CHAPTER VIII.

On the Prevention and Treatment of Certain of the more Common Tropical Diseases.

Although the main essentials of domestic sanitation have already been dealt with at some length, and incidental mention has necessarily been made of their bearing on the avoidance of particular maladies, it appears desirable to devote a few pages to the separate consideration of the avoidance of some of the more common tropical diseases. Some apology may be necessary for the inclusion in the following remarks of some brief references to medical treatment, but it is difficult to keep absolutely distinct the subject of prevention and cure in a popular work, and while there is no desire to convert this little book into a treatise on family medicine, it is thought that a few words on the subject of remedial treatment may not be out of place, especially as most of the writers that treat of this subject popularly, from the tropical point of view, are hopelessly out of date.

It must be clearly understood that what little is said on this subject is in no way intended to supersede the necessity of medical advice, whenever that may be available; but in these out-lands, the number of doctors to the square yard is far smaller than it is in Europe, and even in comparatively settled regions, it is quite easy to place twenty miles or more between yourself and the nearest medical man.

It must be remembered that in tendering general advice of this sort the prescriber is considerably hampered by the necessity of recommending nothing that is likely to do harm should the amateur doctor’s diagnosis be faulty, and that he is thus debarred from suggesting many measures that would be perfectly appropriate were the case under competent supervision.

I do not of course refer merely to the question of poisons, as there are few drugs that are of any real use that are not capable of causing dangerous symptoms if administered in adequate doses--and many of the drugs recommended are as a matter of fact powerful poisons--but rather to the fact that even assuming reasonable care and intelligence in weighing and measuring, one must needs direct only such measures as will not be harmful in the by no means unlikely event of a mistaken diagnosis. In only too many of the scourges that devastate these latitudes, there is no time to wait for the arrival of a doctor living a day’s journey away, as the chances are that the fate of the patient will be no longer in the balance when at last he arrives; so that for anything to be of any use it must be done quickly.

This method of treating the subject necessarily involves occasional repetition, but in view of the importance of the details thus emphasised, this may not be entirely disadvantageous.

CHOLERA.

When the writer first went to India some quarter of a century ago, there was still a tendency to invest this disease and its propagation with certain mysterious attributes, and a certain pompous obscurantist who was then at the head of affairs invented the awe-inspiring term of “pandemic waves” to account for, or rather cover, ignorance as to its method of spread; nor was it altogether safe for his subordinates to record facts that appeared to indicate a more common-sense explanation. But even then, the theory that the disease was usually conveyed from man to man by infected water, was held practically by all whose opinions were worth having. Still we were very much in the dark as to the methods whereby it gained access to water, and had no means of distinguishing infected from harmless water; and our measures of prevention, being thus based on guess work, were uncertain and often ineffective. At the present day, thanks in the main to the labours of Koch and Hankin, there is no disease about which our knowledge is more definite. In dealing with semicivilised communities it is still, it is true, quite impossible to prevent or foresee outbreaks of the disease, but when it occurs our knowledge now enables us to bring an epidemic to a speedy termination, always provided we are permitted to do so by the population; and personal prophylaxis may almost be said to amount to security.

We now know that the germs of cholera can exist only in the human organisation, but that they are capable of living and also _multiplying_ in water. In very impure water, they cannot long survive, as they soon get crowded out of existence, in such situations, by putrefactive and other germs that are most at home under such conditions. For their _multiplication_ the presence of a certain amount of otherwise harmless organic and mineral matter is of course necessary, but if introduced into water containing this, they can survive some time in the purest natural waters, though they ultimately die out in such situations. Owing to these habits of life on the part of the germ, it follows that the taste and appearance of water are absolutely valueless as regards its safety, and that the _chemical_ examination of water is an equally futile test. The disease is carried about from place to place by infected human beings; but in ninety-nine cases out of a hundred is conveyed from man to man not directly, but indirectly through the agency of drinking water. In the hundredth case the germs may be carried in food, and of course milk, being often intentionally or accidentally mixed with water, is a frequent vehicle.

Direct infection from man to man does probably occasionally occur, but the contingency is too remote an one to be worthy of consideration, as it implies close personal contact, and in fact is usually traceable to those in attendance on the sick getting their hands or clothing fouled with the discharges and neglecting due measures of disinfection before eating or drinking. Save in this way, there is practically no risk whatever in the proximity of, or of attendance on, cholera cases, and no one need shrink from nursing persons stricken down with the disease, provided they observe a few very obvious precautions.

Fortunately the cholera germ is rather a delicate sort of plant, and but for its sharing with man a preference for good drinking water it would be comparatively harmless, as it soon perishes elsewhere, and is very soon destroyed by drying or too great heat. It is needless to remark that it cannot stand boiling, for the germs that can stand that sort of treatment are few and far between; but it is also very sensitive to the action of most of the ordinary disinfectants, which destroy it in dilutions far weaker than is the case with the agents of most other diseases; and it is also killed by a sufficiently long exposure to the action of carbonic acid, from which fact there outcomes the useful bit of knowledge that it is quite safe, _qua_ cholera, to drink aerated waters even of doubtfully careful preparation, provided that they have been kept a few days in the house before use. Owing to the fact that the cholera germ cannot only survive, but is also capable of multiplying, in drinking water of average purity, the amount of fouling of the water which is required to infect it may be very small indeed, and usually is infinitesimally small.

A traveller draws water from an infected, but chemically practically pure well, and marches on, or it may be travels some hundred miles by train. Arrived at his next halting-place, he lowers his drinking vessel into the well he finds there. The amount of matter carried from the infected to the clean well is necessarily far too small to turn the most delicate balance ever constructed, but that same amount would suffice to infect not one, but an indefinite number of wells, so infinitely small are the individual germs concerned carrying the infection. Moreover, the drinking of infected water does not imply certain infection, as at certain stages of digestion the germs are destroyed in the stomachs of healthy people; and hence it is quite possible for the disease to be introduced by a person who has not himself suffered, though perhaps it is more common for it to be caused by mild cases; for it is a mistake to think that cholera is always a fatal or terribly serious disease, as in every epidemic large numbers of cases occur of slight upset of the digestive organs, but which we now know by microscopic examination to be really true cholera. These cases, however, are rarely recognised or recorded, and the really virulent form of the disease, which kills, roughly speaking, half of those it attacks, is alone referred to in ordinary statistics of attacks and deaths.

In India, and I suspect in most other semicivilised countries, the commonest method by which wells become infected is by the using of a vessel which has contained infected water to draw water from an uninfected well. The quantity of material required to start the fermentation in a still wholesome well is, as already remarked, infinitesimally minute, and a small drinking vessel and the string used for lowering it into the water, if carried by a traveller from an infected to a healthy place, is amply sufficient, and as the, chemically speaking, still pure water of an infected well is all that is required, it is obvious that no actual fouling of drinking water with the discharges from those stricken down by the disease is either necessary or common. The actual fouling of wells from contiguous latrines or cesspits does no doubt occasionally occur, but owing to the extremely primitive character of Oriental plans of conservancy, is rare.

From what has been said, it will be obvious that it is perfectly easy to suggest measures for the prevention of cholera which may be trusted to be perfectly effectual. The only difficulty lies in carrying them into practice. Practically, all that is required is to protect all supplies of drinking water by covering in wells and fitting them with pumps. But the mere expense of doing so is often beyond the means of the community, and when the pumps have been fitted, there is no one available to keep them in order; so that after a very short period they become useless, and the old infection-carrying bucket and string must needs be reverted to. Nor is it by any means easy to protect one’s own supply, as strangers have a free and easy way of making use of their neighbours’ wells, whether rich or poor. Nor can one’s native servants be trusted either to prevent this or to employ for drawing water a single vessel set apart for the purpose, for being unable to comprehend the reasons for such precautions, they naturally regard them as merely troublesome fads on the part of their employer, to be observed only when he chances to be looking on.

On this account the cardinal precaution of personal hygiene is to drink only water that has been boiled, and to see it boiled oneself. Every housewife knows that even European servants are often singularly obtuse, or neglectful, in recognising when water has actually come to the boil; and that to be certain of the perfection of the domestic cup of tea she must satisfy herself that the water is actually in a state of ebulition. Nor are such precautions onerous or troublesome. Orders should be given that the portable charcoal stove should be brought into the verandah and that the water should be boiling at the time of some meal, when the master of the house necessarily passes through on his way to table; preferably that of late dinner, so that the water may have all night to cool in, and so be ready for the next day’s consumption. The boiling water should be poured directly into the vessels, porous or otherwise, in which it is to stand, and put aside in some place sheltered from dust. They should not be filled too full, as after they have cooled it is desirable to shake the water violently so as to re-aerate it, and so remove the insipid taste which the water has acquired, owing to its dissolved air having been expelled during the boiling process. The still boiling water may generally be trusted to sufficiently sterilise the containers, but it is perhaps well, as an additional precaution, to boil them occasionally in a large cauldron. Above all, do not filter; but trust to settlement. Ordinary filters are perfect germ-traps, while all varieties of the Pasteur filter are slow in action and apt to get out of order. Added to this, their rubber connections may leak without our being aware of it, and even when in their most perfect condition, they afford a protection but little superior to that given by boiling, so that personally I would far prefer to put up even with a little turbidity in boiled water than put any trust even in the best of them. Remember that you can trust no one but oneself to attend to their cleanliness and efficiency, and that to do so implies the sacrifice of a good deal of time on a very irksome job. Drinking water that chances to be impregnated with lime necessarily becomes turbid on boiling, but the turbidity is perfectly harmless. If the deposit be so fine as to be very slow in settling, the process may be hastened by stirring it round a few times with a crystal of alum. These precautions should be, of course, routine ones at all times, but should be maintained with special vigilance at times when cholera is present in one’s place of residence. Aerated waters that have been kept in the house a week may also be drunk, but care should be taken to avoid any articles of food that are consumed raw, such as salads and fruits. Tomatoes may be dipped into boiling water and peeled without detracting from the pleasant, fresh acidity of their taste, but it is well to specially avoid during such periods lettuces and melons, as owing to the circumstances under which they are cultivated they are specially liable to have been wetted with infected water. Cucumbers may be dealt with in the same way as tomatoes, as from their shape it is very easy to sterilise their exterior by dipping them for a few seconds beyond the middle of their length in boiling water and changing end for end. This and the customary subsequent peeling really affords a sufficient practical security, and it must be remembered that the usual dressing of vinegar, “fortified” as this article of consumption usually is with sulphuric acid, affords an additional security, and does away with the necessity of submitting to what would be really a considerable deprivation at the time of the year when cholera is most common; for cholera and cucumbers flourish most at the same season of the year, a coincidence which has led to the not unnatural, but quite erroneous, popular idea that cholera may be caused by eating this vegetable. Of course, too liberal an indulgence in cucumber, like too much of any other rather indigestible good thing, may cause bowel disturbance, and an irritated bowel is especially liable to infection; but apart from superadded infection, no article of food is capable of causing the disease.

