Medical Arrangements on Passenger Ships
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 an exceptionally large proportion of well-to-do persons.
Owing to the engine-rooms and stokeholds our ship may be likened to a manufacturing town, 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 on shore.
Sea-sickness 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 very serious 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 serious medical and surgical cases. The medical department should therefore be highly efficient and the medical officer experienced and reliable if the safety of the travelling public is to be ensured.
The great majority of ships' surgeons can be classified under one of the following four headings :
- Young men who are just qualified, and have not yet held any resident hospital appointment.
- Men who have tried practice on shore, and have not been successful, generally owing to too free an indulgence in alcohol.
- Men who are entirely without capital, and who have become wearied of "assistant" and "locum" work.
- Men who have temporarily taken to a sea life in seareh of health.
Of these four classes, the last is the one that produces the largest number of reliable medical men practising as ships surgeons.
Alcohol is undoubtedly the curse of the ship surgeon's life, and too great 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 voyage 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 serious 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 certain of obtaining the services of a competent medical man. Surgeons are generally graciously permitted to accept presents from passengers, but I need not point out how unpleasant and unsatisfactory this is.
My own experience is that not more than about 20 per cent, 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 consider the pay quite 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 of her giving time to the nursing of second or third class passengers, even if she is willing to do it as a favour.
Many lines carry a male hospital attendant* who also acts as the surgeon's servant. Of those that have come under my notice, the large majority have been trained in the R.A.M.C.; they have been reliable men. The hospital attendants' duties consist in 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 with the exception of 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 hospital, but 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 or 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 very difficult 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 efficeint medical department at a scarcely appreciable increased cost :
- That the medical officer should be required to have held a resident medical and surgical appointment in a large hospital. That the medical officer be permitted to charge fees to first-class passengers for attendance.
- That a fully-trained hospital nurse be carried. That she have no stewardess duties to perform. That she be liable for service with all sick on board irresppctive of class. That she be under the orders and control of the ship's surgeon.
- 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.
- That one first-class and two third-class hospitals (one for men and one for women) be provided and capable of accommodating 2 per cent, of the souls carried.
- That the hospital floors be tiled or tesselated.
- That the hospital bunks be provided with spring mattresses, bedding, blankets, and linen.
- That hot and cold water be laid on to the hospitals and dispensary.
- That in the tropics the hospitals be provided with electric fans.
- That an operating table (collapsible) and steam sterilizer be provided.
C. General Sanitation.
- 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.
- That either a temperance canteen be provided for the third-class, or that sufficient tinned milk be carried on board to permit of a daily ration of milk being given to all third class children under 3 years of age.
- That a glyco-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 vapourized sulphur for disinfection is undesirable, as it is impossible to prevent the odour pervading a considerable area around the particular cabin where
it is being used, and unnecessary alarm and disquietude is thus caused.
In order to show that my suggestions are not unreasonable, I may state that during nine months' experience as surgeon to a mail ship I have had to perform nine operations requiring an anaesthetic (one a successful laparotomy for perforating duodenal ulcer). Amongst other surgical cases I have had a case of cerebral abscess where operation was refused and the patient died, three cases of appendicitis that recovered without operation, and a case of stone in the bladder with retention of urine.
The medical cases have included pneumonia, phthisis with severe haemoptysis, empyema, morbus cordis, aortic aneurysm, exophthalmic goitre, enteric fever, gastro enteritis, acute rheumatism, bulbar paralysis, locomotor ataxia, general paralysis, acute melancholia, and lunacy with delusions. The infectious diseases list includes variola, varicella, and morbilli.
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 good medium for advertisement to justify any expense that can possibly be avoided, and it is practically certain 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.,
Hugh Wansey Bayly, "Medical Arrangements On Passenger Ships", The British Medical Journal, Vol. 2, No. 2377 (Jul. 21, 1906), pp. 172-173