Hints to Travellers, Scientific and General, Vol. 2 / Tenth edition, revised and corrected

by Royal Geographical Society

Diseases and their Prevention and Treatment.

In the tropics, as elsewhere, the diseases to which the traveller is liable are due to widely differing causes, but in hot countries climatic conditions and parasites play a predominant part. Insects are very frequently to blame for the transference of the latter from the sick to the sound, both insects which are not themselves parasitic on man, e.g., the mosquito and the tsetse fly, and those which make man their host, e.g., lice and fleas.

It is useful for the traveller to bear diseases in mind from the standpoint of their etiology, as in this way he can more readily grasp the measures necessary for their prevention.

Accordingly, the following classification is given, merely as a guide, together with a few examples. The diseases themselves, for the sake of convenience of reference, are grouped alphabetically and are not classified in any way.

Table of Diseases Classed according to Etiology.

A.—Parasitic.

(i.) Due to “contact” either direct or through the agency of clothes, bedding, etc. Also due to direct inoculation through the skin or mucous membrane.

Examples: Many skin diseases, venereal diseases, small-pox, tetanus, and blood-poisoning (septicæmia).

(ii.) Due to “mouth to mouth” infection, through the agency of so-called “droplet” infection, expectoration, coughing, sneezing, etc.

Examples: Influenza, pneumonia, and pneumonic plague.

(iii.) Due to “droplet” infection, as above, or to infected scales from the skin, or to infected discharges from the nose, throat, or ear.

Examples: Measles, scarlet fever, small-pox, chicken-pox, diphtheria.

(iv.) Due to excremental infection through the agency of water, food, flies, fingers, dust, and soil.

Examples: Enteric (typhoid) fever, dysentery, diarrhœa, cholera, worm infections of many kinds.

(v.) Due to inoculation through the bites of insects, or the entry through skin abrasions of the infected excreta or infected crushed tissues of insects rubbed or scratched into these lesions.

Examples: Malaria, yellow fever, tick fever, sleeping sickness, filariasis, relapsing fever, typhus fever, bubonic plague.

(vi.) Due to invasion of the body by insects in their adult or larval stages.

Examples: Chigger, myiasis of various kinds.

B.—Non-Parasitic.

(i.) Due to climatic conditions.

Examples: Heat stroke, diarrhœa in some instances, constipation in many cases, rheumatism, prickly heat, chilblains.

(ii.) Due to errors in diet.

Examples: Diarrhœa, beri-beri, scurvy, sprue(?).

(iii.) Due to poisons.

Examples: Scorpion sting, snake-bite, vegetable poisons.

(iv.) Miscellaneous.

Examples: Bed-sores, epilepsy, apoplexy, concussion of the brain, hay fever, and other conditions into the cause of which a mechanical element frequently enters.

It will be seen that some of these diseases, such as small-pox and diarrhœa, come under more than one heading, but this does not detract from the general utility of the above classification.

Bed-sore.

When a patient is confined to his bed for a long time it is necessary to support the lower part of the back on something soft, such as a pad of wool, or an extra pillow, in order to prevent the formation of a bed-sore; pillows should also be placed under the hips and heels.

To harden the skin it is well to rub it with alcohol or to treat it with oil or white of an egg three parts, and spirits one part; zinc ointment is also useful for this purpose.

Besides pressure, the most frequent cause of bed-sores is constant moisture from the passage of urine and motions and consequent damping of the sheets. Great care must be taken to thoroughly dry the back after any evacuation; the lower part of the back should be dusted with a powder of boric acid and zinc oxide.

If a bed-sore is present the patient should lie on a circular pad with a hole in the middle, to take pressure off the bed-sore. The sore should be thoroughly cleaned twice a day with some antiseptic lotion, such as chinosol or permanganate, and subsequently dressed with zinc ointment or vaseline.

If the bed-sore is on the back, the patient should lie if possible on each side alternately, to relieve the pressure.

Beri-beri.

In most cases this is a disease due to some deficiency in the dietary, which leads to a form of what is called peripheral neuritis. The name is possibly derived from a Cingalese word signifying “I cannot.”

Symptoms.—Weakness of the legs and digestive troubles, abnormal sensations in the legs, frequently associated with swelling. The gait alters, and the arms and fingers may be affected. The condition is one of spreading paralysis, and in bad cases the heart is affected. In so-called wet beri-beri the patient becomes bloated as in dropsy, while in dry beri-beri he wastes away until he is little better than a skeleton. There is a “squatting test” which may enable one to recognize the disease at an early stage. The patient, with his hands on the top of his head, is unable to assume a squatting position and to rise from it unaided. If he is squatting and has to rise he accomplishes the act by climbing, as it were, up his own legs.

Prophylaxis.—Avoid overcrowding, as this seems in some cases to predispose to the disease. Give the yeast extract known as “Marmite,” which is supplied in small cubes one-quarter ounce in weight. One should be taken twice a week, either alone or with bread or biscuit, or dissolved in warm water in the form of a soup. Lentils, other legumes, and oatmeal are useful. Eggs and fresh meat, when obtainable, are very valuable.

Treatment.—This is chiefly dietetic. Give yeast, two ounces daily, along with milk and sugar, or marmite in one-cube doses twice a day. Eggs are specially useful, while fresh milk, legumes, and nourishing soups are all indicated. Only small quantities of food should be given at a time. Rest in bed is very important, and the patient must be careful when he is allowed to get up owing to the danger of heart failure. Tonics are required during convalescence.

Blackwater Fever.

Blackwater fever is probably a pernicious complication of malarial fever, and derives its name from the colour of the urine. It must be remembered that dark-coloured urine is usual in all fevers; it is scanty during the height of the fever, especially if there is much sweating. If, however, it is obviously “bloody,” the case is more grave, but as a rule it is only men broken down in health, and those who have resided in blackwater countries, e.g., Tropical Africa, parts of India, the West Indies, etc., for at least a year, especially those who have taken their prophylactic quinine irregularly, who suffer from this complication.

The reason for the occurrence of this condition is not fully known. Some have ascribed the symptoms entirely to the taking of quinine, but as the fever often occurs where no quinine has been given this is impossible. At the same time it appears likely that in certain cases of malaria, owing perhaps to some idiosyncrasy, quinine may help to bring on the symptoms. It is possible that chill occurring during the course of a fever may lead to the production of blackwater fever. Those who have had one attack are particularly liable to a recurrence, and after two consecutive attacks return to a temperate climate is required.

Symptoms.—In addition to the ordinary symptoms of malarial fever, the urine is dark, blood-like, and eventually porter-coloured; it is often scanty, and may become entirely suppressed. The skin is yellow, often a bright orange, there is frequent vomiting, often hiccough, and the vomited matter is usually of a green colour.

Prophylaxis.—With our present knowledge all that can be said is that malaria prophylaxis is also the method to prevent blackwater. Such prophylaxis, so far as quinine is concerned, must be properly carried out. Those who take quinine regularly, and in sufficient doses, do not contract blackwater fever. Chill and excesses of all kinds must be avoided.

Treatment.—Much the same treatment should be adopted as that fully described later for malaria. It is especially important to give an aperient at the beginning, and perhaps five grains of calomel is the best form. In every case, no matter how slight, it is essential to ensure, wherever possible, absolute rest in bed and skilled and careful nursing. If it can possibly be avoided a blackwater patient should never be moved from the place where he is taken ill. So long as he has a bed to lie on, a roof to cover him, and some sensible person to look after him who will carry out the doctor’s orders, he should be treated on the spot. It is better, when it can be arranged, for the nurse to go to the patient than for the patient to come to the nurse.

The chief aim should be to support the strength by fluid nourishment, and to secure free action of the kidneys. The former should be maintained by fluid nourishment given in small quantities at frequent intervals, such as milk, Plasmon, Benger’s food, Allenbury’s foods, invalid Bovril, Brand’s fever food, or Brand’s essence, Maggi’s consommé. A little Plasmon added to any of the meat preparations would be useful, while raisin tea is a valuable preparation.

In order to maintain free action of the kidneys, plenty of fluid should be given, such as barley-water made from Robinson’s prepared barley, flavoured slightly with lime-juice or lemons. Weak tea is useful.

Diuretics which stimulate the kidneys must be avoided. The most effective method of flushing the kidneys is by giving saline injections by the bowel, but these, as a rule, can be administered only by a medical man or by a trained nurse under a doctor’s supervision. It may, however, be stated that the amount usually given is six ounces of physiological salt solution (seven and a half grains of sodium chloride to the ounce of warm water). This is administered every hour, or even oftener, if necessary, in bad cases. In mild cases enemata every four or six hours will suffice. Other measures are the application of poultices or hot fomentations to the loins when suppression threatens, or when there is severe lumbar pain. Diaphoretics, so long as they do not depress the heart, are useful, and so is frequent sponging. Cold applications to the head and especially behind the ears alleviate headache.

The question of giving or of withholding quinine is an important one, but recent work on the subject indicates that in the absence of a medical man who can carry out blood examinations, it is advisable to give quinine as in the case of malaria.

Vomiting is often a serious complication, and the directions for its treatment, given under the head of malaria, should be carefully followed. If it cannot be speedily checked, feeding by the bowel must be carried out. See Nutrient Enema, [p. 259].

So long as plenty of urine is passed and sufficient nourishment is taken there is little cause for anxiety, though wherever possible skilled assistance should be obtained at the earliest opportunity.

After an attack the patient is very weak and anæmic. He requires careful feeding and tonics, especially iron and arsenic. It is advisable that he should be invalided out of the endemic area, and he should be specially warned as to the danger of getting chilled or wet.

Bronchitis, or Inflammation of the Branches of the Windpipe.

Symptoms.—When bronchitis exists, there is a good deal of coughing—at first dry, but afterwards accompanied by frothy expectoration—with a sensation of rawness and tenderness at the upper part of the breastbone.

Treatment.—In the early stages of this condition, opium in some form or other will be found beneficial, and will often cut short an attack; for this purpose, ten grains of Dover’s powder, or fifteen to twenty minims of chlorodyne, may be given every eight hours for twenty-four hours, and then be gradually diminished.

If the breathing is difficult, poultices should be applied to the chest and ipecacuanha, half to two grains, and ammonia, should be given three times a day. Later, stimulating expectorants, such as ammonium carbonate, should be administered.

Inhalation of steam often gives great relief; and the effect is much improved if thirty drops of Friar’s balsam are added to a pint of hot water.

In tropical climates even an ordinary feverish cold very often tends to become malarial in character, therefore the use of quinine, in addition to the other treatment, is usually desirable, and five grains may be given thrice a day.

Burns and Scalds.

Where an extensive burn or scald has occurred, the clothing of the injured part should be removed by cutting, so as to cause as little irritation as possible. If the burn is only slight, the surface may be covered over with lint smeared with zinc or boric ointment, or oil. If there is much blistering, or the surface is charred, the skin should be cleaned up as well as possible with boric acid lotion, and hot fomentations of the same applied for twenty-four hours. After this, the burn may be dressed twice a day with boric ointment spread on lint. Great cleanliness is an important factor in the successful treatment of burns. In a severe burn, stimulants must be given, and the patient put to bed with hot-water bottles, and active treatment of the burn should be left till the patient has somewhat recovered from the shock.

When there is great pain, chlorodyne or laudanum in full doses will be required.

Cerebro-Spinal Fever.

This disease, also known as “spotted fever,” is of special importance at the present time to the traveller in Central Africa, where it is very prevalent amongst the natives, especially in Uganda. It may, however, be encountered in all parts of the world, and in the tropics is very frequently a malady of the dusty months.

Causes.—The disease is very often transmitted from some carrier of the causative organism, which occurs in the throat and nose, and is distributed by coughing, spitting, or sneezing. Infected material, such as handkerchiefs, may play a part, and the spread of the disease is greatly favoured by overcrowding, especially of sleeping quarters.

Symptoms.—In very acute cases the onset may be very sudden, the patient rapidly losing consciousness. As a rule the disease begins with headache, stiffness of the neck and chilly sensations. There may be vomiting, and the temperature is raised. The mind is often confused, and the patient may be delirious. The skin eruption, which occurs especially on the back and about the joints, and which is responsible for the name “spotted fever,” is not very frequently seen, and can hardly ever be detected on a dark skin. In very bad cases there is violent delirium, laboured breathing, and a purulent discharge from the nostrils. One of the most characteristic features is retraction of the head, while a dislike to light is common.

Prophylaxis.—Avoid unnecessary fatigue and guard against overcrowding, faulty conditions of ventilation and those which tend to cause naso-pharyngeal catarrh. Persons who have been in contact with cases of the disease are probably well advised to wash out their noses with a dilute solution of permanganate of potash 1 in 1,000.

Treatment.—In the absence of a medical man this can merely be symptomatic. Hot baths relieve pain and restlessness. Ice to the head, antipyrin, caffeine or aspirin relieve headache, and sedatives may be given for the insomnia and delirium. The patient’s mouth is foul, and should be carefully swabbed and kept clean.

Chicken-Pox.

In the tropics this disease is very largely one of adults.

Incubation period, a fortnight to three weeks. Rash appears first day.

Rash.—Pink spots, upon which blebs form after twelve to twenty-four hours. The blebs are at first transparent, but subsequently become yellowish, and after two to three days shrivel and separate, leaving a pink scar.

The symptoms are usually very mild, perhaps only slight fever, and possibly headache. The appearance of the rash is often the first symptom.

Treatment.—Isolation, and light diet. Bed may not be necessary.

Chilblains and Frostbite.

Chilblains are usually found on the fingers or toes—after exposure to severe cold—especially when tight gloves or boots have been worn. Certainly the best way to promote the formation of chilblains is to toast the semi-frozen fingers or toes at a fire or stove, before the circulation has been re-established.

When chilblains are threatened, the part should be well rubbed with snow, or with camphorated spirit. Sponging with hot vinegar is very effective. Chilblains are checked in the early stages by painting with tincture of iodine. Once they have developed a preparation containing carbolic acid is useful in allaying pain and causing them to disappear. Ulcerated chilblains should be dressed with boric ointment spread on lint.

Prolonged exposure to intense cold leads to development of frostbite. If the case is a bad one, or injudiciously treated, gangrene or death of the part always follows; if this is extensive, amputation may be necessary.

Frostbite should be treated first by vigorous friction with snow or pounded ice. The affected parts should then be well wrapped with cloths wet with cold water. It is extremely dangerous to bring them near a fire. Afterwards, the part should be wrapped in cotton-wool.

Cholera.

Cholera is a serious acute disease, characterised by frequent watery motions, vomiting, cramp and collapse.

Cause.—It is often contracted by drinking contaminated water.

Research has shown the importance of the cholera “carrier,” that is to say the person, usually a native, who harbours in his bowel the specific organism of the disease. He may be perfectly healthy and yet be able to transmit cholera to other people by infecting water or food. The rôle of flies, infected clothes and rags, and faulty conservancy methods must be kept in mind.

Symptoms.—Giddiness, faintness, persistent vomiting and diarrhœa, great prostration, feeble pulse, cold perspiration, colic, intense thirst, and constant desire to pass urine. The vomit and motions rapidly become like rice-water in appearance, and the urine is more or less suppressed. There are severe cramps in the legs, belly, and other parts of the body. If then the pulse becomes weak, the temperature low, and the countenance dusky, the patient will probably sink. On the other hand, reaction may set in, all the symptoms abating, and the pulse, temperature, and colour becoming natural; the water is passed more freely, vomiting is less frequent, and the motions become more natural in colour.

Prophylaxis.—Anti-choleraic inoculations are now practised. They not only afford a considerable degree of protection but lessen the risk of a fatal issue in the inoculated. Hence it is advisable to be vaccinated against cholera whenever there is risk of infection. The inoculation must be repeated after the lapse of four months if the epidemic still persists, as the protection afforded is only temporary. Persons travelling in regions where cholera is present in an endemic form should take a little lactic acid in tea, or add a little vinegar or thirty drops of dilute hydrochloric acid to every ounce of drinking water.

At times of epidemic prevalence it is essential that all water should be boiled. The practice of hand-shaking should be discouraged, indigestible diet should be avoided, and raw fruit, raw vegetables, and meat jellies should not be eaten. Lettuces and celery, being moist and eaten uncooked, are specially dangerous. Patients and contact cases must be isolated, and the former should be protected from flies. It is very necessary to maintain a strict supervision of cooks and cooking arrangements. All kitchen cloths should be washed in permanganate solution or boiled. Milk should always be boiled.

Cholera stools may be disinfected by adding a five per cent. cresol solution to them and allowing it to remain in contact with the stool for at least one hour. Quicklime is excellent as a disinfectant. Add together equal parts of fresh quicklime and water, dilute with three times as much water as previously used, add a quantity of this slaked lime equal to the amount of stool to be disinfected and allow it to remain in contact with the stool for one hour. When the ground has been fouled by dejecta or vomit, disinfect with cresol, or rake hot ashes over it or pour kerosene oil upon it and set the latter alight. Cholera-soiled clothing, bed linen and blankets should be soaked in a two and a half per cent. cresol solution.

Treatment.—Isolate the patient, keep him warm, and give ice to suck. Apply hot bottle to the feet, and mustard leaves to the pit of the stomach.

It is advisable to clear the bowel of irritating material at the outset by giving half an ounce of castor oil with a teaspoonful of brandy. Drugs are of little use in cholera, but some like to give one drop of carbolic acid, together with twenty drops of spirit of camphor (or peppermint, or a little brandy), five grains of bismuth, and ten grains of soda, suspended in one ounce of gum water, every four hours. Chlorodyne may be given to allay severe pain.

Even in the mildest cases absolute rest in bed is essential, and a warm bed-pan should be provided.

In the early stages no food at all should be given, but plenty of fluid should be allowed, though it must be administered only in sips. Stimulants may be necessary. Later on fluid food such as milk should be given carefully, and the quantity gradually increased.

The special treatment for cholera can only be carried out by a medical man, and recourse should be had to his help at the earliest possible moment, as everything depends upon immediate treatment. If, after the acute symptoms subside, diarrhœa continues a dose of bismuth is often useful.

Colic.

This is the name given to the well-known severe twisting or griping pains in the belly, usually due to excessive flatulence, and resulting from constipation, or some error of diet.

Treatment.—Hot fomentations should be applied to the belly, or better still, the Instra, which is the best means of applying continuous heat to any part of the body. A turpentine enema (a tablespoonful to a pint of warm water) will nearly always cut short the symptoms; in the absence of turpentine, give warm water alone. A full dose of opium (20 minims) should also be given if the pain is severe, preferably in a tablespoonful of castor oil.

Bicarbonate of soda, carbonate of ammonia and ginger should be freely given in full doses, and the bowels should be well opened as soon as the severe pain has passed off.

Concussion of the Brain.

