TREATMENT OF RENAL SYMPTOMS.

tion.

Of far graver importance to my mind is the train of symptoms which leads to uræmia, and which are announced by partial or complete suppression of urine. I believe this to be the gravest accident that can happen in the course of yellow fever. The amount and character of the urinary secretion should be a matter of frequent inquiry in every case, grave or mild, from the inception to convalescence. A sudden and irregular increase in the amount of albumen should put us on our guard against possible urinary suppression, and prompt treatment should be instituted and maintained. Counterirritation over the region of the kid-Counterirrita neys with turpentine or mustard, dry cups, the application of hot-water bags, all should be tried. A tisane of watermelon seeds has long enjoyed the reputation of being almost a specific among the Creole population of New Orleans, and I can bear personal testimony to its efficacy alone or given in combination with spirits of nitrous ether. Of almost equal reputation is a tisane of orange leaves, ange leaves or preferably of the bitter variety, given in large quantities. and frequently. A remedy much used in Brunswick in 1893, and vaunted as almost specific by those very successful in the management of the disease, was spirits of turpentine, which was sometimes given in heroic quantity, as much as a teaspoonful at a dose and repeated. I can not speak of the remedy from personal experience, but the results claimed for it warrant its more extended use.

Tisane of or.

watermelon

TREATMENT OF BOWEL CONDITIONS.

mata.

A point in the treatment of yellow fever, with the impor- Vale of enetance of which I am much impressed, is the frequent washing out of the lower bowel with enemata of warm water and soap. Constipation is the rule in yellow fever, and no one who has noted the exceedingly fetid, almost putrid, character of the stools of a yellow-fever convalescent can fail to see the wisdom of removing the chances of septic absorption by frequent washing away of this fermenting mass. Pass a well-oiled rectal tube as far up into the bowel as possible, and with a fountain syringe elevated not more than a foot or two force slowly 2 or 3 pints of warm, soapy water into the bowel. The whole operation should be performed with the patient upon a bedpan, not seated upon a vessel or close stool. The effect upon the temperature and general condition of the patient is most marked.

Quinine
Cinchonidia.

USE OF ANTIMALARIAL REMEDIES.

As to the use of quinia or allied preparations in yellow fever, I concur in the generally accepted verdict that they are without specific effect. But as yellow fever almost always occurs in regions where malarial diseases are also rife, and as the intercurrence of a malarial paroxysm is one of the most disagreeable incidents that can mar the course of a case of yellow fever, I consider it good practice in such regions to administer 2 to 3 grams of quinine or cinchonidia in the first twenty-four hours, exhibiting the drug per rectum if the stomach is irritable.

DIETETIC MANAGEMENT.

A most important point in the management of yellow fever is the diet. Many a patient, his crisis past and the borders of convalescence reached, has been hurried into an untimely grave by the misplaced kindness of an apparently simple meal. The yellow fever patient should never be starved; on the contrary, he should be well nourished, but the most scrupulous care should be exercised in the selection and administration of his diet. "A little and that often" should be the rule. For the first few days milk with limewater given cold, then animal broths, concentrated but free of fat, should be the regimen. The fever being reduced, soft-boiled eggs, milk toast, and small bits of the white meat of chicken and tenderest steak may be permitted. Probably at least ten days or two weeks should elapse before the convalescent, by the easiest stages, should be permitted to resume ordinary diet.

HYGIENE OF PERSONS LIVING WITHIN AN AREA OF YELLOW

FEVER INFECTION.

By Surg. H. R. CARTER.

As I understand the problem the persons with whom we are concerned, living within a radius of yellow fever infection must more or less at intervals or continuously be exposed to yellow fever infection. The measure of no direct communication with infected points will then not be considered, although I think it will frequently be possible to substitute indirect communication for direct.

NOT ALL PLACES WITHIN RADIUS ARE INFECTED.

its of infection as to distance.

All places within a yellow fever infected district, or town Probable lim even, are not infected or are infected in unequal degrees. The infection is especially confined to the habitations of men and their environment, and is conveyed a short distance, possibly 220 meters down the wind, from an infected focus. Two hundred and twenty meters is given as the maximum distance this infection can be conveyed, it being the longest distance claimed in any instance in modern times.

The general consensus, however, is that this observation (Melier's) is altogether exceptional, and that less than half that distance covers the distance to which the infection is conveyed from a single focus.

