cases, yellowishness of the skin, or vomitings of matters like coffee-grounds, or both, occasionally supervene. * * * If the disease be not actively treated at the commencement, an unfavourable termination takes place between the 3rd and 7th day; but it is often prolonged beyond this period, and it then generally occasions visceral disease."

Nearly the same characters are assigned to bad cases of the "bilio-inflammatory form" of the disease: "the countenance and skin become dusky or yellow;" and, "after vomiting has continued some time, the appearance of the matters is changed, and ultimately assumes, in fatal cases, the cha racters just described;" i. e. like coffee-grounds.

We need scarcely say that it must be extremely difficult to distinguish such cases of aggravated Remittent (or semi-remittent) from the genuine Yellow fever, more especially as it (the former) also, like the bad form of the Ardent or seasoning fever, chiefly affects new comers into tropical countries, and occasionally prevails there epidemically in unhealthy seasons, as stated by Dr. Copland.

But there is yet another form of endemic tropical fever described by him as the adynamic or malignant remittent, which brings us a step nearer still to the very worst cases of the genuine Hæmagastric pestilence. We shall now give his description of the former and the remaining portion of the description of the latter (the earlier portion having already been given in page 190), that the reader may judge of the close resemblance between these essentially distinct diseases," and also between them and the malignant form of ardent fever, already described.

Yellow Fever.-"In plethoric persons and in the sanguine temperament, the attack is often most violent; and in addition to the symptoms just mentioned, the countenance appears bloated and heavy, with an unnatural expression, or wild and agitated. The heat of the surface, which was at first great and pungent, falls first in the extremities, and afterwards over the whole body, especially after the occurrence of black vomiting; and ultimately it sinks below the natural standard. The skin becomes compacted, losing its vascularity, and is insensible to the irritation of blisters. It is rarely dotted with petechiæ, but much oftener streaked with yellowish lines, particularly in the course of large blood-vessels, or is covered by patches of a blueish or leaden colour, especially in flaccid parts. The sense of internal distress increases as the febrile action subsides. Distension of the hypochondria, and explosions of flatus from the stomach, are frequent, with occasional obscure hiccuppings. Sometimes the vomitings are hardly complained of until the more febrile symptoms begin to

Malignant Remittent. "In some cases the vascular excitement is at first more or less intense, with remarkable determination to the head, liver, and stomach, and maniacal delirium, the disease very nearly approaching the inflammatory, or bilio-inflammatory forms, In others, vascular reaction is very low and imperfect; the pulse small and quick; the abdomen tumid and hot, whilst the extremities are cold or clam my; the evacuations foul, morbid, and offensive; the tongue fuliginous; the gums spongy, or oozing a bloody sanies; the vomiting constant, and ultimately grumous and dark; the stools, towards the close, black or pitchy; the urine scanty or nearly suppressed; the solids flaccid; and the skin earthy and discoloured. In both these states, a yellowness of the surface occasionally presents itself about the third or fourth day, beginning in the conjunctiva, neck, and breast. The yellowness often passes to a pale greenish hue, in patches, shortly before death; and the soft solids present a liquescent state, having lost their vital cohesion.

1847]

Description of Malignant Remittent.

abate, when they become unrestrainable: the matters ejected are then muddy or turbid, like unstrained coffee; occasionally they are of inky blackness, like the juice of the cuttle-fish. The evacuations by stool sometimes also present a black appearance at this stage. In the more severe states, the disease frequently terminates fatally within the fifth day. In the less severe cases, signs of an imperfect crisis sometimes appear about the seventh day; and improve to favourable indications; but occasionally they are arrested in their course, and superseded by an unfavourable train of symptoms, as hæmorrhages from the throat, gums, mouth, and sometimes from other outlets of mucous canals. The blood is dissolved, dark, incoagulable or grumous, particularly at a far advanced period of the disease.

"The fourth form of the pestilence seems a modification of the symptoms by temperament and habit of body, although the precise conditions of these cannot always be assigned, the phlegmatic, apparently, most frequently exhibiting it. In this the symptoms are not so violent as in the third form, but they are equally fatal. It often commences insidiously, the patient complaining, for hours, or even longer, of nothing but languor or fatigue, which is followed by chilliness or rigor, with pains in the loins and calves of the legs. The headache is not very severe. The pulse is quick and small. The heat of skin is very little increased; but there are great anxiety and oppression at the precordia, and an indifference to surrounding objects. The bowels are obstinately confined, and the secretion of urine is arrested. The tongue is often unnaturally clean, and of a clear shining vermilion colour. Hæmorrhage appears early from the nose, gums, or mouth, and is sometimes attended by petechiæ and vibices. There is little or no thirst, but great irritability of stomach, with hiccough and black vomiting, attended sometimes, as the distemper proceeds, especially towards the fatal close, by an involuntary discharge of the same apappearance from the bowels. The peculiar change of countenance, with yellow skin, takes place as in the other

