Chapter XIX: Introduction (4)

_Prophylaxis._—Avoid long drinks, warm clothing, too much exercise, and all conditions producing excessive perspiration. Sea-bathing should be avoided, and soap should not be used in the bath. One should sleep under as hygienic conditions as possible, with a well-ventilated bed and without unnecessary clothing. A dusting powder of equal parts of boric acid, oxide of zinc, and starch is useful.

_Treatment._—Ryan strongly recommends the so-called “Sulphaqua” bath charge, which is sold in packets ready for use. The above-mentioned dusting powder is helpful, as is the application of a lotion containing salicylic acid and spirit. Some prefer oily applications. Whatever is used, care should be taken to see that the bowels are well opened at the beginning of an attack, preferably by a saline purge.

_Ulcers._—Ulcers are often very troublesome to the traveller, as the healing process is frequently retarded by exposure, dirt and dust, and the chafing of clothes. Want of sufficient animal food greatly favours the spread of large ulcers.

A simple dressing of iodoform ointment, or ointment of boric acid, is effective when the ulcer can be protected, and rest can be given to the affected part. When the ulcer is deep and large it may be stimulated to heal by the application of lint or cotton-wool, moistened with carbolic oil, carbolic lotion, or other antiseptics.

Large, unhealthy ulcers should be well bathed with some antiseptic such as carbolic acid, one in sixty of water, or a solution of chinosol (1 in 600); and after the sore has been cleansed it may be lightly dusted with iodoform and then covered with a piece of lint moistened with carbolic oil or smeared with iodoform ointment and supported by an evenly applied bandage. Boric ointment, lano-creoline, izal ointment or other antiseptic dressing may take the place of iodoform ointment.

In addition to the above general account, certain conditions leading to ulceration require consideration.

_Oriental Sore._—This condition is commonly known as Baghdad Boil, Aleppo Button, Frontier Sore, etc. It occurs in various hot countries, such as Egypt, Syria, Asia Minor, Arabia, and Mesopotamia, and has been met with in Europe and Greece. A special form affecting both skin and mucous membranes is widely distributed in South America.

_Cause._—The cause is an organism to all appearance identical with that which produces leishmaniasis or kala-azar. Indeed, Oriental sore is a form of cutaneous leishmaniasis. In all probability infection is conveyed by sand-flies, but our knowledge is still defective on this point.

_Symptoms._—The incubation period varies from a fortnight to a year. The sore may occur on any exposed part of the body, but is most common on the forearm, hands, and face. Multiple sores are frequent. The first sign is a small red, scaly papule, which increases in size and eventually breaks down, forming a painless ulcer, with a hard, dry edge. Non-ulcerating forms occur, but are not common. The condition is very chronic, but healing usually sets in after six to twelve months. When the ulcer heals a white or pink scar is left, which is disfiguring.

_Prophylaxis._—Sleep under a sand-fly net, containing 22 holes to the linear inch. Warn against the danger of infection by personal contact and the risk of re-infecting oneself by scratching. It is advisable to paint the sites of all fly and insect bites with iodine as soon as possible.

_Treatment._—The best treatment at present known is intravenous injection of tartar emetic. This, of course, can be carried out only by a medical man. Good results have, however, been obtained by applying a 2 per cent. ointment of tartarate of antimony, and this method can be carried out by the patient himself. Local injections of emetine have been recommended, and there are various other ways of treating Oriental sore, but they need not be here considered.

_Tropical Ulcer._—This is a special and serious form of ulcer found in all parts of the world, and especially amongst East African natives. It is found chiefly in the lower third of the leg and in the region of the foot and ankle.

_Cause._—This is somewhat obscure, but it is believed to be due to certain organisms possibly acting in association with one another.

_Symptoms._—The condition starts as a small, tender, and often itchy papular bleb, surrounded by a dense inflammatory zone. An ulcer results, which is more or less painless, and one of the characteristics of which is the way it spreads and destroys all the tissues with which it comes in contact. It is often mistaken for a syphilitic ulcer, but it does not usually yield to anti-syphilitic remedies.

_Treatment._—The best remedy would appear to be formalin, though the iodoform ointment mentioned under ulcers may aid the condition. It can be effectually treated only by a medical man.

_Veldt Sore._—This condition, which is also known as Barcoo Rot, is frequently in evidence in countries with hot, dry climates, as, for example, Egypt, Palestine, South Africa, Mesopotamia, etc.

_Cause._—It is due to certain bacteriological organisms, and is apt to occur in persons who are debilitated, who are not receiving proper food, or who are living under conditions where it is not easy to keep clean. Some think the sores are commonest in men who have to deal with horses.

_Symptoms._—Veldt sores are most common on the hands and forearms. They begin as itchy papules, which become blebs, then pustules, and finally ulcers. They are usually multiple, and when they heal they leave areas of thin, glossy skin.

_Prophylaxis._—As for boils.

_Treatment._—The spread of ulcers can be checked by removing the hairs from their bases and round their margins. Very often the ulcer can be started on its healing process by employing dressings soaked in a solution of 1.5 per cent. sodium citrate and 20 per cent. common salt. Vaccines are often successfully used in this condition, and the stannoxyl mentioned under boils may be employed, as may a salicylic acid ointment, 20 grains to the ounce.

_Sleeping Sickness._

This is the old “Negro lethargy,” and must not be confounded with what is now called sleeping sickness in the British Isles and on the Continent, which is quite a different disease. True sleeping sickness is limited to Africa, and there are two chief types: that occurring in parts of the West Coast and the French and Belgian Congos, in Angola, in portions of the Anglo-Egyptian Sudan, in Uganda, and in parts of the Tanganyika territory; and that which occurs in Northern Rhodesia, Nyasaland, Portuguese West Africa, and the region of the Rovuma River.

