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YACK. (See Ox.)

YELLOW FEVER." This fever is one of specific character, and confined to situa tions in which great moisture is joined with great heat. It prevails in the West Indies, certain parts of Asia, South America, occasionally in the northern parts of North America, and pretty constantly in the southern. It is endemial in many portions of the globe, and especially in the tropical climates, and is occasionally epidemic in certain of the higher north ern latitudes, as at Baltimore, Philadelphia and New York. It is most common in seaports, and on large bodies of water, but is occasionally found in inland situa tions. It differs materially from the endemial remittent of tropical climates, and is, of course, not merely an exalted form of the bilious remittent of such places. It differs from the endemial remittent of the West Indies, in its attacking strangers to such climates only. The natives, and even such as have been born or lived long in similar situations, are altogether exempt from its attacks; and, should the stranger survive the dangers of an attack, he remains free, for the most part, subse quently, though not exempt from the endemial remittent of the place. This immunity, however, may be forfeited by the stranger living for a year or two in a northern latitude: should the stranger. escape for a year or two, he becomes ac climated, and is no longer liable to be attacked by yellow fever. This disease has been looked upon, by some, as contagious; but this notion is now altogether abandoned by far the greater part of the profession; and especially such as have had opportunities to observe its phenome na, and ascertain its habits for themselves. That it spreads rapidly sometimes, is admitted; but this is owing to the causes which make it an epidemic, and not to any contagious quality. This disease varies in its mode of attack, as well as in the violence of its symptoms. In almost every other febrile disease, as a general rule, the risk is in proportion to the vio lence of the symptoms; but the masked or insidious form of yellow fever, is most commonly the most difficult of manage ment, and, consequently, the most dan gerous. Hence the "walking cases" are almost sure to prove fatal. There are three modes of attack in yellow fever; and the phenomena of either may vary,

as the remote cause may have been more or less active or concentrated. They may also be influenced by individual habits or constitutions,, or by the force of the occasional or exciting cause; and hence we find it run its course rapidly sometimes; that is, in from two to five days, a part of the cases terminating in black vomit. In this form of the disorder, the symptoms are generally less fero cious, and less distinctly marked, though more certainly and speedily fatal; or it may run on to the fifth or to the seventh day; and though the sufferings are of a more acute kind, the danger is less, as more time is given for the application of remedies; or it may present, like a regu larly-formed remittent, regular exacerba tions and remissions. If it assume this form, it may run on to the ninth or eleyenth day. The first form observes no very regular period of attack, though the evening is the most common. The second generally takes place after noon; and the third, most frequently in the morning. The mode of attack, however, is pretty generally marked by the same train of symptoms, differing more in force than in character, if we except the first, which often has the peculiarity of betraying itself by scarcely any outward signs, except weakness, slight headache, or nausea. This insidious character lulls the patient and his friends into a fatal security. The patient has been known to walk about until within a few minutes of dissolution. The unmasked or violent attack of yellow fever is, therefore, less to be dreaded than the seemingly mild form, as the derangement of the system is more palpable, though it is always highly dangerous. This disease differs in its attack from almost every other form of fever, as it is seldom ushered in by a well-defined chill, though the sensation of cold, and a reduced temperature of the skin, will remain sometimes a long time before reaction will take place. Much languor is always experienced; for the most part, intense headache, distress about the precordia, and the eyes are of a peculiar red. The heat of the skin is seldom great in the beginning, but soon increases in intensity, conveying to the mind the sensation of pungency. The pulse is rarely open and strong; indeed, it usually appears rather more feeble than natural to the inexperienced practitioner, which sometimes betrays him into dangerous errors. The pulse in this state is termed the oppressed or depressed pulse by authors; and, instead of requiring the aid of stimuli, as has

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, extreme ly 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 oppres sion 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 in tense in color, and small in quantity; the extremities lose their heat; the gums be come 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 substance, 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 extinct; or it may be slow, composed, and might, by the inexperienced, be even pronounced natural. Sleep forsakes the patient, or he dozes, to suffer more; his respiration is hurried, or preternaturally slow. His mind may wander, but delirium is not a very usual symptom in yellow fever. Indeed, the patients, in this disease, 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 generally when delirium is present, and when the brain, from sympathy, seems to sustain the great force of attack. The patient 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 darkbrown 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 vomit, 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 considerable quantities of blood, which renders the aspect of the patient truly hideous. The teeth become incrusted with sordes; the tongue black and dry; the pulse preternaturally slow and feeble; or it may be, at the wrist, extinct; the skin and extremities cold; coma, or low, muttering delirium, takes place; sometimes convulsions; then death. The prognosis in this disease must always be regarded, even in its commencement, as unfavorable, though this fever is not inevitably fatal. If the disease have commenced in an open, undisguised form, the chance is increased; but if it attack insidiously, the danger is almost in proportion to the absence of prominent or decided symptoms. If the disease assume, or can be made to put on, a regular form, that is, have its remissions and exacerbations in pretty regular order, though the symptoms run high, there appears a better chance to increase the one and moderate the other. But, on the other hand, if the disease discover no tendency to regular remission, or if reaction be but feeble and transitory, the risk is greatly augmented. If the patient sigh deeply, immediately after waking, and before he have recovered the powers of speech, the presage is bad; or if he complain of much soreness and pain, without the part having any morbid appearance, it is equally unfavorable. Those whose arms become rigid seldom get well; and those who have an entire suppression of urine never recover. Black vomit is always a very unfavorable symptom, especially when attended by hiccough, but is not necessarily fatal, particularly in young people. The "puking of wind," as it is called, is perhaps as deadly a symptom as black vomit. On the other hand, should there be a general abatement of the symptoms, especially of headache, with a softened skin; a general and equally distributed warmth; less jactitation; diminution of thirst, without nausea or vomiting, and the tongue beginning to clean; less tenderness in the epigastrium; bilious focal discharges; a free flow of lighter colored urine (and particularly if it deposit a lateritious sediment); a moderate, and generally-diffused perspiration, after the abatement of the exacerbation,-the disease may be considered as less desperate, and as tending to a healthy solution. The pulse, in this disease, betrays, from beginning to end, less concern, if we may so term it, than in almost any other with which we are acquainted. Indeed, but little dependence is to be put upon it, if it alone