In dealing with drinking water on a large scale, such as the disinfection of wells and tanks, we have several available methods, for one or the other of which the materials are almost everywhere available. The most valuable of these agents is undoubtedly the permanganate of potash, and the suggestion of its use for the disinfection of drinking water from the germs of cholera is undoubtedly due to Mr. Hankin, our official bacteriologist at Agra. No doubt more than one medical officer had previously made experiments with this chemical for the purification of drinking water, but the credit of definitely proposing its use on a large scale in cholera epidemics, and of proving that it is lethal to the cholera germ, even when greatly diluted, is undoubtedly due to him alone.

The enormous practical importance of the discovery has, however, been but slowly realised, though its capabilities were put to the test of practical application by the writer immediately after Mr. Hankin published his suggestion, with the result that a severe epidemic in a town of over 10,000 inhabitants was brought to an abrupt termination within three or four days.

The method of disinfection of wells by means of this chemical has already been described on page 47, _et seq._

The addition of a few ounces of common sulphuric acid increases, I believe, the lethal effects of the permanganate on the cholera germ, but is certainly not necessary, and I have no personal experience in its employment, as the taste imparted is somewhat persistent; and in dealing with suspicious races such as those inhabiting our Indian possessions, it is desirable that all obvious change in the taste or appearance of the water should pass off as soon as possible.

The alternative agents are alum and quicklime, either of which is very fairly effectual, though by no means as trustworthy as permanganate. Their great advantage lies in the fact that they are obtainable almost everywhere, and that being familiar articles of daily life their use is less likely to give rise to misunderstandings in dealing with ignorant and suspicious populations, who regard with mistrust the treatment to their wells with a chemical so strange and striking as permanganate must appear to them. Nearly all races are, however, familiar with the cleansing powers of lime, and in the case of Indians, the wonderful powers of alum in clearing turbid water is a bit of household knowledge familiar to everyone. A pound or two of alum, or half a hundredweight of lime, are required for each well. If alum is employed, it should be roughly powdered.

To further avert all suspicion I find it a good plan to hand the necessary money to an inhabitant of the place and ask him to fetch me from the local shop the amount of alum or lime required. I then, if alum be chosen, tell him to pound it up with a brick and himself to throw it into the well, myself standing somewhat aloof. As everyone is familiar with the use of alum in purifying water, and there is obviously no possibility of the surreptitious introduction of anything else, with ordinary tact, no objection will ever be made. Of course, the person thus impressed into the service of sanitation should always be a man of good caste, preferably a Bhraman.

Both these agents act, I believe, mechanically by coagulating certain forms of organic matter present in the water, and so carrying to the bottom, entangled with it, the germs present in the water, in which situation they perish on account of the free access of water containing their nourishment being impeded, and on this account at least two days should be allowed to elapse before the water is again taken into use, during which all disturbance of the water should be carefully avoided.

Neither of these agents is in any degree as trustworthy as permanganate, but their employment should not be neglected in cases where the latter is either unobtainable or objections are raised to its use. Of the two, lime is probably the better, but alum much the handier.

Whichever agent be adopted, it is well to treat as large a number of wells as possible. A certain number must needs, of course, be left untouched, for use during the time the treated wells must be left undisturbed, and these should be dotted about the town, so that the minimum of inconvenience may be inflicted on the townsfolk; but always leave as few as possible, as objections may be raised on your second visit, a couple of days after, to complete the process by disinfecting the remaining wells, and it may hence happen that you may have to rest content with what you have been able to effect on your first visit. Always, too, commence operations on the well you have reason to suspect is infected, or, in other words, that used by the people of the house in which the first local case has occurred.

Permanganate has now had a long trial in India. I have never known it fail, wherever it has been used in the manner above described, and the operation has been conducted _by an European officer in person_. The native medical officer, even when trained after our European methods, is seldom really convinced of its efficiency, and moreover he lacks the prestige of prophets hailing from abroad, and so may be really unable to carry out his instructions. An even commoner mistake is to go to work piecemeal, disinfecting a few suspected wells and leaving the rest till fresh cases spring up, as they necessarily must, as buckets infected from the first infected wells will inevitably be taken to other wells during the time that the former are unusable, and they can scarcely fail to infect them, and so start new foci of infection, if sufficient time be allowed for the germs to increase and multiply to a dangerous extent in their new location. Reports of failure I have received in plenty, but on investigation they have always proved to be due to some such cause as those indicated above. It is, of course, only rarely that a layman will find himself called upon to conduct such operations on a large scale; but the knowledge of how to do so may be of such great public benefit to the readers’ coloured fellow-subjects, that it is most desirable that every European should know how to proceed, and, at any rate, I would strongly advise my readers, should cholera appear in their neighbourhood, never to omit the precaution of disinfecting all wells under their own control, as it is a great protection to one’s servants and other native attendants. It is well, too, to repeat the process occasionally as long as the disease continues near one.

By the simple precautions as to food and drink described above, the danger of being attacked by cholera may be reduced to a very small contingency, even when it is raging around one, and there is no reason whatever for the almost superstitious fear with which the disease used to be regarded.

It remains to say a few words as to the treatment of cases should they arise in your household in places where medical aid is unobtainable.

In the first place, it should be remembered that the danger of handling and nursing patients is but small, for, as already remarked, you cannot “catch” cholera in the same way as you can small-pox or plague. To become infected by the germs you must eat or drink them. The discharges in cholera are, of course, intensely poisonous, and it is impossible to nurse a case without the hands, and perhaps one’s clothing, becoming fouled; but the germs are perfectly harmless applied to the skin, and with due precautions as to cleanliness and disinfection of the hands, there should be no danger of their gaining access to the nurse’s mouth. To avoid contamination of clothing, a washable overall should be worn, such as can be improvised from a sheet, with a hole for the head cut in the middle, secured round the waist with a cord, and the sleeves should be turned up well above the elbows. Care should be taken not to touch the lips or face with the hands while in attendance on the patient. On leaving him, the overall should be wrung out in sublimate lotion and spread out in the full blaze of the sun to dry, and the hands and arms should be thoroughly washed first with warm soap and water and then with sublimate lotion, care being taken not to eat or drink until these precautions have been complied with.

Medical science is absolutely at fault in the treatment of cholera, so that no treatment can be recommended beyond such measures as naturally suggest themselves to relieve the patient’s sufferings.

The symptoms of the disease consist of violent purging and vomiting, the discharged matter being watery and almost colourless, with small particles and shreds of whitish matter floating in it, being, in fact, to quote the usual simile, very like rice water. Very often the patient suffers from violent muscular cramps, which cause great suffering. This active onset is followed by a stage of collapse, in which the skin becomes cold and livid and the face and hands singularly pinched and blue. If the patient survive this stage, it will be found that the urine is suppressed, the functions of the kidneys being, for the time, absolutely suspended; and the patient can never be considered out of danger till this function has resumed its natural course.

Now as to treatment. It must be in the first place remembered that it is absolutely useless to worry the patient with attempts to administer medicines by the mouth, as the digestive and absorptive functions are for the time totally stopped, and it is quite as much to the purpose to put your remedies in the patient’s pocket as to force him to swallow them. To have any chance of acting, medicines must be administered by being injected beneath the skin by means of the hypodermic needle; and so powerless are all known drugs in this disease, that I should hesitate to recommend such medications to be attempted by amateur physicians. The only drug which has ever appeared to me to effect any good has been chloral hydrate dissolved in water and injected under the skin in 5-grain doses every few minutes until 30 or even 40 grains have been administered. There can be no doubt that this treatment controls the violence of the symptoms, and usually does away with the horrible suffering caused by the terrible cramps that are so common in the disease. I am even inclined to believe that a somewhat better percentage of cases recover under the treatment, though this is doubtful. Failing this, massage and frictions with the hands do much to relieve the cramps, and in the cold stage, every care should be taken to maintain the heat of the body by covering the patient with blankets and placing around him bricks heated in the fire and wrapped round with strips of wet blanket. During the reaction that follows on the cold stage, in favourable cases, attempts should be made to stimulate the kidneys by the application of mustard plasters to the loins. To attempt to give food during the acute stage is obviously worse than useless, but there is no harm in letting the patient suck small lumps of ice to assuage the terrible thirst of the disease. In the stage of collapse, stimulants naturally suggest themselves, but are seldom of any use when given internally. A few drops of ether inhaled from a handkerchief is, if available, perhaps the best method of stimulation, but the weakened kidneys have quite enough to do without having to deal with alcohol, so that it should be but sparingly resorted to, if at all. When the patient shows such signs of recovery that it appears likely that food can be tolerated, small quantities only of easily digestible food, such as milk, rendered mucilaginous by the addition of a little arrowroot, Brand’s extract, &c., should be given, but it can easily be understood that after so severe a shock to the digestive system, the greatest care will have to be exercised in the feeding of the patient. Finally, it should not be forgotten that all the discharges of the patient are virulently infective, and that they and everything soiled by them should at once be disinfected. When the supply of disinfectants is limited, a good plan is to place in the bed-pan and basins used a sufficiency of sawdust, and to at once burn the contents by emptying them on to a brisk fire.

DYSENTERY.

We cannot claim to know much definitely as to the exact method in which this disease arises. Four or five vegetable germs and at least two small parasites belonging to the animal kingdom have been found, but none of these are present in all cases, and many of them may be quite commonly discovered in the interior economy of quite healthy persons, so that either the true germ remains to be discovered, or those we know of have only a secondary importance, becoming harmful only when they find themselves in contact with an irritated bowel. As a matter of fact, there are a good many kinds of dysentery, but to enter into their various characteristics would only confuse the lay reader.

The common characteristic is the discharge of frequent scanty motions, with much pain, and an intolerable sensation that more is to come. The material voided is always extremely offensive, of a mucous consistence, and wanting in the natural bilious colour. In severer cases, the mucus becomes streaked with blood, and sometimes little else will be seen, and the actual loss of blood itself may become a serious element of danger.

The disease does not usually occur as an epidemic, though something very like one is not unfrequently to be met with among bodies of men subjected to severe hardships and privations, as for example among soldiers during an arduous campaign in extreme climates. Some predisposing cause capable of causing irritation of the intestine seems to be essential to enable the germs, known or unknown, to take action. This irritant may be mechanical, such as coarsely ground, ill-cleaned grain; or chemical, as in the dysentery that is apt to appear among persons feeding on too newly reaped barley, or from foul or saline water; but the commonest of all causes appears to be the decomposition of the contents of the bowel which almost inevitably occurs when, from any reason, the production of the bile is arrested.

The peculiar yellowish-green secretion of the liver known as the bile appears not only to assist in the solution and digestion of the food, but to act as a natural antiseptic, which checks the too great multiplication of the various germs which are naturally always to be found in the intestine. It is comparatively rarely that the liver itself strikes work, but what does very commonly happen is that a chill, or a mechanical or chemical irritation of the bowel, may extend to the bile duct, and by causing swelling, or spasmodic action of its muscles, prevent the contents of the gall bladder, in which the bile secreted by the liver is stored up, from passing on into the intestine. The chill or irritant that thus stops the flow of the bile necessarily at the same time produces a greater or less amount of catarrh and inflammation of the lower bowel, which, lying as it does next to the wall of the abdomen, is most easily affected by cold; but stoppage of the flow of bile into the intestine seems an essential element in the production of dysentery, as a more or less complete absence of bile from the motions is a universal symptom of the condition, and to restore the action of the liver is, practically speaking, in cases taken sufficiently early, equivalent to curing the disease.

