Model course 1 15 medical care (200 edition) course compendium volume 2 1

Severe abdominal pain: aseoc- - , symptoms and signs Diagram' Position and type of pain - •• _ ---~ Diarrhoea General condition of patient A.. All patients 1 all over abdomen,or mainly

Medical Care

Volume 2

Chapters 8-19, Annexes 1-6 and the index of the Compendium for Model Course 1.15

Chapter 8

Other diseases and medical problems

\

Gout and gouty arthritis 200

MEDICAL CARE: COM~

International Medical Guide for- SIIip5

Abdominal pain neither advisable nor possible, Note that in the

Minor abdominal conditions very early stages of abdominal conditions such

as appendicitis or perforated ulcers, diarrhoea,This group of conditions includes ig.~ 4MH1. vomiting, headaches, or fevers are seldom

"wind", flatulence, mild abdominal colic (spas- present other than in a mild form If these modic abdominal pain without diarrboca and toms are present, the illness is much more likelyfever), and the effects of overindulgence in food to be a diarrhoea and vomiting type of illness

symp-or alcohol The patient can often tell quite a lot (see page 188)

about the possible causes of his minor

abdomi-nal conditions or upsets, so always encourage Examination of the abdomen

him to tell you all he can Ask about intolerance

to certain foods, such as fried foods, onions, The abdomen should be thoroughly examined.sauces, and other spicy foods, any tendency to Tbe first thing to do is to lay the patient downlooseness, diarrhoea, or constipation, and any comfortably in a warm, well-lit place He shouldregularly felt type of indigestion and any known be uncovered from his nipples to the thigh andreasons for it Mild abdominal pain will usually the groin should be inspected (see Hernia, pagecure itself if the cause(s) can be understood and 207) Look at the abdomen and watch if it moves

Guard against total acceptance of the patient's either action causes him pain and, if so, where hetake a deep breath and to cough; ask him ifexplanation of the causes of his pain until you felt it and what it was like Probably, if the painhave satisfied yourself, by exammmg his is sharp he will point with his finger to the spot,abdomen, that he is not suffering from a serious but if it is dull he will indicate the area with thecondition (Fig 122 and Table 5) Note that a flat of his hand.

peptic ulcer may sometimes start with symptoms

Look for any movement of the abdominal

con-of slight pain (page 217)

tents and note if these movements are

accompa-General management nied by pain and/or by loud gurgling noises.The patient should be put on a simple diet for Note if the patient lies very still and appears to

be afraid to move or cough on account of pain1-2 days, and given 2 aluminium hydroxide tab-

or if he writhes about and cries out when thelets three times a day Repeat these at night, if

pain is at its height Spasmodic pain the patient is in pain If the condition does not

accompa-nied by loud gurgling noises usually indicatesresolve itself within two days of starting this

abdominal colic or bowel obstruction When the

patient lies still with the abdomen rigid, thiNk in

Anyone who has persistent or unexplained mild

terms of perforated appendix or perforation of aabdominal symptoms should be seen by a doctor

peptic ulcer

at the next port

Abdominal emergencies such as appendicitis When you have completed your inspection,

lis-ten to the bowel sounds for at least two minutesand perforated gastric or duodenal ulcer are

by placing your ear on the abdomen just to thehigh on the list of conditions that, ashore,

right of the navel

would be sent to hospital for surgical treatment

While there is no doubt that early surgical treat- • Normal bowel sounds occur as the process of

ment is usually best, this does not mean that normal digestion proceeds. Gurgling soundsother forms of treatment are unsuitable or inef- will be heard at intervals, often accompaniedfective In most abdominal emergencies on by watery noises There will be short intervalsboard a ship at sea, surgical treatment is usually

MEDICAL CARE: COMPENDIUM

International Medical Guide for Ships

Table 5 Severe abdominal pain: aseoc- - , symptoms and signs

Diagram' Position and type of pain - •• _

-~ Diarrhoea General condition of patient

A All patients

1 all over abdomen,or mainly none usually not at first, not ill; usually walks about,

going in spasms

2 in upper part and under left present, IIIId usu- not at first; it may wretched,becauseof

ribs, a steady burning pain ally ~ follow 24-48 nausea,vomiting, and

hours later weakness,but soon

im-proving

3 shooting from loin to groin may be present, none severe distress

and testicle; very severe but only with the

4 shootingfrom the upper part may be present, none severe distress

of the right side of abdo- but only with the

men to the back or right spasms

shoulder;agonizingspasms

5 around navel at first, settling soon after onset of sometimesonce at an ill patient, tends to lie

later in the lower part of pain, usually on- commencement still

the right side of abdomen; Iy once or twice of

6 all over the abdomen;usual- present, becoming usually none an extremely ill patient

pain

T spasmodicat first, but later increasing in fre- none;complete very ill

amountof brown fluid

8 in the groin, a continuous not at first, but none; as with very ill

obstruction

B Female patients

10 lower abdominal pain-one sometimeswith usually an ill patient; there may be

or both sides just above onset of pain none vaginal discharge or

10 suddenonset of lower ab- sometimeswith none an ill patient; may collapse

may be vaginal bleeding

if vaginal bleeding is severe

crotch; scalding pain on

frequent urination

• Numbers refer to Fig 122.

MEDICAL CARE: COMPENDIUM

International Medical Guide for Ships

-at least one gurgle should be heard every The urine of any patient suffering from minute nal pain or discomfort should always be exam-

abdomi-• Frequent loud sounds with little or no interval ined and tested (page 107)

occur when the bowels are "working over- When you have completed the examination oftime", as in food poisoning and diarrhoea to the abdomen and recorded the temperature andtry to get rid of the "poison", and in intestinal pulse rate, use Table 5 and Fig 122 to diagnoseobstruction (total or partial, page 210) to try the condition or to confirm your diagnosis.move the bowel contents The sounds will be

loud and frequent and there may be no quiet More information about each condition and theintervals The general impression may be one treatments are given separately under the var-

of churning and activity At the height of the ious illnesses

noise and churning, the patient will usually

experience colicky pain which, if severe, may Alcohol abuse

cause him to move and groan

Warning

• Absence of bowel sounds means that the bowel

is paralysed This condition is found with Breath smelling of alcohol means that a drinkperitonitis following perforation of an ulcer or has been taken; it does not tell how much has

of the appendix, or serious abdominal in- been consumed, nor does it mean that the juries The outlook is always serious RADIO dition of the patient is due to alcoholic intoxica-MEDICAL ADVICE is required, and the pa- tion Head injuries, certain drugs such as sleep-tient should go to a hospital ashore as soon as ing tablets, and some illnesses can make apossible patient behave as if he were drunk Therefore,

con-always assume that the person may have otherWhen you have learned all that you can by injuries, or may be ill, until you have examinedlooking and listening-and this takes time-you him carefully.

should then feel the abdomen with a warm hand. Every year, a number of seamen die as a directBefore you start, ask the patient not to speak, result of the excessive drinking of liquor or frombut to relax, to rest quietly, and to breathe gently accidents, such as falling from wharves andthrough his open mouth so that his abdominal gangways, while under the influence of drink Inmuscles will be as relaxed as possible Then be- addition there have been cases in which men,gin your examination by laying your hand flat brought on board in a semi-comatose condition,

on the abdomen away from the areas where the have been simply put to bed and have beenpatient feels pain or complains of discomfort If found dead some hours later, as a result either ofyou examine the pain-free areas first, you will get absorbing a fatal quantity of alcohol from their

a better idea of what the patient's abdomen feels stomachs or of being choked by their own vomit.like in a part that is normal Then, with your Being extremely drunk may therefore place apalm flat and your fingers straightened and kept man in a critical condition Accordingly, drunk-together, press lightly downwards by bending at enness, common though it may be, should neverthe knuckle joints Never prod with the finger- be ignored or regarded as merely funny On thetips Feel systematically all over the abdomen, contrary, men returning on board in a severelyleaving until last those areas that may be "bad" drunken state should be treated as sick personsones Watch the patient's face as you feel His requiring close watching and careful nursing, ifexpression is likely to tell you at once if you are their lives are not to be further jeopardized.touching a tender area In addition you may feel

the abdominal muscles tensing as he tries to Ordinary drunkenness

protect the tender part When you have finished

your examination, ask him about the pain and A description of this is scarcely necessary excepttenderness he may have felt Then make a wnt- for the sake of comparison with other forms of

Other diseases and medical problems

muscles, finding it difficult to walk or talk upset The patient should not take further properly, and is unable to perform common- hol He should take plenty of non-alcoholicplace actions His face is flushed and the whites fluids to combat the dehydration caused by the

alco-of his eyes may be "bloodshot" He may vomit alcohol, paracetamol tablets, and, if necessary,

He may be in a happy, excited mood, or want to an antacid (magnesium hydroxide suspension, afight, or he may cry and be very depressed owing 5-ml teaspoonful in half a glass of water, three

to the loss of his normal controlling powers of times a day)

reason and judgement The stomach upset and other complaints will

Alcohol in any form is a poison; when a large takes no more alcohol, very little food, if any,amount has been taken during a short time, and plenty of fluid.

especially on an empty stomach, serious poison- The shakes

ing or intoxication may develop This may prove The shakes are a sign of withdrawal of alcohol infatal as a result of respiratory or heart failure

a person who has, over a long period of time,The poisonous spirit of illicit origin offered to become dependent on alcohol Trembling of theseamen in some ports is especially dangerous A

hands, shaking of the body, and sweating willman who is "dead drunk" lies unconscious with appear in the morning when a person has notslow noisy breathing, dilated pupils, a rapid had alcohol since the previous evening Thepulse, and some blueness of the lips His breath

alcohol-dependent person usually prescribes hiswill smell of alcohol, but remember that his

own cure by taking a further drink On boardstupor or coma may not always be solely due to

ship during a voyage it is reasonable to allow adrink The signs of a drunken stupor are much small dose of alcohol in such circumstances,like those of other conditions causing uncon- provided that the patient is not showing any signsciousness The man must be examined carefully of mental or emotional imbalance The patient

to make as sure as possible that it really is a case should be referred for treatment for alcohol

de-of alcoholic poisoning pendence at the earliest opportunity.

