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THE ROYAL COMMISSION ON SOUTH AFRICAN HOSPITALS.
349 rationalism as applied to the treatment of a before me. A man, 35 years old, was a great sufferer from indigestion, and had become pale, emaciated, nervous, and irritable. He went to the continent and consulted several specialists there. They drew off the conte ts of the stomach at various intervalsafter taking food, and examined them chemically with a view to discovering the power of the stomach to digest different articles of diet, those which were not properly digested being removed from the dietary until finally the patient wasrestricted to three or four. The amount of fixed and free acids was also carefully estimated and special drugs were administered in order to correct certain defects that the calculation revealed. The result of this very scientific treatment was that he steadily lost weight and that he got more anasmic, more irritable, and more nervous. Yet this treatment all sounds very plausible, and the physician who adopts it, or the like of it, in such a case as this, would no doubt persuad himself, and perhaps others,’hat he is very scientific and amdst advanced and up-to-date exponent of scientific medicine ; but he is really guilty of the worst form of pseudorationalism. When I saw this patient he was a veritableskeleton. I did not examine his stomach. I found that he was a great reader, that he had astigmatism, and that his teeth were not good. As he was in a very exhausted state I had him put to bed and fed up. There was no need to be very particular about his diet, for from the very beginning he digested his food quite well when the sources of irritation in the eyes and teeth were removed. If the stomach had method. not digested the food then I should have fed the patient The truth of my contention is well shown by observing per rectum and given the stomach a rest. I should, in fact,. the principles which govern the ophthalmic surgeon in his have kept to a common-sense rationalism all through: drug treatment. It is essentially routine. Let anyone visit the out-patient department of a hospital like the Moorfields Hospital, and he will find that the surgeons there trouble themTHE ROYAL COMMISSION ON SOUTH selves very little about rationale in their employment of drugs. For each affection of the eye there is laid down a routine AFRICAN HOSPITALS. drug treatment which has been tested over and over again, and the best way to learn how to employ drugs most effecTHE Commissioners to consider and report upon tively in these diseases is first to learn to identify the diseases, the care and treatmentappointed of the sick and wounded during theand then to fix in our minds the routine treatment for each of them. A further and even more convincing proof of the present Ssuth African campaign, in submitting their report correctness of my contention is afforded by the drug treat- state that they have divided it into four parts together with ment of diseases of the skin. Probably in no class of disease the minutes of evidence and an appendix. are drugs employed so effectively as in these, and it is In Part I. is given a brief account of the proceedings certain that the methods adopted are essentially routine. taken to enable them to discharge their duties.. Some Were a physician having no knowledge of the routine observations are added upon the evidence and upon the work treatment of these affections to attempt to cure them on done by the Commission. a priori considerations he would make a sorry mess of it. To In Part II., without dealing with the particulars of the be successful he must first learn to recognise them, and various complaints made as to the care of the sick and next to apply the routine treatment of the experienced wounded in the present campaign in South Africa, they state specialist. certain conclusions come to by them on various points of a. I am not, of course, contending that we should banish all character. They also refer to some facts important rationalism from our drug treatment: what I am con- generalborne to be in mind when dealing in detail with those tending is that we should rely mainly on experience. We complaints. are guided by rational considerations when, in a case of In Part III. they investigate the complaints so far as they bronchitis, for instance, we give a sudorific to make a were of a character to require special notice and state the dry skin act, an aperient to relieve constipation, or an conclusions come to in regard to them. in to a viscid We can, fact, expectorant liquefy sputum. In Part IV. they recommend some steps being taken with a rarely wholly eliminate the factor of rationalism. I