By the late William Henry Crosse, M.D.
Revised and brought up to date by Andrew Balfour, C.B., C.M.G., M.D.
The following hints, which were compiled by the late Dr. W. H. Crosse, formerly the experienced medical adviser of the Royal Niger Company, based upon previous editions of this work, have been edited so as to bring them up to date. A good deal remains as Dr. Crosse wrote it, but several sections have been almost entirely re-written, in order to bring them into line with modern views. New sections have been introduced and there have been numerous additions and corrections.
In the following pages the chief emphasis has been laid upon the care of the health in the tropics; but it must be remembered, that whilst by far the greater proportion of travellers go to the tropics, most of these hints for the preservation of health apply equally well for all climates.
Though many subjects have been briefly dealt with, certain matters have been rather more fully written up, such as the treatment of wounds. It is, in the author’s opinion, so important that the traveller should thoroughly understand what is meant by ‘surgical cleanliness’ that the usual methods observed by surgeons to ensure it have been plainly set forth. The author, of course, understands that in many cases it would be quite impossible to carry out the instructions in every detail, but it is hoped that a thorough knowledge of the principles underlying the correct treatment of wounds will assist the traveller in doing the best possible for his patient in any emergency, and under even the most unfavourable circumstances.
It is hardly necessary to observe that travellers in remote regions, and especially in tropical climates, are much more exposed to physical ills and diseases than most residents at home, and that they are more likely to be placed beyond the reach of skilled medical and surgical aid when it is most required. It is chiefly for the use of the non-professional traveller that the following pages have been written, and with this aim in view the symptoms and general treatment of the diseases and injuries with which he is most likely to be brought in contact are dealt with in simple, non-technical language.
Every traveller should supply himself with either Bernard Myer’s ‘Atlas of First Aid Treatment’ or Hastings Young’s ‘First Aid to the Sick,’ books of general utility. Travellers visiting countries with hot climates will find Garry’s ‘Some Factors Influencing Health in Tropical and Sub-tropical Climates’ a useful book, despite a few errors, while the small ‘Primer of Tropical Hygiene’ by Colonel R. J. Blackham, is a valuable guide to things hygienic as is Professor Simpson’s ‘Maintenance of Health in the Tropics.’
A few books may be mentioned as specially suitable for those travelling in the countries with which they deal, such as ‘Hints for Residents and Travellers in Persia’ by A. R. Neligan, ‘Health Preservation in West Africa’ by J. C. Ryan, ‘Hygiene and Disease in Palestine’ by Masterman, and ‘The Epidemics of Mauritius’ by Anderson.
Those who read German will find the ‘Gesundheitlicher Ratgeber für Auswanderer,’ issued under the auspices of the Institut für Schiffs- und Tropenkrankheiten in Hamburg, of considerable service, and if they intend visiting South America it is worth noting that from the same source a series of small books to guide the traveller in different parts of that continent will soon be forthcoming. This series will also include works on Mexico, Angola and Siberia. These German guides are obtainable from L. Friederichsen & Co., Hamburg.
Persons who intend to travel should undergo a thorough medical examination, in order to ascertain if they are likely to be able to stand the fatigues, exposures and privations to which they will probably be subjected.
Fig. 1.—Diagram showing some of the Principal Organs of The Body, and the Course of the Main Blood-vessels.
Most people of good constitutions and regular temperate habits can, with care, maintain a good state of health in the tropics, and many of those who have been by no means strong at home are able with some extra caution to do well even in the hottest climates.
The intending traveller should attend a course of ambulance lectures in order to prepare himself for the responsibilities which he will have to undertake. As much time as possible should be devoted to discussing with some professional friend the uses, correct doses, and proper methods of prescribing and combining the drugs which are to be taken on the journey, and in becoming familiar with the position of the principal bones, vessels and other important structures of the human body.
A traveller should understand how to use the clinical thermometer, how to twist or tie a bleeding vessel, how to use the hypodermic syringe and the syphon stomach tube. He should learn how to cleanse a wound, how to treat a case of snake-bite, and should know the best way in which to set a broken limb. Such things are not easily learnt from books, and experience alone will give the necessary skill and confidence. Many valuable lives have been saved by travellers who have fairly mastered the rudiments of medical and surgical treatment, and who have been able in an emergency to give the necessary drugs, administer an antidote, or to stop severe bleeding.
The ideal traveller is a temperate man, with a sound constitution, a digestion like an ostrich, a good temper, and no race prejudices. He is capable of looking after details, e.g., seeing that drinking water has really been boiled, and is willing to take advice from those who have made journeys in countries similar to the one in which he is about to travel.
A traveller should be supplied with suitable housing, food and clothing, and should have a proper supply of medicines, dressings, and medical comforts.
In selecting the drugs with which the traveller should be provided before leaving home care should be taken to see that only reliable products be purchased. In the tropics, and in exploration generally, the medical outfit is subjected to very severe tests, and it is a mistaken policy to economise on medicines. The latter should be as portable as possible and be properly packed.
Seeing that these hints will be chiefly required by travellers in tropical or sub-tropical climates, it may be well to indicate some of the chief risks which are to be met with in warm climates, and the best methods of meeting them.
It will be noted that any detailed reference to questions of outfit, such as the supply of proper food or clothing, is omitted, as these matters have been fully dealt with in ‘Hints on Outfit,’ published by the Royal Geographical Society uniformly with this ‘Hints to Travellers,’ and it is understood that this work will be consulted by all who read these hints.
Chill.—The most prominent feature of a tropical climate is undoubtedly heat, and yet the greatest risk arises not so much from excessive high temperature as from a risk of chill, which is due mainly to the excessive perspiration which takes place. This must be guarded against by the use of proper clothing, the most important point being that the underclothing should be partly of absorbent material. For general use cotton is best, and the vest or undershirt should in the tropics be of the Aertex Cellular type. It is a mistake to wear wool next the skin in hot countries, for it soon gets sodden with perspiration and is irritating. A light flannel shirt worn over the open cotton mesh is probably the best arrangement though a mixture of wool and cotton may be employed for the shirting. This question is fully dealt with in ‘Hints on Outfit.’ It is particularly important to avoid sudden changes of temperature, and if exposed to the cooling sea breeze, special care must be taken as to proper clothing. Parke laid great stress on the importance of avoiding chills, draughts, or wettings. He remarked “In crossing Equatorial Africa the Relief Expedition found that every wetting meant an attack of fever.” The sea breeze, which is so refreshing and cool, by checking the perspiration, frequently acts as the exciting cause of an attack of fever. There is special liability to chill and subsequent fever when ascending an eminence, as the exertion causes profuse perspiration, and the cool breeze encountered on arrival at the top is very likely to produce ill effects.
