CHAPTER VIII.

On the Prevention and Treatment of Certain of the more Common Tropical

Diseases.

Although the main essentials of domestic sanitation have already been

dealt with at some length, and incidental mention has necessarily been

made of their bearing on the avoidance of particular maladies, it

appears desirable to devote a few pages to the separate consideration of

the avoidance of some of the more common tropical diseases. Some apology

may be necessary for the inclusion in the following remarks of some

brief references to medical treatment, but it is difficult to keep

absolutely distinct the subject of prevention and cure in a popular

work, and while there is no desire to convert this little book into a

treatise on family medicine, it is thought that a few words on the

subject of remedial treatment may not be out of place, especially as

most of the writers that treat of this subject popularly, from the

tropical point of view, are hopelessly out of date.

It must be clearly understood that what little is said on this subject

is in no way intended to supersede the necessity of medical advice,

whenever that may be available; but in these out-lands, the number of

doctors to the square yard is far smaller than it is in Europe, and even

in comparatively settled regions, it is quite easy to place twenty miles

or more between yourself and the nearest medical man.

It must be remembered that in tendering general advice of this sort the

prescriber is considerably hampered by the necessity of recommending

nothing that is likely to do harm should the amateur doctor’s diagnosis

be faulty, and that he is thus debarred from suggesting many measures

that would be perfectly appropriate were the case under competent

supervision.

I do not of course refer merely to the question of poisons, as there are

few drugs that are of any real use that are not capable of causing

dangerous symptoms if administered in adequate doses--and many of the

drugs recommended are as a matter of fact powerful poisons--but rather

to the fact that even assuming reasonable care and intelligence in

weighing and measuring, one must needs direct only such measures as will

not be harmful in the by no means unlikely event of a mistaken

diagnosis. In only too many of the scourges that devastate these

latitudes, there is no time to wait for the arrival of a doctor living a

day’s journey away, as the chances are that the fate of the patient will

be no longer in the balance when at last he arrives; so that for

anything to be of any use it must be done quickly.

This method of treating the subject necessarily involves occasional

repetition, but in view of the importance of the details thus

emphasised, this may not be entirely disadvantageous.

CHOLERA.

When the writer first went to India some quarter of a century ago, there

was still a tendency to invest this disease and its propagation with

certain mysterious attributes, and a certain pompous obscurantist who

was then at the head of affairs invented the awe-inspiring term of

“pandemic waves” to account for, or rather cover, ignorance as to its

method of spread; nor was it altogether safe for his subordinates to

record facts that appeared to indicate a more common-sense explanation.

But even then, the theory that the disease was usually conveyed from man

to man by infected water, was held practically by all whose opinions

were worth having. Still we were very much in the dark as to the methods

whereby it gained access to water, and had no means of distinguishing

infected from harmless water; and our measures of prevention, being thus

based on guess work, were uncertain and often ineffective. At the

present day, thanks in the main to the labours of Koch and Hankin, there

is no disease about which our knowledge is more definite. In dealing

with semicivilised communities it is still, it is true, quite impossible

to prevent or foresee outbreaks of the disease, but when it occurs our

knowledge now enables us to bring an epidemic to a speedy termination,

always provided we are permitted to do so by the population; and

personal prophylaxis may almost be said to amount to security.

We now know that the germs of cholera can exist only in the human

organisation, but that they are capable of living and also _multiplying_

in water. In very impure water, they cannot long survive, as they soon

get crowded out of existence, in such situations, by putrefactive and

other germs that are most at home under such conditions. For their

_multiplication_ the presence of a certain amount of otherwise harmless

organic and mineral matter is of course necessary, but if introduced

into water containing this, they can survive some time in the purest

natural waters, though they ultimately die out in such situations. Owing

to these habits of life on the part of the germ, it follows that the

taste and appearance of water are absolutely valueless as regards its

safety, and that the _chemical_ examination of water is an equally

futile test. The disease is carried about from place to place by

infected human beings; but in ninety-nine cases out of a hundred is

conveyed from man to man not directly, but indirectly through the agency

of drinking water. In the hundredth case the germs may be carried in

food, and of course milk, being often intentionally or accidentally

mixed with water, is a frequent vehicle.

Direct infection from man to man does probably occasionally occur, but

the contingency is too remote an one to be worthy of consideration, as

it implies close personal contact, and in fact is usually traceable to

those in attendance on the sick getting their hands or clothing fouled

with the discharges and neglecting due measures of disinfection before

eating or drinking. Save in this way, there is practically no risk

whatever in the proximity of, or of attendance on, cholera cases, and no

one need shrink from nursing persons stricken down with the disease,

provided they observe a few very obvious precautions.

Fortunately the cholera germ is rather a delicate sort of plant, and

but for its sharing with man a preference for good drinking water it

would be comparatively harmless, as it soon perishes elsewhere, and is

very soon destroyed by drying or too great heat. It is needless to

remark that it cannot stand boiling, for the germs that can stand that

sort of treatment are few and far between; but it is also very sensitive

to the action of most of the ordinary disinfectants, which destroy it in

dilutions far weaker than is the case with the agents of most other

diseases; and it is also killed by a sufficiently long exposure to the

action of carbonic acid, from which fact there outcomes the useful bit

of knowledge that it is quite safe, _qua_ cholera, to drink aerated

waters even of doubtfully careful preparation, provided that they have

been kept a few days in the house before use. Owing to the fact that the

cholera germ cannot only survive, but is also capable of multiplying, in

drinking water of average purity, the amount of fouling of the water

which is required to infect it may be very small indeed, and usually is

infinitesimally small.

A traveller draws water from an infected, but chemically practically

pure well, and marches on, or it may be travels some hundred miles by

train. Arrived at his next halting-place, he lowers his drinking vessel

into the well he finds there. The amount of matter carried from the

infected to the clean well is necessarily far too small to turn the most

delicate balance ever constructed, but that same amount would suffice to

infect not one, but an indefinite number of wells, so infinitely small

are the individual germs concerned carrying the infection. Moreover, the

drinking of infected water does not imply certain infection, as at

certain stages of digestion the germs are destroyed in the stomachs of

healthy people; and hence it is quite possible for the disease to be

introduced by a person who has not himself suffered, though perhaps it

is more common for it to be caused by mild cases; for it is a mistake to

think that cholera is always a fatal or terribly serious disease, as in

every epidemic large numbers of cases occur of slight upset of the

digestive organs, but which we now know by microscopic examination to be

really true cholera. These cases, however, are rarely recognised or

recorded, and the really virulent form of the disease, which kills,

roughly speaking, half of those it attacks, is alone referred to in

ordinary statistics of attacks and deaths.

In India, and I suspect in most other semicivilised countries, the

commonest method by which wells become infected is by the using of a

vessel which has contained infected water to draw water from an

uninfected well. The quantity of material required to start the

fermentation in a still wholesome well is, as already remarked,

infinitesimally minute, and a small drinking vessel and the string used

for lowering it into the water, if carried by a traveller from an

infected to a healthy place, is amply sufficient, and as the, chemically

speaking, still pure water of an infected well is all that is required,

it is obvious that no actual fouling of drinking water with the

discharges from those stricken down by the disease is either necessary

or common. The actual fouling of wells from contiguous latrines or

cesspits does no doubt occasionally occur, but owing to the extremely

primitive character of Oriental plans of conservancy, is rare.

From what has been said, it will be obvious that it is perfectly easy to

suggest measures for the prevention of cholera which may be trusted to

be perfectly effectual. The only difficulty lies in carrying them into

practice. Practically, all that is required is to protect all supplies

of drinking water by covering in wells and fitting them with pumps. But

the mere expense of doing so is often beyond the means of the community,

and when the pumps have been fitted, there is no one available to keep

them in order; so that after a very short period they become useless,

and the old infection-carrying bucket and string must needs be reverted

to. Nor is it by any means easy to protect one’s own supply, as

strangers have a free and easy way of making use of their neighbours’

wells, whether rich or poor. Nor can one’s native servants be trusted

either to prevent this or to employ for drawing water a single vessel

set apart for the purpose, for being unable to comprehend the reasons

for such precautions, they naturally regard them as merely troublesome

fads on the part of their employer, to be observed only when he chances

to be looking on.

On this account the cardinal precaution of personal hygiene is to drink

only water that has been boiled, and to see it boiled oneself. Every

housewife knows that even European servants are often singularly obtuse,

or neglectful, in recognising when water has actually come to the boil;

and that to be certain of the perfection of the domestic cup of tea she

must satisfy herself that the water is actually in a state of ebulition.

Nor are such precautions onerous or troublesome. Orders should be given

that the portable charcoal stove should be brought into the verandah and

that the water should be boiling at the time of some meal, when the

master of the house necessarily passes through on his way to table;

preferably that of late dinner, so that the water may have all night to

cool in, and so be ready for the next day’s consumption. The boiling

water should be poured directly into the vessels, porous or otherwise,

in which it is to stand, and put aside in some place sheltered from

dust. They should not be filled too full, as after they have cooled it

is desirable to shake the water violently so as to re-aerate it, and so

remove the insipid taste which the water has acquired, owing to its

dissolved air having been expelled during the boiling process. The still

boiling water may generally be trusted to sufficiently sterilise the

containers, but it is perhaps well, as an additional precaution, to boil

them occasionally in a large cauldron. Above all, do not filter; but

trust to settlement. Ordinary filters are perfect germ-traps, while all

varieties of the Pasteur filter are slow in action and apt to get out of

order. Added to this, their rubber connections may leak without our

being aware of it, and even when in their most perfect condition, they

afford a protection but little superior to that given by boiling, so

that personally I would far prefer to put up even with a little

turbidity in boiled water than put any trust even in the best of them.

Remember that you can trust no one but oneself to attend to their

cleanliness and efficiency, and that to do so implies the sacrifice of a

good deal of time on a very irksome job. Drinking water that chances to

be impregnated with lime necessarily becomes turbid on boiling, but the

turbidity is perfectly harmless. If the deposit be so fine as to be very

slow in settling, the process may be hastened by stirring it round a few

times with a crystal of alum. These precautions should be, of course,

routine ones at all times, but should be maintained with special

vigilance at times when cholera is present in one’s place of residence.

Aerated waters that have been kept in the house a week may also be

drunk, but care should be taken to avoid any articles of food that are

consumed raw, such as salads and fruits. Tomatoes may be dipped into

boiling water and peeled without detracting from the pleasant, fresh

acidity of their taste, but it is well to specially avoid during such

periods lettuces and melons, as owing to the circumstances under which

they are cultivated they are specially liable to have been wetted with

infected water. Cucumbers may be dealt with in the same way as tomatoes,

as from their shape it is very easy to sterilise their exterior by

dipping them for a few seconds beyond the middle of their length in

boiling water and changing end for end. This and the customary

subsequent peeling really affords a sufficient practical security, and

it must be remembered that the usual dressing of vinegar, “fortified” as

this article of consumption usually is with sulphuric acid, affords an

additional security, and does away with the necessity of submitting to

what would be really a considerable deprivation at the time of the year

when cholera is most common; for cholera and cucumbers flourish most at

the same season of the year, a coincidence which has led to the not

unnatural, but quite erroneous, popular idea that cholera may be caused

by eating this vegetable. Of course, too liberal an indulgence in

cucumber, like too much of any other rather indigestible good thing, may

cause bowel disturbance, and an irritated bowel is especially liable to

infection; but apart from superadded infection, no article of food is

capable of causing the disease.

