CIECULAE No. 6. WAR DEPARTMENT, SURGEON GENERAL'S OFFICE, "Washington, November 1, 1865. EE P O E T S ON THE EXTENT AND NATURE OF THE MATERIALS AVAILABLE FOR THE PREPARATION OF A MEDICAL AND SURGICAL HISTORY OJ THE REBELLION. PRINTED FOB THE SURGEON GENERAL'S OFPIC BY J. B. LIPPINCOTT & CO. PHILADELPHIA. 1865. ERRATA. Pago 9, fifth paragraph, for 604 read 104. Page 41, fifth paragraph, for "fractured wounds" read "punctured wounds." Page 43, line fifteen, for "internal carotid" read "internal maxillary." c* Surgeon General's Office, Washington, D. C, November Ist, 1865. Tlie following Circular is published for tlie information of the IVtedical Officers of the Army. JOSEPH K. BARNES, Surgeon General. CIRCULAR NO. 6. Surgeon General's Office, Washington, D. C , October 20th, 1865. BREVET MAJOR GENERAL JOSEPH K. BARNES, Surgeon General U. S. Army. General :—: — In response to your inquiries relative to the nature, extent, and value of the surgical data that have accumulated in the department of your office under my charge, and in regard to the progress that has been made in arranging these materials, I have the honor to make the following report : The materials in the office relating to the surgery of the late war consist of the reports of the medical officers engaged in it, and of illustrations of these reports in the shape of pathological specimens, drawings, and models. The documentary data are of three kinds : first, the numerical returns, in which the number alone of the different forms of wounds, accidents, injuries, and surgical diseases is given; secondly, what may be called the nominal returns, in which are furnished the name and military description of each patient, and the particulars of the case, with more or less of detail; and thirdly, the miscellaneous reports. To the first class belong the "classified return of wounds and injuries" which every medical officer has been required to furnish immediately after every engagement, the " tabular statement of gunshot wounds," and the portion of the "monthly report of sick and wounded" referring to surgical diseases and accidents. The second class comprises the "quarterly reports of wounded" and the "quarterly reports of surgical operations" required of all general and post hospitals, the quarterly "sanitary reports" of regimental surgeons, the "nominal lists of wounded" forwarded by medical directors after every general engagement, and extracts from "case books." In the third class are included the reports of medical directors of armies l 2 INTRODUCTION. in regard to the operations of the Medical Department, and the succor given to the wounded; reports and dissertations on new methods and modes of treatment, and modifications of surgical apparatus and appliances; pathological researches on morbid processes pertaining to surgery, as hospital gangrene, osteomyelitis, pyaemia, and the like; plans for ambulance organization, and the transportation of the wounded by land and water. The extent of these materials is simply enormous. The returns are of as huge proportions as the armies that have been engaged in active operations for the last four years. The great body of the medical officers have made the reports required of them with commendable diligence and promptitude, and their zeal is the more deserving of praise when the engrossing nature of their field duties is considered. The result has been the accumulation of a mass of facts and observations in military surgery of unprecedented magnitude. It is as yet impracticable to determine with accuracy the number of wounds received in action during the late war, though data for a near approximative estimate are accessible. But a comparison of a portion of the returns with the complete statistics of other armies will sufficiently indicate the vast numbers that are dealt with. In the British Army in the Crimea, during the entire war there were 12,094 wounded and 2755 killed, or a total of 14,849.* In the French Army in the Crimea, of a total effective force of 309,268, according to the report recently made by M. Chenu, there were 39,868 wounded and 8250 killed, or a total of 48,118, although in his report of injuries of different regions M. Chenu records but 26,681 cases.-j* In the late war, the monthly reports from a little more than half the regiments in the field give, for the year ending June 30th, 1862, an aggregate of 17,496 gunshot wounds. The reports from rather more than three-fourths of the regiments, for the year ending June 30th, 1863, give a total of 55,974 gunshot wounds. The battle-field lists of wounded for the years 1864-65 include over 114,000 names. But these returns are to be completed by collating with them the reports of general hospitals, where many wounded were received whose names the recorders of field hospitals or regimental medical officers failed to obtain, and by adding the names of those killed in battle. In comparing the numbers of cases of some important injury, as, for example, gunshot fractures of the femur, it is found that in the French Crimean Army there were 459 such injuries, and in the English Army 194, while over 5000 such cases have been reported to this office. Or if one of the major operations is selected for comparison, as excision of the head of the humerus, the Crimean returns give 16 of these excisions in the British, and 38 in the French Army, but the registers of this office contain the detailed histories of 575 such operations. * Medical and Surgical History of the British Army which served in the Crimea, during the war against Russia, in the years 1854, 1855, 1856. London, 1858. Vol. ii. p. 259. t Rapport au Conseil de Sant6 dcs Arme6s sur les Resultats dv Service M6dico-Chirurgical aux Ambulances de Crime'e et aux H6pitaux Militaires Franc. ais en Turquie pendant la Campagne d'Orient en 1854, 1855, 1856. Par J. 0. Ohenu, D.M., MGdecin Principal, Biblioth6caire de 1' cole Imperiale de M6decine Militaire, Officier de la L6gion d'Honneur, etc. Paris : Victor Masson et Fils, 1865. 3 INTRODUCTION. The surgical specimens of the Army Medical Museum number 5480; and not only in specimens of recent injuries, but in illustrations of reparative processes after injury, of morbid processes, of the results of operations, and of surgical apparatus and appliances, this institution is richer, numerically at least, than the medico-military museums of France or Great Britain. The value of these materials has been foreshadowed in referring to their nature and extent. It may be emphatically said that they throw much light on some of the great moot points in surgery; that they comprise on some subjects, as, for example, on the question of the propriety of excising the head of the femur for injury, fuller data than are now extant in the entire range of surgical literature; and that it may be hoped, without temerity, that they include the elements for the solution of many grave surgical problems. To render intelligible an account of the progress that has been made in collating and classifying the surgical records of this office, and the collections of the Army Medical Museum, it is requisite to review briefly the measures that have been adopted by the Medical Department to gather and preserve the observations of the medical officers of the Army, and to compile, in an available form, the results of their inquiries and of their vast surgical experience in the late war. In 1861, and during the first eight months of 1862, the "case book" and "register," made obligatory by regulations, the monthly and quarterly reports of sick and wounded, and the sanitary reports required of regimental surgeons, and of the surgeons in charge of hospitals, were the channels through which medical officers communicated such professional facts as they desired to place on record. These sources of information have been decried in some quarters, and in an official report to this office,* in July, 1863, it was declared that previous to September, 1862, "the surgical statistics of the war were absolutely worthless," and that " the only information procurable is such as can be derived from the examination of a mass of reports, all of which present merely certain figures under the vague and unsatisfactory heading, 'Vulnus sclopeticum.' " That the surgical records of a period including the casualties of the first and second battles of Manassas, the battles on the Chickahominy, Ball's Bluff, Cedar Mountain, and Shiloh, and in which the returns from about one-half of the regiments in the field give an aggregate of over thirty thousand cases of gunshot injury, were deserving of such emphatic censure would be a source of grave regret, and it is gratifying to be able to state that a careful re-examination of these records proves that they contain a large amount of material that is far from valueless. The reports of the Washington, Fort Monroe, Baltimore, and Philadelphia hospitals of the treatment of the wounded from the Peninsular campaign, are replete with interest; the reports of the hospitals at Alexandria give voluminous materials in regard to the wounded from Cedar Mountain and the second Bull Run. The surgical records of the Fort Donelson campaign are very complete. The returns of the casualties incurred in the operations in North Carolina are satisfactory. The extracts from the case books of Surgeons Page and Clements, and Assistant Surgeons Peters and Billings, of the Army, and of Sur- * Consolidated Statement of Gunshot Wounds. Washington, July 1, 1863. Octavo, pp. 11. 4 INTRODUCTION. geons Neill, Bontecou, and Bently, of the Volunteers, give a multitude of observations that throw light on some of the most important subjects in military surgery. On May 21st, 1862, it was enjoined upon medical officers, by a circular order from the Surgeon General's Office, to enter upon the monthly reports details in regard to the surgical cases that came under their care, and to forward pathological specimens to the Surgeon General's Office, with the view to the establishment of an Army Medical Museum. In June, 1862, a "tabular statement of gunshot wounds" was appended to the monthly report of sick and wounded. A consolidation of these tables for the months of September, October, November, and December, 1862, was published. The tabular statements of the first two quarters of 1863 have been consolidated also, but it has not been deemed expedient to publish them, because materials are on hand in which fewer sources of error exist. On March 25th, 1863, Circular No. 4, of the Surgeon General's Office, established the "classified return of killed and wounded in battle." On November 4th, 1863, by General Order 355, War Department, medical directors of armies in the field were directed to forward to this office duplicates of their reports of killed and wounded; and, in promulgating this order, you instructed medical directors to detail suitable officers to collate and prepare all obtainable statistics and data in connection with past or future operations in the field that might be useful in the accurate compilation of the medical and surgical history of the war, and you directed the attention of all medical officers to this subject, and urged their co-operation in the work. Circular 26, of November 26th, 1863, S. G. 0., called the attention of medical officers in charge of general hospitals to the importance of preserving representations of the results of surgical operations for the Army Medical Museum. " It was found that the details in regard to wounds, accidents, and injuries, inserted in the monthly and quarterly reports of sick and wounded, were insufficient, and that, although the defects in the reports were supplied by those officers who diligently recorded their cases in the registers and case books, yet such fidelity was not universal, and the histories of many cases were meagre or imperfect, or omitted altogether. It was considered that the register in use was too bulky for field service, and too small for the requirements of general hospitals. A board of medical officers was accordingly directed to recommend a new form of register. The recommendations of the board were approved, and small portable registers were issued to medical officers in the field, while to each general hospital two large folio volumes were distributed, one as a register of sick and wounded, the other as a register of surgical operations. These registers contained minute directions as to the form in which cases should be entered under appropriate headings. The form of the register of sick and wounded is illustrated in the portion of this report that refers to injuries of the head, and the form of the register of surgical operations is given in connection with the subject of excisions of the head of the femur. To assist in the compilation of these registers, a new form of bed-card was adopted. Blank forms of quarterly reports of wounded and of surgical operations corresponding with the registers were prepared, and, on December 26th, 1863, by a special circular from this office, the officers in charge of general hospitals were INTRODUCTION. 5 required to fill up these forms for the months of October, November, and December, 1863. In January, 1864, the new registers were introduced in all the general hospitals, the "consolidated statement of gunshot wounds" was discontinued, and a quarterly transcript from the registers of all cases of wounds or of operations was required. The new system has been found to work well, and the surgical records of the last quarter of 1863, and for 1864-65, are believed to possess a higher degree of statistical accuracy than has heretofore been attained. Early in 1864, the new forms of reports of wounds and operations began to arrive at this office, and the work of transcribing and classifying their contents began. The cases of wounds w^ere recorded in ten books, the new hospital registers being used for this purpose. The classification was as follows: nine volumes of gunshot injuries, viz.: 1. Wounds of the Head and Face. 2. Wounds of the Neck and Chest. 3. Wounds of the Abdomen, Back, and Spine. 4. Wounds of the Perineum and Genito-Urinary Organs. 5. Fractures of the Upper Extremities. 6. Fractures of the Lower Extremities. 7. Flesh Wounds of the Upper Extremities. 8. Flesh Wounds of the Lower Extremities. 9. Wounds of Arteries, Veins, and Nerves ; and a tenth volume embracing Sword, Bayonet, and Miscellaneous Wounds. The cases of operations were recorded in five books, viz.: 1. Amputations in the Continuity. 2. Amputations in the Contiguity. 3. Excisions. 4. Ligations. 5. Miscellaneous Operations. On September Ist, 1864, there had been transcribed upon these registers the histories of 30,435 wounds, and of 1179 operations. It was objected to this mode of registration, that injuries of the gravest and most trivial nature were confounded, and that the great mass of materials contained in the special reports, which medical officers had been encouraged to forward, was entirely omitted from the records. The least important cases received as much attention as the most serious, or even more, because the patients with trifling wounds were more likely to be transferred from hospital to hospital, and their histories were traced with greater difficulty. Moreover, the registers, though well adapted to the requirements of hospitals, were unsuitable for permanent records, the space being inadequate for the requisite details of important cases, or for summaries of the treatment and results in cases protracted through several quarters. It was therefore determined that an effort should be made to arrange the records in a form more convenient for reference and study. In the first place, the early returns of the war were examined, and cases of the more important injuries were gleaned from them, and tabulated upon the new form of surgical reports. This work was of necessity performed by medical officers, or by clerks possessing a competent share of surgical information. In October, 1864, suitable books of record having been procured, the task of revising the surgical records began. It was decided to make numerous subdivisions, and, while avoiding impracticable refinements, to group together similar classes of injuries. On the new registers were entered, in the first place, the cases extracted from the early reports. Then the registers in use were examined, and the category in which each case should be placed was indicated; or, if from Jack of precision in the report this was impossible, additional information was sought from the source from which the report had originated. Thus the cases recorded in the register of gunshot wounds of the head and face were distributed in six registers, viz.: those G INTRODUCTION. of Fractures of the Cranium, of Fractures of the Bones of the Face, of Fractures of the Vertebrae, of Scalp Wounds, of Flesh Wounds of the Face, and of Flesh Wounds of the Neck. Especial attention was given to collecting all the information on file in the office in relation to gunshot wounds of the three great cavities, gunshot fractures of the femur, and the less common surgical operations. The histories of several thousand specimens at the Army Medical Museum, that had been forwarded prior to the adoption of the new system of reports, were tabulated upon the proper forms and transcribed upon the records; and, on the other hand, the records were found to furnish histories for many later specimens that had been forwarded without memoranda. An endeavor was made to co-ordinate and harmonize these data. The following classification of wounds and their results and of operations was finally adopted. It is less elaborate than that employed in the British statistics of the surgery in the Crimea, and more detailed than that followed by M. Chenu, in the French surgical report of the Crimean war. The appended figures give the number of cases of each class that were revised and corrected upon the new registers on September 30th, 1865. Classification of Wounds and Injuries, and their Results, Classification of Surgical Operations followed in the Division followed in the Division of Surgical Records S. G. 0. of Surgical Records S. G. O. Gunshot Fractures and Injuries of the Cranium.... 1108 Amputations of the Fingers 1849 ! Gunshot Fractures of the Bones of the Face 1579 Amputations at the Wrist-Joint 46 ' Gunshot Fractures of the Spine, not involving the Amputations of the Forearm 992 Chest or Abdomen 187 Amputations at the Elbow-Joint 19 Gunshot Fractures of the Ribs, without injury of Amputations of the Arm 2706 the Thoracic or Abdominal Viscera 180 Amputations at the Shoulder-Joint 437 Gunshot Fractures of the Pelvis, not involving the Amputations of the Toes 802 Peritoneal Cavity 397 Amputations of the Foot (Partial) 160 Gunshot Fractures of the Scapula and Clavicle, Amputations at the Ankle-Joint 73 not implicating the Thoracic Cavity 389 Amputations of the Leg 3014 Gunshot Fractures of the Humerus 2408 Amputations at the Knee-Joint 132 Gunshot Fractures of the Radius and Ulna 785 Amputations of the Thigh 2984 Gunshot Fractures of the Carpus and Metacarpus. 790 Amputations at the Hip-Joint 21 Gunshot Fractures of the Femur 1957 Excisions of the Head of the Humerus 575 Gunshot Fractures of the Patella and Knee-Joint.. 1220 Excisions of the Elbow 315 Gunshot Fractures of the Tibia and Fibula 1056 Excisions of the Wrist 34 Gunshot Fractures of the Tarsus and Metatarsus... 629 Excisions of the Ankle 22 Gunshot Penetrating Wounds of the Chest, and in- t? • ¦ ih n r f Shaft of Humerus.. "1 juries implicating the Thoracic Viscera 2303 in tne i,ontin- I Radh]s . Gunshot Penetrating Wounds of the Abdomen, and uity of the Upper Ex- j Ulna 695 injuries involving the Abdominal Viscera 565 remi les |^ Radius and Ulna... J Gunshot Scalp Wounds 3942 „ .. „,, „, „, „ f Tibia ] Gunshot Flesh Wounds of the Face 2588 Excisions of the Shafts of FUmla Gunshot Wounds of the Neck , 1329 the Tlbla and Flbula [ Tibia and Fibula.. J Gunshot Wounds of the Thoracic Parietes 4759 Excisions of the Knee 11 Gunshot Wounds of the Back 5195 Excisions of the Shaft of the Femur 68 Gunshot Wounds of the Abdominal Parietes 2181 Excisions of the Head of the Femur Gunshot Wounds of the Genito-Urinary Organs 468 Excisions of Bones of the Face or Trunk 101 Gunshot Wounds of the Upper Extremities 21,248 Trephining 221 Gunshot Wounds of the Lower Extremities 25,152 Ligations of Arteries 404 Gunshot Wounds of Arteries 44 Extractions of Foreign Bodies 726 Gunshot Wounds of Veins 3 Operations for Surgical Diseases 443 Gunshot Wounds of Nerves 76 Operations not included in other categories 23 Sabre Wounds 106 Bayonet Wounds 143 Simple Fractures, and Miscellaneous Wounds and Cases of Tetanus 363 Cases of Secondary Haemorrhage 1035 Cases of Pyaemia 754 Total 87,822 Total 17,125 i INTRODUCTION. 7 Some observations on each of these classes will be offered in another portion of this report. The several circulars requesting medical officers to forward preparations to the Army Medical Museum met with very general and liberal responses, and, in January, 1863, a numerical list of 1248 surgical specimens was published by this office. Shortly afterwards, a suitable building was procured, and cases were erected in it for the reception of specimens. Several artists were engaged: a colorist to prepare illustrations of surgical pathology and representations of remarkable injuries; a draughtsman to make maps and plans; and two engravers. The requisite workshops were connected with the Museum. A medical officer was detailed to describe and classify the preparations. In short, this branch of the office was rapidly augmenting in importance. At the end of 18G4, the number of specimens had quadrupled. Among the later specimens a large proportion of illustrations of reparative and morbid processes and of the results of operations were included. A valuable collection of drawings had been accumulated; draughtsmen having been sent to battle-fields and hospitals to portray the effects of recent wounds, or the results of surgery. A photograph gallery was now established at the Museum. Typical specimens were reproduced, and the photographs, accompanied by brief printed histories, were distributed to medical directors, to be shown to the medical officers serving with them, in order that the knowledge to be obtained from a study of these instructive examples might be generally disseminated. Other preparations were photographed for the use of the engravers. Many of them are reproduced in this report. Numerous patients in hospitals were photographed, and the Museum now possesses four quarto volumes, with over a thousand photographic representations of wounded or mutilated men. Meanwhile the work of describing and classifying the collections at the Museum has been steadily pursued, and the descriptive catalogue is now nearly ready for publication. To state, then, in brief, what the records of the surgery of the late war are, and what progress has been made in their arrangement, over 40,000 monthly regimental reports of sick and wounded are on file, which furnish, under Class V.,* the total number of wounds, accidents, and injuries in the army, and the resulting mortality, as ascertained by the regimental medical officers, and which, having served their purpose of informing military commanders, month by month, of the extent of the losses in their commands, by the casualties of war, are now available for estimating the entire losses of the army from diseases and wounds. These reports have been consolidated for the first two years of the war and for the greater portion of the third year. But, as a certain number of regimental medical officers failed to make the required reports, it is necessary to correct these results by other numerical returns. Prior to September, 1862, these are only to be sought in special reports and case books of hospitals, and in the reports by medical directors of battles and minor engagements. It is found that these supply the deficiencies of the regimental returns to a satisfactory degree. For the latter part of 1862, and the whole of 1863, the "tabular statements of gunshot wounds" give the number of such injuries, separated according to regions, and the * The form of the Report of Sick and Wounded being printed in the accompanying Report on the Medical Statistics of the War, it is not inserted here. 8 INTRODUCTION. number of operations to which they gave rise. These tabular statements have been consolidated for the entire period, and the results for 1862 have been published. After March, 1863, consolidated classified returns of wounds and injuries were rendered, after every engagement, by the medical directors of armies or detached commands. This series is very complete. It serves as a check upon the monthly reports, and as a basis for estimating the frequency and fatality of wounds according to regions, and the total losses of the army in killed and wounded for the period covered by phe returns. These results are not yet worked out, although satisfactory progress has been made towards their attainment. Throughout the war, many medical directors had transmitted to this office nominal lists of the wounded in battle ; but after November 4th, 1863, this was made obligatory. After October Ist, 1863, all general hospitals reported by name all wounded men received, and gave full details of their injuries. From these two sources nearly complete lists of the wounded for the last two years of the war have been procured; for the names of those who died before reaching the base or general hospitals are found on the battle-field casualty lists. The progress that has been made in classifying and collating these returns has been already indicated. It will appear, hereafter, that the additional information afforded by case books and special reports has not been neglected. The formal reports of medical directors of armies give a general view of the operations of the Medical Department. For the Army of the Potomac, the reports of Medical Directors Tripler, Letterman, and McParlin furnish a connected narrative of the services rendered by the medical staff 1 . For the Western armies, the reports of Medical Directors McDougall, Murray, Cooper, Perm, Moore, and Hewit afford similar information. These papers will guide the future historiographer of the surgery of the war, and enable him to put in evidence the immensity of the task that devolved on the Medical Department, and to vindicate its achievements, in showing the extent of the succor given to the wounded in despite of almost incredible obstacles. Besides these authoritative documents, there are on file in the office, to serve as supplementary reports, individual narratives of observations in active service from each member of the regular or volunteer medical staff. The remaining papers for reference are the reports of boards on surgical improvements and appliances, or methods of transport for the wounded; 17,000 descriptive lists of surgical cases; 4200 reports from the manufacturers of artificial limbs of cases of recovery after amputation; and the surgical essays and dissertations that have been contributed. All of these have either been bound, or indexed and filed in a convenient and accessible form. Lastly, the great treasures of the Army Medical Museum, comprising over five thousand illustrations of military surgery, have been so far classified and arranged as to be available for scientific inquiry. 2 9 ON SPECIAL WOUNDS AND INJURIES. It is now proposed to review briefly the records of special wounds and injuries, of some of their complications, and of the operations which they have rendered necessary. GUNSHOT INJURIES OP THE HEAD. In this important class of injuries, the utmost pains has been taken to secure completeness and accuracy in the records. The registers have been copied by experienced clerks, and have been supervised by a medical officer. Exclusive reliance has not been placed upon the field and hospital reports; but in a large proportion of cases, specific inquiries in regard to the extent and results of individual injuries have been made by letter. All, or nearly all, cases of gunshot injuries of the head that have been reported to the office from the commencement of the war to October Ist, 1864, have been entered in the records. They number 5046, and have been recorded in two classes : first, the gunshot fractures and injuries of the cranium, including the perforating and penetrating and depressed fractures, the fractures without known depression, and the contusions of the skull resulting in lesions of the encephalon; and, secondly, the simple contusions and flesh wounds of the scalp. It is quite possible now to establish subdivisions in the first class; but to have attempted this heretofore, would have been premature, and likely to produce confusion. In the first class 1104 cases are recorded. Of 604 of them, of which the results have been ascertained, 505 died and 199 recovered. In 107 of these terminated cases the operation of trephining was performed, of which 60 died and 47 recovered. In 114 cases fragments of bone or of foreign substances were removed by the elevator or forceps, without the use of the trephine; and of these 61 died and 53 recovered. When operative procedures were instituted, the recoveries were 45*3 per cent. But it must be apprehended that this favorable exhibit will be materially modified when a larger number of results are ascertained, and that a great proportion of the field operations of trephining, in which the results are stated to be undetermined, were lost sight of, and terminated fatally. In the 483 cases treated by expectancy, the ratio of recovery is only 20-5 per cent. But the latter group of cases includes nearly all of the penetrating and perforating fractures, and it would be unwise to base on these figures an argument in favor of operative interference. The gunshot contusions and wounds of the scalp that have been entered on the records number 3942, of which 103 terminated fatally. It is altogether probable that in all of these fatal cases some undiscovered injury was done to the cranium or its contents; or that the pericranium was removed, and death of bone ensued, with consecutive lesions of the encephalon. The histories of many of these cases are now under investigation. So far as ascertained, the fatal results have depended upon concussion or compression of the brain, or upon the formation of abscesses in the liver or lungs, in 10 ON SPECIAL WOUNDS AND INJURIES. consequence of inflammation in the veins of the diploe. Compression has resulted either from extravasation of blood, or inflammation of the brain or its membranes, or from suppuration. The following is an example of a scalp wound, followed by inflammation of bone and meningitis : Fio. ].—section of a cranium, exhibiting five trepinno per- (orations tor the evacuation of pus, th« result of a gun- shot contusion of the right parietal. Spec. 2000, a m. m. Private Joseph E , Co. E, 151 st New York Vols., received, in a reconnoissance near the Eapidan, November 27th, 1863, a gunshot wound of the scalp. The nature of the missile was unknown. The patient was removed to Fairfax Seminary General Hospital near Alex- andria. There were no cerebral symptoms at the time of his admission, and it was hoped that the pericranium had escaped uninjured. He was up, and apparently well on December 13th, 1863, when he was suddenly seized with convulsions, which were followed by coma. Surgeon 1). P. Smith, U. S. Vols., laid bare the calvana at the seat of injury, and ? , .. . . ? . ? , . •,» c 3 finding the bone diseased, applied the trephine. Matter was tound immediately beneath the bone and oozing from the diploe. It was thought expedient to make five perforations with the trephine, in order to remove the diseased bone and to give free exit to pus. Convulsions did not recur, but the comatose condition continued, and the case terminated fatally twelve hours after the operation. The autopsy revealed diffuse inflammation of the arachnoid and of the dura mater. The foregoing case illustrates the fallacy of Pott's views in relation to trephining for pus under the skull-cap; and yet, under such circumstances, the best modern authorities advise the use of the trephine as affording the patient the only chance of recovery. The records attest how slight this chance is, and corroborate the observation of Mr. Hewett, that "the successful issue of a case of trephining for matter between the bone and the dura mater is almost unknown to surgeons of our own time."* The Army Medical Museum furnishes very ample illustrations of almost every variety of gunshot injury of the skull and its contents. The number of osteological specimens relating to this class of injuries is 246, of wet preparations 22, of drawings, photographs, engravings, and plaster casts 97. There are 22 specimens of gunshot contusion of the cranium. In these, either necrosis has taken place, with exfoliation of the external table only, or of the entire thickness of the bone, or else inflammatory suppuration has occurred in the diploe or between the skull and dura mater. The Museum possesses eight examples of that rare and interesting variety of Fio. 2. — Section of skull-cap, exhibiting a depressed fracture of the vitreous table. Spec. 1568.A.M.M, gunshot fracture of the cranium, in which the external table is unbroken, while the vitreous table is fissured and sometimes depressed. One of the most perfect of these specimens (No. 1568, A. M. M.) is figured in No. 94, Photographic Series, S. G. 0. An abstract of the case is subjoined: Private David P , Co. C, 35th "Wisconsin Vols., was wounded at Tupelo, Mississippi, July 18th, 1864, by a musket-ball, which struck the skull obliquely, and apparently inflicted a scalp wound merely, between the sagittal suture and the left parietal protuberance. There were no signs of cerebral disturbance. The wound was dressed simply, and the patient was conveyed to Memphis, Tennessee, and admitted into the Adams U. S. General Hospital on July 23d. He was then perfectly rational and free from head symptoms. Two days subsequently, indications of compression of the brain were observed, and on the after- noon of the 25th they had rapidly become aggravated. The pulse was slow, the respiration labored, the pupils dilated, the sphincters relaxed. A very careful exploration of the wound was made, but, of course, no cranial fracture could be detected. The treatment was limited to cold applications to the head, scarified cups to the nucha, and brisk purging. On the 26th, the patient gradually became comatose. The discharges from the bowels and bladder were involuntary. * A System of Surgery, Theoretical and Practical, in treatises by various authors, edited by T. Holmes, M.A. Cantab. London, 1861. Vol. ii. p. 101. 11 GUNSHOT INJURIES OF THE HEAD. The patient continued to sink on the 27th, and died at 1 a.m. on the 28th of July. - of the left parietal was found to be fractured and depressed at a point corresponding with the wound in the scalp. The dura mater was wounded, and there was a large abscess in the left cerebral hemisphere. In a specimen which is believed to be unique, without any apparent lesion of the external table, a fragment of the vitreous plate of the frontal bone was found to be completely detached and depressed upon the dura mater. The history in this case is unfortunately imperfect. Private A L , Co. C, 78th New York Vols., was wounded by a conoidal musket-ball, at the battle of the Wilderness, May 6th, 1864, and entered Armory Square Hospital, at Washington, on May 12th. He was in a comatose At the autopsy the internal table Fid. 3. — Exterior view of the foregoing specimen. condition when admitted, and died on May 24th, eighteen days after receiving the injury. No further particulars of the case could be obtained. At the autopsy a fracture was discovered of the inner table of the frontal bone, near the coronal suture, to the left of the median line. There was no solution of continuity in the outer table; but it was softened where the pericranium was destroyed by the ball. A fragment, an inch and a half in length and half an inch broad, was completely detached from the vitreous table. The specimen was forwarded by Surgeon D. W. Bliss, U. S. Vols. In a case which was observed by Surgeon Bontecou, U. S. V., who had examined the specimens above referred to, the probability of a depression of the vitreous table Fig. 5. — Exterior view of the foregoing specimen. Fig. 4. — Fracture of the vitreous table I *^* was in^ erre^^ an d the diagnosis was verified, during life, by the 2313, A. M. M. n.TYnlip.a.tirm nf flip f.rpnliinp. TTnlm.rmil v nn nVisnoee liarl ¦fXvmorl application of the trephine. Unhappily, an abscess had formed in the brain, and the operation, though performed as soon as evidence of compression existed, was too late to save the patient. Private D S , Co. E, 2d Virginia Cavalry, aged twenty-one, was wounded at Appomattox Court House, April 6th, 1865, and admitted to Harewood Hospital, at Washington, on April 19th, with a gunshot wound of the scalp, just below the coronal suture. The bone was denuded of its pericranium, but there was no apparent fracture. Prior to his admission, the patient had chills, which recurred at intervals of twelve hours, until April 25th, quinia having no appreciable influence upoa the paroxysms. There was no pain in the head nor disturbance of the cerebral faculties until April 26th. On the 25th, inflammation of the lower lobe of the right lung was observed, and on the 26th, there was endocarditis. At 10 p.m. of the 26th, the patient became unconscious. Shortly afterwards he was trephined. When the external table was passed, pus exuded from the cells of the diploe. A depressed fracture of the inner table was discovered, and the detached Fio. 0. — Section of cranium, showing a depressed fracture of the vitreous table. There was a contusion only of the outer table. Spec. 4344, A. M. M. fragments were removed. The patient did not arouse from his comatose state, and died the next morning, April 27th, 1865. A photograph of this patient, prior to the operation, was preserved at the Museum. (Photo. Surg. Cases, vol. i. No. 58.) Specimens 3639, 3406, 622, 1922, and 646, A. M. M., afford other examples of this rare form of injury, to which S. Cooper,* Guthrie,f Hennen,| Hewett,§ Williamson,|| and Legouest^f allude, illustrating their observations by a case examined by Mr. Dean, of Cambridgeshire, a specimen in the Dupuytren Museum, which is figured in M. Legouest's work, and specimen No. 2893 of the Netley Collection. * S. Cooper, Dictionary of Practical Surgery. \ Hennen, Military Surgery, p. 326, cd. 1829. || Williamson, Military Surgery, pp. 29, 30. t Guthrie, Commentaries, paragraph 262. \ Holmes' System of Surgery, vol. ii. p. 114. }T Legouest, Traite de Chirurgie d'Armee, p. 283. See also Compendium de Chirurgie, t. ii. p. 573. 12 ON SPECIAL WOUNDS AND INJURIES. t It is believed that this accident results, in most instances, from a small projectile striking the cranium very obliquely, or possibly, in some cases, from a comparatively slight blow from a body with a large plane surface. Closely allied, clinically, to the foregoing cases are those in which a ball produces linear fissure of the external table with displacement of the inner table. Specimen No. 24, of the Army Medical Museum, affords an excellent illustration. The following is an abstract of the case : Private M. L. H , Co. E, 21st Virginia (Rebel) Regiment, aged twenty years, was wounded and taken prisoner in one of the later engagements prior to the capitulation of the Army of Northern Virginia, and was admitted Fig. 7. — Section of the frontal bone exhibiting a fissure over the left supra-orbital region. Spec. 24, A. M. M. into the Lincoln General Hospital, at Washington, on March 25th, 1865, with a wound over the left supraorbital ridge, inflicted apparently by a glancing musket-ball. There were no cerebral symptoms when the patient was admitted, and he seemed to be doing well for several days, being quite free from pain or any febrile movement. The pulse was normal nnrl thp hnwpls in cnnd onndition Fro. B.— lnternal view of the foregoing specimen, showana tne DOWdS in gOOa COnaiUOn. ing the extensive splintering of the vitreous table. On April Ist, he complained of a dull deep-seated pain over the left eye. Later in the day he was feverish and restless, his countenance was pale, and his pulse slow and weak. On April 2d, he failed rapidly. On the night of the 3d, he was delirious. On the 4th, there was violent raving, which continued until his death, on the afternoon of April sth, 1865. At the post-mortem examination, a fissure was found extending into the right orbit, and upwards beyond the left frontal prominence. The vitreous table beneath was largely depressed. There was a small abscess in the anterior lobe of the left cerebral hemisphere. Fig. 9. — Gunshot fracture of right temporal. Spec. 183, A. M. M. Of fractures without depression, the cases in which the mastoid process is knocked off by a ball afford examples. Specimen 183, A. M. M., is a very perfect illustration of this accident. The mastoid cells were opened. After a fortnight, meningitis supervened. Specimen 3451 was furnished by a fortunate case of recovery after a fracture of the mastoid process. Private William F , Co. G, 98th Pennsylvania Vols., was wounded near Fort Stevens, Washington, July 12th, 1864, by a glancing shot from a conoidal musket-ball, and was admitted into Mount Pleasant Hospital on the following day. A little above the right auditory meatus was a scalp wound an inch and a half long. A piece of the mastoid process was chipped off, and a fracture extended into the petrous portion of the temporal. The patient did well with simple Fig. 10.— Exfoliation from thermit parietal and temporal, resulting from gunshot injury. Spec. 3451, A. M. M. dressings and rest and gentle cathartics till the 20th of July, when the wound began to slough. Applications of nitric acid, creosote, etc., failed to arrest the sloughing, which presently gave rise to repeated haemorrhages from branches of the temporal artery. The gangrene continued to spread until August 9th, when the eschars separated, leaving a space five inches in diameter on the right lateral region of the head, denuded of integument, fascia, and muscles. During this long period, the patient complained of no inconvenience at the seat of fracture, though there was at times acute frontal pain. Early in September, it was evident that the exposed portions of the temporal and parietal bones were necrosed, and on September 6th a fragment of the squamous portion of the temporal was removed. Two days subsequently other fragments were detached and extracted. After this the wound began to cicatrize rapidly, and on December 3d, 1864. the patient was reported to be entirely out of danger, and in fact nearly well, Several cases of undepressed fracture are reported in which a ball gouged out a small portion of the external table. A number of instances are recorded in which considerable 13 GUNSHOT INJURIES OF THE HEAD. portions of the calvaria have been removed by explosions of shell, without depression. Very rarely a musket-ball produces the same effect, as in the following remarkable case. The patient is represented in Photograph No. 58, A. M. M. : Private Edson D. Bemis, Co. X, 12th Massachusetts Vols., was wounded at Antietam by a musket-ball, which fractured the shaft of his left humerus. The fracture united kindly, with very slight angular displacement and quarter of an inch shortening. Promoted to be corporal, Bemis received, May 6th, 1864, at the battle of the Wilderness, a wound from a musket-ball in the right iliac fossa. He was treated in the Chester Hospital, near Philadelphia. There was extensive sloughing about the wound, but it Jtimately healed entirely, leaving a large cicatrix, parallel with Poupart's ligament. Eight months after the injury, Bemis returned to duty with his regiment. On February sth, 1865, Corporal Bemis was again severely wounded at the engagement at Hatcher's Run, near Petersburg, Virginia. Surgeon A. Vanderveer, 66th New York Vols., reports that the ball entered a little outside of the left frontal protuberance, and passing backwards and upwards, removed a piece of the squamous portion of the temporal bone, with brain substance and membranes. When the patient entered the hospital of the Ist Division of the 2d Corps, brain matter was oozing from the wound. Respiration was slow ; the pulse 40 ; the right side paralyzed ; insensibility total. On February Bth, the ball was removed from the substance of the left hemisphere. In a few days paralysis disappeared. The patient was transferred to Fort Richmond, New York Harbor. He recovered perfectly, and on July 15th visited Washington, and was photographed at the Army Medical Museum. The wound in the head was then nearly healed. There was a slight discharge of healthy pus from one point. The pulsations 6f the brain could be felt through the integument. The mental and sensory faculties were unimpaired. The corporal had been discharged from service, and recommended for a pension. From the numerous instances of fracture with depression of both tables of the skull, a very few are selected. The first is an example of a common class of cases, in which symptoms of compression of the brain depend upon extravasation of blood, or inflammation of the membranes, and come on tardily. Private Leonard L , Co. F, 74th New York Vols., was wounded at the battle of Williamsburg, May sth, 1862, and was admitted into Broad and Cherry Streets Hospital, at Philadelphia, May 13th, 1862. A musket-ball had struck near the left parietal eminence, and, producing a slight depression of the outer table, had lodged under the scalp, whence it had been removed by a surgeon on the field. The wound had a healthy aspect when the man was admitted, and there was no cerebral disorder. This favorable condition continued unaltered till May 20th, when a febrile movement set in, accompanied by nausea and vomiting ; drowsiness and stupor Flo . l2— interior view of the foregoing 0 / tyeV s e edZcture Bh o O f W ih? followed, and the patient died comatose on May gS^SS™ 8 "" 1111^ outer table, 224, A. M. M. e j ghteen dayg after the in j ury . At the aut op S y, a small clot was found beneath the depressed portion of the vitreous plate; the dura mater was uninjured; the arachnoid, near the seat of injury, was opaque, and studded with deposits of lymph ; the gray matter of the brain was softened. Private George V , Co. C, 84th New York Vols., was wounded at Chancellorsville, May 3d, 1863, and admitted into Carver Hospital, at Washington, D. C, on May 7th, 1863. His injury was supposed to be a simple scalp wound from a musket-ball. It was situated over the right parietal protuberance, and, on admission, f • BE' was granulating kindly. Ten days subsequent- "'^-'"¦l ly, the patient, after a walk out of doors, had /-s^hM^ Hi mi headache and nausea, and the wound gaped, /JmM P*s 'iJ^JHMiSwi and its edges ulcerated. On the 18th of May, the probe detected denuded bone; but no frac- jB ture was discovered. There were no febrile or no -^b^ ot^ t iST O fA: c e M r^. tpBrl " cerebral symptoms. On May 20th, a depres- f,*. ulterior view of the fcregolng sion of the outer table of the skull was de- specimen. tected. At night there was delirium, and the following day the pulse became feeble and irregular, the stomach irritable, the tongue heavily furred. The patient died on May 22d, 1863, being conscious and rational to the last. At the autopsy, extensive inflammation of the dura mater was observed, and softening of the middle lobe of the right cerebral hemisphere. 14 ON SPECIAL WOUNDS AND INJURIES. The next case is an example of the classical "punctured" gunshot fracture of systematic writers Flo. 15. — Fracture of the frontal bone by a pistol -ball, Spec. 1073, A. M. M. Private James X , Co. U, 6th New York Cavalry, was wounded at the battle of Gettysburg, July 3d. 1863, by a pistol-ball, which produced a punctured fracture of the os frontis. He was conveyed to a hospital at Baltimore, and from thence to Carver Hospital, at Washington, on July 24th. He stated that, at Baltimore, he walked about and felt no inconvenience from his wound. On July 27th, he had a convulsion. The wound, which was nearly healed, was laid open, and depressed bone being detected, an effort was made to elevate it. Several small necrosed fragments were removed, and a small quantity of fetid pus escaped. The patient had become comatose, and the operation had no influence in relieving the symptoms. Death took place a few hours subsequently. Fio. 16. — Interior view of the foregoing specimen. At the autopsy, the extended depression of the inner table was discovered, and a large abscess of the brain Instances were not uncommon of the splitting of round musket-balls in striking the skull at an acute angle. The following is an example : Fia. 17. — Section of a Irontal bone, with a split musket ball. S/in: 1293, A. M. M. Corporal John N , aged eighteen years, Co. H, 159 th New York Vols., was struck on the left side of the forehead, on April 14th, 1863, at an engagement at Irish Bend, Louisiana, by a round musket-ball. He was admitted to the University Hospital, at New Orleans, on April 17th. The ball had been removed on the field. Several depressed fragments of bone were removed, and cold water-dressings were applied. The case progressed without a bad symptom until April 30th, when there were clonic spasms, which, after a few hours, were followed by a somi-comatose condition, which continued until death, on May 2d, 1863. A necroscopic examination revealed extensive meningitis, and a large abscess of the left cerebral hemisphere. The lateral ventricles were filled with sero-purulent matter. The surfaces of the pons Varolii and of the medulla oblongata were covered with lymph. The specimen was forwarded by Assistant Surgeon P. H. Conner, U. S. A. Conoidal balls were less liable to split after this fashion, yet such instances were occasionally observed. Private C. C. W , Co. I, 6th Wisconsin Vols., aged twenty-one years, was wounded at Spottsylvania, May 12th, 1864, and was admitted to Douglas Hospital, in Washington, four days subsequently. It was ascertained that the cranium was fractured, but the symptoms were not urgent, being limited to slight paralysis of the right upper extremity, and operative interference was deferred. On May 31st, a conoidal musket-ball and several fragments of the left parietal were removed by Assistant Surgeon Wm. F. Norris, U. S. A. One large fragment of the vitreous plate was pressing on the dura mater ; this was elevated and removed. The next day symptoms of compression of the brain were manifested. An exploration of the wound was made and a quantity of pus evacuated. On June 4th, 1864, twenty- three days after the injury, the case terminated fatally. At the autopsy, the arachnoid was found little altered. There was an „ „ *„ . , „ abscess in the posterior lobe of the left hemisphere near the longitu- Fig.lB. — Skull-rap, exhibiting gunshot fracture near the vertex, by a conoidal musket-bail which has split against dinal sinus, of the size of a walnut. Its walls were of a greenish-yellow the laniiua of the left parietal. Spec. 3543, A. M. M. , T . , , ... ? , , , . . , n ,i . , . , . , color. It communicated with the lateral ventricle, lhe right ventricle was filled with sero-sanguinolent fluid. There was a deposition of lymph at the base of the brain, extending from the medulla oblongata to the bifurcation of the optic nerves. The specimen and facts connected with it were contributed by Assistant Surgeon William Thomson, U. S. A. The depressed fractures produced by cannon-balls, or by the explosion of large shells, were commonly attended by frightful comminution and disjunction of the sutures, and were almost always immediately fatal, and hence had little surgical interest. A single example is given : 15 GUNSHOT INJURIES OF THE HEAD. A Confederate soldier was wounded in the demonstration on Washington, July 17th, 1864, by a shell from one of the large guns of Fort Stevens, and was admitted into Lincoln U. S. General Hospital, on that day, and died two hours after admission. Over the anterior superior angle of the left parietal bone there was an extended scalp wound. On reflecting the scalp, multiple depressed fractures of the vault of the cranium came into view. The point of greatest depression is an inch to the left of the median line, near the coronal suture. The depressed fragments measure from before backwards two inches, and from right to left three inches, and involve both parietals and the os frontis. A fissure runs through the squamous portion of the left temporal, and all the sutures of this bone are separated. Fig. 19.— Cranium fractured by the explosion There have been a very few extraordinary and excep- of ttn n - iach sheU - <*«=. 