On completing a day’s journey, the underclothing, at least, should be changed without delay, and the skin should be well dried by the free use of a rough towel. If at all possible a warm bath should be taken.
The cummerbund is a useful article of clothing, especially for men in the evening. It does away with the need for a waistcoat, which often proves hot and uncomfortable, and yet provides the necessary safeguard against chill to the abdominal organs.
A word as to the use of a flannel cholera belt, about which opinions differ. Experience in many tropical countries leads the writer to recommend its use at night, and at night only. Even so, it is unnecessary and uncomfortable in places where the nights are invariably hot and steamy, and is chiefly of value in dry, desert climates where there is a great difference between the day and night temperatures.
Effects of the Sun.—It is difficult to overestimate the importance of the protection of the head from the direct rays of the sun. It is best, where possible, to avoid going out in the heat of the day, but where this is necessary the head should be protected by a suitable helmet, which should be light in weight and colour, which should be ventilated, and which should have a good protection for the back of the head. A large green leaf inside the helmet might be an additional protection, and a sun umbrella should also be used wherever practicable. A helmet should as a rule be worn when going out during the day-time in the tropics. Sometimes, however, the helmet is found very troublesome, as, for example, by the sportsman in the bush. He may then have recourse to a double Terai hat, or even to an ordinary wide-brimmed felt hat provided he inserts a crumpled-up handkerchief in its crown. This will usually afford a reasonable protection.
Errors of Diet.—The lassitude which is often so much felt by Europeans resident in the tropics too frequently tempts them to the abuse of alcoholic stimulants and highly-spiced foods. The habit is a most pernicious one, for such indulgence is one of the most fruitful causes of the permanent ill-health so often wrongly attributed to the mere residence in a hot climate. There is no doubt that food should be taken with greater moderation in hot than in cold climates; heat-producing articles of diet, such as fat, should be taken in far smaller quantity, but an ample supply of vegetables is essential. The meals should never be heavy, especially during the heat of the day, and intervals of about four hours should always separate consecutive meals.
Cooking should always be conducted with great care in the tropics, for the stomach and liver are less able to bear any extra strain, such as would be induced by the attempt to digest imperfectly-cooked food. Parasites are often introduced into the system by insufficiently cooked food.
Natural milk must be boiled; condensed milk should be mixed with boiled water.
Excess in the use of alcoholic stimulants is one of the most fatal errors into which the tropical resident can fall, and their habitual use as beverages is totally unnecessary, tea, coffee and cocoa being the best beverages for ordinary use. A small supply of brandy, champagne, and port wine may be of service in certain cases of illness, but they are better regarded as belonging strictly to the medical equipment.
Avoid native drinks, as they will probably have been diluted with dirty water, or prepared in unclean vessels.
Great moderation in the use of alcohol is quite as necessary in arctic as in tropical climates. In the latter no alcohol should be taken till the sun has set, and even then the quantity should be strictly limited. There is no reason why a glass of light beer, a whisky and soda, or a little light wine should not be drunk with the evening meal. Alcohol taken at this time often promotes appetite and aids digestion, but alcohol between meals is bad, chiefly perhaps because the habit of exceeding the daily allowance is thereby apt to be engendered. It is largely a question of self-control, and it must be remembered that in the tropics self-control, so far as drinks are concerned, is very apt to weaken. Apart from the question of its habitual use alcohol is often of great service as a restorative, as, for example, after a fatiguing march, and especially if one has got wet and chilled. Champagne is possibly the best form to take on such occasions and it should be used as an apéritif or drunk along with food.
Risks due to Drinking Water.—The use of water for drinking purposes must be attended with great care in all tropical climates. As the water of the lakes, streams and pools of these countries usually contains a large proportion of impurities, and the germs or parasites of many diseases, it should be strained and subsequently boiled before being used.
As, however, it is not always possible or convenient to incur the delay of boiling the drinking water and allowing it to cool, it is advisable that a reliable filter should be taken.
Most filters—charcoal or otherwise—are merely death-traps, as the accumulation of germs and injurious matter within the filtering substance soon renders the water more dangerous than if unfiltered. There are, however, a few filters which, with ordinary care in cleansing, are in themselves efficient safeguards. The most highly recommended of these are the Pasteur Chamberland and the Doulton filters. In any case, spare filtering candles should be taken, and these should be cleaned and boiled at least every three days. It is recommended that the filter-makers should be consulted immediately the probable requirements of any expedition are known. It should be remembered that no filter combines rapid delivery of water with efficient sterilization. A mistake commonly made is to boil water and then filter it. This should never be done.
The drinking of very cold water, to which there is great temptation when one is exhausted by prolonged heat and copious perspiration, should be carefully avoided; thirst often induces tropical residents to have recourse to iced water, which is always apt to be dangerous if taken when one is heated. The drinking of copious draughts of water is also a habit to be deprecated; it certainly weakens the muscular energy, and as the water is rapidly lost by perspiration, the feeling of exhaustion is increased. Hot or cold weak tea, without milk or sugar, is one of the least injurious of all beverages.
The traveller should endeavour to land in a perfectly healthy condition, and to this end he should on the voyage out take plenty of exercise, drink little or no alcohol, be moderate as to diet, and avoid much meat and rich dishes. Neglect of these obvious rules frequently ends in the traveller arriving in a flabby, bilious condition, in which state he is predisposed to attacks of malaria, dysentery, and other diseases.
Constipation is frequent at sea, and a seidlitz powder, a dose of fruit salt, or one or two cascara tabloids may be necessary. If constipation is severe, then one or two four-grain blue pills should be taken at bedtime, followed in the early morning by a seidlitz powder or some other saline aperient.
In order to avoid chill the traveller should be properly clothed during the evening or when there is a cool breeze, and should not stand in draughty doorways and passages on board. If he is proceeding to a country where there is endemic malaria he should begin his course of prophylactic quinine on ship-board, because even a single night spent ashore in a malarious locality may result in his acquiring infection. It is therefore advisable to begin taking quinine in the manner described on p. 207 at least two days before arrival at the place of disembarkation.
What is true of the journey out is of even greater importance on the voyage home. There is a serious danger of illness owing to chills contracted on board ship when leaving a hot climate. Quinine should be systematically taken as recommended on p. 208.
Never take a cold bath in the Tropics unless ordered to do so by a doctor.—In the case of persons who have already suffered from many attacks of fever, dysentery, or any disease of the liver or other important organs, warm bathing should alone be used. Bathing should never be resorted to during the period of digestion, i.e., three to four hours after meals. Wear warm clothes at night. Avoid the direct rays of the sun. Do not take too much animal food. Never begin work on an empty stomach. Never neglect a slight attack of fever or diarrhœa. Keep the bowels gently opened—once a day is quite enough—but avoid strong purgatives.
