Chapter XVII: Introduction (2)

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

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

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

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

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

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

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

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

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

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

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

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

In dysentery, as in severe diarrhœa, the patient should _not_ be allowed to get up to stool. A box cut across obliquely will make a rough slipper bed-pan; put sand in it, and pad the edges.

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

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

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

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

_Enteric or Typhoid Fever, including the Paratyphoid Fevers._

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

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

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

The incubation period is from ten to fifteen days.

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

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

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

_Prophylaxis._—As for dysentery (_see_ p. 186). Preventive inoculation is very important and confers immunity for a considerable period (_see_ “Inoculation,” p. 168).

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

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

The motions must be burned, or carefully disinfected.

_Epilepsy._

_Symptoms._—This is the most common form of fits. There are three stages. _1st stage_—The patient falls down completely unconscious and without warning, the face is pale, the limbs become stiff and rigid, and the breathing ceases. _2nd stage_—Convulsive movements take place, the tongue being often bitten, the breathing becomes heavy and laboured, and the motions may be passed unconsciously. _3rd stage_—A confused mental condition, sometimes acute mania, usually sleepy for some time. In some cases the fit may only last a few minutes. They almost always recur.

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

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

_Faintness._

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

_Filariasis._

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

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

_Gonorrhœa._

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

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

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

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

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

_Hay Fever._

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

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

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

_Influenza._

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

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

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

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

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

_Insect Pests._

(_See also Myiasis and Skin Diseases._)

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

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

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

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

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

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

_Tsetse Flies._—These are considered under Sleeping Sickness (_see_ page 234).

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

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

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

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

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

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

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

A note on the troublesome _Chigger flea_ or _Jigger_ will be found under “Skin Diseases” (_see_ p. 228).

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

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

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

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

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

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

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

_Iritis, or Inflammation of the Eyeball Itself._

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

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

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

_Jaundice._

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

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

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

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

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

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

_Laryngitis, or Inflammation of the Upper Part of the Windpipe._

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

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

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

_Leeches._

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

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

_Leishmaniasis._

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

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

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

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

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

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

_Liver, Congestion of_:—

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

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

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

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

_Liver, Acute Inflammation of_:—

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

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

_Liver Abscess._

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

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

_Malaria._

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

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

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

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

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

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

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

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

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

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

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

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

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