Treatment

Delirium tremens (DTs)

People who are drunk but conscious should be

encouraged to drink 1-2 glasses of water to An attack of the DTs can be a serious medicalprevent a hangover caused by alcoholic de- emergency It occurs only in people who havehydration, and to go to bed If they are seriously been regular heavy drinkers for many years.drunk, they should not eat anything until they Attacks do not follow a single bout of heavyhave recovered It is advisable for someone to drinking by a person who normally takes only astay with a person who is seriously drunk, be- small or moderate amount of alcohol On thecause he may inhale his vomit while asleep other hand, it is often a bout of drinking (such

If in port, a person unconscious from alcohol as a seaman who is alcohol-dependent may should be sent to hospital If the patient has to dulge in after a prolonged voyage) that leads to

in-be kept on board, he should in-be put to in-bed and an attack, or it may be brought on when a heavymanaged as in the routine for unconscious pa- drinker has an injury or illness that results in thetients (page 104) Remember that he should sudden cessation of his excessive "normal"

never be left alone in case he moves out of the intake.

unconscious position and then dies from inhal- The patient with delirium tremens is at firsting vomit irritable and restless, and will not eat These

Hangover early signs are followed by shaking all over,especially of the hands He is confused and may

A hangover is usually made up of a headache, a not know where he is and may not recognize

MEDICAL CARE: COMPENDIUM

International Medical Guide for Ships

temperature may rise to 39°C, the face is alcohol is possible Alcohol-dependent peopleflushed, and the tongue is furred He may be are often very cunning and devious They fre-extremely disturbed, or even raving; this is usu- quently have bottles hidden in their cabin andally worse at night when he is unable to sleep and work areas and may try to get to these bottles orsees imaginary creatures like snakes, rats, and may trick other people into fetching them theirinsects, which frighten him and which he may try bottle of "medicine"

to pursue He may deteriorate to a state of de- It should be remembered that delirium related tolirium in which there is a danger of his commit-

alcohol abuse is only one type of delirium.ting suicide or even homicide This condition

usually lasts for 3 or 4 days, after which the

patient either improves and begins to acquire Other types of delirium

natural sleep, or else passes into coma, complete

exhaustion, and death Delirium may be due to mental disease; to

poi-It is the severe mental and emotional distur- sons that accumulate from certain systemic in-fections such as kidney diseases; or to drug andbance that differentiates the DTs from the poison intoxication caused by a variety of agentsshakes such as lead, carbon monoxide, narcotics, and

General treatment some medicaments It may also accompany ex-haustion, chronic illness, or high fever, and

fol-The patient should be confined and nursed as low severe injury Delirium may take the form ofdescribed for the mentally ill (page 103) There a fairly quiet restlessness in which the patientshould be subdued lighting by day and by night fidgets and mutters to himself for hours on end;

to reduce as far as possible the imaginary visions or it may take the form of wild, noisy, and

he is likely to see He should be encouraged to violent actions

drink plenty of sweetened fluid and, if he will eat,

should be given food The attack may end with The characteristics of the low muttering type of

the patient sleeping for up to 24 hours delirium are: constant or occasionally

discon-Specific treatment nected and irrational speech, restless impulses,disturbing dreams, attacks of weeping or

excite-First try to calm the patient with a glass (50 ml) ment, impaired mental and muscular power,

of whisky If this proves unsuccessful, physical involuntary urination and defecation, and, restraint will be necessary In either event, give quently, plucking at the bedclothes When rest-

fre-50 mg of chlorpromazine by intramuscular in- lessness is present, the patient continually triesjection This may be repeated after 6 hours, if the to get out of bed and not infrequently attemptspatient is still uncontrolled In addition, give to escape This type of delirium may be present

10 mg of diazepam by intramuscular injection in all acute infectious fevers, especially in and then give one 10-mg tablet of diazepam, phoid fever.

ty-every 4 hours until the patient is calm Once

In the violent type of delirium usually associatedtreatment is started, it is essential that no more

alcohol is given with toxic conditions due to uraemia, alcohol

dependence, and poisoning by drugs, there is

If in any doubt about diagnosis or treatment get wild maniacal excitement At different times, theRADIO MEDICAL ADVICE In any event, patient may be noisy or quiet, violent or calm.refer the patient for treatment for alcohol depen- He is always difficult to control and is usuallydence at the earliest opportunity insensible to his surroundings His speech is

Subsequent management rapid and incoherent or irrelevant, eyes openand staring with pupils usually dilated, and

. When a person has got over an attack of DTs, it face flushed Homicidal mania may develop

Other diseases and medical problems

~eme~ber that the ?nset of delirium of any type with allergic reactions include antibiotics,I~ a senous danger signal, and that special atten- acetylsalicylic acid, laxatives, sedatives, andtIon should be paid to identifying the underlying tranquillizers Eczematous dermatitis may resultcause or condition which must be treated or from contact of the skin with metals, dyes, fab-controlled rics, resins, drugs, insecticides, industrial chemi-

to most people An allergic individual is sensitive plants; house and industrial dusts; mould

to allergens, which are substances that enter the spores; animal danders (skin and hair shed bybody by being inhaled, swallowed, or injected, domestic or wild animals); feathers found in

or through contact with the skin They may pillows; kapok; and insecticide sprays or othercome from bacterial or fungal infections in the v~pours In some instances, foods (such as eggs,body A manifested allergy may be relatively milk, nuts, wheat, shellfish, chocolate, andmild, for example, a light attack of hay fever or fruits) may cause acute or chronic symptoms.

a brief episode of urticaria; or it may be severe There are many other possible factors inducingand very serious, for example, an acute attack of allergy, including sunlight, heat, cold, and para-asthma, a stubborn or uncomfortable skin rash, sites.

or sudden collapse Avoidance of the allergenic substance or When an allergen reaches a sensitive area of the stances offers the greatest hope of permanentbody, the tissues react irritably or even violently relief from an allergic disease In drug allergy,

sub-to produce sympsub-toms of allergy The allergic once the diagnosis is suspected or established,r~actions l}1ayoccur in almost any organ or the allergenic agent should be stopped and an-tissue of the body, with symptoms determined other drug substituted In allergic contact der-

by the location When the nose and throat are matitis from substances such as cashew shell oil,

!nvolved, an individual may have sneezing, stuff- fuel oil, paints, and tar, the patient should try tomess, running nose, and itching of the throat protect his skin from direct and indirect contactand eyes The symptoms represent hay fever with the agents, even if he has to change his(allergic rhinitis) If bronchial tissues are af- occupation Patients allergic to an inhaled sub-fected, there is wheezing, coughing, and difficult stance (such as feathers or animal danders) maybreathing (asthma) When the skin is affected, be unable to avoid them Airborne pollens aredermatitis or urticaria appears If the digestive difficult to avoid A physician may be able to

~ra~t is i?volved, there may be nausea, vomiting, desensitize the patient by a series of injections.mdlgestIon, abdominal pain, diarrhoea, or Anaphylactic shock

cramping An allergic reaction may also affect

the brain, causing headache (See also: Shock, page 17.)

Countless substances can cause allergic reac- Anaphylactic shock is a severe allergic reactiontions Penicillin is a common cause of drug and can often be fatal It commonly occurs afterallergy, and may be manifested by urticaria, an injection of a medicament such as penicillin.anaphylactic shock (see this page), skin rash, or It may occur within seconds or minutes of con-swelling of various body parts; alternatively, a tact with the incompatible substance, which mayreaction characterized by malaise, fever, and have been taken by mouth or inhalation or in-possibly arthritis, may occur about 10days after troduced by injection, bite, or sting In the verypenicillin is given Drugs that may be associated worst type of allergic attack, the patient may

MEDICAL CARE: COMPENDIUM

International Medical Guide for Ships

suddenly begin to wheeze, become pale, sweat, Hay fever

and feel dizzy The heart beat may become so

Hay fever is a common allergy that affects thefeeble that he may lose consciousness and, unless

upper respiratory tract Generally caused bytreated promptly, he may die This reaction can

pollen, it is a seasonal disease that is prevalent inoccur after contact with almost any allergen

the spring, late summer, and autumn SymptomsPrevention is best Before giving injections or

resemble those of an aggravated head cold, i.e.,administering any medication, the patient should

congestion of nose and eyes, sneezing, and

asth-be asked if he has ever had an allergic reaction

ma (see Asthma, page 171) An attack may last

in the past If he has, RADIO MEDICAL

from 4 to 6 weeks, during which the patient mayADVICE should be obtained before any drug

lose a lot of weight

is administered to him A skin rash or other

unusual side-effect following treatment is a

Treatment

warning to avoid the same medicine in the

future At sea, the treatment is entirely symptomatic.

Treatment Patients with hay fever are usually familiar with

the symptoms and with the effects of their For anaphylactic shock, the patient should be ious remedies Usually they do not have to go toplaced in a prone position The following bed or stop their regular work Give ephedrinemedicaments should be administered intramus- sulfate capsules, 25 mg, three to four times acu]arly, immediately: ]: ]000 epinephrine day More severe symptoms may be treated withhydrochloride injection, I ml; chlorphenamine chlorphenamine, one 4-mg tablet four times amaleate, 10mg; and hydrocortisone sodium day Because the medication may induce drowsi-succinate, ]00 mg The three medicines should ness as a side-effect, all precision work, poten-

var-be given from separate syringes and at dif- tially hazardous work, or standing watch shouldferent body sites The epinephrine hydrochloride be curtailed for the patient

injection may be repeated in 20 minutes, if

the patient's condition remains senous or

becomes worse Obtain RADIO MEDICAL Anaemia

is inserted under the skin, pull the piston back

It can result from haemorrhage of a large and ensure that blood does not enter the syringe

vol-before epinephrine is injected ume of blood or from constant loss of small

amounts of blood, from destruction of the redNote Hydrocortisone should be injected very

cells in certain diseases (such as malaria), orslowly; the duration time of the intramuscular

from deficient or defective formation of red cells,injection should be about 30 seconds

but usually it is due to lack of available iron orcertain vitamins in the diet

with-out laboratory facilities, but you may noticeAsthma is a disease in which the patient suffers when you are carrying out your examination offrom periodic attacks of difficulty in breathing a patient that the conjunctivae and membranesout, during which time he wheezes and feels as if of the mouth are very pale compared with those

he were suffocating Many cases of asthma are of a healthy person The colour of the cheeks isallergic manifestations in sensitized persons For no guide, as such things as fever and excitementdiagnosis and treatment, see section on Asthma, will redden them, while natural sallowness of thepage 171

complexion may simulate extreme pallor

Other diseases and medical problems

The symptoms of severe anaemia vary, but they The skin has a white, sodden appearance and theare best summarized as those of physical weak- area is bordered by a red inflamed zone The skinness and rapid fatigue, together with palpita- surface is typically abraded by frequent scratch-tions ing, which prolongs and worsens the condition.Anaemia is generally a chronic condition that Threadworm infestation should be excluded as arequires no emergency treatment except when it cause (page 240)

is severe and of recent development In that case

Treatment

the patient should be referred to a doctor at the

next port of call so that a blood examination can Any haemorrhoids should be treated (page 201).

be undertaken, the type of anaemia diagnosed,

and the correct treatment prescribed After the bowels have moved, the area round the

anus should be washed gently with soap and

Anal fissure warm water, then patted dry with a towel before

An anal fissure is an ulcer that extends into the applying zinc oxide paste Calamine lotion mayback passage from the skin at the anal margin also be applied Loose-fitting cotton

boxertrunks should be worn Scratching must beThe fissure is usually narrow, elongated, and strongly discouraged If the impulse to scratchpurple-coloured When passing faeces intense becomes irresistible, the knuckles or back of thepain is experienced, which may continue for half hand, never the fingers, should be used Consult

an hour or more A little slime and blood may be a doctor at the next port.

noticed

Place the patient in the position described under

Appendicitis

haemorrhoids (page 201) Put on polythene

gloves before examining the anus With one fin- Appendicitis is the commonest abdominal ger gently open out a small segment of the anal gency, occurring mostly in people under 30 yearsedge Continue until the whole circumference old, though it can appear in people of any age.has been inspected This may give rise to intense When considering appendicitis as a diagnosis,pain and make a complete examination impos- always ask the patient if he knows whether hissible appendix has already been removed, and lookThrombosed external piles (page 201) or an ab- for the operation scar in the right lowerscess in the anal region are the only other likely abdomen area.

emer-reasons for such pain The illness usually begins with a combination of

Treatment colicky abdominal pain, nausea, and perhapsmild vomiting The pain is usually felt in the

Relieve pain with acetylsalicylic acid or para- midline just above the navel or around the navel.cetamol The area should be washed with soap Later, as the illness progresses, the pain movesand water, then carefully dried after each bowel from the centre of the abdomen to the rightaction Calamine lotion may be applied locally lower quarter of the abdomen (see Fig 123).TheThis treatment should be continued until the character of the pain changes:icky, diffuse, and not well localized when it isfrom being col-patient is seen by a doctor at the next port around the navel, it becomes sharp, distinctly

felt, and localized at the junction of the outerand middle thirds of a line between the navel and

Anal itching (anal pruritus) the front of the right hipbone.