merely view of remedying in the future defects observed by them in wish to insist that it should be kept within proper bounds. the campaign. As with drug treatment, so with treatment in general : We shall deal with the whole report in detail. For the we should, as far as possible, rely upon sound routinewe content ourselves with reprinting the suggesroutine which has been tried and approved-while at the present tions of the Commissioners with a view of remedying certain same time we make proper use of rationalism. The kind of defects in the Royal Army Medical Corps, as reference to ’’ rational" treatment that I deprecate is that in which the these suggestions is made in a leading article this week. is for with his ever physician meddling patient, watching the symptoms from hour to hour, and adopting special SueaESTIONS WITH A VIEW OF REMEDYING DEFECTS IN THE ROYALARMY MEDICAL CORPS. measures to combat the morbid processes which he believes In previous parts of this report, and especially in Part II., we have to underlie them. I have already condemned this pernicious mentioned several matters connected with the Royal Army Medical method in another place and in the section on the vis Corps as at present constituted, and the care of our sick and wounded, medicatrix. A broad, common-sense rationalism-not a in which improvements are required. The extent to which, and the in which, these improvements can practically be made, require meddling, finicking, pseudo-rationalism-is what is needed. way detailed and careful consideration by military and medical experts. Thus, if there is a source of peripheral irritation-astigmat- We recommend the appointment at some early convenient time of a. ism, impacted cerumen in the auditory meatus, a carious departmental or other committee of experts to inquire into and report the steps needed to effect the following objects :tooth-we seek to remove it; if a patient is over-burdened upon 1. The establishment of the staff of officers and orderlies of the Royal with fat we reduce his weight ; if he is emaciated we try to Army Medical Corps, and its equipment, on a scale sufficient to enable make him fatter ; if he eats too quickly we urge him to it to discharge adequately the duties ordinarily cast upon it in times masticate properly ; if the kidneys cannot get rid of the of peace and by the smaller wars in which the Empire by its vast extent is so frequently engaged. nitrogen properly we limit the nitrogenous input; and so’ 2. Regulations and provisions which will enable surgeons and trained forth. All this is simple common-sense, but it is eminentlyF orderlies in sufficient numbers to be rapidly obtained and added to the ordinary staff of the Royal Army Medical Corps in the event of rational. a great war; and that will also ensure a supply of all hospital I will complete my remarks on this head by contrastingr and other equipment required for the due care of the sick and wounded i with in such a war. or rationalism a would-be scientific, simple pseudo-,
a correspondingly minute and accurate knowledge of the action of drugs, we might conceivably devise a rational system of drug treatment for each case—one that should antagonise the various morbid processes going on in the body. But think for a moment what a perfection of knowledge this implies, and of the many opportunities for I say we might conceivably error that present themselves. devise such a system, but common-sense tells us that it is altogether impracticable, and I repeat what I have stated elsewhere, that the physician should not allow himself to be deceived by such pseudo-scientific nonsense. I have as much respect for the alchemist of old as for the so-called I rationalpharmacologists of to-day ; nay, I have more, for the old alchemists were at least sincere searchers after right methods and they did not sin against light. Suppose, for instance, we are treating a gouty patient. Such a one does not eliminate his uric acid in proper quantities, and the learned pharmacologist tells us-or used to tell us, for the view is now disputed-that salicylic acid forms with uric acid salicyluric acid, which being highly soluble is eliminated readily by the kidneys and thus increases the output of uric acid. Now shall we give salicylate of soda in gout because of this supposed action ?&ic rc; or sha.11 we employ a drug-this or some other-which experience has shown to be useful in gout, though we may be entirely ignorant of how it does good2 Shall we, in short, employ the strictly empirical method or the pseudorational method?7 There should be no question as to our answer. If we are wise we shall follow the empirical
treat, and
common-sense case
that
came
.
.