As has been already noticed, dysentery may be caused by a variety of mechanical and chemical irritants, but by far the commonest cause is undoubtedly chill to the surface of the abdomen, and the reason the disease is so common in tropical climates is their peculiarly treacherous feature of the chill that precedes the dawn. The earlier part of the night is often intolerably close and sultry, and it is only with difficulty that the jaded European manages to get off to sleep, and then naturally with next to no covering of the body. As the hours pass, the temperature falls somewhat and he sleeps more easily and deeply, and when the peculiar chill falls that usually precedes a tropical dawn, he is too far off in the land of dreams to be roused by the cold; and the abdomen, bared probably by his restless movements during the earlier part of the night, is left exposed to the treacherous chill.

That there are other ways of getting dysentery I have no doubt, but a tolerably long experience has convinced me that the above is the history of nine cases out of every ten that one meets with, and it follows from this _that the all-important safeguard against dysentery is to protect the abdomen from chill_. From this it follows that a cardinal measure of precaution in the preservation of health in hot climates is the adequate clothing of this part of the body. It is this fact that accounts for the general consensus of opinion as to the value of the familiar article of clothing known as the “cholera belt,” though I am by no means inclined to regard the said garment as the best, or even a good, method of attaining the object. At best the thickness of material is inadequate, it is generally made too narrow to include the liver above and much of the lower part of the abdomen below within its protection, and it naturally has a strong tendency to “ruck” together so as to form merely a very uncomfortable sort of belt, quite valueless for the purpose for which it is intended. For wear during the day a much more comfortable and efficient garment is the well-known Oriental “kamarband,” a long, narrow scarf of woollen, cotton, or silk, according to taste, folded into a broad band and worn twisted round the waist in place of a waistcoat, over which it possesses the superiority of leaving the upper part of the body free. The elasticity of the folded scarf gives also a comfortable feeling of support, without any of the sensation of constriction inseparable from a belt, and its adaptation to climatic needs is testified by the fact of its being, in one form or another, in use by every tropical race, if we except the Negro, who seems to the manner born, and to want little artificial protection while he keeps within the limits, to meet the conditions of which he evolved. How the Negro gets on with no clothing at all, and the really much civilised Bengali contrives to survive without a hat, are problems which we poor products of centuries of artifice cannot be expected to solve; but the bald fact remains that the Northern European, when translated to the Tropics, must protect his viscera against cold in equatorial climates, even more carefully than in his native north, if he wants to get back there alive.

The cholera belt is especially fallacious at night. Unsupported as it then is by other clothing, it is at no other time so liable to slip down and leave unprotected the very parts that it is most important to keep covered. In the dark hours one wants a protection that is unlikely to be disturbed by forgetfulness, and is more likely to fall back into place than be cast off. This exigency is met by a folded blanket thrown across the trunk, within which are massed the delicate viscera essential to life; the ends of the folds lying on either side on the ground, and folded so that, without too thoroughly rousing oneself, one can spread the rug out a bit, above or below, should the chill of the morning become disagreeable to the chest or the lower limbs.

Provided that the feet, chest and arms are left free, a blanket arranged in this way gives no feeling of oppression; and after a short period of habituation, its deprivation conveys a distinct sensation of discomfort. Lying across the body, with either end on the ground, it is unlikely to be disturbed by the uneasy movements of the body. The fact of the ends resting on the ground makes it difficult to shake it off, and it affords far better protection than any closely-fitting garment, is more comfortable, and less likely to cause prickly heat. Care in this matter, especially during the hours of sleep, is second only in importance to the protection of the head against the sun during the day.

Never let the mildest dysentery, or even diarrhœa, continue unchecked. Taken early, no disease is more tractable, while if allowed to pass on to a chronic condition, no malady is more troublesome; while really severe chronic dysentery is practically incurable. Some knowledge of how to deal with such cases is therefore of special importance, as without embarking on the career of an explorer, any one may find himself a day or two’s distance from competent medical assistance in the countries with which we have to deal.

Practically speaking, to restart the action of the liver is to cure dysentery in all recent cases, and hence it is of the greatest importance not to give opium, or that dangerous abomination “chlorodyne,” both of which are most efficient in diminishing the flow of bile. They are doubly dangerous, because they quiet not only the action of the gall bladder, but also that of the intestines, and this, it must be remembered, without really curing the disease. The flux from the bowel is not really the disease, but merely an outward symptom of mischief going on within, and is further the useful and salutary effort of Nature to get rid of the irritating matter that is causing the mischief; and hence to stop the movements of the bowel, before the peccant matters have been got rid of, is a most dangerous step to take; so that no drug of the above description should on any account be given during the earlier stages of an attack of this sort. Next to this the matter of greatest importance is to give the irritated intestine rest by at once stopping the ordinary diet of solid food and substituting some mucilaginous preparation, such as milk thickened with a little arrowroot and taken _cold_. Where the attack is sharp, a few hours’ fast is by no means unadvisable, but must not, of course, be continued too long. Wherever possible, it is best for the patient to rest in bed, and if there be much abdominal pain a hot-water bottle placed against the pit of the stomach will afford great relief. In a large proportion of cases no other treatment than rest and avoidance of opiates is required. Avoid also alcohol in all forms, at any rate unless extremely diluted. If, however, the symptoms fail to moderate under this treatment, it is well to secure the removal of any irritating or poisonous matter that may remain in the bowel by the administration of a dose of castor oil, a full ounce for a grown-up person down to a teaspoonful for small infants. The great advantage of this drug is that besides acting as a safe and certain laxative, the oil itself forms a most soothing application to the irritated bowel, just in the same way as it does to the skin when that structure is scorched or otherwise inflamed. To treat an intestinal flux by the administration of a laxative may appear strange to the lay mind, but you need never fear to employ castor oil, however violent the flux may be, and in children especially, it is a good routine commencement of treatment for any looseness of the bowels. A good plan for getting down this remedy, which, it must be admitted, is usually most obnoxious to adults, is as follows. Select a wide, shallow drinking vessel, such as a champagne glass, and moisten its interior thoroughly with a teaspoonful of some strongly-flavoured spirit, such as gin, turning the glass about until all parts are wetted, then add a couple of tablespoonsful of water, and into the middle of this pour the oil, avoiding the sides, so that it floats separately, like the yolk of an egg surrounded by the white. If now the contents of the glass be swallowed as nearly as possible at a single gulp, the oil passes through the mouth and throat so completely surrounded by the spirit and water that its presence cannot be noticed. A tabloid containing ¹⁄₄₀ grain of perchloride of mercury should be taken shortly after, and after a lapse of three or four hours the disinfection of the contents of the intestine may be completed by taking a 10-grains tabloid of resorcin every four hours.

As a rule, under this treatment the yellow colour soon reappears in the motions and all symptoms disappear; but should the liver refuse to act, as is indicated by the continued absence of the natural yellow colour in the motions, it will be necessary to give a large dose of ipecacuanha--to get this drug down without setting up vomiting, requires a certain amount of preparation--as in smaller doses, it is one of the safest and most certain of emetics. It is best to give the dose the last thing at night, when the patient is naturally likely to be sleepy, and half an hour before it is given, a preparatory dose of a grain of opium should be administered. The patient should lie as quietly as possible, and after the dose (30 grains, or half a dozen 5-grain tabloids of ipecacuanha) all liquids should be withheld. It is also important to use as little water as possible to wash down the tabloids, as success in keeping down the drug depends mainly on the absence of any notable amount of fluid from the stomach; and this abstinence from fluids, as well as from food, should be continued until the next morning, when in all probability a copious bile-stained motion will show that the drug has taken its desired effect. As a rule, after this, two or three tabloids, containing ¹⁄₄₀ of a grain of perchloride of mercury _per diem_, for a few days, will suffice to maintain the action of the liver and to disinfect the bowel, but occasionally the medication with ipecacuanha may have to be repeated. Remember, however, that no drugs will be of much service in this disease without the greatest care in diet.

An Indian medical officer has generally a variety of institutions under his charge, and usually amongst them a prison, of which he is not only the medical officer, but also the military governor--a sensible combination of offices which might well be imitated elsewhere. Now, although dysentery is a disease which gives much trouble in Indian prisons, the writer did not lose a single one of his jail-birds from that cause for several years; and he imputes his success to the practice he made of at once relegating each case of dysentery to a solitary cell, where it was utterly impossible for the patient to obtain any other food than that ordered for him. When left in the general wards they could not be kept from obtaining more or less of the bread and vegetable curry that formed the ordinary diet of those not seriously ill.

Soups are rarely well borne in dysentery, and hence the diet must be restricted to milk foods, the milk being always rendered mucilaginous by the addition of a little arrowroot or gelatin, cornflour, &c. When there is much dyspepsia the milk may be given semidigested by combining it with one of the numerous pancreatised proprietary articles, such as Benger’s food. Afterwards a raw egg may be given beaten up with the milk or Benger’s food, and subsequently rice pudding and fish; but great caution is always required in resuming the ordinary diet, as the bowel always remains easily irritated for some time after the attack has subsided. Everything should be given cold (preferably moderately iced), and in small quantities at a time.

DIARRHŒA.

Diarrhœa in tropical climates arises from much the same causes as dysentery, and like it, is very apt to be set up by chills to the abdomen; in fact, these diseases may be regarded, for the practical purposes of prevention and treatment, as different degrees of the same condition; the more serious disease being further complicated by concomitant affection of the liver. Heavy dosing with ipecacuanha will not, of course, be required in the milder disease, but otherwise its prevention and treatment may be regarded as the same, especially as in tropical climates, the mildest access of diarrhœa should always be respectfully dealt with, as it may easily develop into dysentery if neglected.

Hill diarrhœa is a peculiar form of chronic looseness of the bowels that is not uncommon in the Himalayas, and, I believe, in other elevated regions. Certain people appear specially liable to it, much in the same way as some are subject to hay fever, while others are never affected; and the proclivity is so marked in some persons that it is impossible for them to reside in such localities, and they are hence debarred from taking refuge from the fierce heat of the plains. We are not very clear as to its causation, though the disease is traceable in some places to the presence of finely divided mineral matter (mica) in the drinking water, and so may be guarded against by careful filtration of all water used for drinking or cooking. The climate of the hills, again, though pleasant enough, is during the rains even more treacherous than that of the plains--damp cold, alternating with warmth; but withal, as has already been remarked, the disease is mainly one of personal proclivity, and where the tendency is very marked the only course is to avoid residing in places where it is apt to occur. Should you, when travelling in the hills, be attacked with this malady, careful filtration of water and care in diet should be attended to, and a pill or tabloid containing one grain each of euonymin, blue pill and ipecacuanha may be taken at night; but should the trouble persist, no time should be lost in returning, if possible, to within range of competent medical assistance, as if neglected, the disease is apt to develop into a most troublesome condition known as sprue.