Localized itching around the anus is commonly The patient usually loses his appetite and oftencaused by excessive sweating, faecal soiling, or a feels ill The bowels are often sluggish and the

Other diseases and medical problems

strual period and whether the periods are regular with desperate efforts to breathe His lips and

or irregular If the sexual history allows for the face, at first pale, may take on a blue tinge andpossibility of pregnancy, always consider that be covered with sweat, while his hands and feetthe case may be one of ectopic pregnancy become cold His pulse is rapid and weak, and

Salpingitis (page 251) Salpingitis is infection of may be irregular Fortunately, less severe the Fallopian tubes Always inquire about evi- tacks, without such great distress, are more com-dence of infection such as recent history of sex mono

at-contacts, pain on urinating, and vaginal dis- An attack may last only a short while, but it maycharge and bleeding The fever is usually higher be prolonged for many hours Eventually, how-than in the case of appendicitis ever, the breathing gradually becomes easier,

and coughing may then produce some sputum

Asthma After an attack, the patient may be exhausted,

but very often he appears to be, and feels, Asthma is a disease in which the patient suffers paratively well Unfortunately this relief mayfrom periodic attacks of difficulty in breathing only be temporary and attacks may recur atout and a feeling of tightness in the chest, during varying intervals.

com-which time he wheezes and feels as if he were

Asthma must not be confused with choking duesuffocating

to a patient having inhaled something, for The causes of asthma are usually: stance food, into his windpipe In choking symp-

in-• exposure to irritants to which the sufferer is toms occur immediately (see page 42).

sensitive-these may be either inhaled (e.g.,

dust, acrid fumes, or simply cold air) or in- Treatment

gested (e.g., shellfish or eggs);

General treatment

• mental stress in highly strung and

overcon-scientious persons; The patient should be put to bed in a position he

• certain chest diseases, such as chronic bron- finds most comfortable, which is usually halfchitis sitting up If he is emotionally distressed, try toAsthma may begin at any age There is often a calm him.

previous history of attacks from time to time in In severe cases of asthma, RADIO MEDICALthe patient's life ADVICE should be obtained.

The onset of an attack may be slow and

Specific treatment

preceded by a feeling of tightness in the chest, or

it may occur suddenly Sometimes the attack A person who knows that he is liable to attacksoccurs at night when the patient has been lying has usually had medical advice and been sup-flat plied with a remedy In such cases the patient

In the event of a severe attack, the patient is in probably knows what suits him best, and it is

then wise merely to help him as he desires and to

a state of alarm and distress, unable to breathe

interfere as little as possible He should be properly, and with a sense of weight and tight-

al-lowed to select the position easiest for himself.ness around the chest He can fill up his chest

with air but finds great difficulty in breathing A bedside vaporizer or turned-on hot showerout, and his efforts are accompanied by cough- should be used to humidify the air that is inhaleding and wheezing noises due to narrowing of the by the patient with asthma To offset possibleair tubes within his lungs His distress increases dehydration, the patient should be encouragedrapidly in severe cases, and he sits or stands as to drink plenty of fluids, especially water Morenear as possible to a source of fresh air, with his palatable liquids such as fruit juices and hot teahead thrown back and his whole body heaving may be helpful

MEDICAL CARE: COMPENDIUM

International Medical Guide for Ships

Medicaments to enlarge the air passageways ate treatment (see Muscular rheumatism, page(bronchodilators), such as ephedrine sulfate, 222) the pain will settle down within several

25 mg, should be given by mouth every 4-6 days The patient may then be allowed to behours If the patient is unduly nervous or unable more active, but heavy work is inadvisable

to sleep, 15-30 mg of phenobarbital should be Some patients have severe backache from thegiven by mouth every 4-6 hours

onset and, occasionally, the main leg nerve For acute asthmatic episodes, 0.3 ml to 0.5 ml of comes affected, resulting in sciatica (see Neuritisaqueous epinephrine hydrochloride injection and neuralgia, page 215) The patient will then1: 1000 should be givensubcutaneously and, if experience a sensation of numbness and tinglingnecessary, repeated after 60 minutes or a burning pain travelling down the leg.After obtaining RADIO MEDICAL ADVICE Treatment

be-on treatment, a 500-mg aminophylline

supposi-It is essential that the patient should keep thetory may be used The use of a suppository

should be restricted to only one or two occasions spine straight at all times If a board to lie on canbecause repeated usage might cause severe rectal be fitted to the bed, he should remain in bed inirritation the position that is most comfortable Other-Antibiotics may be given in acute asthma, be- wise, he should lie on a hard, flat surface withminimal padding until the pain eases Whenevercause most adult asthma patients will have a possible, he should eat meals standing up with abronchial infection that mayor may not be ap- straight back He should be washed in bed, butparent RADIO MEDICAL ADVICE should allowed to go to a lavatory rather than use a

be obtained as to whether antibiotics are in- bedpan Local application of heat to the backdicated (using a hot-water bottle) will help to relieve

If all or some of the above procedures are used, muscle spasm and pain If pain is severe, givemost acute asthma attacks can be treated ade- acetylsalicylic acid tablets If pain continues itquately (see Bronchitis, page 177) should be controlled (see Use of analgesics, page

305) Treatment should be continued and the

Backache patient kept at rest until a doctor can be

con-Pain in the small of the back is a symptom of suIted at the next port.

many conditions that affect the spine, spinal Biliary colic (gallstone colic)ligaments, back muscles, and nerves Pain is

usually the only symptom, and the general Biliary colic is usually caused by a gallstonehealth remains normal However, backache can stuck in the neck of the gall-bladder or in a bile

be an indication of more serious underlying dis- duct There is usually a history of vague ease, especially kidney disease (see Urinary tion and intolerance to fat An attack starts veryproblems, page 235), so in every case the urine suddenly without warning symptoms and mayshould be tested for protein (page 107) and the cease just as abruptly.

indiges-temperature and pulse rate taken The bouts of colic, often very severe, are felt in

Simple backache the right upper abdomen just below the lowestrib, but occasionally at the same level, only more

This is usually of sudden onset; it may follow a towards the mid-line Sometimes pain is also feltperiod of heavy work or some quick movement passing inwards through the body to the angle of

of the back, but it can appear for no known the shoulder blade The patient feels cold, sweatsreason The pain may vary from a dull ache to a profusely, and is extremely restless Nausea issevere disabling pain Some degree of spasm of always present, and vomiting may occur Thethe back muscles, which is made worse by move- abdomen feels bloated, and the bowel is con-ment, is always present With rest and appropri- stipated The pulse is rapid, and the temperature

Other diseases and medical problems

is normal or slightly raised A moderately raised Bites and stings

temperature may indicate that the gall-bladder is

Animal bitesalso inflamed

Examine the abdomen, look for jaundice (page

Animal bites may cause abrasions, lacerations,and punctures There is a danger of bacterial210), record the temperature, pulse rate, and infection, including tetanus, from these wounds,respiration rate, note the colour of the urine and and rabies is also a threat

test it for protein (page 107), and examine the

All animal bites should be treated by thoroughfaeces Rigid abdominal muscles prevent exam-

ination during an acute spasm of pain Between washing (not scrubbing) with soap and waterspasms, feel for tenderness in the gall-bladder and swabbing with 1% cetrimide solution. Allarea When the outflow of bile is blocked, the traces of soap should be removed before usingfaeces become pale or putty-coloured because the cetrimide solution The wound should thenbile pigment is deficient However, the urine, be covered with a dressing You should checkcontaining excess bile pigment, becomes much that the patient is protected against tetanusdarker in colour Look for jaundice each day If (page 145) If an hour or more later the woundprotein is present in the urine, consider renal is throbbing, the patient should be given the

read the section on rabies (page 143)

General treatment Anyone bitten by a rat should be given the stan-dard antibiotic treatment (page 308) The wound

Put the patient to bed Record the temperature, should be cleansed with soap and water andpulse rate, and respiration rate every four hours covered with a sterile dressing

If feverish, give only fluids for the first 48 hours

Snake bites

A fat-free diet should be provided thereafter

Many snakes are harmless but there are three

Specific treatment poisonous types:

As soon as possible, mix 15 mg of morphine with • cobras, mambas, African spitting cobras, etc;0.6 mg of atropine in one syringe and inject the • vipers and adders; and

mixture intramuscularly The morphine will re- • the highly poisonous sea snakes of the Pacificlieve the pain, and the atropine the spasm and Indian Oceans

Reassure the patient that the injection will act in

about 15 minutes If the pain returns, the injec- Snake bites are likely to occur ashore or fromtion should be repeated after four hours and cargo Unprovoked bites of humans seldom oc-RADIO MEDICAL ADVICE should be cur Even if a snake is disturbed and bites, shoes

Subsequent management If large amounts of venom have been injected,

Isolate any jaundiced patient (.page 297) and get shock (see page 17) occurs, with heart pal RADIO MEDICAL ADVICE All cases should tions, difficulty in breathing, collapse, andsee a doctor at the next port sometimes convulsions Delayed blood clotting

pita-MEDICAL CARE: COMPENDIUM

International Medical Guide for Ships

may occur These symptoms can present be- Jellyfish

tween 15 minutes and 1 hour after the bite

It is sensible not to swim in waters where jellyfish

General management. The common symptoms in abound If someone has a part of a jellyfish stucksnake bite are fright and fear of sudden death to him, this could contain sting cysts AlcoholResearch has shown that serious poisoning is should be applied to the affected part to kill therare in humans and death is highly exceptional undischarged sting cysts The tentacles and slimeReassurance is therefore most important Acetyl- should then be scraped off Do not rub the stingsalicylic acid tablets may be given to relieve the with wet hands or a wet cloth as this will ag-

If vomiting occurs, guard against inhalation, if In severe cases with rapid collapse, artificial necessary by putting the patient in the uncon- piration and heart compression may have to bescious position (page 6) carried out (page 6)

res-If the snake has been killed, it should be lifted Poisonous fish

with a stick into a container and retained for

These exist in most tropical waters, especiallyidentification Do not attempt to find or kill a

round the islands of the Pacific and Indiansnake, as this might result in further bites Do