It is essential that all the members of an expedition should be re-vaccinated if they have not suffered from small-pox or been vaccinated within two years. A proper supply of vaccine should be carried on the journey. Heat and bright sunlight are very detrimental to vaccine lymph. Hence the proper transport of such lymph in hot climates is a matter of great importance and by no means always easy to arrange. Where a thermos flask is available it may be used for storing and carrying the capillary tubes, or they may be wrapped up in green leaves and inserted into a hollow bamboo, the ends of which are closed with cotton wool.
Owing to the prevalence of typhoid and paratyphoid fevers in hot countries it is essential that all persons, and more especially young adults, proceeding to tropical countries should undergo preventive inoculation. Two injections of the so-called triple vaccine, at ten days’ interval, are necessary, and both should be given shortly before leaving or, if arrangements can be made, one or both may be given on ship-board.
On the outbreak of an infectious complaint, such as small-pox (which is very common amongst negro carriers), the sufferer should be promptly isolated, and one or more attendants should take charge of the case and not be allowed to come to camp. It is wise to select as attendants those who have either had the disease, or who are protected (as by vaccination) against it.
In Nigeria it was found most convenient to build grass huts, which were burnt to the ground, together with the clothing and bedding of the patient and attendants, on the termination of the outbreak.
All vessels which are not destroyed must be boiled thoroughly. The motions, etc., of patients suffering from typhoid fever, cholera and dysentery should be disinfected, preferably by boiling, or, better still, destroyed by fire.
The traveller should remember that of late years the rôle of the healthy human “carrier” in the transmission of many communicable diseases has been established. This is true of such diseases as enteric fever and cholera, and when engaging servants, porters, and camp followers it is important to inquire into their previous history and, if necessary, to make certain that they do not harbour the specific organisms of such diseases.
In the tropics, as elsewhere, the diseases to which the traveller is liable are due to widely differing causes, but in hot countries climatic conditions and parasites play a predominant part. Insects are very frequently to blame for the transference of the latter from the sick to the sound, both insects which are not themselves parasitic on man, e.g., the mosquito and the tsetse fly, and those which make man their host, e.g., lice and fleas.
It is useful for the traveller to bear diseases in mind from the standpoint of their etiology, as in this way he can more readily grasp the measures necessary for their prevention.
Accordingly, the following classification is given, merely as a guide, together with a few examples. The diseases themselves, for the sake of convenience of reference, are grouped alphabetically and are not classified in any way.
(i.) Due to “contact” either direct or through the agency of clothes, bedding, etc. Also due to direct inoculation through the skin or mucous membrane.
Examples: Many skin diseases, venereal diseases, small-pox, tetanus, and blood-poisoning (septicæmia).
(ii.) Due to “mouth to mouth” infection, through the agency of so-called “droplet” infection, expectoration, coughing, sneezing, etc.
Examples: Influenza, pneumonia, and pneumonic plague.
(iii.) Due to “droplet” infection, as above, or to infected scales from the skin, or to infected discharges from the nose, throat, or ear.
Examples: Measles, scarlet fever, small-pox, chicken-pox, diphtheria.
(iv.) Due to excremental infection through the agency of water, food, flies, fingers, dust, and soil.
Examples: Enteric (typhoid) fever, dysentery, diarrhœa, cholera, worm infections of many kinds.
(v.) Due to inoculation through the bites of insects, or the entry through skin abrasions of the infected excreta or infected crushed tissues of insects rubbed or scratched into these lesions.
Examples: Malaria, yellow fever, tick fever, sleeping sickness, filariasis, relapsing fever, typhus fever, bubonic plague.
(vi.) Due to invasion of the body by insects in their adult or larval stages.
Examples: Chigger, myiasis of various kinds.
(i.) Due to climatic conditions.
Examples: Heat stroke, diarrhœa in some instances, constipation in many cases, rheumatism, prickly heat, chilblains.
(ii.) Due to errors in diet.
Examples: Diarrhœa, beri-beri, scurvy, sprue(?).
(iii.) Due to poisons.
Examples: Scorpion sting, snake-bite, vegetable poisons.
(iv.) Miscellaneous.
Examples: Bed-sores, epilepsy, apoplexy, concussion of the brain, hay fever, and other conditions into the cause of which a mechanical element frequently enters.
It will be seen that some of these diseases, such as small-pox and diarrhœa, come under more than one heading, but this does not detract from the general utility of the above classification.
When a patient is confined to his bed for a long time it is necessary to support the lower part of the back on something soft, such as a pad of wool, or an extra pillow, in order to prevent the formation of a bed-sore; pillows should also be placed under the hips and heels.
To harden the skin it is well to rub it with alcohol or to treat it with oil or white of an egg three parts, and spirits one part; zinc ointment is also useful for this purpose.
Besides pressure, the most frequent cause of bed-sores is constant moisture from the passage of urine and motions and consequent damping of the sheets. Great care must be taken to thoroughly dry the back after any evacuation; the lower part of the back should be dusted with a powder of boric acid and zinc oxide.
If a bed-sore is present the patient should lie on a circular pad with a hole in the middle, to take pressure off the bed-sore. The sore should be thoroughly cleaned twice a day with some antiseptic lotion, such as chinosol or permanganate, and subsequently dressed with zinc ointment or vaseline.
If the bed-sore is on the back, the patient should lie if possible on each side alternately, to relieve the pressure.
In most cases this is a disease due to some deficiency in the dietary, which leads to a form of what is called peripheral neuritis. The name is possibly derived from a Cingalese word signifying “I cannot.”
Symptoms.—Weakness of the legs and digestive troubles, abnormal sensations in the legs, frequently associated with swelling. The gait alters, and the arms and fingers may be affected. The condition is one of spreading paralysis, and in bad cases the heart is affected. In so-called wet beri-beri the patient becomes bloated as in dropsy, while in dry beri-beri he wastes away until he is little better than a skeleton. There is a “squatting test” which may enable one to recognize the disease at an early stage. The patient, with his hands on the top of his head, is unable to assume a squatting position and to rise from it unaided. If he is squatting and has to rise he accomplishes the act by climbing, as it were, up his own legs.
Prophylaxis.—Avoid overcrowding, as this seems in some cases to predispose to the disease. Give the yeast extract known as “Marmite,” which is supplied in small cubes one-quarter ounce in weight. One should be taken twice a week, either alone or with bread or biscuit, or dissolved in warm water in the form of a soup. Lentils, other legumes, and oatmeal are useful. Eggs and fresh meat, when obtainable, are very valuable.
