The ship-surgeon's handbook

Front matter

THE

SHIP-SURGEaN’S

HANDBOOK

Preface To Second Edition

The unexpected yet wholly gratifying reception accorded to the first edition has prompted the author to publish a second. While most of the fundamental principles have been retained almost unaltered, save for amplification in certain instances, the book has been considerably enlarged by the addition of five chapters. Two of these are special ones having regard to the routine of the American Passenger Service, and require no comment ; whereas, the others are of a general nature, affecting all ship-surgeons. The one entitled ‘ Ship Etiquette and Customs ' it is hoped will justify inclusion.

In the chapter on ' Medical Logs ' special attention has been paid to the question of ‘ professional secrecy ' in relation to ship-surgeons, as it has always seemed that the prevailing custom at sea is somewhat at variance with generally accepted rules of procedure, and one, moreover, which should be settled by a medical authoritative body.

In conclusion, the author wishes to tender sincere and grateful thanks to all his numerous critics and friends for advice and suggestions in regard to the former and present editions, more especially to Dr. G. W. Pfromm, of Philadelphia, for most invaluable hints and help in preparing the manuscript for the press.

A. V. E.

At Sea, igio.

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Preface To First Edition

The author’s excuse for writing upon what at first sight appears to be a commonplace subject is the absence of any literature wholly devoted to the life and work of a ship-surgeon. His book is intended to be a guide only to the uninitiated, and it is hoped that it may save such from the numerous pitfalls to which they may find themselves exposed while engaged in their work. Some of these the author’s own experience, and that of many contemporaries, has shown to be of actual daily occurrence. Where the text is somewhat colloquial and verbose, containing in places self-evident facts, it may be explained that it has been made so with a view to providing for nearly every contingency likely to be met with by the novice. In the author’s opinion, no class of men undertake their professional duties knowing less of the surroundings in which these are performed than surgeons going to sea for their first voyage. He begs indulgence for literary style, or rather for lack of it, and hopes the book wiU be accepted in the spirit in which it has been written — as a guide, and not a textbook.

London, 1906.

IX

Contents

CHAPTER

I. CHOICE OF SHIP _ - - - -

II. OUTFIT AND UNIFORM . _ - -

Appendix

I. UNIFORM AND OUTFIT . . -

II. BOARD OF TRADE SCALE OF DRUGS -

III. BOARD OF TRADE SCALE OF INSTRUMENTS -

IV. ADDITIONAL STORES - - - -

V. EMERGENCY APPLIANCES - - _

XI xii Contents

APPENDIX PAGE

VI., CERTIFICATES _ _ - _ _ 344

VII. MEDICAL RECORD OF CASES - - - - 347

VIII. AMERICAN SERVICE ----- 348

IX. GLOSSARY OF COMMON NAUTICAL TERMS - - 36 1

X. ABSTRACTS FROM THE MERCHANT SHIPPING ACTS - 364

XI. LIST OF PRINCIPAL STEAMSHIP COMPANIES EMPLOY-

ING SURGEONS - - - - - 377

INDEX 383

THE

Chapter I Choice Of Ship

A MEDICO having made up his mind to go to sea, should decide more or less upon how much time he is prepared to spend in W under jahre. If a year or two are of no material object, then it is better for him to enter the service of some large steamship company, such as the White Star, Cunard, Peninsular and Oriental, etc., and, stay there until he wishes to give up the sea and settle down on shore.

If, however, he only wishes to make a trip or two after obtaining his medical qualihcations, to see the world or to take a holiday, there are many ships which carry a surgeon for the voyage only. They give him the option of leaving or ‘ signing on ’ again for a second trip on completion of the round voyage. Among such may be mentioned the British India Steam Navigation Company, Holt’s Blue Funnel Line, and the China Mutual Steamers, etc.

Others, again, such as Thompson’s Aberdeen Line (Australia), Lund’s Blue Anchor Line, Federal, Houlder, and Shire Lines, etc., will carry a surgeon for the outward or homeward passage only. In these ships the surgeon receives no pay, and simply ‘ works his passage.’ To comply with the law, he signs articles at is. a month. Some of these companies even require him to pay a sum varying from £io to £20 for the privilege of ‘ working a passage ’ (vide p. 90) .