Oceans They have long spines covered bynot handle a dead snake as head reactions can

venom-secreting tissues The stings cause an persist for up to one hour after death

in-tense and often agonizing local pain

Treatment. If the bite occurs ashore or in port, If possible, immerse the affected part in the transport the patient to hospital immediately In test water the patient can bear The pain is thenother cases, seek RADIO MEDICAL ADVICE, relieved within seconds Remove the limb quick-giving, where possible, a description of the snake ly from the water to avoid blistering Re-and the nature of the bite immerse as pain recurs (usually after about 30

hot-If the bite is on the hand, arm, foot, or leg, the minutes) If the affected part of the body cannotbest immediate treatment is to cleanse the be immersed in hot water (face or trunk), thewound with soap and water, cover it with a puncture wound should be infiltrated with lido-sterile dressing, and apply a broad, firm, but not caine as follows.

tight, crepe bandage above the bite (see note Prepare a syringe containing 1% lidocaine regarding tourniquet application, page 17) Al- drochloride Sterilize the skin with spirit, andternatively, immobilize the whole limb by the push the point of the needle just under the skin.same means The bitten limb should be moved as Inject sufficient lidocaine to raise a small bloblittle as possible because movement spreads the under the skin Wait for a few minutes tovenom allow the anaesthetic to act Lower the barrelSucking the venom out of a bite is not generally under the skin, push it forward, and inject aof the syringe so that the needle is kept justrecommended, because of the danger of ag- further small amount of lidocaine Pull thegravating bleeding, introducing infection, and needle back, move the barrel round throughpoisoning the person giving the treatment about 60 degrees, push the needle forward, andVigorous sucking at frequent intervals may, inject again By repeating this process, an area ofhowever, be used for bites on the face and about 3 4 cm in diameter can be anaesthetizedbody where immobilization is not possible (see Fig 124).

hy-The person sucking should spit out the venom

extracted

Sea urchins

If venom from a spitting cobra enters the eye, The spines of sea urchins can produce painfulbathe the eye thoroughly with water injuries when they pierce the skin This is par-

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International Medical Guide for Ships

abounds with potentially harmful bacteria Treatment

However, self-inflicted bites of the tongue and

General treatment

lip are tolerated well

The bite should be treated in the same way as Where there is a small boil with localized other wounds (see page 67) and observed care- flammation and no rise in temperature, there isfully for any infection Treatment for tetanus is no need to give antibiotics The area round thenot needed because the causative organism is not boil should be swabbed with 1% cetrimide solu-found in the human mouth tion and, when it has been dried, a light dry

in-dressing should be applied Where there is a

Boils, abscesses, and large boil, a carbuncle, or an abscess, any hair

round the area should be clipped short before

carbuncles swabbing or eventual incision.

(See also Cellulitis, page 178)

Rest the patient and apply heat locally, in the

solu-tion (two level teaspoonfuls of table salt to one

A boil is an area of inflammation that begins at litre of water) can be used for the compresses.the root of a hair It commences as a hard, The temperature of the solution should beraised, red, tender spot which enlarges It may around 43°C If the compresses cannot be han-subside in two or three days, but more often it died comfortably by the attendant, then they aresoftens on the top and forms a yellow "head" too hot for the patient.

The top breaks and the pus drains out, after

To relieve the pain, give acetylsalicylic acid which the boil heals Normally the boil does not

tab-cause an increase in body temperature but lets, in the usual dose (see page 305).

lymphangitis (page 212) may occur If(a) the abscess does not appear to be ready for

Carbuncles incision (see below), that is if you cannot detect-by gentle pressure on either side-fluctuation

A carbuncle is a collection of small boils very of pus in it, and (b) the temperature remainsclose together The boils cause a large swelling above 38°C, give antibiotic treatment For awhich is very painful The temperature may rise patient not allergic to penicillin, give procaine

to 38 °C and the patient will feel ill benzylpenicillin, 600000 units intramuscularly,

and at the same time start the standard

An abscess is a localized collection of pus which As soon as you are satisfied that pus is present,gives rise to a painful throbbing swelling At first open the abscess and evacuate the pus Do notthe swelling is red, hot, hard, and very tender, wait for the abscess to burst

and after a day or two it becomes distended with

pus and increasingly painful At this stage, the

Treatment by incision

skin over it becomes thinned and purplish in

colour and it "gives" slightly when it is lightly The following items are required for dealingtouched There is usually a rise in temperature to with an abscess with pus in it:

38-40°C There may also be considerable

swell-• scalpeling around the area, and the glands draining the

area may be enlarged and painful (see Lym- • tissue forceps

phatic inflammation, page 211) • dressing forceps

• Autoclave or boil these instruments forThe commonest sites for abscesses are on the 20 minutes in the sterilizer Place thearm, in the armpit, on the neck, in the groin, and sterilizer (with water drained oft) on a cleanbeside the anus towel Allow it to cool.

Other diseases and medical problems

• a bowl of hot (37°C) antiseptic lotion (I % perature settling, put on a simple sterile gauze

• a kidney dish to collect the pus

Note Boils or carbuncles on or around the nose,

• a container for the disposal of soiled swabs

• a 30-cm strip of sterile ribbon gauze opened There is always a danger of the infection

being extended to the brain, with serious Clean your hands thoroughly with soap, water, quences These lesions should be allowed to dis-and nail-brush, and get an assistant to arrange charge spontaneously Get RADIO MEDICALthe patient comfortably and in a good light ADVICE on whether to give antibiotics in such

conse-I Inspect the area closely and decide exactly cases.

where to make the incision It should be at the Subsequent management

siteof greatest fluctuation and since, as a general

rule, blood vessels and nerves run in the long If the patient feels ill and has a temperature, heaxis of the body, along this axis; with such an should be put to bed and given either 2 para-incision, there is less likelihood of damaging cetamol or 2 acetylsalicylic acid tablets every 6these structures than with a transverse incision hours, to control the pain If the temperature

2 Paint the abscess and a wide area of surround- continuesMEDICALfor moreADVICEthan a day, get RADIOon whether to give ing healthy skin with antiseptic solution (l % biotics.

anti-cetrimide)

3 Take a scalpel and make a deliberate incision As the discharge is infected, you should dispose

of the dressing carefully, sterilize any

instru-at least 1.5 cm long over the most prominent ments or bowls you have used, and wash yourfluctuant area If the abscess is on a limb, in- hands thoroughly.

struct the assistant to steady it Pus should

dis-charge freely If it does not, insert the closed The dressings should be changed daily

blades of the forceps into the wound and open

Always test the urine for glucose if any patientthem up widely Next withdraw the forceps and,

has an abscess, carbuncle, or bad boil The testtaking a swab in each hand, exercise gentle pres-

is best carried out on a specimen of urine passedsure on each side of the abscess to help evacua-

about 2-2 V2 hours after a substantial meal Iftion of the pus Squeezing is unnecessary and

glucose is found in the urine the patient shouldmay be dangerous, since it can spread infection

see a doctor at the next port because he may

4 Using dressing forceps, pick up a length of have diabetes (see page 186)

sterile ribbon gauze and insert it into the

wound Pack it in lightly and leave about

Bronchitis

10 cm on the surface of the wound The object

is to keep the wound open so that it drains Bronchitis is an inflammation of the bronchi,effectively and heals from the bottom up which are the branches of the windpipe inside

5 Clean the area with a sterile swab the lungs There are two forms, acute (of recent

origin) and chronic (of long standing)

6 Apply sterile gauze, cotton wool, and

ban-Acute bronchitisdages

Continuation treatment This may occasionally occur as a complication

of some infectious fever (for instance, measles)Keep the part at rest for 24 hours and then or other acute disease More usually, however, itremove the gauze drain If the discharge is very is an illness in itself It usually commences as a

MEDICAL CARE: COMPENDIUM

International Medical Guide for Ships

then the patient develops a hard dry cough, with give phenoxymethyl penicillin potassium tablets

a feeling of soreness and tightness in the chest (500 mg) at once, followed by 250 mg ofwhich is made worse by coughing Headache the same drug every 6 hours for the next 5and a general feeling of being unwell are usually days If the patient is allergic to penicil-present In mild cases there is little fever, but in lin, sulfamethoxazole + trimethoprim tabletssevere cases the temperature is raised to about (400+80 mg), 2 tablets every 12 hours for 538-39°C and the pulse rate to about 100, while days, should be given instead.

the respiration rate is usually not more than 24

Should there be no satisfactory response to

In a day or two the cough becomes looser, treatment after 3 days, seek RADIO MEDICALphlegm (sputum) is coughed up (at first sticky, ADVICE.

white, and difficult to bring up, later

greenish-Note Sulfamethoxazole + trimethoprim mustyellow, thicker, and more copious), and the tem-

perature falls to normal The patient is usually not be given to a woman who is pregnant or mightwell in about a week to 10 days, but this period be pregnant.

may often be shortened if antibiotic treatment is

Subsequent management

gIven

Note The patient should remain in bed until his

tem-• The rise in temperature is only moderate perature has been normal for 48 hours.

• The increase in the pulse and respiration rates Examination by a doctor should be arranged at

is not very large the next port.

• There is no sharp pain in the chest

Chronic bronchitis

These symptoms distinguish bronchitis from

This is usually found in people past middle agepneumonia (see page 221), which gives rise to

much greater increases in temperature and pulse who are aware of the diagnosis Exposure torate, with obviously rapid breathing and a blue dust and fumes and inhalation of tobacco smoketinge to the lips and sometimes the face The predispose to the development of chronic bron-absence of pain distinguishes bronchitis from chitis Sufferers usually have a cough of longpleurisy (page 220), for in pleurisy there is severe standing If the cough is troublesome, givesharp pain in the chest, which is increased on codeine sulfate, 15 mg (half a tablet), repeatedbreathing deeply or on coughing after 4 hours if necessary.