_Infantile Diarrhœa_ is terribly common in hot countries, and hence the least disturbance of this sort should never be neglected in young children. The rapid rise in the infantile death-rate that coincides with any approach to a tropical temperature in Europe, shows well how full of risk is a child’s tenure of life in latitudes where such temperatures are not the exception, but the rule. The liquid food, which alone is suitable to the infantile digestion, is perilously liable to decomposition when the temperature of the air rises much over 70° F., and, under such conditions, food which, to the nose and eye, shows no appreciable change, may yet be virulent with a poison as lethal in its effects as arsenic, and far more deadly, weight for weight. As a matter of fact, the poisons which may be generated in food subjected to high atmospheric temperatures, differ only from the most active of mineral poisons in their greater virulence, and to commence treatment in such cases with any agent that checks the action of the bowels ensures an unfortunate result with even greater certainty than if we were dealing with antimony or vitriol.

The first _desideratum_ is to get rid of the supply of poison which has already been generated within the bowels, and the second to stop the fermentation which alone can generate the poison. To meet the first indication an unirritating laxative should be at once administered. When the symptoms are severe, one or two teaspoonfuls, according to the age of the child, of castor oil is probably the safest remedy, but in less violent disturbances a drachm of our old friend, Gregory’s powder, will be more appropriate. The laxative should be promptly followed by the administration of one of the intestinal antiseptics, amongst which I have a personal preference for 5-grain doses of resorcin; but β naphthol grs. ii., salicylate of bismuth grs. v., or perchloride of mercury gr. ¹⁄₆₄, if more readily to hand are equally valuable, and are, I know, preferred, one or the other, by practitioners according to their individual favourable experiences; but opiates of all sorts are always to be avoided as long as active mischief continues, though fifteen or twenty drops of paregoric or some other preparation of the poppy may possibly accelerate the cessation of obvious symptoms when the “causing cause” of the disease has been disposed of.

The germs that produce this intensely poisonous matter are quite different from those whereby milk “turns sour,” and the fermentation which produces it may go on some time without giving rise to changes obvious to the nose or eye. Hence, though it is no doubt possible for the germs to reach the stomach in other ways, as a rule the changes have commenced before the food is swallowed.

Diarrhœa is naturally rare in infants fed entirely at the breast, and from what has been said it will be clear that the surest protection against this terribly fatal malady lies in the avoidance of bottle feeding; for to carry out the latter safely in a tropical climate, would tax the resources of a skilled bacteriologist. It is, however, unfortunately the fact that European women residing in such climates are very often really unable to suckle their children, in spite of all the good will to do so; and when the supply is inadequate and has to be supplemented by artificial feeding there is little real gain, as the bottle, with all its dangers, must needs be used several times in the day. On this account, whenever the mother is unable to fully nourish her infant, by far the safest course is resort to wet nursing. I have met with people who have a sentimental objection to entrusting their child to a woman of another race; and are even capable of believing that the mental and moral qualities of their offspring may be affected by such a diet; but it should be needless to say that there is no foundation whatever for any such idea. Great care is of course necessary in the selection of the foster-mother, who should be young, healthy, and vigorous. Her own baby ought not to be much older than the one she is to nurse, while it is needless to say that she should never be permitted to nourish both infants together. It is also most important that she should be examined, and, if possible, selected, by a medical man.

When, however, artificial feeding is unavoidable, the most elaborate care as to the purity and cleanliness of the milk and all utensils that come in contact with it are required. In hot climates it is not enough to merely wash the bottles and jugs which are used. They should be boiled at least once a day, and in very hot weather, even each time after using. The simpler the bottle is in its construction the better, those with long tubes and elaborate screw stoppers being so dangerous that it is far better to resort to spoon feeding than be tempted to use one, even as a temporary expedient. The form of bottle which presents least dangers, because the most easily cleaned, is that in which the nipple is in one piece, with an elastic cap that is made to fit the mouth of the bottle, thus doing away with the necessity of any stopper or cork. Moreover, if the special bottle chance to get broken, it is generally easy to find some medicine phial, or other small bottle, over which the cap can be stretched and which serves equally well. Rubber will not stand repeated boiling, hence, when not in use the nipple should be always kept immersed in a strongish solution of boracic acid (10-15 grs. to the ounce) and rinsed before and after using in ordinary drinking water. In making the boracic solution, a sufficient approach to chemical accuracy may be made by placing an eggspoonful of boracic acid in a breakfast cup and filling up with boiling water.

Asses’ milk is probably the best substitute for an infant’s natural food; and failing this, goats’ milk is to be preferred to that from the cow. Whichever is employed, it is best to buy the animals and have them kept in one’s own compound, so that one can ensure, by personal supervision, their being cleanly kept and carefully fed. Before milking, the animal’s teats and the hands of the milker should be washed in boracic solution, which should be kept ready made up in a large earthen vessel (an Indian gurrah, for example).

A great drawback of cows’ milk as a food for infants in India lies in the fact that, whereas human milk has a distinct alkalinity, that of the breeds of kine indigenous to that country is often (in my own experience, always) rather strongly acid, even when freshly milked from perfectly sound and well-cared for animals.

Generally speaking, indeed, the acidity is so considerable that the amount of alkali contained in even twice its bulk of lime water, is quite insufficient to neutralise it. In place, therefore, of the conventional lime water, it is better to add about as much as will stand on a sixpence, of a mixture of equal parts bicarbonate of soda and citrate of potash, to each bottle. Of course, if you wish to be exact, you can get from your chemists some books of litmus paper which change to a redder tint when dipped into an acid fluid and become bluer when moistened with an alkali; and it is a good plan to test in this way, at any rate to commence with, in order to ascertain roughly the amount required for the milk of the particular cow that yields the milk. The citrate of potash, besides being for practical dietetic purposes an alkali, has the additional valuable property of preventing the milk, after it has reached the infant’s stomach, from curdling in large masses, as cows’ milk is apt to do unless treated in this way. Human milk, when curdled in the process of digestion, does so in small flocculi; and the tendency of cows’ milk to curdle in large masses makes it a frequent cause of dyspepsia as well as of diarrhœa. Whether or no the peculiarity of possessing a so strongly acid reaction is shared with the milk yielded by cows in other hot climates I cannot say. Whatever may be the source of the artificial food, it is needless to remark that it should be sterilised by means of one of the numerous appliances now sold everywhere for the purpose, and that care should be exercised to guard against chill to the abdomen.

The prevention of infantile diarrhœa is in fact purely a question of guarding against impure and unsuitable food, and though the same is no doubt also true for more temperate climates, precautions which may be sufficient in an English summer, break down at once in a moist heat of 90° in the shade.

Should, however, in spite of all precaution, the disease appear, steps should at once be taken to get rid of the food that is fermenting within the stomach by administering a teaspoonful of castor oil, and if any obviously large proportion of the oil be thrown up within half an hour of taking the oil, give another half teaspoonful. The milk given should be much more diluted than usual, and if it obviously continues to disagree, as evidenced by continued sickness after the bottle, it should be pancreated by means of Benger’s food, which will often be kept down where the simply sterilised milk is rejected. If, however, milk in any form prove unsuitable, meat juice may be substituted for a few hours.

Meat juice is made by mincing raw lean meat, sprinkling lightly with salt, and adding just enough blood-warm water to cover it. Place the mixture aside in a covered jug in the sun for two hours and then place the pulpy mixture in a clean cloth and squeeze out the juice into a basin by wringing the cloth. Before administration, a sufficiency of sugar to make the mixture palatable should be added.

Another very useful food, as a temporary substitute for milk, when the latter disagrees, is egg albumen. To prepare this, beat up the white of a small egg with enough cold water to make a bottle, add just enough sugar to perceptibly sweeten, and let it stand till the froth produced in the beating has settled. Should these novel delicacies be refused by the infant, the addition of even a teaspoonful of milk will often lend sufficient of the desired flavour to induce the child to take it. The egg albumen should always be given cold, as even warming the bottle by placing it in hot water might easily coagulate a little of the albumen and so convert an exceptionally bland food into a very dangerous and indigestible material. After the oil has acted, about 5 grains of Gregory’s powder may be given once or twice a day, and if the natural yellow of the child’s napkins be not rapidly recovered a grain of grey powder should be added.

The course of infantile diarrhœa is often appallingly rapid, so that all may be over with the little sufferer in a few hours, and on this account there should be no delay in obtaining medical assistance, even on the appearance of slight symptoms of the kind, wherever such help is at hand.

PLAGUE.

Strictly speaking, this terrible scourge cannot be said to be in any sense a disease peculiar to warm climates, for the one climatic condition that appears to check the course of epidemics of this disease is extreme heat, which always moderates their virulence as long as it lasts. In reality, it is a disease of low civilisation; and appears to be practically incapable of attaining any serious spread amongst people of European habits. During the terrible recrudescence of this disease, which, for the last decade, has been ravaging the semicivilised world, although repeatedly introduced, it has never succeeded in seriously establishing itself in any European town. Even the admittedly backward sanitation of Spanish towns appears to be too advanced to admit of the spread of plague, and, what is more remarkable, the European portion of the population of plague-stricken Eastern towns has remained practically unscathed, while the indigenous population have been dying around them in their thousands. When first the disease invaded India there was naturally a good deal of alarm amongst the European population of Bombay, but nowadays the official, commercial, and social life of the European community goes on unmoved, even at times when the disease is doing its worst--and is so assured of its own immunity that timid ladies out for their evening airing will scarcely turn their head as the bodies of the plague-stricken are carried past them on the way to the burning ghaut. Perhaps this immunity may be to some small extent a question of race, but the main determining cause is undoubtedly difference of habits of life, as natives who have adopted European habits share in it.

The most important conditions favouring the spread of plague appear to be overcrowding and inadequacy of air space and ventilation in dwellings; and especially lack of light, as well as the want of domestic cleanliness, and the treasuring up or neglect to do away with dirty rags, dust and rubbish. A further reason in India is the sacredness of animal life, which leads to the unrestricted multiplication of rats and vermin of all sorts.

The germs of the disease are easily destroyed by moderate heat, strong light, and most disinfectants, but are apparently capable of preservation for long periods when protected from such agencies; and hence the disease is capable of being transported from place to place by the agency of dirty clothing, infected rags and such like, but the characteristic which most embarrasses our efforts to deal with the malady is the fact that plague is a disease not only of man, but also of many other animals; and that rodents in particular are specially liable to be affected by it, and are in fact generally seriously involved before an epidemic has attained any serious spread amongst human beings. Not infrequently, the first warning of an impending epidemic is the discovery of dead and dying rats in large numbers; and the best considered plans of dealing with the disease are necessarily constantly defeated by the impossibility of extending to these proverbially secretive and cunning animals the measures of isolation and disinfection that are indispensable to success. It is obviously to little purpose to disinfect the room in which a human patient has died, when in hollows in its walls, roof and floors are hidden whole families of rats in every stage of the disease; and it can avail little to isolate the comparatively few human patients, while hundreds of infected rats are left to wander about at will. Luckily, the infection of plague requires close contact to secure transmission, and there is practically no danger of contracting the disease in the ordinary open-air intercourse of life.