2871, a. m. m. tional recoveries after penetrating and perforating fractures of the cranium, and, in rare instances, the fatal termination has been long delayed. In the following curious case, the presence of a ball within the cranial cavity was unsuspected: Corporal G. W. S , 12th Massachusetts Vols., aged twenty-nine years, was wounded at the battle of Fredericksburg, December 13th, 1862, and was admitted to Camden Street Hospital, Baltimore, six days subsequently. The humors of the right eye had been evacuated by a ball, which had likewise inflicted a slight wound of the lower Fia. 20. — Conoidal ball embedded between the sphenoid and parietal bones. Spec. 114*, A. M. M. lid. The left eye was observed to be unnaturally prominent, but its func- tions were undisturbed. The patient did not complain of pain or any in- toms, and no one suspected that Ilie Fig. 21. — Exterior view of the foregoing specimen. projectile had entered the brain. The wound healed kindly, and, after three weeks, the man walked about the city habitually, with a hospital pass. He appeared to be well, except that he had an occasional pain over the left eye, until February 6th, 1863, when he had a chill, followed by a febrile reaction. No marked cerebral disorder supervened, however, until February 10th, when delirium was noticed at night. On the following day the patient was comatose, and at midnight of February 15th, he died. The autopsy revealed a conoidal musket-ball wedged between the sphenoid and the left orbital plate of the frontal bone, and lying in contact with the dura mater. The orbital plate was pressed inwards and fractured, and a fissure extended through the superciliary ridge. Over the ball, at the base of the anterior lobe of the left hemisphere, was an abscess containing two drachms of pus. The ball was incrustecl by callus, and the opening it had made in entering through the walls of the right orbit was greatly diminished by osseous deposition. In the next case, half of the ball had deeply penetrated the brain Sergeant J. N. H , Co. X, 19th Maine Vols., aged thirty-six years, was struck on the right side of the head, by a musket-ball, in a skirmish at Morton's Ford, on the Eappahannock, February 6th, 1864. The ball was smoothly cut in two, one-half lodging under the scalp, and the other passing into the brain. The patient was perfectly rational until February 11th, when his mind wandered at times. On the 12th, Surgeon Justin Dwinelle, 101 st Pennsylvania Vols., extracted the fragment of the ball which had buried itself in the brain. Its track communicated with the right lateral ventricle. The other portion of the ball had been removed from under the scalp immediately after the injury. When the patient recovered from the influence of the chloroform, he was rational, and continued so for twenty-four hours or more. Coma gradually supervened, and Fl^:J^kef baf Utut *I?i&f! death took place on February 15th. The left ventricle was found filled with pus. a. m. m. A very remarkable case of perforating fracture of the skull, with recovery, is represented by No. 16 of the Surgical Series of Drawings, S. G. 0. The ball entered a little to the right of the occiput, and passed out somewhat below and to the left of the vertex. The intervening bridge of bone was about three inches wide. There had been a cerebral hernia at the wound of exit, and, when the drawing was made, four months after the reception of the injury, there was still a small tumor, covered by halfformed 16 ON SPECIAL WOUNDS AND INJURIES. cicatricial tissue. There was a firm depressed cicatrix at the aperture of entry. There were no evidences of impairment of the cerebral faculties. At the time the drawing was made, the man was employed as an orderly. The next case illustrates Mr. Erichsen's remark that the greater splintering of the inner table does not depend exclusively upon its greater density and brittleness, but partly on the direction of the fracturing force. At the aperture of exit, the outer table is splintered more than the inner. In the same specimen the bones forming the right orbit are fractured by contre-coup: Fjd. 23.— Skull, exhibiting an extensive fracture " by grapeahot. Spec. 1318, A. M. M. A soldier of Longstreet's Corps was killed in a charge upon a Union battery, in the second battle of Manassas, August 29th, 1862, by a grapeshot at short range. The cranium was picked up a year subsequently by Surgeon F. Wolfe, 39th New York Vols., under an abatis near the stone bridge over Bull Eun. The missile entered the left parietal near the lambdoidal suture, and made its exit through the squamous portion of the temporal. According to Mr. Teevan's experimental inquiries,* the aperture of exit in gunshot perforations of the cranium is always larger than the aperture of entry, because it is made by the ball plus the fragments of bone driven out from the proximal table and the diploe. While the number of fatal results after trephining are very great, the examples of success are yet numerous. The data are not sufficiently complete to admit of fair comparative analysis; still it is difficult to avoid the impression that a larger measure of success has attended this operation in the late war, than the previous experience of military surgeons would have led us to anticipate. Surgeon D. W. Bliss, U. S. Vols., alone has reported eleven successes after the use of the elevator or trephine. Even in those almost hopeless cases in which compression of the brain follows a gunshot injury of the skull at a late date, instances of recovery are reported. In the following case it is not likely that suppuration had occurred, a complication that has rarely presented itself prior to the fifteenth day after the injury; but it can hardly be doubted that meningitis was averted or relieved by the opportune employment of the trephine : Private John McX , Co. H, 105 th Pennsylvania Vols., was wounded at Petersburg, Virginia, June 14th, 1864, by a conoidal musket-ball, which struck the right side of the skull very obliquely, and produced a slightly Fig. 24.— Exfoliation from the right parietal bone. Spec. 3452, A. M. M. depressed fracture of the right parietal bone. He was admitted to Mount Pleasant General Hospital, Washington, on June 24th, with the report that the progress of the case had been so far eminently satisfactory. After admission, he found to be insensible, and a few hours subsequently, convulsions supervened in rapidly recurring paroxysms. Twelve ounces of blood were taken from the temporal artery without apparent benefit. A trephine was then applied to the seat of fracture, and, upon the removal of a button of bone, a portion of the inner table was found slightly depressed. This was elevated, and the patient soon afterwards regained consciousness. On the 28th of June, the wound in the scalp became erysipelatous, and before the inflammation subsided, there was extensive loss of substance of the integuments and pericranium, denuding a large portion of the parietal bone. Necrosis ensued, and embraced the whole thickness of the bone. In September, 1864, a portion of the parietal, three inches by four, had become so much loosened that it was readily removed. After this, cicatrization went on rapidly, and, at the date of the last report, December 2d, 1864, the wound had contracted to an ulcer less than an inch in diameter. The patient's mental faculties were impaired somewhat, the ward physician thought, but not to a great extent. The specimen was contributed by Assistant Surgeon C. A. McCall, * British and Foreign Medico-Chirurgical Review, vol. xxxiv. p. 205. GUNSHOT INJURIES OF THE HEAD. 17 U. S. A. A colored drawing was made representing the appearance of the parts prior to the separation of the exfoliation. (No. 74, Surgical Series of Drawings, S. G. 0.) The occurrence of hernia or fungus cerebri is mentioned in connection with 18 cases of gunshot fracture of the skull, complicated by lacerations of the dura mater and brain. In 4 of these cases, recovery took place without operative interference with the protruding fungous mass, which, in these instances, gradually contracted, was then covered by granulations, and finally cicatrized. In those cases in which bandaging and compression were resorted to, cerebral oppression was soon manifested, and stupor and coma eventually supervened. In those in which the tumor was sliced off, as usually recommended, at the proper level of the brain, it was commonly speedily reproduced, and death from irritation ensued. Charles T , Co. H, 63d New York Yols , aged seventeen years, was admitted to Hospital No. 1, Frederick, Maryland, on September 28th, 1862, with a fracture of the skull. He was wounded at Antietam, September 17th, 1862, by a conoidal musket-ball, which struck at the lower anterior angle of the right parietal, fractured both tables of the cranium, and lodged under the scalp in the occipital region. The scalp was lacerated, and a dark pulsating mass protruded in the wound. The left side of the body was paralyzed. The patient's mental faculties were unimpaired. On September 29th, flaps of integument were reflected by a T-shaped incision. The ball and a number of fragments of bone were removed, some of the latter being embedded in the brain substance. The inner table was found badly splintered, but the fracture of the external table was still more extensive. The protruding cerebral mass was shaved off. The rough edges of the fractured bone were smoothed by cutting forceps. The following day, the paralysis was more complete than before the operation. There was severe headache. The pulse was slow and weak. On October 3d, the fungus was sprouting and sloughing. The left arm was powerless ; the paralysis of the left leg was less complete. On October 4th, the hernia was again sliced off, and gentle compression was applied. There was great irritability and restlessness. On October 21st, the patient had improved. His appetite was voracious. He was less irritable, and the hemiplegia was much less complete. He was very sensitive to cold. The temperature of the left side was lower than that of the right. The fungus was of the size of a pigeon's egg. On November 17th, a dilata- Fia. 25.— Gunshot fracture of right parietal, followed by necrosis. Spec 3859, A. M. M. tion of the left pupil was first noticed. Sensation in the left leg, and partial control of the muscles had returned. Since the last report the tumor of the brain had continued to grow and slough away, so that it remained of about the same size. On December 7th, the report states that little change had taken place, except a gradual amelioration of the hemiplegia, and improvement in regard to the fretfulness and irritability. On this day there was a severe chill. After this, the patient never regained his accustomed readiness and clearness of mind. The discharge from the wound became watery, unhealthy, and more copious. There was an exacerbation of fever every afternoon. On December 17th, there was a severe convulsion, which lasted half an hour, and was terminated by death. At the autopsy, an irregular portion of the right parietal, four inches in diameter, was found to be necrosed and detached. The dura mater was much thickened in the vicinity of the fracture, and was adherent to the margins of the healthy bone. Except in the immediate vicinity of the hernia, the brain matter appeared to be in a healthy state. In looking over the registers of gunshot injuries of the head, two general facts are noticed : First, that in the after-treatment of scalp wounds, a multitude of surgeons did not consider spare diet, perfect rest, and antiphlogistic measures as of essential importance; and, secondly, that in the treatment of cranial fractures, the general tendency was to the practice recommended by Guthrie in regard to operative procedures, rather than the more expectant plan insisted upon by the majority of modern European writers on military surgery. The interest of the material and the importance of the subject alike invite extended comment; but in this brief and cursory review, the motto of Montaigne, je raconte, je ne juge pas, must be rigorously adhered to. A few more cases of gunshot injuries of the head are appended, to illustrate the form of the register of wounds now in use in the army. 3 18 ON SPECIAL WOUNDS AND INJURIES. From what other ? ? """SLh" 1 " DIAGNOSIS. SSaStolf w . From what mitted. <* ca *" Hospital. NAME. Rank. Co. Regiment. Age. J^^t General Hos- In Surgical Cases, state Seat and Character Wo^ aecl aecl' Plt ferred anB " Field Tom ' of Wound or Injury. Field Hospital, etc. Hygeia Hospi- Burd, Charles W. Lieutenant. F 4th Maine 26 Feb. 20, Prison in .Gunshot fracture of both tables of os frontis • Bull Ron tal Old Point Volunteers. 1862. Richmond at left frontal eminence. Penetration of July 21,1861. Comfort, Va tne substance of the brain by a portion of the ball. National Hob- Stallman, John Private. A 4th Perm. 21 Sept. 8, Sandy Hook, Missile entered at the right temple, and Winchester, pital, Balti- Cavalry. 1864. Maryland. emerged at the opposite side of the head. Va., July 24, more, Mary- 18b4-land. Cuyler Hospi- Stallman, John H. Private. A 4th Perm. 21 Deo.ll, National, MUsile entered the right side of the frontal Winchester tal Philadel- Cavalry. 1864. Baltimore. bone near its superior margin. Evidently July 24, 1864. phia, Perm. passed through the brain, and emerged on the opposite side. Mower Hospi- Stallman, J. H. Private. A 4th Perm. 21 May 10, Cuyler, Ball passed through brain, carrying away Winchester, tal, Philadel- Cavalry. 1865. Phila., Perm. anterior portion. July .44,1864. phia, Perm. Armory Kennedy, Charles Lieutenant. I 28th Perm. 25 May 7, Hospital Missile removed the superior angle of the Chancellors- Square Hospi- Volunteers. 1863. Transport, occipital bone and the dura mater beneath, ville, Va., tal, Washing- May 2, 1863. ton, D. C. Ist Division Kennedy, Charles Lieutenant. I 28th Perm. 25 Nov. 14, Armory From Hospital, An- Volunteers. 1863. Square. furlough, napolis, Md. 13,254. U.S.A. Gene- W , Charles Private. E 14th Virginia 22 Sept. 17, Field. Missile entered the left temporal, bone one Berryville, ral Hospital, Infantry. 1864. inch from the meatus auditorius externus, Sept. 3, 1864. Frederick, Md. and penetrated the cavity of the skull, lodging on the side of the Bella turclca. Grafton Hospi- W , Charles Private. E 14th Virginia 22 Nov. 2, Frederick, tal, West Vir- Infantry. 1864. Maryland, ginia. 788. 10 GUNSHOT INJURIES OF THE HEAD. IN SURGICAL CASES ONLY. RESULT. Weapon!" TREA ™ ENT - Trans- Toother Readmit- REMARKS. Round or ESo^ iOn " D ** c ° f ™»»»» HoTpTtal. , V"' Deserted. ,°** r^ Death. F^-tough Here state cause of death, of discharge, or K Zfcarot X ht iOD opera: *° -*' *££« B ft? ° ml - nl "<* "J*"^ of transfer to Veteran Reserve Corps. Bullet, tion " " itafe. Co^ 8< C^_ y * Date. Date - — **"«• "™- Solid Shot Simple dress- n . n . Dale. „„, Bayonet, in^s " '• DaU - Date - Date - Sword. Musket A portion of the ball March, During his imprisonment he suffered from Ball. was removed from 1863. pain in the head, but had no delirium, under the integu- coma, or paralysis. Was perfectly well ment, on the field. when he rejoined his regiment. (Vide Seven months after- Special Report from Surgeon R. B. Bonwards the fistulous tecou, U.S.V. General Index A, No. 59.) orifice of the wound was dilated, depressed bone was removed, and a portion of the ball from within the cavity of the cranium. Musket Simple dressings. Dec. 10, When admitted, his bowels were consti- Ball. 1864, to pated, and nausea was almost constant. Cuyler His pulse was slow and feeble. His pupils Hospital. were constantly dilated. When discharged his mental operations seemed slow and uncertain, but there was no aberration of mind, and his memory was unimpaired. (See Report of Assistant Surgeon Schell, U.S.A.) May 10, 1865, to Mower Hospital, PhiU., Pa. May 23, 1865. Probably May 7th. Hair shay- June 20 On admission, substance of brain protruded a piece of en, water-dressings, 1863. about one inch and a half; wound was shell. cathartics, injec- about two inches long and one inch wide; tions and anodynes, pulsationwasdistinct; total loss of vision; leeches to temples pulse 60; inclined to sleep but could not ; and behind the mind dull ; partial paraplegia. May 11th. ears. May 13th. A Rests quietly but cannot sleep; has not splinter of bone slept from date of injury; no alvine evacremoved. uation. May 12th. Not so much pain. May 13th. Had four dejections. May 15th. Fungus retracted somewhat, with a healthy granulating surface; vision partially restored. June 16th. Sitting about ward, talking and laughing; fungus retracted entirely, but pulsation distinct; vision restored; pulse and bowels regular; sleeps well; intellect perfect; no pain. The wound is represented in Nos. 26 and 27 Surgical Series of Drawings, S. G. 0. Jan'yl2, • 1864. Conoidal Part of ball extracted To Graf- When admitted, patient had paralysis of MuHket from under the ton, Nov. 2, 2d, 3d, 4th, sth, 6th, and 7th nerves of the Ball. scalp in the frontal 1864. left side. No pain in the head. General region, by forceps. health of patient was good. His pulse, This fragment was skin, and bowels were natural. His conabout one-third of sciousness perfect. His articulation was the ball. thick, but improved, and after the extraction of the ball became almost natural. There was a free evacuation of pus after the operation, the pupil of the lelt eye diminished in size, and vision partially returned. Oct. 10th, 1864. Was so far recovered as to walk about and assist in nursing in the ward. If, however, he exerted himself too much he suffered from headache. While being transferred to Grafton, Va., he drank a large quantity of whiskey. The day after his arrival he had a violent chill, followed the next morning by convulsion, and strabismus of right eye; these continued during the day, and coma succeeded on the following morning, and he died without reaction. Post-mortem showed 1 the larger portion of a conoidal musket-ball resting against the sella turcica. The encephalon was extensively disorganized ; the ventricles, and nearly the whole base of the brain, balhed in pus. (Med. Dcs List, from J. H. Bartholf, A. A. Surg U.S.A.) ...-.« Nov. 6, , 1864. 20 ON SPECIAL WOUNDS AND INJURIES. GUNSHOT WOUNDS OF THE FACE. Of 4167 gunshot wounds of the face transcribed from the reports from the beginning of the war to October, 1864, there were 1579 fractures of the facial bones, and 2588 flesh wounds. Of the former 891 recovered, 107 died, and the terminations are still to be ascertained in 581 cases. Secondary haemorrhage has been the principal source of fatality in these injuries. It is a frequent complication in gunshot fractures of the facial bones; and the difficulties in securing bleeding vessels in this region are very great. Recourse has often been had to ligations of the carotid, with the result of postponing for a time the fatal event. Owing to the great vascularity and vitality of the tissues in this region, gunshot wounds of the face have commonly healed rapidly, and many creditable plastic operations for the relief of deformities following such injuries have been accomplished. Such operations are illustrated at the Army Medical Museum by numerous casts and photographs. An interesting example is the case of Private Rowland Ward, Co. E, 4th New York Heavy Artillery. A fragment of shell removed the anterior portion of the lower jaw within one inch of the ramus on both sides, destroyed the genio-hyoglossus and genio-hyoid muscles, and afforded the occasion for a very successful cheiloplastic operation by Surgeon J. C. McKee, U. S. A. (See Photographs of Surgical Cases, S. G. 0., vol. iii. p. 1, et seq.) GUNSHOT WOUNDS OF THE NECK Of the 1329 cases of this category that have been entered on the records, the ultimate results have been ascertained in 546 cases only. Time has not been found to trace the histories of many of the remaining cases. In the terminated cases, the mortality is 14 per cent. Several instances are recorded in which large grapeshot, on striking the hyoid bone, were deflected, and buried themselves in the supra-spinous fossa of the scapula, or among the muscles of the back. These patients died from laryngitis or oedema of the glottis, and might have been saved, perhaps, by tracheotomy; but they died suddenly, when surgical assistance could not be immediately procured. Wounds of the neck, with lesions of the vertebrae, are classified with fractures of the spine. There are eight examples of gunshot perforations of the larynx or trachea among the specimens at the Army Medical Museum. The series of surgical drawings includes several curious illustrations of the escape of the great blood-vessels of the neck from injury, when balls have traversed the neck directly in their course. Cases in which the great vessels were injured are classified with wounds of the arteries. GUNSHOT WOUNDS OF THE BACK AND SPINE. In this class have been included the fractures of the vertebral column which were not complicated by penetrating wounds of the chest or abdominal cavity, and flesh wounds of the region covered by the trapezius, latissimus dorsi, and gluteal muscles. 21 GUNSHOT WOUNDS OF THE CHEST. Of 187 recorded cases of gunshot fracture of the vertebrae, all but 7 proved fatal. Six of these were fractures of the transverse or spinous apophyses. The seventh case is that of a soldier wounded at Chickamauga, September 20th, 1863, by a musket-ball, which fractured the spinous process of the fourth lumbar vertebra, and penetrated to the vertebral canal. The ball and fragments of bone were extracted at a Nashville hospital. The patient was transferred to Louisville, thence to Jefferson Barracks, Missouri, thence to Madison, Indiana, and finally, on July 26th, 1864, to Quincy, Illinois. The last report states that he was likely to recover. Gunshot lesions of the vertebrae and spinal cord are illustrated at the Army Medical Museum by 66 specimens. An engraving of one of these is subjoined. Private Frederick L , Co. H, Bth New York Vols., aged twenty-six years, was wounded at Cold Harbor June 3d, 1864, and admitted into Carver Hospital, at Washington, D. C, June 11th, 1864. A conoidal musket-ball had entered the right side of his back and penetrated the vertebral canal, shattering the transverse and articular processes of the eighth and ninth dorsal vertebrae. The patient stated that, immediately upon the reception of his injury, he lost all sensation and power of motion below the wound. On admission, he was in a very feeble state; his pulse was slow, his respiration labored, his skin cool, clammy, and cyanosed, his excretions involuntary. In this wretched condition he lingered till the 27th of June, when symptoms of extreme gastric irritability supervened, and every form of nourishment was promptly rejected by the stomach. He died July 2d, 1864. At the autopsy, the spinal cord appeared to have been completely severed at the seat of injury, and was disorganized above and below. Fig. 26. — Eighth, ninth, and tenth dorsal vertebrre, with a conoidal ball in the vertebral canal. Spec. 2939, A. M. M. Five thousand one hundred and ninety-five gunshot flesh wounds of the back have been recorded, of which a large proportion are injuries from shell. Troops being often ordered to lie down under a shell fire, this region becomes particularly exposed. GUNSHOT WOUNDS OF THE CHEST. Of 7062 gunshot wounds of the chest that have been examined and transcribed from the reports belonging to the period prior to July, 1864, there were 2303 that either penetrated the thoracic cavity or were accompanied by lesions of the thoracic viscera. The results have been ascertained in 1272 of these, and were fatal in 930, or 73 per cent. The 4759 flesh wounds presented a very small ratio of mortality. It was observed, however, that they were commonly long in healing, in consequence, no doubt, of the mobility of the thoracic parietes. The cases of wounds of the lung by the sharp edges of the fractured ribs, or of contusion of the lung by non-penetrating gunshot injuries, have been recorded with the penetrating wounds. In the treatment of penetrating wounds of the chest, venesection appears to have been abandoned altogether. Haemorrhage was treated by the application of cold, perfect rest, and the administration of opium. These measures seem to have proved adequate generally, and no instances are reported of the performance of paracentesis or of the enlargement of wounds for the evacuation of effused blood. Haemorrhage from the vessels of the costal parietes has been exceedingly rare, and, in the few instances recorded, was a secondary accident. Hence the management of bleeding from wounded intercostal arteries has presented theoretical rather than practical difficulties. 22 ON SPECIAL WOUNDS AND INJURIES. It has been the common practice to remove splintered portions of fractured ribs, and to round off sharp edges that were likely to wound the pleura or lung. After this, with the exception of extracting foreign bodies whenever practicable, and performing paracentesis when empyema was developed, it has been usual to leave these cases to the natural process of cure. The records of the results of the so-called method of "hermetically sealing" gunshot penetrating wounds of the chest are sufficiently ample to warrant an unqualified condemnation of the practice. The histories of the cases in which this plan was adopted have been traced, in most instances, to their rapidly fatal conclusion. The following case is the only recorded exception : Corporal Peter Welker, Co. A, Ist U. S. Sharpshooters, was admitted July 30th, 1863, into Mount Pleasaac Hospital, at Washington, having received, at Manassas Gap, July 23d, 1863, a gunshot wound of the chest. The missile entered near the nipple, between the fourth and fifth ribs, traversed the lung, and emerged at the inferior border of the scapula, fracturing the sixth rib. Treatment : Opiates and stimulants, the wound being hermetically sealed. When admitted, the patient had much pain in the chest, and dyspnoea. The latter increased almost to suffocation, and was accompanied by fever. On July 31st, the posterior wound gave way, and a profuse discharge of clotted blood and purulent matter escaped. The next day the anterior wound was opened, and a pint of matter of similar character escaped, after which the patient became much better. He continued to improve until furloughed. On December 13th, 1863, when readmitted, he had entirely recovered. Few examples of recovery are recorded where the track of the ball passed near the root of the lung. The cases in which there was a fracture of the rib at the wound of entry were very dangerous. The established opinion, that penetrating wounds with lodgement of the ball are more fatal than perforating wounds, was amply illustrated. But very few recoveries with balls lodged in the lung are recorded, and the histories of such cases are less explicit and complete than could be desired. Private John H. Prouty, Co. G, 27th Illinois Vols., was admitted into the Sherman U. S. General Hospital, at Nashville, Tennessee, from the Field Hospital at Chattanooga, Tennessee, with gunshot wound of the thorax. He was struck in the left chest at Dallas, Georgia, May 25th, 1864, by a musket-ball, which lodged in the substance of the left lung, and was not extracted. The case progressed favorably, and on July 14th, 1864, the patient was furloughed and went to his home. Private Isaac Miller, Co. B, 139 th Pennsylvania Vols., was admitted into the Haddington General Hospital, at Philadelphia, on the 3d of August, 1864, from Fort Schuyler Hospital, New York Harbor. He was wounded at the battle of the Wilderness, May sth, 1864, by a musket-ball, which entered at the left shoulder, and passed downwards and inwards, and lodged in the left lung. He was fairly convalescent when admitted to Haddington Hospital, and ultimately regained his usual health almost, and on May 3d, 1865, was transferred to the Veteran Reserve Corps. In the following case the ball was believed to have lodged in the body of one of the upper dorsal vertebrae : Private Daniel Rich, Co. B, 55th Pennsylvania Vols., aged twenty-one, was wounded at the battle of Pocotaligo, October 22d, 1862, and was admitted to Hospital No. 1, at Beaufort, South Carolina, on October 24th. The ball had entered at the left sterno-clavicular articulation, traversed the apex of the left lung, and lodged in the vertebral column. Immediately after his injury, he had haemoptysis. He was able to walk from the field of battle to the hospital steamer, six miles distant. He stated that the wound bled very freely. When admitted to the hospital his face was dusky, his pulse accelerated, and crepitant rales were audible in the left chest. There was partial paralysis of the arms. He was ordered of a grain of tartarized antimony every two hours, low diet, and perfect quiet. On October 25th, there was less vascular excitement and less dyspnoea. The medicine had nauseated and purged the patient. There was great tenderness of the spine in the upper dorsal region, and the vertebral column was perfectly rigid. The patient would allow no one to touch him anywhere but on the head. He was lifted by his head into an upright position, like a stick. The antimony was continued till October 31st. At this date an abscess pointed over the sternum, and was evacuated by a free incision. The wounds were poulticed. On November 13th, he was allowed to sit up a portion of the time, and was much less troubled by a cough in this position. On November 20th, he began to walk about the ward, and the wounds discharged but little. On December Ist, a necrosed bit of the sternum was removed. Cerate dressings were applied to the wounds. On December 20th, erysipelas attacked the wounds GUNSHOT WOUNDS OF THE CHEST. 23 and spread over the chest. On December 28th, the patient had recovered from the erysipelas, the wounds were nearly healed, but the immobility of the spine continued. He was this day sent to a Northern hospital, on the steamer " Star of the South." He ultimately recovered, and was transferred to the First Battalion of the Veteran Reserve Corps. A photograph of the recent wound is preserved. (See Photographs of Surgical Cases, S. G. 0., vol. i. No. 47.) In the next case the ball was extracted. Nature made an effort to repair the fractured ribs, but the wound of the lung was followed by fatal suppuration. Private S B , Co. A, 83d New York Vols., was wounded at the battle of Fredericksburg, and was admitted into the Lincoln Hospital, at Washington, December 23d,. 1862. He had been struck by a conoidal musket-ball in the back of the right chest, the ball entering over the attachment of the eleventh rib, and passing forwards. The ball was extracted and simple dressings were applied. Pleuro-pneumonia ensued, and resulted in empyema. On January 3d, 1863, a pint of pus was evacuated from the pleural cavity. The case terminated fatally on January 21st, J863. The specimen was contributed by Surgeon H. Bryant, U. S. Vols., and the particulars of the case were furnished by Surgeon J. Cooper McKee, U. S. A. At FIG. of the eleventh and twelfth ribs of the right side, exhibiting gunshot fractures of the shafts with attempts at reparation. Spec. 845, a. the point of fracture, necrosed splinters are seen, attached by large irregular formations of callus. A remarkable recovery is recorded, in a case in which the anterior mediastinum was opened. Private Charles P. Betts, Co. I, 26th New Jersey Vols., aged twenty-two, was struck by a three-ounce grapeshot, on the morning of May 3d, 1863, in a charge upon the heights of Fredericksburg. The ball comminuted the sternum, at the level of the third rib, on the left side, and tore through the costal pleura. It remained in the wound and was removed by the patient. On the following day, Betts entered the hospital of the Second Division of the Sixth Corps. Through the wound the arch of the aorta was distinctly visible, and its pulsations could be counted. The left lung was collapsed. When sitting up there was but slight dyspnoea. Several fragments of the sternum were removed, and the wound soon granulated kindly. On May 10th, a colored drawing of the wound was made. (No. 19, Surgical Series of Drawings, S. G. O.) On July sth, the patient was transferred to Washington, convalescent. He ultimately recovered perfectly. The result was less favorable in the next case. Private Patrick H. B , Co. C, 147 th Pennsylvania Vols., was wounded at Chancellorsville, May 2d, 1863, by a conoidal musket-ball, which entered between the second and third ribs, on the right side, two inches from the median line, fractured the sternum, and lodged beneath it. The wound bled profusely, but the haemorrhage was arrested by pressure. The patient was conveyed to Douglas Hospital, at Washington, on May Bth, and died the following day. He had haemoptysis and the symptoms of traumatic pneumonia. Only four cases are recorded of gunshot wounds of the heart that came under treatment. The specimens from these four cases are preserved in the Army Medical Museum. The patient that lived longest after a gunshot wound of the heart survived twelve hours (Spec. 837, A. M. M.). In this case a small pistol-shot entered the left ventricle and passed out through the right auricle. Fio. 28. — Sternum, showing a gunshot fracture by a musket-dull. The misshapen, battered ball is attached. S/nr. 1073, A. M. M. Not a few cases are recorded ot gunshot wounds involving both the thoracic and abdominal cavities. Among them occur the following remarkable instances of recovery from this formidable kind of injury : Lieutenant Daniel B , 63d New York Vols., was wounded at Gettysburg, July 2d, 1863, by a conoidal musket- ball, which passed through the belly of the biceps of the right arm, entered the chest, traversed the base of the right lung and diaphragm, wounded the intestines, and passed out above the anterior superior spinous process of the left ilium. When admitted to the field hospital, he had dyspnoea and bloody sputa, and there was a faecal discharge from the wound of exit. He was treated by large doses of opium, and, at the end of three weeks, convalescence was fairly established. In the course of a few months his wounds had entirely closed, and he rejoined his regiment for duty. 24 ON SPECIAL WOUNDS AND INJURIES. Captain Robert S , Co. A, 29th New York Vols., was wounded at Chancellorsville, on the 2d of May, 1863. A round musket-ball, fired from a distance of about one hundred and fifty yards, entered the eighth intercostal space of the left side, at a point nine and a half inches to the left of the extremity of the ensiform cartilage, and fractured the ninth rib. Without wounding the lung apparently, the ball passed through the diaphragm, and entered some portion of the alimentary canal. Captain S walked a mile and a half to the rear, and entered a field hospital. On examining his wound, the surgeons found a protrusion of the lung of the size of a small orange, which they unavailingly attempted to reduce. The wound was enlarged, and still it was impracticable to replace the protruded lung. On May 3d, the field hospital where Captain S lay was exposed to the enemy's fire. He walked half a mile further to the rear, and was there placed in an ambulance, and taken across the Rappahannock, at United States Ford, to one of the base hospitals. Here fruitless efforts were again made to reduce the hernial tumor, after which a ligature was thrown around its base and tightened. A day or two subsequently the patient passed into the hands of Surgeon Tomaine, who removed the ligature from the base of the tumor. A small portion of gangrenous lung separated and left a clean granulating surface beneath. On May 7th, the ball was voided at stool. On May Bth, the patient was visited by Surgeon John H. Brinton, U. S. Vols., who found him walking about the ward, smoking a cigar. There was an entire absence of general constitutional symptoms ; no cough, no dyspnoea, no abdominal pain ; the bowels were regular and appetite good. The protruding portion of the lung was carnified, and there was a dullness on percussion and absence of the respiratory murmur in a zone an inch and a half in width around the circumference of the base of the tumor. Surgeon Tomaine stated that the hernia had been gradually diminishing in volume. It was at this date half the size of an egg, and covered with florid granulations. On May 10th, a drawing of the parts was executed by Mr. Stauch, artist of the Army Medical Museum. On June 2d, Captain S was transferred to Washington. There was an elastic partly reducible tumor, over which was an oval granulating surface, an inch and a half by three-quarters of an inch. The vesicular murmur was perfect throughout the lung, except in the immediate vicinity of the tumor. Compression of the tumor was advised. After a furlough of sixty days, Captain S was again examined. The wound had entirely healed ; the respiratory sounds were normal ; there was still a slight hernia of the lung. The general health of the patient was excellent. At this date a second drawing was executed. Private B. S. Sheridan, Co. A, 9th Massachusetts Vols., was wounded at Malvern Hill, July Ist, 1862, by a musket-ball, which entered the right side between the ninth and tenth ribs, and passed out a little to the right of the xyphoid cartilage. Soon after the reception of the injury, a portion of the lung protruded from the anterior wound, and from the posterior wound there was a constant dripping of bile. On July 4th, Sheridan walked from the ambulance station to James River, a distance of a mile and a half, with the hope of getting on board of a gunboat. He was disappointed, and was taken prisoner and conveyed to Richmond. No dressings were applied to the hernia of the lung. It was uncovered, and the patient occasionally washed it. He suffered little pain or dyspnoea, and there was an amazing absence of shock or prostration. On July 25th, the bile had ceased to dribble from the posterior wound, and the hernia of the lung had greatly receded. The imperfect field notes state that the patient ultimately recovered, and was exchanged. Private Latimer Whipple, Co. H, 73d New York Vols., was wounded at Bristoe Station, Virginia, August 27th, 1862, and admitted to the First Division Hospital, at Alexandria, on August 31st. A musket-ball struck him on the right side, four inches above the crest of the ilium, and six inches from the spine, passed upwards and inwards, and lodged. On admission, the patient had cough, with bloody expectoration, and crepitant rales in the lower lobe of the left lung. There was a profuse discharge of bile from the wound. There was acute pain and tenderness in the hepatic region, but no evidence of peritonitis. At the end of a week the symptoms of acute inflammation of the lung subsided, but a cough, with purulent expectoration, persisted for months. Early in October the discharge of pus and bile from the wound began to diminish, and in November the pain ceased in the hepatic region, and was referred to the immediate vicinity of the orifice of the wound. The patient now began to walk about the ward. Throughout the treatment there was great tendency to constipation, which was obviated by enemata. In the middle of December the cough had nearly disappeared, and there was but a scanty discharge from the wound. On January 12th, 1863, the wound was entirely healed, and the patient was discharged from service. GUNSHOT WOUNDS OF THE ABDOMEN. Of 2707 gunshot wounds of the abdomen reported from the beginning of the war to July Ist, 1864, there were 2164 flesh wounds, and 543 cases in -which the peritoneal cavity was penetrated or the abdominal viscera injured. Among the flesh wounds, 114 fatal cases are recorded, which were, in most instances, cases of sloughing from injuries of the abdominal parietes by shells. Of the 543 penetrating wounds, the results have been ascertained in 414, and were fatal in 308, or 74 per cent. The number of recoveries GUNSHOT WOUNDS OF THE ABDOMEN. 25 is unexpectedly large, but includes only cases in which the reports showed, beyond question, that the abdominal cavity had been involved. Abstracts of several such cases are subjoined: Private John Barr, Co. E, 76th New York Vols., aged forty- five years, was admitted into Douglas Hospital, at Washington, May 18th, 1864, with a penetrating gunshot wound of the abdomen, received on May 9th, at the battle of the Wilderness. A conoidal musket-ball had entered at the junction of the left twelfth rib with its cartilage, and, passing downwards, backwards, and outwards through the ilium, lodged in the gluteal muscles, whence it was removed by incision. On admission, the wound copiously discharged a thin translucent fluid, resembling diluted bile, which evidently came from the small intestine, for, among other reasons, it had no faecal odor. Were further proof of the origin of the discharge required, it would be furnished by the fact that three ascarides lumbricoides escaped from the wound during the second and third weeks of the treatment. The discharge, for nine days prior to admission, was, according to the patient, similar to that above noted. The patient was kept perfectly quiet in a recumbent posture. The discharge from the wound was facilitated by large masses of charpie being used to absorb it. For several weeks the patient was nourished solely by milk, milk-punch, and beef tea. His appetite was poor, his sleep much disturbed by cough. But there was no abdominal pain or tenderness, and at no time, throughout the treatment, was there any symptom of peritoneal inflammation. On May 22d, a soap and water enema was administered without result. Nothing more was attempted in this direction, as the patient was doing well, and nature seemed competent to meet every indication. On June 3d, the discharge had entirely ceased, and the patient was much improved. On June 6th, he had a large alvine evacuation, the first since May 9th. On June 11th, with the aid of an enema, he had another large dejection. From this time he improved rapidly. On August 16th, a fragment of necrosed bone, that could be recognized as a portion of the ilium, was removed from the wound in the gluteal region. About the same period bits of necrosed cartilage were taken from the fistulous orifices opening near the wound of entrance. The bowels were disposed to costiveness, and flatulence was troublesome. Early in October there was an attack of dysentery, which lasted one week. On May sth, 1865, a needle-shaped bit of bone escaped from the wound of entrance. On May Bth, both wounds were entirely healed. On July 16th, the patient was photographed at the Army Medical Museum. He was then in good health. Private George H. Bowers, Bth Illinois Cavalry, was wounded in a skirmish near Frederick, Maryland, September 13th, 1862, by a musket-ball, which entered two inches above the umbilicus, an inch to the left of the linea alba, and made its exit beneath the tenth rib, three inches to the left of the spinous process of the tenth dorsal vertebra. Immediately after he was shot, he vomited blood copiously until syncope supervened. Haematemesis recurred frequently for seven days, and blood was passed at stool. Acute peritonitis ensued. The medical attendants had no doubt that the stomach was perforated. Liquids taken into the stomach passed freely through the anterior wound. The case was treated by opium in large doses. In May, 1863, the patient was transferred to the hospital at Stewart's Mansion, in Baltimore. The wound had healed, and the digestive organs had resumed their normal action. But the body was bent forward by intra-abdominal adhesions. The patient was subsequently discharged from service. In many instances faecal fistuloa were produced. They commonly closed after a time, without operative interference, reopening at intervals, and then healing permanently. Sergeant Lewis E. Morley, Co. F, 61st New York Vols., was wounded at Gettysburg, July Ist, 1863, by a conoidal musket-ball, which entered a little below the umbilicus and to the left of the linea alba, and passed directly through the body, dividing the intestine in its passage. When brought to the field hospital he was in a state of collapse. Faeces escaped from the wound. There was excessive tenderness and pain. Opiates were freely administered, and the symptoms of peritonitis gradually abated. On July 10th, the patient was in a condition to be removed to Baltimore. The discharge of faeces from Ihe wounds continued until September 28th, when there was an evacuation by the rectum. The wounds soon afterwards closed, and on October 27th, the patient was sent home on furlough. Private A. J. Marker, Co. I, 4th Maine Vols., aged eighteen years, was wounded at Centreville, September Ist, 1862, by a conoidal musket-ball, which entered the left hypochondriac region, between the eighth and ninth ribs, and lodged under the skin a little to the left of the spinous process of the second lumbar vertebra. He entered Epiphany Hospital, at Washington, on the following day, and the ball was removed by an incision. There was immediately a copious faecal discharge through the incision. It was ascertained that the ninth rib was fractured, and fragments of it were removed. On September sth, a portion of gangrenous omentum presented at the posterior wound and was excised. A sphacelated portion of the descending colon was also removed. The faecal fistula persisted until May, 1863, when the discharge from the anterior wound became sero-purulent. A month afterwards both wounds healed up soundly, and the patient was sent to his home in Belfast, Maine. In November, 1863, while the wounds were still discharging stercoraceous matter, a colored drawing was made, which is No. 15 of the Surgical Series of Drawings, S. G. 0. Private John Harm, Co. I, 20th Indiana Vols., was wounded at the battle of Fair Oaks, May 31st, 1862, by a 4 26 ON SPECIAL WOUNDS AND INJURIES. musket-ball, which entered three inches to the right of the spine and one inch above the crest of the ilium, and, passing upwards across the abdominal cavity, made its exit in the left hypochondriac region. He was admitted to Broad and Cherry Streets Hospital, in Philadelphia, on July 29th, 1862. He stated that there was free haemorrhage from the wounds at first, and subsequently a discharge of faeces. At the date of his admission, the wound of exit had closed; but faeces and flatus still escaped by the posterior wound. At the end of October, 1862, this wound also closed; but it reopened a few weeks subsequently, and a fragment of flannel was extracted from it. After this it healed soundly, and the patient was discharged from service. Private Franklin Harsh, Co. G, 7th Ohio Vols.. was wounded at Chancellorsville, May 3d, 1863, by a conoidal musket-ball, which entered the abdomen six inches to the right of the umbilicus, and passed out posteriorly, having wounded the ascending colon and the crest of the right ilium. He was admitted to Armory Square Hospital, at "Washington, and remained there for a long time with a faecal fistula. On September 13th, 1863, the anterior wound had closed, and the discharge from the posterior wound was much diminished. Ultimately the fistula closed, and the patient was discharged from service. Early in the history of the case, a colored drawing of the patient was made. (Nos. 21 and 22, Surgical Series of Drawings, S. G. 0.) Sergeant Joseph E. Fletcher, Co. D, Bth Connecticut Vols., aged twenty, was struck at the battle of Antietam, September 17th, 1862, by a musket-ball, which entered six inches to the left of the umbilicus, and, passing somewhat downwards, emerged an inch and a half to the left of the spine. The ball opened the descending colon, and when the patient was examined by Surgeon T. H. Squire, 89th New York Vols , there was a profuse faecal discharge from the wound of exit. The ensuing peritonitis was circumscribed, and the patient was transferred to Frederick, a few weeks subsequently, in a satisfactory condition. The faecal fistula finally closed and the patient recovered. Lieutenant G. P. Deichler, Co. I, 69th Pennsylvania Vols., aged twenty-two years, was wounded by a conoidal musket-ball, at Hatcher's Eun, Virginia, in March, 1865. The ball entered the right iliac region, and, passing through the ascending colon, made its exit a little to the left of the last dorsal vertebra. The patient was taken to a field hospital, and from thence to Armory Square Hospital, at Washington, where he was admitted on April Ist, in an exhausted condition, with grave symptoms of peritonitis. There was a copious faecal discharge from both wounds. Appropriate dressings were applied, a fourth of a grain of sulphate of morphia was ordered to be given every second hour, and stimulants were directed. On April 7th, sloughs separated from both wounds, and left a clean granulating surface. A large piece of sphacelated omentum was removed from the anterior wound. The opiate treatment was continued till April 27th, when there was a faecal evacuation by the anus, for the first time since the injury. On June 12th, the discharge from the wounds was very slight. The edges of the wounds were now refreshed and approximated by adhesive strips. On August 10th, the anterior wound was firmly healed. There was a small fistulous sinus at the posterior wound, discharging pus scantily. On this day, a photograph was taken at the Army Medical Museum, from which the plate opposite is copied, and the patient left the hospital for his home in excellent general health. Private Eobert Brierly, Co. A, Ist Delaware Vols., aged twenty-two, was wounded at the battle of Antietam, by a conoidal musket-ball, which entered a little to the left of the umbilicus, and lodged under the muscles near the anterior superior spinous process of the right ilium. There was great prostration, with nausea and vomiting, which were treated at the field hospital by the administration of opiates. Three weeks subsequently, the patient was transferred to Frederick, Maryland. On October 25th, faeces escaped through the lower wound, which had been for several days in a sloughing state. The artificial anus continued open until November 15th. On November 25th and December 11th, there were attacks of colic, followed by reopening of the faecal fistula. By the end of December, the wounds appeared sound and permanently healed, and the patient was transferred to Baltimore, and subsequently was discharged from service. Private James T. Dowdy, 28th Virginia (Rebel) Regiment, aged twenty-three years, was wounded at the battle of Gettysburg, July 3d, 1863, by a conoidal musket-ball, which entered at the tip of the ensiform cartilage, and remained in the body. He was removed to one of the Gettysburg field hospitals. On July 4th, fourteen hours after he was shot, he passed the ball at stool. There was no general peritonitis, and the wound healed promptly, and the patient was transferred to Baltimore, and thence sent to City Point, Virginia, for exchange. Recoveries after wounds of the large intestines have been much more numerous No case has been reported in which it was thought expedient to apply a suture to the intestines after gunshot wounds. Gunshot wounds of the liver were usually followed by extravasation into the abdominal cavity and rapidly fatal peritonitis. Of 32 cases in which the diagnosis was unquestionable, all but 4 terminated fatally. Abstracts of two of the fortunate cases are appended : Private Fritz Sicbel, Co. D, 139 th New York Vols., aged twenty-three years, was wounded at Cold Harbor, •* r.S/NCLAfHS LITH PH/L W BELL, DEL PERFORATING GUNSHOT WOUND OF THE ABDOMEN. CASE OF LIEUTENANT DEICHLER. % PERFORATING GUNSHOT WOUND OF THE ABDOMEN CASE OF LIEUTENANT DEICHLER 27 GUNSHOT WOUNDS OF THE ABDOMEN. Virginia, June 3d, 1863, by a musket-ball, which entered the right hypochondriac region, below the tenth rib, and passed out posteriorly an inch and a half to. the right of the spine. He was admitted to Hare wood Hospital, at Washington, on June 18th, in a very feeble state. There was a faecal discharge from the wound, mixed with bile. The ball had passed through the colon and the liver. There was great abdominal pain, aa anxious countenance, nausea, and the other symptoms of traumatic peritonitis. A cold water-dressing was applied, and opium was administered in full doses. On July Ist, the pain on pressure was circumscribed, and the general symptoms were less threatening. The discharge from the wound was unaltered. On September Ist, the wound of exit had healed, and the anterior wound discharged only a thin serum. On September 14th, the wound of entrance closed. The patient was furloughed on October Bth, 1863, and on the expiration of his furlough was returned to duty. Corporal W. A. 0. Biles, Co. X, 25th North Carolina (Kebel) Regiment, was wounded at Gettysburg, July 3d, 1863, by a conoidal musket-ball, which passed through the lower portion of the right lobe of the liver. He was treated at one of the field hospitals at Gettysburg, and his case was carefully observed by Surgeon H. Janes, U. S. Vols. There was a free discharge of bile from both the wound of entry and of exit. There was circumscribed pain and tenderness on pressure, but apparently no extra-abdominal extravasation. The wounds continued to discharge bile until August. 