open, a calomel tablet, one-tenth grain each, should be given every 15 minutes until 10 have been taken. Every six hours thereafter the patient should take 5 grains of quinine for two or three days and then 5 grains three times daily for the next two weeks.

If vomiting occurs, a mustard plaster may be placed over the region of the stomach, above the navel, and cracked ice may be given by the mouth. Headache may be relieved by cold applications or by 10 grains of aspirin taken with a cup of hot tea.

In pernicious types of malarial fever the treatment should be more active. No time should be lost in giving the quinine; 20 grains should be given immediately, with 2 grains of calomel. A physician should be summoned if the services of one can be obtained, as dilute solutions of quinine may have to be injected into the patient's veins in order to save his life.

YELLOW FEVER.

The mosquito which conveys yellow fever from one person to another is a striped black and white mosquito, Edes calopus, and therefore the disease only occurs where this mosquito abounds. Moreover, the mosquito must have been previously infected by biting a person ill with the disease during the first few days of his illness. An interval of about 12 days or more after this bite appears to be necessary before the mosquito is capable of communicating the disease to a person.

Symptoms. The onset in yellow fever is sudden. It frequently comes on at night or in the early morning. The patient is taken with a chill, headache, a pain in the back, and fever. The pulse is rapid at first, but afterwards falls, even though the temperature remains high. The eyes are injected, the skin has a slight flush, and the upper lip is often swollen. Albumen is often present in the urine as early as the second day. The test for albumen has been described on page 170. Jaundice appears early, and is especially noticeable as a yellowness of the eyes. The stomach is irritable and the bowels constipated. The fever lasts for two or three days and is succeeded by a period of calm. In mild cases the fever does not return, but in others the temperature again rises after a few hours and severe symptoms set in. The pulse is slow and weak, the jaundice deepens, and the vomiting increases. The vomited. matter may consist of altered blood of a coffee-ground color, whence the name black vomit which has been given to this condition. The urine is scanty and albuminous and may be entirely suppressed. The strength rapidly fails, and the patient dies from exhaustion.

Diagnosis. It is often difficult to tell yellow fever from malarial fever and dengue. Great care should be taken to determine as far as

possible the disease from which the patient is suffering, as the treatment is different in each case and a mistake may be followed by serious results.

The yellow fever chill usually occurs in the night or early morning; the chill of malarial fever may take place at any time during the day. The yellow fever chill is much less severe than the malarial chill. Jaundice come on early in yellow fever and is of a much lighter color than in malarial fever. If the malarial fever is of the intermittent variety, there will only be fever for a few hours and the patient will feel comparatively well until the next paroxysm takes place. It is often difficult for the layman with the facilities available to distinguish between these two diseases.

Yellow fever and dengue are similar, but the pains in the latter disease are much more severe. There is seldom jaundice or albumen in the urine in dengue and the skin eruption helps to distinguish between the diseases.

Prevention. The patient should be immediately isolated in a screened room, as it is important that no mosquito should be allowed to bite him during the first few days of his illness, as one of them may become infected with yellow fever and other members of the family may subsequently be given the disease by being bitten by it. If the patient dies during the first three or four days of his illness, the room should be immediately fumigated with sulphur (see p. 65) for two hours in order to kill any mosquitoes that have come into the room and become infected. If the patient is alive after this period he should be carefully moved out of the room for a few hours, the room fumigated, and then the patient returned to it. Great care should be taken, however, in moving the patient, as the least exertion may be followed by a fatal result. He should be kept flat on his back and not allowed to sit up.

A vessel arriving at a port where there is yellow fever should, if possible, anchor at a point that is too far away for the mosquitoes to fly on board, and it should be so placed that they will not be blown aboard by the prevailing winds. It should be remembered that mosquitoes may be brought to the vessel by bumboats on fruits and vegetables or on the coats of persons in such boats. These boats should, therefore, be warned off and told to keep away. If boats have to come alongside, their contents and occupants should first be freed from mosquitoes. As the yellow fever mosquito bites in the day time as well as night, shore leave should not be granted to the crew in yellow fever ports. If the vessel has to go to the dock or if it is impossible to keep mosquitoes off it, the living quarters should be screened and measures described on page 64 should be taken to prevent their breeding on board. A person on board who has fever

or feels ill should immediately be placed in a screened room until it is ascertained that he is not suffering from yellow fever.

The yellow fever mosquito is a domestic mosquito and breeds in small collections of water, in old tin cans, buckets, barrels, cisterns, and other containers around dwellings. It is therefore important that such breeding places should either be eliminated or screened. The methods for the eradication of mosquitoes are described on page 56.

Treatment.-As soon as the attack of yellow fever begins, place the patient at rest in bed on a blanket, and immediately give him a hot footbath. The foot tub shuld be half full of warm water, to which a pound of mustard may be added. The patient's feet and legs are then placed in the water, and a quantity of hot water is added, so as to make the bath as hot as he can stand it. While it is being given the entire body of the patient should be covered with blankets, and he should drink hot tea. After the footbath is removed, the patient should be allowed to perspire for 10 minutes. His body must then be quickly dried and wrapped in a fresh blanket. A 5-grain dose of calomel should then be given, which may be followed in six hours by a tablespoonful of Rochelle salt in a glass of water, or in place of the calomel two compound cathartic pills may be given. If vomiting occur, a large mustard plaster should be placed over the region of the stomach and small pieces of ice in the patient's mouth.