From what has been said, it will be seen that for Europeans resident in plague-stricken towns personal prophylaxis is a comparatively simple matter, as it is instinctively carried out as a matter of national habit. There is comparatively little danger in entering infected buildings during the day, or even in handling the sick, but unless it be a part of his duty to do so, it is better for the European to avoid passing through the infected portion of the town; to keep a keen eye on the health of his servants; and generally to restrict, as far as possible, association with the native community. The house should be kept freely open to air and light, avoiding the closing of doors and windows to exclude the heat, as in doing so we reproduce the domestic habits which cause the natives to suffer so severely. If the weather admit of it, it is better to sleep in the open; and should any mortality among rats be observed within the dwelling, there should be no waiting for any second hint, but the place should be vacated at once, and thoroughly disinfected; nor is it well to return to it for at least three weeks. Among the very small number of cases in which Europeans have fallen victims to the disease, neglect to take timely warning from the death of rodents within the house has occurred in more than one instance directly reported to the writer.

On the personal prophylaxis of plague no more need be said, but in out-of-the-way places, it not unfrequently devolves on the non-medical European to have to take measures for the protection of the indigenous community, in the absence of medical advice. To be effective, the little that can be done must be done at once, and therefore a few words on the general or public prophylaxis against the disease may not be out of place. One of the few redeeming features in the natural history of plague, is that it at first spreads very slowly. It is doubtful if, in any case, the bulk of the infections are from man to man, and it appears on the whole probable that, after the first introduction of the infection, time is usually required to admit of the thorough establishment of the disease amongst the rats before it can attain any formidable spread amongst men. During this early stage there is no great difficulty in dealing with the disease, and hence it is absolutely of the most vital importance to obtain information as to the occurrence of the first cases. In the case of these first attacks, whether imported or apparently of local origin, no measures of disinfection and isolation can be too rigorous; but the people should be made to clearly understand that except at their own express desire and by their own enforcement, compulsion in such matters will be at once relaxed should the disease unfortunately gain a firm footing in their midst. As a matter of fact it is unfortunately too true that there is really very little that can be done to any purpose, when once the disease has fairly fixed itself on the susceptible mass of an oriental urban population, and above all things it is worse than useless to attempt to enforce sanitary measures by compulsion, as it only leads to the concealment of extent and localisation of the disease, and to organised obstruction to all remedial measures attempted by those in authority.

It should be the duty of a civilised government to place at the disposal of the population every possible means of combating the disease which our superior knowledge and civilisation enables us to recommend, but it should be made absolutely clear that these benefits of civilisation are there to be simply taken or left, as they please. In the cases of measures particularly liable to be mistrusted, such as inoculation, it may even be well to charge a small fee for the operation, to be remitted of course in cases when the patient can show that he is really impecunious. The joy of getting to windward of the too credulous official by a pardonable understatement of finances, would be a temptation hard to resist by the average Oriental, and there is no harm in writing out such a receipt; for the folks who require Hibernian driving of this sort cannot read, and it was one of their countrymen who could not only read, but think very much to the purpose, who suggested the expedient to the writer.

I believe my good native friend was right, for I have actually seen ordinary vaccination eagerly sought for by Orientals over whom we had no shadow of political control, and who would have been up in arms at the idea of compulsion; through the simple stimulus of the nominal fee system.

As a matter of fact, there are few things that the Indian cannot be persuaded to do by a tactful European official who has been allowed to remain sufficiently long in a locality to become known and trusted by the people among whom he has to work; but the notion of utilising the personal factor in administration is, unfortunately, far from the Indian bureaucracy, and the theory of one man being as good as another for any purpose has been adopted to such an extent, that combatant magnates were actually selected to control the operations of the medical experts in dealing with plague. The attack on the plague bacilli with so tactless a weapon as the bayonet naturally failed, but we certainly secured a striking and no doubt valuable demonstration of “how not to do it.”

The opportunities that should be placed at the disposal of the population may be epitomised as follows:--

(1) _Evacuation._--The truth of the old proverb as to the policy of “running away,” is illustrated in the case of plague, if possible, even more forcibly than in that of the late Boer war, and as the population, like the warlike Boer, should always have a new position ready to fall back on, a certain number of huts should be set up in the open for the accommodation of those who are wise enough to take Nature’s hint in good time, and to leave the germs of infection behind them to “stew in their own juice” till they die for want of material.

The ruder these structures are made the better, it being essential that they should cost so little that they can be burned without regret should they become infected; and hence nothing beyond the provision of shelter against the sun and rain should be aimed at. In the case of village communities, complete evacuation of an infected site is generally possible, but in towns of any size such a plan may be out of the question. A small camp should, however, be provided for the accommodation of such as are wise enough to avail themselves of it. Where, as is the case with tea-garden and mine managers, the European superintendent for all practical purposes constitutes the government on the spot for the time being, the policy of instant evacuation of “the lines” wherever a case of plague has appeared cannot be too strongly insisted upon. Even when left to themselves, the germs have a strong tendency to die out in the course of a few weeks; and aided as it can be by systematic disinfection of the inhabited site, there can be no doubt that this policy of flight is the sheet anchor of our armament for meeting the disease.

(2) A hospital constructed of the same temporary materials should be provided for the reception of travellers and vagrants, as well as for such cases in which, on account of panic, the friends and relatives decline to attend to the sick; a contingency which, however, is but rarely met with in India.

The patients should be left to choose their own medical attendants as far as possible, but the paid attendants should, if possible, be subjected to protective inoculation, and the people should be further encouraged to bring their sick to this hospital for treatment and nursing by themselves, but no attempt should be made to isolate the persons employed in nursing, or, indeed, to enforce isolation in any form, as experience has shown that, however desirable it might be to do so, such measures cannot practically be carried out.

(3) _Protective Inoculation._--Although there is some doubt as to the extent and duration of the protection conferred by injection with Haffkine’s protective emulsion, there can be no doubt that it confers a considerable power of resistance. The operation is one that can only safely be undertaken by professional men, but it should certainly be placed at the disposal of the community wherever practicable. As a matter of example, it is as well for Europeans to submit to the process, though in view of the rareness with which they are attacked, it can hardly be considered necessary, except in the case of those whose duty brings them into close and constant association with the native community.

(4) The destruction of rats is a measure of no small importance, and one which should be undertaken in all towns where there is even a probability of the introduction of the disease. Most communities possess professional rat-catchers, and the services of these men should be enlisted, though where a reward is offered for dead rats, only full-grown animals should be paid for, as otherwise it may lead to breeding rats for the sake of the reward.

Quarantine, protective cordons, train inspections, and the like, have been tried, and found rather worse than useless; as like all other systems that interfere with personal liberty, they lead to concealment of cases, and concealment necessarily involves the treatment of the sick under circumstances that render the spread of the disease to relatives and attendants almost certain. At the same time, measures of this class are those that are regarded with most favour by natives, and provided they are assured that, in case of the discovery of cases, there will be no forcible interference with their habits and customs, they will generally adopt and themselves carry out the more useful and practicable of the measures of this class, such as the watching of new comers by road and rail, and even the inspection of the dead. It is a mistake to think they are not as anxious to keep the pestilence out of their towns as their European rulers can be, and, as a rule, they will make no objection to the proper disinfection of houses that have become infected, but they will prefer to run any risk rather than submit to any interference with their domestic customs.

(5) The means of thorough disinfection should be provided. The best of all disinfectants is fire, and, as far as possible, all infected bedding, clothing and rubbish should be burned, and paid for. In order to secure, to some extent, the destruction of rats and other vermin, as a preliminary measure, the house should be fumigated by means of sulphur fumes, and after this has been completed and the house opened, the floor, walls and furniture should be thoroughly washed down with strong solution of corrosive sublimate (¹⁄₁₀₀₀) thoroughly acidified with hydrochloric acid. Phenyl has also proved serviceable. The men employed in this work should have been, if possible, inoculated. They should thoroughly grease all exposed parts of the skin before commencing work, and should be thoroughly clothed, being made to wear nether garments reaching to the ankles and tucked into boots of European pattern, which should be kept well greased, so that they may not get hard from contact with the disinfecting solutions. I cannot recommend the digging up of earthen floors, as the task is undoubtedly a very dangerous one to the men employed in the work, and there can be no possible real need for it, as, of all parts of a dwelling, the floor is that which can most easily be saturated with powerful disinfectants.

Lastly, after washing down with perchloride do not lime-wash or attempt in any way to employ these agents in any combination, as to do so shows a pitiable ignorance, not only of the Board School rudiments of chemistry, but of the behaviour of the specific germ of plague to external surroundings. I am perfectly aware that the combination is ordered in several sets of Indian regulations, but in justice to the service to which I have had the honour to belong, I hope my readers will accept my assurance that these ludicrous recommendations are one of the natural results of the meddling of ignorant amateurs, military and civilian, who unfortunately have often been allowed to assume the command of sanitary matters within our great bureaucratic dependency.

If the inhabitants of infected houses can be induced to migrate for a time into camp, so much the better, as in such cases the enormous additional disinfecting powers of air and light can be utilised by removing, for a time, portions of the tiling or thatch, and it must be remembered also that time alone is also an excellent disinfectant. The danger they run in immediately returning should be clearly pointed out, but if return they will, they must be let do so, as compulsion means opposition, and the benefit of the disinfection to the general community is only lessened by their return in so far that should they fall victims to their own rashness they form fresh foci of infection and the process has to be gone over again. In the case of small compact communities, such as gangs of coolies working under commercial corporations, a more autocratic course of action is, of course, practicable, but should never be carried to such an extent as to bring about organised opposition, and however stupid and prejudiced they may appear to the ordinary European mind, no effort should be spared to obtain the co-operation of the people themselves, and it is in securing this that the personal element of long association and mutual trust is especially valuable.

In spite of the great advances in our knowledge of the disease that have been made during the present recrudescence of the disease, we are still a great deal in the dark on many points, and especially as to the mechanism of infection in the majority of cases. Each year of the progress of the epidemic demolishes some one or other of the few standpoints of certainty that we had imagined as firmly established, and it is evident that some great discovery remains to be made before plague will cease to be, from many points of view, an almost complete mystery.

SMALL-POX.