27th. On November Ist, the patient was transferred to West's Buildings Hospital, at Baltimore, and on November 12th, 1863, he was sent to City Point, Virginia, for exchange, his wound being entirely healed. All the cases of gunshot wounds of the spleen that have been reported, were fatal. No symptoms are mentioned that particularly distinguished these from other gunshot injuries involving the abdominal cavity, and it is quite possible that the list of recoveries may include cases in which this viscus was injured, though the diagnosis was not made out. A case is recorded of a lacerated wound of the abdominal walls, with lesion and protrusion of the pancreas, a portion of which is reported to have been excised. It appears probable that it was rather a portion of the omentum that was removed. Several cases are reported in which it was believed that recovery took place after gunshot wounds of the kidney : Private Groff, Co. D, 61st Pennsylvania Vols., was admitted on June Bth, 1862, to Fifth Street Hospital, in Philadelphia, for wounds received at the battle of Fair Oaks, June Ist, 1862. He had a flesh wound of the left hip, another of the right thigh, and a wound in the left lumbar region, which was considered to be a penetrating wound of the abdomen. Immediately after he was struck, blood passed freely by the urethra. When he entered the hospital, he had haematuria. His wounds healed, however, kindly, and he left the hospital entirely well. Sergeant Galloway, Co. H, Bth Pennsylvania Reserves, was wounded at South Mountain, September 14th, 1862, by a musket-ball, which passed through the abdomen. He was treated at Satterlee Hospital, in Philadelphia. He had haematuria, and pain and tenderness in the region of the left kidney. He ultimately recovered. It can hardly be considered that the evidence of gunshot wound of the kidney was, in these cases, unequivocal. Gunshot wounds of the bladder, when the projectile entered above the pubes or through the pelvic bones, have proved fatal, so far as the records have been examined. There are many examples of recovery, however, from injuries of the parts of the bladder uncovered by the peritonceum. Several examples of recovery, after protrusions of the abdominal viscera through gunshot wounds, have been reported. In two cases in which loops of small intestine issued, they were immediately returned and retained by means of adhesive strips and bandages, and the patients recovered with ventral hernia. The escape of omentum, through wounds, would, not appear to be a very serious complication, for in many cases portions of protruding omentum have been excised, and the patients have, nevertheless, recovered promptly. In relation to gunshot wounds of the great vessels of the abdomen, a few words will be said in treating of ligations. Penetrating wounds of the abdomen, complicated with fractures of the vertebras, 28 ON SPECIAL WOUNDS AND INJURIES. uniformly proved fatal. A single extract will suffice to show the usual progress of such cases. Fin. 29.— Gunshot fracture of tho second and third lumbar vertebras. Spec. 3583, A.M. M. Corporal John E , Co. M, 14th New York Heavy Artillery, was wounded before Petersburg, in July, 1864. He was sent to "Washington, and admitted to Douglas Hospital, with peritonitis and complete paraplegia. A musket-ball had entered at the right hypochondriac region, passed downwards through the right lobe of the liver and the abdominal cavity, and fractured the second and third lumbar vertebrae. He died on August 3d, 1864. At the Army Medical Museum are specimens of 18 gunshot wounds of the stomach or intestines, 10 of the liver, 8 of the spleen, 10 of the kidneys, 4 of the bladder, and 6 of the genitourinary organs. GUNSHOT FRACTURES OF THE PELVIS The records under this head include only the cases in which the abdominal cavity was not penetrated. From the beginning of the war to October Ist, 1864, 359 such cases have been reported. Recovery took place in 97, death in 77, and the result is still to be ascertained in 185. In 256 cases the ilium alone was injured, the ischium alone in 19, the pubes in 12, the sacrum in 32, and in 40 cases the lesions extended to two or more portions of the innominata. The gravity of these cases depended upon the location and extent of the fracture. The majority of recoveries were from fracture of the ilium by musket-balls, in which the crest was grooved, or comparatively slight injury was inflicted. Yet there were many examples of perforation of the body of the ilium with ultimate recovery. The following is an abstract of such a case : Major H. A. Barnum, 12th New York Vols., was wounded at Malvern Hill, July Ist, 1862, by a conoidal musketball, which entered midway between the umbilicus and the anterior superior spinous process of the left ilium, passed through the middle of the ilium, and emerged posteriorly. On July 2d, he was captured and taken to Libby Prison, a distance of eighteen miles, in an express wagon. On July 17th, he was taken to Aikens' Landing in an ambulance, a distance of seventeen miles, and exchanged. He was conveyed by water to Albany, and thence by rail to Syracuse, New York. At no time were any symptoms of peritonitis manifested. On October Ist, Major Barnum went to Albany, where Dr. March dilated the anterior wound by an incision and extracted several fragments of the ilium, and directed that a tent should be worn. Promoted to the command of the 149 th New York Vols., Colonel Barnum took the field in January, 1863. He wore the tent about a month, when the anterior wound healed. About the middle of March, a large abscess formed, and evacuated itself at the site of the anterior wound. In April, Dr. March again cut down to the ilium, and introduced a tent. No loose fragments of bone were found. The Colonel resumed his duties, and commanded his regiment at Gettysburg. In January, 1864, another large abscess formed, and discharged posteriorly. The orifice was enlarged by Dr. L. A. Sayre, of New York, and a seton of oakum was passed from before backwards through the entire track of the ball. This was worn for several weeks, when Surgeon M. K. Hogan, U. S. Vols., substituted a seton of candle-wick, which was gradually reduced in size, and finally replaced by a single linen thread. A photograph of the patient was taken at the Army Medical Museum in August, 1865. The wound still discharged slightly, and the thread seton was still worn. Promoted to be a brigade commander, General Barnum has been almost continually in the field for the past two years. He participated in the campaigns of Atlanta, Georgia, and Carolina, was shot through the right forearm at Kenesaw Mountain, and received a shell wound of the side at Peach Tree Creek. In most cases of injury of the pelvic bones, very tedious suppuration ensued, and surgery could do but little, except to facilitate the escape of pus, and to remove dead bone as it became separated. The returns corroborate the observation of Stromeyer, that there is a great liability to pysemia in gunshot fractures of the pelvis. 29 GUNSHOT WOUNDS OF THE UPPER EXTREMITIES. GUNSHOT WOUNDS OF THE GENITOURINARY ORGANS. In this category are included gunshot wounds of the genitals or urinary organs that are not complicated with fractures of the pelvis, or with penetration of the abdominal cavity. To October Ist, 1864, the reports furnish 457 such wounds, of which 37 had a fatal result. Surgeon S. W. Gross, U. S. Vols., reports the singular history of a soldier of the 16th U. S. Infantry, struck at Shiloh, on the right side of the penis, by a conoidal musket-ball, which buried itself in the corpus cavernosum, and became encysted. It gave no pain, and the patient refused to have it extracted. The following is an interesting case of gunshot wound ot the bladder : Private Conrad L , Co. A, 23d Indiana Vols., aged thirty-two years, was wounded at Vicksburg, Miss., June 23d, 1863, by a fragment of a hand-grenade, which entered the right nates two inches outside of the end of the coccyx, and passed into the bladder, where it lodged. Urine passed -rn^^s^v by the wound immediately after its reception. The patient was admitted into the General Hospital at Jefferson Barracks, Missouri, August sth, 1863. His general health was much impaired. The urine passed mainly by the wound, and was largely mixed with pus and blood. The treatment directed comprised warm fomentations, mild diuretics, stimulants, and nutritious diet. On February 20th, 1864, a catheter was with much difficulty passed by the urethra, and the presence of a foreign body was ascertained. Fl ?- 30.— Fragment of p-onade inenuted with oalon" • ' " b J lous matter, extracted from the bladder by lithotomy. On March 19th, the general condition was improved, the wound was so far Spec.ss, a. m. m. closed as to admit only a large sized probe. Attempts to pass a catheter or to probe the wound caused chills and febrile irritation. On April 2d, 1864, the lateral operation of lithotomy was performed by Surgeon John F. Eandolph, U. S. A., the patient being anaesthetized by equal parts by bulk of chloroform and ether. A rectangular fragment of shell, largely incrusted with earthy phosphates, was extracted. It was two inches in length, seven-eighths of an inch in width, and three-eighths of an inch in thickness. It weighed two ounces and five grains troy. On April 12th, the urine passed by the wound. On April 27th, the wound had healed, and the patient was soon afterwards restored to his ordinary condition of health. The incrusted fragment of shell is preserved in the collection of the Army Medical Museum (Spec. 88). It weighs 898 grains, portions of the phosphatic deposit having crumbled away. GUNSHOT WOUNDS OP THE UPPER EXTREMITIES. When unaccompanied by lesions of the vessels and nerves, the gunshot flesh wounds of the upper extremity are not very serious injuries. All foreign bodies having been extracted, they commonly heal, under the use of water- dressings and the lightest bandaging, in a few weeks. The 21,248 cases entered on the registers are all copied from the reports for the last quarter of 1863 and the first two quarters of 1864. The gunshot fractures of the upper extremity are recorded in four classes: those of the scapuia and clavicle, which are not, at the same time, penetrating wounds of the chest; those of the shaft of the humerus and either of its articular extremities; those of the ulna and radius; and those of the carpus and metacarpus. It is only with the second class that much progress has been made. This comprises 2408 cases of gunshot fractures of the humerus that have been examined and recorded. Recovery followed in 1253 cases, death in 436, and the result is as yet undetermined in 719 cases. In the 1689 completed cases, amputation or excision were practised in 996, and conservative treatment was adopted in 693, with a ratio of mortality of 21 per cent, in the former and 30 per cent, in the latter. But it is premature to make deductions from statistics which are daily augmenting and tending towards completion. • 30 ON SPECIAL WOUNDS AND INJURIES Gunshot lesions of the upper extremity are illustrated at the Army Medical Mv scum by 978 specimens, including examples of almost every variety of contusion and fracture, of the repair of fractures, of consecutive diseases of bones, and of excisions, amputations, and their secondary lesions. A few specimens are copied here. Private William F , Co. F, 18th Massachusetts Vols., aged thirty years, was wounded at the second battle of Bull Eun, August 30th, 1862, by a conoidal musket-ball, which entered to the left of the spinal column, and, passing outwards, traversed the body of the scapula and the muscles of the upper part of the arm. The patient was conveyed to Union Chapel Hospital, at Alexandria. On the 3d, and again on the sth of September, misshapen pieces of ball and a few fragments of bone were extracted through an incision on the outer edge of the scapula. On Septem- Fio. 31. — Left scapula, showing a gunshot fracture, • i ii" jl *i -c t A nearly parallel with the spine of the scapula, with two ber 19th, symptoms of purulent infection were manifested fragments of a conoidal musket-bail. Spec. 809, A. An active treatment by st im U lants, quinia, iron, and am monia, was instituted, but unavailingly, and on September 25th, 1862, the case terminated fatally. At the autopsy, a large collection of extravasated blood was found beneath the scapula, and between the muscles of the shoulder. There was extensive serous effusion in the left pleural cavity, and numerous metastatic foci in both lungs. A soldier of the 2d Division of the 12th Army Corps had his left arm shattered by an elongated musket-ball, in the attack on the stone wall on the heights at Fredericksburg, December 14th, 1862. Primary amputation at the shoulder-joint was performed, and the patient recovered. The specimen illustrates the ordinary longitudinal splitting produced by a conoidal ball in the shaft of a long bone. Private B W , Co. I, 37th New York Vols., aged twenty-two years, was wounded at Williamsburg, Virginia, May sth, 1862, in the right elbow, by a conoidal musket-ball. A simple dressing was applied, and he was re moved to Yorktown, and thence to Phil adelphia, where he was admitted to Eace Street Hospital. No report could be ob tamed of the progress of the case until FlO. 32.— Left hu- merus, comminu- March 13th, 1863, when the patient was ted by a conoidal Fw. 33.-Necrosi 8 of the shaft of the humerus, following a gunshot wound of transferred to the McClellan General «"| ke A t - b ""- 1^' ec ecthe elbow, spec. 2749, a. m. m. Hospital, at Nicetown, with extensive necrosis of the shaft of the humerus and caries of the elbow-joint. About the joint and arm there were numerous sinuses, through which a profuse purulent discharge escaped, and, occasionally, small fragments of detached bone. Under a supporting treatment, the general condition improved. About the middle of July, it was first noticed that the patient's legs were cudematous. General anasarca ensued, and an examination of the urine showed that it was highly albuminous. The patient became rapidly worse, «,nd on August 12th, an uncontrollable diarrhoea set in, accompanied by vomiting. The case terminated fatally, August 22d, 1863. The characteristic lesions of Bright's disease were revealed by the autopsy. GUNSHOT WOUNDS OF THE LOWER EXTREMITIES. Of these, 30,014 cases have been recorded, of which 4862 were fractures, and 25,152 were flesh wounds. The latter were transcribed from the reports from October Ist, 1863, to October Ist, 1864. It has not been practicable as yet to tabulate the flesh wounds of the lower extremities that occurred in the earlier part of the war. For gunshot fractures of the femur, two registers have been kept. On one, all cases were entered. On the other, only those in which the histories of the cases had been carefully scrutinized, and in which the locality and extent of the injury were clearly designated in the reports. In the latter register 1823 cases had been entered on September Ist, 1865, or about one-third of the total number that have been reported. GUNSHOT WOUNDS OF THE LOWER EXTREMITIES. 31 Gunshot wounds of the knee-joint, with or without fracture of the patella, or of the epiphyses of the femur or tibia, have been recorded in like manner, to the number, thus far, of 1183. Of the 1823 cases of gunshot fracture of the femur that have been entered on the permanent records, the results have been ascertained in 1233. Of the 1183 cases of gunshot wounds of the knee-joint, the results are known in 740. While it is deemed premature to discuss these results when it may be reasonably hoped that the completed statistics will definitely settle the important questions that are here involved, it is yet thought expedient to report them, chiefly that the magnitude of the subject may be put in evidence, and that the absolute necessity for long and patient investigation may be acknowledged. The following table exhibits at a glance the results of 2003 cases of gunshot fracture of the femur, or of gunshot wounds of the knee-joint, out of a total of 3106 cases hitherto recorded. The fractures of the femur are separated according to regions. The left hand column gives the number of cases belonging to each region of which the ultimate results have been satisfactorily determined. The right hand column gives the total number of cases of injuries of each region that have been recorded. The intermediate columns give the comparative results of treatment by amputation, excision, or attempt at conservation of the limb, the number of recoveries and deaths and unfinished cases in each category being mentioned, and the rate of mortality calculated for the finished cases alone. Table, exhibiting the Results of 2003 Terminated Cases of Gunshot Fracture of the Femur, or of Gunshot Wounds of the Knee- Joint, out of 3106 Cases that have been entered on the Records. Amputation. Exciaiorr. Conservative Measures. ToTAI - -s-l "S si "2 ii ago«e- TEEMIN - . « 2-S . .2 2£ . a 2^ gate. ATED> 1 § -&§ "g g £?S 1 g I 1!I 1 ! s • ¦§ s I " • "isi *- • ¦§ 3 § M fi U S-S « ft 0 S-a M fi P By a conoidal ball. Sj>ec. 505, A. M. M. the femur by the conoidal musket-ball, the following is a fair example : Private John Draker, Co. I, 57th Pennsylvania Yols., aged twenty-five years, was wounded while on picket duty on the Rapidan, November 27th, 1863. A conoidal musket-ball passed through the muscles of the right thigh, and, entering the middle of the left thigh at its inner side, flattened itself against the femur, and shattered the bone. The patient was transferred to Alexandria by rail, and admitted, December 4th, 1863, to the Second Division U. S. A. General Hospital. He died December 13th, 1863. The later writers on military surgery have duly insisted upon the different effect upon bones of the impact of round musket-balls and of the cylindroconical projectiles. The degree of difference in the injuries inflicted has, perhaps, been exaggerated. It Fig. 35.— Fracture of the shaft of the left femur by a musketball. Spec 1907, A. M. M. is unquestionably true, however, that the round ball usually produces much less longitudinal splintering than the conoidal ball, with its greater weight and immense force of propulsion and wedge-like action. In the case which furnished Specimen 3228, A. M. M., where a round ball entering the outer condyle Fia. 37.— Condyle of left femur nearly piuiurnted by a round niuakct-l>all. Spec. 3228, A. M. M. 6 Private Samuel S. Kopp, Co. B, 10th Pennsylvania Reserves, was shot through the lower third of the right thigh, by a musket-ball, at the second battle of Bull Run, August 28th, 1862. The ball entered just above the patella, and made its exit in the popliteal space. The patient was taken, after a few days, to Alexandria. On September 20th, 1862, his thigh was amputated at the middle. He survived the operation two days. F^n™^^&.%^e! behind, passed upwards, forwards, and inwards through the bone, it was practicable to amputate successfully much nearer the track of the ball than would have been admissible in the case quoted just before. One curious effect, occasionally produced by the heavy conoidal ball in striking the femur, has not been very generally noticed. ball m striking the femur, has not been very generally noticed. The bone is fissured and comminuted, though less than is common, Just above the condyles, where the cancellated structure of bone predominates, musket-balls often make a clean perforation. But the wedge-like action of the elongated musket-ball almost invariably involves longitudinal splintering. The following is a good illustration : 34 GUNSHOT WOUNDS OF THE LOWER EXTREMITIES. at the point at which the ball impinges, while at two or three inches above or below this point, according as the point of impact is below or above the middle of the shaft, a nearly transverse fracture of the shaft is produced. The accompanying figure is an example; but the Museum contains dozen better illustrations. The best are of cases in which a ball has struck the condyles anteriorly, and the shaft is snapped across two inches above. In several of these specimens, the transverse fracture is not connected by fissures with the comminuted fracture produced by the ball. It appears that these injuries were produced by balls fired at short range. When the femur is simply contused by a ball, a limited necrosis commonly ensues from the destruction of the periosteum, and inflammation of the medullary cavity often results, and death from pyaemic infection. The records would indicate that gunshot contusions of the Fio. 38. — Fracture of the upper third of the left femur by a conoidal musket-ball. Spec. 1148, A. M. M. long bones, a subject ably discussed* of late by Surgeon J. A. Lidell, U. S. Vols., are Private Orson B. Norwood, Co. X, 3d Michigan Cavalry, was wounded July 15th, 1863, in a skirmish near Jackson, Tennessee. He was acting as a vidette at the time, and was stationed on a bridge. The ball, fired from below, produced a long fissure in the lower third of the inner aspect of the femur, and was itself split by the compact lamina of the bone. This 'niur,'spiitiby^conoidiu inus- ket-baii. spec. 1788, a.m. m. patient was removed to the General Hospital, at La Grange, Tennessee, July 22d, 1863. The thigh was then erysipelatous, and amputation was deemed inadvisable. September 27th, 1863, he was removed to the Washington Hospital, at Memphis, where he died of pyaemia, October 2d, 1863. The fragment of the inner surface of the femur, though but slightly separated from the diaphysis, was found to be necrosed. The series at the Army Medical Museum, illustrating the reparative efforts of nature after gunshot fractures of the femur, consists of 190 specimens, and is of exceeding interest. A few cases are selected. The first shows the extent of repair ten weeks subsequent to the injury. Private E. W. A , Co. G, sth Florida (Rebel) Regiment, aged eighteen years, was wounded July 3d, 1863, at the battle of Gettysburg, by a conoidal musket-ball, which shattered the upper third of the left femur. He was first treated at a field hospital, but on August sth, 1863, was admitted to Camp more dangerous accidents than comminuted gunshot fractures even. Of gunshot contusions of the femur, there are seventeen specimens at the Army Medical Museum. Several of these bones were sawn through the long axis, immediately after the death of the patient, and colored drawings were prepared, exhibiting the appearances of the inflamed or suppurating or gangrenous medulla. Cases in which a portion of the shaft of the femur is gouged out, or a part of its cylinder crushed without entire division of the continuity, are also very fatal. The following is an example Fia. 40. — Left femur, exhibiting attempts at repair after a gunshot fracture of the upper third. The patient survived ten weeks. Spec. 1938, A. M. M. Letterman General Hospital. At that date, the patient was reduced by profuse suppuration ; he was greatly emaciated, and large bed-sores had formed on his back. On August 12th, a troublesome diarrhoea set in. He lingered * American Journal of Medical Sciences, vol. xlix. p. 17, et seq. 35 ON SPECIAL WOUNDS AND INJURIES. till September 15th, 1863, when he died from exhaustion. The large foliaceous masses of callus uniting the fragments were extremely delicate and brittle. In the next case, the patient likewise survived ten weeks after a comminuted gunshot fracture of the middle third. Corporal H. Burns, Co. H, 31st New York Vols., was struck by a conoidal ball, at the battle of Chancellorsville, May 3d, 1863. The missile fractured the shaft of the left femur, with the usual longitudinal splintering. On May Bth, the patient was admitted to Douglas Hospital, at Washington, and it was decided to attempt to save the limb. This was first suspended by Smith's anterior splint. Afterwards Hodgen's apparatus was applied, and apparently answered a better purpose; but large abscesses having formed in the thigh, and free incisions becoming requisite, a long fracture-box, filled with bran, was substituted. On June 16th, 1863, the ball and several fragments of detached bone were removed. The patient died on July 11th, 1863, from exhaustive suppuration. Several days before his death gangrenous patches appeared on the left leg. (Figure 41.) In the next case, the patient survived more than four months Sergeant Sewell T. Douglas, Co. G, Ist Eegiment Maine Heavy Artillery, aged twenty-eight years, was wounded at the battle of Spottsylvania, and was admitted to Emory Hospital, at Washington, May 22d, 1864. A musket-ball entering posteriorly, had fractured the lower third of the left femur, and lodged in the medullary cavity. The injured limb was placed on a double inclined plane, and moderate extension was Flo. 42.— Partially consolidated gnm-hot fracture of the left fumur. Spec. 3267, A. M. M. used. Internally, stimulants and tonics were employed. In August, 1864, the patient suffered from severe diarrhoea. There was a copious ill-conditioned discharge from the wound. The patient died September 26th, 1864, from exhaustion, and, at the autopsy, a deposition of callus was found at the seat of injury, enclosing several necrosed splinters and a battered musket-ball. In the following case the process of repair had gone on for nine months, and union was nearly com- plete, when the patient was carried off by an intercurrent disease. Fio. 41. — Partially consolidated gunshot fracture of the middles third of the left femur. Spec. 1643, A. M. M. Private Christian Holzworth, Co. B, 20th Indiana Vols., was wounded at the second battle of Manassas, August 29th, 1862, by a conoidal musket-ball, which entered on the anterior aspect of the upper third of the left thigh, and lodged against the femur, which was fractured with extensive longitudinal splitting. He was conveyed to Armory Square Hospital, at Washington. No particulars of the treatment employed can be ascertained, but it is reported that in March, 1863, he was able to go about on crutches, and that he was "doing well" until the latter part of May, when an attack of cerebro-spinal meningitis supervened, and terminated fatally on May 25th, 1863. Upon examination of the injured limb, the fractured extremities of the femur were found to be united, with great angular deformity, by irregular arches of callus. A fragment of the ball was enclosed between the arches. The specimen was contributed by Assistant Surgeon Byrne, U. S. A. (Figure 43.) The next figure represents a specimen in which consolidation is quite firm. The patient succumbed to phthisis seven months after the injury. Private Luman M. Millius, Co. X, 6th Pennsylvania Keserves, was wounded at Antietam, September 17th, 1862, by a conoidal musket-ball, which entered a little below the great trochanter of the right thigh, shattered the upper third of the femur, and lodged beneath the skin on the inner part of the right thigh, whence it was extracted through an incision. The patient was treated in a field hospital until the Fio. 43. — Partially consolidated gunshot fracture of the left femur. Spec. 1161, A. M. M. middle of October, when he was transferred to the General Hospital, at Smoketown. Although a slender man, with a narrow chest and feeble organization, his condition on admission was not unpromising. During the autumn of 1862, the suppuration was copious, and fragments of necrosed bone were occasionally discharged. Under a nourishing diet, the patient's strength was supported remarkably. On January 21st, 1863, the fracture was firmly consolidated. The 36 GUNSHOT WOUNDS OF THE LOWER EXTREMITIES. limb was shortened four inches. The wound on the inner side of the thigh had closed. There was a slight fistula. h'laAi — Upper half of right femur, exhibiting a consolidated gunehut fracture. Spec. 1042, A. M. M. was contributed by Surgeon Israel Moses, U. S. Vols Dr. Bellanger has recorded* five fatal cases of gunshot injuries of the knee-joint treated by free incisions into the articulation, and with trifling discharge at the wound of entrance. The patient passed several hours daily in the open air, on crutches. About this time, cough and night-sweats, and other indications of tuberculosis of the lungs, appeared, and confirmed phthisis was soon established. The patient died March 9th, 1863. (Figure 44.) Of gunshot injuries of the knee-joint, the Museum possesses 355 specimens. A number of illustrations will be given. The case that furnished Specimen No. 2134 (Private Baldwin, Co. X, 42d Indiana Yols.) was treated by laying open the kneejoint, by free incisions, as soon as suppuration was established. The patient was wounded September 20th, at Murfreesboro', and died December 12th, 1863. The injury to the outer condyle was very slight. The specimen FlO. 45. — Outer condyle ot right femur, grooved by a musket-ball. Spec. 2134, A. M. M. Surgeon Lidell, U. S. Vols., has published three such cases.f The records contain a score of similar examples. Yet amputations for gunshot injuries of the knee that have reached the secondary period are scarcely less disastrous. aspect of the knee. On the next day, there was pain and tenderness of the joint. Death took place July 18th, 1863. In the next case a conoidal ball, fired from a great distance, has crushed the anterior part of the femur just above the condyles, and produced fissures that extend to the joint. The patient Fw. 46.— Gunshot fracture of the internal condj le of the leftkuee. Spec. 1399, A M. M. that furnished this specimen was wounded at Petersburg, March 31st, was amputated at Emory Hospital, April 7th, and died on June 24th, 1865. The specimen was contributed by Surgeon N. B. Mosely, U. S. Vols. The two following figures exhibit the common appearances of fractures of the bones composing the knee-joint by round musketballs. Private Richard Williams, 28th Pennsylvania Vols., was wounded September 16th, 1862, at the battle of South Mountain, by a musket-ball, which entered near the outer hamstring, and lodged between the condyles of the right femur. He was conveyed to Washington, D. C, The next case well illustrates the obscurity of symptoms and difficulty of diagnosis of a serious gunshot injury of an articulation so accessible for examination as the knee. The fracture of the internal condyle was not discovered until after death. The specimen was contributed by Surgeon J. A. Lidell, U. S. Vols. Private Kisner, aged twenty-nine, Go. E, 7th Michigan Cavalry, was wounded June 19th, 1863, while on picket at Chantilly, Virginia, by an elongated carbine-ball, which entered in front at the middle of the left thigh. He was admitted to hospital, in Washington, on June 26th, and the ball was cut out from beneath the integument on the inner Fig. 47.— Partial fracture of the left femur by a conoidal ball, which has lodged in thecancellated structure. Spec. 4071, A. ML M. * American Journal of Medical Sciences, vol. xlvi. p. 42. f Ibid., vol. xlix. p. 295. GUNSHOT WOUNDS OF THE LOWER EXTREMITIES. 37 and admitted into Mount Pleasant General Hospital, September 22d, 1862. On September 30th, his right thigh was amputated by flap incisions. At this date the limb was excessively swollen ; the discharge MSTT* of pus was profuse; abscesses had burrowed in the soft parts, and irritative fever existed to an alarming degree. The case terminated fatally on October 2d, 1862. Private , a soldier of the 3d Division of the Ist Army Corps, was wounded at Gettysburg, Pennsylvania, on July Ist, 1863, by a musket-ball, which entered through the right popliteal space, fissured the internal condyle of the femur, and lodged in the head of the tibia. He underwent amputation at the lower third of the thigh on July 15th, and died July 17th, 1863. The specimen was contributed by Sur- geon Quinan, in charge of the Division Hospital. (Figure 49.) Three patients have been photographed j'm. 49.-Amputated end of right femur and head of tibia, with a round musket ban impacted in the latter. Spec. 1481, A. M. M. at the Army Medical Museum who had recovered without amputation after gunshot injuries of the knee-joint. (Photographs Nos. 63, 64, and 78.) Four or five additional cases appear upon the records. In scarcely any of these Fin. 48. — Lower extremity 01 Titbit femur, the outer condjie split off by a round musket-ball. Spec. 59, A. M.M. cases could it be asserted that the danger of consecutive disease of the knee-joint was passed. The "curious fact," adverted to by Surgeon I. Moses, U. S. Vols.,* "that more men had been discharged . . , ? , i. |-T • Ml TT J. 1 1 1. 1 J i the service at that post Louisville, Kentucky who had received * «... i gunshot wounds of the knee-joint with recovery than when ampu- tation of the thigh had been performed," is directly contradicted by the official reports from that post. The following is the most carefully compiled of the abstracts of cases of recovery after gunshot wounds involving the knee. Photograph 63, A. M. M., represents the patient. Private Peter Stuck, Co. E, 116 th Pennsylvania Vols., was wounded on May 12th, 1864, at the battle of Spottsylvania, and was admitted, on May 18th, to Douglas Hospital, in Washington. The projectile, which was probably a conoidal musket-ball, had entered at the inner edge of the right patella, passed directly through the articulation, and made its exit near the centre of the popliteal space. The inner condyle was slightly grooved, but the ball passed mainly through the intercondyloid notch. There was an abundant thin discharge of mingled pus and synovia. The joint was somewhat swollen, but the inflammatory symptoms and constitutional disturbance were moderate. The patient was of a delicate organization. The treatment was limited to rest and water-dressings. On June 9th, there was swelling and pain in the joint, and a febrile reaction. Poultices were applied to the wound of exit, the anterior wound having healed. In a few days the bad symptoms abated. In the latter part of August, 1864, the patient began to walk about on crutches, the leg being flexed at an angle of 135° with the thigh. In October, the limb was bandaged to a movable angular splint, and the flexion was gradually reduced. Almost-complete extension was obtaiued without exciting inflammation in the joint. The patient kept his bed during this period of the treatment. For the following eight months nothing of special interest transpired. There were several attacks of inflammation of the joint; but they were moderate in degree, and were readily subdued by poulticing. On such occasions abscesses sometimes formed in the thigh. For the greater part of the time the patient's appetite was fair, his bowels regular, his sleep refreshing. When inflammatory mischief was threatened, poultices, hot fomentations with flannel covered with oiled silk, and applications of tincture of iodine were employed. At other times, cold water-dressings, with charpie to absorb the discharge, were used. Ice was never applied. A photograph was taken July 9th, and the patient was discharged from service and the hos- •i i t i ii.i io/-ir mi lZi j j.-ii i v. ill pital July 14th, 1865. The posterior wound wa3 still open, and a probe could be Via. so.—Destruction of the left knee by a Blioll explosion. Spec. 709, A. M. M. * American Journal of Medical Sciences, vol. xlvii. p. 341. 38 ON SPECIAL WOUNDS AND INJURIES. introduced through it for three inches. There was a large deposit of new bone. The patella was firmly anchylosed to the femur. The facts of the case were forwarded by Assistant Surgeon Win. F. Norris, U. S. A. Two more illustrations of gunshot injuries of the knee-joint are here introduced: The patient who furnished the first (Private B. M , Co. A, 28th Massachusetts Vols.) was brought to Washington on December 26th, 1862, his left knee having been shattered by a shell at the battle of Fredericksburg, on December 14th. He died on December 29th. Evidently primary amputation could alone have saved this man, and this was probably impracticable on that disastrous day. (See Figure 50 on the preceding page.) In the next case of shell wound involving the knee-joint (Private C. H. M , Co. F, Ist Maine Heavy Artillery), primary amputation was performed on October 2d, by Surgeon Jamieson, 86th New York Vols. The patient died of exhaustive suppuration on October 27th, 1864. (Figure 51.) urn Fin. 61. — Upper portion of left tibia comminuted by a fragment of the base of a shell, which is attached. Spec. 4121, A. M. M. Of gunshot injuries of the tibia and fibula, two examples are given, one of fracture by a musket-ball, the other of comminution by solid shot : fib. 52.—Right tibia turcdbyamufl f ket- ban. spec 3604, A general officer was wounded at the assault on Port Hudson, May 27th, 1863, by a conoidal musket-ball, which passed from the inner to the outer aspect of ihe right leg, and shattered the upper thirds of the tibia and fibula. A staff surgeon extracted a number of detached fragments of bone, and dressed the limb, and, on June 2d, the patient was removed to New Orleans. The wounds were opened, and decomposed coagula, pus, and bone splinters in large quantities were evacuated. The constitutional symptoms were of the most aggravated character. About the middle of June, amputation was performed at the lower third of the thigh by Professor Warren Stone, with the very slightest hope of success. The patient, however, struggled through, and ultimately wore an artificial limb with comfort. The specimen and the particulars of the case were contributed by Prof. F. Bacon, of Yale College, formerly Surgeon U. S. Vols. (Figure 52.) Major General D. E. Sickles, U. S. Vols., was wounded on the evening of the second day of the battle of Gettysburg, by a twelve-pounder solid shot, which shattered his right leg. General Sickles was on horseback at the time and unattended. He succeeded in quieting his affrighted horse and in dismounting unassisted. Aid arriving promptly, he was removed a short distance to the rear, to a sheltered ravine, and amputation was performed low down in the thigh by Surgeon Thomas Sim, U. S. Vols. The patient was then sent to the rear, and the following day was transferred to Washington. The stump healed with great rapidity. On July 16th, the patient was able to ride about in a carriage. Early in September, 1863, the stump was completely cicatrized, and the general was able again to mount his horse. ne specimen was contributed to the Army Medical Museum by General Sickles, and the facts of the case by his staff surgeon, Dr. Sim. (Figure 53.) GUNSHOT WOUNDS OF THE ARTERIES. Flo. 53.— Right tibia and fibula shattered by a cannonsbot. Spec. 1335, A. M. M. The number of cases reported under this head is extremely small. In the campaign of the Army of the Potomac from the Rapidan to the James, in May, June, and July, 1864, of a total of 36,508 gunshot wounds, only 27 belonged to this category. The cases of compound fracture complicated with injuries of the large vessels, the cases in which limbs are carried away by solid shot or shell, and the cases in which all the tissues of a limb are disorganized by contusion from a large projectile and the vitality of the arteries is destroyed, are all returned under other heads. Those only are included in which the canal of a large vessel is primarily opened, and in which this 39 SABRE AND BAYONET WOUNDS. is the principal accident. Such cases are to be sought for among the dead on the battle-field rather than in the field hospitals. Surgeon J. A. Lidell, U. S. Vols., reports that on the morning of March 25th, 1865, he examined 43 bodies of soldiers killed in the combat near Fort Steadman, in the lines before Petersburg; 23 were shot in the head, 15 in the chest, and sin the abdomen. " The bodies of all those wounded in the abdomen were very much blanched, as if they had died of hoemorrhage, and the same remark held true in regard to all but two or three of those wounded in the chest." In the few cases of primary gunshot lesions of the arteries that came under treatment, it was usually found that only a portion of the calibre of the vessel had been carried away, and that retraction had been thus prevented. But 44 cases are entered on the records. In most of them, ligatures were placed above and below the seat of injury; but, in a few instances, the main trunk was tied at a distance, and amputation was practised when the bleeding recurred. Twenty of the 44 cases terminated fatally. A number of drawings at the Army Medical Museum, exhibiting the course of balls directly in the track of the great vessels of the neck or of the limbs, illustrate the fact so well known to military surgeons of the great resiliency of the large arteries. The dread of primary haemorrhage on the battle-field is confined to the inexperienced. It was so exaggerated at the beginning of the war, that it was seriously proposed by several benevolent associations that every soldier should carry a field tourniquet with his equipments. GUNSHOT WOUNDS OF VEINS. No cases have been reported in which the bleeding could not be controlled by pressure. GUNSHOT WOUNDS OF NERVES. Only those cases are recorded as yet upon the register that were reported in the last quarter of 1863 and the first quarter of 1864. Numerous and careful observations on this class of injuries have been received from the Christian Street Hospital, in Philadelphia, in which wards were especially assigned, in 1863, for the treatment of such cases. SABRE AND BAYONET WOUNDS. The number of sabre and bayonet wounds that have come under treatment has been comparatively small ; 105 cases of the former, and 143 of the latter comprise nearly all that have been reported for the first three years of the war. Of these wounds, two-thirds were received in action, and the remainder were inflicted by sentinels or patrols. There are 11 deaths from sword wounds recorded, and 6 from bayonet wounds. At the Army Medical Museum there are 9 specimens of sabre cuts of the cranium,* a specimen of punctured fracture of the skull by a bayonet, and a preparation exhibiting a bayonet thrust through the stomach.f From General Sheridan's t Specimen 2258, A. M. M. * Specimens 235, 970, 971, 974, 1672, 2623, 3307, 3684, 4206. 40 ON SPECIAL WOUNDS AND INJURIES. campaign in the Shenandoah Valley, 25 sabre wounds are reported; and from the battle of Jonesborough, in Georgia, 30 bayonet wounds. After the first battle of Bull Run, several of the wounded left upon the field were bayoneted by the insurgents.* A patient, brought afterwards to Georgetown, received no less than fourteen stabs. A Fig. 54. — Three sabre cuts on the left parietal. Spec. 3307, A. M. M. similar instance occurred after the battle of Fair Oaks.f Later in the war such atrocities were very infrequent. A few abstracts are subjoined of cases of sword and bayonet wounds : Private E H , Co. 0, 7th Colored Regiment, U, S. Artillery, was wounded at Fort Pillow, Tennessee, April 12th, 1864, by three sabre cuts on the left side of the head, one of the wounds penetrating the skull. The symptoms are not recorded, but it is stated that the patient died on April 21st, 1864, and that the post-mortem examination revealed a large extravasation of blood upon the brain, and a splinter an inch and a half long from the inner table driven through the dura mater. Private J. T. B , Co. F, 7th Michigan Cavalry, was captured on July 3d, 1863, at Gettysburg, his horse being shot under him. He was hurried to the rear with other prisoners. In the subsequent retreat he was Flo. 55. — Section of the posterior portion of a cranium, showing a sabre cut of both parietals parallel to the lambdoidal suture. Spec. 1672. A. M. M. unable to keep up with the column, and all efforts to goad him on being unavailing, a confederate lieutenant, in command of the provost guard, cut him down, and left him for dead by the roadside. He was brought in by a scouting party, and admitted to the Cavalry Corps Hospital. On the 25th of July, he was sufficiently rational to give the above account to Surgeon Eulison, 9th New York Cavalry. He was in a very depressed state at this time. His pulse was weak, and beat from 40 to 45 per minute. He was indisposed to mental exertion ; but when aroused and interested was quite rational. He lingered until August 15th, 1863, the tendency to stupor becoming greater and greater towards the close. The autopsy revealed a sabre cut six inches long, which had raised an osseous flap, adherent at its base, from the left parietal, and cloven the right parietal, with great splin. tering of the vitreous plate. The sabre had penetrated the dura mater on the left side, and on the right side the meninges were injured by the de- pressed inner table. The posterior lobes of both hemispheres of the brain were extensively disorganized. The specimen, with the above history, was contributed by Surgeon W. H. Rulison, 9th New York Cavalry, since killed in battle. Private John H , aged twenty-five, of the guard of Lovell General Hospital, Portsmouth Grove, Rhode Fig. 56.— Portion of a sphenoid bone transfixed by a sword. Spec. 1612, A. M. M. Island, was confined on February 28th, 1863, in a strong box, as a punishment for bringing liquor into camp. When released, he rushed upon the sergeant of the guard and struck him, whereupon the sergeant drew his sword and put himself en garde. In this position the prisoner made a second assault, but the ground being uneven he slipped, and fell heavily upon the point of the sword, and to the ground. When raised, his face was bleeding, and he was insensible. He was examined by the medical officer of the day, who found a slight cut on the ala of the nose, and ascribed the insensibility to intoxication, and to the fall on the head. The prisoner was removed to the guard-house and there spent the night. In the morning, he was still unconscious and breathed stertorously, and had a slow pulse and dilated pupils. He was removed to a ward in the hospital, and the remedies commonly employed in cases of apoplexy were prescribed. There was no return of consciousness, and the case terminated fatally on March 2d, thirty-one hours after the injury. At the autopsy, it was found that the sword had entered at the right nostril, pierced the right superior turbinated bone and the body of the sphenoid, and caused a transverse fracture at the base of the posterior clinoid process. There was much extravasated blood in the cranial cavity, especially on the surface of the right hemisphere. * Surgeon Joseph R. Smith's Report. t Report of Assistant Surgeon H. B. Brown, 70th New York Vols. 41 TETANUS. Private Thomas B , Co. B, 90th Ohio Vols., was admitted into Hospital No. 1, Nashville, Tennessee, on November 27th, 1863, with a bayonet wound behind the left parietal protuberance, inflicted by a sentinel, whom the patient, being intoxicated, had refused to obey. For several days after admission he was somnolent and obstinately constipated. Under the use of powerful purgatives this condition was removed, and the wound nearly cicatrized. But, on December Bth, the patient complained of headache, and a probe passed through the small orifice of the wound revealed the presence of denuded and detached bone. A crucial incision was made and the fragments of dead bone were removed. On December 11th, there was more headache, and a tendency to stupor; the pulse was at 48; there was intolerance of light and sound ; the scalp was tumid ; the wound gaping, and filled with fungous granulations. The incisions in the scalp were extended, an ice-bladder was applied to the head, and purgatives and purgative enemata were employed. A day or two subsequently cerebral hernia took place; then extended suppuration in the left hemisphere; then delirium and coma, and death on December 23d, 1863. The description and specimen were contributed by Assistant Surgeon C. J. Kipp, U. S. Vols. Fia. 57. — Skull-cap, exhibiting a fracture of the left parietal bone by a bayonet. Spec. 2179, A. M. M. SIMPLE FRACTURES AND MISCELLANEOUS WOUNDS. The number of cases reported is quite large, and the record is still very incomplete. For the first two years of the war, the monthly reports give of simple fractures alone 2864 cases with 92 deaths. The Army Medical Museum possesses comparatively few illustrations of this class of injuries, and it is to be desired that this department of the collection may be augmented. Specimen No. 6 presents a good example of a united simple fracture of the femur through the trochanters. It was taken from a man of forty, who died of pneumonia two years after recovery from the local injury. The number of incised and fractured wounds received in broils and altercations is quite numerous. The following is an interesting example of this class of cases Fig. 59.— Fourth, fifth, and a portion of the sixth dorsal vertebras, sawn asunder to exhibit v dirk which traversed the spinal canal. Spec. 1160, A. M. M. TETANUS. Private George S , Co. B, 15th New York Engineers, was stabbed in the back by a dirk, April 20th, 1863, at Falmouth, Virginia, in an altercation with a comrade. The blade passed between the transverse processes of the fourth and fifth vertebrae, and severed the spinal cord. The man fell instantly, completely paraplegic. He was admitted to Armory Square Hospital, at Washington, April 22d. On April 27th, he began to pass his faeces and urine involuntarily, and bed-sores appeared on the portions of the lower part of the body exposed to pressure. He sank gradually, and died from exhaustion on May 27th, 1863. The specimen was contributed by Assistant Surgeon C. 0. Byrne, U. S. A. Flo. 58. — Firmly consolidated simple fracture of the left femur. Spec. No. 6, A. M. M. The 363 cases of traumatic tetanus recorded in the register for that subject are all that have been reported during the war. The proportion to the total number of wounds is not large. In the Schleswick Holstein war, Stromeyer had 6 cases among 2000 wounded. In Napoleon's campaign in Egypt, in the Peninsular campaign, and 6 42 ON SPECIAL WOUNDS AND INJURIES. in the revolt in India, the ratio appears to have been larger than this. Among 12,094 wounded, the British in the Crimea had 19 cases only. The histories of the 363 reported cases of tetanus are generally satisfactory in their details of symptoms, progress, and treatment: 336 cases terminated fatally. Of the 27 recoveries reported, the disease was of a chronic form in 23. In the 4 remaining cases, the symptoms were very grave. In 2, recovery took place under the use of opiates and stimulants; in 2, after amputation of the wounded part. The great majority of the cases were treated by the free use of opium, conjoined with stimulants and concentrated nourishment. Chloroform inhalations were very generally employed during the paroxysms of spasmodic contraction. Subcutaneous injections of the salts of morphia and atropia were frequently used. Cathartics, quinia, camphor, cannabis indica, bromide of potassium, strychnia, belladonna, and aconite are mentioned among the remedies employed. Cups, blisters, turpentine stupes, and ice were among the applications made to the spine; and fomentations with opium or tobacco were, in some cases, applied to the wound. Amputation, the division of nerves, and the extirpation of neuromata in stumps were the surgical measures sometimes employed. The results have not modified the conclusion of Romberg, that "wherever tetanus puts on the acute form, no curative proceeding will avail, while in the milder and more tardy form, the most various remedies have been followed by cure." The value of nicotine, of the Calabar bean, and of curare* as curative agents in tetanus was not tested. Autopsies were made in many cases; but with almost negative results. There were no microscopic examinations to corroborate or disprove the assertions of Rokitansky and Demme,f that tetanus has a constant anatomical lesion, consisting in a proliferation of the connective tissue of the white medullary substance of the medulla oblongata, of the inferior peduncles of the cerebellum, of the crura cerebri, and of the spinal cord, producing a viscous mass, abounding in nuclei, and never progressing to the formation of fibres. It is frequently mentioned, however, that great congestion of the brain and spinal cord was observed, a condition on which the lesions of the connective tissue above described are believed to depend. The records abound with illustrations of the influence of sudden vicissitudes of temperature in producing this fatal affection, and of the effect which unextracted balls and other foreign bodies and matter confined under fasciae appear to exercise upon its development. It seems probable also that the disease occurred in a larger proportion of cases among the troops serving in the more Southern States; but this and other generalizations must be deferred until the records are more minutely examined. SECONDARY HAEMORRHAGE. On this important subject the records are still very incomplete. There are 1450 special reports relating to it yet to be examined, which will furnish a large number of cases to be transcribed upon the register. The cases have been reported in three * According to H. Demme, of 22 cases of traumatic tetanus treated by the latter agent, 8 recovered. See Schweiz. Zeitschrift fur Heilkunde, ii. 356. t Schmidt's Jahrbucher, vol. cxii. 43 SECONDARY HAEMORRHAGE. — PYAEMIA. classes : bleeding proceeding from a stump, from a gunshot wound, or from an artery previously ligated in its continuity. Cases of the latter series have not been placed on the registers of secondary haemorrhage, but the repetition of the bleeding has been noted in the history of the case in the volume of the registers of surgical operations devoted to ligations.