosphere, in spite of cross ventilation, was very close; there was no sense of freshness, but a very powerful odour of uncleanness. There is an officer over the nursery, but she is much handicapped in her work by the ignorant mothers, who are very difficult to manage. The lavatory and bath room attached to this department was littered and untidy, and anything but wholesome.

Besides these two departments for children, there is a probationary ward for the detention of fresh admissions without their parents for ten or more days at the discretion of the medical officer before they are sent into the schools.

The aged and infirm, as is the case in all Irish workhouses, form a separate class, and are located in blocks quite away from the hospitals. That for women was one of the best parts of the house; they are in small huts which run three sides round a garden where are seats, flowers, and grass, all of easy access from the wards. The wards themselves had a bright, home-like appearance, the cross-lights and the distance from the high buildings allowing of plenty of sunshine. The old men are not so well placed; they are in one of the stone blocks, their wards are dark and low-pitched, are crowded, and altogether are destitute of the comfort that one looks for for the aged.

Here we were introduced to the "harrow" bed, which is quite a feature in an Irish workhouse; it consists of five parallel wooden bars supported at the foot on an iron crossbar and two iron legs, and at the head it rests on a continuous rail fixed on iron uprights about 6 inches from the wall, or, failing the rail, its place is taken by two legs; there is no bed head, the tick and pillows resting against the wall, and there are no sides. The bed is 2 feet 3 inches wide, stands about a foot from the ground, and on this is placed the straw tick. A variation of this bed is two low trestles, supporting two or three planks.

These old people are under the care of inmates, themselves only one remove from the stage of infirmity; no one is supposed to be in these wards who requires any help during the night, and that is as well, taking into consideration that the infirm are locked in their wards at 7 P M., with only such assistance as they can render each other; and also that the only sanitary appliances are the commodes or pails in the wards. We did not notice anything but benches for the old men, either in their day room or wards.

The lunacy wards are beyond these blocks, and separated from them by locked gates. The wards are large, but very full, the beds being placed in double rows back to back down the middle of the ward, as well as down the sides, an arrangement that appeared to us to be an unusual one for that class of patient. some of the more helpless cases were in crib or box beds filled with straw; the wards were distinctly overcrowded, for the ceiling was low-pitched and the windows small. Several of the inmates were in the court, but many were in bed. One recent admission, the victim of puerperal mania, was disturbing the whole ward by her cries, and arousing some of the patients to restlessness; this patient was restrained in bed by the usual lunatic's nightgown, and the matron was going to put on extra pauper assistants for the night. We were informed that there is no padded room, as violent cases are sent at once to the asylum; but in this case, the attack being recent, the doctor wished not to send the woman to the asylum. There is a great want all through the various departments of small wards for isolation. These wards are under the charge of officers, but they are not trained in lunacy work, and the number of patients under their care, amounting sometimes to 60 or more, makes it quite impossible for the attendants with only the help of the deputies to do more than keep these unfortunates in their places; indeed, it appeared to us that neither in their accommodation nor treatment was much done for these unhappy patients. The male lunatics are similarly circumstanced, if possible more crowded.

The maternity block is near the gate, and is a small self-contained house, accommodating 40 beds in four wards. On the ground floor there are two wards for the labour cases; the wards are used indiscriminately, there being no separate room for the confinement, and above are the wards for pregnant women. There is no day room. The walls are whitewashed, and there is a want of light, the block being overshadowed by taller buildings. The number of confinements varies from 80 to 100 per annum. The women are attended by a midwife, who at the time of our visit was incapacitated from duty by a poisoned hand; her place was taken by a midwife from outside. Here also there is no small ward for the isolation of an infected case, which, considering the large number who pass through the wards, must sometimes present itself.

We were surprised to learn that there are no sanitary appliances in this block. The matron showed us a privy at some little distance, to which everything has to be carried. There is no bath room, slop-sink, or any of these adjuncts to nursing; and as there appeared to be structural space for the addition of these offices, we are at a loss to discover the cause of their absence.

The wards are heated by open fireplaces; many of them are old-fashioned and wasteful of heat and coals. In the winter there are besides steam-pipes running round the skirting of the wards; these pipes are of very large diameter. The windows throughout the buildings are small, set in heavy frames, and they do not reach the cornice. Sometimes they open on a pivot, and otherwise the upper half of the sash falls inwards, on a toothed bar; as the frames are heavy, these are awkward to manage. Gas is used throughout the workhouse.

The sanitary system is in course of alteration, many new closets are being added to the wards, and additional bath rooms with hot and cold supply are being fixed; these will be a great improvement. The new closets are fitted in the modern style with the flush, and they are on the landings near the wards; this situation appeared to us too near to be sanitary, as the space did not admit of an intercepting lobby. There are some closets outside the male wards that are flushed automatically. We were informed that the cistern discharges itself every four hours, but, whatever may be the interval, it is evidently insufficient, as the trough was full of filth, and the fittings, floor. etc., were in a dirty state. There also appeared to be a deficiency in the arrangements for the disposal of foul clothing, as we came across a soiled tick hung over the railing outside a ward, making the air quite insanitary; we were informed that it was on its way to the laundry.

The laundries and kitchens are attached to each hospital, and are under the control of the officers; some of them were well-appointed kitchens, with suitable appliances for expeditious and economical cooking. There are, besides, the main kitchen and laundry for general service. This union kills its own meat; we saw the victims in a paddock close to the building awaiting their turn of sacrifice. The bread also is baked in the house. The sick diet is in the hands of the medical staff; the children are largely fed on eggs and milk. The inmates were assembling for dinner at 2 o'clock; this is surely a long interval for the old and young, the breakfast hour being 8 o'clock.

RECOMMENDATIONS.

The impression that we carried away was that there are too many departments crowded into the space, and that it was quite impossible for efficient control to be exercised over such a heterogeneous establishment. The hospitals alone outnumbered several of the general hospitals in the city, for whose government a far more generous staff is considered necessary. It is a counsel of perfection to suggest the removal of the sick to more modern quarters and sanitary surroundings on the outskirts of the city, but that would be the most satisfactory solution of the difficulty, and such a move is bound to come in time. The staff in attendance on the sick is quite inadequate — 13 nuns and less than half that number of deaconesses for the nursing by night and day of 1,000 sick, for the "deputies " cannot be reckoned on the nursing staff; and then we must take into consideration that the nuns are untrained. We yield to none in our admiration for the devotion of these religious ladies to their work, for the order and system that they have introduced into the wards, and for the care with which they minister to the poor committed to their care; if only to these qualities they could add the hospital training their efficiency would be increased, but as it is, too much of the nursing is in the hands of the "deputies." This union should take its place as one of the large training schools for the workhouse nurses, but until the entire staff is trained and until the deputies are swept away this cannot be done. We would also suggest that the attendants in the lunacy wards should be trained in the asylum, and that their number be increased; that attendants be provided for the infirm wards, whose quarters should be placed close to these wards, for assistance at night in case of emergency; and that the nursery officer should have better assistants; that the infants be placed under her entire charge, the mothers only having access to their infants at stated times. We fear encountering the wrath of the Board as it reads our suggestions, but they are made with an earnest desire to place before the guardians the impressions that we carried away, and we do not hesitate to say, from long experience in these matters, that, after the first outlay, the work would be done with greater economy and efficiency, and the South Dublin Union would take the position that belongs to it of right — that of the pioneer in the matter of workhouse reform.