state of remission. If the word is meant simply, as in other instances, to refer to a diminution of febrile excitement, it is very ill-applied to an apyrexia confessedly total-a complete intermission-"a stadium," says Lining, "without any fever." The headache is now relieved; the pains in the back and limbs. subside or disappear; the skin is more pliable, cooler, and moister; the pulse is nearly natural, perhaps a little more frequent and softer than in health; the breathing is easier; the pain and burning of the stomach lessened, its irritability not so urgent, and the act of vomiting attended with less effort; the face is less flushed, the eye less red and suffused, and on the adnata a yellow tinge is gradually substituted. The well known orange hue overspreads the surface; it is erroneously confounded with jaundice by many writers. I regard it rather as owing to a depraved condition of the blood itself, and to a weak and morbid state of the capillary circulation. It has been seen pervading the cel lular substance throughout and in the periosteum; but this I have not met with. The stadium thus characterized, lasts but for a few hours-never longer, I think, than from twenty-four to thirty-six, perhaps usually about twelve to eighteen; when the disease, if not subdued or controlled, develops a violence and rapidity of progress infinitely disproportioned to the enfeebled powers of resistance in the constitution. Of this third and last stage, the prominent feature is the collapse, as it has been called-the extreme prostration of the subject. His pulse sinks, is quick, unequal, depressed. The skin grows dark, and assumes a mahogany or bronze hue, especially on the face and hands; the discoloration of which may be removed by pressure, and a paleness substituted, disappearing slowly when the finger is taken off. The tongue sometimes continues whitish, soft, swollen, and moist on the sides, with a dark brown, dry streak in the centre; it often becomes dryish and of a fiery red, and smooth, with fissures perhaps oozing an offensive blood. Of the same hue and appearance is the whole lining membrane of the mouth. The stomach is now so irritable that it retains nothing, and the vomiting hitherto attended with some retching and straining, is very easy as well as frequent. Occa sionally we observe that the fluid thrown up at this stage consists entirely of colorless mucus, rather tenacious and difficult to be got rid of. This is I suppose what is called in the West Indies "the white vomit," described by Blair as follows: "The white, ropy, acid fluid which is frequently ejected at the close of the second stage in considerable quantities, and with much relief to the symptoms, is generally attended with considerable retching; this is the fluid which, during our epidemic, was called 'premonitory or precursory' fluid, or white vomit." His editor, in a note, says that "in the late endemic in Barbadoes, a fluid answering tolerably to the description in the text, was of not unfrequent occurrence, though not so frequent as to arrest attention." Davy thinks it serous or albuminous. About this time a number of variable phenomena present themselves, which belong to the history rather of individual cases than of the average course of the disease. Different epidemics are characterized by material variations in this respect. In 1824, the tendency to hemorrhage was most generally exhibited, and at this point of time even the cases which seemed improving, and promised a favorable termination, showed some epistaxis, or oozing from the gums or mouth. In 1852, there was what I was inclined to call a scorbutic diathesis. The gums became livid and soft and spongy; the mouth was filled with saliva of an offensive odor, and the aspect of the patient was very similar to that of one laboring under mercurial ptyalism. In some of the cases, I found it very difficult to satisfy myself that no mercury had been taken. In others, without any such effusion into the mouth, the parotid and sub-maxillary glands were enormously swollen. I saw, with Prof. Frost, a patient whose death he attributed to difficulty of deglutition and breathing from these tumors, having thought him in a way to recover before they supervened. Petechia and vibices-sometimes large ecchymoses-showed themselves. Eruptions have been often spoken of as belonging to the history of yellow fever. They do occur, but much less frequently than one would infer from the statements. Out of 275 cases admitted to the Roper Hospital between the 2d September and the 1st November, 1852, but 5 were marked with eruptions-and no two of them were alike. One of them looked very much like the efflorescence of measles, and another resembled urticaria. They came out about the termination of the second stage, and their presence was coincident with no observable change or crisis. In some of the worst cases, there was about this period a superficial inflammation of the scrotum in males and of the vulva in females; vesication followed, and the sore exuded an offensive serum and looked gangrenous. Flores mentions having seen such a spot upon the penis of a patient; and ascribes it to the acrid irritation of a drop or two of black vomit, which he says had fallen on the part. In the early part of this delusive interval or stadium-too often, indeed, delusive-the patient is cheerful and hopeful; but if the disease progresses, he soon becomes conscious of his actual condition, and his countenance betrays great anxiety. The mind is often clear