as the remote cause may have been more Y.

or less active or concentrated. They may also be influenced by individual

habits or constitutions, or by the force Yack. (See Or.)

of the occasional or exciting cause; and Yellow FEVER.' This fever is one of hence we find it run its course rapidly specific character, and confined to situa- sometimes; that is, in from two to five tions in which great moisture is joined days, a part of the cases terminating in with great heat. It prevails in the West black vomit. In this form of the disorder, Indies, certain parts of Asia, South Ameri- the symptoms are generally less feroca, occasionally in the northern parts of cious, and less distinctly marked, though North America, and pretty constantly in more certainly and speedily fatal; or it the southern. It is endemial in many may run on to the fifth or to the seventh portions of the globė, and especially in day; and though the sufferings are of a the tropical climates, and is occasionally more acute kind, the danger is less, as epidemic in certain of the higher north- more time is given for the application of ern latitudes, as at Baltimore, Philadelphia remiedies; or it may present, like a reguand New York. It is most common in larly-formed remittent, regular exacerbaseaports, and on large bodies of water, tions and remissions. If it assume this but is occasionally found in inland situa- form, it may run on to the ninth or elevtions. It differs materially from the en- enth day. The first form observes no demial remittent of tropical climates, and very regular period of attack, though the is, of course, not merely an exalted form evening is the most common. The secof the bilious remittent of such places. It ond generally takes place after noon; and differs from the endemial remittent of the the third, most frequently in the morning. West Indies, in its attacking strangers The mode of attack, however, is pretty to such climates only. The natives, and generally marked by the same train of even such as have been born or lived symptoms, differing more in force than in long in similar situations, are altogether character, if we except the first, which exempt from its attacks; and, should the often has the peculiarity of betraying itself stranger survive the dangers of an attack, by scarcely any outward signs, except he remains free, for the most part, subse- weakness, slight headache, or quently, though not exempt from the This insidious character lulls the patient endemial remittent of the place. This and his friends into a fatal security. The immunity, however, may be forfeited by patient has been known to walk about the stranger living for a year or two in a until within a few minutes of dissolution. northern latitude: should the stranger The unmasked or violent attack of yellow escape for a year or two, he becomes ac- fever is, therefore, less to be dreaded than climated, and is no longer liable to be the seemingly mild form, as the derangeattacked by yellow fever. This disease ment of the system is more palpable, has been looked upon, by some, as con- though it is always highly dangerous. This tagious; but this notion is now altogether disease differs in its attack from almost abandoned by far the greater part of the every other form of fever, as it is seldom profession; and especially such as have ushered in by a well-defined chill, though had opportunities to observe its phenome- the sensation of cold, and a reduced temna, and ascertain its habits for themselves. perature of the skin, will remain sometimes That it spreads rapidly sometimes, is a long time before reaction will take place. admitted; but this is owing to the causes Much languor is always experienced; which make it an epidemic, and not to for the most part, intense headache, disany contagious quality. This disease tress about the precordia, and the eyes are varies in its mode of attack, as well as in of a peculiar red. The heat of the skin the violence of its symptoms. In almost is seldom great in the beginning, but every other febrile disease, as a general soon increases in intensity, conveying rule, the risk is in proportion to the vio- to the mind the sensation of pungency. lence of the symptoms; but the masked The pulse is rarely open and strong; inor insidious form of yellow fever, is most deed, it usually appears rather more feecommonly the most difficult of manage- ble than natural to the inexperienced ment, and, consequently, the most dan- practitioner, which sometimes betrays gerous. Hence the “ walking cases” are him into dangerous errors. The pulse in almost sure to prove fatal. There are this state is termed the oppressed or dethree modes of attack in yellow fever; pressed pulse by authors; and, instead and the phenomena of either may vary, of requiring the aid of stimuli, as has

nausea.

a

APPENDIX. (YELLOW FEVER.)