Superimposed on his chronic condition, a

pa-General treatment tient may also have an attack of acute

bron-The patient should be put to bed and propped chitis, for which treatment (as above) should be

up with pillows, because the cough will be fre- given If this occurs, the body temperature isquent and painful during the first few days A usually raised and there is a sudden change fromcontainer should be provided for the sputum, a clear, sticky or watery sputum to a thick yellowwhich should be inspected Frequent hot drinks sputum Anyone with chronic bronchitis shouldwill be comforting Smoking should be discour- seek medical advice on reaching his home port.aged

Cellulitis

Specific treatment

This is a septic skin condition, but is unlike anGive 2 tablets of acetylsalicylic acid every 4 abscess in that the inflammation spreads underhours This is sufficient treatment for milder the skin without being localized The skin is redcases with a temperature of up to 38°C which and swollen and, when the infection has takencan be expected to return to normal within 2-3 hold, the skin will pit on pressure as in oedemadays If the temperature is higher than 38 DC, (page 216) The patient will usually feel unwell

Other diseases and medical problems

and shivery, and often has a headache and fever More information about each condition and theThe nearby lymph nodes will become enlarged treatments are given separately for the variousand painful (page 211, Lymphatic inflammation) illnesses

General treatment the gall-bladder

All patients with fever should be put to bed If Cholecystitis may occur in either acute or the swelling is other than very slight, the affected ic form and is nearly always associated with thepart should, if possible, be elevated presence of stones in the gall-bladder The pa-

chron-Specific treatment

tient is usually middle-aged or older, overweight,and in chronic cases there is often a history ofGive procaine benzylpenicillin, 600 000 units long-standing indigestion with flatulence madeintramuscularly, then the standard antibiotic worse by fried or fatty foods In a typical acutetreatment (page 308) attack, there is a sudden onset of pain in theright, upper quarter of the abdomen in the gall-

Chest pain bladder area The pain is usually moderatelysevere, constant rather than colicky, and may

When the patient has been examined, the tem- spread through the body towards the rightperature, pulse, and respiration rates recorded, shoulder-blade and sometimes to the rightand the signs and symptoms noted, use Fig 125 shoulder-tip Fever, nausea, and vomiting areand Table 6 to diagnose his condition or to present, and the patient tends to lie still inconfirm your diagnosis bed rather than roll about This stillness is an

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International Medical Guide for Ships

important diagnostic sign In distinguishing 2days If the pain and fever increase or biliarycholecystitis from biliary colic where the patient colic starts (page 172) or jaundice appears (page

is extremely restless during the spasms of colic 210), get RADIO MEDICAL ADVICE.(page 172)

On feeling the abdomen, local tenderness over Colds (common cold,

the gall-bladder is often found, with an asso- coryza, rhinitis)

ciated hardness of contracted, right, upper The symptoms of the common cold are: abdominal muscles perature, runny nose, red and watery eyes, mal-

tem-If the hand is slid gently under the rib margin in aise, aching muscles, chilliness, and often a sorethe gall-bladder area while the abdominal mus- scratchy throat and cough A cold lowers a per-des are drawn in during a deep breath, it is son's resistance to other diseases and permitsusually possible to find a localized, very tender secondary infections Symptoms of a cold may

patient should be watched carefully for other

In diagnosis, cholecystitis must not be confused symptoms of these diseases A septic sore throatwith biliary colic, right-sided pneumonia, hepa- may start as a cold A cold may lead to bron-titis, perforation of a peptic ulcer, or right-sided chitis, pneumonia, and middle-ear disease.pyelitis (see Table 5,pages162-163, and Table 6,

Treatment

pages 180-181)

Unless symptoms develop that indicate a moreserious disease, the treatment for a cold should

General treatment bed until the temperature is normal and he feelsreasonably able to function Acetylsalicylic acid,

The patient should be confined to bed and solid 600mg, should be given by mouth every 3-4food should be withheld until the nausea sub- hours to help relieve the symptoms If it is notsides, but adequate fluids (except milk) should well tolerated by the patient, paracetamol,

be given Thereafter, a bland diet without fried 500mg, may be tried at the same frequency.

or fatty foods should be offered A hot-water Antibiotics should NOT be given.

bottle applied to the gall-bladder area will

al-leviate pain The temperature, pulse, and res- The patient should drink plenty of fluids such aspiration should be recorded The white of the water, tea, and fruit juices He should be advisedeye should be inspected each day for jaundice, to blow his nose gently to avoid forcing infec-and the urine and faeces examined for changes tious material into the sinuses and middle ear.associated with jaundice (page 210) When symptoms subside for 24 hours, the pa-

Further management. All cases, even if re- for a day or two before returning to full duty.tient should get out of bed but restrict activitiescovered, should be seen by a doctor when con- This will also help to stop the spread of the cold

Specific treatment Warning Anyone who is deaf or slightly deaf asthe result of a cold, should not travel by air or go

Give phenoxymethyl penicillin potassium 250- skin-diving

mg tablets, 2tablets to start with, then 1tablet

every 6 hours for5days If the patient is allergic

Constipation

to penicillin, give the alternative standard

anti-biotic treatment (see page 308) In an uncom- Constipation is a symptom, not a disease, and isplicated case, the condition should improve after rarely an acute or serious medical problem.

Other diseases and medical problems

Treatment fection and degeneration of the air passages) InFrequently changes in diet, environment, type of all cases of chronic cough, a doctor on shorework, degree of physical activity, and emotional should be consulted.

or nervous upsets may result in constipation The following general observations may be The patient should be advised to eat regularly, ful

help-drink ample amounts of water, and take regular Simple bronchitis usually follows a viral exercise A gentle laxative such as magnesium tion or "cold" that is accompanied sometimes byhydroxide suspension may be given Prunes or a sore throat, a raw heavy feeling behind theprune juice could be added to the patient's diet breastbone, and a dry cough that changes into aPersistent constipation of recent onset or a productive cough.

infec-change in bowel habits may indicate a serious Pleurisy is manifested by a severe pain in theunderlying bowel condition The seaman should chest wall that is aggravated by deep breathing.

be advised to seek medical attention when port

is reached Withpneumonia, there is usually fever, often a

As a temporary relief from constipation, mag- productive cough with pus or sputum, and painin the chest.nesium hydroxide suspension may be given (1-2

Tuberculosis of the lungs may be associated with15-ml tablespoonfuls daily)

a slight but prolonged cough

Cough

Cancer of the lung has become alarmingly quent in persons who have been heavy smokers.Coughing is a sudden forceful expulsion of air Early diagnosis of cancer is difficult but cough,from the lungs, usually in a series of efforts spitting blood, persistent fever, and loss ofAlthough annoying, a cough helps to get rid of weight may be early warnings.

fre-phlegm (sputum) that builds up in air passages When a cough accompanies an acute illness,

espe-Coughs may be productive (of sputum) or non- dally when there is fever, a full history should beproductive (dry) The sputum may be purulent obtained from the patient After examining the(with pus), copious or scanty, thick or thin and patient and his sputum, the most likely cause offluid, clear or frothy, odourless or foul-smelling, the illness should be determined Prepare a re-blood-streaked or manifestly bloody A cough quest to obtain RADIO MEDICAL ADVICE.may be acute or chronic, occasional or persis- Treatment

tent, slight or severe, painful or painless

Coughing is not a disease in itself but a symp- Coughs due to colds and viral bronchitis aretreated symptomatically with acetylsalicylictom An acute cough is usually caused by an acid, as described under Bronchitis (page 177).infection of the upper respiratory system A

productive cough that lasts for more than 3 For persistent and severe coughing months frequently means that the patient is suf- nying respiratory infections, give half of a 30-mgfering from chronic bronchitis, even though he tablet of codeine, several times a day, if neces-does not recognize that he is ill until he becomes sary.

accompa-short of breath Because of cigarette-smoking Specific treatment should be directed to theand air pollution, thousands of people become cause of the illness The patient's pulse, tem-victims of chronic bronchitis and eventually of perature, and rate and depth of respirationemphysema Chronic cough with fever suggests should be noted.

a more serious condition, such as tuberculosis,

pneumonia, or even carcinoma of the lung (See also: Asthma, page 171; Bronchitis, pageChronic cough without fever may indicate heart 177; Pleurisy, page 220; Pneumonia, page 221;disease, bronchial asthma, or bronchiectasis (in- and Tuberculosis, page 145.)

International Medica! Guide for Ships

Denial emergencies

The following dental first aid procedures are

intended to relieve pain and discomfort until

professional care is available

Bleeding

Bleeding normally occurs following removal of a

tooth However, prolonged or profuse bleeding

from a tooth socket must be treated

Treatment

To treat bleeding, excessive blood and saliva

should be cleared from the mouth Then, a piece

of gauze 5 em x 5 cm, should be placed over the

extraction site and biting pressure applied by the

patient It is important to fold the gauze to a

proper size well adapted to the extraction site

The pad should be left undisturbed for 3-5

mi-nutes, then replaced as necessary Once bleeding

has stopped, the area should be left undisturbed

If bleeding is difficult to control, a piece of

gauze, 5 em x 5 cm twisted into a thin cone

shape or rolled (see Fig 126) should be packed

into the site and a second gauze pressure pack

placed over it The patient should apply biting

pressure for 30 minutes to I hour and continue

biting if necessary The mouth should not be

rinsed for 24 hours A soft diet should be

main-tained for two days

Lost fillings

Fillings may come out of teeth because of

recur-rent decay around them, or a fracture of the

filling or tooth structure

Treatment

If pain is absent, no treatment will be required

for a lost filling and the patient should be

ad-vised to see a dentist when in port If the tooth

is sensitive to cold, a temporary dressing should

be put into the cavity First, the tooth is isolated

~y placing a 5 cm x 5 em piece of gauze on each Toothache without swell ing

sIde A cotton pellet can be used to dry the

cavity A drop of oil of cloves should be placed This condition is usually caused by irritation or

on cotton and gently pressed into the cavity; this infection of the dental pulp from a cavity, lostwill usually control the pain and may be re- filling, or a recurrent problem in a tooth that haspeated 2 or 3 times daily as necessary a filling in place

Other diseases and medical problems

Treatment being allergic, to penicillin, oral erythromycinThe patient who has a toothache without swell- should be used in the same dosage and fre-quency The patient should be kept on the anti-ing of the gums or face should be advised to biotic for at least 4 days after he becomeschew on the other side of his mouth Foods afebrile (without fever) He should be instructedshould not be too hot or too cold Pain may be

relieved with acetylsalicylic acid, 600 mg by to see a dentist at the earliest opportunity.

mouth If the patient does not tolerate this drug, The patient should be advised to rinse the mouth

a 5OO-mgparacetamol tablet should be given with warm saline solution (a quarter teaspoonfulThe patient with a toothache should be told to of table salt in 200 ml of warm water) for 5swallow the acetylsalicylic acid and never to minutes of each waking hour This will cleansehold the tablets in the mouth as this will bum the the mouth and help to localize the infection insoft tissues If the aching tooth has a large cav- the mouth Also, saline solution may produceity, the instructions for placing a sedative cotton earlier drainage and relief from pain After thedressing, described on page 184, under Lost fill· pain and swelling subside, the oral rinsingings, should be followed should be continued until the patient is seen by

a dentist

Toothache with swelling

Toothache with swollen gums or facial tissue is Dental infection

often the result of infection by tooth decay that Dental infection usually occurs when decay involves the dental pulp and spreads into the tends into the pulp of the teeth Bacteria fromtissues of the jaws through the root canals The the mouth will enter the tissues of the jaws viacondition is also common as a result of infec- the canal in the tooth's root The infection maytions associated with diseases of the gums, remain mild or may progress to a swelling in theperiodontal membrane, and the bone that sup- mouth or face, after producing fever, weakness,ports the teeth In all cases, there is frequently and loss of appetite.

