Handbook of Health for Overseas Service [2nd ed., rev. 3rd printing 1944. Reprint 2014] 9780674422698

Citation preview

HANDBOOK OF HEALTH

HANDBOOK OF HEALTH FOR OVERSEAS SERVICE BY GEORGE CHEEVER SHATTUCK, M . D . AND WILLIAM JASON MIXTER,

M.D.

SECOND EDITION, REVISED

HARVARD

UNIVERSITY

CAMBRIDGE,

PRESS

MASSACHUSETTS 1944

COPYRIGHT 1942, 1943 B Y GEORGE C H E E V E E 8HATTUCK

Third Printing

PRINTED AT THE HARVARD U N I V E R S I T Y PRINTING OFFICE CAMBRIDGE, MASS., U.S.A.

PREFACE This second edition of the Handbook of Health for Overseas Service has been extensively revised and, in part, rewritten. Some valuable new material has been added, but the weight of the volume has not been increased because the paper is slightly thinner. As in the first edition, the chapter on First Aid has been abridged from the Handbook of First Aid issued by the United States Office of Civilian Defense, Washington, 1941, which was originally prepared by the American National Red Cross. Permission to use the material was kindly granted by the United States Office of Civilian Defense. The Handbook is intended for use by persons who are engaged in more or less dangerous work overseas and who, from time to time, may be unable to obtain medical advice or assistance. Because of the need for brevity, descriptions of disease are schematic, and some locally important diseases have not been mentioned. No statement has been made herein regarding the importance of restricting the use of certain drugs by flight personnel. The omission was intentional because the authors believe that every responsible Flight Surgeon will, in any case, issue orders regarding these matters.

vi

PREFACE

The methods of treatment that can be recommended for use by the layman are restricted by his lack of medical skill and limited diagnostic ability, as well as by the necessity for avoiding undue risk of doing harm. The use of powerful drugs, without medical supervision, is only justifiable when medical advice cannot be obtained. In order to prevent the possibility of harm resulting from use of the Handbook in the United States where medical aid is available, sales will be restricted, ordinarily, to persons or groups who are going overseas. The first edition was financed by the Office of the Coordinator of Information, Washington, D. C. (now the Office of Strategic Services), and was distributed gratis. Inasmuch as that Office does not wish to finance a second edition, and because the demand for the book continues, arrangements have been made with the Harvard University Press to publish the second edition. The Harvard Travellers Club kindly gave permission to use material contained in the second edition of its Handbook of Travel. The chapter on the Arctic and the section on Poisonous Snakes and Snake-Bite have been adapted from the Handbook of Travel. The impetus given by Mr. Harold J. Coolidge, Jr. to publication of the first edition of the Handbook of Health for Overseas Service is acknowledged with thanks. In accordance with his suggestion, water-resistant ink and paper have been used in both editions.

vii The suggestions of officials of the Pan American Airways and of Transcontinental & Western Air, Inc., as well as those of a number of other persons, have been most helpful. Personal thanks and acknowledgments are offered to Dr. Elmer D. Merrill of the Arnold Arboretum, for advice about poisonous plants; to Dr. Joseph C. Bequaert of Harvard, for information about protection from biting insects; to Dr. George Gilbert Smith and to Dr. Francis M. Thurmon of Boston, who provided information respectively about treatment of gonorrhea and of soft chancre; and to Dr. Frederick J. Stare of Harvard, for information on vitamin therapy, and to Dr. Champ Lyons concerning the use of sulfonamide compounds. The authors are grateful to Miss Alice B. Newell for help with the manuscript and attention to the proof. PREFACE

G. C. S.

CONTENTS I. II.

KEEPING FIT

3

COMMON A I L M E N T S OF W O R L D - W I D E O C C U R RENCE

21

I I I . T H E T R O P I C S . H Y G I E N E AND E Q U I P M E N T IV.

DISEASES

IMPORTANT

IN

THE

.

TROPICS

. OR

COMMON IN L I M I T E D R E G I O N S V. VI. VII. VIII. IX.

47

63

B I T I N G I N S E C T S , V E R M I N , AND S N A K E S . . .

98

T H E ARCTIC

112

SURGERY

121

FIRST AID

163

M I S C E L L A N E O U S M E D I C A L INFORMATION

.

.

197

A P P E N D I X : P A C K I N G M E D I C A L AND SURGICAL EQUIPMENT

217

T A B L E S OF W E I G H T S AND M E A S U R E S . . . .

218

INDEX

221

HANDBOOK OF HEALTH

CHAPTER I KEEPING FIT PKELIMINARY REQUIBEMENTS

Persons going to a foreign country where they may be out of reach of medical advice should take the following important steps in advance. 1. Obtain information about: a. Climate b. Living conditions c. Prevalent diseases 2. Have the teeth put into the best possible condition. Fillings which might become loose should be replaced. 3. Have the eyes examined and, if they are needed, take two pair of well-fitted glasses. 4. Have the feet examined: (a) for fungus infection ("athlete's foot") (b) flat-foot (c) ingrowing toenail If any of these conditions are present, get full instructions from your physician about dealing with them. 5. Get into good physical condition and keep so by

4

HANDBOOK OF HEALTH

taking plenty of sleep and sufficient but not excessive exercise. 6. Take the following essential vaccinations: a. Smallpox b. Typhoid and paratyphoid. Take a series of three injections of a standard mixed vaccine. If you have had such within one year, a single injection may suffice to maintain immunity. c. Tetanus (lockjaw) 7. If going to the African or South American tropics, yellow fever vaccination is important. 8. Other vaccinations to be considered: a. Typhus fever b. Cholera c. Plague It is desirable that a series of vaccinations of several different kinds should be spaced over a period of from one to two months, depending upon the number required. Therefore, get medical advice early. It must be borne in mind that vaccinations usually provide only partial protection. They reduce enormously the risk of infection and the chance of serious consequences should infection occur. 9. Provide yourself with all needed equipment before leaving and take it with you. Time is often required to select and to obtain suitable equipment and clothing. Therefore attend to them promptly. Detailed information about equipment for the tropics and for the arctic is offered in ensuing chapters.

KEEPING FIT

5

C A R E OF D I G E S T I O N

Digestion is favored by: 1. Simple food 2. Eating slowly and chewing well 3. Regularity of meals 4. Rest after meals 5. Good cooking 6. Regular and normal action of bowels 7. Sufficient exercise Digestion is handicapped by: 1. Neglect of the foregoing precautions 2. Overeating, particularly of "rich" food 3. Bad teeth 4. Excessive use of strong alcoholic beverages 5. Pronounced fatigue, physical or mental Individuals discover idiosyncrasies of digestion which should not be disregarded without good reason. NUTRITION

Digestibility. Speaking broadly, heavy bread or cake, highly seasoned foods, rich sauces, pastry, and fried things, particularly when greasy, unripe fruit, tough meat, insufficiently cooked fibrous vegetables, salted meat, ham or bacon in large quantities, and baked beans are difficult to digest. "Wholesome food may be rendered indigestible by bad cooking. If too tough to be chewed properly, meat should be

6

HANDBOOK OF HEALTH

hashed or put through a meat grinder. Meat is more wholesome roasted than fried. Quantity. The quantity of food required varies in individuals. Hard work, mental or physical, in any climate requires plenty of food. To eat too lightly or at too long intervals is to risk exhaustion. Young persons require more food than older persons, and prolonged exposure to cold demands abundance of food, especially fats and sweets. Inactivity, particularly in a warm climate, calls for reduction of food and especially of greasy dishes and sweets. Meals. When a long hard day is ahead, eat a substantial breakfast and, if possible, eat something every three or four hours to prevent fatigue. Eat enough during the day so that a heavy meal will not be needed at night, because fatigue hinders digestion and a full stomach under these conditions may disturb sleep. Prolonged exertion on an empty stomach tends to cause exhaustion, but a meal or two can be skipped from time to time without harm. Cooking. Considerable losses in certain nutrients, especially the water-soluble vitamins (B-complex and C), and to some extent vitamin A and minerals, will take place in cooking unless precautions are taken. These losses result from the combined action of heat and oxidation and the fact that those nutrients that are soluble in water will be lost if the cooking water is discarded. In general, it is best to use the minimum amount of heat and water consistent with rendering

KEEPING FIT

7

the food edible and free from pathogenic contaminants. Stir no more than necessary because stirring mixes in air and thus increases oxidation. DIET

A nutritious diet contains adequate amounts of protein, carbohydrate, fat, minerals, vitamins, and water. Proteins. Meat, fish, milk, cheese, eggs, nuts, and legumes (peas, beans and peanuts) are the best sources of protein. Animal protein including milk and eggs is of higher biologic value than vegetable protein; but the vegetable protein can well furnish half of the protein of the diet. A diet high in protein is wholesome. I t is well to include in the daily diet of the normal adult at least a pint of milk, one egg, and a serving of meat, and to eat liver, heart, or kidney frequently. These organs are rich in vitamins. Carbohydrates are the chief constituents of foods such as bread, potatoes, rice, macaroni, cassava, tapioca, taro, and sago. The various sugars, including honey, are practically pure carbohydrates. Fats are important for furnishing energy and as carriers of the fat-soluble vitamins. The fats are represented by various animal and vegetable oils. Butter is a highly nutritious fat and is a good source of vitamin A. Oleomargarine made from animal or vegetable oils is as nutritious as butter for adults and probably for children if adequately fortified with

8

HANDBOOK OF HEALTH

vitamin A. A vitamin A content of 9000 International (U.S.P.) Units per pound is amply sufficient. Red palm oil, eaten on rice in the Congo, contains much vitamin A. Mineral oils have no nutritional value and, in excessive amounts, interfere with the assimilation of fat-soluble nutrients, particularly vitamin A. Minerals. Small amounts of common salt, of calcium, and of iron are required for adequate nutrition. Calcium and iron are present in the leafy vegetables, and milk contains much calcium. When one is sweating much, an increased amount of salt should be taken (p. 93). Vitamins. These are definite chemical substances which occur in natural foods and which in small amounts are necessary for life. They are divided according to their solubility into fat-soluble and watersoluble vitamins. The fat-soluble vitamins are vitamins A, D, Ε and K. Of these, vitamin A is the most important from the practical point of view in the nutrition of adults. The best sources of vitamin A are butter, cream, whole milk, egg yolk, liver, kidney; and of its precursor carotene, the dark green leafy and the yellow vegetables. Certain fish liver oils are rich sources of vitamins A and D. The water-soluble vitamins are ascorbic acid (vitamin C) and those of the B-complex (thiamine, riboflavin, niacin, choline, pyridoxine, pantothenic acid, biotin, and others less well defined). The best sources

KEEPING FIT

9

of ascorbic acid are citrus fruits, particularly lemons, oranges, grapefruit, and tangerines. Tomatoes, berries, raw cabbage, other raw greens, and potatoes cooked in the skin contribute appreciable amounts of vitamin C. This vitamin is easily destroyed by oxidation and heat, particularly in an alkaline environment. From the nutritional viewpoint it is best to consume foods rich in vitamin C shortly after the food is prepared, preferably raw, and if cooked, to use a minimum of heat in their preparation. The vitamins of the B-complex are found principally in meats, milk, cheese, nuts, legumes, and the cereal grains. Highly refined foods such as white flour contain considerably less of these vitamins than the less refined dark flours. The ideal daily diet should contain milk, eggs, meat, butter, whole grain bread and cereals, dark green leafy and yellow vegetables, potatoes, citrus and other fruits. When one is taking an adequate diet, it is useless and wasteful to take pharmaceutical vitamin preparations in addition. Preserved Foods. Recent advances in the preservation of tinned foods have resulted in the conservation of much of their vitamin content. As a rule, canned foods retain approximately as much vitamin A as do corresponding fresh foods. Canned tomatoes are rich in vitamin C. Progress is also being made in the preservation of vitamins in dried foods of various

10

HANDBOOK OF HEALTH

kinds. It is said that the vitamin C content of dried apples, peaches and prunes is considerable. BEVERAGES

Cocoa, particularly when made with milk, fresh or powdered, is a nutritious drink which is very refreshing when one is fatigued. Tea and coffee have no food value aside from the sugar or cream that may be added to them. Fruit juice beverages when fresh are rich in vitamin C. Unless prepared in a cleanly manner, fruit juices and ices made from them may be a source of intestinal infection (pp. 11 and 71). The milk of a freshly opened green cocoanut sucked out of the nut is refreshing and safe to drink. Alcoholic Drinks. Cold beer may disturb the digestion, particularly in hot weather. Strong liquor may interfere with digestion unless taken slowly, well diluted, and with meals. Liquor should be taken, if at all, in great moderation and after the day's work is done. The addition of whisky to contaminated water does not render it safe. In many parts of the tropics, alcoholism is a curse alike to native and to foreigner. PRECAUTIONS FOR M I L K AND M I L K PRODUCTS

Fresh milk is highly nutritious, containing as it does a wholesome combination of protein, carbohy-

KEEPING FIT

11

drate and fat and also important minerals and variable amounts of vitamins, especially A, and some of the B-complex. The content of vitamin C is usually low, especially in milk which has been boiled. Where sanitation is or might be defective, the only safe rule is to boil or at least to pasteurize all milk, to pasteurize cream, and to avoid ice-cream unless it has been made from pasteurized milk. Powdered milk prepared with boiled water is an excellent and safe substitute for fresh milk. Fresh butter is suspect, but salted butter, particularly after being stored for a few months, is reasonably safe. Cheeses a few months old are probably safe, but fresh cream cheese is of doubtful safety. PRECAUTIONS FOR VARIOUS KINDS OF FOOD

Intestinal Diseases. The diseases which may be contracted from contaminated water can also be acquired from food. Direct contamination of food may occur through the use of human excreta as fertilizer, from contact with infected water, by uncleanly handling, or indirectly through the agency of flies which have had access to human excrement. Because some healthy persons carry dangerous disease germs in their bowels, cooks and food-handlers should be scrupulously cleanly in their habits. When in doubt as to the safety of food, eat nothing

12

HANDBOOK OF HEALTH

which has not been freshly cooked except thickskinned fruits which you peel yourself. Thin-skinned fruits, such as tomatoes, can be rendered safe by dipping them into boiling water. They then peel easily. Salads made from raw vegetables are always to be avoided except in well-sanitated areas. Lettuce may be eaten after cooking, but washing it in permanganate of potash or other chemicals does not render it safe. Perishable leftovers should be discarded in warm weather unless refrigeration is available. Canned food need not be removed from the tin after opening. It may be put back if it can be prevented from becoming rancid. Eating utensils must be clean, because they may become infected like water or food. Ice should not be permitted to come in contact with food, unless made from safe water. Worms Acquired from Food. The eggs of the common round-worm (Ascaris) may be ingested along with raw vegetables. The eggs develop and the worms mature in the intestine. Tapeworms (Taenia) may be acquired by eating raw or inadequately cooked beef, pork, or fish. Treatment for these worms is not urgent. Trichinosis {Trichina), a common disease of swine, is frequently contracted by persons who eat underdone pork or raw pork products in the form of sausage. Underdone pork is pink. Rarely, bear meet is infected. Preserved foods occasionally are infected with dan-

KEEPING FIT

13

gerous organisms. This is more often true of vegetables preserved at home than of the commercial products. Preserved food of any kind which has become altered in appearance or smell should be discarded. Deterioration of canned food may be shown by the formation of gas. The sealed can then gives out a hollow sound when tapped on the top, and the ends of the can may show bulging. PRECAUTIONS FOR D R I N K I N G - W A T E R

Where sanitation is inadequate, drinking-water is liable to contamination with human excreta and thus to become a possible cause of typhoid fever, dysentery, or even cholera, in places where cholera exists (pp. 71 and 75). Schistosomiasis (p. 86) and guineaworm disease may be acquired from water in certain parts of the tropics (p. 88). Contamination of water with the excrement of animals is not ordinarily a source of danger to man. Drinking-water should be considered dangerous unless from a public supply which is known to be good. Wells are often so placed as easily to become contaminated. Sewage is frequently discharged into streams or rivers. Boiled Water. When there is doubt as to the purity of water, it can be rendered safe for drinking by being boiled for three minutes. Subsequent contamination must be prevented. A day's supply for several persons can be boiled

14

HANDBOOK OF HEALTH

and kept in a large kettle or in a pot having a cover. When the cover of the pot is removed, the inside of it should not be allowed to touch anything. Nothing should be dipped into the drinking water, except that a dipper with a hooked handle may be used if boiled with the water and left hanging inside the pot when not in use. Boiled water can be easily and safely handled in canteens. Few servants can be trusted to boil and to safeguard drinking water. Bottled water of a reliable brand is satisfactory, but it is a common practice in small places to refill bottles from the local water supply. To prevent substitution, insist that the seal be broken and the bottle opened in your presence. These precautions are as necessary for charged water or for "soft drinks" as for still water. Unsafe water should not be used for rinsing the mouth or brushing the teeth. Ice made from water of doubtful purity should not be put into any drink. Chlorination of Water. When it is impracticable to boil your drinking water, chlorination is the next best method of treating it. As used for municipal water supplies, the concentration of chlorine may be inadequate to eliminate the ameba of dysentery. Superchlorination, within the limits of practicable use of the water, usually is adequate to destroy amebic cysts. Small quantities of drinking water in canteens or in clean carafes or bottles can be chlorinated by means

KEEPING FIT

15

of halazone tablets. These tablets, intended for individual use, should contain about 0.004 Gm. grain) of halazone each. Such a tablet is supposed to be enough to treat one liter or one quart of water. In the field, however, where available water is apt to contain organic matter, larger quantities of halazone are usually required. The following procedure is advised: 1. Do not fill the canteen completely. 2. Drop into it two tablets of halazone and insert the stopper. 3. Shake the canteen to hasten solution of the tablets. 4. After a full half hour has elapsed, shake the canteen again. Remove the stopper and see whether chlorine can be detected easily by smell. 5. If not, put in one or two more tablets of halazone and repeat the procedure. A pronounced taste of chlorine is not seriously objected to by those who are accustomed to it, nor does the chlorine appear to exert any harmful effect. If, after dissolving 6 tablets of halazone in the canteen, free chlorine cannot be readily detected, it is probable that a quantity of organic matter in the water has used up the chlorine. The only safe procedure then is to boil the water. Halazone tablets are sometimes too hard to dissolve readily. They should then be placed within a folded bit of paper and crushed immediately before

16

HANDBOOK OF HEALTH

use. To prevent deterioration, halazone should be carried in bottles containing not more than a hundred tablets each; they should be protected from moisture and from prolonged exposure to light. When thus protected, halazone retains most of its effectiveness even after a year in the moist tropics. Two or three drops of tincture of iodine added to a canteen of water and allowed to act for 30 minutes may serve, but this method is regarded as less reliable than chlorination and the iodine might irritate the stomach if used frequently. Permanganate of potash is no longer recommended for sterilizing drinking water or for washing foods (page 12). PERSONAL HYGIENE IN CAMP

Regular exercise tunes up all bodily functions, improves the action of the bowels, and clears the head. Too much exercise causes exhaustion, and may provoke indigestion or sleeplessness. The bowels should act normally at least once a day. Cleanliness is frequently neglected by the inexperienced. In hot weather a bath should be taken after the work of the day. After the bath, clothing which touches the skin should be changed. Underclothing and socks should be washed at frequent intervals. In the tropics, this precaution is essential to prevent infections of the skin. The Feet. Heavy woolen socks are usually to be

KEEPING FIT

17

preferred because they wrinkle less than thin ones and give more protection against chafing. Still better protection is afforded by drawing the woolen socks on over a pair of smoothly fitting cotton socks. Boots or shoes should be adapted to requirements. When tight or ill-fitting, they cause blisters. Canvas leggings which fit closely over the shoe weigh little and will often suffice when, otherwise, a high boot would be required. When one is doing much walking and, above all, in hot weather, the feet should be washed thoroughly after the day's work and wiped dry, particularly between the toes. Socks and shoes should then be changed. Talcum powder or foot powder issued by the Army may be used freely upon the feet, between the toes, and in the shoes. It helps to prevent chafes and blisters. Another method is to rub soap freely on the outside of the socks. For treatment of chafes and blisters, see page 158. Eyes. Eyestrain may be caused by reading in a poor light. When reading, the light should fall upon the page from over the shoulder. Other causes of eyestrain, sore eyes, or headache are glare from water, snow, ice, light-colored roads, or desert sand. A pair of smoked or colored goggles of superior grade may be indispensable. Some of the newer kinds are said to be excellent. Polaroid glasses have been widely used, but occasionally they cause headache. For motoring on dusty roads, goggles are very useful to

18

HANDBOOK OF HEALTH

protect the eyes. They are indispensable in the arctic and may be so in the tropics. Clothing* When tenting in cool or cold weather, one needs woolen outer clothing, and many prefer woolen underclothing as well. Wool is more absorbent than cotton and feels warm even when damp, whereas cotton becomes clammy. Those whose skin is irritated by wool should wear thin cotton under it. Bedding.* Because evaporation from the skin is constant, bedding can be kept dry only by adequate ventilation and by sleeping cool enough to avoid sweating. Whenever possible, bedding should be aired and dried. A waterproof sleeping bag has the disadvantage that it becomes soggy and causes chilling. When night clothes are not carried, a dry suit of underclothing should be put on at night. Exposure. Wet clothing does no harm provided chilling is avoided by exercise. Chilling may cause diarrhea, muscular stiffness, or respiratory infection. When one is carrying a load, even in cold weather, it is difficult to avoid profuse sweating. This can sometimes be prevented by removing cap and gloves and unbuttoning the shirt. When this procedure is quickly reversed after stopping, the effect is nearly as great as that of putting on an overcoat. Arctic travel presents special problems of this kind. Alcoholic beverages should be avoided during exposure to cold because they accelerate loss of body * See also Chapters III and IV.

KEEPING FIT

19

heat by increasing surface circulation, and thus they may predispose to pneumonia. They may aid recovery if used after shelter has been reached. H Y G I E N E FOR THE CAMP

Camp hygiene is of great importance for large parties making prolonged stops, especially in warm weather. Drinking Water. (See also pp. 13 and 60.) Habitations along a stream render its water unsafe for drinking. The water of large rivers in very sparsely settled countries may be safe, if taken above the camp and from midstream. Wash and bathe below the point from which drinking water is to be taken. Protection of Food. The cook should wash his hands carefully after attending to the calls of nature because he may be a carrier of dysentery or typhoid germs. All food to be eaten raw and all cooked food should be scrupulously protected from flies, because they may infect it from the excreta of man. In order to keep flies at a minimum, nothing should be exposed that will attract them. Garbage should be burned or buried, and excreta should be passed into a pit and covered immediately with earth. Horse manure is very attractive to flies, and they breed freely in it. Latrines should be dug at least a hundred yards away from the kitchen and at a level lower than that

20

HANDBOOK OF HEALTH

of the water supply. Promiscuous defecation near the camp must be prevented. An open latrine should be provided with a horizontal bar to sit on. This reduces straining — a frequent contributory cause of piles. There should also be a shovel with which to bury the excreta. Incinerators. A useful incinerator for a small and temporary camp can be made by filling a good-sized hole with stones and building the cooking fire upon it. Garbage can be burned and the slops poured under the stones. The special precautions required against certain diseases, and particularly against infectious diseases found chiefly in the tropics, are indicated in the sections dealing with these diseases in Chapter IV.

CHAPTER II COMMON AILMENTS OF WORLD-WIDE OCCURRENCE GENERAL INFORMATION

Diagnosis of Ailments. When one is in doubt about the nature of an ailment, it may still be possible to assign the malady to a group of conditions for which the treatment is similar, and, failing this, one can still treat the distressing symptoms. Many ailments get well with time if not made worse by neglect or by unwise treatment. Therefore strive to do no harm. Classification of Maladies. The maladies which follow are classified, some by the name of a prominent symptom and others by disease names. Of the less serious conditions, the commonest are described; of the more serious, those which are not uncommon and those for which something useful might be done. D I E T S FOR ILLNESS

A liquid diet is generally used when the digestion is disturbed or when there is much fever. Small quantities should be given at intervals of from two to four hours.

22

HANDBOOK OF HEALTH

Milk, or powdered milk, prepared in the usual way will serve. Hot, clear soup, fruit juice, or weak tea may also be taken. Should nausea or vomiting result, the milk should be diluted with equal parts of water or, better, with charged water, and the quantity taken should be reduced, or rice-water or clear soup should be substituted for the milk. When all goes well, the nutritive value of the diet can soon be increased by adding broth from which the grease has been skimmed, and later by adding rice or flour to the broth, or by allowing gruel and white of egg. Soft solids include cereals, rice, eggs cooked soft, custard, junket, and toast or crackers softened with milk. Toast or crackers may be taken dry if preferred. A simple diet includes most of the ordinary foods plainly prepared. Greasy foods (except butter), hot bread, pastry, puddings, cheese, and the coarser vegetables, such as cabbage, beets, turnips, and beans, should be excluded. CONSTIPATION

Causes. Careless irregularity about evacuating the bowels, unsuitable diet, insufficient drinking of liquids, lack of exercise. Treatment. 1. The habit of regularity and avoidance of haste at stool do much to keep the bowels in order.

COMMON AILMENTS

23

2. Fruits, fresh or stewed, leafy or fiber-containing vegetables, oatmeal, cracked wheat, or bran-containing bread are beneficial. Free drinking of water, especially before breakfast, and a total of six to eight glasses per day is helpful. 3. When constipation persists, a mild cathartic (p. 206) pill should be taken. Continued use of cathartics, however, tends to increase constipation. 4. For an occasional clearing of the bowels after persistent constipation, a purgative may be required (p. 206).

INDIGESTION OR " B I L I O U S N E S S "

Causes. Incomplete digestion of food due to indigestible food, insufficient chewing, overeating or overdrinking, or lack of exercise. Symptoms. There may be vomiting, griping, diarrhea, constipation, belching, flatulence, headache, "acid stomach," lassitude, irritability, or any combination of these. The odor of the stools is often foul, but there is no blood and little if any mucus in them. Caution. There is some danger of mistaking acute appendicitis (p. 154) or some other acute inflammation in the abdomen for indigestion. Treatment. Indigestion does not often require rest in bed, but rest and liquid or soft-solid diet (p. 21) or temporary abstinence from food is desirable. When there is nausea or a burning sensation in the throat or in the "pit of the stomach," stir up a tea-

24

HANDBOOK OF HEALTH

spoonful of sodium bicarbonate in a glass of water and sip it. If not soon relieved, wash the stomach by drinking copiously of warm water and induce vomiting by putting the finger down the throat. This method is also useful to check recurring vomiting. When there is griping (colic) or much flatulence, it is necessary to evacuate the bowels. Immediate results can be obtained by an enema. (See also Colic.) In mild cases when immediate results are not required, a purgative may be used. After the intestine has been thoroughly cleaned out, the stools no longer have an abnormally foul odor, and flatulence and discomfort cease. Meanwhile, abstinence from food is advisable, but liquids may be allowed. DIARRHEA

Diagnosis. Simple diarrhea without fever is usually caused by decomposition in the bowel of partly digested food. The color of the stools at first is unusually dark and the odor is abnormally foul. There may be colic or other symptoms of indigestion. After the bowels have moved freely several times, the color of the dejecta is lighter and the odor is less. When diarrhea is caused by chilling, there is no abnormal odor. Treatment. Drink little, eat little, preferably liquids and soft solids, keep thoroughly warm and avoid exertion while the diarrhea lasts. After the bowels

COMMON AILMENTS

25

have cleared themselves by moving copiously, take a teaspoonful of bismuth, preferably the subcarbonate, mixed with a little water, three or four times daily, half an hour before eating. As alternatives, take one "C.O.T. pill" (p. 207) every eight hours until the diarrhea stops, but not more than three pills in 24 hours; or 1 teaspoonful of paregoric (p. 207) every 2 hours with water, but not more than 8 teaspoonfuls in 24 hours; or boiled tea (p. 207). Diarrhea which is accompanied by fever or which does not respond within a day or two to treatment as above, should be treated as dysentery (p. 71). Colic is a "griping" pain in the abdomen which comes and goes, and which is somewhat relieved by firm pressure. It is a common symptom of indigestion and is often associated with diarrhea or with dysentery. This symptom can be relieved, more or less, by the application of heat to the abdomen. A hot-water bag or a hot stone wrapped in a towel may be used. Caution. It is important to distinguish from colic, appendicitis and certain other causes of abdominal pain (p. 154). JAUNDICE

Diagnosis. Jaundice is a symptom which may be associated with indigestion, with various infectious diseases, including yellow fever, with gallstones, or with certain other less common conditions. The presence of jaundice is indicated by a yellowish color of

26

HANDBOOK OF HEALTH

the eyeballs and skin, abnormally dark urine, and whitish stools. Treatment. The commonest variety of jaundice (catarrhal) is associated with symptoms of indigestion. Recovery takes place within a few weeks. Treat as for indigestion and exclude fats from the diet. Similar dietary restrictions are likely to help in any form of jaundice. PILES (HEMORRHOIDS)

Diagnosis. Piles m a y be external or internal. The former are easily seen. Either may cause the passage of bright red blood. Piles m a y result either from constipation or from diarrhea. External piles are painful in the early stages, but they shrink ultimately into tabs which cause no pain and little inconvenience. Treatment. T o cure either external or internal piles, it is essential to obtain normal action of the bowels. Painful external piles should be washed carefully with cold water after each evacuation and then pushed up inside the orifice. Pain can be eased by rest in bed and frequent applications of ice or of cloths wrung out in cold water. HEADACHE

Causes. Headache is often due to constipation, to indigestion, to heat, or to eyestrain. I t m a y also be caused by hunger or excessive fatigue. M a n y persons

COMMON AILMENTS

27

suffer from headaches affecting one side of the head only and associated with digestive disturbances. Such headaches are spoken of as "sick headaches" and are called by physicians migraine. Headache with fever of 101° F. or more may mean the beginning of an infectious disease. (See Fevers, p. 29.) Treatment. Try to find the cause of the headache and treat accordingly. Very severe headache should be treated as follows: (1) Take a cathartic. (2) Rest in a darkened room. (3) Eat little. (4) Drink water freely. (5) Apply an ice bag or hot-water bag, or towels wrung out of hot or cold water. For migraine, heat usually gives more relief than cold. For other kinds of headache, cold is generally better than heat. (6) Aspirin often gives relief. Do not use morphine for recurring headache, lest a drug habit result. EARACHE

Treatment. Apply cold behind the ear by ice bag or by cloths dipped in cold water and changed often. A little warm oil may be poured into the ear. If pus discharges, the ear must be washed out three or four times a day with a warm solution of boric acid until the discharge ceases. An "antitoxin" syringe (p. 198) is good for this purpose but must be used very gently to prevent driving the pus in. Between washings, keep ear loosely plugged with absorbent cotton and change the cotton frequently. When the pain is not very

28

HANDBOOK OF H E A L T H

severe, it can be relieved by taking drugs as for headache. If not so relieved, 0.016 Gm. (J grain) of morphine may be prescribed. TOOTHACHE

Treatment. Clean the cavity with absorbent cotton wrapped around a toothpick or roughened wire. Change the cotton, dip it into oil of cloves, and plug the cavity with it. Wash the cavity daily and replug as before. When the cavity cannot be reached, rub the oil on the gum. If the tooth is loose, pull it out. E Y E TROUBLES

Cinders. Tell the patient to open the eye wide. If nothing can be seen in it, tell him to look up. Meanwhile, pull down lower lid with finger. If nothing is seen there, tell him to look down hard. Grasp lashes of upper lid firmly, and, with the other hand, press the head of a match against base of upper lid. While holding the match in place, pull lid forward and then turn it up and back. While holding lid back with thumb, take clean handkerchief or cotton swab and wipe off the cinder. It will often be found on the upper part of the eyeball where it cannot be seen until the lid is turned. When the eye is very sensitive, apply holocaine solution and wait a few minutes for the anesthetic effect before examining.