been too often supposed, calls loudly for the proper use of the lancet. The face assumes a peculiar, or, rather, a specific flush, which is totally distinct from the redness of ordinary fever. This reddening gives a very marked character to the countenance, and can never be mistaken, by an eye experienced in this disease, for a symptom of common fever: on the contrary, it always denotes a high degree of yellow fever. The tongue is usually moist and clammy; but rarely dry, rough or red, in the commencement, though these conditions of this organ are sure to follow in a short time. The skin is dry and harsh, for the most part; though occasionally it is found wet, with hot perspiration. This sweat is sometimes early in its appearance, and, at times, extremely profuse in its quantity; but it neither abates the action of the heart and arteries, nor mitigates the local sufferings-as headache, pains in the limbs, or oppression in the lungs. It is therefore not critical, but, on the contrary, rather betrays malignancy. There is rarely so great an abatement of symptoms, at any period of the day, as to amount to a remission, though there frequently is an exacerbation that is every way alarming, from its intensity; and this may happen twice, or even thrice, in the twenty-four hours. When this happens, the disease proceeds, with hasty strides, to its fatal termination; for should not remedies at this time, especially bleeding, abate the severity of the symptoms very soon after their application, more fatal symptoms quickly supervene; the eye becomes more sad; lividity is added to the deeptoned color of the cheek; the tenderness is much increased by pressure over the region of the stomach; nausea and vomiting commence or increase; the patient tosses himself into every position; delirium ensues; the urine becomes intense in color, and small in quantity; the extremities lose their heat; the gums become swollen and livid; the tongue red, or brown, and dry; thirst insatiable; and the drinks rejected, perhaps, as fast as swallowed. After a continuance of these symptoms for a few hours, the system seems to make a compromise with the disease, and passively yields itself up to its ravages; for there is no diminution of the danger at this moment, though the system seems less morbidly excited; for if the suffering be less, danger is increased. Now the stomach gives way; the most tormenting nausea and thirst, with almost incessant vomitings, take place. The

fluids discharged are, for the most part,
nothing but the drinks which the patient
has swallowed; for these, even in the
beginning, are rarely tinged with bile.
But a threatening change soon follows;
the fluids become thicker, and somewhat
ropy, and are now found to have mixed
with them a flaky substance, of a dark
color. These flaky substances, there is
reason to believe, are portions of the
villous coat of the stomach, detached,
and made to mix with the ejected fluids,
by the effort of vomiting. The urine, at
this time, is usually very scanty, or may
be even suppressed; the bowels are tardy,
or yield a blackish, tarry-looking sub-
stance, of considerable tenacity. The
whole surface of the body, with the
exception, perhaps, of the abdomen,
is colder than natural; sometimes dry,
sometimes moist; the hands and feet
deathly cold, mottled with stagnating
blood; the pulse feeble, fluttering, or ex-
tinct; or it may be slow, composed, and
Sleep forsakes the
might, by the inexperienced, be even pro-
nounced natural.
patient, or he dozes, to suffer more; his
respiration is hurried, or preternaturally
slow. His mind may wander, but deliri-
um is not a very usual symptom in yellow
fever. Indeed, the patients, in this dis-
ease, often possess the entire use of their
faculties to the very last moment of life.
Some die most tranquilly, declaring, with
almost their latest breath, that nothing
ailed them; while others die in great
agony. When this happens, it is gene-
rally when delirium is present, and when
the brain, from sympathy, seems to sus-
tain the great force of attack. The pa-
tient may now become more tranquil,
from an evident mitigation of all the
severer symptoms; and this short-lived
truce gives rise, in the inexperienced, to
hopes that are never to be realized; for
now the yellowness of the skin, which
gives its name to the disease, begins to
show itself, and becomes the harbinger
of the dreaded and fatal "black vomit."
This matter is thrown from the stomach,
sometimes in incredible quantities, and
of various shades of color, from dark-
brown to the color of coffee-grounds, or
blackness. It is ejected with very little
effort, and the patient, for the most part,
denies the existence of pain. Black vom-
But
it, however, does not always precede
death

it is occasionally absent.
when this is the case, its place is supplied
by the eructation of prodigious quantities
of gas, rapidly and constantly secreted
by the stomach. The gums, and other

