Chapter XVIII: Introduction (3)

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

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

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

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

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

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

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

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

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

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

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

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

_Malta Fever._ (See _Undulant Fever._)

_Measles._

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

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

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

_Treatment._—Similar to that of scarlet fever (_see_ p. 222). It is very important to guard against chill; to ensure plenty of fresh air.

_Complications._—Measles may be followed by pneumonia.

_Mumps._

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

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

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

_Myiasis._

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

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

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

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

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

_Ophthalmia, Simple._

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

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

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

_Ophthalmia, Purulent._

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

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

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

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

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

_Piles._

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

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

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

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

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

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

_Plague._

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

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

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

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

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

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

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

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

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

_Pleurisy, or Inflammation of the Membrane Covering the Lung._

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

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

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

_Pneumonia, or Inflammation of the Lungs._

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

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

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

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

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

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

_Quinsy, or Inflammation of the Tonsils._

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

_Relapsing Fever._

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

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

The true tick fever of Africa, which is also a relapsing fever, is considered separately. (See _Tick Fever_, p. 241.)

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

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

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

_Rheumatism._

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

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

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

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

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

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

_Rupture or Hernia._

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

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

_Sand-Fly Fever._

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

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

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

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

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

_Scarlet Fever, or Scarlatina._

This fever is very uncommon in hot climates.

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

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

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

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

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

_Scorpion Sting and Spider Bite._

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

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

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

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

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

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

_Scurvy._

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

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

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

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

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

_Sea-Sickness._

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

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

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

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

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

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

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

_Skin Diseases._

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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