_Cause._—The cause is a tiny animal blood parasite conveyed from the sick to the healthy by certain species of tsetse flies. In the tsetse fly the parasite, which is called a trypanosome, undergoes a definite development.

The two species of tsetse fly meriting special consideration here are _Glossina morsitans_ and _Glossina palpalis_. The former, as a rule, occurs in thin, deciduous bush, or low, comparatively open forest, while the latter haunts the neighbourhood of streams and lakes, and is rarely found any great distance from the water edge. These flies are about the size of a small blue-bottle, but are not so stoutly built and, when closed, their wings overlap and project beyond the end of the abdomen. _Glossina morsitans_ is brownish coloured, with bands on its abdomen. _Glossina palpalis_ is much darker, indeed almost black-looking. They have a quick and darting flight, and are attracted by rapidly-moving objects, like motor-bicycles and motor-cars. Once they alight they do not move about. As a rule they bite only during the day, but they may attack man on bright moonlight nights.

_Symptoms._—The incubation period is probably about three weeks. The fly bite may be painful; and causes a slight local irritation. The disease begins insidiously, with an irregular fever, and there may be a skin eruption. The fever comes and goes, and the patient gets weaker and suffers from headache. The glands in his neck and possibly in other parts of his body become enlarged and may be tender. The first stage of the disease is called trypanosome fever, and may end in recovery. More usually the central nervous system becomes affected, and then the symptoms of true sleeping sickness develop, slowly or with considerable rapidity. The patient becomes dull and drowsy. Both his speech and movements are affected. His face gets puffy, and he shuffles when he walks. He still has fever, continues to lose flesh, and gradually passes into a sleepy condition, which may be associated with convulsions. Saliva dribbles from the lips, and half-masticated food may remain in the mouth. The patient becomes helpless and indifferent to his surroundings, and either dies from coma or from some intercurrent disease, such as pneumonia or dysentery.

_Prophylaxis._—Personal prophylaxis consists in avoiding being bitten by tsetse flies. When passing through fly belts in affected areas veils and gloves may be worn.

_Treatment._—If taken in time sleeping sickness can be readily cured by the use of the arsenical preparation atoxyl, combined with antimony. The course of treatment, however, extends over a considerable period, and it must be carried out under the supervision of a medical man.

_Sleeplessness._

This is common in those broken down by malaria, dysentery or debilitating diseases; it is also induced by the irritation caused by mosquitoes and other pests, such as the itch parasite. It is at times due to errors of diet, prickly heat, mental worry and exhaustion, abuse of tea and coffee, coldness of the feet and indigestion, and as most acute diseases are worse at night, sleeplessness is very common amongst sick people.

_Treatment._—As far as possible remove the cause; kneading the feet and legs, or the application of a hot-water bottle to the feet, will often be of service. A cup of hot milk or soup should be taken at bedtime, and again on waking in the night. The bowels must be regulated and alcohol taken very sparingly.

The taking of sedative drugs should be avoided as much as possible. The least harmful of these is sulphonal in doses of from twenty to thirty grains, given several hours before bedtime, or bromide of potassium in twenty or thirty-grain doses given at bedtime. A warm bath at night often acts more satisfactorily than any other remedy. Only very rarely should chloral, chlorodyne, or opium be resorted to.

Regular habits and plenty of work are potent factors in the production of that healthy condition which predisposes to natural refreshing sleep.

The unfortunate man who has no hard work to do, who is without even a hobby to occupy him, and has no interest in life but the torpid condition of his liver, is a constant sufferer from insomnia. He should be purged and put on a light plain diet. Alcohol must be forbidden and plenty of exercise must be taken. A tumblerful of hot water is to be taken the first thing in the morning and the last thing at night.

_Small-pox._

Very prevalent in the tropics, hence the importance of revaccination before going abroad.

Incubation period, twelve days. Rash appears third day.

_Rash._—Before the appearance of the typical rash there are occasionally earlier rashes, viz., a diffuse blush covering the whole body, resembling scarlet fever, or a dark purple rash of effused blood beneath the skin of the lower part of the belly, or occasionally in the armpit. The small-pox rash proper consists of small red raised spots which first appear on the face, forehead, and scalp, subsequently coming out over the rest of the body, commencing at the top and working downwards. These spots become prominent, and have a characteristic “shotty” feeling under the finger. On the third day after their appearance a small bleb forms in the centre of each spot; it is transparent at first, but subsequently becomes yellowish, from the formation of matter in its interior. The centre becomes depressed on the sixth day, then the bleb breaks down, and discharges matter. Two or three days later the spot begins to dry up, and ultimately heals under a scab. During the period of most active inflammation the face may be very swollen and sodden.

The spots and pustules are not confined to the skin, but may occur on the roof of the mouth and in the throat.

_Prophylaxis._—This consists in efficient vaccination, and as travellers may themselves have to carry out the technique of vaccination, it is important they should know something about it. The usual faults in technique are a lack of cleanliness, resulting in sepsis, the use of too strong an antiseptic when cleaning the skin, over-heating of the lancet, needle or scarifier when purifying it, drawing too much blood, which washes away the lymph, exposure of the recently vaccinated area to the hot sun, and charring of the lymph in the capillary tube when sealing. All that is necessary is to clean the part to be vaccinated with soap and water, using a nail-brush, then rub the skin with alcohol, and when the latter dries proceed with the little operation. There should be four incisions, and the total area which will eventually be occupied by the vaccine vesicles should not be less than half a square inch. It may be noted that the vesicle is fully ripe on the seventh day after vaccination.

