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Mild cases most dangerous from

DO NOT BE DILATORY IN REPORTING FIRST CASES.

It will not do to advocate the notion that any place is free from the chance of infection, nor to insist that all the old-time symptoms must be present, with a death or two added, before one suffers with a twinge of honesty and risks his present prosperity by doing what should be done with a first case.

Scares and false alarms are hurtful, but they do not usually kill. I would as little trust an alarmist as one who “would die before he would report a suspicious case.” Duty to one's self, to one's family, and to all communities demand careful observation of every fever case, with proper action in case there is reason to suspect yellow fever. A lot of “rejected” cases have spread the infection. It is established that only yellow fever makes yellow fever, but it is not so well known that a mild case of yellow fever is as dangerous as a case that ends fatally in sixty hours. I think the mild case much more dangerous than a “genuine” One.

“MILD CASES” ARE DANGEROUS DISEASE SPREADERS.
Now, to quicken your senses, to increase your usefulness,

sanitary stand and to assist you in giving your best efforts to your people

point.

I presume to give you some hints as to discovery of first
cases. I do not claim to be expert, but I have a long record
of lucky decisions which warrant me in speaking freely to
those who have been so fortunate as to have an abiding
place or a place called “home.” I am not infallible, but I
am in earnest in my desire to do good to others and to save
my people from the horrors of an epidemic and the provo.
cations of quarantine. Mild cases of yellow fever are the
mildest cases of disease that can be seen. Walking cases,
nursing cases, and transient cases are more common than
doctors realize. Mild cases transmit infection as easily
and effectually as bad cases, and thus make “genuine”
cases in the proper persons. Mild cases are not so quickly
apprehended as severe ones, but they can be isolated more
easily and at less expense than bad ones. Mild cases are
the cases to look out for.
It is not true that a prevalence of the disease must be

Don't wait for begun by a death or black vomiting. It is true that a

black vomit be

fore announcing, walking case introduced the disease into a village last year

Hibernation.

where the earmarks of yellow fever were shown the best,
and the results were worst in comparison with all other
infected towns of which there is a record.
I do not believe in recrudescenee or hibernation of the
fever in small towns or in the country, but many health

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officials do, and as there is a possibility that all is not known of past epidemics and that there is much to be learned yet of the yellow-fever pest, it behooves us to be watchful—first, for the sake of our professional probity, and second, in the interest of our people.

I am reiterative in order to gain your attention. Pardon me if I seem to be prolix.

POINTS TO BE CAREFULLY NOTED. First. As to the region lately beset by the Cuban plague, permit me to remind you of what the doctors think-i. e., that the disease recurs; this remark is to prepare you for rumors that there is yellow fever in your practice or community now! So be prepared to affirm or deny by the card. Note taking is a good thing for doctors!

Second. If there is reported yellow fever within the com. munications of your place, suspect every case of febrile disease but say nothing! Get to thinking! Here is the chance for careful observation and some taking of notes. Keep carofal Not long ago a physician blundered as to the date of his “ first visit! His memory of the pulse, temperature, and nausea was of same sort-his patient died.

Third. If called to any person who sickened in the night or early morning and complains of headache and malaise or body and leg ache with some stomach distress, suspect the case and make inquiry as to where he got it. A chill Initial chill. is called for in the books, but one sufficiently severe to be told of to you is rare; there will be a story of chilliness or waking up in discomfort. Distress in the early morning is a rule; a failure to eat a good breakfast is a bad omen, but hints at a mild case. Fever of 101 to 103 with pulse of 110 to 120; cutting pain through the forehead, with aching eyes; fullness of eyes with some pain and suffusion, generally with injection are probable signs. The back and thighs will be sore in a severe case; there is some soreness in the mildest cases. Severer cases will have pain in Duodenal back of neck and in calves. Ask few questions. Press firmly and deeply over where you think the gall bladder lies and you will generally elicit a squeak-don't mention it! The face will be full and less mobile than in health with a fullness of the upper lip rendering a smile less Swollen lip. gracious.* These sigus depend somewhat on an acquaintance with the person. The cheeks will be of a dusky red color-more or less—and depending on the patient's color;

pain.

* Passed Assistant Surgeon White reports that he made two diag. noses with the swollen upper lip as the first noticeable symptom.