In dealing with drinking water on a large scale, such as the

disinfection of wells and tanks, we have several available methods, for

one or the other of which the materials are almost everywhere

available. The most valuable of these agents is undoubtedly the

permanganate of potash, and the suggestion of its use for the

disinfection of drinking water from the germs of cholera is undoubtedly

due to Mr. Hankin, our official bacteriologist at Agra. No doubt more

than one medical officer had previously made experiments with this

chemical for the purification of drinking water, but the credit of

definitely proposing its use on a large scale in cholera epidemics, and

of proving that it is lethal to the cholera germ, even when greatly

diluted, is undoubtedly due to him alone.

The enormous practical importance of the discovery has, however, been

but slowly realised, though its capabilities were put to the test of

practical application by the writer immediately after Mr. Hankin

published his suggestion, with the result that a severe epidemic in a

town of over 10,000 inhabitants was brought to an abrupt termination

within three or four days.

The method of disinfection of wells by means of this chemical has

already been described on page 47, _et seq._

The addition of a few ounces of common sulphuric acid increases, I

believe, the lethal effects of the permanganate on the cholera germ, but

is certainly not necessary, and I have no personal experience in its

employment, as the taste imparted is somewhat persistent; and in dealing

with suspicious races such as those inhabiting our Indian possessions,

it is desirable that all obvious change in the taste or appearance of

the water should pass off as soon as possible.

The alternative agents are alum and quicklime, either of which is very

fairly effectual, though by no means as trustworthy as permanganate.

Their great advantage lies in the fact that they are obtainable almost

everywhere, and that being familiar articles of daily life their use is

less likely to give rise to misunderstandings in dealing with ignorant

and suspicious populations, who regard with mistrust the treatment to

their wells with a chemical so strange and striking as permanganate must

appear to them. Nearly all races are, however, familiar with the

cleansing powers of lime, and in the case of Indians, the wonderful

powers of alum in clearing turbid water is a bit of household knowledge

familiar to everyone. A pound or two of alum, or half a hundredweight of

lime, are required for each well. If alum is employed, it should be

roughly powdered.

To further avert all suspicion I find it a good plan to hand the

necessary money to an inhabitant of the place and ask him to fetch me

from the local shop the amount of alum or lime required. I then, if alum

be chosen, tell him to pound it up with a brick and himself to throw it

into the well, myself standing somewhat aloof. As everyone is familiar

with the use of alum in purifying water, and there is obviously no

possibility of the surreptitious introduction of anything else, with

ordinary tact, no objection will ever be made. Of course, the person

thus impressed into the service of sanitation should always be a man of

good caste, preferably a Bhraman.

Both these agents act, I believe, mechanically by coagulating certain

forms of organic matter present in the water, and so carrying to the

bottom, entangled with it, the germs present in the water, in which

situation they perish on account of the free access of water containing

their nourishment being impeded, and on this account at least two days

should be allowed to elapse before the water is again taken into use,

during which all disturbance of the water should be carefully avoided.

Neither of these agents is in any degree as trustworthy as permanganate,

but their employment should not be neglected in cases where the latter

is either unobtainable or objections are raised to its use. Of the two,

lime is probably the better, but alum much the handier.

Whichever agent be adopted, it is well to treat as large a number of

wells as possible. A certain number must needs, of course, be left

untouched, for use during the time the treated wells must be left

undisturbed, and these should be dotted about the town, so that the

minimum of inconvenience may be inflicted on the townsfolk; but always

leave as few as possible, as objections may be raised on your second

visit, a couple of days after, to complete the process by disinfecting

the remaining wells, and it may hence happen that you may have to rest

content with what you have been able to effect on your first visit.

Always, too, commence operations on the well you have reason to suspect

is infected, or, in other words, that used by the people of the house in

which the first local case has occurred.

Permanganate has now had a long trial in India. I have never known it

fail, wherever it has been used in the manner above described, and the

operation has been conducted _by an European officer in person_. The

native medical officer, even when trained after our European methods, is

seldom really convinced of its efficiency, and moreover he lacks the

prestige of prophets hailing from abroad, and so may be really unable to

carry out his instructions. An even commoner mistake is to go to work

piecemeal, disinfecting a few suspected wells and leaving the rest till

fresh cases spring up, as they necessarily must, as buckets infected

from the first infected wells will inevitably be taken to other wells

during the time that the former are unusable, and they can scarcely fail

to infect them, and so start new foci of infection, if sufficient time

be allowed for the germs to increase and multiply to a dangerous extent

in their new location. Reports of failure I have received in plenty, but

on investigation they have always proved to be due to some such cause as

those indicated above. It is, of course, only rarely that a layman will

find himself called upon to conduct such operations on a large scale;

but the knowledge of how to do so may be of such great public benefit to

the readers’ coloured fellow-subjects, that it is most desirable that

every European should know how to proceed, and, at any rate, I would

strongly advise my readers, should cholera appear in their

neighbourhood, never to omit the precaution of disinfecting all wells

under their own control, as it is a great protection to one’s servants

and other native attendants. It is well, too, to repeat the process

occasionally as long as the disease continues near one.

By the simple precautions as to food and drink described above, the

danger of being attacked by cholera may be reduced to a very small

contingency, even when it is raging around one, and there is no reason

whatever for the almost superstitious fear with which the disease used

to be regarded.

It remains to say a few words as to the treatment of cases should they

arise in your household in places where medical aid is unobtainable.

In the first place, it should be remembered that the danger of handling

and nursing patients is but small, for, as already remarked, you cannot

“catch” cholera in the same way as you can small-pox or plague. To

become infected by the germs you must eat or drink them. The discharges

in cholera are, of course, intensely poisonous, and it is impossible to

nurse a case without the hands, and perhaps one’s clothing, becoming

fouled; but the germs are perfectly harmless applied to the skin, and

with due precautions as to cleanliness and disinfection of the hands,

there should be no danger of their gaining access to the nurse’s mouth.

To avoid contamination of clothing, a washable overall should be worn,

such as can be improvised from a sheet, with a hole for the head cut in

the middle, secured round the waist with a cord, and the sleeves should

be turned up well above the elbows. Care should be taken not to touch

the lips or face with the hands while in attendance on the patient. On

leaving him, the overall should be wrung out in sublimate lotion and

spread out in the full blaze of the sun to dry, and the hands and arms

should be thoroughly washed first with warm soap and water and then with

sublimate lotion, care being taken not to eat or drink until these

precautions have been complied with.

Medical science is absolutely at fault in the treatment of cholera, so

that no treatment can be recommended beyond such measures as naturally

suggest themselves to relieve the patient’s sufferings.

The symptoms of the disease consist of violent purging and vomiting, the

discharged matter being watery and almost colourless, with small

particles and shreds of whitish matter floating in it, being, in fact,

to quote the usual simile, very like rice water. Very often the patient

suffers from violent muscular cramps, which cause great suffering. This

active onset is followed by a stage of collapse, in which the skin

becomes cold and livid and the face and hands singularly pinched and

blue. If the patient survive this stage, it will be found that the urine

is suppressed, the functions of the kidneys being, for the time,

absolutely suspended; and the patient can never be considered out of

danger till this function has resumed its natural course.

Now as to treatment. It must be in the first place remembered that it is

absolutely useless to worry the patient with attempts to administer

medicines by the mouth, as the digestive and absorptive functions are

for the time totally stopped, and it is quite as much to the purpose to

put your remedies in the patient’s pocket as to force him to swallow

them. To have any chance of acting, medicines must be administered by

being injected beneath the skin by means of the hypodermic needle; and

so powerless are all known drugs in this disease, that I should hesitate

to recommend such medications to be attempted by amateur physicians. The

only drug which has ever appeared to me to effect any good has been

chloral hydrate dissolved in water and injected under the skin in

5-grain doses every few minutes until 30 or even 40 grains have been

administered. There can be no doubt that this treatment controls the

violence of the symptoms, and usually does away with the horrible

suffering caused by the terrible cramps that are so common in the

disease. I am even inclined to believe that a somewhat better percentage

of cases recover under the treatment, though this is doubtful. Failing

this, massage and frictions with the hands do much to relieve the

cramps, and in the cold stage, every care should be taken to maintain

the heat of the body by covering the patient with blankets and placing

around him bricks heated in the fire and wrapped round with strips of

wet blanket. During the reaction that follows on the cold stage, in

favourable cases, attempts should be made to stimulate the kidneys by

the application of mustard plasters to the loins. To attempt to give

food during the acute stage is obviously worse than useless, but there

is no harm in letting the patient suck small lumps of ice to assuage the

terrible thirst of the disease. In the stage of collapse, stimulants

naturally suggest themselves, but are seldom of any use when given

internally. A few drops of ether inhaled from a handkerchief is, if

available, perhaps the best method of stimulation, but the weakened

kidneys have quite enough to do without having to deal with alcohol, so

that it should be but sparingly resorted to, if at all. When the patient

shows such signs of recovery that it appears likely that food can be

tolerated, small quantities only of easily digestible food, such as

milk, rendered mucilaginous by the addition of a little arrowroot,

Brand’s extract, &c., should be given, but it can easily be understood

that after so severe a shock to the digestive system, the greatest care

will have to be exercised in the feeding of the patient. Finally, it

should not be forgotten that all the discharges of the patient are

virulently infective, and that they and everything soiled by them should

at once be disinfected. When the supply of disinfectants is limited, a

good plan is to place in the bed-pan and basins used a sufficiency of

sawdust, and to at once burn the contents by emptying them on to a brisk

fire.

DYSENTERY.

We cannot claim to know much definitely as to the exact method in which

this disease arises. Four or five vegetable germs and at least two small

parasites belonging to the animal kingdom have been found, but none of

these are present in all cases, and many of them may be quite commonly

discovered in the interior economy of quite healthy persons, so that

either the true germ remains to be discovered, or those we know of have

only a secondary importance, becoming harmful only when they find

themselves in contact with an irritated bowel. As a matter of fact,

there are a good many kinds of dysentery, but to enter into their

various characteristics would only confuse the lay reader.

The common characteristic is the discharge of frequent scanty motions,

with much pain, and an intolerable sensation that more is to come. The

material voided is always extremely offensive, of a mucous consistence,

and wanting in the natural bilious colour. In severer cases, the mucus

becomes streaked with blood, and sometimes little else will be seen, and

the actual loss of blood itself may become a serious element of danger.

The disease does not usually occur as an epidemic, though something very

like one is not unfrequently to be met with among bodies of men

subjected to severe hardships and privations, as for example among

soldiers during an arduous campaign in extreme climates. Some

predisposing cause capable of causing irritation of the intestine seems

to be essential to enable the germs, known or unknown, to take action.

This irritant may be mechanical, such as coarsely ground, ill-cleaned

grain; or chemical, as in the dysentery that is apt to appear among

persons feeding on too newly reaped barley, or from foul or saline

water; but the commonest of all causes appears to be the decomposition

of the contents of the bowel which almost inevitably occurs when, from

any reason, the production of the bile is arrested.

The peculiar yellowish-green secretion of the liver known as the bile

appears not only to assist in the solution and digestion of the food,

but to act as a natural antiseptic, which checks the too great

multiplication of the various germs which are naturally always to be

found in the intestine. It is comparatively rarely that the liver itself

strikes work, but what does very commonly happen is that a chill, or a

mechanical or chemical irritation of the bowel, may extend to the bile

duct, and by causing swelling, or spasmodic action of its muscles,

prevent the contents of the gall bladder, in which the bile secreted by

the liver is stored up, from passing on into the intestine. The chill or

irritant that thus stops the flow of the bile necessarily at the same

time produces a greater or less amount of catarrh and inflammation of

the lower bowel, which, lying as it does next to the wall of the

abdomen, is most easily affected by cold; but stoppage of the flow of

bile into the intestine seems an essential element in the production of

dysentery, as a more or less complete absence of bile from the motions

is a universal symptom of the condition, and to restore the action of

the liver is, practically speaking, in cases taken sufficiently early,

equivalent to curing the disease.

