when the stomach is empty, more benefit is derived from two tablespoonsful of arrow-root every half hour, than from any medicine I have known. Sulphuric æther, and even ardent spirits, to restrain vomiting, as the heat and vascular motion subside, have been taken with partial relief

This state may continue for two days, or even longer, before there is any relief. The first favourable symptom is usually a refreshing sleep, and the absence of delirium. A warm and moderate perspiration covers the surface; and if the skin and eyes have been yellow, the colour becomes more bright.

Convalescence from this stage of fever is much more slow than from the first. Much attention to the state of the bowels, and the liberal use of the decoction of bark, with vitriolic acid, if there be. much oozing of blood from the gums and fauces, are necessary. From that stage in which the black vomit is the prominent symptom, fewvery few recover.-Dark-coloured fluids, however, have been often taken for black vomit, where the latter did not exist, and thus nurses, and even medical men, have been deceived. All the cases that recovered at this hospital were certainly unexpected. This dreadful symptom had continued in all of them about twelve hours; oozings of blood from various parts, stools as black as ink, &c. were present. The first sign of amendment was the stomach becoming retentive, and the enjoyment of a few hours sleep. The yellow colour of the eyes and skin became daily brighter, till at last the patient had the most perfect jaundiced look: the colour of the stools keeping pace with that of the eyes and skin. The stimulating plan of treatment, after full and copious evacuations in the earliest stage of the disease, was gradually begun with these patients long before the vascular action had been reduced to its natural standard. Wine frequently, and in small quantities-the carbonate of ammonia-capsicum, with arrow-root, were assiduously administered; and whenever the appetite of the patient craved for brisk porter, spruce beer, &c. they were never denied; but these and other drinks were given in small quantities at a time, as larger caused instant vomiting.

Relapses from this fever frequently terminate fatally-Want of appetite, and sensation of fulness at the stomach, usually precede the common train of symptoms. In these cases, I found an emetic give instantaneous relief. The patient generally vomits a large quantity of æruginous-colou: ed matter, and the evacuation is attended by immediate ease: two or three drachms of the tartarised antimonial wine, (Edin. Phar.) are generally sufficient for the purpose. In the usual practice of the hospital, emetics are omitted: they delay the exhibition of brisk purgatives, which are required to move the bowels in this fever. But there is one form of the endemic commencing with diarrhoea, and sometimes dysenteric symptoms, in which emetics are employed with advantage. When the fever, however, commences in this way, it is less dangerous, though more protracted, than where costiveness and torpidity of the bowels attend.*

"The most favourable cases of the yellow fever, are those in which a bilious "diarrhoea comes ou; while the most fatal are those in which the bowels are so "torpid as to be insensible to any stimulus, either from their own contents or * from medicine."-Blane, 3d ed. p. 450.

It has been said, that persons who have once had the yellow fever are not again liable to be attacked. This is not the fact: I have more than once had a man under my care with yellow fever, who afterwards died of another attack of the same disease,

In this, as in other diseases, anomalous symptoms will occasionally occur, requiring slight modifications of treatment; but these can be only learnt at the bedside. On this account, forbear to enumerate laudanum, æther, ginger tea, effervescing draughts, champaigne, &c. which in high practice are sometimes prescribed.

On the Inflammatory Endemic of New Comers to the West Indies from temperate Chimates. By NODES DICKINSON, Esq. Member of the Royal College of Surgeons, &c.*

SEC. VI. Introduction.-This disease is the effect of sudden change of climate upon new comers of a sanguine temperament; and is commonly designated the Yellow Fever, from the occurrence of an incidental symptom.

In a few weeks the stranger is brought from a climate in which the atmospheric temperature, at the time of his departure is, perhaps, under 30° to 90° of Fahrenheit in the shade; and 130° when exposed to the direct action of the solar rays.

The inflammatory endemic being, exclusively, incidental to strangers from the temperate regions, will be found to occur with a prevalency proportioned to their numbers: sporadically when these are few, and, in appearance, epidemically when many are introduced at the same time.

When it happens in a mild degree it is appropriately called a "seasoning." The reduction of the system by the evacuations employed for its removal is very frequently preventive of a future seizure.

The probability of an attack of the inflammatory endemic very much depends upon the degree of inflammatory diathesis. The causes which produce a severe affection in young and plethoric strangers, seldom affect the older residents. Natives of the country and Africans escape its seizure. Women and children, the aged and weakly, are less liable than the robust and strong.

