founded under the common name of yellow fever. The opinions of Chisholm upon this point are well known. Bally proposes to admit one species which is contagious, and another which is noncontagious. Devèze says, very properly, I think, in regard to these and all other like distinctions, that they are arbitrary and unfounded.1

scurely hot over the stomach and liver; the eye clear; and the entire aspect, to superficial observation, promising. Yet, in less than forty hours, the surgeon will be alarmed and confounded by black vomiting, soon followed by death. Although the patient will say, every time that he is visited, that he is better, and that, could he only eat, he would be well; on looking closely, it will be perceived that his answers do not always bear on the questions put; that amid his account of improvements, he never attempts to lift his head from the pillow till desired, and hurriedly lets it down again; that he dozes rather than sleeps, sighs frequently, and has difficulty in filling the lungs; and that the eye, though clear, is vacant, or fixed without an object."-Memoirs of the West Indian Fever, p. 8, et seq.

Traité de la Fièvre Jaune. Par Jean Devèze.

CHAPTER VI.

MARCH AND DURATION.

SEC. I.-March, or Type. Yellow fever does not belong to the class or family of periodical diseases; it is not properly remittent, nor intermittent, in its type; it is not marked by any obvious and regular series of recurrent phenomena. The periodical element in pathology may sometimes be engrafted upon it, or mixed up with it, as happens occasionally with other diseases; but the two affections are essentially and fundamentally dissimilar. Upon this point most modern observers, I believe, are agreed, although many of the older writers maintained an opposite doctrine. This was the case especially with those who were zealously contending for the domestic and miasmatic origin of the disease. They conceived the cause they were advocating to be strengthened by every analogy and resemblance which they could discover between the two forms. of disease; and this influence led many of them to adopt the doctrine that yellow fever is only an aggravated form or a high grade, as they call it, of ordinary remittent fever. It is well known that this was the opinion of Dr. Rush. He says that, in every case of the disease which came under his notice, there were remissions or intermissions of the fever, or of such symptoms as were substituted for the fever, generally occurring in the forenoon, and that these remissions were more evident than in the common bilious fever. I think, however, that a careful estimate of Dr. Rush's remarks upon this subject, with the aid of subsequent and more accurate investigations, will lead to the conclusion that his observations. are not to be trusted. His description of the remissions is any. thing but clear and distinct; and when we take into consideration the extent to which his judgment was perverted, and his vision blinded, by his preposterous dogma of the unity of disease, it can hardly be considered unreasonable, if, in the settlement of this question, we set his opinions wholly aside.'

1 Nowhere, perhaps, does Dr. Rush make a more absurd exhibition of this favorite article of his philosophical creed, than in connection with the subject of

I have just stated that yellow fever, like other diseases prevail. ing in malarious regions, may sometimes assume something of a periodical character. This subject, deserving of further investigation, has recently been studied by Dr. Lewis, of Mobile.

He has described a form of the disease which he calls remittent and intermittent yellow fever. During the epidemic of 1843, at Mobile, simple remittent fevers prevailed extensively in the southern part of the city, mostly amongst the native and acclimated population. Dr. Lewis says that he attended, in this district of the city, sixteen cases of remittent or intermittent fever, assuming the rank and grade of yellow fever. These cases were all amongst the unacclimated. Dr. Lewis estimates the numbers of these cases, during the epidemic of 1843, at one hundred; fifty of which terminated fatally. He says the intermittents were more fatal than the remittents. With the exception of this periodical element, the disease in these cases did not differ from the ordinary unmixed forms of yellow fever; it went regularly through its several stages, and terminated in its usual manner, and at its usual periods. Of twentyeight cases of fatal intermittent yellow fever, all terminated within the seventh day from the initial chill. Dr. Lewis does not give any full description of these cases, but there is no reason whatever for doubting the correctness of his conclusions. He is a competent and trustworthy observer, and he is in no way influenced in hist opinions by preconceived prejudices or notions, since he recognizes, without any qualification, the essential dissimilarity of periodical and yellow fever. In another paper, Dr. Lewis mentions particularly seven cases, occurring in 1842, which he calls congestive, simulating yellow fever. They occurred in persons who had been living

the text. "Science," he says, "has much to deplore from the multiplication of disease. It is as repugnant to truth in medicine, as polytheism is to truth in religion. The physician who considers every different affection of the different systems in the body, or every affection of different parts of the same system, as distinct diseases, when they arise from one cause, resembles the Indian or African savage, who considers water, dew, ice, frost, and snow, as distinct essences; while the physician who considers the morbid affections of every part of the body, however diversified they may be in their form or degrees, as derived from one cause, resembles the philosopher who considers dew, ice, frost, and snow, as different modifications of water, and as derived simply from the absence of heat. Humanity has likewise much to deplore from this paganism in medicine. The sword will probably be sheathed forever, as an instrument of death, before physicians will cease to add to the mortality of mankind by prescribing for the names of diseases."

