Prophylaxis.—As for dysentery (see p. 186). Preventive inoculation is very important and confers immunity for a considerable period (see “Inoculation,” p. 168).
Treatment.—Absolute quiet in bed. If constipated, bowels should be kept open by soap and water enema only.
Milk only (three to four pints daily) should be given during the whole course of the illness and till ten days after the temperature has descended to, and remained, normal. Stimulants, if pulse is feeble and rapid; opium only if there is much pain. If bleeding occurs from the bowel, an ice poultice or cold-water cloths should be applied to the belly; ice may be given to suck; opium and an astringent, such as tannin, administered by the mouth, or an opium enema be given. Milk should be given in small quantities only, and to each half-pint five grains of bicarbonate of soda should be added.
The motions must be burned, or carefully disinfected.
Symptoms.—This is the most common form of fits. There are three stages. 1st stage—The patient falls down completely unconscious and without warning, the face is pale, the limbs become stiff and rigid, and the breathing ceases. 2nd stage—Convulsive movements take place, the tongue being often bitten, the breathing becomes heavy and laboured, and the motions may be passed unconsciously. 3rd stage—A confused mental condition, sometimes acute mania, usually sleepy for some time. In some cases the fit may only last a few minutes. They almost always recur.
Treatment.—During the attack nothing can be done beyond loosening all tight clothing, and gently preventing the sufferer from injuring himself in his struggles. It is especially important to keep the teeth apart with a piece of cork or rubber to prevent the tongue from being bitten.
Bromide of potassium (ten to twenty grains) may be given three times a day as a preventive.
Bending the head firmly down between the knees is the best and most rapid way of dealing with an attack. Another method is to lay the patient on a couch, loosen any clothing which is round the neck, bathe his face and arms with cold water, and fan him vigorously. Give three grains of carbonate of ammonia in an ounce of water. Alcohol may be given if the pulse is very weak, but sal volatile or carbonate of ammonia is more efficacious.
This term connotes several pathogenic conditions, but the most important form of filariasis in man is that due to a small blood-worm which is conveyed by the bite of one or other species of mosquito. The most important symptom of filariasis is the condition known as elephantiasis, but the presence of filaria in the blood also causes a febrile state and various other symptoms which need not be detailed.
Prophylaxis.—Protect from the bites of mosquitoes, especially those which breed in the vicinity of human habitations. The most effective method of doing this is the careful use of a mosquito net.
Gonorrhœa, or clap, is an acute inflammation of the urethra or pipe, attended with a discharge of more or less matter. It is nearly always due to direct contagion.
Symptoms.—At first there is some itching about the end of the pipe, which is followed by a yellowish-white discharge. This lasts from three to five days. Then great pain is noticed on passing water, and the discharge becomes thick and yellowish-green in colour, with redness and swelling about the lips of the opening of the pipe. After a time the pain on making water disappears, and the discharge becomes thin and watery, a condition known as “gleet.”
Treatment.—Forbid alcohol in any form. Give large quantities of liquid—water, weak tea, or milk—to thoroughly flush the system. Light diet and as complete rest as possible. Keep bowels well open with saline and other purges. Give sandal-wood oil or copaiba, twenty drops three times a day, and urotropin, ten grains twice a day.
If there is much pain in the acute stage, a mixture containing fifteen grains of bicarbonate of soda, and five drops of chlorodyne or laudanum, in an ounce of water, may be given twice a day. Except in very acute cases the pipe should be syringed out with a very weak solution of permanganate of potash, or better, a solution of protargol (quarter to two per cent.); later on, a lotion containing four grains of sulphate of zinc to one ounce of water may be used as an injection.
If the glands in the groin become tender and inflamed, they should be painted with tincture of iodine. If, in spite of this, the pain and swelling increase, they should be poulticed frequently, and treated as ordinary abscesses.
This is a very severe catarrh which attacks certain individuals yearly, when grasses and other plants are flowering. It is most probably due to the irritation of the nose by pollen grains in the air.
Treatment.—Exposure to the irritating substances which are known to provoke an attack should be avoided.
The nose may be syringed out with a lotion containing boric acid and bicarbonate of soda (five grains of each in four ounces of water), or one containing bicarbonate of soda and salt (five grains of each in four ounces of water), to which has been added two to four drops of carbolic acid. The interior of the nostrils may be anointed with vaseline. Menthol snuff is of great value. A substance called “Pollantin” has a specific action in many cases, but it should be employed only under medical supervision.
Influenza has been introduced into many tropical countries, in which it has spread rapidly and caused in many instances a very heavy mortality. The actual cause of the disease is still a matter of dispute, but there can be no doubt that it is chiefly spread by personal contact.
Symptoms.—What may be called the respiratory type is pretty well known to everyone, but it should not be forgotten that sometimes the main stress of the disease falls either on the alimentary or the nervous system, while there is also a type of what is known as febrile influenza in which the heat-regulating centre is greatly upset. In this latter form the temperature may be intermittent and it is then apt to be mistaken for malaria.
The respiratory type is the most important. Its incubation period is short, one or two days. The onset is sudden and is characterized by shivering, pains in the back and limbs, severe headache and a feeling of malaise. The patient may be giddy and suddenly collapse, his throat is often dry and sore and he has an irritating cough. His temperature rises and runs up to 102° to 104° F. His face becomes flushed, his eyes reddened and his tongue is furred. Constipation is common. Uncomplicated influenza, if promptly attended to, is not a very serious disease, and improvement usually sets in about the third day. The most serious complication of influenza is bronchial pneumonia, and in some forms of the disease the heart is very apt to be affected.
Prophylaxis.—Isolation of cases; free ventilation; treat patients as much as possible in the open air. Nurses and those attending the sick should be careful about contracting infection from the patient’s invisible mouth spray. Indeed in some epidemics the use of face masks has been recommended.
Treatment.—Rest in bed as soon as possible; free purgation at the outset; an early dose of twenty to thirty drops of laudanum (Tinct. opii) is often very beneficial but the drug must be administered with care. Aspirin in ten-grain doses thrice daily frequently relieves the more urgent symptoms. In cases where there is vomiting and collapse with high temperature a dose of fifteen grains of aspirin with half to one ounce of brandy and three drachms of liquor ammon. acetat. may act like a charm. According to our present knowledge, however, it would seem that drugs are of little use in influenza, and that the important thing is to ensure good nursing and to keep up the patient’s strength. Quinine in effervescing form is very useful for convalescent cases.
(See also Myiasis and Skin Diseases.)