ex-pain, swelling, and the development of an

ab-scess with pus formation Treatment

Treatment Discomfort from a dental infection may be

con-The patient with mouth and facial swelling trolled with acetylsalicylic acid, 600 mg bymouth If the patient does not tolerate should be observed closely and the following salicylic acid, a 500-mg paracetamol tabletdata noted: (1) the exact area of the swelling, should be given Antibiotics are used as de-initially and during the illness; (2) the type of scribed in the section Toothache with swelling,swelling, whether soft, firm, or fluctuant (mov- but RADIO MEDICAL ADVICE should beable tissue containing a pus-filled cavity); (3) obtained beforehand.

acetyl-degree of difficulty in opening and closing the

mouth; and (4) the oral temperature, morning Painful wisdom tooth

and night These data are important for follow- (pericoronitis)

ing the patient's progress and evaluating the

effectiveness of the treatment Pericoronitis is an infection and swelling of theThe pain should be controlled with acetylsalicyl- tissues surrounding a partially erupted tooth,usually a wisdom tooth (third molar) Often a

ic acid as described above under Toothache small portion of the crown or a cusp of thewithout swelling offending tooth can be seen through the softFor infection, an initial dose of 500 mg of tissues The soft tissues appear swollen and thephenoxymethyl penicillin potassium should be degree of inflammation or redness may varygiven by mouth, followed by 250 mg every six considerably When the infection is severe, thehours If the patient is allergic, or suspected of patient may complain of difficulty in opening the

MEDICAL CARE: COMPENDIUM

International Medical Guide for Ships

mouth When the area is examined carefully, pus in localized areas usually requires some may be found coming from underneath the soft ation or adjustment of the denture by a dentist.tissues in the area of the partially erupted tooth These localized areas are usually located where

alter-the border of alter-the denture rests against alter-the

For a painful wisdom tooth, the area be~ween Treatment

the crown of the tooth and the soft tIssues

should be flushed with warm saline solution (a The patient should avoid using the denture untilquarter teaspoonful of table salt in 200 ml of the soft tissues have healed The denture shouldwarm water) In addition, the patient should be be cleaned carefully with mild soap and watertreated as directed under Toothache with swell- and stored in a water-filled container to avoiding (page 185) dehydration of the base material The patient

., should be referred to a dentist for appropriateTrench mouth (Vmcent S adjustment of the denture

infection)

Vincent's infection is a generalized infection of

the gums During the acute stage it is Diabetes

characterized by redness and bleeding of the

gums Usually there is a film of greyish tissue In dIabetes, t~e body ISunable to use or store allaround the teeth There is usually a very ~he sugar der~ved from the carbohydra~es eatendisagreeable odour and a foul metallic taste in m a normal dIet ~he excess s~gar rem~ms m thethe mouth The acute stage may be accompanied bl.oo~ and passes mto the UrIne, carrymg water

by a moderately high fever Lymph glands in the wIth It ThIS.loss of sugar a.nd water from theneck may be swollen body causes mcreased appetIte and thIrst

Diabetics do not produce enough insulin, which

Treatment is a hormone (regulating the blood sugar level)The patient should be advised to eat an adequate secreted into the blood by the pancreas Adjust-diet but avoid hot or spicy foods The fluid ments in the metabolism of sugar have to beintake should be increased made by changing the diet and/or amount ofFor pain 600 mg of acetylsalicylic acid should insulin Urine sugar (gl~cose) d~terminations

be given by mouth every3-4 hours as needed If ~elp to find the proper dIetary adjustment and

it is not well tolerated by the patient, try 500 mg msuhn needs

of paracetamol at the same frequency Diabetes is characterized by loss of weight,For infection, an initial dose of 500 mg of weakness, excessive ~~irst, and.the frequent pas-phenoxymethyl penicillin potassium should be sage of large qua~tItles of un.ne These symp-given by mouth, followed by 250 mg every 6 toms ~ay be modIfied accordmg to the age ofhours If the patient is allergic, or suspected of the patIent

being allergic, to penicillin, oral erythromycin In young people, the symptoms are present in ashould be given at the same dosage The patient more severe form of the disorder, which mayshould be kept on the antibiotic until at least 4 show itself as a rapid, acute illness In olderdays after the fever has gone He should be people, particularly if they are overweight, theinstructed to see a dentist at the earliest opportu- disease may come on more gradually and onlynity be suggested by the development of thirst andDenture irritation more freque~t passage of u~ine In both ~ge

groups, the dIsease may show Itself by succeSSIveGeneralized inflammation in the denture area is crops of boils or carbuncles Diabetes can beusually due to poor oral hygiene Inflammation made worse by infection

diabetes are present, it should be assumed that 104) and get RADIO MEDICAL ADVICE.the patient is suffering from the disease until

there is proof to the contrary If the p~tlent IS passmg mto a coma but not

unconscIOus and the problem seems to be toolittle insulin, ask him if he has any insulin and

Put the patient on a strict diet containing no none, put him to bed, and get RA~IO starchy or sugary foods This will normally ~AL ADVIC~ I~ the p~oblem IS t?O ~uchavoid complications such as coma (see below) msulm and he IS still conscIOUS, then glve.hlm 4until full diagnosis and treatment can be carried lu~ps or 2 heaped teaspoonfuls of suga,r dlssolv-

stnct observatIOn

diabetic coma and insulin coma If It ~s dlffic':llt to dlstl?gUlsh ~etween the two

condItIOns, gIve a conscIous patIent the sugar, as

• Diabetic coma can occur as the first sign of it will do no harm, even if too little insulin isdiabetes in a young person with the acute present

form of the disease or develop in a known

diabetic when the insulin level is too low and If 10 doubt always obtam RADIO MEDICALthe sugar in his blood has risen too high ADVICE

• Insulin coma is seen in the known diabetic who Note on insulin and other drugs There are ahas taken too much insulin or not enough number of different kinds of insulin which varyfood and whose blood sugar is too low in strength and length of action, and all are givenTable 7 describes the features that distinguish by injecti?n There are also ot~er drugs used tothese two types of coma control dJabete~ an~ th~se are 10 tablet form If

you have to gIve msuhn or other drugs to a

If the patient is unconscious, it may be possible diabetic, always check the instructions on the

to confirm the diagnosis from clues in his be- container very carefully Insulin should only belongings A known diabetic taking insulin or given in accordance with advice from a doctor.another diabetic drug may carry a supply of Diabetics should not be employed at sea

International Medical Guide for Ships

Diarrhoea and dysentery • Signs and symptoms of dehydration, Is the

~Iarrhoea IS defined as an abno~a" mcrease thirsty? Do the eyeballs seem sunken? If you

m the ~mount, freq~ency" and ~uldlty ~f the pinch the skin, does the fold return slowly toeva~uatlO!ls from the mtestme Diarrhoea !Snot its former position? Is there vomiting, rash,

~ dls~ase Itself but a ~ymptom ~f ~ro1!ble m the fever abdominal pain? Is the patient alert orm~estmal tract In t~IS respect, It IS hke cough, drow'sy?

chtlls, a!ld fever, which are general symptoms of • History, Has the patient ever had intestinalmany diseases, symptoms before? If so, when? Does the pa-

Dysen ery, c arac enzt h t· ed by gnpmg a' bdomma I tient have any idea what might be causing thet?

pams an requent stoo s contammg 00 an E 'A ' I I I b d th

mucus, IS caused by an mflammatlOn of the h', k? Wh t t d th t' t

mtestmes, particularly of the large bowel h' ? Wh t h th t

ave m common a ave ey ea en mDiarrhoea and dysentery are often used inter- common, on board or on shore?

changeably to describe a variety of conditions Data on all these points should be reported towith loose stools Normally, during the process the doctor on shore, when he is requested by

of digestion, food is moved slowly through the radio for advice on handling the case or anintestines to allow for its absorption In diar- outbreak of diarrhoea among the crew

rhoea, the motion of the intestines (peristalsis) is

speeded up and the stools are soft or semisolid, Treatment of diarrhoea

but they may become watery, possibly frothy, The principle of diarrhoea treatment is to and may have a very foul odour place water and salt lost in stools and vomit; in

re-, f most cases this can be done orally Oral There are many different causes 0 diarrhoea tion salts (ORS) are packed in sachets or alumin-and dysentery, ~ener~lly, the s~mpt?ms a~e ium bags (each containing 3.5 g of sodiumproduced by an mfectlous orgams~, ItS tOXIC chloride, 2,9 g of trisodium citrate (or 2.5 g ofproducts, t,?xms, or a.llergen~ InfectIOn ~ay be sodium bicarbonate or baking-soda), 1.5 g ofcaused by vlruse~, a wide vanety of bacten a, and potassium chloride, and 20g of glucose, which

rehydra-~>ne-c~lled paraslt~s such as ~mo,ebae The non- have to be dissolved in a litre of drinking-water).mfectlOus causes mc1ude p01sonn~g from hea~y IfORS are not available, a suitable drink can bemetals such as, mercury, allergies to certam made by mixing 8 level teaspoons of sugar andfoods, and emotional upsets 1 level teaspoon of salt in a litre of water The

In most cases of diarrhoea there is no inflamma- solution should be given first rapidly and then intion of the intestines The loss of fluid through small volumes, one glass (200 ml) afte~ e~chlarge watery stools may cause serious dehydra- bowel movement, to replace the contmumgtion; shock, collapse, or death may occur when losses

diarrhoea is very severe This is due to a loss of When the patient is in shock (see page 17) andthe water and salts from the body, Severe de- unable to drink and he continues to lose a greathydration may occur rapidly amount of wat~r, get RADIO MEDICAL AD.S'Igns th ta may be use u mf 1· d te ermmmg" the, VICE on the necessity of giving him intravenous0'"

f' t t' I'll d't ·t ' I d fluids, such as 0.9Yo (9g/htre) sodlUm chlondecause0 m es ma I ness an I s seven y mc u e: I t' d t " t' 60/ d d'

so u Ion, or ex ran mJec lOn, /0, an so lUm

• Character of stools. Are they watery? What is chloride, 0.9%, available in the ship's medicinethe colour? Is there blood, mucus, or pus? Is it chest (or others, like lactated Ringer's solution).all liquid, or are there some formed pieces? Intravenous infusions (see page 117) may be

• Frequency of stools, How often does the pa- ordered only by a physician, and they are tient pass stools? quired only for very severe cases

re-To relieve diarrhoea, a 30-mg codeine sulfate amoebiasis will produce mild abdominal tablet may be given; this may be repeated after comfort with diarrhoea containing blood and

dis-4 hours, if necessary mucus alternating with periods of constipation

Th t' t h ld b k t' b d d d The diagnosis requires laboratory identification

e pa len s our t bl 'ble ep 10 e anA I· 'd I ma e as·d 0f the amoe a 10b' th ~e laeces.