* Of the two other classes, 1037 cases have been examined and recorded on the registers of secondary haemorrhage. Of these, 387 were cases of secondary bleeding from a stump, and 650 were cases of secondary haemorrhage from gunshot wounds. Of the first class, 233, or 60 per cent., ended fatally; of the second, the termination was fatal in 330 cases, or 51 per cent. In the 1037 recorded cases, the femoral artery was ligated 93 times for bleeding from stumps, and 45 times for bleeding from wounds; the subclavian was tied 5 times for bleeding after amputation at the shoulder-joint, and 6 times for haemorrhage from gunshot wounds of the axilla. The common carotid was ligated 15 times for haßmorrhage from the deep branches of the internal carotid. Amputation was practised 78 times for secondary bleeding from gunshot wounds, and reamputation was performed 14 times when other means of arresting haemorrhage from stumps had failed. The 387 cases of secondary haemorrhage from stumps were chiefly examples of arterial bleeding. In 95 cases, the haemorrhage was, perhaps, mainly venous, and was checked by elevating the stump, or applying cold water, ice, pressure, or the solution of the persulphate of iron. When the haemorrhage was arterial, the most common practice was to tie the main vessel, at the second bleeding, as near as was prudent to the end of the stump. In a few cases, the artery was successfully tied on the face of the stump. The results of tying the vessel above, according to Anel's method, were very unfortunate. In reviewing the 650 recorded cases of secondary haemorrhage from gunshot wounds, it appears that, during the earlier part of the war, there were many surgeons who were not sufficiently impressed by the precepts of Bell and Guthrie, and who frequently treated secondary haemorrhage from gunshot wounds by tying the main trunk at a distance from the wound, even when the bleeding occurred at a comparatively early period. Later in the war, however, it was the universal practice to endeavor to secure both ends of the bleeding vessel at the seat of injury, and some brilliant examples are recorded in which this was accomplished in wounds of the posterior tibial or popliteal, when limbs had become infiltrated and swollen, and the difficulties of the operations were immense. PYAEMIA. On this subject 281 reports have been examined, and the individual cases detailed in them have been transcribed upon the registers : 251 special reports on the subject remain to be examined. The histories of 754 cases are recorded in the register, the post-mortem observations accompanying a large proportion of the fatal cases. These number 719, or 95*35 per cent. Pyaemia supervened in 377 cases of gunshot injury in which no operation had been performed, and after 295 cases of amputation, of which * See page 85 of this Report. 44 SURGICAL OPERATIONS. 155 were cases of amputation in the continuity of the femur. The purulent infection was subsequent to excision of the shafts of long bones in 27 cases, and to excisions of joints in 28 cases. These figures by no means represent the frequency with which pyseinic poisoning has occurred. It has been one of the great sources of mortality after amputations, and its victims are to be counted by thousands. The small number of cases on the register are taken from special reports. Several valuable papers have been contributed on the pathology of this affection, and a number of statistical reports on its treatment. The conclusions of the latter are adverse to the therapeutical utility of the sulphites and hyposulphites in this disease. A series of colored drawings, illustrating the embolic phenomena attendant on pyaemia, the metastatic depots, etc., have been prepared at the Army Medical Museum. SURGICAL OPERATIONS. All surgical operations are recorded on the registers of the office, according to the form which will be presented on a subsequent page, in treating of excisions of the head of the femur. The name and military description of the patient are given, the nature and date of his injury, an account of the operation, a notice of the local lesions which made it necessary, and of the constitutional condition of the patient at the period it was performed. A summary of the progress and after-treatment follows, and the result, if ascertained, the name of the operator, and the post-mortem appearances, when known, if the case terminated fatally. If the case furnished a pathological preparation to the Army Medical Museum, a reference is made to the number of the specimen on the catalogue. "While this plan involves much labor, it effectually precludes the duplication of cases, and ensures, probably, the highest attainable degree of statistical accuracy. The name and military designation of the patient being known in all cases, the ultimate results of operations can be traced, hereafter, and errors may be corrected. Operations have been reported in this form from all general hospitals since October, 1863. But nearly half of the sixteen thousand operations now recorded were taken from special reports and field returns belonging to an earlier period of the war, and it was necessary that these should first be transcribed on the proper forms, a task that has been accomplished by clerks who were students of medicine, their work being revised by a medical officer. 45 AMPUTATIONS. AMPUTATIONS. The histories of 13,397 amputations for gunshot injury have been examined and recorded, and the final results have been ascertained in 9705 cases. The following table exhibits the number belonging to each region, and includes both primary and secondary cases. It shows the regular increase in the rate of mortality as the trunk is approached. Recovered. Died. Total. Amputation* of the Superior Extremities. jnoruuuy. Fingers and Parts of the Hand 1778 29 1807 1-60 Wrist 34 2 86 5-55 Elbow 19 0 19 Forearm 500 99 599 16-52 Arm 1535 414 1949 21-24 Shoulder-Joint 144 93 237 39-24 Total of Upper Extremity 4010 637 4647 13-70 Amputations of the Inferior Extremities. Toes 784 6 790 -75 Partial Amputations of the Foot 108 11 119 9-24 Ankle-Joint 58 9 67 13-43 Leg 1737 611 2348 26-02 Knee-Joint 52 64 116 55-17 Thigh 568 1029 1597 64-43 Hip-Joint 3 18 21 85-71 Total of Lower Extremity 3310 1748 5058 34-55 Aggregate 7320 2385 9705 24-57 Amputations of the Fingers and Portions of the Hand. — The cases that have been transcribed on the records form but a small proportion of the total number included in the reports. In the 1807 terminated cases, the mortality has been comparatively large. The causes of death in the 29 fatal cases is stated to have been : in 4, pyaemia; in 4, erysipelas; in 2, gangrene; in 1, tetanus; in 18, different intercurrent diseases, as typhoid and malarial fevers, pleurisy, etc. Amputations at the "Whist. — The disarticulation at the wrist has been performed in preference to the amputation of the forearm, when the hand was totally disorganized. When practised by the circular method it is a good operation. The results of the cases examined are satisfactory, the mortality being ten per cent, less than in amputation of the forearm. Amputations of the Forearm. — Except in those cases in which the wrist or lower extremity of the radius have been shattered by large projectiles, this amputation has commonly been practised secondarily. It has been impracticable to examine all the cases that have been reported. Of the terminated cases that have been transcribed upon the records, 99 died and 500 recovered. Of the latter, 397 have been supplied 46 SURGICAL OPERATIONS. with artificial limbs. In the forearm, the amputation by the double flap method has been generally preferred. Amputations at the Elbow. — The returns corroborate the conclusions of Dupuytren, Malgaigne, and Legouest, who combat the disfavor into which this operation has fallen. It was done infrequently in the late war, but 19 cases having been reported. But in all of these the ultimate results have been ascertained, and were favorable in every instance. The success of Salleron and other French surgeons with this operation in the Crimea is well known. Whenever, then, it is impracticable to amputate the forearm, disarticulation at the elbow should be preferred to amputation of the arm. The oval method answers the purpose best in this locality. Amputations of the Arm. — Of 2774 cases of amputation of the arm that have been entered on the registers, the results are ascertained in 1949 cases: 1535 recovered, and 1014 of these patients have been furnished with artificial arms. Amputations at the Shoulder-Joint. — It is creditable to the surgery of the war that the number of cases of amputation at the shoulder-joint reported is less than the number of cases of excisions of the head of the humerus, and that the latter operation appears to have been adopted in nearly all the cases in which it was admissible. The reported cases of amputation at the shoulder-joint, for the entire period, number 458; of excisions of the head of the humerus, there were 575. Of the 237 terminated cases of amputation, 93 died, a ratio of mortality of 39*2, which is 6 - 7 per cent, greater than the mortality in excisions. The amputations of the upper extremity for gunshot injuries are illustrated at the Army Medical Museum by 89 examples of diseases of stumps, and by a large number of plaster casts and photographs, exhibiting the successful results of operations. Amputations of the Toes. — Of 784 cases that have been examined, 6 were fatal. Tetanus supervened in one case, and phlegmonous erysipelas invaded the leg in another. In the four remaining cases, the fatal termination was due to causes foreign to the operation. Partial Amputations of the Foot. — Of the 160 recorded cases, 119 were terminated, with a mortality of 924 per cent. The tarso-metatarsal operation of Hey or Lisfranc was performed 25 times; the medio-tarsal operation of Chopart 45 times. The remaining cases were ablations of toes with one or more of the metatarsals. There are several casts of stumps, made by Chopart's method, at the Army Medical Museum, which exhibit the drawing up of the heel which so frequently occurs after this operation. Amputations at the Ankle-Joint. — The record is far from complete. In the terminated cases, Syme's method was employed in 25 cases, Roux's method in 2 cases, and Pirogoff's in 9 cases. Several casts and photographs of well-rounded stumps, obtained by the latter procedure, are deposited in the Army Medical Museum. But tjie operation appears to be regarded with but little favor. Baron yon Horronitz, Surgeonin-Chief of the Russian Marine, in his recent visit to this office, mentioned that Pirogoff had himself abandoned it, finding the segment of the os calcis likely to become necrosed. An abstract of a favorable case, with an illustration, is subjoined : 47 AMPUTATIONS. Lieutenant W. 0. W , Co. I, sth Michigan Cavalry, was wounded April Ist, 1865, at the battle of Five Forks, by a conoidal musket-ball, which passed through his left ankle-joint He was immediately carried to the hospital at City Point, and amputation at the ankle was performed on the same day by Surgeon St. Clair, sth Michigan Cavalry. The articulating surfaces of the tibia and calcaneum were removed, and the cut surfaces were brought into apposition. On April 16th, 1865, the patient was transferred to Armory Square Hospital, at Washington. On admission, he was in a feeble condition. An erysipelatous blush extended above the knee on the injured side; an abscess had formed in the lower part of the leg; and no union of the flap had taken place. With the employment of stimulants and nutritious diet with emollient applications to the limb, there was a gradual improvement, until April 28th, 1865, when symptoms of pysemic infection supervened. Eapidly recurring chills, an icteroid coloration of the skin and conjunctiva, anorexia, and a frequent feeble pulse, suggested the gravest prognosis. Energetic treatment was adopted. An ounce of brandy was given every two hours, and quinia, sesquichloride of iron, and beef tea were freely administered. On May 6th, the grave symptoms began to subside, and, by the end of the month, the patient was fairly convalescent. On June 26th, he was pronounced well. The os calcis had firmly united to the tibia, and- there was a good solid stump. A cast in plaster was taken from it (Spec. 2298, A. M. M.), and a few days subsequently a photograph, which is numbered 75 in the Photographic Series of the Army Medical Museum. Fin. 60. — Stump after a Pirogoff amputation. Amputations of the Leg. — Of the 3302 amputations of the leg that have been recorded, the results have been ascertained in 2348. The ratio of mortality was 26*02, which will doubtless be augmented by further examination of the returns. The operation just above the malleoli, sometimes called Lenoir's operation, has not been very largely practised, but it has given some excellent results, and its mortality rate is surprisingly small. The majority of the cases were amputations at the middle of the leg and at the place of election. The circular method has been most commonly employed. Larrey's operation through the head of the tibia has been done but little, though an examination of the specimens at the Army Medical Museum leads to the conviction that this procedure might have been substituted, in some instances, for disarticulation at the knee-joint, or amputations at the lower third of the thigh. Of the 1737 patients that recovered after amputation of the leg, 1057 have been furnished with artificial limbs. Amputations at the Knee-Joint. — This operation has found numerous advocates during the war, and has been frequently performed. The returns to October, 1864, give 132 cases, of which 52 recovered and 64 died. In 6 cases, amputation of the thigh was subsequently performed, with 3 recoveries and 3 deaths. In 10 cases, the result is undetermined. These figures are encouraging, and if we look at the primary operations alone, the result is still more gratifying. Of 49 cases of primary amputation at the knee-joint, 31 recovered and 16 died; while 2 underwent reamputation, of whom 1 recovered, and 1, a tuberculous subject, died. This gives a percentage of mortality in primary amputations at the knee-joint of 34-9. The mortality in primary amputation at the lower third of the thigh is much larger than this : indeed, it has been already indisputably proved by the Crimean statistics, and by M. Malgaigne, that the mortality in amputation augments in exact proportion as the incisions approach the trunk. At the Army Medical Museum there is a photograph, accompanying Specimen 2778, of the fine, well-rounded stump of Private Nevelling, Co. A, 71st Pennsylvania Vols., who was wounded at White Oak Swamp, and amputated, at Philadelphia, by Acting Assistant Surgeon T. G. Morton. The objection to amputations at the knee-joint, that the resulting stump is ill adapted to the use of an artificial limb, is set at rest by the results obtained by Hudson and other manufacturers, who distinctly declare that the stumps from the operation at the knee-joint give a base of support far better than any possibly to be gained in thigh-stumps. It is well known that M. Legouest emphatically pronounces the disarticulation at the knee "une mauvaise operation, plus grave que l'amputation de la cuisse dans la continuity, et gui doit etre rejetee de la pratique," basing this assertion on the Crimean returns ; but it is probable that the more extended experience of the late war will lead surgeons to share the convictions of Macleod, Baudens, and Malgaigne, that this operation is altogether preferable to the amputation at the lower third of the thigh. Amputations of the Thigh. — In 1597 terminated cases, 568 recovered and 1029 died, or 64*43 per cent., which is within a fraction of the mortality after amputations of the thigh in the English army in the Crimea during the latter part of the campaign. In the French army in the Crimea, the whole number of amputations of the thigh for gunshot injuries was 1666, of which 1531, or 91*89 per cent., terminated fatally. Of these 1597 amputations, the date of operation is ascertained with precision in 1061. Of these, 423 were primary and 638 were intermediate or secondary. The ratio of mortality was 54*13 in the former, and 74*76 in the latter. In the 568 recoveries after amputation of the thigh above mentioned, the patients have been supplied with artificial limbs in 254 cases, and reports are on file of 439 other cases of recovery after this operation in which artificial limbs have been provided. These cases are not entered on the registers, because the returns exhibiting the deaths for the corresponding periods have not yet been reached. Amputations at the Hip-Joint. — At the commencement of the war, the uniform fatality of amputation at the hip-joint in the Crimean war was impressed upon the minds of surgeons, and many believed that the operation should be discarded altogether. Still, it has been occasionally performed, and several lives have unquestionably been saved by it. A noted case is that of Kelly, whose appearance, after recovery, is represented in the plate opposite. The following is an abstract of the case : Private James E. Kelly, Co. B, 56th Pennsylvania Vols., aged twenty-eight years, was wounded at about 9 o'clock of the morning of April 29th, 1863, in a skirmish of the First Division, First Corps, on the Bappahannock, nearly opposite the " Pratt House," below Fredericksburg. A conoidal musket-ball, fired from a distance of about three hundred yards, shattered his left femur. A consultation of the senior surgeons of brigades decided that exarticulation of the femur was expedient, and the operation was performed, at four in the afternoon, at the " Fitzhugh House," by Surgeon Edward Shippen, U. S. Vols., Surgeon-in-Chief of the First Division. The single flap method was adopted, and the amputation was accomplished with slight loss of blood. The patient was at first placed in a hospital tent, and was transferred, May 22d, to the Corps Hospital, progressing favorably. By May 28th, all the ligatures had been removed. On June 15th, 1863, the patient was captured by the enemy, and was removed to the Libby Prison, in Eichmond. Up to this date there had been no bad symptoms. On July 14th, Kelly was exchanged, and was sent to the Annapolis U. S. A. General Hospital. On his admission, he was much exhausted by profuse diarrhoea. The internal portion of the wound had united, but the external portion was gangrenous. Applications of bromine were made to the sloughing surface without amelioration. A chlorinated soda lotion was substituted, and in the latter part of July, there was a healthy granulating surface. On December 23d, 1863, the wound had entirely healed, and Kelly visited Washington and obtained an honorable discharge from service, and a pension. Kelly then went to his home, near Black Lick P. 0., Indiana County, Pennsylvania. A letter dated January 12th, 1865, was received from him at this office, and represented him as in excellent health and spirits at that time. A year after the operation, a photograph of the stump was obtained. The accompanying plate is copied from it. 48 SURGICAL OPERATIONS. SHIPPEN'S SUCCESSFUL AMPUTATION AT THE HIP JOINT. SHIPPEN'S SUCCESSFUL AMPUTATION AT THE HIP JOINT. 49 AMPUTATIONS. A successful primary case, operated upon at Memphis, by Dr. Fenner, is reported by a student of Dr. F. H. Hamilton, late Medical Inspector U. S. A., who saw the subject of it after his complete recovery. A successful secondary case, reported by Assistant Surgeon C. Wagner, U. S. A., was a reamputation of a diseased stump. Necrosis of the femur was induced by osteomyelitis, and the disarticulation was effected at a period when the traumatic phenomena had entirely disappeared. The particulars of this case are subjoined : Private Eben. E. Smith, Co. A, 11th Maine Vols., aged nineteen years, was wounded at the engagement at Deep Bottom, near Drury's Bluff, Virginia, on August 16th, 1864, by a musket-ball, which fractured the head of the right tibia. He was admitted at the U. S. General Hospital, at Beverly, New Jersey, on August 22d, 1864. On admission, the injured knee-joint wias swollen and painful, and there was irritative fever of a moderate grade. On September 12th, secondary haemorrhage occurred, and the thigh was amputated by circular incisions at the lower third, by Acting Assistant Surgeon T. M. Morton, U. S. A., the patient being under chloroform. The case progressed favor- Fio. 61. — Appearance of stump three months after secondary amputation at hip joint. ably until October 17th, when secondary haemorrhage recurred, and was arrested by ligating the femoral artery in Scarpa's triangle. The stump remained swollen and painful, and furnished a profuse foetid suppuration. Osteomyelitis supervened ; the end of the femur protruded, and was removed by the chain-saw. Necrosis finally extended as high as the trochanters, and numerous abscesses formed. On January 19th, 1865, amputation at the hip-joint was performed, under chloroform, by Acting Assistant Surgeon J. H. Packard, U. S. A., the antero-posterior flap operation being adopted. On January 27th, there was haemorrhage from the stump, and the external iliac artery was tied. The ligature separated on February 17th, and two days afterwards there was profuse bleeding from the divided artery, which was controlled by pressure for fourteen days. After this the patient rapidly improved. In April he was reported well, and Hospital Steward Baumgras, one of the artists of the Army Medical Museum, was sent to Beverly, and made the drawing from which the engraving was taken. It is numbered 67 in the Surgical Series of Drawings of the Surgeon General's Office. On April 12th, 1865. Smith was transferred to White Hall Hospital, near Bristol, Pennsylvania. Assistant Surgeon W. H. Forwood, U. S. A., reports that, on May 27th, 1865, he was discharged from service quite well and strong, the wounds being entirely healed. The necrosed lower portion of the femur is Specimen 3709; the upper portion is Specimen 81, A. M. M. Another successful secondary disarticulation of the femur is reported, which was also a case of reamputation, necessitated by disease of the femur. The first amputation was performed at the lower third of the thigh on account of a bayonet wound of the knee-joint. The case is consequently excluded from the tabular statement of amputations for gunshot injury. The patient is represented in Photograph 113, A. M. M. Private Lewis Francis, Co. I, 14th New York Vols., aged forty-three years, was admitted to Ladies' Home U. S. A. General Hospital, New York City, on October 28th, 1863. He had been wounded by a bayonet in the right knee, at the battle of Bull Eun, July 21st, 1861, and was taken prisoner, and suffered amputation of the thigh in Richmond, Virginia, May 28th, 1862. The femur becoming diseased subsequently, its protruding extremity had been sawn off. What remained of the femur was necrosed, when the patient arrived in New York, and, on May 21st, 1864, the flaps were laid open, and the necrosed femur was removed by Surgeon Alexander B. Mott, U. S. Vols. No untoward symptoms followed, and the patient recovered, and was discharged from the service, August 12th, 1864. A memorandum is subjoined of all amputations at the hip-joint for gunshot injury that have been reported. Nine were primary, and twelve were secondary operations. This is followed by a table exhibiting the results of this operation in previous wars. 7 50 SURGICAL OPERATIONS. AMPUTATIONS AT Mo. Name of Operator. Name and Rank of Patient. Nature and Date of Injury. 1 David P. Smith, Surgeon U. S. Private on Hospital Steamer Comminution of the upper half of the femur Vols. Crescent City. by canister, April 6th, 1862. 2 Prof. Geo. E. Blackman, Act. Private on Hospital Transport. Gunshot fracture of upper extremity of femur, Asst. Surgeon U.S.A. April 6th, 1862. 3 E. S. Fenner, Surgeon P. A. C. S. A private of the Confederate Gunshot fracture of the left femur, March, Army. 1862. 4 Edward Shippen, Surgeon U. S. Private James E. Kelly, aged 28, Conoidal ball comminuted upper extremity of Vols. Co. B, 56th Perm. Vols. left femur, April 29th, 1863. 6 B. Howard, Asst. Surgeon U.S.A. Private J. Martin, aged 20, Co. I, Conoidal ball fractured the upper part of left 146 th N. Y. Vols. femur, July 13th, 1863. 6 Unknown. Private William Waters, Co. X, Gunshot fracture of left femur, May 15th, 123 d N. Y. Vols. 1864. 7 Prof. J. M. Carnochan, Act. Asst. Private of 9th Corps, aged 28. Left femur shattered by a shell, May 18th, Surgeon U.S. A. 1864. 8 Edward Shippen, Surgeon U. S. Private J. M. Brown, Co. X, 63d Fracture of upper third of right femur by a Vols. Indiana Vols. conoidal musket-ball, June 16th, 1864. 9 Edward Shippen, Surgeon U. S. Private of 23d Corps. Conoidal ball shattered head and neck of Vols. femur, and involved the hip-joint. 10 Peter Pineo, Medical Inspector Private P. Johnson, Co. C, 2d Fracture of the upper third of the right femur, U. S. A. Delaware Vols. and wound of the femoral artery, by a conoidal musket-ball, Dec. 14th, 1862. 11 Alexander Ingram, Asst. Sur- Private Charles Lackey, aged 19, Upper third of right femur fractured by a geon U. S. A. Co. E, 7th Wisconsin Vols. musket-ball, May 12th, 1864. 12 H. C. Roberts, Asst. Surgeon Private Levi Eckley, aged 33, Gunshot fracture of left thigh, May 20th, U.S. Vols. Co. I, 67th Ohio Vols. 1864. 13 Albert C. Gorgas, Surgeon U.S. Seaman George Cook, aged 21. Rifle-ball passed through both testicles, and Navy. entered left thigh, comminuting the femur and passing out, Feb. Ist, 1864. 14 Edwin Bently, Surgeon U. S. Private Michael O'Neil, aged 19, Gunshot comminuted fracture of right femur, Vols. Co. E, 58th Mass. Vols. by a conoidal musket-ball, June 3d, 1864. 15 J. C. McKee, Asst. Surgeon Private Daniel H. Bowman, aged Gunshot comminuted fracture of upper third U. S. A. 24, Co. C, 110 th Perm. Vols. of right femur, July 27th, 1864. 16 F. Hassenburg, Act. Asst. Sur- Private Lewis Larry, aged 23, Amputation of thigh on account of gunshot geon U. S. A. Co. A, Ist New Orleans Vols. fracture. Subsequent necrosis of femur. . First injury July 17th, 1864. 17 Dr. Gurdon Buck, New York Lieutenant Charles H. Hawkins, Amputation of right thigh, on account of City. Co. C, 4th N. Y. Cavalry. gunshot fracture of femur received June Bth, 1862. 18 Edwin Bently, Surgeon U. S. Sergeant Lewis Carroll, aged 33, Gunshot fracture of right femur just below Vols. Co. A, Ist Delaware Vols. lesser trochanter, by a musket-ball, Oct. 22d, 1864. 19 J. H. Packard, Act. Asst. Sur- Private Eben. E. Smith, aged 19, Amputation of right thigh on account of gungeonU. S. A. Co. A, 11th Maine Vols. shot fracture. Subsequent necrosis of femur. First injury Aug. 16th, 1864. 20 C.Wagner, Asst. Surgeon U.S.A. Private John Williams, aged 44, Gunshot fracture of left femur, Sept. 30th, Co. F, 13th Ohio Cavalry. 1864. 21 E. Griswold, Surgeon U. S. Vols. Private Geo. M. Spencer, aged 17, Gunshot fracture of right femur, March 31st, Co. B, 2d N. Y. Mounted Rifles. 1865. 51 AMPUTATIONS. THE HIP-JOINT. Date of Operation. Result. Authority. Remarks. April 8, Died in five days. Smith's Report, Surgical Records, A, No. 11. Was transferred to a hospital at 1862. J. H. Brintori's Report. • St. Louis. April 8, Died in twenty minutes. Surgeon J. H. Brinton's Report. A patient wounded at Shiloh. 1862. March, Recovered. Report from Memphis U. S. A. General Hos- Operation performed twenty-four 1862. pital. hours after reception of wound. April 29, Recovered. Shippen's Report. Vanderkieft's Report. Was quite well in the summer of 1863. Letters from Kelly. 1865. Spec. 1148, A. M. M. Drawings 31 and 72, Surg. Series, S.G.O. July 14, Died in forty-eight hours. Report of Surgeon Flandrin, N. Y. Vols. His- See Specimen 1379, Army Medical 1863. toryof Specimen 1379, Army Med. Museum. Museum. May 15, Died May 15th, 1864. Report of Army of Cumberland, Book ix. 1864. p. 355, S. G. 0. May 18, Died in ten hours. Letter of Prof. Carnochan of Nov. 7th, 1864. Done at 9th Corps Hospital, at 1864. battle of Spottsylvania. June 16, Died in one hour. Special Report of Surgeon Shippen, U. S. A primary operation. 1864. Vols. 1864. Died in less than one hour. Special Report of Surgeon Shippen, U.S. A primary operation. Vols. Dec. 27, Died in a few hours. Letter from Medical Inspector Pineo. See Specimen 710, Army Medical 1862. Museum, and Photographic Series A. M. M., No. 14. May 21, Died in twenty-four hours. Quarterly Report of Surgical Operations 1864. from Judiciary Square Hospital. May 24, Died in four days. Quarterly Report of Chesapeake Hospital. 1864. 1864. Died in less than two Report from U. S. Naval Hospital, Norfolk, See Specimen 2773, Army Medical hours. Va. Museum. August 10, Died in nineteen days. Quarterly Report from Third Division Gen- Ligation of external iliac artery. See 1864. eral Hospital, Alexandria, Va. Spec. 3098, Army Med. Museum. Sept. 15, Died in one day. Quarterly Report from Lincoln General Hos-1864. pital, Washington, D. C. Sept. 21, Died in nine days. Quarterly Report from University General Reamputation. 1864. Hospital, New Orleans, La. Sept. 21, Died in one day. Report from St. Luke's Civil Hospital, New Reamputation. 1864. York City, and letter from Professor Buck. Nov. 11, Died in eight days. • Report from Alexandria Hospital. See Specimen 1020, Army Medical 1864. Museum. January 9, Recovered. Quarterly Report from U. S. A. General Hos- Reamputation. See Specimen 81, 1865. pital, Beverly, New Jersey. Army Medical Museum, and Photographic Series A. M. M., No. 29. Feb. 17, Died in one day. Quarterly Report from U. S. A. General Hos- See Specimen 84, Army Medical 1865. pital, Beverly, N. J. Museum. April 12, Died before removal to Quarterly Report from Judiciary Square An excision of the head of the 1865. the ward. General Hospital, Washington, D. C. femur was first practised. 52 SURGICAL OPERATIONS. Table, showing the Mortality of Amputations at the Hip- Joint for Gunshot Injury, including Primary, Intermediate, and Secondary Cases. Recovered. Died. Total. Larrey's primary cases 6 6 Larrey's intermediate cases 1 1 Guthrie's Ciudad Rodrigo case (intermediate) 1 1 Guthrie's Waterloo case (primary) 1 1 S. Cooper's case 1 1 Blandin's cases (in 1794) 3 3 Hutin (Mdm. deMed. Mil., t. xliv.) 2 2 Brownrigg (Elvas, 1811) 1 1 Wedemeyer (Bull, de Fe>usac, t. iii. p. 161) 2 2 Letulle (Si3 £ For the tifiiiliiiii Atlantic Region 1-96 2-03 1-77 202 2-65 3-20 2-88 2-37 2-50 3-04 312 3-35 32-54 Central Region -93 296 3-52 4-63 6-25 6-54 8-69 8-78 10-06 6-46 7-10 5-90 80-18 Pacific Region 1-72 100 1-34 1-43 1-75 1-04 -19 -83 -89 -49 -75 -77 11-65 TABLE 11. Monthly Mortality of the Armies of the United States during the year ending June ZOth, 1863, expressed in ratio per 1000 of mean strength. 1862. 1863. S fe u . ji For the • 1 ' 1 I ' 1 1 f 'II ft ' < t I ~ •3=lBl 1 I 3 | *5 oB o m m i-s pr a -< a >-s Atlantic Region 3-93 5-69 4-27 4-58 4-52 4-82 3-79 2-96 2-55 2-00 1-25 1-73 41-40 Central Region 7-69 6-11 5-72 6-20 8-49 8-30 8-68 9-93 9-14 7-31 5-46 4-94 89-55 Pacific Region -76 -00 -34 -77 -71 -96 -50 1-01 -32 1-24 -77 1-05 838 96 GENERAL PREVALENCE OF DISEASE. The monthly reports from which the foregoing rates of mortality from disease were computed give also a certain amount of information as to the mortality from wounds and injuries. The deaths from these causes, reported during the first year of the war, were 4857 out of the strength given above, or seventeen (16*7) per 1000 of mean strength; during the second year, 10,142, or sixteen (15*7) per 1000. These rates, however, by no means represent the real losses from wounds and injuries, since they do not include those slain in battle, or those who died of their wounds while prisoners of war or otherwise absent. To form a correct estimate of the total losses from wounds, I must therefore refer to the Surgical History of the War. GENERAL PREVALENCE OP DISEASE. The directions for making the monthly sick reports in the armies of the United States require every man excused from duty, on account of sickness, to appear on the report. The total number taken sick represents thus slight indispositions as well as severe illness, and the figures are therefore much larger than in those armies in which such only are reported as are received into hospital. It follows that the comparative health of the several divisions of our army is to be ascertained rather by considering the monthly number taken sick with serious diseases, such as fever and diarrhoea, than by merely observing the total number of cases reported. The statistics show the ratio of cases to have been such, during the first two years of the war, that on the average each soldier must have been taken on sick report several times a year. The figures of the second year show a slight diminution in the number of cases. The ratio for the whole army was 2966 per 1000 of mean strength for the first year, 2694 for the second. In the Atlantic region, the number of cases was 2749 per 1000 of mean strength for the first year, 2563 for the second. In the Central region, 3422 for the first year, 2832 for the second. In the Pacific region, 2168 for the first year, 2123 for the second. Tables 111. and IV. give the monthly rates for each of these regions. TABLE 111. Monthly Sickness Sates of the Armies of the United States during the year ending June 30th, 1862, expressed in ratio per 1000 of mean strength. 1861. 1862. jj £ $ ¦ £ Forthe ¦3||lll I | 1 i 1 Atlantic Region.... 39135 372-18 298-26 267-14 255-90 230-99 199-92 183-33 167-25 214-52 208-45 239-75 2748-83 Central Region 267-22 378-81 336-66 331-35 304-11 313-51 33903 254-19 257 07 287-09 259-43 233-73 3421-93 Pacific Region 163-15 199-67 197-48 187-10 236-80 153-68 128-99 210-57 193-97 140-77 220-84 187-06 2168-48 CONSTANT SICKNESS RATES. 97 TABLE IV. Monthly Sickness Bates of the Armies of the United States during the year ending June 30th, 1863, expressed by ratio per 1000 of mean strength. 1862. 1863. I o' 6 . £, For the tliiiilia • year " Atlantic Kegion 310-79 250-21 242-82 285-79 239-11 229-10 222-44 181-51 180-50 149-34 163-43 159-10 2563-25 Central Region 244-21 220-26 263-22 271-47 262-23 244-14 255-76 23618 23926 207-46 192-60 219-32 283164 Pacific Region 182-43 230-73 211-15 180-10 189-35 166-87 173-39 145-63 152-49 172-23 150-60 183-20 2122-92 At first sight it might appear that these figures repres ent an extraordinary amount of disease; but if they be compared with those of the published statistics of the United States army in time of peace, it will be found that the effect of the war on the health of the troops is rather in the increased number of serious diseases and the consequent mortality than in the number taken on sick report. The average number taken on sick report annually in time of peace, from 1840 to 1859, was 2558 per 1000. CONSTANT SICKNESS RATES. In this connection, the constant sickness rates assume the highest interest, especially to the military authorities. As every regimental sick report contains a separate statement of the number of sick and wounded under treatment at the close of each month, it might be supposed that the sum of these reports would furnish the number sick in the whole army at the close of each month, and that this would give a fair notion of the constant sickness. But the rates thus deduced give no idea of the number "absent sick," and the proportion of sick "absent" or "present" is not uniform, but varies continually. An army lying in winter quarters generally makes provision for most of its sick with it, while on the march all serious cases are sent to the general hospitals at the base of operations; so that constant sickness rates, which do not include those absent in hospital, are of no value. Now, for the early part of the war, it has not been possible to compute reliable constant sickness rates, because very many of the reports received were the old "quarterly" form, and only show the remaining at the end of each quarter, which would hardly give a just idea of the constant rates; moreover, in these quarterly reports the "remaining" were not discriminated into "sick" and "wounded," but given in gross. The figures, therefore, give the constant sickness rates plus the number of wounded under treatment. Subsequently to the period named, however, it is possible to compile quite accurate constant sickness rates from the data of the Surgeon General's Office, by taking the number "remaining" in general hospitals into the count and carefully discriminating "sick" from "wounded." It might perhaps be hoped that the monthly and tri-monthly returns of the Adjutant General's Office would supply the missing information for the early part of the war, 13 98 COMPARATIVE FREQUENCY OF THE SEVERAL DISEASES. but this is not the case. These returns are prepared for military, not for medical purposes. The monthly returns represent the number "present sick," but not the number "absent;" and under the head "present sick" (i.e. on sich report), they include those who are really "present wounded." The tri-monthly returns, indeed, represent the number "absent sick" as well as those "present sick;" but under the term sick, as in the monthly returns, both sick and wounded are included. All ratios hitherto compiled, and published unofficially, which purport to be based on the returns in the Adjutant General's Office, are open to this objection, that they include the wounded with the sick, and are therefore to be regarded as wholly valueless in forming a notion of the health of the army. The following table of constant sickness rates extends only from October Ist, 1862, to June 30th, 1863. It compares the health of the troops in the three regions. The figures include only those under treatment for disease, and not those suffering from wounds. TABLE V. Constant Sickness Hates for apart of the year ending June 30th, 1863, expressed in ratio per 1000 of mean strength. Atlantic Central Pacific Kegioo. ltegion. Kegion. 1862. October 123 102 65 November 134 106 77 December 118 91 66 1863. January 112 106 82 February 108 109 71 March 93 105 67 April 79 88 71 May 81 83 67 June 104 97 62 Average rate 106 98 70 The data from which this table was compiled are not as complete in all respects as could be desired: still the rates presented are believed to be close approximations. It will be observed the Atlantic region has a rate slightly higher than the Central, but that in both the rate is about 10 per cent, of the strength. The rate for the Pacific region, 7 per cent., is in striking contrast with the slight mortality of that region. COMPARATIVE FREQUENCY OF THE SEVERAL DISEASES. The monthly sick reports of the several regiments, detachments, and garrisons give the number taken sick during the month, and the number of deaths from each of the more important diseases ; the reports of the general hospitals give the number of admissions and deaths from each disease. The form employed during the first year of the war differed in arrangement and in some other points from the improved form adopted in the summer of 1862. Among the changes may here especially be mentioned a change in classification and the omission of the designation unclassified — (morbi varii) — the diseases not embraced in the list being directed to be reported as "other diseases," under the COMPARATIVE FREQUENCY OF THE SEVERAL DISEASES. 99 heads of the several orders to which they belong. In compiling the statistical tables for the first year of the war, the material contained in the reports has been rearranged to make its classfication correspond with that adopted for the second and subsequent years. The classification adopted is, with some slight alterations, that proposed by Dr. Farr, and employed in the reports of the Registrar General of England, and in the annual reports of the British army. The chief points of difference are, that "parasitic diseases" have been made a separate class, instead of being included with "zymotic diseases;" that "diseases of the eye" and "of the ear" are made separate orders of "local diseases," instead of being included with "diseases of the nervous system;" that "developmental diseases" are omitted as having no special applicability to army statistics, and that the class of "wounds, accidents, and injuries" is subdivided in a less elaborate manner than in Farr's classification. To these may be added the minor point that Farr includes rheumatism and tonsillitis among miasmatic diseases, instead of which, in our classification, rheumatism is placed among "constitutional diseases," and tonsillitis with diseases of the digestive organs. The classification has been adopted as a matter of convenience in grouping the facts, rather than as an expression of any well-considered natural relationship between diseases. Thus, at the very threshold, the question may be raised whether the fundamental notion which furnished the name "zymotic," is not a mere conjecture; but if, without thereby meaning to insist upon the idea of a ferment, we retain the term to indicate certain grave constitutional disorders determined by dietic errors, by inoculation or contagion, by epidemic or endemic influences, or by those groupings of conditions found in camps which act like epidemic influences on many at once, it may be asked whether many of the affections now placed under local diseases ought not to be transferred to this class ? Thus, for example, in the tables of Farr, simple coryza and catarrh, as well as epidemic catarrh, are placed in the first order of zymotic diseases; while acute bronchitis and pneumonia are placed among local diseases. It would appear, however, that all these affections belong in fact to one category, are developed by a like series of conditions, acting with different intensities or in constitutions of different resisting powers; that catarrh stands at one end of the scale, pneumonia at the other; and that, regarded as the expression of more or less exposure to unfavorable climatic influences, the proper place for all these affections is with miasmatic diseases. Without entering into a further discussion as to the scientific accuracy of the English classification, it may be remarked that one of the arguments most frequently used in its favor is derived from a very different source. It is claimed that the various affections embraced under the class of zymotic diseases are to be regarded as essentially preventable, while diathetic, local, developmental, and violent diseases are more or less inevitable. The classification therefore has this special advantage for military and political purposes, that the amount of disease which, by proper sanitary precautions, might have been avoided, is kept constantly in view; a consideration which must undoubtedly act as a constant stimulant to sanitary effort. Unfortunately, however, our notions of the causation of disease are not sufficiently accurate to enable us to draw any sharp boundary between preventable and unavoidable affections; and, indeed, if such a 100 COMPARATIVE FREQUENCY OF THE SEVERAL DISEASES. boundary were attempted, it would certainly not correspond with the classification under consideration; a large proportion of the "local" inflammatory affections being conditioned in frequency and severity at least, if not determined, by want of proper clothing and shelter, unnecessary exposure to cold and moisture, and other causes quite as well understood, and certainly more readily modified by hygienic means, than the causes of diphtheria, of enteric fever, or of epidemic cholera. But notwithstanding these critical objections, the English classification appears to be the most convenient and rational hitherto proposed, and, with the slight modifications above mentioned, it has been thought best to employ it. T he following tables give the number of cases and deaths in each of the three great regions for the several classes, orders, and individual diseases during the first and second years of the war. Under the head of "taken sick," in these tables, all cases occurring in the field and in garrison are included, but not the "admissions" into general hospitals; because this would have involved a repetition of cases previously reported in the field or in garrison. Under the head of deaths, however, the deaths in general hospitals are included. In calculating the ratio of cases to strength in the following tables, then, the strength employed includes only the troops represented in the reports, and this because it was among them only that the cases occurred. In computing the ratio of deaths to strength, however, as already explained under the head of mortality rates, the strength in hospital is included. The average annual strengths represented in the reports from which the following tables were compiled, are as follows: For the first year — Atlantic region, 177,899 in field and garrison, 4687 in general hospitals; Central region, 96,583 in field and garrison, 5072 in general hospitals; Pacific region, 6695 in field and garrison, — no general hospitals. For the second year — Atlantic region, 283,703 in field and garrison, 27,802 in general hospitals; Central region, 306,405 in field and garrison, 17,885 in general hospitals; Pacific region, 8713 in field and garrison, — no general hospitals. These strengths are those employed in computing all the ratios given in this paper. The six tables now presented are arranged as follows: Table VI. shows the numbers taken sick and died for each class of disease in each of the three regions, and for the whole army, during the first year of the war. The ratio of cases and deaths to strength, in each region and for the whole army, is also given. Table VII. contains similar figures for the second year. Tables VIII. and IX. are arranged in the same manner, and give the number taken sick and died, and the ratio to strength for each order. Tables X. and XI. contain the number taken sick and died from each individual disease and injury for the two years. The years spoken of here, and throughout the paper, are congressional fiscal years, beginning on the Ist of July and terminating on the 30th of June following. 101 COMPARATIVE FREQUENCY OF THE SEVERAL DISEASES. TABLE VI Summary of Cases and Deaths, by the several Classes of Diseases and Injuries, for the year ending June 30th, 1862. Atlantic Region. Central Region. Pacific Region. Total. ©©©QOOOO O O © O © Q © ® CLASSES. ji Sg.d *JJ % £ 8 £ -^Jfi .g 8, • ,*!£ .jj w. • - a§f alt - §.if s.|f -b &ga> 8.? a» « &S? its H ft « M H O « H fi M M H ft M « I. Zymotic diseases 249,120 4,032 1400-34 22-08 207,799 5,269 2151-51 51-73 6,561 32 979-99 4-78 463,480 9,333 1648-36 32-08 11. Constitutional diseases 35,777 285 201-11 1-56 15,090 367 156-24 3-61 1,607 14 240-03 2-09 52,474 666 186-62 2-29 111. Parasitic diseases 640 3-60 408 4-22 10 ... 1-49 1,058 3-76 IV. Local diseases 198,951 1,375 1118-34 7-53 105,054 2,341 1087-71 23-03 5,917 26 883-79 3-88 309,922 3,742 1102-23 12-86 V. Wounds and injuries... 27,862 2,410 156-62 13-20 15,149 2,386 156-85 23-47 1,875 61 280-06 9-11 44,886 4,857 159-64 1669 VI. Unclassified diseases... 4,526 262 25-44 1-43 2,149 175 22-25 1-72 428 5 6318 0-75 7,098 442 25-24 1-52 Total 516,876 8,364 2905-45 45-81 345,649 10,538 3578-78 103-66 16,393 138 2448-54 20-61 878,918 19,040 3125-85 65-44 TABLE VII. Summary of Gases and Deaths, by the several Glasses of Diseases and Injuries, for the year ending June 30th ? 1863. Atlantic Region. Central Region. Pacific Region. Total. I „ Ml HI 1 „ MtNIl 1 „ I 8!I 8 ! HI 1 „ !!!.!!! I. Zymotic diseases 428,603 9,529 1510-75 30-69 686,329 20,158 1913-58 62-16 10,317 23 1184-09 264 1,025,249 29,710 171211 46-10 11. Constitutional diseases 62,660 812 22090 2-61 49,135 1,736 160-36 6-35 1,943 8 223-00 0-92 113,738 2,556 189-94 8-97 111. Parasitic diseases 3,103 1 10-94 0-003 4,218 1377 33 ... 378 7,354 1 12-28 0002 IV. Local diseases 232,836 2,565 820-70 8-20 227,947 7,146 743-94 22-04 6,204 42 712-04 4-82 466,987 9,743 779-84 15-12 V. Wounds and injuries.. 54,431 5,344 191-86 17-16 41,903 4,757 136-76 14-67 2,141 41 245-72 4-71 98,475 10,142 164-45 15-74 Total 781,633 18,2412755-11 58-56 909,532 33,797 2968-40 104-22 20,638 114 2368-64 13-08 1,711,803 52,152 2858-62 80-92 102 COMPARATIVE FREQUENCY OF THE SEVERAL DISEASES. TABLE VIII. Summary of Gases and Deaths, by the several Orders of Diseases and Injuries, for the year ending June 30th, 1862. Atlantic Region. Central Region. Pacific Region. Total. §000 OQOO 0000 0000 «w» ~t4 ~i4 4 ts^l^ss 4 rsd ?!£ -a *M tls ¦a % ;so« i°« -a 3 sou s'ss -a i §ss i»ts * 3 %** I. 1. Miasmatic Diseases. 231,671 3,989 1302-26 21-85 201,291 5,216 2084-13 51-31 3,755 30 560-87 4-48 436,717 9,235 155317 3174 2. Enthetic Diseases... 15.504 5 8715 -02 6,786 8 59-91 "08 2,511 ... 375-06 23,801 13 84-65 -04 3. Dietic Diseases 1,945 38 10-93 -21 722 45 7-47 -44 295 2 44-06 -30 2,962 85 10-53 -30 11. 1. Diathetic Diseases... 33,689 38 18937 -21 14,094 62 145-93 -61 1,556 6 23241 -89 49,339 106 17547 -36 2. Tubercular Diseases 2,088 247 11-74 1-35 996 305 10-31 3-00 51 8 7-62 1-19 3,135 560 11-15 1-92 111. Parasitic Diseases 640 3-60 408 422 10 ... 1-49 1,058 376 IV. 1. Diseases of Nervous System 17,970 232 101-01 1-27 8,844 233 91-57 2-29 461 9 68-86 1-34 27,275 474 97-00 1-63 2. Diseases of the Eyo.. 5,503 31-27 4,457 1 46-15 -01 356 ... 53-17 10,376 1 36-90 -003 3. Diseases of the Ear.. 3,263 18-34 1,721 4 17-81 -04 95 ... 14-19 5,079 4 18-06 -01 4. Diseases of Organs ofCirculation 2,231 68 12-54 -37 821 61 8-50 -60 35 4 5-23 -60 3,087 133 10-98 -46 5. Diseases of Respiratory Organs 89,875 866 505-20 4-74 48,440 1,797 501-54 17-67 2,058 8 307-39 1-19 140,373 2,671 499-23 918 6. Diseases of Digestive Organs 61,215 183 344-10 1-00 33,496 225 346-81 2-21 2,202 5 328-90 -75 96,913 413 344-67 1-42 7. Diseases of the Urinary and Genital Organs 2,839 22 15-96 -12 1,220 8 12-63 -08 85 ... 12-70 4,144 30 1474 -10 8. Diseases of the Bones and Joints... 359 2-02 188 1 1-95 -01 7 ... 1-05 554 1 1-97 -003 9. Diseases of the Integumentary System 15,636 4 87-89 -02 5,867 11 60-75 -11 618 ... 92-31 22,121 15 78-67 -05 V. Wounds, Accidents and Injuries 27,862 2,410 156-62 13-20 15,149 2,386 156-85 23-47 1,875 61 28006 9-11 44,886 4,857 159-64 16-69 VI. Unclassified Diseases... 4,526 262 25-44 1-43 2,149 175 22-25 1-72 423 5 63-18 -75 7,098 442 25-24 1-52 Total 516,876 8,364 2905-45 45-81 345,649 10,538 3578-78 103-66 16,393 138 2448-54 20-61 878,918 19,040 3125-85 65-44 TABLE IX. Summary of Gases and Dealhs> by the several Orders of Diseases and Injuries, for the year ending June ZQth, 1863. Atlantic Region. Central Region. Pacific Region. Total. ORDERS. m £g.a M »J ~£ji M ~JsA M °{a ¦a &af Ml 1 ' s £*£ ' s s-St all •= s.|i s.|| S j .2_2 o^£ go • o g o«S g _; o.£ o^S S j 2 S »*£ 1 3"ss «%« -a I i'ss i-ss -a §ps ~ois I tj-st; tsos h a M M h A M M g ft tf tf h ft M ~a I. 1. Miasmatic Diseases. 406,433 9,395 1432-60 30-16 560,637 19,968 1829-72 61-57 6.688 17 767-59 1-95 973,758 29,380 1626-13 45-58 2. Enthetic Diseases... 17,868 13 62-98 -04 20,347 29 66-41 -09 2,793 4 320-56 -46 41,008 46 68-48 -07 3. Dietic Diseases 4,302 121 15-16 -39 5,345 161 17-44 -50 836 2 95-95 -23 10,483 284 17-51 -44 11. 1. Diathetic Diseases... 59,046 167 208-13 -54 44,983 301 146-81 -93 1,861 ... 213-59 105,890 468 176-83 -73 2. Tubercular Diseases 3,614 645 12-74 2-07 4,152 1,435 13-55 4-43 82 8 9-41 -92 7,848 2,088 13-11 3-24 111. Parasitic Diseases 3,103 1 10-94 -003 4,218 13-77 33 ... 3-79 7,354 1 12-28 -002 IV. 1. Diseases of the Nervous System 25,084 567 88-42 1-82 26,147 917 85-33 2-83 605 7 69-44 -80 51,836 1,491 86-56 2-31 2. Diseases of the Eye. 7,480 26-37 16,294 53-18 527 ... 60-50 24,301 40-58 3. Diseases of the Ear. 4,611 2 16-25 -006 5,727 1 18-69 -003 168 ... 19-28 1U,506 3 17-54 -005 4. Diseases of Organs ofCirculation 6,018 266 21-21 -85 4,418 320 14-42 -99 70 6 8-03 -57 10,506. 591 17-54 -92 5. Diseases of Respiratory Organs 61,636 1,188 217-26 3-81 58,761 4,818 191-78 14-86 881 13 101-11 1-49 121,278 6,019 202-53 9-34 6. Diseases of Digestive Organs 96,769 445 341-09 1-43 91,675 914 299-20 2-82 2,906 15 333-52 1-72 191,350 1,374 319-54 2-13 7. Diseases of the Urinary and Genital Organs 5,862 63 20-66 -20 5,406 93 17-64 -29 163 2 18-71 -23 11,431 158 19-09 -25 8. Diseases of the Bones and Joints... 1,711 4 6-03 -01 1,351 25 4-41 -08 27 ... 3-10 3,089 29 5-16 -05 9. Diseases of Integumentary System.... 23,665 20 83-41 -06 18,168 58 59-29 -18 857 ... 98-36 42,690 78 71-29 -12 V. Wounds, Accidents and Injuries 54,431 6,344 191-86 17-16 41,903 4,757 136-76 14-67 2,141 41 245-72 4-71 98,475 10,142 164-45 15-74 Total 781,633 18,241 2765-11 68-56 909,532 33,797 2968-40 104-22 20,638 114 2368-64 13-08 1,711,803 52,152 2858-62 80-92 103 COMPARATIVE FREQUENCY OF THE SEVERAL DISEASES. TABLE X. Showing the Number of Gases and Deaths, by Individual Diseases and Injuries, for the year ending June SOth, 1862. Atlantic Region. Central Region. Pacific Region. Total. LIST OF DISEASES. ¦ Taken sick. Died. Taken sick. Died. Died. Taken sick. Died. Class I.— Zymotic Diseases. Order I. Miasmatic Disease*. Typhus Fever 463 101 359 89 2 1 824 191 Yellow Fever Typhoid Fever 12,616 2,736 9,312 2,864 49 8 21,977 5,608 Common Continued Fever 7,645 40 4,008 105 118 1 11,771 146 Remittent Fever 21,792 182 17,934 187 321 1 40,047 370 Quotidian Intermittent Fever 18,145 1 21,622 31 608 ... 40,375 32 Tertian Intermittent Fever 13,666 5 12,776 28 308 ... 26,750 33 Quartan Intermittent Fever 1,546 3 1,855 1 50 ... 3,451 4 Congestive Intermittent Fever 1,500 201 727 160 | 7 ... 2,234 361 Acute Diarrhoea i 90,472 40 72,715 187 1,364 ... 164,551 227 Chronic Diarrhoea 4,881 52 10,876 440 58 1 15,815 493 Acute Dysentery 18,392 116 13,472 230 373 1 32,237 347 Chronic Dysentery 1,180 30 1,407 94 24 3 2,611 127 Asiatic Cholera Erysipelas 1,309 39 1,292 81 51 1 2,652 121 Small-pox and Varioloid 678 210 464 190 168 12 1,310 412 Measles 10,055 173 11,558 377 63 1 21,676 551 Scarlet Fever 93 7 40 3 133 10 Mumps 4,536 2 6,660 7 20 ... 11,216 9 Epidemic Catarrh 6,649 2 4,649 3 16 ... 11,314 5 Debility 11,670 39 6,529 116 125 ... 18,324 155 Other diseases of this order 4,383 10 3,036 23 30 ... 