YELLOW FEVER. 715 



panied by headache, generally located immediately over the eyes, or 

 shooting through from temple to temple, and often very severe. But 

 the headache is frequently trivial in comparison with the frightful pains 

 in the loins, which make the patient writhe in agony. The pulse is 

 generally full, strong, and rapid, beating from ninety to a hundred and 

 twenty times a minute. The skin is hot and dry, the face flushed, the 

 eyes bloodshot, brilliant, and watery, and the tongue covered with a 

 creamy white fur, but with red, clean tip and edges. There is usually 

 some uneasiness of the stomach from the first, and in from twelve to 

 twenty-four hours this develops into nausea and a persistent sensitive- 

 ness, which will not allow anything to be retained. The pit of the 

 stomach is very tender on pressure, and vomiting is almost incessant. 

 With all this there is intense thirst, and iced drinks are exceedingly 

 grateful to the patient. The bowels are at first generally costive, and 

 sometimes obstinately so, but, as the disease progresses, they become 

 loose. The patient is usually very much debilitated, but is uneasy and 

 tosses about in bed, and occasionally will try to rise and walk about the 

 room. In most cases there is some confusion of intellect, not amount- 

 ing to delirium, and the face expresses the greatest anxiety and dis- 

 tress. The fever continues for two or three days, being most severe in 

 the evening, the temperature often reaching 104 or 105, and, accord- 

 ing to La Roche, in malignant cases, even 110. Then the fever sub- 

 sides, never to return, and the temperature within twelve hours may 

 become nearly normal. The other symptoms mostly disappear, and the 

 organs resume their natural functions. At this time, i. e., on the third 



O 7 7 



or fourth day, the yellow discoloration of the skin appears upon the 

 face and thence extends over the body. If the attack is mild, recovery 

 is now rapid. In the vast majority of cases, however, this lull in the 

 symptoms is deceitful, and lasts only from a few hours to a day, when 

 the gravest stage of the disease sets in. The pulse soon becomes small 

 and thready, beating only thirty or forty to the minute, and the heart 

 often works vigorously after the pulse can no longer be felt at the 

 wrist. The nausea and vomiting return and become constant, the res- 

 piration is often embarrassed, the tongue becomes dry and brown, the 

 skin is cool and dry, there is often a distressing hiccough, and the thirst 

 is insatiable. The mind is often clear, but singularly apathetic, or there 

 may be delirium or stupor. The disorganization of the blood and the 

 tissues has now gone so far that the small vessels of the mucous mem- 

 branes no longer retain their contents, and blood oozes into the stomach. 

 This produces intense nausea, and the blood is vomited up, changed in 

 color by the acids with which it is mingled. This forms the dreadful 

 " black-vomit," and varies in hue from brown to almost jet black, gen- 

 erally appearing like coffee-grounds floating in a thin, watery fluid. 

 The urine, which becomes scanty early in the disease, may now be en- 

 tirely suppressed, or, if excreted at all, is black and bloody. The dis- 

 coloration of the skin increases, until the body is of a dusky brown, 