comlor a e as pOSSI e, IqUl or ow-resl ue

diet should be given that includes soft drinks and If there is a suspected case of this infection onbroths containing salt, as soon as the patient board ship, get RADIO MEDICAL ADVICE.feels hungry Spicy, fatty, or greasy foods should Cholera

be avoided If there is blood in the vomit or in

the stools, signs of dehydration (especially a See page 128,

da!ly weight loss of 2 kg or more) ?r decreasing Enteric fever

urmary output (less than 500 ml 10 24 hours),

RADIO MEDICAL ADVICE should be See page 130

promptly obtained

Virus infections

In most cases of diarrhoea, no antibiotics are , ,

required But in severe cases with high tem- Infe~t~on wIth several vI~uses ~1l1 cause nausea,perature (39-40DC) phenoxymethyl penicillin vomlt1Og, ';lpper abdommal dlscomfo~t, head-potassium tablets, 250 mg every 6 hours for 5 ache, malaise, low-gra~e fever, and diarrhoea.days, should be given (this medication should be The sto~ls are watery without blood and mucus.replaced by erythromycin, in the same dosage T,he patIent often ~e~ls well between b.outs ofand frequency, in patients allergic to penicillin) dlarr~oea and voml,t1Og.Oral rehydratIOn salt

solutIOn should be given for treatment (see page

In a~ute cases of diarrhoea, the possibility of 188), 1-2 litres or more daily, depending on theenterIC fever (see page 130), cholera (see page amount of fluid lost by the patient (see Fluid128), and malaria (see page 135) should be con- balance, page 101)

sidered and appropriate treatment given

Every case of diarrhoea should be treated as an

infectious condition, and the patient should be See: Personal hygiene, page 299; Food hygiene,isolated in his (single) cabin, or in the ship's page 285; Liquid transport and potable water,hospital (see Standard isolation, page 298) page 288; Disinfection procedures, Annex 5,

If h d" d I' h· 48 h page 354; Enteric fever, page 130

t e con ItIon oes not sett e Wit 10 ours

or if many cases of diarrhoea occur among the Drug abuse

crew at the same time, get RADIO MEDICAL

ADVICE, It is a matter of great concern that some

sea-farers obtain and use drugs illegally

Specific causes of diarrhoea and some special '

treatments are outlined below, The commonest drug used by seafarers IS

can-nabis or pot When it is smoked there is an

Am odour of burnt leaves or rope Attempts are

oeblc dysentery often made to disguise this smell, Pot-smoking isThis is caused by a one-cell parasite, an amoeba more often a communal than a solitary activity.that infects the bowel and is particularly, , ,. It'IS very d'ffiI ICUIt t0 I en I y'd t'f b·Y 10specIOnt' theprevalent 10the tropics The 1OfectlOn,known asb , 'I d· h· h varIOUS' "hard" drugs, as they are supp Ie·1'd '10amoe laSlS,IS an 10testma. t h' rIsease w IC may·,Th . varIOUSshapes, Sizes,colours, and consistencies.' 'appear 10 acu e or c romc lorm e patIent

with acute amoebiasis usually has abdominal Prolonged use of any drug results in mentalpains, chills, and bloody and mucoid diarrhoea, deterioration and personality changes of varyingwith many loose stools during the day Chronic degree It may be very difficult for a ship's officer

MEDICAL CARE: COMPENDIUM

International Medical Guide for Ships

Table 8 Narcotics and other drugs commonly abused; guide to identification a

names•

AMPHETAMINES AND aggressive behaviour, gig- pills, tablets or capsules of hallucinations, death from

METHAMPHETAMINE gling, silliness, rapid varying colours, chain- overdose; speeds rate of (bennies, pep pills, speech, confused thinking, smoking, syringes heart-beat, may cause

Iy; chain-smoking, extreme restlessness, irritability, violence, feeling of perse- cution, abscesses

BARBITURATES drowsiness, stupor, dull- tablets or capsules of vary- unconsciousness, coma, (barbs, blue devils, ness, slurred speech, ing colours, syringes death from overdose, goof balls, candy, yel- drunk appearance, vomit- physiological addiction, low jackets, phennies, ing, sluggish, gloomy, convulsions or death from

downers, red birds)

BARBITURATE-LIKE

DRUGS

chloral hydrate (knock- similar to barbiturates capsules (blue and white, gastric distress is common; out drops, joy juice, rust, and red), and syrup circulatory collapse may

(mixed with alcohol))

benzodlezeplne - similar to barbiturates Librium capsules (green and

capsules (red and yellow);

other sizes or brands may

be different in appearance methaqualone similar to barbiturates; also tablets (white, green, pink); especially dangerous in (Iuds, sopors, as, the vomiting, hypotension, capsules (light and dark combination with alcohol love drug, quads) pulmonary oedema blue, light and dark

green)

CANNABIS sleepiness, talkativeness, strong odour of burnt inducement to take stronger (pot, grass, reefers, hilarious mood, enlarged leaves or rope, with narcotics, antisocial locoweed, Mary Jane, pupils, lack of coordina- characteristic sweetish behaviour

hashish, tea, gage, tion, craving for sweets, odour; small seeds in

joints, sticks, weed, erratic behaviour, loss of pocket lining, cigarette

muggles, mooters, In- memory, distortions of paper, discoloured

fin-dian hay, mu, griffo, time and space, intellec- gers, pipes

mohasky, giggle- tual deterioration

smoke, jive)

COCAINE muscular twitching, convul- white odourless powder convulsions, death from

ted pupils

HALLUCINOGENS severe hallucinations, cube sugar with discolora- LSD causes suicidal

LSD (acid, sugar, feelings of detachment, tion in centre, strong tendencies, unpredictable Big D, cubes, trips) incoherent speech, cold odour, small tube of liquid behaviour, brain damage

tendencies, chills, ing, irregular breathing

shiver-The slgns and symptoms of addl.ctlon vary ac- the arms and thighs, or septic spots that arecordlO.g to the drug, and t.h~ picture may be the result of using unsterile needles

comJ?hcate~ by the user mlxlOg two drugs to • Jaundice (hepatitis) through the use of obtam ~axlmum effect The symptoms may' be properly sterilized syringes and needles (pagesudden 10onset because of overdosage or wlth- 210)

im-drawal, or they may appear slowly during

prolonged use If you have suspicions, make discreet inquiries

of other crew members These may reveal

alter-Th fi II d·· b h I f I· d ations in behaviour patterns in the patient

e 0 owlOg10 Icatlons may e e p u 10

e-·d· d·· f d b There may be rumours of drug problems on

CI109upon a Iagnosls 0 rug a use board

• Unexplained deterioration in work perfor- Do not accept the patient's word that he is not

U I· d h· f beh· a rug-user, as YlOg,c eatlOg, an concea ment

• t nexp alOe c angesd th 10pattern 0 aVlOur are a parII t f th t

0 epIc ure

owar s0 ers

• Changes in personal habits and appearance, In Table 8 the most commonly used narcoticsusually for the worse are listed (by their pharmacological and slang

• Loss of appetite names), and descriptions are given of the

physi-• Inappropriate behaviour: for example, wear- cal symptoms typical of intoxication with theming long-sleeved shirts in very hot weather to and dangers connected with their abuse

International Medical Guide for Ships

the Eustachian tube, which leads to the upper

~em<?ve any drugs fr<?mthe patIent and try to part of the throat The Eustachian tube allowsIdentify them and theIr source the air pressure in the middle ear to equal that ofAlways obtain RADIO MEDICAL ADVICE air entering the external ear canal A nose or

throat infection can spread to the middle ear by

If the patIent ISuncons~lOus, gl~e the appropn- way of the Eustachian tube Blowing the noseate treatment (UnconscIous patient, page 104) may force infected material into the middle ear

If the sympt?ms are those of mental dIsturbance, An infection of the middle ear may result in ansee Mental Illness, page 213 abscess and running ears Sometimes infectionNote Police and Customs officials take a very may extend from the middle ear to the m~s~ofd

strong interest in certain drugs and how they cellsm th~ temporal bone an? cause mastOIdItIs.come to be on your ship Any confiscated drug When thIs happens, a bram abscess or per-should be clearly labelled and locked away in a manent deafness may result

secure place and noted in the official logbook Themastoid process is the large, rounded, bony

If you are returning to your country the presence prominence behind the pinna It contains many

of prohibited drugs on board should be reported tiny cavities resembling a honeycomb It is

to the Customs, which will take appropriate sometimes inflamed by the spread of infection

In other countries inquiries as to the proper Vibrations that are carried to the inner ear byprocedure should be made through the ship's the external canal, the ear-drum, and the ossiclesagents are converted into nerve impulses and trans-

mitted to the brain by the auditory nerve The

Ear diseases inner ear consists of theosseous (bony) labyrinth

labyrinth is composed of a series of cavities:The ear is concerned with the functions of hear- the vestibule, three semicircular canals, and theing and equilibrium There are three divisions of cochlea ("snail-shell") The membranous laby-the ear: outer ear, middle ear, and inner ear. rinth is located within the osseous labyrinth andThe outer ear is comprised of the auricle (pin- has the same general shape The sense of hearing

na), a skin-covered cartilaginous framework is transmitted to the auditory nerve through thewhich projects from the head, and the external c~chlea 'J!te semicircular canals a~e co~cerned

auditory canal. This canal, lined with hairs and wIth equlhbnum They are filled wlt~ flUId,andglands that secrete earwax (cerumen), is about any movement of the head results m a corre-2.5 em long, and extends to the middle ear sponding movement of the fluid in the three

canals The movement of the fluid generatesThe ear-drum (tympanic m~mbrane or typanum) nerve impulses, which cause a person to makeseparates the external audItory canal from the adjustments in position to maintain balance.middle ear In the middle ear, three tiny movable The motion of an aeroplane or of a ship canb?nes.(the ossicles) modify and cond~ct sound produce dizziness and nausea Thismotion sick-

vIbratIOns from the ear-drum to the mner ear nessmay be called "sea sickness", "air sickness",The ear-drum and the ossicles are so delicate or "bus sickness", depending upon the type ofthat violent vibrations of the air, like those vehicle in which the person is riding when hecaused by the explosion of a bomb or the firing experiences the symptoms

of ~ heavy gun, may injure them "!"hethree How to examine an ear

osslcles of each ear are calledmalleus, inCUS,and

stapes and, in the order named, resemble a min- Compare the appearance of both ears Look foriature hammer, anvil, and stirrup swelling or redness of the pinna and the sur-

them with those of the other ear (page 211) Th~ ears frequently a~he, feel sore, or have a

feehng of fullness dunng a head cold or other

In a good light, pull the pinna gently backwards disease in which the respiratory passages areand upwards to enable inspection further inside affected Acute infection of the middle ear causesthe ear passage severe earache and usually results in the forma-

tion of an abscess

Press firmly on both mastoid processes

Tender-ness of one may indicate middle ear or mastoid Wax in the ear

infection

Accumulated wax may cause only slight Check the duration, intensity, and nature of any fort in the ear passage but, if it has hardened andearache Establish if hearing has been dimin- is near the ear-drum, pain may be felt whenished or if there are added noises in the ear and swallowing or blowing the nose Hearing is often

discom-if the sense of balance has been impaired diminished, especially if water gets into the

pas-sage It s often possible to see the wax plug when

E h the entrance to the ear passage is examined in

An earache may be caused by infection of the

middle ear; an inflammation, an abscess, or a Treatment

boil of the external auditory canal; inflammation No attempt should be made to scrape out the

of the Eustachian tube; dental conditions; wax

International Medical Guide for Ships

The patient should lie down with the affected ear BoiI in the ear

01 10t e ear passage causes a t ro 109pamSlightly warmed vegetable oil should be put into which incre~s~s in severity over se~eral days.the ear passage and left for 5 minutes before When the ~oIlls about to burst, there.ls a suddenwiping away any drops that run out when the stab of p~m follow~d by a sm~ll dlsc~arge ofhead is tipped sideways blood-stamed pus wIth much relIef of pam If the

pinna is gently drawn upwards and backwards,Repeat this treatment twice a day for 3 days Do it is often possible to see the boil in the earnot put a cotton-wool plug in the ear passage Pulling the pinna in this manner usually

increases the pain and confirms the diagnosis

If relief of symptoms is not satisfactory, ear- An inflamed middle ear causes similar pain, butsyringing should be arranged at the next port pulling the pinna does not make the pain worse