’
rapid
350 3. The attraction to the Royal Army Medical Corps of a sufficient regular supply of officers of good professional attainments. And ’the improvement of the position of the officers by the allowance of sufficient holidays; and by provisions enabling them to become adequately acquainted with the advancements in medical and surgical science; and the necessity of employing in the higher posts men selected for their merits rather than by seniority. 4. The employment, to a greater extent than that recognised and practised until the later stages of this war, of nurses in fixed hospitals for the care of the wounded and of fever and dysenteric patients, and such others as can properly be nursed by females. 5. The appointment of properly qualified officers of the Royal Army Medical Corps to undertake sanitary duties. And with regard to other matters :6 The improvement of the existing ambulance wagons. 7. The selection and employment of the form of hospital tents best suited for the reception of sick and wounded in a campaign. We also think that the committee might usefully consider the following questions, on which we ourselves express no opinion beyond what appears in Part II. of this report :(a) Whether it is advisable and practicable to some, and if any what extent, that the Royal Army Medical Corps should have exclusive ’possession of and control over all necessaries for the sick and wounded (other than ordinary food and clothing, not being hospital clothing), - so as to avoid the necessity of requisitioning upon the Army Service Corps or the Ordnance authorities. (b) Whether the administrative and clerical duties of the principal medical officers can be lightened and in particular to what extent the reports and returns which have to be made can and should be shortened. (c) Whether the men of the bearer companies, when not engaged on the field, could be employed to assist in the field hospitals, and whether with this object it is advisable that the staff of the bearer ’company and of the field hospital of a brigade should be under one chief officer. (d) Whether in times of peace a regimental doctor should be attached - to each regiment for some fixed time. .(<) Whether general hospitals could be advantageously divided into smaller units. (f) Whether it is practicable and advisable that the reception and distribution of all charitable gifts for the sick and wounded should be by some organised body on their behalf; and if so, what that body should be. The following are not matters for inquiry by the suggested committee. It will be sufficient if the attention of the Royal Army Medical Corps be specially called to what we are about to state, with a view to our recommendations being acted on. Having regard to what we have said on the subject in Part II.. we think that strict inquiry should be made in the various military hos,pitals in South Africa and proper steps be taken in order to stamp out, where it exists, pilfering by orderlies of the stimulants, comforts, or property of patients, and the receipt of bribes by orderlies from
following day, when the medical attendant expressed himself as being of opinion that both men were suffering from influenza with lung complications. They became rapidly worse and expired on the 15th and the 16th respectively. Their bodies were subsequently removed to the city mortuary where the medical officer of health, in conjunction with Mr.
and
,patients. We also suggest that the officers should, so far as it is possible and consistent with due discipline to do so, relax the strict military rule generally adopted in military hospitals, so as to give an additional feeling of ease to the patients and enable them to better appreciate the comforts of a hospital. The power and duty of every officer in this campaign in cases of .emergency to buy for his hospital at the expense of the Government any necessary not in hospital and not procurable without delay elsewhere has been fully recognised by the authorities, and the power has ’been by many freely exercised. But, as we have already pointed out. some officers appear not to be fully acquainted with the existence of the power, and it is advisable that it should be made widely known that any exercise of that power will be favourably viewed by the .authorities, unless, of course, in cases of its abuse.
THE PLAGUE AT HULL. WE noted in THE LANCET of Jan. 26th, 1901, p. 275, that ’several cases of plague had occurred on board of a ship sailing from Alexandria to Hall and which is now lying in the latter
port. The following is a detailed account of the outbreak .and the measures taken up to the night of Jan. 30th :The s.s. Friary, with a crew of 21 hands all told, arrived .at Hull on Jan. 10th with clean bills of health from Alexandria, having on board the dead body of an able The crew were subjected to the seaman, aged 30 years. usual medical inspection, and after inquiries it was believed that the death of the seaman on board was due to natural The causes, and the body was duly interred on the 14th. remainder of the crew were found to be in good health on the vessel’s arrival at Hull. The vessel belonged to Cardiff .and left that port on Nov. 23rd, 1900, for Alexandria, where The crew had enj ayed good she arrived on, Dec. 10th. health during the outward passage. The Ji’riary left .Alexandria on the 22nd, took in coals at Algiers on the 30th, and left that port on the 31st direct for Hull. the master went ashore at Algiers. On Jan. 13th, 190L, it was reported that two of the crew of the Friarry were ill, and the medical officer of health again visited the ship and examined an able seaman, aged -28 years (a Greek), who sickened on the 12th, and also an able seaman, aged 30 years, who sickened on the same day. They were believed to be suffering from influenza and medical treatment was recommended. Medical advice was sought on the
Only
,
’,