The methods of obtaining a surgeoncy are as follows : —

1. By personal or written application at the company’s offices, with registration thereof and waiting until a vacancy occurs. This is often slow and uncertain.

2. Through certain agents, wholesale druggists as a rule, whose names and addresses can be obtained by consulting the advertisement pages of the medical press.

Appointments obtained through these sources are subject to payment of a fee, which varies according to the monthly salary paid by the ship selected.

3. Through private influence, or that of friends in the steamship companies. Needless to add, this is the most satisfactory form of all.

The pay of surgeons other than ‘ passage-workers ’ varies from £6 to £14 a month. The average rate is about £g per month.

Salaries at sea are always computed by the completed calendar month, odd days being reckoned at the rate of thirty to the month.

With certain exceptions, such as the Booth and Holt Lines, etc., who are endeavouring to create a medical branch on a permanent basis, long service carries no increase of pay with it. The raw ‘ first voyager ’ receives exactly the same remuneration as the seasoned veteran.

It is well to bear in mind that the candidate who is free to sail at once (he should take care to impress this

Choice of Ship

fact when applying) will stand a far better chance of obtaining a ship than he who is holding some appointment at the time, and is only at liberty after a certain date. Of course, in the case of the larger mail companies, which generally have a big list of waiting candidates, application may be made while holding a hospital appointment. In these cases the applicant should state clearly when such term of office expires, and take his chance of a speedy appointment.

Previous tenure of house-office, although not absolutely essential, is a great recommendation in obtaining a surgeoncy in the better class of company.

Ships only ‘ sign on ’ surgeons as vacancies occur, and cannot wait until any particular man is at liberty. As these generally occur at short notice, they are therefore hlled by men ready to sail. It is certainly unwise for an applicant to walk into a steamship office and say he will be free on such and such a date, and wishes to sail in this or that ship. Applications in this form tend to give rise to unfavourable impressions, and in all probability will be relegated to the waste-paper basket.

Ships on agents’ books cannot exactly be considered as hrst-class employment, and on inquiry generally prove to be cargo-boats taking a limited number of passengers. Such, while good enough for one voyage as a holiday, are valueless for a term of service. With this class of ship the surgeon should make full inquiries about her and her trade before dehnitely committing himself.

The usual form of procedure is for the agent to say : —

‘ We have a ship sailing on or about a certain date to India, or one to China or Australia. No uniform will be required.’ No details as to name or class are given until the appointment is settled, or until closely questioned, when perhaps the name of the owners may be divulged. Under such circumstances, agreement or articles once signed, a man may hnd himself bound down to an inferior ship and a miserable existence for four or hve months, or even longer, as letters to the medical press from time to time disclose.

The commission charged by agents is generally about £i IS. to 3s., according to the rate of monthly pay being £6, £8, or £io. Strictly speaking, payment of such commission is illegal, as it may conceivably be held to come under the term of ' crimping.’ Hence these fees are always payable in advance.

Before affixing his signature to the articles, the surgeon must thoroughly acquaint himself with the conditions of service laid down therein, especially in the smaller ‘ tramp ’ type of ship. When crews are engaged, the articles are usually gabbled through by the shipping-master or his deputy at so many words a minute, quite regardless of their intelligibility. When disputes arise subsequently, there is no redress, as the articles were read over prior to signing, according to the law (vide Appendix X.> p. 374 and p. 273). Articles once signed, a man may be prosecuted if he fails to join.

Incidentally it may be stated that, according to the Merchant Shipping Act, every seaman is entitled to an ‘ advance note ’ for the sum of one month’s pay as soon as he has signed articles. This is cashed by the owners two or three days after the ship has sailed on receipt of proof from the purser or master that the payee has actually joined the ship.