The ear passage of the affected side may be

Infection of the outer ear obviously narrowed and red in comparison with

ThIs IS a common infection in hot weather or

after swimming, especially in the tropics and Treatment

subtropics The condition frequently affects

both ears whereas boils and middle ear infection Use alummlUm acetate ear-drops every 2 hoursoccur mainly in one ear Pain is not a feature of until the pain g?es If the boil bursts, clean thethe disease but the ear may be uncomfortable ear passage, whIch should subsequently be keptand itch, with a discharge from the ear passage clean and dry

The skin of the ear passage is liable to bleed

slightly and appears red, shiny, and abraded I f n ec Ion t· f th ·ddl

(otitis media)

Treatment An infection of the nose or throat may spread toThe ear passages should be thoroughly mopped the middle-ear cavity via the Eustachian tubeout with cotton-wool swabs until dry (Fig 127, page 193)

Som~times it is better fo~ ~he patient to do this When normal drainage of the middle earfo! ~Imself under supervISIon Next, a fe~ alu- through the Eustachian tube is impaired, pres-mmlUm acetat~ ear-dro~s sh~)UI~ be put 10?ne sure within the small cavity increases Infectedear passage whIle the ~attent ~s lymg on 0!lesIde secretions will then burst through the ear-drum,After he has spen~ 5 mmutes 10that pOSlt!O~, the causing a perforation

ear should be drted and the other ear sImIlarly

treated Repeat the treatment at 2-hourly inter- At first there is deep-seated earache, throbbingvals until the discharge has ceased If there is no and nagging like toothache, with some deafnessimprovement after 2 days, tetracycline ear-drops and maybe noises in the ear The patient feels ill,should be put in the ear passage(s), 3-4 drops and his temperature rises As the pressure in-three times a day, until the patient sees a physi- creases, the pain becomes worse until the ear-ciano drum perforates Discharge through the perfora-

tion brings relief of both pain and fever TheThe patient must not swim or get water into his lymph glands around the ear are not enlarged.ears when washing until he has been seen by a The mastoid bone may be tender to pressuredoctor or his ears have been normal for 2 weeks firmly applied The sequence of events may beUnder no circumstances should cotton-wool or modified if the infection responds rapidly toother ear plugs be used antibiotic treatment

General treatment In new middle-ear infections, mastoids shouldThe patient should be put to bed and the tem- be suspected wh~never a patient continues to ~eelperature, pulse, and respiration rate recorded u~well, compla~ns of ~arache and contmumgevery 4 hourso Two acetylsalicylic acid tablets dIscharge, and IS fevensh 10-14 ~ays after theshould be given every 4 hours until the pain onset There wtll be extreme ma~t?ld tenderness,disappears Warm olive oil ear-drops may be e~en thou~h ~ full couorse of antlb~ott~s has b~en

may reqUIre speclahzed treatment ashore Get

Specific treatment RADIO MEDICAL ADVICE

Even if you only suspect that the patient may •

have otitis media you should give as soon as Epilepsy (and other convulsive

possible, in order to prevent perforation of the seizures)

• procame benzylpemctllm, 600000 umts mtr~- characterized by muscular convulsions with

par-~us~ularly, followed by the standard antl- tial or complete loss of consciousness The blottc treatment, or zures are brief (several seconds), recur suddenly

sei-• 500 mg of erythromycm, foll.owed by ~50 mog at irregular intervals, and are usually followede~ery 6 hours ~o~ 5 days, If the patIent IS by several hours of confusion, stupor, or deep

al erglc to pemcllhn sleep Epilepsy has been called "falling sickness"

If the patient is not better at the end of the 5 because the patient falls suddenly and usuallydays, seek RADIO MEDICAL ADVICE makes no effort to protect himself from injury

Epilepsy may vary from mild to severe In the

Subsequent mana ement mild form, the~e is mom~ntary loss of

When antibiotic treatment is completely success- without fallingo In the severe form, the patientful, the inflammation will settle, pain and fever suddenly falls as if struck by an overwhelmingwill subside, and there will be no perforation or blow

n epl eptlc may ave a seIzure at any ttme

Ifperforation does occur, the ear passage should Th to tOIl dd I ·t I· d

I th t th tOb· to h t k d Th fall downo He may strike the floor or any object

a one IS 0 Yusua Y comes s I an nglWhen the patient feels better and has no fever, for a short time, during which he stops breathing

he can be allowed out of bed, but the ear must and becomes blue or purple in the face This

be kept as clean and dry as possible All cases phase of the seizure is followed by generalizedshould be seen by a doctor when the ship is next spasmodic convulsions of the entire body with

in port; swimming and air travel are not advised jerking of the arms, legs, and head, contortionsuntil approved by a doctor of the face, and foaming at the mouth The eyes

may roll back and forth, but there is no feelingInfection of the mastoid cells in them and they can be touched without the

10ectlon when a perforated ear-drum, together

with a septic discharge, has been present for Usually, after several minutes, the convulsion

International Medical Guide for Ships

or fall into a deep stuporous sleep that may last In the case of status epilepticus, obtain RADIOfor several hours When he awakes, he may be MEDICAL ADVICE, regarding treatment.confused or very grouchy and ill-tempered He While waiting for this advice, give the patient anprobably will have no recollection of the attack injection of diazepam, 10 mg intramuscularly If

It IS0b·VIOUS,romf the suddenness an na ured t 0f the seizure is not interrupted in 5 minutes you" .th'e seIzures, th ta epl ep ICSs ou·1 t· h Idnot be per- may repeat thIs drug mtramuscularly and m the

·tt d t I ft AI th h Id b same doses, every 10 mmutes, four or five times

ml e 0 go a o so, ey s ou never e

allowed to enter the engine-room, where there Between attacks

are moving parts of machines on which they

might fall, or other potentially dangerous places There is little that can be done at sea to treat

In general, a person known to be an epileptic epilepsy, except to keep the patient from injuringshould be advised not to accept employment at himself during an attack, and to prevent recur-

may have been prescribed for the patient

The seventy and frequency of attacks may be

During the convulsion reduced by phenobarbital RADIO MEDICAL

ADVICE should be obtained on the dosage ofBystander~ sho.uld try to prevent the p~tlent this medicament

from hurtmg hImself and should make hIm as

comfortable as possible His movements should Convulsions similar to epilepsy

not be restrained completely, unless he is in "

danger of falling from a high place or injuring These may occur m otherwI~e normal p.er~o~s ashimself in some unusual manner To keep him the ~es~l~ of a sev~r~ ac~te tI.1nes.s,.br~m m]u.ry,from biting or chewing his tongue, something menmgltIs, nephntls, msuhn m]eC~lOn, hIghshould be inserted carefully between his teeth, blo?d press~re, p~ral~tIc stroke, bra~n tu~our,such as a twisted handkerchief or a pencil wrap- ~oxms, cyamde pOlsonmg, or strych~me pOlson-ped in cloth Hard objects should never be mg The treatment of s~ch convul~lons shouldinserted A coat or pillow should be placed un- be the same as that outlIned for eptlepsy.der his head, and his threshing legs and arms

covered with a blanket to prevent self-injury Eye diseases

during the convulsion Medicines should not be

given by mouth Artificial respiration will not be (See also: Eye m]unes, page 76.)

needed, because the phase during which the

pa-tient ceases to breathe is usually very short Anatomy of the eye

After the seizure, while dazed, exhausted, or The eye is a sphere approximately 2% cm inasleep, the patient may be carried or helped to diameter formed by a tough outer coat called thehis bunk Enough bedding should be placed over sclera and the clear front portion known as the

the patient to keep him comfortably warm Usu- cornea Six muscles attached to the sclera work

ally, he will sleep for some time However, if he in various combinations to move the eye Ocular

is awake and restless he may be given one dose movements are very precise and rapid

of phenobarbital, 60 mg by mouth Th' h d h h h· h I' h

e cornea IS t e wm ow t roug w IC Ig tSometimes, a patient may pass from one seizure enters the eye There are no blood vessels in theinto another, without intervening recovery of normal cornea, and it is extremely sensitive andconsciousness This condition, known as status especially susceptible to injury or infection Ifepilepticus, always involves danger to life The scarring occurs from injury, the cornea loses itspatient may become profoundly exhausted, transparency at the site of the scar, which maylapse into coma, and die Otherwise, an epileptic markedly impair vision The cornea has an ex-attack is seldom fatal tremely high concentration of nerve fibres which

tearing and redness (inflammation) of the eye way as the film in a camera, but converts the

Th b k f: f th l'd d th d light rays it receives into nerve impulses which

e ac sur ace0 e eye I san e expose

t· f th h't t f th ( I) are transmitted to the bram by theoptIC nerve. Inpor IOn0 e w I e par 0 e eye sc era are

r d 'th thO II d th the bram, the nerve Impulses are mterpreted as.me WI a paper- m covermg ca e e con- sight

Junctlva; It does not cover the cornea The

con-junctiva may become infected and produce a red Chronic eye diseases

eye with a variable amount of pus, mucus, or

water discharge This infection is called conjunc- Cataracts

tivitis A cataract is a clouding of the lens of the eye.The internal portions of the eye are the anterior This usually occurs as a feature of aging in

chamber, iris, lens, vitreous body, and retina (see people over 60, but may occur at a much Fig 128) The anterior chamber, a space filled er age

young-with watery fluid: lies between ~h~ cornea ~n~ Cataracts may develop without an obvious

the ~oloured portIOn of the eye (IrIs) !he zrzs IS cause, but some are the result of severe injuries

a pIgmented muscular structure whIch opens

and closes the pupil to allow more or less light to P~~sons suspe~ted of havmg a cataract shouldenter the eye, depending on the level ofillumina- VISita specialIst on shore for a complete eyetion This works much the same as the iris dia- examination In almost all cases, the cure forphragm that controls the amount of light enter- cataracts is surgical removal

aucoma

Just behind the ~ris is the lens, which can change Glaucoma is an eye disease in which the fluidshape to focus lIght rays on the ba~k of the eye substance in the eyeball is under higher pressureWhen the lens becomes cloudy, It IS called a th I

B h· d h I h· b d an usua

cataract. e m teens IS t e vitreous 0 y,

a cavity filled with a clear jelly known as the Acute congestive glaucoma is an extremely

vitreous humour. serious condition requiring immediate treatment