and calm, however. The stomach grows more and more irritable. The mucus and fluids thrown up are now found to contain flakes of a dark color, the proportion of which increases, until they come to resemble a mixture of soot or coffee-grounds in water. This is the black vomit, a justly dreaded and terrible symptom. The amount ejected is often astohishing. It escapes sometimes in the act of hiccuping, and occasionally spouts forth from the mouth with some force, involuntarily, as the patient lies on his back. The contractile power of the stomach, on the other hand, ceases entirely in some cases to act, and there is no vomiting; the belly is distended, and a loud gurgling is produced by every movement of the body. The bowels, so reluctant at first, may now yield; the alvine discharges becoming frequent and abundant, consisting often of a fluid identical with the black vomit. The powers of life rapidly decline; breathing is laborious, with deep sighing and inoaning, and intolerable oppression and distress about the præcordia and the epigastric region. The skin is cold and clammy; the eyes dim and hollow; the tongue black and tremulous; there is low muttering delirium. Hemorrhage ensues in a considerable proportion of cases, the blood exuding from the gums, tongue, fauces, nostrils, stomach, intestines, urethra, eyes, and ears; and death finally relieves the miserable patient from sufferings dreadful to contemplate. Such as I have above described, are the usual phenomena of yellow fever. In the great majority of instances, it puts on among us the features of open inflammatory excitement, yet the deviations from this regular history and progress are by no means unfrequent, and offer to us pictures of strange and almost unaccountable diversity. Like other fevers, it often assumes a congestive disposition, the tokens of openly developed vascular action being absent or notably deficient, and the system appearing to sink prostrate at once before the extreme force of the morbid causative agency. The organs are variously affected in cases of this kind. The head being the centre of determination, lethargy, stupor, or coma may supervene, or death ensue in a few hours, preceded by frightful convulsions. The lungs are occasionally attacked with great oppression and dyspnoea. The stomach being assailed, the symptoms are exceedingly similar to, or indeed identical with those which follow the administration of the more intense poisons, such as arsenic; all regularity of febrile progress being lost in the overwhelming derangement of this most important organ and its extensive sympathies. Early and irretrievable collapse, with abundant black vomit, are the usual attendants. The cases are almost uniformly marked by a peculiar bronzed or dark mahogany discoloration of the skin, ascribed to the sluggish or suspended action of the extreme vessels of the capillary system; visible on the surface, inferable as present everywhere. It is one of the worst symptoms, and is attended by many circumstances all portending great danger. The patient usually utters little complaint, though the countenance, which is often listless, unmeaning, and apathetic, occasionally assumes an indescribable expression of anguish and horror. All the susceptibilities seem blunted; the stomach is not tender on pressure, or obscurely so; the bowels are insensible to purgatives or enemata; the skin becomes pale under pressure applied, slowly resuming its dark hue; sinapisms or blisters laid upon it are unnoticed, and if they produce inflammation, the parts are apt to become black and sphacelate. I have seen this occur as long as five days before death, though such malignant attacks generally terminate on the third, fourth, or fifth day. It would be vain, if not useless, to attempt a detail of the many varied forms assumed by this pestilence at different times and in different localities. They are rather to be regarded as interesting pathological curiosities, than as forming definite classes. Among them, we may note what Rush used to call the "walk about cases," in which the patients scarcely feel or acknowledge they are ill; refuse to lie down, and are unwilling to be prescribed for; but, with hardly an exception, sink and die promptly. The duration of yellow fever differs relatively to the form it puts on. Congestive attacks terminate early, say on the third and fifth days. The ordinary inflammatory cases die on the fifth, sixth, and so on to the ninth. In extreme instances, death may take place in a few hours, on the one hand, and on the other, a typhoid condition may be protracted, as I have known, to the nineteenth, twenty-first, and twentyfifth day. Recoveries are in general slow; the tedious and lingering convalescence is apt to be harassed by the formation of abscesses on the body and limbs, which suppurate unkindly. Relapses are rare, or rather unknown; indeed, few affirm their occurrence. Of second attacks, I have already spoken, and am prepared to maintain, that although some well attested instances are recorded, yet the immunity is very nearly complete; and that this may be fairly alleged as one of the characteristics of the disease under discussion. Prognosis.