Frederick Wilson, who had been called in on behalf of the Portions of owners, performed a post-mortem examination. the lungs, spleen, and inguinal glands were forwarded to the Local Government Board, and also by special messenger to Professor E F. Trevelyan, of the Yorkshire College, Leeds, The results showed the for bacteriological examination. cases to be pneumonic plague. During the night of Jan. 14th two others of the crew, aged 25 years and 24 years respectively, firemen, became unwell, and they, along with four more of the crew, were removed to the Evan Fraser Hospital, the former for observation and the latter for isolation. Work on the vessel was suspended, and on the 17th the medical officer of health formally declared the vessel to be infected with plague. The vessel was subsequently removed from the dock to the appointed mooring station in the river, where she underwent a thorough fumigation. Those of the crew who were not removed to hospital were kept on the vessel in the river. A fireman, aged 30 years, after admittance into the hospital, sickened with similar symptoms to the others. He died on the 22nd, and from the bacteriological examination his death also was proved t6 be due to plague. A man who had acted as watchman on the vessel on the Monday after her arrival in port and had assisted some of the sick men reported himself at the Sanitary He was immediately reOffice on the 21st to be sick. moved to the hospital, where he died on the 27th. The medical attendant, who had been called in to attend some of the sick crew and who had assisted at the post-mortem examination on the two bodies already referred to, became unwell on the 18th, and on the 21st he was admitted into the Evan Fraser Hospital. Specimens of sputa were submitted for bacteriological examination and he, too. was found to be suffering trom pneumonic plague. For some days he remained in a very critical condition, but there is now a marked improvement in his health. Up to the night of the 29th there had been in all seven deaths, four in hospital and three on the ship, and there is little doubt that they were all due to pneumonic plague. Another of the crew at present in hospital remains in a critical condition. On examination of the persons affected there were no enlarged glands discovered. The whole of the bodies, excepting the one on board on the vessel’s arrival, were cremated at the city crematorium. The whole of the crew, the nursing staff at the hospital, and others who had been exposedto infection, have undergone Haffkine’s prophylactic treatment as supplied by the Local Government Board. The names and addresses of all who had been on board or otherwise associated with the infected ship were obtained and these persons have been kept under daily observation. Subject to the remainder of the cargo being discharged into lighters before re-entering the dock, and the holds of the vessel being battened down and thoroughly stoved to the satisfaction of the medical officer of health, the vessel will be declared free from plague. The Sanitary Committee have met daily and the Port Sanitary Authority have had several meetings, at which the medical officer of health has presented reports as to the progress of the disease, and the authorities are taking every As precaution to prevent any spread of the disease. previously stated there had been no sickness noticed amongst the crew except that of the one who was dead on the vessel’s arrival, and the origin of the outbreak remains obscure. It should be stated, however, that some of the crew had discovered dead rats on board after thevessel left Alexandria, and a cat which went on board at the latter port had shown signs of illness. Unfortunately, the cat was thrown overboard when the vessel left for the mooring-station. The dog on board the ship, which was ailing, was killed. Portions of the viscera have been submitted for examination, bat the bacteriological test has not yet been completed. The Friary was released from quarantine on Jan. 30th and is discharging cargo. The master, his wife, and nine others who have been under observation were also discharged from hospital on Jan. 30th. No further cases have arisen and it is a matter for satisfaction that the outbreak has been kept in hand and confined to the one centre of
contagion.
a correspondingly minute and accurate knowledge of the action of drugs, we might conceivably devise a rational system of drug treatment for each case—one that should antagonise the various morbid processes going on in the body. But think for a moment what a perfection of knowledge this implies, and of the many opportunities for I say we might conceivably error that present themselves. devise such a system, but common-sense tells us that it is altogether impracticable, and I repeat what I have stated elsewhere, that the physician should not allow himself to be deceived by such pseudo-scientific nonsense. I have as much respect for the alchemist of old as for the so-called I rationalpharmacologists of to-day ; nay, I have more, for the old alchemists were at least sincere searchers after right methods and they did not sin against light. Suppose, for instance, we are treating a gouty patient. Such a one does not eliminate his uric acid in proper quantities, and the learned pharmacologist tells us-or used to tell us, for the view is now disputed-that salicylic acid forms with uric acid salicyluric acid, which being highly soluble is eliminated readily by the kidneys and thus increases the output of uric acid. Now shall we give salicylate of soda in gout because of this supposed action ?&ic rc; or sha.11 we employ a drug-this or some other-which experience has shown to be useful in gout, though we may be entirely ignorant of how it does good2 Shall we, in short, employ the strictly empirical method or the pseudorational method?7 There should be no question as to our answer. If we are wise we shall follow the empirical
treat, and
common-sense case
that
came
.
