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

ST. PANCRAS.

The St. Pancras Workhouse is in every respect one of the most important in the metropolis, not only on account of the very large number of inmates (1869, according to the estimate of the Poor-law Board, but really a much larger number at times) which it contains, but especially on account of the large number of sick persons who are treated within its walls. It possesses, in the first place, a special separate infirmary; this is placed in a four-storied building which occupies more than half one side of the large rectangle formed by the workhouse buildings. The "infirm" wards occupy the whole of another block (two-storied), which stands on the same side of the enclosure, and also the two upper stories of an extensive range of buildings on the opposite aide. The "insane" wards fill the lower story of the latter range. On the 28th of January, 1865, as appears from the official return procured by Mr. Farnall, there were 232 inmates of the infirmary, 746 inmates of the infirm wards, and 116 insane,¹ making a total of 1112 persons more or less under medical care and inspection; nor does this estimate take any account of the lying-in department, or of the nursery, with its important population, 36 in number.

If we were to take only the infirmary proper and the insane department as under strictly medical charge, we have here an hospital which equals in size and importance such establishments as St. George's or the Middlesex Hospital. Under these circumstances, the first question which an observer naturally asks is, whether the guardians have provided a staff of medical officers and of skilled nurses which in any way corresponds to the needs of an hospital of this size. The class of cases admitted to the infirmary and insane wards are the subjects of diseases very nearly as severe, and requiring as much and as continuous medical attention, as those of any metropolitan hospital or county lunatic asylum (with the exception of the surgical department); and the combination of the two establishments under one roof renders the task of medical administration a singularly difficult and responsible one. What, then, is the strength of the medical staff ? There are two resident medical officers to attend to the whole of these enormously burdensome hospital duties, who are also charged with the care of the lying-in department, the 700 and odd infirm persons (many of whom are seriously ill), and the general medical superintendence of the house! That is to say, the medical staff is about one-fourth as large as would be tolerated for an instant by the managing committee of any charity for the sick which was open to the light of day and the criticisms of the medical profession and the public.

The fact which we have now mentioned would raise the suspicion that the guardians of St. Pancras are ignorant of their duties towards the enormous and heterogeneous population of their workhouse. At the first glance this suspicion does not seem to be borne out by actual inspection, The natural advantages of the site of the workhouse are very great: the situation is elevated, and the soil gravelly; and although the buildings are arranged in the vicious form of a rectangle, their division into separate blocks allows of a considerable circulation of fresh air. The general drainage and the water-supply are good. The infirmary wards are, with few exceptions, light and cheerful, with two rows of windows; and the insane wards may be described in the same terms, with the exception of a gloomy apartment tenanted by female epileptics. Several of the infirm wards, however, are low-pitched and very dark; and the block which contains the lying-in department and the nursery is objectionably placed, being so situated behind other buildings that its light and air are seriously interfered with. This whole department must be described as unhealthy and improper in its arrangement. The furniture of many wards is insufficient: thus a large number of the bedsteads were found by actual measurement to be only 5 feet 8 inches in length — a great cruelty to the patients; and the single flock mattress which is allowed to each bed was, on the occasion of our first visit, found lumpy and uncomfortable, in many instances, from its inadequate stuffing. We learned that the guardians, from motives of economy, had actually reduced the allowance of stuffing for each mattress from 40lbs. to 25lbs! There appears to be an improvement in this respect at present. There are only about four hand-basins for the washing purposes of each of the larger wards, containing about thirty-one patients. The average allowance of cubic space to each bed in the infirmary proper is 531 feet in the men's side, and 615 feet in the women's side; and although by the aid of open windows and Arnott's ventilators the air may be kept tolerably sweet in warm weather, yet with a lower temperature and the consequent inevitable closing of ventilating openings, the atmosphere must be very close, even were the nominal number of inmates never exceeded. But by a gross abuse it has become the practice to allow great overcrowding in the winter months, so much so that the floors of some wards have been spread with beds for patients who could not otherwise be accommodated. And the allowance of cubic space in some of the infirm wards is very far below the above-mentioned standard. Our attention was especially attracted also to the nursery, in which thirty-six children were crowded together in an unhealthy manner; the apartment smelt bad, and we were shocked to find that, although the majority of the children were washed in this room, there was but one tub for them all, and no other convenience for ablution. There was a great deficiency of towels throughout all the wards, and this circumstance was unpleasantly obvious in the men's itch and syphilis ward. On inquiry, we find that this neglect is the fault of the nurses only. Hot and cold water taps were found in each ward; but there are no proper bath-rooms or lavatories, and only four movable baths to the whole infirmary. The ventilation of several waterclosets which adjoined infirm wards was found to be deficient. One closet, in particular, smelt very offensive; the tap for flushing it would not act, and the pan was very foul.

One of the consequences of the various onslaughts which have been made from time to time on the abuses of St. Pancras Workhouse is the adoption of paid nurses in numbers which are unusual in workhouses: altogether there are sixteen of these functionaries, whose united salaries amount to about £340 per annum. Their good influence is plainly visible in the general style of neatness and efficiency, comparatively speaking, which marks the nursing in this establishment; still it is only an instalment of what is urgently required to be done in this direction. The night-nursing, for instance, is still committed to the charge of pauper nurses, although there is a "night superintendent," whose duty it is to watch over this department in the infirmary. The paid nurses in the insane department deserve especial commendation, though they are far too few in number, and there is no really efficient arrangement for night-nursing of the insane.