Surg-eons in mail-steamers are appointed direct by the owners and rarely through agents, except in cases of sudden emergency. Here, naturally, personal influence or a chance call at the office when an unexpected

Choice of Ship 5

vacancy occurs are important factors in obtaining a surgeoncy.

The Merchant Shipping Act requires the doctor to be a ‘ duly qualified and registered medical practitioner ’ before he can sign on as ' surgeon.’ When joining for the first voyage, the medico should have with him his diploma or certificate of registration. This will have to be produced before the shipping-master as evidence of identity and eligibility. As a rule, however, the current Medical Register is accepted as proof of registration. For subsequent voyages the ‘ Continuous Discharge Book,’ granted by the Board of Trade at the end of the first trip, need only be produced {vide p. 275).

Undoubtedly one of the best companies to join is the Peninsular and Oriental, otherwise familiarly known all the world over as the P. & O. It is the only line affording such a variety of runs — India, China and Japan, Australia, and yachting cruises — so that at the end of his period of service (formerly two years, now twelve months, with option of further service) a man has seen a good deal of the world.

Australia, yachting cruises to the Mediterranean, Near East, and Norwegian Fjords are included in the Orient Steam Navigation Company’s itinerary. The Royal Mail Steam Packet Company’s services to South America and the West Indies, also the Union Castle Line to South Africa, require no further mention. The Far East and Far West are reached by the Canadian Pacific Railway Company’s ships.

In the Atlantic trade, which is one almost deserving the title of ‘ speciality ’ as compared with the ordinary run of medical work in the mercantile marine, ships of the Cunard and White Star Lines offer a form of permanent employment to a man who likes the sea life, and yet who does not care for the routine of the Navy Medical Service.

The White Star Line maintains the following services in which a surgeon is carried : — Australian passenger ; New Zealand passenger, in conjunction with Messrs. Shaw, Savin, and Albion Company ; Mediterranean to Boston and New York ; Liverpool to Canada, Boston and New York; and, finally, the mail service from Southampton to New York. Thus, a man who has worked his way through this fleet has had a wide and varied field of travel and clinical experience. During the busy passenger season the larger ships carry temporary assistant-surgeons in the event of there being more than 1,300 third-class passengers. Included in this company’s fleet is also a sea-going training-ship, the Mersey, which offers a sailing-ship voyage to the Antipodes to any medico desirous of making such in a professional capacity.

Space forbids other lines being mentioned, although most of those employing surgeons will be found in Appendix XL It might be mentioned here that the table has been compiled from details kindly supplied by the various shipping companies in response to a circular letter addressed to them by the author. Where none are given, information was either definitely refused or the circular was not returned by the firm in question.

In conclusion, a word of warning may be given, which is not to remain at sea too long. Not that there is any want of practice — a crowded passenger ship will generally afford a large and varied scope of work — but there is a danger of getting into a roving and unsettled state of mind from which it is very difficult to withdraw and settle down into a practice on shore. The longer a man stays at sea, the harder will it be for him to give it up.

Choice of Ship

Further, go to sea fairly young, see everything possible, and enjoy the world before commencing a regular medical career. It is harder to ‘ swallow the anchor ’ and retain it at forty than at twenty-seven or twenty-eight ; also, later on in life it is difficult to go to sea, even for a voyage, when a practice has to be sold or left to a locum tenens, and family ties bind a man to the shore.

Chapter II

The initial expense of uniform is mainly dependent upon the service a man enters. Some require much lace and trimmings, as well as full-dress, undress, and mess uniforms. Others are very modest : — a double-breasted reefer suit, with eight or ten brass buttons, distinctive rank stripe and cap with company’s badge meeting all requirements. In some instances it may be possible to take over one’s predecessor’s badge, buttons, etc., for a mere trifle, thus saving a considerable sum, as these adornments of uniform are somewhat expensive to buy new. Some companies provide these gratis every two or three voyages.

