us refute this opinion, as the symptom and the læsion were not found co-existent in the greater proportion of the cases. Others, on the contrary, have attributed it to the high state of excitement in the cutaneous capillaries, conjoined with a diseased state of the blood, producing an exudation of yellow serum into the cutis, the subcutaneous cellular tissue, &c., or to the blood circulating through the white capillaries, becoming yellow from disease. This reasoning is hypothetical. If we look to the dissections, we shall find that in many of those cases the blood presented, as far as could be seen, no trace whatever of disease; in others it was inflammatory. Nevertheless, I confess that I am inclined to hold this last opinion, hypothetical though it be; it agrees with the other symptoms and phænomena, and it is probable that the day will soon arrive when the blood in all these cases will be proved to have undergone a particular modification, which our present ignorance on this subject prevents us from detecting. It is difficult to conceive that in two cases apparently similar, and arising from the same cause, one should exhibit a change in the constitution of the blood, and the other not. Is it not more rational to suppose that in both this change exists, but in different degrees; and that we detect it in the one only because it is evident to our senses? Real jaundice occasionally accompanies fever arising from gastro-hepatic irritation; it is distinguished easily from yellow suffusion by the mildness of the general symptoms, and by the existence of the bile in the other secretions; by the whiteness of the stools, or by a bilious diarrhoea; by the colour of the urine, &c.

Black Vomit.

This symptom made its appearance in seven cases during the course of the disease, and in one it was observed mixed with blood in the stomach after death. In five of these seven cases the blood had undergone a change, and was found fluid. I have related a case at the commencement of this work, in which black vomit was observed in a woman, (produced apparently from putrefaction of the retained placenta and gan

grene of the uterus,) in whom no inflammation of the stomach or intestinal canal, at least none which was sufficiently great to account for this symptom, was found. When it has occurred in the diseases which form the subject of this treatise, gastritis has invariably existed in an acute form. It makes its appearance most frequently at the time that the general excitement ceases, often suddenly. The patient makes a slight effort to vomit, and throws up a large quantity of chocolate-looking matter. When it has once commenced it continues, with longer or shorter intervals, to the close. If we examine the patient we are struck with the quantity of this matter which is thrown off the stomach, and the apparent ease and force with which it is ejected; he rarely lifts his head off the pillow; but turning it slightly to one side by a sudden effort, but without straining, casts a stream of it from him, generally to a considerable distance. The stomach fills again rapidly, and the same phænomena are reproduced. From the moment that black vomit makes its appearance the patient begins to sink, the extremities become cold, whilst the heat on the trunk is hot and pungent, the pulse becomes feeble, and death soon puts a stop to the sufferings. This is what usually occurs; but in one case the patient had strength enough to get out of bed without assistance until the last moment. It is a fatal symptom, and a patient, under these circumstances, may fairly be considered beyond the powers of science. Some of these cases are reported to have recovered, and the recoveries have been attributed to the treatment employed; but the honest man ceases to entertain hopes, and should, contrary to his expectation, the lucky sufferer escape from his perilous situation, he will attribute it to the extraordinary powers of resistance with which nature has endowed certain constitutions. When this black matter is voided per anum instead of by the mouth, we may be pretty sure that it has arisen from the intestinal canal itself, and not from the stomach, and the patient presents a much better chance of recovery.

Black vomit, it is now well known, is blood which has undergone a peculiar change in the arrangement of its par

