1. Fellow Remittent Fever. This naturally occupies the first rank. The etiology, symptomatology, pathology, and treatment, are ably pourtrayed by our most intelligent author, and will form an admirable manual to our younger brethren on first entering the Western Tropics. It is hardly necessary to say, that the grand agent in the production of this fever, in all parts of the world, is that invisible, inexplicable something, designated "vegeto-animal, or marsh effluvium," which issues from the soil of tropical climates, and even temperate climates, at certain seasons when atmospheric temperature rises towards the tropical range.

As to the symptomatology of these fevers, it is unfortunately too well known to the British profession to need any recapitulation here. The pathology has appeared to our author very uniform, from the inspection of a great number of bodies.

"The principal organ affected was the liver and it is not a little singular, that in those cases of the worst kind of this fever, which terminated fatally, this viscus was found either in a loose, dissolved putrid state; or sphacelated, and having the consistence, the feel, and colour of rotten cork! or full of abscesses:-in such cases, too, the biliary ducts were rendered impervious by stricture; little bile in the gall-bladder, and that always black, ropy, and granulated. In many cases, several portions of the intestinal canal were inflamed, particularly the duodenum; and here and there evident marks of gangrene were observed. The spleen was greatly enlarged. The mesenteric glands were, generally, enlarged, in a state of scirrhus, or full of pus. The stomach, in general, had its coats thickened, the villous coat abraded, and the blood vessels much distended. No bile was found in it ;—but black mucus, or the fluid discharged resembling coffee grounds. Every part of the body appeared tinged with a deep yellow colour.-It was remarkable that the blood, in the large vessels, was in very small quantity, and had more the appearance of serum or water, tinged with a yellowish red colour, than of blood." 44.

In many of these fevers, whether endemic or epidemic, other authors have found the brain bearing the marks of the vascular excitement which occurred in the course of the fever.

Treatment. The first object, Dr. Chisholm justly observes, is to freely evacuate the primæ viæ, and deplete the vascular system. If the patient be seen early, "a copious bleeding and plentiful evacuation by stool, very often put a stop at once to the disease." "If, however, the disease persists, the bleeding must be repeated, and alvine evacuations again plentifully procured."

"When, at this period, irritability of the stomach seems likely to prevent the retention of the purgative medicine, it should be always preceded by about a grain of opium, or a draught containing 20 or 30 drops of laudanum. If the disease still appears disinclined to yield, the mercurial plan must be adopted without delay, but further bleeding is generally unnecessary or hurtful-five grains of calomel, with or without opium, according to the state of the stomach and bowels, are then to be given in a little treacle or syrup, and repeated every two, three, or four hours, according to the urgency of the symptoms, and the degree of danger apprehended.-Thirty or forty grains have, generally, brought on ptyalism.—When this happens, all the alarming symptoms disappear. In three or four days after, the patient becomes convalescent-but the disease has too often proved obstinate under this milder treatment.-When, therefore, the symptoms of a more formidable fever appear, and the dauger is evidently imminent, the dose of calomel should be increased even to 20 or 30 grains every third or fourth hour; and, if the vomiting increases, various means should be employed to allay the irritation of the stomach. These means are opium, ether, effervescing draughts, blisters to the inside of the thighs, and the very frequent use of common laxative clysters, or of those consisting of a watery solution of assafoetida.-But mercury, assisted by cold affusion, must be mainly trusted to; and its exhibition, under the untoward circumstance of an irritable stomach, must be varied in every possible way-by injection, by friction, without measuring or attending to the division, of the strongest ointment, into portions, but rubbing it on every part of the body, ad libitum, until the effect, on which alone safety depends, is produced. I can confidently assure the young practitioner, that not a single patient in my practice, died, even under the worst form of the disease, if mercury could be introduced in sufficient quantity to produce ptyalism. But the practitioner must not be afraid to use this medicine with the utmost freedom in such cases;-he must have confidence in it, and persevere until the object is obtained. Abundant fœculent discharges are necessary, whilst mercury is producing its specific effect; and this may be done by mercury (calomel) alone; or, if there is constipation, by the addition of jalap, or the extract of colocynth: but an opposite state of the bowels, is, by far, more frequent, and rather requires the restraining power of opium.-I may sum up the treatment, I have uniformly adopted since the year 1791, in Yellow Remittent Fever, thus: it is my first intention to relieve the system in general, by plentiful and reiterated bleeding and purging; but having effected this, during the first 24 or 30 hours of the disease, long experience has convinced me, that it is upon a new action being excited that the safety of the patient depends. Although many instances have occurred, of a copious and protracted diaphoresis, or an abundant and sudden flow of urine, having removed every complaint, yet I was chiefly, perhaps always, directed in forming a favourable prognosis, by the supervention of mercurial action on the gums and salivary glands.-Many instances have occurred to me,