These are best divided into the Winged and Wingless forms. Of the winged pests Mosquitoes are undoubtedly the most important in the tropics, as they are known to transmit such diseases as malaria, yellow fever, dengue fever and filariasis. The anopheline mosquitoes are those responsible for transmitting malaria, and they can easily be recognized by the facts that their wings are usually spotted and that they appear as it were to stand on their heads when resting on any flat surface. The culicine mosquitoes, which include Stegomyia fasciata, the carrier of yellow fever, do not as a rule have spotted wings and they rest parallel to the surface on which they alight. There are also marked differences in the water stages of these insects which cannot, however, be here considered.
The best way of protecting oneself against mosquitoes is the proper use of an effective mosquito net, the mesh of which should contain at least sixteen holes to the linear inch. Mosquito boots or buskins are also useful, and in certain places hoods for the face and neck, such as the “Mosquinette” variety, will be found of value.
Repellent substances applied to the skin may also be employed. Cassia oil, with brown oil of camphor in vaseline, is useful. Vermijelli, containing a little citronella oil, is fairly effective but is not so pleasant to use. The irritating effect of mosquito bites may be diminished by the application of tincture of iodine. The same measures are effective in the case of some of the biting midges.
The insects generally known as Sand-flies are really owl midges or moth flies, tiny and hairy insects which have been proved to transmit sand-fly fever (see page 221). These flies breed in damp places where there is rotting vegetation, dark and damp cellars, cracks and fissures in the soil, tunnels, etc., and they are often very troublesome. The repellents mentioned above may be used to drive them away, as may eucalyptus oil, camphor and tobacco smoke. The ordinary mosquito net is useless against their attacks, and one containing twenty-two holes to the linear inch is required.
Buffalo gnats, which are often called sand-flies, are insects which breed in running water and amongst cataracts and rapids. They are formidable biters although they are not known to cause any disease. The same protective measures are indicated in their case as in that of owl midges.
House Flies.—There are several species of these. They are definitely known to distribute certain harmful bacteria and protozoa and to contaminate food by carrying the organisms on their bodies, wings and legs, or depositing them by regurgitation or in their droppings. Hence it is very important to protect all food and drink from flies and to destroy these insects wherever possible. The subject of their destruction is too large a question to be dealt with here, so all that need be said is that the traveller should provide himself with wire mesh fly covers to screen food and also with pieces of mesh or calico weighted with beads, which can be utilized for covering vessels containing milk or other liquids. It is worth noting that ordinary fish netting hung over a tent door or used to screen the windows or doors of a house will effectively exclude flies, despite its large mesh.
Tsetse Flies.—These are considered under Sleeping Sickness (see page 234).
The Congo Floor-maggot Fly.—It is the maggot or larva of this fly which is important, as in many parts of Africa it infests the floors of native huts and it is a blood-sucker feeding at night. So far as is known it does not convey any disease but it is an unpleasant visitor, and if its numbers are great they may extract comparatively large quantities of blood from their unconscious victims.
Prophylaxis.—General cleanliness and enforcement of sanitary measures, the use of high beds, the scrutiny of sleeping mats and blankets in which eggs or larvæ may be concealed. Infected huts can be rendered habitable by firing the ground or by removing the surface soil, which can then be disinfected.
Wingless Pests.—Lice.—These are known to transmit typhus fever. Further, they often cause great cutaneous irritation and are loathsome companions. It is no easy matter to get rid of lice when infection is on a large scale, but very often this is not the case and it is possible to detect their presence only by careful examination. There is no real difference between head lice and body lice; they are simply varieties of the same insect. The presence of head lice may be recognized by the discovery of their eggs, which are known as nits and are minute, yellowish-white, goblet-shaped bodies about the size of a full-stop on this page. Examination for head lice is much facilitated by the use of a fine tooth comb. Persons suspected of harbouring body lice should be examined first for the actual bites of the insect on the skin. Their clothes, and especially their under-garments, should then be carefully examined, attention being more particularly directed to the seams and folds where the eggs, if present, are most likely to be found.
The best preventive measure against lice is strict personal cleanliness. Clothes should be frequently changed, and as frequently washed. The hair should be kept cropped short, especially at the sides and back of the head, and in the tropics it is very advisable to shave all hairy parts of the body.
Space does not permit a full account of how to deal with verminous persons and verminous clothing, but it may be said that the only reliable methods of destroying lice are by hot air, steam, boiling water, or hydrocyanic acid gas. At the same time it should be noted that the heads of those infested with head lice should be thoroughly combed and treated with paraffin, petrol, or white precipitate ointment, and then well washed with carbolic soap. The nits may be loosened by treatment with warm vinegar or acetic acid. In the case of body lice possibly the most satisfactory grease for application to the underclothing is one composed of crude unwhizzed naphthalene from the coke oven, four parts, and soft soap, one part. It is important that the proper type of naphthalene be used.
A useful palliative method is the ironing of clothing, especially along the seams, with heavy hot irons.
Fleas.—Bubonic plague is known to be transmitted by fleas, and it is possible that they play a part in the transmission of that form of leishmaniasis which is known as kala-azar (see p. 202). Fleas dislike powdered naphthalene and pyrethrum powder, and either of these may be applied to the clothes to ward them off.
A note on the troublesome Chigger flea or Jigger will be found under “Skin Diseases” (see p. 228).
Bed-Bugs.—The traveller sleeping in hotels or inns abroad is very apt to be attacked by bed-bugs, which harbour in wooden beds and bedding, crevices in walls, floors and ceilings, and other places which are dark and sheltered. Fortunately, so far as is known, the bed-bug does not carry any disease, but its bites are annoying, and its presence is a sign of insanitary conditions. It is difficult to protect oneself against bed-bugs without instituting a campaign against their hiding-places and breeding-places, but a skin ointment like vermijelli is useful, and powdered naphthalene or Keating’s powder may deter the insects to some extent.
Note.—Keating’s powder, which contains pyrethrum, is slow in its effects, and therefore, if possible, should be shaken over the sleeping bag or blankets some hours before bedtime. If not, the pests will struggle through it and find renewed vigour on the sleeper. It is best in very bad quarters to rub the powder on the skin as well as to dust it over the bed. It will not kill a full-grown bug under an hour, but it is extraordinarily effective with fleas. It is important to obtain a good pyrethrum powder, as such preparations are frequently adulterated.
The Itch Insect is the cause of the skin disease known as scabies. It is a mite, the female of which burrows under the skin to lay her eggs. The favourite site for her operations is between the fingers, but other parts of the body may be affected, and the rash produced may assume various forms, so that it is well in the case of any skin eruption in the tropics to remember the possibility of scabies.
Treatment.—Its effective treatment is by no means easy, and would take much too long to detail here. All that can be said is that the skin should be washed well with soap and hot water, and that thereafter a liberal quantity of sulphur ointment should be thoroughly rubbed into the skin twice daily for three days. On the fourth day recourse should be had again to soap and hot water, if possible in the form of a hot bath. Meanwhile, clothing and bedding should be boiled or destroyed.
