2-10 



class recover. Defervescence takes place between the seventh and the 

 eleventh day, and the albumen shortly after disappears from the urine, 

 often in a sudden manner. In severe cases the convalescence is often tedious, 

 liable to be complicated with skin eruptions, abscesses, parotitid, dyspeptic 

 troubles, or malaria. When uraemic delirium has developed during the 

 attack, the intellectual faculties may not be fully restored until several 

 weeks after defervescence. In fatal cases death generally occurs by asphyxia, 

 by syncope, or by cerebral complications. 



Melano-albuminuric Yellow Fever. — From the moment when albumen 

 has been detected in the urine, a second distinctive sign must be constantly 

 looked for. That sign consist in the appearance in the vomit or in the 

 alvine discharges of the black or brown matter known as black vomit or of 

 red blood. The slightest evidence of either at once greatly aggravates the 

 prognosis, as may be judged by the fact that few cases of yellow fever die 

 without having presented that symptom, if vomiting or purging have 

 existed during the advanced stage, or without showing at the autopsy that 

 the black matter or blood had been retained owing to the paresis of the 

 stomach and bowels. Neither the height of the initial fever nor the inten- 

 sity of the other symptoms can be considered as safe guides in estimating 

 the possibility of the ominous symptom declaring itself. The fever may be 

 unusually high without black vomit necessarily following, or it may be 

 lower than usual in cases which later on will take the melania type. The 

 pains also may be so slight that the patient declares that he has 

 felt scarcely any, in cases where black vomit makes an early appearance. 

 Great irritability of the stomach, if continued from the first to the second 

 stage, absence of any noticeable remission, high temperature continuing 

 after the second or third day, severe apigastralgia, frequent retching, even 

 when nothing is brought up, a distended or pastry condition of the bowels, 

 irregular breathing, great despondency, an anxious countenance, a dry 

 skin or cold clammy perspiration, are all significant signs that the case is 

 likely to be one of the melanic type. But such indications may fail, and 

 the black vomit declare itself quite unexpectedly, perhaps after some 

 imprudent exertion or mental excitement. It is said, upon good authority, 

 that black vomit has sometimes been observed without albumen having 

 been previously found in the urine. Such an occurrence, however, must 

 be extremely rare. I have met with cases in which the quantity of albumen 

 was but small at the time when black vomit began to appear, but the al- 

 buminuria subsequently became more intense, or else could no longer be 

 detected owing to suppresion of urine. As a rule, therefore, the occurrence 

 of haemorrhagic symptoms from the stomach or bowels need not be feared 

 so long as the urine continues to be secreted and shows no signs of albumen. 

 It is generally after the third or fourth day, or at latest on the eighth or 

 ninth, that blood or black vomit makes its first appearance; but in the 

 worst cases it may be seen as early as the second day, some say even on. 