portions of the body, at this time, yield be taken as a guide ; for it has been considerable quantities of blood, which known to resemble a pulse in health, renders the aspect of the patient truly when dissolution has been near at hand; hideous. The teeth become incrusted while, again, it has been known to cease, with sordes; the tongue black and dry; yet the patient recover.—Treatment. The the pulse preternaturally slow and feeble ; treatment of this disease is very far from or it may be, at the wrist, extinct; the being as efficacious or certain as its danskin and extremities cold ; coma, or low, ger requires; yet it is not so fatal, unmuttering delirium, takes place; some- der favorable circumstances, as might, times convulsions ; then death. The at first sight, be supposed. In tropical prognosis in this disease must always be climates, it rages among strangers almost regarded, even in its commencement, as exclusively; and these, for the most unfavorable, though this fever is not in- part, are of a description unable to proevitably fatal. If the disease have com- cure the best means of mitigating suffermenced in an open, undisguised form, the ing or averting danger. In northerly chance is increased; but if it attack insidi- situations, where the disease is, as it were, ously, the danger is almost in proportion to accidental, the mortality, under the best the absence of prominent or decided symp- circumstances, is considerably less, though toms. If the disease assume, or can be still very much too great. We may atmade to put on, a regular form, that is, have tribute some portion of the mortality its remissions and exacerbations in pretty to the discrepancy in the views that have regular order, though the symptoms run been taken of the habits and nature of high, there appears a better chance to in- the disease. Some suppose it contacrease the one and moderate the other. gious in a high degree: this infallibly But, on the other hand, if the disease dis- increases the mortality, by causing the cover no tendency to regular remission, or necessary means to be withheld from the if reaction be but feeble and transitory, the suffering, under the apprehension of perrisk is greatly augmented. If the patient sonal danger ; while others look upon its sigh deeply, immediately after waking, and nature to be the same as that of typhus, before he have recovered the powers of and fatally adopt a treatment conformaspeech, the presage is bad; or if he com- ble to such a view ; and, consequently, plain of much soreness and pain, without thousands are sacrificed to a hypothesis. the part having any morbid appearance, it The opinion is now, however, daily gainis equally unfavorable. Those whose arms ing ground, that yellow fever is essenbecome rigid seldom get well; and those tially an inflammatory disease, and one who have an entire suppression of urine which requires a vigorous and strictly never recover. Black vomit is always a antiphlogistic plan of treatment. But very unfavorable symptom, especially neither a correct pathology, nor the best when attended by hiccough, but is not concerted means, will avail, if the proper necessarily fatal, particularly in young peo- time for their application be lost. "To be ple. The “ puking of wind,” as it is called, successful in the treatment of yellow feis perhaps as deadly a symptom as black ver, no time must be spent in temporizing. vomit. On the other hand, should there Yellow fever, as has just been stated, be a general abatement of the symptoms, must, agreeably to the best authorities, be especially of headache, with a softened looked upon as an erquisite gastritis ; a skin ; a general and equally distributed fact that should never be lost sight of: warmth ; less jactitation; diminution of it is for the relief of this condition of the thirst, without nausea or vomiting, and stomach, almost exclusively, that remethe tongue beginning to clean; less tender- dies are to be sought. It has been menness in the epigastrium; bilious fæcal tioned, that the pulse, from its similated discharges; a free flow of lighter colored weakness, and the feebleness of reaction urine (and particularly if it deposit a late- in its more dangerous forms, has misled ritious sediment); a moderate, and gene- the practitioner to the fatal use of stimurally-diffused perspiration, after the abate- lants. It is the depressed, or oppressed ment of the exacerbation, the disease pulse, so called—a pulse that always acmay be considered as less desperate, and quires vigor by the abstraction of blood. as tending to a healthy solution. The The quantity to be taken at any given pulse, in this disease, betrays, from be- time, cannot well be defined; for this ginning to end, less concern, if we may so state of the arterial system may require term it, than in almost any other with which the loss of a large quantity of blood to we are acquainted. Indeed, but little de- relieve it, or the pulse may become open pendence is to be put upon it, if it alone and free by the abstraction of only a few