_Treatment._—Isolation, similar to that of scarlet fever. The body may be sponged and vaseline applied if there is much itching. The eyelids and eyes should be frequently washed with weak boric acid solution.

_Snake Bite_ (_see_ p. 281).

_Sprue._

This is a chronic form of tropical diarrhœa, often called “white diarrhœa,” the leading symptom of which is the frequent passage of large, frothy, and pale-coloured motions; dyspepsia, and soreness of the tongue and mouth, are also present, and there is marked anæmia and advancing debility. The disease may follow attacks of diarrhœa or dysentery.

_Cause._—The actual cause of sprue is unknown, but the disease usually develops in persons who have been for some considerable time in the tropics, and it is commoner in India, Ceylon, and the Far East than elsewhere.

_Treatment._—Put the patient to bed, give a simple aperient such as castor-oil, to clear out the bowels; allow only a milk diet, to which, as the symptoms begin to abate, meat juices and jellies should be cautiously added. If any other disease, such as scurvy, is present, it must be treated. Drugs are not usually of much service; however, a mixture containing bismuth, soda, and one drop of carbolic acid in an ounce of gum-water may be given three times a day for a week. The soreness of the mouth and tongue may be treated by the application of borax and glycerine, or mild antiseptic mouth washes, such as a weak solution of permanganate of potash, or a lotion of boric acid. Special symptoms, such as pain and collapse, must be treated as they arise. As soon as the patient is strong enough, he should be removed to a temperate climate.

_Stroke, or Apoplexy._

This disease is caused by the rupture or blocking up of one of the blood-vessels in the brain.

_Symptoms._—The person attacked falls down suddenly, and is unable to move one or more of his limbs. He may be quite insensible, or soon become so, or perhaps he is unable to talk. The mouth may be drawn to one side, and the tongue, when protruded, be pushed to the right or left. The condition is serious.

_Treatment._—Tight clothing must be removed. Six grains of calomel powder should be placed on the back of the tongue, and the patient kept lying on his back with the head slightly raised. Cold should be applied to the head and a hot-water bottle to the feet, the room darkened, and absolute quiet observed. An enema of hot water may be given, and while the patient is insensible the lips should be moistened only with water. Food may be given by the bowel on the second or third day. Stimulants are absolutely forbidden. If the patient gets over the attack he ought to be sent home.

_Note._—It must not be forgotten that many of the above symptoms might be caused by injury or poison.

_Sun-Stroke and Heat-Stroke._

These conditions are distinct. Sun-stroke, which is comparatively rare, is due to the direct action of the sun on the brain and spinal cord. Heat-stroke, on the other hand, would appear to be due to the lack of escape of heat from the body, owing to insufficient evaporation from the skin, and to the effect of muscular fatigue. As a result, poisonous substances accumulate and act detrimentally upon the nerve cells. There is also a deficient supply of oxygen to the blood. High relative humidity plays a very important part in producing attacks of heat-stroke. The milder forms are known as Heat exhaustion and Heat prostration; the severe form is often associated with true sun-stroke.

_Symptoms._—Heat exhaustion is really a form of faintness, and recovery soon takes place after a rest. The symptoms of heat prostration are giddiness, often associated with nausea. The patient is bathed in a clammy sweat, his pulse is thready, his breathing shallow, and, it may be, sighing. The condition may pass into unconsciousness, but the temperature is not raised, and death rarely results.

There are two kinds of true Heat-stroke; one a form with high temperature, the other what is called Heat cramp, which is common amongst ships’ firemen in the tropics. An early warning sign of heat-stroke is a desire for frequent micturition, and other premonitory symptoms are a dry skin, giddiness, drowsiness, headache, and intolerance of light. The pulse becomes quick and irregular, the skin is hot and dry, and the temperature elevated. The patient may become comatose, or exhibit delirium or convulsions. There is an asphyxial type, in which the face becomes cyanosed and the breathing is in abeyance.

_Prophylaxis._—Avoid severe exercise in a hot sun. Wear suitable clothing, which should be loose and easy, and protect the head, and especially the nape of the neck, from the sun’s rays. Dark or tinted glasses are useful. Water should be taken freely, and the bowels kept open; but alcohol must be avoided. Sniffing a mixture of water and vinegar and damping the face are helpful measures.

_Treatment._—In the case of Heat prostration the patient should be laid in the shade on his back, his clothes should be loosened, his limbs massaged, and, if he is collapsed, stimulants in the form of ammonia or camphor should be administered. The asphyxial type of heat-stroke can only be treated by means of artificial respiration, which may have to be continued for as long as a couple of hours. The ordinary form, which has been called the paralytic type, must be treated promptly and vigorously. One must aim at reducing the temperature, getting rid of the toxic material in the body and preventing heart failure. Probably the best way of treating the condition as an emergency is to lay the patient naked on an inclined plane and drench him with cold water. When doing so it is well to take the rectal temperature, and to stop this chilling process when the thermometer registers 102° F. After the drenching wrap the patient in blankets and apply hot bottles to the trunk and limbs. An ice bag, if available, should be applied to the head, which in any case should be swathed in cold cloths. It should be noted that in the absence of ice, a sheet soaked in cold water or dilute alcohol, over which a draught of air plays, is a useful substitute. A fan may be used to create the air draught. Auxiliary methods of treatment can be efficiently carried out only under medical supervision. As soon as the patient has recovered somewhat, a dose of calomel should be given, followed by salines.