This term is applied to the partial suspension of the functions of the brain, produced by the severe shaking of its substance by a fall or blow.

Symptoms.—At first the patient lies in an unconscious condition, skin cold and clammy, pulse and breathing very feeble, and temperature extremely low; he can be slightly roused by shouting; he cries out if he is moved, or when painful applications are made, but quickly relapses into insensibility. The stage of unconsciousness may pass off almost at once, it may be prolonged for hours or days, or the patient may never recover from it. The second stage—that of reaction—is marked by returning consciousness and frequently by vomiting, the skin becomes warm, and gradually the patient recovers; on the other hand, inflammation of the brain may set in, or he may again become unconscious and die.

Treatment.—Keep the patient perfectly quiet in bed, in a darkened room, give a milk diet, and if he is much excited, apply cold cloths or an ice-bag to the head. If there is much prostration apply a hot-water bottle, and restore the circulation by rubbing the limbs. When reaction sets in, give five grains of calomel.

Stimulants should be avoided in cases of concussion of the brain, unless the collapse is very alarming (when ammonia should be given), as they tend to cause too violent reaction, which might be followed by inflammation of the brain and its coverings.

Constipation.

This condition is very frequent in tropical climates, where it is associated with sluggishness of the liver. One of the best remedies is the two-grain tablet of cascara, of which one may be taken three times a day. Rhubarb is also a very useful drug. In addition to this, an occasional dose of a saline purge should be used, or a large enema of soap and water may be given. Five grains of blue pill or three grains of calomel will be found to act as a very efficient aperient, especially if followed in about six hours by a saline such as fruit salt. Castor oil is a valuable remedy, but it must be remembered that in the tropics its effects are sometimes rather severely felt, and hence it is well to give it in somewhat smaller doses than those usually employed in temperate climates. Three-quarters of an ounce may be given where an ounce would otherwise be employed.

As a rule, the general health of people suffering from simple constipation is not seriously affected.

In cases of chronic constipation one of the anti-constipation products, otherwise known as the Aloin Co., given three times a day and gradually reduced, will be found useful.

In most acute diseases, such as malaria, pneumonia, etc., if constipation is present, it should be treated at once by means of suitable aperients.

Note.—In peritonitis, i.e., inflammation of the bowels, hernia, and in some cases of typhoid, constipation is a leading symptom, and is accompanied by severe pain in the belly. On no account should an aperient be given by the mouth in these cases. If it is necessary to clear the bowels, this should be done by means of an enema.

Coryza, or Cold in the Head.

When a cold is confined to the head it can usually be cut short by retiring to bed early, taking a ten-grain dose of Dover’s powder, followed by hot drinks to encourage the perspiration which the action of this drug produces, together with the use of as many additional bed-clothes as can be borne. Care must be taken to avoid chill on the following morning. Once it is established the condition is difficult to cure, but marked relief will often be afforded by washing out the nose with a solution made from naso-pharyngeal products. In fact, a simple nasal glass douche should form part of the traveller’s outfit, at least, if he is liable to bad colds in the head. In tropical regions five grains of quinine should be added to the dose of Dover’s powder. When there is a liability to colds in the head the use of preventive vaccines is recommended, but these should not be employed without the advice of a medical man.

Cystitis, or Inflammation of the Bladder.

Causes.—Injury or the result of operations, extension of inflammations such as gonorrhœa, retention and decomposition of urine; debilitated or gouty persons are especially liable to this affection.

Symptoms.—Intense pain in the lower part of the belly, and in the crutch, continual desire to pass water, with frequent passage of small quantities. The urine is scanty, high-coloured, foul-smelling, and occasionally blood-stained, and there may be some fever.

Treatment.—Hot baths, leeches, or fomentations to the crutch, and a sedative, such as opium (preferably given by the bowel), will be required. If the disease continues the bladder should be washed out through a catheter with weak boric acid solution, five grains to the ounce, or chinosol (1 in 2000), twice a day. Urotropin, ten grains, and copaiba or sandal-wood oil in ten-drop doses.

The diet should be restricted to milk.

Dengue.

This disease, also known as dandy fever and break-bone fever, occurs in many parts of the world, and it is most common along littorals, probably because the Stegomyia mosquito which carries the infection is usually numerous in sea-coast places.

Cause.—The organism of dengue fever is unknown, but the infection has been proved to be carried by at least one species of mosquito.

Symptoms.—The incubation period varies from about five to ten days. The onset is very sudden, the temperature rising rapidly. Within an hour or two an initial rash appears, which varies in appearance and is transient. The patient suffers from severe headache and pain in the joints and back. Indeed, the condition closely resembles a sharp attack of influenza, but, as a rule, there are no signs of coryza. The eyes are very painful and insomnia is present. The high temperature lasts for three or four days, then drops, continues low from twelve hours to three days and rises again sharply. During the interval the patient feels better but the symptoms start again when the temperature rises for the second time. In the second stage the true rash of dengue appears, which is rather like that of measles, and it is followed by desquamation of the skin. The disease, though often causing great weakness, is very rarely fatal.

Prophylaxis.—Protect against mosquito bites by using a proper mosquito net or by employing mosquito repellents such as “sketofax.”

Treatment.—Light diet, rest in bed, phenacetin and aspirin for the relief of pain and headache. Cold sponging helps the febrile condition and the insomnia. During convalescence there is often much depression, and the patient benefits by being ordered tonics and a sound wine.

Diarrhœa.

Diarrhœa, or looseness of the bowels, is one of the most common and one of the most serious ailments of the tropics, and should never be neglected. In many cases it is a sign of enteric fever, dysentery, cholera, or sprue, the symptoms of which are given below. Ordinary attacks are usually due to the presence of some irritant in the bowels, such as irritating sand, bad food, unripe fruit, or other poisonous material. Amongst African and other natives diarrhœa is often due to a faulty or ill-cooked dietary. The importance of flies in fouling food should not be overlooked.

Treatment.—Begin the treatment by administering castor oil, fruit salt, cascara, or other mild aperient, to clear out the cause of the diarrhœa. If castor oil is used the following note as to its administration is likely to be of service. Place an ounce of brandy in a glass or cup. Carefully pour the oil into the centre of the brandy and then add one ounce of water. The mass of oil will then resemble the yolk of an egg enclosed in the white. Lime juice may be used instead of brandy. Failing these, black coffee helps to cover the taste and “feel” of the oil. Sometimes three grains of calomel with fifteen grains of sodium bicarbonate act better than castor oil. A warm-water enema of about a pint is useful.

If the diarrhœa continues, give chlorodyne (20 minims) and tincture of ginger (10 minims) in an ounce of water two or three times a day.

This treatment should not be persisted in for more than two days.

If the diarrhœa is persistent, an astringent is needed: five grains of tannin, or two or three grains of sulphate of iron may be given three times a day. Ten grains of quinine should be given each day.

All food should be semi-solid and tepid; milk diet, as recommended below for enteric fever, is the safest food, but soup thickened with rice or arrowroot is good. The patient should keep in bed and wear a flannel band round the belly. Sometimes in the tropics, as the result of excessive purgation, diarrhœa is very acute and may be alarming. In such cases a hot bath, stimulants and the administration of astringents are indicated.

If the trouble continues for more than a few days it is probably due to dysentery, or typhoid.

Diphtheria.

Diphtheria is an acute infectious disease, the essential feature of which is a peculiar inflammation of the lining membrane of the mouth, nose, throat, and windpipe, characterised by the formation of a membrane upon the inflamed surface. Diphtheria occurs in the tropics but happily does not spread much in hot countries.

Causes.—It may be contracted from some person suffering from the disease, from a healthy “carrier” harbouring the specific micro-organism (Bacillus diphtheriæ) in his throat or nose, or from infected milk, etc.

As the disease is a very grave one, and skilled treatment is often an absolute necessity, measures should be immediately taken to summon medical assistance on the first appearance of diphtheria, or the patient should be sent as speedily as possible to a place where medical aid is likely to be obtained; for if the breathing becomes so difficult that the patient gets blue in the face, an operation for opening the windpipe will be necessary.

Incubation period, two to six days or even longer.

Symptoms.—Headache, discomfort, loss of appetite, sore throat, and sickness, with swelling of the glands at the angle of the jaw. On examination the palate and tonsils are seen to be swollen, with a white deposit of membrane upon the surface. The membrane may be thick and tough, and if stripped off will leave numerous small bleeding points.

The temperature may run up, and is irregular in type. The pulse is rapid and feeble, and the bodily strength is quickly lost.

If the nose be affected there is copious discharge from the nostrils, with difficulty of breathing and much discomfort. If the windpipe is affected the voice will become hoarse or absent, and there will be greater difficulty in breathing, accompanied by a loud crowing noise.

Diphtheria may be accompanied by cough and pneumonia.

Treatment.—Isolation. Bed. If diphtheria anti-toxin is obtainable, it should be administered at the earliest opportunity, but this should only be carried out by a doctor.

Nourishing foods and stimulants should be given frequently in small quantities. The throat should be thoroughly and frequently washed out with chinosol (1 in 1000) or other antiseptic lotion. If the difficulty in breathing is marked, warm baths should be given at intervals of about four hours. A steam kettle should be placed near the bed. The expulsion of the membrane may often be aided and great relief afforded by the administration of emetics, such as ipecacuanha, but these must be given with care owing to the risk of heart failure.

Complications.—Diphtheria may be followed by paralysis of the windpipe with loss of voice, or paralysis of other parts of the body, therefore great care should be taken not to allow convalescents to get up too soon, no matter how well they may appear.

Dysentery.

This disease, which is due to an inflammatory condition limited as a rule to the lower or large bowel, may be the result of a variety of causes, but there are two chief types which must be clearly distinguished: (1) Amœbic dysentery, due to a protozoon or animal organism, (2) Bacillary dysentery, caused by certain micro-organisms belonging to the vegetable world.

Amœbic dysentery is much more of a tropical complaint than is bacillary dysentery, but the latter is also common both in tropical and temperate climates. Both forms are transmitted in much the same way and their symptoms are very similar. Hence from the layman’s point of view no good purpose is served by considering them separately, at least so far as methods of transmission and symptoms go. The treatment of the two forms, however, differs, and to carry out such treatment effectively medical skill is required.

Causes.—Dysentery is conveyed by impure drinking water, contaminated food, infected flies, and possibly also by infected dust. In both forms, but especially in the amœbic variety, the so-called “carrier” plays an important part, because in the latter case the organism produces cysts which are passed by the bowel, and these cysts are frequently found in the dejecta of persons who have suffered from amœbic dysentery and who are either convalescent or possibly in quite good health. If these cysts find their way into food or water and are then swallowed they are capable of developing in the human intestine and producing dysentery. Carriers are also met with in the bacillary form of the disease. Dysentery may be provoked by chills, general debility and exhausting conditions, such as chronic malaria.

Symptoms.—Diarrhœa with pains in the belly, straining and frequent desire to go to stool. The motions soon become small in amount, slimy, lose their natural colour, and contain more or less blood; when there is ulceration of the coats of the bowel, the motions are extremely offensive, and bleeding may be very free. There is heat, tenderness, and bearing down about the outlet of the bowel, with considerable prostration and probably some fever; there is frequently a constant desire to pass water. All these symptoms may be due to severe ordinary diarrhœa; but in the tropics it is best to treat them as if they were dysenteric. Some guide may be obtained as to the form of dysentery from which the patient is suffering by taking his temperature. As a rule there is little or no fever associated with the amœbic form, while in the case of the bacillary type the temperature is always raised and in severe cases may be considerably elevated. It is in this form that the small intestine is apt to become involved and then the condition is more serious.

One help in diagnosis, though not a very reliable one, is the character of the stool. In amœbic dysentery the blood is apt to be mixed with the dejecta and to be dark in colour, while the whole mass looks brown or greyish green. The stool of bacillary dysentery, on the other hand, has a whitish appearance, the blood in it is bright coloured and is often in the form of streaks or spots. The amœbic form is apt, if not promptly and efficiently treated, to be followed by inflammation of the liver, which may go on to liver abscess.

Prophylaxis.—Avoid chill and debilitating causes of all kinds. In countries where there is a great difference between the day and the night temperature wear a cholera belt. Carefully protect food and water from contamination of any kind, and especially from flies. Doubtful water should be boiled or rendered sterile by some chemical method. All milk should be boiled. Care should be taken not to employ as cooks natives who have recently suffered from dysentery, and scrupulous cleanliness should be observed in the preparation of food. Unripe fruit and other materials apt to cause diarrhœa should be avoided. Camp conservancy methods should be carried out on approved sanitary principles which prevent the access of flies to human excrement and prevent the latter from being disseminated by wind or in any other way. All dysenteric stools should be carefully disinfected or burnt.

Treatment.—The general treatment is common to both forms, the essentials being rest, warmth and suitable food. Put the patient to bed, apply a cholera belt and get the bowels open by an initial dose of castor oil. If there is much pain ten drops of tincture of opium may be added to the oil. The usual dose of the oil is an ounce, but if the patient is feeble or exhausted half an ounce will be sufficient.

As regards diet do not give any milk at first, and indeed if the case is recognized as being one of bacillary dysentery milk should not be given at all as it tends to favour putrefaction. Albumin water, rice water, chicken broth are required during the first twenty-four hours. Thereafter in the amœbic form milk diluted with barley water or with citrate of soda (three grains to the ounce) can be given. Soups are often useful, and at a later period custard, arrowroot and jellies are indicated. In the bacillary type arrowroot, meat and fruit jellies and beef-tea can be given from the outset. In both types the food should be given in small quantities frequently, and it should be neither too hot nor too cold. Alcohol is deleterious.

Fortunately we now have a specific drug for treating amœbic dysentery and that is emetine, which is the active principle of ipecacuanha. It is best given in the form of emetine bismuthous iodide, which is supplied in capsules and the dose of which is three grains per day for twelve consecutive days. The dose is best given in the evening along with a cup of hot tea on a full stomach when the patient is in bed. If it causes much vomiting it is well to give ten or fifteen drops of tincture of opium before administering the emetine. The latter can also be given by subcutaneous injection, but this method of treatment should only be carried out by a physician. Where emetine is not available ipecacuanha itself may be used and is given as follows:—

Treatment by Ipecacuanha.—When the bowels have been opened, give twenty grains of ipecacuanha, either solid or mixed with a wineglass of water, or less; arrowroot, starch, or gum-water, which will help to suspend the drug. Of course, ipecacuanha will act more quickly if it can be taken suspended in a liquid, instead of in the solid form. To prevent vomiting, put a mustard leaf to the pit of the stomach. Absolute quiet must now be observed; darken the room, and allow no moving in bed or talking. Withhold food and liquid for at least two hours if possible, but if there is much thirst, teaspoonful doses of water may be given.

If there is no vomiting for an hour, probably a good part of the ipecacuanha has been digested; if it has been vomited, wait for half-an-hour, and then give another full dose. If vomited again, wait for two hours, and give twenty drops of chlorodyne, followed by twenty grains of ipecacuanha; the chlorodyne is to quiet the stomach, enabling it to retain the ipecacuanha. In about twelve hours from the first dose, repeat it in exactly the same way. If thirty grains are too much at a time, give twenty, three times a day, for not less than sixty grains should be given in twenty-four hours. The drug is not a dangerous one, and, if the patient can take it, too much can hardly be given. Between the doses feed the patient, giving but little at a time. If the ipecacuanha is going to do good, marked improvement should be apparent in four or five days; failure of the drug is often due to its not being given or retained in sufficiently large quantities.

In addition to the emetine or ipecacuanha treatment it is well, save in mild or trivial cases, to give a saline mixture once a day, for example one ounce of sodium or magnesium sulphate. Other methods which are helpful are enemata of warm water, hot hip baths, or a soothing injection made by soaking an ounce of linseed for several hours in two pints of warm water. Sedatives, such as laudanum or chlorodyne, should be used only in cases where there is severe pain, sickness and great distress. The full dose in ordinary cases is twenty drops three times a day, but if less is sufficient so much the better, and it is advisable to avoid these remedies wherever possible.

The object of treatment is not to block up the bowel—as might be done by giving large doses of opium or tannin—it is to cure the disease of which the looseness is only one symptom. The most favourable sign during an attack is a return of the colouring matter to the motions; this shows that the liver is again acting, and that the treatment is doing good. With the return of colour (which at first may be intermittent), the other symptoms, such as pain and bloody discharge, will abate, and the motions will become more solid and healthy.

In dysentery, as in severe diarrhœa, the patient should not be allowed to get up to stool. A box cut across obliquely will make a rough slipper bed-pan; put sand in it, and pad the edges.

In bacillary dysentery emetine is nearly or quite useless, and recourse should be had to a saline treatment. A mixture containing sixty grains of sodium or magnesium sulphate, fifteen drops of dilute sulphuric acid, and five drops of tincture of ginger can be given in half an ounce of peppermint water, if necessary, every two hours at first, and then every four or six hours, until the stools are watery and bile-stained. An alternative method of treatment, but one which is not so satisfactory, is to give half-grain doses of calomel every hour for twelve hours on three successive days. The patient must, however, be watched for such symptoms as tenderness of the gums, salivation (i.e., great increase of the saliva), and a metallic taste in the mouth. Should such symptoms arise the doses must be reduced or the drug discontinued.

The general treatment is the same as that for amœbic dysentery. As colic is often very severe, turpentine stupes or poultices to the abdomen are often indicated.

A specific anti-dysenteric serum is now employed in cases of bacillary dysentery, but its administration requires medical skill.

When the acute dysenteric attack is over, bismuth may be given, and various astringent enemata may be tried, but these should not be administered in the absence of a physician. A simple form of enema, however, is one containing a teaspoonful of alum or ten grains of sulphate of iron to the pint.

Enteric or Typhoid Fever, including the Paratyphoid Fevers.

It is impossible to give a full account of the enteric fevers here, and moreover the presence of a medical man, still more of a good nurse, is absolutely necessary for their proper treatment. The chief early symptoms, however, will be given, and a few hints as to their treatment. For all practical purposes paratyphoid fever may be considered as a mild variety of typhoid.

The disease is characterised by ulceration of the small bowel, with continued high fever, and is usually accompanied by diarrhœa.

Causes.—It is generally caused by the drinking of impure water, but may also be transmitted by all the causes operative in the case of dysentery (see [p. 185]).

The incubation period is from ten to fifteen days.

Symptoms.—The early symptoms of the disease are often so slight that the patient will not believe he is really ill; he may just feel out of sorts, or complain of headache, but still go about his work. There may be diarrhœa, or occasionally constipation. After five or six days the patient is generally compelled to give up and go to bed, headache or diarrhœa, or both, being the chief complaint. The temperature goes up in a characteristic manner, rising a little more every evening till it eventually reaches 103° or 104° F. There may be some cough, and often this symptom is a very troublesome one.