COMMON AILMENTS

29

Sore Eyes. The lids are sticky, swollen, and red. The eyeball may be red, and there is usually much sensitiveness to light. The soreness may be caused by eyestrain, by excessive exposure to bright sunlight or glare (see Snow Blindness), or by various kinds of infection. Among the common infections are the sty (a pimple on the edge of the lid), "pink eye" (a mild infection of short duration), and trachoma, which causes a chronic inflammation requiring special methods of treatment. Treatment. Rest for the eyes, protection from bright light, and cleanliness are necessary. In severer cases in which signs of infection appear, wash the eyes frequently with cold boiled water or, preferably, with boric acid solution every three or four hours. The application of clean cloths dipped in cold boiled water helps to relieve discomfort. Never poultice an eye, and do not put a bandage over it. FEVERS

Temperature, Pulse, and Respiration. The normal temperature taken by mouth varies from 98° to 99° F. and is usually 98.6° F. Temperatures below 98° may be due to prolonged exposure, to insufficient nourishment, to exhaustion, or to debilitating diseases. Temperatures above 99° are called "fever." When the temperature is from 100° to 101° F., rest

30

HANDBOOK OF HEALTH

should be taken until relieved. Temperatures of more than 101° are common in acute infectious diseases, after exposure to heat, or as a result of wound infection. The normal pulse rate is usually between 68 and 75 per minute. Continuously higher pulse rates occur when there is fever, weakness of the heart, or increased thyroid secretion. Transient rapidity of the pulse may be caused by nervousness or excitement. A pulse rate of 120 or more with fever or with signs of heart weakness indicates possible danger. The usual respiration rate is about fifteen per minute. Fever increases the rate more or less. Rates of thirty or more are common in severe cases of heart weakness in which the patient is so short of breath that he cannot lie down. When such rates occur with high temperatures in pneumonia, typhoid, or other fevers, they are a sign of grave danger. GENERAL R U L E S FOR TREATMENT OF FEVERS

There are many kinds of fever for which no especially useful drug is known. In any case, the treatment of fevers involves the best obtainable nursing and intelligent treatment of distressing symptoms. Most fevers run a limited course tending toward recovery. 1. Conserve strength by rest to give the body the best chance of recovery. Stay in bed and don't get

COMMON AILMENTS

31

up unless absolutely necessary. Fatigue or chilling, incidental to travel, may have fatal consequences. 2. Take a purgative to clear the bowels, and follow it the next day with an enema if the bowels have not moved freely. Until the temperature returns to normal, move the bowels at least every other day by means of enemas or cathartics. 3. Eight to ten glasses of water should be taken daily. Even more may be needed when there is high fever or much sweating. The diet, as a rule, should consist of liquids and soft solids administered in small quantities at intervals of 2 to 4 hours. 4. The quantity of food must be regulated by appetite and power to digest. High fever, a heavily coated tongue, or nausea indicates that food should be offered in very small amounts and at intervals of two or three hours. 5. Diarrhea or vomiting demands reduction of food and, if persistent, should be treated as directed on page 24. 6. Headache, for treatment of, see page 26. 7. Abdominal pain may be relieved by applications of heat or perhaps by an enema. 8. Severe pain in the back or limbs, prolonged sleeplessness, or delirium may require an occasional dose of morphine, but it should be used sparingly because it tends to upset the stomach even when used hypodermically. Ten grains of aspirin may be given once or twice a day for pain or discomfort.

32

HANDBOOK OF HEALTH

9. High fever can be reduced and comfort promoted by sponging once or twice daily with cold water. The best way to do this is to lay the patient between blankets and to uncover and sponge one portion of the body at a time. 10. The eyes and mouth must be kept clean by swabbing several times daily with warm boiled water or boric acid solution. 11. Vitamin concentrates (p. 205) should be taken regularly. 12. Emaciation results from long-continuing fever when insufficient nourishment has been taken. Whisky, well diluted with water, can be taken up to a pint or more daily with marked benefit in some of these starved cases. As a rule, alcoholic drinks are not needed. They are harmful in the earlier stages of fevers. Caution. Leave nothing which can be used as a weapon within reach of a delirious patient. Restrain him with the voice; attend him constantly to see that he does not injure himself. Use morphine only if he cannot be otherwise controlled. A patient who is bound may exhaust himself by struggling. The urine and stools of persons who have typhoid fever, dysentery, or certain other infectious diseases are infectious. They should be sterilized or buried, and the utensils and linen disinfected. Attendants should scrub their hands before eating.

COMMON AILMENTS

33

BAD COLDS, SORE THROAT, BRONCHITIS AND " F L U "

Any of these conditions may result from a recent infection of the respiratory tract, and, as a rule, recovery is spontaneous unless prevented by imprudence. Pneumonia is a dangerous sequel which may be brought on by neglect. Treatment. Take it easy and get extra sleep; stay in a warm room day and night; eat according to appetite; and keep the bowels free. A hot drink at bedtime may promote comfort. Smoke little if at all. If there is fever, stay in bed. For cough or sore throat, gargle every few hours with a cup of hot water in which is dissolved a half teaspoonful of table salt. Bronchitis or " f l u " may result in cough and spitting lasting for several weeks. It may cause wheezing, and there may or may not be fever. When there is fever, it is important to stay in bed lest pneumonia develop. Otherwise, it is only necessary to "take care of yourself." P E R S I S T E N T COUGH

Persistent cough may be due to excessive smoking, particularly of cigarettes, to whooping cough, or to tuberculosis of the lungs. Treatment. A smoker's cough can be mitigated or even cured within a few days by cutting out the smoking. Whooping cough is often fatal to "natives" among

34

HANDBOOK OP HEALTH

whom it is of recent importation. If there is much fever, treat as for pneumonia. Otherwise, there is nothing to do except to avoid catching cold and to allow the disease to run its course. Tuberculosis of the lungs should be suspected when a persistent cough, with or without fever, is associated with much loss of weight. Caution. The sputa of tuberculous persons are infectious and should be burned or boiled. Handkerchiefs, towels, or linen soiled with sputa should be boiled. PNEUMONIA

Diagnosis. Body temperature rising rapidly or gradually to 103° F. or more, associated with a pulse rate of a hundred or more per minute, sharp pain in the chest, increased by deep breathing, and bloody or rusty-looking sputum, usually indicates pneumonia. The usual duration of high fever is about one week. The temperature may then fall suddenly or gradually to normal. Not all cases are typical. Some run a milder course. Treatment. 1. Do not transport the patient. 2. Keep him in bed, promote comfort, and spare exertion by such nursing as can be given. 3. At the outset, clear the bowels by enema or cathartic; repeat this every other day. 4. Water should be taken at frequent intervals and not less than eight or ten glasses per day.

COMMON AILMENTS

35

5. Diet: liquids until the bowels have moved freely, and thereafter liquids and soft solids in small amounts every three or four hours. 6. After the bowels have been cleared, relieve the pain in the chest by morphine if necessary, because pain is exhausting and rest essential. 7. Sulfadiazine may be tried in the same dose and with the same precautions as for sepsis (pp. 128 and 210). Caution. 1. Do not give morphine when expectoration is profuse lest you drown the patient by checking the cough. 2. A delirious patient should be watched constantly lest he commit suicide or injure himself. RHEUMATISM

The term "rheumatism" is used vaguely to include painful inflammation or pain without visible inflammation in joints, back, or muscles. The symptoms may be acute (i.e., of recent origin), chronic (of longer duration), or recurring. Only a few of the common varieties can be described here. The term "arthritis" means acute or chronic rheumatism of the joints but does not refer to muscles. Acute Arthritis. This is accompanied usually by swelling and redness about the affected joints and often by fever. When several joints are involved, the case may be one of rheumatic fever.

36

HANDBOOK OF HEALTH

When there is fever, rest in bed is important, and aspirin should be used in large doses, for example, 2 tablets every 6 to 8 hours with a full glass of water and after taking food, for a few days, and then continued in small doses. Recovery may or may not be rapid. Affected joints may be protected by wrapping with cotton wool, or by means of bandages and splints. Chronic Arthritis. Treatment should be based upon careful study of the case and improvement of general condition. Aspirin may be tried in small doses. P A I N IN THE BACK

Pain in the back, or "lumbago," may be caused by chilling of the back muscles from a wet undershirt, by a strain which may have appeared trivial at the time, or by arthritis of the spine. The pain may be merely annoying or seriously disabling. Treatment. Some relief can often be given by the application of heat, by rubbing and kneading the stiffened back muscles, by a tight, wide belt worn low, or by strips of adhesive plaster put on tightly and overlapping each other to give added support to the back. The strapping should be applied to the lower part of the back while standing straight. When sitting, use a straight-back chair. Sagging beds are to be avoided. They can be improved by placing boards under the mattress. Aspirin may give some relief. See also p. 152 and p. 153.

COMMON AILMENTS

37

VENEREAL DISEASES

Prevention. If exposure might occur, consult your doctor about the best methods of prevention before leaving home. Venereal diseases are extremely prevalent in the tropics. Gonorrhea, syphilis, and soft chancre are the most common, but there are several other varieties not described here. The means of prevention are the same. Gonorrhea. Symptoms begin within about a week following exposure. There is a whitish discharge and a burning pain on passing water. The penis and sometimes the testicles may become swollen and painful. At a later stage, especially in neglected cases, the prostate gland may become infected. In chronic cases, a slight discharge may be noticed only in the morning, but the urine is more or less cloudy. A quick cure can only be obtained by prompt and adequate treatment from the beginning. See a physician if possible. Treatment. 1. Avoid all forms of sexual excitement. 2. Take no alcohol in any form. 3. Avoid unusual or strenuous activity. 4. Drink water freely, eight to ten glasses per day. unless it causes added discomfort. 5. Get medical advice as soon as possible. 6. Sulfathiazole or sulfadiazine tablets may be taken in the dose of one tablet of 0.5 Gm. with a glass of water every six hours. Usually, improvement fol-

38

HANDBOOK OF HEALTH

lows promptly but there are cases which are not benefited. The use of either of these drugs must not be continued for more than ten days. Use of them without medical supervision involves some risk. Should soreness of the eyes or other toxic effects appear, discontinue the drug at once. For other signs of toxicity, see Sulfonamides (p. 211). Caution. Wash hands carefully after touching the affected part or anything soiled by it. The infection, when transferred to the eye, causes severe inflammation or even blindness. Burn used dressings. Chancroid (Soft Chancre) develops on the penis and causes a soft, ragged ulceration more or less covered with greenish slough and bathed in pus. Sometimes there is also painful swelling of the glands in the groin. Treatment. Wash thoroughly at least twice daily with warm water and soap or with 2 per cent boric acid solution. Apply sulfathiazole ointment, 5 per cent, from five to eight times daily. There are certain other venereal infections of the genitalia which might be mistaken for soft chancre. The same treatment is applicable to them. Syphilis. Although usually of venereal origin, syphilis can be contracted by kissing. The first sign of syphilis is a small reddish lump which becomes a shallow ulcer, causes little pain, and has a firm, thickened margin. This is called a "hard chancre" or "primary sore." I t appears usually on the penis, develops in from two weeks to a month after exposure, and persists from six to twelve weeks.

COMMON AILMENTS

39

The secondary symptoms are extremely variable and may be either slight or pronounced. Usually there is slight fever, a measles-like rash which rarely itches, and a sore throat of moderate severity. The rash may last for weeks or months. The tertiary stage of syphilis may or may not develop. Usually, it appears years later in the shape of chronic ulcers (see Yaws) on the shins or elsewhere, or it may cause diseases of the internal organs or of the nervous system. Treatment. The layman cannot safely use the more powerful drugs and cannot hope to cure syphilis, but he may do much toward causing the disappearance of tertiary symptoms by prescribing potassium iodide. Dose. The dose is 0.65 Gm. three times daily after meals with a glass of water. This can be conveniently taken as 2 tablets of 0.32 Gm. (5 grains) each. Ulcers should be kept clean by washing and dressing twice daily and protected with light dressings. To prevent possible infection of others, use separate towels and eating utensils and boil them afterward. Burn used dressings. HEART WEAKNESS

Prevention. The elderly, even when fit, are advised to avoid unusual exertion and excessive fatigue.* Diagnosis. Shortness of breath follows comparatively slight exertion and is often associated with pain * Altitudes of 1500 meters or over (4500 feet) may cause serious circulatory disorders in persons who have weak hearts. Air travel may be unsafe for them.

40

HANDBOOK OF HEALTH

in the chest or in the "pit of the stomach" and sometimes with vomiting. These symptoms can be caused by nervousness alone.* They are then of no consequence. A soft, painless swelling of the ankles and lower legs, slight at first, develops in most cases of real heart weakness. In severe cases, the patient breathes most easily when sitting up, the lips or face may have a bluish tinge, the pulse rate is apt to be above 100 per minute and irregularity is common. Treatment. When symptoms of heart weakness come on suddenly as a result of severe exertion such as mountain climbing, the person affected should sit down at once, remain quiet until the symptoms have passed off entirely or, preferably, for an hour longer. If he cannot be transported back to camp, he should begin walking very slowly and should return by easy stages with frequent rests. Thereafter he should avoid exertion which causes shortness of breath. ASTHMA

Diagnosis. Asthma is of two kinds, namely, (1) bronchial asthma, which is akin to "hay fever," may be produced by a great variety of causes, is most common in youth, and recurs from time to time for years, and (2) cardiac or renal asthma, which is a common symptom of serious disorder of the heart or kidneys, * Nervous symptoms of this type are seen especially in young people and but rarely in those of middle age.

COMMON AILMENTS

41

and usually develops in the elderly and unfit. Attacks of either type of asthma usually come on at night, force the patient to sit up to get his breath, and are characterized by difficult breathing and by wheezing especially when breathing out. Asthma comes on without exertion. Treatment. Those who are subject to bronchial asthma should get competent advice before leaving home. Cardiac asthma demands medical advice as soon as possible. Morphine should never be administered in asthma because dangerous. Inhalation of steam may relieve. A subcutaneous injection of 0.25 to 1 cc. of adrenalin solution, 1:1000, usually brings prompt relief and may be repeated at intervals of one hour, if needed. VITAMIN D E F I C I E N C Y D I S E A S E S

A great variety of symptoms and several diseases may be caused by deficiency of one or more of the vitamins. The symptoms vary in accordance with the nature of the deficiency. In multiple deficiencies, which are common especially in chronic alcoholics, symptoms are combined. Treatment. Most of the symptoms of deficiency begin to disappear within a few days when a balanced diet (p. 7) is taken which contains an abundance of all the necessary food factors including the vitamins. Vitamin concentrates (p. 205), in addition to an adequate diet, are useful in the treatment of vitamin deficiency.

42

HANDBOOK OF HEALTH

The food-sources of vitamins have been listed on page 8. RECOGNITION OF SPECIFIC D E F I C I E N C I E S

Vitamin A. Lack of vitamin A frequently causes reduction of the power to see in semi-darkness. The skin may become abnormally rough and ingrowing hairs may be numerous. Vitamin B-complex, or "vitamin B," is a mixture of several vitamins and other substances. The signs of deficiency of this complex may be those of beriberi or of pellagra or they may combine some of the signs of each. In the early stages of deficiency of the vitamin Bcomplex, there is apt to be loss of appetite, mild digestive disorders, and marked loss of weight. The tongue becomes smooth, red and sore at the tip and edges. Beriberi, which is by no means confined to the tropics, is characterized by rapid pulse, shortness of breath, abdominal pain and pronounced swelling of the legs or by weakness and pain in the legs followed by paralysis. The signs of heart weakness indicate danger and the necessity of avoiding all exertion. These heart symptoms begin to respond within a few days to adequate intake of vitamins. Pronounced weakness or paralysis of the legs indicates neuritis, recovery from which is slow. Pellagra. In well-marked cases of pellagra, there is

COMMON AILMENTS

43

usually dermatitis of the hands and face or other exposed parts, which resembles sunburn. With this goes acid indigestion, pain in the pit of the stomach, emaciation and pronounced physical weakness. Vitamin C and Scurvy. Well-marked deficiency causes scurvy. Among the common symptoms are swelling and bleeding of the gums, loosening of the teeth, swelling and pain in the legs, weakness, pallor, and a red rash on the limbs or bleeding into the skin so that it appears to have been bruised. Response to suitable diet (p. 8) begins within a few days. ACUTE SKIN DISEASES

A few of the most common and easily recognized acute skin diseases will be described. Hives is associated with digestive disturbances. In some individuals, it regularly follows the ingestion of certain foods to which they are allergic. It is characterized by the appearance on the skin of pink swell· ings which itch very much and which come and go hourly or from day to day. Treat by free evacuation of the bowels and a light diet for a few days. For the itching, dissolve one-half teaspoonful of sodium bicarbonate in a glass of water and paint it on the skin. Pimples are superficial infections with formation of pus in the skin. They may recur for months or years. Free use of warm water and soap, avoidance of greasy food and of chocolate, and applications of sulphur

44

HANDBOOK OF HEALTH

ointment, 15 per cent, are advised. For boils, see page 137. Impetigo is a bacterial infection of the superficial layers of the skin. Yellowish crusts form on the skin, and there are shallow ulcers under them. Use soap and warm water freely and apply sulphur ointment after each washing. When impetigo occurs on the hairy parts of the face, cure can be hastened by pulling out the hairs. Acute dermatitis (inflammation of the skin) may result from sunburn or other superficial burns (p. 135); chemical irritants including those contained in the juices of certain plants or the sawdust from some kinds of wood (turpentine, poison ivy); plant hairs (nettles); or insect hairs (brown-tail moth). Treatment. Irritating plant juices or chemical irritants should be promptly and gently but thoroughly washed off with soap and warm water. Thereafter, wash the parts seldom, apply lanolin or other soothing ointment twice daily to the affected skin, and protect it with a thin layer of cloth. An old, soft handkerchief is excellent for the purpose. If blisters form, allow them to dry up without opening unless they become filled with yellowish pus, which indicates infection. They should then be opened, washed with soap and water, and smeared with sulphur ointment before redressing. When ulcers form, more or less infection becomes inevitable. The ulcers may discharge serum freely or

COMMON AILMENTS

45

may become bathed in pus. Cleanliness then becomes of paramount importance. Sponge gently with absorbent cotton or gauze, and apply sulphur ointment and a clean dressing twice daily. Strong antiseptics are to be avoided in acute dermatitis because they usually delay healing. CHRONIC SKIN DISEASES

These include a great variety of conditions, many of which are difficult to diagnose or to treat. Such of them as are infectious, can be prevented by scrupulous cleanliness of the body and frequent washing of underclothing, socks and towels. Eczema. This term is often erroneously used. Some of the causes of true eczema are obscure but the disease is not infectious. Usually, there are patches of skin which show scaling and more or less redness. Eczema may be dry or moist. Contact with soap and water aggravates eczema. It should be treated by application of lanolin or a very mild antiseptic such as boric ointment. Stronger applications should never be used for eczema unless prescribed by a physician. Ringworm and Athlete's Foot. See page 97. Scabies, "the itch," is caused by a very small insect (,Sarcoptes scabiei). The itching is intense at night, and the skin often becomes covered with scratch marks. The eruption consists of small red swellings or dots which are found especially between the fingers,

46 HANDBOOK OF HEALTH on the fold of the armpit, and about the groin and genitals. It never extends to the face or scalp and seldom below the knee except in native races of the tropics. Treatment, to be successful, must be thorough. All those living together who are affected must be treated at the same time. 1. Soak in a hot bath to soften the outer layers of the skin. 2. Scrub thoroughly with soap and a large nail brush. 3. After the bath, rub sulphur ointment all over the body except on the face and head. 4. Repeat this treatment on two or three successive days. 5. After completion of the course of treatment, see that underclothing, night clothing and sheets used during the treatment are boiled. Dress in clean underclothing. Smaller amounts of sulphur will suffice, and the messiness of the ointment can be avoided by using 18 per cent of sulphur in a soap base (Nolan's method) on two successive days or by incorporating 0.72 Gm. of sulphur in a lathering tablet (Carter's method). Each tablet serves only for a single treatment. Sulphur sometimes irritates a sensitive skin. Other methods of treatment which are more drastic may be tried under medical direction (e.g. benzyl benzoate or rotenone).

CHAPTER III T H E TROPICS H Y G I E N E AND EQUIPMENT

Provide yourself in advance with the following things and put them into your hand baggage: 1. A mosquito net (see Malaria; Nets). 2. One or two canteens, each holding one quart. 3. Chlorinating tablets for disinfecting drinking water. Those who dislike chlorinated water may prefer to carry a small covered pot in which to boil their drinking water and some tins of "solid alcohol" for use while traveling. 4. Sun glasses, two pair. 5. Such clothing and other equipment as is essential and which cannot, perhaps, be obtained at a later stage of the journey. 6. A bottle of 50 atabrine tablets of 0.1 Gm. each, or 100 quinine tablets of 0.32 Gm. (5 grains) each, and a few other medicaments. Information about the climatic conditions likely to be encountered where you are going should be obtained before departure. Inquire about the diseases prevalent in the country to be visited. When sufficient information has not been obtained in advance, consult reliable physicians living in the countries visited.

48

HANDBOOK OF HEALTH R U L E S FOB KEEPING W E L L

1. Protect yourself by all practicable means against intestinal diseases (p. 71) and malaria (p. 63). Precautions against relapsing fever or other diseases dealt with in Chapter IV should also be taken in the regions in which these diseases are common. 2. Follow the ordinary rules of hygiene in a common-sense way (Chapter I). 3. Take the following additional precautions: a. Regular exercise is far more necessary in the tropics than in a temperate climate. b. Of equal importance is temperance in everything. c. If you are getting overtired, take a siesta after lunch andget at least eighthours' sleep at night. d. Indigestion is especially to be avoided because it may prepare the way for dysentery. Eat slowly, chew well, select the simplest food. Do not eat heartily when much fatigued. e. Meat, green vegetables,* and fruit * should be eaten freely to prevent vitamin deficiency; starchy food and sweets less freely; and fried, greasy, or oily food should be taken sparingly. f. Meat and fish should be thoroughly cookedlest they cause tapeworm infection or trichinosis. g. Maintain strength by eating enough to prevent rapid or excessive loss of weight. * Subject to precautions against intestinal diseases.

THE TROPICS

49

h. To compensate for loss of salt in the sweat, use salt liberally at meals. Additional salt may be required (p. 93). i. Iced drinks are a fruitful cause of indigestion, but hot tea increases sweating and has a cooling effect. j. Cleanliness of the skin and underclothing helps greatly to prevent "dhobie itch" and other skin infections. k. A bath, hot or cool, should be taken at least once a day, but chilling is to be avoided. 1. Wear clothing suited to the climate (p. 53). TROPICAL DIETARIES

In many parts of the tropics, facilities for the refrigeration and storage of food are scanty or lacking. Consequently, many common articles of food are obtainable only at intervals or seasonally. This ia notably true of fruits and other perishable foods. In consequence, those who can afford to do so are prone to depend too much upon canned or preserved foods which may be deficient in vitamins. To obviate this difficulty, the stranger should take full advantage of such locally produced fresh foods as are obtainable. Primitive tribes in Africa and in Brazil regularly eat "greens" which they grow or gather. Before eating wild fruits, nuts or greens with which you are not familiar, you should consult the natives

50

HANDBOOK OF HEALTH

of the region or others who know what is wholesome. Only thick-skinned fruits which can be washed in boiled or chlorinated water and peeled at the table should be eaten raw (see Dysentery, p. 71). A good state of nutrition promotes resistance to disease. Fruit, whole-grain products and butter, red palm oil or other food containing vitamin A, should be eaten daily. EQUIPMENT AND ITS U S E

The special equipment required for protection from malaria, dysentery, and certain other diseases which are rife in the tropics is more fully described under those heads (Chapter IV). Tents may not be necessary where some sort of shelter is available or when rain is not to be expected. When frequent, heavy rains must be reckoned with, a wall-tent is recommended. A fly pitched over the tent and providing an adequate air space between fly and tent roof is a necessary protection from the heat of the sun when camping in open country. The wall of the tent can then be rolled up to admit air freely. A ground-sheet, particularly in wet weather, and an extension fly are desirable luxuries. Tents have special value in countries in which relapsing fever (p. 82) is transmitted by ticks (p. 102). Mending equipment is essential when tents are to be used on a long trip.

THE TROPICS

61

For camping in the forest where rain is not too frequent, it is sufficient that each member of the party should have a fly large enough to cover his hammock or cot bed. Beds and Bedding. A folding cot bed is generally used for camping in a tent or traveling where accommodations are primitive. The Gold Medal cot is light and packs easily, but is not very strong. More durable cots are apt to be heavier. Some sort of thin mattress, or a heavy blanket folded double and laid on the cot, is needed to hold down the edge of the mosquito net. The net should be tucked under this all the way around and not allowed to hang to the floor or ground. Where a fresh breeze is blowing, large safety pins may be needed to hold the net down. In America, the hammock is ordinarily used near sea level from Yucatan southward to the Amazon Basin, and the smaller hotels may be furnished with hammock hooks rather than beds. The traveler provides the hammock. When camping in forested country, a hammock can be quickly and easily slung between two trees, but a hammock slung either too long or too short is uncomfortable. The hammock loosely slung, so that one can lie diagonally with the body nearly horizontal, more or less enveloped in a very thin woolen blanket, and using as a pillow a small, rolled bath towel, is ideally comfortable for hot nights in the tropics. The blanket

52

HANDBOOK OF HEALTH

is needed to prevent the back from feeling cold. A corner of the blanket or a belly-band should always cover the abdomen to prevent chilling and diarrhea. (See also p. 54.) The legs and shoulders may be covered or not as desired. The best hammocks are obtainable where they are used. Cloth has advantages over netting in that it does not catch buttons. The continuing heat of the tropics causes one to become unbelievably sensitive to falling temperatures. Should the mercury drop to 60° F., one shivers. A heavy blanket should therefore be available. Nets. The mosquito net is of prime importance. The best are made of bobbinet having a fine mesh. Twenty holes to the linear inch will exclude all but the smallest varieties of mosquito. With good care, nets will serve for a year or more of constant use. Every rent should be mended promptly. When traveling, the net should be packed in a small bag to protect it from chafing. Whether designed for use with cot or hammock, the net should have tape loops at the four corners of the top so that it can be hung up anywhere. It should be much wider at the bottom than at the top so that it can be spread over a hotel bed, if necessary. When a cot is provided with a frame to support the net, the net should be suspended inside the frame. Otherwise it cannot be tucked in snugly. In lieu of a frame, sticks can be lashed to the corners of the cot. A band of light cotton cloth twelve to eighteen

THE TROPICS

53

inches wide, to be tucked in under the mattress, may be attached to the lower edge of the netting. It is more durable and less expensive than bobbinet and, if wide enough, it can provide a little additional protection against mosquito biting (p. 64). Where "sand flies" (Phlebotomus) abound, an extremely fine mesh is needed to exclude them. The midge or "sandfly" (Culicoides) can only be stopped by cheesecloth. There is in the Philippine Islands a very small species of mosquito which is a carrier of malaria. For use with a hammock, a special type of net is required. It must have pockets for spreaders at the ends of the top, and sleeves which can be tied around the hammock ropes. Unless there is a drawstring with which to close the net underneath after getting into the hammock, one should tie loose knots in either end of the net so as to raise it above the floor and to cause it to close spontaneously under the hammock. Clothing. Where the weather is continuously hot, suits of cotton duck or drill are commonly worn. The lighter the material and the less it is starched, the better. While working, one may be comfortable in a shirt and trousers without underclothing or coat. Those who sweat profusely should wear underclothing to absorb the sweat and to promote its evaporation in situ. Cotton suits are worn, for example, in the Philippine Islands, in the Amazon Basin, in Central Amer-

54

HANDBOOK OF HEALTH

ica along the coasts, in Singapore, and in Java where heat is continuous, but where rapid changes of temperature may occur, as in India during the rains, light woolens are needed. Unless certain that the temperature will not vary much, one should have a warm overcoat at hand. The raglan shoulder has the advantage that it is comfortable to sleep in. Such a coat can replace a blanket. Under desert conditions, where nights are cold, a warm overcoat and a heavy blanket are essential. A belly-band can be worn to advantage on hot nights to prevent chilling of the abdomen and consequent diarrhea. A strip of cotton flannel a foot wide and long enough to wrap once and a half around the body over the pajamas serves well. The end can be pinned in place or the corner tucked in. A belly-band is unsatisfactory for use during the day because it is apt to become wet with perspiration and to get wrinkled. Nothing except good rubber gives complete protection from rain. The poncho is heavy but has the advantage of allowing ventilation so that it does not become wet with perspiration inside. Underclothing should be porous to facilitate evaporation. A mesh weave may be preferred. The supply should be ample to allow for frequent changes. Underclothes will generally be needed for warmth in the evening if not in the daytime. Shorts are much worn by English hunters in Africa,

THE TROPICS

55

but they do not protect the knees from insects or from thorns. Protection from the sun is discussed in Chapter IV. Footgear. Leather boots, having hobnails, are good for tramping in dry country. High boots, lacing up the front of the leg, such as are commonly worn by American engineers when in the field, protect the lower legs from thorns, insects, and snakes. The disadvantages are weight and lack of ventilation for the feet. Leather boots cause chafes and blisters unless they fit well and are sufficiently roomy to take a pair of heavy woolen socks. It is probably wise to wear a pair of white cotton socks under the woolen pair for further protection. A disadvantage of leather boots in a wet country is that neither leather nor stitching will "stand u p " unless the boots, including the soles, are kept well greased or oiled. When the stitching gives way in the bush, it is useful to have at hand a shoemaker's awl and "waxed ends." Shoes of heavy canvas coming high enough at the ankle to lap well under a canvas legging, and having heavy rubber soles, have served well on long trips in the African as well as in the American tropics. On hot, dry ground, a leather sole is cooler to the foot, but, for wading, the canvas upper has the great advantage that no water can accumulate in the boot, and that it is not so easily injured by heat when being

56

HANDBOOK OF HEALTH

dried as is leather. A single pair of canvas boots may serve for from two hundred to four hundred miles of trail travel on foot. Three pairs of canvas boots weigh less than one pair of high leather boots. Canvas boots do not blister or chafe if worn over woolen socks, but they should be wetted and tested for shrinkage before one leaves home. If leggings are to be worn over them, it is advantageous to snip off the hooks with wire cutters and to lace the boots to the top through the eyes which remain. "Mosquito boots" have their uses (p. 64). Leggings of canvas are not injured by repeated wetting and they are lighter and cooler than leather. MISCELLANEOUS EQUIPMENT

Machetes or axes may be needed for clearing the trail when traveling in the forest with pack animals. Flashlights are invaluable when one is overtaken by darkness on the trail and are very useful in camp. Moreover, it is risky to stumble about in the dark where there may be poisonous snakes, leopards, and the like. Extra bulbs and batteries should be available. Head-nets and gloves will seldom be used in the hot and humid parts of the tropics, unless for night duty as a protection from malaria. A wash basin of rubber, canvas, or enamel ware is essential. A folding bathtub of rubber or canvas is

THE TROPICS

57

very nice. A folding canvas bucket is excellent for filling baths and for other purposes. Bath towels should be carried. Camp Furniture. A folding table and stools are useful luxuries. A tool chest might contain the following: hammers, screwdrivers, assorted nails, assorted screws, tin shears, pliers and wire-cutters, adhesive tape, copper wire, small saw, and mending materials for boots and tents. Hurricane lamps are excellent for camp purposes but poor to read by. One should consider seriously the question of providing light adequate for the purpose in view. An acetylene lamp may be useful but will attract swarms of insects unless used in a screened room. A folding grate is a convenience to the cook and may save him much time, because firewood in the tropics is often unsatisfactory. A knapsack, saddlebag, or other convenient container is needed for things that may be wanted on the march or immediately on arrival at the camp site. Spare rope is sure to be needed. The desert water bag cools drinking water admirably, and water can be chlorinated in it. At least once a week, it should be scrubbed inside and out with hot water containing a little sodium bicarbonate and then dried in the sun. A compass is of special value in the tropics because

58

HANDBOOK OF HEALTH

the sun may be so high as to give no clear indication of direction. Insecticides or insect repellents may be most useful. (See pp. 64, 99, 100 and 101.) Containers. During the rainy season in the tropics, it is very advantageous to carry some of the clothing, papers, and other materials that might be damaged by water in small tin trunks having watertight lids. Fiber boxes are strong, durable, and withstand rain well. They are excellent for certain kinds of equipment. Waterproof duffel bags are needed for bedding and rough clothing. Plywood boxes are lighter than ordinary wooden boxes of equal strength. They serve well for canned goods and other articles not damaged by rain. The maximum size of containers must be determined by the weight of the single load that can be handled easily under the circumstances of transportation. For example, the load for a porter in different parts of Africa varies from 30 to 60 pounds. In Mexico and Central America, it is 60 pounds or more. FOOD FOR THE CAMP

The weight of food required per man per day is variously estimated at from one to five or even six pounds. The minimum figure is probably too low and the maximum too high, even including the weight of the containers.