66

ounces. The management of the bleed- ing, followed, in three hours, by a dose of ing must, therefore, be left to the discretion castor oil, if it do not operate previously of the medical attendant. If the pulse to the expiration of this time. During rise, as it is wont to do under this condi- the whole disease, the bowels should be tion of the system, by the loss of blood, kept open by the milder purgatives, but its abstraction should be continued until especially by oil, or by injections; for it become soft under the finger. Nor purging is uniformly hurtful, unless it can any rule be laid down for the repeti- be on the decline of the disease, and after tion of the bleeding, but one-namely, the liver has begun to secrete large quanthat recourse must be had to it, whenever tities of bile, which requires to be carried the system reacts with force, by which off. The mildest drinks should be given every symptom becomes aggravated, even during the whole attempt at cure, and if this occur several times in the twenty- these cold, almost always; that is, unless four hours.' It is mainly owing to not cold drinks be less acceptable to the taking down the excess of action of stomach than tepid, which is sometimes the heart and arteries when it occurs, the case. Ice swallowed frequently, in that fatal disorganization takes place so small portions at a time, is both acceptfrequently ; therefore, every paroxysm able and useful, and should never be should be carefully watched, that no one withheld when it can be procured. All may pass without having the force of the the drinks may be rendered cold by this pulse abated, by the loss of blood; for it substance ; and these should consist of may be confidently said, that the system gum-arabic water, barley water, linseed never reacts forcibly in this disease, when tea, slippery-elm bark tea, &c. Drinks it will not bear the abstraction of blood, should always be given in small quantieither generally or topically. If topical ties at a time, lest the stomach reject bleeding be resorted to, it must be from them. If there be much sickness of stomthe epigastrium; therefore, either leech- ach, attended by much tenderness upon ing or cupping must be the mode of ab- pressure, the epigastrium should be leechstraction. This state of the system is ed or cupped; and this may be followed rarely found, however, after the expiration by a blister if the nausea or vomiting conof eight-and-forty hours, unless the dis- tinue. Should the headache be great ease have been vigorously treated by pre- after due depletion from the arm, the vious blood-letting. Should this period temporal artery may be opened, or leeches have been lost, bleeding from the general or cups be applied to the temples, behind system can rarely be successful: topical the ears, and to the back of the neck. bleeding alone now promises relief; and Under these circumstances, if the feet be this may be tried at almost any period of cool or cold, they should be placed in the disease, if the sensibility of the epi- hot water, with which is mingled a quangastrium remain active. As regards the tity of the flour of mustard, and the feet feebleness of reaction, as just stated, we suffered to remain in it for fifteen or must not be mistaken in its cause, in the twenty minutes. This may be repeated, beginning of this disease ; as it is almost pro re nata. Fresh air should be admitsure to depend upon the depressed state ted freely into the room; the bed clothes of the pulse. For after blood has been and body linen changed as often as practaken in an appropriate quantity, the heat ticable ; light excluded, and noise proof the skin and activity of the pulse will hibited. If there be much determinaboth increase; but if stimulants be used, tion to the head, cold applications should both will be diminished. But it is al- be made to it, after reducing the quantity ways proper, when reaction is feeble, the of hair, should this be thick. Partial skin cooler than natural, and the extremi- heat may be reduced by sponging. Doclies perhaps cold, but certainly preternat- tor Jackson, in his treatise on fever, recurally cool, to use external stimuli with ommends large bleedings, in the first a view of aiding the powers of the system eight hours of attack, even ad deliquium in their efforts to produce a warmth upon animi. This, in robust constitutions, and the surface. Bottles or jugs of hot water, when the disease commences with high heated bricks, sinapisms, Cayenne pepper, excitement, has been found very bene&c., should be applied to the feet and ficial; but it rarely can be proper where legs, and used until a proper warmth be the disease is of a highly malignant charrestored. The bowels should be freely acter, as is almost always the case where opened, but not violently purged: for this much indirect debility suddenly shows purpose, eight or ten grains of calomel itself, and, consequently, where the powshould be given immediately after bleed- ers of the system are inadequate to pro