amined.

Stools to be ex- to the spinal column the duodenum lies. If the stools could be all and carefully examined sometime a mass of white mucus with a black or brownish middle will be found. Maybe there will be a stool of black mucus once only. It is fair to say that there is always a clay or bismuth stool with the mucus clot stained with black. The "bloody sweat" from the duodenum, and in bad cases from upper intestines and stomach, starts in the duodenum.

Fulminant

cases.

Choice of physician.

a

Sometimes the symptoms come in such quick succession that we think the attack is necessarily fatal. Many times in such cases we have no chance to ask the patient how matters fared with him twenty-four or thirty-six hours before, when he was sick, but would not admit the fact. Walking cases are as common in this as in the other bed diseases. I have known a man, suffering with headache for three days on duty, to vomit black on the stairs on the way to his deathbel. I have given immune certificates to persons who never went to bed.

In ordinary, the patient should like the medical attendIf the physician is distrusted, he should be called off or feign illness, so that a favored one can be called in. Consultations over the patient are injurious. I would have the doctor do his share in keeping up courage, hope, and life-purpose in his patient; to minimize the aches, distress, and fears, and to carry his patient's mind away from the now with its dreads to to-morrow, with its reward or rePsychological Venges. Several people are living now because, in their desire to take vengeance on me for what they thought was my indifference, they forgot themselves and their conditions.

effects.

Mild cases

Age limits.

NOT EVERY CASE NEEDS TREATMENT.

It is fair to say that of one hundred cases seventy five need only to be let alone by the extra-attentive nurse or friend and heroic physician. They will get well under any plan of treatment and under miserable local conditions; notably so with infants, who, if they die, are generally sacrificed by curds or some acrid medication.

These seventy-five are "cases" and should be recorded, but only for sake of good records and to establish their immunity. They should receive only what occasion de mands and be watched for untoward incidents.

Of the twenty-five some will need formal attention and careful procedure; others will die in spite of all reasonable aid. Some vicious habit or chronic disease will add to the trouble, and in some cases uncontrollable fear will insure a fatal result.

My oldest patient to get well was 109 years of age; the

eases and habits

frank disease.

youngest was 52 hours old when she threw up black vomit. One of my children had black vomiting five days after she was born. I know of the recovery of a chronic Chronic dis Bright's disease sufferer; of a morphiomaniac's recovery, as factors. and last summer gave a diabetic doctor such cheerful council that he had a severe attack without fatal result, and has been in better health since than before. I cite these cases to show the triviality of the disease if "taken right and in time." I have often said "Yellow fever is the Yellow fever a most honest, most trivial, and cheapest to treat of all diseases that kill." It is "honest" because it comes with definite signs and leaves no trace, always insuring the afflicted one that he is hereafter immune; it kills, if at all, in a few days, and is merciful in the killing, as the doomed one is usually conscious to the last and does not linger as a consumptive or one afflicted with cancer; "trivial" because 50 per cent of those who suffer with it are scarcely aware of serious illness, and have no sequels to make them miserable the remainder of their lives; also, because it rarely takes off children, and they, by reason of the attack, gain the privilege of living in its habitat; "cheapest to Cheapness of reat" because it is so; the delicacies, liquors, etc., sometimes provided are generally consumed by the disbursers and attendants and are not fairly chargeable to the sick; the medicine actually needed costs very little.

TREATMENT OF YELLOW FEVER.

treatment.

calling for

ment.

When called to a man (most of my work has been with Initial signs men) who has had a chill some time during the previous prompt treat. night, has a pulse of 100 to 112, with temperature of 101.5° to 103°, headache (cutting across the forehead), backache running down into the thighs, sore muscles, skin hot if you hold your hand on it a while (hands and wrist not hot to gentle touch), anorexia, white tongue (may be a yellow center far back-the red edges and red diamond on tip will not show at once), suffused eyes, and notably or faintly purpled cheek bones with semipuffed upper lip, the hundred chances are you have a case of yellow fever.*

Yellow fever usually begins at night when the person is in bed and in a relaxed condition; malarial fever usually attacks when the person is at work. Regardless of books, I reasoned this point out as a diagnostic fact over twenty years ago, and am flattered that others discovered it too. Night watchmen have sickened in daytime. A restless early morning in bed with little desire for breakfast is a frequent history; everything eaten as breakfast does harm in such cases. Dengue pains are worst in joints-yellow fever soreness is between the joints. As malaria coincidents there is no rule for differentiation excepting perhaps the attack in bed or at work.

Initial purge necessary.

tives in your pocket.

Give three or four compound cathartic pills at once and as soon as possible give a hot foot bath (an all-over bath is better, but is not always possible), with or without mustard and salt. Mustard at this time is really a nonessential, but sometimes the patient thinks it is the proper thing; so with the table salt. As to the cathartic: calomel at first is too slow and usually must be sent for, the pills contain enongh of it and are in your vest pocket. Every yellow fever docCarry purgator should carry first doses of compound cathartic pills, compound acetanilide tablets, and such other pocket remedies as may be needed on emergency. A parade of a small medicine chest is not advised. Do not begin to make a reputation for wonderful medical skill now. Dwell on the dengue symptoms and the signs of malaria, and without great formality convince the patient that "it is not yellow," Don't let the but do not say so. Keep back information about the patient know he is very ill. actual temperature all the way through, but tell them about the height of the fever. No patient should ever hear that his fever went above 102° until after he gets well. (I saved a doctor once by hiding his thermometer and using my French scale, which he could not translate.)

Coal-tar derivatives.

