Medical Arrangements on Passenger Ships - 1906

Sir, —In these days of large steamers of 10,000 tons and over, that carry emigrants in addition to first- and second-class passengers, the total number of souls on board often reaches close on 2,000. We, therefore, have to consider the ship as a small town containing a considerable proportion of well-to-do persons.

Our ship may be likened to a manufacturing town owing to the engine-rooms and stoke-holds, and this, taken in conjunction with the surgical accidents due to rough weather, raises the percentage of surgical cases considerably above that of a town with a similar population onshore.

Seasickness also increases the liability to hernia and miscarriage, and considerably adds to the seriousness of many diseases. The prevention of infectious and contagious disease is of the highest importance in this little community, as the unavoidable crowding and the difficulty in obtaining complete isolation render an epidemic a grave matter.

A ship such as I mention can, therefore, be regarded as a small town particularly liable to infection, and where there is an abnormally high proportion of severe medical and surgical cases. The medical department should, therefore, be highly efficient, and the medical officer experienced and reliable if the safety of the traveling public is to be ensured.

The vast majority of ships' surgeons can be classified under one of the following four headings:

1. Young men who are just qualified and have not yet held any resident hospital appointment.

2. Men who have tried practice onshore, and have not been successful, generally owing to too free an indulgence is alcohol.

3. Men who are entirely without capital, and who have become wearied of "assistant" and "locum" work.

4. Men who have temporarily taken to sea life in search of health.

Of these four classes, the last is the one that produces the most substantial number of reliable medical men practicing as ship surgeons.

Alcohol is undoubtedly the curse of the ship surgeon's life, and too high stress cannot be laid on the importance of only appointing strictly sober surgeons.

It is difficult, however, to see how a regular supply of reliable men is to be obtained under the present conditions, for the pay is so low (£8 to £10 per treatment while at sea only), and the surgeon is not permitted in most lines to demand a fee even from first-class passengers who come on board suffering from some severe malady that requires constant attendance.

Many first-class passengers have, however, told me that they would much prefer not to have free medical attendance if, by paying ordinary fees, they could always be sure of obtaining the services of a competent medical man.

Surgeons are generally graciously permitted to accept presents from passengers. Still, I need not point out how unpleasant and unsatisfactory this is. My own experience is that not more than about 20 percent of first-class passengers that have been under medical treatment ever send the surgeon any fee at all.

Considering the responsibility and the amount of work to be performed by a conscientious surgeon in medical charge of such a ship as I have mentioned, I believe the pay wholly inadequate to attract and retain medical men competent to undertake single-handed all the work that may arise.

The Nursing Arrangement

I find the "nurse-stewardess," like all half-measures, far from satisfactory, as the nurse signs on as a stewardess, and is only liable for service with the first-class passengers.

She is under the orders of the purser, and not of the surgeon. In a full ship, her stewardess duties do not permit her giving time to the nursing of second or third-class passengers, even if she is willing to do it as a favor.

Many lines carry a male hospital attendant, who also acts as the surgeon's servant. Of those that have come under my notice, the vast majority have been trained in the R.A.M.C.; they have been reliable men.

The hospital attendants' duties consist of keeping the hospitals, dispensary, and instruments clean and in good order, in attending to the sick, and in giving the surgeon any assistance that may be required.

I consider, however, that a female nurse would be able to perform all his professional duties except scrubbing the floors and would have the advantage of being able to nurse both sexes.

Under the "nurse-stewardess" and "hospital-attendant'' system, the third-class female passenger is entirely unprovided for. She is often in a filthily dirty condition when admitted to the hospital.

Still, there is no one to wash her or nurse her except her fellow-passengers, and they very naturally almost invariably refuse if there is any question of the case being of a contagious or infectious nature.

That a third-class woman passenger should be entirely dependent on the surgeon and male hospital attendant for nursing appears to me neither civilized nor decent.

If a nurse were carried in the place of a hospital attendant, the only additional cost would be that of a youth, who would act as doctor's servant, and do the rough hospital work, such as scrubbing floors, etc.

With ordinary wooden decks to the hospitals, it is challenging to keep the third-class hospitals clean, as it is impossible to prevent the third class patients from, expectorating, and occasionally vomiting, on to the floor.

I consider that the following suggestions if adopted, would ensure an efficient medical department at a scarcely appreciable increased cost:

A. Staff

1. That the medical officer should be required to have held a resident medical and surgical appointment in a large hospital. That the medical officer is permitted to charge fees to first-class passengers for attendance.

2. That a fully trained hospital nurse be carried. That she has no stewardess duties to perform. That she be liable for service with all sick on board irrespective of class. That she be under the orders and control of the ship's surgeon.

3. That a male hospital attendant, if carried, should have some certificate of training. That he should be under the orders and control of the ship's surgeon.

B. Sick Accommodation

1. That one first-class and two third-class hospitals (one for men and one for women) be provided and capable of accommodating 2 percent, of the souls carried.

2. That the hospital floors be tiled or tessellated.

3. That the hospital bunks be provided with spring mattresses, bedding, blankets, and linen.

4. That hot and cold water be laid on to the hospitals and dispensary.

5. That in the tropics, the hospitals be provided with electric fans.

6. That an operating table (collapsible) and steam sterilizer be provided.

C. General Sanitation

1. That one bathroom (with hot water laid on) be provided for every 100 third-class passengers, one for firemen and sailors, one for stewards and servants.

2. That either a temperance canteen be supplied for the third-class, or that sufficient tinned milk be carried onboard to permit of a daily ration of milk being given to all third-class children under 3 years of age.

3. That a glycol-formalin disinfecting apparatus be carried on board.

As regards the last two recommendations, the diet for third-class passengers and emigrants, though generally ample, wholesome, and well suited to adults, is not fitted for children of tender age, and is thus one of the causes of the sickness and mortality among them.

The use of vaporized Sulphur for disinfection is undesirable, as it is impossible to prevent the odor pervading a considerable area around the particular cabin where it is being used, and unnecessary alarm and disquietude is thus caused.

To show that my suggestions are not unreasonable, I may state that during nine months' experience as a surgeon to a mail ship, I have had to perform nine operations requiring an anesthetic (one a successful laparotomy for perforating duodenal ulcer).

Amongst other surgical cases, I have had a case of cerebral abscess where an operation was refused, and the patient died, three cases of appendicitis that recovered without surgery, and a case of stone in the bladder with retention of urine.

The medical cases have included pneumonia, phthisis with severe hemoptysis, empyema, Morbus Cordis, aortic aneurysm, exophthalmic goiter, enteric fever, gastroenteritis, acute rheumatism, bulbar paralysis, locomotor ataxia, general paralysis, acute melancholia, and mania with delusions. The infectious diseases list includes variola, varicella, and morbidly.

Surely it would be policy to devote a small part of the many thousands of pounds spent in decorating a modern first-class mail steamer to equipping and maintaining an efficient medical department.

The medical department, however, is not considered a sufficiently suitable medium for an advertisement to justify any expense that can possibly be avoided, and it is practically confident that no steamship company will adopt the reforms that I have suggested unless driven to do so by the force of public opinion.—I am, etc.,

Hugh Wansey Bayly, M.A.Cantab., M.R.C.S., L.R.C.P., late Surgeon R.M.S.P. Co.

New Oxford and Cambridge Club.

Dr. Hugh Wansey Bayly, "Medical Arrangements On Passenger Ships" in The British Medical Journal, Vol. 2, No. 2377, 21 July 1906, pp. 172-173.

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