The inflammatory endemic, which, in its mildest form, has been regarded a "sporadic febricula" is under a severer aspect, when attended by a yellowness of the skin and black vomiting, often erroneously considered an infectious epidemic of malignant character.

It is a disease in which there is from the beginning a state of universally increased excitement, with a direct tendency to general inflammation, soon accompanied by the actual inflammation of certain organs. Very much of the mischief ensues from a want of moderat

The following valuable observations have been kindly drawn up by my able and esteemed friend, Mr. Dickinson of this Metropolis, whose ample experience, as a Staff Surgeon in the West Indies, enabled him to present to the public an important work on the inflammatory Endemic in question, of which the present paper may be considered a very concentrated Analysis. It will be observed that Mr. D. confines himself to that form of the fever which attacks new comers, and is produced by Insolation.

ing the first excitement. If this be subdued there is little to apprehend from consequent debility. The patient will recover, and with the advantage of a system prepared for the climate in future, in so far as the indammatory endemic is concerned.

Producing Causes and Prevention.-The causes of the inflammatory endemic are predisponent and exciting. The predisposition consists in an inflammatory diathesis-an aptitude to diseases of general increased excitement: this appears sufficiently manifest by a consideration of the subjects already stated as exclusively liable to its attacks. The exciting cause is an exposure to solar radiation while unaccustomed to its influence, and unprepared to resist the force of its impression by the adoption of preventive measures. The effect of heat is liable to augmentation if accompanied by violent exercise, by full living, and intoxication.

Whatever tends to diminish the predisposition forms the groundwork of prevention: it is founded in reason and proved by experience. The detail consists in bleeding, purging, cold bathing, abstinence from fermented liquors, and a spare diet of animal food. These should be employed, agreeable to the state of individual predisposition, until the inflammatory diathesis is reduced. If the immediate exciting cause be diminished in its power, by the new comer repairing at his arrival in the West Indies to an elevated situation, where the temperature is low, compared with the heat of the maritime towns, his safety will be greatly inured. To avoid, as much as possible, exposure to the direct and powerful radiation of the sun to use exercise, in moderation only, and to observe an undeviating rule of temperance and sobriety, are to obviate the action of the exciting causes and prevent the disease. Diurnal vicissitudes of temperature should be carefully guarded against by the unseasoned stranger. A dangerous state of excitement is liable to result from the increased susceptibility induced by the sudden application of cold to the surface, when this, although trifling in degree, is immediately succeeded by the stimulation of inordinate heat.

Symptoms and Treatment.-The history of the inflammatory endemic and its general character are such as the nature of its causes must obviously suggest.

It occurs with different degrees of severity in the ratio of the impression of its exciting causes and individual predisposition. Two cases are seldom precisely alike in this particular. It varies from a "seasoning" or mild synocha to the most formidable seizure.

A slight attack has seldom been recognised to bear strict affinity with the much dreaded "yellow fever." Considered merely a "seasoning," it has rarely been regarded of the same kind, produced by the same causes, and prevented, or removed by the same general means, which are applicable to the more violent disease.

The inflammatory endemic in its severe aspect, and when neglected at the attack, consists of two stages. In the first, there is increased excitement, resulting from an unusual stimulus applied in an excessive degree to a system peculiarly sensible to its impression: it produces a derangement in the functions of some or many viscera. If this goes on, the second stage appears, in which the structure of

