1872 THE ROYAL NAVY MEDICAL SERVIOE.

with me that this proves at any rate rural sanitary authoritiesare not so indolent as some good folk will have us believe.

I am, Sir, yours faithfully,HUGH STOTT,

Medical Officer of Health, Combined SanitaryAuthorities of East Sussex,

Lewes, Sussex, June 16th, 1908.

*** The newspaper cutting to which Mr. Stott refers givesa full account of the hearing before the Haywards HeathBench on Feb. 24th of a charge against a butcher namedBetting of Hurstmonceux. He was convicted in three oasesfor exposing meat in an advanced condition of tuberculosis-for sale. The carcass of a pig in his possession was foundto be tuberculous in nearly every part. The man had a goodrecord, but the Bench rightly took a serious view of his- oSences and fined him £50, with 5 guineas costs.-ED. L.

HUGH STOTT,Medical Officer of Health, Combined Sanitary

Authorities of East Sussex,

A QUESTION OF MEDICAL DEFENCE.To the Editor of THE LANCET.

SIR,-We note that in THE LANCET of Jane 13th it issuggested by a correspondent "that an insurance companymight be willing to issue a policy covering medical prac-’titioners against the risk of damages being awarded againstthem for alleged negligence or malpractice." We desire tostate that such a policy is now being issued to our clients by.’One of the leading non-tariff companies. The premium dependson the amount of indemnity required. The qaestion of- champerty and maintenance has been fully considered, andwe are legally advised that there is no possibility of anyaction of this character.

It has been said that to give a medical practitioner com-plete indemnity against damages and legal expenses willtend to carelessness, but we fail to see how this can be true.’There will still remain the moral stigma and the inevitableloss of practice which would follow an adverse verdict.

We are, Sir, yours faithfully,43, Warwick-street, Regent-street, W. AKED & AKED.

THE ROYAL NAVY MEDICAL SERVICE.To the Editor of THE LANCET.

SIR,-I have read with great interest your leading articleon the Royal Navy Medical Service in your number ofMay 30th last. As the subject is one which in order toattract that amount of attention that will lead to any hope ofreform, needs further discussion it would be very kind of youto spare room in your valuable paper for further correspond-ence. Firstly, let me thank you on behalf of many withwhom I have discussed it for that valuable article, which,although putting the case very mildly, is extremely fair andaccurate. As regards the appointment of the new Director-General you are quite right. From what I have heard with-out exception his appointment has been spoken of as a greatthing, and, moreover, was hopefully talked of for someconsiderable time before there was any chance of a

vacancy. This fact shows one of the very greatcauses of complaint and reasons for thinking thatthere is need of serious attention to the presentstate of the service. There is a universal expressionof opinion by senior (here let me state that I havealways discussed these matters with seniors who usually all- agree with me) as well as j junior officers that the position ofDirector-General is no enviable one and the majoritysympathise with him ; this because definite statementsmade to medical officers when visiting the Admiralty showthat he is merely a figure-head and, in fact, is treated in avery undignified manner as the senior of his department;that changes are made with which he does not agree and thatit is not on his opinion or by his direction that the service ismanaged. Now the present Director-General has the

reputation of being a man of firm character who willnot be afraid to resist the authorities and who will dohis best to carry out such plans as he may thinknecessary. It is commonly said that the Admiraltyloathe to appoint the best man to this appointment asthey do not want anyone whom they cannot easily manage.Hence probably the reason that men conspicuous for theirprofessional abilities do not reach that post. Now in hispresent isolated position the Director-General is very helplessto carry out any radical changes, changes that most of us

think ought to be made. We have, it is true, a MedicalConsultative Board" (please do not let those gentlemen thinkI have any animus against their personal abilities), but theydo not form any part of the medical branch at the Admiralty ;they examine candidates for entry and promotion, and evenin those matters their advice is not taken. Would it not bea good thing if one or all of the members of that board wouldanswer some of the following questions ? I strongly appealto them as representing the highest branch of the medicalprofession to do so and to interest themselves on behalf oftheir medical colleagues who in their present position areunable to agitate except anonymously.

1. Do they think that as constituted at present they havethe power to assist the general working and efficiency of theservice ? or are they purely consultative and not allowed toadvise ? Do they fully realise that the medical officers ofthe service look to them for help ?

2. Are they able in their present position to support theDirector-General in his dealings with the Admiralty ? and ifnot do they think that a board under altered conditions andwith power to act as a body would do better ?

3. Are they fully acquainted with the inner working ofour naval hospitals and institutions, the manner of appoint-ments, the lack of practice and unfair distribution of hos-pital courses and appointments in which medical officers cangain experience? Do they realise that many serve con-

tinuously at sea and never have any opportunity of showingtheir professional abilities, and that there is no method bywhich the Admiralty can ascertain them, and that socialinfluence far outweighs professional ability ?