In collecting uniform and outht together, the point to bear in mind is that the uniform itself will probably never be actually worn out, and therefore to buy as little as possible, consistent, of course, with the company’s regulations on this matter. On being appointed to a ship, the surgeon will invariably be given a long list of outfit which he is to obtain. If he intends remaining at sea for two or three years, then he can well carry out instructions ; but if he is only making a voyage or so, there are certain items which may be omitted and the initial expenditure kept down. For instance, a uniform waistcoat need never be worn except with mess uniform.

It is not in evidence, and any civilian garment will suffice. Thus, a saving of los. 6d. to 15s. per uniform suit is effected.

A regulation navy-pattern overcoat may seem superfluous seeing it is not required for use on the bridge, and the price (£4) is somewhat high. It should, however, be ordered, as during one’s sea-service it serves the double duty of overcoat — for boat or gangway duty — and dressing-gown. In later years a capital driving and travelling coat, which will wear almost indefinitely, is obtained by the substitution of plain for uniform buttons.

For undress uniform a medium-weight serge is better than the blue-black cloth sometimes suggested, as it can also be worn elsewhere after removal of buttons. Moreover, although not quite so smart in appearance at the outset as cloth, the serge will look better at the end of six months’ wear. Further, serge does not pick up fluff, dust, etc., or wrinkle so markedly as cloth.

The quantity and quality of outfit, apart from actual uniform, is regulated by the duration of the voyage, climatic conditions, and the chances of getting washing done at intermediate ports of call. The latter item in mail-steamers is practically impossible, or certainly not to be relied upon, as their stay in port is usually so short.

In ships engaged on a tropical voyage, where white material is worn for a considerable part of the run, it is advisable to get only a minimum number of white suits in England before leaving. The balance should be obtained in the East, where prices average from 30 per cent, to 60 per cent, less, and the fit is just as good as that of the English-made article. When ordering from lo The Ship-Surgeon’s Handbook

a native tailor, it is customary to let him have one suit as a model to cut others from. He will unpick it and afterwards sew it up again, returning it with the order. Care should therefore be taken to see that the ‘ model suit ’ is a good-fitting one.

A comparison of prices may be of interest. In England white suits made to measure usually cost from 15s. to 25s. each ; although some can be obtained for los., they are not to be recommended. In Calcutta the price varies from 3 to 5 rupees (4s. to 6s. 8d.), according to material. A white uniform mess-jacket will cost anything from £1 is. upward in England, whereas a very satisfactory one can be obtained in Calcutta for about 4 rupees (5s. 4d.).

Of course, nothing looks so nice as a well-cut, closehtting suit of white drill ; but the European price makes it an item of luxury, as, owing to constant washing, a suit soon loses its shape and smartness. As a rule, a suit will last for two days ; with care three or four days’ wear can be squeezed out of it. Hence a stock of suits is imperative. When ordering it is advisable to have extra stiffening put into the collars, which should also not be cut too high for the wearer, as nothing looks so untidy as a clean white jacket all crumpled at the neck an hour or so after it is put on.

In ships where white suits are not regulation uniform khaki-coloured drill can be substituted to advantage, both as regards original cost and subsequent laundry bills.

If required officially, a solar topee or sun-helmet is bought at Port Said almost as cheaply as anywhere. Prices for this article in England — as, indeed, for all other items of the so-called ‘ colonial or marine outht ’ — are very high. In the tropics a topee is really necessary

1 1

when going ashore, or in parts of the ship not covered by awnings. Care should be taken to see that the nape of the neck is well covered by the overhanging brim of the hat. The author is inclined to believe that a large number of cases of severe headache, heat-exhaustion, and even sunstroke are brought about through lack of this precaution.

The best underwear for use with white suits is a light woollen merino vest, with sleeves to the elbow, or a navy-pattern flannel ‘ jumper vest ’ to slip over the head. The temptation to discard all underwear must be strongly resisted owing to the liability to taking a chill. With regard to under-pants, the coolest form of these for the very ho’t weather is a pair of knitted cotton bathingdrawers, with the centre seam suitably unpicked.

The use of a ' cholera belt ’ is optional. Although greatly reducing the risk of abdominal chill and its sequelae, it has the one drawback that, once used, it must be continually worn, both day and night. For men of advanced years its adoption is, however, almost obligatory.