which have taught me not to despair whilst the most distant hopes remained of accomplishing that: and, therefore, where this action has been tardy, and where there are, at the same time, symptoms of the most imminent danger, I have endeavoured to introduce the medicine in every possible way, and assisting the means I employed by cold bathing, and, if necessary, by the use of spiced wine and nourishing food made as acceptable to the stomach as possible." 46.

Our own observations confirm the truth of the above therapeutics, which we recommend to the serious attention of the young tropical practitioner.

The second chapter of this division of the work is on intermittents, and contains many excellent remarks and judicious instructions. When the fever intermitted regularly, whatever was the type, our author exhibited the cinchona or arsenical solution (the latter is the more powerful of the two) after proper evacuations. When the paroxysms did not cede to this, a pill composed of colocynth extract and pil. hyd. was ordered every night at bed time-a precaution very necessary, Dr. C. observes, when the bark is given.

"But when the succession of paroxysms is very frequent, the intermissions very imperfect, and 'no indisposition appears in the fever to become otherwise, local congestion and inflammation should be considered as the real disease, and the irregular fever as purely symptomatic. In this case, no time should be lost in giving mercury, with such freedom, and so guarded with opium, if necessary, as to excite ptyalism, as soon as possible. This medicine, thus given, has never failed to stop the progress of the disease. It has, unfortunately, happened, sometimes, that the disease has been so insidious, that the second pasoxysm, after an imperfect intermission, has completely overwhelmed the patient, and put an end to his existence.I have therefore made it a rule of practice, in these irregular fevers with aggravated symptoms, to ascertain with anxious minuteness, whether pain and fulness exist in the hepatic region-and if they do, to begin the treatment with copious bleeding and purging; and then to proceed to the use of mercury, in the same confident manner as in the yellow remittent fever.-The disease, in truth, arises from the same cause, is then marked with the same symptoms, produces the same morbid changes, is possessed of the same danger, and consequently must be treated in the same manner."

51.

In our author's experience, there were few or no relapses when the cure was effected by mercurial ptyalism after proper evacuations;-owing, he conceives, to the removal of local disease, of which the more violent kinds of intermittents, as well as remittents, are symptomatic. Removal, however, from the sphere of the miasmal exhalation is necessary to prevent relapses in all cases. The usual sequelæ of fever, as visceral obstructions, bowel complaints, &c. do not occur

when the fever has been checked by a mercurial action in the system. Dr. Chisholm has seen the most unequivocal proofs of sol-lunar influence on intermittents within the Tropics.

Chap. III. Dysentery. Dr. Chisholm observes that there are two species of dysentery between the tropics-one proceeding from suppressed perspiration, irregularities in diet, clothing, &c. exposure to currents of air when the body has been heated. The other species, and by far the more dangerous, occurs in the hot and rainy season, and has for its cause, Dr. Chisholm thinks, the miasmata of marshes. The first is sporadic-" and the proximate or immediate cause seems evidently to be irritation of the larger intestines from an overcharge of their vessels, and consequent inflammation of their coats." The second is always a symptomatic disease, having its seat in the liver and small intestines." Although we believe the function of the liver to be implicated in all cases of dysentery, we cannot bring ourselves to go the length of Dr. Chisholm's position that this organ is the exclusive seat of the disease in those epidemic dysenteries which spread devastation through marshy countries.