THE TROPICS

59

At outposts of civilization, one can generally buy the staples of the country, and canned goods of sorts are generally available, albeit very expensive. Because native food supplies may be scanty, a few may live well where a large party would starve. Do not scorn the greens and fruits eaten by the natives. Get fresh fish or game where you can. Choice of Food. Probably, two-thirds or more of the weight of food required will be represented by carbohydrates (p. 7). The starch-containing staple of northern Brazil is manihot (farinha); in China and in many other parts of the Far East, it is rice; and much taro is eaten in the Hawaiian Islands. Jam and marmalade have a high food value because of the sugar they contain and, though they are heavy, one would not wish to be without them. Beans, milk, and cheese have high food value and can serve to a great extent as substitutes for meat. Powdered milk can be recommended not only for quality but also for lightness. Bacon and ham do not keep long in the tropics unless specially prepared for that purpose, but they have a high food value. Dried vegetables and fruits differ so much in quality that one should try various brands before ordering. Canned fruits and vegetables contain so much water and so little nourishment that they should be regarded as luxuries for occasional use only.

60

HANDBOOK OF HEALTH

Meat in the tropics, whether wild or domestic, is often so tough that to chew it up is well-nigh impossible. A meat grinder then saves labor and helps the digestion. Poisonous Foods, see page 91. Packing. Food should be packed in relatively small containers which exclude insects and dampness, and should be kept, so far as possible, in locked boxes to minimize thieving. On the other hand, one may be astonished at the restraint of savages who could easily have stolen food but did not. One who wishes to conserve food should satisfy himself that it has been properly packed before shipment, that it is being properly handled when in the field, and that excessive quantities are not being cooked. For field trips during the rains, practically all kinds of food must be carried in hermetically sealed tins. Otherwise, much of it will inevitably spoil. MUDDY WATER

Muddy water or filthy water is a problem in parts of Africa and in some other places where water is scarce. Pollution by mud or by animals is unpleasant but harmless. In either case, boiling followed by standing will help to clarify the water and will remove any possible danger. Probably, the best method of clarification is by means of crystalline potassium or ammonium alum.* The amount of alum necessary depends upon the * Advice of Melville C. Whipple, Harvard Engineering School.

61 amount of turbidity and upon the reaction of the water. The quantity required can be determined in each case only by testing. The precipitate formed by the alum is fine at first and should appear within an hour. Water only slightly turbid might be clarified by the addition of 0.065 Gm. (1 grain) of alum per gallon. Very turbid water might require the addition of six or eight times as much alum; and a very turbid and soft water might need so much alum as to render it acid. It would then be necessary to alkalinize the water in order to obtain proper precipitation. For this purpose, 0.02 Gm. grain) of sodium carbonate * (washing soda) for each (0.065 Gm.) per gallon of alum could be added. (Double the amount of sodium bicarbonate, cooking soda, probably would serve.) Hard waters are sufficiently alkaline and would not require the addition of an alkali. Precipitation should be complete within a few hours. Filtration by pumping through a porous porcelain candle may be satisfactory, but the candle may become plugged inside with fine silt and it then becomes useless. If such devices are to be relied upon, they should be thoroughly tested and their management well understood before one leaves home. Filtration through cloth or by squeezing out of a woolen garment is better than nothing. Sedimentation.f When the water contains so much THE TROPICS

* A strong alkali having caustic effects. t Notes received from Col. Francis T. Colby.

62

HANDBOOK OF HEALTH

mud, slime, or filth as to clog a filter, one may add to a bucket of such water a pinch of powdered alum and then stir vigorously. If enough alum has been added, a precipitate forms promptly. If no precipitate forms, add a little more alum. Too much alum gives the water a bitter taste. The precipitate usually settles to the bottom within fifteen or twenty minutes. The clarified water can be poured or siphoned off. It may then be filtered, if desired, but it must be boiled. Filtration.* There are many kinds of filters. Pump filters are too much bother and furnish water too slowly. The kind I use and like is of agate ware. It holds about two gallons of water and consists of two containers, one of which fits on above the other. The upper container has a cover and is provided with two porcelain candles which are screwed into the bottom and project upward inside. When water is poured into the upper container, it percolates through the candles and drips into the lower container, from which it can be drawn off through a faucet. Such filters are made in various sizes. They are not easily broken, are easy to clean, cost about ten dollars in Africa, and can be bought there at the large centers. Both chambers of the filter should be carefully washed every few days and then rinsed with boiling water. At the same time, the candles should be taken out and scrubbed. A set of extra candles should be taken along. Water so filtered is not safe to drink; it must be sterilized subsequently by boiling or chlorination. * Notes received from Col. Francis T. Colby.

CHAPTER IV DISEASES IMPORTANT IN THE TROPICS OR COMMON IN LIMITED REGIONS MALARIAL FEVERS

Transmission. Malaria of all kinds is ordinarily transmitted by mosquitoes of the genus Anopheles but only by those mosquitoes which have become infected by biting an infected person. The chances of infection are, therefore, increased in the immediate vicinity of habitations. Mosquitoes of the genus Anopheles can often be recognized by the fact that, when sitting, the body is tipped forward at an angle. PREVENTIVE M E A S U R E S

Camp sites, whenever possible, should be in open ground where there is a breeze, half a mile or more to windward of marshes, pools of water or native dwellings. Nets. Carry a mosquito net in your hand baggage to have it always available. On entering a port or a country where there is much malaria, sleep under the net, even if the inhabitants say that there are no mosquitoes. The net should be in place before sundown because, if it is put up later, mosquitoes may become enclosed in it. Before going to sleep, search out with

64

HANDBOOK OF HEALTH

an electric torch and kill any mosquitoes found inside. (Nets are described on page 52.) It is essential that the bed be large enough so that the limbs need not come in contact with the net during sleep. It is necessary to learn to sleep without rolling against the net. Restless sleepers may do well to replace the lower part of the netting with a band of cotton cloth which will extend a foot above the level of the bed when in place. This has the disadvantage in hot weather of cutting off air movement. Because malaria-carrying mosquitoes may bite in darkened rooms, the net should be used during the siesta. It is well to sleep under a net, even in a screened room, because screening is seldom completely effective. "Flit" or some similar preparation is most useful for killing mosquitoes indoors.* Leggings or boots should be used to protect the legs from mosquitoes under desks or tables, and after sundown. When wearing "whites" and low shoes in the evening, white leggings or spats which cover the instep or mosquito boots should be worn. When on duty out of doors at night, one should use a mosquito repellent on the face and hands or wear a head-net and gloves. Preventive medication against malaria is advised in highly malarious regions for persons who have important work to do within a period of weeks or months, even if they are living in screened quarters * Pyrethrum spray has been recommended of late.

65 and using nets. For those who do not have these safeguards, medication is essential wherever malaria is prevalent. Atabrine and quinine are about equally effective in suppressing the effects of malarial infection while they are being taken, but a person who has become infected is likely to have an attack of malaria subsequently. Quinine may be taken as a preventive in the dose of two tablets of 0.32 Gm. (5 grains) daily after the evening meal. One should begin taking the drug on arrival in a malarious region and should continue taking it in the same dose for a month after cessation of exposure to malaria. Sulphate of quinine is as effective as the more expensive salts of quinine if the drug be not adulterated and if it be prepared in tablets or pills which soften quickly in water. To prevent forgetting to take quinine, have the bottle put on the table at the evening meal and see that it is passed around. When traveling with servants or porters, it is advisable to provide quinine for them also and to see that they take it. Even if it is not certain that the symptoms are due to malaria, they should be dosed with quinine promptly when sick. Atabrine (di-Hydrochloride) has been used in recent years as a substitute for quinine for the prevention and treatment of malaria. For the toxic effects of quinine, and of atabrine, see pages 68 and 69. TROPICAL DISEASES

66

HANDBOOK OF HEALTH

The dose advised as a preventive is 1 tablet of 0.1 Gm. (about grains) twice a day after meals on two days of each week at intervals of three to four days. Resistance to malaria is greatly enhanced by robust health. Keep in condition by wholesome living and avoid, especially, chilling and fatigue. Tonic pills (p. 205) and vitamin concentrates (p. 205) should be taken if one is losing strength or appetite. DIAGNOSIS

The symptoms of malaria are extremely varied but are nearly always accompanied by fever and often by well-marked chills. There are three species of malarial parasites: the tertian, the subtertian or estivoautumnal, and the quartan. The tertian-parasiteis common in subtropical countries as well as in the tropics. Typically, it causes a rapidly rising attack of fever accompanied by a chill which is soon followed by sweating and a quick fall of the temperature to normal. On the second day there is no fever, but on the third day the symptoms recur. A "double infection" may cause daily chills with short intervals of normal temperature. The quartan parasite is not common except in parts of Central Europe and in limited areas in the tropics. The fever which it causes recurs on every fourth day. The fever of subtertian malaria is irregular and transitory or irregularly continuous and may or may

TROPICAL DISEASES

67

not be accompanied by chills. It is often associated with vomiting or diarrhea which may be so persistent as to cause rapid emaciation. Most of the cases of severe "tropical malaria" and many deaths are caused by this parasite. Alarming symptoms such as prostration, delirium, unconsciousness, or convulsions, may develop within a few hours and may be quickly followed by death. A severe attack of malaria may be mistaken for heat stroke. In cases of long duration and after repeated relapses, "blackwater" may develop. In these cases the urine is dark in color. The quantity is small, or there may even be none. Atypical manifestations, such as recurring headache, are so common in malaria that one should suspect this disease after exposure to it, whatever the symptoms. They are milder and less characteristic in the natives of malarious countries. Treatment. To treat an attack of malaria, proceed as follows: Rest, preferably in bed, is essential when there is fever. The bowels should be cleared at the outset by taking a purgative (p. 206). Thereafter, see that the bowels move at least every other day. Prescribe a cathartic or enema if needed. Fluids. While the fever lasts, eight or ten glasses of water should be taken daily. The diet should be liquids or soft solids according to

68

HANDBOOK OF HEALTH

appetite. Food should be offered in small amounts every two to four hours when the patient is awake. Quinine. Take two quinine tablets of 0.32 Gm. (5 grains) three times daily with a full glass of water after taking food (i.e. two tablets every 8 hours). Ordinarily, this dose will suffice to bring the temperature down to normal after 3 or 4 days and to keep it there. Should the temperature not respond promptly to the drug, 2 tablets in addition should be taken during the night (i.e. 2 tablets every 6 hours). When the temperature continues at normal, reduce the dose to 2 tablets twice daily and continue this dosage for another week. The taking of quinine may cause "sour stomach." This can be relieved by sipping a glass of water containing a teaspoonful of sodium bicarbonate. If the quinine is not vomited and if the temperature does not come down after four days, it is almost certain that the disease is not malaria. Then consider other febrile diseases described in Chapter II and in this chapter, or treat as for fevers in general (p. 30). When repeated vomiting prevents the use of quinine by mouth, it can be injected into the muscle of the buttocks. A special preparation of quinine and a certain technic is required for intramuscular injection. Toxic Effects of Quinine. Quinine is a remarkably safe drug for indiscriminate use. The dosage advised above is too large for susceptible individuals. In them it may cause vomiting, or urticaria, or a rash

TROPICAL DISEASES

69

like scarlet fever. It will cause ringing in the ears and some deafness in most persons. Unless there is marked deafness, the ear symptoms should be disregarded, but, if any disturbances of sight develop, the quinine must be discontinued at once. When these symptoms have entirely disappeared, it can be resumed in smaller dosage. Rarely, "blackwater" (p. 70) is brought cm or made worse by quinine. Should this symptom appear, no more quinine should be given. Rest and abundant water drinking may help. Atabrine is an excellent substitute for quinine. It is to be preferred to quinine for persons who cannot take quinine in ordinary dosage without suffering unusual discomfort. The usual dosage of atabrine for the treatment of an attack of malaria is one tablet of 0.1 Gm. (If grains) three times daily after meals for 5 to 7 days. This will usually suffice to bring the temperature to normal and to relieve all symptoms temporarily. A second course of this treatment may be taken for five days, one week later. Toxic Effects of Atabrine. Prolonged use of atabrine may cause yellow discoloration of the skin which persists for several weeks after discontinuance of the treatment. The discoloration is caused by the excretion of the drug into the skin; it has no serious consequences. Unpleasant symptoms caused occasionally by

70

HANDBOOK OF HEALTH

atabrine are pain in the pit of the stomach, lightheadedness, excitement, and, rarely, delirium. Usually, these symptoms disappear within a few days after the use of the drug has been discontinued. Rarely, atabrine causes "blackwater." Should any of these symptoms occur, the drug should be stopped, and the bowels should be moved freely by means of a cathartic. Cure of Malaria. Relapses are very common even when preliminary treatment has been thorough. The following points are important: 1. Avoid excessive fatigue and exposure to chilling. 2. Build up resistance by careful attention to hygiene, diet, and rest and by taking tonic pills and vitamin concentrate if the appetite is poor or the diet unsatisfactory. 3. When going from the tropics to the temperate zone, the change of climate tends to cause relapse or to bring on an attack of malaria. It is well, therefore, to take prophylactic doses of quinine or of atabrine (pp. 65 and 66) during the voyage. BLACKWATER FEVER

"Blackwater" is a grave, but unusual, sequel of chronic "tropical malaria." Rarely, it is induced by taking quinine or atabrine. Diagnosis. The urine is abnormally dark or smoky

TROPICAL DISEASES

71

in color, becomes scanty, and its excretion may cease for a time. Usually, there is irregular fever as in tropical malaria and there may be vomiting. The scanty and highly colored urine caused by deficient ingestion of water and the bile-stained urine which goes with jaundice, must be distinguished from blackwater. Treatment. Any drugs which are being taken should be omitted. Rest and abundant water-drinking are imperative. If the stomach is not upset, onehalf teaspoonful of sodium bicarbonate dissolved in a full glass of water should be sipped every four hours. DYSENTERY

Occurrence. The dysenteries are of two kinds; namely, the bacillary and the amebic. The bacillary form causes epidemics or scattered cases throughout the world but it is most common in the tropics. The amebic form occurs chiefly in the tropics. In general, bacillary dysentery is about ten times as common as the amebic. It is often difficult to distinguish the one from the other except by laboratory examination. Prevention. The dysenteries are contracted by ingestion of contaminated food or water. Prevention, therefore, depends upon proper management of food and drinking water (pages 11 and 13). Bacillary dysentery can be caused by several species of the dysentery bacillus.

72

HANDBOOK OF HEALTH

Mild cases in which there is little or no fever and not much diarrhea require only the treatment recommended for diarrhea (p. 24). In severe cases there is much pain. The bowels may move from 10 to 30 times per day and the stools consist chiefly of fluid containing blood and mucus or pus. Generally there is a temperature of 104° Γ. more or less. Treatment. (1) Rest in bed and best possible nursing to conserve strength. (2) Water should be taken in large quantities to counteract loss by diarrhea. (3) Diet should be limited to fluids given in small quantity at frequent intervals until symptoms abate. (4) Morphine, 0.016 Gm. (J grain) hypodermically, may be required for a time at intervals of four to six hours to control pain or very frequent action of the bowels. (5) Sulfaguanidine has given gratifying results in many cases and, as yet, there have been no serious ill effects from the dosage recommended. When used within the first five days of the illness, it has generally controlled the diarrhea within a few days. A dose of 3.5 Gm. (52 grains) of the powdered drug mixed with water or other liquid may be taken every 4 hours day and night for a few days (not more than five) or until the number of stools becomes less than 5 in 24 hours. Then continue with the same dosage at intervals of 8 hours until the stools have been

TROPICAL DISEASES

73

normal for 4 days. The entire course of treatment with sulfaguanidine should not exceed 10 days. Meanwhile, much water should be taken in order to maintain a normal output of urine. If sulfaguanidine is not promptly effective, the case may be one of amebic dysentery. When sulfaguanidine is not available, sulfadiazine or sulfathiazole may be tried * (p. 211). Loss of salt and of vitamins incidental to the diarrhea should be made up by taking extra salt with the nourishment and also vitamin concentrates. Amebic dysentery is caused by a single species of parasitic ameba. The symptoms can be mild or severe. Usually, they begin more gradually than in bacillary dysentery, there is less fever, the bowel movements are less frequent and contain more fecal matter. Treatment. In mild cases with little diarrhea and no fever, exertion should be avoided and the diet should be restricted as for diarrhea (p. 24) but it is not necessary for the patient to remain in bed. Severe cases having irregular fever and frequent stools containing blood and mucus require rest in bed, abundant water and a diet of liquids only. Unlike bacillary dysentery, neither the pain nor the diarrhea is likely to be severe enough to require * Unless water can be taken in sufficient quantity to maintain a nearly normal output of urine, these drugs are dangerous.

74

HANDBOOK OF HEALTH

morphine. The medication advised below is suitable for amebic dysentery whether mild or severe. Carbarsone contains arsenic and may cause ill effects. Should signs like a cold in the head or an unexplained rash develop, discontinue the drug at once. Dose. One capsule containing 0.25 Gm. twice daily after taking food. Continue for 7 days and, if diarrhea recurs, repeat the course of carbarsone after an interval of not less than 10 days or try treatment as for bacillary dysentery. Chiniofon can be used as a substitute for carbarsone in cases of amebic infections in which there is not much diarrhea. It tends to cause a temporary increase of diarrhea, usually slight. Dose. Two to four pills of 0.25 Gm. each, taken three times daily after eating, for seven days. The course can be repeated after a week, if desired. Vioform may be preferred to chiniofon. The dose is 1 pill of 0.25 Gm., 3 to 4 times daily. Diodoquin, another drug of similar character, has been little used as yet. TYPHOID FEVER

Diagnosis. Ordinarily, the temperature rises gradually for a few days to about 103° or 104° F., then continues high for 10 days or 2 weeks and subsequently falls gradually. In malaria, the temperature may go higher, but it usually approaches normal at frequent intervals. The

TROPICAL DISEASES

75

fever of malaria responds to quinine but that of typhoid does not. Treatment. When in a malarial region, try treatment as for malaria. If this fails, treat as for fevers in general (p. 30). When a fever continues for several weeks, as is usual in typhoid, the problems of nursing and nutrition become of primary importance. CHOLERA

Cholera persists in India and in China. Epidemics spread from time to time to other parts of the world. Transmission is by ingestion of contaminated food or water (pp. 11, 13). Prevention. In the presence of an epidemic, take the following precautions: (1) Be vaccinated at once unless this has been done within three months. (2) Drink only freshly boiled or chlorinated water. (3) Eat only hot food. (4) Protect all food from flies. (5) Wash hands with soap before eating. (6) If possible, avoid contact with the sick. Diagnosis. The attack usually begins abruptly with vomiting and very profuse watery diarrhea lasting from 2 to 12 hours. Resulting dehydration causes muscular cramps, emaciation of the body, and wrinkling of the skin of the hands. There is little or no fever. Collapse, with clammy skin, may follow soon

76

HANDBOOK OF HEALTH

and may be rapidly fatal. In cases which survive this stage, slight or moderate fever supervenes. Death may come later. Treatment. Mild cases may recover with little or no treatment. In the ordinary case, treat as follows: (1) Rest is of paramount importance. To secure it, cleanliness of the bed must be sacrificed to some extent. (2) Replacement of fluid lost by diarrhea and vomiting is vital. Water should be taken in small amounts at very frequent intervals. Several quarts will be needed daily while diarrhea continues, to replace loss of fluid and to maintain urinary excretion. (3) Keep the patient's abdomen and legs warm by application of hot-water bags well wrapped to prevent burning. (4) Some of the salt lost by diarrhea can be replaced by adding one-half a level teaspoonful of table salt to each quart of water taken unless vomiting prevents. (5) No food other than rice-water or barley-water should be offered during the first 48 hours or until the diarrhea begins to abate. Thereafter, liquid nourishment should be administered in very small amounts every 2 to 4 hours. Add table salt to all nourishment to the limit of palatability. (6) After vomiting and diarrhea have ceased, vitamin concentrate and fruit juice should be administered along with small quantities of soft solids.

TROPICAL DISEASES

77

AFRICAN SLEEPING SICKNESS

This disease is confined to parts of tropical Africa. It has no relation to the sleeping sickness of other regions. It is common in the Congo Basin and in the vicinity of Lakes Victoria, Edward, Albert, Tanganyika, and Nyasa, and it occurs in nearly all parts of the tropical belt. Transmission. Man becomes infected by the bite of certain species of tsetse fly. Other species are harmless to man. Fortunately, only a small proportion of the flies are infected, so that the chance of escaping the disease is good, even when one is often bitten. The tsetse fly bites only in the daytime, and it is attracted by dark-colored clothing. Prevention. Where sleeping sickness is prevalent: 1. Avoid particularly the bushes near lakes or streams where the tsetse (Glossina palpalis) may be enormously abundant. If it is necessary to pass through such a region, a head-net and gloves may be worn, or one may traverse it with safety on a dark night. A species of similar habits (G. tachinoides) frequents the southern edge of the Sahara. Another species, G. morsitans, is found especially in the northeastern part of Rhodesia, in Nyasaland, and in Mozambique. It is not confined to the vicinity of water and it frequents open country. 2. Camp on open, rising ground at least one hun-

78

HANDBOOK OF HEALTH

dred yards away from water, where there is a breeze, and well away from native habitations. Diagnosis. The symptoms develop gradually a few weeks after infection. There may be slight fever or a rash at first. In the second stage, glands, hard or soft, small or large, and tender or not, may be felt behind the ears or in the neck, but symptoms may not yet attract attention. In the third stage, weakness and emaciation are followed by somnolence and death. The disease runs its course in a year or two. Tsetse flies are easily recognized by their smokecolored bodies and dark wings, the outer borders of which are parallel when the fly is on its legs. Treatment. Accurate diagnosis and efficient treatment require the services of a physician familiar with the disease. If begun before somnolence develops, cure can be effected in most cases. YELLOW FEVEK

Distribution. In Africa, small epidemics of yellow fever have occurred on the west coast from Senegal southward to the Congo River, in the Sudan and in Uganda. In South America, there have been outbreaks in the interior of Colombia, of Ecuador, and of Peru, and in the state of Bahia, Brazil. Prevention. 1. Protective vaccination is recommended before going to a locality where yellow fever exists.

TROPICAL DISEASES

79

2. Yellow fever is transmitted in towns by mosquitoes of the genus Aedes, which bite in the daytime but seldom in bright sunlight. The vector of "jungle yellow fever" is another kind of mosquito. Anti-mosquito measures, such as individuals may take against malaria, afford some protection. Diagnosis. The initial fever lasts about a week, as a rule, and is followed by a brief remission and a secondary rise of temperature lasting for 3 or 4 days. Vomiting is apt to be frequent and the vomit is likely to contain dark-colored blood. Yellow fever must be differentiated from other diseases in which jaundice (p. 25) is a symptom. A form of infectious jaundice known as Weil's disease, closely simulates yellow fever. Treatment. The patient must stay in bed. The only nourishment to be taken during the first 3 days is fruit juices. Unless vomiting prevents, an abundance of water should be ingested. The water can well be rendered alkaline by adding a teaspoonful of sodium bicarbonate per quart. Increase diet cautiously. Because of danger of circulatory collapse, do not transport the patient until convalescence is established. PLAGUE

Distribution. Human plague is particularly prevalent in India and in Tibet. There are active foci of human infection in Burma, in Madagascar, and in

80

HANDBOOK OF HEALTH

parts of South America and of Africa. Wild rodents are infected with plague in many sparsely settled parts of the world, including the western United States, northern Argentina, Russia, South Africa, and northern China. Transmission. Usually from rat to rat and from rat to man by the rat flea. The pneumonic form is extremely contagious and is transmitted directly from man to man by droplets expelled when coughing. Prevention. Bubonic plague is seldom a serious menace to the traveler. Therefore, vaccination against it is advised only when one is proceeding to a place where plague has occurred recently. Protect yourself so far as possible from fleas (p. 98), and avoid congested native quarters, markets, and bazaars. Never handle rodents found dead. Treatment. Anti-plague sera have been used with some benefit for bubonic plague. Suppurating, soft buboes may have to be incised. Other treatment should be as for fevers (p. 30). TULAREMIA

Tularemia, or "rabbit fever," is a disease primarily of wild rodents, particularly rabbits and ground squirrels. Distribution. Common in parts of the western United States of America and known in parts of Europe, Russia, and Japan.

TROPICAL DISEASES

81

Transmission may be direct, through the handling of infected animals, or indirect, through the agency of biting flies, of ticks of the family Ixodidae ("dog ticks"), or other parasitic insects. Prevention. Where tularemia is common, it is unwise to handle, still more so to dress, rodents. Biting insects and sick animals of any sort are to be avoided Diagnosis. The disease may begin with chills, sweats, headache, and pain in the back and limbs. The fever begins suddenly and continues irregularly for two or three weeks. Meanwhile, pain, swelling and ulceration or an abscess may appear at the point of original infection, and the lymph glands of the region become swollen and painful. When the infection begins on the hands, the swollen glands will be at the elbow or in the armpit; when on the foot or leg, the swollen glands will be in the groin. Cases in which there are swollen and painful glands resemble plague and may be mistaken for it or vice versa, where both diseases exist as, for example, in many of the western States of the United States of America. Treatment. As for fevers (p. 30) and surgical treatment of local infection. See Sepsis (p. 128). RELAPSING FEVER

Distribution. Forms of this disease are widely distributed in Europe, in Asia, and in the drier parts of

82

HANDBOOK OF HEALTH

Africa and of the Americas. The tick-borne variety is called "kimputu" in Africa. Transmission. In Europe and in Asia, the disease is transmitted, as a rule, by lice; but in Africa and in America the vector is a tick of the genus Ornithodorus. The ticks commonly found on animals do not transmit relapsing fever. Like the bedbug, Ornithodorus inhabits crevices in the walls of huts, or houses, and bites at night. It may be found in the dust of the ground at camp sites. Prevention. Keep free of lice and, where this disease is transmitted by ticks, sleep in a tent under a net and avoid entering native huts. Diagnosis. The fever comes on suddenly like malaria, for which it is often mistaken, lasts a few days, and drops quickly to normal. After an interval of about 5 days, the fever recurs in similar form. Several attacks of fever of diminishing severity usually succeed one another. Treatment. This fever can be cured quickly, as a rule, by a few injections of neoarsphenamine, but they should be given by a physician. D E N G U E AND SAND-FLY FEVER

Distribution. Dengue, sand-fly, and other fevers of short duration, are common in the tropics and subtropics. They are very rarely fatal. Diagnosis. The onset of symptoms is sudden, ac-

TROPICAL DISEASES

83

companied by much pain in the limbs and about the eyes. Often there is a rash not unlike that of measles. It appears first on the hands and feet. The duration of the fever is from three days to a week. Transmission. Dengue is transmitted, as is yellow fever, by mosquitoes of the genus Aedes; and sand-fly fever by a very small gnat, Phlebotomus. This insect is not to be confused with the still smaller midge, Culicoides, which is also called sand-fly. Prevention of these diseases is most difficult. Phlebotomus bites at dusk or after dark and it is partial to shade. It can pass through a net unless the mesh is very small. Treatment. As for fevers (p. 30). Aspirin can be given for the pain. Undulant

Fever

Undulant fever, or Malta fever, has long been common in the Mediterranean Basin but may occur almost anywhere. Transmission. It is usually contracted in Europe by drinking unboiled goat's milk, and in the United States from raw cow's milk. The disease can be acquired by contact with infected animals; especially cows, goats or pigs. Prevention. Drink no unboiled milk. Diagnosis. The fever may run a long course, punctuated with remissions.