Treatment.—This is chiefly dietetic. Give yeast, two ounces daily, along with milk and sugar, or marmite in one-cube doses twice a day. Eggs are specially useful, while fresh milk, legumes, and nourishing soups are all indicated. Only small quantities of food should be given at a time. Rest in bed is very important, and the patient must be careful when he is allowed to get up owing to the danger of heart failure. Tonics are required during convalescence.
Blackwater fever is probably a pernicious complication of malarial fever, and derives its name from the colour of the urine. It must be remembered that dark-coloured urine is usual in all fevers; it is scanty during the height of the fever, especially if there is much sweating. If, however, it is obviously “bloody,” the case is more grave, but as a rule it is only men broken down in health, and those who have resided in blackwater countries, e.g., Tropical Africa, parts of India, the West Indies, etc., for at least a year, especially those who have taken their prophylactic quinine irregularly, who suffer from this complication.
The reason for the occurrence of this condition is not fully known. Some have ascribed the symptoms entirely to the taking of quinine, but as the fever often occurs where no quinine has been given this is impossible. At the same time it appears likely that in certain cases of malaria, owing perhaps to some idiosyncrasy, quinine may help to bring on the symptoms. It is possible that chill occurring during the course of a fever may lead to the production of blackwater fever. Those who have had one attack are particularly liable to a recurrence, and after two consecutive attacks return to a temperate climate is required.
Symptoms.—In addition to the ordinary symptoms of malarial fever, the urine is dark, blood-like, and eventually porter-coloured; it is often scanty, and may become entirely suppressed. The skin is yellow, often a bright orange, there is frequent vomiting, often hiccough, and the vomited matter is usually of a green colour.
Prophylaxis.—With our present knowledge all that can be said is that malaria prophylaxis is also the method to prevent blackwater. Such prophylaxis, so far as quinine is concerned, must be properly carried out. Those who take quinine regularly, and in sufficient doses, do not contract blackwater fever. Chill and excesses of all kinds must be avoided.
Treatment.—Much the same treatment should be adopted as that fully described later for malaria. It is especially important to give an aperient at the beginning, and perhaps five grains of calomel is the best form. In every case, no matter how slight, it is essential to ensure, wherever possible, absolute rest in bed and skilled and careful nursing. If it can possibly be avoided a blackwater patient should never be moved from the place where he is taken ill. So long as he has a bed to lie on, a roof to cover him, and some sensible person to look after him who will carry out the doctor’s orders, he should be treated on the spot. It is better, when it can be arranged, for the nurse to go to the patient than for the patient to come to the nurse.
The chief aim should be to support the strength by fluid nourishment, and to secure free action of the kidneys. The former should be maintained by fluid nourishment given in small quantities at frequent intervals, such as milk, Plasmon, Benger’s food, Allenbury’s foods, invalid Bovril, Brand’s fever food, or Brand’s essence, Maggi’s consommé. A little Plasmon added to any of the meat preparations would be useful, while raisin tea is a valuable preparation.
In order to maintain free action of the kidneys, plenty of fluid should be given, such as barley-water made from Robinson’s prepared barley, flavoured slightly with lime-juice or lemons. Weak tea is useful.
Diuretics which stimulate the kidneys must be avoided. The most effective method of flushing the kidneys is by giving saline injections by the bowel, but these, as a rule, can be administered only by a medical man or by a trained nurse under a doctor’s supervision. It may, however, be stated that the amount usually given is six ounces of physiological salt solution (seven and a half grains of sodium chloride to the ounce of warm water). This is administered every hour, or even oftener, if necessary, in bad cases. In mild cases enemata every four or six hours will suffice. Other measures are the application of poultices or hot fomentations to the loins when suppression threatens, or when there is severe lumbar pain. Diaphoretics, so long as they do not depress the heart, are useful, and so is frequent sponging. Cold applications to the head and especially behind the ears alleviate headache.
The question of giving or of withholding quinine is an important one, but recent work on the subject indicates that in the absence of a medical man who can carry out blood examinations, it is advisable to give quinine as in the case of malaria.
Vomiting is often a serious complication, and the directions for its treatment, given under the head of malaria, should be carefully followed. If it cannot be speedily checked, feeding by the bowel must be carried out. See Nutrient Enema, p. 259.
So long as plenty of urine is passed and sufficient nourishment is taken there is little cause for anxiety, though wherever possible skilled assistance should be obtained at the earliest opportunity.
After an attack the patient is very weak and anæmic. He requires careful feeding and tonics, especially iron and arsenic. It is advisable that he should be invalided out of the endemic area, and he should be specially warned as to the danger of getting chilled or wet.
Symptoms.—When bronchitis exists, there is a good deal of coughing—at first dry, but afterwards accompanied by frothy expectoration—with a sensation of rawness and tenderness at the upper part of the breastbone.
Treatment.—In the early stages of this condition, opium in some form or other will be found beneficial, and will often cut short an attack; for this purpose, ten grains of Dover’s powder, or fifteen to twenty minims of chlorodyne, may be given every eight hours for twenty-four hours, and then be gradually diminished.
If the breathing is difficult, poultices should be applied to the chest and ipecacuanha, half to two grains, and ammonia, should be given three times a day. Later, stimulating expectorants, such as ammonium carbonate, should be administered.
Inhalation of steam often gives great relief; and the effect is much improved if thirty drops of Friar’s balsam are added to a pint of hot water.
In tropical climates even an ordinary feverish cold very often tends to become malarial in character, therefore the use of quinine, in addition to the other treatment, is usually desirable, and five grains may be given thrice a day.
Where an extensive burn or scald has occurred, the clothing of the injured part should be removed by cutting, so as to cause as little irritation as possible. If the burn is only slight, the surface may be covered over with lint smeared with zinc or boric ointment, or oil. If there is much blistering, or the surface is charred, the skin should be cleaned up as well as possible with boric acid lotion, and hot fomentations of the same applied for twenty-four hours. After this, the burn may be dressed twice a day with boric ointment spread on lint. Great cleanliness is an important factor in the successful treatment of burns. In a severe burn, stimulants must be given, and the patient put to bed with hot-water bottles, and active treatment of the burn should be left till the patient has somewhat recovered from the shock.
When there is great pain, chlorodyne or laudanum in full doses will be required.
This disease, also known as “spotted fever,” is of special importance at the present time to the traveller in Central Africa, where it is very prevalent amongst the natives, especially in Uganda. It may, however, be encountered in all parts of the world, and in the tropics is very frequently a malady of the dusty months.