_Syphilis._

Syphilis, or the Pox, is an infectious venereal disease, nearly always communicated by direct contagion. The course of the disease is marked by a primary sore, the chancre; early constitutional (secondary) symptoms, and late constitutional (tertiary) symptoms.

In primary syphilis the disease is limited to the part or organ originally infected, and the glands connected with that spot. After an incubation period of from three to six weeks a small painless pimple appears at the seat of infection; it breaks down, and forms a small ulcer from which oozes a little watery fluid. The base of the ulcer and the skin surrounding it are hard like gristle. The nearest glands, usually those of the groin, enlarge and occasionally become tender. Unless badly neglected, the original sore gradually heals and the glands resume their normal size. Secondary symptoms now make their appearance. These are fairly definite, and comprises (_a_) A skin rash, consisting of numerous irregularly shaped copper-coloured spots, spread over the face, upper part of the chest, the loins and the back of the arms. They do not itch. (_b_) Moist lumps and warts form in the crutch, around the scrotum (purse) and the outlet of the bowel. (_c_) Ulcerated sore throat. Large deep ulcers form on each tonsil, having ragged undermined edges. (_d_) Iritis or inflammation of the eye may also occur. These symptoms, even if untreated, tend to heal, but always leave more or less marked traces behind.

The discharge from either primary or secondary sores is infectious and may convey the disease, so that great care needs to be taken in handling such sores.

After an interval of apparent health, lasting perhaps only a few months, but often for a year or two, the tertiary symptoms or “reminders” make their appearance. These take the form of localised swellings, which soon break down, forming deep ulcers, and if untreated, produce extensive destruction of the part involved, with much deformity.

_Prophylaxis._—The methods available are now so well known that they need not be discussed in a work of this kind. Mention need merely be made of the fact that in some foreign countries, owing to unhygienic conditions, there is a greater liability to contract the disease by what may be called unusual methods, and therefore every care should be taken to prevent such sources of infection, as, for example, the contaminated seats of closets, etc.

_Treatment._—As soon as the disease is recognised, the treatment must be commenced.

Local treatment.—Keep the sore perfectly clean by washing it with an antiseptic solution such as chinosol (1 in 1000). Between the washings, dress it with a piece of lint soaked in “black wash,” or dust it with iodoform powder and cover it with a piece of lint smeared with boric ointment.

For the sore throat, use an antiseptic gargle (_see_ Ulceration of Throat, p. 244).

General treatment.—The patient must be put on a course of mercury at once. Calomel, one grain twice a day, or grey powder, one grain three times a day, must be administered, and continued until skilled advice can be obtained. The effect of the mercury must be carefully watched, and if the patient complains of soreness of the gums, a coppery taste in the mouth and excessive flow of saliva, the dose must be reduced or the administration of the drug stopped until these symptoms have disappeared. If the calomel or grey powder causes looseness of the bowels, five grains of Dover’s powder may be added to each dose.

In some cases, the addition of three grains of the iodide of potash to each grain of calomel does good from the very first.

For the later symptoms, continue the mercurial treatment, and give at least five grains of the iodide of potassium three times a day.

Since the above was written the whole treatment of syphilis has been revolutionized by the introduction of certain organic arsenic compounds as therapeutic agents. Of these the best known is the German salvarsan, represented in this country by kharsivan, the so-called “606.” Treatment with arsenic has now largely replaced the old method with mercury; but it cannot be carried out except by one having medical training, and so need not be further considered.

_Tick Fever._

One of the diseases which may be produced by the bites of insects is a form of fever, conveyed by the bite of a tick, which is common in many parts of Africa. This produces a series of symptoms which are similar to those found in the disease known as relapsing fever, which has been known to occur even in the United Kingdom, and which used to be called “famine fever” (_see_ p. 218).

_Cause._—The cause is a corkscrew-shaped organism found in the blood, and its vector is the tick above mentioned, which in its adult state and unfed is roughly about the length of a finger-nail, that is, four-tenths of an inch. It is of a greenish brown colour, and is covered by a leathery integument, which looks as if it was spotted all over and which is grooved in several places. When the tick is gorged, these grooves disappear. A gorged female tick may be well over half an inch in length, and very nearly of an equal breadth.

The tick lives in native houses and in rest houses, especially along caravan routes. At night it sallies forth in search of blood, but during the day it conceals itself in cracks and corners in the walls and floors, and sometimes in cracks in native wooden bedsteads. Its bite is painful, but the infection takes place not through the bite, but as a result of the infected excreta of the tick contaminating the tick bite. One tick is sufficient to cause infection.

_Symptoms._—The chief symptoms are those of a severe attack of fever, ushered in by a shivering fit and acute symptoms such as are usually found in cases of fever, for example, pains in the back and limbs, rapid pulse, and sometimes severe vomiting and diarrhœa, frontal headache, and painful bloodshot eyes are rather characteristic. The fever, which is of the relapsing type, generally keeps up for about a week, after which there may be an interval without fever for a few days, to be followed later on by another attack of fever. There are usually several relapses. As many as eleven have been noted.

_Prophylaxis._—Avoid sleeping in native huts and rest houses which have been occupied by natives. Do not sleep on the ground or on wooden native bedsteads. If the latter have to be used, their legs should be smoothed to prevent ticks from climbing up them. In badly infested places, it is well to employ a hammock. A mosquito-net is useful, as it excludes the ticks; and it is well to make use of a night-light, which also keeps them away. Packs and blankets should be periodically inspected to see that they do not harbour ticks. If one has to camp on an infected area, the ground should be fired and the floors of huts dug up and thereafter removed and buried or treated with fire, care being taken that the ticks do not escape during the process. Wandering ticks can be kept away from a tent to some extent by digging round it a trench and filling it with wood ashes.