AERIAL CONVEYANCE GREATER IN LARGE INFECTIONS

(PROBABLY).

On the other hand, it seems probable that if the focus of infection was large, i. e., a badly infected camp or part of a town, that the aerial conveyance of infection would be decidedly farther than from a single house or ship. I know of no observations on this matter. The presence of any object-such as a hedge of trees, bushes, etc.-which breaks the wind hinders the conveyance of infection.

Foliage ob structs spread.

PROBABLE MEDIA OF SPREAD.

The microorganism, however, is unquestionably a saprophytic facultative parasite, and foci of infection can be established at a distance from the primary focus by the conveyance into suitable culture media of the microorganInfection isms-thus, along sewers, about the dumping places of spreads in damp and shaded spots. refuse, etc., and by fomites. For the same reason the infection spreads slowly along ditches and on damp and shaded grounds to a considerable distance, always to leeward. Taking all these methods of propagation, it may go far from the habitations of men and become general over all parts of a town, yet, in fact, seldom does so.

night.

A place which has become infected may remain infected for a considerable period of time, being freed from it by cold weather, ventilation, etc.

"CONCENTRATED" AND DIFFUSED INFECTION.

We will consider, then, the (1) house infection, and (2) general infection-"out of doors" infection. This is frequently called atmospheric infection, but I think the term is liable to mislead. The first is in general far the most apt to infect one exposed to it-"concentrated," "virulent," is usually said of it. The latter, with the exceptions above indicated, is usually confined to the resident part of the town, and especially to the neighborhood of infected houses.

INFECTION GREATEST NEAR THE GROUND.

The infection is heavy and hangs and spreads near the ground. It is unable to pass a close wall of any considerable height, although under the shady side of such a wall Activity at it may spread well when once started. It seems especially active at night, and certainly, out of doors, is less apt to be contracted on clear dry days. It is believed, I think, universally, to be taken into the human system by inhalation, although other avenues of entrance (besides the respiratory tract) are, since the observations of Sanarelli, accused by pathologists-rather from analogy, however, than from clinical observations.

Dust as a propagator.

RATE OF PROPAGATION OF INFECTION AND EFFECT OF
WEATHER.

The rate of propagation of outdoor infection is increased in cities in dusty weather, apparently being conveyed with the dust. It is temporarily lessened after full rains, to increase more rapidly afterwards. Strong, steady winds in clear weather lessen the infection.

MEASURES OF PREVENTION.

With this brief résumé of well-known facts we can proceed. The measures seem naturally to divide themselves into

(1) Selection and hygiene of the living place; (a) to prevent exposure to infection of its residents; (b) to prevent its becoming infected should fever develop among them. (2) Guarding communication between known foci of infection.

(3) Personal hygiene to prevent the individual from de- Personal hy veloping yellow fever.

(4) Measures to control (limit) infection when introduced in the living place-house, town, camp.

I. SELECTION AND HYGIENE OF RESIDENCE.

giene.

As far as the choice of a living place is possible it must be chosen, itself noninfected, as far from any known focus of infection, or residence portion of the town liable to be or become such a focus, as possible. It should, if sufficient distance be unattainable, be to the windward (prevailing wind) of such portion of the town or separated from it by trees, etc. All this is to prevent exposure to infection. It should be on high, well drained ground, as, if infected, Flevated sites preferable. the outdoor infection will be less. As much exposed to wind as possible and not so shady as to be damp-better too much sun than too much shade. I can not find that moderate elevation makes any difference to the house infection of yellow fever. Dryness, sun, and ventilation do.

WATER SUPPLY.

Parenthetically it may be well to note that there is no reason to believe that yellow fever as usually propagated in this country is water-borne-the fresh-water tanks of infected vessels have never been and are not now emptied at our maritime quarantines. Nor am I aware of any facts which accuse this method of propagation in the tropics, and profoundly disbelieve that this is a usual method of propagation.

Yet from the analogies of growth of the bacillus icteroides of Sanarelli, most prominent now as a causative agent, with the colon group, it would seem well to secure a water supply free from possible contamination with this bacillus.

The same theoretical reasons exist to suspect food as a means of conveying the fever. There is less evidence of its innocence.

10918-21

Probably not a waterborne disease.