The belly is usually distended and slightly tender, and there may or may not be the characteristic typhoid rash, consisting of rose-pink circular, slightly raised spots, about the size of a large pin’s head. They occur chiefly on the chest and abdomen, and come out on successive days, often only three or four at a time. These spots are frequently absent, and then one must be guided by the presence of other symptoms. They are difficult to be seen upon a dark skin.

The possibility of enteric fever should always be remembered in cases where there is constant fever, unaccompanied by any definite symptoms, such as the recurrent shiverings of malaria, or the spitting of blood in pneumonia.

Prophylaxis.—As for dysentery (see [p. 186]). Preventive inoculation is very important and confers immunity for a considerable period (see “Inoculation,” [p. 168]).

Treatment.—Absolute quiet in bed. If constipated, bowels should be kept open by soap and water enema only.

Milk only (three to four pints daily) should be given during the whole course of the illness and till ten days after the temperature has descended to, and remained, normal. Stimulants, if pulse is feeble and rapid; opium only if there is much pain. If bleeding occurs from the bowel, an ice poultice or cold-water cloths should be applied to the belly; ice may be given to suck; opium and an astringent, such as tannin, administered by the mouth, or an opium enema be given. Milk should be given in small quantities only, and to each half-pint five grains of bicarbonate of soda should be added.

The motions must be burned, or carefully disinfected.

Epilepsy.

Symptoms.—This is the most common form of fits. There are three stages. 1st stage—The patient falls down completely unconscious and without warning, the face is pale, the limbs become stiff and rigid, and the breathing ceases. 2nd stage—Convulsive movements take place, the tongue being often bitten, the breathing becomes heavy and laboured, and the motions may be passed unconsciously. 3rd stage—A confused mental condition, sometimes acute mania, usually sleepy for some time. In some cases the fit may only last a few minutes. They almost always recur.

Treatment.—During the attack nothing can be done beyond loosening all tight clothing, and gently preventing the sufferer from injuring himself in his struggles. It is especially important to keep the teeth apart with a piece of cork or rubber to prevent the tongue from being bitten.

Bromide of potassium (ten to twenty grains) may be given three times a day as a preventive.

Faintness.

Bending the head firmly down between the knees is the best and most rapid way of dealing with an attack. Another method is to lay the patient on a couch, loosen any clothing which is round the neck, bathe his face and arms with cold water, and fan him vigorously. Give three grains of carbonate of ammonia in an ounce of water. Alcohol may be given if the pulse is very weak, but sal volatile or carbonate of ammonia is more efficacious.

Filariasis.

This term connotes several pathogenic conditions, but the most important form of filariasis in man is that due to a small blood-worm which is conveyed by the bite of one or other species of mosquito. The most important symptom of filariasis is the condition known as elephantiasis, but the presence of filaria in the blood also causes a febrile state and various other symptoms which need not be detailed.

Prophylaxis.—Protect from the bites of mosquitoes, especially those which breed in the vicinity of human habitations. The most effective method of doing this is the careful use of a mosquito net.

Gonorrhœa.

Gonorrhœa, or clap, is an acute inflammation of the urethra or pipe, attended with a discharge of more or less matter. It is nearly always due to direct contagion.

Symptoms.—At first there is some itching about the end of the pipe, which is followed by a yellowish-white discharge. This lasts from three to five days. Then great pain is noticed on passing water, and the discharge becomes thick and yellowish-green in colour, with redness and swelling about the lips of the opening of the pipe. After a time the pain on making water disappears, and the discharge becomes thin and watery, a condition known as “gleet.”

Treatment.—Forbid alcohol in any form. Give large quantities of liquid—water, weak tea, or milk—to thoroughly flush the system. Light diet and as complete rest as possible. Keep bowels well open with saline and other purges. Give sandal-wood oil or copaiba, twenty drops three times a day, and urotropin, ten grains twice a day.

If there is much pain in the acute stage, a mixture containing fifteen grains of bicarbonate of soda, and five drops of chlorodyne or laudanum, in an ounce of water, may be given twice a day. Except in very acute cases the pipe should be syringed out with a very weak solution of permanganate of potash, or better, a solution of protargol (quarter to two per cent.); later on, a lotion containing four grains of sulphate of zinc to one ounce of water may be used as an injection.

If the glands in the groin become tender and inflamed, they should be painted with tincture of iodine. If, in spite of this, the pain and swelling increase, they should be poulticed frequently, and treated as ordinary abscesses.

Hay Fever.

This is a very severe catarrh which attacks certain individuals yearly, when grasses and other plants are flowering. It is most probably due to the irritation of the nose by pollen grains in the air.

Treatment.—Exposure to the irritating substances which are known to provoke an attack should be avoided.

The nose may be syringed out with a lotion containing boric acid and bicarbonate of soda (five grains of each in four ounces of water), or one containing bicarbonate of soda and salt (five grains of each in four ounces of water), to which has been added two to four drops of carbolic acid. The interior of the nostrils may be anointed with vaseline. Menthol snuff is of great value. A substance called “Pollantin” has a specific action in many cases, but it should be employed only under medical supervision.

Influenza.

Influenza has been introduced into many tropical countries, in which it has spread rapidly and caused in many instances a very heavy mortality. The actual cause of the disease is still a matter of dispute, but there can be no doubt that it is chiefly spread by personal contact.

Symptoms.—What may be called the respiratory type is pretty well known to everyone, but it should not be forgotten that sometimes the main stress of the disease falls either on the alimentary or the nervous system, while there is also a type of what is known as febrile influenza in which the heat-regulating centre is greatly upset. In this latter form the temperature may be intermittent and it is then apt to be mistaken for malaria.

The respiratory type is the most important. Its incubation period is short, one or two days. The onset is sudden and is characterized by shivering, pains in the back and limbs, severe headache and a feeling of malaise. The patient may be giddy and suddenly collapse, his throat is often dry and sore and he has an irritating cough. His temperature rises and runs up to 102° to 104° F. His face becomes flushed, his eyes reddened and his tongue is furred. Constipation is common. Uncomplicated influenza, if promptly attended to, is not a very serious disease, and improvement usually sets in about the third day. The most serious complication of influenza is bronchial pneumonia, and in some forms of the disease the heart is very apt to be affected.

Prophylaxis.—Isolation of cases; free ventilation; treat patients as much as possible in the open air. Nurses and those attending the sick should be careful about contracting infection from the patient’s invisible mouth spray. Indeed in some epidemics the use of face masks has been recommended.

Treatment.—Rest in bed as soon as possible; free purgation at the outset; an early dose of twenty to thirty drops of laudanum (Tinct. opii) is often very beneficial but the drug must be administered with care. Aspirin in ten-grain doses thrice daily frequently relieves the more urgent symptoms. In cases where there is vomiting and collapse with high temperature a dose of fifteen grains of aspirin with half to one ounce of brandy and three drachms of liquor ammon. acetat. may act like a charm. According to our present knowledge, however, it would seem that drugs are of little use in influenza, and that the important thing is to ensure good nursing and to keep up the patient’s strength. Quinine in effervescing form is very useful for convalescent cases.

Insect Pests.

(See also [Myiasis] and [Skin Diseases].)

These are best divided into the Winged and Wingless forms. Of the winged pests Mosquitoes are undoubtedly the most important in the tropics, as they are known to transmit such diseases as malaria, yellow fever, dengue fever and filariasis. The anopheline mosquitoes are those responsible for transmitting malaria, and they can easily be recognized by the facts that their wings are usually spotted and that they appear as it were to stand on their heads when resting on any flat surface. The culicine mosquitoes, which include Stegomyia fasciata, the carrier of yellow fever, do not as a rule have spotted wings and they rest parallel to the surface on which they alight. There are also marked differences in the water stages of these insects which cannot, however, be here considered.

The best way of protecting oneself against mosquitoes is the proper use of an effective mosquito net, the mesh of which should contain at least sixteen holes to the linear inch. Mosquito boots or buskins are also useful, and in certain places hoods for the face and neck, such as the “Mosquinette” variety, will be found of value.

Repellent substances applied to the skin may also be employed. Cassia oil, with brown oil of camphor in vaseline, is useful. Vermijelli, containing a little citronella oil, is fairly effective but is not so pleasant to use. The irritating effect of mosquito bites may be diminished by the application of tincture of iodine. The same measures are effective in the case of some of the biting midges.

The insects generally known as Sand-flies are really owl midges or moth flies, tiny and hairy insects which have been proved to transmit sand-fly fever (see [page 221]). These flies breed in damp places where there is rotting vegetation, dark and damp cellars, cracks and fissures in the soil, tunnels, etc., and they are often very troublesome. The repellents mentioned above may be used to drive them away, as may eucalyptus oil, camphor and tobacco smoke. The ordinary mosquito net is useless against their attacks, and one containing twenty-two holes to the linear inch is required.

Buffalo gnats, which are often called sand-flies, are insects which breed in running water and amongst cataracts and rapids. They are formidable biters although they are not known to cause any disease. The same protective measures are indicated in their case as in that of owl midges.

House Flies.—There are several species of these. They are definitely known to distribute certain harmful bacteria and protozoa and to contaminate food by carrying the organisms on their bodies, wings and legs, or depositing them by regurgitation or in their droppings. Hence it is very important to protect all food and drink from flies and to destroy these insects wherever possible. The subject of their destruction is too large a question to be dealt with here, so all that need be said is that the traveller should provide himself with wire mesh fly covers to screen food and also with pieces of mesh or calico weighted with beads, which can be utilized for covering vessels containing milk or other liquids. It is worth noting that ordinary fish netting hung over a tent door or used to screen the windows or doors of a house will effectively exclude flies, despite its large mesh.

Tsetse Flies.—These are considered under Sleeping Sickness (see [page 234]).

The Congo Floor-maggot Fly.—It is the maggot or larva of this fly which is important, as in many parts of Africa it infests the floors of native huts and it is a blood-sucker feeding at night. So far as is known it does not convey any disease but it is an unpleasant visitor, and if its numbers are great they may extract comparatively large quantities of blood from their unconscious victims.

Prophylaxis.—General cleanliness and enforcement of sanitary measures, the use of high beds, the scrutiny of sleeping mats and blankets in which eggs or larvæ may be concealed. Infected huts can be rendered habitable by firing the ground or by removing the surface soil, which can then be disinfected.

Wingless Pests.—Lice.—These are known to transmit typhus fever. Further, they often cause great cutaneous irritation and are loathsome companions. It is no easy matter to get rid of lice when infection is on a large scale, but very often this is not the case and it is possible to detect their presence only by careful examination. There is no real difference between head lice and body lice; they are simply varieties of the same insect. The presence of head lice may be recognized by the discovery of their eggs, which are known as nits and are minute, yellowish-white, goblet-shaped bodies about the size of a full-stop on this page. Examination for head lice is much facilitated by the use of a fine tooth comb. Persons suspected of harbouring body lice should be examined first for the actual bites of the insect on the skin. Their clothes, and especially their under-garments, should then be carefully examined, attention being more particularly directed to the seams and folds where the eggs, if present, are most likely to be found.

The best preventive measure against lice is strict personal cleanliness. Clothes should be frequently changed, and as frequently washed. The hair should be kept cropped short, especially at the sides and back of the head, and in the tropics it is very advisable to shave all hairy parts of the body.

Space does not permit a full account of how to deal with verminous persons and verminous clothing, but it may be said that the only reliable methods of destroying lice are by hot air, steam, boiling water, or hydrocyanic acid gas. At the same time it should be noted that the heads of those infested with head lice should be thoroughly combed and treated with paraffin, petrol, or white precipitate ointment, and then well washed with carbolic soap. The nits may be loosened by treatment with warm vinegar or acetic acid. In the case of body lice possibly the most satisfactory grease for application to the underclothing is one composed of crude unwhizzed naphthalene from the coke oven, four parts, and soft soap, one part. It is important that the proper type of naphthalene be used.

A useful palliative method is the ironing of clothing, especially along the seams, with heavy hot irons.

Fleas.—Bubonic plague is known to be transmitted by fleas, and it is possible that they play a part in the transmission of that form of leishmaniasis which is known as kala-azar (see [p. 202]). Fleas dislike powdered naphthalene and pyrethrum powder, and either of these may be applied to the clothes to ward them off.

A note on the troublesome Chigger flea or Jigger will be found under “Skin Diseases” (see [p. 228]).

Bed-Bugs.—The traveller sleeping in hotels or inns abroad is very apt to be attacked by bed-bugs, which harbour in wooden beds and bedding, crevices in walls, floors and ceilings, and other places which are dark and sheltered. Fortunately, so far as is known, the bed-bug does not carry any disease, but its bites are annoying, and its presence is a sign of insanitary conditions. It is difficult to protect oneself against bed-bugs without instituting a campaign against their hiding-places and breeding-places, but a skin ointment like vermijelli is useful, and powdered naphthalene or Keating’s powder may deter the insects to some extent.

Note.—Keating’s powder, which contains pyrethrum, is slow in its effects, and therefore, if possible, should be shaken over the sleeping bag or blankets some hours before bedtime. If not, the pests will struggle through it and find renewed vigour on the sleeper. It is best in very bad quarters to rub the powder on the skin as well as to dust it over the bed. It will not kill a full-grown bug under an hour, but it is extraordinarily effective with fleas. It is important to obtain a good pyrethrum powder, as such preparations are frequently adulterated.

The Itch Insect is the cause of the skin disease known as scabies. It is a mite, the female of which burrows under the skin to lay her eggs. The favourite site for her operations is between the fingers, but other parts of the body may be affected, and the rash produced may assume various forms, so that it is well in the case of any skin eruption in the tropics to remember the possibility of scabies.

Treatment.—Its effective treatment is by no means easy, and would take much too long to detail here. All that can be said is that the skin should be washed well with soap and hot water, and that thereafter a liberal quantity of sulphur ointment should be thoroughly rubbed into the skin twice daily for three days. On the fourth day recourse should be had again to soap and hot water, if possible in the form of a hot bath. Meanwhile, clothing and bedding should be boiled or destroyed.

Ticks.—The most important tick from the traveller’s point of view, at least, in Africa, is the species responsible for the transmission of tick fever (see [p. 242]). It would seem that the fowl tick may occasionally attack man, and some believe that it may spread the infection of certain kinds of relapsing fever (see [p. 218]). The larval stages of certain ticks are often very troublesome in many parts of the world, owing to their habit of burrowing into the skin of persons coming into contact with them.

Treatment.—When a larval tick is found half buried in the skin, force should not be used in an attempt to remove it, because either the surrounding skin is unnecessarily damaged or, as is most probable, the head of the tick is ruptured, its rostrum or beak remaining buried in the skin. The result is severe irritation which may lead to septic infection. The best way, therefore, of dealing with a tick larva lodged in the skin is to dip a small camel’s hair brush in turpentine, benzene, petrol or paraffin, and apply it between the skin and the under surface of the tick. In a short time the tick will let go its hold and may be swept from the skin with the brush. Vaseline is also effective if smeared over the tick. To remove a rostrum which remains in the skin after a tick has been forcibly ejected, cocaine should be applied to the spot, and the rostrum extracted with needle forceps, iodine being thereafter applied. A special form of tick-case devised for dealing with this condition is upon the market, and is a useful addition to the traveller’s outfit.

Ants.—These are often very troublesome owing to their depredations on foodstuffs, and it must be remembered that experimentally ants have been shown capable of carrying the organisms of typhoid fever and cholera, though under ordinary conditions they are not likely to be very dangerous in this respect. Some form of pyrethrum powder, such as Keating’s, will be found useful in checking the depredations of ants, or they can be prevented from getting at food on tables by tying paraffin-soaked rags round the legs of the latter. Powdered borax or paraffin are useful in dealing with so-called “ant-routes” into tents or houses.

Iritis, or Inflammation of the Eyeball Itself.

Symptoms.—In this there is pain, the vision is dimmed, and the transparent part of the eye is found to be cloudy. Skilled assistance is necessary.

Treatment.—Apply hot fomentations and boric acid lotion; leeches or a blister to the temples are of service, and the pupil, which is contracted, should be dilated by dropping two or three drops of a one per cent. solution of atropine on to the eye twice a day or oftener till it is well dilated; only enough drops should be applied afterwards to prevent the pupil from contracting. Dark glasses may be worn with advantage. The bowels should be kept well open, and one grain of calomel may be given three times a day for a week, or longer if it does not cause a coppery taste in the mouth, with tenderness of the gums and excessive flow of the saliva. As the inflammation subsides a shade may be adopted.

Fig. 2.

Night blindness and snow blindness are due to exposure to the glare either of the sun or of the snow. To avoid these complaints tinted glasses should be worn. Travellers in snowy regions should be provided with smoked glasses; if these get broken or lost, some opaque substance may be smeared over the surface of an ordinary pair, leaving a narrow horizontal slit of clear glass—in the Esquimaux fashion, as shown in the accompanying illustration. On snow it must be remembered that the perforated wire gauze sides are essential for protection from the reflected rays of the sun. Elastic may be substituted with advantage for the ordinary metallic attachments, between the glasses as well as around the head.

Jaundice.

Jaundice, which is a condition in which the skin and mucous membranes assume a yellow colour, may be due to various causes. One of the commonest forms is that known as catarrhal jaundice, which is induced by chill, exposure, dietetic disturbances, etc. It should be treated by calomel and salines. Violent purges are to be avoided. Bismuth and bicarbonate of soda should be given, and the diet should be regulated and should consist of simple and bland articles of food, free, as far as possible, from fats.

There is a form of jaundice associated with infective conditions, such as the enteric fevers, dysentery, malaria, relapsing fever and yellow fever. In these cases the jaundice is to be treated like the catarrhal form, and the accompanying condition requires attention.

In addition to the above there is a camp or infectious jaundice, the nature of which is somewhat obscure, but which is associated with a considerable degree of illness.

Symptoms.—The condition commonly begins with shivering, a rise of temperature, headache, giddiness, general malaise, sleeplessness, loss of appetite, nausea, and it may be vomiting. The tongue is coated, and there may be pains in the back and legs. The jaundice usually lasts from seven to nine days, and about the fifth day the temperature falls, though there may be a secondary fever.

Prophylaxis.—So far as we know at present this is a question of enforcing good sanitary surroundings, and paying special attention to the hygiene of food and drinks, which should be guarded from the access of flies.

Treatment.—This is entirely symptomatic and should be that of any ordinary febrile attack, together with the measures employed in catarrhal jaundice. There is a severe form of jaundice of an infective nature which is associated with the presence of a parasite in the blood, very like that of yellow fever, and which apparently is derived from infected rats. This form of jaundice is, however, not very common and need not be further considered, especially as it requires skilled medical attendance.

Laryngitis, or Inflammation of the Upper Part of the Windpipe.