Causes.—The disease is very often transmitted from some carrier of the causative organism, which occurs in the throat and nose, and is distributed by coughing, spitting, or sneezing. Infected material, such as handkerchiefs, may play a part, and the spread of the disease is greatly favoured by overcrowding, especially of sleeping quarters.
Symptoms.—In very acute cases the onset may be very sudden, the patient rapidly losing consciousness. As a rule the disease begins with headache, stiffness of the neck and chilly sensations. There may be vomiting, and the temperature is raised. The mind is often confused, and the patient may be delirious. The skin eruption, which occurs especially on the back and about the joints, and which is responsible for the name “spotted fever,” is not very frequently seen, and can hardly ever be detected on a dark skin. In very bad cases there is violent delirium, laboured breathing, and a purulent discharge from the nostrils. One of the most characteristic features is retraction of the head, while a dislike to light is common.
Prophylaxis.—Avoid unnecessary fatigue and guard against overcrowding, faulty conditions of ventilation and those which tend to cause naso-pharyngeal catarrh. Persons who have been in contact with cases of the disease are probably well advised to wash out their noses with a dilute solution of permanganate of potash 1 in 1,000.
Treatment.—In the absence of a medical man this can merely be symptomatic. Hot baths relieve pain and restlessness. Ice to the head, antipyrin, caffeine or aspirin relieve headache, and sedatives may be given for the insomnia and delirium. The patient’s mouth is foul, and should be carefully swabbed and kept clean.
In the tropics this disease is very largely one of adults.
Incubation period, a fortnight to three weeks. Rash appears first day.
Rash.—Pink spots, upon which blebs form after twelve to twenty-four hours. The blebs are at first transparent, but subsequently become yellowish, and after two to three days shrivel and separate, leaving a pink scar.
The symptoms are usually very mild, perhaps only slight fever, and possibly headache. The appearance of the rash is often the first symptom.
Treatment.—Isolation, and light diet. Bed may not be necessary.
Chilblains are usually found on the fingers or toes—after exposure to severe cold—especially when tight gloves or boots have been worn. Certainly the best way to promote the formation of chilblains is to toast the semi-frozen fingers or toes at a fire or stove, before the circulation has been re-established.
When chilblains are threatened, the part should be well rubbed with snow, or with camphorated spirit. Sponging with hot vinegar is very effective. Chilblains are checked in the early stages by painting with tincture of iodine. Once they have developed a preparation containing carbolic acid is useful in allaying pain and causing them to disappear. Ulcerated chilblains should be dressed with boric ointment spread on lint.
Prolonged exposure to intense cold leads to development of frostbite. If the case is a bad one, or injudiciously treated, gangrene or death of the part always follows; if this is extensive, amputation may be necessary.
Frostbite should be treated first by vigorous friction with snow or pounded ice. The affected parts should then be well wrapped with cloths wet with cold water. It is extremely dangerous to bring them near a fire. Afterwards, the part should be wrapped in cotton-wool.
Cholera is a serious acute disease, characterised by frequent watery motions, vomiting, cramp and collapse.
Cause.—It is often contracted by drinking contaminated water.
Research has shown the importance of the cholera “carrier,” that is to say the person, usually a native, who harbours in his bowel the specific organism of the disease. He may be perfectly healthy and yet be able to transmit cholera to other people by infecting water or food. The rôle of flies, infected clothes and rags, and faulty conservancy methods must be kept in mind.
Symptoms.—Giddiness, faintness, persistent vomiting and diarrhœa, great prostration, feeble pulse, cold perspiration, colic, intense thirst, and constant desire to pass urine. The vomit and motions rapidly become like rice-water in appearance, and the urine is more or less suppressed. There are severe cramps in the legs, belly, and other parts of the body. If then the pulse becomes weak, the temperature low, and the countenance dusky, the patient will probably sink. On the other hand, reaction may set in, all the symptoms abating, and the pulse, temperature, and colour becoming natural; the water is passed more freely, vomiting is less frequent, and the motions become more natural in colour.
Prophylaxis.—Anti-choleraic inoculations are now practised. They not only afford a considerable degree of protection but lessen the risk of a fatal issue in the inoculated. Hence it is advisable to be vaccinated against cholera whenever there is risk of infection. The inoculation must be repeated after the lapse of four months if the epidemic still persists, as the protection afforded is only temporary. Persons travelling in regions where cholera is present in an endemic form should take a little lactic acid in tea, or add a little vinegar or thirty drops of dilute hydrochloric acid to every ounce of drinking water.
At times of epidemic prevalence it is essential that all water should be boiled. The practice of hand-shaking should be discouraged, indigestible diet should be avoided, and raw fruit, raw vegetables, and meat jellies should not be eaten. Lettuces and celery, being moist and eaten uncooked, are specially dangerous. Patients and contact cases must be isolated, and the former should be protected from flies. It is very necessary to maintain a strict supervision of cooks and cooking arrangements. All kitchen cloths should be washed in permanganate solution or boiled. Milk should always be boiled.
Cholera stools may be disinfected by adding a five per cent. cresol solution to them and allowing it to remain in contact with the stool for at least one hour. Quicklime is excellent as a disinfectant. Add together equal parts of fresh quicklime and water, dilute with three times as much water as previously used, add a quantity of this slaked lime equal to the amount of stool to be disinfected and allow it to remain in contact with the stool for one hour. When the ground has been fouled by dejecta or vomit, disinfect with cresol, or rake hot ashes over it or pour kerosene oil upon it and set the latter alight. Cholera-soiled clothing, bed linen and blankets should be soaked in a two and a half per cent. cresol solution.
Treatment.—Isolate the patient, keep him warm, and give ice to suck. Apply hot bottle to the feet, and mustard leaves to the pit of the stomach.
It is advisable to clear the bowel of irritating material at the outset by giving half an ounce of castor oil with a teaspoonful of brandy. Drugs are of little use in cholera, but some like to give one drop of carbolic acid, together with twenty drops of spirit of camphor (or peppermint, or a little brandy), five grains of bismuth, and ten grains of soda, suspended in one ounce of gum water, every four hours. Chlorodyne may be given to allay severe pain.
Even in the mildest cases absolute rest in bed is essential, and a warm bed-pan should be provided.
In the early stages no food at all should be given, but plenty of fluid should be allowed, though it must be administered only in sips. Stimulants may be necessary. Later on fluid food such as milk should be given carefully, and the quantity gradually increased.
The special treatment for cholera can only be carried out by a medical man, and recourse should be had to his help at the earliest possible moment, as everything depends upon immediate treatment. If, after the acute symptoms subside, diarrhœa continues a dose of bismuth is often useful.
This is the name given to the well-known severe twisting or griping pains in the belly, usually due to excessive flatulence, and resulting from constipation, or some error of diet.