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be taken as a guide; for it has been known to resemble a pulse in health, when dissolution has been near at hand; while, again, it has been known to cease, yet the patient recover.-Treatment. The treatment of this disease is very far from being as efficacious or certain as its danger requires; yet it is not so fatal, under favorable circumstances, as might, at first sight, be supposed. In tropical climates, it rages among strangers almost exclusively; and these, for the most part, are of a description unable to procure the best means of mitigating suffering or averting danger. In northerly situations, where the disease is, as it were, accidental, the mortality, under the best circumstances, is considerably less, though still very much too great. We may attribute some portion of the mortality to the discrepancy in the views that have been taken of the habits and nature of the disease. Some suppose it contagious in a high degree: this infallibly increases the mortality, by causing the necessary means to be withheld from the suffering, under the apprehension of personal danger; while others look upon its nature to be the same as that of typhus, and fatally adopt a treatment conformable to such a view; and, consequently, thousands are sacrificed to a hypothesis. The opinion is now, however, daily gaining ground, that yellow fever is essentially an inflammatory disease, and one which requires a vigorous and strictly antiphlogistic plan of treatment. But neither a correct pathology, nor the best concerted means, will avail, if the proper time for their application be lost. To be successful in the treatment of yellow fever, no time must be spent in temporizing. Yellow fever, as has just been stated, must, agreeably to the best authorities, be looked upon as an exquisite gastritis; a fact that should never be lost sight of: it is for the relief of this condition of the stomach, almost exclusively, that remedies are to be sought. It has been mentioned, that the pulse, from its similated weakness, and the feebleness of reaction in its more dangerous forms, has misled the practitioner to the fatal use of stimulants. It is the depressed, or oppressed pulse, so called-a pulse that always acquires vigor by the abstraction of blood. The quantity to be taken at any given time, cannot well be defined; for this state of the arterial system may require the loss of a large quantity of blood to relieve it, or the pulse may become open and free by the abstraction of only a few

ounces. The management of the bleeding must, therefore, be left to the discretion of the medical attendant. If the pulse rise, as it is wont to do under this condition of the system, by the loss of blood, its abstraction should be continued until it become soft under the finger. Nor can any rule be laid down for the repetition of the bleeding, but one-namely, that recourse must be had to it, whenever the system reacts with force, by which every symptom becomes aggravated, even if this occur several times in the twentyfour hours. It is mainly owing to not taking down the excess of action of the heart and arteries when it occurs, that fatal disorganization takes place so frequently; therefore, every paroxysm should be carefully watched, that no one may pass without having the force of the pulse abated, by the loss of blood; for it may be confidently said, that the system never reacts forcibly in this disease, when it will not bear the abstraction of blood, either generally or topically. If topical bleeding be resorted to, it must be from the epigastrium; therefore, either leeching or cupping must be the mode of abstraction. This state of the system is rarely found, however, after the expiration of eight-and-forty hours, unless the disease have been vigorously treated by previous blood-letting. Should this period have been lost, bleeding from the general system can rarely be successful: topical bleeding alone now promises relief; and this may be tried at almost any period of the disease, if the sensibility of the epigastrium remain active. As regards the feebleness of reaction, as just stated, we must not be mistaken in its cause, in the beginning of this disease; as it is almost sure to depend upon the depressed state of the pulse. For after blood has been taken in an appropriate quantity, the heat of the skin and activity of the pulse will both increase; but if stimulants be used, both will be diminished. But it is always proper, when reaction is feeble, the skin cooler than natural, and the extremities perhaps cold, but certainly preternaturally cool, to use external stimuli with a view of aiding the powers of the system in their efforts to produce a warmth upon the surface. Bottles or jugs of hot water, heated bricks, sinapisms, Cayenne pepper, &c., should be applied to the feet and legs, and used until a proper warmth be restored. The bowels should be freely opened, but not violently purged: for this purpose, eight or ten grains of calomel should be given immediately after bleed