The insane department of St. Pancras Workhouse possesses special features which require notice. As has been recently shown (in an article in the Journal of Mental Science for October), the guardians of several unions, and notably those of St. Pancras, have latterly shown a disposition to attempt the treatment of all cases of insanity occurring amongst paupers in the workhouse, rather than incur the larger expense of maintaining them in County Asylums. It is quite impossible that this can be done properly with any such organization as can be found in existing workhouses. Here, for instance, at St. Pancras, there are at present no less than 140 insane patients, presenting every variety of mental alienation, and great numbers of them suffering from the more severe and acute forms of the disease. The only medical supervision which they can have is that of the two excellent and conscientious resident officers, who are already extravagantly overworked by having 240 acute cases of sickness and more than 700 infirm patients under their charge; and it is plain that such medical attendance is altogether inadequate to the necessities of the case. A few good paid nurses (one man and three women) have been provided, and some praiseworthy attempts have been made to give the wards a cheerful appearance and to furnish the patients with amusements. But the day-rooms, especially that for men, are too small; there are no means of secluding violent male cases except in the padded rooms; the exercise-grounds are miserably confined; and there are none of those opportunities for healthy labour, especially in the open air, which are so particularly necessary for melancholic and for many demented patients. We found an entire absence of mackintoshes for wet cases, and only one air-cushion in the whole department. In short, there is a superficial and mischievous imitation of proper asylum treatment, such as can alone be expected to furnish a large proportion of cured or improved cases of insanity; and we must repeat the protest often made by the Commissioners in Lunacy against the cruelty and shortsighted folly of the guardians in attempting to charge their meagre establishments with the additional responsibility of maintaining insane wards for any but the most harmless and incurable cases of imbecility. Even the object of economy is not really gained by it.

The medical officers — Dr. Roberts, and his assistant, Mr. Butt — are both provided with comfortable apartments in the infirmary, and with board, firing, gas, washing, &c. Their salaries are £160 and £85 per annum respectively. All drugs are found by the guardians; and a salaried dispenser is kept, who makes up all medicines.² Full liberty of action is said to be accorded to the medical officers, both as regards the use of expensive drugs and of extra articles of diet. So far as these things go, it may be said that the position of the medical officers of St. Pancras Workhouse is a satisfactory one. But we must again remark, that it is utterly impossible for them to execute thoroughly well the work which is put into their hands; and we can only say that great credit is due to them for the zeal with which they endeavour to carry out the duties of their office.

The class of diseases admitted to the infirmary is, as we have already observed, nearly the same as would be found in an ordinary hospital. With regard to the prevalence of epidemic affections, taking the six years from 1858 to 1863 inclusive, we find the following history:— In 1858, an epidemic of measles, with much fatality; in 1859 again measles, though not so severe; in 1860 (the children having now been removed to the Hanwell schools, with the exception of a limited number of the younger ones) there was an almost entire exemption from epidemic disease; in 1861 and 1862, however, scarlatina and measles prevailed with severity, and there were several cases of erysipelas and puerperal fever in the lying-in ward; in 1863 there was severe and fatal small-pox, a good deal of measles, and a few cases of erysipelas, pyaemia, and puerperal fever. In earlier times St. Pancras Workhouse acquired a bad notoriety for harbouring fatal forms of continued fever; but since the sanitary improvements which followed on the Government inspection by Dr. Bence Jones, in 1856, matters have improved. At present zymotic diseases are, as far as possible, excluded from the house, and, if accidentally admitted, are sent away to the Fever Hospital. The average mortality from all causes, during the seven years from 1857 to 1863 inclusive, was 410.85; the respective annual numbers being 347, 438, 376, 472, 464, 428, and 434. The average mortality, though large, might, perhaps, be accounted for by the numerous circumstances which are known to operate unavoidably on the death-rate of workhouses. But it is certainly remarkable that the death-rate should have leaped from 345 in 1860, to 472 in 1861, seeing that this cannot be accounted for by zymotic diseases, which caused only 29 deaths altogether in the latter year; in fact, the mortality from this latter cause is too small to account for any of the fluctuations during the seven years referred to. It might be conjectured that the distress amongst the poor which was caused by the American war was the source of the high mortality of the last three years, by crowding the workhouse with an unusual number of debilitated and diseased persons; but there is no such theory to explain so high a death-rate as that which occurred in 1858 — viz., 438, and the impression left on our minds is that defects in the management must from time to time have influenced the mortality in a very considerable degree. To sum up our observations on the St. Pancras infirmary:—

1. We report that the wards of the infirmary proper and the insane department are in themselves deserving of praise; but that the infirm wards, the nursery, and the lying-in wards, are by their construction unfit for the reception of sick persons.

2. All the wards are deficient in their allowance of cubic space, even when but moderately filled; and the practice of overcrowding, which has been customary in the winter season, must render the wards in which it occurs unhealthy.

3. The furniture and conveniences, even of the infirmary wards, are insufficient; that of some of the infirm wards very decidedly so. The waterclosets are in several cases highly objectionable.

4. The nursing department requires further development by the engagement of additional paid nurses, and particularly by the establishment of a proper system of night-nursing.

5. The medical staff ought to be considerably augmented.

6. The present large insane department ought to be abolished, and only such cases of mental disease should be admitted as are chronic, incurable, and perfectly harmless. All cases of mania, of melancholia, of insanity from drink, and of epilepsy, ought to be sent to the county asylum.

On the whole, we are able to report that the St. Pancras infirmary is one of those which might, with certain modifications of structure, and with an improved management, be developed into a good pauper hospital. This being the case, we regret to learn that it probably cannot be retained, but will be sold to a railway company.

¹ On the occasion of our final visit, a day or two since, the numbers were much higher than this, every department being fuller; and the general population of the house was more than 100 above the estimated number.

² On further inquiry, we learn that the dispenser, instead of being constantly resident on the premises, as of course he should be, comes at nine in the morning, and leaves at four in the afternoon! All the dispensing needed at other times is thus thrown upon the unfortunate medical officers.