Ticks.—The most important tick from the traveller’s point of view, at least, in Africa, is the species responsible for the transmission of tick fever (see p. 242). It would seem that the fowl tick may occasionally attack man, and some believe that it may spread the infection of certain kinds of relapsing fever (see p. 218). The larval stages of certain ticks are often very troublesome in many parts of the world, owing to their habit of burrowing into the skin of persons coming into contact with them.
Treatment.—When a larval tick is found half buried in the skin, force should not be used in an attempt to remove it, because either the surrounding skin is unnecessarily damaged or, as is most probable, the head of the tick is ruptured, its rostrum or beak remaining buried in the skin. The result is severe irritation which may lead to septic infection. The best way, therefore, of dealing with a tick larva lodged in the skin is to dip a small camel’s hair brush in turpentine, benzene, petrol or paraffin, and apply it between the skin and the under surface of the tick. In a short time the tick will let go its hold and may be swept from the skin with the brush. Vaseline is also effective if smeared over the tick. To remove a rostrum which remains in the skin after a tick has been forcibly ejected, cocaine should be applied to the spot, and the rostrum extracted with needle forceps, iodine being thereafter applied. A special form of tick-case devised for dealing with this condition is upon the market, and is a useful addition to the traveller’s outfit.
Ants.—These are often very troublesome owing to their depredations on foodstuffs, and it must be remembered that experimentally ants have been shown capable of carrying the organisms of typhoid fever and cholera, though under ordinary conditions they are not likely to be very dangerous in this respect. Some form of pyrethrum powder, such as Keating’s, will be found useful in checking the depredations of ants, or they can be prevented from getting at food on tables by tying paraffin-soaked rags round the legs of the latter. Powdered borax or paraffin are useful in dealing with so-called “ant-routes” into tents or houses.
Symptoms.—In this there is pain, the vision is dimmed, and the transparent part of the eye is found to be cloudy. Skilled assistance is necessary.
Treatment.—Apply hot fomentations and boric acid lotion; leeches or a blister to the temples are of service, and the pupil, which is contracted, should be dilated by dropping two or three drops of a one per cent. solution of atropine on to the eye twice a day or oftener till it is well dilated; only enough drops should be applied afterwards to prevent the pupil from contracting. Dark glasses may be worn with advantage. The bowels should be kept well open, and one grain of calomel may be given three times a day for a week, or longer if it does not cause a coppery taste in the mouth, with tenderness of the gums and excessive flow of the saliva. As the inflammation subsides a shade may be adopted.
Fig. 2.
Night blindness and snow blindness are due to exposure to the glare either of the sun or of the snow. To avoid these complaints tinted glasses should be worn. Travellers in snowy regions should be provided with smoked glasses; if these get broken or lost, some opaque substance may be smeared over the surface of an ordinary pair, leaving a narrow horizontal slit of clear glass—in the Esquimaux fashion, as shown in the accompanying illustration. On snow it must be remembered that the perforated wire gauze sides are essential for protection from the reflected rays of the sun. Elastic may be substituted with advantage for the ordinary metallic attachments, between the glasses as well as around the head.
Jaundice, which is a condition in which the skin and mucous membranes assume a yellow colour, may be due to various causes. One of the commonest forms is that known as catarrhal jaundice, which is induced by chill, exposure, dietetic disturbances, etc. It should be treated by calomel and salines. Violent purges are to be avoided. Bismuth and bicarbonate of soda should be given, and the diet should be regulated and should consist of simple and bland articles of food, free, as far as possible, from fats.
There is a form of jaundice associated with infective conditions, such as the enteric fevers, dysentery, malaria, relapsing fever and yellow fever. In these cases the jaundice is to be treated like the catarrhal form, and the accompanying condition requires attention.
In addition to the above there is a camp or infectious jaundice, the nature of which is somewhat obscure, but which is associated with a considerable degree of illness.
Symptoms.—The condition commonly begins with shivering, a rise of temperature, headache, giddiness, general malaise, sleeplessness, loss of appetite, nausea, and it may be vomiting. The tongue is coated, and there may be pains in the back and legs. The jaundice usually lasts from seven to nine days, and about the fifth day the temperature falls, though there may be a secondary fever.
Prophylaxis.—So far as we know at present this is a question of enforcing good sanitary surroundings, and paying special attention to the hygiene of food and drinks, which should be guarded from the access of flies.
Treatment.—This is entirely symptomatic and should be that of any ordinary febrile attack, together with the measures employed in catarrhal jaundice. There is a severe form of jaundice of an infective nature which is associated with the presence of a parasite in the blood, very like that of yellow fever, and which apparently is derived from infected rats. This form of jaundice is, however, not very common and need not be further considered, especially as it requires skilled medical attendance.
The organ of the voice is called the “larynx.”
When the windpipe is affected it is somewhat tender on pressure, there is hoarseness, cough, and pain in swallowing. Treatment similar to that for cold in the head may be adopted; in addition, the upper part of the front of the throat should be kept well poulticed for a day or two, and then wrapped up in cotton wool for some days longer. A piece of mustard leaf covered with six layers of a handkerchief and secured by a bandage, can usually be borne for a considerable time, and is often more efficacious than the poultice; when the smarting is great the mustard leaf should be removed and the tender part smeared with oil or vaseline.
Inhalations of steam are of use in promoting expectoration. Carbonate of ammonia, three grains, or bicarbonate of potash, five grains, with half to two grains of ipecacuanha, will help to promote secretion from the affected part. A teaspoonful of Friar’s balsam in a pint of hot water makes a good inhalation.
Persons travelling in India, Ceylon, the Far East generally, and the Philippine Islands, are likely to make the acquaintance of the Asiatic leech, which is a very troublesome and indeed dangerous species of vermin. It is very small, only about an inch long, and of the thickness of a knitting-needle. It is able to penetrate through the interstices in clothing, and when in vast numbers it is a foe difficult to combat. The bites of these leeches are painless and much blood may be lost before their presence is discovered. It is very difficult to obtain any kind of boot or puttee which will keep these creatures at bay, and the traveller in these countries should be provided with a solution of salt or weak acid which, on application, causes the leeches to loose their hold. It is a mistake to try and drag them off the skin, as parts of their biting apparatus are apt to be left behind and set up inflammation and suppuration. Tincture of iodine should be applied to the site of a leech bite. In forest regions where these leeches abound protective measures must be taken at night, the best being the use of a properly adjusted mosquito net of very fine mesh.
The tropical water leech is found in the Azores, the Canary Islands, Africa, Palestine, Syria, Armenia and Turkestan. It may reach a length of four inches, and if swallowed with drinking water usually fastens on the mucous membrane of the mouth or throat. As a preventive measure drinking water should be passed through a piece of muslin or similar form of sieve.