84

HANDBOOK OF HEALTH

Treatment. As for fevers (p. 30), until a physician can be consulted. T Y P H U S F E V E R AND SIMILAR D I S E A S E S

Distribution. Typhus fever and allied diseases are world-wide in distribution, but they are a serious menace only in certain localities or under circumstances which favor their spread. FEVERS OF THE T Y P H U S GROUP Name European typhus or Epidemic typhus

Distribution Transmitted by Russia, Central Europe, Louse Near East, North Africa

Murine typhus or Endemic typhus

Locally common in both hemispheres

Rat flea

Rocky Mountain spotted fever

Western mountain states, "Dog tick" sparsely in the Alleghanies, Dermacentor U. S. A. Säo Paulo typhus Eastern Brazil Amblyomma Mediterranean typhus North Africa, South Africa Ticks of various species or "Fiövre boutonneuse Japanese river fever Japan, Formosa, Korea, Mites (p. 100) or "Tsutsugamushi' Malaya

Prevention. The commonly used vaccines are of doubtful value. Protect yourself so far as possible from the bites of the insects which transmit the type or types of typhus which occur where you are. (See also, Biting Insects, Chapter V.)

TROPICAL DISEASES

85

Symptoms may be mild or severe. Fever increases rapidly for two or three days, remains high for a week more or less, and subsides quickly. A rash, more or less pronounced, appears on the body about the third day. It spreads later to the limbs. There may be delirium. The pulse may become more and more rapid and feeble and death follow from circulatory collapse. Treatment. As for fevers in general (p. 30); with special attention to nursing, as in typhoid fever (p. 74). HOOKWORM DISEASE

The hookworm is common in nearly all parts of the moist tropics and subtropics. After passing through the skin, the immature hookworm develops into the adult form in the intestine. Thence the eggs are discharged in the stools. They hatch in moist earth.* The infection is contracted by contact with polluted soil. Most cases of infection are light and cause no symptoms. Heavy and repeated infection may lead to anemia and swelling of the legs and face. Prevention. Where the hookworm is prevalent, soil pollution should be prevented by the use of latrines, and boots should be worn to protect the feet. Treatment is not urgent. It should be directed by a physician. * In an arid country, the infection can be acquired on the banks of canals or irrigation ditches.

86

HANDBOOK OF HEALTH SCHISTOSOMIASIS OR BILHARZIASIS

Distribution. One or the other form of the disease is common locally in Puerto Rico, northeastern South America, in parts of tropical and subtropical Africa, the Yangtse Valley, locally in Japan, and in the southern islands of the Philippine Archipelago. Detailed information about its occurrence can best be obtained by consulting physicians living in the localities visited. Diagnosis. There are two principal varieties of schistosomiasis, which are caused by closely related parasites. The one attacks the bladder and urinary passages and the other the bowels and liver. Infection of the urinary passages causes pain in the region of the bladder or in the penis and more or less blood and pus in the urine. It may be mistaken for gonorrhea. Where the disease prevails, one may see natives who have suffered from it for many years and who present a variety of complications of a serious and distressing nature. The intestinal form may be mistaken for dysentery or for bleeding piles. Like the bladder form, it is of long duration. Prevention depends upon the knowledge that the three or four species of the parasite undergo a stage of development in fresh-water snails of certain genera. These snails live in canals, irrigating ditches, sluggish streams, or along the muddy margins of ponds or

TROPICAL DISEASES

87

lakes. At a subsequent stage, the immature parasite leaves the snail and swims freely about. It is too small to be readily seen. It penetrates the unbroken skin of the legs or any part of the body with which the infected water comes in contact, migrates through the body, establishes itself in the bladder or the bowels, grows to maturity, and lays its eggs. After being passed with the discharges into water, the eggs hatch. 1. Drinking water should be treated as described on page 13. 2. Water for washing or bathing can be made safe by heating to 130° F. (55° C.) or by storing it for forty-eight hours in containers free from snails. During this interval, the embryos of the schistosomes will die. 3. Avoid wading or washing in sluggish water in the vicinity of habitations. Treatment by means of antimonials is usually effective. These drugs should be administered only under medical supervision. TROPICAL E L E P H A N T I A S I S

This disease is prevalent in the Congo Basin, in the Island of Haiti, and in Fiji, and it occurs in many other parts of the tropics. It is caused indirectly by infection with Filaria bancrofti. Usually, infection with this parasite causes no symptoms, but there

88

HANDBOOK OF HEALTH

may be attacks of fever associated with swelling of a limb or of the scrotum. As a rule, the inflammation subsides spontaneously after a few days, but most of the swelling persists. Prevention. The larvae of F. bancrofti are transmitted by a mosquito of the genus Culex, which bites by day as well as by night. The traveler and even the white resident rarely suffer from this disease. Because local bacterial infection generally plays an important part in the development of elephantiasis, one should guard against it with special care where elephantiasis is common. Scratching is to be avoided. Abrasions should be promptly disinfected and protected by a clean dressing. Cracks of the skin between the toes or blisters of the feet should be carefully treated. Treatment. The attack of fever and attendant symptoms require rest in bed for a few days. During this time, the affected member should be elevated on an inclined plane to favor reduction of the swelling. In other respects, treat as for fevers (p. 30) or sepsis (p. 128). GUINEA-WORM DISEASE

Guinea-worm disease (Dracontiasis) is widely but locally distributed in tropical Africa and it occurs in Arabia, Persia, Turkestan, northwestern India, some of the West Indies, the Guianas, and eastern Brazil. The disease is caused by the presence in the tissues

TROPICAL DISEASES

89

of the adult female worm. It is threadlike in shape and from twenty to thirty inches in length. The end of the worm appears usually on the leg, where at first it causes a blister and subsequently an ulcer surrounded by a painful swelling. Whenever cold water touches the skin, the worm discharges a fluid containing embryos. T h e embryos develop in Cyclops (water flea). The disease is contracted b y drinking unfiltered water containing infested Cyclops. Treatment is difficult and also dangerous until after the worm has discharged all its embryos. T o ascertain this, the affected part should be douched daily with cold water to stimulate discharge. When this process has been completed, after a period of two weeks or more, the worm no longer resists extraction and may be gently wound out on a toothpick or it may die and become absorbed. Quicker results can be obtained b y methods requiring the services of a physician. WORMS FROM FISH, CRABS, OR CRAWFISH

The eating of raw fresh-water fish, crabs, or crawfish, a common practice in Japan, is risky. The fish may be infected with a kind of tapeworm, or crabs and crawfish with worms of other kinds. Thorough cooking kills these parasites.

90

HANDBOOK OF HEALTH TROPICAL U L C E R

Tropical ulcer is very common upon the lower legs of natives of the hot, moist parts of the tropics. It often follows a slight injury which has been neglected and it is seen particularly in ill-nourished individuals. Syphilis or yaws may complicate the condition or may cause chronic ulcers of a somewhat similar character. Treatment. Of first importance is cleanliness. Wash the ulcer with soap and warm water daily until free from pus and slough. Trim off unhealthy skin edges with scissors and leave no pockets to collect pus. Dress daily with dry gauze until the surface becomes red and clean. Thereafter, smear with boric ointment and cover with a layer of smooth cloth. When syphilis or yaws are causative, special treatment is required. Malnutrition requires a nutritious diet and vitamin concentrates. YAWS

Yaws, or frambesia, is closely related to syphilis but is usually transmitted by non-sexual contact or perhaps by flies which have fed upon sores. Sexual transmission is possible. Yaws is extremely common in native races in many parts of the tropics. It is generally contracted in childhood and the initial lesion is usually on an exposed part of the body. It is a raspberry-like swelling which is covered with

TROPICAL DISEASES

91

a crust of dried serum. T h e secondary eruption, which follows in 2 to 8 weeks, is more or less generalized and is very apt to involve the face. T h e later manifestations of yaws, which take a variety of forms, are usually seen in adults. Y a w s ulcers are apt to be multiple; they tend to develop where bone lies near the surface; and they closely resemble the ulcers of neglected tertiary syphilis. " C r a b y a w s , " common in African natives, causes swelling, cracking, and pain in the soles of the feet. Treatment. Y a w s yields promptly to injections of neoarsphenamine and to certain other powerful drugs. T h e layman cannot safely use these, but he can give much relief b y cleaning and dressing the ulcers. POISONOUS FOODS

Certain species of tropical fish are poisonous at some seasons and others throughout the year. One should eat only such fish as the natives eat. T h e " v o m i t i n g sickness of J a m a i c a " is a poisoning caused b y eating the -pink -parts of a fruit (Blighia sapoda) called " a k e e " which is in great demand in the West Indies. T h e white parts of the fruit are entirely wholesome. A native of West Africa, this fruit has been introduced into m a n y tropical countries including Central and South America, Mexico and Hawaii and it is adaptable to Florida. Epidemic dropsy, which resembles beriberi, is

92

HANDBOOK OF HEALTH

found in certain parts of India, where it is attributed to an impurity of mustard oil. The latter is much used in curries. HEAT EFFECTS

Cause. Heat stroke, heat exhaustion, and heat cramps are different types of response to exposure to heat. They may develop with or without exposure to the sun. The actinic or ultraviolet rays of the sun are no longer believed to be the cause of "sunstroke." Prevention. (1) Keep fit by hygienic living (p. 48). (2) Wear clothing suited to local conditions and climate (p. 53). (3) Take exercise, but avoid overexertion, rapid movement, and needless exposure to the sun during the hotter hours of the day. An umbrella is useful for shade. (4) When indoors, have the freest possible ventilation and, if there is no breeze, provide for air-movement by means of a punka or fan. (5) Drink water enough at all times to keep the urine normally dilute (i.e., of light color) and partake freely of salt at meals to replace that lost in the sweat. (6) Marked depletion of body fluids can result from profuse sweating in the presence of heat and humidity or in a very hot and dry atmosphere when sweating is less apparent. In order to prevent serious

TROPICAL DISEASES

93

heat effects, it is necessary that lost fluid should be replaced promptly. When sweating much, a minimum of 5 or 6 liters (quarts) of water should be taken daily. It is best to drink the water in rather small amounts at frequent intervals. Common salt ("table salt" or sodium chloride) is excreted in the sweat. When sweating is profuse, the supply of salt in the body may become seriously depleted. To prevent such depletion and the symptoms which may result from it, the lost salt must be replaced by adding J of a level teaspoonful of table salt or a salt tablet of 1 Gm. (15 grains) to every other full glass of water (8 ounces or 250 cc.). (7) It is essential to keep the head reasonably cool. When one is exposed to a hot sun, a pith helmet is cooler than any other hat because it is better ventilated. It is much lighter than cork but less durable, and it needs a waterproof cover if exposed to rain. In the American tropics and in the Philippine Islands, a high-crowned, broad-brimmed felt hat with ventilation holes on the sides is commonly worn. It gives sufficient protection to most people, but it is heavy, insufficiently ventilated, and hot. When wearing a felt hat in the sun, it is well to put a sponge or wet leaves into the crown. A Panama hat and an umbrella combine well. Persons who have suffered ill effects from the sun should wear helmets. (8) Do not take alcoholic drinks before sunset. Diagnosis. Symptoms, mild or severe, caused by

94

HANDBOOK OF HEALTH

heat may simulate malaria, or those of malaria may simulate heat effects. Mistakes of diagnosis, therefore, are common. Treatment. For headache with or without slight fever, take a cool bath. Then sit in the shade where there is a breeze, eat lightly, drink cool but not cold water freely, and avoid hot or alcoholic drinks until relieved. In heat exhaustion the skin is clammy, the temperature normal or but slightly elevated, and there is rapidity and weakness of the pulse. Recovery is the rule. Loosen the clothing, provide for rest in the shade, and administer freely strong tea, sweetened to taste. Tea is an excellent stimulant for the circulation. The food-value of the sugar is also stimulating. Water should be taken freely and to it should be added about 1 Gm. (15 grains) of salt to each full glass or 4 tablets to each liter (quart). If nausea results, reduce the amount of salt. In heat stroke (or "sunstroke"), the skin is hot and dry and the temperature is 103° to 106° F. (rarely higher). In severe cases, the pulse is very rapid and there may be unconsciousness or convulsions. Fatalities are common. In milder cases, the patient should be stripped in the shade, sponged with cold water, and fanned meanwhile until the temperature has fallen to 101° by mouth. He should then be put to bed and covered

TROPICAL DISEASES

95

lightly. Several quarts of water which is cool, but not iced, should be taken but in small amounts at a time, lest vomiting occur. To each glass of water should be added a salt tablet or one-quarter of a level teaspoonful of table salt unless it causes nausea. In severe cases, the treatment is similar to that for the milder cases, but must be more thorough and more prolonged. In the presence of unconsciousness or convulsions, the temperature must be taken by inserting the thermometer into the rectum. Finally, after the initial treatment has restored the patient to good condition, he should take a cathartic to move the bowels freely. For heat cramps, the patient should rest in the shade and drink copiously of salted water as for heat stroke. A warm bath or massage may help to relieve the cramps. SKIN DISEASES

Skin diseases of various kinds are particularly numerous in the tropics because heat and moisture favor the development of some of them and because insect bites and other minor injuries serve as portals of entrance for various kinds of infection. Prevention of skin diseases, therefore, involves particular attention to cleanliness of clothing and of person and the avoidance, so far as possible, of insect bites, scratching, and other minor injuries to the skin. (See treatment of insect bites, p. 106.)

96

HANDBOOK OF HEALTH

Prickly Heat is very troublesome to some persons in hot weather. It attacks chiefly the crotch and armpits, where sweating is most profuse. The skin is reddened but not swollen, and there is a sensation of burning and itching. Sometimes there are many small vesicles. Keep the skin as free from sweat and as dry as possible by use of light, well-ventilated clothing, by frequent washing, and by the application of talcum powder. Avoid scratching, lest secondary infection develop. In chronic prickly heat, a profuse papular eruption with slight thickening of the skin may develop where sweat accumulates; e.g. under the belt or at the ankles. Itching is intense. Painting with tincture of iodine may bring relief from the itching and improvement in the condition. Ringworm, or "dhobie itch," is a slowly developing, superficial infection of the skin caused by a minute fungus. Where the skin is smooth, the patch or spot has a sharply defined edge and tends to be circular. The parts most often affected are the limbs, the crotch, the armpit, and the skin between the toes. On parts of the body where the skin keeps dry, the affected area is rough and scaling, but where there is moisture, and especially between the toes, the superficial layers of skin become so soft that they can be scraped off easily. Cracks or ulcers may develop and these may lead to infection. In the crotch or armpit, ringworm looks like a red patch without swelling or

TROPICAL DISEASES

97

scaling, and it may itch intensely. It is known to athletes as "red-flap." Ringworm on the body can usually be cured by thorough washing and by applications of tincture of iodine on three alternate days. Frequent change and boiling of underclothes helps to prevent recurrence. Ringworm between the Toes ("Athlete's Foot"). Strong antiseptics and tincture of iodine should not be used between the toes lest they increase or cause inflammation. "When there are cracks in the skin, ulcers, soreness or swelling, only soothing or mildly antiseptic ointments or foot powder should be applied. The toes should be kept separated by placing between them several layers of soft tissue paper. After the inflammation has subsided and the ulcers and cracks have healed over, Whitfield's ointment, half strength, may be used cautiously at intervals of a day or two for its antiseptic effect. It should be applied only before going to bed for the night and should never be used when on the march. When there is much inflammation of the toes and especially when sensitiveness and swelling appear in the glands of the groin, one should avoid walking and should keep the feet elevated lest infection spread dangerously.

CHAPTER V BITING INSECTS, VERMIN, AND SNAKES BITING INSECTS AND VEKMIN

Lice. There are three kinds of lice: the "gray-back" or body louse, which inhabits the clothes and body in general, the head louse, and the pubic louse or "crab." The body louse lays its eggs in the seams of clothing, the head louse on the hair of the head, and the pubic louse on the hair of other parts. Treatment. It is easy to kill the lice, but the eggs, or nits, are more resistant. For body lice, scrub the body, boil or steam clothes and inner layers of bedding in a large pot or oven, or dip them in gasoline, or press them with a hot iron, paying special attention to the seams of the clothing. Steaming destroys leather garments, and shoes do not need it. Wash the body, and put on clean clothing. For head lice, clip the hair short to remove the nits; then shampoo. For pubic lice, clip the hair of affected parts and pick off the lice with the point of a knife. Fleas. Some persons are very attractive to fleas; others are practically immune. High boots or leggings and long drawers help to keep fleas out. A strong

INSECTS, VERMIN, AND SNAKES

99

solution of Epsom salts in water allowed to dry on the skin is said to serve as a deterrent. " F l i t " can be used to great advantage on outer clothing and bedding. If used too freely on underclothes or socks, it irritates the skin. Floors should be kept free from dust and may well be washed occasionally with water containing kerosene, which is deadly to all insects. Flake naphthalene scattered freely between sheet and mattress and between sheet and blanket is a potent deterrent to fleas. Pet animals are apt to be infested with fleas which will often bite man. Such animals should be washed with tar soap or rubbed with derris powder. Chiggers. The true chigger, jigger, chigoe, or nigua (South America), is a small kind of flea (see also Mites, p. 100) which is abundant in the American tropics and in parts of West Africa and of India. This flea attacks not only men but also various animals, wild or domestic, particularly pigs. Chiggers bite like other fleas, but, in addition, the female burrows into the skin, usually on the toes or feet, sometimes under a nail. In the course of a few days, the insect swells to the size of a small pea and can then be recognized as a whitish spot with a dark brown dot in the center. Resulting bacterial infection usually causes more or less inflammation in the vicinity. Dangerous sepsis may follow neglect. Prevention. As for other fleas. Avoid native huts especially where there are pigs.

100

HANDBOOK OF HEALTH

Treatment. Shell out the swollen female chigger with a sterile needle or knife-point. Then apply tincture of iodine and a dressing to keep out dirt. Bedbugs are apt to be a pest in ill-kept dwellings or ships. They may be found in almost any part of the world, and there is a species peculiar to the tropics. They hide during the day and lay their eggs in the cracks of bedsteads, floor, and walls. They bite the face and other parts of the body during sleep. The bugs and their eggs can be killed by applying kerosene, gasoline, or alcohol to their hiding places. Clothing and blankets can be picked over. Free use of " F h t " may help to keep bedbugs away, but naphthalene and insect powder will not deter them when they are hungry. A bright light kept burning through the night may be useful. Mites. Aside from the mite which causes scabies, there are a number of varieties whose bites cause the most intense itching and even wheals which may be mistaken for hives. Such mites are extremely widely distributed in the Americas, Europe, Asia, Australia, Japan, the East Indies, and Malaya. In the three latter regions, they are capable of transmitting a form of typhus fever. In those parts of the mid-western United States where mites abound, they are particularly numerous in the late summer and early autumn, and farther south they may be numerous even in winter. In the Amazon Basin they are an outstanding nuisance.

INSECTS, VERMIN, AND SNAKES

101

In the larval stage, they attack many kinds of mammals and even birds, as well as man. They are known in the United States as red bugs or harvest mites and, erroneously, as jiggers or chiggers. The true chigger is a flea (p. 99). In South America, the red bug is known as böte rouge, coloradillo, bicho Colorado, or mucuim. Even though bright red in color, the insect is so small as to be scarcely visible without a lens. The bites do not begin to itch for a few hours, but subsequently the itching persists for days. Protection. Avoid contact with long grass or other herbage. Should this become necessary, high boots or wrap puttees offer much protection to the legs, and finely powdered sulphur or pyrethrum powder dusted into the underclothing and socks is somewhat efficacious as a repellent. On return to camp after being exposed to mites, it is well to change all clothing and to sponge the body with a mild and not too irritating disinfectant, such as a one per cent solution of lysol and, finally, to wash it off. A new method of applying sulphur has been recently published and highly recommended by Weigel. A mixture of one part of powdered sulphur with four parts of a vanishing cream * is spread thinly over the body before going into the field. On returning, one is advised to take a bath with soap and to reapply the cream. * "Hazeline Snow" proved satisfactory ("War Medicine. A Symposium." By W. S. Pugh. 1942; p. 514).

102

HANDBOOK OF HEALTH

Sulphur irritates sensitive skins and some persons are allergic to pyrethrum. Clothing can be freed from mites by pressing with a hot iron. Ticks. Information about ticks of the Argasid family (genus Ornithodorus) is presented under Relapsing Fever. The habits of dog ticks, or wood ticks, of the Ixodid family are very different. They may be so numerous in vegetation where there are cattle or wild animals as to be a serious nuisance. Not only the adults but also the small, immature forms, or seed ticks, will bite. In the Amazon Basin one may be obliged, after a short walk through grass or bushes, to pick off a hundred or more from the body. Protection. The precautions to be taken against mites are applicable also to Ixodid ticks, except that sulphur is less likely to be helpful. Ticks can easily be picked off by grasping them between the edge of a knife and the thumb but, in regions where there is tick-transmitted typhus fever or tularemia, ticks should not be handled or crushed because they may be infected. They can be removed from the body with forceps or by means of an alcohol rub. The skin of the entire body should be inspected for ticks twice daily. Bedding should never be laid upon the ground and it should be inspected daily. Scorpions are of various lands and are common in most tropical countries. The sting is painful, but serious consequences are rare and treatment is seldom needed. Deaths of young children have been re-

INSECTS, VERMIN, AND SNAKES

103

ported, however, from certain districts of Mexico where there is a more than usually poisonous species. Spiders. The bites of spiders may cause local pain and swelling but serious consequences are rare. One should beware of the black widow, varieties of which exist pretty much throughout the world. It is a largebodied, long-legged spider, black, and marked with red or orange. Its bite may cause symptoms of collapse which are occasionally followed by death. Maggots are the larvae of flies. They may be found in wounds which have been exposed to flies, in the nasal passages, or they may be discharged from the intestine. Wounds which become naturally infested with maggots are apt to be foul-smelling and heavily infected with bacteria. The maggots may be removed or not as desired. In some instances they seem to promote healing. The presence of maggots in the nasal passages is associated with foul-smelling discharges. Because they are difficult to get at and because dangerous complications may develop, medical aid should be sought at the first opportunity. Maggots can be removed from the intestine by taking a purgative. Botflies. Varieties of these flies are common in the American and African tropics, but they occur also in the temperate zone. The maggot burrows into the skin, where it causes a painful swelling like a boil.

104

HANDBOOK OF HEALTH

Treatment. Dropping oil or liquid paraffin at intervals onto the aperture in the skin deprives the larva of air. As a result, it extrudes part of its body, and it can then be expelled by firm pressure upon the skin at either side with the thumbnails. It can be killed by putting on a dressing of wet tobacco and then can be squeezed out. Ants. Voracious army ants in the forests of Africa or of South America may invade a camp or a house in such numbers as to drive the inhabitants out. After killing every insect and small animal which they catch, they pass on. They can be fought off with fire, with kerosene, or with gasoline, which are deadly to all insects. They will not cross a line on the ground over which kerosene has been poured. In the forests of tropical America, ants of many kinds are found. One must be constantly on guard to avoid their stings. Severe pain and other symptoms may follow the sting of a very large species called the tucandera. Termites may destroy clothing to which they gain access at night. The kissing bug or barbeiro (Brazil) is an elongated night-flying bug, one-half to one inch in length, belonging to the family Reduviidae. It is locally common in Yucatan, in Central America, and in northern South America, where it can transmit Chagas' disease (American trypanosomiasis) to man. Native huts, neglected houses, and stables are likely to be infested by these bugs. In well-constructed dwellings

INSECTS, VERMIN, AND SNAKES

105

adequate protection is given by screening. Otherwise, sleep under a mosquito net. Vampire bats are common locally in parts of tropical America from Yucatan southward. They bite only on exposed parts of the body during the night. A mosquito net gives adequate protection. These bats bite horses and other pack animals freely and cause much loss of blood. Moreover, they are capable of transmitting rabies to man and murrina, a serious trypanosome disease, to horses in Panama. Leeches are locally common in ponds or sluggish streams, where they attach themselves to bathers. Small land leeches are a pest in the tropical forests of the Far East. They are very numerous in the high forest, and are never found in grass-lands or even in secondary forests. They are about three-quarters of an inch long and the thickness of a match-stick. They will crawl through the eyelets of laced boots or leggings. High boots do not exclude them unless the tongues are sewn in. The best protection is given by spiral puttees worn with riding breeches. Soap should be rubbed freely onto the breeches where they open at the knee. A lighted cigarette, a little table salt, or tincture of iodine applied to a leech will quickly cause it to drop off. The bites should be painted with tincture of iodine to prevent secondary infection.

106

HANDBOOK OF HEALTH TREATMENT FOR INSECT B I T E S

Itching from insect bites may prevent sleep. The itching can be relieved, at least for a time, by touching the bites individually with tincture of iodine. A 20 per cent solution of salicylic acid in 80 per cent alcohol is perhaps more efficacious, and 10 per cent salicylic acid ointment can be used to advantage except on a delicate skin. Infection. A common result of the itching and scratching caused by insect bites is superficial infection of the skin by bacteria. Such infections should be prevented by applying tincture of iodine to bites which have been scratched. Should infection occur, treat it with sulphur ointment. In the moist tropics, scratching often produces infected ulcers which are extremely difficult to heal even when frequently and carefully dressed. They get well rapidly and spontaneously, however, when one returns to a cooler climate. If you must scratch, keep the nails cut short. POISONOUS SNAKES AND S N A K E - B I T E *

Protection. In desert countries one often sleeps on the ground. Snakes may then crawl into the bedding or into the tent for warmth. Barefooted or ill-shod * This section has been adapted from that written by Dr. Thomas Barbour for the Handbook of Travel, second edition.

INSECTS, VERMIN, AND SNAKES

107

field workers are often bitten in the hand, foot, or ankle. High leather boots give nearly complete protection. Canvas leggings and spiral woolen leggings (puttees) give some protection. On account of the discomfort of wearing high boots or leggings, I look carefully where I step and do not put my foot down until I have looked. Where this is impossible owing to dense vegetation, by all means wear boots. Many cases of snake-bite formerly occurred at night because many of the venomous species are more or less nocturnal, but the modern flashlight has changed this. In India and the East Indies where bathrooms are likely to drain directly out of doors, snakes often get into the house and hide in dark corners. I have never heard of a snake climbing into a camp cot. The Viperine types have long, movable fangs folded back against the roof of the mouth. To this class belong the rattlesnakes, the moccasins, the copperhead in North America, as well as the fer-de-lance, the bushmaster, and all the poisonous snakes of America except the coral snakes. Vipers occur in all parts of the Old World as well. The bite of a viper is very characteristic. It is a sharp, hard blow, after which the head is quickly withdrawn; in almost every case there is a distinct drag at the site of the bite during the withdrawal of the long, slender fangs. The Elaphid types, the other group of venomous

108

HANDBOOK OF HEALTH

species, have short, thornlike fangs which are placed far forward on the upper jaw and stand constantlyerect. With these snakes, biting is almost always followed by a more or less prolonged series of chewing motions. The American coral snakes occur from the Carolinas to Argentina. They live largely underground. They have very small mouths and extremely short fangs, so that comparatively few cases of the bite of the coral snake are recorded. The percentage of mortality is very high. The coral snakes are brilliantly banded, usually with black, red, and yellow. Certain harmless snakes closely simulate coral snakes in color. A few other species of more or less poisonous snakes belong to a group in which the fangs are situated far back on the jaw and hence they are unlikely to do harm. Effects of Snake Poison. The poison of the vipers is called hemolytic for the reason that it breaks down the red blood cells. It also causes rapid gangrene and renders the walls of the blood vessels permeable, so that much discoloration and oozing of blood results. The venom of the Elaphid types attacks the nerves and hence is called neurotoxic. The South American rattlesnake differs from almost all other vipers in that its poison is neurotoxic and frequently causes blindness. This rattlesnake occurs throughout Central and South America.

INSECTS, VERMIN, AND SNAKES

109

In almost all the poisons, both elements exist but the vast majority of vipers have predominantly hemolytic poison, whereas the vast majority of Elaphine snakes have neurotoxic poison. When no serum is available or when it may not be obtainable for some little time, it is advisable to apply a tourniquet to arm or leg. This should be loosened at intervals of not more than fifteen minutes' duration and an opportunity given for circulation to be resumed for five to ten minutes at least. Continued application of a tourniquet, with viper bites especially, will lead to more rapid gangrene in the affected member. Sucking should be instantly resorted to, because the venom is distributed with incredible rapidity. Unless a sharp cut can be made across the site of the bite almost instantly, cutting may do more harm than good by giving added opportunity for secondary infection with bacteria. A cupping bulb and cup may be carried conveniently. Permanganate, snake stones, and quack remedies practised by natives, are probably all ineffective. A large dose of whisky taken at the moment the bite is received is harmful because it speeds up the distribution of the venom through the body. Use of Antivenin, i.e., serum. The total amount of venom which any individual can neutralize depends largely upon his body weight. The object of treatment is to remove or to neutralize that portion of the venom which the body cannot neutralize.