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"In other cases of this form, the symptoms are at first mild, and the excitement inconsiderable; when, after two, three, or four exacerbations, the powers of life appear suddenly exhausted; the pulse becomes weak and fluttering; the tongue foul, black, and dry; the evacuations offensive; the prostration of strength extreme; and the fætor of the perspiration remarkable. At last, great anxiety; tenderness and tension of the epigastrium; fulness of the hypochondria; collapsed features; a squalid or yellowish surface; vomiting of dark or grumous matters, supervene, and indicate the utmost danger. This insidious modification of the adynamic form generally occurs in persons highly predisposed, or who have suffered from bowel complaints, or who are debilitated and are subjected to the more concentrated effluvia.

"In some instances the remittent commences in so mild a form, that the patient is even able to walk about his apartment; and, for several days, complains only of irregular exacerbations of fever, when, suddenly, violent and malignant febrile action supervenes, which rapidly exhausts vital power, and either. quickly carries off the patient, or induces serious structural change in several of the abdominal organs. In other cases, vascular excitement is hardly manifest at any period of the disease, the exacerbations consisting merely of increased anxiety, restlessness, general distress, and mental depression, occasionally with augmented sickness; and pain in the head, epigastrium, and loins; the pulse being but little accelerated until the close, and the temperature, unless at the epigastrium, rather under than above natural. In these, however, the weak, soft and open or irregular pulse; the dark-coated, or soft, flabby, and lobulated tongue; and the blackish, greenish-brown, and morbid excretions, in connexion with the other symptoms, denote extreme danger. It would seem as if the causes had nearly annihilated the irritability of the moving fibre, and deprived the system of its ability of reacting upon or superseding, the morbid condition induced by their first impression."

O *

states, and is frequently accompanied with a low muttering delirium."

*

"In the most violent seizures, the patient is suddenly struck, and the distemper proceeds rapidly without re-action, or nervous or vascular excitement, to vital and structural dissolution, with every indication of extreme vital depression, of vascular contamination, and of impaired or nearly lost irritability and cohesion of the tissues." *

"When the infectious agent is very powerful relatively to the constitutional powers of the patient, the attack may then be so violent, and its subsequent course so malignant, as to deprive the vital energy of all power of reaction. In this case, the invasion is sudden and severe, and is attended with general tremor, dread, terror, or despondency; the vital depression of this period passing into vital and even structural dissolution, with greater or less rapidity, and either with no attempts at reaction, or with weak and abortive efforts merely.” In the majority of cases, however, the stage of vital prostration is preceded by one of high and violent febrile excitement. Vol. III., p. 140 & 142.

To this minute description we shall merely add, that this malignant form of intertropical remittent is variously modified, in different circumstances and persons. It sometimes assumes more of a cerebral or typhoid character; at others, it is bilious or gastric, according to peculiarity of season or concentration of the cause. In some intertropical countries it becomes epidemic, or rather this endemic is more than usually prevalent. Occasionally the remissions are indistinct from the commencement, and they generally become so after three or four days." Vol. I., p. 948.

As affording a graphic illustration of a malignant remittent in a tropical region, we shall here insert the account of an epidemic fever at Batavia, as given by Mr. Shields, and inserted in Dr. Johnson's work on Tropical Climates. We are the more desirous of drawing the reader's attention to this narrative, from the circumstance of certain writers having inaccurately stated that the fevers of the East never exhibit the peculiar features-we allude to the discolouration of the skin and the black vomit-of those of the West Indies and of the African coast, and too dogmatically asserted that the true yellow fever is wholly unknown in the eastern hemisphere.*

Edam, where the dreadful pestilence was experienced, is a small island, a few miles distant from Java: it is over-run with jungle, and is full of marshes. The time of the year was August, when the sun was nearly vertical. After some introductory remarks, Mr. Shields observes :

"The patient, without much previous notice, was suddenly seized with giddiness and cold chills, sense of debility and vomiting, and with pain over the orbits and in the epigastric region. He frequently fell down, and was insensible during the paroxysm; his body covered with cold clammy sweats, except at the pit of the stomach, which always felt hot to the palm of the hand: the pulse was small and quick. On recovering a little, the train of symptoms was succeeded by flushings of heat, increased pain over the orbits and in the sinciput, pain and a

It is rather singular that one of the earliest appellations of the yellow fever was Maladie de Siam.