7,449 33 Order 11. Enthetic Diseases. Syphilis 6,139 5 1,028 7 1,244 ... 9,011 12 Gonorrhoea 7,416 3,185 1,037 ... 11,638 Orchitis 1,631 906 185 ... 2,722 Stricture of the Urethra 309 56 43 ... 408 Serpent-bite 9 11 1 20 1 Other diseases of this order 2 ... 2 Order 111. Didic Diseases. Scurvy 933 6 321 3 74 ... 1,328 9 Delirium Tremens 426 21 178 35 52 2 656 58 Inebriation 586 11 223 7 169 ... 978 18 Class ll.— Constitutional Diseases. Order I. Diatlietic Diseases. Gout 45 51 96 Acute Rheumatism 17,686 7 7,435 19 1,136 3 26,257 29 Chronic Rheumatism 10,204 9 3,701 10 311 ... 14,216 19 Lumbago 2,848 2 1,367 74 ... 4,289 2 Anannia 636 8 590 4 3 1 1,229 18 General Dropsy 259 11 491 22 8 1 758 34 Cancer "... 14 18 4 11 88 5 Tumors 360 75 12 ... 447 Other diseases of this order 1,637 1 366 3 11 ... 2,014 4 Order 11. Tubercular Diseases. Consumption 1,678 243 795 299 35 8 2,508 550 Scrofula 410 4 201 6 16 ... 627 10 Class lll.— Parasitic Diseases. Worms 640 408 10 ... 1,058 Carried forward 285,537 4,317 223,297 5,636 8,178 46 517,012 9,999 104 COMPARATIVE FREQUENCY OF THE SEVERAL DISEASES. TABLE X. — Continued. Atlantic Region. Central Region. Pacific Region. Total. LIST OF DISEASES. — Taken sick. Died. Taken sick. Died. Died - Taken sick - Died - Brought forward 285,537 4,317 223,297 5,636 8,178 46 517,012 9,999 Class IV.— Local Diseases. ' Apoplexy °— l ~"^ 1 *~" *-" 124 60 68 58 4 3 196 121 5,307 1 i,m ...... nj ... 7134 1 Inflammation of Brain 92 43 57 49 4 2 153 94 St. Vitus Dance 49 1 28 1 1 ... 78 Z Er)ileDBV 843 19 326 18 30 1 1,199 38 SSSS^zz'z:zz:zzzz: 253 7 m ; 4 1 420 17 Spinal Irritation 271 3 281 5 7 ••• 559 8 Insanity 162 4 55 4 10 ... 227 8 MeTanfe":::::::::::::::::.:::.:.:::::: 152 1 m 2 s Inflammation of Membranes of Brain 113 58 51 47 6 ... i'JJ wo 5^:=::::":=:::::::::::EE::::::: 4.5J .....' JS ~i » ; £ * £$£• :::::::::::::::::::::::::::::::::::::::: *X tj *S? -s 5 i 73» 7 '3» « Other diseases of this order 658 24 241 28 9 1 908 53 Order 11. Diseases of Eye. Amaurosis 109 33 5 ... 147 Cataract 52 18 1 ... 71 Inflammation of Iris 205 66 11 ... ZXZ Night Blindness 97 H 1 ••• V™ •••••• Ophthalmia 4,269 3,969 1 326 ... 8,564 1 Inflammation of Retina 66 63 3 ... 1<" Other diseases of this order 765 297 9 ... 1,0/1 Order 111. Diseases of Ear. Earache 1,137 600 34 ... 1,771 ...... Inflammation of Internal Ear 913 504 1 43 ... 1,460 1 Otorrhoea 926 479 1 5 ... 1,410 1 Deafness 182 71 10 ... 263 ...... Other diseases of this order 105 67 2 3 ... 175 I Order IV. Diseases of Organs of Circulation. Aneurism 21 2 13 8 1 1 M « Angina Pectoris 167 8 55 3 11 ... 233 6 Inflammation of Heart 114 11 30 10 5 ... 149 21 Inflammation of Endocardium 75 10 34 5 109 Inflammation of Pericardium 167 20 55 20 3 2 225 42 Inflammation of Veins 36 1 37 2 73 3 Varicocele 726 258 4 ... 988 ...... Varicose Veins 534 236 1 6 ... 776 1 Other diseases of this order 391 21 103 17 5 1 499 89 Order V. Diseases of Respiratory Organs. Asthma 881 4" 288 7 1 ... 1,170 11 Acute Bronchitis '. 18,247 48 7,857 54 97 ... 26,201 102 Chronic Bronchitis 2,588 21 1,295 15 19 ... 3,902 36 Catarrh 53,721 1 28,455 4 1,661 ... 83,837 5 Haemorrhage from Nose 293 1 112 2 11 406 4 Haemorrhage from Lungs 745 13 294 9 13 ... 1,052 Dropsy of Chest 15 3 8 2 23 5 Inflammation of Larynx 1,671 22 885 11 41 1 2,597 34 Inflammation of Pleura 3,023 40 1,964 42 92 2 5,079 84 Inflammation of Lungs 4,582 601 6,366 1,529 118 4 11,061 2,134 Other Diseases of this order 4,109 112 916 122 20 ... 5,045 234 Order VI. Diseases of Digestive Organs. Abdominal Dropsy 77 9 69 7 4 ... 150 16 Cholera Morbus 2,818 12 1,464 21 26 ... 4,308 33 Colic 7,524 3 3,695 8 155 ... 11,374 11 Constipation 17,395 1 8,631 4 1,172 ... 27,198 5 Dyspepsia 4,265 1 1,719 165 ... 6,149 1 Carried forward 436,618 5,509 303,158 7,772 12,705 67 752,381 13,348 l_ COMPARATIVE FREQUENCY OF THE SEVERAL DISEASES. 105 TABLE X.— Concluded. Atlantic Region. Central Region. Pacific Region. Total. LIST OP DISEASES. Taken sick. Died. Taken sick. Died. T T g R , k £ n Died. Taken sick. Died. Brought forward 436,518 5,509 303,158 7,772 12,705 67 752,381 13,348 Ordeb VI. Diseases of Digestive Organs — Continued. Inflammation of Bowels 455 43 695 48 4 1 1,154 92 Inflammation of Stomach 1,033 15 868 20 55 ... 2,556 35 Fistula 263 99 13 ... 375 Haemorrhage from Stomach 137 1 40 2 10 ... 187 -I Piles 3,861 1,823 3 89 ... 5,773 3 Acute Inflammation of Liver 1,018 9 1,042 12 19 ... 2,079 21 Chronic Inflammation of Liver 538 7 585 12 15 2 1,188 21 Hernia 2,516 3 1,259 3 34 ... 3,809 6 Jaundice ! 5,110 9 6,795 31 24 ... 10,929 40 Prolapsus Ani 219 121 4 ... 344 Inflammation of Peritoneum 161 44 260 23 4 1 425 68 Inflammation of Spleen 98 180 2 3 ... 281 2 Inflammation of Tonsils 7,782 5 3,488 3 197 1 11,467 9 Other diseases of this order 5,345 21 1,663 26 209 ... 7,217 47 Order VII. Diseases of Urinary and Genital Organs. Stone and travel 56 34 3 ... 93 Inflammation of Bladder 258 5 135 8 ... 401 o Diabetes 89 1 35 1 124 2 Incontinence of Urine 136 1 33 1 ... 170 1 Retention and Difficulty of Urination 641 1 239 8 ... 888 1 Inflammation of Kidneys 506 6 410 4 16 ... 932 10 Hydrocele and Haematocele 194 99 10 ... 303 Sarcocele 91 35 1 ... 127 Non-Syphilitic Ulcer of Penis 255 66 15 ... 336 Other diseases of this order 613 8 134 3 23 ... 770 11 Order VIII. Diseases of Bones and Joints. Anchylosis 67 I 56 2 ... I 125 Exostosis 68 41 2 ... 11l White Swelling 77 33 1 1 ... HI 1 Necrosis 147 58 2 ... | 207 Order IX. Diseases of the Integumentary System. Abscess 3,648 1 1,474 6 171 ... 5,293 7 Carbuncle 976 198 1 13 ... 1,187 1 Whitlow 944 j 306 48 ... 1,298 Boil 2,752 651 132 ... | 3,535 Skin Diseases 3,111 1 1,961 1 114 ... ! 5,186 2 Ulcers 2,878 2 1,092 8 121 ... [ 4,091 5 Other diseases of this order 1,327 185 I 19 ... | 1,531 Class V.— Wounds, Accidents, and Injuries. Burns 656 1 292 1 50 ... 998 2 Concussion of Brain 81 8 48 8 17 2 146 18 Compression of Brain 25 10 34 6 1 ... 60 16 Contusion 4,730 17 1,675 7 494 ... 6,899 24 Fracture 761 24 426 24 59 1 1,246 49 Frost-bite 102 1 69 8 19 ... 190 4 Dislocation 374 224 40 ... 638 Sprain 2,249 717 1 185 ... 3,151 1 Incised Wounds 3,178 5 704 11 179 ... 4,061 16 Contused and Lacerated Wouuds 3,162 48 1,769 64 319 ... 5,250 112 Punctured Wounds 1,024 19 317 16 47 2 1,388 37 Gunshot Wounds 9,270 2,205 7,837 2,167 389 49 17,496 4,421 Poisoning 183 11 89 8 21 ... 293 19 Suicide 25 15 5 45 Others of this class 2,067 36 948 55 55 2 3,070 93 Unclassified Diseases 4,526 262 2,149 175 423 5 7,098 442 Total 516,876 8,364 345,649 10,538 16,393 138 878,918 19,040 14 106 COMPARATIVE FREQUENCY OF THE SEVERAL DISEASES. TABLE XL Showing the Number of Cases and Deaths, by Individual Diseases and Injuries, for the year ending June 30th, 1863. Atlantic Region. Central Region. Pacific Region. Total. LIST OF DISEASES. ~ Taken sick. Died. Taken sick. Died. T^™ Died. Taken sick. Died. Glass I.— Zymotic Diseases. Typhoid FeveT 1^"" 1 " 0^""' 17,050 4,356 14,218 6,106 106 5 31,374 10,467 TySus Fever 469 128 424 252 6 1 899 381 TSoUTariaiF^r:::::::::::::::: 12,093 489 io, 42 6 6 4 0 133 ... 22,652 1,129 Yellow Fever 356 100 356 100 Remittent Fever" 35,056 339 48,219 828 441 ... 83,716 1,167 Quotidian Intermittent' Fever Z.Z 28,968 29 67,087 115 608 ... 96,663 144 Tertian Intermittent Fever 22,295 20 57,380 96 378 ... 80,053 116 Quartan Intermittent Fever 2.687 5 6,693 73 54 ... 9,434 78 Congestive Intermittent Fever 1,098 243 2,728 776 21 1 3,847 1,020 Acute Diarrhoea 175,152 210 197,089 659 1,686 1 373,927 870 Chronic Uiarrh^a 28 062 1,974 34 900 5,510 121 4 63,083 7,488 AcutrDvsentery ... 24 597 249 39 637 671 470 2 64,704 922 c^oi)yM2J^:::::::::::::::::::::.: w 3 0 9 4,mi m ™ ... 8,747 w Asiatic Cholera " "',"'].'' "oor Ervsinelas 1,996 76 4,612 759 68 1 6,5/b 835 BmVltpoxand'VarioioW.:::......:..... 802 375 1,974 757 46 ... 2,822 1,182 Measles 5,106 110 11,217 1,203 22 ... 16,345 1,818 Scarlet Fever 115 7 89 19 2 ... 206 26 Diphtheria 1,046 143 1,317 136 81 ... 2,444 279 Mumps 3,005 13 lO^Ql 17 133 ... 13,429 30 BpidemloCatawh .'........; 28,391 3 32,915 21 1,896 ... 63,202 24 Other diseases of this order 14,336 218 14,580 553 363 2 29,2/9 773 Syphilis ° RDER n '™^?": 6,118 4 6,439 20 1,224 3 13,781 27 Gonorrhea".:::::::.: 9,348 io, 98 2 c 1,302 ... 21,632 c Orchitia 1,537 1,580 3 199 ... 3,316 Stricture of the Urethra 441 2 279 37 1 757 Purulent Ophthalmia 222 878 4 ... 1,104 Serpent-bite 9 17 3 ... M ...... Other diseases of this order 193 7 172 24 ... 389 7 Order 111. Dittic Diseases. _. Scurvy 3,090 36 3,774 53 631 1 7,395 90 Purpura 85 14 217 17 2 ... 304 31 Delirium Tremeus 314 40 385 70 73 1 772 111 Inebriation 437 11 560 11 224 ... 1,221 22 Chronic Alcoholism 101 3 120 7 6 ... 226 10 Other diseases of this order 275 17 289 3 1 ... 565 20 Class ll.— Constitutional Diseases. Order I. Diathelic Diseases. . .. „ „ Gout 42 78 6 ... 126 Acute Rheumatism 25,723 27 18,887 57 1,067 ... 45,677 84 Chronic Rheumatism 26,571 25 18,483 40 704 ... 45,758 65 Ansemia 4,596 59 4,746 106 17 ... 9,359 165 General Dropsy 725 18 1,564 27 5 ... 2,294 45 Cancer 92 4 53 5 5 ... 150 9 Tumors 306 2 279 1 23 ... 608 3 Dry Gangrene 58 11 7 13 1 ... I 66 ,24 Other Diseases of this order 933 21 886 52 33 ... 1,852 <3 Order 11. Tubercular Diseases. _ _„. „ _.„ Consumption 2,566 630 2,983 1,402 50 8 5,599 2,040 Scrofula 957 9 1,075 23 32 ... 2,064 32 Other diseases of this order 91 6 94 10 185 16 Class lll.— Parasitic Diseases. . . 000 Itch 2,435 3,790 7 ... 6,232 Tape-worm 85 49 6 ... 140 Other intestinal worms 550 1 336 20 ... 906 1 Other diseases of this order 33 43 76 Carried forward 494,366 10,342 639,682 21,894 12,293 31 1,146,341 32,267 107 COMPARATIVE FREQUENCY OF THE SEVERAL DISEASES. TABLE XI. — Continued. Atlantic Region. Central Region. Pacific Region. Total LIST OF DISEASES. : ' ; Taken Bick. Died. Taken sick. Died. T B^ n Died. Taken sick. Died. Brought forward 494,366" 10,342 639,682 21,894 12,293 31 1,146,341 32,267 Class IV.— Local Diseases. Apoplexr 8111 - I'"^^^""'"^ 1 '"^^^""'"^" 1 " 170 107 221 146 7 2 398 255 Epilepsy """"..."!"".!" 1,386 44 1,166 61 33 ... 2,585 105 Headache' 11,059 9,384 202 ... 20,645 Insanity 407 8 410 12 14 ... 831 20 1nf1wniaain'0f'8rain"".!....!...!!....;.."!!...!!...! 175 137 271 307 4 2 450 446 Inflammation of Membranes of Brain 130 69 165 139 2 ... 297 208 Inflammation of Spinal Cord 319 10 713 32 5 ... 1,037 42 SSSSt :::::::::: & I S I» E &S Other diseases of this order 1,232 128 1,419 108 30 1 2,681 237 Obder 11. Diseases of Eye. Amaurosis 280 226 7 ... 513 Cataract 106 192 3 ... 301 Inflammation of Conjunctiva 6,540 14,490 448 ... 20,478 Inflammation of Iris 295 294 30 ... 619 Night Blindness 691 451 5 ... 1,147 Other diseases of this order 568 641 34 ... 1,243 Order 111. Diseases of Ear. Earache 2,454 3,020 47 ... 5,521 Inflammation of Internal Ear 537 1 1,000 54 ... 1,591 1 Deafness 439 316 20 ... 775 Otorrhoea 1,057 1 1,310 1 39 ... 2,406 2 Other diseases of this order 124 81 8 ... 213 Order IV. Diseases of Organs of Circulation. Aneurism 50 10 48 10 1 1 99 21 Valvular Disease of Heart 789 97 424 85 4 ... 1,217 182 Dropsy from Heart Disease 123 16 109 31 232 Dropsy of Pericardium 62 14 57 21 35 Inflammation of Pericardium 279 24 263 71 11 2 553 Inflammation of Endocardium 122 15 133 32 4 ... 259 47 Inflammation of Veins 58 4 70 2 4 ... 132 6 Varicose Veins 2,070 1 1,270 4 ... 3,344 1 Varicocele ? 1,929 1,566 9 ... 3,504 ...... Other diseases of this order 536 85 478 68 33 2 1,047 155 Order V. Diseases of Sespiratory Organs. 9q Asthma 1,987 8 1,455 21 26 ... 3,468 Bronchitis A cuta 29,727 48 20,815 139 257 ... 50,799 187 Bronchitis Chronica 4,695 31 4,771 170 52 ... 9,518 201 Dropsy of Chest 63 6 128 24 191 30 Haemorrhage from Nose 528 1 I 478 7 ... 1,013 3 Inflammation of Larynx 2,822 81 3,011 121 86 ... 5,919 152 Inflammation of Lungs 5,894 933 14,450 4,014 122 10 20,466 4,957 Inflammation of Pleura 4,986 37 5,252 130 121 2 10,359 169 Heemorrhage from Lungs 923 24 1,066 39 27 ... 2,016 63 Other diseases of this order 10,011 69 7,335 158 183 1 17,529 228 Order VI. Diseases of Digestive Organs. lno , _ Colic . . .: .. 12,195 5 12,094 11 139 2 24,428 18 Constipation 20,720 1 18,630 5 1,408 ... 40,758 6 Cholera Morbus 4,010 42 4,553 54 60 ... 8,623 96 Cirrhosis of Liver 46 3 67 2 1 ... 114 5 Dropsy from Hepatic Disease 569 24 897 50 1,467 7o Dyspepsia „ 7,466 4 5,574 6 191 1 13,231 11 Diseases of Pancreas 22 18 15 ... 55 ...... Diseases of Spleen 167 2 741 10 4 ... 912 12 Fistula in Ano 410 457 5 10 ... B<7 5 Hernia 5,573 7 4,329 15 75 1 9,977 23 Haemorrhage from Stomach 150 3 211 5 7 ... 368 Carried forward 650,523 12,456 798,600 28,113 16,455 61 1,465,578 40,630 108 COMPARATIVE FREQUENCY OF THE SEVERAL DISEASES. TABLE XL— Concluded. Atlantic Region. Central Reoion. Pacific Region. Total. LIST OF DISEASES. Taken sick. Died. Taken sick. Died. n Died. Taken sick. Died. Brought forward 650,523 12,456 798,600 28,113 16,455 61 1,465,578 40,630 Order VI. Diseases of Digestive Organs— Continued. Heemorrhage from Bowels 336 13 407 32 ... 743 45 Inflammation of Tonsils 9,680 17 7,751 22 304 ... 17,735 39 Inflammation of Stomach 1,532 43 2,141 135 89 ... 3,62 I*B Inflammation of Bowels 859 92 1,292 176 26 3 2,177 2/1 Inflammation of Peritoneum 147 62 297 97 102 3 546 162 Acute Inflammation of Liver 1,467 22 2,477 58 52 4 3,996 84 Chronic Inflammation of Liver 1,307 15 2,235 49 48 ... 3,590 64 Jaundice 16,853 28 14,702 93 85 ... 31,640 121 PileB 10,252 2 9,551 20 229 ... 20,032 22 Other diseases'of this 'order 3,008 60 3,251 69 60 ... 6,319 129 Order VII. Diseases of Urinary and Genital Organs Stone and Gravel 431 430 6 6 ... 867 6 Diabetes 158 7 266 11 8 ... 432 18 Bright's Disease 298 18 197 19 3 ... 498 37 Diseases of Prostate 39 86 1 2 ... 127 1 Diseases of Testis 486 397 8 2 ... 885 8 Inflammation of Kidneys 1,744 18 1,877 34 20 1 3,641 53 Inflammation of Bladder 602 7 544 9 16 ... 1,162 16 Incontinence of Urine 859 419 2 2 ... 1,280 Hydrocele 256 1 258 8 ... 522 Other diseases of this order 989 12 932 8 96 1 2,017 21 Order VIII. Diseases of Bones and Joints. Anchylosis 152 179 7 ... 338 Caries 166 1 69 1 1 ... 236 2 Inflammation of Joints 756 1 473 3 7 ... 1,236 4 Inflammation of Bones 46 42 1 1 ... 89 Inflammation of Periosteum 252 190 3 1 ... 443 Necrosis 223 249 16 3 ... 475 16 Other diseases of this order 116 2 | 149 1 7 ... 272 Order IX. Diseases of Integumentary System. Abscess 8,665 17 7,624 52 544 ... 16,833 69 Boils 8,101 5,307 80 ... 13,488 Carbuncle 1,096 1 1,046 2 24 ... 2,166 3 Ulcers 206 1 4 206 5 Whitlow 1,998 1,300 79 ... 3,377 Skin Diseases 3,699 1 2,891 130 ... 6,620 1 Class V.— Wounds, Accidents, and Injuries. Order I. Wounds, Accidents, and Injuries. Burns 1,510 6 1,122 29 47 ... 2,679 35 Contusions 5,911 15 4,087 19 728 ... 10,726 34 Concussion of Brain ! 109 22 167 38 12 1 288 61 Drowning 50 ..- 69 4 123 Dislocation 424 2 432 1 35 ... 891 3 Simple Fractures 743 15 807 28 68 ... 1,618 43 Compound Fractures 105 78 190 54 295 132 Gunshot Wounds 31,165 4,782 24,599 3,946 210 27 55,974 8,755 Incised Wounds 3,5 - 95 6 1,759 75 182 ... 5,536 81 Lacerated Wounds 1,591 39 2,335 222 321 1 4,247 262 Punctured Wounds 803 54 770 54 47 1 1,620 109 Poisoning 461 10 346 15 50 ... 857 25 Asphyxia 8 4 23 1 31 5 Sprains 5,972 3,730 293 ... 9,995 Other accidents and injuries 2,033 204 1,534 138 148 5 3,715 347 Order 11. Homicide 12 13 1 26 Order 111. Suicide *1 39 *2 48 1 *3 88 Order IV. Execution of Sentence 6 7 13 Total 781,633 18,241 909,532 33,797 20,638 114 1,711,803 52,152 * Attempted. 109 CAMP FEVER. In order to facilitate the appreciation of the foregoing tables, a few considerations, derived partly from the statistical facts, partly from contributed papers and from pathological observations conducted in this branch of the office, are presented with regard to some of the more important affections. CAMP FEVER— (TYPHO-MALARIAL FEVER). On account of the great mortality resulting from it, camp fever has been, during the two years under consideration, the most important of the diseases of the army. Under the general designation of Camp Fever, all those cases are here included which were reported, during the first year of the war, under the heads of Typhus, Typhoid, Common Continued, and Remittent Fevers, and, during the second year, under the heads of Typhus, Typhoid, Typho-Malarial, and Remittent. This grouping is by no means intended to express a doubt as to the propriety of regarding typhus, typhoid or enteric and remittent fevers as distinct affections. The enteric lesion characteristic of typhoid fever enables a ready distinction to be effected between it and a genuine typhus or a true remittent, on the autopsy at least. But as the diseases have occurred in our army during the present war, the phenomena of these two affections have continually complicated each other in the same patient: so that, in fact, the enteric fevers have broken out among men campaigning in a malarial region, with constitutions more or less thoroughly impregnated with the malarial poison ; the remittents among soldiers, peculiarly prone by their exposures and mode of life to enteric disease; and both have occurred, almost without exception, in men whose health has been more or less modified by camp diet, and who were therefore suffering in some degree from a condition best characterized as the scorbutic taint. These three modifying conditions or tendencies, each of which, acting alone, might produce simple enteric fever, periodic fever, or scurvy, when acting simultaneously produce mixed types of disease that vary infinitely in accordance with the predominance of one or another of the three sets of determining conditions. For these variable resulting fevers I proposed the general name of Typho-Malarial Fever, which, in June, 1862, was, at my suggestion, adopted in the statistical nomenclature of the monthly reports of sick and wounded. Typho-malarial fever is then the most important and frequent of the diseases included here under the head of Camp Fever, and its several varieties embrace the great majority of the continued fevers of the army. Undoubtedly cases of simple enteric and simple remittent fevers did occur, especially among recruits not yet brought under camp influences, and among the attendants in hospitals or others not exposed to them. It would be difficult to state the real frequency of such uncomplicated cases, and when the extreme diversity of opinion existing among physicians on the subject of fevers is considered, it will be understood that the number of cases reported as Typhoid and Remittent Fevers are, to a great extent, to be regarded simply as those in which the typhoid or the paroxysmal phenomena predominated. Using then the term Camp Fever in the broad sense above indicated, the following statistical facts may be presented : The whole number of cases during the first year of the war was 74,619, the deaths 110 CAMP FEVER. 6315; during the second year, 138,641 cases and 13,144 deaths, — the total for the two years being 213,260 cases and 19,459 deaths. The distribution among the several affections included in the statistical reports is shown in Table XII. TABLE XII. Number of Cases and Deaths, from the several forms of Camp Fever, during the first two years of the war. Year ending June 30, 1862. Year ending June 30, 1863. Taken sick. Died. Taken sick. Died. Typhus 824 191 899 381 Typhoid 21,977 5,608 31,374 10,467 Typho-Malarial 22,652 1,129 Common Continued 11,771 146 Remittent 40,047 370 83,716 1,167 Total 74,619 6,3-15 138,641 13,144 The ratio of cases and deaths to strength is very similar for both years. In a general way, it may be said that each year about one-quarter of the men suffered from some form of the fever, and that the deaths amounted to about two per cent, of the strength. The whole number of deaths from these fevers during the first year was nearly one-half the total mortality from disease; during the second year, owing to the increased mortality from other diseases, and especially from diarrhoea and dysentery, only about one-third the total mortality from disease, though still maintaining nearly the same ratio to strength. The ratio of cases and deaths to strength for each year, and for the average of the two years, is shown in the following table : TABLE XIII. Total Number of Cases and Deaths from Camp Fever for the first two years of the war, with the annual ratio per 1000 of mean strength. Annual ratio Annual ratio _ , . . „ . of cases per of deaths per Taken sick. Died. loOOofmean 1000 of mean' strength. strength. Year ending June 30, 1862 74,619 6,315 265-45 21-71 Year ending June 30, 1863 138,641 13,144 231-52 20-39 For the two years 213,260 19,459 242-34 2080 A comparison of the reports from the three great regions shows camp fever to have been far more frequent in the Atlantic and Central regions than in the Pacific. In the Atlantic region, during both years, the number of cases was somewhat less than one-fourth the strength; the deaths for each year about seventeen per 1000 of strength. 111 CAMP FEVER. In the Central region, the ratio of both cases and deaths was much greater during the first year than the second. During the first, the cases amounted to nearly one-third the strength; the deaths to about thirty-two per 1000 of strength. During the second year, the cases were somewhat less than one-fourth the strength; the deaths twentyfour per 1000 of strength. In the Pacific region, the cases for each year amounted only to between seventy and eighty per 1000 of strength; the deaths somewhat over one per 1000 during the first year, somewhat less than one per 1000 during the second. These relations are here presented in detail. TABLE XIV. Number of Cases and Deaths from Camp Fever in each of the three regions. Year ending June 30, 1862. Year ending June 30, 1863. Ratio per 1000 Ratio per 1000 Ratio per 1000 Ratio per 1000 _, , . , _, . of mean of mean „ . . , „, , of mean of mean Taken sick. Died. strength strength Taken sick. Died. strength strength taken sick. died. taken sick. died. Atlantic Region 42,516 3,059 238-99 16-75 64,668 5,312 227-94 17-05 Central Region 31,613 3,245 327-31 31-92 73,287 7,826 239-16 24-13 Pacific Region 490 11 73-19 1-64 686 6 78-74 0-69 Total 74,619 6,315 265-38 21-71 138,641 13,144 231-52 20-39 The modifying influence of region on the mortality is shown still more strikingly when, instead of comparing the deaths with strength, they are compared with the number of cases. It is then seen that the disease is not only more frequent, but more fatal in proportion to the number of cases, in the Central region than in the Atlantic, and in this more than in the Pacific. In the Central region there was one death to every 9*7 cases for the first year; one for every 9 3 for the second. In the Atlantic region one to 14 cases for the first year; one to 12 for the second. In the Pacific region, as there were but eleven deaths in the first year and six in the second, much importance cannot be attached to its ratios. The relationship of deaths to cases for each year and region is shown in the following table : TABLE XV. Relation between Cases and Deaths of Camp Fever. to ,„„« -.r c ,„ „ Annual Average foe the Year ending Jbne 30, 1862. Year ending June 30, 1863. TWO years. Ratio of Number of Ratio of Number of Ratio of Number of deaths per cases to each deaths per cases to each deaths per cases to each 1000 cases. death. 1000 cases. death. 1000 cases. death. Atlantic Kegion 7195 13-90 82-14 12-17 78-10 12-80 Central Region 102-65 9-74 106 79 9-36 105-54 9-48 Pacific Region 22 57 44-31 8-75 114-29 14-46 6916 Total 84-63 11-82 94-81 10-55 91-25 10 96 112 CAMP FiiVJtR. A comparison of the monthly ratios of cases to strength in each region indicates the autumnal character of many of these fevers, and confirms the idea of a malarial element in their causation, as already indicated. In fact, the season wave for camp fever during the first year of the war is similar in many respects to that of the intermittent fevers, the malarial origin of which is universally admitted. During the second year, the season wave, which in other respects is similar, is somewhat masked by the large figures for July and August in the Atlantic and Central regions. How far this deviation is due to the character of the campaigns of the great armies in these regions and the location in which they operated, is a question the discussion of which must be postponed for the present. Tables XVI. and XVII. give the monthly ratio of cases to strength in each of the three regions for the first and second years of the war. TABLE XVI. Monthly Rates of Camp Fever in the Armies of the United States during the year ending June ZOth, 1862, expressed in ratio per 1000 of mean strength. 1861. 1862. I . i i », b Forthe *tllilf!4<.t4 year " fIIIII I I I I I I Atlantic Region 8-30 18-78 25-60 27-64 2788 19-74 13-85 13-81 10 99 17-42 24-88 27-07 238-99 Central Region 16-87 38-26 39-98 37-60 36-25 2689 23-28 18-59 16-97 23-96 29 33 27-79 327-31 Pacific Region 1-72 5-31 5-35 6-67 4-31 4-90 2-15 3-45 6-34 9-19 20-44 12-59 73-19 TABLE XVII. Monthly Rates of Gamp Fever in the Armies of the United States during the year ending June 30th, 1863, expressed in ratio per 1000 of mean strength. 1862. 1863. S fe fe • ?. Forthe * 1 1 I f I I I\ i i * ' i y ~ r " I if ill jij 2 Ij Atlantic Region 36-20 28-59 19-54 27-67 21-72 18-51 17 61 14 32 14-06 12 29 13-87 14-87 227-94 Central Region 2818 27-18 24-81 2414 19-24 16-94 18-77 20 16 19-23 16-83 16-74 18-76 239-18 Pacific Region 4-21 9-45 18-92 983 9-19 6-74 2-29 1-91 2-79 5-09 419 5-85 78-74 ! i I I The upper diagram of the plate facing this page represents the monthly fluctuations indicated in these tables. Materials for an elaborate discussion of the subject of camp fever have been collected, and a careful investigation of its pathological anatomy has been conducted under my direction at the Army Medical Museum. The space to which it has been thought best to limit this paper does not, however, permit the presentation of further 113 CAMP FEVER. details than the foregoing remarks, and the brief sketch of the pathological specimens of the affection now in the Museum, which will be given in the account of the medical and microscopical sections of tha^ collection. Besides the forms of continued fever which may be properly included under the general designation of Camp Fever, three other forms, which have occurred during the war, deserve a brief mention in this place, viz.: True Typhus Fever, Spotted Fever, and Yellow Fever. Of typhus fever, 824 cases and 191 deaths are reported during the first year; 899 cases and 381 deaths during the second. There is evidence, however, which will be presented in the Medical History of the War, that many of these cases were not true typhus, but rather cases of typho-malarial, or of ordinary enteric fever of an adynamic character, with strongly marked typhous symptoms, or complicated with scurvy; congestive intermittents occurring in scorbutic patients, and perhaps other diseases, were also occasionally diagnosed as typhus. These facts led me for a long while to doubt whether true typhus fever had ever occurred in our army during the rebellion, and inclined me to look upon the few hundred cases above quoted as belonging chiefly to typho-malarial fever; they have therefore been included in the foregoing statistics of camp fever. Subsequent facts, however, have been brought to my knowledge, which induce me to admit the occasional occurrence of a limited number of cases of true typhus, in connection with overcrowded and ill-policed camps, and especially in the case of those of our soldiers who were detained as prisoners in the enemy's hands. Spotted fever, called also cerebro-spinal meningitis, attracted attention chiefly at a period later than that embraced in the present paper. Large numbers of cases, autopsies and other interesting materials on this subject have been contributed, with the mere mention of which I must here content myself. Yellow fever, from which the army wholly escaped during the first year of the war, made its appearance at Key West, Florida, in July, 1862, and subsequently at Hilton Head, South Carolina. The outbreak was limited to a few hundred cases and the deaths to a hundred. In both places, there was the most decisive evidence that the disease was imported in consequence of the neglect or violation of quarantine regulations. The fear that yellow fever would prove a terrible obstacle to the operation of our troops in the Southern States has proved wholly unfounded. It may here be mentioned that the only subsequent outbreak of importance which has occurred up to the date of writing was the epidemic at Newbern, North Carolina, in the summer of 1864. But even here the mortality, so far as our troops were concerned, was limited to a few hundred men. In the case of this outbreak, Surgeon D. W. Hand, U. S. Vols., Medical Director of the Department, expresses the belief that the fever was not imported, but that it originated on the spot in consequence of the neglect of hygienic precaution by the citizens of the place and by the refugees who had made it an asylum. There is now in the possession of this office a most interesting set of papers, contributed by surgeons who were eye-witnesses, giving the whole history of the several outbreaks of yellow fever during the war, with descriptions of the disease, of the treatment employed, etc. etc. It is proposed to publish these papers in extenso in the Medical History of the War. 15 114 INTERMITTENT FEVER. INTERMITTENT FEVER. The several forms of intermittent fever played a conspicuous part among the diseases of the army, as might indeed have been anticipated, from a consideration of the frequency of these affections in the United States. They were not the source of any very great mortality; nevertheless the malarial influence, of which the frequency of these simple manifestations may be regarded as the measure, played a part in so many more serious and more fatal affections, that the rate of the occurrence of intermittents assumes a high significance in the appreciation of the comparative mortality of the several regions. Intermittent fevers were reported under the several heads of Quotidian, Tertian, Quartan, and Congestive. The total number of all forms reported was 72,810 during the first year, 189,997 during the second; making a total during the two years of 262,807 cases reported. The mortality, however, was extremely small, with the exception of the so-called congestive form — (the Pernicious Fever of Dr. Wood). The whole number of deaths, including this more fatal variety, was 430 during the first year and 1358 during the second, or 1788 during the two years. Excluding the congestive cases, the mortality of the other varieties was but 407 deaths for the two years, or one death to every 631 cases. It has not, however, been thought proper to omit these cases, as, after all, in the present state of our knowledge they are to be regarded simply as extremely intense cases of intermittent fever, and are therefore a proper element to be included in considering the mortality of this affection. Embracing them in the computation, it will be found that there was one death to every 147 cases during the two years. It may be remarked, however, that possibly a certain number of cases of spotted fever and of cerebro-spinal meningitis may have been erroneously included under the head of Congestive Fever. The following table shows the number of cases and deaths reported from each variety of intermittent fever. It will be seen that, according to the reports, Quotidian was somewhat the most frequent form, next comes the Tertian: the Quartan is comparatively rare, the Congestive still rarer. TABLE XVIII. Number of Cases and Deaths from the several forms of Intermittent Fever during the first two years of the war. Year ending June 30, 1862. Year kndino June 30, 1863. Taken sick. Died. Taken sick. Died. Quotidian Intermittent 40,375 32 96,603 144 Tertian Intermittent 26,750 33 80,053 116 Quartan Intermittent 3,451 4 9,434 78 Congestive Intermittent 2,234 361 3,847 1,020 Total 72,810 430 189,997 1,358 INTERMITTENT FEVER. 115 Intermittent fever was more frequent during the second year than the first. In both, however, the total number of cases during the year amounted to considerably more than one-fourth of the strength. The mortality for the first year was a little over one per 1000 of strength, for the second a little over two per 1000. TABLE XIX. Total Number of Gases and Deaths from Intermittent Fever for the first two years of the war, with the annual ratio per 1000 of mean strength. Annual ratio Annual ratio _, . . . _. , of cases per of deaths per Taken sick. Died. looOofmean 1000 of mean strength. strength. Year ending June 30, 1862 72,810 430 258-95 1-15 Year ending June 30, 1863 189,997 1,358 317-29 211 For the two years 262,807 1,788 298-64 1-91 Intermittent fever was more frequent and fatal in the Central than in the Atlantic, and in this than in the Pacific region. In the Pacific region, there were no deaths during the first year and but one during the second. In the Atlantic region, the deaths were somewhat over one per 1000 of strength the first year, somewhat less than one per 1000 during the second; while in the Central region, the deaths were somewhat over two per 1000 during the first year, somewhat over three per 1000 during the second. These relations are exhibited in detail in Table XX. TABLE XX. Number of Cases and Deaths from Intermittent Fever in each of the three regions. Year ending Jcne 30,1862. Year ending June 30,1863. Ratio per 1000 Ratio per 1000 Ratio per 1000 Ratio per 1000 _ , , , _. , of moan of mean . , of mean of mean Taken sick. Died. strength strength Taken sick. Died. strength strength taken sick. died. taken sick. died. Atlantic Region 34,857 210 195-94 1-15 55,048 297 194-03 0-95 Central Region.... 36,980 220 382 88 2-16 133,888 1,060 436-96 3-27 Pacific Region 973 000 145-33 0-00 1,061 1 121-77 0-11 Total 72,810 430 258-95 1-48 189,997 1,358 317-29 2-11 The proportion of deaths to cases was slightly greater in the Central than in the Atlantic region, especially during the second year. In the Pacific region, for the two years, the proportion was over two thousand cases to each death. 116 INTERMITTENT FEVER. TABLE XXI. Relation between Cases and Deaths of Intermittent Fever. Annual Average for the Year ending June 30, 1862. Year ending Jdne 30, 1863. IWO Years. Ratio of Number of Ratio of Number of Ratio of Number of deaths per cases to each deaths per cases to each deaths per cases to each 1000 cases. death. 1000 cases. death. 1000 cases. death. Atlantic Region 6-02 16611 539 185-53 5 64 17730 Central Region 6-22 160-77 7-91 126-42 7-49 133-51 Pacific Region 0-00 000-00 0-94 1063-83 0-49 2040-82 Total 5-91 169-20 7-20 138 89 6-80 14706 The influence of season on the frequency of the disease is shown in Tables XXII. and XXIII. It will be seen that intermittents occur at all seasons of the year, but that they are most frequent in the latter portion of the summer, and during the autumn months. In the Atlantic region, the maximum was attained in September during the first year, in October during the second; in the Central region, in August and October during the first year, October during the second; in the Pacific region, in August during the first year and September during the second. The curve formed by the monthly ratios in each region is an autumnal one, and, on the whole, September and October would appear to be the months of greatest frequency. To appreciate fully, however, the effects of season, it would be necessary to study the detailed statistics of the several armies in each region, with their location and exposures, which is out of the question in a brief pamphlet. Full materials for such a comparison are in course of compilation. The lower diagram of the plate facing page 112 represents these fluctuations, and may be advantageously compared with the diagram showing the monthly rates of camp fever, which occupies the upper part of the same plate and is constructed on the same scale. TABLE XXII. Monthly Sates of Intermittent Fever in the Armies of the United Slates during the year ending June 30th, 1862, expressed in ratio per 1000 of mean strength. 1861. 1862. S3 |j v . £ For the ffllllllllll Atlantic Region.... 10-97 27-96 39-32 34-46 22-08 14-08 7-87 8-43 7-00 12-01 15-25 16-88 195-94 Central Region 39-19 66-93 56-46 66-77 42-13 30-60 21-87 17-37 1907 27-68 2809 26-25 382-88 Pacific Region 6-46 21-56 9-36 17-17 18-99 13-54 7-29 10-20 8-87 10-01 872 12-97 145-33 117 DIARRH(EA AND DYSENTERY. TABLE XXIII. Monthly Rates of Intermittent Fever in the Armies of the United States during the year ending June 30lh, 1863, expressed in ratio per 1000 of mean strength. 1862. 1863. S S; C . For the illiii I i i s i i Atlantic Region.... 20-12 22-85 25-40 30 98 19-35 13-67 11-54 8-74 939 10-48 15-37 19-16 194-03 Central Region 31-39 36-33 56 85 63-05 45-59 33-38 28-46 26-93 29 25 28-37 29-20 44-02 436-96 Pacific Region 11-87 12-51 15-86 13-91 11-19 8-67 8-27 5-94 7-39 8-94 8-26 990 121-77 Before passing from ihe subject of intermittents, a word may be said with regard to some other manifestations of malarial poisoning, and especially with regard to jaundice. Besides developing intermittent fever and complicating other diseases, such as camp fever and diarrhoea, the malarial influence manifests itself with considerable frequency among troops exposed to its action by the development of a peculiar form of anosmia, which may be designated Chronic Malarial Poisoning. This condition, attended usually with enlargement of the spleen and frequently with an increase in the number of the white corpuscles of the blood, manifests itself externally by languor, feebleness, and pallor, attended commonly with neuralgic pains, and, as it actually occurred among our troops, often complicated by slight scorbutic symptoms. Attacks of fever, pneumonia, or other acute diseases occurring among patients in this condition are peculiarly apt to prove fatal. A yellowish complexion is a frequent phenomenon in the form of anaemia here referred to, and often amounts to decided jaundice. Mild epidemics of jaundice, running a course of from two to six or eight weeks, and usuajly terminating in recovery, have also been of frequent occurrence among our troops in malarial regions. That this form of the affection also stands related to the malarial poison, is shown by the fact that, as a general rule, it was most common in those localities in which intermittents were most frequent. In Tables X. and XI. jaundice will be found reported among diseases of the digestive organs. The number of cases reported during the first year was 10,929, during the second year 31,640, making in all 42,569 cases. The deaths were only 40 during the first year and 121 during the second, or 161 in all, which is but one death in 264 cases. Of the large number of cases reported, only 24 during the first year and 85 during the second occurred in the Pacific region; none of these cases died. DIARRHOEA AND DYSENTERY. These disorders were reported under the four heads — Acute Diarrhoea, Chronic Diarrhoea, Acute Dysentery, and Chronic Dysentery. The words diarrhoea and dysentery were somewhat loosely used during the war. The disease most generally called Chronic Diarrhoea was, in fact, usually an affection of the large intestine, which was thickened, softened, and often ulcerated. The term dysentery would have been more 118 DIARRHCEA AND DYSENTERY. exact, and was bestowed by many surgeons on the same affection which others called diarrhoea. Hence it has been thought advisable, in considering the figures, to group together all cases reported under these heads. The extreme frequency of diarrhoea and dysentery makes it most important to understand these disorders. They constitute more than one-fourth of all the cases of disease reported during the period under consideration. The annual number of cases for the whole army was greater than three-fourths of the mean strength, and next, after camp fever, they were the chief cause of mortality from disease. The total number of cases reported during the first year was 215,214, with 1194 deaths; during the second year 510,461 cases and 10,366 deaths— the total, 725,675 cases and 11,560 deaths. It will be seen that the proportionate mortality of the second year is by far the greatest, showing the prevalence of cases of a more formidable type. 'The following table presents the number of cases and deaths as actually reported under each of the heads above mentioned : TABLE XXIV. Number of Cases and Deaths from the several forms of Diarrhoea and Dysentery during the first two years of the war. Year ending Jcne 30, 1862. Year ending June 30, 1863. Taken sick. Died. Taken sick. Died. Acute Diarrhoea 164,551 227 373,927 870 Chronic Diarrhoea 15,815 493 63,083 7,488 Acute Dysentery 32,237 347 64,704 922 Chronic Dysentery 2,611 127 8,747 1,086 Total 215,214 1,194 510,461 10,366 Taking the total of these several forms, it will be seen the ratio of cases was 765 per 1000 of mean strength during the first year and 852 per 1000 for the second; so that considerably more than three-fourths of the whole strength was attacked each year. The mortality was 4 per 1000 of strength during the first year and 16 during the second; the disease being just four times more fatal during the second year than the first. TABLE XXV. Total Number of Cases and Deaths from Diarrhoea and Dysentery for the first two years of the war, and the annual ratio per 1000 of mean strength. Annual ratio Annual ratio Total nick TtipA of cases per of deaths per Total sick. Viea. 1000 of mean 1000 of mean strength. strength. Year ending June 30, 1862 215,214 1,194 765-40 4-10 Year ending June 30, 1863 510,461 10,366 852-44 16-08 For the two years 725,675 11,560 824 63 12-36 119 DIARRH(EA AND DYSENTERY. The greatly increased mortality during the second year will be at once understood if the acute cases of diarrhoea and dysentery, as given in Table XXIV., are added together for each year and their mortality compared with that of the chronic cases. Of acute diarrhoea and dysentery, 196,788 cases and 574 deaths were reported during the first year, 438,631 cases and 1792 deaths during the second; the mortality being one death to every 331 cases in the first year and one to every 245 in the second. It appears, therefore, that the acute forms remained comparatively mild. Of chronic diarrhoea and dysentery, there were 18,426 cases and 620 deaths during the first year, 71,830 cases and 8574 deaths during the second; the mortality increasing, therefore, from one death in every 30 cases for the first year to one in every 8 for the second. This increased mortality, which shows that the chronic forms assumed a more formidable type during the second year, becomes at once intelligible on the presumption that a certain length of time is required before the influences to which a soldier is exposed culminate in chronic diarrhoea. Indeed, individual experience shows that the same soldier has frequently, perhaps usually, repeated attacks of acute diarrhoea, which terminate in temporary recovery, and which, of course, are each reported as a separate case, before the more serious and continuous disorder sets in, on which the term "chronic" is usually bestowed. Like camp fever and intermittents, diarrhoea and dysentery were most frequent in the Central region; less so in the Atlantic, and least in the Pacific region. In the Central region, the cases were more numerous than the strength during the first year and nearly equal to the strength during the second; in the Atlantic, they were more than half the strength during the first year and more than three-quarters during the second; in the Pacific region, during each year somewhat over one-quarter the strength. The differences between the ratio of mortality to strength in the three regions was still more striking: in the Central region, the mortality was 9 per 1000 of mean strength during the first year, 23 per 1000 during the second; in the Atlantic, 1 per 1000 during the first year, 9 per 1000 during the second; in the Pacific region, less than 1 per 1000 during each year. TABLE XXVI. Number of Cases and Deaths from Diarrhoea and Dysentery in each of the three regions. Year ending June 30, 1862. Year ending June 30, 1863. Ratio per 1000 Ratio per 1000 Ratio per 1000 Ratio per 1000 __. . , _, . of mean of mean _ , . , _. . ol mean of mean Taken sick. Died. strength strength Taken sick. Died. strength strength taken sick. died. taken sick. died. Atlantic Region 114,925 238 646-01 1-30 231,564 2,742 816-22 8-80 Central Region 98,470 951 1019-54 9-36 276,567 7,617 902-62 23-49 Pacific Region 1,819 5 271-10 0-75 2,330 7 267-42 0-80 Total 215,214 1,194 765-40 4-10 510,461 10,366 852-44 16 08 120 DIARRH(EA AND DYSENTERY. The ratio of deaths to cases shows the influence of region in a striking manner. TABLE XXVII. Eelation between Cases and Deaths of Diarrhoea and Dysentery. -, o« io»n •» -r on ¦•„.,„ • Annual Average for the Year ending Jone 30, 1862. Year ending June 30, 1863. TWO years. Ratio of Number of | Ratio of Number of Ratio of Number of deaths per caws to each i deaths per cases to each deaths per cases to each 1000 cases. death. 1000 cases. death. 1000 cases. death. Atlantic Region 2-07 48309 11-84 84-46 8-60 116 28 Central Region 9-66 103-52 27-54 36-31 22-85 43-77 Pacific Region 2-75 363 64 3-00 333-33 2-89 34602 Total 5-55 18018 20-31 49-24 15-93 62-77 If now we consider the influence of season in each of the regions, it will be found that diarrhoea and dysentery were by far most frequent in the summer and autumnal months. In the Atlantic region, the greatest monthly ratio was during July, 1861, after which it diminished through the fall and winter, but again increased from March to June, 1862 ; July, 1862, was the maximum month for the second year. The cases greatly diminished in August — after the Army of the Potomac had withdrawn from the Peninsula to near Washington; but increased in September, and attained a second maximum in October, which is the month in which intermittents were most frequent in this region; it then diminished steadily till April, 1863, increasing again in May and June. In the Central region, the maximum month is August, 1861, after which there is a gradual diminution till December; an increase in January, 1862; a falling off in February, and a great increase in March and April. The monthly ratio became gradually less during May, June, July, and August, but increased considerably in September, after which it gradually diminished until January, 1863, when it increased again, and made subsequently but slight fluctuations. On the Pacific coast, the disease was most frequent during the summer and autumnal months. The following tables give the rates, and the upper diagram of the plate facing this page represents them to the eye : TABLE XXVIII. Monthly Rates of Diarrhoea and Dysentery in the Armies of the United States during the year ending June 30th, 1862, expressed in ratio per 1000 of mean strength. 18bl. 1862. | i S3 .: * forthe Atlantic Region.... 168-23 116-29 70-80 62 66 4606 28-64 23-20 22-20 35 22 67-20 70-92 87-06 646 01 Central Region 93-06 139-99 97-94 94-68 70 91 63-34 71-87 55-53 70-73 107-12 97-99 83-78 1019-54 Pacific Region 28-41 40-96 29-63 27-03 30-85 13-54 10-74 16-54 18-13 16-57 22-93 35-82 271-70 121 DIARRH(EA AND DYSENTERY. TABLE XXIX. Monthly Bates of Diarrhoea and Dysentery in the Armies of the United Stales during the year ending June 30th, 1863, expressed in ratio per 1000 of mean strength. 1862. 1863. S3 i i h . £ For the « "a * ¦S •= E? x ¦ y - yearfifiiijiiiii I Atlantic Region.... 129-56 94-40 105-00 111-22 73-47 63-64 58-50 45-52 38-57 31-85 58-02 59-96 816-22 Central Region 79-76 67-64 88-45 86-93 66-27 60-03 84-54 70-84 76-73 67-86 71-48 86-36 902-62 Pacific Region 38-43 36-21 33-53 28-38 26-97 18-66 14-65 7-55 12-54 18-38 15-09 21-16 j 267-42 Much interesting material has been collected bearing on the causes, symptoms, nature and treatment of these formidable affections. This consists, besides detailed statistics, of a number of papers on the subject by medical officers, of numerous histories of cases and accounts of autopsies, of pathological specimens, drawings, and microscopical preparations, and of the records of microscopical investigations in the Army Medical Museum. The subject is one of such general interest that, although it is utterly impossible to present in this place even an outline of the material collected, it may not be amiss to make a few remarks suggested by these studies. The origin of the diarrhoea and dysentery of troops is to be sought in no one condition, but in the co-operation of several, each of which should be the subject of hygienic precautions, if the health of an army is to be preserved. Some of the chief of these, but assuredly not the only ones, are the scorbutic taint dependent upon camp diet, the malarial influences operating in certain seasons and regions, the overcrowding and filth of camps and barracks, the heat of summer, the exhaustion and fatigue of campaigns, and the use of water containing saline or organic impurities. Whether there has ever existed, in addition to these intelligible conditions, any specific causative momentum deserving the designation of epidemic influence, is a grave question which receives no affirmative reply from any experience reported during this war. The causation of chronic diarrhoea and dysentery is to be found in the long-continued action of the influences above mentioned, and in the consequent frequency and duration of attacks, but not in any specific cause or set of causes different from those which induce the acute form. The influence of the scorbutic taint in the production of diarrhoea and dysentery is shown not only by the increased frequency of these disorders whenever supplies of fresh meat and vegetables have been deficient, but also by the presence of readilyrecognized scorbutic symptoms in the patients. When, on marches or active campaigns, the diet is reduced to a minimum, often consisting chiefly of hard bread and coffee, with but a scanty supply of salt pork, and of beef on the hoof, the number of acute attacks of a mild form, as also of attacks which become chronic, is always greatly increased. It would be a grave error, however, to suppose, as has been done for example by Dr. J. H. Salisbury, of Ohio,* that this is the efficient cause of the disorder, and to reject the consideration of other momenta. To neglect the influence of climate in the production * Annual Eeport of the Surgeon General of Ohio for the year 18(J4. 