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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. False alarms Scares and false alarms are hurtful, but they do not not so bad as neg. lected cases. 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. Mnd cases most Now, to quicken your senses, to increase your usefulness, dangerous from 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 caşes 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 fore announcing. walking case introduced the disease into a village last year

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. Hibernation. I do not believe in recrudescence or hibernation of the

fever in small towns or in the country, but many health

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

notes.
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, gener-
ally 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 Duodon a !
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 men-
tion 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 signs depend somewhat on an acquaint-
ance 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.

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 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 diarrheic 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 lation.

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. (Vide Pulse rate.

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 Urino. 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. Stools.

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. omiting 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 bas had proper bowel actions. After vomiting of last food taken and a little bile the Pyloric rogur

gitation. 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

from dengao. 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 malarts. 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 vessels 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

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. Malaria and As a hint for you to consider in deciding on the first case dengue.

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. 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

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