This condition is named after Sir William Leishman, who discovered the parasite producing it. There is a general and febrile form of the disease and also a form attacking the skin and mucous membrane of the mouth and nose, which is considered under Skin Diseases.
The systemic form of the disease is commonly known as kala-azar, which signifies “black sickness.” It is common in certain parts of India, notably Assam, but is found also throughout the Far East, and it occurs in Arabia, in the Anglo-Egyptian Sudan and in the Mediterranean area. A case has also been described in South America, in parts of which it is possibly more common than is generally supposed.
Cause.—The parasite, which lives in the blood and tissues, is known, but its exact method of transmission to man is still in the realm of uncertainty.
Symptoms.—The disease begins in an indefinite manner and then assumes the form of a continued fever, associated with enlargement of the spleen and liver and progressive emaciation. Bleeding from the nose is not uncommon, and in Europeans the peculiar earthy-grey colour of the skin is very striking. The disease lasts for months and even years and is very frequently fatal.
Prophylaxis.—As we do not know how the disease is spread it is not easy to recommend preventive measures, and all that can be said is that every care should be taken to isolate the sick, to live under healthy conditions and to avoid contact with vermin of all kinds. As dogs may possibly be carriers of the disease they should be destroyed if proved infected.
Treatment.—Antimony is the best and indeed the sole remedy, but it can be given only by a medical man, so that nothing further need be said here regarding it.
The Liver, which is mainly on the right side, lies below the right lung, and is protected by the lower ribs. In health it extends vertically from one-and-a-half inches below the right nipple to the lower edge of the ribs; in certain diseases it is enlarged, and its edge can be felt well below the ribs.
Congestion of the liver is frequent in the tropics, and is often due to malaria or dysentery. Very frequently it is caused by abuse of alcohol, over-indulgence in food, and the excessive use of hot condiments, or by constipation and want of exercise. In the tropics the liver is more easily affected by excesses than in temperate climates.
Symptoms.—A furred tongue, sallowness of the face, headache, lassitude, disinclination for work, loss of appetite, tendency to vomit, occasional slight jaundice, and a sense of oppression about the region of the liver.
Treatment.—Light diet, abstinence from alcohol and spices, and the use of calomel or other aperient will usually effect a cure. Ammonium chloride, five to ten grains, three times a day, should be given.
In this complaint there is severe pain, some fever, and frequently jaundice. The complaint is serious, as abscess of the liver frequently follows it, at least if it is due to amœbic dysentery.
Treatment.—The patient should be put to bed, hot fomentations applied to the seat of pain, and the bowels well relieved. Emetine should be at once administered as for dysentery, or ten grains of ipecacuanha should be given three times a day. Ammonium chloride in full doses (twenty grains three times a day) often does good, and can be retained when ipecacuanha cannot, but it is unpleasant to take, so the dose should be given in one or two ounces of water. The wisest course for one who has had a severe inflammation of the liver is to get away to a healthy climate.
It is extremely difficult for the traveller to decide if abscess of the liver is present; it may be suspected if a patient, convalescent from dysentery, still remains feeble and ill, or if he has an irregular temperature, a muddy complexion, night sweats, wasting, and pain or uneasiness in the right shoulder. Sometimes a definite swelling can be made out. A dry cough is not uncommon.
Treatment.—Emetine is the specific treatment for the prevention of liver abscess, and it would seem in some cases actually able to bring about a cure even when the abscess has formed. It should be given as for amœbic dysentery (p. 187), and it is essential that a patient with liver abscess should as soon as possible come under medical control, as it may be necessary to give emetine by the needle subcutaneously or even to inject it into the abscess cavity. Ammonium chloride may be given; the patient’s strength must be supported, and he should be as quickly as possible placed under the care of a surgeon, who will probably decide to operate. If this cannot be done, then the patient should not be interfered with surgically, for he will have a better chance of recovery if the abscess is allowed to burst naturally than he would if the traveller attempted to operate.
Of all diseases in the tropics malaria is the one which is most likely to trouble the traveller. Hence it is essential that he should be well posted regarding it. In addition to the books which have already been indicated he will find the recently published ‘Malaria at Home and Abroad,’ by Colonel S. P. James, a work of much value and interest. It is true it is more especially intended for the medical man, but any intelligent layman can study it with interest and profit, and the chapters dealing with prophylaxis and treatment are specially valuable and well up to date. Here it is possible to give only a mere outline of the chief facts concerning the disease.
1. Malarial fever is caused by a small animal parasite which lives chiefly in the blood of patients attacked by it. 2. Under ordinary conditions in nature it can be conveyed only from one person to another by the bite of a mosquito which has previously sucked the blood of an infected person. 3. The parasite undergoes a series of changes in the mosquito’s body and eventually finds its way to the salivary glands of the insect whence it is injected through the mosquito’s proboscis into another victim. 4. There are only certain species of mosquitoes, belonging to the family Anophelinæ (from a Greek word signifying “harmful”), which can carry malaria, and it is only the females of these species which are affected as the males are not blood-suckers. Anopheline mosquitoes breed in shallow puddles and in almost all collections of stagnant or gently flowing water. It is therefore very dangerous to pitch camps close to stagnant pools, sluggish reed-grown streams or marshy places. 5. In the tropics one of the chief reservoirs of infection is the native, and more especially the native child, who frequently harbours the malarial parasite in the form which is adapted for life and reproduction in the mosquito and hence is a distinct source of danger. It is therefore inadvisable to camp in the vicinity of native villages or to spend a night in the neighbourhood of native habitations unless efficiently protected from the bites of mosquitoes.
Symptoms.—Malarial fever presents itself under two chief forms, though it should be noted that malaria is one of the most protean of all diseases and may simulate any malady. (1) Intermittent fever. In this disease the temperature may rise high, but returns each day to normal or lower; hence there is, after each attack, a period of complete freedom from fever. An intermittent fever or ague is usually less serious than a remittent fever, but it is harder to cure in the long run. (2) Remittent fever. In this the temperature, though it varies, keeps constantly above the normal, and the higher the fever, and the slighter the difference between the extremes of temperature, the more serious is the condition of the patient. Where the temperature is remittent, and appears to be unaffected by quinine, the disease is probably not malarial, but may be a case of enteric fever, and should be treated as advised below under that heading.
