sometimes faintly purplish. Sweating will diminish these face signs in a few hours. The injection of the scleroties 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 exceptions. Frequently pressure on the eye balls will cause complaint-sure to do so in bad cases. Primary complete Constipation. 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.

Sluggish circulation.

Pulse rate.

Urine.

Stools.

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 yellow 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. (Vide 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 prevent the slow beating from being observed.

The above signs are sufficient to warrant isolation and disinfection of all discharges, clothing and discarded bedding, 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 confirmatory; rather late for diagnosis. So with nausea and vomiting. Mild cases suffer with distaste for usual food only.

Of course there is anorexia from the beginning; usually Anorexia. vomiting of the last food taken; bile will be vomited early if the early nausea is not checked; no bile will be vomited after about thirty-six hours if the patient has had proper bowel actions.

After vomiting of last food taken and a little bile the Pyloric regurgitation. vomit will usually be white, and will remain so until blood Cozes 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 something 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 stillbe 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.

Differentiation from dengue.

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

dengue.

blood.

and

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 malaria. 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 examined by the new agglutinative test by Dr. Archinard, 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 acquainted 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

much time by going direct from depots. Again, if I have names I can from time to time refute the secondary rumor without doubt as to persons and places.

I fear I have tired you, but I am so desirous of enlisting your aid and arousing your interest in this very important matter that I am willing to be blamed for prolixity. Command me in any way, personal or professional. Yours, sincerely,

R. D. MURRAY,

Surgeon, Marine-Hospital Service.

DIAGNOSIS OF YELLOW FEVER.

By Acting Asst. Surg. JOHN GUITERAS.*

When ordered by the Government to inspect points in the South as a yellow fever expert, I have assumed it to be my duty, not solely to report upon the diagnosis of individual cases, but to form an opinion as to the actual state of the outbreak, whether it be possible to localize it and stamp it out; or, on the other hand, whether the outbreak is beyond the control of our means of sanitation. I have even deemed it possible, when yellow fever was not found in one of the Southern States, to predict whether it was likely to break out or not during the summer. The diagnosis, then, from my point of view, is of two kinds, namely, as to the epidemic status of the locality, and as to the individual cases.

A careful study of the conditions existing in Cuba during the earlier part of the present summer made it very probable that yellow fever would extend from that island to this country. There probably has never been so much yellow fever in Cuba as there has been during the present season.

DETERMINATION OF EPIDEMIC STATUS.

First, as to the epidemic status: There are several features characteristic of the community where yellow fever is prevailing that make the fact known to an experienced observer, even when willfully or otherwise its presence is denied by the physicians and local authorities. Without seeing a single case of the disease I have often made up my mind as to the existence of yellow fever from the reports of prevailing sickness given by the physicians.

In the first place, many cases of acute febrile attacks of mild character are reported and an attempt is made to show why they can not be cases of yellow fever. They are usually ascribed to an epidemic of dengue or to a prevailing malarial infection. The report that some of these cases have shown albumin in the urine becomes extremely suspicious. Fatal cases are reported, but some 'intercurrent disease or previously existing condition is supposed to be the cause of the fatal termination. On investigation it is found that most of these cases are of

*Acting assistant surgeon Marine-Hospital Service during the yellow fever epidemic of 1897.

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