Too high a price should not be paid for stiff-fronted white shirts. A large stock is required, and the process of washing at most ports other than Chinese, especially after linen has lain soiled for some time in a bag, is even more destructive than in England. A fair price to pay for a serviceable white stiff-fronted shirt is from 3s. 6d. to 5s., and having it recuffed and refronted as required. In the author’s experience the life of a 7s. 6d. shirt is no longer than that of one bought for 3s. 6d., and the balance saved can be profitably expended in having the latter refitted.

For ordinary daily wear the soft-fronted, stiff-cuffed shirt of a cellular type will be found most comfortable, and can be obtained at prices ranging from 3s. 6d. to 4s. 6d.

The use of a single or double collar is optional, although only the former is uniform, and it looks better when worn with frock-coat and mess-jacket.

Only plain black silk ties are to be worn with uniform ; they should not exceed inches in width.

Gloves are uniform with frock-coats, and are either to be of white or brown leathei, according to company’s regulations.

For general underwear, light flannel or woollen material should always be worn next to the skin, whether in or out of the tropics. A chill caught at sea is very difficult to get rid of, and may be attended with serious consequences. In hot weather, when diaphoresis is very free and renal activity diminished, chills and colds are very resistant to treatment and may persist until a change of air is obtained. During the passage of the ship from tropical to temperate latitudes extra precautions against catching cold should be taken by those unaccustomed to these changes.

A mosquito-net to fix up over the bunk will be found a great boon when lying in ports where these little pests are prevalent. It will insure an undisturbed night’s rest, and absence of the facial disfigurement and discomfort some people are so subject to when bitten, not to mention immunity from a possible malarial infection.

In collecting an outfit together it should be borne in mind that ‘ marine outfitters ’ are accustomed to give even longer credit than ordinary firms, and put up their prices accordingly. As a rule, they allow 5 per cent, discount for cash settlement. Even with this rebate, in many instances one is paying a big price, as the quality of their goods is in no way superior to that of other firms of men’s outfitters. In fact, nothing but actual ' externa] ’ uniform should be ordered from the regulation tailor (each steamship company has its own recognized firm). The other items which go to make up an outht can be obtained elsewhere, in a decidedly cheaper market.

Credit must, however, be given to the regulation tailors for the rapidity with which orders are executed and delivered on board at short notice. Further, it is only they who can put on braid and lace in the orthodox manner. The civilian tailor invariably fails in attempting an order of this nature, and some companies are very particular on this point.

To prevent theft and laundry losses among a large stock of underwear it is well to make an inventory, and check it personally with one’s servant occasionally, and also to make him check washing on its return to the ship. As marine washing is generally done at so much a dozen pieces, everything included — usually from 2S. 6d. to 3s. a dozen — -and returned as so many dozen, items are not infrequently found wanting or exchanged : generally for the worse.

In Appendix I. will be found a rough specimen list of outfit with approximate cost of various special articles.

With regard to the stock of professional literature, opinions and tastes will naturally vary. The author offers a list which covers most of the branches of work likely to be met with. Gray’s ‘ Anatomy ’ may be a bulky and heavy volume to carry about, but the writer strongly urges the advisability of having some good manual of this kind on board. When once the dissecting-room and wards are left behind, anatomical details are some of the first to slip from memory, and yet they are liable to be wanted at any moment.

Manual of Medicine . .

Treatment

Tropical Medicine . .

Surgery

Operative Surgery . .

Midwifery

Gynaecology . .

Ophthalmology

Anatomy

Rose and Carless.

Allingham, Wheeler, Treves.

Dakin, Jellett; also Herman’s ‘ Difficult Labour.’

May and F. A. Worth.

Gray, Buchanan Morris, or some volume on surgical anatom}^

Martindale and Westcott’s ‘ Extra Pharmacopoeia ’ is a handy little book to have by one. Others may be added according to choice, although one of each group mentioned above should figure on the shelf.