The diet in yellow fever is very important. For the first day or two very little if any food should be given. A little milk diluted with vichy water may be allowed every three hours. Later a little broth and very gradually, when the fever is reduced, other light and easily digestible articles may be allowed in small quantities at regular intervals.

If the fever is high and the patient is restless, 10 grains of aspirin may afford relief, and, if necessary, a second dose may be given after an interval of three hours. Vichy or other alkaline mineral water should be given in small quantities frequently repeated. The bowels should then be kept open by means of rectal injections of warm, soapy water. A long tube attached to the syringe should be passed into the bowels as far as possible and at least a quart injected once or twice a day.

BREAK-BONE FEVER (DENGUE).

This disease occurs during the summer and autumn in the southern part of the United States and throughout the year in tropical countries. It is believed that it is conveyed by mosquitoes, especially those belonging to the species Culex fatigans.

Symptoms. It begins with a slight chill, accompanied by fever and severe pains in the bones, muscles, and joints. There is a red

flush on the skin. These symptoms last for two or three days and the temperature then goes down and the patient has a profuse sweat. The patient feels sore, but greatly relieved. After several days another paroxysm occurs, but the second is much milder than the first. The eruption that appears upon the skin varies in intensity and character, but it often resembles measles, begins on the hands and legs and extends thence to the body. The disease leaves the patient in a weak condition, and convalescence is protracted.

Prevention.-Prevention consists in protecting oneself as far as possible from the bites of mosquitoes. (See p. 56.)

Treatment.—Ten grains of aspirin may be given to the patient and repeated if necessary. Morphine (one-fourth of a grain) may be required if the pains are severe. The patient should be kept in bed while the fever lasts and be given a generous diet of milk, soup, eggs, and gruels. During convalescence plenty of meat, bread, vegetables, and fruit should be eaten to enable the patient to regain his strength.

SPOTTED FEVER (CEREBRO SPINAL MENINGITIS).

This disease is caused by a germ which produces inflammation of the membranes covering the brain and spinal cord. It is thought to be communicated principally through carriers, that is, persons who are not ill or only slightly so but who have germs of the disease in their nose and throat. The disease prevails principally among children and young adults, especially in cold climates during the winter and spring, and is more likely to attack those living in ill ventilated, overcrowded houses. Some epidemics have occurred exclusively in villages.

Symptoms. The disease begins with a convulsion or a chill, followed by pains in the muscles, severe headache, fever, rapid pulse, and increased respiration. Vomiting is nearly always associated with these symptoms. Delirium usually appears early. The muscles may be contracted so that the legs can not be extended, the neck is stiff, and the back rigid. The pains are often so severe that the patient cries out. This is especially the case if he is disturbed by a noise, if the bed is jarred, or if an attempt is made to turn him or move him. The eruption from which the disease takes its name, "spotted fever," consists of small, round purplish spots either scattered over the whole body or limited to certain areas. It is caused by hemorrhages under the skin and is not always present.

Prevention.-Persons suffering from this disease should be isolated. The nose and throat of the patient and of all persons who come in contact with him should be sprayed with a chlorazene solution (18 grains of chlorazene to 1 pint of water) or a menthol solution (menthol, 5 grains; liquor petrolatum, 1 ounce). If the

disease is prevalent, it is well for all persons to use this spray, as they may be carriers and convey the disease to others, especially to children and young adults. The bowel discharges, urine, and sputum should be disinfected with a solution of bleaching powder made by adding 1 pound of bleaching powder to 4 gallons of water. Equal parts of the solution and the substance that is to be disinfected should be used. The mixture should be allowed to stand at least one-half hour before emptying. The person caring for the patient should not be permitted to mingle with other people and should be careful to wash his hands with the bleaching-powder solution or with a bichloride solution, 1 to 2,000 (see p. 104), whenever he handles the patient. All towels, sheets, and other clothes used about the patient should be boiled or disinfected with the bleaching-powder solution.

Treatment. The patient should be kept in a darkened room, as far as possible away from noise. Aspirin (10 grains) should be given as required to relieve pain. For very severe pain, morphine may be required. If morphine is combined with hyoscine, a smaller amount is required; the dose of each in this case would be morphine, one-eighth of a grain; hyoscine, one two-hundredths of a grain. It is important to obtain the services of a physician early, if it is possible to do so, in order that a lumbar puncture may be made with a hollow needle, the excess fluid drawn off, and a curative serum injected. The earlier the serum is used the more likely will it prove beneficial.

CHOLERA (EPIDEMIC CHOLERA, ASIATIC CHOLERA).

Cholera is an infectious disease caused by a specific organism discovered in 1884 by Koch, of Berlin, Germany, and named Comma bacillus, because its shape as seen under the microscope is not unlike that of a comma.

Cholera is not endemic in any part of the word except Asia. Its home is in India, where in certain localities it has been endemic probably for centuries.

Every epidemic of cholera is probably due to a spread of the disease, directly or indirectly from its home in India. It is apt to be developed in the wake of moving masses of human beings. It follows the great lines of travel to different parts of the world. It is spread through the agency of the dejections from cholera patients, which contain the comma bacilli. The disease may also be transmitted by persons known as carriers who have the comma bacilli in their intestines but are not sick with the disease. This is one of the chief means by which the disease is spread, as these carriers may have the bacilli of cholera in their stools for many weeks and thus convey the disease to many persons with whom they come in contact.