_Treatment._—This is mainly symptomatic. Careful nursing is required together with a light diet. In some cases the arsenic preparation known as salvarsan (kharsivan) is found of value, but the specific treatment of this malady can only be carried out by a medical man. In many cases digitalis or strophanthus is required, owing to the risk of heart failure.

_Typhus Fever._

This disease is not so common in the tropics, but in certain sub-tropical countries, such as Egypt, it frequently occurs, and it is of course closely associated with military operations in the field.

_Cause._—The exact nature of the infection is as yet unknown, but the disease is transmitted by lice, both the head and the body louse having been proved to be carriers of the virus.

_Symptoms._—Incubation period 5 to 14 days, as a rule 12 days. Symptoms vary, but at first somewhat resemble those of an influenzal attack without the cold in the head. The patient is feverish and uncomfortable, but not until the third day do the typical symptoms of typhus make their appearance. Then the patient’s face becomes flushed and his eyes congested, his pulse rate increases, and very soon his temperature rises and runs up to 103 or 104° F. The rash, which varies in type, generally appears on the fifth day, being found first on the upper part of the abdomen. It does not occur upon the face, but is usually very profuse on the back. If the rash develops the patient becomes seriously ill, and all his symptoms are intensified. He becomes dull and lethargic, his mouth is foul, and his general aspect is somewhat like that of a drunken man. His voice becomes husky, his hands are tremulous, and his breathing is rapid. In the second week, in most cases, he becomes delirious or comatose, and lies in bed more or less like a log. In cases that recover, improvement sets in about the fourteenth day, and is usually rapid and complete. In cases which die the temperature remains high or rises, the general condition becomes worse, and death usually takes place from heart failure.

_Prophylaxis._—Get rid of lice according to the methods detailed on page 196. Those attending typhus patients should be protected from lice by wearing overalls, etc. Patients suffering from typhus should be thoroughly cleansed, their hair cut or shaved, and completely cleared of lice. Bedding and clothing must be disinfected.

_Treatment._—Good nursing is of more importance in this disease than the administration of drugs. The mouth must be kept in a good condition, and the food must be strengthening, nourishing soups being indicated. It is important to give the patient as much fresh air as possible, and as a rule he will require stimulants, especially heart tonics such as digitalis or strophanthus. Other measures can be carried out only under medical supervision.

_Ulceration of the Throat._

Gargle with a weak antiseptic solution such as permanganate of potash or chinosol. An astringent gargle may be made by dissolving five grains or more of tannin in two ounces of hot water. Sulphate of iron can be used for the same purpose, two grains or more to an ounce of water. If there is much pain, apply poultices to throat.

If due to syphilis give one grain of calomel and three grains of iodide of potassium, twice a day, in addition to the local treatment. Kharsivan, or similar treatment, is also indicated (_see_ p. 240).

_Undulant (Malta) Fever._

The term Undulant Fever is applied to Malta Fever partly because the latter is not a good name, as the disease occurs in various parts of the world, and partly because the term Undulant affords a good description of the type of the temperature curve.

_Cause._—The organism is a small bacterium, which is found in the blood and tissues. Although theoretically the disease can be spread like enteric fever or dysentery, in practice it is found that it is nearly always conveyed by infected goats’ milk. Goats are apt to harbour the organism and excrete it in their milk. It is also found in certain milk products, such as cream and cheeses which are not allowed to ripen. In addition to man and goats, cows, sheep, horses, mules and dogs, are all liable to natural infection.

_Symptoms._—Incubation period 5 to 15 days. The disease begins with headache, malaise, anorexia, and sleeplessness. The patient is usually constipated, and there is tenderness in the splenic region, the spleen being enlarged at an early date. The temperature rises gradually for three or four days in a step-like manner, and then falls by a similar descent, reaching the normal on or about the tenth day. At this early stage bleeding from the nose may occur, and profuse night sweats are not uncommon. The tongue is flabby and coated. When the temperature falls the patient feels better for a few days, but is still apt to suffer from night sweats, and continues to lose flesh. A relapse occurs, and is usually accompanied by joint troubles and sometimes neuralgic pains. A series of febrile waves continues to follow each other at short intervals, and the illness is a very wearisome one, running an average course of 60 to 70 days. It may, however, extend for nearly a year, and in some cases terminates fatally. The long course of the illness results in the patient becoming anæmic, and he often suffers from mental depression. There are irregular forms of the fever which are apt to be puzzling, and it is always well to remember that any cases of prolonged pyrexia from tropical or sub-tropical regions may be Malta fever.

_Prophylaxis._—Avoid drinking goats’ milk and eating the local products of such milk. If goats’ milk must be drunk it should be boiled. General hygienic measures are also important, and it should not be forgotten that the organism of the disease is found in urine, which should therefore be disinfected.

_Treatment._—This is for the most part entirely symptomatic. Medical attention and good nursing are essential. A vaccine has been introduced and is worth trying, but vaccine treatment is best left to an expert. It is sometimes necessary to give morphia for the joint pains and the neuralgia, but there is a distinct risk of the patient’s acquiring the morphia habit. Sleeplessness, which is often troublesome, should be treated as indicated on page 235.

_Urine, Retention of._

Retention of, or inability to pass the water may be caused by stricture, injury, shock, spasm, inflammation of some part of the passage, the effects of drinking, or by chill.