.
’
rapid
350 3. The attraction to the Royal Army Medical Corps of a sufficient regular supply of officers of good professional attainments. And ’the improvement of the position of the officers by the allowance of sufficient holidays; and by provisions enabling them to become adequately acquainted with the advancements in medical and surgical science; and the necessity of employing in the higher posts men selected for their merits rather than by seniority. 4. The employment, to a greater extent than that recognised and practised until the later stages of this war, of nurses in fixed hospitals for the care of the wounded and of fever and dysenteric patients, and such others as can properly be nursed by females. 5. The appointment of properly qualified officers of the Royal Army Medical Corps to undertake sanitary duties. And with regard to other matters :6 The improvement of the existing ambulance wagons. 7. The selection and employment of the form of hospital tents best suited for the reception of sick and wounded in a campaign. We also think that the committee might usefully consider the following questions, on which we ourselves express no opinion beyond what appears in Part II. of this report :(a) Whether it is advisable and practicable to some, and if any what extent, that the Royal Army Medical Corps should have exclusive ’possession of and control over all necessaries for the sick and wounded (other than ordinary food and clothing, not being hospital clothing), - so as to avoid the necessity of requisitioning upon the Army Service Corps or the Ordnance authorities. (b) Whether the administrative and clerical duties of the principal medical officers can be lightened and in particular to what extent the reports and returns which have to be made can and should be shortened. (c) Whether the men of the bearer companies, when not engaged on the field, could be employed to assist in the field hospitals, and whether with this object it is advisable that the staff of the bearer ’company and of the field hospital of a brigade should be under one chief officer. (d) Whether in times of peace a regimental doctor should be attached - to each regiment for some fixed time. .(<) Whether general hospitals could be advantageously divided into smaller units. (f) Whether it is practicable and advisable that the reception and distribution of all charitable gifts for the sick and wounded should be by some organised body on their behalf; and if so, what that body should be. The following are not matters for inquiry by the suggested committee. It will be sufficient if the attention of the Royal Army Medical Corps be specially called to what we are about to state, with a view to our recommendations being acted on. Having regard to what we have said on the subject in Part II.. we think that strict inquiry should be made in the various military hos,pitals in South Africa and proper steps be taken in order to stamp out, where it exists, pilfering by orderlies of the stimulants, comforts, or property of patients, and the receipt of bribes by orderlies from
following day, when the medical attendant expressed himself as being of opinion that both men were suffering from influenza with lung complications. They became rapidly worse and expired on the 15th and the 16th respectively. Their bodies were subsequently removed to the city mortuary where the medical officer of health, in conjunction with Mr.
and
,patients. We also suggest that the officers should, so far as it is possible and consistent with due discipline to do so, relax the strict military rule generally adopted in military hospitals, so as to give an additional feeling of ease to the patients and enable them to better appreciate the comforts of a hospital. The power and duty of every officer in this campaign in cases of .emergency to buy for his hospital at the expense of the Government any necessary not in hospital and not procurable without delay elsewhere has been fully recognised by the authorities, and the power has ’been by many freely exercised. But, as we have already pointed out. some officers appear not to be fully acquainted with the existence of the power, and it is advisable that it should be made widely known that any exercise of that power will be favourably viewed by the .authorities, unless, of course, in cases of its abuse.