The attack may be sudden, but it is usually preceded by a feeling of languor, yawning, and general discomfort; this is followed by the cold stage, which, in the tropics, is usually short, and in the more ordinary attacks is ushered in by a violent shivering fit or rigor, though this is not common in Central Africa. The sensation of cold is entirely subjective, for though the patient feels chilly and piles clothes upon himself his temperature will be found elevated. At this period violent vomiting is not infrequent. Then comes the hot stage, often of long duration, followed by the sweating stage, during which the perspiration pours from the patient and soaks everything on and about him. After this there is a period of remission, or intermission of the feverish symptoms with corresponding relief to the patient. Usually, after some hours, the attack comes on again, beginning with the cold stage, but if the fever is treated very early, the disease may now pass off. The whole attack lasts as a rule from six to ten hours, say one hour for the cold stage, three or four for the hot period, and two to four for that of defervescence. There is sometimes a feeling of pain and discomfort in the right side owing to the congestion of the spleen, which enlarges during the rigor.
There are three distinct species of malarial parasite, and each causes a different type of fever. According to the type with which the patient has become infected, the fever recurs after one, two, or three days. At the same time all kinds of febrile irregularities are met with, so that it is often impossible to diagnose the disease in the absence of blood examination for the detection of the parasite.
Anæmia is a constant feature of the malarial attack, as is but natural, considering the great destruction of red blood cells brought about by the parasites which have infected them.
Prophylaxis.—Only those preventive measures which can be put into operation by the individual will be here considered. This may be called personal prophylaxis. By far the most important means of avoiding malaria is the proper use of an efficient mosquito net. The oblong type is best, and it should contain sixteen meshes to the linear inch. Round the foot of it should be sewn a stout layer of calico 2 feet in depth. This will permit of a foot of the material being tucked under the mattress while the upper foot remains in the form of a belt or zone round the bed. It is necessary, because in its absence the sleeper is very liable to be bitten through the mosquito-net mesh, with which his arms or legs are apt to come in contact. Care must be taken to see that the net is kept in good repair—a most important matter—and in very malarious countries it is advisable to provide every member of an expedition, native or otherwise, with a good mosquito net. In what may be called the dry tropics, the top of the net may be of mesh; in the moist tropics, it is best made of calico in order to keep off the heavy dews. The traveller often sleeps out on the deck of river steamers, and then it is certainly advantageous to have the roof of the net composed of stout calico, as sparks from the funnel are very apt to alight upon it, and naturally holes will be burnt much more readily in mesh than in thick cotton. It is foolish to sleep even for one night in a malarious locality unprotected by a net.
The net is for use during the period of sleep, but one is very apt to be bitten by infected mosquitoes just after sunset, and hence it is well to make use of some form of mosquito canopy. A good type is the so-called mosquito umbrella tent. Such a canopy may be arranged so that the evening meal can be taken in it. One servant will be inside the canopy and receive the dishes through a guarded opening from the attendant outside.
Other methods of protection exist in the shape of mosquito boots or buskins. The best type of mosquito boot is the form which reaches right up the thigh. They may be made of untanned leather or of stout khaki cloth. All mosquito boots and buskins should be provided with soles to protect the feet from wet and damp. In the absence of boots it is well to know that a mosquito will not bite through two pairs of stockings, one super-imposed over the other. This is a way in which women can protect their legs and ankles, or they can employ the buskin, leggings, gaiters, or puttees.
Mosquito veils have been mentioned, the best type being the “Mosquinette” hood.
Mosquitoes are apt to bite through chairs with cane seats or with perforated seats, and these should be guarded by a layer of brown paper, newspaper, or a cushion.
Repellent substances may be used, smeared on the skin. They contain essential oils, such as oil of cassia or eucalyptus oil. These repellents are effective only for a short time, but lessen in some degree the liability to infection.
The prophylactic use of quinine has recently fallen somewhat into disrepute, owing to its comparative failure in many of the war areas, but there can be no doubt that under conditions of civil life it is a valuable auxiliary method, if properly employed. One of the troubles about it is that quinine is rapidly excreted from the body, and hence after a dose it remains in the blood only a comparatively short time; for example, if the dose be taken at 6 p.m. it is very doubtful if enough quinine will be left in the blood at 2 o’clock in the morning to kill any malarial spores which may be introduced into it by an infected mosquito. The ideal method of taking quinine prophylactically would be to take a dose of 5 or 6 grains with the evening meal shortly before sunset. This will protect until it is time to get under the mosquito net. If for any reason it is impossible to employ the latter, then a second dose of quinine should be taken at midnight. This is difficult to accomplish, and hence something may be gained by taking a larger dose of quinine at night on the chance that some of it may remain in the blood for a longer period than would the smaller quantity. As much as 10 grains may therefore be taken under these conditions. Some persons, however, cannot stand 10 grains of quinine daily for a long period of time.
It is clear from what has been said that prophylactic quinine should never be taken in the morning, and also that it is merely an auxiliary method, and does not do away with the necessity of using the mosquito net. Sugar-coated tablets should be avoided, and care must be taken to see that the products or tablets which may be used are readily soluble. It is a good plan to crack the products before swallowing them. A good salt of quinine is the bisulphate, which is soluble and comparatively cheap. When the drug is given in powder, tablet, or pill form, it should be followed by a wine-glassful of water, and it is advisable to acidify the latter by a few drops of hydrochloric acid. There is no doubt that as a general rule quinine is best taken in solution, but in the case of persons travelling about this is not always easy to arrange, and if the above precautions be taken the solid form will generally be found effective. It is better to take prophylactic quinine in daily doses, because if an interval is allowed to elapse between doses one is apt to forget to take the drug at the proper time. Hence it is well to make it a kind of ritual to take the quinine along with the evening meal, for it is certainly an advantage to do so on a full stomach. It should be remembered that persons who take their quinine regularly do not suffer from blackwater fever, while the irregular taking of quinine certainly appears to favour the occurrence of the latter. It is better not to take prophylactic quinine at all than to take it in a haphazard and irregular manner.
Treatment.—The three great principles of treatment are: (1) To open the bowels; (2) to produce perspiration; (3) to give quinine. The routine to be adopted is as follows. Put the patient to bed in flannel pyjamas, and covered up well with blankets; in all cases, save where there is diarrhœa, give an aperient, such as four grains of calomel, or two tabloids of Cathartic Co, or two Livingstone’s Rousers, and if this does not act, repeat the dose in about four hours. If free evacuation is not produced, a warm-water enema should be given. A hot-water bottle in bed is useful. Sponging with warm water often gives relief at the beginning of a fever, and tends to shorten the cold stage. At the same time hot drinks should be given, such as weak tea, in order to promote perspiration and cut short the hot stage, and at this stage, i.e., at the outset of the fever, 10 grains of Antipyrin, or 10 grains of Phenacetin, may be found useful for inducing perspiration, or four tablets of Warburg’s Tincture, which contains some quinine, may be substituted for them. Antipyrin and Phenacetin should not be given except in the earliest stages of the fever.