10 122 DIARRHCEA AND DYSENTERY. of the disease, for example, would be almost as unfortunate as to neglect the consideration of diet. The influence of climate, in this connection, is abundantly proved by the detailed statistics of individual armies and localities, too voluminous to be presented in this place, but which will appear in the official volumes. It is also worthy of note that the month of the greatest prevalence of diarrhoea and dysentery in any army is often also the month of the greatest prevalence of intermittent fever. But since it is not possible, in campaigning in malarial countries, to avoid exposure to malaria, the chief interest here attaches to the connection of climate with treatment. This connection is of such a nature, that the number of recoveries bears a direct relation to the latitude of the climate in which the patients are treated and to its freedom from malaria. Passing by the figures of the first year of the war, during which the deaths from chronic diarrhoea and dysentery were comparatively few, the second year gives the following results, which are of especial significance. During the second year of the war, the proportion of deaths from chronic diarrhoea and chronic dysentery in the general hospitals of New England was one to every fortynine (48*8) patients admitted for these disorders; in the general hospitals of New York City and State, including the hospital at Newark, New Jersey, one to every nineteen (18*7) cases; in the general hospitals of Philadelphia and at other places in Pennsylvania and Delaware, one to every fifteen cases; in the general hospitals of Maryland and the District of Columbia, including those of Washington, Georgetown, Alexandria, Frederick, Baltimore, Annapolis, etc., one to every eleven cases (11*4); in the general hospitals at Fortress Monroe and on the coast of North and South Carolina, one to every seven cases (7 - l). The mortality was greater in the Central region of the continent, but the relative influence of latitude was still observed. In the general hospitals of Ohio, Indiana, Illinois, lowa, Missouri, Kansas and Kentucky, including those at Cincinnati, Louisville and St. Louis, the mortality was one death to every nine (8*53) cases; in those of Tennessee, Northern Mississippi and Arkansas, including among others the hospitals of Nashville, Memphis and Helena, one in five (5*4); in the hospitals of Louisiana, including New Orleans and Baton Rouge, one in four. Nor will a separate consideration of the mortality from these affections in the hospitals of the great cities on the Mississippi River be less instructive. In the hospitals of Keokuk, la., the mortality was one in nine cases (9*1); in St. Louis, one in five (5*2); in Cairo, one in four (3-98); in Memphis, one in five (54); and at New Orleans, somewhat less than one in five (4*7). The extreme mortality, it may be noted, is not at the point farthest south, but at Cairo, situated on the alluvial peninsula formed by the junction of the Mississippi and Ohio Rivers, where, as is well known, most intense malarial influences prevail. It is impossible to escape the conviction, based upon the foregoing observations, that a change of climate is one of the most important elements in the treatment of these diseases. The value of such a change, familiarly known to those surgeons of our army who had enjoyed the experience of the Mexican war, did not escape the attention of the Surgeon General's Office ; and throughout the war, patients suffering from the fevers and bowel affections of southern latitudes were, as far as the exigencies of 123 DIARRHCEA AND DYSENTERY. the service would permit, transferred to the North. In October, 1863, Surgeon C. McDougall, Medical Director of the Department of the East, recommended the transfer of patients suffering from chronic diarrhoea in the Atlantic region to the hospitals in the State of Vermont, where the freedom from malaria and the fine mountain air would, it was hoped, afford the most favorable results. The experiment was tried, as far as practicable, and with much success. In the West, also, such cases were sent, as far as possible, to hospitals in high northern regions, as at Keokuk, la., Madison, Wis., Chicago, Detroit, etc. etc. It was never possible to give the full benefit of climatic influences to all those patients who needed it; but the Medical Department was fully alive to the advantages to be derived from this source, and availed itself of them as far as, at the time, with a full knowledge of all the circumstances of the case, it was believed to be practicable. Papers have been contributed by various surgeons, detailing the history, symptoms, and treatment of numerous cases of diarrhoea and dysentery. These reports, properly elaborated, will be a most important contribution to our knowledge of those diseases. An analysis which should do justice to them is quite out of the question in the present paper; but a few salient points, in connection with the chronic form, will be briefly touched upon. The most common and characteristic chronic form, as already intimated, was anatomically a chronic ulcerative colitis, occasionally an entero-colitis. Designated correctly chronic dysentery by many surgeons, it was most generally known as chronic diarrhoea, or chronic camp diarrhoea; and it is to this form that the few remarks here offered are limited. Among its most striking phenomena may be mentioned the usual absence of fever throughout the greater part of its course, the progressive and ultimately often extreme emaciation, the dry, harsh condition of the skin, and the presence of complicating phenomena of malarial and scorbutic nature. The frequent complication of the disease with camp fever is also notable. Sometimes the attack of fever begins the disorder, and diarrhoea is left subsequently as a result. Often, however, camp fever occurs in patients who have already long suffered from chronic flux. In fatal cases of either variety, the anatomical lesions characteristic of diarrhoea are found variously combined with those of camp fever, as will be seen in the brief description of the specimens of this sort in the Museum, which is given in a subsequent paragraph. Chronic flux, unaccompanied by camp fever, may run its course to its own natural termination in extreme emaciation, with death from debility and exhaustion; or, as perhaps happens more frequently, terminate at an earlier period, in consequence of the occurrence of some disastrous complication. Often, for example, after the disease has lasted a long time without fever, the stools varying from two or three to twenty or more daily, the patient still walking about and suffering little pain, acute dysenteric symptoms set in with fever, delirium, abdominal tenderness, tormina, tenesmus, rapid sinking and death in a few days. An autopsy shows the colon, which is more or less ulcerated according to the previous duration and severity of the flux, to be coated with a yellowish or greenish-yellow, sometimes brownish-yellow, pseudo-membrane, which often extends also through the small intestines. The nature of this pseudo-membrane has been made the subject of careful investigation in the Museum, and the examination of a large number of cases leaves no doubt on the matter. It is simply the croupous lymph, pseudo-plastic lymph, caco-plastic lymph, or false membrane 124 DIARRHCEA AND DYSENTERY. of medical writers. The examination by the microscope of properly prepared sections shows it to be composed of innumerable round cells (lymph cells, pus cells), held together by an adhesive granular matrix more or less resembling coagulated fibrin. With such sections, there is no difficulty in tracing the origin of this membrane to a rapid multiplication of the epithelial cells and superficial connective tissue corpuscles of the diseased mucous membrane. The condition thus described is not always fatal, tubular casts of false membrane having been found in the stools of patients, with the abovedescribed symptoms, who have subsequently recovered. Another grave complication is diphtheria, with the formation of a similar false membrane in the fauces and respiratory passages. The membrane does not differ from that formed in ordinary diphtheria in civil life. The Museum contains several fine specimens. I have made a careful examination of the false membrane in a number of cases of this sort. It is anatomically similar to the false membrane of the intestine, and its origin is as readily traced to the epithelium of the mucous membrane, the connective tissue of which is, however, less frequently involved in the cell multiplication. The early stage of the diphtheritic affection, in these cases, is often associated with oedema of the glottis, which sometimes suddenly proves fatal before the formation of the false membrane. It may be mentioned in this place, that oedema of the glottis, with or without the formation of a diphtheritic false membrane, has been a not unfrequent mode of death in cases of protracted suffering from gunshot wounds. Other fatal complications of common occurrence in chronic diarrhoea are pneumonia, congestion of the lungs, serous apoplexy, Bright's disease of the kidneys, etc. etc. An interesting complication which has several times been brought to my notice in autopsies is the formation .of metastatic foci, generally in the liver, but sometimes also in the lungs and spleen. These foci precisely resemble those which occur in pyaemia after gunshot wounds. I have met them in the bodies of men dead of diarrhoea, who had received no wound or injury, but who had extensive ulceration of the colon. These are the only cases in which, with propriety, "embolism" can be spoken of as a complication of chronic diarrhoea. The heart clots (death polypi), observed in the autopsies of this disease, differ in no respect from those so frequently occurring in patients dead of the most diverse affections, and even, under certain circumstances, in animals killed by violence; and all the evidence which careful investigation has hitherto accumulated on the subject is in favor of the opinion that they are formed during the death agony — consequences and not causes of the fatal issue. Ordinary abscesses of the liver, sometimes of great size, were not very rare, and a number of illustrative specimens have been received at the Museum. Considerable interest attaches to the examination of the faeces in chronic diarrhoea, and especially to their examination with the microscope. The naked eye at once recognizes as a prominent fact the presence in the stools of undigested portions of the food, the characters of which are often but little altered. This, however, is also frequent in ordinary acute diarrhoea, and is simply an expression of diminished digestive power. In the case of soldiers in the field using hard bread as a part of the ration, lumps of this article but little altered by their passage through the alimentary canal are very commonly present. The most various substances derived from the food are frequently observed; the microscopic appearances of some of them being well calculated 125 DIAERH(EA AND DYSENTERY. to deceive the unwary pathologist, especially if he attempts the microscopical study of the excreta without a prior knowledge of the minute structure of the articles of diet likely to be encountered. Besides such undigested fragments, mucus, blood and pus, in variable quantities, are commonly met, with excess, deficiency, or absence of the products of the intestinal transformation of the hepatic secretions. For the recognition of blood and pus, when they exist in small quantity, the microscope is necessary; in large amounts they can be recognized by the naked eye. Especial significance is to be attached to the presence of pus, which, in moderate quantities, can be recognized in a vast number of cases, probably in all those in which there are ulcers of any size in the colon. Of course, it may happen that though pus exists, its corpuscles have been destroyed by the peculiar form of putrefaction which the intestinal contents sometimes undergo; for, coincident with the diminished activity of the digestive processes, forms of fermentation and even of putrefaction occur, which are not usually met with in the healthy human body. The frequent occurrence in the stools of torula cells, indicative of the setting up of fermentation among the saccharine and starchy elements of the undigested food, has been mentioned by Dr. Salisbury in the paper before referred to. This quite accords with my own observations; but the account given in his paper of the presence of other "algoid forms," etc. is, I presume, based upon some misinterpretation. For a brief statement of some facts as to the pathological anatomy of this disease, see subsequent remarks on the specimens in the Museum. The papers above referred to contain also much interesting detail as to the treatment of these affections, which cannot be here introduced on account of its bulk. A few remarks may, however, be made in reference to the chronic variety. In this form, the two most important elements of treatment would appear to be diet and climate. The diet should be antiscorbutic. Fresh meat and broth made from it, eggs, milk, oysters, etc. are of the greatest value; but fresh vegetables also exercise a favorable influence. If the disease remains obstinate under this diet and suitable medication, the patient should be transported to a non-malarial northern locality. As to medication, the whole range of vegetable and mineral tonics, astringents and alteratives have been employed with variable success. Among the remedies which have been brought into extensive use in this country for the first time during the present war, I may briefly mention subnitrate of bismuth, strychnia and arsenic. Subnitrate of bismuth is perhaps the most generally available of these articles. The first paper published on its use in camp diarrhoea was that of Acting Assistant Surgeon J. B. Trask,* who recommended it in both the acute and chronic forms. Dr. Trask advised the bismuth to be given daily in one large dose of from one to four scruples, which he regarded as more efficacious than its use in divided doses. He was very sanguine as to its success in all cases in which the patient was not actually dying when the treatment was commenced. He says: "In not a case of the two hundred and seventy treated at Finley Hospital during the period named, and by this agent, was there a failure in promptly and radically arresting the disease, when given in the quan- * Keport on the Treatment of Acute and Chronic Diarrhoea with Subnitrate of Bismuth at Camp Downey, California, and Finley Hospital, Washington, D. C, by J. B. Trask, M.D., Acting Assistant Surgeon U. S. A. San Francisco, 1863. 126 SMALL-POX. tities and time as stated." In September, 1863, Surgeon T. Rush Spencer, U. S. Vols., made an official report on the use of the remedy in seventy-six cases, sixty of which were chronic and sixteen acute. Seventy-one of these cases were cured and five still under treatment at the date of his report. The treatment in the successful cases lasted from one to eight days. Influenced by these and other reports, I myself tried the remedy quite extensively, and was cognizant of its use in a large number of cases of both acute and chronic diarrhoea. It generally showed itself a most valuable agent. In a few cases, however, tormina, tenesmus, and other dysenteric phenomena, with an aggravation of all the symptoms, followed its use, and in a very considerable proportion of the severe chronic cases it appeared to be wholly without effect. The subsequent experience of many surgeons in the field and in hospital gave similar results; so that while it must be admitted to be a quite useful remedy, especially when given in large doses, the extravagant expectations which were at first entertained with regard to it by some must be abandoned. Strychnia was also extensively used by some surgeons. It was given in the form of sulphate, or as extract of nux vomica. Very generally it was combined with quinine, or with quinine and iron, and proved valuable in many atonic and paralytic conditions of the bowels, but was far from being of general availability in the treatment of severe chronic cases. Arsenic in pill, or in the form of Fowler's solution, was more frequently useful? and by some surgeons this remedy was regarded almost as a specific. So far as I have been able to learn, it was chiefly available in cases complicated with chronic malarial poisoning. The utter failure of these, or indeed any therapeutic agents, to command general confidence, or to come into general use, will serve to show how subordinate their effect is to be regarded to that of proper dietic and climatic conditions. Asiatic cholera did not make its appearance during the war, nor was any similar affection of a severe type frequent. The whole number of deaths from cholera morbus was 33 during the first year and 96 during the second. SMALL-POX. From a very early period in the war the attention of the Medical Bureau was directed to the subject of vaccination, and strenuous efforts were made to render this method of protection universal. That these efforts were to a great extent successful, is shown by the comparatively small number of cases reported: 1310 cases of small-pox and varioloid were reported during the first year and 2822 during the second — making a total of 4132; the deaths were 412 during the first year and 1132 during the second — being 1544 in all. According to these figures, the mortality would be one death to about every three (2*67) cases. Since, however, a certain number of cases of variolous disease originated in the general hospitals themselves, and upon the statistical system employed the deaths from among these cases would be included in the above figures, it is probable that the ratio of deaths to cases thus obtained is somewhat too high. If, however, the experience of some of the larger small-pox hospitals, in which it is known that the cases received were treated to their termination, be compared, it will be found that the mortality shown in their reports closely approximates the above. Thus, in the two 127 EPIDEMIC MUMPS. largest establishments of the kind, the Small-pox Hospital at St. Louis, Missouri, and that at Washington, D. C, the total number of cases of small-pox and varioloid treated during the two years was 2319; the number of deaths 597, or one in four (3*88) cases. A considerable amount of material is on file concerning the frequency and fatality of variolous disease among those who have been vaccinated, as compared with the unprotected, and on other matters of interest connected with this subject. Most of this material belongs, however, to a period subsequent to that referred to in this paper. I will only mention here the occurrence in many instances, especially in the Central region, of foul or gangrenous ulcers as an accident attendant upon vaccination. The earliest cases of the sort referred to in the official reports occurred in the latter part of 1863 in the District of the Frontier, and are reported by Surgeon George H. Hubbard, U. S. Vols., Medical Director of the district. They were supposed to be caused by the accidental admixture of syphilitic matter with the virus employed. Other cases subsequently occurred in Missouri, the Northern Department, Kentucky, Tennessee, etc., and were made the subject of careful inquiry by Colonel C. S. Tripler, Medical Director of the Northern Department, and other surgeons. The opinion generally arrived at was, that they were the expression of scorbutic or other cachectic conditions of the patients, and not due to any poisonous admixture with the vaccine virus; and it was frequently observed that the same scab which had produced a number of successful vaccinations would, in other men vaccinated at the same time, produce the ulcers referred to. An exceedingly interesting paper which illustrates this point, as observed in a number of cases among citizens at Horicon, Wisconsin, has been contributed by Surgeon Howard Culbertson, U. S. Vols. The subject is one which deserves a full discussion hereafter. CAMP MEASLES. Epidemic measles was one of the characteristic affections of the war. It occurred chiefly in regiments recently raised, and among recruits, and appeared to be due wholly to the incidental exposure of men brought up in rural districts who had hitherto escaped the contagion : 21,676 cases and 551 deaths were reported during the first year of the war, 16,345 cases and 1313 deaths during the second; but there is reason to believe that the actual number of cases was considerably greater, since it is well known that the disease frequently prevailed epidemically in new regiments, after the men began to come together in the State to which they belonged, but before they were mustered into the service of the United States, and therefore before their medical officers began to report to the Surgeon General's Office. The disease resembled ordinary measles in adults, except when aggravated by the effects of crowd poisoning or other depressing influences. The direct mortality was not great, being only one death to every twenty cases, but tedious catarrh, pneumonia, and pleuro-pneumonia were frequent sequelae; and a part of the mortality from these affections was due indirectly to measles. EPIDEMIC MUMPS. Another affection, which prevailed extensively, was Epidemic Mumps (parotitis). It occurred both as an independent affection and as a complication of other diseases. It was seldom fatal. During the first year 11,216 cases and 9 deaths were reported; during 128 INFLAMMATORY DISEASES OF THE RESPIRATORY ORGANS. the second 13,429 cases and 30 deaths. The inflammation of the gland seldom terminated in abscess, except in those cases which occurred as complications of camp fever. Metastasis to the testicle was not unfrequent. The disease appeared to spread by contagion, affecting almost exclusively those who had never previously suffered. INFLAMMATORY DISEASES OF THE RESPIRATORY ORGANS. The last of the miasmatic group of zymotic affections on which remarks will here be made is Epidemic Catarrh, of which 11,314 cases and 5 deaths were reported during the first year, and 63,202 cases and 24 deaths during the second. Considerable confusion, however, appears to have existed as to the precise signification and limits of the terms Catarrh, Epidemic Catarrh, and Acute Bronchitis; precisely similar cases being reported by different surgeons under each of these heads. It appears probable, moreover, that the causes determining inflammatory affections of the several portions of the respiratory apparatus are intimately allied, the total number of cases representing the effect of exposure to unfavorable climatic influences, such as cold, dampness, etc.; while the mortality is determined partly by the intensity of the cause, partly by the hygienic surroundings and constitutional condition of the patients. Influenced by these and other reasons, it has been considered advisable to bring together into a single group all the disorders of this class. This group will be designated Inflammatory Diseases of the Respiratory Organs, and will include all the cases reported as Epidemic Catarrh, Catarrh, Acute and Chronic Bronchitis, Laryngitis, Pleurisy, and Pneumonia. The whole number of the cases of this group reported during the first year of the war was 143,991 cases and 2400 deaths; during the second year, 160,263 cases and 5690 deaths — making a total for the two years of 304,254 cases and 8090 deaths. These cases were distributed among the several affections included in the group, as shown in the following table : TABLE XXX. Number of Cases and Deaths from Inflammatory Diseases of the Respiratory Organs during the first two years of the war. Year ending June 30,1862. Year ending June 30,1863. Taken sick. Died. Taken sick. Died. Catarrh 83,837 5 Epidemic Catarrh 11,314 5 63,202 24 Laryngitis 2,597 34 5,919 152 Acute Bronchitis 26,201 102 50,799 187 Chronic Bronchitis 3,902 36 ' 9,518 201 Pleurisy 5,079 84 10,359 169 Pneumonia 11,061 2,134 20,466 4,957 Total spoken of as Inflammatory Diseases of the Respiratory Organs.. 143,991 2,400 160,263 5,690 The total number of cases during the first year amounted to more than one-half the mean strength; during the second year, however, to not much more than one-quarter of the strength. The deaths were between 8 and 9 per 1000 of strength during each year. INFLAMMATORY DISEASES OF THE RESPIRATORY ORGANS. 129 TABLE XXXI. Total Number of Gases and Deaths from Inflammatory Diseases of the Respiratory Organs for the first two years of the war, with the annual ratio per 1000 of mean strength. Annual ratio Annual ratio Trlcpti «irlr TMi.il of cases per of deaths per lafcensicfc. Died. looOofmean 1000 of mean strength. strength. Year ending June 30, 1862 143,991 2,400 512-10 8-25 Year ending June 30, 1863 160,263 5,690 267-63 8-83 For the two years 304,254 8,090 345-74 8-65 It will thus be seen that the ratio of cases to strength during the second year is only about one-half that during the first while the ratio of deaths to strength is about the same; so that while the proportionate number of cases greatly diminished during the second year, their comparative fatality increased and the proportion of mortality to strength remained about the same. The greater prevalence of slight cases during the first year thus indicated is probably to be attributed, to a certain extent at least, to the large number of men taken suddenly, during the fall and winter, from the shelter and comforts of civil life and subjected to the exposure of camps. The greater number of cases of measles during the first year is also undoubtedly connected with the greater prevalence of catarrhal cases. Unlike camp fever and diarrhoea, the inflammatory affections of the respiratory organs occurred with nearly equal frequency in the three regions, the only exception being in the case of the Pacific region, which suffered somewhat less than the others during the first year, somewhat more during the second. The proportion of mortality to strength, however, followed the same general law as the other important camp diseases, being most frequent in the Central and least so in the Pacific region. In the Central region it was 16 per 1000 of strength during the first year, 14 during the second; in the Atlantic about 4 per 1000 of strength during both years; in the Pacific about 1 per 1000 during both. Table XXXII. gives the details. TABLE XXXII. Number of Gases and Deaths from Inflammatory Diseases of the Respiratory Organs in each of the three regions. Year ending June 30, 1862. Year ending June 30, 1863. Ratio per 1000 Ratio per 1000 Ratio per 1000 Ratio per 1000 _ , . , _. . of mean of mean _ , , , _. . of mean of mean Taken sick. Died. strength strength Taken sick. Died. strength strength taken sick. died. taken sick. died. Atlantic Region 90,481 735 508-61 4-03 76,515 1,083 269-67 3-48 Central Kegion 51,471 1,658 532-92 16-31 81,214 4,595 26505 14-17 Pacific Region 2,039 7 304-56 1-04 2,534 12 290-83 1-38 Total 143,991 2,400 512-10 8-25 160,263 5,690 267-63 8-83 130 INFLAMMATORY DISEASES OF THE RESPIRATORY ORGANS. The proportion of deaths to cases was likewise greater in the Central than in the Atlantic, and in this than in the Pacific region, and, as already intimated, it was greater during the second year than during the first. In the Atlantic region there was one death to every 123 cases during the first year, one to every 71 during the second; in the Central region one to every 31 cases during the first year, one to every 18 during the second; in the Pacific region one to every 291 cases during the first year, one to every 211 during the second. The average for all regions and both years was one death to every 38 cases. TABLE XXXIII. Relation between Cases and Deaths of Inflammatory Diseases of the Respiratory Organs. Year ending June 30, 1862. Year ending June 30, 1863. TWO y bars , Batio of Number of Ratio of Number of Ratio of Number of deaths per cases to each deaths per cases to eacb deaths per cases to each 1000 niscs. death. 1000 cases. death. 1000 cases. death. Atlantic Region 8-15 122-70 14-15 70-67 10-91 91-66 Central Region 32-21 3105 56-58 17-67 47-13 21-22 Pacific Region 3-44 290-70 4-74 210-97 4-15 240-96 Total 1670 59-88 35-50 28-17 26-62 37-57 The effect of season on the development of these diseases is indicated, as might be expected, by the occurrence of the greatest number of cases during the winter. On the Atlantic coast the number of cases taken sick each month gradually increased from July, 1861, to January, 1862, after which it diminished to August, 1862, increased till December, and then diminished through 1863 till the close of the fiscal year in June, with the exception of an irregular increase in March. In the Central region the disease pursued an essentially parallel wave, and this was the case during the second year in the Pacific region. In the Pacific region during the first year, however, the wave was less regular. The following tables exhibit these relationships in detail : . TABLE XXXIV. Monthly Rates of Inflammatory Diseases of the Respiratory Organs in the Armies of the United States during the year ending June 30th, 1862, expressed in ratio per 1000 of mean strength.* 1861. 1862. fe fe C , A For the *s a •§ - 0 t 5 • year. i!II11 I I I i i I Atlantic Region.... 27-06 29-17 28-32 35-75 52-95 64-32 67-17 59-64 44-51 32-73 17-86 13-27 506-86 Central Region 16-83 21-41 30-45 35-37 53-40 75-89 98-29 62-92 63-37 38-37 19-87 15-38 532-92 Pacific Region 7-53 1-01 22-18 21-46 32-73 23-86 24-38 56-80 40-44 15-75 17-45 12-19 304-56 * The Table of Catarrhal Affections published for this year in the Circular of September 8, 1863, before alluded to, did not include Pneumonia or Pleurisy, and hence differs considerably from the above. 131 INFLAMMATORY DISEASES OF THE RESPIRATORY ORGANS. TABLE XXXV. Monthly Rates of Inflammatory Affections of the Respiratory Organs in the Armies of the United States during the year ending June 30th, 1863, expressed in ratio per 1000 of mean strength. 1862. 1863. S3 ai >> For *'ie 1111 l lE-id • yettr ' H < an © M A £ & JS ¦< £ >? Atlantic Region.... 13-46 9-37 10-34 13-87 24-55 32-82 33-12 28-13 35-19 24-51 12-44 7-21 269-70 Central Region 12-01 1003 10-14 17-07 33-10 35-03 30-75 32-34 28-30 20-49 11-29 828 26505 Pacific Region 12-63 13-18 16-65 18-66 27-67 32-99 35-38 31-10 22-72 32-66 25-78 1800 290-83 The rates contained in the foregoing tables are presented also in the lower diagram of the plate opposite page 120, where they may be instructively contrasted with the course of diarrhoea and dysentery. A reference to Table XXX. will show that by far the greatest number of deaths from the inflammatory affections of the respiratory organs were reported under the head of Pneumonia. Out of a total of 8090 deaths from respiratory affections, 7091 are reported as due to this cause. It might perhaps be claimed that this mortality is too great, on account of a certain number of cases of fatal pleurisy and bronchitis having been erroneously included. But the same deficient knowledge of auscultation and percussion which would lead to this error, would produce also an error in the opposite direction, and cause the slight cases of pneumonia to be reported as bronchitis. While then it is possible that the ratio of deaths from pneumonia to strength is somewhat too great, the probabilities are in favor of the approximative correctness of the proportion of deaths to cases; and this proportion is so great, as compared with the results in modern civil hospitals, as to direct attention to the general want of success which appears to have attended the treatment of this disorder. The experience of the two years gives a mortality of one death to every seven (6 'B) cases in the Atlantic region and one to every four (3'B) in the Central, as is shown in the following table: TABLE XXXVI. * Ratio of Deaths from Pneumonia to Cases in the three regions. First Year. Second Year. For the two Years. Number of i Number of Number of Cases. Deaths. cases to Cases. Deaths. cases to Cases. Deaths. cases to each death. each death. each death. Atlantic Region 4,582 601 7-6 5,894 933 6-3 10,476 1,534 6-8 Central Region 6,366 1,529 4-2 14,450 4,014 3-6 20,816 5,543 3-8 Pacific Region 113 4 28-3 122 10 12-2 235 14 16-8 Total 11,061 2,134 51 20,466 4,957 4-1 31,527 7,091 4-4 132 CERTAIN OTHER DISEASES. The great proportion of deaths to cases thus indicated was undoubtedly connected to a certain extent with the character of the disorder. The two chief types to which, as far as can be learned, the majority of the cases belonged, were Typhoid Pneumonia and Adynamic Pleuro-Pneumonia; the first characterized in fatal cases by the condition of the lung designated Splenization, the second, besides the lung lesion, by the presence on the pleura of considerable masses of yellow opaque lymph, with fluid in the pleural cavity. Both these forms occurred in a large number of cases as sequelae to measles, or intercurrent affections in the course of chronic diarrhoea and chronic malarial poisoning. In many instances, moreover, what was called pneumonia proved, on the autopsy, to be camp fever, in which the usual intestinal lesions were associated with congestion of the lungs, with capillary bronchitis, or with pneumonia: of course these circumstances would lead to the expectation of a greater mortality than is found among uncomplicated cases occurring in civil practice. The mortality from pneumonia in the British army in the Crimea was still greater than our own figures, being one death to every 3*6 cases. A considerable amount of valuable material has been contributed on the symptoms, postmortem appearances, and treatment of this disorder, a careful analysis of which will be presented at the proper time. With regard to treatment, it may be stated that the use of alcoholic stimulants, supporting diet, quinine in large doses, and the expectant plan found numerous advocates, as well as opium, ipecacuanha, veratrum viride, antimony, cupping, and mercurials. The attempt to appreciate these methods must be postponed for the present. CERTAIN OTHER DISEASES. The most important affections reported under the head of Enthetic Diseases were the several forms of venereal. The reports give separate figures for syphilis, gonorrhoea, orchitis, and stricture of the urethra. The latter two affections being gonorrhoeal sequelae, may be grouped under the head of Gonorrhoea. Of syphilis, there were 9011 cases and 12 deaths during the first year; 13,781 cases and 27 deaths during the second — total, 22,792 cases and 39 deaths. Of gonorrhoea and its sequelae, 14,768 cases and no deaths during the first year; 25,705 cases and 12 deaths during the second — total, 40,473 cases and 12 deaths. The number of cases of all kinds of venereal was 23,779 for the first year and 39,486 for the second, being 85 cases per 1000 of strength for the first year and 66 per 1000 for the second. The ratio of venereal to the total amount of disease was one case of venereal to every 35 taken sick during the first year; one to every 41 taken sick during the second. If these figures be compared with the experience of other armies, we cannot fail to congratulate ourselves on the comparative exemption of our troops from these loathsome affections. The published statistics of the English army, for example, show that in 1859 there were 422 admissions to hospital for venereal among every 1000 men serving in the United Kingdom; in 1860, 369 per 1000; in 1861, 354, and in 1862, 330— being thus between one-third and one-half the whole number of admissions to hospital. It may be thought, perhaps, that the active occupations of a war carried on in an extensive 133 CERTAIN OTHER DISEASES. and comparatively thinly-populated country will account for this difference in our favor; but the published statistics of the United States army from 1840 to 1859 give a mean annual rate of only 99 cases of venereal per 1000 of mean strength during that period; and this, though larger than the rates above given for the first two years of the war, is less than one-third of the most favorable rate above quoted from the English statistics. When the frequency of venereal among the troops of the three regions is made the subject of comparison, it is found that in the Atlantic region the rate was 87 cases per 1000 of strength for the first year, 61 for the second; in the Central region, 60 per 1000 for the first year, 63 for the second; in the Pacific region rates are, however, attained which closely approximate those of the English army, viz.: 375 per 1000 for the first year and 317 for the second. TABLE XXXVII. Prevalence of Syphilis and Gonorrhoea in the several regions. Year ending June 30,1862. • Year ending June 30,1863. Atlantic central pacific tflt»t atlantic central pacific tfltat REGION. REGION. REGION. REGtON. REGION. REGION. . . - . v „ . . . 1- Is Id! I- la is 1- Is O be O tjp 2 Ml O 6J) S5 t>o — -D ® efl © bl) I-lg 1 ~l £ •—I S I H gj H J 1-H qj Hj) H S fe« fei S^ j fe£ fe| feis fe| fe| J |a J |s J a J |a J |a I 5 |a J |a J Syphilis 6,139 3451 1,628 16-86 1,244 185-81 9,011 32-05 6,118 21-56 6,439 21-01 1,224 140-48 13,781 2303 Gonorrhoea and its sequelae 9,356 52-59 4.14T 42 J94 1,265 188-95 14,768 52-52 11,326 39-92 12,841 41-91 1,538 17652 25,705 42-93 Total 15,495 87'1O 5,775 59-79 2,509 374-76 23,779 84-57 17,444 61-49 19,280 62-92 2,762 317-00 39,480 65-94 The annual rate of venereal in the Pacific region, as given in this table, is greater than that deducible from the published statistics of eighteen years of peace. But even during that period it was about twice as great as in the rest of the army. Among the documents connected with syphilis which have been received for publication, may be mentioned certain interesting papers with regard to the attempts made by the military authorities in the Cities of Nashville and Memphis to limit the spread of syphilis among the troops stationed near those places, by regulating prostitution after the plan practised by the French government in Paris —a plan which is reported to have produced the most salutary results in both places. Under the head of Dietic Diseases, the chief affections included are scurvy and the abuse of alcohol. As to the latter of these causes of disease, the activity of the campaigns, and the stringent regulations very generally enforced with regard to sutlers, reduced the frequency of intoxication to a comparatively low figure in the large armies of the Atlantic and Central regions. During the first year, 656 cases of delirium tremens and 978 cases of drunkenness (ebrietas) are reported— drunkenness here including only those cases in which, in consequence of the debauch, the man was obliged to go on sick report; during the second year, 772 cases of delirium tremens, 1221 of drunkenness, and 226 of chronic alcoholism 134 CERTAIN OTHER DISEASES. were reported. This would give a ratio of 6 cases of all kinds per 1000 of mean strength for the first year; 4 per 1000 for the second. It is worthy of remark that the proportional number of cases was much greater on the Pacific coast, where the conditions of peace being more nearly approximated to, the men must of course have had more opportunity and more leisure for debauch. In the Atlantic region, the ratio of cases from the abuse of alcohol was 6 per 1000 of mean strength for the first year of the war; 3 for the second. In the Central region, 4 per 1000 for both years; while in the Pacific region it was 33 per 1000 for the first year and 35 for the second. The amount of Scurvy reported was comparatively small: 1328 cases and 9 deaths for the first year; 7395 cases and 90 deaths for the second. To this may probably be added the greater part of the 304 cases and 31 deaths of purpura reported during the second year. This extremely small number of cases of scurvy is unparalleled in the history of armies, being but 5 per 1000 of mean strength for the first year and 13 for the second. It undoubtedly stands related to the quantity and comparatively good quality of the army ration, — to the immense supplies of antiscorbutics, of medical stores and comforts issued to the men by the Government, and to the large pay of the private soldier, which is very many times greater than in any other army in the world, and which, in part at least, was often spent at the sutler's on pickles, apples, pies containing dried fruit, etc. From all these sources, ours have undoubtedly been the bestfed soldiers in the world ; and besides all this, they received at various times and localities, stores collected and distributed by several benevolent and patriotic associations, whose supplies, though of course comparatively small when contrasted with those of the Government, were yet of considerable value in aiding to form the sum total of the soldiers' resources. Still it is not claimed that the alimentation of our troops was all that could have been desired; for recognizable scurvy existed to a limited extent, and a scorbutic taint, more or less pronounced, was a prominent phenomenon in most of the diseases of the war. The open question of the army ration, and of its possible economical improvement, is one of great importance, which will not be here discussed. That some alteration is needed, cannot be denied. The scorbutic taint manifested itself very generally in the form of rheumatic pains in the back and limbs, associated with the scorbutic clay-like appearance of the skin, sometimes even with sponginess of the gums, much more rarely with petechiae, scorbutic discolorations about the flexure of the knee, etc. Most of the physicians called upon to treat these cases, having had in their previous private practice little experience with scurvy, reported them as rheumatism, lumbago, or neuralgia. It is by no means insinuated that all the cases reported under these heads were of a scorbutic nature. Many of malarial neuralgia and many of malingering were thus reported. Undoubtedly also a great deal of true rheumatism existed; certainly, however, the latter affection formed but a small part of the enormous number of rheumatic cases reported. During the first year of the war 26,257 cases of acute rheumatism, 14,216 of chronic, and 4289 of lumbago were reported, making a total of 44,762 rheumatic cases; during the second year 45,677 cases of acute rheumatism, 45,758 of chronic, making 91,435 rheumatic cases; of neuralgia, 7546 during the first year, 18,533 during the second. The sum is 162,276 cases of rheumatism DISCHARGES ON SURGEON'S CERTIFICATE OF DISABILITY. 135 and neuralgia for the two years, being 186 per 1000 of mean strength for the first year; 184 for the second. How many of these were rightly named? What proportion of them were in fact, as a vast number unquestionably were, simply the outward manifestation of incipient scurvy? What proportion of malingerers was there among those lame backs which were so common? These are questions which, unfortunately, cannot be answered with any approach to precision from our statistics, but in connection with which there exists some valuable material for future discussion. Under the head of Tubercular Disease, the most important is pulmonary consumption, the number of cases of which, however, was not great: 2508 cases and 550 deaths are reported during the first year; 5599 cases and 2040 deaths during the second — being 8-9 cases per 1000 of mean strength for the first year; 9-3 for the second. The deaths were one to every 4*5 cases during the first year; one to every 2-7 during the second. In the British troops in the United Kingdom, the number of cases of pulmonary consumption reported in 1861 was 9 per 1000 of mean strength; in 1862, 10 per 1000; the deaths for both years, one in every three cases. Space does not permit further or more extended comments in this direction. It is trusted, however, that enough has been said to give an idea of the scope and character of the statistical work in progress. The figures hitherto presented refer wholly to the white troops of our army. Separate statistical tables are projected for our colored troops and for the prisoners of war in our military prisons. Good data for these tables are on file. Elaborate tables are also being prepared on the subject of discharges from service on surgeons certificate of disability ; these are reported by name to the Surgeon General's Office, with the cause specified in each case, so that data exist for a complete and trustworthy discussion of the subject. DISCHARGES ON SURGEON'S CERTIFICATE OF DISABILITY. The monthly reports of sick and wounded from hospitals, garrisons, and troops in the field contain in the general summary a statement of the number of soldiers discharged the service during the month on surgeon's certificate of disability. On the reverse of the report, a nominal list is given setting forth, precisely as in the case of deaths, the name, company, regiment, date of discharge, and nature of disability in each case. From these nominal lists, the number of discharges for disability and the nature of the disabilities can be computed with great accuracy. The various duties devolving upon this branch of the office during the progress of the war were such that it was not possible, until a few months since, to attempt the reduction of this voluminous material; and although the work is now fairly under way, the figures for the second year of the war could not be completed in time for the present publication. The statistical tables here offered, therefore, are limited to the first year. The total number of men reported to the Surgeon General's Office as having been discharged the service on surgeon's certificate of disability during the year ending June 30th, 1862, was 28,620, or 98-3 per 1000 of mean strength. Of this number, 1937 were discharged for wounds and injuries, and 26,683, or 9T7 per 1000, for disease. These discharges were apportioned as follows among the several States: 136 DISCHARGES ON SURGEON'S CERTIFICATE OF DISABILITY. TABLE XXXVIII. Showing the Number of Men discharged the Service for Diseases and Wounds, during the year ending June 30th, 1862, for each State. „ . . Discharged fo „. , . Discharged for State. Discharged WoU ndsand State. Discharged wounda and for disease. juries. for disease. i^uries. Maine 1,119 59 Brought forward 22,164 1,500 New Hampshire 509 27 Wisconsin 1,095 59 Vermont 370 27 lowa 1,050 111 Massachusetts. 1,825 143 Minnesota 179 30 Connecticut 887 16 Missouri 796 62 Rhode Island 194 13 Kentucky... 330 14 New York 7,051 441 Arkansas 1 New Jersey 401 46 Kansas 115 32 Pennsylvania 3,160 169 Nebraska. 59 4 Delaware 73 4 Colorado 4 1 Maryland 85 1 New Mexico 4 3 Distriot of Columbia 6 1 California 33 1 Virginia 125 10 Oregon 3 Ohio 2,317 142 Washington Territory 2 Indiana 1,638 166 Regulars 754 114 Illinois 1,719 182 Miscellaneous 94 6 Michigan 1,185 53 Total 26,683 1,937 Carried forward 22,164 1,500 It will be extremely interesting to compute the ratio of discharges per 1000 of strength actually in service from each State, but the above table has been too recently constructed to afford time for the necessary comparisons, which, moreover, will be still more instructive when the tables for the remaining years of the war are completed. The following tables show the number of discharges from the several classes, orders, and individual diseases and injuries. They may be instructively compared with Tables VI. VIII. and X., the last columns of which give the total taken sick and died for the same year. In making the comparison it must be remembered that the column "taken sick" in the tables referred to does not include secondary affections or sequelae. TABLE XXXIX. Showing the Number of Discharges for Disability by Glasses of Diseases and Injuries, for the year ending June 30th, 1862. Class. J . N T ber J discharged. I. Zymotio Diseases 5,194 11. Constitutional Diseases 7,298 111. Parasitic Diseases , 000 IV. Local Diseases 9,904 V. Wounds, Accidents, and Injuries 1,937 VI. Developmental Diseases 678 Unclassified and cause not stated 3,609 Total 28,620 DISCHARGES ON SURGEON'S CERTIFICATE OF DISABILITY. 137 TABLE XL. Showing the Number of Discharges for Disability by Orders of Diseases and Injuries, for the year ending June 30th, 1862. Class. Order. ?. N T ber , discharged. fl Miasmatic Diseases 4,645 I. \2 Enthetic Diseases 518 [3 Dietic Diseases 31 jt fl Diathetic Diseases 3,960 t2t 2 Tubercular Diseases 3,338 f 1 Diseases of the Nervous System 1,480 2 Diseases of the Eye 529 3 Diseases of the Ear 319 4 Diseases of the Organs of Circulation 1,410 IV. - 5 Diseases of the Respiratory Organs 1,764 6 Diseases of the Digestive Organs 3,011 7 Diseases of the Urinary and Genital Organs 377 8 Diseases of the Bones and Joints 660 [9 Diseases of the Integumentary System 354 V Wounds, Accidents, and Injuries . 1,937 VI Developmental Diseases 678 Unclassified and cause not stated 3,609 Total 28,620 TABLE XLI. Showing the Number of Discharges for Disability by Individual Diseases, during the year ending June 30lh, 1862. LIST OF DISEASES.. dtadSSd. LIST OF DISEASES. dSrg'ed. Class I. — Zymotic Diseases. Brought forward 5,194 Order I. Miasmatic Diseases. Typhoid Fever 258 Class ll.— Constitutional Diseases. Remittent Fever 70 Order I. Diathetic Diseases. Intermittent Fever 56 n , . Diarrhoea 865 £? ut...... 4 Dysentery 118 Rheumatism 3,585 Erysipelas 17 £ n{emia A \ Smallpox 12 £ ancer * Varioloid 13 humors 40 Measles 81 Obesity Diphtheria 4 Marasmus 6 Debility 3 139 Dropsy 237 other disea^sof this ordy."::.":::::.\\7.:.":.'.":::: '12 other diseases of this order 39 Order 11. Enthetio Diseases. ° RDEB IL Tvb ™ lar *»*-• Syphilis 399 Consumption 3 161 Gonorrhoea 9 Scrofula 177 Orchitis 49 nl TTT T , t.. Stricture of the Urethra 60 olass IV.— Local Diseases. Other diseases of this order .... 1 Order I. Diseases of Nervous System. Apoplexy 1 Orderlll. Dietic Diseases. Epilepsy. 669 Scurvy 7 Headache 8 Delirium Tremens 4 Insanity 246 Inebriation 20 Inflammation of the Brain 25 Carried forward 5,194 Carried forward 13,441 18 138 DISCHARGES ON SURGEON'S CERTIFICATE OF DISABILITY. TABLE Xhl.-Concluded. LIST OF DISEASES. d£c"h™r|ld. LI ST OF DISEASES. dX^gld. Brought forward 13,441 Brought forward 1 21,005 Order I. Diseases of Nervous System — Continued. Order VII. Diseases of Urinary and Genital Organs. Nostalgia 8 I Diabetes 13 Neuralgia 39 Diseases of Testis 7 Paralysis 252 Gravel 8 Sun-stroke 21 I Inflammation of the Kidneys 112 Chorea 18 Inflammation of the Bladder 5 Other diseases of this order 193 Incontinence of Urine 36 Bright's Disease 33 Order 11. Diseases of Eye. Other diseases of this order 163 Amaurosis 109 •• _. Oohthalmia 139 Order Till. Diseases of Bones and Joints. Other diseases of this order 281 Anchylosis 199 Caries 25 Orderlll. Diseases of Ear. Inflammation of Joints 93 Deafness... 260 Inflammation of Bones 1 Otalffia.. 3 Inflammation of Periosteum.... 20 Otorrho3a3!"""""l!""!""!""""""""!!"" I ! Necrosis 161 Other diseases of this order 55 j Exostosis II Diseases of Spine o9 OrderlV. Diseases of Organs of Circulation. Other diseases of this order 100 Heart Diseases 824 OrderlX. Diseases of Integumentary System. Varicose Veins 299 Varicocele 287 Abscess Ulcers -sob Order V. Disease* of Respiratory Organs. Skin Diseases 35 Asthma 244 Other diseases of this order 12 Bronchitis 803 Aphonia 42 Olass V. — Wounds, Accidents, and Injuries. Inflammation of the Larynx 27 Burns and Scalds 3 Inflammation of the Lungs 253 Contusions . 69 Inflammation of the Pleura 97 Concussion o f the Brain 2 Haemorrhage from the Lungs 151 g ing 57 Other diseases of this order 147 Dislocations 103 Order VI. Diseases of Digestive Organs. I „ . O7T J " " Fractures 27/ Colic 3 Gunshot Wounds 825 Constipation 2 Incised Wounds 37 Dyspepsia 69 Lacerated Wounds 3 Diseases of the Spleen 13 I Wounds (unspecified) 179 Fistula in Ano 82 I Amputations 85 Hernia 2,300 I Other accidents and injuries 287 Prolapsus ani 38 Hcemorrhage from the Bowels 2 „, tw i . » <¦*¦ Inflammation of the Tonsils l Class Vl.— Developmental Diseases. Inflammation of the Stomach 37 Atrophy 25 Inflammation of the Bowels 21 Hypertrophy 9 Inflammation of the Peritoneum 14 Deformities 238 Inflammation of the Liver 136 Old Age 274 Jaundice 17 Under Age 128 Piles 215 Feebleness 4 Loss of Teeth 37 Other diseases of this order 24 Unclassified and cause not stated 3,609 Carried forward 21,005 Total 28,620 An inspection of Table XLI. shows that the diseases from which the greatest number of discharges were reported were : Rheumatism, 3585 ; Consumption, 3161 ; Debility, 3139; Hernia, 2300; Diarrhoea, 865; Heart Diseases, 824; Bronchitis, 803; and Epilepsy, 669. It will be perceived that the discharges reported under these headings constitute over two- thirds of those discharges for disease the causes of which are specified in the reports. The large proportion of discharges indicated by these 139 ARMY MEDICAL MUSEUM. — MEDICAL SERIES. figures would appear to justify some of the criticisms that have been made on the manner in which recruits were examined and discharges granted during the early part of the war. It certainly cannot be denied that these criticisms had a certain foundation, and that many men found their way into the service who were either physically disqualified at the time, or whose constitutions were so feeble from youth, age, or predisposition to disease, that they soon broke down under the labors and exposures of actual campaigns. But when it is considered with what haste it was necessary to organize those large armies, this fact ceases to be surprising, and it becomes rather a matter of wonder that the discharges for disease should be represented by a figure no greater than nine per cent, of the strength. It is also to be remarked that it is well known that numbers of those who were discharged for curable diseases recovered and re-enlisted; so that while the humane policy of releasing promptly from military restraint those who were not likely to recover if they continued in service was doubtless the means of saving thousands of lives, it is probable that the army rather gained than lost in actual strength by this liberality. The statistics of the several drafts and of the Veteran Keserve Corps belong to the Bureau of the Provost Marshal General.* ARMY MEDICAL MUSEUM. Besides the statistical material and the documents accompanying it, such as the reports of medical directors of armies, etc. etc., much valuable material of a strictly pathological nature has been collected. To this category belong numerous valuable memoirs on subjects connected with the leading diseases of the troops, histories of cases, autopsies, etc., and the work done in connection with the Army Medical Museum. The portions of this institution under my charge are the medical and microscopical collections. The Medical Series of the Museum, which is still growing, consists at present of about 700 specimens, chiefly wet preparations preserved in alcohol. Each preparation, after careful dissection, in order that the lesion to be exhibited may be as clearly displayed as possible, is suspended in alcohol from a glass hook in the stopper of a fine glass jar. The jar has tied on its neck a parchment label, with the number of the preparation, and the name of the lesion shown. Besides a number of miscellaneous pathological preparations, the Museum contains good collections on valvular disease of the heart, * For interesting information on this subject, reference may be made to the published reports of the Provost Marshal General for 1864 and 1865. 