THE PLAGUE AT HULL. WE noted in THE LANCET of Jan. 26th, 1901, p. 275, that ’several cases of plague had occurred on board of a ship sailing from Alexandria to Hall and which is now lying in the latter
port. The following is a detailed account of the outbreak .and the measures taken up to the night of Jan. 30th :The s.s. Friary, with a crew of 21 hands all told, arrived .at Hull on Jan. 10th with clean bills of health from Alexandria, having on board the dead body of an able The crew were subjected to the seaman, aged 30 years. usual medical inspection, and after inquiries it was believed that the death of the seaman on board was due to natural The causes, and the body was duly interred on the 14th. remainder of the crew were found to be in good health on the vessel’s arrival at Hull. The vessel belonged to Cardiff .and left that port on Nov. 23rd, 1900, for Alexandria, where The crew had enj ayed good she arrived on, Dec. 10th. health during the outward passage. The Ji’riary left .Alexandria on the 22nd, took in coals at Algiers on the 30th, and left that port on the 31st direct for Hull. the master went ashore at Algiers. On Jan. 13th, 190L, it was reported that two of the crew of the Friarry were ill, and the medical officer of health again visited the ship and examined an able seaman, aged -28 years (a Greek), who sickened on the 12th, and also an able seaman, aged 30 years, who sickened on the same day. They were believed to be suffering from influenza and medical treatment was recommended. Medical advice was sought on the
Only
,
’,
Frederick Wilson, who had been called in on behalf of the Portions of owners, performed a post-mortem examination. the lungs, spleen, and inguinal glands were forwarded to the Local Government Board, and also by special messenger to Professor E F. Trevelyan, of the Yorkshire College, Leeds, The results showed the for bacteriological examination. cases to be pneumonic plague. During the night of Jan. 14th two others of the crew, aged 25 years and 24 years respectively, firemen, became unwell, and they, along with four more of the crew, were removed to the Evan Fraser Hospital, the former for observation and the latter for isolation. Work on the vessel was suspended, and on the 17th the medical officer of health formally declared the vessel to be infected with plague. The vessel was subsequently removed from the dock to the appointed mooring station in the river, where she underwent a thorough fumigation. Those of the crew who were not removed to hospital were kept on the vessel in the river. A fireman, aged 30 years, after admittance into the hospital, sickened with similar symptoms to the others. He died on the 22nd, and from the bacteriological examination his death also was proved t6 be due to plague. A man who had acted as watchman on the vessel on the Monday after her arrival in port and had assisted some of the sick men reported himself at the Sanitary He was immediately reOffice on the 21st to be sick. moved to the hospital, where he died on the 27th. The medical attendant, who had been called in to attend some of the sick crew and who had assisted at the post-mortem examination on the two bodies already referred to, became unwell on the 18th, and on the 21st he was admitted into the Evan Fraser Hospital. Specimens of sputa were submitted for bacteriological examination and he, too. was found to be suffering trom pneumonic plague. For some days he remained in a very critical condition, but there is now a marked improvement in his health. Up to the night of the 29th there had been in all seven deaths, four in hospital and three on the ship, and there is little doubt that they were all due to pneumonic plague. Another of the crew at present in hospital remains in a critical condition. On examination of the persons affected there were no enlarged glands discovered. The whole of the bodies, excepting the one on board on the vessel’s arrival, were cremated at the city crematorium. The whole of the crew, the nursing staff at the hospital, and others who had been exposedto infection, have undergone Haffkine’s prophylactic treatment as supplied by the Local Government Board. The names and addresses of all who had been on board or otherwise associated with the infected ship were obtained and these persons have been kept under daily observation. Subject to the remainder of the cargo being discharged into lighters before re-entering the dock, and the holds of the vessel being battened down and thoroughly stoved to the satisfaction of the medical officer of health, the vessel will be declared free from plague. The Sanitary Committee have met daily and the Port Sanitary Authority have had several meetings, at which the medical officer of health has presented reports as to the progress of the disease, and the authorities are taking every As precaution to prevent any spread of the disease. previously stated there had been no sickness noticed amongst the crew except that of the one who was dead on the vessel’s arrival, and the origin of the outbreak remains obscure. It should be stated, however, that some of the crew had discovered dead rats on board after thevessel left Alexandria, and a cat which went on board at the latter port had shown signs of illness. Unfortunately, the cat was thrown overboard when the vessel left for the mooring-station. The dog on board the ship, which was ailing, was killed. Portions of the viscera have been submitted for examination, bat the bacteriological test has not yet been completed. The Friary was released from quarantine on Jan. 30th and is discharging cargo. The master, his wife, and nine others who have been under observation were also discharged from hospital on Jan. 30th. No further cases have arisen and it is a matter for satisfaction that the outbreak has been kept in hand and confined to the one centre of
contagion.