4. Do they not think that charges such as the followingwould benefit the Royal Navy as a whole and that they wouldjustify additional expenditure? (a) To increase the staff ofall the naval hospitals and to make appointments to theseinstitutions shorter so as to make way for more medicalofficers to pass through them annually. (I believe, Sir, thatno one can deny that with the present small number ofvacancies at hospitals there are not enough places at theseinstitutions for every medical officer to hold one vacancy oncein every eight years, nor are hospital courses awarded insufficient numbers to do this by one quarter.) (b) That thethree large naval hospitals should be used as teaching centresfor all medical officers indiscriminately. (0) That medicalofficers might, if willing, be allowed to proceed on full-payleave for 6-12 months to study at civil hospitals, or even holdhouse appointments at civil hospitals if able to obtain them.(This is at present allowed to be done by medical officers onjoining, but without pay ; but it is later during our careerthat we need it so badly.) It is a fact that an army medicalofficer has lately held for some months such an appointmentat a large London hospital as there was not sufficient workfor him in the district in which he was serving.Now these medical officers would thus make themselves more

efficient, to the benefit of the service as well as themselves,and it would prepare the way for suitable men to obtainexperience so as to act as pathologists, anaesthetists, aurists,oculists, &c., and instructors to the surgeons on entry, and,most important of all, instructors to the sick berth staff.Certainly strict care should be taken that only hard-workingofficers obtained these privileges and furnished proof of theirwork and that the privilege was not given in the same wayto people wanting a holiday or avoiding half pay, as has beendone over the present hospital courses. Most certainly ifthe medical officers are to prevent themselves falling intothat state of professional ignorance and uselessness, as is somarked in the case of many senior officers (the fault lies withthe system, not the officers), some arrangement should bemade that after two years at sea a medical officer shouldalways have at least three months at a naval or civil hospital.Now how are these medical officers to be spared ? It is a

fact that we are nearly 80 short of our numbers but for allthat they are easily obtained. If more are recruited it willnot increase the number of hospital appointments. You sayin your article that the constant presence of medical officersin harbour ships, &c., is necessary. That is where you showyour want of experience of the inner workings. You willfind that the majority of men admit the fact that the con-stant presence of two men in any ship in the Navy is quiteunnecessary. Much more so in ships with nucleus crews. Ifthey are supposed to be able to be quickly mobilised whycannot the medical officers be borne on the ship’s books andmobilise if wanted at 24 hours’ notice. In the ChannelFleet there is not work for one medical officer on any ship.Provided that the principal medical officer of the fleet was

1873THE MANCHESTER PUBLIC ABATTOIR.

allowed full control one half of the officers couldin peace time be away and arrangements for relievingand exchanging duties when officers were sick or neededleave would be done by the principal medical officer. Iwish most strongly to point out that provided he can joinwithin 24 or 48 hours one medical officer might be absentfrom his ship for months at a time ; this in the Channel orHome Fleets. There are no duties that cannot be as easilymanaged by a surgeon as by a fleet surgeon, and, as youprobably know, the surgeon is generally fresher at his work.

I quite agree with you that purely naval grievances comesecond to medical but there are many that are worthy ofattention. The power given to a medical officer generallyis very small and he usually only advises and cannot com-mand, and has to mildly submit the diagnosis of all hiscases to the captain of the ship and frequently answer ques-tions on his methods of treatment. This causes much diffi-culty, especially in the case of venereal disease. As tocabin accommodation, though difficulty rarely arises, theregulations state that THE medical officer is to have acabin; perhaps you do not realise the ignominious position thejunior is placed in by the official status he occupies. Further,if a medical officer is appointed late he may have to put upwith a cabin inferior to that held by many of his juniors, asif a cabin has once been allotted to anv officer he cannot beturned out unless it is a marked cabin. Also, in ships ontrooping service a medical officer on passage has to take acabin after all the officers of the ship and may even have togo without. The question of boats is one of the reasons whymedical officers cannot visit their own hospitals sufficiently,but from my experience the commanding officer has enoughtrouble to supply others besides the medical officers. Theboat question affects all officers. Owing to messing arrange-ments, unless willing to be considerably out of pocket,medical officers cannot regularly visit their hospitals duringworking hours. There is room for improvement in the prac.tice of putting an officer on half pay between his two

appointments for no other obvious reason than to make himpay his own travelling expenses, which are thus doubled,Also the delay in prcmoting them to higher rarks when 2vacancy occurs.As regards being placed in the same position as arm3

medical officers, naval cfficers certainly do not wish thatIf the senior medical officer of a naval hospital had power t(give small punishments for offences arising out of theimproper performance of medical duties by the sick bertlstaff, or if he deemed a severer sentence necessary couldafter first trying the case, recommend the sentence to th4executive officer or have it confirmed by him, it would preventoccurrences such as the following. A second sick bertlsteward at a depot was disrated for having passed a catheteon a patient at midnight. He took the responsibility odoing this as the catheter had only been passed a few hour,previously, and he had been frequently encouraged to dminor details for the surgeons to avoid calling them. Thisentence ruined his career and none of the medical officerwere able to do anything for him, although he was considereione of the best and most promising men in the depot.What you say as to the course of instruction at Haslar an4