140 ARMY MEDICAL MUSEUM. — MEDICAL SERIES. diphtheria, pleurisy and pleuro-pneumonia, camp fever, and camp diarrhoea and dysentery. A collection illustrating the diseases of the freedmen has lately been commenced, and promises to be of considerable interest. The manuscript catalogue, containing the description of these specimens and the histories of the cases, occupies 350 pages folio. A few words may be said with reference to the specimens illustrative of fever and diarrhoea. The series illustrative of camp fever consists of about 160 specimens, chiefly preparations exhibiting the condition of the intestine in this form of disease. The pieces have been mounted upon frames of glass rod, and suspended in alcohol, so that they can be viewed by either reflected or transmitted light. The specimens in this series are arranged in several groups. In the first, the characteristic lesion is enlargement of the solitary follicles of the small intestine, and especially of the ileum. Thickening of Peyer's patches may be quite absent, or may be present to a variable extent. All degrees of enlargement have been noticed, from the slightest change to cases in which the follicle attains the size of a pea. The most characteristic specimens may be thus described : In the fresh intestine, as received at the Museum, the ileum presents patches of deep congestion of variable extent; the solitary follicles, enlarged to the size of large pin-heads, are frequently black with pigment deposits. The Peyer's patches, sometimes quite healthy, are more generally the seat of pigment deposits in the individual follicles composing the patch, which appears of a gray color, dotted over with blackish points, presenting a resemblance to the freshly-shaven chin. The name "shaven-beard appearance" has been quite currently bestowed upon this condition. In other cases, the Peyer's patches are somewhat thickened, and occasionally as much so as in ordinary cases of enteric fever. In the preparations, as preserved in the Museum, the color of the piece, including that of the pigment deposit, gradually disappears. The enlarged solitary follicles, and the alterations in the Peyer's patches, are, however, well preserved. The solitary follicles are not ulcerated in these cases, except rarely some of the largest, which may present a minute point of ulceration on the apex. The form of fever from which these specimens are obtained is that which attracted attention in 1862, under the designation of Chickahominy Fever, but which, before and since, has prevailed whenever our armies have operated in malarial regions. It is a continued fever, which presents also a more or less decidedly remittent type, at the beginning at least. It is accompanied by diarrhoea and abdominal tenderness, but usually without tympanites. Cerebral and pulmonary complications are common, as in ordinary enteric fever. Enlargement of the spleen is frequent, and often excessive. The fever usually lasts from three to five weeks, and terminates in a lingering and protracted convalescence. This variety I have proposed to designate as the Malarial form of Typho-Malarial Fever. The second group of specimens are less numerous, and represents, so far as I have been able to learn, a rarer form of disease. As first received at the Museum, the ileum presents intense reddish-black patches of congestion, which sometimes extend throughout its whole length. The patches of Peyer are converted into livid, blackish, pulp-like sloughs, which are often remarkable for their size and fungoid appearance. Petechialike blotches in the mucous membrane of the colon, the small intestine, and the stomach are of frequent occurrence. Similar discolorations are at times observed in other organs. The cadaver often presents petechioe on the external surface of the body and scorbutic 141 ARMY MEDICAL MUSEUM. MEDICAL SERIES. alterations of the mouth. During life, these cases are marked by the extremely adynamic character of the symptoms, by petechise, at times even by the characteristic scorbutic lesions of the mouth, by haemorrhage from the bowels, and other haemorrhages which complicate the disorder and often prove fatal. The specimens preserved in the Museum, although they have lost their color, show satisfactorily the pulpy slough-like transformation of Peyer's patches. This variety I have proposed to designate the Scorbutic form of Typho-Malarial Fever. It occurred chiefly at times when other scorbutic diseases were prevailing among the troops. Specimens of the third group are quite identical with those obtained from the typhoid or enteric fever of civil life, and the cases in many instances are undoubtedly that affection in its ordinary form. As it occurred among the troops, however, the course of the disease was so generally more or less modified by the influence on the soldier of malaria, or of the scorbutic taint, or both, that I have proposed to indicate such cases as the Enteric variety of Typho-Malarial Fever. Besides these groups, there is a fine series of preparations showing the several forms of ulceration left by the softening and destruction of the patches and solitary glands in each of the varieties, the different methods of perforation, of cicatrization, etc. A few brief abstracts of cases, selected from the foregoing series, are here presented in illustration, especial prominence being given to the conditions observed in the autopsies : Private C , 61st New York Vols., was admitted to Satterlee Hospital, West Philadelphia, Pa., July 10th, 1862, from the Army of the Potomac, then on the Peninsula. His disease was registered Typhoid Fever. He died August 24th, 1862. Autopsy, August 25th: Organs generally healthy, except that the solitary glands were thickened, and both these and Peyer's glands of a black color, resembling the bluish-black of tattooing. The surrounding parts of the mucous membrane were pale and devoid of anything like congestion. No. 270, Medical Series, is a piece of the ileum, showing numerous solitary glands the size of large pin-heads, and a Peyer's patch, which is not perceptibly diseased. The whole ileum was received at the Museum in alcohol, and none of the Peyer's patches were prominent Contributed by Prof. J. Leidy, then Acting Asst. Surgeon U. S. A. Private D , 17th U. S. Infantry, was admitted to Satterlee Hospital, West Philadelphia, Pa., August 10th, 1862, from the Army of the Potomac. His disease was registered Typhus Fever. He died August 22d. Autopsy : Age about twenty-two ; body moderately emaciated; ecchymoses on the surface of the trunk. There were a number of minute ulcers in the lesser curvature of the stomach ; the ileum was congested in patches; most of Peyer's glands were healthy, a few of them slightly thickened, but none ulcerated ; the solitary glands were enlarged ; the colon was slatecolored, with patches of congestion, a number of spots of ecchymosis, and in the descending portion a few small ulcers. Nos. 273 to 276, Medical Series, are successive portions of the ileum, showing the enlarged solitary follicles and a few slightly-thickened Peyer's patches. No. 272 is the stomach, with minute ulcers in the lesser curvature. Contributed by Prof. J. Leidy. Private B , 7th Maine Vols., was admitted to Satterlee Hospital, West Philadelphia, August 10th, 1862, from the Army of the Potomac. His disease was registered Diarrhoea. He died October Bth. Autopsy : Age about twenty-seven years; body much emaciated; skin ecchymosed. There was continuous congestion throughout the small intestine, which was most intense in its lower part; the ileum was of a deep maroon color; Peyer's glands were not perceptibly altered ; the solitary glands numerous and conspicuous from enlargement ; the ascending colon was also congested, and presented a few spots of ecchymosis with pigment in some of its solitary follicles. Nos. 237 and 238, Medical Series, are successive portions of the ileum of this patient; each presents a normal Peyer's patch and a number of enlarged solitary follicles. Contributed by Prof. J. Leidy. Private W , 20th Michigan Vols., was admitted to Satterlee Hospital, West Philadelphia, December 1 3th, 1862, from the Army of the Potomac. His disease was registered Diarrhoea. He died December 26th, 1862. Autopsy, December 27th : Age about twenty-two years. Body rather emaciated ; spots of purpura on the trunk ; recent pleurisy on both sides, most marked on the right ; pneumonia in the lower lobes of both lungs ; bronchitis; liver and spleen enlarged ; moderate congestion diffused throughout ileum and colon ; enlargement of the solitary glands in lower part of ileum ; Peyer's glands reddened ; slight enlargement of the solitary follicles of large intestine. Nos. 107 and 108, Medical Series, are successive portions of ileum, No. 108 taken from just above the ileo-coecal valve; 142 ARMY MEDICAL MUSEUM. — MEDICAL SERIES. both exhibit well-marked enlargement of the solitary follicles, many of which are as large as bird-shot. Each piece exhibits a Peyer's patch, in which, in the alcoholic specimens, nothing abnormal is visible. No. 109, Medical Series, is the enlarged spleen of this patient, 7£ inches long, 5 wide by 3 thick. Contributed by Prof. J. Leidy. Corporal S , 9th Wisconsin Vols., was admitted to Satterlee Hospital, West Philadelphia, December 16th, 1862, from the Army of the Potomac. HisNJisease was registered Diarrhoea. He died December 24th. Autopsy the same afternoon : Age about thirty years ; cadaver rather emaciated ; spots of purpura on chest and abdomen ; lobular pneumonia in lower lobes of both lungs ; the inflamed portions numerous, from the size of a marble to that of a walnut, and in a state of gray hepatization ; bronchitis ; stomach much contracted ; patches of congestion in small intestines ; Peyer's patches congested and dark red in color, with, however, only the slightest degree of thickening in some of the lowest of them ; the solitary glands looked like yellow mustard-seeds sprinkled on a red ground ; large intestine streaked with ash color and dark red, and with purpura-like spots of ecchymosis. Nos. 93 to 98, Medical Series, are successive portions of the ileum of this patient. As preserved in the Museum, Peyer's patches are not perceptibly diseased, except the large patch in No. 98, which was taken from just above the ileo-ccecal valve, and which is slightly thickened. The solitary follicles in all the pieces are enlarged to the size of mustard-seeds. Contributed by Prof. J. Leidy. Private D , 100 th Pennsylvania Vols., aged eighteen, was admitted to Carver Hospital, Washington, D. C, July sth, 1864, from hospital at City Point, Va. He was considerably emaciated ; his tongue thickly coated ; pulse rapid and feeble; there was headache, anorexia, and diarrhoea; the left parotid gland was swollen and painful. July 15th. The parotitis has terminated in suppuration; the abscess was opened to-day; the febrile symptoms continue; there are distinct remissions during the forenoon of each day; persistent diarrhoea. July 22d. Patient has grown gradually worse ; the integument over the parotid has sloughed ; diarrhoea continues ; there is deafness and low delirium, especially at night ; the remissions have not been so distinct for the last few days ; died this evening. Autopsy : Emaciation; lungs congested; heart pale and flabby; Peyer's patches congested, but not thickened; the solitary follicles of the ileum considerably enlarged ; several very minute ulcers in the vermiform appendix and the ascending colon. Nos. 385, 386, and 387, Medical Series, are successive portions of the ileum, showing marked enlargement of the solitary follicles. Peyer's patches are not perceptibly diseased. Contributed by Acting Assistant Surgeon 0. P. Sweet. Private V , 126 th Ohio Vols., was admitted to Carver Hospital, Washington, D. C, from Field Hospital, Army of the Potomac, July 4th, 1864. He was much emaciated, and suffering from symptoms resembling typhoid fever. Tongue coated with thick, dry, brown fur, teeth with dark sordes ; tympanites ; petechiae on abdomen and chest ; the diarrhoea was severe, but the stools feculent ; the patient at first improved, but July 25th the diarrhoea began to grow worse and delirium set in; death July 30th. Autopsy: Old pleuritic adhesions on both sides ; two ounces of serum in pericardium ; liver large and pale ; spleen large and firm ; the solitary follicles of small intestine enlarged to the size of large pin-heads ; Peyer's patches congested, but not thickened ; the colon thin, presenting a number of ulcers, which, in the descending colon, were large and irregular. No. 416, Medical Series, is a portion of the ileum of this patient, taken from just above the ileo-coecal valve, showing pin-head enlargement of the solitary follicles. The whole ileum (preserved in alcohol) was received at the Museum. No disease of Peyer's patches was visible. Nos. 417 and 418, Medical Series, are from the transverse and descending colon, and present a number of irregular ulcers. Contributed by Acting Assistant Surgeon O. P. Sweet. Private W , 7th Western Virginia Vol. Cay., aged nineteen, was admitted to Carver Hospital, Washington, D. C, from the Army of Western Virginia, August 21st, 1864. He was considerably emaciated, and had been sick for some time with fever, diarrhoea, and vomiting. When admitted, he appeared exhausted ; his pulse was frequent and feeble ; he had slight diarrhoea and incessant vomiting ; under treatment, the vomiting disappeared, and the diarrhoea greatly improved, but he remained in a typhoid condition, and died August 25th. Autopsy : Hypostatic congestion of posterior part of lungs ; the right side of heart contained a large fibrinous clot ; the ileum presented patches of congestion, with enlargement of the solitary follicles ; there were numerous ulcers of Peyer's patches, which, however, presented this peculiarity, that three, four, or more small oval ulcers, a few lines in diameter, were seated in each patch, but the remaining portions were nearly normal. This condition is well shown in the portions preserved in the Museum, Nos. 407 and 408, Medical Series. In the colon, the solitary follicles were the seat of pigment deposits. Contributed by Acting Assistant Surgeon O. P. Sweet. Private C was admitted to Hospital No. 3, Alexandria, Va., from the Field Hospital at City Point, November 30th, 1864. He was in an extremely typhoid condition, with sordes about the mouth, muttering delirium, petechial spots on the surface, and haemorrhage from the nostrils and bowels. He died December 3d. Autopsy: Peyer's patches converted into black, pultaceous sloughs ; the solitary follicles enlarged, near the ileo-coecal valve some of them ulcerated ; a few small ulcers in the coecum. No. 468, Medical Series, is the lower part of the ileum, which well exhibits the sloughs described. After nearly a year's immersion in alcohol, they have not yet lost their dark color. Contributed by Acting Assistant Surgeon W. Miner. Private F , 42d Massachusetts Vols., was admitted to Hospital No. 3, Alexandria, Va., October 29th, 1864. He was taken sick about a week before with a decided chill, followed by hot skin, severe headache, thirst, and diarrhoea ; has had no epistaxis or tympanites ; is wakeful, with hot skin, pulse 120, thirst, scanty urine, coated dry 143 ARMY MEDICAL MUSEUM. — MEDICAL SERIES. tongue, and some bronchial irritation. November 12th. Improved under treatment until this morning ; his respiration is now hurried ; there is a renewal of all the febrile symptoms, more cough, and dark flushed cheeks, but none of the physical signs of pneumonia. November 15th. Better. November 16th. Feeble, skin cool. November 17th. Bilious vomiting several times last night ; some pain in the epigastric region ; no tympanites ; pulse feeble ; the stomach continues irritable, with frequent vomiting, the matters vomited resembling coffee-grounds towards the last ; death at 8 p.m. Autopsy : Not much emaciation ; intestines glued together with pasty-yellow lymph ; abdominal cavity contained two pints of yellow turbid fluid, with faecal odor ; a perforation about |of an inch in diameter near middle of ileum ; Peyer's glands much enlarged ; spleen enlarged and softened. No. 439, Medical Series, is a piece of the ileum of this patient, presenting two deep typhoid ulcers quite like those encountered in ordinary enteric fever. One of the ulcers has perforated, and the peritoneal surface of the piece is coated with pseudo-membrane. Contributed by Surgeon E. Bentley, U. S. Vols. The series illustrative of diarrhoea and dysentery consists of over 200 specimens, grouped as follows: The first group embraces the examples of follicular ulceration of the colon. The specimens present all the transition forms of simple enlargement of the solitary follicles of the colon, the rupture of the same, and the formation of punched-out ulcers of moderate size. The colon is usually more or less thickened, the thickening, in some cases, amounting to a quarter of an inch. The ulcers are usually rounded or oval, extending nearly or quite to the muscular coat, and looking much as if they had been cut out with a punch; when received fresh at the Museum, the appearances varied with the stage of the process. In the few cases in which the solitary follicles were simply enlarged, without ulceration, the intestine was seldom thickened. It was often normal in color; sometimes, however, slate or ash colored; sometimes it presented patches of congestion. The enlarged solitary follicles were often the seat of pigment deposits; sometimes also an areola of pigment, deposited in and among the glands of Lieberkiihn, surrounded the enlarged and blackened solitary follicles. These patients had generally died of some other disease, as of camp fever supervening upon the diarrhoea, with lesions of the small intestine — of gunshot wounds, etc. In the more serious cases of diarrhoea, the colon was more or less thickened, and presented punched-out ulcers which had originated in the solitary follicles. The colon was then seldom normal in its color. Sometimes it was red, reddish brown, or reddish black; at other times greenish, slate, or ash colored; at others, again, unnaturally pale. Its texture, when cut into, was sometimes tough and lardaceous; sometimes it was softened. The ulcers usually presented a grayish or yellowish-gray base. They were sometimes filled with mucus, at other times contained pus. In the majority of the cases of this class, the small intestine was not involved, unless camp fever had existed as a complication. In the second group of cases, the follicular ulcers have extended until, in extreme instances, the greater part of the mucous membrane of the colon is destroyed by the vast erosions thus produced. The follicular ulcers usually extend by burrowing in the submucous connective tissue; in this way, in some of the specimens, several of these ulcers communicate with each other in the submucous tissue, though still retaining distinct orifices. The mucous layer containing the glands of Lieberkiihn, undermined by the extension of the ulcer, not unfrequently hangs in shreds like a fringe from its edge; the undermined portion being occasionally destroyed by ulceration, but more frequently perishing by sloughing. In such specimens, when received fresh at the Museum, the mucous membrane was generally of a dark-red, brownish, greenish-brown, or slate color. The ulcers presented yellowish-brown or yellowish bases, often with blackish or brown 144 ARMY MEDICAL MUSEUM. MEDICAL SERIES. sloughs adhering to their surface or edges. It would appear that this second group of cases represents simply a more advanced stage of the disease shown in the first group; and that the conditions determining the degree of ulceration are the duration of the disorder on the one hand, on the other, the constitutional condition of the patients; those who labored under the scorbutic taint, or who were otherwise brought to an extremely adynamic condition, presenting the most extensive ulcers. In the third group, the cases present more or less ulceration of the bowel, similar to that seen in the first and second group; but, in addition, the surface of the gut is more or less coated with a yellowish or greenish-yellow pseudo-membranous layer, like that observed in the air-passages in diphtheria. This condition is generally the result of an acute dysenteric process supervening upon a previous diarrhoea of long standing. The appearances of the gut, when fresh, are masked by the plastered layer of greenish-yellow or yellowish pseudo-membrane which coats its surface. The fourth group includes those cases in which the small intestine is diseased as well as the large. Most of these are examples of the complications of diarrhoea with camp fever, and the lesions in the small intestine are therefore similar to the lesions already described as existing in fever cases. In some instances the history of the case shows fever to have been the primary disorder, from which, however, the patient never wholly convalesced, but finally succumbed to the diarrhoea which supervened. In other cases, the fever occurred after the patient had suffered from diarrhoea for months. The character of the lesions in the small intestine and colon usually corresponds to this history. But besides these cases, in which the affection of the small intestine is evidently the result of fever, the Museum contains several specimens in which, from the character of the lesion, it must be inferred that the affection of the small intestine is simply an extension of the disease upwards from the colon. In these cases, the ileum is more or less thickened, — the thickening being greatest near the ileo-coecal valve. The thickened ileum presents ulcers of variable size, which appear, as a rule, to have their origin in the solitary follicles, and not in the patches of Peyer. The fifth group embraces tubercular ulceration of the bowels. The ulcers are more characteristic in the small intestine than in the large; but both small and large intestines are usually affected. The patients have tubercles in the lungs; cheesy transformation of the mesenteric glands; at times, other tubercular lesions. In the small intestine, Peyer's patches appear to determine the position of the ulcers, which are usually irregular ovals, with their long diameter transverse to the gut, as has been observed in tubercular ulceration of the bowels in civil practice. Frequently also small tubercles can be seen on the peritoneal surface of the piece opposite the ulcers. Of this condition, fine specimens exist in the Museum. With this lesion of the small intestine, thickening and ulceration of the colon are associated. The ulcers are quite similar always to some one of the forms above described. Usually they are extensive and deep, the colon being much thickened. I have not been able to satisfy myself that they originate in tubercular deposits. On the contrary, they seem quite like the colon ulcers of other patients from the same command who have no tubercular disease whatever. Besides the foregoing groups, there are specimens of perforating ulcers of the colon, cicatrices of colon ulcers, etc. etc. 145 ARMY MEDICAL MUSEUM. MEDICAL SERIES. Abstracts of a few cases are here very briefly presented in illustration of the foregoing series : Private R , 4th lowa Cavalry, was admitted to Hospital No. 3, Vicksburg, Miss., October 10th, 1863. He had suffered from diarrhoea for nine months previous to his decease. The attack began as dysentery, with frequent bloody stools, which, in a day or two, greatly diminished in number, becoming mucoid and gelatinous. After five weeks, the disease assumed the characters of chronic diarrhoea, which continued till his admission ; the dysenteric symptoms, however, recurring from time to time. He died November 17th. Autopsy: A few calcareous tubercles and cicatrices at the apex of each lung ; patches of congestion in small intestine ; at the lower end of the ileum a few of Peyer's glands were slightly prominent; coecum of a deep red color, its mucous coat softened; the rest of the colon much thickened, cutting like cartilage, pale, with livid spots or stains, and presenting great numbers of small punched-out follicular ulcers ; spleen small. Nos. 119 to 123, Medical Series, are successive portions of the colon, which show very well its thickness and the follicular ulcers. Contributed by Surgeon George F. French, U. S. Vols. Private B , sth Illinois Cavalry, aged twenty-one, was admitted to Hospital No. 3, Vicksburg, Miss., October 10th, 1863. Has been sick eight months. His disease began with an attack of intermittent fever, which was succeeded by dysentery for a few days, when the stools became watery, and the complaint assumed the character of chronic diarrhoea, which it retained, with occasional dysenteric symptoms, until the date of his admission. Death, November 19th. Autopsy: Old pleuritic adhesions; patches of congestion in small intestine; solitary glands enlarged to the size of small shot; Peyer's glands healthy; coecum inflamed ; descending colon and rectum extensively ulcerated. No. 145, Medical Series, is a piece of the ileum, with enlarged solitary follicles. No. 146, of the ulcerated colon. Contributed by Surgeon George F. French, U. S. Vols. Private C ,2d Battalion, Veteran Reserve Corps, on duty at the Fairfax Seminary Hospital, near Alexandria , Va., applied for treatment August 6th, 1864. He stated that he had suffered from frequent attacks of diarrhoea during the previous six months. He was pale and sallow, with furred tongue, quick pulse, and dry skin. The stools were from ten to fifteen daily, consisting of thin frothy mucus mixed with blood. He died November 25th. Autopsy: Small intestine normal; colon extensively ulcerated, and coated with a dark-colored pseudo-membrane, which hung in shreds from the edges of the ulcers. Nos. 383 and 384, Medical Series, are successive portions of the colon, exhibiting the conditions described. Contributed by Assistant Surgeon H. Allen, U. S. A. Private M , 108 th New York Vols., was admitted to Douglas Hospital, Washington, D. C, February 13th, 1863. Had been taken sick in the Army of the Potomac, and was brought from Aquia Creek in a very feeble condition. He was greatly emaciated, pulse 110, tongue red, stools frequent and liquid. He gradually sank, the abdomen became tender and tympanitic, and he died March 20th. Autopsy: Pleuritic adhesions of lower lobe of right lung; nutmeg liver ; patches of inflammatory congestion in small intestine ; the colon thickened, with numerous large ulcers ; the remainder of its mucous surface plastered with pseudo-membrane. Nos. 288 and 289, Medical Series, are successive portions of the colon in this case. Contributed by Assistant Surgeon William Thomson, U. S. A . Private McD , 39th Massachusetts Vols., was admitted to Douglas Hospital, Washington, D. C, from the Army of the Potomac, September 9th, 1864. He had suffered from frequent attacks of diarrhoea during the summer, and had also had intermittent fever. For three weeks prior to his admission, he had been in field hospital. On admission , he was emaciated and feeble ; conjunctiva yellow ; tongue furred ; pulse 80 ; abdomen flat and tender, especially over the course of the colon ; frequent stools; slight cough. Death, September 30th. Autopsy: Pleuritic adhesions on both sides; peritonitis; the pelvic cavity filled with thin pus; the viscera coated with patches of yellow lymph; small intestine normal ; large intestine greatly thickened, with extensive irregular ulcers. No. 400, Medical Series, is a portion of the colon of this patient. Contributed by Assistant Surgeon W. F. Norris, U. S. A. Private S , 2d New York Heavy Artillery, was admitted to Douglas Hospital, Washington, D. C, from the Army of the Potomac, September 9th, 1864, with chronic diarrhoea. At the time of his admission, he was much emaciated, with jaundice and frequent bilious vomiting. Abdomen flat and tender; stupor; low delirium; involuntary stools; and death on the 17th. Autopsy by Assistant Surgeon E. Curtis, U. S. A.: Emaciation; jaundice; thoracic organs healthy ; small intestine normal ; mucous membrane of colon greatly thickened, with large irregular ragged ulcers ; a perforation the size of a dime in the caput coli ; peritoneal adhesions, principally between right lobe of liver and colon ; numerous metastatic foci in liver, especially in right lobe. No. 448, Medical Series, is a piece of the ulcerated colon. No. 449, a section of the liver. The small yellow foci scattered through the liver consisted of granular matter and the debris of normal tissue, but contained no pus. The condition was similar to what is often observed in pyaemia due to gunshot wounds. Contributed by Assistant Surgeon W. F. Norris, U. S. A. Corporal C , 160 th Pennsylvania Vols., act. twenty-four, was admitted to Columbian College Hospital, Washington, D. C, October 30th, 1864, for chronic diarrhoea. There was great emaciation, frequent pulse, and five or six loose stools daily. November 11th. Attention was drawn to a dry cough at night, with frequency of respiration. Death, November 18th. Autopsy: A large abscess was found in upper part of right lobe of liver. It had burst through the diaphragm into right pleural cavity, which contained a gallon of sero-pus. The fifth, sixth, and seventh ribs on this side were denuded of periosteum by the burrowing of the pus. The lower parts of the ileum and colon I!) 146 ARMY MEDICAL MUSEUM. — MICROSCOPICAL SERIES. were thickened, with follicular ulcers, and coated with patches of pseudo-membrane. The mesenteric glands enlarged. No. 435, Medical Series, is a portion of the liver in this case, exhibiting the abscess cavity. Nos. 436 and 437 are successive portions of the ulcerated colon. No. 434, the collapsed right lung, coated with pseudo-membrane. No. 435, the seventh rib of the same side, its inner surface denuded of periosteum, and presenting several new formations of bone. Contributed by Surgeon Thomas Crosby, U. S. Vols. Private R , Ist Regt. Veteran Reserve Corps, aged forty-one, was admitted to the Post Hospital, Fort McHenry, Md., September 30th, 1865. He had suffered from chronic diarrhoea for several months, and was much emaciated ; stools, from eight to ten daily. October 18th. He complained of a violent pain, which appeared to have its seat in the kidneys. Death, October 21st. Autopsy: Hypostatic congestion of the posterior parts of both lungs; four ounces of blc ody serum in right pleural cavity ; the right lobe of the liver, adherent to the abdominal walls, presented three abscesses, each containing about four ounces of thick flaky pus ; spleen very large and soft; colon ulcerated from one extremity to the other ; some of the ulcers very large, and penetrating to the muscular coat. No. 668, Medical Series, is the liver from this case. Contributed by Brevet Major De Witt C. Peters, Assistant Surgeon U. S. A. The arrival of recent specimens at the Museum has afforded good opportunities for making drawings representing the appearance of the preparations immediately after their removal from the body. Accordingly a series of careful water-color drawings has been made, which show most of the typical forms of camp diseases. The drawings are the work of Mr. Hermann Faber, and are faithful to the minutest detail. Some experiments have been made which show that they can be reproduced with reasonable fidelity by chromo-lithography. The chromo-lithograph here presented will, it is hoped, give an idea of the capabilities of this kind of illustration. (See plate opposite.) It represents a portion of intestine, taken from near the middle of the ileum, of a patient who died in the Third Division General Hospital, Alexandria, Virginia, December 11th, 1864. His disease is given in the mortality report of the hospital as typhoid fever. He stated on admission, however, that he had suffered from diarrhoea for several months before the febrile symptoms set in. On the autopsy, the ileum was found to present considerable vascularity, with patches of congestion. The solitary follicles were enlarged to the size of pin-heads. The patches of Peyer slightly thickened, with pigment deposits, giving them the shaven-beard appearance. There were a few small ulcers of the solitary follicles near the ileo-ccecal valve. The colon was thickened, with numerous follicular ulcers, especially in the ccecum and sigmoid flexure. In the transverse colon, several of the ulcers were in the different stages of cicatrization. The portion of ileum here represented is No. 465 in the Medical Series of the Museum. No. 466 is a portion of the transverse colon, showing the cicatrizing ulcers. This case belongs to the class in which typho-malarial fever supervenes in the course of chronic diarrhoea. The drawing here presented is equally characteristic of the uncomplicated cases of the malarial form of this fever. The plate represents the portion of ileum slit up along its mesenteric attachment, and spread out for examination. The blush of congestion in the lower part of the piece, the injected condition of the vessels, the pin-head tumors formed by the enlarged solitary follicles, the shaven-beard appearance of the small Peyer's patch near the top of the piece, and of the larger one near the bottom, are all shown with reasonable accuracy. It is desired to publish in the Medical History of the War about thirty plates, in this style, to illustrate the most important phases of the anatomical lesions in camp fevers and camp diarrhoea. The Microscopical series of the Museum consists already of about 1400 specimens, of which 400 have been obtained by purchase and the rest have been prepared ILEDM IN MALARIAL FORM or TIFMitD-MM.AMAIL Flflll . ILKDM IN MALARIAL fe'OKM o v 147 ARMY MEDICAL MUSEUM. — MICROSCOPICAL SERIES. in the Museum. The Microscopical series grew out of the attempt to conduct exact investigations into the minute anatomical changes characteristic of the several camp diseases, and especially of fever and diarrhoea. The great mortality of these affections has already been intimated, and the vast practical importance of the present study will therefore be at once understood, when it is recollected that no intelligent efforts to prevent or cure diseases can be made without a reasonable comprehension of their nature, and that this must rest as a basis upon a just knowledge of their pathological anatomy. Unfortunately, in the United States, pathological anatomy is but little studied, and especially the application of the microscope to this branch of investigation has not received the attention it deserves, so that there appeared little probability that an exact study of the pathological anatomy of our camp diseases would be attempted, if it were not undertaken in the Army Medical Museum, and it became an imperative duty to make an effort in this direction. The result of this effort is the microscopical series, which, although small when contrasted with some of the European collections, is the only considerable micro-pathological collection in the United States. The majority of the specimens thus far placed in the cabinet are sections illustrative of the normal histology of the intestines, and of the changes they undergo in fever and diarrhoea ; but the actual number of specimens preserved indicates only a small part of the work done. Investigations have been continually made into pathological processes, in which want of time and of a sufficient number of assistants have not permitted the preservation of specimens. And this branch of the Museum has also been frequently consulted in questions of adulterations, etc. requiring microscopical investigation for their solution; a duty of considerable importance, which, of itself alone, would more than repay the trifling cost of the establishment of this branch of the Museum. The greater number of the preparations hitherto made in the microscopical branch of the Museum are the work of Brevet Captain Edward Curtis, Assistant Surgeon U.S.A., whose patience and dexterity are deserving of high praise, and to whose intelligent assistance I owe much of the success attained in this direction. In addition, Acting Assistant Surgeon J. C. W. Kennon, who has recently been assigned as an assistant in this branch of the Museum, is preparing a series of very beautiful minute injections, which will form an important part of the collection. It would be wholly impossible to present here a detailed account of the results arrived at by the microscopical work performed. This must be postponed to its appropriate place, in the discussion of the pathological anatomy of our camp diseases in the Medical History of the War. It may, however, be noted, as a matter of interest, that the general results attained are not only of value in connection with camp diseases, but have an important bearing on the general comprehension of normal structure and of morbid action, as must in fact be the case with all studies honestly and earnestly directed to any one series of pathological lesions. In a general way, it may be said that the results of the investigations made in the Museum accord, in many respects, with the ideas of the modern Berlin school of pathological anatomy, are contradictory of the doctrine of exudation, taught so generally in the older medical text-books in use in this country, and at variance also in several particulars with the views of Dr. Lionel Beale, lately so favorably received in England. 148 ARMY MEDICAL MUSEUM. — MICROSCOPICAL SERIES. The best means of making the results of our microscopical studies available for the information of medical men in America has exercised my most serious thought. Much can be done by good drawings executed with the aid of the camera lucida. Some valuable work in this direction has been executed by Mr. H. Faber, the artist before referred to. Such drawings, however, have always attached to them more or less suspicion of being in part at least ideal; and for this reason numerous attempts have already been made, both in Europe and America, to photograph objects as seen with the microscope. Among the experiments in this country, I may especially mention those of Prof. O. N. Rood, of Columbia College, New York, of Mr. L. M. Rutherfurd, of the same city, and of Dr. J. Dean, of Boston. The first two of these gentlemen directed their attention to test objects, and have obtained results which show the practicability of the idea. Dr. Dean has recently published a paper on the anatomy of the spinal cord, illustrated with photo-lithographs from micro-photographs of sections seen with low powers. This is the first attempt made in America to reproduce micro-photographs by photo-lithography, a method which, if successful with high powers, would be highly satisfactory, since no doubt could be entertained as to the fidelity of the picture. It was therefore resolved to attempt the photographic reproduction of the microscopical preparations necessary for the comprehension of the subjects under consideration, and, after some preliminary experiments made at the Douglas Hospital by Brevet Major W. Thomson, Assistant Surgeon U. S. A., on preparations furnished by the Museum, the necessary apparatus was constructed, and Assistant Surgeon E. Curtis was directed to undertake the labor of preparing the necessary illustrations. The task was by no means an easy one. The subject of microphotography is comparatively new, and the processes still require much improvement. On the whole, however, the results attained by Dr. Curtis have exceeded the expectations formed when the experiment was undertaken, and justify the hope that they will eventuate in the satisfactory preparation of all the illustrations required. With low powers, no serious obstacle was encountered in obtaining excellent photographs of properly selected preparations. The higher powers offered difficulties, most of which, however, have been overcome. In experimenting with the higher powers, the lined diatomaceaß were selected as test objects on account of their definite and well-known structure. With these the utmost success has been realized. A photograph of Gyrosigma angulatum (Navicula angulata) has been obtained, for example, magnified about 7000 diameters, in which the hexagons appear of the same size and nearly as distinct as in the cut, which was made by transferring to wood a tracing from the original photograph. In fact, any of the markings Fig. 1. on diatoms that are visible with the microscope can be photo- graphed with the utmost clearness and ease, and the time has arrived when the inability to photograph alleged markings will throw doubts on the correctness of the observers who have supposed they saw them. The plan employed in the photographic work, hitherto executed with high powers, is as follows : The direct rays of the sun, reflected in a constant direction from the mirror of a Silbermann's heliostat (loaned for the purpose by the Coast Survey), are condensed by a large lens upon the plane mirror of the microscope, whence they are 149 ARMY MEDICAL MUSEUM. — MICROSCOPICAL SERIES. reflected through the achromatic condenser in the usual way. Before reaching the achromatic condenser, however, the rays pass through a cell containing a solution of the ammonio-sulphate of copper of sufficient density to absorb nearly all the rays except those at the violet end of the spectrum.* The light used, therefore, is essentially monochromatic, and contains, with enough illumination for agreeable vision, the greater part of the actinic force of the sun's rays. The heating rays being chiefly at the other extremity of the spectrum are of course excluded, and great actinic force is obtained, therefore, without any danger to the preparations or the balsam cementing of the object-glasses. The object-glass employed in the photograph of Gyrosigma above alluded to was a one-eighth of an inch, by W. Wales & Co., of Fort Lee, New Jersey. This glass is so constructed as to bring the actinic rays to a focus. At the bottom of the draw-tube was placed an achromatic concave lens — the amplifier of Tolles (of Canastota, N. V.), and an ordinary medium eye-piece completed the optical apparatus. The eye-piece extremity of the microscope was thrust into one end of a long camera box, the connection made light-tight by means of a black silk hood, and the image, received on a piece of plate glass, observed by means of a focussing glass, while the focal adjustments were made. As with the very long camera used, the arm of the observer cannot reach the milled head of the fine adjustment of the microscope, this head was grooved, and connected by a band with a grooved wheel at the end of a long steel rod, the other extremity of which is near the observer, who, by means of it, can focus accurately with any required length of camera. There is nothing peculiar in the chemicals employed, and, with ordinary collodion, and the high power above spoken of, from thirty to forty seconds' exposure was quite sufficient. Of the foregoing devices, most importance is to be attached to the employment of monochromatic light (the violet end of the spectrum), and the use of an object-glass constructed with special reference to the actinic rays. Both these points were suggested to me by Mr. L. W. Rutherfurd, of New York, so well known by his connection with telescopic photography, who has thought much, and made many satisfactory experiments in this direction. I believe, however, that the apparatus, as above described, loses some of its advantages by the use of the eye-piece, which I propose to substitute by a lens of proper magnifying power, corrected, like the object-glass, in such a way as to bring to a focus the actinic rays. Such a lens is now in process of construction for further experiment. The pathological photographs hitherto satisfactorily executed in the Museum have chiefly been made with moderate magnifying powers, twelve to fifty diameters, though some experiments with higher powers justify me in the belief that with the improvements above described, all that is desired in this direction can be attained. Among these experiments, I may particularly mention a view, magnified about four hundred diameters, of the polygonal cells and flat cholesterin tables of a cholesteatoma, which was found on the inner surface of the frontal bone of a soldier who died of epilepsy in the neighborhood of Washington. * Einleitung in die Hohere Optik, yon Dr. August Beer. Braunschweig, 1853, p. 48. 150 ARMY MEDICAL MUSEUM. — MICROSCOPICAL SERIES. For the preservation of these photographs for study, glass positives have been printed, and mounted with a piece of ground glass behind them to serve as a background. These are held between the eye and the light, and present, when thus examined, a faithful image of the field of the microscope in every particular except color. To render these photographs available for the general illustration of the subjects to which they refer, especially of the minute pathological anatomy of camp diseases, it was attempted to reproduce them by photo-lithography, instead of copying them by any other method of drawing or engraving. After trial, however, I was reluctantly obliged to conclude that, in its present undeveloped condition, photo-lithography is inadequate to represent the objects in question, which are among the most delicate and beautiful within the range of microscopical observation, and all the details of which are fully preserved in the photographs. Although I much regret this failure, and am not without hopes that, at an early day, improvements in heliographic methods of lithographing or engraving will give a process adequate to copying even the. most difficult photographs, I regret it the less because I have been fortunate enough to find in Mr. H. Faber, the artist already mentioned, an engraver perfectly competent to make faithful copies of the photographs to be reproduced. As an illustration of what may be expected in this direction, I present on the opposite page the reproduction of a photograph of a perpendicular section of ulcerated colon, from the form of Chronic Diarrhoea or Dysentery described on page 143. The blood-vessels were not injected in preparing this section. The picture is not exaggerated, and is a good representation of the original photograph, which, with the specimen, is preserved in the Army Medical Museum, where both can be seen by any one desirous of comparing them with the engraving. The Fio. 2. — Outline of the plate on opposite page. AAA A. Follicles of Lieberktlhn. 88. Muscle of Brttcke. CCC C. Submucons connective tissue. DDD D. Circular muscle of the colon. XXX. Longitudinal muscle, cut transversely; at II 11, two of the longitudinal bands of this layer. FF F. Peritoneal layer. ( 1 (i ( 1 (I . Points of very active cell multiplication. 1 1. An artery and vein cut through transversely. 1. A deep follicular ulcer, extending to the muscular layer. 2. A smull superficial ulcer, which has penetrated to the submucous connective tissue. 3. An ulcer of greater ai/.0, penetrating nearly to the muscular layer, which is covered with granulations. wood-cut here introduced gives an outline of the plate opposite, and is lettered for the purposes of description. The section was cut perpendicularly through the colon transversely to its length, and presents three points of ulceration, marked 1, 2, 3 in the figure. To render this representation more intelligible, it may be remarked that two forms of ulceration have been observed in the colon in these cases of Chronic Diarrhoea. In the first, the process begins in the closed follicles; in the second, in the intestinal epithelium or the glandular layer. In the first form, the closed follicles enlarge by multiplication of their cellular elements till they project as little tumors above the surface, as shown in Fig. 3, in which L is the enlarged solitary follicle. This figure is PERPENDICULAR SECTION OF ULCERATIEED COLOWtCIMRO'IKIIIC EAWBIP DIABHIHiIIA CUT TRANSVERSELY. ARMY MEDICAL MUSEUM. — MICROSCOPICAL SERIES. 