Treatment.—Hot fomentations should be applied to the belly, or better still, the Instra, which is the best means of applying continuous heat to any part of the body. A turpentine enema (a tablespoonful to a pint of warm water) will nearly always cut short the symptoms; in the absence of turpentine, give warm water alone. A full dose of opium (20 minims) should also be given if the pain is severe, preferably in a tablespoonful of castor oil.
Bicarbonate of soda, carbonate of ammonia and ginger should be freely given in full doses, and the bowels should be well opened as soon as the severe pain has passed off.
This term is applied to the partial suspension of the functions of the brain, produced by the severe shaking of its substance by a fall or blow.
Symptoms.—At first the patient lies in an unconscious condition, skin cold and clammy, pulse and breathing very feeble, and temperature extremely low; he can be slightly roused by shouting; he cries out if he is moved, or when painful applications are made, but quickly relapses into insensibility. The stage of unconsciousness may pass off almost at once, it may be prolonged for hours or days, or the patient may never recover from it. The second stage—that of reaction—is marked by returning consciousness and frequently by vomiting, the skin becomes warm, and gradually the patient recovers; on the other hand, inflammation of the brain may set in, or he may again become unconscious and die.
Treatment.—Keep the patient perfectly quiet in bed, in a darkened room, give a milk diet, and if he is much excited, apply cold cloths or an ice-bag to the head. If there is much prostration apply a hot-water bottle, and restore the circulation by rubbing the limbs. When reaction sets in, give five grains of calomel.
Stimulants should be avoided in cases of concussion of the brain, unless the collapse is very alarming (when ammonia should be given), as they tend to cause too violent reaction, which might be followed by inflammation of the brain and its coverings.
This condition is very frequent in tropical climates, where it is associated with sluggishness of the liver. One of the best remedies is the two-grain tablet of cascara, of which one may be taken three times a day. Rhubarb is also a very useful drug. In addition to this, an occasional dose of a saline purge should be used, or a large enema of soap and water may be given. Five grains of blue pill or three grains of calomel will be found to act as a very efficient aperient, especially if followed in about six hours by a saline such as fruit salt. Castor oil is a valuable remedy, but it must be remembered that in the tropics its effects are sometimes rather severely felt, and hence it is well to give it in somewhat smaller doses than those usually employed in temperate climates. Three-quarters of an ounce may be given where an ounce would otherwise be employed.
As a rule, the general health of people suffering from simple constipation is not seriously affected.
In cases of chronic constipation one of the anti-constipation products, otherwise known as the Aloin Co., given three times a day and gradually reduced, will be found useful.
In most acute diseases, such as malaria, pneumonia, etc., if constipation is present, it should be treated at once by means of suitable aperients.
Note.—In peritonitis, i.e., inflammation of the bowels, hernia, and in some cases of typhoid, constipation is a leading symptom, and is accompanied by severe pain in the belly. On no account should an aperient be given by the mouth in these cases. If it is necessary to clear the bowels, this should be done by means of an enema.
When a cold is confined to the head it can usually be cut short by retiring to bed early, taking a ten-grain dose of Dover’s powder, followed by hot drinks to encourage the perspiration which the action of this drug produces, together with the use of as many additional bed-clothes as can be borne. Care must be taken to avoid chill on the following morning. Once it is established the condition is difficult to cure, but marked relief will often be afforded by washing out the nose with a solution made from naso-pharyngeal products. In fact, a simple nasal glass douche should form part of the traveller’s outfit, at least, if he is liable to bad colds in the head. In tropical regions five grains of quinine should be added to the dose of Dover’s powder. When there is a liability to colds in the head the use of preventive vaccines is recommended, but these should not be employed without the advice of a medical man.
Causes.—Injury or the result of operations, extension of inflammations such as gonorrhœa, retention and decomposition of urine; debilitated or gouty persons are especially liable to this affection.
Symptoms.—Intense pain in the lower part of the belly, and in the crutch, continual desire to pass water, with frequent passage of small quantities. The urine is scanty, high-coloured, foul-smelling, and occasionally blood-stained, and there may be some fever.
Treatment.—Hot baths, leeches, or fomentations to the crutch, and a sedative, such as opium (preferably given by the bowel), will be required. If the disease continues the bladder should be washed out through a catheter with weak boric acid solution, five grains to the ounce, or chinosol (1 in 2000), twice a day. Urotropin, ten grains, and copaiba or sandal-wood oil in ten-drop doses.
The diet should be restricted to milk.
This disease, also known as dandy fever and break-bone fever, occurs in many parts of the world, and it is most common along littorals, probably because the Stegomyia mosquito which carries the infection is usually numerous in sea-coast places.
Cause.—The organism of dengue fever is unknown, but the infection has been proved to be carried by at least one species of mosquito.
Symptoms.—The incubation period varies from about five to ten days. The onset is very sudden, the temperature rising rapidly. Within an hour or two an initial rash appears, which varies in appearance and is transient. The patient suffers from severe headache and pain in the joints and back. Indeed, the condition closely resembles a sharp attack of influenza, but, as a rule, there are no signs of coryza. The eyes are very painful and insomnia is present. The high temperature lasts for three or four days, then drops, continues low from twelve hours to three days and rises again sharply. During the interval the patient feels better but the symptoms start again when the temperature rises for the second time. In the second stage the true rash of dengue appears, which is rather like that of measles, and it is followed by desquamation of the skin. The disease, though often causing great weakness, is very rarely fatal.
Prophylaxis.—Protect against mosquito bites by using a proper mosquito net or by employing mosquito repellents such as “sketofax.”
Treatment.—Light diet, rest in bed, phenacetin and aspirin for the relief of pain and headache. Cold sponging helps the febrile condition and the insomnia. During convalescence there is often much depression, and the patient benefits by being ordered tonics and a sound wine.
Diarrhœa, or looseness of the bowels, is one of the most common and one of the most serious ailments of the tropics, and should never be neglected. In many cases it is a sign of enteric fever, dysentery, cholera, or sprue, the symptoms of which are given below. Ordinary attacks are usually due to the presence of some irritant in the bowels, such as irritating sand, bad food, unripe fruit, or other poisonous material. Amongst African and other natives diarrhœa is often due to a faulty or ill-cooked dietary. The importance of flies in fouling food should not be overlooked.
Treatment.—Begin the treatment by administering castor oil, fruit salt, cascara, or other mild aperient, to clear out the cause of the diarrhœa. If castor oil is used the following note as to its administration is likely to be of service. Place an ounce of brandy in a glass or cup. Carefully pour the oil into the centre of the brandy and then add one ounce of water. The mass of oil will then resemble the yolk of an egg enclosed in the white. Lime juice may be used instead of brandy. Failing these, black coffee helps to cover the taste and “feel” of the oil. Sometimes three grains of calomel with fifteen grains of sodium bicarbonate act better than castor oil. A warm-water enema of about a pint is useful.
