Chapter VIII (2)

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.

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.

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.