During the hot stage cold applications, such as cloths wrung out of cold or iced water and sprinkled with eau de cologne, vinegar or spirit may be applied to the forehead and behind the ears. The bed-clothes should be lightened and drink freely supplied, unless it seems to promote vomiting. If the temperature shows signs of getting above 105° F. sponge the patient with warm water or cradle the bed-clothes, as it is called—that is, remove them from contact with the body by some simple means. In the sweating stage strip off the soaked pyjamas and sheets and get the patient into warm, well-aired night-clothes and bed-clothes. If there is any tendency to collapse a little stimulant may be given—say, a dessertspoonful of brandy. In most cases alcohol is better avoided. If vomiting is bad withhold all food, and give bits of ice to suck if it can be obtained.
Whilst the above methods of treatment are important, it should be clearly recognised that the one drug which can alone counteract the malarial affection is quinine, and it is upon the proper administration of quinine that successful treatment largely depends.
This proper administration necessitates at the outset rest in bed, and it also necessitates a continuance of the drug for a sufficient length of time. For ordinary cases the best way is to give quinine by the mouth, and here again it is best given in solution, though it can be administered in solid form if the precautions above indicated are duly observed. Various doses have been advocated, but probably the best quantity to administer is 30 grains every twenty-four hours. This is usually given in three doses of 10 grains each, but there would appear to be an advantage in giving four doses instead of three, and Colonel James advocates the following times for administration, i.e. 12 midnight, 6 a.m., 12 noon, 6 p.m. He does so, because such a method of administration is likely to ensure that there shall be a sufficient concentration of quinine in the blood at the time when the youngest forms of the parasite are present. The patient should remain in bed, if possible, for ten days, or, if this is impossible, for at least half that period; and it is essential that the quinine should be given as soon as possible, and quite irrespective of the stage of the attack or the height of the fever. If its administration is followed by vomiting, give a small teaspoonful of bicarbonate of soda in warm water. If this is rejected repeat the dose, and then give some form of stomach sedative, such as bismuth, and dilute hydrocyanic acid or 20 drops of chlorodyne. A mustard leaf applied to the pit of the stomach is often helpful. Sometimes drop doses of tincture of iodine, well diluted, will check these troublesome symptoms. Under ordinary conditions this 30-grain quinine treatment should be steadily continued for at least five days, but in troublesome cases it may be necessary to carry on with it for as long as three weeks. Thereafter what is called the “after treatment” is begun and must be continued for a period of three months, in order to ensure, if possible, an eradication of the infection.
There are several ways of carrying out this after treatment, but one of the simplest and most effective is to administer 10 grains of quinine every day, the dose being taken an hour or two before the time at which the fever was apt to come on during the attack.
If, despite quinine treatment, relapses occur, the patient must go to bed and be treated as for the first attack, and the after treatment must again be carefully carried out.
Under certain conditions quinine has to be injected by the needle, either into the muscles or into a vein; but, as a rule, this should not be done save by the medical attendant. It should, however, be remembered that the drug may be given by the bowel, in which case twice the quantity of quinine which would be administered by the mouth should be given. It is only exceptionally that this procedure will have to be followed, but it is sometimes useful in the case of children.
The feeding of the malaria patient is important. Between the attacks of fever, or during the sweating stage, he should be given food in fluid form, such as chicken broth, eggs beaten up with milk, raisin tea, etc.; and as soon as his stomach will stand it, the diet should be increased. Tonics, such as iron and arsenic, are required during convalescence.
In cases where there is acute malarial poisoning, with temperature 106° F., or even higher, do not wait to undress the patient or get a bath; but empty gallons of water over him, one boy keeping the head constantly soused; while this is being done a bath can be procured and the patient then undressed, or, better still, have his clothes cut off, because it is dangerous to lift such a patient about too much. Remember that when a patient is very ill and weak, he should not be allowed to stand or sit up suddenly, as he may faint.
Delirium with high temperature, say 106° F. or over, is a certain sign that the fever is doing harm, and must be reduced.
The temperature and pulse should be carefully watched when the cold water treatment is employed.
Incubation period, ten days. Rash occurs on the fourth day.
Rash.—Pink spots, round or irregular, slightly raised above the surface, tending to run together in patches over the body, leaving the unaffected skin between them clear. In the early stages often best marked on the face and behind the ears.
Symptoms.—Fever, catarrh, congested eyes, running from the nose, sickness and cough.
Treatment.—Similar to that of scarlet fever (see p. 222). It is very important to guard against chill; to ensure plenty of fresh air.
Complications.—Measles may be followed by pneumonia.
This is an infectious disease, characterised by swelling of the salivary glands. Its chief importance to the traveller is that if once it makes its appearance it may spread rapidly through his native attendants, and that it is apt to be followed by inflammation of the testicle.
Symptoms.—The invasion is accompanied by fever, which is usually slight, but is sometimes severe. There is pain just below the ear on one side, followed by a swelling which gradually increases, causing great enlargement of the neck and side of the cheek. In a day or two the other side of the face is usually affected, and sometimes the condition spreads under the lower jaw. It persists from seven to ten days, then gradually subsides. Inflammation of the testicle may be troublesome. It is usually one-sided.
Treatment.—Rest in bed during the height of the disease. Get the bowels freely open and keep the patient on a light diet. No medicine is required unless the fever is high. Either cold or hot applications may be made to the swelling. If the testicle is involved it should be treated by rest and protection with cotton wool.
This is the name applied to the condition in which the larvæ of flies are found parasitic in the body. It may be cutaneous, nasal or intestinal. The last named is not of great importance. Different species of flies may be concerned; thus in Africa, one of the best known flies producing this condition is called on the West Coast the Tumbu fly. The fly itself is about the size of a small blue-bottle, and is yellowish-grey in colour. It has a fat white larva, which burrows under the skin and produces a small boil or wheal, in the centre of which there is an opening which, unless blocked up by discharge, looks black owing to the presence of excrement from the posterior end of the larva. The skin round the hole becomes inflamed and very itchy. The commonest site is the forearm, but in Europeans various parts of the body may be attacked.
Treatment.—When small the larvæ can easily be squeezed out. They are, however, best extracted with forceps, and this is more readily done if a little chloroform is injected into the maggot before it is removed. Apply local sedatives, such as lead and opium and, after removal of the maggot, paint the skin with iodine. Indeed, if there is some delay in getting the maggot removed, it is well to apply tincture of iodine to the skin to prevent the occurrence of suppuration.
In Central and South America we meet with the so-called Ver macaque, which is the larva of another species of fly, and which gets under the skin in much the same way as does that of the Tumbu fly. It causes a great deal of pain, especially when it is moving about. It should be treated on the same lines as above.