As has been already noticed, dysentery may be caused by a variety of

mechanical and chemical irritants, but by far the commonest cause is

undoubtedly chill to the surface of the abdomen, and the reason the

disease is so common in tropical climates is their peculiarly

treacherous feature of the chill that precedes the dawn. The earlier

part of the night is often intolerably close and sultry, and it is only

with difficulty that the jaded European manages to get off to sleep, and

then naturally with next to no covering of the body. As the hours pass,

the temperature falls somewhat and he sleeps more easily and deeply, and

when the peculiar chill falls that usually precedes a tropical dawn, he

is too far off in the land of dreams to be roused by the cold; and the

abdomen, bared probably by his restless movements during the earlier

part of the night, is left exposed to the treacherous chill.

That there are other ways of getting dysentery I have no doubt, but a

tolerably long experience has convinced me that the above is the history

of nine cases out of every ten that one meets with, and it follows from

this _that the all-important safeguard against dysentery is to protect

the abdomen from chill_. From this it follows that a cardinal measure of

precaution in the preservation of health in hot climates is the adequate

clothing of this part of the body. It is this fact that accounts for the

general consensus of opinion as to the value of the familiar article of

clothing known as the “cholera belt,” though I am by no means inclined

to regard the said garment as the best, or even a good, method of

attaining the object. At best the thickness of material is inadequate,

it is generally made too narrow to include the liver above and much of

the lower part of the abdomen below within its protection, and it

naturally has a strong tendency to “ruck” together so as to form merely

a very uncomfortable sort of belt, quite valueless for the purpose for

which it is intended. For wear during the day a much more comfortable

and efficient garment is the well-known Oriental “kamarband,” a long,

narrow scarf of woollen, cotton, or silk, according to taste, folded

into a broad band and worn twisted round the waist in place of a

waistcoat, over which it possesses the superiority of leaving the upper

part of the body free. The elasticity of the folded scarf gives also a

comfortable feeling of support, without any of the sensation of

constriction inseparable from a belt, and its adaptation to climatic

needs is testified by the fact of its being, in one form or another, in

use by every tropical race, if we except the Negro, who seems to the

manner born, and to want little artificial protection while he keeps

within the limits, to meet the conditions of which he evolved. How the

Negro gets on with no clothing at all, and the really much civilised

Bengali contrives to survive without a hat, are problems which we poor

products of centuries of artifice cannot be expected to solve; but the

bald fact remains that the Northern European, when translated to the

Tropics, must protect his viscera against cold in equatorial climates,

even more carefully than in his native north, if he wants to get back

there alive.

The cholera belt is especially fallacious at night. Unsupported as it

then is by other clothing, it is at no other time so liable to slip down

and leave unprotected the very parts that it is most important to keep

covered. In the dark hours one wants a protection that is unlikely to be

disturbed by forgetfulness, and is more likely to fall back into place

than be cast off. This exigency is met by a folded blanket thrown across

the trunk, within which are massed the delicate viscera essential to

life; the ends of the folds lying on either side on the ground, and

folded so that, without too thoroughly rousing oneself, one can spread

the rug out a bit, above or below, should the chill of the morning

become disagreeable to the chest or the lower limbs.

Provided that the feet, chest and arms are left free, a blanket arranged

in this way gives no feeling of oppression; and after a short period of

habituation, its deprivation conveys a distinct sensation of discomfort.

Lying across the body, with either end on the ground, it is unlikely to

be disturbed by the uneasy movements of the body. The fact of the ends

resting on the ground makes it difficult to shake it off, and it affords

far better protection than any closely-fitting garment, is more

comfortable, and less likely to cause prickly heat. Care in this matter,

especially during the hours of sleep, is second only in importance to

the protection of the head against the sun during the day.

Never let the mildest dysentery, or even diarrhœa, continue unchecked.

Taken early, no disease is more tractable, while if allowed to pass on

to a chronic condition, no malady is more troublesome; while really

severe chronic dysentery is practically incurable. Some knowledge of how

to deal with such cases is therefore of special importance, as without

embarking on the career of an explorer, any one may find himself a day

or two’s distance from competent medical assistance in the countries

with which we have to deal.

Practically speaking, to restart the action of the liver is to cure

dysentery in all recent cases, and hence it is of the greatest

importance not to give opium, or that dangerous abomination

“chlorodyne,” both of which are most efficient in diminishing the flow

of bile. They are doubly dangerous, because they quiet not only the

action of the gall bladder, but also that of the intestines, and this,

it must be remembered, without really curing the disease. The flux from

the bowel is not really the disease, but merely an outward symptom of

mischief going on within, and is further the useful and salutary effort

of Nature to get rid of the irritating matter that is causing the

mischief; and hence to stop the movements of the bowel, before the

peccant matters have been got rid of, is a most dangerous step to take;

so that no drug of the above description should on any account be given

during the earlier stages of an attack of this sort. Next to this the

matter of greatest importance is to give the irritated intestine rest by

at once stopping the ordinary diet of solid food and substituting some

mucilaginous preparation, such as milk thickened with a little arrowroot

and taken _cold_. Where the attack is sharp, a few hours’ fast is by no

means unadvisable, but must not, of course, be continued too long.

Wherever possible, it is best for the patient to rest in bed, and if

there be much abdominal pain a hot-water bottle placed against the pit

of the stomach will afford great relief. In a large proportion of cases

no other treatment than rest and avoidance of opiates is required.

Avoid also alcohol in all forms, at any rate unless extremely diluted.

If, however, the symptoms fail to moderate under this treatment, it is

well to secure the removal of any irritating or poisonous matter that

may remain in the bowel by the administration of a dose of castor oil, a

full ounce for a grown-up person down to a teaspoonful for small

infants. The great advantage of this drug is that besides acting as a

safe and certain laxative, the oil itself forms a most soothing

application to the irritated bowel, just in the same way as it does to

the skin when that structure is scorched or otherwise inflamed. To treat

an intestinal flux by the administration of a laxative may appear

strange to the lay mind, but you need never fear to employ castor oil,

however violent the flux may be, and in children especially, it is a

good routine commencement of treatment for any looseness of the bowels.

A good plan for getting down this remedy, which, it must be admitted, is

usually most obnoxious to adults, is as follows. Select a wide, shallow

drinking vessel, such as a champagne glass, and moisten its interior

thoroughly with a teaspoonful of some strongly-flavoured spirit, such as

gin, turning the glass about until all parts are wetted, then add a

couple of tablespoonsful of water, and into the middle of this pour the

oil, avoiding the sides, so that it floats separately, like the yolk of

an egg surrounded by the white. If now the contents of the glass be

swallowed as nearly as possible at a single gulp, the oil passes through

the mouth and throat so completely surrounded by the spirit and water

that its presence cannot be noticed. A tabloid containing ¹⁄₄₀ grain of

perchloride of mercury should be taken shortly after, and after a lapse

of three or four hours the disinfection of the contents of the intestine

may be completed by taking a 10-grains tabloid of resorcin every four

hours.

As a rule, under this treatment the yellow colour soon reappears in the

motions and all symptoms disappear; but should the liver refuse to act,

as is indicated by the continued absence of the natural yellow colour in

the motions, it will be necessary to give a large dose of

ipecacuanha--to get this drug down without setting up vomiting,

requires a certain amount of preparation--as in smaller doses, it is one

of the safest and most certain of emetics. It is best to give the dose

the last thing at night, when the patient is naturally likely to be

sleepy, and half an hour before it is given, a preparatory dose of a

grain of opium should be administered. The patient should lie as quietly

as possible, and after the dose (30 grains, or half a dozen 5-grain

tabloids of ipecacuanha) all liquids should be withheld. It is also

important to use as little water as possible to wash down the tabloids,

as success in keeping down the drug depends mainly on the absence of any

notable amount of fluid from the stomach; and this abstinence from

fluids, as well as from food, should be continued until the next

morning, when in all probability a copious bile-stained motion will show

that the drug has taken its desired effect. As a rule, after this, two

or three tabloids, containing ¹⁄₄₀ of a grain of perchloride of mercury

_per diem_, for a few days, will suffice to maintain the action of the

liver and to disinfect the bowel, but occasionally the medication with

ipecacuanha may have to be repeated. Remember, however, that no drugs

will be of much service in this disease without the greatest care in

diet.

An Indian medical officer has generally a variety of institutions under

his charge, and usually amongst them a prison, of which he is not only

the medical officer, but also the military governor--a sensible

combination of offices which might well be imitated elsewhere. Now,

although dysentery is a disease which gives much trouble in Indian

prisons, the writer did not lose a single one of his jail-birds from

that cause for several years; and he imputes his success to the practice

he made of at once relegating each case of dysentery to a solitary cell,

where it was utterly impossible for the patient to obtain any other food

than that ordered for him. When left in the general wards they could not

be kept from obtaining more or less of the bread and vegetable curry

that formed the ordinary diet of those not seriously ill.

Soups are rarely well borne in dysentery, and hence the diet must be

restricted to milk foods, the milk being always rendered mucilaginous by

the addition of a little arrowroot or gelatin, cornflour, &c. When there

is much dyspepsia the milk may be given semidigested by combining it

with one of the numerous pancreatised proprietary articles, such as

Benger’s food. Afterwards a raw egg may be given beaten up with the milk

or Benger’s food, and subsequently rice pudding and fish; but great

caution is always required in resuming the ordinary diet, as the bowel

always remains easily irritated for some time after the attack has

subsided. Everything should be given cold (preferably moderately iced),

and in small quantities at a time.

DIARRHŒA.

Diarrhœa in tropical climates arises from much the same causes as

dysentery, and like it, is very apt to be set up by chills to the

abdomen; in fact, these diseases may be regarded, for the practical

purposes of prevention and treatment, as different degrees of the same

condition; the more serious disease being further complicated by

concomitant affection of the liver. Heavy dosing with ipecacuanha will

not, of course, be required in the milder disease, but otherwise its

prevention and treatment may be regarded as the same, especially as in

tropical climates, the mildest access of diarrhœa should always be

respectfully dealt with, as it may easily develop into dysentery if

neglected.

Hill diarrhœa is a peculiar form of chronic looseness of the bowels that

is not uncommon in the Himalayas, and, I believe, in other elevated

regions. Certain people appear specially liable to it, much in the same

way as some are subject to hay fever, while others are never affected;

and the proclivity is so marked in some persons that it is impossible

for them to reside in such localities, and they are hence debarred from

taking refuge from the fierce heat of the plains. We are not very clear

as to its causation, though the disease is traceable in some places to

the presence of finely divided mineral matter (mica) in the drinking

water, and so may be guarded against by careful filtration of all water

used for drinking or cooking. The climate of the hills, again, though

pleasant enough, is during the rains even more treacherous than that of

the plains--damp cold, alternating with warmth; but withal, as has

already been remarked, the disease is mainly one of personal proclivity,

and where the tendency is very marked the only course is to avoid

residing in places where it is apt to occur. Should you, when travelling

in the hills, be attacked with this malady, careful filtration of water

and care in diet should be attended to, and a pill or tabloid containing

one grain each of euonymin, blue pill and ipecacuanha may be taken at

night; but should the trouble persist, no time should be lost in

returning, if possible, to within range of competent medical assistance,

as if neglected, the disease is apt to develop into a most troublesome

condition known as sprue.