It is a good plan to arrange for some one or other of the weekly medical journals to be forwarded to various ports of call, as by this means a man can keep in touch more or less with his profession — granted, of course, that he reads them. Professional reading is generally set aside for the charms of light literature when once away at sea. Moreover, during the day there are too many interruptions of routine and other nature for serious reading. It is only ‘when the lights are low,’ or one should say out, that it is possible to settle down quietly to study.

A sea-going medico should make a principle of getting in touch with colleagues at the various local hospitals en route. It is a medical education in itself to see the different methods employed to obtain similar results. It tends to do away with a man’s natural inclination to become ‘ hospital hide-bound/ according to the dictum of his own medical Alma Mater. The author speaks feelingly of the unvarying kindness and courtesy extended to him by colleagues in hospitals all over the world.

A microscope is decidedly a luxury, and very rarely likely to be wanted at sea. The necessary reagents and extras required for use with it make it clumsy and cumbersome. Moreover, unless thoroughly well protected, the sea atmosphere will soon ruin a good instrument. Specially prepared cover-slips for blood-hlms, etc., might be taken, and subsequently studied at leisure under more suitable conditions.

If the surgeon is a photographer, he should certainly take a camera, although developing at sea is always subject to difficulties of thermal conditions and rude interruptions in the form of calls for medical attendance at critical moments, etc. For those who like it, the latter-day method of ‘ tank developing ’ does away with a good many of the foregoing objections. For the author this system robs photography of half its charm. Tabloid or powder is the best way of carrying reagents.

Chapter III Drugs

The most cursory glance at the scale of drugs required by law to be placed on board all foreign-trade ships carrying emigrants will show it to be inadequate in some respects and somewhat superfluous in others. As an instance of the latter may be cited linum contusum, which must be carried at the rate of 6 pounds for every^hundred passengers. It is bulky to stow away, and will probably never be used from the day of sailing to arrival home again, when it will either be left in the ship or returned to store and reshipped for the ensuing voyage.

Oleum Uni, too, would also appear to be of more use to the chief officer and ship’s painter for decorative purposes than to the surgeon. Carrying the liquor Jerri perchlor. fort., in addition to the tincture, seems unnecessary.

Relatively speaking, a large quantity of ether is required, for reasons as yet unknown to the author. As an anaesthetic it is practically useless for the greater part of a tropical voyage owing to the high external temperature and the omission to include a suitable form of inhaler in the scale. The apparatus officially supplied consists of a soft patent-leather, felt-lined conical mask.

The liq. amnion, acetatis is too unstable for use at sea ; the concentrated form should becarried, being broken down for use when required.

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Among the more common drugs in general use not officially carried may be mentioned the tinctures of nux vomica, cinchona, and rhubarb. The equivalents of the two former— strychnince and quin, sulph. — are not always indicated, and are also somewhat difficult to dispense accurately in small doses, especially so if there is much vibration or movement of the ship.

Bromide of potassium — that sheet-anchor for cerebral nerve storms — is conspicuous by its absence, the ammonium salt taking its place.

Vermifuges are apparently not required on long ocean voyages.

The scale contains no simple safe and reliable hypnotic such as paraldehyde. Sulphonal is too slow and uncertain in its action, more so in warm weather ; chloral, chlorodyne and opium are not always indicated or desirable, taking their subsequent astringent action into account. Veronal is a preparation which seems to have vagaries of its own as yet undetermined by the author.

Hypodermic tablets of pilocarpine nitrate grain) might be carried with advantage, also some preparation of eserine. In hve years the author has met with four cases of acute glaucoma on the high seas, which were tided over by this means until arrival into port.

Urotropine will be found useful in cases of renal and bladder troubles, etc., and should certainly be carried.

Salol and beta naphthol, too, are of great use as intestinal antiseptics.

Flavouring agents are confined to the spts. menth. pip. and chloroformi, and perhaps tinct. card. co. Miscible oil of lemon or tablets of saccharine make good concentrated preparations of this nature. The standard syrups are not recommended, as they are liable to ferment if kept any length of time in hot weather.