If the diarrhœa continues, give chlorodyne (20 minims) and tincture of ginger (10 minims) in an ounce of water two or three times a day.
This treatment should not be persisted in for more than two days.
If the diarrhœa is persistent, an astringent is needed: five grains of tannin, or two or three grains of sulphate of iron may be given three times a day. Ten grains of quinine should be given each day.
All food should be semi-solid and tepid; milk diet, as recommended below for enteric fever, is the safest food, but soup thickened with rice or arrowroot is good. The patient should keep in bed and wear a flannel band round the belly. Sometimes in the tropics, as the result of excessive purgation, diarrhœa is very acute and may be alarming. In such cases a hot bath, stimulants and the administration of astringents are indicated.
If the trouble continues for more than a few days it is probably due to dysentery, or typhoid.
Diphtheria is an acute infectious disease, the essential feature of which is a peculiar inflammation of the lining membrane of the mouth, nose, throat, and windpipe, characterised by the formation of a membrane upon the inflamed surface. Diphtheria occurs in the tropics but happily does not spread much in hot countries.
Causes.—It may be contracted from some person suffering from the disease, from a healthy “carrier” harbouring the specific micro-organism (Bacillus diphtheriæ) in his throat or nose, or from infected milk, etc.
As the disease is a very grave one, and skilled treatment is often an absolute necessity, measures should be immediately taken to summon medical assistance on the first appearance of diphtheria, or the patient should be sent as speedily as possible to a place where medical aid is likely to be obtained; for if the breathing becomes so difficult that the patient gets blue in the face, an operation for opening the windpipe will be necessary.
Incubation period, two to six days or even longer.
Symptoms.—Headache, discomfort, loss of appetite, sore throat, and sickness, with swelling of the glands at the angle of the jaw. On examination the palate and tonsils are seen to be swollen, with a white deposit of membrane upon the surface. The membrane may be thick and tough, and if stripped off will leave numerous small bleeding points.
The temperature may run up, and is irregular in type. The pulse is rapid and feeble, and the bodily strength is quickly lost.
If the nose be affected there is copious discharge from the nostrils, with difficulty of breathing and much discomfort. If the windpipe is affected the voice will become hoarse or absent, and there will be greater difficulty in breathing, accompanied by a loud crowing noise.
Diphtheria may be accompanied by cough and pneumonia.
Treatment.—Isolation. Bed. If diphtheria anti-toxin is obtainable, it should be administered at the earliest opportunity, but this should only be carried out by a doctor.
Nourishing foods and stimulants should be given frequently in small quantities. The throat should be thoroughly and frequently washed out with chinosol (1 in 1000) or other antiseptic lotion. If the difficulty in breathing is marked, warm baths should be given at intervals of about four hours. A steam kettle should be placed near the bed. The expulsion of the membrane may often be aided and great relief afforded by the administration of emetics, such as ipecacuanha, but these must be given with care owing to the risk of heart failure.
Complications.—Diphtheria may be followed by paralysis of the windpipe with loss of voice, or paralysis of other parts of the body, therefore great care should be taken not to allow convalescents to get up too soon, no matter how well they may appear.
This disease, which is due to an inflammatory condition limited as a rule to the lower or large bowel, may be the result of a variety of causes, but there are two chief types which must be clearly distinguished: (1) Amœbic dysentery, due to a protozoon or animal organism, (2) Bacillary dysentery, caused by certain micro-organisms belonging to the vegetable world.
Amœbic dysentery is much more of a tropical complaint than is bacillary dysentery, but the latter is also common both in tropical and temperate climates. Both forms are transmitted in much the same way and their symptoms are very similar. Hence from the layman’s point of view no good purpose is served by considering them separately, at least so far as methods of transmission and symptoms go. The treatment of the two forms, however, differs, and to carry out such treatment effectively medical skill is required.
Causes.—Dysentery is conveyed by impure drinking water, contaminated food, infected flies, and possibly also by infected dust. In both forms, but especially in the amœbic variety, the so-called “carrier” plays an important part, because in the latter case the organism produces cysts which are passed by the bowel, and these cysts are frequently found in the dejecta of persons who have suffered from amœbic dysentery and who are either convalescent or possibly in quite good health. If these cysts find their way into food or water and are then swallowed they are capable of developing in the human intestine and producing dysentery. Carriers are also met with in the bacillary form of the disease. Dysentery may be provoked by chills, general debility and exhausting conditions, such as chronic malaria.
Symptoms.—Diarrhœa with pains in the belly, straining and frequent desire to go to stool. The motions soon become small in amount, slimy, lose their natural colour, and contain more or less blood; when there is ulceration of the coats of the bowel, the motions are extremely offensive, and bleeding may be very free. There is heat, tenderness, and bearing down about the outlet of the bowel, with considerable prostration and probably some fever; there is frequently a constant desire to pass water. All these symptoms may be due to severe ordinary diarrhœa; but in the tropics it is best to treat them as if they were dysenteric. Some guide may be obtained as to the form of dysentery from which the patient is suffering by taking his temperature. As a rule there is little or no fever associated with the amœbic form, while in the case of the bacillary type the temperature is always raised and in severe cases may be considerably elevated. It is in this form that the small intestine is apt to become involved and then the condition is more serious.
One help in diagnosis, though not a very reliable one, is the character of the stool. In amœbic dysentery the blood is apt to be mixed with the dejecta and to be dark in colour, while the whole mass looks brown or greyish green. The stool of bacillary dysentery, on the other hand, has a whitish appearance, the blood in it is bright coloured and is often in the form of streaks or spots. The amœbic form is apt, if not promptly and efficiently treated, to be followed by inflammation of the liver, which may go on to liver abscess.
Prophylaxis.—Avoid chill and debilitating causes of all kinds. In countries where there is a great difference between the day and the night temperature wear a cholera belt. Carefully protect food and water from contamination of any kind, and especially from flies. Doubtful water should be boiled or rendered sterile by some chemical method. All milk should be boiled. Care should be taken not to employ as cooks natives who have recently suffered from dysentery, and scrupulous cleanliness should be observed in the preparation of food. Unripe fruit and other materials apt to cause diarrhœa should be avoided. Camp conservancy methods should be carried out on approved sanitary principles which prevent the access of flies to human excrement and prevent the latter from being disseminated by wind or in any other way. All dysenteric stools should be carefully disinfected or burnt.