110

HANDBOOK OF HEALTH

Each poison causes its peculiar reaction according to the proportions of the different active principles it contains, but there are similarities in the venoms of related groups or species. Death is the result of the sum of the activities of the several toxic factors. Whenever possible, that antivenin should be used which has been prepared from venom of the species which has inflicted the bite. When this is not possible, a polyvalent antivenin made from a mixture of venoms of a number of species of snakes is often effective. Any antivenin is better than none. Antivenin should be resorted to as promptly as possible in every case. A cure is often effected even when the patient's condition appears to be hopeless. Large snakes may inject several times the minimum fatal dose of venom. A snake which has fed within a few days has used up its poison. Persons bitten by such snakes, or by small snakes, recover spontaneously. A child requires far more antivenin than does a heavy man for successful treatment. Antivenin should he injected into the muscles well away from the area which has been bitten for, in this vicinity, distribution by the circulation is less effective. Antivenin should be administered two or three times if improvement is not prompt. Antivenin is put up in small glass ampules, each containing a normal dose of about 10 cc. of the product. Scratch the neck of the vial with a file, break it off

INSECTS, VERMIN, AND SNAKES

111

and suck the contents into a clean antitoxin syringe. The best of the antivenins now being made last a considerable time even when kept under unfavorable conditions. They are most effective when freshly made and kept cold. Types of Antivenins. The traveler should get upto-date information about available antivenins. In North America a polyvalent antivenin is prepared by the Antivenin Institute of America. For Central America an anti-crotalic antivenin is made to combat the peculiar poison of the rattlesnake of the American tropics; there is also an anti-bothropic type for the tropical fer-de-lance and its allies; and an antiophidic type which is polyvalent. Similar antivenins are made for South America at the Instituto Butantan, in Säo Paulo, Brazil. There were Pasteur Institutes in Saigon, Bangkok, and Pondicherry where antivenin against the cobra venom was being produced, and, no doubt, other products are now being made elsewhere. The Walter and Eliza Hall Institute at Melbourne, Australia, may be producing antivenin against some of the Australian species. Wounds by Poisoned Weapons. The treatment is like that for snake bite, except that antivenin is useless unless snake venom was a constituent of the poison.

CHAPTER VI T H E ARCTIC* Maintenance of health in the arctic is largely a matter of food and clothing. The entire winter outfit of an Eskimo weighs less than our ordinary winter clothes without an overcoat. On entering a hut, the native takes off both shirts and his boots to avoid sweating them. He usually receives company arrayed only in trousers and stockings. Food. Dietary requirements in cold climates do not differ from those in temperate climates except in the need for more of the energy-yielding foods which, in order of importance, are fat, protein and carbohydrate. Two serious diseases, symptoms of which may develop alone or in combination after a number of months in the arctic, are scurvy (p. 43) and beriberi (p. 42). They are caused respectively by deficiency in vitamin C and in constituents of vitamin B. The animal food which forms the exclusive diet of the Eskimo for long periods when he lives in the traditional way, protects him against these diseases because he eats the internal organs which are rich in * This section is taken mainly from that written by the late George P. Howe, M.D. for the first edition of the Handbook of Travel.

THE ARCTIC

113

vitamins and because much of his food is eaten raw. The visitor who does not wish to adopt the diet of the Eskimo, should inform himself about the vitamin content of preserved foods (p. 9) and he should be well supplied with vitamin concentrates (p. 205). Drink. Snow or ice should not be swallowed except in small quantity. If thirsty, hold a piece of ice or a little snow in your hand until it is wet and then suck the water off. If you eat snow or ice, your tongue will get sore, and your thirst will increase. Ice gives more water than snow. It is dangerous to take alcohol during exposure. Clothing and bedding should be light to prevent sweating, loose to be warm, and well-ventilated to keep dry. Never sleep in a garment which binds anywhere, because it impedes the circulation, and never use a waterproof sleeping-bag, because it becomes soggy. Frostbite, or superficial freezing, is generally due to exposure to wind as well as to cold. It shows as a white spot on the skin. See also p. 195. A warm hand held over the spot causes it quickly to disappear, but hard rubbing with the hand or, worse still, with snow is apt to rub off the skin. When there has been loss of skin, the resulting ulcer should be treated like a burn. Do not pick or chip frozen parts. They heal better if let alone. Exposure. Look out for springs along the banks of streams or water on the ice. If the feet or any other

114

HANDBOOK OF HEALTH

part get wet, change to dry clothing at once or make a fire, if possible, and dry out. See also p. 160. When lost in a blizzard or in darkness, an Indian finds shelter which will prevent the snow from drifting against the warmer parts of the body where it might melt, pulls his arms inside his shirt, squats down and waits for daylight or for moderation of the storm. The principles he follows are three, namely, to keep dry, to save body heat, and to save strength. Exhaustion comes on in men enfeebled by hardship. To save life, a warm shelter must be quickly reached. Then give the man a cup of strong, hot tea, strip and wrap him in blankets previously warmed, and lay him in a comfortable position. If hands and feet stay cold, but are not frozen, rub them and presently give some more tea or a small drink of brandy. As soon as strength begins to return, give food in small amounts at frequent intervals until he is relieved. Starvation. Starving people may be ravenously hungry or weak and exhausted. The former may overeat to the point of danger if allowed to do so. The latter may require tea or an alcoholic drink to start them on the road to recovery. They should then be fed with liquids administered frequently in small quantities. When appetite and strength begin to return, solid food can be allowed in moderation. Snow blindness varies in severity from slight irritation to severe inflammation and loss of vision. The

THE ARCTIC

115

same sort of irritation or inflammation may be caused by the glare of a tropical sun on water or in a desert, and it must be guarded against especially where there is sun on snow or ice. Treatment. At the first sign of irritation, protect the eyes from bright light and use them only when absolutely necessary. If you must go on without goggles, rest the eyes by keeping them fixed on a dark object, and blacken the lids, cheeks, and bridge of the nose. If the eyes become painful and swollen, stay in the dark for a few days and let them get well before proceeding, lest you lose your sight. Meanwhile, keep the eyes clean by bathing them every few hours with clean warm water and a soft clean cloth. Then, put in drops of boric acid or zinc sulphate solution and grease the edges of the lids with boric ointment to prevent them from sticking. If there is much pain, put drops of holocaine solution in the eyes every four hours for a few days. When blindness develops, it is slow to get well and requires prolonged care of the eyes, prevention of exposure to bright light or strain, and wholesome living. As a rule, part at least of the sight can be restored. Vermin. The body louse is the principal pest. It can be killed in cold weather by leaving clothing out overnight, but the clothing must be placed out of the reach of dogs. Indian and Eskimo squaws are expert at picking off nits.

116

HANDBOOK OF HEALTH ARCTIC CLOTHING AND SLEEPING GEAR *

The enemies to be overcome during the summer season are winds, sleet, and rain, with much of the ground underfoot sodden and cold. Footwear should be of good waterproof leather, either imported or native. Anyone unaccustomed to wearing shoes without heels and with soft soles will be much more comfortable in well-made leather boots, but they should be really waterproof. He should be careful to supply himself with the necessary materials to re-waterproof his boots. To one accustomed to moccasins, the native sealskin boots will be both comfortable and all-sufficient and will have the added advantage of being very light and easily replaceable. Whatever shoes are used should be large enough to permit of wearing at least two pairs of heavy socks. Light rubber boots either knee or hip length will be useful if the party is to travel much along the coast by boat. Good woolen underwear and outer garments which are both rainproof and windproof should be carried, but during the finer weather, ordinary clothing will be sufficient. Light gbves or mittens will be necessary at times during the summer. In selecting hats or caps, those not easily blown off and still giving fair protection to the eyes should be favored. * This section, by the late Maj. L. T. Burwash, F.R.G.S., was originally published in the second edition of the Handbook of Travel.

THE ARCTIC

117

Colored goggles should be taken if either water travel or work on the ice fields is to be undertaken. The frames of the goggles should fit the face closely so as to exclude light from the side, but ventilation must be secured to prevent fogging. The part touching the face should be of felt or of wood, because metal, cotton, or leather tends to favor frostbite. A serviceable kind of goggle is made of fine wire mesh of dark color. There are large openings for ventilation along the top which are so placed that reflected light cannot enter. They should be circular in form and about one-eighth of an inch in diameter. The native-made goggles of wood or bone, having a horizontal slit, have the advantage of good ventilation but the disadvantage that one cannot see the ground close to the feet, and this results in many falls. A goggle designed like the native goggle but having a semicircular piece of colored glass, set below the horizontal opening so that the ground underfoot could be seen, would be better than either the native or commercial goggle. Two pairs of goggles, dark and medium, should be taken, as well as spare goggles. Insects. For work on shore, especially if it be undertaken back from tidal waters, both mosquito nets for the bed and head nets should be provided. The summer bed can be either of blankets or a summer-weight eiderdown robe, the latter being lighter and warmer. Caribou skins for ground sheets

118

HANDBOOK OF HEALTH

are good but may be supplemented by a waterproof canvas which can be of service as a cover for the bed roll when one is on the move. In summer, as in winter, a good soft pillow adds greatly to comfort and warmth. Between-Season Clothing. During spring and fall, it will be necessary to draw on both the summer and the winter outfits. A light caribou-skin hooded shirt is often useful in the spring and late summer, and the leather boots of civilization can be replaced with advantage by the winter sealskin boots which admit of a much warmer foot dressing. Winter Clothing, Good woolen underwear and socks will be used in conjunction with native furs, but the basis of a winter costume will be caribou skins. Although a compromise of some of each may be made to serve, I do not think that woolen clothing can replace the fur trousers and shirts of the native costume. The primitive Eskimo costume included fur trousers and a hooded fur shirt with the fur worn next the skin. In ordinary weather with but little wind, this would suffice, but during the greater part of the winter an outer shirt, also hooded, and outer trousers, both of fur and worn with the fur out, are necessary. Both pairs of trousers are made fairly loose and reach low enough to cover the boot top, at which point they are loose enough to permit of ventilation. The hooded shirts hang loosely from the shoulders and reach to a point half way between the hips and

THE ARCTIC

119

the knees. These, too, should permit of ventilation. N o hat or cap is worn, the hoods being quite warm enough and also allowing good ventilation. Choice skins properly dressed are undoubtedly better in every way than are native-dressed skins. It m a y be possible to secure them before leaving civilization and, later, to have them made into various articles of clothing by Eskimo women. Footwear of caribou or other fur lasts only four days at most without resoling and is useless if moisture is encountered. Soles of polar-bear skin are more durable but are very slippery and cause many bad falls. If seal or white whaleskins are not available, an outer slipper of ten-ounce duck worn over the fur boot will be an advantage. Woolen socks must be supplemented by fur socks or slippers. Wear only a reasonable amount of either wool or fur between ankle and knee, but have an outer covering that is windproof. During winter travel in the arctic, by far the greatest problem is to keep clothing and bedding dry. This can best be done so far as clothing is concerned by careful ventilation. Should one be called upon to exert himself unduly when on the trail, he should be sure to remove some of his outer clothing. Fifteen minutes of overexertion when heavily dressed may result in wet clothes for the following twenty-four hours. The design and care of a bed is a much more difficult

120

HANDBOOK OF HEALTH

matter, as it is not possible to ventilate it properly. A primitive Eskimo sleeps between two caribou skins, which may or may not be sewn together at the foot, and, further, he sleeps without clothing of any sort. His ability to keep warm in this way is, I think, a question of training from infancy and can scarcely be equaled by a white man. My best beds have been made of caribou skins sewn into a bag with the hair inside, care being taken to select medium-weight skins that will be neither too cold nor too warm. In no event should a caribou sleeping-bag be covered with other material; if this is done, moisture condenses between the bag and the cover, which will be solidly frozen the following night. The keys to successful dressing are: for summer, wind and rainproof clothing; for winter, clothing that is warm and windproof with sufficient ventilation to prevent perspiration.

CHAPTER VII SURGERY Note. Because it is impossible to cover surgery and first aid briefly, the presentation is incomplete. Persons contemplating journeys in difficult or dangerous country are advised to study the Revised First Aid Textbook of the American Red Cross. For some diseases and injuries, older and perhaps outmoded forms of treatment are advised because some of these older methods are easier to carry out in the field. It is hoped that these pages will serve to guide the traveler in an emergency. The doctor who reads this little book should understand that simplicity and routine treatment have been the aim rather than more ideal but more complicated procedures. ASEPSIS

Dressings and Sterile Towels. Gauze for dressings can be carried in small packages already sterilized. It is useful for swabbing, for packing infected wounds, and for covering clean wounds. As a substitute, handkerchiefs or pieces of cloth can be boiled for twenty minutes. Towels can be prepared in the same way and used to lay sterile instruments on or to cover unsterile

122

HANDBOOK OF HEALTH

parts or objects which might be touched by the hands of an operator while at work. Metal instruments, except knives, should be tied up in a towel and boiled for twenty minutes. When wanted, the towel is spread out with the instruments upon it. Knives are dulled by boiling. The blade of the Bard-Parker knife should be washed in soap and water and soaked twenty minutes in alcohol, 70 per cent. Suture material means silk, catgut, or other substances used for sewing. When used for tying, these materials are called ligatures. They should be boiled or carried in glass tubes sterilized and ready for use. When the suture material is in such a tube, scratch the tube with a file and drop the tube into the disinfectant. The operator can then pick it out when needed, break the tube, holding it in a sterile towel or piece of gauze to protect his hands, and get his suture without "breaking his asepsis." Hands of the Operator. Cut and clean the nails. Scrub the hands and especially the nails with soap and brush for five to ten minutes. Use several changes of warm water. Rinse in alcohol, 70 per cent, or boric acid solution, 2 per cent. Then touch nothing not previously sterilized. If you do so, wash the hands again thoroughly with soap and rinse them in the antiseptic. Soap and clean water is more reliable than an antiseptic. Both are better than either alone.

SURGERY

123

Preparation for Operation. The assistance of a second person is very important if the operator is to maintain his asepsis. Before beginning the operation, however trivial, think of every step to be taken and prepare all the things that will be needed, as follows: (1) Get the patient into a convenient position where the light is good. For any operation he should lie down lest he faint. (2) Have a table for the instruments; (3) a bowl of disinfecting solution to rinse the hands; (4) materials and solutions for cleansing the wound; (5) instruments — knife, snaps, forceps, scissors; (6) suture material and needles; (7) sterile material for dressings; (8) bandage and padded splint if needed. Wounds. The skin about a wound may be cleansed by washing with alcohol or painting with 3.5 per cent tincture of iodine or tincture of metaphen, 0.5 per cent. If the skin is covered with mud, dirt, or grease, it may be washed with soap and water and dried before the disinfectants are used. The wound itself should not be scrubbed, and no strong disinfectants should be poured into it. Use sulfanilamide (p. 211). U S E S OF INSTRUMENTS

The hemostatic forceps, or "snap," is most useful to pick up bleeding vessels. An automatic catch holds them on until released. When looking for a bleeding vessel, wipe away the

124

HANDBOOK OF HEALTH

blood with gauze, remove it quickly, and snap directly on the bleeding point. A common mistake is to see the spurting blood and to try to pick up at random the vessel from which it comes. Always take time enough to see exactly where the bleeding comes from and do not poke around in a pool of blood. If it is necessary to apply several pairs of snaps, leave them all in place until convenient to tie all the vessels. After a short time has elapsed, small vessels can be prevented from bleeding by twisting the snap before removing. The Knife. Decide where to cut and then cut cleanly and firmly. As a rule, cut lengthwise with the limb or body. The same is true of the use of scissors. Sutures. Catgut is best for tying bleeding vessels and suturing muscles or deeper layers of wounds. Curved needles should be used for carrying catgut or any suture where a large bite of tissue is to be taken. It is best to hold the needle in a snap. Straight, triangular needles (Glover's needles) should be used for sewing skin; silk or cotton should be used and all stitches tied with the ordinary square knot. The same knot may be used on catgut, but it should be tied three times. Silkworm gut is also an excellent material for skin sutures. It is in nearly every fisherman's kit in the form of leaders. To ligate a blood vessel which has been picked up with a snap, the ligature should be tied down firmly about the tissue beyond the end of the snap. It is

SURGERY

125

always best to have the snap removed by an assistant in order that the tightening process may be completed at the same time. If this is not done, the ligature will probably come off. Do not try to tighten again after the snap has been completely removed. In tying a large vessel, such as an artery of the arm or leg, it is well to remove a little of the soft tissue about the vessel in order that the ligature may be properly applied at right angles to the vessel and tightly drawn up. The Tourniquet. A tourniquet may be improvised from a handkerchief or piece of cloth, not less than two inches wide, which can be firmly tied about the injured part. Wire or cord should not be used. The usual tourniquet employed by surgeons is a rubber tube drawn around very tightly over a folded towel. If some nonelastic substance, such as a handkerchief, is used, it is best to tie it loosely; then, using a stick, twist it up windlass fashion until bleeding ceases. It is often an advantage to place a rolled-up handkerchief beneath the tourniquet over the course of the main artery. Unless a tourniquet is applied tightly enough to stop arterial bleeding, it increases bleeding. For bleeding in the hand or arm the tourniquet should be applied high up in the armpit. For bleeding in the foot or leg, about the top of the thigh. The tourniquet should be kept on no longer than is absolutely necessary. It is very apt to cause paralysis through too much pressure on the nerves, or, if for

126

HANDBOOK OF HEALTH

any very long period, gangrene of the part. A good rule is to loosen a tourniquet every fifteen minutes and not tighten it again unless bleeding begins afresh. (See also "First Aid," p. 170.) Bandaging. A bandage should be firmly and evenly applied, care being taken not to draw any one turn tighter than the others. If too tight, it may cause pain and swelling of the parts beyond it. Hold the rolled bandage in the right hand and wind it about the part, letting the roll slip in the hand. Carry it around by passing to the left hand. Bandages applied to irregular parts, such as the ankle, should be in the form of a figure eight, a turn being taken first above and then below the heel. CONTROL OP BLEEDING

Bleeding from wounds may be of three kinds: (1) arterial bleeding, in which the blood is bright red, flows in a spurting stream, and is not controlled, as a rule, by a pad over the point of injury; (2) bleeding from a vein, in which the blood is dark in color, runs in a constant stream, and can be easily controlled by slight pressure and elevation of the part; (3) capillary oozing from a slight wound, which is, as its name implies, a steady oozing from the injured surface. Arterial bleeding demands immediate attention. As a rule, it is best to apply a tourniquet if the injury is in a limb.

SURGERY

127

The wound should be cleaned at once (p. 123), and the artery, which usually appears as a small whitish tube that does not collapse, should be picked up with snaps and tied. Bleeding from a vein, as a rule, is easily controlled. A firm pad of gauze held in place by a rather tight bandage is usually sufficient. Nosebleed is often troublesome at high altitudes, and is best controlled by sitting the patient upright with the head well back and plugging his nostrils with cotton. Take a strip and carry it back as far as possible with forceps. Use enough to make a firm plug. I t is sometimes necessary also to plug the back of the nose where it enters the throat. This is difficult and should not be attempted unless absolutely necessary. Ice or other cold applications to the nose are of service at times. Bleeding from, the lungs, stomach, or bowels is practically beyond direct control. The patient should be kept absolutely quiet, should receive morphine 0.016 Gm. (J grain) subcutaneously, and should not be stimulated. Stimulation elevates blood pressure and increases bleeding. Bruises. Bruises are local bleeding under the skin from rupture of small vessels by violence. If extreme, they are best treated by immobilization of the affected part on a splint, and by the application of cloths soaked in cold water and changed repeatedly. Rupture of a large vessel causes a firm lump to ap-

123

HANDBOOK OF HEALTH

pear. I t is formed by clotted blood in the tissues. Treatment is the same except that, if very large, it may be opened carefully after a few days under aseptic precautions, the blood clot turned out, and a pressure bandage applied. A lump, of this sort looks like an ordinary bruise, but there is much more swelling and it feels like a rubber bag containing water. TREATMENT OF WOUNDS AND CONTROL OF SEPSIS

The sulfonamide drugs are of great importance in the prevention and control of sepsis. For information about their use, see page 210. Sepsis is commonly called "inflammation" or, if rapidly spreading, "blood poisoning." In either case it is the result of bacterial action in the tissues of the body. I t includes such varying processes as the ordinary pimple or boil, any infected wound, and such spreading infections as erysipelas or infection of the bloodstream. All accidental wounds must be considered as infected or potentially infected and treated with that idea constantly in mind. Sepsis in wounds does not show itself for several days after the injury. The signs are fever, heat, redness, swelling, and tenderness around the wound, and sometimes discharge of pus, pain, and throbbing in the affected part, and often tenderness and swelling in the armpit if the wound be on the hand or arm, or in the groin if it be on the lower extremity. Red

SURGERY

129

streaks running up the limb always mean a serious type of infection. Treatment demands rest for the affected part, preferably on a splint, more frequent dressings or poultices for the wound, and improved drainage by the insertion of a rubber tube (e.g., a piece of catheter) or by enlarging the opening of the wound to allow free escape of the discharge. If the wound has been sewn up, remove all stitches and pull the skin edges apart gently. Septic wounds or wounds with spreading infection about them, such as erysipelas, should be dressed more frequently than clean wounds. Sulfanilamide (p. 211) should be used freely in the wound and sulfadiazine (p. 211) given by mouth beginning 6 hours later. Erysipelas is a superficial infection of the skin which sometimes appears near septic wounds. It means danger. It appears as a bright red patch of slightly swollen skin, having a sharply defined margin. It spreads slowly and it is generally associated with pain, fever and prostration. Bleeding from Cuts. Do not be too easily alarmed by bleeding. A free flow of blood from a wound tends to wash out dirt. Only if a fair-sized artery is spurting is there any real danger. Remove promptly any clothing which prevents free access to the wound. Control bleeding as directed above. If the wound is in a limb and there is free arterial bleeding from one of the main arterial trunks; a tourniquet is usually

130

HANDBOOK OP HEALTH

advisable. Bleeding from one of the smaller arteries should be controlled with a sterile gauze pad covered with a pressure bandage. Cover the wound with the cleanest material at hand, preferably a first-aid dressing. If the first-aid packet contains one of the sulfonamide drugs, use that as directed. Fasten on the first-aid dressing and move the patient to the place where you can really care for the wound. Prepare the skin about the wound with tincture of iodine, 3.5 per cent. Irrigate the wound with clean, boiled water, picking out any foreign material such as gravel, grass, or splinters of wood. Sprinkle the wound well with sulfanilamide powder, enough to make it look white as with hoarfrost (p. 211). Incised (cut) or lacerated (ragged) wounds seldom should be sutured by the amateur. It is better to endeavor to approximate the skin edges by position of the part or by adhesive straps a little away from the wound rather than to run the risk of wound sepsis, a danger always present in a sutured wound. This is particularly true of wounds on the flexor surfaces. Take, for example, wounds of the hand. If the wound is on the back of the hand or the knuckle, the skin edges will come fairly well together if a splint is used on the front of the hand which will hold the fingers straight or even bent back a little. If the cut is on the front or palmar surface the hand should be closed about the sterile gauze dressing and held closed by a bandage or even by adhesive plaster strips from the

SURGERY

131

back of the fingers to the wrist. The same principle holds true for wounds about the larger joints and even for those of the groin. There are certain exceptions. Wounds on the face which, if left open, would produce disfiguring scars may be sutured. Another type of wound that may be loosely sutured by the amateur is one in which a flap of skin or skin and tissue has been turned down. The application of one or two sutures to a wound of this sort may shorten convalescence considerably and minimize the resulting scar. If the decision is reached that suture of the wound is essential, use as few stitches as possible. Stitches of silk, cotton, or silkworm gut should be placed one quarter to one eighth inches back from the edge of the wound and should include about an equal amount of the fatty tissue under the skin. Stitches placed too close to the edge and without sufficient depth will permit gaping between the stitches. Tie each stitch with a square knot drawn just tight enough to make the edges come together. Stitches tied too tightly will cut the tissues and promote infection. An extremely dirty wound or one which has received no attention for several hours after infliction should not be sutured. The wound may be dressed with plain sterile gauze, or with sterile gauze smeared with boric ointment or one or other of the sulfonamide ointments so common in travelers' kits today. The function of the dressing should be to protect the wound from infection from

132

HANDBOOK OF HEALTH

the outside and also to immobilize it. Do not hesitate to use a well padded splint for immobilization. Aftercare of Wounds. General Principles. All extensive or deep wounds and all large wounds that show evidence of inflammation should be considered to be infected. Recent experience has shown that sulfadiazine given by mouth as routine in such cases will ward off or lessen sepsis. Therefore, in all such wounds give sulfadiazine by mouth (p. 211). Sulfanilamide powder may be used in infected wounds at each dressing (p. 211). It is not necessary to use sulfadiazine routinely in small superficial wounds. Aftercare of Cuts. If the wound is comfortable, the dressing need not be removed till the eighth day, when, if union is firm, the stitches may be removed. If, on the other hand, the wound becomes increasingly painful, it should be inspected. If found swollen, reddened, and unduly tender, it is probable that it is infected. Part or all of the stitches should be removed to permit drainage of pus. Gunshot Wounds. Perforating wounds made by the modern high-power rifle with wounds of entrance and exit should be cleaned, bits of dead tissue trimmed off, the wound sprinkled freely with sulfanilamide powder, and dressed with a sterile dressing. Debridement, now used frequently in military surgery, should not be attempted by the amateur. Penetrating wounds without wound of exit should be handled in a similar

SURGERY

133

manner but are more serious on account of the presence of the projectile in the wound. Injury to bones, nerves, and internal organs adds to the risk. Sepsis of the most virulent kind is an ever-present danger. Only persons having the most serious sort of gunshot wounds cannot be transported. Unless in shock (p. 172) it is far better to move your patient to a competent surgeon than to deprive him of such aid. Perhaps the most terrible type of gunshot wound is that inflicted by a shotgun at close range. As a rule, bits of clothing are driven into the tissues with the shot. The wound should be thoroughly washed out with boiled water, bits of clothing and shot removed, and dead bits of tissue trimmed off. The wound should be liberally sprinkled with sulfanilamide and loosely packed with sterile gauze. I t should not be sutured. Severe shock (p. 172) is usually present and should be treated before the wound is cleaned up. Stab wounds, whether made with a knife or some other sharp instrument, should be liberally treated with sulfanilamide powder and left open. A common wound of this sort is caused by stepping on a nail. If the nail has been contaminated with garden soil or stable manure, it is essential to keep the wound open on account of the danger of tetanus (pp. 4 and 157). Penetrating wounds of the chest or abdomen are always serious. Such wounds should not be operated on except by a surgeon and should never be irrigated. The external part of the wound should be carefully cleaned

134

HANDBOOK OF HEALTH

and dressed with sulfanilamide powder. The patient should lie quiet, and if necessary for pain or restlessness, morphine should be used subcutaneously in the dose of 0.016 Gm. (J grain) and repeated in four hours or more if needed. In abdominal cases, liquid food should be given very sparingly, and the bowels should not be moved for two or three days, even by enema. Water should be allowed in small amounts at a time. Such patients should be propped up in bed for the first two days, except that, when there is pronounced shock (p. 172) the patient should lie flat with head low until the pulse improves. Unless it be very extensive, do not sew up the wound at all. Never sew it up entirely. Where muscles or tendons have been completely cut across in a deep wound, the cut ends should be drawn together, if possible, with stitches and the limb then placed on a splint in such a position that there is the least possible tension on the injured parts. In other words, if a tendon in the palm of the hand has been sewn together, the hand should be half closed; if on the back, the hand should be kept straight on a splint. Such an operation is a difficult one and it may be advisable to treat only the surface wound recognizing the fact that the cut tendon should be repaired later by a surgeon. Accidental amputations should be thoroughly cleaned as for any other wound and left open after working sulfanilamide into all the crevices. If possible, draw

SURGERY

135

the skin down over the stump with adhesive plaster strips and traction (p. 139). The amputation will have to be revised by a surgeon at some later date. I t is not wise for the traveler to attempt a formal amputation. Bites and clawings of animals are sure to be infected. Wash the wound thoroughly with soap and water. Then work in sulfanilamide powder and leave the wound open. Bites of animals suspected of having hydrophobia should be kept open for several days and Pasteur treatment instituted as soon as possible. For bites of poisonous snakes, see page 106. Burns. The surface of a burn is rendered more or less aseptic by the heat; therefore, it should not be scrubbed or painted with strong antiseptics. I t should be considered to be sterile and treated only with sterile material and sterile instruments. One of the great dangers with a burn is that it will become septic. This is prevented as long as possible by rigid aseptic precautions. Almost as many methods of treatment have been advised for burns as for headache. One simple form of treatment which has proved satisfactory is outlined. I t is simple and easy to carry out. Other methods may be equally good or better. Under rigid aseptic precautions, bits of charred clothing and loose charred skin may be picked off. Then the wound is covered with strips of soft, boiled

136

HANDBOOK OF HEALTH

cloth liberally spread with boric ointment * (p. 208). A large dressing of sterile cotton waste, sterile cotton or sterile gauze is placed over the cloth strips and the whole firmly bandaged preferably with an elastic bandage. It takes some skill to apply a good, even pressure bandage but once applied the patient is much more comfortable and swelling and blistering are kept at a minimum. If you have no proper material for treating the burn, do not use butter or lard, because they are contaminated. Clean cylinder oil that has been heated well above the boiling point of water and allowed to cool is far better. Coat thickly with the oil, and then apply boiled cloth strips as directed above. The dressing should not be disturbed until it becomes uncomfortable or offensive. When the burn is dressed, the skin over the blisters should not be trimmed away unless they contain pus. If infection takes place, sprinkle lightly with sulfanilamide and give sulfadiazine (p. 211). If infection is slight, give full doses only for a day or two. Wet boric dressings may be used instead of sulfanilamide powder. Extensive burns cause shock and may cause considerable loss of salt and protein in the fluid secreted from them. Treat as for shock (p. 172) and give plenty of water and nourishing drinks. Extra salt may be needed, particularly in warm climates (p. 93). * The sulfonamide ointment issued to the Army Medical Corps is equally good.