The organ of the voice is called the “larynx.”

When the windpipe is affected it is somewhat tender on pressure, there is hoarseness, cough, and pain in swallowing. Treatment similar to that for cold in the head may be adopted; in addition, the upper part of the front of the throat should be kept well poulticed for a day or two, and then wrapped up in cotton wool for some days longer. A piece of mustard leaf covered with six layers of a handkerchief and secured by a bandage, can usually be borne for a considerable time, and is often more efficacious than the poultice; when the smarting is great the mustard leaf should be removed and the tender part smeared with oil or vaseline.

Inhalations of steam are of use in promoting expectoration. Carbonate of ammonia, three grains, or bicarbonate of potash, five grains, with half to two grains of ipecacuanha, will help to promote secretion from the affected part. A teaspoonful of Friar’s balsam in a pint of hot water makes a good inhalation.

Leeches.

Persons travelling in India, Ceylon, the Far East generally, and the Philippine Islands, are likely to make the acquaintance of the Asiatic leech, which is a very troublesome and indeed dangerous species of vermin. It is very small, only about an inch long, and of the thickness of a knitting-needle. It is able to penetrate through the interstices in clothing, and when in vast numbers it is a foe difficult to combat. The bites of these leeches are painless and much blood may be lost before their presence is discovered. It is very difficult to obtain any kind of boot or puttee which will keep these creatures at bay, and the traveller in these countries should be provided with a solution of salt or weak acid which, on application, causes the leeches to loose their hold. It is a mistake to try and drag them off the skin, as parts of their biting apparatus are apt to be left behind and set up inflammation and suppuration. Tincture of iodine should be applied to the site of a leech bite. In forest regions where these leeches abound protective measures must be taken at night, the best being the use of a properly adjusted mosquito net of very fine mesh.

The tropical water leech is found in the Azores, the Canary Islands, Africa, Palestine, Syria, Armenia and Turkestan. It may reach a length of four inches, and if swallowed with drinking water usually fastens on the mucous membrane of the mouth or throat. As a preventive measure drinking water should be passed through a piece of muslin or similar form of sieve.

Leishmaniasis.

This condition is named after Sir William Leishman, who discovered the parasite producing it. There is a general and febrile form of the disease and also a form attacking the skin and mucous membrane of the mouth and nose, which is considered under Skin Diseases.

The systemic form of the disease is commonly known as kala-azar, which signifies “black sickness.” It is common in certain parts of India, notably Assam, but is found also throughout the Far East, and it occurs in Arabia, in the Anglo-Egyptian Sudan and in the Mediterranean area. A case has also been described in South America, in parts of which it is possibly more common than is generally supposed.

Cause.—The parasite, which lives in the blood and tissues, is known, but its exact method of transmission to man is still in the realm of uncertainty.

Symptoms.—The disease begins in an indefinite manner and then assumes the form of a continued fever, associated with enlargement of the spleen and liver and progressive emaciation. Bleeding from the nose is not uncommon, and in Europeans the peculiar earthy-grey colour of the skin is very striking. The disease lasts for months and even years and is very frequently fatal.

Prophylaxis.—As we do not know how the disease is spread it is not easy to recommend preventive measures, and all that can be said is that every care should be taken to isolate the sick, to live under healthy conditions and to avoid contact with vermin of all kinds. As dogs may possibly be carriers of the disease they should be destroyed if proved infected.

Treatment.—Antimony is the best and indeed the sole remedy, but it can be given only by a medical man, so that nothing further need be said here regarding it.

Liver, Congestion of:—

The Liver, which is mainly on the right side, lies below the right lung, and is protected by the lower ribs. In health it extends vertically from one-and-a-half inches below the right nipple to the lower edge of the ribs; in certain diseases it is enlarged, and its edge can be felt well below the ribs.

Congestion of the liver is frequent in the tropics, and is often due to malaria or dysentery. Very frequently it is caused by abuse of alcohol, over-indulgence in food, and the excessive use of hot condiments, or by constipation and want of exercise. In the tropics the liver is more easily affected by excesses than in temperate climates.

Symptoms.—A furred tongue, sallowness of the face, headache, lassitude, disinclination for work, loss of appetite, tendency to vomit, occasional slight jaundice, and a sense of oppression about the region of the liver.

Treatment.—Light diet, abstinence from alcohol and spices, and the use of calomel or other aperient will usually effect a cure. Ammonium chloride, five to ten grains, three times a day, should be given.

Liver, Acute Inflammation of:—

In this complaint there is severe pain, some fever, and frequently jaundice. The complaint is serious, as abscess of the liver frequently follows it, at least if it is due to amœbic dysentery.

Treatment.—The patient should be put to bed, hot fomentations applied to the seat of pain, and the bowels well relieved. Emetine should be at once administered as for dysentery, or ten grains of ipecacuanha should be given three times a day. Ammonium chloride in full doses (twenty grains three times a day) often does good, and can be retained when ipecacuanha cannot, but it is unpleasant to take, so the dose should be given in one or two ounces of water. The wisest course for one who has had a severe inflammation of the liver is to get away to a healthy climate.

Liver Abscess.

It is extremely difficult for the traveller to decide if abscess of the liver is present; it may be suspected if a patient, convalescent from dysentery, still remains feeble and ill, or if he has an irregular temperature, a muddy complexion, night sweats, wasting, and pain or uneasiness in the right shoulder. Sometimes a definite swelling can be made out. A dry cough is not uncommon.

Treatment.—Emetine is the specific treatment for the prevention of liver abscess, and it would seem in some cases actually able to bring about a cure even when the abscess has formed. It should be given as for amœbic dysentery ([p. 187]), and it is essential that a patient with liver abscess should as soon as possible come under medical control, as it may be necessary to give emetine by the needle subcutaneously or even to inject it into the abscess cavity. Ammonium chloride may be given; the patient’s strength must be supported, and he should be as quickly as possible placed under the care of a surgeon, who will probably decide to operate. If this cannot be done, then the patient should not be interfered with surgically, for he will have a better chance of recovery if the abscess is allowed to burst naturally than he would if the traveller attempted to operate.

Malaria.

Of all diseases in the tropics malaria is the one which is most likely to trouble the traveller. Hence it is essential that he should be well posted regarding it. In addition to the books which have already been indicated he will find the recently published ‘Malaria at Home and Abroad,’ by Colonel S. P. James, a work of much value and interest. It is true it is more especially intended for the medical man, but any intelligent layman can study it with interest and profit, and the chapters dealing with prophylaxis and treatment are specially valuable and well up to date. Here it is possible to give only a mere outline of the chief facts concerning the disease.

1. Malarial fever is caused by a small animal parasite which lives chiefly in the blood of patients attacked by it. 2. Under ordinary conditions in nature it can be conveyed only from one person to another by the bite of a mosquito which has previously sucked the blood of an infected person. 3. The parasite undergoes a series of changes in the mosquito’s body and eventually finds its way to the salivary glands of the insect whence it is injected through the mosquito’s proboscis into another victim. 4. There are only certain species of mosquitoes, belonging to the family Anophelinæ (from a Greek word signifying “harmful”), which can carry malaria, and it is only the females of these species which are affected as the males are not blood-suckers. Anopheline mosquitoes breed in shallow puddles and in almost all collections of stagnant or gently flowing water. It is therefore very dangerous to pitch camps close to stagnant pools, sluggish reed-grown streams or marshy places. 5. In the tropics one of the chief reservoirs of infection is the native, and more especially the native child, who frequently harbours the malarial parasite in the form which is adapted for life and reproduction in the mosquito and hence is a distinct source of danger. It is therefore inadvisable to camp in the vicinity of native villages or to spend a night in the neighbourhood of native habitations unless efficiently protected from the bites of mosquitoes.

Symptoms.—Malarial fever presents itself under two chief forms, though it should be noted that malaria is one of the most protean of all diseases and may simulate any malady. (1) Intermittent fever. In this disease the temperature may rise high, but returns each day to normal or lower; hence there is, after each attack, a period of complete freedom from fever. An intermittent fever or ague is usually less serious than a remittent fever, but it is harder to cure in the long run. (2) Remittent fever. In this the temperature, though it varies, keeps constantly above the normal, and the higher the fever, and the slighter the difference between the extremes of temperature, the more serious is the condition of the patient. Where the temperature is remittent, and appears to be unaffected by quinine, the disease is probably not malarial, but may be a case of enteric fever, and should be treated as advised below under that heading.

The attack may be sudden, but it is usually preceded by a feeling of languor, yawning, and general discomfort; this is followed by the cold stage, which, in the tropics, is usually short, and in the more ordinary attacks is ushered in by a violent shivering fit or rigor, though this is not common in Central Africa. The sensation of cold is entirely subjective, for though the patient feels chilly and piles clothes upon himself his temperature will be found elevated. At this period violent vomiting is not infrequent. Then comes the hot stage, often of long duration, followed by the sweating stage, during which the perspiration pours from the patient and soaks everything on and about him. After this there is a period of remission, or intermission of the feverish symptoms with corresponding relief to the patient. Usually, after some hours, the attack comes on again, beginning with the cold stage, but if the fever is treated very early, the disease may now pass off. The whole attack lasts as a rule from six to ten hours, say one hour for the cold stage, three or four for the hot period, and two to four for that of defervescence. There is sometimes a feeling of pain and discomfort in the right side owing to the congestion of the spleen, which enlarges during the rigor.

There are three distinct species of malarial parasite, and each causes a different type of fever. According to the type with which the patient has become infected, the fever recurs after one, two, or three days. At the same time all kinds of febrile irregularities are met with, so that it is often impossible to diagnose the disease in the absence of blood examination for the detection of the parasite.

Anæmia is a constant feature of the malarial attack, as is but natural, considering the great destruction of red blood cells brought about by the parasites which have infected them.

Prophylaxis.—Only those preventive measures which can be put into operation by the individual will be here considered. This may be called personal prophylaxis. By far the most important means of avoiding malaria is the proper use of an efficient mosquito net. The oblong type is best, and it should contain sixteen meshes to the linear inch. Round the foot of it should be sewn a stout layer of calico 2 feet in depth. This will permit of a foot of the material being tucked under the mattress while the upper foot remains in the form of a belt or zone round the bed. It is necessary, because in its absence the sleeper is very liable to be bitten through the mosquito-net mesh, with which his arms or legs are apt to come in contact. Care must be taken to see that the net is kept in good repair—a most important matter—and in very malarious countries it is advisable to provide every member of an expedition, native or otherwise, with a good mosquito net. In what may be called the dry tropics, the top of the net may be of mesh; in the moist tropics, it is best made of calico in order to keep off the heavy dews. The traveller often sleeps out on the deck of river steamers, and then it is certainly advantageous to have the roof of the net composed of stout calico, as sparks from the funnel are very apt to alight upon it, and naturally holes will be burnt much more readily in mesh than in thick cotton. It is foolish to sleep even for one night in a malarious locality unprotected by a net.

The net is for use during the period of sleep, but one is very apt to be bitten by infected mosquitoes just after sunset, and hence it is well to make use of some form of mosquito canopy. A good type is the so-called mosquito umbrella tent. Such a canopy may be arranged so that the evening meal can be taken in it. One servant will be inside the canopy and receive the dishes through a guarded opening from the attendant outside.

Other methods of protection exist in the shape of mosquito boots or buskins. The best type of mosquito boot is the form which reaches right up the thigh. They may be made of untanned leather or of stout khaki cloth. All mosquito boots and buskins should be provided with soles to protect the feet from wet and damp. In the absence of boots it is well to know that a mosquito will not bite through two pairs of stockings, one super-imposed over the other. This is a way in which women can protect their legs and ankles, or they can employ the buskin, leggings, gaiters, or puttees.

Mosquito veils have been mentioned, the best type being the “Mosquinette” hood.

Mosquitoes are apt to bite through chairs with cane seats or with perforated seats, and these should be guarded by a layer of brown paper, newspaper, or a cushion.

Repellent substances may be used, smeared on the skin. They contain essential oils, such as oil of cassia or eucalyptus oil. These repellents are effective only for a short time, but lessen in some degree the liability to infection.

The prophylactic use of quinine has recently fallen somewhat into disrepute, owing to its comparative failure in many of the war areas, but there can be no doubt that under conditions of civil life it is a valuable auxiliary method, if properly employed. One of the troubles about it is that quinine is rapidly excreted from the body, and hence after a dose it remains in the blood only a comparatively short time; for example, if the dose be taken at 6 p.m. it is very doubtful if enough quinine will be left in the blood at 2 o’clock in the morning to kill any malarial spores which may be introduced into it by an infected mosquito. The ideal method of taking quinine prophylactically would be to take a dose of 5 or 6 grains with the evening meal shortly before sunset. This will protect until it is time to get under the mosquito net. If for any reason it is impossible to employ the latter, then a second dose of quinine should be taken at midnight. This is difficult to accomplish, and hence something may be gained by taking a larger dose of quinine at night on the chance that some of it may remain in the blood for a longer period than would the smaller quantity. As much as 10 grains may therefore be taken under these conditions. Some persons, however, cannot stand 10 grains of quinine daily for a long period of time.

It is clear from what has been said that prophylactic quinine should never be taken in the morning, and also that it is merely an auxiliary method, and does not do away with the necessity of using the mosquito net. Sugar-coated tablets should be avoided, and care must be taken to see that the products or tablets which may be used are readily soluble. It is a good plan to crack the products before swallowing them. A good salt of quinine is the bisulphate, which is soluble and comparatively cheap. When the drug is given in powder, tablet, or pill form, it should be followed by a wine-glassful of water, and it is advisable to acidify the latter by a few drops of hydrochloric acid. There is no doubt that as a general rule quinine is best taken in solution, but in the case of persons travelling about this is not always easy to arrange, and if the above precautions be taken the solid form will generally be found effective. It is better to take prophylactic quinine in daily doses, because if an interval is allowed to elapse between doses one is apt to forget to take the drug at the proper time. Hence it is well to make it a kind of ritual to take the quinine along with the evening meal, for it is certainly an advantage to do so on a full stomach. It should be remembered that persons who take their quinine regularly do not suffer from blackwater fever, while the irregular taking of quinine certainly appears to favour the occurrence of the latter. It is better not to take prophylactic quinine at all than to take it in a haphazard and irregular manner.

Treatment.—The three great principles of treatment are: (1) To open the bowels; (2) to produce perspiration; (3) to give quinine. The routine to be adopted is as follows. Put the patient to bed in flannel pyjamas, and covered up well with blankets; in all cases, save where there is diarrhœa, give an aperient, such as four grains of calomel, or two tabloids of Cathartic Co, or two Livingstone’s Rousers, and if this does not act, repeat the dose in about four hours. If free evacuation is not produced, a warm-water enema should be given. A hot-water bottle in bed is useful. Sponging with warm water often gives relief at the beginning of a fever, and tends to shorten the cold stage. At the same time hot drinks should be given, such as weak tea, in order to promote perspiration and cut short the hot stage, and at this stage, i.e., at the outset of the fever, 10 grains of Antipyrin, or 10 grains of Phenacetin, may be found useful for inducing perspiration, or four tablets of Warburg’s Tincture, which contains some quinine, may be substituted for them. Antipyrin and Phenacetin should not be given except in the earliest stages of the fever.

During the hot stage cold applications, such as cloths wrung out of cold or iced water and sprinkled with eau de cologne, vinegar or spirit may be applied to the forehead and behind the ears. The bed-clothes should be lightened and drink freely supplied, unless it seems to promote vomiting. If the temperature shows signs of getting above 105° F. sponge the patient with warm water or cradle the bed-clothes, as it is called—that is, remove them from contact with the body by some simple means. In the sweating stage strip off the soaked pyjamas and sheets and get the patient into warm, well-aired night-clothes and bed-clothes. If there is any tendency to collapse a little stimulant may be given—say, a dessertspoonful of brandy. In most cases alcohol is better avoided. If vomiting is bad withhold all food, and give bits of ice to suck if it can be obtained.

Whilst the above methods of treatment are important, it should be clearly recognised that the one drug which can alone counteract the malarial affection is quinine, and it is upon the proper administration of quinine that successful treatment largely depends.

This proper administration necessitates at the outset rest in bed, and it also necessitates a continuance of the drug for a sufficient length of time. For ordinary cases the best way is to give quinine by the mouth, and here again it is best given in solution, though it can be administered in solid form if the precautions above indicated are duly observed. Various doses have been advocated, but probably the best quantity to administer is 30 grains every twenty-four hours. This is usually given in three doses of 10 grains each, but there would appear to be an advantage in giving four doses instead of three, and Colonel James advocates the following times for administration, i.e. 12 midnight, 6 a.m., 12 noon, 6 p.m. He does so, because such a method of administration is likely to ensure that there shall be a sufficient concentration of quinine in the blood at the time when the youngest forms of the parasite are present. The patient should remain in bed, if possible, for ten days, or, if this is impossible, for at least half that period; and it is essential that the quinine should be given as soon as possible, and quite irrespective of the stage of the attack or the height of the fever. If its administration is followed by vomiting, give a small teaspoonful of bicarbonate of soda in warm water. If this is rejected repeat the dose, and then give some form of stomach sedative, such as bismuth, and dilute hydrocyanic acid or 20 drops of chlorodyne. A mustard leaf applied to the pit of the stomach is often helpful. Sometimes drop doses of tincture of iodine, well diluted, will check these troublesome symptoms. Under ordinary conditions this 30-grain quinine treatment should be steadily continued for at least five days, but in troublesome cases it may be necessary to carry on with it for as long as three weeks. Thereafter what is called the “after treatment” is begun and must be continued for a period of three months, in order to ensure, if possible, an eradication of the infection.

There are several ways of carrying out this after treatment, but one of the simplest and most effective is to administer 10 grains of quinine every day, the dose being taken an hour or two before the time at which the fever was apt to come on during the attack.

If, despite quinine treatment, relapses occur, the patient must go to bed and be treated as for the first attack, and the after treatment must again be carefully carried out.

Under certain conditions quinine has to be injected by the needle, either into the muscles or into a vein; but, as a rule, this should not be done save by the medical attendant. It should, however, be remembered that the drug may be given by the bowel, in which case twice the quantity of quinine which would be administered by the mouth should be given. It is only exceptionally that this procedure will have to be followed, but it is sometimes useful in the case of children.

The feeding of the malaria patient is important. Between the attacks of fever, or during the sweating stage, he should be given food in fluid form, such as chicken broth, eggs beaten up with milk, raisin tea, etc.; and as soon as his stomach will stand it, the diet should be increased. Tonics, such as iron and arsenic, are required during convalescence.

In cases where there is acute malarial poisoning, with temperature 106° F., or even higher, do not wait to undress the patient or get a bath; but empty gallons of water over him, one boy keeping the head constantly soused; while this is being done a bath can be procured and the patient then undressed, or, better still, have his clothes cut off, because it is dangerous to lift such a patient about too much. Remember that when a patient is very ill and weak, he should not be allowed to stand or sit up suddenly, as he may faint.