these viscera is altered to a degree incompatible with the living state. Thus the disease proceeds from high excitement to irreparable exhaustion, as we shall perceive by attending to the history of its symptoms. In the less severe example there is chilliness at the onset, soon followed by a permanent and universal sense of heatflushed face-inflamed eyes-head-ache-increased susceptibility to the impressions of light and sound-vertigo-drowsiness-sighing -white tongue-arid fauces-thirst-wandering pains-loss of appetitecostiveness-high-coloured urine-dry skin-nausea-full and frequent pulse ;-should these symptoms in a severe degree remain without control, the disease is soon increased to its most aggra vated form. The patient is extremely restless, with a continual desire to alter his position, but without relief. The heat and head-ache are intense the carotids throb with unusual violence. There is sometimes a furious delirium-tinnitus aurium and even loss of sight. There is, occasionally, a dry cough with pain in the side, and almost invariably a sense of heat, oppression, and pain on pressure at the præcordia, accompanied by constant sighing. Vomiting sometimes comes on very early in the attack. There is often great drowsiness but no refreshing sleep. In some cases an acute pain is felt in the right side and a yellow colour of the skin often supervenes. This yellowness is occasioned by the presence of bile, which is also detected in the urine and serum discharged from blisters. Should the passage of the bile into the intestines spontaneously take place or be procured by the action of purgatives, this jaundiced appearance, will, generally, be prevented: nevertheless, in some cases it may possibly arise from a redundant secretion, even when the bilious canals are free and a bilious vomiting and purging may occur with the yellowness of the skin and carry off the attack. These symptoms proceed with various degrees of violence, and they occupy an uncertain period. Within 12-24-or 36 hours; or, perhaps, after a longer, but indefinite time, an important change takes place. It marks the commencement of the second stage. Many of the most urgent symptoms decline. The pain and heat of surface subside. There is a sense of cold with dampness of the skin. This change at first so much assumes the appearance of febrile remission as to give great hope to the inexperienced practitioner; but it speaks a state of the utmost danger. In some cases the patient sinks, at once, after the subsidence of excitement, apparently destroyed by the general affection, without any previously severe determination of blood to particular organs; and he dies at the moment of hope in his amendment. But more cominonly the catastrophe is not so sudden. With the diminution of heat and pain, the pulse falls the countenance exhibits great distress-the eye is sunk-the pupil dilated, sometimes delirium continues at others, there is great insensibility with tendency to Vomiting, occasionally, continues without intermission :--at times, however, the stomach remains tranquil : and this, when there is much cerebral disturbance.

:

coma.

As the disease advances a discolouration of the skin often takes place. It appears in yellow, brown, and livid patches. This dis colouration never comes on until the subsidence of the symptoms of

excitement, however early in point of time. It occurs with the passive hæmorrhagy from various parts: from the nose, corners of the eyes, ears, &c.; and at the same time with the black vomiting. This change of colour appears to arise from ecchymosis proceeding from exhaustion of the vis vitæ in the capillary vessels of the surface in consequence of previous inordinate excitement. It is very dissimilar from the bilious yellowness already noticed as an incidental symptom of the first stage of the disease.

The first discharges from the stomach are merely the ingesta; afterwards a large quantity of serous fluid is ejected when little has been drunk. In a more advanced stage of the complaint the material thrown up is ropy and mixed with numerous small shreds, flocculi, or membranaceous films which float in the ejected liquid. These soon acquire a dark brown, purple, or black colour, but do not, at first, communicate much general tint to the fluid in which they are suspended. Afterwards, the matters vomited are more intimately mixed together; and with the addition of dark-coloured blood which is effused into the stomach, vitiated bile, and other morbid secretions, give an appearance in the aggregate of coffee-grounds. There is at this period, usually, a purging of dark-coloured matter resembling tar mixed with black blood.

Sometimes within the first forty hours, at others after a more protracted period, the scene draws toward a close with the ordinary phenomena of approaching dissolution, which accompany the last stages of acute disease in general. There are dilated pupil-strabismus singultus-subsultus tendinum-coma- deliquium-hæmorrhage from various channels-suppression of urine-low muttering delirium total insensibility-occasionally violent raving, and an incessant disposition to rise in bed. These are among the last symptoms of an unsubdued attack, and they mark the near approach of death.

An examination post mortem exhibits unequivocal vestiges of previous inflammation. In the brain, increased vascularity and a deep redness of the membranes-rupture of the vessels-adhesion of the hemispheres and membranes--coagulable lymph-extravasated blood - serous effusion. In the stomach, a lymphatic film adheres to the surface of the villous coat in different parts; but is easily detached. During the last remains of life it is ejected with the fluid contents of this organ. Numerous dark-coloured spots are interspersed upon the villous coat which present the mouths of vessels from whence there oozes black blood. The same appearances are seen throughout the track of the intestines-the liver is occasionally much diseased it is livid and overspread with dark coloured patches--frequently of a deep purple colour throughout its structure-greatly enlarged, and filled with blood.

These are the usual symptoms of the inflammatory endemic, and of its destructive inroads, upon the healthy fabric of the body, sup posing it to pursue an uninterrupted course in an example of great severity. These symptoms are, nevertheless, very irregular both in their general appearance, their degrees of violence, their precise order of succession and duration. Thus we find that after a period of