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sometimes faintly purplish. Sweating will diminish these
face signs in a few hours. The injection of the sclerotics
will increase until after thirty-six hours some yellowing
may be observed; in children, the eyes will remain pearly
excepting the suffusion and the red streaks; some excep-
tions. Frequently pressure on the eye balls will cause
complaint—sure to do so in bad cases. Primary complete
or semi constipation is always present. I never heard of
a diarrhoeic person being attacked. The cases you hear of
will bear explanation or further inquiry.
The circulation in the skin will be faulty; the skin may
be streaked by the passing finger or paled for a quarter of
a minute by pinching; this is a good sign, and best after
thirty-six hours. The skin will be moist, as a rule, and
will keep moist to the end, whether medicine is given or
not. In diagnosis early or for first cases don't look for yel-
low skin. The pain of back and legs will be in the muscles
and not in the bones and joints; you can make this point
by care; squeeze the thighs or calves. Note that unless
there is nausea or headache the person lies quiet. (Wide
dengue.) There will be less rapidity of the pulse than the
height of fever warrants, judging from lung disorders and
enteric fever. Do not blunder over one who smokes too
much, for his pulse will count less when he reduces his
daily quantity or has to quit smoking. Also, consider the
effect of your presence on your patient's excitability. The
pulse should be counted without the patient's knowledge.
After two and a half or three days the pulse will fall below
70 and later on lower yet; fright and irritations will pre-
vent the slow beating from being observed.
The above signs are sufficient to warrant isolation and
disinfection of all discharges, clothing and discarded bed-
ding, even if there is no known fever within a thousand
miles. Also, warrant for sending for me if you need me.
Please note that these signs may be in minimum—any old
nurse can comprehend the maximums. After sixty hours
there should be some albumen in the urine—it is possible
for no urine to be procured and that no albumen is found.
In women urine is not reliable; in children it is difficult to
get. But it must be obtained. Do not confound albumen
with mucin and do not treat other symptoms lightly
because you do not get albumen.
At this stage some brown mucus, or black discharges, or
“bismuth” stools may be looked for rather early in mild
cases—may be late in severe ones. This is only confirma-
tory; rather late for diagnosis. So with nausea and vomit-
ing. Mild cases suffer with distaste for usual food only.

Of course there is anorexia from the beginning; usually Anorexia. *omiting of the last food taken; bile will be vomited early if the early nausea is not checked; no bile will be vomited =fter about thirty-six hours if the patient has had proper Totowel actions. After vomiting of last food taken and a little bile theo. " vomit will usually be white, and will remain so until blood oozes into the duodenum or stomach. As to black vomiting, do not be hypercritical, the chances are vastly in favor of yellow fever. Please notice the hiccough and retching, and listen to the black fluid regurgitating through the pylorus into the stomach. But this is rather late for diagnosis of a first case, and is not applicable in mild cases. Mild cases demand examination of the feces. Always consider the chances of infection to and from your patient.

DIFFERENTIAL DIAGNOSIS.

Yellow fever is like a language; you should know some- . Differentiation thing of others. Differentially considered, dengue has a ** demonstrable rash in the fauces always, between the shoulder blades, generally, and often over the big joints and on the trunk. The pains of dengue are in the bones and joints. A dengue patient is in pain and can not lie still— he don't want to get up. Yellow fever pains, except the head, are in the muscles, and the patient after four or five days is comfortable in bed, but wants to get up and do a lot of work. He gets up only to faint and return to bed. The dengue patient gets up, but keeps on growling about his pains. This is a late distinction, but it is valuable.

Malaria is usually prodromed for some days by malaise, From malaria. loss of appetite, discontent, and a general tired feeling. It nearly always attacks in the daytime or when the victim is at his work, and is ushered in with a positive chill. Constipation is the rule, but not so marked a feature as in yellow fever. The malarial tongue is full—swelled—too big for the mouth—tooth marked and heavy coated, with white edge and yellow or dirty top area. A yellow-fever tongue is rarely indented—if it is, there is malaria in the patient; it

... soon shrinks and gets a red edge and red tip; the red tip

is diamond-shaped, the front of the diamond being made by
the edges. I do not know about the congestion of the ves-
sels under the tongue in yellow fever and the paleness of
same in malaria. You, may be, will have a chance to make
observations.

Malarial vomiting is attended with more bile than is
usual in yellow fever; this is a guess-point in diagnosis, but

Malaria and

dengue.

the statement is true. Malarial attacks generally permit
the fever to decline without medicine and the fever will
not cease unless medicine is given. Another good point in
differentiation is the presence or absence of labial herpes
in convalescents, particularly in young persons; herpes
does not occur in yellow fever cases; it is common in mala-
ria. Of course, this is a late sign so far as the individual
is concerned, but it has aided me much in giving a hint as
to what the other sick one suffers with.
As a hint for you to consider in deciding on the first case
permit me to say that the yellow fever patient gets up “all
knocked out; was never so weak in my life after so short
a sickness;” the dengue patient gets up “sore and tired;
ache all over yet;” the malarial patient is able to work
every other day. Another hint, but late for diagnosis: the
yellow fever patient is mentally alert; the dengue patient
complains much; the malarial don't care much. These
points do not apply to individual cases, but are valuable if
you have a number of patients to visit.
I have given you sufficient reasons, symptoms, and signs
to either put you on your guard or to permit you to act for
the benefit of all. Yellow fever is not a “bogey,” neither
is it uncontrollable.
I hope you will duly consider the possibility of cases
occurring in your rounds and also the importance of early
action in first cases.
I am at liberty to visit you on call by letter or telegram
at any time at no expense to you or your clients, and to the
best of my ability and the limit of my time I will be glad
to serve you.
Please notice that rumors of fever are plenty here and
there, and consider that a prompt denial will oftentimes
prevent a panic; also a prompt notice will save lives by
permitting orderly exit from danger centers.

Examination of The service has arranged to have samples of suspected

blood.

blood examined by the new agglutinative test by Dr. Archi.
nard, of New Orleans. Samples of malarial blood can be
examined in the hospital at Mobile. If you wish special
instructions please make request of me.
In return for what I hope to do for you I request that
you send me, at least, a weekly report of health conditions
in your region and that you inform me in detail of all
rumors and suspected cases. As I am pretty well ac-
quainted with the town and people it is needful that I get
names and addresses. Sometimes it may be advisable for
me to go in person, and if I know the residence can save

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