Delirium with high temperature, say 106° F. or over, is a certain sign that the fever is doing harm, and must be reduced.

The temperature and pulse should be carefully watched when the cold water treatment is employed.

Malta Fever. (See Undulant Fever.)

Measles.

Incubation period, ten days. Rash occurs on the fourth day.

Rash.—Pink spots, round or irregular, slightly raised above the surface, tending to run together in patches over the body, leaving the unaffected skin between them clear. In the early stages often best marked on the face and behind the ears.

Symptoms.—Fever, catarrh, congested eyes, running from the nose, sickness and cough.

Treatment.—Similar to that of scarlet fever (see [p. 222]). It is very important to guard against chill; to ensure plenty of fresh air.

Complications.—Measles may be followed by pneumonia.

Mumps.

This is an infectious disease, characterised by swelling of the salivary glands. Its chief importance to the traveller is that if once it makes its appearance it may spread rapidly through his native attendants, and that it is apt to be followed by inflammation of the testicle.

Symptoms.—The invasion is accompanied by fever, which is usually slight, but is sometimes severe. There is pain just below the ear on one side, followed by a swelling which gradually increases, causing great enlargement of the neck and side of the cheek. In a day or two the other side of the face is usually affected, and sometimes the condition spreads under the lower jaw. It persists from seven to ten days, then gradually subsides. Inflammation of the testicle may be troublesome. It is usually one-sided.

Treatment.—Rest in bed during the height of the disease. Get the bowels freely open and keep the patient on a light diet. No medicine is required unless the fever is high. Either cold or hot applications may be made to the swelling. If the testicle is involved it should be treated by rest and protection with cotton wool.

Myiasis.

This is the name applied to the condition in which the larvæ of flies are found parasitic in the body. It may be cutaneous, nasal or intestinal. The last named is not of great importance. Different species of flies may be concerned; thus in Africa, one of the best known flies producing this condition is called on the West Coast the Tumbu fly. The fly itself is about the size of a small blue-bottle, and is yellowish-grey in colour. It has a fat white larva, which burrows under the skin and produces a small boil or wheal, in the centre of which there is an opening which, unless blocked up by discharge, looks black owing to the presence of excrement from the posterior end of the larva. The skin round the hole becomes inflamed and very itchy. The commonest site is the forearm, but in Europeans various parts of the body may be attacked.

Treatment.—When small the larvæ can easily be squeezed out. They are, however, best extracted with forceps, and this is more readily done if a little chloroform is injected into the maggot before it is removed. Apply local sedatives, such as lead and opium and, after removal of the maggot, paint the skin with iodine. Indeed, if there is some delay in getting the maggot removed, it is well to apply tincture of iodine to the skin to prevent the occurrence of suppuration.

In Central and South America we meet with the so-called Ver macaque, which is the larva of another species of fly, and which gets under the skin in much the same way as does that of the Tumbu fly. It causes a great deal of pain, especially when it is moving about. It should be treated on the same lines as above.

The Screw-worm is also met with in America, and is the maggot of a fly which lays its eggs on the surface of wounds and in the ears and nose of persons sleeping in the open air. The maggots burrow into the tissues and may bring about a very serious condition if not detected at an early date and removed.

Treatment.—Injections of chloroform are one of the best ways of getting rid of maggots in the ear or nose, but medical attention is required. Wounds should be protected and kept clean. If infected they may be treated with turpentine, a painful but effective method.

Ophthalmia, Simple.

Simple ophthalmia, conjunctivitis, or inflammation of the membrane covering the eye and the inner side of the eyelids, is usually due to cold or dust.

Symptoms.—The affected eye is bloodshot and painful, waters freely, and cannot bear a bright light; there is a feeling of grittiness, as if the trouble were due to something between the eye and eyelid.

Treatment.—The eye should be carefully washed, the eyelids being opened and clean, cold water allowed to run over them and over the eye; any particles of dust must be removed—for this purpose a small clean camel-hair brush will be found useful. A lotion should be made consisting of six grains of boric acid, or two grains of sulphate of zinc, to an ounce of water, and ten drops or more of this should be dropped on to the eyeball six or eight times a day. To prevent the lids sticking together during the night, they should be smeared with vaseline or a salve containing 4 grains of calomel to an ounce of vaseline. Sometimes hot fomentations give relief.

Ophthalmia, Purulent.

This is a more serious inflammation, and is caused by some poison, e.g., germs carried by flies, or by the fingers from unhealthy sores and discharges. It may also result from injury, such as a septic wound.

Symptoms.—The symptoms of simple ophthalmia are present, but are all intensified, the eyelids are swollen and the eyeballs red, there is a discharge of yellow matter or pus, and the patient feels ill. There is great danger of the affected eye infecting the sound one, therefore warn the patient not to touch the sound eye for fear of infecting it. There is also great danger lest the attendant’s own eyes should become infected.

Treatment.—The patient should be kept in bed and the eyes should be shielded from bright light. Protect the sound eye (especially when the affected one is being washed) by placing a pad of wool or lint over it, kept in its place by strips of strapping so as effectually to close the eye and prevent infection. Thoroughly wash out the space between the eyelids and the eye, and remove any matter or foreign body which may be found.

When the inflamed surfaces are clean, wash them very thoroughly with a solution of corrosive sublimate, 1 in 5000, and finally smear a little vaseline along the edges of the lids, to prevent them sticking together. This treatment must be repeated as frequently as possible. Once a day the inflamed surfaces may be brushed over with a solution of nitrate of silver, 10 grains to the ounce, applied with a camel’s-hair brush, followed immediately by the application of a few drops of common salt solution.

Hot fomentations may give relief. When this is so, the eye should be kept covered with a pad of moist lint, which must be changed frequently. Benefit has followed the administration of very large doses of salicylate of soda.

Piles.

Piles are very common in the tropics, and are often due to want of exercise, chronic constipation, dysentery, too free use of alcohol, and over-eating. No one who suffers from piles should become a traveller till skilled advice has been obtained.

Internal Piles, though not usually painful, are by their frequent bleeding a cause of anæmia and debility; they lie inside the orifice of the bowel, but sometimes they come down on straining, and are then nipped by the muscle surrounding the opening, and may swell up, become very painful, and bleed profusely.

Treatment.—Keep the bowels freely but gently opened by taking cascara regularly; if the piles come down they should be returned, and an ointment of galls and opium or an injection of hazeline (one tablespoonful mixed with seven of water) used. Tannin, five grains to the ounce, or sulphate of iron, three to five grains to the ounce, may be used instead of hazeline. Hazeline suppositories are often of great use for internal piles, but ordinary suppositories do not keep well in very hot countries; if they are taken to the tropics they should therefore be specially made and packed. If the piles bleed profusely or cause great pain, an operation will be necessary.

External piles do not bleed, but from time to time they become inflamed and swollen, causing great agony.

Treatment.—The bowels should be kept well opened; the sufferer should lie with his hips raised; hot fomentations should be frequently applied, and the piles should be well greased. Glycerine of belladonna, smeared on a pad of lint, is a valuable application, as is dry calomel powder.

Some sedative, such as Dover’s powder, may be necessary to procure rest and sleep.

Plague.

There are two chief varieties of plague, the bubonic and the pneumonic.

Causes.—Bubonic plague, which is due to a small vegetable organism, the Bacillus pestis, exists primarily as a disease in rats and other rodents, such as the Manchurian marmot and the Californian brown squirrel, and is transmitted from these animals to man by means of the flea. It is the rat flea that is chiefly concerned in the spread of plague. Both the brown and the black rat are affected and, speaking generally, the black rat is the more dangerous, as it lives in closer association with man. It is now known that certain forms of merchandise, especially grain and, to a lesser extent, raw cotton, are more to be dreaded as vehicles of the bubonic plague infection than the infected human being.

The flea does not inoculate the bacillus by its bite. It sucks up blood containing plague bacilli. The latter multiply in the insect to such an extent that they block the entrance of the flea’s stomach and prevent it from feeding. The starved flea makes violent efforts to obtain more blood and, as a result, the contents of its gullet are discharged, together with the plague bacilli, upon the skin of the healthy person on whom it is trying to feed. If there is any little wound in this skin the bacilli gain an entrance and they set up the disease. Infection may also occur from the bacilli-containing excreta of the flea being voided on the skin and rubbed into wounds. When rats become ill or die the fleas leave them and attack man. It should be noted that the rat flea may remain infective for 43 days.

Pneumonic plague, although due to the same bacillus, is quite a different kind of disease, and is transmitted from the sick to the sound by droplets of sputum expelled in coughing, and probably also by the invisible spray which pneumonia patients discharge from the mouth. When the disease is epidemic domestic animals may suffer from it and become sources of infection.

Symptoms.—Both forms of plague are characterised by sudden onset, sharp fever, giddiness, great weakness, a drunken gait, appearance and speech, and a tendency to heart failure.

In bubonic plague there is lassitude, headache and shivering, and the face is pale and anxious. The patient looks haggard, his eyes are often bloodshot, and his expression is frequently one of fear or horror. His temperature runs up to 102°, 104° F., or even higher, and his face gets hot and flushed. There is intense thirst, the tongue becomes dry and brown, the urine is scanty, and there may be delirium. About the second or third day the glandular swellings known as buboes make their appearance, usually in the groin, but they may occur in the armpits, the neck, and elsewhere. As a rule there is only one bubo, which varies in size. There may be a good deal of pain associated with the swelling, and sometimes it is very severe. The bubo, if not dealt with surgically, eventually softens and bursts, discharging matter and sloughs. In cases which are going to recover, improvement is noted about the fourth or fifth day, and is heralded by a profuse perspiration. In fatal cases, death usually takes place between the third and fifth days.

Pneumonic plague usually begins with shivering and vomiting. There is a cough, accompanied by breathlessness and blueness of the face, the sputum is profuse, watery and blood-stained, and as it is full of plague bacilli it is exceedingly dangerous. Very few cases of pneumonic plague recover.

Prophylaxis.—Ward off attacks of fleas. A substance called pesterine is good for this purpose, and consists of kerosene 20 parts, soft soap 1 part, and water 5 parts. Powdered naphthalene and tricresol powder are useful. Attendants on plague patients should be protected from infection. They should wear puttees or gum-boots, gloves, and overalls, and those looking after pneumonic cases must wear masks, goggles, and overalls. There is a protective vaccine for plague, and those travelling in districts where plague is epidemic should avail themselves of its protective power.

Treatment.—The only treatment which is of any value, and this only in bubonic plague and when given early, is the administration of plague anti-toxin, which should only be given by a medical man. The symptoms should be treated in order to relieve the patient’s distress. Belladonna and glycerine may be applied to the buboes, and they should be opened and carefully dressed once suppuration is established. Morphia is often required for the restlessness and insomnia, and cardiac stimulants are indicated in nearly every case.

Pleurisy, or Inflammation of the Membrane Covering the Lung.

This is more a disease of cold climates, and is usually the result of chill following severe exertion.

Symptoms.—Pleurisy is accompanied by less fever and general sickness than pneumonia; its characteristic symptom is the “stitch in the side”, which always accompanies it. There is also a short, dry cough, without expectoration, which the patient tries to restrain, as it “catches” in the side, and causes acute pain. For the same reason the breathing is shallow, as any attempt to draw a deep breath causes extreme suffering.

Treatment.—The patient suffers greatly, therefore in the early stages treatment must be directed to the pain. If leeches are procurable, the application of half-a-dozen to the painful region of the chest is advisable. Mustard leaves or poultices should be applied over the part, or it may be painted with tincture of iodine; opium may be given to relieve the acute pain, in the form of Dover’s powder, fifteen grains three times a day. Five grains of quinine may be given twice a day.

Pneumonia, or Inflammation of the Lungs.

It has been definitely proved that the black races are specially susceptible to the organism which is the cause of pneumonia, and it is a frequent source of invaliding amongst the native attendants of travellers in Africa and elsewhere.

Causes.—As predisposing factors may be noted change of climate, chill, insanitary conditions of life, fatigue, and overwork. Malaria, syphilis, alcoholism, and excessive tobacco-smoking also play a part. The disease is believed to be spread by personal contact, but this has not been definitely established.

Symptoms.—These usually begin with a severe attack of shivering; the temperature rises rapidly, the pulse and breathing are greatly quickened, and the patient is completely prostrated. The face is flushed, the skin feels hot and dry, and there is a short cough, dry at first, but afterwards accompanied by expectoration of a moderate quantity of slimy, rust-coloured, blood-stained, and almost frothless matter. Usually there is pain on the affected side, which in most eases is the right side of the chest, above the liver. In African natives heart failure is very common.

Prophylaxis.—In order to prevent the occurrence of pneumonia amongst native followers good food should be provided, properly cooked; and it is important to see that they are supplied with sufficient blankets at night if travelling through cold regions. If it can possibly be avoided natives from hot, humid localities should not be taken to chilly, elevated and wind-swept places, as under such conditions they are very apt to contract pneumonia. Overcrowding in huts or tents should be avoided, and any sore throats which develop should be promptly treated.

Treatment.—A patient attacked with pneumonia should take to bed at once. The affected side should be surrounded with a large poultice. Five grains of quinine should be given every eight hours. If the heart’s action is weak, give some preparation of ammonia, as a stimulant, and administer alcohol, up to half an ounce, every two hours. Opium should only be given to calm the patient, as large doses do harm by checking free expectoration; if there is much distress, then ten or fifteen grains of Dover’s powder may be given.

An ice poultice applied to the chest will give great relief by lowering the temperature and diminishing the pain (see [page 274]).

Quinsy, or Inflammation of the Tonsils.

Apply poultices to the neck. Gargle with a hot, weak solution of permanganate of potash, or a solution of chinosol (1 in 2000), at least every hour. Administer quinine and iron as a tonic. Keep the bowels well open. Surgical aid is sometimes required in bad cases.

Relapsing Fever.

This is the old “famine fever,” and it occurs in various parts of the world.

Causes.—It is due to a corkscrew-shaped blood parasite, which is conveyed from the sick to the healthy by means of lice. Some hold that certain forms of this fever in Palestine, Cilicia, and Persia are transmitted by means of the common fowl tick, which often harbours in the cracks in native bedsteads and in crevices in the walls of huts and other dwelling places.

The true tick fever of Africa, which is also a relapsing fever, is considered separately. (See Tick Fever, [p. 241].)

Symptoms.—These differ a little in different parts of the world. The incubation period is usually from five to ten days. The onset is remarkably sudden. The patient has a chill or shivering fit, becomes giddy, develops a bad frontal headache, feels as if he had been beaten all over, and frequently vomits. He has often a difficulty in walking, and soon becomes seriously ill. Delirium is not infrequent. The tongue, unlike that in typhus fever, remains moist throughout the illness. Thirst, restlessness, and vomiting are very characteristic of the condition, and the urine is scanty. As a general rule recovery takes place, but sometimes the patient grows gradually worse and dies. As a rule, however, the temperature falls very suddenly, and the patient is better. After a week or so a relapse occurs. The temperature again shoots up, and remains up for several days. Then there is a second crisis, another relapse, and so on for perhaps three or four times. Most cases recover, and once convalescence is established the patient soon gets well.

Prophylaxis.—The disease being lice-borne, it is necessary to take all steps to prevent contact with these insects (see Lice, [p. 196]). The organism has been shown to be capable of passing through intact mucous membranes and unbroken skin. Hence it is advisable to be careful when attending a case, for the organism has been found in sweat and tears, while the patient’s blood is, of course, infectious.

Treatment.—Careful nursing and a light diet. Attend to the state of the mouth and of the bowels. The arsenic preparation, known as salvarsan (kharsivan), is a specific remedy, and can cut the disease short; but it can be administered only by a medical man. Otherwise there is no treatment save the symptomatic.

Rheumatism.

This is a disease which frequently follows exposure to damp and cold, and is on that account not uncommon in the tropics. It is often hereditary. After one attack, rheumatism is always liable to recur in the same individual, and on this account it is necessary that persons liable to the disease should use special precautions.

Acute rheumatism or Rheumatic Fever.—This is really an infectious disease due to a specific organism, and is quite different from the ordinary rheumatism of everyday life.

Symptoms.—It begins by a shivering fit, with rise of temperature and general sickness, and the joints, usually wrists, ankles, or knees, become painful, tender, and afterwards swollen. It resembles other feverish conditions in the rapid pulse and breathing, the constipation, scanty and high-coloured urine, etc., but it differs from most of them in the presence of a profuse and sour-smelling perspiration, resembling the odour of butter-milk.

Treatment.—The best remedy for acute rheumatism is salicylate of soda, of which fifteen grains should be given every six hours. The joints should, at the same time, be kept wrapped up in cotton wool, covered with oiled silk and a flannel bandage. This treatment will nearly always correct the acute symptoms in two or three days. If the symptoms subside sooner, the quantity of the salicylate should be diminished; if there is delirium, the dose must be lessened at once, for many people are very susceptible to salicylates and are easily affected by them, the delirium being characteristic. Dover’s powder may be given to relieve pain and to secure sleep.

Chronic rheumatism.—In this disease there is chronic pain and tenderness of the joints, without fever.

Treatment.—Bicarbonate of potash and salicylate of soda, each in five-grain doses, should be given every eight hours. Painful joints may be painted with tincture of iodine, rubbed with turpentine liniment, or bathed with hot water. The bowels should be kept well open, and alcohol and much meat avoided.

Rupture or Hernia.

A rupture or hernia is a protrusion of some portion of the bowels under the skin, and is usually found in the groin. It is generally reducible, i.e., it can be pushed back into the belly. It reappears when the pressure is removed, especially if the patient coughs or strains. When reduced, a properly-fitting truss should be applied and worn during the day. It can be taken off at night, after lying down, but should be re-adjusted in the morning, whilst the patient is still in bed. No patient should go abroad without having an operation for the cure of the hernia.

The great danger of any rupture is that it may become irreducible—a condition which is very likely to be followed by constriction or “strangulation” and subsequent death of the ruptured part of the bowel. If unrelieved, this constricted condition is always fatal. The existence of strangulation is known by local pain and tenderness, development of severe colicky pains in the belly (especially about the navel), absolute constipation, vomiting, hiccough, and symptoms of collapse. When this condition is observed, the patient’s hips should be raised by supporting them with pillows, and the tumour should be only very gently kneaded with the view of getting back the protruded bowel. The treatment is considerably aided by immersing the patient in a warm bath, and giving about twenty drops of laudanum or chlorodyne. Ice placed round the swelling for half an hour or so is often very effective. If these means fail, surgical aid is absolutely necessary. Purgatives should not be given.