_Infantile Diarrhœa_ is terribly common in hot countries, and hence the

least disturbance of this sort should never be neglected in young

children. The rapid rise in the infantile death-rate that coincides with

any approach to a tropical temperature in Europe, shows well how full of

risk is a child’s tenure of life in latitudes where such temperatures

are not the exception, but the rule. The liquid food, which alone is

suitable to the infantile digestion, is perilously liable to

decomposition when the temperature of the air rises much over 70° F.,

and, under such conditions, food which, to the nose and eye, shows no

appreciable change, may yet be virulent with a poison as lethal in its

effects as arsenic, and far more deadly, weight for weight. As a matter

of fact, the poisons which may be generated in food subjected to high

atmospheric temperatures, differ only from the most active of mineral

poisons in their greater virulence, and to commence treatment in such

cases with any agent that checks the action of the bowels ensures an

unfortunate result with even greater certainty than if we were dealing

with antimony or vitriol.

The first _desideratum_ is to get rid of the supply of poison which has

already been generated within the bowels, and the second to stop the

fermentation which alone can generate the poison. To meet the first

indication an unirritating laxative should be at once administered. When

the symptoms are severe, one or two teaspoonfuls, according to the age

of the child, of castor oil is probably the safest remedy, but in less

violent disturbances a drachm of our old friend, Gregory’s powder, will

be more appropriate. The laxative should be promptly followed by the

administration of one of the intestinal antiseptics, amongst which I

have a personal preference for 5-grain doses of resorcin; but β naphthol

grs. ii., salicylate of bismuth grs. v., or perchloride of mercury gr.

¹⁄₆₄, if more readily to hand are equally valuable, and are, I know,

preferred, one or the other, by practitioners according to their

individual favourable experiences; but opiates of all sorts are always

to be avoided as long as active mischief continues, though fifteen or

twenty drops of paregoric or some other preparation of the poppy may

possibly accelerate the cessation of obvious symptoms when the “causing

cause” of the disease has been disposed of.

The germs that produce this intensely poisonous matter are quite

different from those whereby milk “turns sour,” and the fermentation

which produces it may go on some time without giving rise to changes

obvious to the nose or eye. Hence, though it is no doubt possible for

the germs to reach the stomach in other ways, as a rule the changes have

commenced before the food is swallowed.

Diarrhœa is naturally rare in infants fed entirely at the breast, and

from what has been said it will be clear that the surest protection

against this terribly fatal malady lies in the avoidance of bottle

feeding; for to carry out the latter safely in a tropical climate, would

tax the resources of a skilled bacteriologist. It is, however,

unfortunately the fact that European women residing in such climates are

very often really unable to suckle their children, in spite of all the

good will to do so; and when the supply is inadequate and has to be

supplemented by artificial feeding there is little real gain, as the

bottle, with all its dangers, must needs be used several times in the

day. On this account, whenever the mother is unable to fully nourish her

infant, by far the safest course is resort to wet nursing. I have met

with people who have a sentimental objection to entrusting their child

to a woman of another race; and are even capable of believing that the

mental and moral qualities of their offspring may be affected by such a

diet; but it should be needless to say that there is no foundation

whatever for any such idea. Great care is of course necessary in the

selection of the foster-mother, who should be young, healthy, and

vigorous. Her own baby ought not to be much older than the one she is to

nurse, while it is needless to say that she should never be permitted to

nourish both infants together. It is also most important that she should

be examined, and, if possible, selected, by a medical man.

When, however, artificial feeding is unavoidable, the most elaborate

care as to the purity and cleanliness of the milk and all utensils that

come in contact with it are required. In hot climates it is not enough

to merely wash the bottles and jugs which are used. They should be

boiled at least once a day, and in very hot weather, even each time

after using. The simpler the bottle is in its construction the better,

those with long tubes and elaborate screw stoppers being so dangerous

that it is far better to resort to spoon feeding than be tempted to use

one, even as a temporary expedient. The form of bottle which presents

least dangers, because the most easily cleaned, is that in which the

nipple is in one piece, with an elastic cap that is made to fit the

mouth of the bottle, thus doing away with the necessity of any stopper

or cork. Moreover, if the special bottle chance to get broken, it is

generally easy to find some medicine phial, or other small bottle, over

which the cap can be stretched and which serves equally well. Rubber

will not stand repeated boiling, hence, when not in use the nipple

should be always kept immersed in a strongish solution of boracic acid

(10-15 grs. to the ounce) and rinsed before and after using in ordinary

drinking water. In making the boracic solution, a sufficient approach to

chemical accuracy may be made by placing an eggspoonful of boracic acid

in a breakfast cup and filling up with boiling water.

Asses’ milk is probably the best substitute for an infant’s natural

food; and failing this, goats’ milk is to be preferred to that from the

cow. Whichever is employed, it is best to buy the animals and have them

kept in one’s own compound, so that one can ensure, by personal

supervision, their being cleanly kept and carefully fed. Before milking,

the animal’s teats and the hands of the milker should be washed in

boracic solution, which should be kept ready made up in a large earthen

vessel (an Indian gurrah, for example).

A great drawback of cows’ milk as a food for infants in India lies in

the fact that, whereas human milk has a distinct alkalinity, that of the

breeds of kine indigenous to that country is often (in my own

experience, always) rather strongly acid, even when freshly milked from

perfectly sound and well-cared for animals.

Generally speaking, indeed, the acidity is so considerable that the

amount of alkali contained in even twice its bulk of lime water, is

quite insufficient to neutralise it. In place, therefore, of the

conventional lime water, it is better to add about as much as will stand

on a sixpence, of a mixture of equal parts bicarbonate of soda and

citrate of potash, to each bottle. Of course, if you wish to be exact,

you can get from your chemists some books of litmus paper which change

to a redder tint when dipped into an acid fluid and become bluer when

moistened with an alkali; and it is a good plan to test in this way, at

any rate to commence with, in order to ascertain roughly the amount

required for the milk of the particular cow that yields the milk. The

citrate of potash, besides being for practical dietetic purposes an

alkali, has the additional valuable property of preventing the milk,

after it has reached the infant’s stomach, from curdling in large

masses, as cows’ milk is apt to do unless treated in this way. Human

milk, when curdled in the process of digestion, does so in small

flocculi; and the tendency of cows’ milk to curdle in large masses makes

it a frequent cause of dyspepsia as well as of diarrhœa. Whether or no

the peculiarity of possessing a so strongly acid reaction is shared with

the milk yielded by cows in other hot climates I cannot say. Whatever

may be the source of the artificial food, it is needless to remark that

it should be sterilised by means of one of the numerous appliances now

sold everywhere for the purpose, and that care should be exercised to

guard against chill to the abdomen.

The prevention of infantile diarrhœa is in fact purely a question of

guarding against impure and unsuitable food, and though the same is no

doubt also true for more temperate climates, precautions which may be

sufficient in an English summer, break down at once in a moist heat of

90° in the shade.

Should, however, in spite of all precaution, the disease appear, steps

should at once be taken to get rid of the food that is fermenting within

the stomach by administering a teaspoonful of castor oil, and if any

obviously large proportion of the oil be thrown up within half an hour

of taking the oil, give another half teaspoonful. The milk given should

be much more diluted than usual, and if it obviously continues to

disagree, as evidenced by continued sickness after the bottle, it should

be pancreated by means of Benger’s food, which will often be kept down

where the simply sterilised milk is rejected. If, however, milk in any

form prove unsuitable, meat juice may be substituted for a few hours.

Meat juice is made by mincing raw lean meat, sprinkling lightly with

salt, and adding just enough blood-warm water to cover it. Place the

mixture aside in a covered jug in the sun for two hours and then place

the pulpy mixture in a clean cloth and squeeze out the juice into a

basin by wringing the cloth. Before administration, a sufficiency of

sugar to make the mixture palatable should be added.

Another very useful food, as a temporary substitute for milk, when the

latter disagrees, is egg albumen. To prepare this, beat up the white of

a small egg with enough cold water to make a bottle, add just enough

sugar to perceptibly sweeten, and let it stand till the froth produced

in the beating has settled. Should these novel delicacies be refused by

the infant, the addition of even a teaspoonful of milk will often lend

sufficient of the desired flavour to induce the child to take it. The

egg albumen should always be given cold, as even warming the bottle by

placing it in hot water might easily coagulate a little of the albumen

and so convert an exceptionally bland food into a very dangerous and

indigestible material. After the oil has acted, about 5 grains of

Gregory’s powder may be given once or twice a day, and if the natural

yellow of the child’s napkins be not rapidly recovered a grain of grey

powder should be added.

The course of infantile diarrhœa is often appallingly rapid, so that all

may be over with the little sufferer in a few hours, and on this account

there should be no delay in obtaining medical assistance, even on the

appearance of slight symptoms of the kind, wherever such help is at

hand.

PLAGUE.

Strictly speaking, this terrible scourge cannot be said to be in any

sense a disease peculiar to warm climates, for the one climatic

condition that appears to check the course of epidemics of this disease

is extreme heat, which always moderates their virulence as long as it

lasts. In reality, it is a disease of low civilisation; and appears to

be practically incapable of attaining any serious spread amongst people

of European habits. During the terrible recrudescence of this disease,

which, for the last decade, has been ravaging the semicivilised world,

although repeatedly introduced, it has never succeeded in seriously

establishing itself in any European town. Even the admittedly backward

sanitation of Spanish towns appears to be too advanced to admit of the

spread of plague, and, what is more remarkable, the European portion of

the population of plague-stricken Eastern towns has remained practically

unscathed, while the indigenous population have been dying around them

in their thousands. When first the disease invaded India there was

naturally a good deal of alarm amongst the European population of

Bombay, but nowadays the official, commercial, and social life of the

European community goes on unmoved, even at times when the disease is

doing its worst--and is so assured of its own immunity that timid ladies

out for their evening airing will scarcely turn their head as the bodies

of the plague-stricken are carried past them on the way to the burning

ghaut. Perhaps this immunity may be to some small extent a question of

race, but the main determining cause is undoubtedly difference of habits

of life, as natives who have adopted European habits share in it.

The most important conditions favouring the spread of plague appear to

be overcrowding and inadequacy of air space and ventilation in

dwellings; and especially lack of light, as well as the want of domestic

cleanliness, and the treasuring up or neglect to do away with dirty

rags, dust and rubbish. A further reason in India is the sacredness of

animal life, which leads to the unrestricted multiplication of rats and

vermin of all sorts.

The germs of the disease are easily destroyed by moderate heat, strong

light, and most disinfectants, but are apparently capable of

preservation for long periods when protected from such agencies; and

hence the disease is capable of being transported from place to place by

the agency of dirty clothing, infected rags and such like, but the

characteristic which most embarrasses our efforts to deal with the

malady is the fact that plague is a disease not only of man, but also of

many other animals; and that rodents in particular are specially liable

to be affected by it, and are in fact generally seriously involved

before an epidemic has attained any serious spread amongst human beings.

Not infrequently, the first warning of an impending epidemic is the

discovery of dead and dying rats in large numbers; and the best

considered plans of dealing with the disease are necessarily constantly

defeated by the impossibility of extending to these proverbially

secretive and cunning animals the measures of isolation and disinfection

that are indispensable to success. It is obviously to little purpose to

disinfect the room in which a human patient has died, when in hollows in

its walls, roof and floors are hidden whole families of rats in every

stage of the disease; and it can avail little to isolate the

comparatively few human patients, while hundreds of infected rats are

left to wander about at will. Luckily, the infection of plague requires

close contact to secure transmission, and there is practically no danger

of contracting the disease in the ordinary open-air intercourse of life.