ticles; this has been supposed to take place in the stomach after its effusion from the circulation, from the action of the gastric juice. Such is not, however, the fact; the stomach in these cases is not in a state to digest anything; and in hemetemesis when this organ is comparatively healthy, black vomit is never observed. Neither is the time that the blood remains in the stomach sufficiently long to allow of its becoming changed by its digestive powers, enfeebled as they are. We can sometimes distinguish this organ becoming more and more distended under our fingers, as the matter accumulates, which it does in about ten minutes, and sometimes in a shorter period; and when filled the vomiting is renewed. It appears to me that the change in the blood is effected in the minute vessels of the mucous membrane, by a peculiar orgasm, with which we are unacquainted, but which appears to resemble that by which the albumen is changed into pus in the progress of phlegmon. Be the cause what it may, we find that the matter of black vomit exists not only in the cavity of the stomach, but we detect it in the vessels of its mucous membrane also, and can succeed in detaching it from them by means of a needle. I have already alluded to the spotted appearance of this tissue in some of the cases in which black vomit existed. It has been supposed that these spots were the terminating extremities of the exhalent vessels, and no doubt this opinion is correct, but I am not quite sure that the ducts of the mucous follicules do not enter into their production to a certain extent; in other words, that the matter vomited is not partially effused from the follicular ducts as well as from the excretory branches of the capillaries. That black vomit, as well as yellow suffusion, may be connected with a morbid condition of the blood, I think is probable, but not yet proved.

When this black matter is submitted to the test of litmus, or turmeric paper, we occasionally find it acid, now and then alkaline, and often neutral. When any change is detected in the colour of the test, I believe it is always attributable to the other contents of the stomach, and not to the black vomit itself. It would, however, be very difficult to ascertain this point

correctly. There is now and then a strong and peculiar odour diffused through the apartment in which this matter is kept, which attaches itself to the furniture, and even to the clothing of those who are exposed to it.

I have heard of cases in which the matter ejected from the stomach was perfectly black, dying indelibly the linen with which it came into contact. My own experience has never shown me anything of the kind.

Stiffness of the Articulations.

In some cases the extremities for a short period preceding death were observed to be half bent; and the articulations were rigid; so that on attempting to straighten the limb, we met with a certain degree of resistance, and this was effected with a jerk. This symptom was always coupled with others, and the case invariably terminated unfavourably; it appears to me to indicate either intense inflammation of the stomach and bowels or softening of their mucous membrane.

Critical Days.

Though crises or critical evacuations are as rarely witnessed in these diseases as in any other, it is quite the reverse with respect to critical periods. Every one who has any experience in these cases must be struck with the peculiar influence which certain days seem to possess over them. Most writers upon this subject allude to them in language more or less strong, and attach to them a great deal of importance. Dr. Jackson* has correctly observed that almost all these diseases, no matter of what type, assume a tendency to a tertiary period. In St. Lucia the attendants on the sick are greatly astonished when the disease does not present its bon and its mauvais jour. The friends of the patient draw their opinion of the result by attending to the symptoms on a certain day, and their prognosis occurs with a correctness which would astonish those who had not witnessed it. A similar observation is made by Op. Cit. p. 243.

*

M. Rochoux,* amongst the inhabitants of Guadaloupe. This periodical tendency must always be borne in mind by the medical practitioner, as it not only demonstrates the intimate connexion which exists between fevers of an intermittent and continued type, and the facility with which they may change one into the other, but it is also of the utmost importance in the treatment. For instance, malignant intermittents, if left to themselves, generally terminate fatally at the close of the third paroxysm; whilst those of a continued type, when they terminate in death, it is observed to be in the greater number of cases on the fifth and seventh days; and it is on the fourth and sixth that a favourable change is generally observed; indeed, during the second, fourth, and sixth days, the symptoms are milder than during the third, fifth, and the seventh, in the greater number of instances where the course of the disease has not been materially interfered with. By attending to this, complete intermission is often induced on the second day in a case which would otherwise have been continued, and even so late as on the fourth, a change so favourable may be induced, as to lead us to expect the gradual conversion of the disease into an intermittent or remittent.

CHAPTER VIII.

SEAT AND NATURE OF THE ENDEMIC FEVERS OF ST. LUCIA.

BEFORE we can enter fully upon this subject, we must first be of accord in our opinion as to the identity or non-identity of these diseases.

Identity of cause will produce identity of effects, but these effects will always be modified by the temperament and idiosyncrasy of the individual.

If this be granted, the effects of malaria will be in every

Recherches sur la fièvre jaune,