Dr. Chisholm's description of the idiopathic dysentery (as distinguished from the hepatic or miasmal) does not differ from that of other writers; and the same may be said of the post-mortem appearances. The following extract will exhibit one mode of treating the mild species, where circumstances render the mercurial treatment inadmissible.

"Although the early symptoms of dysentery are generally deceitful, and although, therefore, it is the part of prudence to employ a remedy of well ascertained efficacy in the treatment; yet I shall here detail the means that may be resorted to in cases evidently of a mild nature, or in which the proximate cause may be supposed or deemed, superficial inflammation of the lining membrane of the intestinal canal, when mercurial ptyalism is inadmissible, from constitutional latent disease, or from the prejudice or fears of the patient. No disease manifests the sympathy between the skin and the intestinal canal, more than dysentery. The great object, therefore, should be to restore the skin to a soft permeable state; for in this disease it is generally, indeed I may say, always, dry and corrugated. When a gentle, .warm diaphoresis is excited, the patient always experiences relief; the motions become less mucous, and more fœculent. When this method of cure is resolved upon, it may be conducted in the following manner.-After the full operation of an emetic, and a purgative, five grains of James's powder may be given every four or five hours, till a copious, warm diaphoresis is thrown out, which ought to be kept up by plentiful dilution with warm rice or barley water, for several hours, or until the griping and tenes

mus cease, and the motions assume a better, that is, a less mucous and a more fœculent appearance.-This state being produced, the bark may be given in pretty large doses, mixed with port wine or with water; and a pill, such as the following, thrice in the day, or only once at bed time, according to the circumstances of the case: B. opii gr. ss. ad. gr. 1 pulv. Jacob. gr. iij. balsam Peruv. q. s. f. pilula. When the sweat is slow in breaking out, it may be promoted by hot fomentations;-or what is better, by wrapping the belly and lower extremities in a blanket, wrung out of boiling water, or a hot decoction of aromatic herbs.-The efficacy of the last application in relieving the symptoms, and bringing on a diaphoresis, I have often witnessed in a very remarkable degree. An excellent mode of exciting diaphoresis, without the disagreeable inconvenience of having the body enveloped in wet, is by means of the vapour bath, which may be very conveniently and agreeably employed in the manner described in the chapter on rheumatism." 57.

Another mode of treatment in recent cases, is an emetic of ipecacuanha or sulphate of zinc, given in the evening, after which, from four to ten grains of the Dover's powder may be administered at bed-time, with from two, to six or seven grains of calomel mixed together in a spoonful of treacle. Our author recommends small doses of sulphate of magnesia the next day, if some stools are not procured by the calomel -after which, the Dover's powder and calomel are to be again repeated in the evening. For many other therapeutical measures we refer to the volume itself.

Hepatic Dysentery. A fixed pain at the pit of the stomach and constant head-ache, at the very commencement of the disease, are the only symptoms which serve to distinguish hepatic from idiopathic dysentery, according to Dr. Chisholm.

"In other respects, it does not seem to differ from the idiopathic or common dysentery; so that it can almost never be known but by the experienced, until those symptoms appear, which, whilst they manifest the peculiar nature of the disease, also, unhappily, point out its approaching fatal termination. It is, therefore, I repeat it, of the highest importance, when the two symptoms I have mentioned appear at the commencement of dysentery, to ascertain the local peculiarities of the patient's place of residence—that is, whether the patient has resided, and contracted the disease in the immediate vicinity of marshes, and what are the diseases which have most frequently occured in the situation—whether there is any epidemic at the time. If the situation is marshy, and the epidemics have been, or are, remittent and intermittent fevers, and hepatic complaints;-then, the pain at the pit of the stomach and headache, accompanied by a disposition to frequent alvine dejection, should be considered as indicating hepatic dysentery. Every chance of success depends on the Vol III. No. 9.

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