Give as soon as convenient, or, if fever is above 1020, at once, any coal-tar derivative in 7-grain doses, with some bicarbonate of soda and caffeine. The antikamnia compound is a good one. If powders or tablets are objectionable to the patient, give antipyrine. I nearly always use acetanilide with soda and caffeine. Have no objection to any, except that I like cheapness and simplicity. After the bath and a good sweating, under blankets, for from four to six hours, rub dry and cover with two blankets. (The clothing should have been hung outside of the house Disposal of or dumped into a tub of water; dispose of the wet sheets changed clothand blankets in like manner. When washed they are ready for use again; this hint in regard to prevention of infection.)

ing.

Drinks.

If a person likes blankets next the skin, so much the better for prevention of skin shock. Quilts and counterpanes are objectionable because of the nasty odors they retain.

Repeat the coal tar derivative every three to six hours if fever keeps above 102°; give for effect and not pro forma. Have the face and hands wiped frequently, give orange-leaf tea, Apollinaris water, lemon-grass tea, hot lemonade, ginger ale, small sips of ice water, and other drinks ad libitum, but not ad nauseam. Always start with the quantity you are willing the patient should have, and let him drain the cup; this particularly in the case of water. Try to supply

fluid for the three or four days' sweating that will be kept up. Apollinaris is good on account of the common salt it contains; for some reason common salt is a good thing to Common salt. give and has been grossly neglected. Passed Assistant Surgeon Smith, on duty at Ship Island last year, used it, methodically, about a drachm a day, with excellent results. I have always given much salt in the food, but never gave it dry. No spirits of any combination should be even thought of for the patient.

The first bowel actions should be had sitting up for the first thirty-six hours or so for physical reasons-and for mental reasons, too. If the bowels are not freely and comfortably relieved within six hours, give a small saline, and let the patient choose the kind. Castor oil is the best thing to give, but many so bitterly object to it that it is not advisable in all cases. Sulphate of soda is the next best. As a rule, the magnesias cause griping and flatulence. Seidlitz powders are good, but cause some gassiness and uneasiness-however, the patient should have his choice, as he feels bad at this time and an insistence on one thing magnifies his dangers, in his own mind. Sometimes an extra pill will do the hoped-for duty. I do not object to sirup of figs, castoria, or other cathartics-only want results. If nausea is present an enema is in order.

DIET (OR LACK OF IT) A MATTER OF FIRST IMPORTANCE.

Bowels to be kept open.

Do not deny food but give the milklike water of long- Diet boiled hominy or corn meal, salted and strained through cheese cloth. Keep the pot boiling all the time! Rice water is good. Sago is better, as it is slightly aromatic, but my experience has been with the poor. Mexican atole is excellent-made from crushed lye-hominy. Sometimes it is well to flavor with a bit of meat juice. Chicken soup, with rice, so thin as to be equal to starch water, is not to be tabooed. The point is to give no food for four or five days, but to appear to give food regularly. Often you must promise food and abuse the nurse in the presence of the patient for the nonfulfillment of your orders, and then apologize to the nurse outside.

If the first form of antipyretic tires the patient, or seems Antipyretics. to him to do no good, change the form; here lactophenin or amonol or antipyrine will serve as substitutes; may be capsules of the same as you were giving will accomplish the object sought. Do not forget the bicarbonate of soda and caffeine. Remember always that the patient is sick; not the doctor.

10918. -20

Conjoint infection malaria and yellow fever.

High enemata.

Here I must advise you to carefully consider the question of malaria, for the Laveran organisms can do their work while the yellow-fever germ is also active. In a malarial region it is advisable to give from 40 to 60 grains of a cinchona salt in the first twelve or twenty-four hours, in order to ward off or forefend a malarial chill which may occur during the period that should be yellow-fever convalescence. I lost two patients with malaria when they were convalescing from yellow fever twenty years ago. In nonmalarious regions, or on shipboard, no routine is necessary, but in Mobile, New Orleans, Scranton, or in the back country, care must be exercised. The preliminary cinchonidia or quinine may be given with the compound cathartic pills, and it is believed that early cinchona aids in producing calm in or to the patient. Do not give all at once, and do not expect the cinchona salt to act instead of the coal tar products. Give them together, or nearly so.

After thirty-six hours or so give an enema every day and try to have a bed pan used. It is impossible for many to use a bed pan; then have the patient helped up on a vessel or commode. Instruct the attendant that the patient must be helped, and not use his own strength. The patient's own muscular force must be saved somehow. If the expected action does not occur, give another enema with a long tube. A short catheter of 30 or 32 caliber should be in every yel low-fever doctor's pocket, which, attached to an ordinary self-injecting syringe, makes a "long tube." I and many others have saved lives by use of a large catheter. The catheter may be washed and used again. Do not fear infection.

Enemas may be made quickest with soapsuds and molasses; ordinarily soapsuds will suffice, later on not too strong. Consider the stools, and if they are not sufficient in quantity, and you have reason to believe there is a fæcal matter high up, think of giving a dose of castor oil 2 drachms and olive (not lard) oil, 6 drachms, more or less as occasion seems to demand. Lemon juice is the best vehicle for the oil. Perhaps it will be better to tell the attendant to give the potion as if you knew nothing about it. Patients like to circumvent the doctor! I believe that Oil catharsis. small doses of castor oil and large doses of sweet oil will not produce the frequent contractions of the colon and the common intussusceptions of the small intestines that are found post mortem. Constant peristalsis downward is necessary; harsh purgation is to be avoided. This remark does not refer to the primary emptying of the bowel, but