Treatment.—The general treatment is common to both forms, the essentials being rest, warmth and suitable food. Put the patient to bed, apply a cholera belt and get the bowels open by an initial dose of castor oil. If there is much pain ten drops of tincture of opium may be added to the oil. The usual dose of the oil is an ounce, but if the patient is feeble or exhausted half an ounce will be sufficient.
As regards diet do not give any milk at first, and indeed if the case is recognized as being one of bacillary dysentery milk should not be given at all as it tends to favour putrefaction. Albumin water, rice water, chicken broth are required during the first twenty-four hours. Thereafter in the amœbic form milk diluted with barley water or with citrate of soda (three grains to the ounce) can be given. Soups are often useful, and at a later period custard, arrowroot and jellies are indicated. In the bacillary type arrowroot, meat and fruit jellies and beef-tea can be given from the outset. In both types the food should be given in small quantities frequently, and it should be neither too hot nor too cold. Alcohol is deleterious.
Fortunately we now have a specific drug for treating amœbic dysentery and that is emetine, which is the active principle of ipecacuanha. It is best given in the form of emetine bismuthous iodide, which is supplied in capsules and the dose of which is three grains per day for twelve consecutive days. The dose is best given in the evening along with a cup of hot tea on a full stomach when the patient is in bed. If it causes much vomiting it is well to give ten or fifteen drops of tincture of opium before administering the emetine. The latter can also be given by subcutaneous injection, but this method of treatment should only be carried out by a physician. Where emetine is not available ipecacuanha itself may be used and is given as follows:—
Treatment by Ipecacuanha.—When the bowels have been opened, give twenty grains of ipecacuanha, either solid or mixed with a wineglass of water, or less; arrowroot, starch, or gum-water, which will help to suspend the drug. Of course, ipecacuanha will act more quickly if it can be taken suspended in a liquid, instead of in the solid form. To prevent vomiting, put a mustard leaf to the pit of the stomach. Absolute quiet must now be observed; darken the room, and allow no moving in bed or talking. Withhold food and liquid for at least two hours if possible, but if there is much thirst, teaspoonful doses of water may be given.
If there is no vomiting for an hour, probably a good part of the ipecacuanha has been digested; if it has been vomited, wait for half-an-hour, and then give another full dose. If vomited again, wait for two hours, and give twenty drops of chlorodyne, followed by twenty grains of ipecacuanha; the chlorodyne is to quiet the stomach, enabling it to retain the ipecacuanha. In about twelve hours from the first dose, repeat it in exactly the same way. If thirty grains are too much at a time, give twenty, three times a day, for not less than sixty grains should be given in twenty-four hours. The drug is not a dangerous one, and, if the patient can take it, too much can hardly be given. Between the doses feed the patient, giving but little at a time. If the ipecacuanha is going to do good, marked improvement should be apparent in four or five days; failure of the drug is often due to its not being given or retained in sufficiently large quantities.
In addition to the emetine or ipecacuanha treatment it is well, save in mild or trivial cases, to give a saline mixture once a day, for example one ounce of sodium or magnesium sulphate. Other methods which are helpful are enemata of warm water, hot hip baths, or a soothing injection made by soaking an ounce of linseed for several hours in two pints of warm water. Sedatives, such as laudanum or chlorodyne, should be used only in cases where there is severe pain, sickness and great distress. The full dose in ordinary cases is twenty drops three times a day, but if less is sufficient so much the better, and it is advisable to avoid these remedies wherever possible.
The object of treatment is not to block up the bowel—as might be done by giving large doses of opium or tannin—it is to cure the disease of which the looseness is only one symptom. The most favourable sign during an attack is a return of the colouring matter to the motions; this shows that the liver is again acting, and that the treatment is doing good. With the return of colour (which at first may be intermittent), the other symptoms, such as pain and bloody discharge, will abate, and the motions will become more solid and healthy.
In dysentery, as in severe diarrhœa, the patient should not be allowed to get up to stool. A box cut across obliquely will make a rough slipper bed-pan; put sand in it, and pad the edges.
In bacillary dysentery emetine is nearly or quite useless, and recourse should be had to a saline treatment. A mixture containing sixty grains of sodium or magnesium sulphate, fifteen drops of dilute sulphuric acid, and five drops of tincture of ginger can be given in half an ounce of peppermint water, if necessary, every two hours at first, and then every four or six hours, until the stools are watery and bile-stained. An alternative method of treatment, but one which is not so satisfactory, is to give half-grain doses of calomel every hour for twelve hours on three successive days. The patient must, however, be watched for such symptoms as tenderness of the gums, salivation (i.e., great increase of the saliva), and a metallic taste in the mouth. Should such symptoms arise the doses must be reduced or the drug discontinued.
The general treatment is the same as that for amœbic dysentery. As colic is often very severe, turpentine stupes or poultices to the abdomen are often indicated.
A specific anti-dysenteric serum is now employed in cases of bacillary dysentery, but its administration requires medical skill.
When the acute dysenteric attack is over, bismuth may be given, and various astringent enemata may be tried, but these should not be administered in the absence of a physician. A simple form of enema, however, is one containing a teaspoonful of alum or ten grains of sulphate of iron to the pint.
It is impossible to give a full account of the enteric fevers here, and moreover the presence of a medical man, still more of a good nurse, is absolutely necessary for their proper treatment. The chief early symptoms, however, will be given, and a few hints as to their treatment. For all practical purposes paratyphoid fever may be considered as a mild variety of typhoid.
The disease is characterised by ulceration of the small bowel, with continued high fever, and is usually accompanied by diarrhœa.
Causes.—It is generally caused by the drinking of impure water, but may also be transmitted by all the causes operative in the case of dysentery (see p. 185).
The incubation period is from ten to fifteen days.
Symptoms.—The early symptoms of the disease are often so slight that the patient will not believe he is really ill; he may just feel out of sorts, or complain of headache, but still go about his work. There may be diarrhœa, or occasionally constipation. After five or six days the patient is generally compelled to give up and go to bed, headache or diarrhœa, or both, being the chief complaint. The temperature goes up in a characteristic manner, rising a little more every evening till it eventually reaches 103° or 104° F. There may be some cough, and often this symptom is a very troublesome one.
The belly is usually distended and slightly tender, and there may or may not be the characteristic typhoid rash, consisting of rose-pink circular, slightly raised spots, about the size of a large pin’s head. They occur chiefly on the chest and abdomen, and come out on successive days, often only three or four at a time. These spots are frequently absent, and then one must be guided by the presence of other symptoms. They are difficult to be seen upon a dark skin.
The possibility of enteric fever should always be remembered in cases where there is constant fever, unaccompanied by any definite symptoms, such as the recurrent shiverings of malaria, or the spitting of blood in pneumonia.