From what has been said, it will be seen that for Europeans resident in

plague-stricken towns personal prophylaxis is a comparatively simple

matter, as it is instinctively carried out as a matter of national

habit. There is comparatively little danger in entering infected

buildings during the day, or even in handling the sick, but unless it be

a part of his duty to do so, it is better for the European to avoid

passing through the infected portion of the town; to keep a keen eye on

the health of his servants; and generally to restrict, as far as

possible, association with the native community. The house should be

kept freely open to air and light, avoiding the closing of doors and

windows to exclude the heat, as in doing so we reproduce the domestic

habits which cause the natives to suffer so severely. If the weather

admit of it, it is better to sleep in the open; and should any mortality

among rats be observed within the dwelling, there should be no waiting

for any second hint, but the place should be vacated at once, and

thoroughly disinfected; nor is it well to return to it for at least

three weeks. Among the very small number of cases in which Europeans

have fallen victims to the disease, neglect to take timely warning from

the death of rodents within the house has occurred in more than one

instance directly reported to the writer.

On the personal prophylaxis of plague no more need be said, but in

out-of-the-way places, it not unfrequently devolves on the non-medical

European to have to take measures for the protection of the indigenous

community, in the absence of medical advice. To be effective, the little

that can be done must be done at once, and therefore a few words on the

general or public prophylaxis against the disease may not be out of

place. One of the few redeeming features in the natural history of

plague, is that it at first spreads very slowly. It is doubtful if, in

any case, the bulk of the infections are from man to man, and it appears

on the whole probable that, after the first introduction of the

infection, time is usually required to admit of the thorough

establishment of the disease amongst the rats before it can attain any

formidable spread amongst men. During this early stage there is no great

difficulty in dealing with the disease, and hence it is absolutely of

the most vital importance to obtain information as to the occurrence of

the first cases. In the case of these first attacks, whether imported

or apparently of local origin, no measures of disinfection and isolation

can be too rigorous; but the people should be made to clearly understand

that except at their own express desire and by their own enforcement,

compulsion in such matters will be at once relaxed should the disease

unfortunately gain a firm footing in their midst. As a matter of fact it

is unfortunately too true that there is really very little that can be

done to any purpose, when once the disease has fairly fixed itself on

the susceptible mass of an oriental urban population, and above all

things it is worse than useless to attempt to enforce sanitary measures

by compulsion, as it only leads to the concealment of extent and

localisation of the disease, and to organised obstruction to all

remedial measures attempted by those in authority.

It should be the duty of a civilised government to place at the disposal

of the population every possible means of combating the disease which

our superior knowledge and civilisation enables us to recommend, but it

should be made absolutely clear that these benefits of civilisation are

there to be simply taken or left, as they please. In the cases of

measures particularly liable to be mistrusted, such as inoculation, it

may even be well to charge a small fee for the operation, to be remitted

of course in cases when the patient can show that he is really

impecunious. The joy of getting to windward of the too credulous

official by a pardonable understatement of finances, would be a

temptation hard to resist by the average Oriental, and there is no harm

in writing out such a receipt; for the folks who require Hibernian

driving of this sort cannot read, and it was one of their countrymen who

could not only read, but think very much to the purpose, who suggested

the expedient to the writer.

I believe my good native friend was right, for I have actually seen

ordinary vaccination eagerly sought for by Orientals over whom we had no

shadow of political control, and who would have been up in arms at the

idea of compulsion; through the simple stimulus of the nominal fee

system.

As a matter of fact, there are few things that the Indian cannot be

persuaded to do by a tactful European official who has been allowed to

remain sufficiently long in a locality to become known and trusted by

the people among whom he has to work; but the notion of utilising the

personal factor in administration is, unfortunately, far from the Indian

bureaucracy, and the theory of one man being as good as another for any

purpose has been adopted to such an extent, that combatant magnates were

actually selected to control the operations of the medical experts in

dealing with plague. The attack on the plague bacilli with so tactless a

weapon as the bayonet naturally failed, but we certainly secured a

striking and no doubt valuable demonstration of “how not to do it.”

The opportunities that should be placed at the disposal of the

population may be epitomised as follows:--

(1) _Evacuation._--The truth of the old proverb as to the policy of

“running away,” is illustrated in the case of plague, if possible, even

more forcibly than in that of the late Boer war, and as the population,

like the warlike Boer, should always have a new position ready to fall

back on, a certain number of huts should be set up in the open for the

accommodation of those who are wise enough to take Nature’s hint in good

time, and to leave the germs of infection behind them to “stew in their

own juice” till they die for want of material.

The ruder these structures are made the better, it being essential that

they should cost so little that they can be burned without regret should

they become infected; and hence nothing beyond the provision of shelter

against the sun and rain should be aimed at. In the case of village

communities, complete evacuation of an infected site is generally

possible, but in towns of any size such a plan may be out of the

question. A small camp should, however, be provided for the

accommodation of such as are wise enough to avail themselves of it.

Where, as is the case with tea-garden and mine managers, the European

superintendent for all practical purposes constitutes the government on

the spot for the time being, the policy of instant evacuation of “the

lines” wherever a case of plague has appeared cannot be too strongly

insisted upon. Even when left to themselves, the germs have a strong

tendency to die out in the course of a few weeks; and aided as it can be

by systematic disinfection of the inhabited site, there can be no doubt

that this policy of flight is the sheet anchor of our armament for

meeting the disease.

(2) A hospital constructed of the same temporary materials should be

provided for the reception of travellers and vagrants, as well as for

such cases in which, on account of panic, the friends and relatives

decline to attend to the sick; a contingency which, however, is but

rarely met with in India.

The patients should be left to choose their own medical attendants as

far as possible, but the paid attendants should, if possible, be

subjected to protective inoculation, and the people should be further

encouraged to bring their sick to this hospital for treatment and

nursing by themselves, but no attempt should be made to isolate the

persons employed in nursing, or, indeed, to enforce isolation in any

form, as experience has shown that, however desirable it might be to do

so, such measures cannot practically be carried out.

(3) _Protective Inoculation._--Although there is some doubt as to the

extent and duration of the protection conferred by injection with

Haffkine’s protective emulsion, there can be no doubt that it confers a

considerable power of resistance. The operation is one that can only

safely be undertaken by professional men, but it should certainly be

placed at the disposal of the community wherever practicable. As a

matter of example, it is as well for Europeans to submit to the process,

though in view of the rareness with which they are attacked, it can

hardly be considered necessary, except in the case of those whose duty

brings them into close and constant association with the native

community.

(4) The destruction of rats is a measure of no small importance, and one

which should be undertaken in all towns where there is even a

probability of the introduction of the disease. Most communities possess

professional rat-catchers, and the services of these men should be

enlisted, though where a reward is offered for dead rats, only

full-grown animals should be paid for, as otherwise it may lead to

breeding rats for the sake of the reward.

Quarantine, protective cordons, train inspections, and the like, have

been tried, and found rather worse than useless; as like all other

systems that interfere with personal liberty, they lead to concealment

of cases, and concealment necessarily involves the treatment of the sick

under circumstances that render the spread of the disease to relatives

and attendants almost certain. At the same time, measures of this class

are those that are regarded with most favour by natives, and provided

they are assured that, in case of the discovery of cases, there will be

no forcible interference with their habits and customs, they will

generally adopt and themselves carry out the more useful and practicable

of the measures of this class, such as the watching of new comers by

road and rail, and even the inspection of the dead. It is a mistake to

think they are not as anxious to keep the pestilence out of their towns

as their European rulers can be, and, as a rule, they will make no

objection to the proper disinfection of houses that have become

infected, but they will prefer to run any risk rather than submit to any

interference with their domestic customs.

(5) The means of thorough disinfection should be provided. The best of

all disinfectants is fire, and, as far as possible, all infected

bedding, clothing and rubbish should be burned, and paid for. In order

to secure, to some extent, the destruction of rats and other vermin, as

a preliminary measure, the house should be fumigated by means of sulphur

fumes, and after this has been completed and the house opened, the

floor, walls and furniture should be thoroughly washed down with strong

solution of corrosive sublimate (¹⁄₁₀₀₀) thoroughly acidified with

hydrochloric acid. Phenyl has also proved serviceable. The men employed

in this work should have been, if possible, inoculated. They should

thoroughly grease all exposed parts of the skin before commencing work,

and should be thoroughly clothed, being made to wear nether garments

reaching to the ankles and tucked into boots of European pattern, which

should be kept well greased, so that they may not get hard from contact

with the disinfecting solutions. I cannot recommend the digging up of

earthen floors, as the task is undoubtedly a very dangerous one to the

men employed in the work, and there can be no possible real need for it,

as, of all parts of a dwelling, the floor is that which can most easily

be saturated with powerful disinfectants.

Lastly, after washing down with perchloride do not lime-wash or attempt

in any way to employ these agents in any combination, as to do so shows

a pitiable ignorance, not only of the Board School rudiments of

chemistry, but of the behaviour of the specific germ of plague to

external surroundings. I am perfectly aware that the combination is

ordered in several sets of Indian regulations, but in justice to the

service to which I have had the honour to belong, I hope my readers will

accept my assurance that these ludicrous recommendations are one of the

natural results of the meddling of ignorant amateurs, military and

civilian, who unfortunately have often been allowed to assume the

command of sanitary matters within our great bureaucratic dependency.

If the inhabitants of infected houses can be induced to migrate for a

time into camp, so much the better, as in such cases the enormous

additional disinfecting powers of air and light can be utilised by

removing, for a time, portions of the tiling or thatch, and it must be

remembered also that time alone is also an excellent disinfectant. The

danger they run in immediately returning should be clearly pointed out,

but if return they will, they must be let do so, as compulsion means

opposition, and the benefit of the disinfection to the general community

is only lessened by their return in so far that should they fall victims

to their own rashness they form fresh foci of infection and the process

has to be gone over again. In the case of small compact communities,

such as gangs of coolies working under commercial corporations, a more

autocratic course of action is, of course, practicable, but should never

be carried to such an extent as to bring about organised opposition, and

however stupid and prejudiced they may appear to the ordinary European

mind, no effort should be spared to obtain the co-operation of the

people themselves, and it is in securing this that the personal element

of long association and mutual trust is especially valuable.

In spite of the great advances in our knowledge of the disease that have

been made during the present recrudescence of the disease, we are still

a great deal in the dark on many points, and especially as to the

mechanism of infection in the majority of cases. Each year of the

progress of the epidemic demolishes some one or other of the few

standpoints of certainty that we had imagined as firmly established, and

it is evident that some great discovery remains to be made before plague

will cease to be, from many points of view, an almost complete mystery.

SMALL-POX.

Although in no sense a malady in any way peculiar to hot countries,

Europeans are necessarily much more exposed to infection among

semi-civilised communities, where vaccination is at best only partial,

than in Europe; and hence it is well to impress the necessity of

efficient re-vaccination on all who have to live among people by whom

the blessings of vaccination are, as yet, imperfectly appreciated. Even

a single vaccination affords so great a protection that it is rare to

meet with fatal cases amongst those who are foolish enough to live in

the midst of small-pox without being re-vaccinated, but it is hardly

worth while to risk suffering from so revolting a disease, with the

chances of disfigurement for life, for the sake of avoiding so trifling

an inconvenience as that involved in the little operation. On this

account it is very desirable for the intending emigrant to tropical

parts to be re-vaccinated before starting, as an inflamed arm is much

more troublesome when complicated with prickly heat than it is in

temperate climates. In addition to this, it is always wise to submit to

re-vaccination whenever an epidemic of small-pox is raging around one.