Sand-Fly Fever.

This disease, also known as phlebotomus fever, is very widespread and probably occurs in most parts of the world where sand-flies are found.

Cause.—The organism is unknown, presumably being too small to be seen by the highest powers of the microscope, but it is known to be transmitted by what are called sand-flies or pappataci flies, tiny and very hairy midges which breed in such places as heaps of damp stones, bricks, and tiles, cracks in surface soil, the walls of old cellars, cracks and fissures in embankments. These little flies, which sally forth upon the blood quest towards evening, are voracious blood-suckers, and feed principally in the gloaming and at dawn. They chiefly attack the wrists and ankles, and can easily bite through thin socks or light cotton or linen clothing. It has been proved that the bite of one infected fly can convey fever. During the day they hide in dark places, and may be found in the dark corners of rooms. Their bites are painful, and when numerous the bitten part may swell badly. An attack by many flies effectually banishes sleep.

Symptoms.—The fever is short and sharp—indeed, it is often called the three-day fever. The incubation period is four to seven days, and the attack is sudden, beginning with chilly sensations and a tired feeling. There may be rigors, but these are never so severe as the shivering fits of malaria. The patient becomes giddy, has a severe frontal headache with pain at the back of the eyes and pains in the back and legs. The condition, indeed, is very like an influenzal attack except that there is, as a rule, no coryza. The face is flushed and the eyes may be injected. When the latter is the case one can understand how the disease was originally given the name of the “dog disease,” as the appearance of the injected conjunctivæ resembles that sometimes seen in mastiffs and bloodhounds. There may be some sore throat, and sometimes there is a little eruption on the throat or palate. The temperature rises rapidly and may attain 103° F. It remains up for about twenty-four hours and then begins to fall, usually becoming normal on the third or fourth day. Sometimes there is a secondary rise of temperature. The patient may speedily recover or convalescence may be tedious, and the condition is sometimes followed by mental depression and the digestion may be upset. The fever is apparently never fatal but it is troublesome and debilitating.

Prophylaxis.—Protect from the bites of sand-flies. This is best done by the use of a fine-mesh net containing twenty-two holes to the linear inch. It should be of the same general pattern as the net recommended under malaria (see [p. 206]). Tobacco smoke keeps the flies away to some extent and repellents are useful, especially vermijelli, containing some oil of citronella, the preparation known as Sketofax, oil of cassia and oil of eucalyptus. A lump of camphor as a bed-fellow is also useful as the flies dislike its odour. The patient should always be placed under a fine-mesh net to prevent his being a source of infection to others.

Treatment.—Rest in bed, light diet, and one full dose of laudanum, i.e., thirty drops, given as early as possible. Chlorodyne in the same dose may also be used. Quinine is useless and may aggravate the symptoms, but aspirin and the salicylates are helpful. If there is much pain in the muscles the application of hot sand-bags may afford relief.

Scarlet Fever, or Scarlatina.

This fever is very uncommon in hot climates.

Incubation period, three to eight days. Rash appears second day.

Symptoms.—The rash consists of numerous minute red spots, evenly distributed all over the surface of the body, upon a general rose-red blush. The area immediately surrounding the mouth is not affected. Shivering fits, sickness, high temperature, sore throat, headache, pains in the back. The sickness is very characteristic in children. After the rash has subsided, peeling of the skin takes place, beginning on the face as a very fine powdery deposit. The process then spreads to other parts of the body, the last places to peel being the palms of the hands, the soles of the feet, and between the fingers and toes. The peeling process takes from four to six weeks, and the patient is infectious during the whole of this period.

Treatment.—Isolation. Bed in an airy room. Light food. If the fever is high (104° F.), the body may be sponged with tepid water. If the throat is very inflamed, an antiseptic gargle should be used. As the course of infectious fevers cannot be cut short, the chief aim of treatment should be to avert complications and the return of distressing symptoms—over-treatment with drugs must be guarded against.

To prevent the spread of infection from the peeling surface, the body should be rubbed over with boracic ointment, or carbolic or olive oil.

Complications.—As scarlet fever may be followed by heart, kidney, or ear trouble, the patient should not be allowed to get up until at least ten days after the temperature has become normal.

Scorpion Sting and Spider Bite.

Scorpion sting is not infrequent in hot countries, but is very rarely fatal in the case of the adult European unless several stings have been received at one time.

Symptoms.—The usual symptoms in the adult are a brawny swelling in the region of the sting and more or less collapse. There is often severe pain of a throbbing nature, and there may be sickness and vomiting.

Treatment.—Apply a tourniquet above the sting and incise the affected area; then apply an opium lotion. This is usually sufficient to afford relief and prevent extension of the swelling. A serum suitable for use in Egypt and the Sudan only, has been prepared for treating scorpion stings, and when it is available it should be used as soon as possible, as very favourable results have been reported from its employment. It can be obtained in Cairo or in this country from Messrs. Allen and Hanbury.

Spider bite is not so important as scorpion sting, though poisonous spiders do exist in various parts of the world and belong to a genus found in Southern Europe, New Zealand, and various parts of North and South America. Many of these poisonous spiders are brightly coloured, their abdomens being spotted with vermilion. In Peru there is a so-called “pruning-spider,” which belongs to another genus and is also poisonous.

Symptoms.—Locally a reddish papule appears, and there is sharp stinging pain. The papule is followed by a spreading inflammation which sometimes goes on to gangrene, though this is rare. The general symptoms are those of nervous exhaustion and there is high fever, rapid pulse, rapid breathing, and sometimes blood in the urine.

Treatment.—Apply a ligature and suck the wound. Use permanganate of potash locally as in the case of snake-bite. The permanganate should also be given internally, one-quarter to one per cent. solution being given every hour or every two hours. Diffusible stimulants such as ammonia, caffeine, or camphor are useful as diuretics. A strict milk diet should be enforced during treatment.

Scurvy.

This is one of the deficiency diseases. This is not to say that mere general starvation will produce it, but that it is due to the lack of certain substances in the diet. These substances are known to exist in fresh fruit and vegetables, and also to a lesser extent in fresh meat and raw milk, but their exact nature has not yet been determined. Travellers should remember that, apart from the actual disease, there is a scorbutic state in which the symptoms are indefinite, and which, if not recognized and promptly treated, will pass on to true scurvy.

Symptoms.—Scurvy begins insidiously with progressive weakness, pallor, loss of weight, and stiffness in the leg muscles. Later the gums become affected, soft swellings sprouting up between the teeth. As the disease progresses the gums become swollen and spongy, ulcerate and bleed, while in bad cases the mouth becomes very offensive and contains large fungating masses. Other signs of scurvy are hæmorrhages under the skin and mucous membrane and in the muscles. Any injury is apt to be followed by hæmorrhage. Swelling of the legs is an important symptom, especially in the region of the ankles. If untreated, the condition becomes worse, the appetite is impaired, mental depression sets in, there is breathlessness on exertion, and night and day blindness. Death results from heart failure or some complication.

Prophylaxis.—Ensure a good dietary containing sufficient anti-scorbutic elements. Wherever possible, fresh meat, fresh vegetables, and fresh fruit should be supplied. Lemon juice is valuable. It should be noted that it is four times as efficient as the lime juice which used formerly to be employed. The ration should be one ounce daily served with sugar. Germinating peas, beans, and other pulses contain the anti-scorbutic elements in large quantity. It is a simple matter to carry a supply of these pulses and to germinate them when required. The dry seeds must be whole, retaining their original seed-coat. In order to make them germinate they are placed in a clean sack and steeped in a vessel containing clean water, which should be occasionally stirred. Sack and trough should be large enough to allow for the swelling of the pulses to about three times their original size. In a hot climate six to twelve hours is sufficient for this soaking. Thereafter, lift the seeds out of the water and spread them out to a depth not exceeding two or three inches in some vessel which allows free access of air to them. Keep them moist by covering with sacking, which is wetted at intervals. The germination should reach the stage necessary within twenty-four hours in a hot climate, and the pulses should be cooked and eaten as soon as possible after germination. Care should be taken not to overcook them. At a pinch germination may be effected by placing the seeds between wet blankets, but this is a rough-and-ready method not to be recommended.

It is important to attend to oral hygiene, especially the regular use of the tooth-brush. Vegetables should never be overcooked. In the case of African native followers Kaffir beer made from germinated grain is of great value; one pint should be given daily per head. Potatoes and root vegetables are useful, and the onion is a valuable food in this connexion. Fresh meat is not so effective as either fresh fruit or vegetables.

Treatment.—This is chiefly dietetic, and the same foods and substances as are mentioned under prophylaxis are used also for the cure of scurvy. In addition, scurvy patients should be kept in bed, given plenty of fresh air, and have the affected parts massaged. Tonics and mouth-washes are indicated, and a liberal diet with plenty of fat in it should be provided. Where fresh fruit cannot be obtained raw meat and raw fresh eggs in milk form a good substitute.

Sea-Sickness.

Take a saline aperient on the day before embarking, and a light plain meal at least three hours before going on board. A cup of good tea or black coffee soon after starting is often of use.

Those liable to sea-sickness should go to bed directly they get on board: the head should be kept low and the room darkened. A mustard leaf applied to the pit of the stomach is of value in diminishing the tendency to vomit. An abdominal belt is useful from the gentle support it gives. A hot-water bottle may be applied to the feet.

A mixture containing fifteen grains of bromide of soda and five grains of antipyrine to one ounce of water is often of great value. The first dose should be given immediately the patient is in bed, and may be repeated every six hours if required.

Whitla states that the best of all remedies is bromide of ammonium. It should be given in twenty-grain doses for a day or two before embarking. Morphia may be found necessary: a third of a grain may be injected under the skin of adults, but it should on no account be given to children.

I have found that three or four drops of chloroform, dropped on to loaf sugar and sucked, often prevents vomiting.

Those who are vomiting severely should take plenty of hot water or milk, so as to prevent them from straining on an empty stomach.

Very often raisins or raisin tea can be taken when other nourishment is rejected. A recent method of treatment which has sometimes been found effective is to plug the ears firmly with cotton-wool, but this should only be done by a medical man. It is, however, worth trying.

Skin Diseases.

Boils.—Boils are very common in the tropics and occur especially in people who have been run down. They are most frequent during or after the rains and especially in the course of hot, damp summers. In Egypt the so-called Nile boil is quite a feature of the country. In the tropics boils are often multiple and a very favourite site is the buttocks. Any part, however, which is apt to be bathed in sweat is liable to infection. A boil on the face may apparently result from the bite of a mosquito or other blood-sucking insect.

Prophylaxis.—Protect from insect bites and treat even the most trivial of skin lesions with tincture of iodine. Keep the skin clean and change the underclothing frequently. If a boil occurs cover it with a small dressing so that other parts of the skin may not be affected. A change of climate is often the only thing that will do good in the case of a person afflicted with crops of boils.

Treatment.—It is sometimes possible to abort a boil by dipping a sharpened wooden match or a toothpick into pure carbolic acid and thrusting it repeatedly into the heart of the swelling. If the boil has somewhat developed hot fomentations and moist dressings should be applied and iodine should be painted on the skin round the boil. As a rule it is wiser not to open a boil, even when it has suppurated. It is best to let it burst and then to dress it carefully with a boric poultice, which should be frequently changed. Treatment with vaccines has come into vogue and is sometimes very helpful. Sulphide of calcium pills, one grain in each, three times a day, are often given and are said to have a prophylactic effect, but a preparation known as stannoxyl and used in the form of tablets is to be preferred. The usual dose is four tablets the first day, six the second, and eight on subsequent days. The drug is somewhat constipating. A remedy more easily obtained and which is said to be distinctly beneficial is dilute sulphuric acid. It should be taken in doses of twenty to thirty drops, well diluted, every four hours. The general health requires attention and lemon juice, plenty of green vegetables and tonics should be taken.

Carbuncles.—A carbuncle is of the same nature as a boil, but is a more serious complaint, and it is distinguished from a boil by the fact that it opens by several mouths.

To promote ripening of the carbuncle and the separation of the core or dead piece of tissue, poultices and hot fomentations should be freely applied, and if the core can be seen it should be removed, if possible, by a pair of forceps.

To facilitate removal of the core it is sometimes advisable to cut through the skin separating the openings; there may be some slight bleeding, but it will cease after a short time.

Opium may be given to relieve acute suffering. The bowels should be kept well open. A generous diet must be given; tonics of iron, quinine and arsenic are needed, and alcohol may prove necessary.

Carbuncles rarely appear except in people much broken down in health, and their presence is an indication that the sufferer should return to his own country and seek skilled advice.

Chigger.—The chigger is not itself a disease but is a sand-flea producing a condition known by the long name of dermatophiliasis. It is a veritable pest in parts of South America and all over tropical Africa. The insect is like the common flea but smaller, lives in dry sandy soil and sucks the blood of mammals, especially pigs. After impregnation the female burrows into the skin of a mammal or bird, and, nourished by blood, proceeds to ovulation. Her abdomen becomes filled with ripe eggs and enormously distended till it looks like a small pea. Eventually the eggs escape through the opening of the skin and hatch into larvæ which in due time become adult fleas.

Symptoms.—In man the feet are the part most frequently affected, the chiggers being found between the toes and under the toe nails. When people sleep on the ground other parts of the body may become affected and large numbers of chiggers may be present at one time. There is itching and irritation at the place of invasion, and when the latter is examined a little dark dot will be seen. This is the posterior end of the female flea, which is lying head downwards in her burrow. If not removed suppuration occurs round her distended abdomen and the skin gets much inflamed and swollen. When the eggs have been discharged ulceration takes place and the flea is expelled. A small sore, however, is left which is very liable to get contaminated, and, if neglected, may lead to very severe complications.

Prophylaxis.—Do not camp in the neighbourhood of native villages. Clean the camping ground thoroughly and, if necessary, fire it. As insecticides flaked naphthalene or a strong infusion of native tobacco are useful. The latter may be used inside boots or shoes. Walking bare-foot should be avoided, as should sleeping unprotected on the ground. In the case of native carriers or porters a daily foot-parade should be instituted. Some protection is afforded by smearing the feet, especially the spaces between and under the toes, with a preparation like phenofax or with a mixture of five drops of lysol or cresol and an ounce of vaseline.

Treatment.—It is usually better to get a native to remove a chigger as long practice makes them very expert in the little operation. The latter consists in widening the skin orifice with a sharp clean needle, and freeing the flea from the surrounding tissues in order to get it out whole. If it ruptures forceps must be employed, and this is much more painful and difficult than extracting the entire insect. The infected parts should be carefully treated antiseptically.

Fungus Diseases.—There is a great number of tropical diseases due to fungi but only a few can be considered here, and these only very briefly. (1) Dhobie Itch is one of the best known and is so called because it was thought to be derived from clothes infected by the persons (dhobies) who washed them. The parts usually attacked are the groins, the upper part of the thighs and the armpits. The condition is due to a fungus like that of ringworm and the skin becomes red and raised and somewhat scurfy. Dhobie itch causes great irritation and is sometimes associated with considerable pain.

Treatment.—Mild cases are best treated by using an ointment containing resorcin two drachms, salicylic acid ten grains, and vaseline and lanoline, of each four drachms. The parts may be painted with iodine but this is somewhat irritating. An ointment of ammoniated mercury, two to five per cent., is often effective. Bad cases require the application of araroba (chrysarobin) ointment, but it should not be used unless recommended by a doctor. Goulard water or Wright’s liquor carbonis detergens (one tablespoonful to two pints of water) are soothing applications.

(2) There is a fungus disease of the hairs, especially of the armpits and the pubis, which occurs in tropical climates and is often very troublesome. The hairs assume a coated, beaded or nodular appearance and the deposit on them varies in colour and may be black, yellow or red. The underclothing in contact with the affected parts becomes stained and when the disease spreads to the skin, as it often does, the latter becomes inflamed, thickened and painful.

Prophylaxis.—Keep the axillae shaved. It is always well to do so in a tropical climate. Failing this, dust with a mixture of powdered sulphur and fuller’s earth, equal parts. Change the underclothing frequently and bathe the parts liable to infection.

Treatment.—Apply twice daily a lotion containing one drachm of formalin in six ounces of rectified spirit, and at night rub in a two per cent. sulphur ointment. If these measures fail apply tincture of iodine, except in cases where the skin is involved. In such cases bathe with cold water and employ a dusting powder or a soothing lotion.

(3) Ringworm of the head is a disease due to a fungus. The part for some distance round the affected area should be shaved, and any stumps of hairs pulled out. The skin should be lightly painted with tincture of iodine or strong solution of carbolic acid (one in ten of water); or sulphur, white precipitate, or mercurial ointment may be gently rubbed in.

Kraw-Kraw.—This is a term commonly employed by natives of the West Coast of Africa to indicate almost any kind of itchy, papular, or pustular eruption. Many of these appear to be contagious, and most of them are best treated by opening up any pustules which may be present, removing crusts by boric poultices, and scraping ulcers. Then scrub thoroughly with sublimate lotion 1 in 1,000, dust with boric powder and apply a dressing of medicated vaseline. The application should not be disturbed for a week when, as a rule, the skin will be found to have healed up. Clothing and any other articles which have been in contact with the affected parts should be destroyed or thoroughly disinfected.

Prickly Heat.—This condition is very frequent, especially in the moist tropics. It is due to free sweating, and is accompanied by intense heat and itching. The parts closely covered by clothing are specially apt to be affected. The skin becomes covered with numerous slightly inflamed papules, set close together, and the eruption may remain for months at a time, varying in intensity according to circumstances.

Prophylaxis.—Avoid long drinks, warm clothing, too much exercise, and all conditions producing excessive perspiration. Sea-bathing should be avoided, and soap should not be used in the bath. One should sleep under as hygienic conditions as possible, with a well-ventilated bed and without unnecessary clothing. A dusting powder of equal parts of boric acid, oxide of zinc, and starch is useful.

Treatment.—Ryan strongly recommends the so-called “Sulphaqua” bath charge, which is sold in packets ready for use. The above-mentioned dusting powder is helpful, as is the application of a lotion containing salicylic acid and spirit. Some prefer oily applications. Whatever is used, care should be taken to see that the bowels are well opened at the beginning of an attack, preferably by a saline purge.

Ulcers.—Ulcers are often very troublesome to the traveller, as the healing process is frequently retarded by exposure, dirt and dust, and the chafing of clothes. Want of sufficient animal food greatly favours the spread of large ulcers.

A simple dressing of iodoform ointment, or ointment of boric acid, is effective when the ulcer can be protected, and rest can be given to the affected part. When the ulcer is deep and large it may be stimulated to heal by the application of lint or cotton-wool, moistened with carbolic oil, carbolic lotion, or other antiseptics.