_Symptoms._—The bladder is unable to expel its contents and it gets fuller and fuller; it can be felt in its distended condition as a painful, soft swelling in the lower part of the belly, below the navel, underneath the skin and muscles. There may be fever, great pain and constant desire to pass water, with inability to do so. When the bladder becomes greatly distended, there is usually slight dribbling of water, which is somewhat misleading, as the case may be considered, not one of retention but rather of too frequent passing of urine.

_Treatment._—Give a saline purge such as Epsom salts, three or four teaspoonfuls, and let the patient sit in a bath of hot water. If not relieved very quickly, then pass a _clean_ catheter into the bladder, and allow it to empty itself (_see_ Catheters, p. 272). After the bladder has been emptied put the patient to bed and give a dose of opium or bromide of potassium to procure rest. When he desires to pass water again let him have another bath, and if this is not effectual, again withdraw the water through a catheter. Patient should be careful to ward off further attacks by avoiding chills, over-drinking, and other exciting causes. If there is inflammation of the bladder, copaiba or sandal-wood capsules should be used; if the urine is irritating, bicarbonate of soda must be given.

_Urine, Suppression of._

In this serious condition no urine is secreted by the kidneys, so that on passing a catheter the bladder will be found to be empty.

_Causes._—Shock from injury, inflammation and blocking up of the kidneys. Suppression of the urine is a common complication of severe cases of blackwater fever.

_Treatment._—Hot baths, hot poultices to the loins, free use of aperients, especially Epsom salts and other saline purges. Bicarbonate of soda in full doses. Keep the skin acting freely by means of sweet nitre, or Warburg’s tincture, or five-grain doses of antipyrine. Injections of hot water into the lower bowel.

_Worms._

Worms are introduced into the system chiefly by means of dirty water or imperfectly cooked food.

In the case of hook worms (ankylostomes), contaminated soil is the chief medium of infection.

Of the worms which live in the bowels the most important are the following:

_Tape Worms._—These worms may measure many feet in length; and their presence in the body can only be certainly known by the appearance of some of the segments or portions of the worm in the motions although hunger and dyspepsia may be complained of.

_Treatment._—Administer a good aperient overnight so as to empty the bowels; after the aperient nothing should be given by the mouth for eight hours, then give sixty to one hundred and twenty drops of the liquid extract of male fern in one ounce of thin gruel, milk, or gum water, and follow this up in four hours by a good meal, and an aperient to remove the worm, which should now be dead.

When the extract of male fern is not available, one tablespoonful of the oil of turpentine may be used in its place.

If later on fresh segments appear in the motions, then the treatment must be repeated.

_Round Worm._—The round worm resembles the garden worm and is several inches in length; it may be observed in the vomit but more commonly is seen in the motions. The symptoms are similar to those caused by the tape worm and the treatment is the same, except that, instead of the male fern, two to five grains of santonin should be given in a little milk; and the treatment repeated every other day for a week.

_Threadworm._—The threadworm is a small round worm usually measuring less than half an inch in length; it inhabits the lower end of the bowel and causes great heat and itching about the outlet, especially at night.

_Treatment._—Wash out the lower bowel and inject into it about a third of a pint of tea, or a similar quantity of water containing one teaspoonful of salt, tannin, or alum; then apply a little mercurial ointment around the outlet to diminish irritation. This should be done every third day till the worms have disappeared from the motions.

_The Guinea Worm._—The guinea worm often measures several feet in length; it chiefly causes trouble in the feet, ankles, and legs, where in order to obtain an exit from the body it penetrates the skin, causing a small ulcer at its point of exit.

Usually the presence of the guinea worm is attended with inflammation and the formation of matter.

_Prophylaxis._—Infected persons should be kept away from water supplies, and such sources of water supply as wells and water holes should be protected. In areas where guinea worm occurs, all water should be boiled. If this cannot be managed, it should be filtered through a piece of clean cotton cloth, as this will remove from it the small crustacean in which the larva of the guinea worm develops. Another method of treating infected water is by means of permanganate of potash, one ounce to every 2,000 gallons of well water. Caustic potash and quicklime are also effective.

_Treatment._—When the worm can be seen at the base of the little ulcer, it may be secured to a piece of match and a small portion may be wound on to the match daily. If attempts are made to forcibly draw it out, it will probably break and violent inflammation will result. During the time that the worm is being wound out, the part should be kept very clean and an antiseptic ointment applied.

There are other methods of treatment, but these can only be carried out under medical supervision.

_The Hook Worm._—This is the American name for one or other of the species of ankylostomes which infect man. The disease they cause is known as ankylostomiasis, and it is common in many parts of the world, especially in the tropics. It chiefly affects natives, owing to their habits; but it occurs also in Europeans.

_Cause._—Hook worms are small, almost cylindrical worms, which inhabit the human small intestine, to the wall of which they attach themselves by means of their mouths, which are furnished with formidable hooks and lancets. They suck blood, and the symptoms they produce are due in part to loss of blood, in part to the destruction of the lining membrane of the bowel, and possibly also in part to the effects of a poison which they are believed to excrete. Their eggs are passed in the excrement, and develop in the infected soil into larvæ, which are able to penetrate the unbroken skin if they come in contact with it. This is the most important route of infection, but it may occur also by means of infected drinking water and from contaminated food.

_Symptoms._—The most marked feature of the disease is anæmia, which is often associated with digestive troubles. Palpitation of the heart and shortness of breath are frequently met with. In bad cases the appetite is disordered or depraved. The patient becomes pot-bellied, and there is swelling, chiefly about the face and ankles. The face is frequently puffy, and the skin assumes a peculiar earthy hue. It should be noted that a very early symptom is what is called ground itch. This is a skin eruption, usually on the feet and legs, due to the irritation caused by the larvæ penetrating the epidermis.