If needless, the virus will not “take,” and you will suffer nothing

worse than the trifling scratch involved in the operation. If, on the

other hand, it “takes,” it shows that a grave risk would have been run

in neglecting the precaution.

SLEEPING SICKNESS.

This peculiar malady has only come into notice of late years, since the

opening up of Central Africa, and though it was at first thought to be

confined to the negro race, has recently been shown to occasionally

attack Europeans. In its early stages, the disease presents many points

of resemblance to ordinary malarial fever, and has usually been confused

with it, both by patient and doctor; but following this, after an

interval of a few weeks or months, certain peculiar nervous symptoms

appear, from which the disease has taken its name, and which are mainly

characterised by hebetude and somnolence. It would be superfluous, in a

work like the present, to enter into any details as to its

peculiarities, especially as our knowledge on the subject is at present

in its infancy. It may, however, be fairly said that we are almost

certain that the disease is caused by certain peculiar parasites

(_Trypanosomes_) that are found in the early feverish stage of the

disease in the blood, and subsequently, when the peculiar sleepiness

appears, in the fluid that bathes the spinal canal. From the analogy of

malaria, as well as from anatomical considerations, it is tolerably

certain that the disease is conveyed from one human being to another by

means of inoculation through the agency of biting insects.

Further, strong suspicion, approaching moral certainty, strongly points

to certain flies, of the class known as horse and cattle flies, as the

species that acts as the intermediary. These flies are much more common

in tropical climates than they are at home, and are characterised by the

peculiar persistency with which they attack an animal, in spite of all

attempts to drive them off; and so much is this the case that nothing

short of pursuing the insect until it is killed is of any use. They do

not, as a rule, invade houses, and it is exceptional for them to attack

man, but they will do so occasionally, and the stab they give is so

sharp that it is hardly likely to be overlooked.

At present the disease appears confined to Africa, but species of the

same flies are to be found in India, and the writer has more than once

been bitten by them, though no danger attaches to the incident, as the

specific germs of the disease do not occur in that country.

[Illustration: FIG. 14.--Drawing of the fly concerned in the Tsetse, or

Trypanosome, disease of horses.]

They are usually dark grey, flattened insects, with a peculiarly hard

integument, which forms so efficient a protection against injury that,

if merely squeezed between the fingers, they will commonly fly away in a

perfectly unconcerned manner. The easiest way to dispose of them is to

knock the insect down with the whisp of horsehair mounted on a cane,

commonly carried by horsemen when flies are troublesome, and then to

crush it under the boot, giving the foot a good twist, so the wound,

like that of the sergeant-instructor’s bayonet, may be “made incurable.”

The general appearance of these insects may be best gathered from the

above magnified figure.

It is obvious that as far as our knowledge extends, the prevention of

sleeping sickness is purely a matter of avoiding being bitten by insects

of this sort, and it is also clear that as far as indoor life is

concerned, the adoption of metallic gauze protection of the house will

be as effectual as it is in the case of malaria. These flies are,

however, mainly forest insects, and watchfulness, especially when

sitting out of doors, is all that can be suggested. Personally, if

bitten by one of these flies in a country where sleeping sickness

exists, I should be strongly inclined to destroy the bit of tissue

around the bite by means of some powerful caustic, such as pure carbolic

acid dropped into a small cut at the site of the puncture, for as yet no

instance of recovery from the disease has ever been met with, and in all

probability this measure, if done with tolerable promptitude, would

probably suffice to destroy the germs before they gained access to the

general circulation.

SUNSTROKE AND HEAT APOPLEXY.

The disturbances of the nervous system that are grouped under the above

heads vary a good deal, and probably comprise several different

diseases, with as many distinct causations.

It is a curious fact that sunstroke is practically unknown on the high

seas, and in certain countries, notably in South Africa, where the

fierceness of the sun would naturally lead one to expect to commonly

meet with it; and this circumstance, and the fact that something like

epidemics of the disease are occasionally met with, lend a certain

amount of probability to the idea held by certain authorities, that, in

one form at least, the malady belongs to the category of germ-caused

diseases.

The symptoms of the disease are insensibility, combined with a greater

or less elevation of temperature, and a large proportion of the cases

that one hears of are merely instances of fainting, due to fatigue and

exhaustion from heat. Such cases are specially common where large bodies

of men are massed together, and have to undergo great exertion under

unsuitable atmospheric conditions, and where, besides being hot, the air

is foul with dust and the emanations of the closely packed animals and

men, whose sufferings are often aggravated by thirst and the restricted

possibility of evaporation from the surface of the skin that is

inseparable from an inadequate supply of water; while the free play of

the lungs and heart are too often impeded by the unsuitable and

fantastic garments and equipments so dear to the infantile genius of

militarism.

Fainting is due to a sudden weakening in the action of the heart, and in

a certain number of cases of “sunstroke” of this sort, the mischief goes

beyond enfeeblement, the heart stops, and the man is dead. Most of the

cases of sudden death from “sunstroke” that occur on hot “field-days,”

as well as in military operations undertaken in earnest, are probably of

this character; and even when the heart has not absolutely stopped, its

action may be so feeble and fluttering that the insensibility is

prolonged and serious. The temperature of the body is, however, only

moderately raised, and when, under proper treatment, the patient has

regained consciousness, he soon recovers if permitted to rest, and in a

day or two may be little the worse for his adventure. In cases of this

sort all clothing and equipment should at once be loosened or removed,

and the patient should be given the full benefit of what “air” there is

to get. Hence, it is of the first importance to prevent sympathetic

onlookers from crowding round him in a ring. The chest and face should

be freely soused with water, and when the patient is able to swallow, a

little stimulant may be administered.

Some kind of shade should be improvised, at any rate over the head, but

no attempt should be made to move the patient till the pulse can again

be plainly felt, after which he should be placed on some sort of

stretcher and removed as quickly as possible to shade and comfort, where

he will probably speedily recover, for though “sunstroke” of this sort

is a highly dangerous condition while it lasts, it is rare for it to be

followed by any serious after-effects.

Cases of this sort are comparatively rare in civil life, the conditions

which lead to them being usually wanting; for it will be noticed that

even the military officer takes the greatest care not to be “smart” when

he goes out shooting under a tropical sun, his costume, when so engaged,

being generally a model of the way he and his men ought to be equipped

when engaged in the business of their profession.

What may be called true sunstroke is less common, and beyond the bare

fact that the sun’s rays are capable of acting in this way, we are

really quite without any explanation of its causation, as the condition

may be brought about by comparatively short exposure, without any

coincident exhaustion or fatigue; and may occur at times when the

temperature of the atmosphere is by no means excessive. It is probable

that over-stimulation of the nerves of sight by glare may have something

to say in the matter, as it has been found that persons at rest in the

open, in the Tropics, have their temperature less raised if they wear

darkly tinted spectacles than others similarly situated, but having the

eyes unprotected. This cannot, however, be the complete explanation, as

it appears to be exposure, not of the face, but of the skull and

back-bone, to the direct rays of the sun that constitutes the real

danger, and it is not the forehead but the back of the head and temples

that are most sensitive to the influence of “insolation.” So many

unexpected discoveries have been made lately of forms of light whose

very existence was, but a little time ago, unsuspected, that the matter

is less inexplicable than it was before the discovery of the Röntgen

rays made us familiar with light vibrations capable of passing easily

through substances we have been accustomed to regard as quite opaque.

The rays of the sun do not, of course, include vibrations of that

particular description, or none of our ordinary wooden photographic

apparatus would be of any use to us; but they may well have amongst

them other vibrations, as yet not identified, which are capable of

passing through the tissues and affecting the brain and spinal cord

beneath; and no other suggestion appears capable of explaining the

extraordinary way in which a few instants of exposure of the unprotected

head to an Indian sun suffices to cause a sharp headache; as the effect

is utterly inexplicable on any mere assumption of rise of temperature.

It is quite a mistake, for example, to think that it is safe to cross

one’s garden hatless, from the house to one’s stables, in the heat of an

Indian day. One is not of course likely to be stretched out in a state

of insensibility by so short an exposure, but you may easily earn a

splitting headache which will last you the rest of the day; and from the

time the sun is well over the horizon, till it again sinks beneath it,

it is a purposeless imprudence to be found in the open with the head

inadequately protected.

The selection of a suitable headgear for tropical wear is a matter of

the utmost importance, and no material appears to be as effective in

intercepting the peculiar vibrations which cause sunstroke, whatever

they may be, as the pith of the solah, or Indian rush, from which the

well-known tropical sun-hat is made.

Next to this in efficiency, I think, comes felt, and after this cork;

but the latter material, when adequately supported to give sufficient

strength, is really too heavy for comfortable wear; and if any

concession to “smartness” is desired, stiffened felt is to be preferred,

such as, for example, the well-known “Elgin helmet.”

But those who are wise, will abjure such compromises, and stick to pith,

either in the ordinary mushroom form, or in that of the admirable

“Cawnpore tent club” hats. Let it be freely admitted, that either

contrivance is as ugly as well may be, but it is better to keep one’s

brain clear for the appreciation of artistic beauty elsewhere, than to

have them permanently muddled for this and other less æsthetic purposes

in the effort to maintain a becoming exterior. Further, the sun is never

more treacherous than just after it rises, and before it sets; because

just then the nearly horizontal rays can reach the temples and other

parts of the head that are well protected by any ordinary sun hat when

it is higher above the horizon. In fact, as long as the sun is above it,

it is a mistake to go abroad in European head gear, though in the

morning and evening a soft felt hat, which can be bent and manipulated

so as to shield the particular side exposed to the sun, is better than a

solah hat, which of course cannot be adapted in this way. For really

tropical climates, in the heat of the day, no other material but solah

pith is at all adequate; but in South Africa and other sub-tropical

climates a less clumsy and more comfortable covering for the head may be

safely adopted, and for such purposes the broad-leafed Boer felt hat, so

familiar to us of late in the drawings in the _Illustrated London News_,

and _Graphic_, is hard to beat. I do not of course refer to the

melodramatic brigand arrangement that, in feeble imitation of our late

foes, was inflicted on the Imperial Yeomen by the would-be smart

military male milliner, but to the real article, as worn by the real

Boer and, it may be added, by everyone else who has work to do in the

open in that climate, after he has been out there sufficiently long to

have discarded the “helmet,” decked out with a pugaree finished off with

a pair of long tails down the back, with which his London Colonial

outfitter has probably provided him. The true Boer hat is an admirable

example of adaptation of costume to special climatic exigencies; but

though they are, I presume, manufactured somewhere in Europe to suit the

Colonial market, I doubt if such a thing can be purchased in England,

for as is well known the English manufacturer insists on his customers

taking his own designs, and those who would consult their own

requirements must needs deal elsewhere. Hence, if you are bound to “the

Cape” you will be wise to defer providing yourself with a hat till you

land, for the English outfitter’s muslin-bedecked helmet is a natural

object of derision to those who know what is really wanted, and no extra

protection is wanted under the double awning of the big liner that takes

you out to your new home.

The true Boer hat has an ample crown, a very broad brim, and is not

looped up at one side, as anyone but a fool can see that to do so is to

make the hat suitable only for a one-sided world, in which the

inhabitants never require to deviate from a course carefully laid so

that the sun is always kept on the “brimmery” side of the hat. The

Mexican “sombrero,” worn everywhere in sub-tropical America, is

practically identical, and the hat worn by the American “rough riders,”

though not quite so absurd as those of our Yeomen, is another good

example of the mischievous effects of the childish military craving for

“smartness.”