The Screw-worm is also met with in America, and is the maggot of a fly which lays its eggs on the surface of wounds and in the ears and nose of persons sleeping in the open air. The maggots burrow into the tissues and may bring about a very serious condition if not detected at an early date and removed.
Treatment.—Injections of chloroform are one of the best ways of getting rid of maggots in the ear or nose, but medical attention is required. Wounds should be protected and kept clean. If infected they may be treated with turpentine, a painful but effective method.
Simple ophthalmia, conjunctivitis, or inflammation of the membrane covering the eye and the inner side of the eyelids, is usually due to cold or dust.
Symptoms.—The affected eye is bloodshot and painful, waters freely, and cannot bear a bright light; there is a feeling of grittiness, as if the trouble were due to something between the eye and eyelid.
Treatment.—The eye should be carefully washed, the eyelids being opened and clean, cold water allowed to run over them and over the eye; any particles of dust must be removed—for this purpose a small clean camel-hair brush will be found useful. A lotion should be made consisting of six grains of boric acid, or two grains of sulphate of zinc, to an ounce of water, and ten drops or more of this should be dropped on to the eyeball six or eight times a day. To prevent the lids sticking together during the night, they should be smeared with vaseline or a salve containing 4 grains of calomel to an ounce of vaseline. Sometimes hot fomentations give relief.
This is a more serious inflammation, and is caused by some poison, e.g., germs carried by flies, or by the fingers from unhealthy sores and discharges. It may also result from injury, such as a septic wound.
Symptoms.—The symptoms of simple ophthalmia are present, but are all intensified, the eyelids are swollen and the eyeballs red, there is a discharge of yellow matter or pus, and the patient feels ill. There is great danger of the affected eye infecting the sound one, therefore warn the patient not to touch the sound eye for fear of infecting it. There is also great danger lest the attendant’s own eyes should become infected.
Treatment.—The patient should be kept in bed and the eyes should be shielded from bright light. Protect the sound eye (especially when the affected one is being washed) by placing a pad of wool or lint over it, kept in its place by strips of strapping so as effectually to close the eye and prevent infection. Thoroughly wash out the space between the eyelids and the eye, and remove any matter or foreign body which may be found.
When the inflamed surfaces are clean, wash them very thoroughly with a solution of corrosive sublimate, 1 in 5000, and finally smear a little vaseline along the edges of the lids, to prevent them sticking together. This treatment must be repeated as frequently as possible. Once a day the inflamed surfaces may be brushed over with a solution of nitrate of silver, 10 grains to the ounce, applied with a camel’s-hair brush, followed immediately by the application of a few drops of common salt solution.
Hot fomentations may give relief. When this is so, the eye should be kept covered with a pad of moist lint, which must be changed frequently. Benefit has followed the administration of very large doses of salicylate of soda.
Piles are very common in the tropics, and are often due to want of exercise, chronic constipation, dysentery, too free use of alcohol, and over-eating. No one who suffers from piles should become a traveller till skilled advice has been obtained.
Internal Piles, though not usually painful, are by their frequent bleeding a cause of anæmia and debility; they lie inside the orifice of the bowel, but sometimes they come down on straining, and are then nipped by the muscle surrounding the opening, and may swell up, become very painful, and bleed profusely.
Treatment.—Keep the bowels freely but gently opened by taking cascara regularly; if the piles come down they should be returned, and an ointment of galls and opium or an injection of hazeline (one tablespoonful mixed with seven of water) used. Tannin, five grains to the ounce, or sulphate of iron, three to five grains to the ounce, may be used instead of hazeline. Hazeline suppositories are often of great use for internal piles, but ordinary suppositories do not keep well in very hot countries; if they are taken to the tropics they should therefore be specially made and packed. If the piles bleed profusely or cause great pain, an operation will be necessary.
External piles do not bleed, but from time to time they become inflamed and swollen, causing great agony.
Treatment.—The bowels should be kept well opened; the sufferer should lie with his hips raised; hot fomentations should be frequently applied, and the piles should be well greased. Glycerine of belladonna, smeared on a pad of lint, is a valuable application, as is dry calomel powder.
Some sedative, such as Dover’s powder, may be necessary to procure rest and sleep.
There are two chief varieties of plague, the bubonic and the pneumonic.
Causes.—Bubonic plague, which is due to a small vegetable organism, the Bacillus pestis, exists primarily as a disease in rats and other rodents, such as the Manchurian marmot and the Californian brown squirrel, and is transmitted from these animals to man by means of the flea. It is the rat flea that is chiefly concerned in the spread of plague. Both the brown and the black rat are affected and, speaking generally, the black rat is the more dangerous, as it lives in closer association with man. It is now known that certain forms of merchandise, especially grain and, to a lesser extent, raw cotton, are more to be dreaded as vehicles of the bubonic plague infection than the infected human being.
The flea does not inoculate the bacillus by its bite. It sucks up blood containing plague bacilli. The latter multiply in the insect to such an extent that they block the entrance of the flea’s stomach and prevent it from feeding. The starved flea makes violent efforts to obtain more blood and, as a result, the contents of its gullet are discharged, together with the plague bacilli, upon the skin of the healthy person on whom it is trying to feed. If there is any little wound in this skin the bacilli gain an entrance and they set up the disease. Infection may also occur from the bacilli-containing excreta of the flea being voided on the skin and rubbed into wounds. When rats become ill or die the fleas leave them and attack man. It should be noted that the rat flea may remain infective for 43 days.
Pneumonic plague, although due to the same bacillus, is quite a different kind of disease, and is transmitted from the sick to the sound by droplets of sputum expelled in coughing, and probably also by the invisible spray which pneumonia patients discharge from the mouth. When the disease is epidemic domestic animals may suffer from it and become sources of infection.
Symptoms.—Both forms of plague are characterised by sudden onset, sharp fever, giddiness, great weakness, a drunken gait, appearance and speech, and a tendency to heart failure.
In bubonic plague there is lassitude, headache and shivering, and the face is pale and anxious. The patient looks haggard, his eyes are often bloodshot, and his expression is frequently one of fear or horror. His temperature runs up to 102°, 104° F., or even higher, and his face gets hot and flushed. There is intense thirst, the tongue becomes dry and brown, the urine is scanty, and there may be delirium. About the second or third day the glandular swellings known as buboes make their appearance, usually in the groin, but they may occur in the armpits, the neck, and elsewhere. As a rule there is only one bubo, which varies in size. There may be a good deal of pain associated with the swelling, and sometimes it is very severe. The bubo, if not dealt with surgically, eventually softens and bursts, discharging matter and sloughs. In cases which are going to recover, improvement is noted about the fourth or fifth day, and is heralded by a profuse perspiration. In fatal cases, death usually takes place between the third and fifth days.