Large, unhealthy ulcers should be well bathed with some antiseptic such as carbolic acid, one in sixty of water, or a solution of chinosol (1 in 600); and after the sore has been cleansed it may be lightly dusted with iodoform and then covered with a piece of lint moistened with carbolic oil or smeared with iodoform ointment and supported by an evenly applied bandage. Boric ointment, lano-creoline, izal ointment or other antiseptic dressing may take the place of iodoform ointment.

In addition to the above general account, certain conditions leading to ulceration require consideration.

Oriental Sore.—This condition is commonly known as Baghdad Boil, Aleppo Button, Frontier Sore, etc. It occurs in various hot countries, such as Egypt, Syria, Asia Minor, Arabia, and Mesopotamia, and has been met with in Europe and Greece. A special form affecting both skin and mucous membranes is widely distributed in South America.

Cause.—The cause is an organism to all appearance identical with that which produces leishmaniasis or kala-azar. Indeed, Oriental sore is a form of cutaneous leishmaniasis. In all probability infection is conveyed by sand-flies, but our knowledge is still defective on this point.

Symptoms.—The incubation period varies from a fortnight to a year. The sore may occur on any exposed part of the body, but is most common on the forearm, hands, and face. Multiple sores are frequent. The first sign is a small red, scaly papule, which increases in size and eventually breaks down, forming a painless ulcer, with a hard, dry edge. Non-ulcerating forms occur, but are not common. The condition is very chronic, but healing usually sets in after six to twelve months. When the ulcer heals a white or pink scar is left, which is disfiguring.

Prophylaxis.—Sleep under a sand-fly net, containing 22 holes to the linear inch. Warn against the danger of infection by personal contact and the risk of re-infecting oneself by scratching. It is advisable to paint the sites of all fly and insect bites with iodine as soon as possible.

Treatment.—The best treatment at present known is intravenous injection of tartar emetic. This, of course, can be carried out only by a medical man. Good results have, however, been obtained by applying a 2 per cent. ointment of tartarate of antimony, and this method can be carried out by the patient himself. Local injections of emetine have been recommended, and there are various other ways of treating Oriental sore, but they need not be here considered.

Tropical Ulcer.—This is a special and serious form of ulcer found in all parts of the world, and especially amongst East African natives. It is found chiefly in the lower third of the leg and in the region of the foot and ankle.

Cause.—This is somewhat obscure, but it is believed to be due to certain organisms possibly acting in association with one another.

Symptoms.—The condition starts as a small, tender, and often itchy papular bleb, surrounded by a dense inflammatory zone. An ulcer results, which is more or less painless, and one of the characteristics of which is the way it spreads and destroys all the tissues with which it comes in contact. It is often mistaken for a syphilitic ulcer, but it does not usually yield to anti-syphilitic remedies.

Treatment.—The best remedy would appear to be formalin, though the iodoform ointment mentioned under ulcers may aid the condition. It can be effectually treated only by a medical man.

Veldt Sore.—This condition, which is also known as Barcoo Rot, is frequently in evidence in countries with hot, dry climates, as, for example, Egypt, Palestine, South Africa, Mesopotamia, etc.

Cause.—It is due to certain bacteriological organisms, and is apt to occur in persons who are debilitated, who are not receiving proper food, or who are living under conditions where it is not easy to keep clean. Some think the sores are commonest in men who have to deal with horses.

Symptoms.—Veldt sores are most common on the hands and forearms. They begin as itchy papules, which become blebs, then pustules, and finally ulcers. They are usually multiple, and when they heal they leave areas of thin, glossy skin.

Prophylaxis.—As for boils.

Treatment.—The spread of ulcers can be checked by removing the hairs from their bases and round their margins. Very often the ulcer can be started on its healing process by employing dressings soaked in a solution of 1.5 per cent. sodium citrate and 20 per cent. common salt. Vaccines are often successfully used in this condition, and the stannoxyl mentioned under boils may be employed, as may a salicylic acid ointment, 20 grains to the ounce.

Sleeping Sickness.

This is the old “Negro lethargy,” and must not be confounded with what is now called sleeping sickness in the British Isles and on the Continent, which is quite a different disease. True sleeping sickness is limited to Africa, and there are two chief types: that occurring in parts of the West Coast and the French and Belgian Congos, in Angola, in portions of the Anglo-Egyptian Sudan, in Uganda, and in parts of the Tanganyika territory; and that which occurs in Northern Rhodesia, Nyasaland, Portuguese West Africa, and the region of the Rovuma River.

Cause.—The cause is a tiny animal blood parasite conveyed from the sick to the healthy by certain species of tsetse flies. In the tsetse fly the parasite, which is called a trypanosome, undergoes a definite development.

The two species of tsetse fly meriting special consideration here are Glossina morsitans and Glossina palpalis. The former, as a rule, occurs in thin, deciduous bush, or low, comparatively open forest, while the latter haunts the neighbourhood of streams and lakes, and is rarely found any great distance from the water edge. These flies are about the size of a small blue-bottle, but are not so stoutly built and, when closed, their wings overlap and project beyond the end of the abdomen. Glossina morsitans is brownish coloured, with bands on its abdomen. Glossina palpalis is much darker, indeed almost black-looking. They have a quick and darting flight, and are attracted by rapidly-moving objects, like motor-bicycles and motor-cars. Once they alight they do not move about. As a rule they bite only during the day, but they may attack man on bright moonlight nights.

Symptoms.—The incubation period is probably about three weeks. The fly bite may be painful; and causes a slight local irritation. The disease begins insidiously, with an irregular fever, and there may be a skin eruption. The fever comes and goes, and the patient gets weaker and suffers from headache. The glands in his neck and possibly in other parts of his body become enlarged and may be tender. The first stage of the disease is called trypanosome fever, and may end in recovery. More usually the central nervous system becomes affected, and then the symptoms of true sleeping sickness develop, slowly or with considerable rapidity. The patient becomes dull and drowsy. Both his speech and movements are affected. His face gets puffy, and he shuffles when he walks. He still has fever, continues to lose flesh, and gradually passes into a sleepy condition, which may be associated with convulsions. Saliva dribbles from the lips, and half-masticated food may remain in the mouth. The patient becomes helpless and indifferent to his surroundings, and either dies from coma or from some intercurrent disease, such as pneumonia or dysentery.

Prophylaxis.—Personal prophylaxis consists in avoiding being bitten by tsetse flies. When passing through fly belts in affected areas veils and gloves may be worn.

Treatment.—If taken in time sleeping sickness can be readily cured by the use of the arsenical preparation atoxyl, combined with antimony. The course of treatment, however, extends over a considerable period, and it must be carried out under the supervision of a medical man.

Sleeplessness.

This is common in those broken down by malaria, dysentery or debilitating diseases; it is also induced by the irritation caused by mosquitoes and other pests, such as the itch parasite. It is at times due to errors of diet, prickly heat, mental worry and exhaustion, abuse of tea and coffee, coldness of the feet and indigestion, and as most acute diseases are worse at night, sleeplessness is very common amongst sick people.

Treatment.—As far as possible remove the cause; kneading the feet and legs, or the application of a hot-water bottle to the feet, will often be of service. A cup of hot milk or soup should be taken at bedtime, and again on waking in the night. The bowels must be regulated and alcohol taken very sparingly.

The taking of sedative drugs should be avoided as much as possible. The least harmful of these is sulphonal in doses of from twenty to thirty grains, given several hours before bedtime, or bromide of potassium in twenty or thirty-grain doses given at bedtime. A warm bath at night often acts more satisfactorily than any other remedy. Only very rarely should chloral, chlorodyne, or opium be resorted to.

Regular habits and plenty of work are potent factors in the production of that healthy condition which predisposes to natural refreshing sleep.

The unfortunate man who has no hard work to do, who is without even a hobby to occupy him, and has no interest in life but the torpid condition of his liver, is a constant sufferer from insomnia. He should be purged and put on a light plain diet. Alcohol must be forbidden and plenty of exercise must be taken. A tumblerful of hot water is to be taken the first thing in the morning and the last thing at night.

Small-pox.

Very prevalent in the tropics, hence the importance of revaccination before going abroad.

Incubation period, twelve days. Rash appears third day.

Rash.—Before the appearance of the typical rash there are occasionally earlier rashes, viz., a diffuse blush covering the whole body, resembling scarlet fever, or a dark purple rash of effused blood beneath the skin of the lower part of the belly, or occasionally in the armpit. The small-pox rash proper consists of small red raised spots which first appear on the face, forehead, and scalp, subsequently coming out over the rest of the body, commencing at the top and working downwards. These spots become prominent, and have a characteristic “shotty” feeling under the finger. On the third day after their appearance a small bleb forms in the centre of each spot; it is transparent at first, but subsequently becomes yellowish, from the formation of matter in its interior. The centre becomes depressed on the sixth day, then the bleb breaks down, and discharges matter. Two or three days later the spot begins to dry up, and ultimately heals under a scab. During the period of most active inflammation the face may be very swollen and sodden.

The spots and pustules are not confined to the skin, but may occur on the roof of the mouth and in the throat.

Prophylaxis.—This consists in efficient vaccination, and as travellers may themselves have to carry out the technique of vaccination, it is important they should know something about it. The usual faults in technique are a lack of cleanliness, resulting in sepsis, the use of too strong an antiseptic when cleaning the skin, over-heating of the lancet, needle or scarifier when purifying it, drawing too much blood, which washes away the lymph, exposure of the recently vaccinated area to the hot sun, and charring of the lymph in the capillary tube when sealing. All that is necessary is to clean the part to be vaccinated with soap and water, using a nail-brush, then rub the skin with alcohol, and when the latter dries proceed with the little operation. There should be four incisions, and the total area which will eventually be occupied by the vaccine vesicles should not be less than half a square inch. It may be noted that the vesicle is fully ripe on the seventh day after vaccination.

Treatment.—Isolation, similar to that of scarlet fever. The body may be sponged and vaseline applied if there is much itching. The eyelids and eyes should be frequently washed with weak boric acid solution.

Snake Bite (see [p. 281]).

Sprue.

This is a chronic form of tropical diarrhœa, often called “white diarrhœa,” the leading symptom of which is the frequent passage of large, frothy, and pale-coloured motions; dyspepsia, and soreness of the tongue and mouth, are also present, and there is marked anæmia and advancing debility. The disease may follow attacks of diarrhœa or dysentery.

Cause.—The actual cause of sprue is unknown, but the disease usually develops in persons who have been for some considerable time in the tropics, and it is commoner in India, Ceylon, and the Far East than elsewhere.

Treatment.—Put the patient to bed, give a simple aperient such as castor-oil, to clear out the bowels; allow only a milk diet, to which, as the symptoms begin to abate, meat juices and jellies should be cautiously added. If any other disease, such as scurvy, is present, it must be treated. Drugs are not usually of much service; however, a mixture containing bismuth, soda, and one drop of carbolic acid in an ounce of gum-water may be given three times a day for a week. The soreness of the mouth and tongue may be treated by the application of borax and glycerine, or mild antiseptic mouth washes, such as a weak solution of permanganate of potash, or a lotion of boric acid. Special symptoms, such as pain and collapse, must be treated as they arise. As soon as the patient is strong enough, he should be removed to a temperate climate.

Stroke, or Apoplexy.

This disease is caused by the rupture or blocking up of one of the blood-vessels in the brain.

Symptoms.—The person attacked falls down suddenly, and is unable to move one or more of his limbs. He may be quite insensible, or soon become so, or perhaps he is unable to talk. The mouth may be drawn to one side, and the tongue, when protruded, be pushed to the right or left. The condition is serious.

Treatment.—Tight clothing must be removed. Six grains of calomel powder should be placed on the back of the tongue, and the patient kept lying on his back with the head slightly raised. Cold should be applied to the head and a hot-water bottle to the feet, the room darkened, and absolute quiet observed. An enema of hot water may be given, and while the patient is insensible the lips should be moistened only with water. Food may be given by the bowel on the second or third day. Stimulants are absolutely forbidden. If the patient gets over the attack he ought to be sent home.

Note.—It must not be forgotten that many of the above symptoms might be caused by injury or poison.

Sun-Stroke and Heat-Stroke.

These conditions are distinct. Sun-stroke, which is comparatively rare, is due to the direct action of the sun on the brain and spinal cord. Heat-stroke, on the other hand, would appear to be due to the lack of escape of heat from the body, owing to insufficient evaporation from the skin, and to the effect of muscular fatigue. As a result, poisonous substances accumulate and act detrimentally upon the nerve cells. There is also a deficient supply of oxygen to the blood. High relative humidity plays a very important part in producing attacks of heat-stroke. The milder forms are known as Heat exhaustion and Heat prostration; the severe form is often associated with true sun-stroke.

Symptoms.—Heat exhaustion is really a form of faintness, and recovery soon takes place after a rest. The symptoms of heat prostration are giddiness, often associated with nausea. The patient is bathed in a clammy sweat, his pulse is thready, his breathing shallow, and, it may be, sighing. The condition may pass into unconsciousness, but the temperature is not raised, and death rarely results.

There are two kinds of true Heat-stroke; one a form with high temperature, the other what is called Heat cramp, which is common amongst ships’ firemen in the tropics. An early warning sign of heat-stroke is a desire for frequent micturition, and other premonitory symptoms are a dry skin, giddiness, drowsiness, headache, and intolerance of light. The pulse becomes quick and irregular, the skin is hot and dry, and the temperature elevated. The patient may become comatose, or exhibit delirium or convulsions. There is an asphyxial type, in which the face becomes cyanosed and the breathing is in abeyance.

Prophylaxis.—Avoid severe exercise in a hot sun. Wear suitable clothing, which should be loose and easy, and protect the head, and especially the nape of the neck, from the sun’s rays. Dark or tinted glasses are useful. Water should be taken freely, and the bowels kept open; but alcohol must be avoided. Sniffing a mixture of water and vinegar and damping the face are helpful measures.

Treatment.—In the case of Heat prostration the patient should be laid in the shade on his back, his clothes should be loosened, his limbs massaged, and, if he is collapsed, stimulants in the form of ammonia or camphor should be administered. The asphyxial type of heat-stroke can only be treated by means of artificial respiration, which may have to be continued for as long as a couple of hours. The ordinary form, which has been called the paralytic type, must be treated promptly and vigorously. One must aim at reducing the temperature, getting rid of the toxic material in the body and preventing heart failure. Probably the best way of treating the condition as an emergency is to lay the patient naked on an inclined plane and drench him with cold water. When doing so it is well to take the rectal temperature, and to stop this chilling process when the thermometer registers 102° F. After the drenching wrap the patient in blankets and apply hot bottles to the trunk and limbs. An ice bag, if available, should be applied to the head, which in any case should be swathed in cold cloths. It should be noted that in the absence of ice, a sheet soaked in cold water or dilute alcohol, over which a draught of air plays, is a useful substitute. A fan may be used to create the air draught. Auxiliary methods of treatment can be efficiently carried out only under medical supervision. As soon as the patient has recovered somewhat, a dose of calomel should be given, followed by salines.

Syphilis.

Syphilis, or the Pox, is an infectious venereal disease, nearly always communicated by direct contagion. The course of the disease is marked by a primary sore, the chancre; early constitutional (secondary) symptoms, and late constitutional (tertiary) symptoms.

In primary syphilis the disease is limited to the part or organ originally infected, and the glands connected with that spot. After an incubation period of from three to six weeks a small painless pimple appears at the seat of infection; it breaks down, and forms a small ulcer from which oozes a little watery fluid. The base of the ulcer and the skin surrounding it are hard like gristle. The nearest glands, usually those of the groin, enlarge and occasionally become tender. Unless badly neglected, the original sore gradually heals and the glands resume their normal size. Secondary symptoms now make their appearance. These are fairly definite, and comprises (a) A skin rash, consisting of numerous irregularly shaped copper-coloured spots, spread over the face, upper part of the chest, the loins and the back of the arms. They do not itch. (b) Moist lumps and warts form in the crutch, around the scrotum (purse) and the outlet of the bowel. (c) Ulcerated sore throat. Large deep ulcers form on each tonsil, having ragged undermined edges. (d) Iritis or inflammation of the eye may also occur. These symptoms, even if untreated, tend to heal, but always leave more or less marked traces behind.

The discharge from either primary or secondary sores is infectious and may convey the disease, so that great care needs to be taken in handling such sores.

After an interval of apparent health, lasting perhaps only a few months, but often for a year or two, the tertiary symptoms or “reminders” make their appearance. These take the form of localised swellings, which soon break down, forming deep ulcers, and if untreated, produce extensive destruction of the part involved, with much deformity.

Prophylaxis.—The methods available are now so well known that they need not be discussed in a work of this kind. Mention need merely be made of the fact that in some foreign countries, owing to unhygienic conditions, there is a greater liability to contract the disease by what may be called unusual methods, and therefore every care should be taken to prevent such sources of infection, as, for example, the contaminated seats of closets, etc.

Treatment.—As soon as the disease is recognised, the treatment must be commenced.

Local treatment.—Keep the sore perfectly clean by washing it with an antiseptic solution such as chinosol (1 in 1000). Between the washings, dress it with a piece of lint soaked in “black wash,” or dust it with iodoform powder and cover it with a piece of lint smeared with boric ointment.

For the sore throat, use an antiseptic gargle (see Ulceration of Throat, [p. 244]).

General treatment.—The patient must be put on a course of mercury at once. Calomel, one grain twice a day, or grey powder, one grain three times a day, must be administered, and continued until skilled advice can be obtained. The effect of the mercury must be carefully watched, and if the patient complains of soreness of the gums, a coppery taste in the mouth and excessive flow of saliva, the dose must be reduced or the administration of the drug stopped until these symptoms have disappeared. If the calomel or grey powder causes looseness of the bowels, five grains of Dover’s powder may be added to each dose.

In some cases, the addition of three grains of the iodide of potash to each grain of calomel does good from the very first.

For the later symptoms, continue the mercurial treatment, and give at least five grains of the iodide of potassium three times a day.

Since the above was written the whole treatment of syphilis has been revolutionized by the introduction of certain organic arsenic compounds as therapeutic agents. Of these the best known is the German salvarsan, represented in this country by kharsivan, the so-called “606.” Treatment with arsenic has now largely replaced the old method with mercury; but it cannot be carried out except by one having medical training, and so need not be further considered.

Tick Fever.

One of the diseases which may be produced by the bites of insects is a form of fever, conveyed by the bite of a tick, which is common in many parts of Africa. This produces a series of symptoms which are similar to those found in the disease known as relapsing fever, which has been known to occur even in the United Kingdom, and which used to be called “famine fever” (see [p. 218]).

Cause.—The cause is a corkscrew-shaped organism found in the blood, and its vector is the tick above mentioned, which in its adult state and unfed is roughly about the length of a finger-nail, that is, four-tenths of an inch. It is of a greenish brown colour, and is covered by a leathery integument, which looks as if it was spotted all over and which is grooved in several places. When the tick is gorged, these grooves disappear. A gorged female tick may be well over half an inch in length, and very nearly of an equal breadth.