_Prophylaxis._—The chief measure consists in preventing contamination of the soil by infected excrement. It is therefore important when camping to make proper provision in the way of latrines. Care must also be taken to prevent the fouling of water and food stuffs, such as vegetables, which are eaten uncooked. It is very dangerous to go about bare-foot in regions where the disease occurs, and camping sites should always be thoroughly cleansed.

_Treatment._—Efficient treatment can only be carried out in association with microscopic examination of the stools, and hence all that need here be said is that various worm medicines are employed, of which the most effectual are thymol and oil of chenopodium. These should be administered only under careful medical supervision. The anæmia has to be treated, and in the case of natives a nutritious and easily-digested diet is indicated; for example, for native coolies the following has been recommended: bread 1 pound, milk 2 pints, sugar 2 ounces, 2 eggs, and 4 bananas daily. Ground itch should be treated by an ointment containing zinc oxide and salicylic acid.

_The Bilharzia Worm._—This worm, of which there are two species, produces the disease known as Bilharziasis or Schistosomiasis, which occurs in one or other, or both forms, in various parts of the world, but is specially prevalent in Egypt.

_Cause._—The worms, which produce either urinary or rectal bilharziasis, live in parts of the human vascular system, where they produce their eggs. These eggs are furnished with spines, and hence cause irritation when lodged in the tissues. In the urinary form the eggs have a terminal spine, in the intestinal form the spine is lateral. These eggs are passed either in the urine or in the excreta and reach water, where they develop into larvæ. The larvæ enter special species of water snails, in which they develop, producing eventually tiny forms known as cercariæ. These cercariæ escape into the water and can penetrate the unbroken skin or intact mucous membrane. They thus get access to the bodies of persons who are bathing in the infected water, or who may drink it. Once in the human body, the blood carries them to the place where they develop into the adult worms, which eventually unite, and then the females begin producing the spined eggs.

_Symptoms._—In the urinary form the chief symptom is the passage of bloody urine, which usually shows itself about three months after infection, and is often associated with a good deal of irritation of the bladder and the pipe. The intestinal form may produce various symptoms. Sometimes a condition resembling enteric fever occurs, sometimes one like dysentery. Diarrhœa is common. The condition is chronic and, if untreated, sets up all kinds of secondary effects, which need not be discussed.

_Prophylaxis._—Carefully avoid any kind of personal contact with water which may by any possibility be infected from urine or fæces. Bathing, wading, washing in, or drinking any such waters, are all dangerous. Wherever possible, water which may be infected should be boiled. If this cannot be done, sodium bisulphate tablets may be used; two of the 16-grain water-purifying tablets in a quart water-bottle full of water are efficient. Filtration through a Pasteur-Chamberland or Doulton candle is efficient, as it excludes the cercariæ. Bathing water can be rendered safe for immediate use by the addition of undiluted Army cresol in a dilution of 1 in 10,000. If the water is kept overnight, 1 in 90,000 is sufficient, as the storage of water tends to diminish infection.

_Treatment._—Certain forms of antimony have been found to cure the condition, but can only be administered by a medical man. Indeed, either form of bilharziasis can be properly treated only under medical supervision. If this is not obtainable, some relief can be afforded by the use of urotropin and sedative drugs.

There are many other worm diseases which afflict man, but no good object would be served by mentioning them in detail. Most of them can be diagnosed with certainty only by a medical man using the microscope, and they all require scientific treatment which is beyond the scope of the ordinary traveller.

_Yellow Fever._

This disease, the “Yellow Jack” of naval historians, occurs, so far as is known, only in parts of the New World and on the West Coast of Africa. One attack usually protects permanently against a second.

_Cause._—Quite recently the organism has apparently been discovered. It is a corkscrew-shaped parasite which exists in the blood, and which is allied to, though not identical with, the parasites of relapsing fever and tick fever. The infection is conveyed from one patient to another by the mosquito _Stegomyia fasciata_, which is a black and white insect, commonly known from its striped legs as the tiger mosquito. Incubation period two to five days.

_Symptoms._—The onset of the disease is very sudden, the highest temperature being reached almost at once; then follows a period of remission or calm, the pulse becomes abnormally slow, and this stage is usually either succeeded by convalescence, or the symptoms become worse and the patient dies. Some of the symptoms much resemble malaria, but the rapidity of the onset, severe pain in the forehead, eyes, and loins, the early scantiness of the urine, the marked jaundice, the bright eyes, the narrow red tongue, and the absence of pain about the spleen are fairly characteristic.

There is considerable thirst and vomiting, and in bad cases the vomit becomes black, the colour being due to the presence of blood. (In ordinary malaria the vomit is yellow, or in severe cases, such as blackwater fever, it may be of a bright or dark-green colour.) In yellow fever, jaundice is developed about the third day, and tends to increase, whilst in blackwater fever it comes on very early and soon begins to abate.

An important diagnostic sign in yellow fever is found in the fact that the pulse does not increase in rapidity as the temperature rises.

_Prophylaxis._—Avoid being bitten by mosquitoes, employing the methods mentioned on pages 206, 207. It must be remembered that _Stegomyia fasciata_, unlike the anopheline mosquitoes, bites during the day, and therefore it is more difficult to avoid its unwelcome attentions. It usually breeds in the neighbourhood of houses, being what may be called a domestic mosquito; and it is of the greatest importance to abolish all potential breeding places or to protect them from the mosquito. Practically any vessel holding water may become a nursery for Stegomyia, and it is remarkable in what small quantities of water this mosquito will lay her eggs. Patients suffering from the disease must be isolated and kept under a mosquito net or in a mosquito-proof chamber, in order to prevent them from infecting mosquitoes, which they are capable of doing in the early part of the disease.