-Yellow fever must be viewed as one of the most destructive forms of pestilence, exceeding even the plague, perhaps, in proportional mortality. In 1804, in Gibraltar, out of a population of nine thousand civilians, but twenty-eight persons escaped an attack, and the deaths amounted to more than one in three. Musgrave gives a scarcely less terrible account of it in Antigua, in 1816. In Jamaica, under the care of Dr. Hume, three out of four died of it. In the city of Philadelphia, in 1820, there died eighty-three out of one hundred and twenty-five-about two out of three. In the same year, according to official returns, the loss in Spain, at Xeres de la Frontera, was seventy per cent., nearly three out of four. In Philadelphia, in 1853, there occurred 170 cases between July 18th and October 18th (81 days), of which number 128 died, about seventy-five per cent. Blair calculates the mortality of untreated cases at twenty-nine per cent. in Demerara and British Guiana; of all cases, treated, at 13.3 per cent. The difference of proportional mortality in different seasons is very great. In a table given by Davy, from the military hospital at Barbadoes, it is set down for 1841 at 83.33-for 1842 at 17.91. Sir James Fellows tells us that, during the fever of Cadiz in 1800, the "air became so vitiated that its noxious qualities affected even animals; canary birds died with blood issuing from their bills, and in all the neighboring towns which had been infested, no sparrow ever appeared." Rush says that cats died in great numbers in the streets of Philadelphia, from the pestilential state of the atmosphere. Perlee affirms that about Natchez, in 1819, "not only domestic animals, but even the wild deer of the forests shared the influence of the epidemic constitution of the air." In Charleston the proportional mortality has differed in different seasons by a very wide range; in 1817 and 1824, it was very great; much less in 1819 and 1827; in 1852, very little. Considered extensively, it will not average more, I think, than 10 to 13 per cent. In 1854, it did not exceed, as well as can be calculated, 3 per cent. of the sick. The individual prognosis is much modified by circumstances. The attack is apt to be violent, and its progress hasty, in the sanguineous and plethoric. For the intemperate there is almost no hope. National habits and modes of life have a decided influence. The Irish, Germans, and Scotch afford the worst cases; Spaniards, Italians, and Frenchmen are very apt to recover. Midway stands the Englishman, the Northerner, and the Mountaineer, or inhabitant of our interior country. Generally speaking, the more recently a stranger has arrived, the more severe his attack. Among the young children assailed, the ravages of this pestilence are very great everywhere. In ordinary inflammatory cases, the condition of the stomach is of paramount importance; everything depends upon its powers of retention and its tranquillity. Constant nausea and retching, especially if attended with burning at the epigastrium, and notable tenderness on pressure, give a gloomy prospect. The pulse is not generally to be much depended on; it denotes danger if it become small, quick, and irregular. A skin moist and relaxed is unfavorable; so says Rush, and truly. This symptom was observed more frequently in the epidemic of 1838 than in any other. In bad cases, the febrile paroxysm, the first stadium, is usually short; yet I saw a patient recover in whom it had lasted no more than four hours. After the subsidence of this original paroxysm, we are pleased with the supervention of any degree or form of febrile excitement. This indeed has been properly spoken of by Robert Jackson, as "a new stream of life." At this crisis, there is every reason, even in attacks of ordinary severity, to dread a sudden collapse or a gradual sinking of the strength; and it is at this point of time, and under these circumstances of exhaustion, that the black vomit makes its appearance. An unnatural calm and stagnation are substituted for the unquiet agitation which has shaken the patient; from which it is difficult to arouse him by any therapeutical measures. Any irritation which shall excite him, any determination to whatever organ, besides that one which has suffered most from the commencement, will at least protract his fate, and lengthen out his chances for recovery. Hence, even a typhoid heat of skin, and stupor, and muttering delirium, are better than a tranquil indifference; nay, I have seen a quasi phrenitis develop itself more than once, and with favorable results. The stomach is the most vulnerable point, and a division of the force of the assault is apt to be attended with consequences less promptly fatal than its concentration. Hence, also, strangury produced by epispastics, or the internal exhibition of cantharides, is generally recognized as a good symptom; I have, however, lost one patient in whom it had been brought on. We must not confound this with the spontaneous suppression of urine sometimes met with; the defect of renal secretion. This is almost uniformly a fatal sign here, as in cholera. It has happened to me to see two recoveries from it, nevertheless; and in one strange case it lasted five days, and then the secretion was resumed, but after many reverses, and a long protracted illness, the patient died. In such suppression, there is no pain nor distension of the bladder, and the catheter carefully introduced brings away no fluid from it. So far as I have ob served, the appearances on the skin, known as petechiæ, vibices, etc., are forerunners of death. There are recoveries, however, recorded after them. I would say the same of the dissolved condition of the blood-gory, diffluent. Yet Rush affirms that they were removed by venesection, when it had been indicated by the continued tension of |