In India and elsewhere in the Tropics, a broad-leafed felt of this sort

is very useful and comfortable for wear in the early morning and

evening, but is quite inadequate for use in the middle of the day during

the hot weather, though at other seasons a less cumbrous head covering

than the big felt hat may be safely adopted; but, however cool the air,

it is at no season safe to go abroad in India in the ordinary small hat

of Europe.

Children are strongly influenced by the sun in two ways: they are in the

first place enormously benefited by getting plenty of his health-giving

light; in the second their little skulls appear to be remarkably easily

penetrated by the _y_ or _z_ rays that cause sunstroke. Hence, even in

the hottest weather, it is a mistake to shut them up in the darkened

rooms so dear to their mother’s hearts. It is as well, of course, to

keep children out of the direct rays of the sun during the day, more

especially as it is difficult to ensure that they will always keep their

hats on; but it is a mistake to curtail their morning and evening walks

on account of the sun being above the horizon, though it must be

admitted that the greatest vigilance is required to insure their keeping

their hats on their heads.

Ladies resident in hot climates as a rule suffer far more from the want

of the sun and light than from serious sunstroke, their greater

sensitiveness to discomfort rendering them more apt to shrink too much

from light and air in hot weather; but on the other hand their desire to

maintain a pleasing appearance not infrequently leads to their suffering

from the earlier and milder symptoms of insolation. Owing to their not

unnatural objection to the admittedly unbecoming forms of head-gear

which alone can insure safety. The singular preference for the unfitness

of things which appears everywhere to characterise the ritual of

Society, and demands that a man must go a-hunting in English winter

weather in a tall silk hat, ordains that in India ladies shall pay their

conventional calls between the hours of noon and two p.m., when to go

abroad in a hat at all in keeping with their costume is hazardous in the

extreme. Unfortunately, out of the larger towns, closed carriages are

possessed by comparatively few, and the result is that an umbrella,

unsteadily held by the native groom behind her, is all that there is to

shield her head from a tropical sun at the meridian.

That severe headache, lassitude and other less easily defined nervous

symptoms should follow such expeditions is not surprising, and

undoubtedly if a closed carriage be unobtainable, for a lady to attempt

a “round of calls” at the conventional hours, is a proceeding involving

such a real risk that it should never be attempted, and calls should be

postponed to the cool of the evening. Moreover, even for occasions when

not equipped in full uniform, a safe head covering for ladies living in

the Tropics has yet to be popularised. Those who are wise enough to

determine to be out of doors daily, and to take a sufficiency of

exercise, will find it best to wear a hat of the same pattern as those

worn by their husbands and children, and to entirely abjure the absurd

constructions of pith, fashioned in imitation of English head gear,

which have of late years appeared on the scene. Some years ago an

admirable pith head gear, shaped somewhat on the lines of the

“Gainsborough hat,” enjoyed a well-deserved popularity, and it is a pity

ladies cannot see their way to adhere to it; as it not only afforded

excellent shade and protection, but when tastefully bemuslined was by no

means unbecoming in its obvious adaptation to its surroundings.

Recently, however, fashion has chosen as its model the “sailor hat,” and

frankly, inartistic as is the European original, the fantastic deformity

of the Anglo-Indian pith imitation requires to be seen to be

appreciated. It may be doubted if human ingenuity could shape the

material to a worse form, and it is wiser for a lady to keep out of the

sun altogether than to trust herself in the open wearing only such an

ill-contrived head covering.

[Illustration: FIG. 15. FIG. 16.

USEFUL AND FUTILE FORMS OF LADIES’ PITH HATS.]

It is, of course, of the first importance to get a person stricken by

the sun at once into the shade, and as the temperature of the body is

rarely excessive in such cases, cold locally applied to the head is of

more importance than a general bath, which, indeed, unless carefully

watched, is apt to make matters worse, by driving the blood from the

surface and so increasing the congestion of the brain and other internal

organs. Hence it is better to apply ice to the head and to confine

oneself to sponging the extremities as a measure for reducing the

general temperature. In climates where insolation is common, there is

little risk in getting wet, and hence if no proper ice bag be obtainable

the ice, roughly crushed, may be applied to the head, simply tied up in

a towel. Anyone who has suffered from even a mild attack of insolation

remains for a long time specially sensitive to the effects of the sun,

and therefore requires, for a long time, to be especially careful in

avoiding exposure. When prolonged exposure to the sun at its fiercest

must be braved, as in big game shooting, it is well to protect the

spinal column by means of a pad worn outside the coat. Some persons are

much more sensitive to the effects of the sun playing on the back than

others, and though the precaution cannot be considered universally

necessary, no one who feels himself inconvenienced by the effects of the

sun on this part of the body should neglect the warning and fail to

provide himself with a suitable protection. The usual plan is to have

made a pad, cut to the shape of the back piece of the coat, of quilted

cotton wool, covered with the same material as that of the coat and

secured by buttons suitably placed.

The third form of “stroke” is that of heat, and appears to be due simply

to the inability of the regulating powers of the system to keep down the

temperature of the body to the normal level.

Unlike true sunstroke, it nearly always occurs at night, when the

resisting powers of the organism are reduced to their minimum, and

mostly under conditions in which the sleeper has inadequate air room,

such, for example, as in crowded barracks and closely-packed railway

compartments. Such cases may possibly occur, but personally I cannot

recall an instance of this accident occurring to persons sleeping in the

open air. Every year one reads in the Indian press of persons being

taken dead out of railway carriages, and perhaps of a number of cases

occurring simultaneously in a single barrack, but with adequate air

space such an occurrence is, to say the least of it, exceptional.

At the same time, it is just in the hot “stuffy weather of a break in

the rains,” when it is always on the cards that it may rain before

morning, that such cases occur, and apart from the traditional danger of

sleeping outside a room during the rains, one is naturally loth to risk

a ducking. Given, however, adequate shelter from rain, there is no

danger whatever from sleeping in the verandah at such times of the year,

always provided, of course, that protection against infected mosquitoes

is assured by a carefully tucked-in mosquito net, and when the

atmospheric conditions are such as to involve risk of heat stroke, I

personally prefer to sleep on the roof, under the shelter of the top of

a tent, or of a special thatch shelter consisting of a roof without

sides, or at most with one lateral wall to windward, when there is a

probability of a driving rain falling during the night. As a matter of

fact, under atmospheric conditions of this sort, one is unlikely to take

much harm even if one does get damp, and the admittedly enhanced danger

of malaria can be entirely obviated by means of mosquito curtains.

Till lately we heard nothing of the danger of anything worse than

itching being connected with mosquito bites, and naturally those who

were callous enough to popular notions of safety to sleep outside the

house in the rains were about the last folks in the world to trouble

themselves about the tickle of a mosquito bite, and became “moral

examples” by contracting fever accordingly. During periods of great

heat, especially if combined with dampness of the air, under which

conditions heat stroke is likely to occur, severe muscular exertion

should be avoided as far as possible; a light, mainly vegetable, diet

adopted, and the amount of stimulants taken should be very limited,

though it is a great mistake to limit fluids of other descriptions, and

tea taken very hot is often useful and refreshing. Care should also be

taken not to allow oneself to become constipated, and speaking generally

it should be recognised that under the extreme climatic conditions that

bring on heat stroke, the European must live cautiously if he wishes to

come out of the ordeal unharmed.

In this form of the disease the temperature of the body is always high,

103° to 107° F., and the stupor deep and prolonged. Should you have to

do with a case in the absence of medical assistance, every effort should

be made to reduce the temperature of the body, the most efficient means

being to place the patient in a full length bath. As a rule, under such

conditions, the temperature of the water obtainable is too near that of

the body to bring down the temperature sufficiently rapidly, and pieces

of ice require to be added to obtain sufficient cooling power. The

patient should be kept in the bath until the temperature (taken in the

mouth) is restored to the normal level of 98°-99° F., after which he may

be removed; but in serious cases the temperature shows an obstinate

tendency to go up again, and it is generally necessary to keep it down

by continuous sponging, applied especially to the extremities. If, in

spite of these measures, it still continues to rise, the bath must be

again resorted to. If ice be unobtainable wherewith to cool down the

bath, the want of it should, as far as possible, be met by dipping out

the water warmed by contact with the patient’s body, and replacing it

with freshly-drawn water as cool as may be obtainable. It is well also

to try to relieve the bowels by placing 5 grains of ordinary powdered

calomel on the tongue, which will ensure its being gradually swallowed,

even in the deepest coma, and every effort should be made to keep down

the temperature of the air of the room, always provided that the freest

possible ventilation be kept up.

It is never prudent for anyone who has survived a warning of this sort

to remain in a climate the severity of which he has proved himself

unable to resist; and it should be the rule for those who have suffered

to take refuge in a cooler climate as soon as they are sufficiently

recovered to travel.

If stationed far inland, it is best to seek refuge in a mountain

sanatorium, and not to attempt to reach Europe, as the long journey in

the train and subsequent passage of the Red Sea would, in all

probability, finish the record of a person so situated before the

desired relief could be gained. On the coast the quickest relief can be

generally obtained by sending the patient to sea, but if the route

necessarily involves passing through the Red Sea, such a course is too

hazardous at the bad time of the year, and the change to Europe should

be postponed till the dreaded stretch of water can be passed in safety,

or a visit to Australia substituted. It must not be imagined that in

practice cases of “stroke” can be as sharply divided into classes as it

is easy to do upon paper. Naturally a large number are of mixed origin,

but the extent to which heat, pure and simple, is concerned, may be

generally judged by the temperature of the body, and whatever may appear

to be the causation of the disease, whenever this is high, no efforts

should be spared to bring it down as soon as possible.

PRICKLY HEAT AND DHOBI’S ITCH.

Among the minor ills which European flesh inherits in the Tropics there

is none that is more distressing than this troublesome malady. The

symptoms and appearance are too well known to require description, and

the disease is, as a rule, rather irritating and distressing than

involving any danger. The process of regulating the temperature of the

body depends, however, almost entirely on the action of the skin, and

where prickly heat is so extensive and severe as to partially

incapacitate it from its functions, it is obvious this usually trifling

disease may be a predisposing cause of more serious maladies. Then,

again, the loss of sleep and nervous irritation kept up by the constant

itching, pricking, and soreness, are powerful helps in pulling down the

already severely tried powers of resistance to the climate, and often

have a great deal to say in determining an ultimate breakdown.

There is a common popular notion that prickly heat is “healthy,” people

saying that “it is a sign of health,” and that it is a mistake to check

it. This, however, except in so far that healthy, full-blooded persons

usually suffer worse than those in an anæmic condition because they

usually perspire more freely, is an entire fallacy; as though good

health may predispose to prickly heat, it cannot but have an influence

in rapidly reducing that factor in its causation. Then, too, the

numerous small abrasions that result from the bursting of the minute

vesicles, and from scratching, are extremely liable to become infected

with the germs of suppuration, and give origin to crops of boils.

Boils are extremely common, and are most painful and debilitating when

present in large numbers, as they often are in hot climates, and I

believe they should be really regarded merely as _sequelæ_ of neglected

prickly heat and not as a distinct condition. For these reasons the

writer is strongly of opinion that prickly heat should always be

treated, especially as it is usually quite possible to keep it within

moderate bounds, by the use of appropriate remedies. At sea the use of

salt water for bathing should be avoided, but frequent bathing in fresh,

and especially in rain water, is not only a great alleviation, but

tends towards cure by removing the irritating accumulation of saline

matter that results from the constant evaporation of the perspiration.

Almost any metallic astringent, such as sulphate of copper or sulphate

of zinc, 4 grains to the ounce, will be found to be extremely useful in

reducing the extent of the irritation, but none of these are nearly as

effectual as a lotion of perchloride of mercury of a strength of one per

thousand.