SURGERY

137

Bums, even if superficial, covering two-thirds of the body or more are almost always fatal. Boils, Carbuncles, and Abscesses. For a boil, a carbuncle (a large boil with several openings), or a definitely localized abscess (indicated by local redness, swelling, and tenderness), there are two forms of treatment. 1. One may poultice the afflicted part and wait for the abscess to open spontaneously. A poultice is a soft, wet, hot dressing which can be made of clean absorbent cotton wrapped in sterile gauze and wet with some hot, mild antiseptic solution, such as boric acid 2 per cent. A poultice should be changed at least every four hours and may be reinforced by a hot-water bottle or other heater outside the dressing. 2. If poulticing does not bring the abscess to a head so that it opens and drains satisfactorily, or if after a reasonable time the condition of the patient seems to grow worse, or the area of the infection seems to be spreading, the abscess should be laid open thoroughly with a knife to give free drainage. When drainage is adequate, it prevents the spread of the infection and allows healing to begin. When the operator is not a surgeon, he usually errs on the side of an inadequate incision and fears that he will cut some large blood vessel or other important organ. It is probably safe to say that, in any superficial abscess, this danger may be disregarded. In order to be recognized by one who is not a physician, the

138

HANDBOOK OF HEALTH

abscess must be near the surface. If one succeeds in thoroughly laying open the septic area and giving proper drainage, marked improvement will be seen in less than twenty-four hours. Sulfadiazine (p. 211) should be given in maximum doses if the process is extensive, in smaller doses if it is slight. High fever in the presence of infection is a serious sign. When the infected part is draining adequately, there will be no fever. FRACTURES

Note. The immediate treatment for fractures is described under First Aid, page 174. Continuing treatment, in the absence of medical aid, is dealt with in this section. Diagnosis. There are certain things that the traveler must consider when faced with the treatment of a possible fracture without medical aid and the first of these is diagnosis. Sometimes the fracture is immediately evident, being shown by deformity, abnormal mobility, great tenderness at the point of fracture and the telltale grating together of the fragments. In many instances these signs are lacking and a positive diagnosis cannot be made. This is particularly true when the fractured bone is driven together or impacted, where the bone is bent like a green stick or if the fracture is at one end of a long bone. It is a fairly good working rule that fractures of this sort that are difficult to diagnose can be treated by the

SURGERY

139

layman without the use of traction whereas free fractures of the long bones of the leg should, if possible, have the benefit of traction. It will be found that most medical supply kits are furnished with traction splints. If traction splints are not at hand he who would treat a free fracture with traction must use all his ingenuity in improvising an adequate apparatus. (See also Chap. VIII.) Traction by means of the first aid bandage is for temporary use only. If used for more than a few hours it may cause pressure sores or gangrene of the part. For the permanent apparatus, traction should be by long adhesive plaster strips running lengthwise to the leg and extending from the level of the fracture to the ankle. To the end of each adhesive strip is fastened a cord if traction is to be by a weight over a pulley, or a strip of rubber or cord if traction is to be obtained by fastening to the end of the splint. Strips of a rubber inner tube do very well. It may be necessary to use a bridle to prevent these strips from cutting the foot. One must remember also that the lower fragment must be correctly aligned on the upper fragment and not rotated on its long axis. No matter how good the union, a foot which points out instead of pointing straight ahead is a tremendous handicap. As described on page 179 in Chapter VIII, a straight stick can be substituted for the Keller-Blake splint if the proper traction hitch is used at the upper end. Traction at the lower end should be with ad-

140

HANDBOOK OF HEALTH

hesive plaster as described above and not with the cravat hitch. Splints. (See also Chapter VIII.) If no splints are available, many kinds of serviceable splints can be improvised. It is most important that the splint be well padded. 1. Venetian-blind type. Made of a number of small sticks tied together like a Venetian blind, the length and weight of the sticks varying with the part to be immobilized. Such a splint should be wide enough to encircle the limb completely and long enough to immobilize it. Usually, the splint should include the joints at each end of the broken bone. 2. Flat board splint: cut a thin board to approximately the length and width of the part to be supported. Such splints are usually used in pairs and kept in place with strips of adhesive plaster, and the whole covered by a bandage. 3. Pillow splint (for fractures of the lower leg and ankle): take a pillow or a bag of hay or leaves and lay the leg on it lengthwise with the heel four inches above the end. Then fold the edges together under the sole of the foot and over the leg, leaving the toes protruding. Fasten the edges with safety pins and then strap on three straight boards or sticks, one beneath and one each side running the length of the pillow. 4. Tin splint. For the thumb or a finger, a very serviceable splint may be made by cutting a good

SURGERY

141

sized strip from a tin can and bending and shaping it to fit the part to be immobilized. Care should be taken to cover all sharp edges to prevent cutting. Padding for splints is best made from several layers of folded sheet-wadding. I t is better to have too much than too little padding. A splint applied too tightly or with padding which is not adjusted to the irregularities of the part may cause gangrene or paralysis of the part. Whenever possible, have the fingers or toes exposed. Then, if they become purplish or cold, the dressing should be loosened. Fracture of the toes or bones of the foot usually requires a splint running the full length of the sole and fastened to the foot by bandages. Occasionally, a fractured toe can be treated by fastening it to another toe by means of adhesive plaster. Whenever toes or fingers are covered with a dressing, put padding between them to prevent maceration of the skin. The splint should be thickly padded beneath the instep to support the arch. Fractures of the bones of the foot require crutches for at least three weeks. Fracture of the heel bone is almost always impacted and is usually mistaken for severe sprain. Treatment is as for sprain (p. 152) except that the patient should be kept on crutches for a month. Massage only after two weeks. Fracture of the ankle is usually caused by turning the foot outward. The lower end of the small, outer bone (fibula) is broken usually by being forced out-

142

HANDBOOK OF HEALTH

ward. The symptoms are pain and swelling about the ankle joint, often with turning of the foot outward. The patient is usually unable to walk, and pressure on the small bone above the fracture will cause severe pain. Apply a pillow splint (p. 140) and do not allow the patient to walk even with crutches. When the swelling has gone down, the pillow can be dispensed with and the foot held in place by well-padded splints. Keep the foot turned inward a little more than normal and at right angles to the leg, to prevent deformity. Crutches should be used for at least a month. Fracture of both bones of the leg below the knee. Abnormal mobility grating and shortening are almost always present. Traction with a Keller-Blake splint (p. 175) is most desirable. Care should be taken that the foot is placed with the toes pointing slightly inward and the crossbands on the splint must be so adjusted that there is no backward bowing of the broken bones. Traction should be maintained for three to five weeks. At that time there should be some union and traction may be replaced by splints running well up on the thigh. Crutches should be used for a month after traction is given up even if union seems firm and solid. If traction cannot be used, a long pillow splint or Venetian-blind splint running up to just below the buttock may be used. During application of the splints, the foot should be held by an assistant whose duty it is to pull down on the foot to overcome muscle

SURGERY

143

spasm and also to rotate the toes inward a few degrees. Union may be slower and the resulting deformity greater if this method is used instead of traction. Fracture of the upper end of the lower leg involving the knee joint. Treat in the same manner as for fracture of both bones of the leg except that gentle passive motion of the knee should be started at the end of four weeks. Fracture of the knee cap. Caused by falling on the knee or by direct muscular violence. The knee is painful and swollen and the patient is unable to extend it. Usually the fragments can be felt with a considerable gap between them. Operation with suture of the broken bone is the usual treatment but this can be done only by a good surgeon and under good conditions. Place the leg on a long straight splint from ankle to buttock. Adhesive straps should be applied to the skin on either side running from above the upper fragment in front to the side of the knee. If these strips are pulled down as they are applied and if the upper fragment is drawn down by an assistant, the distance between the fragments can be lessened appreciably and resulting union will be more satisfactory. Keep patient in bed a month. Crutches and a posterior splint should be used for two to three months. Operation may be necessary when the patient is returned to the proper surroundings. Fracture of the thigh. This fracture is always a seri-

144

HANDBOOK OF HEALTH

ous problem on account of the long period required for union and the deformity which may result even with careful handling. For fracture of the lower and mid portion of this bone, traction should be used if possible. Keep in mind the fact that the adhesive strips should be carried up to the level of the fracture and that the line of traction should follow that of the upper fragment. It will be found that the upper fragment will tend to cock up and therefore the end of the splint should be supported above the level of the patient's buttocks. If the upper fragment tends to swing out away from the line of the body carry the lower end of the splint out. It is never necessary to carry the lower end of the splint inward across the midline of the body. If the traction splint is well applied, it will be possible to roll the patient on his side to wash and powder his back and to place some improvised receptacle beneath him that he may move his bowels. The care of the patient's back and attention to his bowels are of great importance. Unless these precautions are taken, a bed sore may develop and increase his difficulties tremendously (p. 146). If traction is impossible, a long straight splint from armpit to ankle should be used. Such a splint is kept in place by wide cloth swathes about the trunk and leg. A Venetian-blind splint should be placed about the thigh itself. Fractures of the thigh should be kept in bed for from eight to twelve weeks.

SURGERY

145

Fracture of the Hip. The upper end of the thigh bone is usually impacted. Under no circumstances should this impaction be broken up. The leg is usually shortened and the foot turned outward. Treat like fractured thigh, except that traction should not be used unless the fracture is loose (i.e. not impacted). Hold the leg in place by means of sand bags on each side of it and keep the patient sitting up in bed as much as possible. Fracture of the pelvis is usually caused by a crush between two heavy objects, such as two cars. The shock is severe and there is often tearing of the bladder or urinary passage as well. Use sand bags and broad, tight swathes about the hips. It is often necessary to draw the urine with a catheter. Fracture of the spine or "backbone." This fracture may be accompanied by injury to the spinal cord. If so, the patient, usually, is paralyzed below the point of fracture. There is little that the amateur can do in such a case. If the fracture is below the neck, the patient should be kept lying on his face and sides part of the time. The best plan is to turn him carefully every three or four hours, supporting his back with pillows or cushions. Keep him in one position for three or four hours and then move him to another. It is obvious that he should be turned without twisting his spine as twisting would cause further injury to the already damaged structures. All clothing, particularly if wet, or soiled, should be removed at the

146

HANDBOOK OF HEALTH

earliest possible moment and the back and buttocks carefully dried and powdered. If he is to be kept on a stretcher it must be smoothly padded to prevent pressure at any one point. Small pads under the back and thighs will tend to relieve pressure on the buttocks. Pressure in such a case will cause injury to the skin without local discomfort. Such an injury will progress to large infected sores which are very difficult to heal. It may be necessary to draw the urine with a catheter. Such cases frequently result fatally. If they can be transported to a physician they should be rolled face down on the litter. Travel should be in easy stages and the patient turned on the sides or back while in camp. Fracture of the spine without injury to the spinal cord is serious on account of the danger that any quick motion may cause the broken parts to slip further and damage the cord. For this reason, such a patient should be treated in the manner outlined above. Fracture of the neck should be treated in the same way except that the patient is never rolled on his face. The head is supported b y bags or socks filled with sand placed on each side of the neck and head or by a long soft roll of blanket bent in the shape of a horseshoe about his head. When turned on his side his head must be turned with and kept in the line of his trunk. Fracture of the ribs. Symptoms: sharp pain particularly on deep breathing, with tenderness over the

SURGERY

147

point of fracture. Sometimes grating can be felt. If one hand be placed on the patient's backbone and the other on the breast bone and moderate pressure exerted, it will cause pain at the point of fracture. Swathe the chest with two or three strips of adhesive plaster two or three inches wide running from the backbone behind to the breast bone in front. The adhesive should be put on with all the breath blown out and the chest contracted. Such fractures are seldom serious unless the lung has been damaged. If so, the patient will have serious difficulty in breathing and should be kept in bed but sitting up. Fracture of the finger or bones of the hand may be treated either by means of a straight splint running from wrist to tip of finger or by closing the hand about a roll of bandage. The method which puts the bone in the most normal position should be chosen. Bending the fingers is usually best because these bones are apt to buckle forward and, if this happens, the newforming bone may involve the tendons of the finger and cause great disability. The same is true of fractures involving the bones of the hand. A good diagnostic sign of fracture of bones of the hand is that the knuckle of the bone involved is not as prominent when the hand is clenched as in the normal hand. Another sign of fracture of the fingers or bones of the hand is sharp pain caused by pressure against the ends of the fingers. Immobilize for three weeks.

148

HANDBOOK OF HEALTH

Fracture of the Wrist. As it is impacted in most cases, there is no grating but there is usually considerable deformity. The hand is pushed backward on the wrist from one-fourth to one-half inch which gives it more or less the shape of a silver fork. Such fractures should be reduced by loosening the displaced end of the bone and bringing it into line. As this usually requires anesthesia, it is best to wait until a doctor can be reached. The hand is held in place by anterior and posterior splints from base of fingers to elbow, well padded beneath the wrist to conform to the normal outline. Begin passive motion and massage at the end of two weeks but keep the anterior splint on until three weeks have passed. Fracture of the Arm. Traction in the treatment of these fractures has been omitted except as a first aid measure. It is believed that older and simpler methods are better suited to the needs of the amateur surgeon. Fracture of both bones of the forearm is characterized by abnormal mobility and inability to use arm. Such fractures are difficult to set. Hold the arm in as normal a position as possible by means of anterior and posterior splints to the forearm and hand and a rightangle splint, one leg of which runs down the forearm and the other up to the armpit on the inside of the arm. Fractures about the elbow, with one exception, are best treated in acute flexion. The arm is flexed to an

SURGERY

149

acute angle, care being taken that the angle is not sufficiently acute to impede the circulation of blood in the hand. Fixation is obtained in some instances by the use of a figure-eight sling. The sling is passed behind the flexed arm, then crossed in front and continued up around the neck. This gives a snug pocket in which the arm rests easily with very good fixation of the elbow. If this apparatus is not satisfactory, the hand is placed on the opposite collar bone and the whole arm fastened firmly to the body with wide straps of adhesive plaster and wide bandages. Pads should be placed between all skin surfaces to prevent maceration. The one exception is a fracture where the prominent bone at the back of the elbow is broken off. The end of this bone is drawn upward by the strong muscles at the back of the arm. It is necessary, therefore, to keep the arm out straight and to hold it in place by means of a long wooden splint running from the armpit to the wrist. Fracture of the Upper Arm. The arm is bent at the elbow and a right angle splint applied together with a small Venetian-blind splint about the upper arm and a pad in the axilla. If the fracture is high up in the shaft of the bone, the pad should be considerably thicker at the level of the elbow than it is above in order to tilt the arm outward. The whole arm in the splint is then fixed to the chest by means of a sling and one or two swathes. This fracture is slow to heal

150

HANDBOOK OF HEALTH

and after care should be under the direction of a physician, if possible. Fracture of the upper end of this bone may be free or the shaft may be driven into the head (impacted). If so, the impaction should not be broken up. Such a fracture, frequently, is difficult to differentiate from a severe sprain except by X-ray examination. Any fracture of the humerus should be immobilized for a month or longer if firm union has not taken place. Under the care of a physician, gentle passive motion of the shoulder may be used at a fairly early date to lessen the stiffness which always occurs in the shoulder joint. Fracture of the collar bone usually heals well, but frequently with some deformity. The usual method is to support the arm with a sling and to apply a bandage or swathe about the body. A better method is to hold both shoulders back by a figure-eight bandage of soft cloth, the loops being about the shoulders and the crossings in the middle of the back, or to make two soft, well-padded cloth rings, put one about each shoulder and fasten them together in the back. The arm on the affected side should be supported by a sling. This fracture usually heals in about three weeks. Fracture of the jaw is very difficult to treat. Place a firm bandage about the jaw and head, carrying turns from under the jaw to the top of the head and from the front of the chin around the back of the neck. I t is very important to keep the mouth thor-

SURGERY

151

oughly rinsed and to feed with liquids, because fractures of the jaw are almost always compound. The dressing must be loosened temporarily if the patient vomits. If there is danger of this, a piece of cork or soft wood may be placed between the teeth on both sides to hold the jaws apart. Fracture of the Skull and Concussion of the Brain. The symptoms are unconsciousness or delirium, usually with slow pulse and some rise of temperature, and sometimes bleeding from the ears. Apply ice or cold applications to the head. Move the bowels thoroughly with Epsom salts if the patient can swallow. If not, give an enema. D o not use morphine unless it is absolutely necessary. Transport the patient to a physician, if possible. The patient should be kept quiet for a number of days after all the symptoms have subsided. Compound Fractures. These are always serious on account of the danger of sepsis in the external wound. (See Sepsis, p. 128.) Treat with traction, cover the wound with a sterile dressing, and transport to a doctor without delay. If no doctor is available and the traveler must depend on his own resources, the skin about the wound should be cleansed, sulfanilamide spread in the wound, and a sterile gauze dressing applied. If the wound has been contaminated with garden soil or other infected material, it may be irrigated with boiled water or boiled 2 per cent boric acid solution before the sulfanilamide is put in. The irri-

152

HANDBOOK OF HEALTH

gating solution should be allowed to cool until it is about body temperature. Sulfadiazine should be given by mouth. SPRAINS AND STRAINS

The term " s p r a i n " is used rather loosely to cover all varieties of strains of joints, from a mild wrench which gives little or no trouble to a severe injury with much tearing of ligaments and swelling. Sprains are often difficult to differentiate from dislocations or fractures, but in sprains there is never any bony deformity or grating of fragments of bone, and the joint is in place. Treatment. During the first few hours, much can be done to alleviate suffering and keep down the swelling b y bathing alternately with hot and cold water and by massage. Afterwards, immobilize with bandages or strap with adhesive plaster. B A C K STRAIN

The lower portion of the spine is easily injured b y heavy lifting, violent bending and occasionally by some very minor injury. The back is stiff and painful and there may be radiation of pain down the leg. I t is difficult or impossible to differentiate among such varied injuries as strain, a minor fracture or injury to a cartilage. If mild, strapping with adhesive will usually suffice.

SURGERY

153

The straps should be about two inches wide, run well around toward the front and be applied tightly. Begin at the bottom. Put the lowest strap well down at the upper part of the buttocks. Each succeeding strap should overlap the one below by about one-half an inch. If the condition is severe, keep the patient in bed with boards under the mattress to keep it flat. Use large hot packs (a bath towel wrung out in hot water will do) and control pain with aspirin or if necessary with morphine (p. 203). DISLOCATIONS

A dislocated joint is one in which the joint surfaces have been displaced. The displacement may be partial or complete and, as in fractures, dislocations may be simple or compound. The symptoms and signs are: pain, inability to use the joint, and deformity, the last being the most characteristic. There may be much or little swelling. Dislocations should be reduced within a few days, for the longer the delay, the greater the difficulty. After reduction, the part should be fixed by means of a splint or bandage for a varying length of time, depending on the joint involved. As a rule, dislocations of the smaller joints are fairly easy to reduce if one stretches the joint as much as possible by traction before trying to slip it back. Dislocations of the larger joints are more difficult to handle. Strenuous attempts at reduction may

154

HANDBOOK OF HEALTH

be unwise on account of the danger of causing further damage. If attempted reduction is unsuccessful get the patient to a doctor without delay. Jaw. Dislocation of the jaw is not uncommon. The mouth is open and the patient unable to close it. T o reduce, place both thumbs inside the mouth, one on each side back of the lower wisdom teeth, and press strongly down and back, at the same time attempting to close the jaws with the fingers beneath the chin. Support the chin for a few days with a bandage over the top of the head and warn the patient against opening his mouth wide for several weeks. DANGEROUS DISEASES

The diseases in this group are not very common in persons leading an active outdoor life. Appendicitis. The signs are pain, usually severe and constant, at first all over the abdomen, later localized, as a rule, in right lower part. Firm pressure in the region causes much pain. The muscles over the painful part are strongly contracted and cannot be relaxed. There is generally slight fever and increase of pulse rate, constipation, and, often, vomiting. There may be a story of similar attacks lasting for several days at a time. The attack may clear up in a few days without severe symptoms, or an abscess m a y form around the appendix, or inflammation may spread in the abdomen and cause death.

SURGERY

155

Treatment. Absolute rest, propped up in bed, abstinence from food, permit liquids only, cold applications to painful area, and enemas to move the bowels. Do not give a cathartic. Send for a surgeon if possible. Recovery without operation is the rule unless the inflammation spreads. Morphine (p. 203), 0.01 Gm. (I grain), subcutaneously, may be given often enough to ease the pain but not to hide the nature of the symptoms if a surgeon is on the way. Give sulfadiazine, as in infected wounds, until the inflammation subsides. Inflammation of the Gall Bladder. Pain and other symptoms like those of appendicitis but situated in the right upper abdomen. There may be jaundice and, with it, whitish stools and dark-colored, greenish urine which stains white cloth yellow. Treat like appendicitis. As the patient improves, the diet may be increased, but while jaundice persists, meat should be taken sparingly and fats not at all. Gallstone Colic. Attacks of severe pain in the right upper abdomen, recurring more or less frequently for years without much impairment of health. Pain comes on suddenly, most often at night, may be very severe, and passes off in a few hours leaving a feeling of soreness. The attack is often preceded by a chill and associated with transient fever and vomiting. The danger is that inflammation may develop. Treatment. Hot bath or application of heat to abdomen, light diet, and morphine, if needed.

156

HANDBOOK OF HEALTH

Renal Colic. Due to stone attempting to pass from the kidney. Pain very severe, intermittent, starting in either flank and radiating around abdomen to region of bladder or testicle. There may be vomiting, chills, fever, pallor, and sweating. The urine is often bloody, and it may contain pus. Treatment. Hot bath or application of heat, rest, and morphine, which may be repeated at intervals of from four to eight hours if pain continues to be severe. Abundance of liquid should be taken, preferably hot. Give sulfadiazine, one tablet (0.5 Gm.) four times a day. Stone in Bladder. Pain in region of bladder, urine generally bloody. Treatment as for renal colic. If urine is not passed freely, catheterize every eight hours. Hernia or Rupture. Usually appears in the groin but may come in the navel or in the scar of some abdominal operation. Usually there is a soft mass which can be pushed back into the abdomen without much force. If the contents of the hernia (intestines, etc.) get caught in the ring they may become strangulated, causing pain, vomiting, and stoppage of the bowels. This is a very serious condition. The patient should be seen by a doctor as soon as possible. Even a few hours' delay may be of great importance. Shock. See Chapter VIII, p. 172. Hydrophobia is caused by the bite of a mad dog or other animal having the disease. It is not uncommon

SURGERY

157

in skunks on our western plains. The disease generally takes several weeks to develop, and is invariably fatal. It may be prevented in almost every instance if Pasteur treatment is begun promptly. The longer treatment is delayed following exposure, the more likely is the patient to develop the disease. Pasteur treatment is of no value whatever after symptoms have begun to appear. For treatment of the wound, see page 135. Tetanus or Lockjaw. The germ causing tetanus is common in the soil. Hence this disease sometimes follows a deep punctured wound such as from stepping on a sharp object. In certain tropical countries, the disease is much more common than in temperate or arctic regions. The disease may make its appearance from a few days to many weeks following a deep wound of any sort. It is characterized by muscular spasm, particularly of the muscles of the jaw, and prostration. Usually there is moderate fever. The muscular spasms increase in severity and are extremely distressing. The mortality in untreated cases is very high. The use of tetanus toxoid is an almost certain preventive. Persons going on an expedition should be treated as routinely as for typhoid. Any patient who receives a deep wound, and who has not been inoculated, should receive a prophylactic dose of antitetanic serum. The serum comes in vials ready to use

158

HANDBOOK OF HEALTH

and is given in the same manner as other sera, deeply beneath the skin (p. 199). The serum should be given as soon as possible after the wound is inflicted. In order to determine whether or not the patient is sensitive to horse serum, a small drop of the serum diluted one to ten is placed in one eye. If the eye becomes red and inflamed in a few moments great caution should be used in injecting the prophylactic dose. Only a few drops should be injected at first. Other small portions should be given at hourly intervals until the whole dose has been received. If the patient shows signs of respiratory difficulty (asthma), prostration or abdominal cramps, the treatment should be stopped until it can be given by a physician. If signs of tetanus develop, the wound should be laid open and kept open and the patient placed under medical care. SOKE F E E T

Blisters and abrasions must be protected. The best treatment for the latter is a liberal application of sulphur ointment and a thin cloth dressing. A thick dressing tends to retain sweat and thus to increase softening of the skin. The dressing should be renewed at least twice daily. Another method is simply to paint the abraded surface with tincture of iodine each day. Ingrowing Toenail. Any tendency to ingrowing

SURGERY

159

toenail should be corrected before leaving home. Ingrowing toenail is caused, usually, by too tight shoes, worn perhaps many years earlier. The nail has been bent in at the side and cut off round until the sharp edge tends to cut into the soft flesh beneath. After this has continued for some time, a break in the skin takes place and infection may set in. Under these circumstances there is redness, swelling and tenderness beneath the buried edge of the toenail, often with the formation of a small abscess. Prevention is important. Always cut the toenails straight across, particularly if the edge tends to turn down. Never let the skin at the tip of the toe cover even the smallest portion of the cut edge of the nail. If the condition has already occurred, the buried nail edge should be carefully and gently pried up every day and a tiny pad of absorbent cotton tucked in beneath the nail. If infection is present, the skin must be gently pushed back along the side of the nail and the small collection of pus usually present, let out. Then pry up the edge of the nail at the tip of the toe and pack cotton beneath it as directed above. Wash the inflamed area frequently with dilute alcohol or other antiseptic. If the patient must walk, it may be necessary to cut back the nail at the corner as a temporary measure. As soon as the nail grows out again, pain will recur, perhaps more severely than before. Occasionally, cutting a wedge out of the middle of the nail will

160

HANDBOOK OF HEALTH

allow the cutting edge at the side to grow beyond the point where it cuts into the flesh. Flat Foot. Any tendency toward it should be treated before one leaves home. Pain in the sole of the foot may run up the inside of the ankle and back of the leg. It is increased by walking. Strap stirrupfashion as for sprain of the ankle. Merely raising the inside of the heel of the shoe from one-eighth to onefourth of an inch will often give relief. Any amateur cobbler can put on such a heel. Aspirin will diminish pain. When walking, the feet should be kept parallel because turning the toes out puts added strain on the arch. Athlete's Foot. See Ringworm, p. 97. IMMERSION FOOT AND LIFEBOAT FOOT

In these days of frequent sinking of ships we must consider two conditions that affect the feet as the result of exposure in lifeboat or raft. Immersion foot as experienced in the arctic or in temperate regions in the winter resembles frost bite and is similar to "trench foot" as seen in the last war. After prolonged exposure with the feet in cold water (under 50°) the feet become cold, waxy white and swollen to mid-lower leg or knee. There is little pain at first and the feet are numb. Walking is difficult on account of numbness and inability to determine the position of the feet. After rescue and as the feet

SURGERY

161

warm up, they become bright pink and are intensely painful. Pain is increased by warmth. Blisters may develop and gangrene is not uncommon. To prevent immersion foot, all persons travelling in dangerous waters should wear warm woolen stockings and rubber boots if possible. It is most important that nothing worn on the feet or legs be tight. The skin should be well greased but not sufficiently to mat the stockings with grease. In a lifeboat or on a raft the feet should be lifted to the horizontal at intervals and not allowed to remain hanging down. The toes, ankles, and knees should be moved at frequent intervals. When rescued, the care of the feet is of the utmost importance as the damaged tissues of the feet are further damaged by even the slightest trauma. The patient should under no circumstances be allowed to walk. He should be carried to bed and all clothing carefully removed from the feet. Care should be taken not to break any blisters or to rub the skin even lightly. Brisk rubbing with the idea of restoring circulation should be absolutely forbidden. The feet should be warmed up very gradually over a period of hours. If the patient is brought into a warm room it may be well to retard the warming up process at first by means of rubber water bottles or other containers filled with slightly cool water. Hot water or cold water or snow is absolutely wrong. As the feet warm up, blisters and spots of gangrene may appear against

162

HANDBOOK OF HEALTH

the background of intense pink. One should guard against infection by using only sterilized or at least carefully washed coverings. Pain, which may be intense, is relieved by cooling with a fan or cool water bottles. Morphine may be necessary. The bed clothes should not cover the feet. Lifeboat Foot. This form of exposure is quite different. It is frequently seen in the tropics among persons who have been in lifeboats or on life rafts for some time. Many cases have occurred when the temperature of the water has been 70° or over. The feet are similar in appearance to true immersion foot except that the swelling runs higher on the leg and the color is not so waxy white. The feet are numb, tingling, and painful and there may be difficulty in walking. Blisters and gangrene do not occur. The cause in this group of cases seems to be insufficient drinking water and a diet deficient in protein and vitamins. Persons exposed in this way should endeavor to eke out their diet with fish or sea birds, should keep their bodies and feet covered from the direct rays of the sun and should try to have their feet elevated part of the time. After rescue, they should not walk any more than is necessary and should have a diet rich in protein and vitamins. Gentle massage, passive or active motion of the legs without weight-bearing, and elevation of the feet is of considerable value.

CHAPTER VIII FIRST AID * Definition of First Aid. First aid is the immediate temporary care given by a trained person in case of accident or sudden illness before medical aid is available. It is given in order to prevent death or further injury, to relieve pain and counteract shock. To become expert in first aid requires many hours of training and practice. GENERAL DIRECTIONS

1. Keep the victim lying down. 2. Give immediate attention to serious bleeding or asphyxia. 3. Examine for injuries not clearly seen. 4. Keep victim warm. 5. Fill out identification tag at once. 6. Make injured comfortable. 7. Keep the crowd away. 8. See that someone calls a doctor. 9. D o not give an unconscious person anything to drink. * Abridged by W. J. M., from Handbook of First Aid (Washington: United States Office of Civilian Defense, 1941) originally prepared by the American National Red Cross.

164

HANDBOOK OF HEALTH

10. Do not permit casualty to be moved unless it is necessary and until it is safe. 11. When a casualty has several injuries, treat the most serious first, especially if it involves severe bleeding. 12. Remember you are a first-aid worker and not a physician. CARE OF WOUNDS

The chief dangers of wounds are severe bleeding, the introduction of infection, and the development of shock. Bleeding should be controlled at once, for profuse bleeding may be followed by shock or result in lowered resistance to infection. Serious infections frequently develop in neglected wounds. All wounds should, if possible, be treated by a physician. Cover the wound with sterile gauze, fix it in place with bandage or adhesive plaster, and take the injured person to the doctor. The gauze used must be large enough to cover the wound and a margin of skin on all sides. It must be sterile, and therefore should be from a freshly opened package. If the first aid packet has in it a package containing sulfanilamide powder, this package should be opened and the powder placed in the wound before the sterile dressing is applied. The surface of the gauze to be placed against the wound must not touch anything before it is applied. Do not lift the dressing or slide it about after application.