Although in no sense a malady in any way peculiar to hot countries, Europeans are necessarily much more exposed to infection among semi-civilised communities, where vaccination is at best only partial, than in Europe; and hence it is well to impress the necessity of efficient re-vaccination on all who have to live among people by whom the blessings of vaccination are, as yet, imperfectly appreciated. Even a single vaccination affords so great a protection that it is rare to meet with fatal cases amongst those who are foolish enough to live in the midst of small-pox without being re-vaccinated, but it is hardly worth while to risk suffering from so revolting a disease, with the chances of disfigurement for life, for the sake of avoiding so trifling an inconvenience as that involved in the little operation. On this account it is very desirable for the intending emigrant to tropical parts to be re-vaccinated before starting, as an inflamed arm is much more troublesome when complicated with prickly heat than it is in temperate climates. In addition to this, it is always wise to submit to re-vaccination whenever an epidemic of small-pox is raging around one. If needless, the virus will not “take,” and you will suffer nothing worse than the trifling scratch involved in the operation. If, on the other hand, it “takes,” it shows that a grave risk would have been run in neglecting the precaution.

SLEEPING SICKNESS.

This peculiar malady has only come into notice of late years, since the opening up of Central Africa, and though it was at first thought to be confined to the negro race, has recently been shown to occasionally attack Europeans. In its early stages, the disease presents many points of resemblance to ordinary malarial fever, and has usually been confused with it, both by patient and doctor; but following this, after an interval of a few weeks or months, certain peculiar nervous symptoms appear, from which the disease has taken its name, and which are mainly characterised by hebetude and somnolence. It would be superfluous, in a work like the present, to enter into any details as to its peculiarities, especially as our knowledge on the subject is at present in its infancy. It may, however, be fairly said that we are almost certain that the disease is caused by certain peculiar parasites (_Trypanosomes_) that are found in the early feverish stage of the disease in the blood, and subsequently, when the peculiar sleepiness appears, in the fluid that bathes the spinal canal. From the analogy of malaria, as well as from anatomical considerations, it is tolerably certain that the disease is conveyed from one human being to another by means of inoculation through the agency of biting insects.

Further, strong suspicion, approaching moral certainty, strongly points to certain flies, of the class known as horse and cattle flies, as the species that acts as the intermediary. These flies are much more common in tropical climates than they are at home, and are characterised by the peculiar persistency with which they attack an animal, in spite of all attempts to drive them off; and so much is this the case that nothing short of pursuing the insect until it is killed is of any use. They do not, as a rule, invade houses, and it is exceptional for them to attack man, but they will do so occasionally, and the stab they give is so sharp that it is hardly likely to be overlooked.

At present the disease appears confined to Africa, but species of the same flies are to be found in India, and the writer has more than once been bitten by them, though no danger attaches to the incident, as the specific germs of the disease do not occur in that country.

They are usually dark grey, flattened insects, with a peculiarly hard integument, which forms so efficient a protection against injury that, if merely squeezed between the fingers, they will commonly fly away in a perfectly unconcerned manner. The easiest way to dispose of them is to knock the insect down with the whisp of horsehair mounted on a cane, commonly carried by horsemen when flies are troublesome, and then to crush it under the boot, giving the foot a good twist, so the wound, like that of the sergeant-instructor’s bayonet, may be “made incurable.”

The general appearance of these insects may be best gathered from the above magnified figure.

It is obvious that as far as our knowledge extends, the prevention of sleeping sickness is purely a matter of avoiding being bitten by insects of this sort, and it is also clear that as far as indoor life is concerned, the adoption of metallic gauze protection of the house will be as effectual as it is in the case of malaria. These flies are, however, mainly forest insects, and watchfulness, especially when sitting out of doors, is all that can be suggested. Personally, if bitten by one of these flies in a country where sleeping sickness exists, I should be strongly inclined to destroy the bit of tissue around the bite by means of some powerful caustic, such as pure carbolic acid dropped into a small cut at the site of the puncture, for as yet no instance of recovery from the disease has ever been met with, and in all probability this measure, if done with tolerable promptitude, would probably suffice to destroy the germs before they gained access to the general circulation.

SUNSTROKE AND HEAT APOPLEXY.

The disturbances of the nervous system that are grouped under the above heads vary a good deal, and probably comprise several different diseases, with as many distinct causations.

It is a curious fact that sunstroke is practically unknown on the high seas, and in certain countries, notably in South Africa, where the fierceness of the sun would naturally lead one to expect to commonly meet with it; and this circumstance, and the fact that something like epidemics of the disease are occasionally met with, lend a certain amount of probability to the idea held by certain authorities, that, in one form at least, the malady belongs to the category of germ-caused diseases.

The symptoms of the disease are insensibility, combined with a greater or less elevation of temperature, and a large proportion of the cases that one hears of are merely instances of fainting, due to fatigue and exhaustion from heat. Such cases are specially common where large bodies of men are massed together, and have to undergo great exertion under unsuitable atmospheric conditions, and where, besides being hot, the air is foul with dust and the emanations of the closely packed animals and men, whose sufferings are often aggravated by thirst and the restricted possibility of evaporation from the surface of the skin that is inseparable from an inadequate supply of water; while the free play of the lungs and heart are too often impeded by the unsuitable and fantastic garments and equipments so dear to the infantile genius of militarism.

Fainting is due to a sudden weakening in the action of the heart, and in a certain number of cases of “sunstroke” of this sort, the mischief goes beyond enfeeblement, the heart stops, and the man is dead. Most of the cases of sudden death from “sunstroke” that occur on hot “field-days,” as well as in military operations undertaken in earnest, are probably of this character; and even when the heart has not absolutely stopped, its action may be so feeble and fluttering that the insensibility is prolonged and serious. The temperature of the body is, however, only moderately raised, and when, under proper treatment, the patient has regained consciousness, he soon recovers if permitted to rest, and in a day or two may be little the worse for his adventure. In cases of this sort all clothing and equipment should at once be loosened or removed, and the patient should be given the full benefit of what “air” there is to get. Hence, it is of the first importance to prevent sympathetic onlookers from crowding round him in a ring. The chest and face should be freely soused with water, and when the patient is able to swallow, a little stimulant may be administered.

Some kind of shade should be improvised, at any rate over the head, but no attempt should be made to move the patient till the pulse can again be plainly felt, after which he should be placed on some sort of stretcher and removed as quickly as possible to shade and comfort, where he will probably speedily recover, for though “sunstroke” of this sort is a highly dangerous condition while it lasts, it is rare for it to be followed by any serious after-effects.

Cases of this sort are comparatively rare in civil life, the conditions which lead to them being usually wanting; for it will be noticed that even the military officer takes the greatest care not to be “smart” when he goes out shooting under a tropical sun, his costume, when so engaged, being generally a model of the way he and his men ought to be equipped when engaged in the business of their profession.

What may be called true sunstroke is less common, and beyond the bare fact that the sun’s rays are capable of acting in this way, we are really quite without any explanation of its causation, as the condition may be brought about by comparatively short exposure, without any coincident exhaustion or fatigue; and may occur at times when the temperature of the atmosphere is by no means excessive. It is probable that over-stimulation of the nerves of sight by glare may have something to say in the matter, as it has been found that persons at rest in the open, in the Tropics, have their temperature less raised if they wear darkly tinted spectacles than others similarly situated, but having the eyes unprotected. This cannot, however, be the complete explanation, as it appears to be exposure, not of the face, but of the skull and back-bone, to the direct rays of the sun that constitutes the real danger, and it is not the forehead but the back of the head and temples that are most sensitive to the influence of “insolation.” So many unexpected discoveries have been made lately of forms of light whose very existence was, but a little time ago, unsuspected, that the matter is less inexplicable than it was before the discovery of the Röntgen rays made us familiar with light vibrations capable of passing easily through substances we have been accustomed to regard as quite opaque. The rays of the sun do not, of course, include vibrations of that particular description, or none of our ordinary wooden photographic apparatus would be of any use to us; but they may well have amongst them other vibrations, as yet not identified, which are capable of passing through the tissues and affecting the brain and spinal cord beneath; and no other suggestion appears capable of explaining the extraordinary way in which a few instants of exposure of the unprotected head to an Indian sun suffices to cause a sharp headache; as the effect is utterly inexplicable on any mere assumption of rise of temperature. It is quite a mistake, for example, to think that it is safe to cross one’s garden hatless, from the house to one’s stables, in the heat of an Indian day. One is not of course likely to be stretched out in a state of insensibility by so short an exposure, but you may easily earn a splitting headache which will last you the rest of the day; and from the time the sun is well over the horizon, till it again sinks beneath it, it is a purposeless imprudence to be found in the open with the head inadequately protected.

The selection of a suitable headgear for tropical wear is a matter of the utmost importance, and no material appears to be as effective in intercepting the peculiar vibrations which cause sunstroke, whatever they may be, as the pith of the solah, or Indian rush, from which the well-known tropical sun-hat is made.

Next to this in efficiency, I think, comes felt, and after this cork; but the latter material, when adequately supported to give sufficient strength, is really too heavy for comfortable wear; and if any concession to “smartness” is desired, stiffened felt is to be preferred, such as, for example, the well-known “Elgin helmet.”

But those who are wise, will abjure such compromises, and stick to pith, either in the ordinary mushroom form, or in that of the admirable “Cawnpore tent club” hats. Let it be freely admitted, that either contrivance is as ugly as well may be, but it is better to keep one’s brain clear for the appreciation of artistic beauty elsewhere, than to have them permanently muddled for this and other less æsthetic purposes in the effort to maintain a becoming exterior. Further, the sun is never more treacherous than just after it rises, and before it sets; because just then the nearly horizontal rays can reach the temples and other parts of the head that are well protected by any ordinary sun hat when it is higher above the horizon. In fact, as long as the sun is above it, it is a mistake to go abroad in European head gear, though in the morning and evening a soft felt hat, which can be bent and manipulated so as to shield the particular side exposed to the sun, is better than a solah hat, which of course cannot be adapted in this way. For really tropical climates, in the heat of the day, no other material but solah pith is at all adequate; but in South Africa and other sub-tropical climates a less clumsy and more comfortable covering for the head may be safely adopted, and for such purposes the broad-leafed Boer felt hat, so familiar to us of late in the drawings in the _Illustrated London News_, and _Graphic_, is hard to beat. I do not of course refer to the melodramatic brigand arrangement that, in feeble imitation of our late foes, was inflicted on the Imperial Yeomen by the would-be smart military male milliner, but to the real article, as worn by the real Boer and, it may be added, by everyone else who has work to do in the open in that climate, after he has been out there sufficiently long to have discarded the “helmet,” decked out with a pugaree finished off with a pair of long tails down the back, with which his London Colonial outfitter has probably provided him. The true Boer hat is an admirable example of adaptation of costume to special climatic exigencies; but though they are, I presume, manufactured somewhere in Europe to suit the Colonial market, I doubt if such a thing can be purchased in England, for as is well known the English manufacturer insists on his customers taking his own designs, and those who would consult their own requirements must needs deal elsewhere. Hence, if you are bound to “the Cape” you will be wise to defer providing yourself with a hat till you land, for the English outfitter’s muslin-bedecked helmet is a natural object of derision to those who know what is really wanted, and no extra protection is wanted under the double awning of the big liner that takes you out to your new home.