This agent can be obtained ready measured out into tabloids, which are

always coloured blue to prevent mistakes in handling the solution; which

is a most useful one, not only for this purpose, but as a general

antiseptic. Care should, of course, be taken in the custody of these

tabloids, and also in the handling of the solution; but the latter is

not really more poisonous than the copper solution, or than many other

antiseptics which, like carbolic acid, are nowadays in constant domestic

use. This mercurial solution is undoubtedly by far the best remedy we

have for prickly heat, and I have never seen any harm or signs of

absorption of the mercury result, even from its copious use. The

tabloids should be got of such a size as to make about a quarter of a

pint of the solution, and after the bath and before retiring to bed, all

affected parts of the skin should be dabbed with a bit of lint dipped in

the solution, which should be allowed to dry on to a certain extent

before putting on one’s clothes. A further great advantage over the

other metallic astringents is that, owing to the weakness of the

solution, it does not injure the clothes, and the slight blue aniline

colouration easily washes out. It will be found, too, an almost complete

preventive against boils, if resorted to from the commencement of the

hot season. Powdering with violet powder is also useful in subduing the

irritation, which by the adoption of the above-described plan, may

almost always be kept within moderate bounds.

“Dhobi’s itch” is a troublesome irritation of the skin often met with in

hot climates, which is due to the growth of a minute fungus within the

structure of the scarf-skin. It commonly attacks those parts of the body

where the surfaces of the skin come in contact with each other, as, for

example, between the legs, and in the armpits. The general appearance is

very much that of a “ringworm,” the patches spreading by their edges,

where they are red and irritable and tending to fade in the middle.

There can be little doubt that the disease is generally caught by the

infection of clothing that has been washed in dirty pools along with

that of previous sufferers from the disease, which is very common among

the native races. If neglected, it is apt to spread so as to cover a

large area, under which circumstances it is apt to be troublesome, but

if taken early, there is generally no difficulty in dealing with it. All

that is necessary is to destroy the fungus by means of strong

antiseptics, but in doing so it must be remembered that any solution

strong enough to kill the fungus must necessarily also cause more or

less inflammation and, for the time, increased irritation of the skin.

On this account, if any considerable area be involved, it is a mistake

to attempt to treat the whole of it at once, as such a course may easily

result in producing an amount of soreness and inflammation which may

involve confinement to bed. The patches should be attacked piecemeal, a

couple of separate patches the size of a shilling being quite as much as

is prudent to attack on any one occasion.

Equal parts of tincture of iodine, carbolic acid and glycerine painted

over each patch, to the extent above described, is a safe and efficient

remedy, as also is Goa powder; but the essential point is to be on the

look-out for the contingency, and to at once treat any patch that may

appear before it has time to spread.

The disease is, I believe, common enough in other warm climates, but I

am not acquainted with its popular designation elsewhere than in India,

where it is known by the above name.

ON THE PREVENTION OF DISEASES CAUSED BY INTERNAL WORMS.

_Internal worms_ are extremely common in most hot countries, and

especially in those climates where moisture and heat are combined. Where

they prevail to a serious extent, they often constitute one of the

principal causes of mortality amongst natives, but white residents

rarely suffer, as the habits of the better-class European to a very

great extent protect him from being invaded by these pests.

There are three principal sorts of these parasites: the round-worms,

which usually divide their time between some animal and the outer world,

and the flat-worms and the flukes, both of which must pass through two

or more animal hosts. The life-history of these troublesome guests,

especially those belonging to the two latter classes, include some of

the most wonderful and interesting pages of natural history, but

unfortunately considerations of space prevent our describing these

changes except by the barest allusions.

The commonest round-worms that establish themselves in mankind are the

common thread-worms and round-worms (_Lumbrici_), and that much more

formidable pest of tropical life, the _Ankylostoma_, or hook-worm.

Thread-worms and Lumbrici are common enough everywhere, but are far more

commonly troublesome in hot climates than at home in Europe. The eggs of

both are probably usually carried into the human intestine on food or in

drinking water, and in the case of the Lumbricus this is the only way in

which the numbers of the parasite can be maintained, as its eggs take a

long time to hatch out; but those of the thread-worm, when deposited,

are quite ready to burst at once, and though no individual worm as a

rule resides within the intestine for any great length of time, the

patient infested with them is continually reinfecting himself, so that

their numbers have a tendency to increase. Thread-worms are especially

common in children, on account of the strong tendency of the little

folks to put their fingers in the mouth.

Thread-worms live in the lowest part of the bowel, and so cause much

itching and tickling about its orifice. This prompts the child to

scratch itself, with the result that some of the innumerable eggs laid

by the worms adhere to the fingers, and once there soon find their way,

along with the fingers, into its mouth. The intruders are usually easily

expelled by an injection of salt and water, but it is difficult to get

rid of all of them, and the child is nearly sure to reinfect itself

unless it is made to sleep in drawers. Provided reinfection is prevented

in this way, however, the remaining worms will soon be got rid of, as

this species as a rule does not take up a prolonged residence.

Round-worms can be expelled by the means of a dose of santonin, but as

neither these parasites nor tape-worms usually cause immediate serious

symptoms, and both this drug and most other vermifuges require a certain

amount of care and caution in their administration, it is better to wait

any moderate time until the treatment can be supervised by a medical

man.

The third common round-worm parasite--the hook-worm namely--though but

little known in Europe, is so widely distributed in hot, moist

countries, that in such climates the greater proportion of the

indigenous races are often affected to a greater or less extent. It is

quite a small worm, but fastens on the lining of the bowel in exactly

the same way as leeches attack the outer integuments, and exhibits the

same insatiable appetite for blood. The extent of the mischief wrought

by them depends entirely on the number harboured. When only a few are

present, they may be considered practically harmless, and thousands of

such cases are to be met with in any country where they are common; but

wherever this is so, numbers of subjects will be met with, in whom they

are so numerous as to cause serious symptoms and death; so that there

are many places where they constitute one of the most serious scourges

of the Tropics. The eggs of this parasite, deposited along with the

dejecta of persons infested with them, hatch out in the soil, and

multiply there enormously, so that owing to the insanitary habits of the

populace, the soil round about a native village comes to swarm with this

free stage of the parasite. Now as the population is generally a purely

agricultural one, and none too nice in its habits, it can be easily

understood that persons, eating as they do with unwashed hands, must

constantly carry to their mouths some of the earth containing the minute

embryos which convey the disease, and hence the process of infection is

commonly continuous and progressive. As a matter of fact, out of some

hundreds of specimens of drinking water examined by the writer in Assam,

where the disease is extremely rife, in no one case was there anything

found to show that the malady was commonly conveyed in water, but the

contingency is clearly a possible one; and in any case, it is clear that

very moderate care as to food, water, and personal cleanliness would

suffice to render infection impossible. From what has been said, it is

easy to understand that the disease is practically unknown among

European residents whose habits have reached the most moderate degree of

refinement; but though it may not affect the planter’s health, it reacts

most seriously on his pocket, owing to the disastrous amount of sickness

and mortality it gives rise to among his native labourers. Now it is

perfectly obvious that this disease can be easily prevented by the most

ordinary measures of conservancy, and the question whether the evil can

be obviated or not, is purely one of whether the master has the will and

power to insist on the use of proper latrines. This, however, is by no

means so simple a matter as it looks, where one has to deal with

labourers belonging to a primitive stage of civilisation. Once seen, the

disease is easily recognised by the deadly pallor of the lining membrane

of the eyelids, and of the tongue, especially the latter, which looks

much like a piece of a wet, pipe-clayed buff belt. By treatment with

vermifuges and careful nursing there would be little difficulty in

curing people of European habits; but only those who have had to attempt

it know how impossible it is to get semi-civilised people to adopt, or

even submit to, what to us are the most ordinary sick-room comforts, and

as a matter of fact, there is very little hope for a native who is at

all seriously affected with these parasites.

The best vermifuge we have is thymol; three doses of 30 grains each,

given within six hours, followed up by a dose of castor oil. A certain

amount of caution is required in giving this to cases in a very weak

state, but after all it is the only chance for them. This medication may

have to be repeated once or twice, at intervals of a week, and should

be systematically carried out in all cases that have not gone too far.

The worst of it is, that unless proper sanitary measures can be carried

out, treatment is little better than a waste of drugs, as otherwise the

patients will be sure to reinfect themselves within a few weeks, however

thoroughly the vermifuge may have done its work.

The Guinea-worm is a curious parasite, which is found burrowing under

the skin, and finds an exit through the opening formed by a sort of

boil. It very rarely attacks Europeans, as it may be avoided by the most

ordinary care in the matter of water used for drinking and bathing.

Another curious malady caused by one of the round-worms is the

blood-worm disease, or filariasis. In this the parent worm is found

embedded in the tissues of the host, and periodically discharges into

the blood enormous numbers of its embryonic offspring. As this disease

is undoubtedly communicable through the agency of mosquitoes alone, its

prevention may obviously be secured by the adoption of the same measures

that serve to protect us from malaria.

Tape-worms have a very curious life-history. The long, flat, jointed

strip is really a chain of sexually mature individuals, but when their

eggs are swallowed by an animal there is hatched out from it, not

another tape-worm, but a minute embryo, which has the power of boring

through the tissues of its host till it reaches some favourable

resting-place, where it settles down, protected by a capsule, forming

what is known as a bladder-worm. It may live for years in this

condition, but cannot reach maturity until the capsule has been

swallowed by some carnivorous animal, though some species can multiply

non-sexually and so cause terrible damage to the animal that harbours

it. Both stages of several species of these parasites infest man, but

fortunately their prevention is a very simple matter, at any rate as far

as the adult strings of worms are concerned, as infection is impossible

provided all meat and fish eaten be thoroughly cooked. The mature stage

of the bladder-worm which is found infesting man inhabits the intestine

of the dog, and as it is capable, in this stage, of non-sexual

multiplication, may give rise to large tumours, the effects of which

may be most serious if a vital organ be invaded. Though almost a medical

curiosity in Europe, it constitutes a really serious danger in certain

pastoral colonies, such as Australia, where large numbers of dogs have

to be kept for herding sheep, and are allowed unrestricted access to the

offal of carcases, which is, of course, very abundant where

meat-preserving is an important industry. The disease might be guarded

against by preventing the dogs having access to anything but thoroughly

cooked meat, and by avoiding undue fondling and too close association

with these animals.

The third important class of parasites, the flukes, but rarely infest

man, but in Egypt and, in fact, throughout Africa, a peculiar fluke, the

_Bilharzia_, is found infesting the blood-vessels, especially those of

the kidney, and gives rise to the appearance of blood in the urine. It

is extremely common amongst the natives of Egypt, but it very rarely

attacks Europeans, and though we are quite in the dark as to its

life-history outside the human subject, there is little doubt that

moderate care as to the water used for drinking and bathing is

sufficient to afford complete protection against the disease.

PART II.

OUTLINES

OF

TROPICAL CLIMATOLOGY

ERRATA.

p. 9, line 9 from foot, _for_ “Camerun” _read_ “Cameroon”; and line 12

from foot, _for_ “Shilling” _read_ “Shillong.”

p. 58, line 11 from foot, _for_ “Sangor” _read_ “Saugor.”

p. 63, in table, line 11 from top, _for_ “Ayra” _read_ “Agra.”

p. 84, line 1 in table, and p. 85, line 3 in table, _for_ “Mazattan”

_read_ “Mazatlan.”

OUTLINES

OF

TROPICAL CLIMATOLOGY.

SECTION I.

General Considerations.