_Treatment._—Open the bowels well by means of calomel, six grains, followed by a saline purge and hot-water enema. Some prefer castor oil in large doses. Give ten grains of bicarbonate of soda three times a day. Give cooling drinks, such as fruit salt. Make the skin act. Apply hot fomentations to the back and mustard leaves to the pit of the stomach.

The question of feeding is very important. During the first two or three days of the fever the patient is better without any food at all. As he recovers his appetite returns, and great care must be exercised about gratifying it. Only the plainest foods in very small quantities should be permitted, the amounts being gradually increased, as otherwise relapses may occur. Stimulants are usually required in the later stages of the fever, but they must be carefully employed as they may tend to increase the vomiting. It is possible that the discovery of the parasite may lead to new and more efficient methods of treating the disease.

MEDICINES, MEDICAL APPLIANCES, ETC.

WEIGHTS AND MEASURES.

_Solids._

A Grain Symbol Gr.
20 Grains 1 Scruple { weights now ” ℈
60 Grains 1 Drachm { rarely used ” ℨ
437.5 Grains 1 Ounce ” ℥
16 Ounces 1 Pound ” ℔

_Note._—An ounce weighs not 8 but rather under 7½ drachms.

1 Gramme about 15½ grains.
1 Kilogramme ” 2 lbs. 3¼ ozs.

_Liquids._

1 Minim About 1 drop, or 0.06 c.c. Symbol ♏
60 Minims One fluid drachm ” ℨ
8 Fluid drachms (480 Minims) One fluid ounce ” ℥
20 Fluid ounces One pint ” O
1 Cubic centimetre 17 Minims.

A teaspoonful About one fluid drachm.
A dessertspoonful About two fluid drachms.
A tablespoonful About half a fluid ounce.
A wine-glassful About two fluid ounces.
A tumblerful About half a pint.
A litre About a pint and three quarters.

All bottles containing drugs should be doubly labelled, and the labels should be varnished, otherwise they will probably come off in a damp climate. Poisons should be kept in bottles of a special shape.

Drugs in a liquid state are inconvenient for travellers. They are bulky, and require very careful packing and handling.

As far as possible, therefore, compressed drugs should be selected. These must be of good quality.

Tablets are often taken in the solid form, but they will act more quickly and certainly if dissolved or suspended in about an ounce of water.

Some preparations, chiefly those used for preparing lotions, etc., _e.g._, of chinosol, are also made in compressed form.

In regard to drugs, I have kept well within the maximum dose, so that there may be no trouble on that account. For instance, in certain cases a medical man would give sixty drops of laudanum for a dose, but I advise travellers rarely to give more than sixty drops in twenty-four hours. The urgency of the case must be the guide as to the quantity of the drug to be given. The smallest dose which is effective is the best.

A supply of antiseptic gauze, wool and lint is necessary. The compressed forms are very convenient.

All antiseptic gauzes and other dressings should be very carefully protected from the air in order that their properties may be preserved. They should be wrapped in oiled paper or india-rubber tissue, and kept in a tin box.

A supply of bandages will also be needed. Each bandage should be two inches in width by six feet in length.

_Dressing case._—The traveller should provide himself with a surgical dressing case. A suitable one should contain 1 pair of scissors, 1 pair of Spencer Wells’ artery forceps, 1 probe, 1 scoop and grooved director, 1 knife with two blades, 1 small saw with a detachable handle, and a packet containing silk, wire, needles, and pins.

All active poisons mentioned in the following pages are marked with an asterisk (*).

_Aloin Co. tablets._—One taken three times a day after meals, in chronic constipation, gradually reduced as bowels become regular.

_Alum._—Dose, five to ten grains. Is occasionally used as an internal astringent in the treatment of diarrhœa.

A solution containing five grains to the ounce of water may be used as a mouth wash for bleeding or inflamed gums, as a gargle for relaxed and sore throats, or as a lotion for inflamed eyes.

Ten to twenty ounces of a solution containing five grains to the ounce is sometimes used as an enema to check the diarrhœa in chronic dysentery.

The tablet of alum weighs ten grains.

_Ammonia._—Three preparations of ammonia, viz., Sal volatile, Carbonate of ammonia, and Liquor ammoniæ, are extremely valuable as stimulants, and in this respect they are to be preferred to alcohol. All three are similar in their action, and are useful on account of their stimulating effect upon the heart in cases of fainting, or collapse caused by snake-bite, bullet-wound, or other injury; they relieve spasm, and promote sweating in feverish states. They also cause free expectoration, and are therefore useful in the later stages of bronchitis.

The chief objection to these drugs is that their strength is rapidly lost, unless they are kept in well-stoppered bottles, and in the dark.

All preparations of ammonia should be administered in about one ounce of water.

_Sal volatile, or aromatic spirit of ammonia._—Dose, twenty to sixty drops for a single administration, or up to thirty drops if repeated frequently. This is the most convenient and pleasant preparation of ammonia, but is bulky. As a local application, it is of service in relieving the pain caused by the bites of certain insects, _e.g._, mosquitoes and fleas.

_Carbonate of ammonia._—Dose, three to ten grains.

_Liquor ammoniæ, or solution of ammonia._—Dose, five to twenty drops.

(_Note._—This is not the strong solution, which is always labelled “Liq. Ammon. Fort.,” and which is three times stronger than liquor ammoniæ.)