The true Boer hat has an ample crown, a very broad brim, and is not looped up at one side, as anyone but a fool can see that to do so is to make the hat suitable only for a one-sided world, in which the inhabitants never require to deviate from a course carefully laid so that the sun is always kept on the “brimmery” side of the hat. The Mexican “sombrero,” worn everywhere in sub-tropical America, is practically identical, and the hat worn by the American “rough riders,” though not quite so absurd as those of our Yeomen, is another good example of the mischievous effects of the childish military craving for “smartness.”

In India and elsewhere in the Tropics, a broad-leafed felt of this sort is very useful and comfortable for wear in the early morning and evening, but is quite inadequate for use in the middle of the day during the hot weather, though at other seasons a less cumbrous head covering than the big felt hat may be safely adopted; but, however cool the air, it is at no season safe to go abroad in India in the ordinary small hat of Europe.

Children are strongly influenced by the sun in two ways: they are in the first place enormously benefited by getting plenty of his health-giving light; in the second their little skulls appear to be remarkably easily penetrated by the _y_ or _z_ rays that cause sunstroke. Hence, even in the hottest weather, it is a mistake to shut them up in the darkened rooms so dear to their mother’s hearts. It is as well, of course, to keep children out of the direct rays of the sun during the day, more especially as it is difficult to ensure that they will always keep their hats on; but it is a mistake to curtail their morning and evening walks on account of the sun being above the horizon, though it must be admitted that the greatest vigilance is required to insure their keeping their hats on their heads.

Ladies resident in hot climates as a rule suffer far more from the want of the sun and light than from serious sunstroke, their greater sensitiveness to discomfort rendering them more apt to shrink too much from light and air in hot weather; but on the other hand their desire to maintain a pleasing appearance not infrequently leads to their suffering from the earlier and milder symptoms of insolation. Owing to their not unnatural objection to the admittedly unbecoming forms of head-gear which alone can insure safety. The singular preference for the unfitness of things which appears everywhere to characterise the ritual of Society, and demands that a man must go a-hunting in English winter weather in a tall silk hat, ordains that in India ladies shall pay their conventional calls between the hours of noon and two p.m., when to go abroad in a hat at all in keeping with their costume is hazardous in the extreme. Unfortunately, out of the larger towns, closed carriages are possessed by comparatively few, and the result is that an umbrella, unsteadily held by the native groom behind her, is all that there is to shield her head from a tropical sun at the meridian.

That severe headache, lassitude and other less easily defined nervous symptoms should follow such expeditions is not surprising, and undoubtedly if a closed carriage be unobtainable, for a lady to attempt a “round of calls” at the conventional hours, is a proceeding involving such a real risk that it should never be attempted, and calls should be postponed to the cool of the evening. Moreover, even for occasions when not equipped in full uniform, a safe head covering for ladies living in the Tropics has yet to be popularised. Those who are wise enough to determine to be out of doors daily, and to take a sufficiency of exercise, will find it best to wear a hat of the same pattern as those worn by their husbands and children, and to entirely abjure the absurd constructions of pith, fashioned in imitation of English head gear, which have of late years appeared on the scene. Some years ago an admirable pith head gear, shaped somewhat on the lines of the “Gainsborough hat,” enjoyed a well-deserved popularity, and it is a pity ladies cannot see their way to adhere to it; as it not only afforded excellent shade and protection, but when tastefully bemuslined was by no means unbecoming in its obvious adaptation to its surroundings. Recently, however, fashion has chosen as its model the “sailor hat,” and frankly, inartistic as is the European original, the fantastic deformity of the Anglo-Indian pith imitation requires to be seen to be appreciated. It may be doubted if human ingenuity could shape the material to a worse form, and it is wiser for a lady to keep out of the sun altogether than to trust herself in the open wearing only such an ill-contrived head covering.

It is, of course, of the first importance to get a person stricken by the sun at once into the shade, and as the temperature of the body is rarely excessive in such cases, cold locally applied to the head is of more importance than a general bath, which, indeed, unless carefully watched, is apt to make matters worse, by driving the blood from the surface and so increasing the congestion of the brain and other internal organs. Hence it is better to apply ice to the head and to confine oneself to sponging the extremities as a measure for reducing the general temperature. In climates where insolation is common, there is little risk in getting wet, and hence if no proper ice bag be obtainable the ice, roughly crushed, may be applied to the head, simply tied up in a towel. Anyone who has suffered from even a mild attack of insolation remains for a long time specially sensitive to the effects of the sun, and therefore requires, for a long time, to be especially careful in avoiding exposure. When prolonged exposure to the sun at its fiercest must be braved, as in big game shooting, it is well to protect the spinal column by means of a pad worn outside the coat. Some persons are much more sensitive to the effects of the sun playing on the back than others, and though the precaution cannot be considered universally necessary, no one who feels himself inconvenienced by the effects of the sun on this part of the body should neglect the warning and fail to provide himself with a suitable protection. The usual plan is to have made a pad, cut to the shape of the back piece of the coat, of quilted cotton wool, covered with the same material as that of the coat and secured by buttons suitably placed.

The third form of “stroke” is that of heat, and appears to be due simply to the inability of the regulating powers of the system to keep down the temperature of the body to the normal level.

Unlike true sunstroke, it nearly always occurs at night, when the resisting powers of the organism are reduced to their minimum, and mostly under conditions in which the sleeper has inadequate air room, such, for example, as in crowded barracks and closely-packed railway compartments. Such cases may possibly occur, but personally I cannot recall an instance of this accident occurring to persons sleeping in the open air. Every year one reads in the Indian press of persons being taken dead out of railway carriages, and perhaps of a number of cases occurring simultaneously in a single barrack, but with adequate air space such an occurrence is, to say the least of it, exceptional.

At the same time, it is just in the hot “stuffy weather of a break in the rains,” when it is always on the cards that it may rain before morning, that such cases occur, and apart from the traditional danger of sleeping outside a room during the rains, one is naturally loth to risk a ducking. Given, however, adequate shelter from rain, there is no danger whatever from sleeping in the verandah at such times of the year, always provided, of course, that protection against infected mosquitoes is assured by a carefully tucked-in mosquito net, and when the atmospheric conditions are such as to involve risk of heat stroke, I personally prefer to sleep on the roof, under the shelter of the top of a tent, or of a special thatch shelter consisting of a roof without sides, or at most with one lateral wall to windward, when there is a probability of a driving rain falling during the night. As a matter of fact, under atmospheric conditions of this sort, one is unlikely to take much harm even if one does get damp, and the admittedly enhanced danger of malaria can be entirely obviated by means of mosquito curtains.

Till lately we heard nothing of the danger of anything worse than itching being connected with mosquito bites, and naturally those who were callous enough to popular notions of safety to sleep outside the house in the rains were about the last folks in the world to trouble themselves about the tickle of a mosquito bite, and became “moral examples” by contracting fever accordingly. During periods of great heat, especially if combined with dampness of the air, under which conditions heat stroke is likely to occur, severe muscular exertion should be avoided as far as possible; a light, mainly vegetable, diet adopted, and the amount of stimulants taken should be very limited, though it is a great mistake to limit fluids of other descriptions, and tea taken very hot is often useful and refreshing. Care should also be taken not to allow oneself to become constipated, and speaking generally it should be recognised that under the extreme climatic conditions that bring on heat stroke, the European must live cautiously if he wishes to come out of the ordeal unharmed.

In this form of the disease the temperature of the body is always high, 103° to 107° F., and the stupor deep and prolonged. Should you have to do with a case in the absence of medical assistance, every effort should be made to reduce the temperature of the body, the most efficient means being to place the patient in a full length bath. As a rule, under such conditions, the temperature of the water obtainable is too near that of the body to bring down the temperature sufficiently rapidly, and pieces of ice require to be added to obtain sufficient cooling power. The patient should be kept in the bath until the temperature (taken in the mouth) is restored to the normal level of 98°-99° F., after which he may be removed; but in serious cases the temperature shows an obstinate tendency to go up again, and it is generally necessary to keep it down by continuous sponging, applied especially to the extremities. If, in spite of these measures, it still continues to rise, the bath must be again resorted to. If ice be unobtainable wherewith to cool down the bath, the want of it should, as far as possible, be met by dipping out the water warmed by contact with the patient’s body, and replacing it with freshly-drawn water as cool as may be obtainable. It is well also to try to relieve the bowels by placing 5 grains of ordinary powdered calomel on the tongue, which will ensure its being gradually swallowed, even in the deepest coma, and every effort should be made to keep down the temperature of the air of the room, always provided that the freest possible ventilation be kept up.

It is never prudent for anyone who has survived a warning of this sort to remain in a climate the severity of which he has proved himself unable to resist; and it should be the rule for those who have suffered to take refuge in a cooler climate as soon as they are sufficiently recovered to travel.

If stationed far inland, it is best to seek refuge in a mountain sanatorium, and not to attempt to reach Europe, as the long journey in the train and subsequent passage of the Red Sea would, in all probability, finish the record of a person so situated before the desired relief could be gained. On the coast the quickest relief can be generally obtained by sending the patient to sea, but if the route necessarily involves passing through the Red Sea, such a course is too hazardous at the bad time of the year, and the change to Europe should be postponed till the dreaded stretch of water can be passed in safety, or a visit to Australia substituted. It must not be imagined that in practice cases of “stroke” can be as sharply divided into classes as it is easy to do upon paper. Naturally a large number are of mixed origin, but the extent to which heat, pure and simple, is concerned, may be generally judged by the temperature of the body, and whatever may appear to be the causation of the disease, whenever this is high, no efforts should be spared to bring it down as soon as possible.

PRICKLY HEAT AND DHOBI’S ITCH.

Among the minor ills which European flesh inherits in the Tropics there is none that is more distressing than this troublesome malady. The symptoms and appearance are too well known to require description, and the disease is, as a rule, rather irritating and distressing than involving any danger. The process of regulating the temperature of the body depends, however, almost entirely on the action of the skin, and where prickly heat is so extensive and severe as to partially incapacitate it from its functions, it is obvious this usually trifling disease may be a predisposing cause of more serious maladies. Then, again, the loss of sleep and nervous irritation kept up by the constant itching, pricking, and soreness, are powerful helps in pulling down the already severely tried powers of resistance to the climate, and often have a great deal to say in determining an ultimate breakdown.

There is a common popular notion that prickly heat is “healthy,” people saying that “it is a sign of health,” and that it is a mistake to check it. This, however, except in so far that healthy, full-blooded persons usually suffer worse than those in an anæmic condition because they usually perspire more freely, is an entire fallacy; as though good health may predispose to prickly heat, it cannot but have an influence in rapidly reducing that factor in its causation. Then, too, the numerous small abrasions that result from the bursting of the minute vesicles, and from scratching, are extremely liable to become infected with the germs of suppuration, and give origin to crops of boils.