the want of pathologists and clinical teaching at any hospitais, I think, far too mild. We have no specialists of an;sort, and medical officers who can examine a fundus or detecan error of refraction even amongst the highest ranks arrare. Honestly, the course of instruction at Haslar i

regarded as a farce throughout the service except in thtropical diseases section. What you say as to an amalgamation with the Army Medical School is, I think, a proposethat all, except those enjoying the special billets at Haslafor our own course, would welcome, and the necessitfor payment of officials to teach at our own hospitals wouldiminish if more opportunities for hospital study we!given.

Lastly, I think it only fair that some attention shoulbe paid to the sick berth staff. They have a very bricand indifferent instruction at a naval hospital-thepay bad and promotion very slow. The great concessioof warrant rank to this branch has not done muc

good, as there are so few warrants and promotionextremely slow and even to first-class steward is by rotationThen the manner of their employment is bad ; there is r

distinction between nursing and non-nursing sections.nurse in charge of a special case in a single bed cabin has scrub the floor as well as do any surgical dressings. Sonhospitals, especially the smaller ones, are so understand

that when they have a special or infectious case nurses fromthe wards have to do the work, and there is then double workfor the ward staff. It would be a good thing to copy thearmy by having a nursing and non-nursing section with anexamination of higher quality than what we have at present.This examination, although unpopular, would of necessitygive rise to better instruction. The sick berth staff areanxious to obtain the same rates of pay and promotion asnaval writers. I am, Sir, yours faithfully,June 22nd, 1908.

w

SURGEON, R.N.

THE MANCHESTER PUBLIC ABATTOIR

(FROM OUR SPECIAL SANITARY COMMISSIONER.)

IN the construction of a municipal abattoir Manchesterhas the honour of having been early in the field and suffersin consequence. The Manchester abattoirs were opened atChristmas of the year 1872. This was before the developmentof bacteriology, before any definite notion of asepsis existed,in fact, before any really scientific basis could be provided toguide the planning of a building where foodstuffs were to bepreserved from the risk of contamination. In thesecircumstances it is not surprising to find that the abattoir isin no wise up to date. It is divided into small compartmentswhich are let out to different butchers; therefore, it amountsto this, that the butcher has a small private slaughter-houseat the public abattoir. But as these private places are onlyseparated from each other by partition walls the inspectorshave not far to go in visiting them. Then, on the butcher’sside, there is this advantage, that overhead rails enable himto convey easily his meat to the cooling place or the meatmarket. Further, and in 1894, a cold storage was erectedand it is a great advantage to have all this on the samepremises. Then again, as it was constructed long ago,Manchester had not grown to its present dimensions andthus to-day the abattoir, the cold storage, and the wholesalemeat market are in what has become a central position.This is a great convenience to the trade. On the other hand,the nearer to habitations the greater becomes the necessityof insuring the maintenance of sanitary conditions. Unfor-

tunately, the Manchester slaughter-house is the reverse of amodel establishment. There are low buildirgs and bloodflows out from under the doors on large pavement stoneswhich are not cemented together. The subsoil must be con-taminated in the passages and courts between the buildings.Inside the slaughter pens there is insufficient light; theyare paved with concrete which has worn well. A fewhave flag-stones with "plenty of grit "-that is, they aresufficiently rough not to be slippery. This is needed notonly to prevent the men and beasts from slipping and fallingbut also so as to be able to work a lever under the carcasswhen it is necessary to move its position. These smallslaughter pens or partitions are not over clean. They do notcompare favourably even with the La Villette abattoir inParis. There is a lack of smartness and brightness andthere are many sombre places which help to produce aforbidding effect.By a strange lack of appreciation of what constitutes the

requirements of an abattoir the very department whichneeds the greatest amount of light and the most carefulventilation is the very worst part of the entire premises.The pigs are killed in a small dark structure whereno special means of ventilation are provided. Overheadthere is a low roof with many rafters that cannot

possibly be cleaned. Here the accumulated dust anddirt are kept warm and damp by the constant supply ofsteam from the vats in which the carcasses are scaldedso as to remove the bristles. It will be rememberedthat at Birmingham there is over these vats a different sortof roof so as to carry the steam away immediately andto prevent it from going towards the other parts of theslaughter hall where the careasses are dressed. Nothing ofthe sort exists at Manchester. There is no such systematicdivision of labour with different sorts of ventilation and oflight according to the nature of that labour. The wholecompartment is bad and offers no advantage over a privateslaughter-house, beyond the fact, of course, that it is easierto inspect. For this work there are three veterinarysurgeons and one inspector of meat. Then there are also one-

inspector and two assistant inspectors for fish and fruit andthey also visit the retail meat shops in different parts