FIRST AID

165

Watch for bomb-fragment wounds, which may be very small, often only a scratch. Such wounds have black edges. They must be considered serious because there will probably be damage to muscle and other tissue below the skin surface, and the fragment may still be embedded. A casualty with a wound in the body, however small, whether made by a bomb fragment or other missile, should be treated as for internal injuries. Treatment for shock is important, especially if hemorrhage is severe. Lacerated and crushing wounds are often accompanied by severe shock (p. 172). If a limb is severely torn or crushed, it should be immobilized with a traction splint before the victim is moved. Only moderate traction should be used in these cases. Head Injuries. In any case of head injury, the brain may be damaged. The skull may be fractured. If this has occurred, blood-stained fluid may leak from the ears. If a casualty is dazed or unconscious and there is no obvious injury, examine the head first. Look for bruises or bumps. Even persons with slight or doubtful head injuries must be seen by a physician as soon as possible. If there is a wound of the scalp, apply a sterile compress to the wound and hold it in place with a firmly applied bandage. If there is bloody or watery discharge from the ears, do not plug them with cotton

166

HANDBOOK OF HEALTH

and do not try to clean them. Simply apply a sterile dressing over the ears. Keep the victim warm and quiet. Keep him lying down with his head slightly elevated. Obtain his name and address if possible. Internal Injuries. Serious injury may occur in the abdomen or in the chest as a result of penetration by a missile or crushing. Penetrating wounds about the hip joint or buttocks often cause internal injuries. Internal injury is always accompanied by internal bleeding and shock. The casualty may tear at his clothing in an effort to get more air. He may complain of thirst. If the wound is in the chest, he may cough up blood. Treat for shock, which is always present (p. 172). Keep the victim warm. Never give anything to drink. If the injury is in the abdomen, keep the victim lying down; if it is in his chest, prop up the head and shoulders. All cases of internal injury must be transported on stretchers to a hospital as soon as possible. Except when there is pronounced shock, a casualty suffering from chest injuries should be propped up on the stretcher in a semi-sitting position, leaning toward the injured side. A casualty suffering from an abdominal injury should be transported on his back with legs slightly bent at the knees. Injury to the Face. Probably no injury is so terrifying as an injury to the face. Bleeding is often profuse. Blood may run into the mouth or nose and strangle the victim. The jaw may be broken, in which case

FIRST AID

167

the tongue tends to fall backwards and obstruct the air passages. Determine whether the tongue has fallen into the back of the throat. If it has, grasp it in the fingers and pull it forward. Turn the victim onto his abdomen so that blood will not run into his nose or mouth. Apply a liberal number of sterile gauze dressings to the wound and bind in place with a triangle bandage. DRESSINGS AND B A N D A G E S

One of the most satisfactory dressings for wounds is the bandage compress. It is a piece of gauze attached to the center of a strip of bandage. The compress is to be opened without touching the inside, placed over the wound, and bound in place by the bandage tails. When a bandage compress is not available, use a sterile gauze pad of suitable size and thickness and bind in place with bandage or short strips of adhesive plaster. In emergency work, triangle bandages are useful for this purpose. They can be improvised from many materials. They will hold a piece of gauze in place and keep out dirt and contamination. These are intended as emergency dressings which will be replaced with more permanent dressings by the physician. The Triangle Bandage. The triangle bandage is very useful in first aid. It may be used to keep splints

168

HANDBOOK OF HEALTH

or dressings in position, as a sling to support an injured part, or as a tourniquet. It may be used: 1. As an open triangle spread out to its full extent (Fig. 1A). 2. As a wide folded bandage (wide cravat). Carry the point (the angle opposite the longest edge) to the middle of the longest edge (B), and then fold the bandage again in the same direction (C). 3. As a narrow folded bandage (cravat). Fold the wide cravat bandage once again, long edge to long edge.

FIG. 1

Slings. The large arm sling is used to support the forearm and hand. Spread out a triangle bandage on the front of the casualty with the point toward the injured arm. Pass the upper end around the back of the neck from the sound side so that it appears over the shoulder of the injured side. Carry the point behind the elbow of the injured arm; place the forearm across the middle of the bandage. Then carry the

FIRST AID

169

lower end up around the arm and tie to the upper end. Bring the point forward around the elbow and pin to the front of the sling. Slings may be improvised (1) by pinning a coat sleeve to the front of the coat, (2) by turning up the lower edge of a coat and pinning it to the front of the coat, or (3) by passing the hand inside the coat and then buttoning it.

FIG. 2 HEMORRHAGE

Hemorrhage is a condition which sounds, looks, and is serious. Persons with hemorrhage must have priority treatment and transport. Although the presence of blood requires immediate

170

HANDBOOK OF HEALTH

attention, it is in itself a poor indicator of the severity of the wounds. A little blood goes a long way and may make a minor injury look frightening. On the other hand, a severe wound, a torn-off limb for example, may bleed very little because of shock. Many people think the only way to stop bleeding is to apply a tourniquet. They fail to consider its dangers. They would be horrified to know of the number of limbs lost or paralyzed because tourniquets have been left in place without being loosened every fifteen minutes. A pad over the wound and a firm bandage combined with elevation of the limb will stop bleeding in nearly all cases. Kinds of Bleeding. Bleeding from artery — blood spurts with each beat of heart unless cut artery is deep under tissues, in which case blood will well up. Bleeding from veins will be a steady flow. Bleeding from injury to very small vessels — oozing. Control of Bleeding. 1. Bleeding from an artery. Pressure points are points where arteries lie close enough to bones to permit sufficient compression by the fingers to control bleeding. Hemorrhage may be controlled by pressure on these points until pressure dressings can be applied to the bleeding wound. Tourniquet for Arterial Bleeding. A cravat bandage

FIRST AID

171

or a strip of cloth at least two inches wide, folded with enough thickness to prevent cutting into skin (never use wire or any similar materials), and a stick about six inches long. Wrap folded cloth twice around arm a hand's breadth below the armpit or around leg a hand's breadth below the groin and tie with single knot. Place stick on knot, secure it with square knot, and twist. Make certain the tourniquet stops the bleeding. A tourniquet which is not sufficiently tight may increase bleeding. Prevent stick from untwisting by tying ends of stick to the limb with bandage or handkerchief (Fig. 3). Record the time the tourniquet

FIG. 3

was applied by writing the hour and minute on the tourniquet with a pencil. Precautions: (a) Loosen tourniquet at end of fifteen minutes. If dressing over wound becomes more bloody, tighten tourniquet for another fifteen minutes. If dressing does not show new bleeding, leave tourniquet loose but in place, ready for use if bleeding

172

HANDBOOK OF HEALTH

starts again. Indicate time of loosening and tightening on tourniquet. (.b) Never apply a dressing over a tourniquet. (c) Never transfer responsibility to someone else (nurse, stretcher bearer, ambulance driver) until you make sure he knows a tourniquet has been applied. If part of a limb has been blown off, apply a tourniquet tightly close to the end of the stump and do not remove it. 2. Bleeding from veins. Elevate a bleeding arm or leg unless it is fractured. Apply a sterile dressing over the wound and tie firmly in place. If no sterile dressing is at hand, use the cleanest cloth available, preferably the inside surface of freshly laundered handkerchief or towel. If a fracture is present, stop bleeding in this manner and then give first aid for the fracture. 3. Bleeding from small vessels. Treat as a simple wound. Apply a bandage compress so that it presses firmly on the wound. SHOCK (COLLAPSE)

Shock * is present to some extent in all injuries. It is a serious condition which frequently results in death when the injuries would not of themselves * The term "shock" must not be confused with apoplexy or stroke, which is spoken of as "shock" in some sections of the United States.

FIRST AID

173

prove fatal. It is a depression of the nervous system and the functions of the body. There is a loss of body heat and a decrease in the amount of circulating blood. To compensate for this, the heart beats faster. Severe shock may occur in the absence of conspicuous manifestations, such as hemorrhage. The first-aid worker must not become so intent on the care of an injury that the victim develops severe shock because simple preventive measures were omitted. The first aid measures for the prevention of shock are so simple and commonplace that the inexperienced might see little harm in omitting them. But, simple as they are, shock treatment is vitally important for every case. As the amount of blood in circulation diminishes, the brain does not get enough blood. Keep the casualty lying down so that the blood will go to the heart by gravity and may be pumped to the brain. Apply blankets and hot-water bottles to prevent loss of body heat. This does not consist merely of piling blankets on top of an injured person — it is important to have an equal number of thicknesses underneath him. Warm drinks (unless the casualty is unconscious) are beneficial. Do not remove more clothes from the victim than necessary to treat his injury. Loosen clothing at the neck, chest, and waist. Shock probably causes more fatalities than any other condition. Do not underestimate its dangers. Symptoms. Pallor (especially about the face and

174

HANDBOOK OF HEALTH

lips *); chilly, clammy sweat; nausea; mental confusion; weak, rapid pulse; irregular breathing. There may be unconsciousness. Treatment. Lay flat, with head low and feet raised. Put blankets and wraps under and over the victim. Keep warm with hot-water bottles, but do not burn. Give warm and sweetened drinks, unless the person is unconscious or injured internally. Do not give alcoholic drinks. FRACTURES

The first aid of all fracture cases is very important. Careless handling may transform a simple fracture to a compound fracture by pushing a sharp bony fragment through the skin; nerves or large blood vessels may be damaged; or, in fractures of the spine, the spinal cord may be severed, with permanent paralysis or death as the result. Always examine a suspected fracture gently and treat as though fracture were present even though you only suspect it. It is important to keep patients with fractures motionless until the limb has been splinted. "Splint them where they lie," and use traction splints if you can obtain or improvise them. If the injured person is to be given first aid and is * In injured women, do not let make-up confuse you. Remove it.

FIRST AID

175

to be cared for by a physician in the near future, follow the directions given below. If, however, you are far from medical aid and must depend on your own resources, you must use your own judgment and combine the information given here with that given under surgical treatment (p. 138). The use of traction is given in this section because it is an essential part of first aid. The same principles hold good with the formal treatment of free fractures of the arm and leg above the wrist and ankle. If you are provided with proper traction splints, it probably is better to use them rather than to attempt the various other methods given in the section on surgery. In backwoods surgery one is forced to use one's own ingenuity. For prolonged traction, the traction hitch must be replaced by long strips of wide adhesive running up the limb to the level of the fracture, and, if possible, weights should be used running over a bar or pulley rather than the Spanish windlass. Space permits only suggestion rather than a description of methods and apparatus for prolonged traction. Fixed Traction for the Leg. The half-ring leg splint, known as the Keller-Blake splint (Fig. 5A), which has been adopted by the United States Army, should be used for a fracture of the leg at any point from the hip to the ankle. The splint may be applied without removing clothing. Two first-aid workers are needed for the application of the splint. Apply a traction hitch to the foot as illustrated in

176

HANDBOOK OF HEALTH

Fig. 4. Tie two cravat bandages together; place the knot under the sole of the foot at the instep with or without the shoe, so that it forms a stirrup (A). Carry

FIG. 4

the ends of the bandage over the foot and around the ankle in opposite directions, crossing behind and above the heel (B). Thread the ends under the folds which form the sides of the stirrup on each side (C).

FIRST AID

177

A free end now hangs from each side of the foot (D). These form the traction bands. One person grasps the foot in the traction hitch, keeping the foot at a right angle to the leg with the

the same time, the limb is straightened to a position as nearly normal as possible and the foot is slowlyraised until the heel is a foot or more above the ground. While pull is maintained, the splint is placed in position by slipping the half ring under the upper

178

HANDBOOK OF

HEALTH

portion of the thigh, with the short side-bar inside. Move the splint upwards until the half ring meets the crotch. Then buckle the strap snugly but not tightly across the thigh to the side-bar on the opposite side (Fig. 5B). While one worker maintains traction on the foot, the traction bands are carried over the notched end of the splint by the other worker, drawn up snugly and tied with a square knot. Form a Spanish windlass by inserting a stick about six inches long between the traction bands. Twist the bands with the stick until all slack has been removed and strong traction is established. Then anchor the stick to keep the band from unwinding by tying the ends of the stick to the sides of the splint. Support the limb in the splint as illustrated in Figs. 6 and 7. Hang the center of a cravat over the

FIG.

6

outside bar. Pass the end toward the leg, under the leg, and up between the leg and the inside bar (Fig. 6A). Take one end in each hand and draw outward sufficiently to take any sag out of the leg. Pass the

FIRST AID

ends under the leg in opposite directions and tie at outside bar (B). Five such bandages should be plied: (1) just below the crotch; (2) just above knee; (3) just below the knee; (4) at the middle of lower leg; and (5) at the ankle (Fig. 7B).

179

the apthe the

FIG. 7

After the leg has been splinted, the heel must not touch the ground. The end of the splint may be suspended or rested on something. Improvised Fixed-Traction Splints for the Leg. Improvised fixed-traction splints may be made from

180

HANDBOOK OF HEALTH

boards. For the leg, the board should be not less than four inches wide. It should be two feet longer than the leg (Fig. 8).

Cut a U-shaped notch in both ends of the board. Slip the middle of the cravat bandage into the crotch; bring the ends around the thigh, and tie together with a square knot so that a loose loop is formed. While pulling firmly on the leg, apply a traction hitch to the foot as described on page 176. Place the board on the outside of the leg and slip the looped cravat bandage into the notch in the upper end of the board. Then tie the traction bands over the notch in the lower end of the board. Apply traction by inserting a short, stout stick between the two traction bands and twist until all slack has been taken up and strong traction established. Tie cravat bandages firmly but not tightly around the leg and splint (1) at the crotch, (2) just above the knee, (3) just below the knee, (4) halfway from the knee to the ankle, and (5) at the ankle.

FIRST AID

181

Fixed Traction for Arm. For first aid only. See page 148 for subsequent treatment. The MurrayJones or the Thomas arm splint (Fig. 10A) is a fixedtraction splint for the arm. It should be used for any fracture from the shoulder to a point halfway from the elbow to the wrist. It may be applied without removing clothing. The traction hitch for the arm (Fig. 9) is slightly more complicated than that for the leg. Roll a stick, about 4 inches long, in a triangle bandage so that a long tail hangs from either end (A and B). Place the wrapped stick crosswise in the palm of the victim's hand, and fold his fingers around it, allowing the bandage ends to hang down (C). Place a cravat bandage on the back of his wrist (D); pass the ends around the wrist; cross them on the back of the hand; then bring them over the fingers snugly (E). Carry the ends to the palm side of the wrist (F); tie a single knot; bring the ends to the back of the wrist and tie a square knot (G) completing the hitch (H). The bandage ends hanging from the end of the stick form the traction bands. One operator grasps the wrist and traction bands and applies steady, gentle traction, at the same time straightening the limb to a position as nearly normal as possible. The operator shifts his hands one at a time so the ring of the splint may be threaded over the victim's hand and passed up the arm until the lower part of the ring fits into the armpit. When the

FIG. 9

FIRST AID

183

splint is in proper position, the arm extends down between the sidebars with one bar on the thumb side and the other bar on the little finger side, with the palm toward the victim's side.

FIG. 10

The traction bands are tied in a square knot over the notch at the end of the splint, with enough pull to maintain traction. Bring the arm to as near normal length as possible, using the opposite arm as a guide. To keep the arm from moving in the splint, cradle it as follows: Hang a cravat bandage by its center over the outside bar. Pass the end toward the arm,

184

HANDBOOK OF HEALTH

under the arm, and up between the arm and the inside bar (Fig. 6A). Pass the ends under the arm in opposite directions, and tie at the outside bar (Fig. 6B). Cradle the arm in this manner (1) just below the armpit, (2) just above the elbow, (3) just below the elbow, and (4) just above the wrist.

Improvised Fixed-Traction Splint for the Arm. A board at least four inches wide and two feet longer than the arm is used (Fig. 11). Cut a U-shaped notch in each end. Tie a folded triangle bandage around the arm so that it forms a loose loop in the armpit, with the tied ends over the upper part of the shoulder. Apply a traction hitch to the hand as described on

FIRST AID

185

page 181. Insert the notch in the upper end of the board into the loop, applying the board to the outer surface of the arm. Bring the traction bands from the hand over the notch at the lower end of the splint. With one hand, pull firmly on the wrist. With the other hand, grasp the traction bands and push upward, pulling the bands through the notch to make firm traction. Pass the ends around the board and tie. Encircle the arm and splint twice with folded triangle bandages, and tie snugly (1) at the armpit, (2) just above the elbow, (3) just below the elbow, and (4) just above the wrist (Fig. 10B). Fracture of the Spine. Broken backs and broken necks are so dangerous that they require special first aid measures. Improper care may result in permanent paralysis or death of a person with these injuries. Broken Neck. The victim, if conscious, will complain of pain in the neck. Many cases will hold the head and neck stiff and motionless, but some will be completely relaxed and have no control of the head. Injury to the spine may cause paralysis. Can the injured move his hands? Try his grip (both hands). Record any paralysis or weakness on a tag. Keep him lying in the position in which he was found and prevent motion of the head. Do not give him water, as he may move his head to drink. Cover him with blankets or wraps. Get a doctor. If a victim with a broken neck must be moved, get a door, shutter, or wide board, and place it beside him

F I G . 12

FIRST AID

187

with the end at least four inches above the top of his head. The board should be at least fifteen inches wide and five feet or more in length. One person kneels at the victim's head, holding the head between his two hands and steadies the head so that the head, neck, and shoulders move as a unit with the body, without bending. One or more assistants grasp the victim's clothing at the hips and shoulders and carefully slide him sideways onto the board or door, so that he remains face upward, arms at his sides, head, trunk, and extremities on the board. The

FIG. 13

head must not be raised or the neck bent forward or sideways. The arms may then be folded over the chest and held together with safety pins or bandage. Several straps or triangle bandages should then be placed around the victim and the board to hold him in place during transportation. A folded sweater or coat should be placed around his head to hold it in

188

HANDBOOK OP HEALTH

position, or socks filled with sand or earth may be used. The board is then picked up and the victim transported as though he were on a stretcher (Fig. 13). If a victim with a broken neck is found lying on his face, a door or wide board should be placed beside him as described above, and the arm at that side brought above the head. The person kneeling at the head grasps it firmly at the sides, covering the ear and the back end of the jaw with his hands. Assistants grasp the victim's clothing at the shoulders and hips and gently roll him onto the board, the man at the head steadying the head so that it is kept in line with the rest of the body. Moderate traction should be exerted by the hands holding the head. The head must not be allowed to tilt either forward or backward. Broken Back. When the backbone is broken below the neck, the only symptom may be pain in the back. If the spinal cord is damaged or under pressure, the victim may be unable to move his feet but can move his hands. Any move which doubles the injured man forward may cause death or paralysis for life. He must, therefore, be kept motionless in the position in which he is found. Get a doctor. Keep him warm. Reassure him. Do not let him move. If necessary to move a victim found on his back, place a door or wide board beside him as described above. Raise the arm on the side toward the board so that it is straight above the victim's head. Several assistants kneel alongside

FIRST AID

189

the board opposite the victim and, grasping his clothing on the far side, they roll him slowly and gently towards them so that he lies face downwards on the board. If a door is used, the assistants kneel on the door, leaving enough space for the victim. In making this roll, the body must move as a unit. Then bend one forearm so that the head will rest on it (Fig. 14). If a casualty with a broken back is found lying on his belly, the door or board should be placed beside him. Assistants grasp his clothing and slide him onto

FIG.

14

the board, one person guarding his face. He remains in a face-down position. Several straps or bandages should then be placed around the victim and the board, to bind him firmly in place during transportation. Victims with broken backs should, if possible, be moved only on a rigid support. A blanket may be used if no rigid support is available. If the victim is on his back, he must be rolled onto a blanket. If the victim is found lying on his belly, he must be slid onto the blanket. If the victim is found lying on his

190

HANDBOOK OF HEALTH

side or in a crumpled condition, he must be carefully straightened out. With one person at the feet, a second at the head, and one in the middle, the victim is rolled onto his back in the case of a broken neck and onto his belly in the case of a broken back. If both the neck and back are broken, handle as a broken neck. In case of doubt, handle a suspected fracture as if it were actually a fracture. Fracture of the Pelvis. The patient is unable to stand or move his legs without great pain in his hips and pelvic region. The whole pelvic region should be supported with a wide swathe, fitting snugly but not tightly enough to push the bones inward. Otherwise treat him as though he had a broken back. For fractures of feet, hands, and collar bones see section on Fractures (pp. 141, 147 and 150). One of the great dangers in all splinting is that the splints may be applied too tightly. Watch fingers and toes carefully. If they are blue and the patient says they feel as though asleep, loosen the ties promptly. ARTIFICIAL RESPIRATION

Common causes of arrested breathing or asphyxia are: 1. Electric shock 2. Carbon monoxide poisoning (illuminating gas, exhaust gas, or coal gas)

FIRST AID

191

3. Drowning 4. Concussion from explosions, or from blows on the head or abdomen 5. Suffocation or strangulation due to external obstruction of the air passages 6. Foreign bodies in the throat or windpipe, which obstruct the air passages A person who has stopped breathing from any of these causes must be made to breathe at once or he will die. Do not waste time on unnecessary things but get to work immediately, using the prone pressure method of artificial respiration. Get the victim into fresh air, clear the mouth or throat of any obstructions, and proceed as follows. Standard Technique of Prone Pressure

Method.

1. Lay victim on his belly, one arm extended directly overhead, other arm bent at elbow. Turn face toward extended arm, resting the head on hand and fingers of bent arm so that nose and mouth are free for breathing and may be seen by the operator (Fig. 15). 2. Kneel, straddling the victim's thighs, with your knees just above his knees, adjusting your position so that you can comfortably lean forward and place the palms of your hands on the lower part of his chest with the little fingers resting over the lowest ribs. Your wrists should be about four inches apart. 3. With your arms held straight, swing forward slowly, so that the weight of your body is gradually

FIG. 15

FIRST AID

193

brought to bear upon the victim. Your shoulders should be directly over the heels of your hands at the end of the forward swing. This operation should take about two seconds. Do not bend your elbows. 4. Quickly swing backward so as to remove pressure completely. 5. After two seconds swing forward again. Repeat steps 3 and 4 regularly twelve to fifteen times a minute. 6. Continue artificial respiration without interruption until natural breathing is restored — for hours, if necessary — or until a physician declares the victim dead. 7. Have an assistant loosen tight clothing about the victim's neck, chest, and waist. Keep the victim warm. Do not give him any liquids by mouth until he is fully conscious. 8. Keep the victim lying down after he revives, to avoid strain on his heart. He should be given hot tea or coffee to drink after he is fully conscious. 9. Resuscitation should be carried on as near as possible to the place where the victim received his injuries. Should it be necessary to move the victim from the point of the accident, artificial respiration should be carried on during the time he is being moved. He should not be moved again until he is breathing normally, and then moved only in a lying position. 10. After a temporary recovery of respiration

194

HANDBOOK OF HEALTH

the victim may stop breathing again. He must be watched, and, if natural breathing stops, artificial respiration must be resumed at once. 11. In carrying out resuscitation it may be necessary to change operators. This change must be made without losing the rhythm of respiration. The pressure exerted by the forward swing must be regulated to meet the comparative sizes of operator and victim. Too much pressure is harmful, and the tendency is always to press too hard in an effort to make the victim breathe. The pressure empties the used air from the chest. An inrush of fresh air takes place in the rest interval when no pressure is being exerted. Pressure must be in the correct place to force air from the chest. Make sure that your hands are in the proper position and that they do not get too low. Be sure that the nose and mouth are free of obstruction, so that air can pass in and out. If frothy bubbles collect in the mouth, they should be wiped out by an assistant. Keep the victim warm. Blankets, wraps, or even newspapers should be wrapped around him. You can continue to work through this covering without exposing the victim to the wind. Only by continued practice will you be able to give artificial respiration effectively under the excitement of an emergency. Therefore you should practise regularly on any willing subject. Never give up. Many

FIRST AID

195

persons have been revived after hours of work. Alternate with other workers when you are fatigued. Stop only when the victim has revived or the case has been taken over by a physician. MISCELLANEOUS CONDITIONS

Effects of Heat. Heat stroke (sunstroke); heat exhaustion (prostration); heat cramps. See Chapter IV. EFFECTS OF COLD *

Frostbite. Tingling of the skin followed by numbness. The part becomes dead white, and the patient does not feel it if the part is touched. Thaw the part gradually by placing it against the body or in cool or tepid water. Do not use hot water or expose to a heater. Do not massage, and do not rub with snow. Slow muscular action by the patient will tend to increase circulation to the part. If there is blistering or gangrene, treat as though it were a severe burn. Prolonged Exposure to Cold. This causes numbness, general slowing of the faculties, difficulty in moving, irresistible drowsiness, and finally unconsciousness. Do not warm the patient too rapidly. Use artificial respiration if necessary. As the patient begins to react, raise temperature slowly and give warm stimulating drinks (not alcoholic) and put in warm bed. * See also Chapter VI, p. 113.

196

HANDBOOK OF HEALTH

If the patient is chilled but not unconscious, and there are no frostbites, give hot drinks and warm him up more rapidly. If the feet and legs have been chilled for hours or days by exposure, as in a lifeboat or life-raft, it is important to warm the affected parts very slowly. Pain may be controlled by exposure to cool air or even by an ice bag placed outside of the clothing. (See also p. 161).

CHAPTER

IX

MISCELLANEOUS MEDICAL

INFORMATION

MEDICAL INSTRUMENTS AND USE OF DRUGS

The Clinical Thermometer. The type made for use in the rectum is equally usable in the mouth, and it is less easily broken. It requires at least three minutes to register. The thermometer should be carried in a close-fitting case and protected by a pledget of cotton at either end. Before and after taking a temperature, wash the thermometer in clean, cool water. Hot water will burst it. If the mercury is above the 98° F. mark, shake it down with a snap of the wrist. Insert the thermometer well under the tongue. See that the lips remain completely closed for at least three minutes before reading the thermometer. If a patient is unconscious or cannot keep the lips closed, insert the thermometer gently into the rectum. Rectal temperatures are apt to be about one degree higher than mouth temperatures. Hypodermic Syringe. The all-metal syringe without washers is recommended. Glass syringes break easily, and washers dry up and shrink. Before using the syringe, wrap it and the needle in

198

HANDBOOK OF HEALTH

a handkerchief and boil them. Take \ of a teaspoon of boiled water in a spoon and drop the hypodermic tablet into it. Without touching the tip of the syringe yourself, crush the tablet with it and stir, to hasten solution. When solution is complete, draw the fluid into the syringe. Grasp the needle by the butt, and after pulling out the wire, attach the needle to the syringe giving it a slight twist to make it tight. Do not touch the needle itself. With the syringe held vertically, expel air-bubble by pressing on the plunger until a drop of fluid appears at the tip of the needle. Lay the syringe aside where the needle will not touch anything. Disinfect a bit of loose skin, preferably on the thigh or abdomen, with a dab of tincture of iodine or with soap and clean water. After the disinfected skin has dried, pinch up a fold between thumb and finger. With a quick jab, insert the needle through the fold at an angle. Inject slowly. Wash and dry the syringe and the needle, and reinsert the wire into the needle after use. Antitoxin Syringe. This type of syringe should have a capacitv of 10 to 20 cc. (The hypodermic syringe holds only about 1.5 cc.) The standard type is made entirely of glass and is likely to break if dropped into boiling water or even if boiled with the plunger in. Care is required to reinsert the plunger after boiling without touching any part except the handle. Wash the syringe and needle carefully after use.

MISCELLANEOUS INFORMATION

199

Some antitoxins or sera are marketed in syringe containers. Each package contains instructions for using. When the antitoxin or serum to be used is contained in a simple vial with a long neck, boil your syringe and attach the needle, file the side of the neck of the vial and, holding it in a piece of cloth, break off the neck. Insert the needle with utmost care to prevent it from touching the outside of the vial and draw the serum into the syringe. Then, with the needle pointed upward, expel all air from the syringe. The syringe now being ready, disinfect the skin where the injection is to be made. Because of the quantity of fluid, antitoxin should be injected well under the skin and in a place where there is loose tissue, e.g., on the abdomen. Hot-Water Bag and Fountain Syringe. These should be combined by having a tube which can be inserted into an ordinary hot-water bag in place of the stopper, and which is furnished with tips and a clip for stopping the flow. Caution. A hot-water bag should always be wrapped in something lest it burn the patient. Special care must be exercised if the patient is unconscious. Enemas. An enema is given (1) when it is desirable to empty the bowels without delay, (2) when a cathartic has not acted freely, or (3) to clean the lower bowel when it is to be used to absorb water or nourishment.

200

HANDBOOK OF HEALTH

A satisfactory enema for emptying the bowel consists of a quart of warm water containing soapsuds. The enema fluid should be injected very slowly. The bottom of the bag of the fountain syringe should be held about eight inches above the anus. The rate of flow can be regulated by raising or lowering the bag a very little. If there is pain, lower the bag at least temporarily. The patient should endeavor to hold on until all of the fluid has gone in. An enema may be taken sitting up but is more easily given and more likely to act well if injected while the patient lies on the left side or on the back with hips raised. Caution. The nozzle should be inserted very gently and not more than one inch within the anus, lest the bowel be injured. USES OF DRUGS

General Information. Drug-taking may be the least important part of treatment and is often unnecessary. Most civilized countries have an official list of drugs which specifies required standards of strength and purity. This list, called the pharmacopoeia, does not include all the newer drugs of value, nor the preparations of which the formula is secret. Drugs listed in the current edition of the United States Pharmacopoeia (1942) are designated by "U.S.P." after the name. Because neither the offi-

MISCELLANEOUS INFORMATION

201

cially required strength nor the names of medicines are the same in all countries, it is well, when ordering in a foreign country, to use the official name followed by "U.S.P." Order from the most reliable drugstore, and save money by using the official name. Some useful prescriptions are listed in the National Formulary (1942) which is here designated by the initials "N.F." Valuable information about certain drugs and medicinal preparations which are not included in the United States Pharmacopoeia (1942 edit.) nor in the National Formulary (1942 edit.) can be obtained from New and Nonofficial Remedies (1942 edit.). A new edition of this book is published annually by the American Medical Association. Drugs listed therein are here designated by the initials "N.N.R." Dosage. The doses recommended in the Handhook of Health are intended for adults weighing 80 kilograms, or about 160 pounds, and may be varied upward or downward within reasonable limits. The dose for small adults and for children should usually be proportional to body weight. Pills or tablets can be cut up in order to obtain smaller doses. Caution. A few individuals are hypersusceptible to certain drugs and cannot take them even in ordinary dosage without ill effects. The safe dosage and toxic effects of unofficial preparations of unknown composition may be difficult to ascertain.

202

HANDBOOK OF HEALTH SOME VERY IMPORTANT D R U G S

For Malaria (p. 63) Quinine (Quininae Sulfas, U.S.P.) Atabrine di-Hydrochloride (N.N.R.) For Amebic Dysentery * (p. 73) Carbarsone (Carbarsonum, U.S.P.) Chiniofon (Chiniofonum, U.S.P.) For Various Injections and for Bacillary Dysentery (pp. 37, 72, 129 and 164) Sulfonamide Compounds (U.S.P.) or (N.N.R.) For Chlorination of Water (p. 14) Halazone Tablets (N.N.R.) STIMULANTS

A swallow of strong liquor serves as a quick "pickme-up," but this effect soon passes off and is followed by a sedative effect. The best stimulant, for most purposes, is hot tea. Food is the best bracer when it can be taken. It has a temporary stimulating effect even before absorption, and it provides new energy after absorption. When undergoing severe and continued exertion, or in very cold weather, food should be taken at frequent intervals. * Vioform (N.N.R.) or Diodoquin (proprietary) may be used (p. 74).