The tick lives in native houses and in rest houses, especially along caravan routes. At night it sallies forth in search of blood, but during the day it conceals itself in cracks and corners in the walls and floors, and sometimes in cracks in native wooden bedsteads. Its bite is painful, but the infection takes place not through the bite, but as a result of the infected excreta of the tick contaminating the tick bite. One tick is sufficient to cause infection.

Symptoms.—The chief symptoms are those of a severe attack of fever, ushered in by a shivering fit and acute symptoms such as are usually found in cases of fever, for example, pains in the back and limbs, rapid pulse, and sometimes severe vomiting and diarrhœa, frontal headache, and painful bloodshot eyes are rather characteristic. The fever, which is of the relapsing type, generally keeps up for about a week, after which there may be an interval without fever for a few days, to be followed later on by another attack of fever. There are usually several relapses. As many as eleven have been noted.

Prophylaxis.—Avoid sleeping in native huts and rest houses which have been occupied by natives. Do not sleep on the ground or on wooden native bedsteads. If the latter have to be used, their legs should be smoothed to prevent ticks from climbing up them. In badly infested places, it is well to employ a hammock. A mosquito-net is useful, as it excludes the ticks; and it is well to make use of a night-light, which also keeps them away. Packs and blankets should be periodically inspected to see that they do not harbour ticks. If one has to camp on an infected area, the ground should be fired and the floors of huts dug up and thereafter removed and buried or treated with fire, care being taken that the ticks do not escape during the process. Wandering ticks can be kept away from a tent to some extent by digging round it a trench and filling it with wood ashes.

Treatment.—This is mainly symptomatic. Careful nursing is required together with a light diet. In some cases the arsenic preparation known as salvarsan (kharsivan) is found of value, but the specific treatment of this malady can only be carried out by a medical man. In many cases digitalis or strophanthus is required, owing to the risk of heart failure.

Typhus Fever.

This disease is not so common in the tropics, but in certain sub-tropical countries, such as Egypt, it frequently occurs, and it is of course closely associated with military operations in the field.

Cause.—The exact nature of the infection is as yet unknown, but the disease is transmitted by lice, both the head and the body louse having been proved to be carriers of the virus.

Symptoms.—Incubation period 5 to 14 days, as a rule 12 days. Symptoms vary, but at first somewhat resemble those of an influenzal attack without the cold in the head. The patient is feverish and uncomfortable, but not until the third day do the typical symptoms of typhus make their appearance. Then the patient’s face becomes flushed and his eyes congested, his pulse rate increases, and very soon his temperature rises and runs up to 103 or 104° F. The rash, which varies in type, generally appears on the fifth day, being found first on the upper part of the abdomen. It does not occur upon the face, but is usually very profuse on the back. If the rash develops the patient becomes seriously ill, and all his symptoms are intensified. He becomes dull and lethargic, his mouth is foul, and his general aspect is somewhat like that of a drunken man. His voice becomes husky, his hands are tremulous, and his breathing is rapid. In the second week, in most cases, he becomes delirious or comatose, and lies in bed more or less like a log. In cases that recover, improvement sets in about the fourteenth day, and is usually rapid and complete. In cases which die the temperature remains high or rises, the general condition becomes worse, and death usually takes place from heart failure.

Prophylaxis.—Get rid of lice according to the methods detailed on page 196. Those attending typhus patients should be protected from lice by wearing overalls, etc. Patients suffering from typhus should be thoroughly cleansed, their hair cut or shaved, and completely cleared of lice. Bedding and clothing must be disinfected.

Treatment.—Good nursing is of more importance in this disease than the administration of drugs. The mouth must be kept in a good condition, and the food must be strengthening, nourishing soups being indicated. It is important to give the patient as much fresh air as possible, and as a rule he will require stimulants, especially heart tonics such as digitalis or strophanthus. Other measures can be carried out only under medical supervision.

Ulceration of the Throat.

Gargle with a weak antiseptic solution such as permanganate of potash or chinosol. An astringent gargle may be made by dissolving five grains or more of tannin in two ounces of hot water. Sulphate of iron can be used for the same purpose, two grains or more to an ounce of water. If there is much pain, apply poultices to throat.

If due to syphilis give one grain of calomel and three grains of iodide of potassium, twice a day, in addition to the local treatment. Kharsivan, or similar treatment, is also indicated (see [p. 240]).

Undulant (Malta) Fever.

The term Undulant Fever is applied to Malta Fever partly because the latter is not a good name, as the disease occurs in various parts of the world, and partly because the term Undulant affords a good description of the type of the temperature curve.

Cause.—The organism is a small bacterium, which is found in the blood and tissues. Although theoretically the disease can be spread like enteric fever or dysentery, in practice it is found that it is nearly always conveyed by infected goats’ milk. Goats are apt to harbour the organism and excrete it in their milk. It is also found in certain milk products, such as cream and cheeses which are not allowed to ripen. In addition to man and goats, cows, sheep, horses, mules and dogs, are all liable to natural infection.

Symptoms.—Incubation period 5 to 15 days. The disease begins with headache, malaise, anorexia, and sleeplessness. The patient is usually constipated, and there is tenderness in the splenic region, the spleen being enlarged at an early date. The temperature rises gradually for three or four days in a step-like manner, and then falls by a similar descent, reaching the normal on or about the tenth day. At this early stage bleeding from the nose may occur, and profuse night sweats are not uncommon. The tongue is flabby and coated. When the temperature falls the patient feels better for a few days, but is still apt to suffer from night sweats, and continues to lose flesh. A relapse occurs, and is usually accompanied by joint troubles and sometimes neuralgic pains. A series of febrile waves continues to follow each other at short intervals, and the illness is a very wearisome one, running an average course of 60 to 70 days. It may, however, extend for nearly a year, and in some cases terminates fatally. The long course of the illness results in the patient becoming anæmic, and he often suffers from mental depression. There are irregular forms of the fever which are apt to be puzzling, and it is always well to remember that any cases of prolonged pyrexia from tropical or sub-tropical regions may be Malta fever.

Prophylaxis.—Avoid drinking goats’ milk and eating the local products of such milk. If goats’ milk must be drunk it should be boiled. General hygienic measures are also important, and it should not be forgotten that the organism of the disease is found in urine, which should therefore be disinfected.

Treatment.—This is for the most part entirely symptomatic. Medical attention and good nursing are essential. A vaccine has been introduced and is worth trying, but vaccine treatment is best left to an expert. It is sometimes necessary to give morphia for the joint pains and the neuralgia, but there is a distinct risk of the patient’s acquiring the morphia habit. Sleeplessness, which is often troublesome, should be treated as indicated on page 235.

Urine, Retention of.

Retention of, or inability to pass the water may be caused by stricture, injury, shock, spasm, inflammation of some part of the passage, the effects of drinking, or by chill.

Symptoms.—The bladder is unable to expel its contents and it gets fuller and fuller; it can be felt in its distended condition as a painful, soft swelling in the lower part of the belly, below the navel, underneath the skin and muscles. There may be fever, great pain and constant desire to pass water, with inability to do so. When the bladder becomes greatly distended, there is usually slight dribbling of water, which is somewhat misleading, as the case may be considered, not one of retention but rather of too frequent passing of urine.

Treatment.—Give a saline purge such as Epsom salts, three or four teaspoonfuls, and let the patient sit in a bath of hot water. If not relieved very quickly, then pass a clean catheter into the bladder, and allow it to empty itself (see Catheters, [p. 272]). After the bladder has been emptied put the patient to bed and give a dose of opium or bromide of potassium to procure rest. When he desires to pass water again let him have another bath, and if this is not effectual, again withdraw the water through a catheter. Patient should be careful to ward off further attacks by avoiding chills, over-drinking, and other exciting causes. If there is inflammation of the bladder, copaiba or sandal-wood capsules should be used; if the urine is irritating, bicarbonate of soda must be given.

Urine, Suppression of.

In this serious condition no urine is secreted by the kidneys, so that on passing a catheter the bladder will be found to be empty.

Causes.—Shock from injury, inflammation and blocking up of the kidneys. Suppression of the urine is a common complication of severe cases of blackwater fever.

Treatment.—Hot baths, hot poultices to the loins, free use of aperients, especially Epsom salts and other saline purges. Bicarbonate of soda in full doses. Keep the skin acting freely by means of sweet nitre, or Warburg’s tincture, or five-grain doses of antipyrine. Injections of hot water into the lower bowel.

Worms.

Worms are introduced into the system chiefly by means of dirty water or imperfectly cooked food.

In the case of hook worms (ankylostomes), contaminated soil is the chief medium of infection.

Of the worms which live in the bowels the most important are the following:

Tape Worms.—These worms may measure many feet in length; and their presence in the body can only be certainly known by the appearance of some of the segments or portions of the worm in the motions although hunger and dyspepsia may be complained of.

Treatment.—Administer a good aperient overnight so as to empty the bowels; after the aperient nothing should be given by the mouth for eight hours, then give sixty to one hundred and twenty drops of the liquid extract of male fern in one ounce of thin gruel, milk, or gum water, and follow this up in four hours by a good meal, and an aperient to remove the worm, which should now be dead.

When the extract of male fern is not available, one tablespoonful of the oil of turpentine may be used in its place.

If later on fresh segments appear in the motions, then the treatment must be repeated.

Round Worm.—The round worm resembles the garden worm and is several inches in length; it may be observed in the vomit but more commonly is seen in the motions. The symptoms are similar to those caused by the tape worm and the treatment is the same, except that, instead of the male fern, two to five grains of santonin should be given in a little milk; and the treatment repeated every other day for a week.

Threadworm.—The threadworm is a small round worm usually measuring less than half an inch in length; it inhabits the lower end of the bowel and causes great heat and itching about the outlet, especially at night.

Treatment.—Wash out the lower bowel and inject into it about a third of a pint of tea, or a similar quantity of water containing one teaspoonful of salt, tannin, or alum; then apply a little mercurial ointment around the outlet to diminish irritation. This should be done every third day till the worms have disappeared from the motions.

The Guinea Worm.—The guinea worm often measures several feet in length; it chiefly causes trouble in the feet, ankles, and legs, where in order to obtain an exit from the body it penetrates the skin, causing a small ulcer at its point of exit.

Usually the presence of the guinea worm is attended with inflammation and the formation of matter.

Prophylaxis.—Infected persons should be kept away from water supplies, and such sources of water supply as wells and water holes should be protected. In areas where guinea worm occurs, all water should be boiled. If this cannot be managed, it should be filtered through a piece of clean cotton cloth, as this will remove from it the small crustacean in which the larva of the guinea worm develops. Another method of treating infected water is by means of permanganate of potash, one ounce to every 2,000 gallons of well water. Caustic potash and quicklime are also effective.

Treatment.—When the worm can be seen at the base of the little ulcer, it may be secured to a piece of match and a small portion may be wound on to the match daily. If attempts are made to forcibly draw it out, it will probably break and violent inflammation will result. During the time that the worm is being wound out, the part should be kept very clean and an antiseptic ointment applied.

There are other methods of treatment, but these can only be carried out under medical supervision.

The Hook Worm.—This is the American name for one or other of the species of ankylostomes which infect man. The disease they cause is known as ankylostomiasis, and it is common in many parts of the world, especially in the tropics. It chiefly affects natives, owing to their habits; but it occurs also in Europeans.

Cause.—Hook worms are small, almost cylindrical worms, which inhabit the human small intestine, to the wall of which they attach themselves by means of their mouths, which are furnished with formidable hooks and lancets. They suck blood, and the symptoms they produce are due in part to loss of blood, in part to the destruction of the lining membrane of the bowel, and possibly also in part to the effects of a poison which they are believed to excrete. Their eggs are passed in the excrement, and develop in the infected soil into larvæ, which are able to penetrate the unbroken skin if they come in contact with it. This is the most important route of infection, but it may occur also by means of infected drinking water and from contaminated food.

Symptoms.—The most marked feature of the disease is anæmia, which is often associated with digestive troubles. Palpitation of the heart and shortness of breath are frequently met with. In bad cases the appetite is disordered or depraved. The patient becomes pot-bellied, and there is swelling, chiefly about the face and ankles. The face is frequently puffy, and the skin assumes a peculiar earthy hue. It should be noted that a very early symptom is what is called ground itch. This is a skin eruption, usually on the feet and legs, due to the irritation caused by the larvæ penetrating the epidermis.

Prophylaxis.—The chief measure consists in preventing contamination of the soil by infected excrement. It is therefore important when camping to make proper provision in the way of latrines. Care must also be taken to prevent the fouling of water and food stuffs, such as vegetables, which are eaten uncooked. It is very dangerous to go about bare-foot in regions where the disease occurs, and camping sites should always be thoroughly cleansed.

Treatment.—Efficient treatment can only be carried out in association with microscopic examination of the stools, and hence all that need here be said is that various worm medicines are employed, of which the most effectual are thymol and oil of chenopodium. These should be administered only under careful medical supervision. The anæmia has to be treated, and in the case of natives a nutritious and easily-digested diet is indicated; for example, for native coolies the following has been recommended: bread 1 pound, milk 2 pints, sugar 2 ounces, 2 eggs, and 4 bananas daily. Ground itch should be treated by an ointment containing zinc oxide and salicylic acid.

The Bilharzia Worm.—This worm, of which there are two species, produces the disease known as Bilharziasis or Schistosomiasis, which occurs in one or other, or both forms, in various parts of the world, but is specially prevalent in Egypt.

Cause.—The worms, which produce either urinary or rectal bilharziasis, live in parts of the human vascular system, where they produce their eggs. These eggs are furnished with spines, and hence cause irritation when lodged in the tissues. In the urinary form the eggs have a terminal spine, in the intestinal form the spine is lateral. These eggs are passed either in the urine or in the excreta and reach water, where they develop into larvæ. The larvæ enter special species of water snails, in which they develop, producing eventually tiny forms known as cercariæ. These cercariæ escape into the water and can penetrate the unbroken skin or intact mucous membrane. They thus get access to the bodies of persons who are bathing in the infected water, or who may drink it. Once in the human body, the blood carries them to the place where they develop into the adult worms, which eventually unite, and then the females begin producing the spined eggs.

Symptoms.—In the urinary form the chief symptom is the passage of bloody urine, which usually shows itself about three months after infection, and is often associated with a good deal of irritation of the bladder and the pipe. The intestinal form may produce various symptoms. Sometimes a condition resembling enteric fever occurs, sometimes one like dysentery. Diarrhœa is common. The condition is chronic and, if untreated, sets up all kinds of secondary effects, which need not be discussed.

Prophylaxis.—Carefully avoid any kind of personal contact with water which may by any possibility be infected from urine or fæces. Bathing, wading, washing in, or drinking any such waters, are all dangerous. Wherever possible, water which may be infected should be boiled. If this cannot be done, sodium bisulphate tablets may be used; two of the 16-grain water-purifying tablets in a quart water-bottle full of water are efficient. Filtration through a Pasteur-Chamberland or Doulton candle is efficient, as it excludes the cercariæ. Bathing water can be rendered safe for immediate use by the addition of undiluted Army cresol in a dilution of 1 in 10,000. If the water is kept overnight, 1 in 90,000 is sufficient, as the storage of water tends to diminish infection.

Treatment.—Certain forms of antimony have been found to cure the condition, but can only be administered by a medical man. Indeed, either form of bilharziasis can be properly treated only under medical supervision. If this is not obtainable, some relief can be afforded by the use of urotropin and sedative drugs.

There are many other worm diseases which afflict man, but no good object would be served by mentioning them in detail. Most of them can be diagnosed with certainty only by a medical man using the microscope, and they all require scientific treatment which is beyond the scope of the ordinary traveller.

Yellow Fever.

This disease, the “Yellow Jack” of naval historians, occurs, so far as is known, only in parts of the New World and on the West Coast of Africa. One attack usually protects permanently against a second.

Cause.—Quite recently the organism has apparently been discovered. It is a corkscrew-shaped parasite which exists in the blood, and which is allied to, though not identical with, the parasites of relapsing fever and tick fever. The infection is conveyed from one patient to another by the mosquito Stegomyia fasciata, which is a black and white insect, commonly known from its striped legs as the tiger mosquito. Incubation period two to five days.

Symptoms.—The onset of the disease is very sudden, the highest temperature being reached almost at once; then follows a period of remission or calm, the pulse becomes abnormally slow, and this stage is usually either succeeded by convalescence, or the symptoms become worse and the patient dies. Some of the symptoms much resemble malaria, but the rapidity of the onset, severe pain in the forehead, eyes, and loins, the early scantiness of the urine, the marked jaundice, the bright eyes, the narrow red tongue, and the absence of pain about the spleen are fairly characteristic.

There is considerable thirst and vomiting, and in bad cases the vomit becomes black, the colour being due to the presence of blood. (In ordinary malaria the vomit is yellow, or in severe cases, such as blackwater fever, it may be of a bright or dark-green colour.) In yellow fever, jaundice is developed about the third day, and tends to increase, whilst in blackwater fever it comes on very early and soon begins to abate.

An important diagnostic sign in yellow fever is found in the fact that the pulse does not increase in rapidity as the temperature rises.

Prophylaxis.—Avoid being bitten by mosquitoes, employing the methods mentioned on pages [206], [207]. It must be remembered that Stegomyia fasciata, unlike the anopheline mosquitoes, bites during the day, and therefore it is more difficult to avoid its unwelcome attentions. It usually breeds in the neighbourhood of houses, being what may be called a domestic mosquito; and it is of the greatest importance to abolish all potential breeding places or to protect them from the mosquito. Practically any vessel holding water may become a nursery for Stegomyia, and it is remarkable in what small quantities of water this mosquito will lay her eggs. Patients suffering from the disease must be isolated and kept under a mosquito net or in a mosquito-proof chamber, in order to prevent them from infecting mosquitoes, which they are capable of doing in the early part of the disease.

Treatment.—Open the bowels well by means of calomel, six grains, followed by a saline purge and hot-water enema. Some prefer castor oil in large doses. Give ten grains of bicarbonate of soda three times a day. Give cooling drinks, such as fruit salt. Make the skin act. Apply hot fomentations to the back and mustard leaves to the pit of the stomach.

The question of feeding is very important. During the first two or three days of the fever the patient is better without any food at all. As he recovers his appetite returns, and great care must be exercised about gratifying it. Only the plainest foods in very small quantities should be permitted, the amounts being gradually increased, as otherwise relapses may occur. Stimulants are usually required in the later stages of the fever, but they must be carefully employed as they may tend to increase the vomiting. It is possible that the discovery of the parasite may lead to new and more efficient methods of treating the disease.