N. O. Med. and Surg. Journ., vol. i. p. 292.

in malarious regions, and were marked by the symptoms of congestive and of yellow fever. Dr. Lewis says: "The pathological appearances of the congestive fever of the interior, and the yellow fever of Mobile, were both apparent in these cases, so that, taken in connection with the symptoms before death, they constituted a perfect example of the blending together of the different febrile poisons, so as to produce a disease of mixed character." Other diseases are frequently mixed up with this periodical element in pathology and not only is there no reason, à priori, why such should not sometimes be the case with yellow fever, but it would be a very singular circumstance if this disease alone should be exempt from this complication.

It is hardly necessary to say that the distinction which Chisholm attempted to establish between what he called Malignant Pestilential Fever and the Yellow Remittent Fever of the West Indies, was wholly gratuitous and unfounded. Lempriere, also, admitted the existence of a distinct disease, in the West Indies, usually showing itself in crowded ships, partaking of the character both of yellow and typhus fever, and, like the latter, contagious. It seems to me quite clear, that this disease was only the malignant or congestive form of true yellow fever.3

1 N. O. Med. Journ., vol. i. p. 35.

2 I find, since writing the above, that Lempriere, towards the close of the last century, noticed particularly this modification of yellow fever in Jamaica. He calls it "a variety of the disease grafted upon the remittent." "In this," he says, "the first attack is marked by the usual symptoms which usher in the remittent, except that the affection of the head is more severe, and the eyes wear a suspicious appearance; remissions and exacerbations proceed alternately as in the common remittent, and bark in large doses is generally retained during the remissions, from which the inexperienced are wont to draw favorable conclusions; but about the third or fourth day, and sometimes later, such symptoms occur as denote the greatest danger; the eye becomes muddy and suffused, the countenance despondent, and the neck, and afterwards the whole body, shows itself dyed with a yellow suffusion; great irritability of stomach, and oppression about the præcordia, delirium, or more frequently coma, and many other symptoms of the genuine yellow fever, supervene."—Observations, etc., by Lempriere, vol. ii. p. 70. Dr. Dickson, of Charleston, S. C., admits explicitly and distinctly the existence of this modified form of yellow fever. "In the summer of 1817," he says, "many northern and foreign sailors had been induced to go as boatmen up our rivers. Considerable numbers of them were brought into our hospitals with country fevers, both remittent and intermittent, which, as soon as yellow fever became prevalent, ran into that epidemic-the fever becoming continued, and black vomit ensuing."-Dickson's Essays, &c., vol. i. p. 335.

3 Observations, etc., by Wm. Lempriere, vol. ii. p. 80.

SEC. II.-Stages. But although there is no regularly recurrent or periodical element in yellow fever, the disease, in fatal cases, is marked by several very constant and striking stages, or periods, through which it passes with great regularity. These stages, or periods, are three in number, to wit: first, the febrile period, or the stage of excitement; second, the passive stage, or remission, or the stage of calm, as Dr. Lewis calls it; and third, the stage of collapse. [It is now common to speak of yellow fever as a disease of one paroxysm. The phrase is useful in drawing the distinction between it and periodic fevers. As sometimes used, it refers to the febrile period only, and the stages of calm and of collapse succeed the "one parox. ysm." In another view, the paroxysm embraces the whole disease, and is divisible into the three stages.] The first stage is marked by general febrile excitement, and it passes into the second with an abatement of the severity of the local pains, and of the fever. The second stage is marked, in addition to the change of symptoms just spoken of, by epigastric distress, nausea, and vomiting, and general restlessness, the latter commonly paroxysmal. The third stage usually commences with the black vomit, and is immediately followed by coldness of the extremities, yellowness of the surface, general sinking of the powers of life, and speedy death. In grave cases, terminating favorably, the period of remission, instead of passing into the stage of collapse, is followed by convalescence; and in the milder forms of the disease, it can hardly be said that there are any of the distinct stages, except the first. Dr. Lewis says: "The collapse stage is more marked and regular some years than others. In 1837, it was irregular; in 1839, it seldom failed to occur on the night of the fourth day, attended with immediate and striking evidences of sinking prostration; in 1843, it occurred between the beginning of the fourth and sixth day of the disease." The duration of these several stages will be found, of course, to vary considerably in different cases and under different circumstances. The most positive information that I am able to find upon this point, is derived from Dr. Lewis. "I have taken," he says, "twenty cases of epidemic fever, in which all these stages were well defined-the notes of many of them furnished by medical friends-and after a careful examination, I ascertained the average duration of each stage to be as follows: fever, twenty-two hours,

IN. O. Med. and Surg. Journ., vol. i. p. 298.