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.

[Illustration: 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.