MISCELLANEOUS INFORMATION

203

F O B SLIGHT OR MODERATE P A I N

Slight pain can often be relieved by applications of heat or cold to the affected part, by change of position, or, in case of a wound, by readjustment of the dressings. Use the mildest remedy that is effective. The following are useful: 1. Aspirin (Acidum acetylsalicylicum, U.S.P.) can be taken safely by most persons in the dose of two tablets of 0.32 Gm. (5 grains) each three or four times a day, preferably after eating and taken with a full glass of water. Useful for almost any kind of pain, and particularly in rheumatic fever, for which larger dosage may be required. 2. Sodium bicarbonate (Sodii bicarbonas, U.S.P.), "cooking soda." The usual dose is % to 1 teaspoonful dissolved in | to 1 glass of water; it can safely be repeated. See Indigestion. Caution. Do not mistake for "washing soda," which is a strong, alkaline caustic. 3. Oil of cloves (Oleum caryophylli, U.S.P.). See Toothache. FOR SEVERE P A I N

Morphine, a derivative of opium, acts more quickly than opium, but the effect of the latter lasts longer. Opium is preferred for continuous effect. Contraindications. 1. Do not use morphine or

204

HANDBOOK OF HEALTH

opium for a pain which may last for weeks or which recurs frequently, lest a drug habit result. 2. The dosage for old and feeble persons should be about half the average. 3. Some people who have taken morphine or opium know that, with them, it causes discomfort or excitement instead of relief. When using either drug in any form on those who have not taken it before, begin with half the ordinary dose except in critical emergencies. Caution. Before giving morphine or opium, note carefully the size of the pupils and the rate of respiration per minute. If, later, the pupils become much contracted or the respiration rate falls below twelve per minute, do not repeat the dose until these effects have passed. Should extreme somnolence develop, the breathing may stop. To prevent this, administer strong tea or coffee, and keep the patient awake by any necessary means. Both morphine and opium have a constipating effect and may cause nausea even when they act well in other respects. The "C.O.T. pill" and paregoric (p. 207) contain small amounts of opium. Morphine (Morphinae sulfas, U.S.P.). Dose: 0.008 to 0.016 Gm. (J to | grain), usually injected hypodermically. The drug is absorbed nearly as quickly if the hypodermic tablet is placed under the tongue and dissolved there. Either dose may usually be repeated after several hours if the pain continues.

MISCELLANEOUS INFORMATION

205

Opium, U.S.P. Dose: 0.016 to 0.065 Gm. (J to 1 grain). Do not repeat the larger dose more than twice in 24 hours. Strong liquor, taken in considerable quantity, deadens pain. TONICS

1. Tonic pills (Pilulae Jerri, quininae, slrychninae et arseni, N.F.). Dose: one pill once or twice daily for a week at a time. 2. Vitamin concentrates increase the appetite and sense of well-being of persons whose diet has been deficient in the vitamins. There are numerous commercial vitamin preparations available today. The preparations of most value to one who may not be able to obtain or to take a nutritionally adequate diet, are those which contain all of the vitamins known to be essential to man, and in amounts which are scientifically reasonable. Such amounts are 5000 I.U.* of vitamin A; 400 I.U.* of vitamin D; 1.8 mg. of thiamine; 2.7 mgm. of riboflavin; 18mgm. of nicotinic acid; and 75 mgm. of ascorbic acid, or simple multiples of these amounts. One should seek medical advice rather than take these preparations indiscriminately. * International Units, which are equal to U.S.P. Units.

206

HANDBOOK OF HEALTH CATHAKTICS

Saline cathartics, of which there are many, should be dissolved in a glass of water and taken one hour before breakfast. They should be used only occasionally to clear the bowels. See Constipation, p. 22. Epsom salts (Magnesii sulfas, U.S.P.). Dose: one or two teaspoonfuls. Larger doses have a purgative effect. Mild cathartic pills should be taken in the evening to act on the following morning. They may be taken daily if needed. Many kinds of pills might be recommended, as for example, "A. S. and B. Pills" (Pilulae aloini, strychninae et belladonnae, N.F.). Dose: one or two pills. PURGATIVES

Purgatives are used to clear the bowels when there is indigestion (p. 23) or at the beginning of a fever. Their action is stronger than that of cathartics. 1. Calomel (Hydrargyri chloridum mite, U.S.P.). A tablet of 0.065 Gm. (1 grain) is best taken at night on an empty stomach. It should act on the following morning. To insure prompt action, take a mild saline cathartic one-half hour before breakfast. To get the best effect of calomel, it is necessary to drink much water at intervals after taking the tablet. 2. Compound Cathartic Pills (Pilulae hydrargyri

MISCELLANEOUS INFORMATION

207

chloridi mitis cornpositae, N . F . ) . Dose: one or two pills in the evening. 3. Epsom salts (see Cathartics). Purgative dose: one tablespoonful dissolved in one glass of water to be taken on an empty stomach and preferably half an hour before breakfast. FOR DIARRHEA

1. Bismuth subcarbonate * (Bismuthi subcarbonas, U.S.P.). Dose for diarrhea \ teaspoonful mixed with a little water and taken two to four times daily. Bismuth causes the stools to become black. 2. Tannin. Strong, boiled tea contains much tannin. It has a marked constipating effect. 3. "C.O.T. Pills" (prescription needed). Each contains camphor, 0.065 Gm. (1 grain); opium, 0.016 Gm. ( j grain); and tannin, 0.13 Gm. (2 grains). If hard, these pills should be broken before taking. Dose: one pill at a time, and not more than three within twenty-four hours. 4. Paregoric (Tindura opii camphorata, U . S . P . ) contains 0.4 per cent of opium, or about 0.016 Gm. per teaspoonful. Usual dose: one teaspoonful repeated, if needed, but not to exceed 8 teaspoonfuls in 24 hours. * The subcarbonate has advantages over the subnitrate although the latter is more commonly used.

208

HANDBOOK OF HEALTH OINTMENTS

Ointments which are to be used in the hot tropics may melt unless prepared with a stiffer base than usual. The containers should be tight. Toilet lanolin is suitable for application to sunburn or to abnormally dry or chapped skin. Bone ointment (Unguentum acidi borici, U.S.P.) is nonirritating and slightly antiseptic. Zinc oxide ointment (Unguentum zinci oxidi, U . S . P . ) is slightly antiseptic and slightly astringent. Sulphur ointment (Unguentum sulfuris, U.S.P.) contains 15 per cent of sublimated sulphur. It has a considerable antiseptic value for superficial infections (see Impetigo and Sore Feet) and for scabies, but may irritate a sensitive skin. Salicylic ointment, containing 10 per cent of salicylic acid (Acidum salicylicum, U.S.P.) can be prepared by any pharmacist. When rubbed in, it helps to relieve pain in the joints or muscles. I t also checks itching, but may irritate a sensitive skin. Whitfield's Ointment * (unofficial). An old standby for the treatment of ringworm. I t is too irritating for frequent use on a sensitive skin. Half the usual strength is recommended. * Salicylic acid, 1 Gm.; Benzoic acid, 2 Gm.; Petrolatum, 30 Gm.

MISCELLANEOUS INFORMATION

209

SOLUTIONS FOR USE IN THE E Y E

Caution. Solutions for use in the eye should be made up in small quantities with boiled water, put into clean bottles, and not kept for many days. Boric acid in 2 to 4 per cent solution makes an excellent cleansing eyewash. Dissolve one tablet of 0.32 Gm. (5 grains) in \ ounce of water. Use with an eye-dropper every three or four hours. Zinc sulphate (Zinci sulfas, U.S.P.) in 0.1 per cent solution has an astringent effect which renders it useful to reduce congestion. Dissolve a tablet, 0.065 Gm. (1 grain) in 60 cc. or two ounces of water. Put a drop in the eye, at intervals of not less than eight hours, for a few days. Phenacaine hydrochloride (Phenacainae hydrochloridum, U.S.P. "Holocaine") in 1 per cent solution can be recommended for painful inflammation of the eye. Dissolve a tablet (0.065 Gm.) in 6 cc. or teaspoonfuls of water. Two drops may be used in the eye at intervals of several hours. ANTISEPTICS

Tincture of iodine (Tinctura iodi, U.S.P.) has a strength of 7 per cent. A strength of 3.5 per cent is sufficiently strong and less irritating to a sensitive skin. Tincture of iodine is used (1) to disinfect the skin; or (2) for certain skin diseases such as ring-

210

HANDBOOK OF HEALTH

worm. Because of its irritating quality, it should not be applied daily or frequently in the same place. It may cause irritation if covered with a bandage or if used on parts of the skin which are moist. Should it cause irritation, it can be washed off with soap and water. If allowed to evaporate in the bottle, tincture of iodine eventually becomes excessively concentrated. Alcohol (Alcohol, U.S.P.) should contain not less than 92.3 per cent of pure ethyl alcohol by weight or 94.9 per cent by volume. As a disinfectant (p. 122) for knives or for the skin, a strength of 70 per cent is sufficient. Commercial alcohols are of various strengths, sometimes only 40 per cent. Alcohol causes severe pain when applied to raw surfaces or to the genitalia. Boric acid (Acidurn boricum, U . S . P . ) , crystalline, is useful in 2 to 4 per cent solution as a mild antiseptic for wounds and wet dressings or as an eyewash. Tincture of metaphen (N.N.R.), 0.5 per cent (p. 123). SULFONAMIDE COMPOUNDS

The use of the sulfonamide or "sulfa" drugs has changed entirely the treatment of sepsis and serious wounds. Some of the sulfonamide drugs are also useful in the treatment of certain infectious diseases. Caution. It should be emphatically stated that, under ordinary circumstances, these drugs should

MISCELLANEOUS INFORMATION

211

never be used by the layman without the advice of a physician. This book was written only for the layman who cannot obtain medical advice. The use of sulfonamide drugs as recommended here entails certain definite risks to the patient which would not be tolerated were medical advice obtainable. Toxic Effects. When used for too long a period or in excessive doses, or when administered to hypersusceptible persons in ordinary dosage, toxic effects, which may be serious, are to be expected. Among the toxic effects which have been observed are nausea or vomiting, bloody urine, anemia, fever, rash, soreness of the eyes, and mental confusion or excitement. Should any of these signs or some other unexpected symptom appear, promptly discontinue use of the drug and, to promote its excretion, drink 10 or 12 glasses of water during the ensuing 24 hours. Sulfanilamide (Sulfanilanidum, U.S.P.). Ampules, each containing 4.0 Gms. (60 grains) of the drug. Used as antiseptic dusting powder for wounds (pp. 123 and 129). Not more than two ampules are to be used in any one day. Sulfadiazine (N.N.R.). Tablets, each 0.5 Gm. (7§ grains). Taken by mouth for sepsis (p. 129). Maximum dosage advised is six tablets for the first dose, followed by two tablets every four hours. This drug should not be taken for more than seven days. The large initial dose should not be repeated. The dosage recommended for use by mouth is suitable for

212

HANDBOOK OF HEALTH

a man weighing 80 kilograms or about 160 pounds. Smaller men should take correspondingly smaller doses. Sulfathiazole (Sulfathiazolum, U.S.P.). Tablets, each 0.5 Gm. (7? grains). Used for gonorrhea (p. 37). Caution. When taking sulfadiazine or sulfathiazole, it is important to drink water very freely, 8 to 10 glasses per day, in order to diminish the chance of toxic effects. In a hot and dry climate or when sweating has been profuse, the urine may become reduced in quantity. There is then danger of injuring the kidneys if sulfa drugs are taken. To obviate this danger, large amounts of water should be taken before and during the period of administration of the sulfa drug. Sulfaguanidine (N.N.R.). Obtainable as powder or in tablets, each 0.5 Gm. (7J grains). For dosage, see Bacillary Dysentery, p. 72. Sulfonamide ointments of various kinds may be used on venereal ulcers, wounds, or burns for their antiseptic effect (pp. 38, 128 and 136). SURGICAL E Q U I P M E N T L I S T

Instruments and Supplies Hemostatic forceps Toothed forceps Scissors, curved blunt tips

MISCELLANEOUS INFORMATION

213

Bard-Parker knife handle, no. 4 Bard-Parker knife blades Needles, straight Glovers, no. 4 Needles, curved, assorted Catgut, chromic, no. 0 Surgical silk, no. 8 Adhesive plaster, 2 in. χ 10 yd. spool Band-Aides, assorted Gauze sponges, 3 x 3 in., individual envelope Gauze sponges, 3 χ 3 in., dozen in package Gauze bandages, 2 in. Gauze bandages, 3 in. Antiseptics, including Sulfonamide compounds, pp. 209 and 210. SELECTION OP M E D I C A L AND SURGICAL EQUIPMENT

The selection of equipment and the quantities of supplies to be taken will differ so much, according to circumstances, that no general list would be useful. The prospective traveler should seek professional advice and should obtain, well in advance, the things which he will require. The information presented in the foregoing pages of this chapter will serve to some extent as a guide.

APPENDIX

APPENDIX PACKING MEDICAL AND SURGICAL EQUIPMENT

Chests and cases can be obtained at medical supply houses but contain standard equipment which cannot always be modified to meet individual needs. Chests of various sizes made for carpenters' tools or tin boxes intended for fishing equipment serve well. Medicines. Dry drugs are to be preferred to fluids, which are heavy and which may leak. Tablets and pills make dosage easy. All medicines should be kept in the dark and protected from moisture and from excessive heat. Medicine chests should be painted white or with aluminum if they may be exposed to a hot sun. Protection from moisture can be assured until a bottle is opened by dipping the stopper and top of the bottle into melted paraffin. Paper labels on bottles and other containers should be shellacked to prevent them from coming off. Adhesive tape makes good labels. For packing bottles, pasteboard mailing cases are excellent. Metal bottle cases which druggists carry may be preferred, and film tins can be used. Instruments should be carefully cleaned and lightly oiled or greased before packing, and again after using. Dressings, if sterile, are best carried in airtight packages. Individual sterile dressings or small packages of them in sealed envelopes are convenient for ordinary use. Nonsterile dressing material should be well wrapped to keep it

218

APPENDIX

clean and should be protected from excessive moisture, which might cause it to become moldy. Articles of rubber should be coated with talcum powder, wrapped in tissue paper, and protected from pressure. W E I G H T S AND M E A S U R E S

The metric system is used by apothecaries everywhere except in the United States and in Great Britain and its dependencies. The British weights and measures differ somewhat from ours, but the metric system is everywhere understood. Therefore, it should be used outside the United States. • M E T R I C SYSTEM

Solids 1 kg. = 1 kilogram or 1,000 Grams (Gms.) 0.1 Gram (Gm.) = 1 decigram 0.01 Gm. = 1 centigram 0.001 Gm. = 1 milligram Liquids 1 liter = 1,000 cubic centimeters (cc.) 1 cc. of water weighs 1 Gm. U. S. Apothecaries' Weights 1 troy pound = 12 ounces, or approximately 373 Gms. 1 troy ounce (3) = 8 drachms, or approximately 30 Gms. 1 drachm (drach. or 3) = 60 grains, or approximately 4 Gms. 1 troy grain (gr.) = 0.065 Gm.

218

APPENDIX

clean and should be protected from excessive moisture, which might cause it to become moldy. Articles of rubber should be coated with talcum powder, wrapped in tissue paper, and protected from pressure. W E I G H T S AND M E A S U R E S

The metric system is used by apothecaries everywhere except in the United States and in Great Britain and its dependencies. The British weights and measures differ somewhat from ours, but the metric system is everywhere understood. Therefore, it should be used outside the United States. • M E T R I C SYSTEM

Solids 1 kg. = 1 kilogram or 1,000 Grams (Gms.) 0.1 Gram (Gm.) = 1 decigram 0.01 Gm. = 1 centigram 0.001 Gm. = 1 milligram Liquids 1 liter = 1,000 cubic centimeters (cc.) 1 cc. of water weighs 1 Gm. U. S. Apothecaries' Weights 1 troy pound = 12 ounces, or approximately 373 Gms. 1 troy ounce (3) = 8 drachms, or approximately 30 Gms. 1 drachm (drach. or 3) = 60 grains, or approximately 4 Gms. 1 troy grain (gr.) = 0.065 Gm.

APPENDIX

219

U. S. Apothecaries' Measures 1 pint (0) = 16fluidounces (f. 3), or approximately 480 cc. 1 fluid ounce (f. 3) = 8 fluid drachms, or approximately 30 cc. 1 fluid drachm (f. 3) = 60 minims, or approximately 4 cc. 1 minim (min.) = 0.062 cc. HOUSEHOLD M E A S U R E S

Liquids 1 pint = roughly, 2 tumblerfuls 1 fluid ounce (f. 3) = roughly, 2 tablespoonfuls or 8 teaspoonfuls 1 fluid drachm (f. 3) = roughly, 1 teaspoonful 1 minim = roughly, 1 drop of a watery or 2 of an alcoholic solution Solids 1 drachm (3) of a powder = roughly, 1 level teaspoonful 1 ounce (3) of a powder = roughly, 2 level tablespoonfuls APPROXIMATE V A L U E S

Weights 1 1 1 1 1

troy ounce (3) = 30 Gms. drachm (3) = 3.88 Gms. grain (gr.) = 0.065 Gm. Gram (Gm.) = 15 grs. teaspoonful = roughly, 4 Gms.

220

APPENDIX Measures 1 fluid ounce (f. §) = 30 cc. 1 fluid drachm (f. 3) = 3.70 cc. 1 minim = 0.06 cc. 1 cubic centimeter = 16 minims 1 teaspoonful = roughly, 4 cc.

THERMOMETRIC EQUIVALENTS*

Atmospheric Temperatures Fahrenheit 0.0 10.0 20.0 32.0 40.0 50.0

Centigrade -17.78 -12.22 - 6.67 0.0 4.44 10.00

Fahrenheit 97.0 98.0 99.0 100.0 101.0

Centigrade 36.11 36.67 37.22 37.78 38.33

Fahrenheit 60.0 70.0 80.0 90.0 100.0 110.0

Centigrade 1S.S6 21.11 26.67 32.22 37.78 43.33

Body Temperatures Fahrenheit 102.0 103.0 104.0 10S.0 106.0

Centigrade 38.89 39.44 40.00 40.S6 41.11

* From United States Dispensatory, 21st edition, 1926. Horatio C. Wood, J r . et al.

INDEX

INDEX Abscess, 137 Ackee poisoning, 91 African sleeping sickness, 77 Alcoholic drinks: see Drinks Amputations, accidental, 134 Antiseptics, 121, 209 Antivenin, 109 Ants, 104 Appendicitis, 23, 25, 154 Arctic, 112 Arthritis, 35 Artificial respiration, 190 Asepsis, 121 Asphyxia, 190 Aspirin, 27, 31, 36, 83, 203 Asthma, 40 Atabrine, 47, 65, 202 Athlete's foot, 3, 97 Bandages, 126, 167 Bath water, 87 Bats, 105 Bedbugs, 100 Beds and bedding, 18, 51, 64, 113, 117, 119 Belly-band, 54 Beriberi, 42, 91, 112 Beverages: see Drinks Bilharziasis, 86 Biliousness, 23 Bismuth, 25, 207 Bites: animals, 135, 156 insects, 77, 81, 84, 95, 98, 106 leeches, 105 snakes, 106 "Black water," 67, 70 Black widow spider, 103

Bleeding: control of, 126, 169 in dysentery, 73 piles, 26 in schistosomiasis, 86 Blisters, 17, 44, 55, 88, 139, 144, 146, 158, 161 Blood poisoning, 128 Boils, 137 Boots, 17, 55, 64, 85, 98, 101, 105, 107, 116, 118, 119 Boric acid solution, 27, 29, 32, 38 122 210 Boric ointment, 45, 90, 116, 208 Botflies, 103 Bowels, 16, 22, 24, 26, 31, 200, 206, 207 Bronchitis, 33 Bruises, 127 Bubonic plague, 80 Burns, 135, 199 Butter, 7, 11 Calomel, 206 C a m p : food for, 58 hygiene, 16, 19 sites, 63, 77 Canned, dried or preserved food, 9, 12, 13, 49, 59 Canteens, 14, 47 Carbarsone, 74, 202 Carbohydrates, 7 Carbon monoxide poisoning, 190 Carbuncles, 137 Cathartics, 23, 206 Chancre, chancroid, 38 Cheese, 11 Chigger, or chigoe, 99 Chilling, 18, 24, 36, 49, 52, 66

224 INDEX Chiniofon, 74, 202 Dropsy, epidemic, 40, 42, 91 Chlorination of water, 14,47, 57, Drowning, 190 202 Drugs: general information, 200 Cholera, 4, 13, 75 Dysentery, 13, 32, 67, 71, 86, Cinder in eye, 28 202, 212. See also Diarrhea Clothing: in general, 18 for Arctic, 113, 116 Earache, 27 for Tropics, 47, 49, 53, 92 Eczema, 45 Colds, 33 Electric shock, 190 Colic, 24, 25 Elephantiasis, tropical, 87 Enema, 24, 31, 199 gallstone, 155 Epsom salts, 99, 206 renal, 156 Equipment, various, 4, 50, 56, 58 Concussion of brain, 151, 165 medical and surgical, 197, Constipation, 22 212, 217 Coughs, 33 Cramps: heat, 92, 95. See also Erysipelas, 129 Exhaustion, 6, 94, 114 Colic Exposure to heat or sun: see Cream, 11 Heat effects, 92-95 Cuts, 129. See also Bleeding, 170 to cold, 18, 113, 160, 195 on sea, 160-162 Delirium, 31, 32, 35, 67, 70 Eyes, 3, 17, 28, 38, 114, 209 Dengue, 82 Dermatitis, 44 Dhobie itch, 49, 96 Fats, 7 Diarrhea, 24, 52, 207. See also Feet, 3, 16, 88, 96, 158, 160 Dysentery Fevers, treatment of, 30 Diet: in general, 7, 49, 112 Filaria bancrofti, 87 for Arctic, 112 First Aid, 163 for illness, 21, 26, 31 Fish, 89, 91 for Tropics, 49 Flat foot, 3, 160 Dietary deficiencies, 42, 112 Fleas, 80, 84, 98 Diodoquin, 74 Flies, 11, 19, 77, 81, 83, 103 Disinfectants, 121, 209 "Flu," 33 Dislocations, 153 Food: canned, dried or preDressings, 121, 167, 217 served, 9, 12, 13, 49, 59 Drinking Water: see Water composition, 7 Drinks: alcoholic, 10, 18, 32, 37, contamination, 11, 19 93,113,114,174, 202, 205 cooking, 6, 89 cocoa, 10 digestibility, 5, 23, 48 coffee, 10 for Arctic, 112 fruit juices, 10 for Tropics, 49, 58 milk, 10, 83 fruits, 9, 12 fruit juices, 9, 10, 12 tea, 10, 25, 114, 202, 207

INDEX 225 packing, 60 Infection, 44, 88, 106, 128. See parasites from, 12 also Sepsis poisonous, 12, 91 Inflammation: see Infection and Footwear: see Boots and Socks Dermatitis Fractures, 138, 174 Influenza, 33 Frostbite, 113, 117, 195 Ingrowing toenail, 3, 158 Inoculations: see Sera and Vaccinations Gall bladder, gall stone, 155 Insecticides, 64, 99, 100 Gangrene, 108, 126, 139, 161 Insects, 45, 53, 77, 98, 117 Garbage, 19, 20 Gases, poisoning from, 190 bites of, 77, 81, 84, 95, 98, Gloves, 56, 64, 77, 116 106 Goggles, glasses, glare, 17, 29, repellents for, 64, 99, 101, 47, 114, 117 104 Gonorrhea, 37 Instruments, 122, 123, 197, 212, 217 Guinea-worm disease, 13, 88 Iodine: see Tincture of Halazone tablets, 15, 202 Itching, 45, 49, 96, 100, 106, 208 Hammocks, 51 Hats and headgear, 93, 116, 118 Jaundice, 25, 79 Hay fever, 40 Jigger: see Chigger Headache, 26, 67, 94 Head injuries, 151, 165 Lanolin, 44, 45, 208 Head nets: see Nets Latrines, 19, 85 Heart weakness, 39, 42 Leeches, 105 Heat: effects of, 92-95 Leggings, 17, 56, 64,98,101,105, Hemorrhage, 126, 169 107 Hemorrhoids ("Piles"), 20, 26, Lice, 82, 84, 98, 115 86 Lifeboat Foot, 160 Hernia ("Rupture"), 156 Liquor: see Drinks Hives, 43 Lockjaw (Tetanus), 4, 157 Holocaine solution, 28,115, 209 Lumbago, 36 Hookworm disease, 85 Hydrophobia (Rabies), 105, 156 Hygiene (Keeping Fit), Chap- Maggots, 103 ters I and III Malaria, 63, 94 Malta fever, 83 Meat, 12, 60 Ice, 10, 12, 14, 49, 113 Metaphen, tincture of, 123, 210 Ice-cream and Ices, 10, 11 Immersion Foot, 160 Midges, 53, 83 Impetigo, 44 Migraine, 27 Incinerators, 20 Milk, 10, 83 Indigestion, 21, 23, 48, 203 Mites, 84, 100

226

INDEX

Morphine, 27, 28, 31, 32, 35, 41, 72, 127, 155, 203 Mosquito boots, 56, 64 Mosquito nets: see Nets Mosquitoes, 63, 79, 83, 88 Murrina, 105 Naphthalene, 99 Neoarsphenamine, 82, 91 Nets: head, 56, 64, 77, 117 mosquito, 47, 52, 63, 105, 117 Nosebleed, 127 Ointments, 208 Oleomargarine, 7 Opium, 203, 205

Puttees, 101, 105, 107 Pyrethrum, 64, 101 Quinine, 47, 65, 68, 202 " R a b b i t fever," 80 Rabies, 105, 156 Red bug, 101 " R e d flap": see Ringworm Relapsing Fever, 48, 50, 81 Repellents: see Insects Resuscitation, 190-195 Rheumatism and Rheumatic Fever, 35, 203 Ringworm, 96, 97, 208 Rocky Mountain Spotted Fever, 84 R u p t u r e (Hernia), 156

Pain: abdominal, 23, 24, 25, 40, 154, 155, 156 back, 31, 35, 36, 152 bladder or kidney, 86,156 chest, 34, 40 drugs for, 203 foot, 158-160 joints and muscles, 35, 208 Paregoric, 25, 204, 207 Pellagra, 42 Piles, 20, 26, 86 Pimples, 43 Pink eye, 29 Plague, 4, 79 Pneumonia, 19, 33, 34 Poisoning: food, 89, 91 gases, 190 plant, 44, 91 snakes, 106 weapons, 111 Potassium Iodide, 39 Prickly Heat, 96 Proteins, 7 Purgatives, 23, 24, 31, 206

Salads, 12 Salicylic ointment, 106, 208 Salt, 8, 49, 73, 76, 92-95 Sandflies and Sandfly Fever, 53, 82 Scabies ( " t h e i t c h " ) , 45, 208 Schistosomiasis, 13, 86 Scorpions, 102 Scurvy, 43, 112 Sepsis, 99, 128, 157, 209, 210 Sera, 80, 109, 157, 199 Shock (Collapse), 172 Shoes: see Boots Skin Diseases, 43,45,49, 95,106, 208, 209 Sleeping sickness, African (Trypanosomiasis), 77 Slings, 168 Smallpox, 4 Snails, 86 Snakes and Snake-bite, 106 Snow blindness, 114 Socks, 16, 55, 116 Sodium bicarbonate (Cooking

INDEX Soda), 24, 43, 61, 68, 71, 79, 203 Sodium carbonate (Washing Soda), 61, 203 Sores: see Blisters and Ulcers Sore throat, 33 Spiders, 103 Splints, 140, 174 Sprains and strains, 152 Starvation, 114 Sterilization: see Asepsis and Water Stimulants, 114, 202 Stings, 102, 104 Sty, 29 Sulfonamide Compounds, 123, 128, 210-212 Sulfadiazine, 35, 37, 73, 211 Sulfaguanidine, 72, 212 Sulfanilamide, 129, 164, 211 Sulfathiazole, 37, 73, 212 Sulphur, 44-46, 101, 106, 158, 208 Sunburn, 44 Sun glasses: see Goggles Sunstroke, 92, 95 Sweating, 8, 49, 53, 92-96 Syphilis, 38, 90 Syringes, 27, 197, 198, 199 Tapeworm, 12, 48 Tea, 25, 49, 94, 114, 202, 207 Teeth, 3, 14, 28, 43 Tents, 50 Termites, 104 Tetanus (Lockjaw), 4, 133, 157 Ticks, 50, 81, 82, 84, 102 Tincture of iodine, 16, 97, 105, 106, 123, 209 Tincture of metaphen, 123, 210 Toes: see Feet Tonics, 66, 205 Toothache, 28, 203

227 Tourniquet, 109, 125, 170 Trachoma, 29 Traction, 139, 175 Trichinosis, 12, 48 Tropical ulcer, 90 Trypanosomiasis: African, 77 American (Chagas Disease), 104 in horses (Murrina), 105 Tsetse flies, 77 Tsutsugamushi disease, 84 Tuberculosis, 34 Tularemia, 80 Typhoid and Paratyphoid fever, 4, 13, 32, 74 Typhus fever, 4, 84, 100 Ulcers, 39, 44, 90, 96, 106, 113, 139, 144,146 Underclothing: see Clothing Undulant Fever, 83 Vaccinations, 4, 75, 78, 80,. 84, 157 Vampire bats, 105 Venereal diseases, 37 Vioform, 74 Vipers, 107 Vitamins, 8, 11, 42, 48, 112 Vitamin concentrates, 32, 41, 66, 73, 90, 113, 205 Vomiting sickness (ackee poisoning), 91 Washing soda, 61, 203 Water: bathing, 87 boiling, 13, 47 bottled, 14 canteens, 14, 47 chlorination, 14, 47, 202 clarification, 60 drinking, 13, 19, 89, 202 filtration, 61, 62

228 INDEX Water-bags, desert, 57 lacerated, 130 Weights and Measures, 218 muscles or tendons, 134 Weil's disease, 79 penetrating, perforating or Whitfield's ointment, 97, 208 stab, 133, 166 Whooping cough, 33 sepsis in, 128, 210 Worms, parasitic, 12, 85-89 treatment of, 123, 128, 132, Wounds: abdomen, 133 164, 210 amputations, 134 bleeding from, 126, 169 Yaws, 90 bomb-fragment, 165 Yellow fever, 4, 78 chest, 133 gunshot, 132 head and face, 165-166 Zinc oxide ointment, 208 incised, 130 Zinc sulphate solution, 115, 209