1847]

Malignant Remittent in Batavia.

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sense of internal heat about the stomach and præcordia, oppressed breathing; the lower extremities at this time not unfrequently covered with cold sweats. The eyes now become as it were protruded, and the countenance flushed. Retching, and at length vomiting of discoloured bilious matter came on; the tongue was white and furred, and the abdomen tense and full, with pain in the loins and lower extremities. The length of this paroxysm varied from 6 to 18 hours, and was generally succeeded by cold rigors; very often low delirium, preparatory to the next stage or paroxysm of the fever. The intellectual faculties now became much impaired, the patient not being at all sensible of his situation or of any particular ailment. If asked how he was, he generally answered 'very well,' and seemed surprised at the question. This was a very dangerous symptom, few recovering in whom it appeared. In this stage all the symptoms became gradually often rapidly aggravated; particularly the headache, pain and tension in the epigastric region and vomiting. Some patients on shore were carried off in 18, 24, 30 or 40 hours, and others not till as many days after the attack, especially when they were removed on board from the noxious air of the island. A great proportion changed in a few days to a bright yellow; some to a leaden colour. Other cases terminated fatally, in a very rapid manner too, without the slightest alteration in that respect. Generally, however, the change of colour indicated great danger. Vomiting of black bilious stuff, resembling the grounds of coffee, frequently commenced early, and continued a most distressing symptom.

典

Hæmorrhage from the mouth and nose seldom occurred; in two cases, which terminated fatally, the blood did not coagulate, but tinged the linen yellow. * Two kinds of eruption appeared about the lips; one such as we often see at a decline of common fevers; the other consisted of small black or brown spots round the lips, and was likewise a dangerous, indeed a fatal, symptom. With this eruption, the teeth, tongue, and fauces generally became covered with a brown or black coat, and the breath intolerably fætid.

In those cases which occurred on board, and where the patient had not slept on shore at Edam, the symptoms were much milder, and the fever resembled more the bilious remittent of other parts of the East."

"Never," continues Mr. Shields, “ was there a disease so deceitful as this fever. I have frequently seen instances where every symptom was so favourable, that I could have almost pronounced my patient out of danger; when, all at once, he would be seized with restlessness, black vomit, delirium, and convulsions, which, in a few hours, would hurry him out of existence !

No

constitution was exempted from the assault of this fever. It seized with equal, or nearly equal, violence on those who had been many years in India and on the most robust and plethoric, or newly-arrived European. Even the Dutch officers and Malays, who had been drawn from different parts of Java, and whom we had prisoners at Edam, fell victims as fast, or nearly so, as the English."

The mortality was frightful. Almost every individual, who slept on shore at Edam, perished. The disease was certainly not infectious or transmissible from one person to another; "for," says Mr. S., on our raising the blockade of Batavia, great numbers of sick, in every stage of the fever, were brought on board from the hospital at Edam, yet not a single

Mr. Shields mentions one case, where the patient felt himself on the 2nd or 3rd day so much relieved that he called for some mutton broth and sago, which he eat with a good appetite; he spoke naturally, and was in good spirits. Towards evening, a change took place, and he was a corpse before morning! Such an occurrence is frequent in the yellow fever of the West Indies. A feeling of hunger in the delusive lull, that so often occurs about the 3rd day or so, is well known to be a frequent forerunner of a mortal change.

nurse or medical attendant of any description ever suffered the slightest attack; nor did any circumstance transpire that could in the least favour the idea of contagion (infection), notwithstanding that the great accumulation of sick on both decks rendered it a matter of impossibility to separate them completely from those who were well, nor at all times to prevent a considerable generation of effluvia."

So much for the phenomena exhibited during the life of the patient in a malignant form of the remittent fever of an intertropical country. Let us now compare the post-mortem appearances, as detailed by Dr. Copland, in the two diseases between which there is so close a resemblance.

It may not be unprofitable to introduce here, for the purpose of comparison with the details now given, the most remarkable post-mortem appearances described by our author as being usually found in the bodies of those who die from a rapidly fatal attack of Ardent or Seasoning Fever.

"The digestive mucous surface is studded with numerous dark or ecchymosed spots, from which a fluid black blood seems to ooze. The liver is frequently con gested, sometimes larger and softer than natural, and of a dark colour, owing to the quantity of black blood in its vessels. The spleen is somewhat enlarged, soft, and friable; and the omentum injected. The serous as well as the mucous surfaces, especially in the abdominal cavity, often present livid or dark patches. The blood is everywhere fluid, black, and dissolved. The internal surface of the heart and large vessels, both arteries and veins, was of a dark red or livid tint in