151 an outline transferred to wood from a tracing of the original photograph, which is quite as beautiful and detailed as that represented in the plate. It is lettered like Fig. 2. The tumor, having enlarged to a certain extent, ruptures, its cellular ele- Fia. 4. Fra. 3. ments escape, and a minute ulcer is formed, as shown in Fig. 4, in which 1 is the ruptured follicle with the minute ulcer; the letters represent the same parts as in the two previous figures. The cells or corpuscles of the connective tissue surrounding the enlarged follicle now multiply, and the ulcer spreads by the superficial cells floating off into the intestinal cavity, while a new base is continually formed by the multiplication of the subjacent cells. If the plate be carefully observed (especially with a lens) , it will be noticed that the connective tissue layer presents a finely granular aspect, in which each granule corresponds to what, with a higher power, is recognized as a connective tissue cell or corpuscle. In the neighborhood of the edges or base of any of the ulcers, it will be seen that these corpuscles are more numerous, giving the tissue a more granular aspect. Whether the corpuscles in question are true cells, with distinct cell walls, as argued by Virchow and the Berlin school, or mere masses of germinal matter without distinct parietes, as Beale would have us believe, is a question which cannot here be entered upon, on account of the space necessary to explain and justify the views entertained. In either case, it must be admitted that it is through the multiplication of these corpuscles by division that the greater number of elements is produced, and not by the equivocal generation of new cells, as has been so generally held. The Museum contains preparations which illustrate all the stages of this multiplication, and it is believed that these can be satisfactorily photographed for the Medical History of the War. The multiplication of the cells or corpuscles of the submucous connective tissue is accompanied by the marked thickening of the intestine so common in the disease under consideration. The ulcers shown at the right and left of the section represented in the plate (and in Fig. 2, x and 3 ) show different stages of the excavation thus produced. The second form of ulceration begins by an abrasion or denudation of epithelium at some point which does not correspond to the position of a solitary follicle. The follicles of Lieberkuhn are next destroyed, and the ulcer spreads in the connective tissue by the process which has just been described. The central ulcer of the plate (Fig. 2, 2 ) is of this variety. Such ulcers are much rarer than those of the first kind, and probably are always secondary to them. It is not possible to go into further details in this direction at present, but it is hoped that a careful and fully illustrated account of the minute anatomy of these diseases will be presented to the medical profession in the Medical History of the War. 152 HOSPITAL ORGANIZATION AND CONSTRUCTION. The material bearing on hospital construction, organization, and administration is extremely rich and complete. It consists of numerous reports in connection with the subject, and of plans and descriptions of all the principal hospitals which have been organized during the war, furnished by the surgeons-in-charge to the Surgeon General, or by the medical inspectors to the Medical Inspector General. In addition, the records of the general hospitals in existence during the war have been turned in to the Surgeon General's Office. From this lavish material, it will be possible to prepare a complete and faithful history of the hospital system and of its transformations, both as to construction and administration. Such a history will be of inestimable value in future wars, and is full of most important applications to the hospitals of civil life. Never before, in the history of the world, was so vast a system of hospitals brought into existence in so short a time. Never before were such establishments, in time of war, so little crowded or so liberally supplied. They differed, too, from the hospitals of other nations, in being under the command of medical officers. Instead of placing at the head of establishments, intended for the treatment of disease and wounds, officers of the line, who, whatever their other accomplishments, could not be expected to understand the requirements of medical science, and who, with the best intentions in the world, might seriously embarrass the action of the surgeon, as was sadly the case in the Crimean war, and has been since in the English hospitals, our Government, with a wiser discretion, made the surgeon the commandant of the hospital, and thus, while holding him responsible for the results of its management, put it into his power to do much to make those results favorable. The medical staff can point with pride to the consequences of this liberal course. Never before, in the history of the world, has the mortality in military hospitals been so small, and never have such establishments so completely escaped from diseases generated within their walls. The hospital buildings used in the beginning, and on occasions of emergency throughout the war, had been erected for other purposes; public buildings, schoolhouses, churches, hotels, warehouses, factories, and private dwellings being fitted up, as circumstances required. But gradually wooden pavilions, erected for the purpose, came into extensive use, and ultimately the majority of the general hospitals belonged to this class. The introduction of these pavilion hospitals was not the work of any one man. Originally suggested by European experience, they were erected in all parts of the country, under the direction of various medical officers, some by order of the Surgeon General, others by the authority of local commanders. The necessities of the service and increasing experience suggested numerous alterations from time to time, and it was not until the summer of 1864 that a circular order was issued directing uniformity in certain essential points. To trace out this gradual evolution of hospital construction is, of course, out of the question here; but as the Circular of July 20th, 1864, gives in a few words an idea of the system as fully developed, it is here reproduced : 153 HOSPITAL ORGANIZATION AND CONSTRUCTION. War Department, July 20th, 1864. The following instructions are promulgated for the information of officers charged with the construction of general hospitals, and will be deviated from only in cases of imperative necessity : Buildings will not be taken or occupied for hospital purposes until after full examination and approval by a medical inspector, or other officer of the Medical Corps detailed for this purpose ; and all alterations will be made in accordance with plans submitted by him and approved by the Surgeon General. Site. — The site of the hospital should be a well-drained plain, with a sub-soil of gravel, and sufficiently extensive to accommodate the buildings. The situation should be elevated; as remote as possible from marshes or other sources of malaria, and must have a convenient supply of pure water. Plan. — General hospitals will be constructed on the principle of detached pavilions, each ward being in a separate building, with beds for sixty patients. Besides the wards, there will be detached buildings for each of the following purposes : General Administration Building, Dining-Room and Kitchen for Patients, Dining-Room and Kitchen for Officers, Laundry, Commissary and Quartermaster's Store-House, Knapsack-House, Guard-House, Dead-House, Quarters for Female Nurses, Chapel, Operating- Room, and Stable. The wards, administration building, kitchens, dining-rooms, and chapel are to be connected by covered walks which will have floors, but no sides. No general plan for the arrangement of the buildings can be directed, as the varying character and dimensions of sites render an uniform adherence to any one impracticable. Wards may be arranged "en echelon" in two converging lines, forming a V, — in this case, the administration building should be at the apex of the V, the other buildings between the wings ; or as radii from the periphery of a circle, ellipse, or rounded oblong, — in this case, the administration building should be one of the radii, the other buildings within the enclosure ; or parallel to each other, — in this case, the administration building should be in the centre of the row, the other buildings in the rear. Other plans may be rendered necessary by the special features of the ground. In any case, the important points to be observed are, to place the buildings far enough apart (&t least thirty feet should intervene between two parallel buildings), and to locate them in such a manner that no one shall interfere with the ventilation of another. It is preferable to locate the wards so that the long diameter may run north and south, or nearly so. Each ward will be a ridge-ventilated pavilion one hundred and eighty-seven by twenty four (187X24) feet. At each extremity, two small rooms nine by eleven (9XH) feet, one on each side of a passage, six (6) feet wide, will be partitioned off. The space remaining for patients will be one hundred and sixty-five by twenty-four (165X24) feet (see Figure 5, A), which gives the location of the beds and position of the doors and windows. The small rooms are occupied as follows: Figure 5, a, chief nurse; b, closet for medicines, etc.; c, bath-room ; d, closet for close stools. Figure 6is the side elevation. The wards will be fourteen (14) feet high from floor to caves — the pitch of the roof to vary in accordance to the materials composing it. The floor to be elevated at least eighteen (18) inches from the soil, with free ventilation beneath it. A ward thus constructed will accommodate sixty (60) patients, allowing more than one thousand (1000) cubic feet of air-space to each. The number of wards will be regulated by the number of patients the hospital is intended to accommodate. A hospital of twelve hundred (1200) beds will require twenty (20) wards. •211 E. M. STANTON, Secretary of War, 154 HOSPITAL ORGANIZATION AND CONSTRUCTION. Administration Building. — For a hospital of six to twelve hundred (600 to 1200) beds, this will be a ridge-ventilated building, thirty-eight by one hundred and thirty-two (38X132) feet, and two stories high; the first fourteen (14) and the second twelve (12) feet high in the clear. This building contains the general office, office of surgeon in charge, linen and store rooms, dispensary, chaplain's office, lodging rooms for officers, etc. Dining-Room and Kitchen for Patients. — The dining-room will be a ridge-ventilated building, large enough to seat a number equal to two-thirds the number of beds. The most convenient form is a long parallelogram, into which the kitchen opens in the centre of the long side. The kitchen will be divided into two unequal parts — the larger for the preparation of ordinary diet, the smaller for the extra diet — the cooking in both to be done on ranges. Where there is an engine, steam may be advantageously used for boiling. Diningßoom and Kitchen for Officers. — A small building for this purpose will be situated near the administration building. Laundry. — A building two stories high, with lodging for the laundresses on the second floor. The roof should be flat, with posts for stretching clothes-lines. Commissary and Quartermaster Store-Room. — A small two-story building, furnished with boxes and shelves for the various parts of the ration, — having an ice-house connected with it for the preservation of meats and other perishable articles, and a room for clothing. The second story to contain lodging-rooms for the cooks. Knapsack-House. — A building to receive the effects of the patients while in hospital. It will contain as many pigeon-holes, each two (2) feet square, as there are beds in the hospital. Guard-House. — A detached building to lodge the guard, with a guard-room for prisoners. Dead-House. — A small building containing two apartments, located so as not to be observed from the wards, and lighted by sky-lights. Quarters for Female Nurses. — A detached building containing lodging-rooms, dining-room, and kitchen for the female nurses. Chapel. — A detached building, fitted for the purpose of religious services, so arranged as to be used also as a library and reading-room. . Fig. 8. Fio. 7. Fig. 9. Operating -Rooms. — Two rooms, each fifteen (15) feet square ; one well lighted by sky-lights, the other by windows. The first for surgical operations, the second for discharge-boards, etc. It should be situated near the administration building. Stable. — For ambulance and officers' horses. Water Supply. — Where practicable, a large tank will be erected and kept supplied from wells or springs by pumps worked by a steam-engine. The engine, if possible, will be situated near the kitchen and laundry, in which case the steam may be made serviceable in cooking, and the power may be employed in working the washing and mangling machines. Sinks. — Where the supply of water is adequate, water-closets may be constructed in one of the small rooms in each ward ; but where this is not the case, privies will be built at a convenient distance from the wards, furnished with water-tight boxes, which must be emptied every night. Ventilation. — During warm and mild weather the wards will be ventilated by the ridge (Figure 7), but during HOSPITAL ORGANIZATION AND CONSTRUCTION. 155 winter* the ridge will be closed (Figure 8), and ventilation by shafts substituted. Four stoves will be allowed to a ward, each partly surrounded by a jacket of zinc or sheet-iron, with an air-box opening beneath it to furnish the supply of fresh air. At eight (8) feet from the stove will be a shaft, properly capped, through which the stove-pipe will ascend. Figure 8 gives a section and Figure 9 a side view of the arrangement. The shaft should be eighteen (18) inches square, and should not come below the tie-beams. A conception of the character and extent of the large pavilion hospitals can be perhaps still better obtained from a description of some one of them than from the foregoing circular. A description of the Lincoln Hospital, one of the hospitals of Washington, D. C, is therefore here presented. This hospital was constructed in the latter part of 1862, and first occupied in January, 1863. The original plans for its construction were furnished to the Surgeon General's Office by the writer of this paper. Several modifications and improvements were, however, subsequently made by the successive surgeons in charge. The following description was furnished by Brevet Lieutenant Colonel J. C. McKee, Surgeon U. S. A., for a long time surgeon in charge. Lincoln Hospital, Washington, D. 0., is located about a mile east of the Capitol Building. Its site is a gentlyundulating, uncultivated plain, without shade-trees. East and south of the hospital, the plain declines towards the Eastern Branch of the Potomac, which is about half a mile distant. The soil is a light sandy loam, resting on a deep stratum of gravel. The hospital covers an area of thirty acres of ground, and consists of twenty detached pavilion wards, arranged en echelon in the shape of the letter V, the apex of which looks westwardly. The administration building is at the apex of the V. The buildings for kitchen, dining-rooms, etc. are in the space between the two sides of the letter. The whole is surrounded by a picket-fence, five feet high, between which and the wards is a wide road for ambulances. (See Figure 10 and the plate opposite to it.) The Wards are pavilion barracks, built of rough boards, white-washed, with roofs of boards covered with tarred paper; they are twenty (20) in number, ten on each wing. Each ward is 187 feet by 24, 16 feet to the eaves and 20 to the ridge, at which there is the usual ridge-ventilation the whole length of the ward. They are plastered on the inside for about eight feet above the floor. At the west end of each are four rooms, occupying fifteen feet in length. These are used for clothing, baths, nurses, and sinks. Each ward contains thirty-four windows and four doors, one at each end and two in the middle, opposite each other. Four ventilating gratings, at regular distances in the floor of the ward, communicate by wooden flues under the floor with the air outside, thus giving a full supply of fresh air whenever the weather requires the doors and windows to be closed. With sixty-two patients, there are 72 square feet of floor and 1447 cubic feet of air-space for each. Thirty-one beds are arranged on each side, with a chair and bedside table between each pair. An avenue of eleven feet is left between the two rows of beds. The wards are lighted at night by kerosene lamps, and heated by stoves in winter. On the inner side of the two wings of the hospital, and running the whole length of each, is a raised covered walk or corridor, on which is laid a railway track two feet wide and 2156 feet long. Box-cars convey the food from the main and extra kitchens to each ward. The Administration Building, at the apex of the triangle, is 184 by 38 feet, 22 feet to the ridge and 16 to the eaves. A hall, 8 feet wide, runs the entire length of the first floor. On the left side of the hall are the following rooms : office of surgeon in charge, 14 by 14; office of military assistant, 11 by 14 (employs two clerks); principal office, 56 by 14 (employs fourteen clerks); printing-office, 19 by 14 (employs two meu); quartermaster's store-room for clothing, etc., 44 by 14 (employs two clerks); wardmaster's room, 13| by 14; bath-room, 4| by 14; post-office, 7 by 14 (employs a postmaster and assistant). On the other side of the hall, and on the right of the entrance door, are the office of the officer of the day, 15 by 14; office of the officer of the guard, 11 by 14 (four clerks); office of surgical records, 11 by 14 (one clerk); private office of surgeon in charge, 12£ by 14; office of medical inspector, 11 by 14; linen-room, 66 by 14, — all washed clothing and bed-linen is sent from the laundry to this room, and thence distributed to the different wardmasters; one clerk and four women are employed here, the latter in mending, etc. The medical store-room, 11 by 14, adjoins the dispensary, and is used for storing supplies. The dispensary, 25 by 14, usually employs four men; the medicines for the whole hospital are compounded here, under the charge of a hospital steward. Lastly, the laboratory, which adjoins the dispensary, is 22 by 14 feet, used for preparing tinctures, ointments, plasters, etc. On the second floor of the Administration Building is the Knapsack-Room, 111 by 37 feet. The effects, accoutrements, etc. of the patients coming into hospital are deposited in this room for safe keeping. It employs two men, who receive the articles deposited, issue tickets for the same, credit them to depositors, and deliver them when the patients leave. There are 2184 boxes, arranged in parallel rows, reaching from the floor to the ceiling. Adjoining the Knapsack-Room is the extra-duty men's room, 50 by 37 feet, used as a sleeping-room by the men employed on extra duty, and a clerks' room, 25 by 23 feet, used by the clerks of the principal office for the same purpose. 156 HOSPITAL ORGANIZATION AND CONSTRUCTION. Within the triangle, formed by the two wings, and east of the administration building, is the Tank, resting upon a platform 25 feet high, and holding 12,000 gallons of water. It is supplied from a well under the engine-room, and the water forced into it by the engine, which drives the machinery of the laundry. This tank supplies each ward with water by means of pipes. There are four other wells in the enclosure, used for drinking and culinary purposes. Fio. 10. — Ground Plan op Lincoln General Hospital, Washington, D. C. Scale, 200 feet to the inch. 1, Administration building. 222 2. Wards. 3 3. Dining-rooms. 4. Kitchen. 5. Laundry. 6. Stewards' quarters. 7. Sisters' quarters. 8. Enginehouse. 9. Meat-house. 10. Coal-house. 11. Commissary building. 12. Sutler. 13. Chapel. 14. Stable. 15. Freedmen's quarters. 16. Guard-house. 17. Dead-house. 18. Barracks for guard. 19 20. Officers' quarters. 21. Covered way. 22. Tank. The tents shown in the plate are not represented in this plan. Twenty yards east of the tank is the Laundry, 61 by 24 feet. The building runs east and west, is two stories high, and has a platform for drying clothes on the roof. Seven men and twelve women are employed in its various departments. The washing is done by steam-power, as is also the drying and ironing. The average wash is 5000 pieces daily — has been pushed to 7000. On the first floor of the laundry is the washing apparatus, consisting of a mangle, steam-boiler, revolving drum for wringing, rinsing-boxes, roller and ironing-table ; on the second floor is the steam drying-room, 36 by 12£ feet. This is in addition to the drying arrangements on the roof. Separated by a partition from the laundry on the first floor, is a sleeping-room for women, 22 by 24 feet; a kitchen for the same, 9£ by 17; a dining-room, 9£ by 18. The engine is in a building adjoining the laundry on the east; it is of six-horse power, and BIRDS EYE VIEW OF LINCOLN GENERAL HOSPITAL, WASHINGTON, D. C. SEEN FROM THE REAR. BIRDS EYE VIEW OF LINCOLN GENERAL HOSPITA L, WASHINGTON, D. C SEEN FROM THE REAR 157 HOSPITAL ORGANIZATION AND CONSTRUCTION. employs one engineer and an assistant. It supplies power for the tank as well as for the laundry. The well which supplies the tank is 40 feet deep, with usually 4 feet of water; its diameter is 6 feet. The steam pump can raise 2000 gallons of water per hour. The building for Sisters' Quarters is 23 by 51 feet, with a wing 16 by 28, forming a letter "L." It is divided into chapel, sitting-room, kitchen, etc. Twenty-eight Sisters of Charity were on duty, and I must bear evidence to their efficiency and superiority as nurses. The extra-diet kitchen is under the care of a sister, and one is detailed by the superior for each ward. They administer medicine, diet, and stimulants, are under the orders of the ward surgeon, and are responsible to him alone. They have been beloved and respected by the men. The Stewards' Quarters are 18 feet north of the engine-room, are two stories high — contain dining-room, kitchen, sleeping-rooms, etc. Five stewards generally occupied this building. The Operating- Room is 25 feet east of the engine-room. It is 17 feet square, and lighted by a sky-light on the north side of the roof. A revolving-table is in the centre of the room ; also a cupboard for instruments, sponges, microscope, etc., with a sink in the northwest corner. The Examining-Room adjoining it is 17 feet 7 inches square, and communicates by a door with the operating-room. The Extra-Diet Kitchen is under the same roof with the general kitchen. It is 18 by 24 feet — has in it a Harrison's European range, 8 feet front, 3 feet 6 inches deep. A room 18 by 12 feet adjoins on the south. This kitchen is under the supervision of a sister, who is generally assisted by from four to six men. The Main Kitchen is 77 by 24 feet. It contains a cooking-range, 28 feet 10 inches long and 3 feet 2 inches wide ; also three of "Peters' and Johnson's bake-ovens or roasters," two boilers for tea and coffee, each with a capacity of 120 gallons, five boilers or cauldrons for soup or hash (60 gallons each), and two for heating water (one 60 gallons, the other 22 gallons). Full diet is prepared here for all the men in the hospital. On either side of the kitchen,' opening from it north and south, are the Dining-Rooms, each 146 by 24 feet, with three tables running the whole length of each, capable of seating in all 860 men. At the distal end of each room a door opens on a corridor and raised walk, so that the patients are protected from the weather in coming to their meals. Cars, with cans fitted in them, are run around the corridors to the several wards with the food for those unable to come to the dining-room. On the northwest corner of the kitchen is a room 30 feet long, 14 feet wide, and 10 feet high, used for washing dishes, roasting coffee, etc. From 40 to 50 men are usually employed in the various departments of the kitchen. Opposite the centre of the northern dining-room, and distant to the west 30 feet, is the Fire-Engine and Hose House, 26 by 20 feet — contains one fire-engine, three hose-carriages carrying 1850 feet of hose, 34 ladders, 22 hooks, 278 axes, and 300 buckets. Thirteen feet south of the kitchen is the Meat-Shop, 14£ by 23. In its centre is an ice-box, 3£ by 14£ and 4 feet deep, lined with zinc. The allowance of ice per day is one pound for each man. East of the kitchen, and connected by a covered way, is the Commissary Building, which is two stories high, — the upper story is used to lodge attendants; the lower story, used for commissary store-room, is 82 by 23£, and is under a commissary steward. In the northeastern corner is the liquor-room, 8£ by 13, heavily planked and secured against marauders. All liquor is issued here on the orders of the ward surgeons. The vegetable-room is in the northwestern corner, and is 9by 13£. An office, 9by 15J, adjoins the liquor-room. The books and accounts are kept in this office. The store-room is provided with a counter 52£ feet long, and gives employment to one steward, one clerk, and two men. At the southern end is the bread-room, 14£ by 23, which employs two men cutting bread for the tables. Adjoining, on the east, is the bakery, 14 by 23£. The oven is 10 by 16 feet. The Chapel is situated 63 feet east of the commissary building. It is a structure shaped like the letter "T," one story in height, with a cupola on top. The main building is 24 by 78 feet. The northern end is used during the week as a reading-room. The left wing. 18 by 26 feet, is used as a library; it contains 3000 volumes, contributed to the hospital from various sources. The right wing is the same size, and is used as a school for the freedmen employed in the hospital, who are instructed by two female teachers. Twenty-four feet south of the chapel is the Sutler's Store, 24 by 68. The Stables, 25 by 101 feet, are 72 east of the sutler's shop; they contain 18 horses, 3 wagons, 3 ambulances, 3 carts and 1 night-cart. Thirteen men are employed as hostlers, drivers, etc. One hundred and twenty-one feet northeast of the stables is the Guard-House, 15 by 47 and one story high. South of this is the Oil-Room and Freedmen' s Quarters, 29 by 69 feet. The oil and lamp room are in the northern part. Kerosene oil was used in lighting the whole hospital, and all the lamps were filled and trimmed in this room. A corporal and two men were employed. Ninety-one feet southeast of the oil-room is the Dead-House, 15 by 40 feet. It is divided into two rooms — the northern one used in making post-mortem examinations, and the southern for plaster-casts, etc. Thirty-two feet south of this room is the Photographic Gallery, 16 by 24 feet. An operator is employed at $100 per month, paid from the slush fund. Surgical cases, pathological specimens, etc. are taken ; also likenesses of all men discharged on surgeon's certificate of disability, as a guard against fraud. On the base line of the triangle are the Medical Officers' Quarters, 63 by 24 and two stories in height; also, in the same line, the quarters for the Veteran Reserve Corps, a building two stories high, with an outside entrance-stairway to the second floor. Ninety feet further back, 100 hospital tents are pitched, placed four end to end, on substantial frames, with floors raised from the ground and a door at each end of the frame. The sides of these tents were always easily raised, and gave the best of 158 HOSPITAL ORGANIZATION AND CONSTRUCTION. ventilation; hence I selected some of them as gangrene wards, and, I think, with the very best results. In winter, each ward was heated by two stoves, with pipes running to a shaft in the centre. Each ward of four tents contained 20 beds. The length.of the fence around the hospital is 1458 yards. The distance of the fence from the tents at the base of the triangle is 124 feet. Sinks were arranged around the whole line of fence. They had movable boxes, which were regularly emptied and limed. Policing was done by a gang of about 20 freedmen. The hospital could accommodate 1240 patients in the 20 barrack wards. Its total capacity in January, 1865, was 2575 beds, including those in tents and the branch barracks, a short distance off. This hospital was opened December 23d, 1862, and closed August 22d, 1865. During this period the movements of patients were as follows: M Admitted. gf . Results. | g I fi I 111 ft I la* t i 4 o 3 5s 111 3W | §|g I I "2 in P E-t j M ¦< M oi Ph S P a P White Troops 12,391 7,837 20,228 3,665 23,793 7,191 9,411 4,400 892 1,053 286 1,000 Colored Troops 13 5 18 18 18 Prisoners of War 174 959 1,133 ' 1,133 924 45 3 161 Total 12,578 8,801 21,379 3,565 24,944 7,191 10,353 4,400 392 1,098 289 1,221 Deducting those sent to general hospital as cases not terminated, and considering that furloughed and deserted amounted to 4686, while only 3565 of these are reported as returned from furlough and desertion, we shall have the following statistics for the terminated cases of white troops treated. Total to be accounted for, excluding those sent to other hospitals 10,817 Returned to duty 6,339 Mustered out of service at the close of the war 852 Loss by desertion and failure to return from furlough 1,121 Discharged for disability 1,053 Transferred to Veteran Reserve Corps 392 Died 1,060 10,817 10,817 These figures represent excellent results, but they are not more favorable than the general statistics of all the hospitals. Making proper corrections for transfers from hospital to hospital, there were over a million of patients treated in the general hospitals during the four years of the war, and the mortality, including both that from disease and that from wounds, was but one death to every twelve patients, or about 8 per cent. Harewood Hospital, Washington, D. C, was constructed on a plan quite similar to that of Lincoln Hospital. The Hampton General Hospital, near Fortress Monroe, was also composed of wards arranged en echelon in the form of a V, but not overlapping 159 HOSPITAL ORGANIZATION AND CONSTRUCTION. each other, as those of the two foregoing hospitals did. The hospital at Point Lookout, Maryland, at Jeffersonville, Indiana, and the Sedgwick Hospital, at Greenville, near New Orleans, La., may be mentioned as examples of constructions in which the pavilion wards radiated from a circular covered way. An idea of this form of construction can be obtained from the following brief account of the latter hospital, abstracted from the Inspection Report of Medical Inspector E. P. Vollum, U. S. A, dated July 10th, 1865: Sedgwick Hospital is situated at Greenville, La., about seven miles above New Orleans, on the east bank of the Mississippi Biver. The site is flat, and drains back from the river into the swamp lands lying between the Mississippi River and Lake Pontchartrain. The soil is a rich, black alluvium. The grounds embrace about 30 acres, which have been for many years under cultivation as a plantation. At present, there is a fine vegetable garden sufficient for all the wants of the hospital. A large part of the premises is shaded by splendid groves of live-oak, pecans, and Flo. 11. — Ground Plan op Sedciwick General Hospital, Greenville, La. Scale, 120 feet to the inch. 1111. Wards. 2. Administration building. 3. Guard-house, knapsack-room, and store-house. 44. Dining-rooms. 5. Kitchen. 6. Cistern. 7. Covered ways, through which a railway runs with hand-cars for carrying food to the wards. oranges, with crape myrtles and the flowering shrubs peculiar to the latitude. The hospital is approached from the river front by a substantial road, and shell-roads and walks connect the several buildings and wind among the groves. The hospital is composed of fifteen one-storied pavilion wards, each 145 by 24 feet, and an administration building, 145 by 158 ventilation; hence I selected some of them as gangrene wards, and, I think, with the very best results. In winter, each ward was heated by two stoves, with pipes running to a shaft in the centre. Each ward of four tents contained 20 beds. The length, of the fence around the hospital is 1458 yards. The distance of the fence from the tents at the base of the triangle is 124 feet. Sinks were arranged around the whole line of fence. They had movable boxes, which were regularly emptied and limed. Policing was done by a gang of about 20 freedmen. The hospital could accommodate 1240 patients in the 20 barrack wards. Its total capacity in January, 1865, was 2575 beds, including those in tents and the branch barracks, a short distance off. This hospital was opened December 23d, 1862, and closed August 22d, 1865. During this period the movements of patients were as follows : Admitted. g 1 Kesdlts. o If 7j i iT i it I* \ 111 1 I fif I I * m P H ! PS •< X m Ph H O « fi White Troops 12,391 7,837 20,228 3,565 23,793 7,191 9,411 4,400 392 1,053 286 1,060 Colored Troops 13 5 18 18 18 Prisoners of War 174 959 1,133 1,133 924 45 3 161 Total 12,578 8,801 21,379 3,565 24,944 7,191 10,353 4,400 392 1,098 289 1,221 Deducting those sent to general hospital as cases not terminated, and considering that furloughed and deserted amounted to 4686, while only 3565 of these are reported as returned from furlough and desertion, we shall have the following statistics for the terminated cases of white troops treated. Total to be accounted for, excluding those sent to other hospitals 10,817 Returned to duty 6,339 Mustered out of service at the close of the war 852 Loss by desertion and failure to return from furlough 1,121 Discharged for disability 1,053 Transferred to Veteran Reserve Corps 392 Died 1,060 10,817 10,817 These figures represent excellent results, but they are not more favorable than the general statistics of all the hospitals. Making proper corrections for transfers from hospital to hospital, there were over a million of patients treated in the general hospitals during the four years of the war, and the mortality, including both that from disease and that from wounds, was but one death to every twelve patients, or about 8 per cent. Harewood Hospital, Washington, D. C, was constructed on a plan quite similar to that of Lincoln Hospital. The Hampton General Hospital, near Fortress Monroe, was also composed of wards arranged en echelon in the form of a V, but not overlapping HOSPITAL ORGANIZATION AND CONSTRUCTION. 159 HOSPITAL ORGANIZATION AND CONSTRUCTION. each other, as those of the two foregoing hospitals did. The hospital at Point Lookout, Maryland, at Jeffersonville, Indiana, and the Sedgwick Hospital, at Greenville, near New Orleans, La., may be mentioned as examples of constructions in which the pavilion wards radiated from a circular covered way. An idea of this form of construction can be obtained from the following brief account of the latter hospital, abstracted from the Inspection Report of Medical Inspector E. P. Vollum, U. S. A, dated July 10th, 1865: Sedgwick Hospital is situated at Greenville, La., about seven miles above New Orleans, on the east bank of the Mississippi River. The site is flat, and drains back from the river into the swamp lands lying between the Mississippi River and Lake Pontchartrain. The soil is a rich, black alluvium. The grounds embrace about 30 acres, which have been for many years under cultivation as a plantation. At present, there is a fine vegetable garden sufficient for all the wants of the hospital. A large part of the premises is shaded by splendid groves of live-oak, pecans, and Fio. 11.— Ground Plan op Sedowick General Hospital, Greenville, La. Scale, 120 feet to the inch. 1111. Wards. 2. Administration buildinfr. 3. Guard-house, knapsack-room, and store-house. 44. Dining-rooms. 5. Kitchen. 6. Cistern. 7. Covered ways, through which a railway runs with hand-cars for carrying food to the wards. oranges, with crape myrtles and the flowering shrubs peculiar to the latitude. The hospital is approached from the river front by a substantial road, and shell-roads and walks connect the several buildings and wind among the groves. The hospital is composed of fifteen one-storied pavilion wards, each 145 by 24 feet, and an administration building, 145 by 160 HOSPITAL ORGANIZATION AND CONSTRUCTION. 40, radiating from the periphery of a circular covered way, in the centre of which are the buildings for kitchens, etc. etc. The arrangement is shown in Figure 11, in which the part towards the bottom of the page is that facing the river front. Outside the circle, at convenient distances, are detached buildings for chapel, cooks' and nurses' quarters, laundry, gas-house, bake-house, dead-house, reservoir, and stables. All these buildings are constructed of boards, set upright and battened ; the roofs shingled, and open at the ridge for ventilation. They are raised 3 feet above the ground on brick piers. The covered way which connects them is twelve feet wide. The ward pavilions have two small rooms partitioned off at each end, leaving a space in the centre, 115 by 24 feet, available for patients. There are two beds between each pair of windows, as in the plan figured on page 153, but the number of beds is less — 40 to each ward. The dimensions allow about 69 square feet of floor and 1200 cubic feet of air-space to each patient. Three of the small rooms mentioned are occupied as sleeping apartments for nurses. The fourth, which is one of those at the outer extremity of each ward, is divided into bath-room and water-closet. The administration building is two stories high, and contains the office, dispensary, officers' reception, lodging, and dining rooms, etc. etc. The hospital kitchen is shown in Figure 12, which explains its arrangement. The building is 80 by 30 feet. There is a patent steam cooking apparatus with boilers, etc., and a carving-table, the pans of which are kept warm by steam. There is also one of Myers, Sandford, Winslow & Oo.'s challenge ranges, No. 10, for roasting and cooking extra diet. The railway, on which cars run to distribute food to the wards, passes through the centre of the kitchen. This kitchen is reported by Medical Inspector Vollum as having been "sufficient and in good condition" at the time of his visits. The laundry is situated on the river bank, and is furnished with a steam washing-machine, capable of washing for 1500 patients. Water for washing, etc. is obtained from a reservoir on the river bank, capable of holding 320,000 gallons, whence it is carried by pipes through the administration building, wards, kitchen, dining-rooms, and dead-house. For drinking purposes, rain-water is collected in a central cistern, which holds 150,000 gallons, and in smaller cisterns, holding 10,000 gallons each, at the end of each ward. The water for these cisterns is carried from the roofs of the buildings by zinc gutters and pipes. For the purposes of drainage, the grounds are graded from the centre of the circle towards the periphery with a descent of one inch to every 10 feet; the surface water flows at the periphery into brick sewers, which also receive the sewage from the water-closets, kitchen, etc. by pipes. The several sewers unite into a common trunk, by which the sewage is carried far to the rear of the hospital into the swamps which drain into Lake Pontchartrain. The water-closets throughout the hospital are furnished with patent pans, and discharge into brick sinks lined with cement and built up to the floor. These sinks, which are of some size, are connected with the sewers into which all the liquid parts drain. The hospital is heated by coal-stoves, and lighted with gas which is generated on the premises. This hospital was opened for the reception of patients April Ist, 1865, and, at the time of writing, is still in existence. On the thirty-first day of October, 1865, which is the date of the last report, there were 97 sick and 8 wounded patients remaining under treatment. Prior to that date, the total number of admissions of white soldiers was 2163, of whom 1869 were sick and 474 wounded. The number of patients sent to other general hospitals was 673. Deducting this number and the remaining, we have 1385 terminated cases to be accounted for, the results of which were as follows : Total to be accounted for, excluding those sent to General Hospitals and the remaining Oct. 31, 1865.... 1385 Returned to duty 848 Mustered out of service at the close of the war 210 Furloughed 181 Discharged for disability 56 Died • 90 1385 1385 As one of the most recently constructed hospitals, I may mention the Hicks' Hospital, at Baltimore, Md. The Hicks' Hospital is situated on the continuation of Townsend Street in the western suburbs of Baltimore near the city boundary. It was opened for the reception of patients June 9th, 1865, and is therefore one of the most recently constructed hospitals. The plan was essentially the circular one already described, but many important improvements and additions were devised by Surgeon Thomas Sim, U. S. Vols., under whose supervision the details of the plan were prepared. The original design contemplated a circular hospital, built on the War Department 161 HOSPITAL ORGANIZATION AND CONSTRUCTION. 21 Fig. 12. — Ground Plan of the Kitchen op Sedgwick Hospital. Scale, 10 feet to the inch. 1. Engine-house. 2. Boiler. 3. Engine and pump. 4 and 5. Store-rooms. 6. Boiling kettles. 7. Carving-table. 8 8. Tables for the delivery of food. 9 9. Shelves. 10. Sink for washing dishes. 11. Extra diet and roasting range. 12. Garbage-box. 13 13 13 13 13 13. Rooms for cooks. 14. Railroad, on which run hand-cars to carry the food to the wards. 15. Steam-pipe to heat kettles and carving-table. 162 HOSPITAL ORGANIZATION AND CONSTRUCTION. plan, with thirty-six radiating pavilion wards, each to accommodate 60 patients. The approach of the end of the war, however, prevented this from being executed, and the hospital, as completed, is a semicircle, in which the wards radiate from a covered way, as in Figure 13. It is, however, both on account of the substantial character of the wooden buildings and the numerous conveniences which have been carefully supplied, one of the most complete of the hospitals built during the war. The wards are built and ventilated as directed in the circular from the War Department. The administration building is 132 by 38 feet and two stories high ; the first story contains offices for the surgeon in charge, executive officer, quartermaster, commissary and their clerks ; it also contains the hospital library and printing-office. On the second floor are sleeping apartments for officers. This building is flanked on each end by a smaller one, 70 by 28 feet, one of which Fig. 13. — Ground Plan of Hicks' General Hospital, Baltimore, Md. Scale, 180 feet to the inch. 1111. Wards. 2. Administration building. 3. Linenroom, etc. 4. Dispensary and operating-room. 5. Dlning-hall. 6. Kitchen and laundry. 7. Ward for detailed men. 8. Knapsack-room. 9. Commissary store-house. 10. Quartermaster's store-house. 11. Tank. 12. Quarters for guard. 13. Stable. 14. Wagon-house. 15. Sutler. 16. Stewards' quarters. 17 18. Officers' houses (of which, also, there are several not in the figure). 19. Guard-room. 20. Guard-house, near entrance gate. 21. Workshop. 22. Contagion ward; this is farther distant than is represented in the figure. The wards, dining-room, and administration building are connected by a covered way, which is indicated by faint lines in the plan. contains the linen-room and post-office, with the officers' dining-room, kitchen, and pantry. The other contains the dispensary, medical store-rooms, room of the discharge board, and an operating-room lighted by a sky-light. The dining-room building is 187 by 48 feet, and is two stories high. The dining-room, which is on the first floor, is capable of seating about 1200 patients. The second floor, which is accessible by stairs on the outside, is occupied by the chapel and by dormitories for female nurses. At the end of the dining-room is a T-shaped building for kitchen and laundry. The general kitchen, extra-diet kitchen, and bakery occupy separate apartments ; the former two each contain a suitable range and steam fixtures, the latter two bake-ovens. The laundry has a separate room for drying by steam, and immediately adjoins the engine-room, which is at the extremity of the building. There are, besides the foregoing, separate buildings for knapsack-room, quartermaster's store-house, commissary store-house, quarters for 163 HOSPITAL ORGANIZATION AND CONSTRUCTION. detailed men, barracks for guard, workshop, contagion ward, dead-house, stewards' quarters, and quarters for married officers. The buildings are plastered inside, are lighted by gas, to be warmed in the winter by stoves, and receive their water supply by pipes from the city water-works, besides which there is a tank for the purpose of keeping a stock of water constantly on hand in case of fire. For the purpose of extinguishing fire, there is abundant hose to fit the steam-pump. There are also water-buckets, axes, etc. At the distal end of each ward is a lavatory and bathroom and a water-closet. Each bath-room has in it a small stove, on which is a boiler for the supply of hot water. In the water-closets the excretions are received in troughs, into which a stream of water runs, and which are emptied by withdrawing a plug several times daily. They discharge into sewers constructed for the purpose, which carry all offensive matters entirely away from the hospital. A very beautiful model of the hospital in holly-wood has been presented to the Army Medical Museum by Surgeon Sim. This hospital was opened for patients June 9th, 1865; and the total number of white soldiers received prior to November 30th, 1865, which was the last report up to the date of writing, was 1247, of whom 984 were sick and 263 wounded. Of these, 366 were transferred to other general hospitals, and 120 remained under treatment at the date of the last report. The number of terminated cases, therefore, was 761, who are thus accounted for : Total to be accounted for, excluding those transferred to other hospitals and those remaining at date of last report , 761 Returned to duty \ 131 Mustered out of service at the close of the war 443 Loss by desertion and failure to return from furlough 52 Discharged for disability 89 Transferred to Veteran Reserve Corps 2 Died 44 761 761 Besides the above, 280 colored soldiers were admitted, of whom 15 died. All the hospitals hitherto described were situated near the base of military operations, and received therefore more severe cases than those at a distance. As an example of the more distant hospitals, the figures of the Lovell Hospital, at Portsmouth Grove, Narraganset Bay, E. 1., may here be given. This hospital, which is composed of twenty-eight fine wooden pavilion wards, situated on a tongue of land jutting out into the bay, was opened in July, 1862, and closed October 10th, 1865. During this period it received 11,696 white soldiers, of whom 8491 were sick and 3205 wounded. Of these, 2461 were transferred to other hospitals, leaving 9235 patients to be accounted for, as follows: Total to be accounted for, excluding those sent to other hospitals 9235 Returned to duty 4386 Mustered out at the close of the war 875 Loss by desertion and failure to return from furlough 961 Discharged for disability 2021 Transferred to Veteran Reserve Corps 716 Died 276 9235 9235 164 HOSPITAL ORGANIZATION AND CONSTRUCTION. On comparing the statistical reports of the hospitals in various parts of the country, we are struck by the fact that the number returned to duty and the ratio of deaths to terminated cases were greater in those hospitals which were nearest the seat of war. On the other hand, the number discharged the service for disability and transferred to the Veteran Reserve Corps was greater in the more distant ones. These facts, which naturally result from the reception of acute cases into the nearest hospitals and the frequent transfers thence to the more distant ones, must be remembered in all comparisons made between the results of treatment in different institutions. To give an idea of the vast extent of hospital accommodations demanded, the following list of general hospitals in existence in September, 1864, is here presented. The hospital system had at that time attained its maximum extent, there being 202 general hospitals and 136,894 beds for patients. The number of beds was gradually reduced till January, 1865, when there were 121,000, and about this number was kept on foot to the close of the war. Hospitals in the Atlantic Begion, September, 1864. No. Name. Locality. Beds. No. Name. Locality. Beds. Department of the East. Brought forward 43,051 1 David's Island New York Harbor 3,000 Middle Department 2 Fort Columbus New York Harbor 100 CnnHniiorl 3 Ladies' Home New York City 400 Continued. 4 St. Joseph's Central Park, N. V 333 9 TiUon Wilmington, Del 352 5 Newark Newark, N. J. ...... 927 i 0i 0 McKim's Mansion Baltimore, Md 300 ° jf™ l. 1 Portsmouth Grove, E. 1 1,644 n officers' Annapolis, Md 409 s s"!£i iT"V New Haven, Conn 1,121 12 Camp Parole Annapolis, Md 2,000 8 Brattleboro' Brattleboro', Yt 1,097 9 Marine Burlington, Yt 250 _, ._ _ , 10 Mason Boston, Mass 60 Department of Wash-11 Buffalo Buffalo, N. V 150 ington 12 MoDougall Fort Schuyler, N. Y. Harbor.. 1,328 * 13 Augusta Augusta, Me 1.052 1 Armory Square Washington, D. C 1,000 14 Grant Willets'Point, N. Y. Harbor.. 1,172 2 Augur Near Alexandria, Va 671 15 Sloan Montpelier, Vt 462 3 Carver Washington, D. C 1,300 16 Albany Albany, N. V 560 4 Campbell Washington, D. C 1,000 17 Elmira Elmira, N. V 300 5 Columbian Washington, D. C 844 18 Rochester Rochester, N. V 608 6 Douglas Washington, D. C 400 19 Officers' Bedloe's Island, N.Y. Harbor.. 80 7 Ricord Washington, D. C 120 20 New York City New York City 151 8 Ist Division Alexandria, Ya 1,295 21 Jews' New York City 50 9 2d Division Alexandria, Va 1,600 22 Brooklyn City Brooklyn City, N. V 100 10 3d Division Alexandria, Va 1,500 23 Sisters of Charity Buffalo, N. V 200 11 Emory Washington, D. C 900 24 Readville Keadville, Mass 910 12 Finley Washington, D. C 1,061 13 Fairfax Seminary Virginia 936 Tirnnriment of Ihr Sim 14 Harewood Washington, D. C 2,000 department of the bus- 15 Judiciary g c Washington; D. C 510 guehanna. 16 Kalorama Washington, D. C 434 , „„„, „ „.., ? . . „ , „., 17 Lincoln Washington, D. C 2,575 1 McClelan Phi ade phia Pa 1,841 18 Mount Pleasant Washington, D. C 2,000 2 Turner's Lane Philadelphia, Pa 310 19 Seminary Georgetown D. C 123 3 Convaescent Phi ade pha, Pa 805 20 Stone....:. Washington D. C 170 4 Satterlee Philadelphia, Pa 3,519 21 Freedman Washington, D. C 98 ° Mower Philadelphia, Pa 3,326 22 Stanton Washington, D. C ! 420 2 Cuyjer "........... Germantown, Pa 700 23 U.S.General Point Lookout, Md 1,090 I Christian Street Phi adelphia, Pa 299 34 Louve^e Alexandria, Va 500 8 South Street..... Philadelphia, Pa 270 25 ciaremont Alexandria, Va 164 9 Citizen's Volunteer Philadelphia, Pa 250 26 Oipshnrn' Oipshoro' D O 535 10 Summit House Philadelphia; Pa 1,204 Uiesboro UiesDoro v. o qm> 11 York York, Pa 2,200 „ „ T,. . . 12 Haddington Philadelphia, Pa 1,225 Department of Virginia 13 Islington Philadelphia, Pa 60 and North Carolina. 14 Officers' Camac Woods, Pa 64 15 U.S.General Pittsburg, Pa 723 1 U.S.General Near Fort Monroe, Va 3,570 16 Broad Street Philadelphia, Pa 527 2 Balfour Portsmouth, Va 850 17 Chester Chester, Pa 1,167 3 Foster Newbern, N. c 475 18 Beverly Beverly, N. J 1,460 4 U.S.General Beaufort, N. C 230 19 White Hall White Hall, Pa 1,373 5 Mansfield Morehead City, N. C 300 Middle Department. Department of the South. 1 National Hotel Baltimore, Md 400 1 Division No. 1 Beaufort.S.C 295 2 Newton University Baltimore, Md 200 2 Division No. 2 Beaufort.S.C 440 3 Convalescent Baltimore, Md 1,200 3 U.S.General Hilton Head, S. C 600 4 Jarvis Baltimore, Md 1,380 4 U.S.General Jacksonville, Fla 174 5 West's Buildings Baltimore, Md 425 5 Officers' Beaufort, S.C 20 6 Division No. 1 Annapolis, Md 1,117 6 Conot St. Augustine, Fla 133 7 Division No. 2 Annapolis, Md 661 7 Field Marietta, Ga 2,115 8 Annapolis Junction Annapolis Junction 290 Total Atlantic Region 78,560 Carried forward 43,051 I 165 HOSPITAL ORGANIZATION AND CONSTRUCTION. Hospitals in the Central Region, September, 1864. No. Name. Locality. Beds. No. Name. Locality. Beds. Northern Department. Brought forward 32,170 1 Seminary Columbus, Ohio 223 . _ 2 U.S. General Camp Chase, Ohio 214 Department of Kansas. 3 U.S. General Cleveland, Ohio 360 4 Dennison Camp Dennison, Ohio 2,500 1 U. S. General Leavenworth, Kansas 240 5 West End Cincinnati, Ohio 120 2 U. S. General Fort Scott, Kansas 148 6 Washington Park Cincinnati, Ohio 150 7 Marine Cincinnati, Ohio 122 8 U.S. General Evansville, Ind 630 Department of the Ar-9 Madison Madison, Ind 2,095 t/i«.«« 10 U.S. General Indianapolis, Ind 256 Kansas. 11 Desmarres Chicago, 111 150 . jr a n« «.oi Tittio T?/vir Ark- 797 19 Mii-i,,,» fij.!<.osr. tii nn 1 U. S. General JUttie kock, ahc i»< il vT%=::=:::= SEBBft'SLT-™-™: 110 * j^Ti EMS'l* i 14 U.S.General QnlMy.lll... 478 » SK L « Kock Ark 129 15 St.Mary's Detroit, Mich 460 * £ ffic en ....... Little Kock Ark l^» 16 U.S.General i Gallipolis, Ohio 800 5 TJ. S. General Helena, Ark ™ 17 Main Street Covington, Ky 300 18 Seminary Covington, Ky 218 _. . . ... -, 19 Grant, Officers' Cincinnati, Ohio 50 Department of the Tennessee. Department of the North- „ .. ?.„ r . 1 Overton Memphis, Term 450 wm. 2 Gayoso Memphis, Term 400 1 Harvey Madison, Wis 586 \ Ad , ams> , " SeZhta KSS 100 2 U.S. General Keokuk lowa 1,350 * «£*« ;••••"••:•• MemSh s' Term 200 3 U.S. General Davenport, lowa 200 \ 4TO _ 7 Webster Memphis, Term 500 Department of Western 8 U.S.General Mound City, 111 63b Virninia 9 Pest Near Vicksburg, Miss 147 Vt W ma - 10 U.S. General No. 2 Vicksburg, Miss 290 1 Frederick Frederick, Md 1,276 11 U. S. General No. 3 Vicksburg, Miss 300 2 Cumberland Cumberland, Md 1,191 12 U.S.General Natchez, Miss 1« 3 Parkersburg Parkersburg, West Va 418 113 Jackson Memphis, Term aw 4 Grafton Grafton, West Va 267 I Department of the Ohio. Department of the Cumberland. 1 Clay Louisville, Ky 970 2 Brown Louisville, Ky 1,000 1 v S General No 1 Nashville, Term 900 3 Eruptive Louisville, Ky 348 2 U S General No 2 Nashville, Term 665 4 U.S.General New Albany, Ind 1,228 3 v' s' General No 3 Nashville, Term 000 5 Ohio New Albany, Ind 300 4 tj' s General No 8 Nashville, Term 540 6 Jefferson Jeffersonville, Ind 2,802 5 v S General No 11 Nashville, Term 720 7 N0.16 Jeffersonville, Ind 110 6 v! S. General No. 15 Nashville, Term 280 8 Nelson Camp Nelson, Ky 500 7 U S General No 16 Nashville, Term 176 9 Nelson (Eruptive) Camp Nelson, Ky 100 8 U S General No 17 Nashville, Term 180 10 Convalescent Camp Nelson, Ky 600 9 v S General No 19 Nashville, Term 629 11 U.S.General Lexington, Ky 463 in Tiimberland Nashville, Term 2,400 12 U.S.General Bowling Green, Ky 128 n Field '..'." Bridgeport, Ala 408 13 U.S.General Ashland, Ky 275 12 U S General Gallatin, Term 108 14 Corps d'Afrique New Albany, Ind 82 13 v S General . . Murfreesboro'. Term 730 15 Totten Louisville, Ky 1,150 14 U.S.General."..... Tullahoma, Term 100 16 Joe Holt. Jeffersonville, Ind 1,350 15 U S General No. 1 .. Chattanooga, Term 6"2 17 U.S.General Knoxville, Term 1,347 16 v S General No 2 ... Chattanooga, Term 1,131 18 Officers' Knoxville, Term 54 17 Yie\k Chattanooga, Term 1,247 19 Holston Knoxville, Term 656 -\a v S General No 14 Nashville, Term "50 20 Officers' Louisville, Ky 33 19 Sherman Nashville, Term 430 21 Branch "A." Bowling Green, Ky 88 20 U S General Lookout Mountain, Term 800 22 Branch "B." Bowling Green, Ky 40 21 Officers' Lookout Mountain, Term 250 22 Provisional Chattanooga, Term 100 Department of the Mis*ouru ouru Department of the Gulf. 1 Marine St. Louis, Mo 208 . __, _ onn 2 Small-pox St. Louis, Mo 235 1 St.James New Orleans, La 300 3 U.S.General Benton Barracks, Mo 575 2 University New Orleans, La bW 4 U.S.General Jefferson Barracks, Mo 1.700 3 Marine New Orleans, La suo 5 U.S.General Jefferson City, Mo 134 4 U. S. Barracks New Orleans, La 1/uo 6 U.S.General Springfield, Mo 200 '0 St. Louis New Orleans, La &00 7 U.S.General Rolla, Mo 120 6 Charity New Orleans, La 650 8 U.S.General Kansas City, Mo 100 7 U. S. Convalescent Baton Rouge, La 4W 9 Prison St. Louis, Mo 300 8 Corps d'Afrique New Orleans, La 1,700 Carried forward 32,170 Total Central Region 58,266 Hospitals in the Pacific Region, September, 1864. sfo. Name. Locality. Beds. No. Name. Locality. Beds. 1 Wright Presidio, San Francisco, Cal... 40 \\ 2 Barnes Benicia Barracks, Cal 28 \\ — — • RECAPITULATION. Atlantic Region 93 Hospitals. 78,560 Beds. Central Region 107 " 58,266 ' Pacific Region 2 " 68 Total 202 " 136,894 " I 166 CONCLUDING REMARKS. In addition to hospital construction, it is important that the system of hospital administration should be faithfully described. The hospital fund and its management, the slush fund, hospital cooking and diet tables, nurses, the question of female nurses, the hospital records and reports, are all subjects on which there are abundant In the foregoing remarks, my intention has been simply to give an idea of the nature and extent of the data for a Medical History of the War to be found in the part of the office under my direction. Many matters of interest have not been touched upon, for a full discussion of which abundant material exists; as, for example, the comparative health of the colored troops, of the prisoners of war held by us, of those of our own men who were unfortunate enough to fall into the hands of the rebels, etc. Moreover, there is much material in other branches of the Surgeon General's Office the consideration of which is necessary to a full understanding of the medical administration of the army. In conclusion, I may express the opinion that, with the utmost brevity and care, it may be hoped to digest the material above sketched, not including surgical cases, into three quarto volumes, of about the size of the volumes of the Medical Statistics heretofore published. The prominent subjects in these volumes would be the medical statistics of the several armies, with the principal facts in their medical histories; the medical statistics of the several general hospitals, with descriptions of their construction and administration, illustrated by a sufficient number of ground plans and perspective views to give a just idea of them; and lastly, an account of the causes, history, symptoms, pathology, and treatment of the principal diseases of the troops, based upon statistical facts, contributed papers, histories of cases and autopsies, and observations made in the medical and microscopical sections of the Museum. This part of the work it is proposed to illustrate with such colored plates of morbid conditions and representations of the microscopical anatomy of the chief diseases as may be necessary to preserve, for the future study of medical men, a faithful account of the costly experience of the Medical Department during the war. Of the subjects thus indicated, about one-half of the statistical matter is compiled, and most of the material required for the remaining portion of the work is collected, and can be prepared for the press with reasonable rapidity. Almost all the necessary drawings are made, and ready for the lithographer; a large number of the wood-cuts are actually executed, and the material for the microscopical illustrations is in a forward condition. I have the honor to be, Very respectfully, Your obedient servant, J. J. WOODWARD, Assistant Surgeon and Brevet Major U. S. A., In charge of the Record and Pension Division, Surgeon General's Office, and of the Medical Section, Army Medical Museum.