Pneumonic plague usually begins with shivering and vomiting. There is a cough, accompanied by breathlessness and blueness of the face, the sputum is profuse, watery and blood-stained, and as it is full of plague bacilli it is exceedingly dangerous. Very few cases of pneumonic plague recover.
Prophylaxis.—Ward off attacks of fleas. A substance called pesterine is good for this purpose, and consists of kerosene 20 parts, soft soap 1 part, and water 5 parts. Powdered naphthalene and tricresol powder are useful. Attendants on plague patients should be protected from infection. They should wear puttees or gum-boots, gloves, and overalls, and those looking after pneumonic cases must wear masks, goggles, and overalls. There is a protective vaccine for plague, and those travelling in districts where plague is epidemic should avail themselves of its protective power.
Treatment.—The only treatment which is of any value, and this only in bubonic plague and when given early, is the administration of plague anti-toxin, which should only be given by a medical man. The symptoms should be treated in order to relieve the patient’s distress. Belladonna and glycerine may be applied to the buboes, and they should be opened and carefully dressed once suppuration is established. Morphia is often required for the restlessness and insomnia, and cardiac stimulants are indicated in nearly every case.
This is more a disease of cold climates, and is usually the result of chill following severe exertion.
Symptoms.—Pleurisy is accompanied by less fever and general sickness than pneumonia; its characteristic symptom is the “stitch in the side”, which always accompanies it. There is also a short, dry cough, without expectoration, which the patient tries to restrain, as it “catches” in the side, and causes acute pain. For the same reason the breathing is shallow, as any attempt to draw a deep breath causes extreme suffering.
Treatment.—The patient suffers greatly, therefore in the early stages treatment must be directed to the pain. If leeches are procurable, the application of half-a-dozen to the painful region of the chest is advisable. Mustard leaves or poultices should be applied over the part, or it may be painted with tincture of iodine; opium may be given to relieve the acute pain, in the form of Dover’s powder, fifteen grains three times a day. Five grains of quinine may be given twice a day.
It has been definitely proved that the black races are specially susceptible to the organism which is the cause of pneumonia, and it is a frequent source of invaliding amongst the native attendants of travellers in Africa and elsewhere.
Causes.—As predisposing factors may be noted change of climate, chill, insanitary conditions of life, fatigue, and overwork. Malaria, syphilis, alcoholism, and excessive tobacco-smoking also play a part. The disease is believed to be spread by personal contact, but this has not been definitely established.
Symptoms.—These usually begin with a severe attack of shivering; the temperature rises rapidly, the pulse and breathing are greatly quickened, and the patient is completely prostrated. The face is flushed, the skin feels hot and dry, and there is a short cough, dry at first, but afterwards accompanied by expectoration of a moderate quantity of slimy, rust-coloured, blood-stained, and almost frothless matter. Usually there is pain on the affected side, which in most eases is the right side of the chest, above the liver. In African natives heart failure is very common.
Prophylaxis.—In order to prevent the occurrence of pneumonia amongst native followers good food should be provided, properly cooked; and it is important to see that they are supplied with sufficient blankets at night if travelling through cold regions. If it can possibly be avoided natives from hot, humid localities should not be taken to chilly, elevated and wind-swept places, as under such conditions they are very apt to contract pneumonia. Overcrowding in huts or tents should be avoided, and any sore throats which develop should be promptly treated.
Treatment.—A patient attacked with pneumonia should take to bed at once. The affected side should be surrounded with a large poultice. Five grains of quinine should be given every eight hours. If the heart’s action is weak, give some preparation of ammonia, as a stimulant, and administer alcohol, up to half an ounce, every two hours. Opium should only be given to calm the patient, as large doses do harm by checking free expectoration; if there is much distress, then ten or fifteen grains of Dover’s powder may be given.
An ice poultice applied to the chest will give great relief by lowering the temperature and diminishing the pain (see page 274).
Apply poultices to the neck. Gargle with a hot, weak solution of permanganate of potash, or a solution of chinosol (1 in 2000), at least every hour. Administer quinine and iron as a tonic. Keep the bowels well open. Surgical aid is sometimes required in bad cases.
This is the old “famine fever,” and it occurs in various parts of the world.
Causes.—It is due to a corkscrew-shaped blood parasite, which is conveyed from the sick to the healthy by means of lice. Some hold that certain forms of this fever in Palestine, Cilicia, and Persia are transmitted by means of the common fowl tick, which often harbours in the cracks in native bedsteads and in crevices in the walls of huts and other dwelling places.
The true tick fever of Africa, which is also a relapsing fever, is considered separately. (See Tick Fever, p. 241.)
Symptoms.—These differ a little in different parts of the world. The incubation period is usually from five to ten days. The onset is remarkably sudden. The patient has a chill or shivering fit, becomes giddy, develops a bad frontal headache, feels as if he had been beaten all over, and frequently vomits. He has often a difficulty in walking, and soon becomes seriously ill. Delirium is not infrequent. The tongue, unlike that in typhus fever, remains moist throughout the illness. Thirst, restlessness, and vomiting are very characteristic of the condition, and the urine is scanty. As a general rule recovery takes place, but sometimes the patient grows gradually worse and dies. As a rule, however, the temperature falls very suddenly, and the patient is better. After a week or so a relapse occurs. The temperature again shoots up, and remains up for several days. Then there is a second crisis, another relapse, and so on for perhaps three or four times. Most cases recover, and once convalescence is established the patient soon gets well.
Prophylaxis.—The disease being lice-borne, it is necessary to take all steps to prevent contact with these insects (see Lice, p. 196). The organism has been shown to be capable of passing through intact mucous membranes and unbroken skin. Hence it is advisable to be careful when attending a case, for the organism has been found in sweat and tears, while the patient’s blood is, of course, infectious.
Treatment.—Careful nursing and a light diet. Attend to the state of the mouth and of the bowels. The arsenic preparation, known as salvarsan (kharsivan), is a specific remedy, and can cut the disease short; but it can be administered only by a medical man. Otherwise there is no treatment save the symptomatic.
This is a disease which frequently follows exposure to damp and cold, and is on that account not uncommon in the tropics. It is often hereditary. After one attack, rheumatism is always liable to recur in the same individual, and on this account it is necessary that persons liable to the disease should use special precautions.
Acute rheumatism or Rheumatic Fever.—This is really an infectious disease due to a specific organism, and is quite different from the ordinary rheumatism of everyday life.
Symptoms.—It begins by a shivering fit, with rise of temperature and general sickness, and the joints, usually wrists, ankles, or knees, become painful, tender, and afterwards swollen. It resembles other feverish conditions in the rapid pulse and breathing, the constipation, scanty and high-coloured urine, etc., but it differs from most of them in the presence of a profuse and sour-smelling perspiration, resembling the odour of butter-milk.