Boils are extremely common, and are most painful and debilitating when present in large numbers, as they often are in hot climates, and I believe they should be really regarded merely as _sequelæ_ of neglected prickly heat and not as a distinct condition. For these reasons the writer is strongly of opinion that prickly heat should always be treated, especially as it is usually quite possible to keep it within moderate bounds, by the use of appropriate remedies. At sea the use of salt water for bathing should be avoided, but frequent bathing in fresh, and especially in rain water, is not only a great alleviation, but tends towards cure by removing the irritating accumulation of saline matter that results from the constant evaporation of the perspiration. Almost any metallic astringent, such as sulphate of copper or sulphate of zinc, 4 grains to the ounce, will be found to be extremely useful in reducing the extent of the irritation, but none of these are nearly as effectual as a lotion of perchloride of mercury of a strength of one per thousand.

This agent can be obtained ready measured out into tabloids, which are always coloured blue to prevent mistakes in handling the solution; which is a most useful one, not only for this purpose, but as a general antiseptic. Care should, of course, be taken in the custody of these tabloids, and also in the handling of the solution; but the latter is not really more poisonous than the copper solution, or than many other antiseptics which, like carbolic acid, are nowadays in constant domestic use. This mercurial solution is undoubtedly by far the best remedy we have for prickly heat, and I have never seen any harm or signs of absorption of the mercury result, even from its copious use. The tabloids should be got of such a size as to make about a quarter of a pint of the solution, and after the bath and before retiring to bed, all affected parts of the skin should be dabbed with a bit of lint dipped in the solution, which should be allowed to dry on to a certain extent before putting on one’s clothes. A further great advantage over the other metallic astringents is that, owing to the weakness of the solution, it does not injure the clothes, and the slight blue aniline colouration easily washes out. It will be found, too, an almost complete preventive against boils, if resorted to from the commencement of the hot season. Powdering with violet powder is also useful in subduing the irritation, which by the adoption of the above-described plan, may almost always be kept within moderate bounds.

“Dhobi’s itch” is a troublesome irritation of the skin often met with in hot climates, which is due to the growth of a minute fungus within the structure of the scarf-skin. It commonly attacks those parts of the body where the surfaces of the skin come in contact with each other, as, for example, between the legs, and in the armpits. The general appearance is very much that of a “ringworm,” the patches spreading by their edges, where they are red and irritable and tending to fade in the middle. There can be little doubt that the disease is generally caught by the infection of clothing that has been washed in dirty pools along with that of previous sufferers from the disease, which is very common among the native races. If neglected, it is apt to spread so as to cover a large area, under which circumstances it is apt to be troublesome, but if taken early, there is generally no difficulty in dealing with it. All that is necessary is to destroy the fungus by means of strong antiseptics, but in doing so it must be remembered that any solution strong enough to kill the fungus must necessarily also cause more or less inflammation and, for the time, increased irritation of the skin.

On this account, if any considerable area be involved, it is a mistake to attempt to treat the whole of it at once, as such a course may easily result in producing an amount of soreness and inflammation which may involve confinement to bed. The patches should be attacked piecemeal, a couple of separate patches the size of a shilling being quite as much as is prudent to attack on any one occasion.

Equal parts of tincture of iodine, carbolic acid and glycerine painted over each patch, to the extent above described, is a safe and efficient remedy, as also is Goa powder; but the essential point is to be on the look-out for the contingency, and to at once treat any patch that may appear before it has time to spread.

The disease is, I believe, common enough in other warm climates, but I am not acquainted with its popular designation elsewhere than in India, where it is known by the above name.

ON THE PREVENTION OF DISEASES CAUSED BY INTERNAL WORMS.

_Internal worms_ are extremely common in most hot countries, and especially in those climates where moisture and heat are combined. Where they prevail to a serious extent, they often constitute one of the principal causes of mortality amongst natives, but white residents rarely suffer, as the habits of the better-class European to a very great extent protect him from being invaded by these pests.

There are three principal sorts of these parasites: the round-worms, which usually divide their time between some animal and the outer world, and the flat-worms and the flukes, both of which must pass through two or more animal hosts. The life-history of these troublesome guests, especially those belonging to the two latter classes, include some of the most wonderful and interesting pages of natural history, but unfortunately considerations of space prevent our describing these changes except by the barest allusions.

The commonest round-worms that establish themselves in mankind are the common thread-worms and round-worms (_Lumbrici_), and that much more formidable pest of tropical life, the _Ankylostoma_, or hook-worm.

Thread-worms and Lumbrici are common enough everywhere, but are far more commonly troublesome in hot climates than at home in Europe. The eggs of both are probably usually carried into the human intestine on food or in drinking water, and in the case of the Lumbricus this is the only way in which the numbers of the parasite can be maintained, as its eggs take a long time to hatch out; but those of the thread-worm, when deposited, are quite ready to burst at once, and though no individual worm as a rule resides within the intestine for any great length of time, the patient infested with them is continually reinfecting himself, so that their numbers have a tendency to increase. Thread-worms are especially common in children, on account of the strong tendency of the little folks to put their fingers in the mouth.

Thread-worms live in the lowest part of the bowel, and so cause much itching and tickling about its orifice. This prompts the child to scratch itself, with the result that some of the innumerable eggs laid by the worms adhere to the fingers, and once there soon find their way, along with the fingers, into its mouth. The intruders are usually easily expelled by an injection of salt and water, but it is difficult to get rid of all of them, and the child is nearly sure to reinfect itself unless it is made to sleep in drawers. Provided reinfection is prevented in this way, however, the remaining worms will soon be got rid of, as this species as a rule does not take up a prolonged residence.

Round-worms can be expelled by the means of a dose of santonin, but as neither these parasites nor tape-worms usually cause immediate serious symptoms, and both this drug and most other vermifuges require a certain amount of care and caution in their administration, it is better to wait any moderate time until the treatment can be supervised by a medical man.

The third common round-worm parasite--the hook-worm namely--though but little known in Europe, is so widely distributed in hot, moist countries, that in such climates the greater proportion of the indigenous races are often affected to a greater or less extent. It is quite a small worm, but fastens on the lining of the bowel in exactly the same way as leeches attack the outer integuments, and exhibits the same insatiable appetite for blood. The extent of the mischief wrought by them depends entirely on the number harboured. When only a few are present, they may be considered practically harmless, and thousands of such cases are to be met with in any country where they are common; but wherever this is so, numbers of subjects will be met with, in whom they are so numerous as to cause serious symptoms and death; so that there are many places where they constitute one of the most serious scourges of the Tropics. The eggs of this parasite, deposited along with the dejecta of persons infested with them, hatch out in the soil, and multiply there enormously, so that owing to the insanitary habits of the populace, the soil round about a native village comes to swarm with this free stage of the parasite. Now as the population is generally a purely agricultural one, and none too nice in its habits, it can be easily understood that persons, eating as they do with unwashed hands, must constantly carry to their mouths some of the earth containing the minute embryos which convey the disease, and hence the process of infection is commonly continuous and progressive. As a matter of fact, out of some hundreds of specimens of drinking water examined by the writer in Assam, where the disease is extremely rife, in no one case was there anything found to show that the malady was commonly conveyed in water, but the contingency is clearly a possible one; and in any case, it is clear that very moderate care as to food, water, and personal cleanliness would suffice to render infection impossible. From what has been said, it is easy to understand that the disease is practically unknown among European residents whose habits have reached the most moderate degree of refinement; but though it may not affect the planter’s health, it reacts most seriously on his pocket, owing to the disastrous amount of sickness and mortality it gives rise to among his native labourers. Now it is perfectly obvious that this disease can be easily prevented by the most ordinary measures of conservancy, and the question whether the evil can be obviated or not, is purely one of whether the master has the will and power to insist on the use of proper latrines. This, however, is by no means so simple a matter as it looks, where one has to deal with labourers belonging to a primitive stage of civilisation. Once seen, the disease is easily recognised by the deadly pallor of the lining membrane of the eyelids, and of the tongue, especially the latter, which looks much like a piece of a wet, pipe-clayed buff belt. By treatment with vermifuges and careful nursing there would be little difficulty in curing people of European habits; but only those who have had to attempt it know how impossible it is to get semi-civilised people to adopt, or even submit to, what to us are the most ordinary sick-room comforts, and as a matter of fact, there is very little hope for a native who is at all seriously affected with these parasites.

The best vermifuge we have is thymol; three doses of 30 grains each, given within six hours, followed up by a dose of castor oil. A certain amount of caution is required in giving this to cases in a very weak state, but after all it is the only chance for them. This medication may have to be repeated once or twice, at intervals of a week, and should be systematically carried out in all cases that have not gone too far. The worst of it is, that unless proper sanitary measures can be carried out, treatment is little better than a waste of drugs, as otherwise the patients will be sure to reinfect themselves within a few weeks, however thoroughly the vermifuge may have done its work.

The Guinea-worm is a curious parasite, which is found burrowing under the skin, and finds an exit through the opening formed by a sort of boil. It very rarely attacks Europeans, as it may be avoided by the most ordinary care in the matter of water used for drinking and bathing.

Another curious malady caused by one of the round-worms is the blood-worm disease, or filariasis. In this the parent worm is found embedded in the tissues of the host, and periodically discharges into the blood enormous numbers of its embryonic offspring. As this disease is undoubtedly communicable through the agency of mosquitoes alone, its prevention may obviously be secured by the adoption of the same measures that serve to protect us from malaria.

Tape-worms have a very curious life-history. The long, flat, jointed strip is really a chain of sexually mature individuals, but when their eggs are swallowed by an animal there is hatched out from it, not another tape-worm, but a minute embryo, which has the power of boring through the tissues of its host till it reaches some favourable resting-place, where it settles down, protected by a capsule, forming what is known as a bladder-worm. It may live for years in this condition, but cannot reach maturity until the capsule has been swallowed by some carnivorous animal, though some species can multiply non-sexually and so cause terrible damage to the animal that harbours it. Both stages of several species of these parasites infest man, but fortunately their prevention is a very simple matter, at any rate as far as the adult strings of worms are concerned, as infection is impossible provided all meat and fish eaten be thoroughly cooked. The mature stage of the bladder-worm which is found infesting man inhabits the intestine of the dog, and as it is capable, in this stage, of non-sexual multiplication, may give rise to large tumours, the effects of which may be most serious if a vital organ be invaded. Though almost a medical curiosity in Europe, it constitutes a really serious danger in certain pastoral colonies, such as Australia, where large numbers of dogs have to be kept for herding sheep, and are allowed unrestricted access to the offal of carcases, which is, of course, very abundant where meat-preserving is an important industry. The disease might be guarded against by preventing the dogs having access to anything but thoroughly cooked meat, and by avoiding undue fondling and too close association with these animals.

The third important class of parasites, the flukes, but rarely infest man, but in Egypt and, in fact, throughout Africa, a peculiar fluke, the _Bilharzia_, is found infesting the blood-vessels, especially those of the kidney, and gives rise to the appearance of blood in the urine. It is extremely common amongst the natives of Egypt, but it very rarely attacks Europeans, and though we are quite in the dark as to its life-history outside the human subject, there is little doubt that moderate care as to the water used for drinking and bathing is sufficient to afford complete protection against the disease.