ing, followed, in three hours, by a dose of castor oil, if it do not operate previously to the expiration of this time. During the whole disease, the bowels should be kept open by the milder purgatives, but especially by oil, or by injections; for purging is uniformly hurtful, unless it be on the decline of the disease, and after the liver has begun to secrete large quantities of bile, which requires to be carried off. The mildest drinks should be given during the whole attempt at cure, and these cold, almost always; that is, unless cold drinks be less acceptable to the stomach than tepid, which is sometimes the case. Ice swallowed frequently, in small portions at a time, is both acceptable and useful, and should never be withheld when it can be procured. All the drinks may be rendered cold by this substance; and these should consist of gum-arabic water, barley water, linseed tea, slippery-elm bark tea, &c. Drinks should always be given in small quantities at a time, lest the stomach reject them. If there be much sickness of stomach, attended by much tenderness upon pressure, the epigastrium should be leeched or cupped; and this may be followed by a blister if the nausea or vomiting continue. Should the headache be great after due depletion from the arm, the temporal artery may be opened, or leeches or cups be applied to the temples, behind the ears, and to the back of the neck. Under these circumstances, if the feet be cool or cold, they should be placed in hot water, with which is mingled a quantity of the flour of mustard, and the feet suffered to remain in it for fifteen or twenty minutes. This may be repeated, pro re nata. Fresh air should be admitted freely into the room; the bed clothes and body linen changed as often as practicable; light excluded, and noise prohibited. If there be much determination to the head, cold applications should be made to it, after reducing the quantity of hair, should this be thick. Partial heat may be reduced by sponging. Doctor Jackson, in his treatise on fever, recommends large bleedings, in the first eight hours of attack, even ad deliquium animi. This, in robust constitutions, and when the disease commences with high excitement, has been found very beneficial; but it rarely can be proper where the disease is of a highly malignant character, as is almost always the case where much indirect debility suddenly shows itself, and, consequently, where the pow ers of the system are inadequate to pro

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is not to thwart or prevent their efforts. We must, therefore, be rather the spectators of the conflict of the system, than active agents against the disease; taking care, however, constantly to remove, as much as it may be in our power, any obstacle that may appear to interfere with the general progress to recovery, as an irregular condition of the bowels, of the stomach, of the state of air, &c. &c. Nausea and vomiting are troublesome conditions of the stomach, and its relief should be attempted by leeching, cupping and blistering, over its region, by Seltzer water, the effervescing draught, lime water and milk, &c., but never, or but very rarely in the beginning of the disease, by stimulants: after decided marks of debility, clove tea, mint tea, or strong coffee, with mustard to the epigastrium, may be tried. When black vomit has come on, the spirit of turpentine, with the oil of cinnamon, in thirty drop doses, has been certainly of temporary use, and occasionally of permanent benefit. Thirst may be abated by small quantities of very cold water, or by frequently swallowing small portions of ice, as directed above: sometimes the feeling of the stomach is in favor of warm drinks; when this is the case, the craving or instinct should be indulged. Hiccough is sometimes extremely distressing in this complaint. Camphor, in doses of from five to ten grains, will sometimes relieve it. Should it offend the stomach, it may be given very advantageously in a gill of rich flaxseed tea, and thin starch, or mucilage of gum-arabic, as an enema. The utmost attention must be constantly paid to the patient by the nurse: he should have the luxury of fresh air constantly, and the frequent renewal of clean, fresh body linen and bed clothes.

duce a quick and sufficiently powerful reaction. In this case, however, stimulation would be more quickly and certainly fatal than bleeding, even indiscreetly urged; for, by the former, you cannot fail to increase the inflammation of the mucous membrane of the stomach, which will necessarily augment the danger; while the latter only diminishes the power of reaction; therefore, by the first practice, the cause of the disease is increased; by the second, the effects of this cause are only augmented. For the first, there may be no adequate remedy; for the second, a remedy may be found: hence, when, in the early stage of yellow fever, recourse is had to internal stimulants, the case is almost uniformly fatal; whereas, bleeding, even when injudiciously employed, only depresses the system, which may recover by the aid of external stimuli; and the case is not as desperate as when stimuli have been thrown into the stomach during the state of active inflammation. In the case, however, under consideration, it is only an abuse of the proper remedy; for, if the abstraction of blood be judiciously made in this state of the system, the system, instead of becoming prostrate, will react promptly; for the pulse, in the beginning of this disease, is in a state of depression, as has already been explained, and not of absolute weakness; for there have been instances of recovery, as already stated, after spontane ous hæmorrhages from various parts of the body, but where the abstraction of blood from the general system by the lancet would certainly have proved fatal. Does not this flow of blood intimate to us the propriety of imitating it, by the application of a leech or two to various parts of the body? One thing is very certain in the generality of cases of yellow fever, that when bleeding, either general or topical, fails to afford relief, stimulants never succeed: therefore, when the time is past for both general and topical bleeding, it is in vain to attempt the relief of the patient by the exhibition of stimulants. By doing little or nothing at this time, the recuperative powers of the system, if left to themselves, may restore the patient; for all that art can do, at this time,

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